Radiologic analysis of C2 to predict safe placement of pedicle screws

Rex A.W. Marco, Christopher I. Phelps, Rebecca C. Kuo, Wu Zhuge, Clinton W. Howard, Vivek P. Kushwaha, Derek T. Bernstein

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Background: Preoperative assessment of C2 pedicle morphology is critical to safe pedicle screw placement. To avoid iatrogenic injury, complex digital templating software has been introduced; however, this technology may not be available in many centers. We report a technique for preoperative assessment of C2 pedicle screw placement safety based upon 2-dimensional sagittal computed tomography (CT) scan images and verify its utility in clinical practice.

Methods: A total of 46 consecutive patients underwent cervical spine CT scans between 2005 and 2011. The C2 pedicle morphology was assessed on sagittal CT imaging by 5 independent reviewers to determine the feasibility and risk associated with pedicle screw placement. Thirty consecutive patients underwent C2 pedicle screw placement and were followed clinically for a minimum of 2 years. The ability to place a screw was noted, and accuracy of screw placement was assessed postoperatively by CT scan.

Results: The CT scan analysis demonstrated that 11% (5/46) of patients had sufficient pedicle size bilaterally to allow safe placement of long pedicle screws with a low risk of vertebral artery injury, whereas 15% (7/46) were considered a high risk bilaterally. Screw placement was deemed low risk in 28%, moderate risk in 38%, and high risk in 34%. Excellent intraobserver reliability and good interobserver reliability was observed. Clinically, 18 of 20 (90%) low-risk and 21 of 24 (88%) moderate-risk pedicle screws were placed safely versus 5 of 16 (31%) high-risk pedicle screws ( P < .001).

Conclusions: Using the described technique for evaluating the C2 pedicle via sagittal CT scan images allows for safe and reliable pedicle screw placement without relying upon complex digital templating software, which may have limited availability.

Level of Evidence: II.

Clinical Relevance: This study aids in the surgical decision-making behind the placement of C2 pedicle screws using CT scans without reliance upon complex digital templating software.

Original languageEnglish (US)
Pages (from-to)30-36
Number of pages7
JournalInternational Journal of Spine Surgery
Issue number1
StatePublished - Jan 1 2018


  • C2 pedicle
  • CT scan
  • High-riding vertebral artery
  • Pedicle screw
  • Vertebral artery
  • Vertebral artery injury

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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