Complete arcuate foramen precluding C1 lateral mass screw fixation in a patient with rheumatoid arthritis: case report.

Case report of a complete arcuate foramen in a human atlas vertebra inhibiting the placement of lateral mass screw instrumentation at C1. Our objective is to report the presentation of the case, the operative considerations, and the management for this anatomic variation. The groove for the vertebral artery on the posterolateral surface of the atlas (C1) varies in size and depth from a slight impression to a clear sulcus. With anomalous ossification the sulcus can be bridged which results in a posterolateral tunnel within the posterior arch of the atlas. With increasing rates of screw fixation instrumentation that include the atlas, it is of paramount importance to know the location and course of the vertebral artery in relation to the planned route of instrumentation. The patient underwent a posterolateral fusion from C1 to C4 using autogenous iliac crest bone graft. Internal fixation from C2 to C4 was obtained using lateral mass screw instrumentation. After the vertebral artery was identified passing through the posterior arch of C1, sublaminar wires were utilized for fixation from C1 to C2. The patient responded well to surgical intervention without complications. Abnormal vertebral artery coursing through a posterolateral tunnel in the posterior arch of C1 has been described and its incidence has a range from 1.14% to 18%. When this variant is present, lateral mass screw fixation at C1 may be contraindicated. We recommend close scrutiny of preoperative radiographs to avoid the possibility of endangering the vertebral artery when this situation exists.