C2 laminar screw and C1-2 transarticular screw combined with C1 laminar hooks for atlantoaxial instability with unilateral vertebral artery injury

Transarticular screw fixation (TASF) is technically demanding, with high risk of vertebral artery (VA) injury. How to manage intraoperative VA injury and choose optimal alternative fixation becomes a concern of spinal surgeons. In this study, the management strategy for a patient with suspected intraoperative VA injury was analyzed. A 53-year-old woman developed type II odontoid fracture and brain stem injury due to a motor vehicle accident 3 months earlier. After conservative treatments, the brain stem injury improved, but with residual ocular motility defect in the right eye. The odontoid fracture did not achieve fusion with displacement and absorption of fracture fragments. After admission, atlantoaxial fixation using bilateral C1-2 transarticular screws (TASs) combined with C1 laminar hooks was planed. The first TAS was inserted successfully. Unfortunately, suspected VA injury developed during tapping the tract for the second TAS. Considering the previous brain stem injury and that directly inserting the screw to tamponade the hemorrhage might cause VA stenosis or occlusion, we blocked the screw trajectory with bone wax. C2 laminar screw was implanted instead of intended TAS on the injured side. The management strategy for suspected VA injury should depend on intraoperative circumstances and be tailored to patients. Blocking screw trajectory with bone wax is a useful method to stop bleeding. Atlantoaxial fixation using C2 laminar screw and C1-2 TAS combined with C1 laminar hooks is an ideal alternative procedure.