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What are the major steps in C1 lateral mass screw insertion?1

1. Exposure of the inferior facet

2. Mobilization of C2 nerve root

3. Drill an awl in the midpoint to avoid slippage.

4. Aim at the anterior tubercle (17 degrees medially, 22 degrees rostrally).

In cases where C2 needs to be part of the construct, what is the safest entry point that warrants higher rates of fusion?

It is certainly the pedicle. Transarticular and lateral mass screws present more of a risk of injury to the vertebral artery, whereas translaminar screws are less stable and may result in C1–2 subluxation.

In the adult spine, what are the considerations in choosing pedicle screws?

1. The major diameter of the screw should be more than 75% of the diameter of the pedicle.

2. Attempting bicortical screw placement can be dangerous, and 75% of the length of the vertebral body is sufficient to ensure stability.

How is the lumbar spine pedicle screw placement evaluated on x-ray?²

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