Safety and Stability of a Combined C2 Screw Placement Strategy With Vertebral Artery Mobilization
In brief
Atlantoaxial cage achieves 92% fusion versus 51% with bone graft in complex C2 fixation
In a retrospective series of 312 patients, a tailored C2 screw protocol that includes vertebral-artery mobilization and an atlantoaxial cage produced a 92% six-month fusion rate, far exceeding the 51% rate with interlaminar bone grafting, while avoiding permanent neurovascular injury. Unilateral pedicle screw plus a contralateral alternative screw was as stable as bilateral fixation, offering a safe, versatile option for difficult craniovertebral junction cases.
- Journal
- Orthopaedic surgery (Q1)
- Published
- 7 August 2026
- Study design
- Cohort / observational study
- Evidence level
- Level 3, Low (CEBM 3b)
- Authors
- Peng Song, Shuangyin He, Tao Chen, Han Chen, Wenfu Yang, Xiyuan Tang, et al.
- PMID
- 42568099
- DOI
- 10.1111/os.70402
Why clinicians should know about it
- Picked for Anatomy (paper of the day, 11 August 2026): C2 screw placement anatomy, craniovertebral surgery
Abstract
BACKGROUND: Although C2 pedicle screws are considered the gold standard for atlantoaxial fixation, the optimal fixation strategy for patients with high-riding vertebral arteries (HRVA) or narrow C2 pedicles (NC2P) remains controversial because of the increased risk of vertebral artery injury and the limitations of alternative fixation techniques. OBJECTIVE: To evaluate the safety, stability, and clinical efficacy of an individualized C2 screw fixation strategy incorporating vertebral artery mobilization for complex upper cervical anatomy. METHODS: A retrospective study was conducted in 312 patients who underwent C2 fixation between 2017 and 2025. Patients were categorized according to fusion method, screw laterality, and VA transposition requirement. Bone fusion rates and screw accuracy (Gertzbein-Robbins grading) were compared across groups using χ2, Fisher's exact, and multivariate logistic regression analyses to control confounders. RESULTS: All procedures were successfully completed without permanent neurovascular injury. At 6 months, the fusion rate with an atlantoaxial fusion cage was significantly higher than with interlaminar bone grafting (92.3% vs. 51.0%, p < 0.001). Unilateral C2 pedicle screw fixation combined with a contralateral alternative screw achieved comparable stability to bilateral fixation (p > 0.05). Screw placement accuracy was 100% clinically acceptable in normal anatomy and 60% in cases requiring VA mobilization, with no VA injury or blood flow compromise. CONCLUSION: The proposed multi-strategy C2 screw placement protocol-integrating fusion cage support and VA mobilization-achieves superior fusion, reliable fixation, and high safety, even in anatomically challenging conditions. This approach provides a reproducible and versatile solution for C2 instrumentation in complex craniovertebral junction surgery.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.