C1 lateral mass screw-induced occipital neuralgia: a report of two cases

C1-2 polyaxial screw-rod fixation is a relatively new technique. While recognizing the potential for inadvertent vertebral artery injury, there have been few reports in the literature outlining all the possible complications. Aim of this study is to review all cases of C1 lateral mass screws insertion with emphasis on the evaluation of potential structures at risk during the procedure. We retrospectively reviewed all patients in our unit who had C1 lateral mass screw insertion over a 2-year period. The C1 lateral mass screw was inserted as part of an atlantoaxial stabilization or incorporated into a modular occiput/subaxial construct. Outcome measures included clinical and radiological parameters. Clinical indicators included age, gender, neurologic status, surgical indication and the number of levels stabilized. Intraoperative complications including blood loss, vertebral artery injury or dural tears were recorded. Postoperative pain distribution and neurological deficit were recorded. Radiological indicators included postoperative plain radiographs to assess sagittal alignment and to check for screw malposition or construct failure. A total of 18 lateral mass screws were implanted in 9 patients. There were three male and six female patients who had C1 lateral mass screw insertion in this unit. Two patients had atlantoaxial stabilization for C2 fracture. There were four patients with rheumatoid arthritis whose C1 lateral mass screws were inserted as part of an occipitocervical or subaxial cervical stabilization. There was no vertebral artery injury, no cerebrospinal fluid leak and minimal blood loss in all patients. Three patients developed postoperative occipital neuralgia. This neuralgia was transient, in one of the patients having settled at 6-week follow-up. In the other two patients the neuralgia was unresolved at time of latest follow-up but was adequately controlled with appropriate pain management. Postoperatively no patient had radiographic evidence of construct failure and all demonstrated excellent sagittal alignment. It has been reported that the absence of threads on the upper portion of the long shank screw may protect against neural irritation. However, insertion of the C1 lateral mass screw necessitates careful caudal retraction of the C2 dorsal root ganglion. The insertion point for the C1 lateral mass screw is at the junction of the C1 posterior arch and the midpoint of the posterior inferior part of the C1 lateral mass. Two patients in our series suffered occipital neuralgia post-insertion of C1 lateral mass screws. This highlights the potential for damage to the C2 nerve root during C1 lateral mass screw placement.