Anatomical Evaluation of the Atlas and Analysis of Accuracy for Freehand C1 Screw Placement

Objective Atlanto-axial fusion surgery for instability is a recognized method. However, the complex anatomical structures of the atlas and axis make freehand C1 screw placement technically challenging. This study investigated the accuracy and safety of C1 screw placement without fluoroscopic or other guidance. Methods A retrospective analysis of radiological data was performed on patients who underwent C1 instrumentation between April 2019 and January 2023, with all procedures performed by a spine surgeon with 4 years of experience. Computed tomography was used to evaluate cortical breaches during C1 screw placement. Breach severity was categorized based on the percentage of screw diameter beyond the cortical edge. Morphometric measurements of 30 healthy individuals and 22 patients who underwent surgery were obtained from preoperative CT scans of the bilateral pedicles at the C1 level. Coronal, axial, and sagittal CT reconstructions were examined to ascertain the distance from the screw entry point to the midpoint of the C1 posterior tubercle, diameter of the central canal of the atlas, screw convergence angle, height of the C1 posterior arch at the screw entry point, and width of the canal. Results The surgeon placed 43 C1 screws in 22 consecutive patients. Seven (16%) breaches were identified, all of which were medial C1 screws. The breaches were classified as grades I, III, and IV in 4 (57%), 2 (29%), and 1 (14%) cases, respectively. No clinical complications arose owing to the breaches. Conclusion The freehand technique for C1 screw placement without guidance yielded accurate and safe results. However, a preoperative morphometric assessment and careful familiarization with the unique anatomy are imperative for improving screw placement precision. Key words: Axis, cervical vertebrae; Bone screws; Cervical vertebrae; Spinal fusion