A Surgical Technique Guide for C1-2 Fixation By the Cervical Spine Research Society.

Abstract

Atlantoaxial (C1-2) instability, arising from etiologies such as trauma, rheumatoid arthritis, congenital anomalies, neoplasms, and degenerative conditions, has been addressed since the early 20th century. Initial treatments utilized suture-based fixation, followed by wire-based techniques that depended on the integrity of posterior elements. The introduction of transarticular screws in the 1980s enhanced stability, yet challenges persist, including risks of vertebral artery injury due to anomalous anatomy and technical difficulties with variable bony structures. This technical note provides a comprehensive guide for C1 lateral mass, C2 pars, pedicle, and translaminar screw placement, emphasizing preoperative CT angiography and imaging to enhance safety and adapt to anatomic variations. A step-by-step surgical technique is described for C1 lateral mass, C2 pars, pedicle, and translaminar screw placement, including patient positioning and joint exposure. Complication avoidance and management are detailed, supported by fluoroscopic guidance and optional navigation. Mastery of multiple C1-2 fixation techniques allows tailored approaches based on patient anatomy, minimizing risks such as vertebral artery injury while achieving high fusion rates (>94%) and patient satisfaction (>88%). Preoperative CT angiography in high-risk cases enhances safety.