Comparison of freehand versus navigation-assisted C2 pedicle screw fixation: A retrospective accuracy and safety...

C2 transpedicular screw fixation is a biomechanically robust technique for upper cervical stabilization yet remains technically demanding due to anatomical complexity.

This was a retrospective nonrandomized comparative study.

Using validated radiological classification systems, this study aims to compare the accuracy, malposition rates, and complication profiles of C2 screw placement using both freehand and navigation-assisted approaches.

Between 2010 and 2019, 100 patients who underwent C2 pedicle screw fixation at two different institutions were included in a retrospective study. There were 197 screws in all: 45 using a freehand technique (FH group) and 152 using a navigation-assisted approach (NA group). Using both Gertzbein-Robbins classification (GRC) and screw zone classification (SZC), screw accuracy was evaluated. Between the groups, demographic, clinical, and surgical data were statistically compared.

The mean age was significantly higher in the NA group (75.37 ± 16.15) than in the FH group (46.29 ± 22.14) (P < 0.001). SZC analysis showed zone 2 placement in 86.7% (FH) and 87.5% (NA) of screws (P = 0.028). GRC analysis revealed that 13.3% of FH screws and 12.5% of NA screws were malpositioned (Grades B-D). No neurovascular complications or screw-related revisions occurred in either group. However, five patients in the NA group required revision due to wound dehiscence.

In C2 pedicle screw placement, both freehand and navigation-assisted techniques showed great accuracy and low complication rates. Although navigation systems provide improved accuracy in the hands of experienced users, the freehand technique remains a safe and efficient alternative. Surgeon experience, patient anatomy, and institutional resources should all help guide the choice of technique.