• Erika Chiapparelli, Ichiro Okano, Stephan N Salzmann, Marie-Jacqueline Reisener, Sohrab Virk, Fabian Winter, Jennifer Shue, Andrew A Sama, Frank P Cammisa, Federico P Girardi, and Alexander P Hughes.
• Spine Care Institute, Hospital for Special Surgery, New York, New York, USA.
• World Neurosurg. 2021 May 1; 149: e576-e581.

BackgroundThe preoperative assessment of C2 morphology is important for safe instrumentation. Sclerotic changes are often seen in C2 pedicles. Evaluating the diameter measurements solely might not accurately assess the safety of screw insertion. We have proposed a novel grading system of the C2 pedicle that includes sclerosis and evaluated the predictive value of this grading system with the surgeon's safety evaluation.MethodsWe reviewed and measured the dimensional values in 220 cervical computed tomography angiograms. Additionally, we used a grading system that divides the findings into 5 grades according to the width measurement and degree of sclerosis in the C2 pedicle. Two spine surgeons independently classified the pedicles as follows: safe (minimal risk of pedicle violation), caution needed (caution to minimize pedicle violation), or dangerous (a high risk of pedicle violation). Finally, we compared the measurements and the surgeons' safety assessments.ResultsA total of 411 pedicles of 203 patients (mean age, 69.5 years; 49.5% women) were included. Of the 411 C2 pedicles, 170 were classified as high risk by ≥1 surgeon. Between the dimensional measurements and grading system, the sclerotic grade showed the best predictive value.ConclusionsWe have introduced a novel tool to evaluate the safety of C2 pedicle screw placement. Our results suggest that our pedicle width-sclerosis grading system is reproducible and predicts the surgeon's assessment of safe screw placement better than C2 pedicle diametrical measurements alone.Copyright © 2021. Published by Elsevier Inc.

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