“ SCREW ERGONOMICS AND ITS TRAJECTORIES IN SPINE SURGERY ”

APPROACH ENTRY POINT TRAJECTORY DIMENSION • RISK REMARKS

D: 3.5mm
Condyle screw can be connected
polyaxial • Carotid, vertebral,
4-5mm lateral to FM, 1-2mm rostral 12-22 deg medial with 3mm rod with C1 lateral
Occipital L: 20-24mm for jugular bulb and
to AO joint 5 deg rostral mass screw or C2 pedicle screw
bicortical hypoglossal n
O-C1 or C1-2 transarticular screw
purchase
transarticular
screw • VA, Cord Target: Middle of occipital
D: 3.5-4mm
C1
Midpoint of posterior C1 lateral
L: 28-32mm lag • ICA 1mm close to condyle
mass exit of screw; Use halo vest following fix
~17 deg medially and screw
• VA is lateral to the
22 deg rostrally
D: 3.5-4mm trajectory,
Midpoint of inferior part of C1 Superior aspect of anterior
C1
lateral mass:
L: 28-32mm lag • Cord medially risk tubercle of C1 on lateral fluro
screw of injury
C1-2
Lateral mass Vertebral artery: if brisk bleed:
C2 pars at the midpoint 20-30 deg medially and screw to stop bleeding (may be
fusion D: 3.5mm; • C2 ganglion
C2 mediolaterally in the superomedial 25 deg rostrally parallel to due to venous plexus): Abort
L 15-20mm (occipital neuralgia
quadrant of surface of C2 isthmus. the pars surgery to C/L side; rule out with
urgent post op angio
C1-2
1-2mm superior to C2-3 facet on the Parasagittal course towards D: 3.5mm; C1-C2 facet is curetted to
transarticular • VA
midline axis of pars interarticularis the C1 lateral mass L 15-20mm facilitate arthrodesis.
facet screw

30 deg laterally (MC) and

1mm medial to the midpoint of
15 deg rostrally (CC) with
An lateral mass
the drill shaft against the
spinous process
D: 3.5mm; On ascending up the cervical
C3-6 • VA
L: 14-16mm spine, the trajectory is more
lateral mass • Cord injury
Rod: 3.5mm cranial; ie: 15deg or less in lower
screw 2mm medial and cranial to the 20-25deg laterally (ML) • Nerve root injury while 22-25deg at C1 and C2.
Magerl
midpoint of lateral mass and parallel to facet (CC)

Roy- 0-10deg laterally (ML)

Midpoint of lateral mass
Camille 0 deg in CC plane
ML: Insert screws with angle
of 25 to 45 degrees from the C3-C6 pedicles have narrow
sagittal plane for the pedicle D: 2.7- 4mm; height. Vertebral artery lies
Lateral to the center of the articular from C3 to C7 L: 25-30mm • Nerve root within its foramen immediately
C3-C6 Pedicle
mass and close to the inferior margin CC: parallel to the upper end preoperative CT • VA lateral to the pedicle and the
screw
of the inferior articular process plate for the pedicles of C5 measurement • Cord cervical nerve root lies within
through C7, and a slightly the spinal canal immediately
cephalad direction in C2 medial to the pedicle.
through C4.
D: 3.5mm
15 deg laterally (MC) and 10
C7 Same as C3-6 L: 14-16mm
deg rostrally (CC)
Rod: 3.5mm
T1,2,3 Mid Tp (CC)
CC: Parallel to superior
&12 Even with lateral edge of pars (ML)
endplate or 10-15 deg caudal 4 methods of screw
D: 80% of pedicle placement:
Top of Tp (parallel to the pedicle)
L: 35-40mm
Just lateral to the mid position of the ML: Angle more medially as • Fluoroscopic guided Remember:
Thoracic pedicle T7,8,9 Narrowest at T4-
base of the superior articular facet you ascend from T12 (-5deg) • Free hand Medial pedicle exposure assist in
screw 7.
(ML) to T1 (27deg); • Laminotomy and deciding the pedicle trajectory
Rod; 4mm; Below
Transition between the above two T12:5 deg laterally; T11: 0 Steinman technique Freehand: steep learning curve
T3: 5.5mm
(ML & CC) deg and as a rough • Navigation: using and precluded by distorted
T4,5,6 gradually move slightly superior approximation it increases by tracking markers anatomy
from midpoint at T1-3 to the top of 2deg per level above T11.
T7-9.
Base of Tp, at the intersection of Mediolateral trajectory equals • Injury to the theca
Mid Tp and lateral aspect of superior the lumbar vertebra number * & CSF leak L1:5; L2: 10; L3: 15; L4:20; L5:
Lumbosacral D: 5-6.5mm
L1-L5 facet 5 deg directed medially • Injury to abdominal 25; S1: 25 deg
pedicle screw L: 40-55mm
With laminotomy location of pedicle CC: Parallel to the vertebral vessels
can be probed end plate • Visceral injury
MC: 40-45 deg medially
Sacral pedicle Inferior border of superior facet of D: 5-5.5mm • L5 nerve root and
S1 CC: Aim toward the
screw S1 L: 35-40mm great vessels
promontery
The true lateral view (with
Aim the acetabulum sciatic notches superimposed) is
Screw trajectory should the primary view for screw
1. Posterior iliac crest
extend within 2 cm above the D: 6-8mm insertion.
2. Inferolateral aspect of S1 • L5 nerve root and
Iliac screw sciatic notch, above the L:60-80mm Expose the posterior-superior
foramina great vessels
acetabulum and towards the aspect of sciatic notch to aim
anterior inferior iliac spine. Removed small bone of PSIS to
prevent discomforting skin
contact of screw
• Abbr: ML: Mediolaterally; CC: Craniocaudally, FM: Foramen Magnum Tp: transverse process; L: length; D: Diameter; VA: vertebral artery
Dr. Suresh Bishokarma, MS, MCH ®

TENETS:
1. Use angles or landmarks for screw trajectories
2. Screw principle: pedicle diameter should be 80% of pedicle size and must cross the ~2/3 f vertebral body
3. The cranial margin of the lamina of C2 is the landmark for the point of screw insertion for C2.
4. Thoracic pedicle screw may demand transitional rod or domino connector to mate the two rods.
5. Using Fluro for thoracic screw placement above T5 is challenging: small pedicle and shoulder obscures.
6. Thoracic pedicles are oriented more AP direction while lumbar pedicles are angulated medially inward.
7. S2-Alar-iliar crest screw fixation: Not discussed
 FIG 1: LATERAL MASS SCREW FIXATION TECHNIQUES: TYPES

FIG 1: SUBAXIAL TRANSPEDICULAR SCREW PLACEMENT: ENTRY POINT AND LAMINOTOMY

FIG 2: SUBAXIAL TRANSPEDICULAR SCREW PLACEMENT: TRAJECTORY: SAGITTAL ANGULATION

FIG 3: TRANSPEDICULAR THORACIC SCREW

The entry point of the lumbar pedicle screw: Landmark for entry for thoracic pedicle screw
Defined as the confluence of any of the four lines: 1. Lateral border of superior facet
1. Pars interarticularis 2. Lateral border of inferior facet
2. Mamillary process 3. Ridge of pars interarticularis and transverse process
3. Lateral border of the superior articular facet
4. Mid transverse process