SPINE Volume 37, Number 12, pp E745–E751

©2012, Lippincott Williams & Wilkins

TECHNIQUE

Translaminar Screw Fixation in the Subaxial

Cervical Spine
Quantitative Laminar Analysis and Feasibility of Unilateral and Bilateral Translaminar Virtual
Screw Placement

Matthew D. Alvin, BS,*† Kalil G. Abdullah, BS,*‡§ Michael P. Steinmetz, MD,†储 Daniel Lubelski, BS,*‡§
Amy S. Nowacki, PhD,‡¶ Edward C. Benzel, MD,*‡§ and Thomas E. Mroz, MD*‡§

volumes (C6–C7) than female patients. Unilaterally, C7 showed 3.5-

Study Design. Morphometric and volumetric analyses and virtual
mm translaminar screw acceptance rates of 100%, C6 showed high
screw placement.
acceptance rates (>64%), and C3–C5 showed lower acceptance rates
Objective. The aim of the study was to (1) define the morphometric
(<52%). C7 accepted bilateral placement at a high rate (96% men,
and volumetric dimensions of the laminae of C3–C7 and (2)
84% women). C3 and C6 accepted bilateral screws at low placement
analyze the feasibility of unilateral and bilateral translaminar screw
rates (8%–24%). C4 and C5 never accepted bilateral translaminar
placement at C3–C7.
screw placement.
Summary of Background Data. Previous studies on translaminar
Conclusion. Subaxial cervical unilateral translaminar screw
screw fixation have primarily focused on upper cervical and
placement is a potentially safe and effective technique to use in
thoracic fixation. Most studies have been conducted on the subaxial
conjunction with preoperative CT scanning for all vertebral levels.
cervical vertebrae in the pediatric population and a few in the adult
The same is true for bilateral placement at C7 but not at C3–C6. A
population. In this study, we used computed tomographic (CT) scans
prospective study to evaluate the long-term outcomes of translaminar
to calculate the spatial anatomical environment for translaminar
fixation at all vertebral levels is currently underway.
screws at C3–C7. We also determined the feasibility of translaminar
Key words: translaminar, cervical fusion, cervical spine, laminar
screw placement at C3–C7 for clinical applicability.
screw. Spine 2012;37:E745–E751
Methods. Morphometric and volumetric analyses were performed
on CT scans of the C3–C7 laminae in 25 male and 25 female

patients. A total of 2000 morphometric and 1000 volumetric
measurements were performed. The feasibility analysis was
performed using unilateral and bilateral virtual screw placement via
BrainLAB software (BrainLAB AG, Heimstetten, Germany) on the
same CT scans.
Results. Male patients had significantly (P < 0.05) longer translaminar
lengths (C5–C7), sagittal-diagonal measurements (C3–C7), and larger
From the *Cleveland Clinic Center for Spine Health, Cleveland Clinic; †Case
Western Reserve University School of Medicine; ‡Cleveland Clinic Lerner
College of Medicine; §Department of Neurological Surgery, Cleveland Clinic;
储MetroHealth Medical Center; and ¶Department of Quantitative Health
Sciences, Cleveland Clinic, Cleveland, OH.
Acknowledgment date: September 30, 2011. First revision date: November
13, 2011. Acceptance date: November 21, 2011.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work.
One or more of the author(s) has/have received or will receive benefits for
personal or professional use from a commercial party related directly or
indirectly to the subject of this manuscript: e.g., honoraria, gifts, consultancies,
royalties, stocks, stock options, decision-making position.
Address correspondence and reprint requests to Thomas E. Mroz, MD,
Neurological Institute, Cleveland Clinic Center for Spine Health, Departments
of Orthopaedic and Neurological Surgery, The Cleveland Clinic, 9500 Euclid
Ave, S-80, Cleveland, OH 44195; E-mail: mrozt@ccf.org
DOI: 10.1097/BRS.0b013e31824c70ef
Spine
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F
ixation of the posterior cervical spine can be achieved
using a variety of different methods that include lateral
mass screws, pedicle screws, and, more recently, trans-
laminar screws.1,2 Translaminar screw placement has been
studied and deemed reliable for C2 and the upper thoracic
spine3–13 and has been compared with pedicle screw place-
ment as a less technically demanding and safer technique.6,7
Decreased risk of vertebral artery injury and direct visualiza-
tion of the lamina contribute to the theory that translaminar
fixation may be useful in axial fixation.3,11,13 Recently, there
has been increasing interest in the use of translaminar screws
in the subaxial cervical spine, especially among the pediatric
population.12,14–17
To our knowledge, the landmarks and dimensions neces-
sary for effective and safe placement of subaxial (C3–C7)
translaminar screws have not been anatomically described in
the adult population. In 1999, Xu et al18 conducted an ana-
tomical analysis of cadaveric C2–L5 vertebrae and examined
height and laminar thickness, but since then, there has not
been a more extensive anatomical analysis directly about the
subaxial cervical laminae for surgical analysis. Most anatomic
studies (e.g., laminar thickness/height/width) conducted since
then have focused on C2 or the upper thoracic spine and their
feasibility for translaminar screw placement.3,9,10
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 TECHNIQUE Subaxial Cervical Translaminar Screw Fixation • Alvin et al

In this study, we used radiographical imaging to mor-

phologically and volumetrically define the laminae of the
subaxial cervical vertebrae (C3–C7) in order to facilitate a
better anatomical and surgical understanding of the subaxial
cervical spine during translaminar screw fixation. Once we
determined the specific laminar anatomy, we then used Brain-
LAB iCranial imaging software (BrainLAB AG, Heimstetten,
Germany) to determine the feasibility of translaminar screw
placement in the subaxial cervical spine and the specific
dimensions of translaminar screws that can safely be used
for fixation.

MATERIALS AND METHODS

Morphometric and volumetric analyses were performed on
the subaxial vertebral laminae in 50 patients who underwent
a cervical spine CT scan at our institution between April and
August 2008. Morphometric analysis was completed using
the Syngo Inspace 3D software package (Siemens Health
Services, Erlangen, Germany).
The measurements (e.g., length, thickness, and height)
were taken in millimeters in axial, coronal, and sagittal planes.
All CT scans had resolutions of less than 2 mm. In the axial
plane, translaminar length measurements were taken from the
junction of the lateral mass and lamina to the contralateral
outer cortex of the spinous process (Figure 1A). Thickness
was defined as the greatest maximum measurement span-
ning from the ventromedial to the dorsolateral sides of the
central portion of the lamina bilaterally (Figure 1B). In the
coronal plane, laminar height was measured as the maximal
height found between the spinous process and the base of the
pedicle (Figure 1C). The sagittal “diagonal” measurement
was defined as the most rostral point of the lamina and termi-
nating at the most caudal portion of the lamina of the same
vertebrae in the sagittal plane (Figure 1D).
Volumetric analysis of the C3–C7 laminae was performed
with the CT-Volume application of the Syngo Inspace 3D
software package (Siemens Health Services) and involved the
tracing of 1-mm axial slices of the lateral mass from the most
rostral portion of the lamina to the most caudal portion of the
lamina in the axial plane. Axial slices were used to provide
an accurate estimation of complex volume via interpolation
of the region defining the measured laminar dimensions (i.e.,
length, width, and height).
Figure 1. Axial views of laminae showing translaminar measurement
(A) and laminar thickness measurement (B), coronal view of laminae
showing laminar height measurement (arrows) (C), and sagittal view of
laminae showing sagittal-diagonal measurement (arrows) (D).
Virtual screw placement was done using a BrainLAB
iCranial software package (BrainLAB AG). We used 3.5-mm
diameter screws to assess feasibility for translaminar place-
ment. Screws were placed unilaterally at the thickest axial
slice of the subaxial cervical vertebrae. If vertebrae accepted
a screw in each unilateral direction, we assessed the feasibil-
ity of bilateral translaminar screw placement. For unilateral
placement, the screw entry point was located at the initiation
of the lamina from the spinous process at the midpoint of its
dorsal arch. For placing two 3.5-mm screws in the bilateral
design, we assumed a minimum required laminar height of
7 mm and a minimum 1-mm distance between the screws
and a minimum 1-mm distance from the ventral, dorsal,
cranial, and caudal aspects of each lamina for safe place-
ment. The cranial screw entry point was at the cranial edge
of the lamina, whereas the caudal screw entry point was at

Figure 2. Axial (A) and oblique (B) views

of bilateral translaminar screw placement.
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BRS204953.indd E746 25/04/12 12:02 PM

 TECHNIQUE
the caudal edge of the contralateral lamina. For evaluation of
feasibility, the cranial screw was sent through the left lamina
whereas the caudal screw was sent through the right lamina.
Trajectories for both unilateral and bilateral screw place-
ment were directed ventrolaterally from the screw entry point
through the contralateral lamina and measured up to the ini-
tiation of the contralateral lateral mass (Figure 2). A screw
was considered to be a “failure” if it violated any cranial/cau-
dal or ventral/dorsal cortical aspect of the vertebra. In addi-
tion, any screw length of less than 7 mm (i.e., not entering the
lamina) was considered to be a “failure.” If the laminar thick-
ness accepted a translaminar screw successfully, we measured
the maximum screw length defined from the entry point on
the dorsal arch of the lamina to the initiation of the contra-
lateral lateral mass. Screw placement was monitored in coro-
nal, sagittal, and axial planes to assess feasibility and avoid
violation of laminar edges. A 3-dimensional rendering of the
screws was used to assess for bilateral feasibility (Figure 3).
Figure 3. BrainLAB interface showing 3-dimensional rendering of translaminar screw insertion (upper left), as well as axial (upper right), sagittal
(lower left), and coronal (lower right) 2-dimensional placement.
Spine
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BRS204953.indd E747
Subaxial Cervical Translaminar Screw Fixation • Alvin et al
JMP 7.0 (2007; SAS Institute, Carey, NC) was used to cal-
culate statistics for all measurements in the study. Descriptive
statistics included mean, standard deviation, range, and con-
fidence intervals. Analysis of variance was used to calculate
the P values for the morphometric comparisons made across
sexes. For pairwise testing for vertebral levels, statistical sig-
nificance was set at less than 0.05 after Bonferrroni adjust-
ments for multiple comparisons were performed for Pear-
son χ2 tests. Intraobserver correlations were calculated for
all morphometric measurements on the basis of 3 successive
measurements by the same observer (MDA).
RESULTS
Patient Demographic Data
Fifty (25 men, 25 women) cervical spine radiographs were
evaluated in this study. The mean age of male patients was
54 ± 12.1 years (range: 31–75 yr) and the mean age of female
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 TECHNIQUE Subaxial Cervical Translaminar Screw Fixation • Alvin et al

patients was 49.2 ± 15.2 years (range: 22–80 yr). Age was
not significantly different between sexes.
Morphometric Analysis
Table 1 provides the mean morphometric (i.e., translami-
nar length, thickness, height, and sagittal-diagonal) mea-
surements at each vertebral level for men and women.
Translaminar length did not significantly (P < 0.05) differ
between sexes at levels C3 or C4. At C5–C7, however, men
had significantly longer translaminar lengths than women.
The C6 lamina was significantly longer than the laminae of
C3–C5. The C7 lamina was significantly longer than C3, C4,
and C6. Laminar thickness did not statistically differ between
men and women for any of the vertebral levels measured. At
all vertebral levels measured, men had significantly greater
laminar sagittal-diagonal measurements than women. No sex
differences existed for laminar height. C4, C5, and C6 were
significantly smaller than C3, and C7 was significantly larger
than C4, C5, and C6. Overall, 2000 discrete morphometric
measurements were made. The correlation coefficients of 3
successive intraobserver measurements for morphometric
and volumetric measurements for C3, C4, C5, C6, and C7
were above 0.72 for all measurements, and generally above
0.80, with an average of 0.83.
Volumetric Analysis
Table 2 provides the mean volumetric measurements at
each vertebral level for men and women. Intraobserver cor-
relations for laminar volume were above 0.8 for all mea-
surements. Laminar volume in both C6 (P = 0.03) and C7
(P = 0.002) were significantly greater in men than in women.
Neither C4 nor C5 was significantly different from C3.
However, C6 was significantly larger than C3, C4, and C5
(P < 0.0001). C7 was significantly larger than C3, C4, C5,
and C6 (P < 0.0001).
Virtual Screw Placement
Table 3 provides the mean unilateral and bilateral translami-
nar 3.5-mm screw lengths and acceptance rates, along with
the number of accepting patients out of total patients for each
sex (i.e., 25 patients for each sex), at each vertebral level for
men and women. Notably, there is 0% bilateral acceptance
for both men and women at C4 and C5, and 100% unilateral
acceptance for both men and women at C7. In addition, a
very high percentage of bilateral acceptance for both men and
women at C7 was determined.
DISCUSSION
There are several methods that have been developed to pro-
vide fixation throughout the subaxial spine, including lat-
eral mass screws and pedicle screws and a variety of wire/
cable techniques. A popular technique employed routinely is
the placement of lateral mass screws. However, variations in
anatomy and pathoanatomy, and prior surgical procedures,
can limit one’s ability to gain adequate fixation or enough
points of fixation of the cervical spine. The purpose of this
study was to determine the suitability of the subaxial spine for
translaminar screws.
In this study, we determined the specific anatomical dimen-
sions of the adult subaxial cervical vertebral laminae and also
analyzed the feasibility of unilateral and bilateral translami-
nar screw placement using CT radiographic analysis. Much
of the current literature on translaminar fixation in the adult
population focuses on the axial and upper thoracic vertebrae.
Limited investigation has been done within the adult popu-
lation to understand the laminar anatomy and feasibility of
translaminar screw placement in the subaxial cervical spine.
Feasibility of subaxial (C3–C7) cervical translaminar screw
placement was studied in a case series of 11 patients by Hong
et al,16 in which they demonstrated successful application of
translaminar screw fixation with limited adverse outcomes.

TABLE 1. Morphometric Analysis of C3–C7 Vertebral Laminae

Length (mm) Thickness (mm) Height (mm) Sagittal-Diagonal (mm)
Vertebra M F M F M F M F
C3 21.0 ± 1.60 20.2 ± 1.60 4.20 ± 0.90 4.10 ± 0.90 9.40 ± 1.80 9.20 ± 1.90 11.8 ± 1.70 10.8 ± 1.40
(17.7–24.3) (16.8–23.1) (2.70–6.0) (2.70–5.60) (5.00–12.5) (5.90–12.5) (7.80–10.8) (8.30–13.6)
C4 21.2 ± 1.60 20.4 ± 1.70 3.80 ± 0.80 3.60 ± 0.80 8.00 ± 1.70 8.10 ± 1.90 12.0 ± 1.60 11.0 ± 1.50
(17.3–24.4) (18.2–23.8) (2.30–5.70) (2.20–5.10) (4.20–11.6) (4.00–12.0) (9.00–15.6) (8.40–14.1)
C5 21.4 ± 1.60 20.5 ± 1.50 3.60 ± 0.70 3.30 ± 0.80 7.40 ± 1.50 7.70 ± 1.90 12.7 ± 1.90 11.4 ± 1.60
(18.1–28.7) (18.2–23.5) (2.40–5.20) (1.80–4.60) (3.80–11.3) (3.60–12.0) (8.30–15.9) (8.70–15.0)
C6 22.3 ± 2.10 21.1 ± 1.90 4.30 ± 0.70 3.90 ± 0.90 8.10 ± 1.80 8.10 ± 2.00 14.5 ± 1.80 12.6 ± 1.60
(18.1–28.7) (18.6–25.5) (3.10–5.60) (2.50–5.80) (5.00–11.6) (4.40–12.2) (10.9–17.6) (9.60–15.4)
C7 25.5 ± 1.70 23.4 ± 2.70 6.30 ± 0.90 5.90 ± 1.40 9.50 ± 1.70 9.20 ± 1.70 17.7 ± 1.40 15.9 ± 2.50
(22.4–29.3) (19.4–29.6) (4.80–8.50) (3.60–8.80) (6.20–13.6) (6.20–14.2) (15.3–20.7) (10.5–20.1)
M indicates male; F, female.

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 TECHNIQUE Subaxial Cervical Translaminar Screw Fixation • Alvin et al

They concluded that translaminar fixation is a simple tech-

TABLE 2. Volumetric Analysis of C3–C7 nique, not limited by the positioning of vascular structures,
Vertebral Laminae and provides high stability to the subaxial cervical spine.16
Volume (cm3) Xu et al18 made anatomical calculations of the subaxial cervi-
cal spine in a cadaveric study of 37 spines, whereby laminar
Vertebra M F height and thickness of the C2–L5 vertebrae were assessed.
C3 0.53 ± 0.17 0.47 ± 0.12 The authors found that most subaxial laminar measurements
were greater in men than in women, C4 had the smallest
(0.31–1.06) (0.29–0.68) height of all vertebrae, and C5 had the smallest laminar thick-
C4 0.50 ± 0.17 0.47 ± 0.13 ness of all vertebrae.18
Much of the remaining literature on adult translaminar
(0.33–1.13) (0.24–0.73)
anatomy and feasibility focuses on C2 and the upper thoracic
C5 0.56 ± 0.18 0.49 ± 0.15 vertebral levels, with limited mention of the subaxial cervical
spine. Wright2 demonstrated that C2 translaminar fixation
(0.38–1.26) (0.27–0.81)
was a safe and effective method for fixation, and since then
C6 0.71 ± 0.18 0.60 ± 0.19 there have been several studies that have applied the technique
(0.40–1.04) (0.34–1.08) to C2. Many studies have reported the clinical feasibility of
using translaminar screws and have cited direct visualization
C7 1.17 ± 0.20 0.96 ± 0.26 of the laminae and simplicity of the technique as 2 popular
(0.76–1.50) (0.56–1.57) advantages.3,11,13 In addition, translaminar screw placement
can be of considerable benefit when lateral mass screw place-
M indicates male; F, female.
ment causes facet fracture, particularly at the terminal end of

TABLE 3. BrainLAB Virtual Translaminar Screw Placement

M F
Vertebra Screw Length (mm) Acceptance Screw Length (mm) Acceptance
C3
Unilateral L 20.6 ± 2.73 52% (13/25) 19.5 ± 2.20 44% (11/25)
Unilateral R 19.6 ± 3.08 48% (12/25) 19.5 ± 2.72 52% (13/25)
Bilateral 20.9 ± 1.95 20% (5/25) 20.6 ± 0.23 8% (2/25)
C4
Unilateral L 18.2 ± 2.63 20% (5/25) 19.4 ± 2.57 20% (5/25)
Unilateral R 21.0 ± 1.45 24% (6/25) 20.3 ± 2.70 32% (8/25)
Bilateral NA 0% (0/25) NA 0% (0/25)
C5
Unilateral L 20.2 ± 2.45 12% (3/25) 19.1 ± 4.01 28% (7/25)
Unilateral R 18.1 ± 5.00 24% (6/25) 18.6 ± 4.12 32% (8/25)
Bilateral NA 0% (0/25) NA 0% (0/25)
C6
Unilateral L 20.7 ± 4.10 76% (19/25) 20.3 ± 3.42 64% (16/25)
Unilateral R 20.8 ± 3.60 84% (21/25) 19.7 ± 4.85 72% (18/25)
Bilateral 23.6 ± 3.48 20% (5/25) 21.1 ± 1.99 24% (6/25)
C7
Unilateral L 26.0 ± 1.70 100% (25/25) 23.5 ± 2.78 100% (25/25)
Unilateral R 25.1 ± 1.93 100% (25/25) 22.9 ± 2.92 100% (25/25)
Bilateral 25.5 ± 1.85 96% (24/25) 23.8 ± 2.64 84% (21/25)
M indicates male; F, female.

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 TECHNIQUE
a construct. In these cases, translaminar screws can be placed
to provide additional fixation points to provide added biome-
chanical stability and decrease the possibility of construct fail-
ure. Furthermore, there exist situations in which placement of
pedicle screws may not be possible or unfavorable because of
abnormal pedicle anatomy or for concern of entering into the
transverse foramen.
Translaminar fixation within the thoracic spine has also
been extensively evaluated in both cadaveric and adult
patients. Kretzer et al5 first evaluated the safe placement of
translaminar screws in T1–T2 in 7 patients and then in a sub-
sequent article they conducted a cadaveric comparison study
of translaminar screws with pedicle screws at the T1–T2
level6 and a similar CT-based morphometric analysis to deter-
mine the critical proportions of the upper thoracic laminae in
adults.
However, most literature examining the feasibility of subax-
ial translaminar fixation,12,14,16,17 as well as laminar CT-based
anatomical dimensions, are based on pediatric populations.15
Chamoun et al14 described a case series of 7 pediatric patients
who all achieved solid fusion in subaxial translaminar fixa-
tion. Two other case series also reported subaxial fixation at
the C3 level as an alternative when the C2 lamina is atrophic
or as a better alternative to lateral mass screws when the lat-
eral mass is too small.12,17 Recently, Chern et al15 conducted
a CT-based morphometric analysis of the C2–C7 vertebrae
in patients younger than 16 years to measure laminar height
and thickness. They concluded that translaminar screws are a
safe option for the majority of the pediatric population. The
authors found no significant sex-related differences but did
find significant age-related differences among all vertebrae.15
Although extensive work has been done within the pediat-
ric population and for other regions of the spine in the adult
population, few studies have investigated translaminar screw
placement in the adult subaxial cervical spine. The present
study provides information on both the anatomical dimen-
sions and the feasibility of placing translaminar screws in the
adult subaxial spine.
In this study, we began the laminar anatomical analy-
sis by taking 2000 morphometric measurements and 1000
volumetric measurements, producing 200 complex volumes.
Men were found to have significantly larger measurements
than women in translaminar length for C5, C6, and C7 in
sagittal-diagonal measurements at all vertebral levels and in
volumes for C6 and C7, which parallels the results of the
1999 study by Xu et al18 on cadaveric vertebrae. Our findings
agreed with those of Xu et al in that the C5 vertebra has the
smallest laminar thickness, whereas they differed in that we
found C5 to have the smallest height (rather than C4).18 We
found that mean laminar thickness decreased from C3 to C5
and then increased from C5 to C7. C7 also had the greatest
laminar height of all the subaxial cervical vertebrae. Similar
anatomical findings for the lateral masses of C7 versus C5
and C6 have recently been reported.19
After obtaining the anatomical dimensions of the sub-
axial cervical laminae, we analyzed the feasibility of plac-
ing 3.5-mm translaminar screws unilaterally and bilaterally,
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BRS204953.indd E750
Subaxial Cervical Translaminar Screw Fixation • Alvin et al
using BrainLAB iCranial imaging software. It is important to
note that the BrainLAB iCranial software package has been
used successfully and reliably in multiple studies.20–23 Unilat-
eral placement acceptance was seen in all subaxial vertebral
levels (C3–C7). Unilaterally, C7 showed acceptance rates of
100%, C6 showed acceptance rates of more than 64%, and
C5, C4, and C3 showed acceptance rates between 12% and
52%. This complements our anatomical analysis data, which
showed decreasing morphometric and volumetric parameters
from C3 to C5 and increasing parameters from C5 to C7.
The results for the feasibility component of our study showed
that only C7 accepted bilateral placement at a high rate (96%
men, 84% women). Although C3 and C6 did accept bilateral
placement, this was seen at a lower rate (C3: 20% men, 8%
women; C6: 20% men, 24% women; see Table 3). C4 and
C5 never accepted bilateral translaminar placement (0% men,
0% women). Men achieved higher rates of bilateral screw
purchase in C3 and C7, whereas women had better purchase
rates in C6.
The morphometric variability of the subaxial cervical lami-
nae and between the various patients suggests the importance
of preoperative CT scanning. The spine surgeon can use the
CT scan to analyze the safety and feasibility of a particular tra-
jectory in the placement of translaminar screws in the subax-
ial vertebrae. It is particularly important for screw placement
in the C4 and C5 vertebrae, which showed as little as 12%
unilateral acceptance in men and 20% unilateral acceptance
in women. Those C4–C5 levels that did accept had laminar
thickness that was greater than 4.0 mm. In most patients, uni-
lateral C6 and C7 translaminar screw placement was found to
be achievable. Bilaterally, C7 showed excellent translaminar
screw acceptance and, as such, may be added to the spine
surgeon’s repertoire. Those C7 levels that did accept bilateral
screw placement had heights generally greater than 8.0 mm.
For trajectory, we analyzed feasibility based on ideal con-
ditions, whereby the translaminar screw passed through the
middle part of the lamina where it was thickest. The mini-
mum thickness needed for successful and safe translaminar
screw fixation has been reported as 4.0 mm or more in the
axis.3,9,14Our anatomical and feasibility results indicate that
within the subaxial cervical spine, translaminar screws of 3.5-
mm diameter achieve sufficient purchase rates in laminae that
have thickness of 4.0 mm or greater.
Although there have been anatomical analyses both of
cadaveric subaxial cervical laminae18 and of CT-based pedi-
atric subaxial cervical laminae,15 to our knowledge, no study
has yet defined using radiographical imaging the anatomi-
cal dimensions of adult subaxial laminae. In addition, there
has not been a study to date that used the subaxial laminar
dimensions to analyze fixation feasibility and calculate accu-
rate screw lengths for surgical applicability. Our study popu-
lation was composed of 50 patients and may not have been
sufficiently large to be generalizable to the greater population.
Despite this limitation, the study accurately reports the lami-
nar anatomy of the subaxial cervical spine and its morpho-
metric and volumetric variations among the subaxial cervi-
cal vertebrae. In addition, we have provided optimal screw
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 TECHNIQUE
dimensions for safe placement during subaxial cervical trans-
laminar fixation and analyzed the feasibility of translaminar
screw placement in both unilateral and bilateral fashions for
all subaxial cervical vertebrae. More research is needed to
validate the results, and our center is currently evaluating the
long-term outcomes of translaminar fixation at all vertebral
levels with prospective studies of translaminar screw fixation
in the subaxial cervical spine.
CONCLUSION
Subaxial cervical unilateral translaminar screw placement is a
potentially safe and effective technique to use in conjunction
with preoperative CT scanning for all vertebral levels. The
same is true for bilateral placement at C7 but not at C3–C6.
➢ Key Points
‰ Relative to women, men exhibit greater translaminar
length from C5 to C7, sagittal-diagonal length from
C3 to C7, and volume from C6 to C7.
‰ C7 has a 100% translaminar unilateral acceptance
rate and a high bilateral acceptance rate, whereas C4
and C5 have limited unilateral acceptance rates and
cannot accept bilateral screws at all.
‰ Men have higher bilateral placement rates than
women for C3 and C7, whereas the opposite is true
for C6.
Acknowledgments
The authors thank Mr. Joe Kanasz, BFA, and Ms. Jennifer
Kerbo (Center for Medical Art and Photography, Cleveland
Clinic Education Institute), for their illustrations, as well as
Mr. Joe Weisenberger and Dr. Richard Drake, PhD.
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