Quantitative anatomic evaluation of cervical lateral mass fixation with a comparison of the Roy-Camille and the Magerl screw techniques

Abstract

Study design: An anatomic and computed tomography (CT) study of the Roy-Camille and the Magerl techniques with quantitative comparison of the safety zones of the two surgical techniques.

Object: The purpose of this study was to compare quantitatively the safety zones of the Roy-Camille and the Magerl techniques as a function of the vertebral level from C3-C6.

Summary of background data: The two most popular techniques for lateral mass screws are the Roy-Camille and the Magerl technique. Nerve roots, vertebral artery, facet joints, and the spinal cord are at risk during the placement of lateral mass screws. Several anatomic studies are reported, but there is no comparative and quantitative evaluation. The influence of the vertebral level was never reported.

Methods: Lateral mass screws were first implanted on four cervical spines according to the two surgical techniques. Screws were then extracted and their cavities filled with a blue casting medium. To determine the precise limits of each safety zone in the sagittal plane, the specimens were sectioned according to the sagittal angulation of the two screwing techniques. The correlations between the anatomic landmarks on the specimen and the anatomic landmarks on the CT scan were established. One hundred and sixty lateral mass screws were then implanted in 20 cervical spines from C3-C6. A CT was done before and after placing lateral mass screws. On the morphologic CT scan, we measured the sagittal safety angle (SSA) for each surgical technique and also performed a morphometry of lateral masses. On the control CT scan, we analyzed screws placement in relation to the sagittal safety zone.

Results: The mean SSA was 15.8 +/- 6.3 degrees for the Roy-Camille technique and 18.7 +/- 3.8 degrees for the Magerl technique, P < 0.005. With respect to the vertebral level, the Roy-Camille safety zone decreased from C3-C6 with a greater angulation at C3-C4 (20.4 +/- 4.7 degrees ) than at C5-C6 (11.6 +/- 4.3 degrees ), P < 0.001. Such variations were not observed for the Magerl technique, the SSA of which was 19.4 +/- 3.6 degrees at C5-C6 and 17.9 +/- 4 degrees at C3-C4, P < 0.01. Lateral masses became more elongated and thinner at the lower segment of the cervical spine with a C3-C4 height/thickness ratio = 1.1 +/- 0.3 and a C5-C6 height/thickness ratio = 1.3 +/- 0.2, P < 0.005. Roy-Camille screws (19%) were found out of the safety zone at C3-C4 whereas 37.5% were found outside at C5-C6, P < 0.05. We observed opposite results for Magerl screws with 38% screws out of the safety zone at C3-C4 and only 17.5% outside at C5-C6, P < 0.05.

Conclusion: The Roy-Camille technique demonstrated a progressive decrease of its safety zone from C3-C6. At C5 and C6 there is a great probability to have a transarticular screw with a Roy-Camille screw. A similar variation was not observed for the Magerl technique. These anatomic results seem to be in relation with the morphologic variability of lateral masses from C3-C6 as demonstrated by an increase of the height/thickness ratio at the lower part of the cervical spine. According to these anatomic considerations and previously published biomechanical data, Roy-Camille technique appears to be the best option at C3 and C4. On the opposite at C5 and C6, the choice is more difficult considering that there is no biomechanical difference between the two techniques and that the Magerl technique is safer but a more demanding procedure.