Use of an aiming device in posterior atlantoaxial transarticular screw fixation. Technical note

Posterior atlantoaxial transarticular screw fixation is an excellent procedure associated with high fusion rates. There is, however, the potential risk of vertebral artery (VA) injury. The authors designed a special aiming device that allows a cannulated screw to be inserted accurately in the most posterior part of the C1-2 joint via the most posterior and medial part of the isthmus of C-2; this screw pathway most safely avoids VA injury. The instruments include an aiming device and a flexible screw-inserting system. The tip of the aiming device is placed on the ridge of the C-2 isthmus just posterior to the atlantoaxial joint. The guide wire should then pass 1 mm below the device tip. The system consists of flexible guide wires, a drill, a tap, and a screwdriver, and the screw is inserted easily via a posterior approach in which the patient's back is not obstructive. Ten patients with atlantoaxial subluxation or osteoarthritis underwent surgery in which the device was used. In all cases, the screws were inserted safely without causing VA injury, although preoperative computerized tomography (CT) reconstructions revealed a high-risk high-riding unilateral VA in three patients. Postoperative CT reconstructions demonstrated that all screws but one were inserted as planned, and successfully cleared the vertebral groove. In conclusion, this newly designed device is practical and useful for the accurate insertion of screws, thus avoiding VA injury during atlantoaxial transarticular screw fixation.