In Reply: Innovative Technique of Anchoring the Upper End of the Cervical Plate With C1 Anterior Arch Screw for Upper Cervical Tumors

To the Editor: We thank the authors1 of the letter for their valuable comments and the opportunity to respond. There is currently no research evidence available to support the claim that the biomechanical strength of the anterior arch screw to be inadequate. However, we have used the anterior arch screw as an anchoring point for the upper end of the cervical plate, rather than as a primary fixation method. C1 anterior arch has more cortical bone, and even a single proper screw can hold the cage in position without risk of screw loosening or dislodgement, which was apparent in case 3.2 We operated all cases after intraoperative computed tomography under navigation. It facilitated accurate placement of C1 arch screws. Use of split titanium mesh cage is cost-effective and has shown superior stability and clinical outcome. Personalized 3-dimensional–printed artificial vertebral bodies are expensive and may not be feasible for routine use in centers with limited funding. It necessitates surgical staging and further delay to accurately assess the construct for 3-dimensional printing. An advantage of the mesh cage is that its fenestrations allow a steep trajectory for C1 arch screw placement using a high-speed drill. Vascularized bone grafting is superior to nonvascularized bone grating with comparable complication rates and functional outcomes, and superior bony fusion.3 We routinely use iliac crest autograft for cervical reconstruction in our Neuroscience Center. The wide anterior portion of the graft, when positioned superiorly, provides support to the C1 lateral mass. It is also suitable for long-segment reconstruction, as we have successfully used it in three-level resections. The tricortical iliac graft provides excellent structural stability and reliable fixation. Even though cervical pedicle screw fixation is an optimal choice for posterior fixation, we selectively used lateral mass screw fixation in cases which were technically more demanding. We routinely use cervical pedicle screw fixation for cervical deformity correction at our center. We are following these patients long-term and also collecting prospective data in additional cases which will be reported separately.