• William Clifton, Steve Edwards, Conrad Dove, Aaron Damon, Leslie Simon, Kristin Rosenbush, Eric Nottmeier, Alfredo Quinones-Hinojosa, and Mark Pichelmann.
• Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA. Electronic address: Clifton.william@mayo.edu.
• World Neurosurg. 2019 Jul 1; 127: e738-e744.

BackgroundAtlantoaxial fusion often requires C2 nerve transection for complete C1 lateral mass exposure. Nerve transection is made ideally at the preganglionic segment proximal to the dorsal root ganglion to minimize the risk of postoperative dysesthesias. If the nerve is transected too proximally, cerebrospinal fluid leak may be encountered by violation of the dura and arachnoid where the sensory and motor nerve rootlets exit the subarachnoid space. In this study we aimed to quantify the length of the C2 nerve preganglionic segment using cadaveric specimens and develop a method for reliable intraoperative localization for sectioning during C1-2 arthrodesis.MethodsUsing microsurgical techniques, 16 C2 nerves from 8 frozen and injected cadaveric cervical spine specimens were dissected. Two key measurements were taken to establish a reliable method of preganglionic segment identification. The "sweet spot" for nerve transection was based on the approximate location of the midpoint of the preganglionic segment.ResultsThe final determination of the ideal spot for C2 nerve transection using these calculations was 3 mm lateral to the medial border of the lateral mass.ConclusionsThis anatomic study found remarkable consistency in the preganglionic segment length. The medial border of the lateral mass appeared to be a consistently reliable landmark for identification of the preganglionic segment of the C2 nerve root. By using relationships between known anatomic structures intraoperatively, safety of atlantoaxial fixation can be optimized to maximize complication avoidance and satisfactory patient outcomes.Copyright © 2019 Elsevier Inc. All rights reserved.

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