What is the course of action for a patient with a fractured screw in the C6 vertebral body from a previous interior fusion plate application from C4 to C6?

Management of Fractured C6 Pedicle Screws in Anterior Cervical Fusion Hardware

This patient requires urgent spine surgery consultation for evaluation and likely revision surgery, as fractured pedicle screws represent hardware failure that can lead to loss of stability, progressive deformity, and potential neurological compromise.

Immediate Assessment Required

The first priority is determining whether the fusion has achieved solid bony union, as this fundamentally changes management. 1

• Obtain CT scan of the cervical spine immediately to assess:

  • Fusion status across C4-C6 levels (look for bridging bone) 1
  • Degree of screw fracture and displacement 2
  • Alignment and any progressive deformity 3
  • Integrity of remaining hardware 4

• Perform neurological examination documenting:

  • Motor strength in all extremities
  • Sensory deficits
  • Myelopathic signs (hyperreflexia, Hoffman's sign, clonus)
  • Radicular symptoms 3, 5

• Obtain flexion-extension radiographs (if neurologically intact and no acute instability suspected) to assess dynamic stability 5

Decision Algorithm Based on Fusion Status

If Solid Fusion is Present (Bridging Bone on CT):

Hardware removal or observation may be appropriate, as the biological fusion provides stability independent of instrumentation. 1

• The fractured screws are no longer load-bearing if solid arthrodesis exists 1
• Monitor clinically and radiographically every 3-6 months for:
  • Development of pain at hardware site
  • Any neurological changes
  • Progressive deformity 1
• Hardware removal is optional and based on symptoms (local pain, prominence) 1

If Fusion is Incomplete or Absent:

Revision surgery is mandatory to prevent catastrophic failure, progressive kyphosis, and neurological injury. 1, 3

• Fractured screws in the absence of fusion indicate ongoing mechanical stress and imminent construct failure 1
• Revision options include:
  • Posterior revision with lateral mass or pedicle screw fixation extending one level above and below if needed 6, 4
  • Replacement of anterior plate with longer construct if anterior column support inadequate 6
  • Addition of posterior instrumentation if not previously present (combined approach provides superior stability) 7

Surgical Planning for Revision (If Required)

Posterior approach with pedicle screw fixation is the preferred revision strategy for failed anterior cervical hardware. 6, 4

• Cervical pedicle screws provide superior biomechanical stability compared to lateral mass screws, particularly important in revision scenarios 4
• Preoperative CT angiography to evaluate vertebral artery anatomy and pedicle dimensions 4
• Intraoperative fluoroscopy or navigation to ensure accurate screw placement and avoid neurovascular injury 4
• Consider extending fusion one level above/below if adjacent segment degeneration present 1

Critical Pitfalls to Avoid

• Do not assume the patient is stable based on plain radiographs alone - CT is mandatory to assess fusion and hardware integrity 2
• Do not delay intervention if fusion is incomplete - fractured screws will progress to complete construct failure 1
• Avoid placing new screws in the same trajectory as fractured hardware without adequate bone stock assessment 4
• Do not overlook C2 nerve root sacrifice option if posterior C1-C2 instrumentation needed for exposure and stability 8

Monitoring and Follow-up

• If observation chosen (solid fusion present): Clinical and radiographic follow-up at 3,6, and 12 months 1
• If revision performed: Postoperative CT to verify hardware position, then dynamic radiographs at 3 months to confirm stability 2, 5
• Assess for delayed complications: Adjacent segment disease, pseudarthrosis, hardware prominence 1

The key determinant is fusion status - solid arthrodesis allows conservative management, while incomplete fusion mandates revision to prevent devastating complications including paralysis from progressive instability. 1, 3