Introduction: Correction of cervical deformity can be achieved using anterior cervical fixation and fusion techniques. However, supplemental posterior fixation is a critical component for ensuring biomechanical longevity and favorable patient outcomes. We present a novel percutaneous technique for posterior cervical fixation in patients where cervical pedicle (CP) screws may not be feasible and midline muscle dissection is not needed. Methods: Three patients presented to our hospital with cervical pathology amendable to circumferential cervical fusion. After adequate deformity correction was performed through an anterior cervical decompression and fusion, staged posterior supplemental fixation was achieved using percutaneous CP inlet (CPI) screws using a percutaneous muscle-sparing approach. Results: All three patients underwent CPI screw placement without postoperative neurovascular complications. Postoperative radiographic follow-up showed the desired, proper screw placement, with continued maintained cervical alignment. Conclusions: CPI screw placement may be alternative hybrid screw that achieves a advantageous safety profile while also avoiding an open midline exposure.

BACKGROUND Pure arterial malformations are characterized as unique cerebrovascular lesions with a dilated, coil-like appearance and tortuous arteries without early venous drainage. Historically, these lesions have been described as incidental findings with a benign natural history. However, pure arterial malformations can rarely demonstrate radiographic progression and develop associated focal aneurysms with an unclear risk of rupture. Whether radiographic progression of these lesions or the presence of an associated aneurysm warrants treatment remains controversial. OBSERVATIONS A 58-year-old male presented with sudden-onset left hemiparesis. Computed tomography revealed a large, acute, right frontotemporoparietal intraparenchymal hemorrhage with underlying irregular curvilinear calcifications. Diagnostic cerebral angiography revealed a dysplastic right middle cerebral artery dissecting aneurysm along the M2 segment associated with a pure arterial malformation, which was treated with endovascular flow diversion in a delayed fashion. LESSONS Pure arterial malformations with associated focal aneurysms may not exhibit a benign natural history as once thought. Intervention should be considered for ruptured pure arterial malformations to mitigate the risk of rerupture. Asymptomatic patients with a pure arterial malformation with an associated aneurysm should at least be followed closely with interval radiographic imaging to evaluate for malformation progression or changes in aneurysmal morphology.