Risk of internal carotid artery injury during C1 screw placement: Analysis of 160 computed tomography angiograms

Romel P. Estillore, Jacob M. Buchowski, Do Van Minh, Kun Woo Park, Bong Soon Chang, Choon Ki Lee, K. Daniel Riew, Jin S. Yeom

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


Background context: Injury to the internal carotid artery (ICA) is a potentially catastrophic complication of C1-lateral mass (C1-LM) or C1-C2 transarticular screw insertion. Purpose: This study was designed to determine the risk of injury to the ICA during placement of these screws using computed tomography angiography (CTA). Study design: Radiographic analysis using CTA. Patient sample: One hundred sixty CTAs were examined, for a total of 320 ICAs. Outcome measures: Not applicable. Methods: Fine-cut intravenous CTAs with multiplanar and three-dimensional reconstruction were reviewed. The position of the ICA in relation to the anterior cortex (AC) of C1, anterior end of the anterior tubercle (AT), and medial margin of the transverse foramen (TF) was measured bilaterally in three ascending and equidistant levels of the C1-AT. Results: The position of the ICA in relation to C1 was variable. The average distance between the ICA and the AC of C1 was only 3.7 mm. Furthermore, 96% of the time the posterior margin of the ICA was located posterior to the anteriormost aspect of the anterior C1 tubercle (average distance, 5.4 mm), making the ICA vulnerable to damage if a drill, tap, or screw was inserted to the depth of the anteriormost portion of the AT as seen on a lateral fluoroscopic or radiographic view. The medial margin of the ICA was located medial to the TF (a location potentially vulnerable to injury with bicortical screw placement) less often at the caudal aspect of the C1-AT (54%) than at its middle or cranial aspect (74% and 75%, respectively). No ICAs were located anterior to the medial 30% of the C1-LM or more medially. Conclusions: Bicortical C1-LM or C1-C2 transarticular screw placement carries a potential risk of ICA injury. Given the wide variation in ICA location relative to C1, if bicortical C1 fixation is required, preoperative CTA should be considered to determine the optimal screw trajectory. In general, inferomedially angulated C1-LM screws appear to be safer with respect to the ICA injury than other potential trajectories.

Original languageEnglish
Pages (from-to)316-323
Number of pages8
JournalSpine Journal
Issue number4
StatePublished - Apr 2011


  • C1 lateral mass screw placement
  • Complication
  • Internal carotid artery
  • Transarticular C1-C2 screw placement
  • Vascular injury


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