• Erika Chiapparelli, Edward Bowen, Ichiro Okano, Stephan N Salzmann, Marie-Jacqueline Reisener, Jennifer Shue, Andrew A Sama, Frank P Cammisa, Federico P Girardi, and Alexander P Hughes.
• Spine Care Institute, Hospital for Special Surgery, New York, NY.
• Spine. 2022 Feb 1; 47 (3): E101E106E101-E106.

Study DesignRetrospective observational study.ObjectiveThe aim of this study was to investigate the spinal cord safety margins for C2 instrumentation.Summary Of Background DataIntraoperative spinal cord injury during C2 spine surgery is a rare, but potentially life-threatening complication. Preoperative planning for C2 instrumentation mainly focuses on C2 pedicle bony dimensions on CT and the vertebral artery location and few studies have evaluated C2 spinal cord safety margins.MethodsWe measured two distances in C2 bilaterally: C2 pedicle to dura distance (P-D), defined as a transverse line that measured the shortest distance between the medial wall of the C2 pedicle and the dural sac, and C2 pedicle to spinal cord (P-SC), defined as a transverse line that measured the shortest distance between the medial wall of the C2 pedicle and spinal cord. We defined the distances >4 mm as safe for instrumentation.ResultA total of 146 patients (mean age 71.2, 50.7% female) were included. The average distances were 5.5 mm for C2 left PD, 5.9 mm for C2 right P-D, 10.1 mm for C2 left P-SC, and 10.6 mm for C2 right P-SC. Twenty-eight (21.4%) patients had C2 P-D distances <4 mm and of those two (7%) patients had distances <2 mm. There were more female patients with C2 P-D distances under 4 mm compared to males. No patient had C2 P-SC distances <4 mm.ConclusionWe demonstrated that around 20% of patients had C2 P-D distance <4 mm, but no patient had C2 P-SC distance <4 mm. Since a lateral misplacement can lead to a potentially fatal vertebral artery injury, medial screw trajectory is recommended for C2 pedicle instrumentation with consideration of these safety margins.Level of Evidence: 3.Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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