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Kuck A, Stegeman DF, van Asseldonk EHF. Modeling Trans-Spinal Direct Current Stimulation in the Presence of Spinal Implants. IEEE Trans Neural Syst Rehabil Eng 2019; 27:790-797. [PMID: 30802867 DOI: 10.1109/tnsre.2019.2900377] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Trans-spinal direct current stimulation (tsDCS) is a technique considered for the treatment of corticospinal damage or dysfunction. TsDCS aims to induce functional modulation in the corticospinal circuitry via a direct current (DC) generated an electric field (EF). To ensure subject safety, subjects with metallic implants are generally excluded from receiving neural dc stimulation. However, spinal injuries often require spinal implants for stabilization. Our goal was to investigate implant imposed changes to EF and current density (CD) magnitude during tsDCS. We simulated the EF and CD, generated by tsDCS in the presence of spinal rods for two electrode configurations and four implant locations along the spinal cord. For each scenario, a no-implant condition was computed for comparison. We assessed changes in EF and CD at the implant location and the EF inside the spinal cord. Our results show that implant presence was able to influence peak CD, compared to the no-implant condition. Nonetheless, the highest calculated CD levels were a factor six lower than those thought to lead to hazardous tissue-damaging effects. Additionally, implant presence did not considerably affect the average EF inside the spinal cord. Our findings do therefore not indicate potentially unsafe CD levels, or significant alterations to stimulation intensity inside the spinal cord, caused by a spinal implant during tsDCS. Our results are relevant to the safety of transcutaneous spinal stimulation applied in the presence of metallic spinal implants.
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Three-Dimensional Patient-Specific Guides for Intraoperative Navigation for Cortical Screw Trajectory Pedicle Fixation. World Neurosurg 2019; 122:674-679. [DOI: 10.1016/j.wneu.2018.11.159] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/15/2018] [Accepted: 11/17/2018] [Indexed: 12/12/2022]
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Pepke W, Almansour H, Lafage R, Diebo BG, Wiedenhöfer B, Schwab F, Lafage V, Akbar M. Cervical spine alignment following surgery for adolescent idiopathic scoliosis (AIS): a pre-to-post analysis of 81 patients. BMC Surg 2019; 19:7. [PMID: 30646880 PMCID: PMC6334400 DOI: 10.1186/s12893-019-0471-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 01/04/2019] [Indexed: 01/05/2023] Open
Abstract
Background Several studies have emphasized the importance of restoring thoracic kyphosis (TK) in the setting of AIS, but very few have discussed changes in cervical spine alignment following surgery. Aim of this study was to evaluate reciprocal cervical alignment change after modification of global and regional thoracolumbar alignment with surgery in the setting of adolescent idiopathic scoliosis (AIS). Methods Baseline and 2-yrs follow-up radiographs of AIS patients (n = 81) were analysed measuring cervical parameters (upper cervical: C2-C0, McGregor Slope; lower cervical: C2-C7, C2-C7 sagittal vertical axis (SVA), C2-T3, C2-T3SVA, C2-T1Harrison (C2-T1Ha), T1 Slope (T1S)), thoracic, lumbar, pelvic and global alignment parameters. Post-operatively, patients were grouped twice; based on changes in TK and SVA. Cervical alignment was compared between groups. Pearson correlation was conducted to examine the relationship between changes in TK, SVA, and cervical alignment. Results Stratification by change in TK, revealed significant alteration of lower cervical alignment T1S [p < 0.001]), C2-T3 [p = 0.019], C2-T1Ha [p = 0.043]), but there was no reciprocal change in the upper cervical spine. Stratification by SVA revealed a significant coexisting change in the lower cervical spine (T1S [p < 0.001], C2-C7SVA [p = 0.034], C2-T3 [p = 0.023], C2-T3SVA [p = 0.001]). SVA change was not associated to a change in the upper cervical spine. The correlation analysis showed that with a post-operative increase in TK, the cervical spine became more lordotic. Changes in TK were significantly correlated with: ΔT1S, ΔC2-C7, ΔC2-T3, and ΔC2-T3SVA. Similarly, increased cervical kyphosis was found when SVA was decreased post-operatively. Furthermore, there was a significant correlation between change of SVA and both ΔC2-T3 and ΔC2-T3SVA. Conclusions In surgically treated AIS patients, changes in global and regional alignment of the thoracolumbar and cervical spinal segments exhibit interdependence. Thus, surgical planning with regard to sagittal deformity in AIS patients should account for the post-operative impact on cervical alignment.
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Affiliation(s)
- W Pepke
- Clinic for Orthopaedics and Trauma Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr.200a, 69118, Heidelberg, Germany
| | - H Almansour
- Clinic for Orthopaedics and Trauma Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr.200a, 69118, Heidelberg, Germany
| | - R Lafage
- Hospital for Special Surgery, New York, NY, USA
| | - B G Diebo
- Department of Orthopaedic Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - B Wiedenhöfer
- Spine Surgery, ATOS Clinic Heidelberg, Bismarckstr. 9-15, 69115, Heidelberg, Germany
| | - F Schwab
- Hospital for Special Surgery, New York, NY, USA
| | - V Lafage
- Hospital for Special Surgery, New York, NY, USA
| | - M Akbar
- Clinic for Orthopaedics and Trauma Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr.200a, 69118, Heidelberg, Germany.
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Leitner L, Bratschitsch G, Sadoghi P, Adelsmayr G, Puchwein P, Leithner A, Radl R. Navigation versus experience: providing training in accurate lumbar pedicle screw positioning. Arch Orthop Trauma Surg 2019; 139:1699-1704. [PMID: 31127409 PMCID: PMC6825638 DOI: 10.1007/s00402-019-03206-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Accurate placement of spinal pedicle screws (PS) is mandatory for good primary segmental stabilization allowing consequent osseous fusion, requiring judgmental experience developed during a long training process. Computer navigation offers permanent visual control during screw manipulation and has been shown to significantly lower the risk of pedicle perforation. This study aims to evaluate whether safety, accuracy, and judgmental skills in screw placement, comparable to an experienced surgeon, can be developed during training using computer navigation. METHODS Lumbosacral PS were placed in 18 patients in a prospective setting, in one segment side with conventional fluoroscopy by a senior spine-surgeon, and computer navigated on the other side by a trainee without prior experience in the technique. At the beginning and at the end of the study, PS were placed freehand in solid foam models by the trainee. PS placement time, intraoperative placement revisions, PS placement accuracy on postoperative CT scans, and postoperative complications were assessed. RESULTS Significant improvement of trainee's PS placement accuracy (Sclafani score 8.2-8.83; p = 0.006) and time (13.3-6.8 min per screw; p = 0.005) to a similar level as the experienced surgeon state (5.2-4.1 min per screw; p = 0.39) was explored; similar improvement was explored in the foam models. The number of intraoperative placement revisions kept on a low level for surgeon (3.3-0.0%) and trainee (5.1-2.6%) during the whole study, no postoperative complications occurred. CONCLUSION Navigated PS insertion allows safe teaching from the early beginning of surgical training, due to steady intraoperative control on PS placement. Adequacy of PS placement is similar to screws placed by an experienced surgeon. Progress in judgmental skills in screw placement can be gained rapidly by the trainee, which can also be transferred to non-computer navigated PS placement.
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Affiliation(s)
- L. Leitner
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - G. Bratschitsch
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - G. Adelsmayr
- Department of Radiology, Medical University of Graz, Graz, Austria
| | - P. Puchwein
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - A. Leithner
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - R. Radl
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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Garg B, Gupta M, Singh M, Kalyanasundaram D. Outcome and safety analysis of 3D-printed patient-specific pedicle screw jigs for complex spinal deformities: a comparative study. Spine J 2019; 19:56-64. [PMID: 29730456 DOI: 10.1016/j.spinee.2018.05.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/04/2018] [Accepted: 05/01/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal deformities are very challenging to treat and have a great risk of neurologic complications because of hardware placement during corrective surgery. Various techniques have been introduced to ensure safe and accurate placement of pedicle screws. Patient-specific screw guides with predrawn and prevalidated trajectory seem to be an attractive option. PURPOSE We have focused on developing three-dimensional (3D) printing technique for complex spinal deformities in India. This study also aimed to compare the placement of pedicle screw with 3D printing and freehand technique. STUDY DESIGN/SETTINGS This is a retrospective comparative clinical study in an academic institutional setting. PATIENT SAMPLE A total of 20 patients were enrolled during the study: 10 were operated on with the help of 3D printing (Group 1) and 10 were operated on with freehand technique (Group 2). Group 1 included six patients with congenital scoliosis, three patients with adolescent idiopathic scoliosis (AIS), and one patient with post-tubercular kyphosis, and Group 2 included five patients with congenital scoliosis, four patients with AIS, and one patient with post-tubercular kyphosis. OUTCOME MEASURES Primary outcomes were measured in terms of screw violation, and secondary outcomes were measured in terms of surgical time, blood loss, radiation exposure (number of shoots required), and complications. MATERIALS AND METHODS MIMICS Base v18.0 software was used for 3D reconstruction from computed tomography scan images of all the patients. 3-Matic software was used to create a drill guide. A 3D printer from Stratasys Mojo with ABS P430 model material cartilage (a thermoplastic material) was used for the printing of the vertebra model and jigs. A two-sample test of proportion was used to compare correctly and wrongly placed pedicle screws with 3D printing and freehand technique. t Test with equal variance was used for operating surgical time and blood loss. RESULTS No superior or inferior screw violation was observed in any of our patients in either group. We found a significant difference (p=.03) between the two groups regarding perfect screw placement in favor of 3D printing. There were 13 Grade 2 medial perforations in the freehand group and 3 in the 3D printing group. There was no Grade 3 medial perforation in either group. Six Grade 2 lateral perforations in the freehand group and seven in the 3D printing group were observed. Three Grade 3 lateral perforations in the freehand group and two in 3D printing group were observed. Analysis showed a statistically significant (p=.005) medial violation in the freehand group. Surgical time was significantly less (p=.03) in the 3D printing group compared with the freehand group. Mean blood loss was higher in the freehand group but was not statistically significant (p=.3) in the 3D printing group. Fluoroscopic shots required were less in number in the 3D printing group compared with the freehand group. There was no neurologic deficit in any of the patients in the two groups. CONCLUSIONS In our study, focusing on spinal deformities with statistically significant higher rates of accurate screw positioning and higher numbers of inserted screws with 3D printing was possible because of enhanced safety, particularly at apical levels. As such, spinal deformities are difficult to treat worldwide. In India, these deformities are often neglected and present at a very late and a much more deformed state when their treatment becomes even more challenging. Developing these patient-specific drill templates will enable an average spine surgeon to treat these patients with much ease and safety.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopedics, Room No. 5036, 5th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi-110029, India.
| | - Manish Gupta
- Department of Orthopedics, Room No. 5036, 5th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Menaka Singh
- Department of Orthopedics, Room No. 5036, 5th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Dinesh Kalyanasundaram
- Centre for Biomedical Engineering, Block-III, Room No. 398, Indian Institute of Technology, New Delhi-110016, India
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Biswas JK, Sahu TP, Rana M, Roy S, Karmakar SK, Majumder S, Roychowdhury A. Design factors of lumbar pedicle screws under bending load: A finite element analysis. Biocybern Biomed Eng 2019. [DOI: 10.1016/j.bbe.2018.10.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Chan A, Parent E, Lou E. Reconstruction and positional accuracy of 3D ultrasound on vertebral phantoms for adolescent idiopathic scoliosis spinal surgery. Int J Comput Assist Radiol Surg 2018; 14:427-439. [PMID: 30519871 DOI: 10.1007/s11548-018-1894-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Determine the positional, rotational and reconstruction accuracy of a 3D ultrasound system to be used for image registration in navigation surgery. METHODS A custom 3D ultrasound for spinal surgery image registration was developed using Optitrack Prime 13-W motion capture cameras and a SonixTablet Ultrasound System. Temporal and spatial calibration was completed to account for time latencies between the two systems and to ensure accurate motion tracking of the ultrasound transducer. A mock operating room capture volume with a pegboard grid was set up to allow phantoms to be placed at a variety of predetermined positions to validate accuracy measurements. Five custom-designed ultrasound phantoms were 3D printed to allow for a range of linear and angular dimensions to be measured when placed on the pegboard. RESULTS Temporal and spatial calibration was completed with measurement repeatabilities of 0.2 mm and 0.5° after calibration. The mean positional accuracy was within 0.4 mm, with all values within 0.5 mm within the critical surgical regions and 96% of values within 1 mm within the full capture volume. All orientation values were within 1.5°. Reconstruction accuracy was within 0.6 mm and 0.9° for geometrically shaped phantoms and 0.5 and 1.9° for vertebrae-mimicking phantoms. CONCLUSIONS The accuracy of the developed 3D ultrasound system meets the 1 mm and 5° requirements of spinal surgery from this study. Further repeatability studies and evaluation on vertebrae are needed to validate the system for surgical use.
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Affiliation(s)
- Andrew Chan
- Department of Biomedical Engineering, University of Alberta, 1098 Research Transition Facility, 8308-114 Street, Edmonton, AB, T6G 2V2, Canada
| | - Eric Parent
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G2G4, Canada
| | - Edmond Lou
- Department of Biomedical Engineering, University of Alberta, 1098 Research Transition Facility, 8308-114 Street, Edmonton, AB, T6G 2V2, Canada. .,Department of Electrical and Computer Engineering, University of Alberta, Donadeo ICE 11-371, 9211-116 Street, Edmonton, AB, T6G 1H9, Canada.
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Bilhar RPDO, Lima DAD, Leite JAD, Porto MA. ACCURACY OF PEDICLE SCREW INSERTION: A COMPARISON BETWEEN FLUOROSCOPIC GUIDANCE AND NAVIGATION TECHNIQUES. ACTA ORTOPEDICA BRASILEIRA 2018; 26:397-400. [PMID: 30774514 PMCID: PMC6362689 DOI: 10.1590/1413-785220182606180635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives: To compare the accuracy of insertion of pedicle screws into the thoracic spine using fluoroscopic guidance or computer-assisted navigation techniques. Methods: Eight cadaveric thoracic spines were divided into two groups: the fluoroscopy group, in which pedicle screws were inserted with the guidance of a C-arm device, and the navigation group, in which insertion of the screws was monitored using computer-assisted navigation equipment. All procedures were performed by the same spinal surgeon. The rate of pedicle breach was compared between the two groups. Results: There was one intra-canal perforation in each group. Both perforations were medial in direction, and the breaches were 2 to 4 mm deep. There were no statistically significant differences in breach rate between the two groups. Conclusions: The accuracy of insertion of pedicle screws in the thoracic spine using computer-assisted navigation is equivalent to that achieved using fluoroscopic guidance. Computer-assisted navigation improves the safety of the surgical team during the procedure due to the absence of exposure to radiation. Therefore, there is a need for future randomized controlled trials to be conducted in the clinical setting to evaluate other outcomes, including duration of surgery and blood loss during the procedure. Level of evidence IV.
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Farah K, Coudert P, Graillon T, Blondel B, Dufour H, Gille O, Fuentes S. Prospective Comparative Study in Spine Surgery Between O-Arm and Airo Systems: Efficacy and Radiation Exposure. World Neurosurg 2018; 118:e175-e184. [DOI: 10.1016/j.wneu.2018.06.148] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 06/17/2018] [Accepted: 06/18/2018] [Indexed: 11/15/2022]
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60
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Park SM, Shen F, Kim HJ, Kim H, Chang BS, Lee CK, Yeom JS. How Many Screws Are Necessary to Be Considered an Experienced Surgeon for Freehand Placement of Thoracolumbar Pedicle Screws?: Analysis Using the Cumulative Summation Test for Learning Curve. World Neurosurg 2018; 118:e550-e556. [DOI: 10.1016/j.wneu.2018.06.236] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/27/2018] [Accepted: 06/28/2018] [Indexed: 11/29/2022]
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61
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A Scaled Bilateral Teleoperation System for Robotic-Assisted Surgery with Time Delay. J INTELL ROBOT SYST 2018. [DOI: 10.1007/s10846-018-0918-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Paredes I, Panero I, Cepeda S, CastaÑo-Leon AM, Jimenez-Roldan L, Perez-NuÑez Á, AlÉn JA, Lagares A. Accuracy of percutaneous pedicle screws for thoracic and lumbar spine fractures compared with open technique. J Neurosurg Sci 2018; 65:38-46. [PMID: 29905430 DOI: 10.23736/s0390-5616.18.04439-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study aimed to compare the accuracy of screw placement between open pedicle screw fixation and percutaneous pedicle screw fixation (MIS) for the treatment of thoracolumbar spine fractures (TSF). METHODS forty-nine patients with acute TSF who were treated with transpedicular screw fixation from January 2013 to December 2016 were retrospectively reviewed. The patients were divided into Open and MIS groups. Laminectomy was performed in either group if needed. The accuracy of the screw placement, the evolution of the Cobb sagittal angle postoperatively and at 12-month follow-up and the neurological status were recorded. AO type of fracture and TLICS score were also recorded. RESULTS Mean age was 42 years old. Mean TLICS score was 6.29 and 5.96 for open and MIS groups respectively. Twenty-five MIS and 24 open surgeries were performed, and 350 (175 in each group) screws were inserted (7.14 per patient). Twenty-four and 13 screws were considered "out" in the open and MIS groups respectively (Odds ratio 1.98. 0.97-4,03 P=0.056). The Cobb sagittal angle went from 13.3º to 4.5º and from 14.9º to 8.2º in the Open and MIS groups respectively (both P<0.0001). Loss of correction at 12-month follow-up was 3.2º and 4.2º for the open and MIS groups, respectively. No neurological worsening was observed. CONCLUSIONS For the treatment of acute thoracolumbar fractures, the MIS technique seems to achieve similar results to the open technique in relation to neurological improvement and deformity correction, while placing the screws more accurately.
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Affiliation(s)
- Igor Paredes
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain -
| | - Irene Panero
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Santiago Cepeda
- Department of Neurosurgery, Rio Hortega University Hospital, Valladolid, Spain
| | - Ana M CastaÑo-Leon
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Luis Jimenez-Roldan
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Ángel Perez-NuÑez
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Jose A AlÉn
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
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Accuracy of Freehand Pedicle Screw Placement in Surgical Correction of Thoracolumbar Kyphosis Secondary to Ankylosing Spondylitis: A Computed Tomography Investigation of 2314 Consecutive Screws. World Neurosurg 2018; 116:e850-e855. [PMID: 29807178 DOI: 10.1016/j.wneu.2018.05.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the accuracy and safety of freehand pedicle screw placement in surgical correction for thoracolumbar kyphosis caused by ankylosing spondylitis (AS). METHODS We retrospectively reviewed 266 consecutive patients with AS who underwent osteotomy for kyphosis correction with freehand screw insertion from January 1998 to April 2015 at our institution. A total of 2314 pedicle screws in 158 patients with AS with postoperative computed tomography scans were included in the study. Postoperative computed tomography was performed to classify accuracy of screws, using the established Gertbein classification (grade 0: no perforation, grade 1: perforation <2 mm, grade 2: perforation between 2 and 4 mm, and grade 3: perforation >4 mm). Patients were divided into 2 groups according to coronal Cobb angle: group A (n = 21, Cobb angle ≥10°), group B (n = 137, Cobb angle <10°). RESULTS Among the 2314 pedicle screws, 2168 pedicle screw placements were categorized as grade 0, 71 were grade 1, 51 were grade 2, and 24 were grade 3. Breaches occurred more frequently in L1-S1 than the thoracic spine (7.1% and 5.4%, respectively). T5 (25.0%) and S1 (17.7%) experienced the greatest breach rate, whereas T8, L1, and L3 had the lowest breach rate. The breach rate of group A was greater than that of group B (7.9% vs. 6.1%). None of the breaches resulted in either neurologic deficits or vascular complications. CONCLUSIONS Freehand pedicle screw placement can be performed safely with acceptable breach rate in patients with AS and thoracolumbar kyphosis.
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Satarasinghe P, Hamilton KD, Tarver MJ, Buchanan RJ, Koltz MT. Thoracic, Lumbar, and Sacral Pedicle Screw Placement Using Stryker-Ziehm Virtual Screw Technology and Navigated Stryker Cordless Driver 3: Technical Note. J Clin Med 2018; 7:jcm7040084. [PMID: 29673199 PMCID: PMC5920458 DOI: 10.3390/jcm7040084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 04/13/2018] [Accepted: 04/13/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECT Utilization of pedicle screws (PS) for spine stabilization is common in spinal surgery. With reliance on visual inspection of anatomical landmarks prior to screw placement, the free-hand technique requires a high level of surgeon skill and precision. Three-dimensional (3D), computer-assisted virtual neuronavigation improves the precision of PS placement and minimization steps. METHODS Twenty-three patients with degenerative, traumatic, or neoplastic pathologies received treatment via a novel three-step PS technique that utilizes a navigated power driver in combination with virtual screw technology. (1) Following visualization of neuroanatomy using intraoperative CT, a navigated 3-mm match stick drill bit was inserted at an anatomical entry point with a screen projection showing a virtual screw. (2) A Navigated Stryker Cordless Driver with an appropriate tap was used to access the vertebral body through a pedicle with a screen projection again showing a virtual screw. (3) A Navigated Stryker Cordless Driver with an actual screw was used with a screen projection showing the same virtual screw. One hundred and forty-four consecutive screws were inserted using this three-step, navigated driver, virtual screw technique. RESULTS Only 1 screw needed intraoperative revision after insertion using the three-step, navigated driver, virtual PS technique. This amounts to a 0.69% revision rate. One hundred percent of patients had intraoperative CT reconstructed images taken to confirm hardware placement. CONCLUSIONS Pedicle screw placement utilizing the Stryker-Ziehm neuronavigation virtual screw technology with a three step, navigated power drill technique is safe and effective.
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Affiliation(s)
- Praveen Satarasinghe
- Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
| | - Kojo D Hamilton
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | - Michael J Tarver
- Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
| | - Robert J Buchanan
- Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
- Department of Neurosurgery, Seton Brain and Spine Institute, Austin, TX 78712, USA.
| | - Michael T Koltz
- Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
- Department of Neurosurgery, Seton Brain and Spine Institute, Austin, TX 78712, USA.
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Jin HM, Bai XQ, Pan XX, Wu J, Wu CC, Yan YZ, Wang K, Wu AM, Wang XY. Does the Iliac Wing Influence L5 Pedicle Screw Fixation? World Neurosurg 2018; 113:e302-e308. [PMID: 29452313 DOI: 10.1016/j.wneu.2018.02.011] [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: 11/13/2017] [Revised: 02/01/2018] [Accepted: 02/02/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To explore whether the iliac wing influences L5 pedicle screw (PS) fixation and to propose methods to reduce such influence. METHODS A total of 100 computed tomography scans (from 50 male and 50 female patients) of the lower lumbar region and pelvis were obtained and 3-dimensionally reconstructed. Cylinders with 6.5-mm diameters were drawn to simulate the different trajectories of L5 PS. The maximum lengths and lateral angles of trajectories, and the vertical distances from the inner edge of the iliac wing to these trajectories, were measured. RESULTS The maximum lengths and lateral angles differed significantly among trajectories; the maximum length, but not the lateral angle, differed significantly between male and female subjects. The influence of the iliac wing was more significant in male than in female subjects. The iliac wing had a greater effect on screws implanted along the pedicle axis than on screws for which the trajectories commenced at Du's entry point and passed through the center of the pedicle. CONCLUSIONS This study elucidates the influence of the iliac wing on L5 PS fixation. Careful attention is required when implanting PSs, especially in male patients. The combined use of Du's technique and a percutaneous method for PS implantation effectively reduces the influence of the iliac wing. To minimize the complications of PS fixation further, preoperative simulation of fixation for each patient is very important.
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Affiliation(s)
- Hai-Ming Jin
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xue-Qin Bai
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xiang-Xiang Pan
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianwei Wu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Cong-Cong Wu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ying-Zhao Yan
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ke Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ai-Ming Wu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.
| | - Xiang-Yang Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.
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Chan A, Parent E, Narvacan K, San C, Lou E. Intraoperative image guidance compared with free-hand methods in adolescent idiopathic scoliosis posterior spinal surgery: a systematic review on screw-related complications and breach rates. Spine J 2017; 17:1215-1229. [PMID: 28428081 DOI: 10.1016/j.spinee.2017.04.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Severe adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity requiring surgery to stop curve progression. Posterior spinal instrumentation and fusion with pedicle screws is the standard surgery for AIS curve correction. Vascular and neurologic complications related to screw malpositioning are concerns in surgeries for AIS. Breach rates are reported at 15.7%, implant-related complications at 1.1%, and neurologic deficit at 0.8%. Free-hand screw insertion remains the prevailing method of screw placement, whereas image guidance has been suggested to improve placement accuracy. PURPOSE This study aimed to systematically review the screw-related complication and breach rates from posterior spinal instrumentation and fusion with pedicle screws for patients with AIS when using free-hand methods for screw insertion compared with image guidance methods. STUDY DESIGN This is a systematic review of prognosis, comparing image guidance with no image guidance in surgery. PATIENT SAMPLE One randomized controlled trial and multiple prospective cohort studies that reported complication or breach rates in posterior spinal instrumentation and fusion with pedicle screws for AIS. OUTCOME MEASURES Number of complications and breaches reported in databases or recorded from postoperative imaging. METHODS Databases searched included MEDLINE, Embase, CINAHL, CENTRAL, and Web of Science. Studies of Level 3 evidence or greater as defined by the Centre for Evidence-Based Medicine were included. Articles were screened to focus on patients with AIS undergoing posterior fusion with pedicle screws or hybrid systems. Two independent reviewers screened abstracts, full texts, and extracted data. The Quality in Prognostic Studies (QUIPS) appraisal tool was used to determine studyrisk of bias (ROB). Level of evidence summary statements were formulated based on consistency and quality of reporting. RESULTS Seventy-nine cohort studies were identified, including four comparing computed tomography (CT) guidance with free-hand methods head-to-head, eight on image guidance, and 671. on free-hand methods alone. Moderate evidence from individual head-to-head studies show CT guidance has lower breach rates than free-hand methods. No complications were found in these studies. From individual cohort studies, moderate evidence shows CT guidance has lower point estimates of breach rates than free-hand methods at 7.9% compared with 9.7%-17.1%. Screw-related complication rates are conflicting at 0% in CT navigation compared with 0%-1.7% in 13 low- and moderate-quality studies. CONCLUSIONS Although point estimates on breach rates are decreased with CT navigation compared with free-hand methods, complication rates remain conflicting between the two methods. Current evidence is limited by small sample sizes, lack of comparison groups, and poorly predefined complications. Randomized controlled trials with larger samples with standardized definitions and recording of predefined breach and complication occurrences are recommended.
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Affiliation(s)
- Andrew Chan
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, 1098 Research Transition Facility 8308-114 St, Edmonton, Alberta T6G 2V2, Canada
| | - Eric Parent
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 8205 114 St 2-50 Corbett Hall, Edmonton, Alberta T6G 2G4, Canada.
| | - Karl Narvacan
- Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 Walter C Mackenzie Health Sciences Centre 8440 112 St NW, Edmonton, Alberta T6G 2R7, Canada
| | - Cindy San
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Edmond Lou
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, 2D, Walter C Mackenzie Health Sciences Centre - 8440 - 112 St, Edmonton, Alberta T6G 2B7, Canada
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67
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Mohanty SP, Bhat SN, Pai Kanhangad M, Gosal GS. Pedicle screw fixation in thoracolumbar and lumbar spine assisted by lateral fluoroscopic imaging: a study to evaluate the accuracy of screw placement. Musculoskelet Surg 2017; 102:47-55. [PMID: 28801863 DOI: 10.1007/s12306-017-0498-4] [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: 05/29/2017] [Accepted: 07/29/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the accuracy of pedicle screw placement, its advantages, and limitations in posterior instrumentation of thoracolumbar and lumbar burst fractures assisted only by lateral fluoroscopic imaging. MATERIALS AND METHODS Pre- and postoperative computerized tomographic (CT) scans of 117 patients with thoracolumbar and lumbar burst fractures, who underwent posterior instrumentation with pedicle screw fixation, were prospectively analyzed. Accuracy of screw placement, reconstruction of the vertebral height, and correction of the kyphotic angle were studied. Position of the pedicle screws were determined, and cortical breach was graded on the postoperative axial CT scans. Percentage of vertebral height reconstruction and kyphotic angle correction were calculated from the postoperative midsagittal CT scans. RESULTS Four hundred and sixty-eight pedicle screws in 234 motion segments were included in this study. 427 screws were centrally placed with an accuracy rate of 91.24%. Out of the 41 (8.76%) screws that breached the pedicle wall, 32 (6.84%) screws had violated the medial wall, while 9 (1.92%) screws breached the lateral wall. There were no "air-ball" screws. No screw penetrated the anterior wall. Postoperatively, none of the patients deteriorated neurologically, and no screw required revision. Postoperatively, there was significant restoration of vertebral height and correction of kyphosis (P < 0.05). CONCLUSION Pedicle fixation performed on a Relton-Hall frame is relatively simple and, when performed carefully using only lateral fluoroscopic imaging, has a lower potential for complications due to cortical breach.
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Affiliation(s)
- S P Mohanty
- Orthopaedics Unit-3, Division of Spine and Hip, Kasturba Medical College, Manipal University, Manipal, 576104, India
| | - S N Bhat
- Orthopaedics Unit-3, Kasturba Medical College, Manipal University, Manipal, 576104, India
| | - M Pai Kanhangad
- Department of Orthopaedics Kasturba Medical College, Manipal University, Manipal, 576104, India.
| | - G S Gosal
- Department of Orthopaedics Kasturba Medical College, Manipal University, Manipal, 576104, India
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68
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Radiation dose reduction in thoracic and lumbar spine instrumentation using navigation based on an intraoperative cone beam CT imaging system: a prospective randomized clinical trial. 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 2017; 26:2818-2827. [DOI: 10.1007/s00586-017-5229-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 07/09/2017] [Accepted: 07/18/2017] [Indexed: 02/06/2023]
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69
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Pedicle screw insertion accuracy in terms of breach and reposition using a new intraoperative cone beam computed tomography imaging technique and evaluation of the factors associated with these parameters of accuracy: a series of 695 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 2017. [DOI: 10.1007/s00586-017-5195-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Chan A, Aguillon J, Hill D, Lou E. Precision and accuracy of consumer-grade motion tracking system for pedicle screw placement in pediatric spinal fusion surgery. Med Eng Phys 2017; 46:33-43. [PMID: 28602642 DOI: 10.1016/j.medengphy.2017.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 04/12/2017] [Accepted: 05/16/2017] [Indexed: 11/17/2022]
Abstract
Adolescent idiopathic scoliosis (AIS) is a 3-dimensional spinal deformity involving lateral curvature and axial rotation. Surgical intervention involves insertion of pedicle screws into the spine, requiring accuracies of 1mm and 5° in translation and rotation to prevent neural and vascular complications. While commercial CT-navigation is available, the significant cost, bulk and radiation dose hinders their use in AIS surgery. The objective of this study was to evaluate a commercial-grade Optitrack Prime 13W motion capture cameras to determine if they can achieve adequate accuracy for screw insertion guidance in AIS. Static precision, camera and tracked rigid body configurations, translational and rotational accuracy were investigated. A 1-h camera warm-up time was required to achieve precisions of 0.13mm and 0.10°. A three-camera system configuration with cameras at equal height but staggered depth achieved the best accuracy. A triangular rigid body with 7.9mm markers had superior accuracy. The translational accuracy for motions up to 150mm was 0.25mm while rotational accuracy was 4.9° for rotations in two directions from 0° to 70°. Required translational and rotational accuracies were achieved using this motion capture system as well as being comparable to surgical-grade navigators.
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Affiliation(s)
- Andrew Chan
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta T6G 2V2, Canada
| | - Janelle Aguillon
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, Alberta T6G 1H9, Canada
| | - Doug Hill
- Department of Surgery, University of Alberta, Edmonton, Alberta T6G 2B7, Canada; Alberta Health Services - Glenrose Rehabilitation Hospital, Edmonton, Alberta T5G 0B7, Canada
| | - Edmond Lou
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta T6G 2V2, Canada; Department of Surgery, University of Alberta, Edmonton, Alberta T6G 2B7, Canada; Alberta Health Services - Glenrose Rehabilitation Hospital, Edmonton, Alberta T5G 0B7, Canada.
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71
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Kaliya-Perumal AK, Charng JR, Niu CC, Tsai TT, Lai PL, Chen LH, Chen WJ. Intraoperative electromyographic monitoring to optimize safe lumbar pedicle screw placement - a retrospective analysis. BMC Musculoskelet Disord 2017; 18:229. [PMID: 28558816 PMCID: PMC5450215 DOI: 10.1186/s12891-017-1594-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/22/2017] [Indexed: 12/16/2022] Open
Abstract
Background The foremost concern of a surgeon during pedicle screw fixation is safety. Assistive modalities, especially intraoperative electromyographic monitoring (EMG) can function as an essential tool to recognize screw malposition that compromise neural integrity, so that the screws can be repositioned immediately rather than later. We intend to study the efficacy of intraoperative EMG monitoring to detect potential pedicle breach and evaluate whether reoperation rates were significantly reduced. Methods Retrospectively, patients who underwent posterior stabilization with pedicle screws for various pathologies were analysed and those with screws among L1-S1 levels were shortlisted. They were divided into two groups. Group 1 included patients in whom trigger EMG (t-EMG) was used to confirm appropriate screw placement and Group 2 included those in whom it was not used. Responses to t-EMG and corresponding stimulation thresholds were recorded for Group 1 patients. The sensitivity and specificity of the test was calculated. Reoperation rates due to postoperative neurologic compromise caused by malpositioned screws were compared between both the groups. Results A total of 518 patients had 3112 pedicle screws between L1-S1 levels. Among Group 1 [n = 296; Screws = 1856], 145 screws (7.8%) showed a positive response for t-EMG at stimulation thresholds ranging between 2.6 to 19.8 mA. The sensitivity and specificity of t-EMG to diagnose potential pedicle breach was found to be 93.33% and 92.88% respectively. Only one patient among Group 1 required reoperation. However, among Group 2 [n = 222; screws = 1256], six patients required reoperation. This indicated a significant decrease in the number of malpositioned screws that caused neurological compromise [p = 0.02], leading to subsequent decrease in reoperation rates [p = 0.04] among Group 1 patients. Conclusions Trigger EMG is well efficient in detecting potential pedicle screw breaches that might endanger neural integrity. In combination with palpatory and radiographic assessment, it will certainly aid safe and secure pedicle screw placement. It can also efficiently reduce reoperation rates due to neurologic compromise provoked by a malpositioned screw.
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Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan.,Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
| | - Jiun-Ran Charng
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Chi-Chien Niu
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan.
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Lih-Huei Chen
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Wen-Jer Chen
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
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Cordemans V, Kaminski L, Banse X, Francq BG, Cartiaux O. Accuracy of a new intraoperative cone beam CT imaging technique (Artis zeego II) compared to postoperative CT scan for assessment of pedicle screws placement and breaches detection. 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 2017; 26:2906-2916. [PMID: 28528479 DOI: 10.1007/s00586-017-5139-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 05/13/2017] [Accepted: 05/14/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE The goal of this study was to compare the accuracy of a novel intraoperative cone beam computed tomography (CBCT) imaging technique with that of conventional computed tomography (CT) scans for assessment of pedicle screw placement and breach detection. METHODS Three hundred and forty-eight pedicle screws were inserted in 58 patients between October 2013 and March 2016. All patients had an intraoperative CBCT scan and a conventional CT scan to verify the placement of the screws. The CBCT and CT images were reviewed by two surgeons to assess the accuracy of screw placement and detect pedicle breaches using two established classification systems. Agreement on screw placement between intraoperative CBCT and postoperative CT was assessed using Kappa and Gwet's coefficients. Using CT scanning as the gold standard, the sensitivity, specificity, positive predictive value, and negative predictive value were calculated to determine the ability of CBCT imaging to accurately evaluate screw placement. RESULTS The Kappa coefficient was 0.78 using the Gertzbein classification and 0.80 using the Heary classification, indicating a substantial agreement between the intraoperative CBCT and postoperative CT images. Gwet's coefficient was 0.94 for both classifications, indicating almost perfect agreement. The sensitivity, specificity, positive predictive value and negative predictive value of the CBCT images were 77, 98, 86, and 96%, respectively, for the Gertzbein classification and 79, 98, 88, and 96%, respectively, for the Heary classification. CONCLUSIONS Intraoperative CBCT provides accurate assessment of pedicle screw placement and enables intraoperative repositioning of misplaced screws. This technique may make postoperative CT imaging unnecessary.
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Affiliation(s)
- Virginie Cordemans
- Neuro Musculo Skeletal Lab (NMSK), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 53, Box B1.53.07, 1200, Brussels, Belgium.
| | - Ludovic Kaminski
- Service D'orthopédie et de traumatologie de l'appareil Locomoteur, Cliniques Universitaires, Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Xavier Banse
- Neuro Musculo Skeletal Lab (NMSK), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 53, Box B1.53.07, 1200, Brussels, Belgium.,Service D'orthopédie et de traumatologie de l'appareil Locomoteur, Cliniques Universitaires, Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Bernard G Francq
- Instiute of Statistics, Biostatistics and Actuarial sciences (ISBA), Université Catholique de Louvain-la-Neuve, Voie du Roman Pays 34/ L1.03.01, Louvain-la-Neuve, 1348, Belgium
| | - Olivier Cartiaux
- Neuro Musculo Skeletal Lab (NMSK), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 53, Box B1.53.07, 1200, Brussels, Belgium
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73
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Preliminary application of a multi-level 3D printing drill guide template for pedicle screw placement in severe and rigid scoliosis. 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; 26:1684-1689. [PMID: 28028644 DOI: 10.1007/s00586-016-4926-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 11/29/2016] [Accepted: 12/16/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE Accurate implantation of pedicle screw in spinal deformity correction surgeries is always challenging. We have developed a method of pedicle screw placement in severe and rigid scoliosis with a multi-level 3D printing drill guide template. METHODS From November 2011 to March 2015, ten patients (4 males and 6 females) with severe and rigid scoliosis (Cobb angle >70° and flexibility <30%)were included. Multi-level template was designed and manufactured according to the part (two or three levels) of the most severe deformity. The drill template was then placed on the corresponding vertebral surface. Then, pedicle screws were carefully inserted along the trajectories. The other screws were placed in free hand. After surgery, the positions of the pedicle screws were evaluated by CT scan and graded for validation. RESULTS 48 screws were implanted using templates, other 104 screws in free hand, and the accuracies were 93.8 and 78.8%, respectively, with significant difference. The deformity correction ratio was 67.1 and 41.2% in coronal and sagittal plane post-operatively, respectively. The average operation time was 234.0 ± 34.1 min, and average blood loss was 557 ± 67.4 ml. CONCLUSIONS With the application of multi-level template, the incidence of cortex perforation in severe and rigid scoliosis decreased and this technology is, therefore, potentially applicable in clinical practice.
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74
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Perna F, Borghi R, Pilla F, Stefanini N, Mazzotti A, Chehrassan M. Pedicle screw insertion techniques: an update and review of the literature. Musculoskelet Surg 2016; 100:165-169. [PMID: 27866324 DOI: 10.1007/s12306-016-0438-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 06/06/2023]
Abstract
Pedicle screw construct have become one of the most practiced procedure in spinal surgery. Despite commonly used, questions remain about their safety especially for the thoracic spine and in deformity where difficulty in positioning can lead to pedicle breach and adjacent structures injury. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the thoracic spine. Hence, various procedures have been described in order to improve pedicle screw insertion accuracy. Aim of this study is to evaluate current concepts on pedicle screws placement techniques to better understand recent attitude and clarify some doubts when selecting the most proper method.
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Affiliation(s)
- F Perna
- Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - R Borghi
- Istituto Ortopedico Rizzoli, Bologna, Italy
| | - F Pilla
- Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - A Mazzotti
- Istituto Ortopedico Rizzoli, Bologna, Italy
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75
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Error Analysis and Experimental Study of a Bi-Planar Parallel Mechanism in a Pedicle Screw Robot System. SENSORS 2016; 16:s16122022. [PMID: 27916869 PMCID: PMC5191003 DOI: 10.3390/s16122022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 11/21/2016] [Accepted: 11/21/2016] [Indexed: 12/18/2022]
Abstract
Due to the urgent need for high precision surgical equipment for minimally invasive spinal surgery, a novel robot-assistant system was developed for the accurate placement of pedicle screws in lumbar spinal surgeries. The structure of the robot was based on a macro-micro mechanism, which includes a serial mechanism (macro part) and a bi-planar 5R parallel mechanism (micro part). The macro part was used to achieve a large workspace, while the micro part was used to obtain high stiffness and accuracy. Based on the transfer function of dimension errors, the factors affecting the accuracy of the end effectors were analyzed. Then the manufacturing errors and joint angle error on the position-stance of the end effectors were investigated. Eventually, the mechanism of the strain energy produced by the deformation of linkage via forced assembly and displacements of the output point were calculated. The amount of the transfer errors was quantitatively analyzed by the simulation. Experimental tests show that the error of the bi-planar 5R mechanism can be controlled no more than 1 mm for translation and 1° for rotation, which satisfies the required absolute position accuracy of the robot.
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76
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Jin B, Su YB, Zhao JZ. Three-dimensional Fluoroscopy-based Navigation for the Pedicle Screw Placement in Patients with Primary Invasive Spinal Tumors. Chin Med J (Engl) 2016; 129:2552-2558. [PMID: 27779161 PMCID: PMC5125333 DOI: 10.4103/0366-6999.192777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Although pedicle screw placement (PSP) is a well-established technique for spine surgery, the treatment of patients with primary invasive spinal tumor (PIST) has high surgical risks secondary to destroyed pedicles. Intraoperative three-dimensional fluoroscopy-based navigation (ITFN) system permits safe and accurate instrumentation of the spine with the advantage of obtaining intraoperative real-time three-dimensional images and automatic registration. The aim of this study is to evaluate the feasibility and accuracy of PSP using ITFN system for patients afflicted with PIST in the thoracic spine. Methods: Fifty-one patients diagnosed with PISTs were retrospectively analyzed, and 157 pedicles screws were implanted in 23 patients using the free-hand technique (free-hand group) and 197 pedicle screws were implanted in 28 patients using the ITFN system (ITFN group). Modified classification of Gertzbein and Robbins was used to evaluate the accuracy of PSP, and McCormick classification was applied for assessment of neurological function. Demographic data and factors affecting accuracy of screw insertion were compared using independent t-test while comparison of accuracy of screw insertion between the two groups was analyzed with Chi-square test. Results: Of 51 patients, 39 demonstrated improved neurological status and the other 12 patients reported that symptoms remained the same. In the free-hand group, 145 screws (92.4%) were Grade I, 9 screws (5.7%) were Grade II, and 3 screws (1.9%) were Grade III. In the ITFN group, 192 screws (97.4%) were Grade I, 5 screws (2.6%) were Grade II, and no Grade III screw was detected. Statistical analysis showed that the accuracies of pedicle screws in the two groups are significantly different (χ2 = 4.981, P = 0.026). Conclusions: The treatments of PISTs include total tumor resection and reconstruction of spine stability. The ITFN system provides a high accuracy of pedicle screw placement.
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Affiliation(s)
- Bo Jin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050; China National Clinical Research Center for Neurological Diseases, Beijing 100050; Department of Neurosurgery, Beijing Jishuitan Hospital, Fourth Medical College of Peking University, Beijing 100035, China
| | - Yi-Bing Su
- Department of Neurosurgery, Beijing Jishuitan Hospital, Fourth Medical College of Peking University, Beijing 100035, China
| | - Ji-Zong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050; China National Clinical Research Center for Neurological Diseases, Beijing 100050, China
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Innovative approach in the development of computer assisted algorithm for spine pedicle screw placement. Med Eng Phys 2016; 38:354-65. [PMID: 26922675 DOI: 10.1016/j.medengphy.2016.01.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 01/19/2016] [Accepted: 01/31/2016] [Indexed: 11/20/2022]
Abstract
Pedicle screws are typically used for fusion, percutaneous fixation, and means of gripping a spinal segment. The screws act as a rigid and stable anchor points to bridge and connect with a rod as part of a construct. The foundation of the fusion is directly related to the placement of these screws. Malposition of pedicle screws causes intraoperative complications such as pedicle fractures and dural lesions and is a contributing factor to fusion failure. Computer assisted spine surgery (CASS) and patient-specific drill templates were developed to reduce this failure rate, but the trajectory of the screws remains a decision driven by anatomical landmarks often not easily defined. Current data shows the need of a robust and reliable technique that prevents screw misplacement. Furthermore, there is a need to enhance screw insertion guides to overcome the distortion of anatomical landmarks, which is viewed as a limiting factor by current techniques. The objective of this study is to develop a method and mathematical lemmas that are fundamental to the development of computer algorithms for pedicle screw placement. Using the proposed methodology, we show how we can generate automated optimal safe screw insertion trajectories based on the identification of a set of intrinsic parameters. The results, obtained from the validation of the proposed method on two full thoracic segments, are similar to previous morphological studies. The simplicity of the method, being pedicle arch based, is applicable to vertebrae where landmarks are either not well defined, altered or distorted.
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Sevuk U, Mesut A, Kiraz I, Kose K, Ayaz F, Erkul A. Delayed Presentation of Aortic Injury by a Thoracic Pedicle Screw. J Card Surg 2016; 31:220-30. [PMID: 26864154 DOI: 10.1111/jocs.12718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Delayed presentation of a thoracic aortic injury is an extremely rare complication after spine surgery. We report a case of delayed presentation of a thoracic aortic injury with a vertebral pedicle screw after posterior spinal surgery without periaortic hematoma, hemorrhage or pseudoaneurysm formation and review the relevant literature.
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Affiliation(s)
- Utkan Sevuk
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Abdullah Mesut
- Department of Neurosurgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Ilker Kiraz
- Department of Neurosurgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Kaan Kose
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Firat Ayaz
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Aylin Erkul
- Department of Anesthesiology, Diyarbakir Obstetrics and Gynecology Hospital, Diyarbakir, Turkey
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Soriano-Sánchez JA, Ortega-Porcayo LA, Gutiérrez-Partida CF, Ramírez-Barrios LR, Ortíz-Leyva RU, Rodríguez-García M, Sánchez-Escandón O. Fluoroscopy-guided pedicle screw accuracy with a mini-open approach: a tomographic evaluation of 470 screws in 125 patients. Int J Spine Surg 2015; 9:54. [PMID: 26609509 DOI: 10.14444/2054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Transpedicular screws are currently placed with open free hand and minimally invasive techniques assisted with either fluoroscopy or navigation. Screw placement accuracy had been investigated with several methods reaching accuracy rates from 71.9% to 98.8%. The objective of this study was to assess the accuracy and safety for 2-D fluoroscopy-guided screw placement assisted with electrophysiological monitoring and the inter-observer agreement for the breach classification. METHODS A retrospective review was performed on 125 consecutive patients who underwent minimally invasive transforaminal lumbar interbody fusion and transpedicular screws placement between the levels of T-12 and S-1. Screw accuracy was evaluated using a postoperative computed tomography by three independent observers. Pedicle breach was documented when there was a violation in any direction of the pedicle. Inter-observer agreement was assessed with the Kappa coefficient. RESULTS A total of 470 transpedicular screws were evaluated between the levels of T-12 and S-1. In 57 patients the instrumentation was bilateral and in 68 unilateral. A substantial degree of agreement was found between the observers AB (κ=0.769) and A-C (κ=0.784) and almost perfect agreement between observers B-C (κ=0.928). There were a total of 427.33 (90.92%) screws without breach, 39.33 (8.37%) minor breach pedicles and 3.33 (0.71%) major breach pedicles. The pedicle breach rate was 9.08% Trajectory pedicle breach percentages were as follows: minor medial pedicle breach 4.68%, minor lateral pedicle breach 3.47%, minor inferior pedicle breach 0.22%, and major medial breach 0.70%. No intraoperative instrumentation-related or postoperative clinical complications were encountered and no surgical revision was needed. CONCLUSIONS Our study demonstrated a high accuracy (90.2%) for 2-D fluoroscopy-guided pedicle screw using electromonitoring. Only 0.71% of the 470 screws had a major breach. Knowing the radiological spine pedicle anatomy and the correct interpretation of EMG are the key factors for this technique.
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Affiliation(s)
| | - Luis Alberto Ortega-Porcayo
- Neurological Center, American British Cowdray Medical Center, Mexico City, Mexico ; Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez," Mexico City, Mexico
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Accuracy of the Free-hand Placement of Pedicle Screws in the Lumbosacral Spine Using a Universal Entry Point. ACTA ACUST UNITED AC 2015; 28:E194-8. [DOI: 10.1097/bsd.0000000000000243] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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81
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Walker CT, Turner JD. Radiation Exposure in Scoliosis Surgery: Freehand Technique versus Image Guidance. World Neurosurg 2015; 83:282-4. [DOI: 10.1016/j.wneu.2015.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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