Technical Feasibility of Subaxial Cervical Pedicle Screws for Distal Anchoring of Occipitocervical Fixation Constructs in the Mid-Cervical Spine: Early Clinical Experience

Occipitocervical fixation and fusion (OCF) is performed for patients who have destabilizing traumatic injuries or pathologies affecting the complex bony and ligamentous structures of the occipitoatlantal and atlantoaxial joint structures. Distal fixation failure and pseudoarthrosis are known risks of these constructs, especially for those constructs ending in the mid-cervical spine. We present the technical feasibility of using cervical pedicle screws (CPSs) as distal fixation anchors to strengthen OCF constructs ending in the mid-cervical spine and present a case series describing our early clinical experience with this technique. We used a freehand technique to place subaxial pedicle screws in the mid-cervical spine as the distal fixation point in OCF constructs. This technique involves performing a laminotomy to provide direct visualization of the pedicle borders to safely guide freehand pedicle screw placement. Our early clinical experience with this technique is presented. Three patients received OCF constructs ending in the mid-cervical subaxial spine between C3 and C6. CPSs were placed at the distal vertebra in each construct. Stable instrumentation and arthrodesis were confirmed postoperatively in all patients. This freehand technique uses direct visualization of the pedicle to aid in safe and accurate subaxial pedicle screw placement. CPS placement is clinically feasible and increases the robustness of OCF constructs in appropriately selected patients. Larger case series are needed to further validate the safety and effectiveness of this technique.