Nuance in Craniovertebral Junction Surgical Approach for Posterior C1-C2 Harms Stabilization: "Window Transposition" of the External Vertebral Venous Plexus for Bloodless C1 Lateral Mass Screw Insertion: Anatomical Aspects and Technical Notes.

Atlas and axis instrumentation may be necessary in cases of several craniocervical junction pathologies. According to the Harms technique, C1-C2 polyaxial screws are inserted respectively in the C1 lateral masses and in C2 pedicles. C1 lateral mass screw insertion requires the careful subperiosteal dissection of the posterior elements of C1, the identification of the screw entry point by the downward distraction of C2 nerve root, and the cautious sparing of the overlying posterior external vertebral venous plexus (peVVP), whose bleeding, obstructing the surgical field, is sometimes barely controlled by hemostatic agents and swabbing. The authors describe in detail the anatomical aspects of an alternative surgical technique developed for the microsurgical transposition of the C1-C2 interposed external vertebral venous plexus in the case of Harms C1-C2 screw stabilization. The longitudinal median incision of the atlantoaxial membrane, followed by bilateral subperiosteal dissection and microsurgical section respectively at the inferior borders of the C1 laminae and at the superior borders of the C2 laminae, allows, as a "window opening," the symmetrical mediolateral transposition of the peVVP. This procedure provides a faster and cleaner anatomical exposition of the posterior surface of the C1 lateral mass and the C2 isthmus, preventing troublesome intraoperative venous bleeding that hinders C1 lateral mass screw insertion.