Lamina-guided lateral mass screw placement in the sub-axial cervical spine

Lateral mass (LM) screws are commonly used in posterior instrumentation of the cervical spine because of their perceived safety over pedicle screws. A possible complication of cervical LM screw placement is vertebral artery injury or impingement. Several screw trajectories have been described to overcome the risks of neurovascular injury; however, each of these techniques relies on the surgeon's visual estimation of the trajectory angle. As the reliability hereof is poorly investigated, alignment with a constant anatomical reference plane, such as the cervical lamina, may be advantageous. The aim of this investigation was to determine whether alignment of the LM screw trajectory parallel to the ipsilateral cervical lamina reliably avoids vertebral artery violation in the sub-axial cervical spine. 80 digital cervical spine CT were analysed (40 female, 40 male). Exclusion criteria were severe degeneration, malformations, tumour, vertebral body fractures and an age of less than 18 or greater than 80 years. Mean age of all subjects was 39.5 years (range 18-78); 399 subaxial cervical vertebrae (C3-C7) were included in the study. Measurements were performed on the axial CT view of C3-C7. A virtual screw trajectory with parallel alignment to the ipsilateral lamina was placed through the LM. Potential violation of the transverse foramen was assessed and the LM width available for screw purchase measured. There was no virtual violation of the vertebral artery of C3-C7 with lamina-guided LM screw placement. LM width available for screw purchase using this technique ranged from 5.2 to 7.4 mm. The sub-axial cervical lamina is a safe reference plane for LM screw placement. LM screws placed parallel to the ipsilateral lamina find sufficient LM width and are highly unlikely to injure the vertebral artery, even in bi-cortical placement. Placing LM screws parallel to the lamina appears favourable over conventional techniques.