Atlantoaxial transarticular screw fixation for a high-riding vertebral artery

Study Design. The feasibility of inserting a screw for the narrow isthmus with a high-riding vertebral artery was evaluated in patients subjected to posterior atlantoaxial transarticular screw fixation. Objective. To demonstrate the feasibility of inserting bilateral screws and obtaining a stable atlantoaxial complex for patients with a high-riding vertebral artery. Summary of Background Data. Posterior atlantoaxial transarticular screw fixation entails the potential risk of vertebral artery injury, which may be lethal. The risk is much higher for the narrow isthmus caused by a high-riding vertebral artery, and many authors recommend that the procedure should be abandoned if the isthmus is too narrow. On the other hand, bilateral screw fixation is stronger than unilateral screw fixation. Methods. For this study 27 consecutive patients who submitted to atlantoaxial transarticular screw fixation were evaluated before surgery for the position of the vertebral artery grooves using computed tomography (CT) reconstruction. Seven of the patients were defined as having a unilateral high-riding vertebral artery. For these patients, bilateral screw insertion through the most posterior and medial part of the isthmus was performed. Results. No massive bleeding or major complications were encountered in any patients with a high-riding vertebral artery. Postoperative computed tomography reconstruction demonstrated that five of the screws cleared the vertebral artery groove successfully, and two slightly breached it. No screws penetrated into the vertebral artery groove. Conclusions. It is possible to insert a screw safely, even into the narrow isthmus with a high-riding vertebral artery, if the surgeon realizes where the screw should be inserted and has the requisite insertion technique. Bilateral screw fixation should provide a high fusion rate.