J Neurosurg Spine 20:11–17, 2014

©AANS, 2014

Risk factors for intraoperative lateral mass fracture of lateral

mass screw fixation in the subaxial cervical spine
Clinical article

Shinichi Inoue, M.D., Ph.D., Tokuhide Moriyama, M.D., Ph.D.,

Toshiya Tachibana, M.D., Ph.D., Fumiaki Okada, M.D., Ph.D.,
Keishi Maruo, M.D., Ph.D., Yutaka Horinouchi, M.D.,
and Shinichi Yoshiya, M.D., Ph.D.

Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan

Object. Although lateral mass screw fixation for the cervical spine is a safe technique, lateral mass fracture dur-
ing screw fixation is occasionally encountered intraoperatively. This event is regarded as a minor complication; how-
ever, it poses difficulties in management that may affect fixation stability and clinical outcome. The purpose of this
study is to determine the incidence and etiology of lateral mass fractures during cervical lateral mass screw fixation.
Methods. A retrospective clinical review of patient records was performed in 117 consecutive patients (mean age
57 years, range 15–86 years) who underwent lateral mass screw fixation using a modified Magerl method from 1997
to 2010 at a single institution. A total of 555 lateral masses were included in this study. The outer diameters of the
screws were 3.5 or 4.0 mm. In the retrospective clinical analysis, the incidence of intraoperative lateral mass fractures
was reviewed. Potential risk factors for this complication were assessed using multivariate analysis.
Results. The incidence of lateral mass fractures during cervical lateral mass screw fixation was 4.7% (26 lateral
masses) among all cases. Among the disorders, the incidence was highest in patients with destructive spondyloar-
thropathy (DSA) (18.8%, 12 lateral masses). There was no significant difference with respect to lateral mass fracture
between the use of 4.0-mm screws (5.6%) and 3.5-mm screws (3.6%). Independent risk factors identified by logistic
regression were DSA (OR 7.89, p < 0.001) and screw insertion in the C-6 lateral masses (OR 2.80, p = 0.018).
Conclusions. The overall incidence of lateral mass fracture during cervical lateral mass screw fixation was 4.7%.
Destructive spondyloarthropathy as an underlying cause of morbidity and screw placement in the C-6 lateral mass
were identified as independent risk factors. Use of a 4.0-mm screw in patients with DSA may be a principal risk fac-
tor for this complication.
(http://thejns.org/doi/abs/10.3171/2013.9.SPINE121055)

Key Words • lateral mass • cervical • spinal fusion • complication •

fracture

T
he lateral mass screw fixation technique is com- tively safe procedure, there are several complications that
monly used for fixation of an unstable cervical may be encountered during screw insertion, such as ver-
spine caused by trauma, degenerative disorders, tebral artery and nerve root injuries, facet violation, and
neoplasms, rheumatoid arthritis (RA), and destructive lateral mass fracture.4,9–12,14,15,24,25 Among these, lateral
spondyloarthropathy (DSA).2–4,12,13,23 This technique was mass fracture is considered to be one of the minor com-
first described by Roy-Camille et al. in the 1960s.23 In plications that does not cause serious insult. However, this
that report, lateral mass screws were used with plates as complication may impair fixation strength or compel the
a component of an internal fixation system for cervical surgeon to extend the fixation level that can potentially
spine arthrodesis. Following this, application of lateral affect the postoperative outcome (Fig. 1). In previous lit-
mass screw fixation has been broadened by Anderson, erature, a few clinical papers referred to this complication
An, and Jeanneret and their colleagues.2,3,13 Based on the with an incidence of 1.6%–4%.12,14,15,24 In our current clini-
subsequent clinical experiences showing its effectiveness cal practice, indications for cervical fixation have expand-
and safety, the advantage of this technique over other pro- ed to include patient populations with severe deformity
cedures has been widely accepted. and instability as well as bone fragility caused by chronic
Although lateral mass fixation is regarded as a rela- morbidities such as DSA, RA, and osteoporosis.12,18,26,29 In
these situations, the incidence of lateral mass fracture may
Abbreviations used in this paper: DSA = destructive spondyloar- be even higher than previously reported.
thropathy; RA = rheumatoid arthritis. The purpose of this study is to determine the inci-

J Neurosurg: Spine / Volume 20 / January 2014 11

 S. Inoue et al.
TABLE 1: Preoperative diagnosis*

No. of Lateral
Disorder No. of Patients Masses
trauma 34 143
CSM 25 119
RA 15 73
OPLL   8 36
destructive spondyloarthropathy 11 64
cerebral palsy   4 30
tumor & other 20 90
total 117 555

* CSM = cervical spondylotic myelopathy; OPLL = ossification of the

posterior longitudinal ligament.
Fig. 1. Intraoperative photograph of a fracture at C-6 on the right.
The arrowhead indicates the screw hole, and the arrow indicates the
fracture line. During surgery, the patient was placed prone. The
cervical spine was maintained in a neutral position using
dence and etiology of lateral mass fractures during cer- 3-pin skull fixation. Fluoroscopy was used only to confirm
vical lateral mass screw fixation in our clinical practice. the alignment of the cervical spine and to identify the level
It was hypothesized that the incidence of lateral mass for screw placement. The subsequent screw procedure was
fracture is higher than reported in previous literature, and performed without the use of fluoroscopic images. After
there are specific patient subgroups exhibiting increased exposure of the posterior elements, the facet joints at the
risk of this complication. fixation level were decorticated. Great care was taken to
protect the facet joint above and below the instrumented
Methods levels. The lateral mass was drilled and tapped prior to
laminectomy or laminoplasty. The entry point was 1 mm
Study Population medial to the midpoint of the lateral mass. An awl was
One hundred twenty patients (583 lateral masses) used to create the starting hole. The intended angle of the
who underwent cervical lateral mass screw fixation be- screw trajectory was directed approximately 30° laterally
tween 1997 and 2010 were included in the study. Among and superiorly (parallel to the facet joint), which is a modi-
these patients, 3 patients (16 screws) who underwent cer- fication of the Magerl method. The superolateral quadrant
vical lateral mass screw fixation via an exceptional type is regarded as the “safe zone,”22 which is considered the
of instrumentation were excluded. Lateral mass screws imaginary target of the trajectory. The depth of the drill
inserted at the C-7 level (10 screws) were excluded from bit started from 14 mm, and the drilling was performed to
the analysis because of the difference in bone morphol- allow for bicortical screw purchase when feasible. In most
ogy. Screw insertion was not attempted in 2 lateral masses cases, fixation of the cervical spine was performed after
at the C-3 level because of inadequate bone stock or size completing decompression. Pedicle screws were used in-
based on the intraoperative assessment of the surgeon. stead of lateral mass screws for C-7 lateral masses. During
Therefore, 117 patients (555 lateral masses) composed the the study period, all procedures were performed by one of
base for this study. All screws were placed using a modi- 5 experienced spine surgeons at our institution.
fied Magerl method. The average age at surgery was 57
years (range 15–86 years). There were 72 male and 45 fe- Definition of Lateral Mass Fracture
male patients who underwent 98, 173, 177, and 107 screw The definition of intraoperative lateral mass fracture
insertions at the C-3, C-4, C-5, and C-6 levels, respective- was based on perception of a crack in the lateral mass dur-
ly. Preoperative diagnoses were traumatic lesion (trauma), ing screw placement (drilling, tapping, and screwing) by
cervical spondylotic myelopathy, RA, ossification of the experienced spine surgeons. Data regarding screw pull-
posterior longitudinal ligament, DSA, cerebral palsy, and out and breakage detected initially by CT scanning in the
tumor and other lesions (Table 1). Diagnosis of DSA was early postoperative period were not included because it
made based on the radiological findings exhibiting nar- was impossible to determine whether the event occurred
rowing of the intervertebral disc space with presence of intraoperatively or in the early postoperative period.
erosion and cysts in the adjacent vertebral plates associat-
ed with minimal osteophyte formation.16 The OASYS sys-
tem (Stryker Spine) with 3.5-mm screws and the Olerud Incidence and Analysis of Risk Factors of Intraoperative
system (Anatomica) with 4.0-mm screws were used in 52 Lateral Mass Fracture
patients (249 lateral masses) and 65 patients (306 lateral The incidence of intraoperative lateral mass fracture
masses), respectively (Table 2). Instrumentation type was during lateral mass fixation among all cases was calculat-
selected arbitrarily for each patient. The surgical proce- ed. Thereafter, subgroup analyses were performed based
dure is illustrated in Fig. 2. on factors such as age, sex, side of fracture, cervical level,

12 J Neurosurg: Spine / Volume 20 / January 2014

Intraoperative lateral mass fracture of lateral mass screw fixation

TABLE 2: Instrumentation systems used in this study on the fracture rate were assessed in patients with DSA,
the incidence of lateral masses fixed with 4.0-mm screws
Screw Outer No. of No. of Lateral was higher than that of those fixed with 3.5-mm screws,
Implant Configuration Diameter (mm) Patients Masses with no significant difference (25.6% vs 8.0%, p = 0.106).
Olerud screw-rod 4.0 65 306 Multivariate Analysis
OASYS screw-rod 3.5 52 249
In the multivariate analysis, independent risk factors
identified by stepwise logistic regression were DSA (OR
screw outer diameter, and underlying morbidity. Patient 7.890 [95% CI 3.430–18.200], p < 0.001) and screw place-
age was stratified as 65 years or older and younger than 65 ment in the C-6 lateral mass (OR 2.800 [95% CI 1.190–
years. In the assessment of potential risk factors for this 6.590], p = 0.018) (Table 5).
complication, univariate and multivariate analyses were Management for Intraoperative Lateral Mass Fracture
used for evaluation.
During intraoperative management to deal with in-
Management for Intraoperative Lateral Mass Fracture traoperative lateral mass fracture, screw insertion at the
corresponding level was abandoned in 15 of the 26 lateral
The operative record of each patient was thoroughly masses with fractures (Table 3). In 3 of these 15 lateral
reviewed to examine how the surgeon coped with the lat- masses, the fusion level was extended to the adjacent lev-
eral mass fracture intraoperatively. el. In the remaining 11 lateral masses in which the screw
Statistical Analysis was placed at the level of fracture, the screw trajectory
or length was altered in 5 lateral masses. Overall, the oc-
Statistical analyses were performed using the Fisher currence of this complication compelled the surgeon to
exact test for analysis of intergroup differences, while reinsert the screw or abandon screw placement in 77% of
the significance of each of the potential risk factors was cases.
assessed using the stepwise logistic regression test. A p
value < 0.05 was considered to be statistically significant.
Discussion
Findings of the Present Study
Results
The present study demonstrated the following find-
Incidence of Lateral Mass Fractures ings. 1) The overall incidence of lateral mass fractures
Incidence of lateral mass fractures during cervical during cervical lateral mass fixation was 4.7%. 2) The in-
lateral mass fixation among all cases was 4.7% (26 lateral cidence was highest in patients with DSA (18.8%). 3) Inde-
masses), or in other words, 20 patients (17.1%) had this pendent risk factors identified using multivariate analyses
complication (Table 3). In the subgroup analysis (Table 4), were patients with DSA and screw placement in the C-6
it was shown that the incidence was significantly higher in lateral mass.
patients with DSA (18.8%, 12 lateral masses). As a result,
we found that more than half of the patients with hemo- Previous Studies on Intraoperative Lateral Mass Fracture
dialysis (63.6%, 7 patients) had this complication. There The previous clinical studies by Katonis et al.,14,15
were 4 patients who had multiple broken lateral masses, 3 Sekhon,24 and Inoue et al.12 reported that the incidence of
of whom had DSA (Fig. 3). Age, sex, and side of fracture lateral mass fractures during cervical lateral mass screw
showed no significant difference (p = 0.835, p = 1.000, fixation was 1.6%–4.0%. The incidence reported in the
and p = 0.851, respectively). Regarding the level of the present study (4.7%) is higher than the value in the pre-
cervical spine, the rate of lateral mass fracture was sig- vious studies. In a cadaveric study by Choueka et al.,6
nificantly higher at C-6 (9.3%) than at other cervical levels however, lateral mass fractures on screw insertion were
(p = 0.035). Incidences of lateral mass fracture were 5.6% detected in 6% of masses fixed with Roy-Camille screws
and 3.6% with 4.0-mm screws and 3.5-mm screws, re- and in 7% of masses fixed with Magerl screws. From a
spectively (p = 0.318). When the effects of screw diameter clinical viewpoint, the apparently higher incidence indi-

Fig. 2. Drawings showing the modified Magerl technique. The entry point of this procedure was 1 mm medial to the midpoint
of the lateral mass. The screws were directed approximately 30° laterally and superiorly (parallel to the facet joint).

J Neurosurg: Spine / Volume 20 / January 2014 13

 S. Inoue et al.
TABLE 3: Patients with intraoperative lateral mass fracture: demographics, screw diameter, number and level of fracture, and fracture
management

Age Screw
Case (yrs), Diameter No. of
No. Sex Disorder Implant (mm) Fractures Fracture Location Fracture Management
1 71, F CSM Olerud 4.0 1 lt C-4 skip to lt C-3 (extended to adjacent level)
2 63, M trauma Olerud 4.0 1 rt C-4 unchanged
3 63, M DSA Olerud 4.0 1 lt C-4 skip to lt C-3 (extended to adjacent level)
4 68, M trauma Olerud 4.0 1 rt C-6 unchanged
5 60, M RA Olerud 4.0 1 lt C-4 skip (removal)
6 62, M DSA Olerud 4.0 2 rt C-4, lt C-6 skip to lt C-7 (extended to adjacent level)
7 49, M DSA Olerud 4.0 4 bilat C-5, bilat C-6 lt C-6 skip (removal), bilat C-5, lt C-6 reinserted (shortened screw
length)
8 18, F trauma Olerud 4.0 1 rt C-6 unchanged
9 68, F DSA Olerud 4.0 2 bilat C-4 skip (removal)
10 56, M DSA Olerud 4.0 1 rt C-3 skip (removal)
11 78, F trauma Olerud 4.0 1 lt C-6 reinserted (shortened screw length)
12 68, F CSM Olerud 4.0 1 lt C-5 unchanged
13 82, F CSM OASYS 3.5 1 lt C-4 skip (removal)
14 76, F other OASYS 3.5 1 rt C-6 reinserted (changed screw trajectory)
15 66, M RA OASYS 3.5 2 rt C-4, lt C-5 skip (removal)
16 55, M tumor OASYS 3.5 1 rt C-6 skip (removal)
17 27, F CSM OASYS 3.5 1 lt C-5 unchanged
18 59, M DSA OASYS 3.5 1 lt C-6 skip (removal)
19 50, F DSA OASYS 3.5 1 rt C-5 unchanged
20 53, F CSM OASYS 3.5 1 lt C-6 skip (removal)

cated in the present study may be attributed to the follow- spine characterized by disc space narrowing, vertebral
ing factors. First, surgical indication has been expanded to erosion, and irregular endplate destruction in conjunction
complex deformities and instabilities as well as patients with minimal osteophyte formation as a complication ob-
with DSA and RA complicated by substantial bone fra- served in patients undergoing long-term hemodialysis.16
gility.12,18,26,28,29 Consequently, the incidence in our cur- Since 1984 the number of reports regarding DSA has been
rent practice may well be higher than the value reported increasing.20 The cervical spine is the most commonly in-
in previous literature. Incidentally, incidence of patients volved spinal region. In a 5-year radiological prospective
without poor bone quality such as either RA or DSA was study, Leone et al.17 reported finding cervical spine DSA
2.6%, which corresponds to the value reported in previ- in 19% of patients. Patients with DSA have severe bone
ous studies. Additionally, there is a difference in skeletal fragility due to renal osteodystrophy and a decrease in
size between the Japanese and Caucasian populations, and bone mineral density.18,19,29 The quality of bone in patients
thus the use of screws of the same size range in our patient with renal osteodystrophy was compromised by vari-
population may have led to an increased incidence of this ous pathologies such as secondary hyperparathyroidism,
complication in this study. 1,25-dihydroxyvitamin D deficiency, previous immuno-
In regard to the risk factors for intraoperative lateral suppression therapy, chronic acidosis, secondary amen-
mass fractures, Katonis et al.14 claimed that an excessively orrhea, and chronic aluminum and heparin exposure.27 It
lateral screw trajectory was a technical factor associated has been reported that the age-adjusted incidence of hip
with increased incidence of lateral mass fracture. Howev- fractures in the hemodialysis population was 4.4 times
er, detailed subgroup comparisons or multivariate analy- greater than that in the general population, while the rela-
ses were not performed in the previous studies, and thus tive risk of hip fracture increased as the time period since
the risk factors leading to this complication have not been first dialysis increased.1 Risk factors for the development
well clarified. of DSA include the duration of renal failure, duration of
hemodialysis therapy, and clinical variables.17,20 The mean
duration of hemodialysis in patients with DSA in the pres-
Bone Fragility in Patients With Long-Term Hemodialysis
ent study was 19 years (range 12–30 years), and the im-
We found that DSA is a highly correlated risk factor paired bony properties in this population were thought to
for intraoperative lateral mass fractures. In 1984, Kuntz be correlated to an increased incidence of intraoperative
et al. first described radiological features of DSA of the lateral mass fracture.

14 J Neurosurg: Spine / Volume 20 / January 2014

Intraoperative lateral mass fracture of lateral mass screw fixation
TABLE 4: Incidence of lateral mass fracture*

No. of Fractured
Variable Lateral Masses (%) p Value†
age at op in yrs 0.835
>65 10/200 (5.0)
<65 16/355 (4.5)
sex 1.000
female 10/209 (4.8)
male 16/346 (4.6)
side 0.851
rt 15/276 (5.4)
lt 14/279 (5.0)
level 0.035
C-3 1/98 (1.0)
C-4 9/173 (5.2)
C-5 6/177 (3.4)
C-6 10/107 (9.3)
screw outer diameter in mm 0.318
3.5 9/249 (3.6)
4.0 17/306 (5.6)
preop diagnosis NA
Fig. 3. Postoperative CT image obtained in a 49-year-old man with
trauma 4/143 (2.8) DSA. Fractures occurred bilaterally at both C-5 and C-6 during cervical
CSM 5/119 (4.2) lateral mass screw fixation with the Olerud system. The arrows indicate
RA 3/73 (4.1) the lateral mass fracture.
OPLL 0/36 (0)
DSA 12/64 (18.8) primary posterior cervical spinal fusion for patients with
cerebral palsy 0/30 (0) DSA, 3.5-mm screws may be selected to reduce the risk
tumor & other 2/90 (2.2) of intraoperative lateral mass fracture. In assessment of
the effect of screw diameter on the incidence of this com-
* NA = not available. plication, the size of the lateral mass can be another fac-
† Chi-square test. Value in boldface is statistically significant. tor influencing the results; however, analysis in this regard
was not feasible due to the lack of data relevant to volume
Level of Fixation of the lateral mass.
The incidence of intraoperative lateral mass fracture Management for Intraoperative Lateral Mass Fracture
was shown to be significantly higher at the C-6 level than Considering the intraoperative management to deal
at other cervical levels. This tendency may be due to the with the occurrence of lateral mass fracture, the screw tra-
anatomical characteristics of the subaxial cervical spine. jectory/length was altered or screw placement at the cor-
It has been shown that the width of the C-6 lateral mass in responding level was abandoned in approximately 80% of
general is thinner than that of C-3.7 Moreover, there have the cases. Sekhon24 recommended conversion to a modi-
been several reports showing anatomical differences be- fied Roy-Camille technique when the insecurity of the
tween C-3 and C-6.5,8 We have previously reported that the fixation was in doubt. Conversion to a modified transar-
majority of facet violations were detected at the C-6 level ticular screw technique as proposed by Miyamoto et al.21
with a significantly higher incidence compared with other is another option. In the case of substantial lateral mass
levels.12 Therefore, the results of this study and findings in fracture at C-6 at the lowest fixation level, conversion to
previous literature may instill caution for placing screws the C-7 pedicle screw technique may be a way to deal with
at the C-6 level. this complication.
Relationship With Screw Diameter
TABLE 5: Analysis of risk factors by multivariate analyses
Our study demonstrated no statistically significant
difference between 4.0-mm and 3.5-mm screws with
Variable OR (95% CI) p Value*
regard to intraoperative lateral mass fracture (5.5% vs
3.6%). In a supplemental subgroup analysis, use of 4.0- DSA 7.890 (3.430–18.200) <0.001
mm screws in patients with DSA was associated with C-6 level 2.800 (1.190–6.590) 0.018
an increased risk for intraoperative lateral mass fracture
compared with 3.5-mm screws (25.6% vs 8.0%). Thus, in * Logistic regression. Boldface indicates significance.

J Neurosurg: Spine / Volume 20 / January 2014 15

 S. Inoue et al.

Study Limitations plates and bone graft. Spine (Phila Pa 1976) 16 (3 Suppl):
S72–S79, 1991
There are some limitations of this study. First, the 4. Aydogan M, Enercan M, Hamzaoglu A, Alanay A: Recon-
study design is a retrospective review based on the op- struction of the subaxial cervical spine using lateral mass and
erative record, and surgeries were performed by multiple facet screw instrumentation. Spine (Phila Pa 1976) 37:E335–
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confounding variables such as errors of entry point or the 5. Barrey C, Mertens P, Jund J, Cotton F, Perrin G: Quantitative
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niques. Spine (Phila Pa 1976) 30:E140–E147, 2005
fracture was solely based on the surgeon’s perception; 6. Choueka J, Spivak JM, Kummer FJ, Steger T: Flexion failure
however, CT scanning is the most effective way of evalu- of posterior cervical lateral mass screws. Influence of insertion
ating the postoperative condition of the lateral masses. If technique and position. Spine (Phila Pa 1976) 21:462–468,
the complication had been assessed by CT in the early 1996
postoperative period, the actual incidence may have been 7. Ebraheim NA, Xu R, Challgren E, Yeasting RA: Quantitative
greater than the value reported here. Third, because bone anatomy of the cervical facet and the posterior projection of its
mineral density data were not available for all patients inferior facet. J Spinal Disord 10:308–316, 1997
in the current study and the volume of the lateral mass 8. Ebraheim NA, Xu R, Yeasting RA: The location of the verte-
bral artery foramen and its relation to posterior lateral mass
was measured by CT reconstruction, it was impossible to screw fixation. Spine (Phila Pa 1976) 21:1291–1295, 1996
analyze this complication in relation to bone quality or 9. Graham AW, Swank ML, Kinard RE, Lowery GL, Dials BE:
lateral mass size. Finally, the effect of this complication Posterior cervical arthrodesis and stabilization with a lateral
on the subsequent clinical course was not examined in mass plate. Clinical and computed tomographic evaluation of
the analysis. A clinical follow-up evaluation for this group lateral mass screw placement and associated complications.
of patients is required to examine the significance of the Spine (Phila Pa 1976) 21:323–329, 1996
present study. 10. Heller JG, Carlson GD, Abitbol JJ, Garfin SR: Anatomic com-
parison of the Roy-Camille and Magerl techniques for screw
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16 (10 Suppl):S552–S557, 1991
Conclusions 11. Heller JG, Silcox DH III, Sutterlin CE III: Complications of
The overall incidence of lateral mass fracture during posterior cervical plating. Spine (Phila Pa 1976) 20:2442–
2448, 1995
cervical lateral mass screw fixation was 4.7%. The occur- 12. Inoue S, Moriyama T, Tachibana T, Okada F, Maruo K, Hori­
rence of this complication compelled the surgeon to rein- nouchi Y, et al: Cervical lateral mass screw fixation without
sert the screw with a different trajectory/screw length or fluoroscopic control: analysis of risk factors for complications
skip the fixation at the corresponding level. Independent associated with screw insertion. Arch Orthop Trauma Surg
risk factors identified by multivariate analyses were DSA 132:947–953, 2012
and screw placement in the C-6 lateral masses. Use of 4.0- 13. Jeanneret B, Magerl F, Ward EH, Ward JC: Posterior stabiliza-
mm screws in patients with DSA may be a principal risk tion of the cervical spine with hook plates. Spine (Phila Pa
factor for this complication. 1976) 16 (3 Suppl):S56–S63, 1991
14. Katonis P, Papadakis SA, Galanakos S, Paskou D, Bano A,
Sapkas G, et al: Lateral mass screw complications: analysis of
1662 screws. J Spinal Disord Tech 24:415–420, 2011
Disclosure 15. Katonis P, Papadopoulos CA, Muffoletto A, Papagelopoulos PJ,
The authors report no conflict of interest concerning the mate- Hadjipavlou AG: Factors associated with good outcome using
rials or methods used in this study or the findings specified in this lateral mass plate fixation. Orthopedics 27:1080–1086, 2004
paper. 16. Kuntz D, Naveau B, Bardin T, Drueke T, Treves R, Dryll A:
Author contributions to the study and manuscript preparation Destructive spondylarthropathy in hemodialyzed patients. A
include the following. Conception and design: Inoue, Okada, Maruo, new syndrome. Arthritis Rheum 27:369–375, 1984
Horinouchi. Acquisition of data: Inoue, Moriyama, Tachibana, Oka­ 17. Leone A, Sundaram M, Cerase A, Magnavita N, Tazza L, Ma-
da, Maruo. Analysis and interpretation of data: Inoue, Moriyama. rano P: Destructive spondyloarthropathy of the cervical spine
Drafting the article: Inoue. Critically revising the article: all authors. in long-term hemodialyzed patients: a five-year clinical radio-
Reviewed submitted version of manuscript: all authors. Approved logical prospective study. Skeletal Radiol 30:431–441, 2001
the final version of the manuscript on behalf of all authors: Inoue. 18. Lindberg JS, Moe SM: Osteoporosis in end-state renal disease.
Study supervision: Yoshiya. Semin Nephrol 19:115–122, 1999
19. Malluche HH, Faugere MC: Renal osteodystrophy. N Engl J
Med 321:317–319, 1989
20. Maruyama H, Gejyo F, Arakawa M: Clinical studies of de-
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