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Cortical bone trajectory screws fixation in lumbar adjacent segment disease: A technique note with case series. J Clin Neurosci 2017; 48:224-228. [PMID: 29208475 DOI: 10.1016/j.jocn.2017.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/09/2017] [Accepted: 11/14/2017] [Indexed: 12/28/2022]
Abstract
Lumbar adjacent segment disease after lumbar fusion surgery often requires surgical intervention. However, subsequent surgical treatment often needs to expose and remove all of the previous instruments. This additional surgery leads to significant post-operative pain, muscular fibrosis, poor wound healing and infection, etc. From October 2015 to March 2016, we collected six cases underwent cortical bone trajectory screws fixation with minimal invasive inter-body cage fusion for lumbar adjacent segment disease. Patients in the study all had improvement after surgery without recurrence or instruments failure during follow-up. The technique negates removal of pre-existing instruments and when combined with minimal invasive fusion surgery, the wound length, blood loss and soft tissue damage could be reduced compared with traditional surgery. We introduce the surgical procedures in detail and wish this technique could be an option for spine surgeons who encounter a similar situation.
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Phan K, Ramachandran V, Tran TM, Shah KP, Fadhil M, Lackey A, Chang N, Wu AM, Mobbs RJ. Systematic review of cortical bone trajectory versus pedicle screw techniques for lumbosacral spine fusion. JOURNAL OF SPINE SURGERY 2017; 3:679-688. [PMID: 29354747 DOI: 10.21037/jss.2017.11.03] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Fusion of the lumbosacral spine is a common surgical procedure to address a range of spinal pathologies. Fixation in lumbar fusion has traditionally been performed using pedicle screw (PS) augmentation. However, an alternative method of screw insertion via cortical bone trajectory (CBT) has been advocated as a less invasive approach which improves initial fixation and reduces neurovascular injury. There is a paucity of robust clinical evidence to support these claims, particularly in comparison to traditional pedicle screws. This study aims to review the available evidence to assess the merits of the CBT approach. Six electronic databases were searched for original published studies which compared CBT with traditional PS and their findings reviewed. Nine comparative studies were identified through a comprehensive literature search. Studies were classified as retrospective cohort, prospective cohort or case control studies with medium quality as assessed by the GRADE criteria. The available literature is not cohesive regarding outcomes and complications of CBT versus PT procedures. Most studies found no difference in operative time, but reported less blood loss during CBT. Radiological outcomes show no difference in slippage at one year although CBT is associated with greater bone-density compared to PT. Results for post-operative pain are inconclusive.
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Affiliation(s)
- Kevin Phan
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales (UNSW), Randwick, Sydney, Australia
| | | | - Tommy M Tran
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kevin P Shah
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Matthew Fadhil
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Alan Lackey
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia
| | - Nicholas Chang
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ai-Min Wu
- Department of Spine Surgery, Zhejiang Spine Surgery Center, the Second Affiliated Hospital, Hangzhou 310000, China.,Department of Spine Surgery, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Ralph J Mobbs
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales (UNSW), Randwick, Sydney, Australia
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Cheng WK, Akpolat YT, İnceoğlu S, Danisa OA. Pedicle screws with modular head vs. preassembled head used in cortical bone trajectory: Can pars and pedicle fractures be prevented in osteoporotic bone? J Clin Neurosci 2017; 47:304-310. [PMID: 29074318 DOI: 10.1016/j.jocn.2017.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 08/24/2017] [Accepted: 09/17/2017] [Indexed: 02/02/2023]
Abstract
Pars and pedicle fractures as a result of CBT (cortical bone trajectory) during pedicle screw placement have been reported. The primary aim of the study is to compare the fracture rate between screws with modular heads to screws with standard pre-assembled tulip heads. The secondary aim of the study is to determine the potential variables that can be identified prior to instrumentation in order to predict risk of fractures. Twenty-four fresh frozen lumbar vertebrae were obtained from five different cadavers. Anatomical landmark measurements were obtained. Right and left pedicles of each vertebra were randomly instrumented with the preassembled head screws (n=24) and modular head screws (n=24) under video recording. X-ray images were obtained for measuring relative angle deviations between tapped and final screw trajectories. Finally, pullout tests were performed. Seventeen out of twenty-four (70.8%) of the spinous processes had to be excised in order to obtain proper trajectories. Six fractures occurred with pre-assembled head screws versus one in the modular head screws (p=0.04). Distances from the midline to the medial wall of the pedicle were marginally significant as a predictor for fracture (p=0.08). The pullout loads between both types of screws were not statistically different (p=0.38). Age was better correlated with pullout load than absolute bone density value (p<0.001). In conclusion, modular head screws had a significantly lower fracture rate than pre-assembled head screws for cortical bone trajectory in osteoporotic bone. There was no clear anatomic variable that could be measured pre-operatively to predict potential fracture risk in CBT.
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Affiliation(s)
- Wayne K Cheng
- Loma Linda University, Department of Orthopaedic Surgery, United States.
| | - Yusuf T Akpolat
- Saint Louis University, Department of General Surgery, United States
| | - Serkan İnceoğlu
- Loma Linda University, Department of Orthopaedic Surgery, United States
| | - Olumide A Danisa
- Loma Linda University, Department of Orthopaedic Surgery, United States
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Review of Cortical Bone Trajectory: Evidence of a New Technique. Asian Spine J 2017; 11:817-831. [PMID: 29093793 PMCID: PMC5662866 DOI: 10.4184/asj.2017.11.5.817] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/06/2017] [Accepted: 03/01/2017] [Indexed: 12/26/2022] Open
Abstract
This article summarizes recent evidence on the cortical bone trajectory (CBT) obtained from published anatomical, biomechanical, and clinical studies. CBT was proposed by Santoni in 2009 as a new trajectory that can improve the fixation of pedicle screws in response to screw loosening in osteoporotic patients. Recently, research interest has been growing with increasing numbers of published series and frequent reports of new applications. We performed an online database search using the terms “cortical bone trajectory,” “pedicle screw,” “CBT spine,” “CBT fixation,” “MISS CBT,” and “traditional trajectory.” The search included the PubMed, Ovid MEDLINE, Cochrane, and Google Scholar databases, resulting in an analysis of 42 articles in total. These covered three aspects of CBT research: anatomical studies, biomechanical parameters, and clinical cases or series. Compared to the traditional trajectory, CBT improves pullout strength, provides greater stiffness in cephalocaudal and mediolateral loading, and shows superior resistance to flexion/extension; however, it is inferior in lateral bending and axial rotation. CBT seems to provide better immediate implant stability. In clinical studies, CBT has shown better perioperative results for blood loss, length of stay in hospital, and surgery time; similar or better clinical postoperative scores; and similar comorbidity, without any major fixation system complications due to instrumentation failure or screw misplacement. In addition, advantages such as less lateral exposure allow it to be used as a minimally invasive technique. However, most of the clinical studies were retrospective case series or case-control studies; prospective evidence on this technique is scarce, making a definitive comparison with the traditional trajectory difficult. Nevertheless, we can conclude that CBT is a safe technique that offers good clinical results with similar biomechanical and perioperative parameters to those of the traditional trajectory. In addition, new applications can improve its results and make it useful for additional pathologies.
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Unilateral Spinous Process Noncovering Hook Type Patient-specific Drill Template for Thoracic Pedicle Screw Fixation: A Pilot Clinical Trial and Template Classification. Spine (Phila Pa 1976) 2017; 42:E1050-E1057. [PMID: 28092341 DOI: 10.1097/brs.0000000000002067] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective clinical pilot study. OBJECTIVE To confirm the accuracy of thoracic pedicle screw placement by using the unilateral spinous noncovering hook type patient-specific drill template (PSDT) made through rapid prototyping (RP) and to analyze previously reported PSDT designs and their characteristics. SUMMARY OF BACKGROUND DATA Pedicle screw fixation is the most common form of the posterior instrumentation of the thoracic and lumbar spine. Various techniques have been introduced to improve pedicle screw placement. Among them PSDT with a preplanned trajectory has been considered a promising solution; however, we don't have consensus on proper character of the template. METHODS Preoperative spiral three-dimensional (3D) computed tomography (CT) was performed on the thoracic spine. The images were stored in DICOM format and transferred to a workstation running MIMICS 17.0 software to generate a 3D reconstruction template for the desired thoracic vertebra. The accurate trajectory and screw diameter and length were calculated with UG Imageware 12.1. The guide template was sterilized and used intraoperatively to assist with the placement of thoracic pedicle screws. After all pedicle trajectory screws had been inserted. We reviewed 12 previous reports and classified them according to the shape and system of PSDT that met the inclusion criteria of the review. RESULTS Ten screws were placed by using the PSDT without violating the single laminar cortex. There was no violation of the spinal canal or the cortex of pedicle on postoperative CT scans. The results of 13 PSDT types included in the current study suggested that there is no significant difference in accuracy between the PSDTs. CONCLUSION The unilateral spinous process noncovering hook type PSDT made through RP provided an accurate trajectory for the thoracic vertebra, and the classification of PSDT in this study could be helpful for further studies. LEVEL OF EVIDENCE 5.
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Senoglu M, Karadag A, Kinali B, Bozkurt B, Middlebrooks EH, Grande AW. Cortical Bone Trajectory Screw for Lumbar Fixation: A Quantitative Anatomic and Morphometric Evaluation. World Neurosurg 2017; 103:694-701. [DOI: 10.1016/j.wneu.2017.03.137] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 01/12/2023]
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Bruzzo M, Severi P, Bacigaluppi S. Midline lumbar fusion with cortical bone trajectory as first line treatment in a selected series of patients with lumbar instability. J Neurosurg Sci 2017; 64:238-242. [PMID: 28497667 DOI: 10.23736/s0390-5616.17.03976-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of the present study was to proof that for certain complex spinal conditions, midline lumbar fusion (MIDLF) technique is very convenient in terms of length of hospitalization, functional recovery and pain relief and time to back to work. METHODS MIDLF indications were set for patients with not more than 3 unstable levels, presence of osteoporosis (alternative to cemented screws), or cardiomyopathy with anticoagulation with or without spinal stenosis, and or discopathy. Surgical difficulties, operative time, hemoglobin loss and postoperative 45 days, 6 months and one-year follow-up data are shown. RESULTS In one-year period MIDLF was applied for 9 patients. For all cases motor deficits improved, pain decreased from a high VAS Score to VAS 1. No complications were seen so far. In one case small pedicles prevented the use of MIDLF technique. CONCLUSIONS Operative time, acceptable hemoglobin loss, short length of stay and encouraging follow-up result indicate that this technique is a valid option to improve patient's quality of life where osteoporosis makes traditional transpedicular screws less stable or where the surgeon has the need to reduce intraoperative blood loss or has to work in a deep surgical field.
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Affiliation(s)
- Mattia Bruzzo
- Department of Neurosurgery, Galliera Hospitals, Genoa, Italy -
| | - Paolo Severi
- Department of Neurosurgery, Galliera Hospitals, Genoa, Italy
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Mullin JP, Perlmutter B, Schmidt E, Benzel E, Steinmetz MP. Radiographic feasibility study of cortical bone trajectory and traditional pedicle screw dual trajectories. J Neurosurg Spine 2016; 25:727-732. [DOI: 10.3171/2016.4.spine151483] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE
In 2009, Santoni and colleagues described a novel technique of posterior instrumentation; the cortical bone trajectory (CBT) was described as a caudocephalad and medial-to-lateral trajectory. Reported indications for CBT fixation include patients with osteoporosis, single-level degenerative disease, or adjacent-segment disease (ASD). In cases of revision surgery, it is technically possible and beneficial to place a traditional pedicle screw and a CBT screw at the same spinal level and side. It remains unclear as to the feasibility of placing both a traditional and a CBT screw at all levels of the lumbar spine and with varying trajectories of the preexisting traditional pedicle screws. Therefore, the authors conducted a study to radiographically assess the feasibility of using CBT and traditional pedicle screws at the same level in a large patient population.
METHODS
Using a 3D Spine Navigation WorkStation, the authors assessed 47 lumbar spine CT scans. These images were obtained from 2 disparate groups of patients: those who had previously undergone traditional pedicle instrumentation (prior surgery group) and those who had not (no prior surgery group). The authors virtually placed traditional pedicle and CBT screws at each lumbar level bilaterally. It was then determined if the dual trajectories were feasible, as defined by the presence or absence of a collision of the screw trajectories based on 3D imaging.
RESULTS
Overall, the authors evaluated 47 patients and were able to successfully plan dual trajectories in 50% of the pedicles. The no prior surgery group, compared with the prior surgery group, had a significantly greater success rate for dual trajectories. This difference was most significant in the lower lumbar levels (L3–5) where the prior instrumented group had success rates lower than 40% compared with the no prior surgery group's success rate, which was greater than 70%. There was a significant difference between each lumbar level in the lower spine.
CONCLUSIONS
There is a significant difference in the feasibility of planning CBT screws in patients who have undergone prior pedicle instrumentation compared with placing CBT and traditional pedicle screws simultaneously, but dual trajectory pedicle screws are a feasible option for posterior lumbar spinal instrumentation, especially as a de novo option in osteoporotic patients or in patients with ASD who underwent previous pedicle instrumentation. Ultimately, the practical clinical utility and biomechanical effects on the spine and instrumentation construct would require additional study.
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Matsukawa K, Yato Y, Imabayashi H, Hosogane N, Asazuma T, Nemoto K. Biomechanical Evaluation of Cross Trajectory Technique for Pedicle Screw Insertion: Combined Use of Traditional Trajectory and Cortical Bone Trajectory. Orthop Surg 2016; 7:317-23. [PMID: 26792576 DOI: 10.1111/os.12212] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 10/12/2015] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To introduce a novel double-screw (cross trajectory) technique that combines use of the traditional trajectory (TT) and cortical bone trajectory (CBT) and to investigate its fixation strength quantitatively by finite element (FE) analysis. METHODS Three-dimensional FE models of 30 osteoporotic L4 vertebrae (patients' mean age: 77.3 ± 7.4 years, 11 men and 19 women) were computationally created. Each vertebral model was implanted with bilateral pedicle screws by TT (using 7.5 mm × 40 mm screws), CBT (using 5.5 mm × 35 mm screws) and cross trajectory (combined use of TT screws of 5.5 mm × 40 mm and CBT screws of 5.5 mm × 35 mm) and compared among three groups. The vertebral fixation strength of a bilateral-screw construct was examined by applying forces simulating flexion, extension, lateral bending, and axial rotation to the vertebrae by non-linear FE analyses. RESULTS Fixation strength using the cross trajectory was the highest among the three different techniques (P < 0.01). The cross trajectory construct demonstrated 320% higher strength than the TT construct in flexion, 293% higher in extension, 102% higher in lateral bending, and 40% higher in axial rotation (P < 0.01). Similarly, the cross trajectory construct showed 268% higher strength than the CBT construct in flexion, 269% higher in extension, 210% higher in lateral bending, and 178% in axial rotation (P < 0.01). CONCLUSIONS The cross trajectory technique offered superior fixation strength over the TT and CBT techniques in each plane of motion. This technique may be a valid option for posterior fusion, especially in osteoporotic spine.
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Affiliation(s)
- Keitaro Matsukawa
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yoshiyuki Yato
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan
| | - Hideaki Imabayashi
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Naobumi Hosogane
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Takashi Asazuma
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan
| | - Koichi Nemoto
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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Minimally invasive cortical bone trajectory screws placement via pedicle or pedicle rib unit in the lower thoracic spine: a cadaveric and radiographic study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:4199-4207. [PMID: 27554355 DOI: 10.1007/s00586-016-4730-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 08/01/2016] [Accepted: 08/01/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the feasibility of cortical bone trajectory (CBT) screws fixation via pedicle or pedicle rib unit in the cadaveric thoracic spine (T9-T12). METHODS Computed tomography (CT) images of 100 patients are analyzed by multiplanar reconstruction. Ten cadaveric thoracic spines are used to insert 4.5 × 35.0 mm CBT screws at all levels from T9 to T12. RESULTS Maximal screw length obtained by CT has a tendency to gradually increase from T9 (29.64 mm) to T12 (32.84 mm), and the difference reaches significant level at all levels except T9 versus T10 (P < 0.01). Maximal screw diameter increases from T9 (4.92 mm) to T12 (7.47 mm) and the difference reaches significant level among all levels (P < 0.01). Lateral angle increases from T9 (7.37°) to T12 (10.47°), and the difference reaches significant level among all levels except T11 versus T12. Cephalad angle from T9 to T12 are 19.03°, 22.10°, 25.62° and 27.50° (P < 0.01), respectively. The percentage of the inner and outer pedicle breakage are 2.5 and 22.5 %, respectively. The violation of lateral pedicle wall occurs at T9 and T10, especially for women at T9. CONCLUSIONS Both radiographic and cadaveric studies establish the feasibility of CBT screws placement via pedicle or pedicle rib unit in the lower thoracic spine (T9-T12). Furthermore, our measurements are also useful for application of this technique.
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Sheng SR, Chen JX, Chen W, Xue EX, Wang XY, Zhu QA. Cortical bone trajectory screws for the middle-upper thorax: An anatomico-radiological study. Medicine (Baltimore) 2016; 95:e4676. [PMID: 27583893 PMCID: PMC5008577 DOI: 10.1097/md.0000000000004676] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/31/2016] [Accepted: 08/02/2016] [Indexed: 01/16/2023] Open
Abstract
To quantify the reference data concerning the morphometrics of the middle-upper thorax to guide the placement of cortical bone trajectory (CBT) screws.Eighty patients were studied on computed tomography (CT) scans. The reference anatomical parameters were measured. Next, 20 cadaveric specimens were implanted with CBT screws based on CT measurements. These specimens were then judged directly from the cadaveric vertebrae and X-ray.The maximum length of the trajectory, the maximum diameter, and the cephaled angle exhibited a slight increase trend while the transverse and sagittal angles of the pedicle tended to decrease from T3 to T8. We recommend that the width of CBT screw for middle-upper thoracic spine is 5.0 mm, the length is 25 to 35 mm. The cadaveric anatomical study revealed that 5/240 screws penetrated in the medial or lateral areas, 5/240 screws penetrated in the superior or inferior pedicle wall, and 2/240 screws did not fit into the superior endplate of the pedicle.The CBT screws are safe for the middle-upper thorax. This study provides a theoretical basis for clinical surgery.
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Affiliation(s)
- Sun-Ren Sheng
- Nan Fang Hospital of Southern Medical University, Guangzhou
- Department of Orthopedics Surgery, Second Affiliated Hospital of Wenzhou Medical University
| | - Jiao-Xiang Chen
- Department of Orthopedics Surgery, Second Affiliated Hospital of Wenzhou Medical University
| | - Wei Chen
- Department of Radiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - En-Xing Xue
- Department of Orthopedics Surgery, Second Affiliated Hospital of Wenzhou Medical University
| | - Xiang-Yang Wang
- Department of Orthopedics Surgery, Second Affiliated Hospital of Wenzhou Medical University
| | - Qing-An Zhu
- Nan Fang Hospital of Southern Medical University, Guangzhou
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Chen YR, Deb S, Pham L, Singh H. Minimally Invasive Lumbar Pedicle Screw Fixation Using Cortical Bone Trajectory - A Prospective Cohort Study on Postoperative Pain Outcomes. Cureus 2016; 8:e714. [PMID: 27610286 PMCID: PMC5001953 DOI: 10.7759/cureus.714] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: Our study aims to evaluate the clinical outcomes of cortical screws in regards to postoperative pain. Background: Pedicle screw fixation is the current mainstay technique for posterior spinal fusion. Over the past decade, a new technique called cortical screw fixation has been developed, which allows for medialized screw placement through stronger cortical bone. There have been several studies that showed either biomechanical equivalence or superiority of cortical screws. However, there is currently only a single study in the literature looking at clinical outcomes of cortical screw fixation in patients who have had no prior spine surgery. Methods: We prospectively looked at the senior author’s patients who underwent cortical versus pedicle lumbar screw fixation surgeries between 2013 and 2015 for lumbar degenerative disease. Eighteen patients underwent cortical screw fixation, and 15 patients underwent traditional pedicle screw fixation. We looked at immediate postoperative pain, changes in short-term pain (six to 12 weeks post-surgery), and changes in long-term pain (six to eight months). All pain outcomes were measured using a visual analog scale ranging from 1 to 10. Mann-Whitney or Kruskal-Wallis tests were used to measure continuous data, and the Fisher Exact test was used to measure categorical data as appropriate. Results: Our results showed that the cortical screw cohort showed a trend towards having less peak postoperative pain (p = 0.09). The average postoperative pain was similar between the two cohorts (p = 0.93). There was also no difference in pain six to 12 weeks after surgery (p = 0.8). However, at six to eight months, the cortical screw cohort had worse pain compared to the pedicle screw cohort (p = 0.02). Conclusions: The cortical screw patients showed a trend towards less peak pain in the short-term (one to three days post-surgery) and more pain in the long-term (six to eight months post-surgery) compared to pedicle screw patients. Both cohorts had a statistically significant reduction in pain levels compared to preoperative pain. More studies are needed to further evaluate postoperative pain, long-term functional outcomes, and fusion rates in patients who undergo cortical screw fixation.
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Affiliation(s)
- Yi-Ren Chen
- Department of Neurosurgery, Stanford University Medical Center
| | - Sayantan Deb
- Medical School, Stanford University School of Medicine
| | - Lan Pham
- Department of Neurosurgery, Stanford University Medical Center
| | - Harminder Singh
- Department of Neurosurgery, Stanford University Medical Center
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Mai HT, Mitchell SM, Hashmi SZ, Jenkins TJ, Patel AA, Hsu WK. Differences in bone mineral density of fixation points between lumbar cortical and traditional pedicle screws. Spine J 2016; 16:835-41. [PMID: 26656170 DOI: 10.1016/j.spinee.2015.11.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/16/2015] [Accepted: 11/04/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The use of a novel lumbar pedicle cortical bone trajectory (CBT) screw has recently gained popularity, allowing for a minimally invasive approach and potentially improved screw purchase. However, to date, no studies have identified the ideal patient population to utilize this technology. PURPOSE This study reports the bone mineral density (BMD) using Hounsfield units (HUs) along a CBT screw pathway. Patients with a greater difference in density of bone in the lumbar vertebrae between the fixation points of the CBT and traditional pedicle screw may be optimal candidates to realize the advantages of this technique. STUDY DESIGN/SETTING A cross-sectional observational anatomic study was carried out. PATIENT SAMPLE The sample comprised 180 randomly selected patients with lumbar computed tomography imaging from L1 to L5 spinal levels. OUTCOME MEASURES This study used computed tomography image-derived HUs as a metric for BMD. METHODS A total of 180 patients without previous lumbar surgery with computed tomography imaging of the lumbar spine met the inclusion criteria. Patients were chosen randomly from an institutional database based on age (evenly distributed by decade of life) and gender. Hounsfield units were measured at the expected end fixation point for both a cortical (superior/posterior portion of the vertebral body) and traditional pedicle trajectory (mid-vertebral body). RESULTS Hounsfield unit values measured at the end fixation point for the CBT screw were significantly greater than that of the traditional pedicle screw in all age groups. The relative difference in HU values significantly increased with each decade of age (p<.001) and caudal lumbar level (p<.001). In the osteoporotic group, as determined by well-established HU values, there was a significantly greater difference in the BMD of the CBT fixation point compared with the traditional trajectory (p=.048-<.001). CONCLUSIONS Bone mineral density as measured by HU values for the fixation point of the CBT screw is significantly greater than that of the traditional pedicle screw. This difference is even more pronounced when comparing osteoporotic and elderly patients to the general population. The data in this study suggest that the potential advantages from the CBT screw such as screw purchase may increase linearly with age and in osteoporotic patients.
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Affiliation(s)
- Harry T Mai
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Sean M Mitchell
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sohaib Z Hashmi
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tyler J Jenkins
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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The use of a pedicle screw-cortical screw hybrid system for the surgical treatment of a patient with congenital multilevel spinal non-segmentation defect and spinal column deformity: a technical note. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3760-3764. [PMID: 27137999 DOI: 10.1007/s00586-016-4561-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION This technical note presents, to the authors' knowledge, the first reported case of a hybrid pedicle-cortical screw system for instrumented fusion in a patient with congenital vertebral column deformity. CASE Cortical screws were navigated using stereotactic guidance to extend a prior non-segmented fusion mass, facilitating instrumentation in a circumstance with completely distorted anatomy. This technique provided a safe trajectory with excellent cortical purchase in an anatomically deformed spine. DISCUSSION Cortical screw fixation may serve to be helpful in augmenting pedicle screw fixation and in circumstances in which the bone quality is suboptimal or the pedicles are compromised. Cortical screw fixation is a relatively new technology, but it may prove to be invaluable in providing an adjunct to pedicle screw constructs in anatomically distorted or osteoporotic spines.
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Matsukawa K, Yato Y, Imabayashi H, Hosogane N, Abe Y, Asazuma T, Chiba K. Biomechanical evaluation of fixation strength among different sizes of pedicle screws using the cortical bone trajectory: what is the ideal screw size for optimal fixation? Acta Neurochir (Wien) 2016; 158:465-71. [PMID: 26769471 DOI: 10.1007/s00701-016-2705-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 01/06/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND The cortical bone trajectory (CBT) has attracted attention as a new minimally invasive technique for lumbar instrumentation by minimizing soft-tissue dissection. Biomechanical studies have demonstrated the superior fixation capacity of CBT; however, there is little consensus on the selection of screw size, and no biomechanical study has elucidated the most suitable screw size for CBT. The purpose of the present study was to evaluate the effect of screw size on fixation strength and to clarify the ideal size for optimal fixation using CBT. METHOD A total of 720 analyses on CBT screws with various diameters (4.5-6.5 mm) and lengths (25-40 mm) in simulations of 20 different lumbar vertebrae (mean age: 62.1 ± 20.0 years, 8 males and 12 females) were performed using a finite element method. First, the fixation strength of a single screw was evaluated by measuring the axial pullout strength. Next, the vertebral fixation strength of a paired-screw construct was examined by applying forces simulating flexion, extension, lateral bending, and axial rotation to the vertebra. Lastly, the equivalent stress value of the bone-screw interface was calculated. RESULTS Larger-diameter screws increased the pullout strength and vertebral fixation strength and decreased the equivalent stress around the screws; however, there were no statistically significant differences between 5.5-mm and 6.5-mm screws. The screw diameter was a factor more strongly affecting the fixation strength of CBT than the screw fit within the pedicle (%fill). Longer screws significantly increased the pullout strength and vertebral fixation strength in axial rotation. The amount of screw length within the vertebral body (%length) was more important than the actual screw length, contributing to the vertebral fixation strength and distribution of stress loaded to the vertebra. CONCLUSIONS The fixation strength of CBT screws varied depending on screw size. The ideal screw size for CBT is a diameter larger than 5.5 mm and length longer than 35 mm, and the screw should be placed sufficiently deep into the vertebral body.
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Affiliation(s)
- Keitaro Matsukawa
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan.
| | - Yoshiyuki Yato
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan
| | - Hideaki Imabayashi
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Naobumi Hosogane
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yuichiro Abe
- Department of Orthopaedic Surgery, Wajokai Eniwa Hospital, Eniwa, Hokkaido, Japan
| | - Takashi Asazuma
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan
| | - Kazuhiro Chiba
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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66
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Patel SS, Cheng WK, Danisa OA. Early complications after instrumentation of the lumbar spine using cortical bone trajectory technique. J Clin Neurosci 2016; 24:63-7. [DOI: 10.1016/j.jocn.2015.07.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 07/24/2015] [Indexed: 01/16/2023]
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67
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Zhang H, Ajiboye RM, Shamie AN, Wu Q, Chen Q, Chen W. Morphometric measurement of the lumbosacral spine for minimally invasive cortical bone trajectory implant using computed tomography. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:870-6. [PMID: 26342703 DOI: 10.1007/s00586-015-4224-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 08/31/2015] [Accepted: 08/31/2015] [Indexed: 01/16/2023]
Abstract
PURPOSE The cortical bone trajectory (CBT) is a novel lumbar pedicle screw trajectory. The aim of this study was to conduct a detailed morphometric measurement of the lumbosacral spine for CBT pedicle screw, using the inferior facet of the cephalad level as a bony landmark. METHODS The three-dimensional computed tomography (3D-CT) scans of 86 adults who underwent examination of the lumbosacral spine were studied. The distances from the starting point to the inferior, lateral and medial border of the inferior facet of the cephalad level were measured. The angles formed between the screw trajectory and the sagittal plane, the superior endplate of the vertebral body and the posterior margin of the pars interarticularis were defined as the transverse angle (TA), cephalad angle 1 (CA1) and cephalad angle 2 (CA2), respectively. RESULTS The distances from the inferior border of inferior facet to the starting point from L1 to S1 were 8.9, 6.3, 4.1, 2.9, 1.4 and 0 mm, respectively. The distances from the medial border of the inferior facet to the starting point from L1 to S1 were between 3 and 4 mm. TA from L1 to S1 was 9.0°, 9.6°, 11.3°, 13.5°, 15.5°, and 8.2°, respectively. CA1/CA2 from L1 to S1 was 26.7°/38.7°, 26.0°/38.7°, 26.9°/38.0°, 24.4°/37.2°, 22.9°/35.1° and 18.4°/47.8°, respectively. The maximum screw diameters from L1 to S1 were 4.8, 5.1, 6.1, 6.8, 7.8, and 6.1 mm, respectively. Twenty-five millimeter can serve as a safe maximum length of CBT pedicle screws. CONCLUSIONS The inferior facet of the cephalad level is an attractive bony landmark for establishing a starting point of CBT for minimally invasive spine surgery.
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Affiliation(s)
- Hua Zhang
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, Zhejiang, China.
| | - Remi Musibau Ajiboye
- Department of Orthopaedic Surgery, University of California at Los Angeles, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA, USA
| | - Arya Nick Shamie
- Orthopaedic Spine Surgery, UCLA School of Medicine, 1250 16th Street, Suite 3145D, Santa Monica, CA, USA
| | - Qionghua Wu
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Qixin Chen
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Weishan Chen
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, Zhejiang, China
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68
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Oshino H, Sakakibara T, Inaba T, Yoshikawa T, Kato T, Kasai Y. A biomechanical comparison between cortical bone trajectory fixation and pedicle screw fixation. J Orthop Surg Res 2015; 10:125. [PMID: 26275401 PMCID: PMC4537537 DOI: 10.1186/s13018-015-0270-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 08/05/2015] [Indexed: 01/16/2023] Open
Abstract
PURPOSE There have been several reports on the pullout strength of cortical bone trajectory (CBT) screws, but only one study has reviewed the stability of functional spine units using the CBT method. The purpose of this study was to compare vertebral stability after CBT fixation with that after pedicle screw (PS) fixation. METHODS In this study, 20 lumbar spine (L5-6) specimens were assigned to two groups: the CBT model group that underwent CBT screw fixation (n = 10) and the PS model group that underwent pedicle screw fixation (n = 10). Using a six-axis material testing machine, bend and rotation tests were conducted on each model. The angular displacement from the time of no load to the time of maximum torque was defined as range of motion (ROM), and then, the mean ROM in the bend and rotation tests and the mean rate of relative change of ROM in both the bend and rotation tests were compared between the CBT and PS groups. RESULTS There were no significant differences between the CBT and PS groups with regard to the mean ROMs and the mean rate of relative change of ROMs in both the bend and rotation tests. CONCLUSION Intervertebral stability after CBT fixation was similar to that after PS fixation.
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Affiliation(s)
- Hiroki Oshino
- Department of Mechanical Engineering, Mie University, Tsu City, Mie, Japan
| | - Toshihiko Sakakibara
- Department of Spinal Surgery and Medical Engineering, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Tadashi Inaba
- Department of Mechanical Engineering, Mie University, Tsu City, Mie, Japan
| | - Takamasa Yoshikawa
- Department of Mechanical Engineering, Mie University, Tsu City, Mie, Japan
| | - Takaya Kato
- Community-University Research Cooperation Center, Mie University, Tsu City, Mie, Japan
| | - Yuichi Kasai
- Department of Spinal Surgery and Medical Engineering, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.
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69
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Phan K, Hogan J, Maharaj M, Mobbs RJ. Cortical Bone Trajectory for Lumbar Pedicle Screw Placement: A Review of Published Reports. Orthop Surg 2015; 7:213-21. [PMID: 26311095 PMCID: PMC6583742 DOI: 10.1111/os.12185] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 06/02/2015] [Indexed: 12/24/2022] Open
Abstract
There have been a number of developments in screw design and implantation techniques over recent years, including proposal of an alternative trajectory for screw fixation aimed at increasing purchase of pedicle screws in higher density bone. Cortical bone trajectory (CBT) screw insertion follows a lateral path in the transverse plane and caudocephalad path in the sagittal plane. This technique has been advocated because it is reportedly less invasive, improves screw-bone purchase and reduces neurovascular injury; however, these claims have not been supported by robust clinical evidence. The available evidence was therefore reviewed to assess the relative merits of CBT and highlight areas for further research. To this end, a search of relevant published studies reporting biomechanical, morphometric or clinical outcomes after use of CBT screws in patients with spinal pathologies was performed via six electronic databases.
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Affiliation(s)
- Kevin Phan
- Neuro Spine ClinicSuite 7a, Level 7, Prince of Wales Private HospitalBarker StreetRandwick
- Neuro Spine Surgery Research Group (NSURG)SydneyNew South WalesAustralia
| | - Jarred Hogan
- Neuro Spine ClinicSuite 7a, Level 7, Prince of Wales Private HospitalBarker StreetRandwick
- Neuro Spine Surgery Research Group (NSURG)SydneyNew South WalesAustralia
| | - Monish Maharaj
- Neuro Spine ClinicSuite 7a, Level 7, Prince of Wales Private HospitalBarker StreetRandwick
- Neuro Spine Surgery Research Group (NSURG)SydneyNew South WalesAustralia
| | - Ralph J Mobbs
- Neuro Spine ClinicSuite 7a, Level 7, Prince of Wales Private HospitalBarker StreetRandwick
- Neuro Spine Surgery Research Group (NSURG)SydneyNew South WalesAustralia
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Andrew Glennie R, Dea N, Kwon BK, Street JT. Early clinical results with cortically based pedicle screw trajectory for fusion of the degenerative lumbar spine. J Clin Neurosci 2015; 22:972-5. [DOI: 10.1016/j.jocn.2015.01.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 01/24/2015] [Indexed: 01/16/2023]
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71
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Minimally invasive PLIF with divergent, cortical trajectory pedicle screws. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24 Suppl 5:654-5. [DOI: 10.1007/s00586-015-3802-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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