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Study Design: A prospective study of anterior transarticular screw (ATS) fixation patients.Objective: To develop a method to determine screw tip position through plain radiography after percutaneous ATS fixation to prevent occipitocervical joint (OCJ) violation.Summary Of Background Data: No studies using plain radiography to prevent OCJ violation during percutaneous ATS fixation have been performed.Methods: In total, 34 subjects (with 68 screws) who had undergone percutaneous ATS fixation were enrolled. To evaluate the screw tip location in relation to the C1 lateral mass (LM), the screw tip positions were graded 1, 2, or 3 on anteroposterior (AP) radiographs, and I, II, or III on lateral radiographs. OCJ violation was analyzed by postoperative computed tomography (CT).Results: Screws with tips located lower (tip I) in the LM did not result in OCJ violation. Only one tip in the tip 3 position showed OCJ perforation, and this screw was also located in tip III. Screw perforation rates of tip 1-tip II, tip 1-tip III, and tip 2-tip III were the highest (100%), followed by tip 2-tip II (10.5%) and tip3-tip III (10%).Conclusion: This study provides insights into OCJ violation during percutaneous ATS fixation. According to AP radiography, a percutaneous ATS with the screw tip located in the lateral part of the LM resulted in a lower rate of OCJ perforation, whereas screws located in the medial LM resulted in the highest rate of perforation. Percutaneous ATS with the screw tip located in the neutral part of the LM should ensure that the screw tip is below the upper part of the LM, preventing OCJ violation. These findings may help surgeons assess screw positioning both during and after the operation.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]