Optimal Trajectory for the Occipital Condyle Screw

Study Design: Retrospective analysis. Objective: To understand what may constitute an optimal trajectory for an occipital condyle (OC) screw. Summary of Background Data: OC screws are an alternative to standard occipital plates as a cephalad fixation point in occipitocervical fusion. An optimal trajectory for placement of OC screws has not been described. Methods: We conducted a computed tomography-based study of 340 human occipital condyls. All computed tomographies were negative for traumatic, degenerative, and neoplastic pathology. On the basis of the current literature, linear measurements of distances were made based on a constant entry point. Medial angulations of 10, 20, and 25 degrees relative to the sagittal midline were used. In addition, 10-, 5-degree cranial, 10- and 30-degree caudal angulations were studied to evaluate the incidence of hypoglossal canal and atlantooccipital joint compromise. Results: Average distances were 17.1 +/- 2.8, 20.4 +/- 2.8, and 22.2 +/- 2.9 for 10, 20, and 25 degrees of medial angulation, respectively. Right-sided and left-sided measurements for each category were not significantly different. However, the difference in the measured distances between 10 versus 20 degrees, 10 versus 25 degrees, and 20 versus 25 degrees was all significantly different (P < 0.01). Hypoglossal canal compromise incidence was 0% and 7.1% for 5- and 10-degree cranial angulation, respectively. Atlantooccipital joint compromise incidence was 21.8% and 99.1% for 10- and 30-degree caudal angulation, respectively. Conclusions: The condylar entry point should be medial to the condylar fossa, midcondylar, and >= 2 mm caudal to the skull base. An optimal trajectory for the OC screw should have a medial angulation of >= 20 degrees relative to the sagittal midline, trying to stay parallel to the skull base. Minor adjustments in angulation can be made, but any adjustment approaching 10 degrees cranial or caudal leads to an increased risk of hypoglossal canal cranially or atlantooccipital joint compromise caudally.