C2 pedicle screw placement on 3D-printed models for the performance assessment of CTA-based screw preclusion

3-D printing technology has a large spectrum of applications in upper cervical spinal surgery, but none have evaluated the radiological analysis of the feasibility of C2 pedicle screw placement. Thus, this study aimed to perform 3.5-mm-diameter C2 pedicle screw placement on models for performance assessment of CTA-based preoperative screw preclusion. We enrolled 152 patients who underwent CTA of the cervical spine between April 2020 and December 2020. Transverse pediculoisthmic width (TPW), oblique pediculoisthmic width (OPW), minimum pediculoisthmic diameter (MPD), internal height, and isthmus height were measured preoperatively. Subsequently, 1:1 3D-printed bone models were created, and a 3.5-mm-diameter C2 pedicle screw was placed on the models. All 3D-printed models underwent postoperative CT multiplanar reconstruction to evaluate the screw trajectory for the performance assessment of CTA-based preoperative screw preclusion. The ROC curves of the MPD, TPW, OPW, Internal height and Isthmus height showed that the optimal cutoff values for each of the five groups were measured values of 4.78, 4.44, 4.37, 4.22 and 5.59 mm, respectively. The AUC, sensitivity, and specificity of MPD were 0.992, 95.1% and 100%, respectively. The MPD had higher metrics than the TPW (AUC, 0.949; sensitivity, 87.9%), internal height (AUC, 0.885; sensitivity, 80.8%; specificity, 84.6%), and isthmus height (AUC, 0.941; sensitivity, 87.2%). We found no evidence of a difference between MPD and OPW in terms of the AUC and sensitivity (0.93 and 95.5%, respectively). C2 pedicle screw placement on 3D-printed models is useful for performance assessment of CTA-based preoperative screw preclusion. MPD measurement with CTA multiplanar reconstruction showed the best performance for judging acceptable or unacceptable screws. However, the definition of HRVA could be modified by a 4.2 mm-internal height or by measuring only the isthmus height for judging the preclusion of C2 pedicle screw placement.