Multiplanar reconstructions of helical computed tomography in planning of atlanto-axial transarticular fixation

The objective of this study was to determine atlanto-axial bone morphometric measurements related to screw transarticular fixation technique. One hundred helical computerized tomography ( helical CT) scans with volumetric acquisition, including the first and the second cervical vertebrae, were studied. The screw insertion axis according to the Magerl technique for C1 - C2 transarticular fixation was the referential to select the correct oblique axial and oblique parasagittal planes obtained with multiplanar reconstruction (MPR) on helical CT. The selected measured parameters on each side of the vertebrae were C2 interarticular isthmus height and width, optimal screw length, optimal screw trajectory sagittal and axial angles, and the distance between the ideal screw trajectory and the vertebral artery groove. C2 interarticular isthmus height measured 7.75 +/- 1.27 mm, C2 interarticular isthmus width 7.94 +/- 1.72 mm, optimal screw length 39.03 +/- 2.81 mm, optimal screw trajectory sagittal angle 57.54 +/- 5.28 degrees, optimal screw trajectory medial angle 7.90 +/- 4.05 degrees. Isthmus narrowing under 5 mm ( height and/or width) was seen in 5% of cases. In 30% of cases reconstructed parasagittal images showed the vertebral artery groove. In those cases, the distance between the vertebral artery groove and the ideal screw path was measured. This distance measured under 2.5 mm in 7% of C2 articular masses. A classification of C2 articular mass morfology was proposed. The C2 articular masses without anatomic variations predisposing to vertebral artery injury were considered type I. The C2 articular masses potentially associated with vascular injury ( 12%) were classified as type II. Potential risk was identified at the C2 isthmus only (3%), at the anterior portion of C2 articular mass only ( 7%) or at both regions (2%). According to selected criteria 18% of patients would have at least one side C2 articular mass with potential risk for the vertebral artery. In 6% of patients the potential risk was identified bilaterally. There is a great variation in the maximum and minimum values of the anatomic measurements. Therefore preoperative CT scans are very important to identify type II cases, such that the surgeon may preoperatively define the bony anatomy trough which the screws will pass.