The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on direct C1 lateral mass screw for cervical spine stabilisation.


Atlantoaxial instability (excessive movement between the first and second vertebrae of the neck) can be caused by trauma, malignancy, inflammatory or congenital defects.  It can present as local spinal pain, but if the spinal cord is compressed symptoms such as clumsiness, lack of coordination, difficulty walking, high cervical paralysis or death may occur.  Treatment is by stabilisation of the C1 on to the C2 vertebrae.

Traditional methods of atlantoaxial fusion involve the use of wires and bone grafts. They require external support in the post-operative period, including the use of halo devices.  Rigid fixation by transarticular screws between C1 and C2 have been described which do not require external fixation but this procedure is not appropriate for every case.  A new procedure has been developed which achieves rigid fixation between C1 and C2 by the use of a screw placed in each bone and connection of these screws with rods and a plate.

Under general anaesthesia, the patient is placed prone and standard posterior exposure of the cervical spine is performed. Screws are inserted into the lateral masses of C1 and fixed by a rod to screws in the lateral masses or pedicles of C2.  The posterior arch of bone compressing the spinal cord may be removed. An onlay graft of bone permits a permanent fusion between C1 and C2.

Coding recommendations

V37.1 Posterior fusion of atlantoaxial joint NEC

V55.1 One level of spine


V37.6 Posterior fusion of atlantoaxial joint using pedicle screw

V55.1 One level of spine

Note: Codes within category V55.- are assigned in second place each time a spinal operation is coded: if the levels of spine are not specified, V55.9 Unspecified levels of spine is used.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.