Cannulated screw systems use thin Kirschner wires (K-wires) that have been drilled into the bone to direct screw trajectories accurately into small bone fragments. Use of the K-wires avoids overdrilling the pilot holes and allows fixation of adjacent bone fragments during screw insertion. Hollow tools and hollow screws are inserted into the bone over the K-wires. Cannulated screw fixation is useful in the cervical spine to stabilize odontoid fractures and to treat atlantoaxial instability. This report describes techniques for successful cannulated screw insertion and methods to minimize complications. Cannulated screws have several distinct advantages compared to noncannulated screws: 1) the K-wires guide the screw position into the bone; 2) the K-wire trajectory can be repositioned easily if the original trajectory was not ideal; 3) the K-wires allow continuous fixation of adjacent unstable bone fragments; and 4) the K-wires prevent migration of unstable bone fragments during screw insertion. Complications associated with the K-wire (breakage, repositioning, and advancement) can be minimized using precise operative techniques, a specialized tool system, and intraoperative fluoroscopic monitoring. A unique cannulated screw tool system was developed specifically for upper cervical fixation to allow percutaneous drilling using long tunneling devices, tissue sheaths, drill guides, and long K-wires. These tools allow delivery of cannulated fracture-fixation screws at a low angle to the spine through long soft-tissue trajectories. Cannulated screws have significant advantages compared to noncannulated screws for fixation of the unstable cervical spine ¹⁾.