J Neurosurg Spine

J Neurosurg 11:000–000,
Spine 11:15–22, 2009

Radiographic and clinical evaluation of free-hand placement

of C-2 pedicle screws

Clinical article
Daniel M. Sciubba, M.D., Joseph C. Noggle, B.S., Ananth K. Vellimana,
Hassan Alosh, B.S., Matthew J. McGirt, M.D., Ziya L. Gokaslan, M.D.,
and Jean-Paul Wolinsky, M.D.

Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland

Object. Stabilization of the cervical spine can be challenging when instrumentation involves the axis. Fixation
with C1–2 transarticular screws combined with posterior wiring and bone graft placement has yielded excellent fu-
sion rates, but the technique is technically demanding and places the vertebral arteries (VAs) at risk. Placement of
screws in the pars interarticularis of C-2 as described by Harms and Melcher has allowed rigid fixation with greater
ease and theoretically decreases the risk to the VA. However, fluoroscopy is suggested to avoid penetration laterally,
medially, and superiorly to avoid damage to the VA, spinal cord, and C1–2 joint, respectively. The authors describe
how, after meticulous dissection of the C-2 pars interarticularis, such screws can be placed accurately and safely
without the use of fluoroscopy.
Methods. Prospective follow-up was performed in 55 consecutive patients who underwent instrumented fusion
of C-2 by a single surgeon. The causes of spinal instability and type and extent of instrumentation were documented.
All patients underwent preoperative CT or MR imaging scans to determine the suitability of C-2 screw placement. In-
traoperatively, screws were placed following dissection of the posterior pars interarticularis. Postoperative CT scans
were performed to determine the extent of cortical breach. Patients underwent clinical follow-up, and complications
were recorded as vascular or neurological. A CT-based grading system was created to characterize such breaches ob-
jectively by location and magnitude via percentage of screw diameter beyond the cortical edge (0 = none; I = < 25%
of screw diameter; II = 26–50%; III = 51–75%; IV = 76–100%).
Results. One-hundred consecutive screws were placed in the pedicle of the axis by a single surgeon using exter-
nal landmarks only. In 10 cases, only 1 screw was placed because of a preexisting VA anatomy or bone abnormality
noted preoperatively. In no case was screw placement aborted because of complications noted during drilling. Early
complications occurred in 2 patients and were limited to 1 wound infection and 1 transient C-2 radiculopathy. There
were 15 total breaches (15%), 2 of which occurred in the same patient. Twelve breaches were lateral (80%), and 3
were superior (20%). There were no medial breaches. The magnitude of the breach was classified as I in 10 cases
(66.7% of breaches), II in 3 cases (20% of breaches), III in 1 case (6.7%), and IV in 1 case (6.7%).
Conclusions. Free-hand placement of screws in the C-2 pedicle can be done safely and effectively without the
use of intraoperative fluoroscopy or navigation when the pars interarticularis/pedicle is assessed preoperatively with
CT or MR imaging and found to be suitable for screw placement. When breaches do occur, they are overwhelmingly
lateral in location, breach < 50% of the screw diameter, and in the authors’ experience, are not clinically significant.
(DOI: 10.3171/2009.3.SPINE08166)

Key Words      •      axis      •      C-2      •      screw fixation      •      pars      •      pedicle

F
usion constructs used to address upper cervical
spine instability have evolved from wiring tech-
niques to more rigid fixations of the axis (C-2) us-
ing transarticular, pedicle/pars interarticularis, or laminar
screws attached to rods. The earlier wiring techniques
Abbreviations used in this paper: PS = pedicle screw; VA = ver-
tebral artery; VB = vertebral body.
described by Brooks-Jenkins, Gallie, and Sonntag have
been criticized for their inability to limit rotation of C-1
relative to C-2, thus necessitating postoperative rigid im-
mobilization and yielding suboptimal fusion rates.1,8,13,16
Jeanneret and Magerl13 improved on this inadequacy by
implementing the C1–2 transarticular screw technique,
allowing rigid fixation about all axes of the spine and
thus improving fusion rates. Specifically, the use of
Magerl’s technique coupled with subsequent posterior

J Neurosurg: Spine / Volume 11 / July 2009 15

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C1–2 wiring and bone grafting has yielded the highest
fusion rates.9,13,21 However, the risk of VA injury may be
increased due to anatomical discrepancies, thus preclud-
ing the placement of such screws in up to 26% of pa-
tients.14,15,20,22,23
More recently, other forms of C-2 fixation have been
developed. Placement of C-2 pedicle/pars interarticularis
screws in conjunction with rod-cantilever constructs, as
described by Harms and Melcher,12 may be a safer and
less anatomically restricted means of achieving C-2 fixa-
tion compared to the use of transarticular screws. In ad-
dition, Puttlitz et al.18 reported that C-2 PS fixation can be
substituted for C1–2 transarticular screw placement with
no relative compromise to stability or instrumentation
stress. However, C-2 PS placement may be technically
difficult due to variable location of the transverse fora-
men and subsequent risk of VA injury.
To aid in successful placement of C-2 PSs, intraop-
erative fluoroscopy has been recommended. However,
trauma to the VA may not be prevented with fluoroscopy
because such imaging does not provide ideal visualization
of the VA as it courses from the C-3 vertebra to the C-1
vertebra. As a result, we suggest that ideal placement of
C-2 PSs is predicated on more extensive dissection, lead-
ing to greater exposure of the superior, medial, and lat-
eral aspects of the pars. In this way, screws can be placed
free-hand by relying exclusively on external anatomy. We
conducted a rigorous CT-based radiographic review of 55
consecutive patients who underwent free-hand placement
of 100 C-2 PSs. Radiographic results were then correlated
with clinical outcomes.
Fig. 1.  Standard coronally reconstructed CT scans used to determine cortical breach of C-2 PS from a posterior slice in the
pars (A), to more anterior coronal slices in the pedicle (B), pedicle-VB junction (C), and VB (D).
16
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D. M. Sciubba et al.
Methods
Data Collection
A prospective review at a single institution by a single
surgeon (J.P.W.) was conducted involving adult patients
with C-2 PSs. Prior to surgery, all patients underwent
preoperative radiological evaluation of the cervical spine,
including CT scanning with multiplanar reconstruction
or MR imaging to assess the anatomy of C-2. Anatomi-
cal restrictions for placement of standard PSs included
anomalies of the VA or a surrounding bone anomaly that
precluded safe screw placement, or absence of bone due
to a destructive lesion, such as a tumor. In these cases,
screws were placed only on one side.
Radiographs and CT scans obtained in the immedi-
ate postoperative period were used to confirm accurate
placement of hardware. In addition, standard lateral or
flexion-extension lateral radiographs were obtained in all
patients at 6 weeks, 3 months, and 6 months when pos-
sible. Patient characteristics (age and sex), clinical pre-
sentation (myelopathy, pain, deformity), cause of cervi-
cal instability (trauma or degenerative disease), length of
follow-up, and complications were reviewed in all cases.
In addition, postoperative CT scans were evaluated to de-
termine the presence and extent of cortical breach. Such
evaluation was done by first reviewing the entire C-2
pars and pedicle from posterior to anterior on coronally
reconstructed CT images (Fig. 1). When a breach was
suspected, the images were reformatted to create views
truly orthogonal to the screw so as to more accurately
quantify the extent of breach in line with the PS (Fig. 2).
J Neurosurg: Spine / Volume 11 / July 2009
Free-hand placement of pedicle screws in the axis

Fig. 2.  Computed tomography images reformat-

ted to show the screw in a coaxial manner for accu-
rate identification of cortical breaches. Using axial
image (A) and sagittally reconstructed image (B),
the coronally reconstructed image represents an
image completely perpendicular to the screw trajec-
tory in 2 planes (C). Dotted white lines represent the
plane of the other images relative to the one being
viewed.

A CT-based grading system was created to characterize
such breaches objectively by location (lateral, medial, or
superior) and magnitude by percentage of screw diameter
beyond cortical edge (0 = none; I = < 25%; II = 26–50%;
III = 51–75%; IV = 76–100%; Fig. 3). Patients underwent
clinical follow-up, and complications were recorded as
vascular or neurological.
Technical Description of C-2 PS Placement
As stated previously, preoperative sagittal CT recon-
struction or sagittal MR imaging scans are used to deter-
mine the suitability for placement of a C-2 PS. It is our
experience that if a sagittal CT reconstruction or parasag-
ittal MR image demonstrates the entire C-2 pedicle on a
single image slice without the transverse foramen within
that slice, then a C-2 PS can safely be placed. Such prac-
tice is based on the assumption that a standard CT im-
age averages roughly 3 mm of anatomical data between
sequential slices, and thus the pedicle is probably > 3 mm
wide. Figure 4 demonstrates a scenario in which the aber-
rant bone anatomy of the left pedicle precluded safe place-
ment of a C-2 PS. In this case, the entire left pedicle could
not be visualized on a standard sagittal CT section (Fig.
4A). In the same patient, the entire right pedicle could be
visualized on a single standard sagittal CT section (Fig.
4B). Figure 4C demonstrates the left pedicle diameter as
2.8 mm on axial CT sections, obviating the possibility of
placing of a 3.5-mm PS, while the right pedicle diameter
measures 7.2 mm, indicating favorable anatomy for place-
ment of a C-2 PS.
The entry point for the C-2 screw is based on thor-
ough evaluation of the distinct anatomy of the C-2 poste-
rior elements. Given that C-2 is a transitional vertebra be-
tween the subaxial cervical spine vertebrae and the atlas,
the distinction between the C-2 pars and pedicle can be
unclear to many at first. However, it helps to note that the
C-2 pars interarticularis lies in between the articular sur-
faces of C-1 and C-2, while the C-2 pedicle, on the other
hand, connects the VB to the posterior elements. In this
way, a C-2 PS travels from the posterior elements, usually
starting in the pars articularis, to the VB anteriorly.
Our entry point is located at the lateral aspect of the
C-2 lateral mass, just caudal to the transition of the lat-
eral mass into the C-2 pars. The point is at least 1.75 mm
caudal to the lateral mass–pars transition zone (Fig. 5A).
This entry point allows a 3.5-mm-diameter screw to have
at least 0.5 mm of bone at its rostral margin along the
pars. The very high and lateral location of the entry point
minimizes the potential for VA injury. The caudal-rostral

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Fig. 3.  Qualification of C-2 pedicle cortical breach. L = lateral, into
VA foramen; J = junctional, into the C1–2 joint. No medial example is
present.
trajectory of the C-2 PS is determined by the slope of
the C-2 pars or isthmus, which can be noted by direct
intraoperative visualization. Using a Penfield #1 dissec-
tor, the pars of C-2 is exposed from the pars–lateral mass
transition toward the C1–2 joint space. The caudal-rostral
trajectory of the C-2 screw path is then directed parallel
to the slope of the C-2 pars (Fig. 5B). This trajectory can
be estimated by laying a Penfield #1 dissector along the
superior border of the C-2 pars.
To determine the lateral-medial trajectory of the
screw path, the medial aspect of the pars of C-2 is iden-
tified forming the lateral edge of the spinal canal. The
lateral-medial trajectory of the screw path is determined
by drawing a 3.5-mm-diameter imaginary line from the
screw entry point so that it stays just within the pars, as the
pars meets the VB (Figs. 5A and C). This trajectory can
be visualized easily without requiring a C-2 laminectomy
if the pars of C-2 is carefully dissected out. Inspection of
external landmarks will help avoid breaching toward the
vertebral foramen, which is just lateral and inferior to the
C-2 pedicle (Fig. 5D).
The information gained from these 3 estimations al-
lows the C-2 PS to be safely placed. At this point, a 3.0-
18
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D. M. Sciubba et al.
mm pilot hole is made at the C-2 screw entry point de-
scribed above. Using a 3.5-mm calibrated fluted conical
tap, the screw hole is made along the caudal-rostral and
lateral-medial trajectory. The tap is sharp enough to al-
low the cancellous bone to be perforated, but is not sharp
enough to violate the cortical margins. The flutes in the
tap will indicate whether significant bleeding is encoun-
tered, which may be suggestive of a VA injury. Of note,
the increased presence of venous blood from the screw
hole may indicate a breach of the transverse foramen and
injury to the venous plexus surrounding the VA. More
significant arterial bleeding may signify a VA injury. If
increased venous bleeding is encountered, the hole should
be palpated with a ball-ended probe prior to proceeding
further with creation of the screw path. We have not en-
countered VA injuries when using this technique, and
thus such indicators as a threshold to avoid encountering
the VA have not been validated. The tap is advanced un-
til the anterior cortical margin of the C-2 VB is encoun-
tered, which will be suggested by increased insertional
torque on the tap after the tap has advanced at least 20
mm. The length of the screw to be used is determined by
the calibration on the tap. The tap is then removed. Prior
to placement of the screw, the screw path is palpated with
a ball-ended dissector to verify that there is no violation
along the path. The average screw placed is 26-mm-long
with a 3.5-mm diameter.
Results
Characteristics of the 55 patients are summarized in
Table 1. Thirty patients were male (55.6%) and 24 were
female (44.4%), with ages that ranged from 14 to 87 years
(mean 56.7 years). The most common reasons for fusion
were: degenerative disease in 20 patients (37.0%), neo-
plastic disease in 12 (22.2%), trauma in 11 (20.4%), con-
genital disease in 8 (14.8%), and infection in 3 (5.6%).
One hundred screws were placed without perioperative
vascular or neurological complications. In 10 cases, only
1 screw was placed because of preexisting VA anatomy
or a bone abnormality on 1 side. In no case was screw
placement aborted because of complications noted during
drilling. No intraoperative and no immediate postopera-
tive complications were noted. Early complications oc-
curred in 2 patients and were limited to 1 wound infection
and 1 transient C-2 radiculopathy, which was believed to
result from C-2 nerve root manipulation during placement
of a C-1 lateral mass screw. There were 15 total breaches
(15%), 2 of which occurred in the same patient. Twelve
breaches were lateral (80%) and 3 (20%) were superior/
junctional; there were no medial breaches. The magni-
tude of the breach was classified as I in 10 cases (66.7%),
II in 3 cases (20%), III in 1 case (6.7%), and IV in 1 case
(6.7%). There were no vascular or neurological injuries.
Regarding the higher grade breaches: the Grade III
breach occurred in the C1–2 joint without event (Fig. 2).
In fact, this patient had undergone instrumented fusion at
C1–2, so there was no concern that such a breach would
lead to adjacent-segment degeneration in a nonfused seg-
ment. The patient with the Grade IV breach was noted to
possess a large left VA foramen preoperatively. Intraop-
J Neurosurg: Spine / Volume 11 / July 2009
Free-hand placement of pedicle screws in the axis
Fig. 4.  Preoperative CT scans obtained in a patient in whom aberrant left C-2 pedicle anatomy prevented the use of the ap-
proach we have described. Sagittal view of the left C-2 pedicle (A), sagittal view of the right C-2 pedicle (B), and axial (C) and
coronal (D) views of C-2 are shown.
eratively, a Penfield #4 dissector was placed into the ver-
tebral foramen from a lateral trajectory to protect the VA
during C-2 pedicle drilling. Although it was noted that
the screw hole possibly breached the vertebral foramen
after sounding of the hole with a ball-tipped probe, no
arterial bleeding was encountered. However, because of
the preoperative surgical plan, which involved a potential
reduction of C-1 on C-2, the screw was placed. Follow-
ing CT evaluation showing obvious breach (Fig. 3, Grade
IV example), an intravenous contrast agent was injected,
and good flow within the left VA was revealed without
pseudoaneurysm formation.
Discussion
Instrumentation for C1–2 instability can be accom-
plished via multiple possible constructs. The traditional
transarticular technique, combined with various wiring
methods, has demonstrated enhanced biomechanical out­
comes when compared with stand-alone wiring meth­
ods.2,9,11,17,19 Highly successful postoperative fusion rates
have been demonstrated both in children and adults,
ranging from 87 to 100%.3–7,9,10,13,15,24,25 However, anatomi-
cal variations in bone anatomy may result in an increased
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risk of VA injury during transarticular screw placement
procedures.
Placement of C-2 pedicle/pars interarticularis screws
may provide long-term, rigid fixation of the axis, but care
must also be taken to avoid damage to the VA. In this
study, 55 consecutive patients underwent placement of
100 C-2 PSs without fluoroscopic guidance. Such free-
hand placement was based on preoperative CT or MR
imaging evaluation and extensive intraoperative exposure
of the medial, lateral, and superior aspects of C-2. All
screws holes were probed prior to screw placement, and
no obvious evidence of cortical breaches were identified
except in 1 case. Perioperatively, no patients experienced
neurological or vascular complications related to screw
placement.
Postoperative CT evaluation revealed that cortical
breaches occurred in 15 screws (15%). Based on our clas-
sification system, 12 of 15 breaches were lateral into the
transverse foramen, and 3 of 15 were superior into the
C1–2 joint. Of the 3 screws breaching the C1–2 joint, 1
was in a patient who underwent C1–2 fusion. The other 2
were in patients with constructs ending at C-2. Neither of
the latter 2 patients have shown signs of C1–2 degenera-
tive disease since surgery. Of note, the majority of breach-
19
 D. M. Sciubba et al.

Fig. 5.  Three-dimensional reconstructions of C-1 and C-2 vertebral segments from CT-acquired data highlighting the entry
point of C-2 PS path and lateral-medial trajectory (A), the inferosuperior trajectory (B), a “bulls-eye” view down the screw (C),
and an anterior view showing the relationship of the vertebral foramen to the C-2 pedicle (D). Dashed arrows indicate the screw
trajectory.

es (66.7%) were Grade I (< 25% of the screw diameter).
Such a minimal radiographic breach may not actually
represent a true cortical breach because of the potential
for metal-related artifact on CT images. Moreover, such
a level of breach, if assumed to be present, represents < 1
mm of screw beyond the cortical margin. Nonetheless, in
this analysis, the strict definition of breach involved any
aspect of the screw noted on CT imaging to breach the
cortical margin.
The 2 high-grade breaches (Fig. 3, Grade III and IV
examples) did not result in any clinical sequelae. Specifi-
cally, the sole Grade IV breach had the potential to injure
the left VA as the screw traversed the vertebral foramen.
There was no intraoperative bleeding at the time of screw
placement, and an intravenous contrast study performed
immediately after surgery demonstrated continuous cir-
culation throughout the left VA. Our findings corroborate
those of Neo and colleagues,17 who reviewed a series of
86 cervical spine PSs placed in 18 patients. They reported
a 29% breach rate, with the overwhelming majority (84%)
occurring laterally. In addition, 13 screws breached > 2
mm beyond the bone cortex without intraoperative bleed-
ing or clinical sequelae, and continuity of the VAs was
demonstrated postoperatively on CT angiography in all
high-grade breaches. The VA was lateral to the screw in
all high-grade lateral breaches.
Based on our analysis, a number of interesting obser-
vations can be made. First, meticulous operative dissec-
tion of the C-2 pars yielded accurate placement of the C-2
PSs in the majority of patients without the use of fluoros-
copy or navigation. Second, when such breaches did oc-
cur, the majority (86.7%) were < 50% of the screw diame-
ter, representing at most 1.75 mm of the screw beyond the
cortical margin. Third, when Grade I and II breaches (up
to 50% of screw diameter beyond the cortical margin) are
identified postoperatively on CT scans, the complications
caused by such screws are probably minimal, given the
results in this patient cohort. Finally, no breach into the
central canal was observed at all in this study, reinforc-
ing the notion that correct placement of C-2 PSs involves
a medial trajectory that is not likely to enter the canal
if extensive identification of the C-2 pedicle trajectory is
done beforehand. Moreover, the cortex around the cen-
tral canal is thicker and stronger than that of the lateral

20 J Neurosurg: Spine / Volume 11 / July 2009

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Free-hand placement of pedicle screws in the axis
TABLE 1: Summary of the clinical characteristics of patients assessment of anatomy on preoperative imaging studies,
undergoing C-2 PS placement combined with accurate identification of the C-2 pars
and pedicle intraoperatively via careful dissection. When
Characteristic Value breaches did occur, they were overwhelmingly lateral in
no. of patients 55 location with < 50% of the screw diameter beyond the
cortical edge, and in our experience, were not clinically
no. of screws 100
symptomatic.
sex (%)
  male 30 (55.6) Disclosure
  female 24 (44.4)
Dr. Gokaslan serves as a consultant for Medtronic, Inc. and
mean age in yrs (range) 56.7 (14–87) re­ceives support from Depuy Spine. He also serves on the Scientific
cause of instability (%) Ad­visory Board of U.S. Spinal Technologies and the Scientific
  degenerative 20 (37.0) Ad­visory Board of Spinal Kinetics. He is a member of the Board of
Directors of AO North America.
  neoplastic 12 (22.2)
  traumatic 11 (20.4) References
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Manuscript submitted April 23, 2008.
Accepted March 19, 2009.
Address correspondence to: Daniel M. Sciubba, M.D., Depart-
ment of Neurological Surgery, 600 North Wolfe Street, Baltimore,
Maryland 21287. email: dsciubb1@jhmi.edu.
J Neurosurg: Spine / Volume 11 / July 2009