How to Transect the C2 Root for C1 Lateral Mass Screw Placement: Case Series and Review of an Underappreciated Variable in Outcome

The techniques for atlantoaxial arthrodesis have been modified over the years, and placing C1 lateral mass screws is a modern approach. C2 neuropathy is a complication of concern; however, sacrifice of the C2 nerve is an accepted and often favored adjunct. The impact of the technique for cutting the C2 nerve is not adequately addressed in the literature. The aim of this study was to evaluate the clinical outcomes from a series of roots sacrificed during C1-2 fusion with attention to the C2 transection method. Clinical data were collected from trauma patients who underwent C1 screw fixation for atlantoaxial fusion. Chart review was performed and outcome assessed through telephone surveys to patients who were at least 6 months postoperative. Quality of life, C2 nerve function, neck pain, and head pain were assessed. Sixty-six roots were divided in 35 patients. There were no cases of occipital neuralgia at routine 3-month follow-up. Delayed telephone surveys were completed in 17 patients and exposed 4 cases of severe head/neck pain but none consistent with occipital neuralgia. C2 neuralgia is rare when sharply dividing the C2 root with the aid of bipolar electrocautery at the midportion of the ganglion where it overlies the C1-2 joint. A literature review suggests the impact of the root sacrifice method is an underappreciated modifiable factor in outcome. In future reports, description of the root transection technique is imperative and trials comparing ganglionectomy versus transection proximal to the ganglion or through the ganglion should be considered.