The Four Fixation Points of the Axis: Technique and Case Report

(A) Lateral x-ray of the cervical spine of a 56-year-old male with Down syndrome and progressive myelopathy. (B) Sagittal magnetic resonance imaging demonstrates severe multilevel spinal cord compression with myelomalacia. (C) Sagittal computed tomography scan demonstrates C6-C7 spondylolishtesis with advanced degenerative changes and endplate erosions at C2-C3, C3-C4, C5-C6, and C6-C7.

Axial computed tomography scan throughout the C2 vertebral body at the level of the pedicles demonstrating the right (A) pedicle, left (B) pedicle, and the lamina. Preoperative planning is critical to both implant and technique selection.

Intraoperative photograph demonstrating placement of polyaxial pedicle screws into the pedicle and lamina of the axis. Preoperative planning is critical to ensure that all 4 screws can be safely placed into the pars/pedicle and lamina of the axis.

Intraoperative photograph demonstrating the use of lateral connectors to connect the rod to the translaminar screw. The left translaminar screw (arrowhead) is attached to the main rod via a cross connector that is anchored to the rod cephalad to the C2 pedicle screw (arrow). The pedicle screws are usually more in line with the rest of the construct and can be directly connected to the rod. Central laminectomy from C5 to C7 is visualized.

Postoperative axial computed tomography scan of the C2 vertebrae demonstrating a right-sided C2 pedicle screw (A) and a left-sided laminar screw (B).

Postoperative antero-posterior and lateral x-rays taken 6 months postoperatively demonstrate maintenance of cervical lordosis.