Accuracy of the freehand technique for 3 fixation methods in the C-2 vertebrae

Intraoperative imaging often does not provide adequate visualization to ensure safe placement of screws. Therefore, the authors investigated the accuracy of a freehand technique for placement of pars, pedicle, and intralaminar screws in C-2.

Sixteen cadaveric specimens were instrumented freehand by 2 experienced cervical spine surgeons with either a pars or pedicle screw, and bilateral intralaminar screws. The technique was based on anatomical starting points and published screw trajectories. A pedicle finder was used to establish the trajectory, followed by tapping, palpation, and screw placement. After placement of all screws (16 pars screws, 16 pedicle screws, and 32 intralaminar screws), the C-2 segments were disarticulated, radiographed in anteroposterior, lateral, and axial planes, and meticulously inspected by another spine surgeon to determine the nature and presence of any defects.

A total of 64 screws were evaluated in this study. Pars screws exhibited 2 critical defects (1 in the foramen transversarium and 1 in the C2-3 facet) and an insignificant dorsal cortex breech, for an overall accuracy rate of 81.3%. Pedicle screws demonstrated only 1 insignificant violation (inferior facet/medial cortex intrusion of 1 mm) with an accuracy rate of 93.8%, and intralaminar screws demonstrated 3 insignificant violations (2 in the ventral canal, 1 in the caudad lamina breech) for an accuracy rate of 90.6%. Pars screws had significantly more critical violations than intralaminar screws (p = 0.041).

Instrumentation of the C-2 vertebrae using the freehand technique for insertion of pedicle and intralaminar screws showed a high success rate with no critical violations. Pars screw insertion was not as reliable, with 2 critical violations from a total of 16 placements. The freehand technique appears to be a safe and reliable method for insertion of C-2 pedicle and intralaminar screws.