ArticleEuropean spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society2026
C2 direct pedicle screw insertion technique in craniovertebral junction anomaly: safety and efficacy in high-riding vertebral artery cases.
Article in European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
purposeThe 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).
methodsA 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.
resultsThirteen 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.
conclusionThe 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.
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