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Purpose <p>The study aims to assess a novel “direct C2 pedicle screw” (C2-DPS) insertion technique in mitigating vertebral artery (VA) injury in the case of high-riding vertebral artery (HRVA) and its application in a wider craniovertebral junction (CVJ) anomaly spectrum, including assimilated C1, C2C3 fusion, and persistent first cervical intersegmental artery (PFCIA).</p> Methods <p>A retrospective analysis of consecutively operated cases of bony-CVJ anomaly with HRVA, from 2022 to 2025, was done. Patients who underwent posterior fixation by techniques other than C1 lateral mass and C2 direct pedicle screw insertion were excluded. Radiological workup included dynamic CT-CVJ, vertebral-angiograms, and MRI. The primary objectives were to assess the safety and screw profile of the C2-DPS technique, with secondary objectives focusing on clinical and radiological outcomes. A p-value &lt; 0.05 was considered statistically significant.</p> Results <p>Thirteen patients with HRVA on twenty-three sides (<i>n</i> = 23/88.4%) were analyzed, with a mean age of 29.7 ± 13.5 years and a follow-up duration of 10.9 months (95%CI:5.8–16.0). the cohort has type-2 (<i>n</i> = 13/56.5%) and type-3(<i>n</i> = 10/43.5%) HRVAs with mean “a” and “e” parameters as 4.4(2.3) mm and 2.5(± 1.2) mm, respectively. 47.8% (<i>n</i> = 11) of the HRVAs had an anomalous course (PFCIA) and 77.8% (<i>n</i> = 14) were dominant/co-dominant. There was a significant improvement in Nurick’s grade (4.69 ± 1.0 vs. 3.0 ± 0.9), atlanto-dental interval (8.9 ± 3.0&#xa0;mm vs. 2.7 ± 1.4&#xa0;mm), and basilar-invagination [6.3&#xa0;mm (95%CI4.4-8.3) vs. 0] postoperatively (p-value &lt; 0.01). The medial and cranio-caudal angulations of C2-DPS were 20.4 ± 6.2 degrees (range 8.5-32.1 degrees) and 21.4degrees (95%CI:13.3–21.1). The effective screw length was 20.2 ± 2.6&#xa0;mm. No incidence of implant failure or associated complications was noted.</p> Conclusion <p>The study demonstrates the effectiveness and safety of the C2-DPS technique in managing complex bony CVJ anomalies with PFCIA and HRVA. It provides a greater effective screw length and a robust construct in a wide spectrum of anomalous CVJ.</p>

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C2 direct pedicle screw insertion technique in craniovertebral junction anomaly: safety and efficacy in high-riding vertebral artery cases

  • 期刊论文

  • 发表日期：

    2025年11月15日

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  • Ashutosh Kumar,
  • Arun Kumar Srivastava,
  • Anantha Chaitanya J,
  • Pawan Kumar Verma,
  • Shreyash Rai,
  • Soumen Kanjilal,
  • Prabhakar Mishra,
  • Jayesh Sardhara,
  • Anant Mehrotra,
  • Awadesh Kumar Jaiswal,
  • Sanjay Behari

摘要

Purpose

The study aims to assess a novel “direct C2 pedicle screw” (C2-DPS) insertion technique in mitigating vertebral artery (VA) injury in the case of high-riding vertebral artery (HRVA) and its application in a wider craniovertebral junction (CVJ) anomaly spectrum, including assimilated C1, C2C3 fusion, and persistent first cervical intersegmental artery (PFCIA).

Methods

A retrospective analysis of consecutively operated cases of bony-CVJ anomaly with HRVA, from 2022 to 2025, was done. Patients who underwent posterior fixation by techniques other than C1 lateral mass and C2 direct pedicle screw insertion were excluded. Radiological workup included dynamic CT-CVJ, vertebral-angiograms, and MRI. The primary objectives were to assess the safety and screw profile of the C2-DPS technique, with secondary objectives focusing on clinical and radiological outcomes. A p-value < 0.05 was considered statistically significant.

Results

Thirteen patients with HRVA on twenty-three sides (n = 23/88.4%) were analyzed, with a mean age of 29.7 ± 13.5 years and a follow-up duration of 10.9 months (95%CI:5.8–16.0). the cohort has type-2 (n = 13/56.5%) and type-3(n = 10/43.5%) HRVAs with mean “a” and “e” parameters as 4.4(2.3) mm and 2.5(± 1.2) mm, respectively. 47.8% (n = 11) of the HRVAs had an anomalous course (PFCIA) and 77.8% (n = 14) were dominant/co-dominant. There was a significant improvement in Nurick’s grade (4.69 ± 1.0 vs. 3.0 ± 0.9), atlanto-dental interval (8.9 ± 3.0 mm vs. 2.7 ± 1.4 mm), and basilar-invagination [6.3 mm (95%CI4.4-8.3) vs. 0] postoperatively (p-value < 0.01). The medial and cranio-caudal angulations of C2-DPS were 20.4 ± 6.2 degrees (range 8.5-32.1 degrees) and 21.4degrees (95%CI:13.3–21.1). The effective screw length was 20.2 ± 2.6 mm. No incidence of implant failure or associated complications was noted.

Conclusion

The study demonstrates the effectiveness and safety of the C2-DPS technique in managing complex bony CVJ anomalies with PFCIA and HRVA. It provides a greater effective screw length and a robust construct in a wide spectrum of anomalous CVJ.