The Reliability of the Lateral Radiograph in Determination of the Optimal Transarticular C1-C2 Screw Length

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Study Design.

This study assessed the value of using lateral radiographs in evaluating the optimal screw length in transarticular C1-C2 screw fixation.


To assess the reliability of the lateral radiograph in determining the optimal transarticular C1-C2 screw length.

Summary of Background Data.

Transarticular C1-C2 screw placement is usually performed using anatomic landmarks and fluoroscopy. A lateral fluoroscopic image is valuable when directing screws in the sagittal plane, but its exact role in determining screw length has not been investigated.


Eight cervical spine specimens were used in this study. Screw placements were performed in each specimen, fixed in the exact lateral position and under direct visualization. After each placement, a lateral radiograph was taken. The odontoid process was divided into three equal portions. Another portion anterior to the odontoid process was called the anterior tubercle region. The number of screw tips appearing in each portion on the radiograph was then recorded for each placement. In addition, 30 C1 specimens were measured to evaluate the anterior part of C1.


The results showed that 12.5% of the screws placed 2 mm short of reaching the ventral cortex and 0 mm overpenetrating the ventral cortex of the lateral mass of C1 projected in the radiograph on the anterior tubercle region, 37.5% on the anterior region of the odontoid process, and 50% on the middle region of the odontoid process. Twenty-five percent of the screws that were placed to overpenetrate, by 2 or 4 mm, the ventral cortex of the lateral mass of C1 were projected on the anterior tubercle region in the radiograph, and 50% and 62.5% were projected on the anterior region of the odontoid process, respectively. The mean vertical distance between the anteriormost point of the anterior tubercle of the anterior ring and the middle of the ventral cortex of the lateral in all specimens was 5.6 ± 1 mm, and the mean transverse angle of the anterior ring relative to the frontal plane was 21.1 ± 3.5°.


This results in this study indicate that a lateral radiograph may not be reliable in determining the optimal screw length, although it is valuable in directing accurate screw angle in the sagittal plane. Preoperative computed tomographic evaluation of the C1-C2 region may be helpful in estimating the location of the screw tip on the lateral radiograph during surgery.

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