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Bindels BJJ, Dronkers BEG, Smits MLJ, Verlaan JJ. Accurate Placement and Revisions for Cervical Pedicle Screws Placed With or Without Navigation: A Systematic Review and Meta-Analysis. Global Spine J 2024; 14:1018-1037. [PMID: 37596998 PMCID: PMC11192121 DOI: 10.1177/21925682231196456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES To evaluate the accuracy of placement for cervical pedicle screws with and without the use of spinal navigation. METHODS A structured search was conducted in electronic databases without any language or date restrictions. Eligible studies reported the proportion of accurately placed cervical pedicle screws measured on intraoperative or postoperative 3D imaging, and reported whether intraoperative navigation was used during screw placement. Randomized Studies (MINORS) criteria were used to evaluate the methodological quality of how accuracy was assessed for cervical pedicle screws. RESULTS After screening and critical appraisal, 4697 cervical pedicle screws from 18 studies were included in the meta-analysis. The pooled proportion for cervical pedicle screws with a breach up to 2 mm was 94% for navigated screws and did not differ from the pooled proportion for non-navigated screws (96%). The pooled proportion for cervical pedicle screws placed completely in the pedicle was 76% for navigated screws and did not differ from the pooled proportion for non-navigated screws (82%). Intraoperative screw reposition rates and screw revision rates as a result of postoperative imaging also did not differ between navigated and non-navigated screw placement. CONCLUSIONS This systematic review and meta-analysis found that the use of spinal navigation systems does not significantly improve the accuracy of placement of cervical pedicle screws compared to screws placed without navigation. Future studies evaluating intraoperative navigation for cervical pedicle screw placement should focus on the learning curve, postoperative complications, and the complexity of surgical cases.
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Affiliation(s)
- B. J. J. Bindels
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B. E. G. Dronkers
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M. L. J. Smits
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J. J. Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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2
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Li K, Yang Y, Wang P, Song H, Ma C, Zhang Y, Dang X, Shi J, Zhang S, Li Z, Wang X. Exploring the micromorphological characteristics of adult lower cervical vertebrae based on micro-computed tomography. Sci Rep 2023; 13:12400. [PMID: 37524928 PMCID: PMC10390556 DOI: 10.1038/s41598-023-39703-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/29/2023] [Indexed: 08/02/2023] Open
Abstract
We will use micro-computed tomography to scan 31 sets of the adult lower cervical vertebrae (155 vertebrae) to observe the morphological characteristics and direction of trabeculae in the lower cervical vertebrae by outlining and reconstructing the regions of interest and to calculate the variation laws of the microstructure in the regions of interest to reveal their structural characteristics and weak areas. As a result, the images showed that the trabeculae in the lower cervical pedicle near the medial and lateral cortices were relatively dense, and their bone plates were lamellar. There were cavities between the superior and inferior articular processes where the ossification centers had not been absorbed after ossified. The lamellar trabeculae in the vertebral plates near the cortical bones were only 1-2 layers, extended and transformed into rod-shaped trabeculae in a radial shape toward the medullary space. The lamellar trabeculae of the vertebral plate extend over the spinous process near the cortical bone. The statistical results of the trabeculae's morphological parameters showed significant differences in bone volume fraction values among the four parts (P < 0.05). There were substantial differences in BS/BV, except for no differences between the pedicle and the vertebral plate (P < 0.05). There was a significant difference in trabecular pattern factor values between the articular process, the spinous process, and the vertebral plate (P < 0.05) and a significant difference between the pedicle, the spinous process, and the vertebral plate (P < 0.05). There were no significant differences in trabecular bone thickness and trabecular space values among the four parts (P < 0.05). The anatomical microstructural perspective confirms that the optimal choice is internal fixation via the pedicle. If using pedicle screws, the nail tract needs to be placed into the spinous process to increase its holding power and resistance to extraction.
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Affiliation(s)
- Kun Li
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
- Human Anatomy Teaching and Research Section, School of Basic Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Yang Yang
- Graduate School, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Peng Wang
- School of Clinical Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Haoyu Song
- School of Clinical Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Chunying Ma
- School of Clinical Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Yansong Zhang
- School of Clinical Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Xingye Dang
- School of Clinical Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Jun Shi
- Physiology Teaching and Research Section, School of Basic Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Shaojie Zhang
- Human Anatomy Teaching and Research Section, School of Basic Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
- Digital Medicine Center, School of Basic Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Zhijun Li
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
- Human Anatomy Teaching and Research Section, School of Basic Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China
| | - Xing Wang
- Human Anatomy Teaching and Research Section, School of Basic Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China.
- Digital Medicine Center, School of Basic Medicine, Inner Mongolia Medical University, Hohhot, 010059, Inner Mongolia, China.
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Wang Y, Hu B, Wu J, Chen W, Wang Z, Zhu J, Fan W, Liu M, Zhao J, Liu P. Subaxial Cervical Pedicular Screw Insertion via the Nonanatomic Axis: Identification of Entry Point and Trajectory Based on a Radiographic Study and Workshop. Global Spine J 2023; 13:360-367. [PMID: 33618552 PMCID: PMC9972273 DOI: 10.1177/2192568221996310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN A radiological study and workshop. OBJECTIVE To propose a novel technique for subaxial cervical pedicle screw (CPS) insertion via the nonanatomic axis (nAA) and identify a new entry point (EP) and trajectory based on a radiological study. METHODS The new EP was determined to be the center of the upper half of the lateral mass, and the nAA was defined as the line connecting the EP and center of the pedicle. CT images of 493 subaxial cervical pedicles from 51 adults were utilized. The pedicle axis length (PAL/nPAL), pedicle transverse angle (PTA/nPTA), sagittal and transverse pedicle screw depth ratio (S-DO, T-DO), and sagittal and transverse angles (S-angle, T-angle) were measured in the anatomical axis (AA) and nAA. nAA-CPS insertions were conducted on dry specimens, and the positions of the screws were graded. RESULTS The nPTA (22.35° ± 1.57°), nPAL (23.75 ± 2.07 mm), T-DO (45.61% ± 3.10%), and S-DO (70.46% ± 4.44%) of the nAA-CPS were significantly different from the PTA (41.86° ± 2.77°), PAL (31.98 ± 2.40 mm), T-DO and S-DO of the AA-CPS (both 100% in ideal conditions), respectively (P < .05). The T-angle and S-angle were 92.78° ± 3.07° and 92.18° ± 3.78°, respectively. A constant EP and consistent trajectory of the nAA-CPS identified by 2 perpendicular angles were summarized and utilized as the manipulation protocols of the workshop, and a perfect position was achieved in 80.00% (24/30) of screws. CONCLUSION The nAA-CPS is a novel alternative to the classic CPS technique. A constant entry point and 2 perpendicular angles in the sagittal and transverse planes for identifying the trajectory of the nAA-CPS should be taken into account in the establishment of a manipulation protocol.
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Affiliation(s)
- Yingbo Wang
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Bo Hu
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Jian Wu
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Wei Chen
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Zhong Wang
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Jun Zhu
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Weili Fan
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Mingyong Liu
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Jianhua Zhao
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Peng Liu
- Division of Spine Surgery, Center for
Orthopedics, Daping Hospital, Army Medical University, Chongqing, China,State Key Laboratory of Trauma, Burns
and Combined Wound, Army Medical University, Chongqing, China,Peng Liu, Division of Spine Surgery, Center
for Orthopedics, Daping Hospital, Army Medical University, No. 10,
Changjiangzhilu, Daping Street, Yuzhong District, Chongqing, 400042, China.
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Benefits and Pitfalls of O-arm Navigation in Cervical Pedicle Screw. World Neurosurg 2021; 159:e460-e465. [PMID: 34958990 DOI: 10.1016/j.wneu.2021.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cervical pedicle screw (CPS) with O-arm-based intraoperative navigation has demonstrated satisfactory results in recent studies. In this article, we introduce our experience and discuss important considerations for CPS placement with O-arm navigation. METHODS We retrospectively reviewed the data of 51 patients with 156 pedicle screws who underwent O-arm navigated CPS from July 2020 to October 2021. The accuracy of each screw placement was evaluated at the initial screw location using intraoperative 3D reconstructed O-arm images and the final screw location using postoperative computed tomography (CT). The screw accuracy was assessed in the axial image. RESULTS The initial accuracy of screws on intraoperative 3D reconstructed O-arm images was 93.6% (146/156). The accuracies of the mid-cervical level (C3, C4, C5) were relatively low (83.3%-85.0%) compared to those of C2, C6, and C7 (93.3%-100.0%), at the initial screw due to the rotation of the vertebral body. Among ten violated screws, five were converted to lateral mass screws or removed intraoperatively, and the other five were retained because the violations were minimal. After converting the screw, the final accuracy of the screws in postoperative CT was 96.7% (146/151). CONCLUSION CPS with O-arm navigation showed relatively low accuracy at the mid-cervical level due to vertebral rotation. However, the opportunity to convert the screw from intraoperative 3D reconstructed O-arm images is the advantage of the O-arm navigation, and it showed excellent accuracy.
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Tarawneh AM, Haleem S, D'Aquino D, Quraishi N. The comparative accuracy and safety of fluoroscopic and navigation-based techniques in cervical pedicle screw fixation: systematic review and meta-analysis. J Neurosurg Spine 2021; 35:194-201. [PMID: 34144517 DOI: 10.3171/2020.11.spine201877] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate the comparative accuracy and safety of navigation-based approaches for cervical pedicle screw (CPS) placement over fluoroscopic techniques. METHODS A systematic search of the literature published between January 2006 and December 2019 relating to CPS instrumentation and the comparative accuracy and safety of fluoroscopic and intraoperative computer-based navigation techniques was conducted. Several databases, including the Cochrane Library, PubMed, and EMBASE, were systematically searched to identify potentially eligible studies. Data relating to CPS insertion accuracy and associated complications, in particular neurovascular complications, were extrapolated from the included studies and summarized for analysis. RESULTS A total of 17 studies were identified from the search methodology. Eleven studies evaluated CPS placement under traditional fluoroscopic guidance and 6 studies addressed outcomes following navigation-assisted placement (3D C-arm or CT-guided placement). Overall, a total of 4278 screws were placed in 1065 patients. Misplacement rates of CPS were significantly lower (p < 0.0001) in navigation-assisted techniques (12.51% [range 2.5%-20.5%]) compared to fluoroscopy-guided techniques (18.8% [range 0%-43.5%]). Fluoroscopy-guided CPS insertion was associated with a significantly higher incidence of postoperative complications relating to neurovascular injuries (p < 0.038), with a mean incidence of 1.9% compared with 0.3% in navigation-assisted techniques. CONCLUSIONS This systematic review supports a logical conclusion that navigation-based techniques confer a statistically significantly more accurate screw placement and resultant lower complication rates.
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Affiliation(s)
- Ahmad M Tarawneh
- 1Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham; and
| | | | - Daniel D'Aquino
- 1Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham; and
| | - Nasir Quraishi
- 1Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham; and
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Kim MK, Lee JJ, Cho SH, Kwak DS. Versatile Usage of the Modified Lateral Mass Screw as an Alternative to Cervical Pedicle Screw Fixation. J Neurol Surg A Cent Eur Neurosurg 2021; 83:231-235. [PMID: 34192784 DOI: 10.1055/s-0041-1728767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Posterior subaxial cervical screw fixation is commonly performed using the cervical pedicle screws (CPS) and lateral mass screws (LMS); however, their compatibility is low. Modified lateral mass screws (mLMS, also called paravertebral foramen screw) fixation was introduced as a salvage technique for LMS fixation and has features of both LMS and CPS techniques. In the present study, the use of mLMS as an alternative to CPS was analyzed based on clinical results. METHODS Seventy-eight screws (38 CPSs and 40 mLMSs) were inserted into 12 patients. The misplacement of the screws was evaluated by computed tomography (CT). The failure of instrumentation and instability were evaluated using plain radiographs. RESULTS The total number of CPS misplacements was 3 (10.5%); however, neurologic complications were not observed. mLMSs were used in the middle segments of the fusion in 10 patients and 2 patients had mLMS fixation for single-level fusion. An additional bridging implant was not required for connecting both CPSs and mLMSs. Instability was not observed during the observation period (4-51 months). Complete fusion was seen in 10 patients. CONCLUSIONS The alternative mLMS fixation can decrease the risk of screw misplacement compared with CPS fixation alone and achieves adequate stability leading to fusion.
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Affiliation(s)
- Moon-Kyu Kim
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Jung-Jae Lee
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Su-Hee Cho
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Dai-Soon Kwak
- Catholic Institute for Applied Anatomy / Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Park JH, Lee JY, Lee BH, Jeon HJ, Park SW. Free-Hand Cervical Pedicle Screw Placement by Using Para-articular Minilaminotomy: Its Feasibility and Novice Neurosurgeons' Experience. Global Spine J 2021; 11:662-668. [PMID: 32875896 PMCID: PMC8165935 DOI: 10.1177/2192568220919089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN. Retrospective study. OBJECTIVE. Cervical pedicle screw (CPS) placement is technically demanding because of the great variation in pedicle size, dimension, and angulations between cervical levels and patients and the lack of anatomical landmarks. This retrospective study was conducted to analyze novice neurosurgeons' experience of CPS placement by using the technique with direct exposure of pedicle via para-articular minilaminotomy. METHODS. We retrospectively reviewed 78 CPSs in 22 consecutive patients performed by 2 surgeons. All pedicle screws were inserted under the direct visualization of the pedicle by using para-articular minilaminotomy without any fluoroscopic guidance. We analyzed the direction and grade of pedicle perforation on the postoperative computed tomography scan. The degree of perforation was classified as grade 0 to 3. Grades 0 and 1 were classified as the correct position and the others, as the incorrect position. RESULTS. In total, the correct position (grade 0 and 1) was found in 72 (92.3%) screws and the incorrect position (grade 2 and 3) in 6 (7.7%). Among the 16 pedicle perforations (grade 1, 2, and 3 perforations), the directions were lateral in 15 (93.8%) and superior in 1 (6.2%). There were no neurovascular complications related to CPS insertion. CONCLUSION. Free-hand CPS placement by using para-articular minilaminotomy seems to be feasible and reproducible.
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Affiliation(s)
- Jong-Hwa Park
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Kangwon National University, Gangwon-do, Republic of Korea
| | - Jong Young Lee
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Jong Young Lee, Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea 150, Seongan-ro, Gangdong-gu, Seoul, Republic of Korea.
| | - Byoung Hun Lee
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Kangwon National University, Gangwon-do, Republic of Korea
| | - Hong Jun Jeon
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Seung-Woo Park
- Kangwon National University, Gangwon-do, Republic of Korea
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Wang Y, Hu B, Wu J, Chen W, Wang Z, Liu M, Zhao J, Liu P. Subaxial Cervical Pedicular Screw Insertion via the Nonanatomic Axis: Technical Notes and Preliminary Clinical Report. Global Spine J 2021; 13:1049-1055. [PMID: 33977762 DOI: 10.1177/21925682211015649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To report the technical details of subaxial cervical pedicular screw insertion via the nonanatomic axis (nAA-CPS) and evaluate its clinical safety and accuracy. METHODS The nAA-CPS technique was performed in 21 patients. Preoperative and intraoperative management-related details are described, and a manipulation protocol is presented. Clinical outcomes were used to assess the safety and accuracy of screws was evaluated using postoperative computed tomography (CT) according to the pedicle perforation grading system, and the nonanatomic pedicle transverse angle (nPTA) and nonanatomic pedicle axis length (nPAL) were assessed based on pre- and postoperative CT images. RESULTS According to "one constant entry point (EP) and two perpendicular trajectory angles" protocol, nAA-CPS was performed without much interference from the muscles. No intraoperative or postoperative neurovascular complications related to the technique were observed. Of the 112 inserted screws, 78 (69.64%) were assessed as grade 0, 24 (21.43%) as grade 1, 4 (3.57%) as grade 2 and 6 (5.36%) as grade 3. The overall rate of correct position (grades 0 and 1) was 91.07% (102/112), and the rate of malposition was 8.93% (10/112), including five screws implanted medially and the other five laterally. The nPTA was highly consistent on pre- and postoperative CT (P < .05), while postoperative nPAL was significantly shorter than preoperative nPAL (P > .05). CONCLUSIONS Clinically, the accuracy and safety of nAA-CPS was similar to the traditional CPS technique. The protocol, derived from previous radiological studies and workshops, greatly helped standardize clinical manipulation; thus, nAA-CPS is a promising alternative to the traditional CPS.
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Affiliation(s)
- Yingbo Wang
- Division of Spine surgery, Center for Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Bo Hu
- Division of Spine surgery, Center for Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Jian Wu
- Division of Spine surgery, Center for Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Wei Chen
- Division of Spine surgery, Center for Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Zhong Wang
- Division of Spine surgery, Center for Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Mingyong Liu
- Division of Spine surgery, Center for Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Jianhua Zhao
- Division of Spine surgery, Center for Orthopedics, Daping Hospital, Army Medical University, Chongqing, China
| | - Peng Liu
- Division of Spine surgery, Center for Orthopedics, Daping Hospital, Army Medical University, Chongqing, China.,State Key Laboratory of Trauma, Burns and Combined Wound, Army Medical University, Chongqing, China
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İştemen İ, Arslan A, Olguner SK, Afşer KA, Açık V, Arslan B, Ökten Aİ, Gezercan Y. Significance of Preoperative Prone Position Computed Tomography in Free Hand Subaxial Cervical Pedicular Screwing. J Korean Neurosurg Soc 2021; 64:247-254. [PMID: 33715326 PMCID: PMC7969039 DOI: 10.3340/jkns.2020.0252] [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: 08/27/2020] [Accepted: 10/28/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The subaxial cervical pedicle screwing technique shows powerful biomechanical properties for posterior cervical fusion. When applying a pedicle screw using the freehand technique, it is essential to analyse cervical computed tomography and plan the surgery accordingly. Normal cervical computed tomography is usually performed in the supine position, whereas during surgery, the patient lies in a prone position. This fact leads us to suppose that radiological evaluations may yield misleading results. Our study aimed to investigate whether there is any superiority between preoperative preparation on computed tomography performed in the prone position and that performed in the supine position. METHODS This study included 17 patients (132 pedicle screws) who were recently operated on with cervical vertebral computed tomography in the prone position and 17 patients (136 pedicle screws) who were operated on by conventional cervical vertebral computed tomography as the control group. The patients in both groups were compared in terms of age, gender, pathological diagnosis, screw malposition and complications. A screw malposition evaluation was made according to the Gertzbein-Robbins scale. RESULTS No statistically significant difference was observed between the two groups regarding age, gender and pathological diagnosis. The screw malposition rate (from 11.1% to 6.9%, p<0.05), mean malposition distance (from 2.18 mm to 1.86 mm, p <0.05), and complications statistically significantly decreased in the prone position computed tomography group. CONCLUSION Preoperative surgical planning by performing cervical vertebral computed tomography in the prone position reduces screw malposition and complications. Our surgical success increased with a simple modification that can be applied by all clinicians without creating additional radiation exposure or additional costs.
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Affiliation(s)
- İismail İştemen
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Ali Arslan
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Semih Kıvanç Olguner
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Kemal Alper Afşer
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Vedat Açık
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Barış Arslan
- Department of Anesthesia and Intensive Care, Adana City Education and Research Hospital, Adana, Turkey
| | - Ali İhsan Ökten
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Yurdal Gezercan
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
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10
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Safety and Feasibility of Cervical Pedicle Screw Insertion in Pediatric Subaxial Cervical Spine Without Navigation: A Retrospective Cohort Study. J Pediatr Orthop 2021; 41:119-126. [PMID: 33027234 DOI: 10.1097/bpo.0000000000001694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of cervical pedicle screws (CPSs) in pediatric subaxial cervical spine has been scarcely reported in the literature. The biomechanical superiority of CPS over other methods of fixation is beneficial in surgery for correcting severe, rigid cervical/cervicothoracic deformity. Our study aims to assess the safety, efficacy, and feasibility of CPS fixation in pediatric subaxial cervical spine without intraoperative navigation. METHODS Eight pediatric patients requiring rigid subaxial cervical spine fixation for complex cervical deformities were operated at a single center between 2014 and 2016. Their hospital records and imaging were retrospectively studied. The feasibility of inserting CPS was assessed by studying pedicle morphometry on preoperative computed tomography (CT) scans. Aberrant vertebral artery anatomy was ruled out using CT angiography. CPS were inserted into selected pedicles without navigation. Postoperative CT scans were studied to look for screw containment within pedicles. Complications were noted and clinicoradiologic follow-up was for a minimum of 36 months. RESULTS Thirty-seven CPS were inserted in 8 pediatric patients with a mean age of 9.2 years (range: 5 to 13 y). Surgery was done for complex cervical deformities due to various causes-neglected cervical spine trauma (n=3), posttubercular kyphosis (n=2), cervicothoracic scoliosis (n=2), and cervicothoracic osteoblastoma (n=1). The level-wise distribution of the inserted CPS was: C3=4, C4=6, C5=10, C6=10, and C7=7. Postoperative CT scans showed grade-1 medial cortical breach in 5/37 screws and grade-2 medial cortical breach in a single screw (16%). No perioperative complications were noted. At a mean follow-up of 3.6 years (range: 3 to 4.33 y), no patient had implant failure or deformity progression. CONCLUSIONS CPS insertion in pediatric subaxial cervical spine without neuronavigation is safe, feasible, and effective in carefully selected cases. Biomechanical advantages of CPS can be extended to the pediatric subaxial cervical spine. LEVEL OF EVIDENCE Level IV-retrospective cohort.
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11
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Xue X, Wang Y, Ji J, Han Y, Sun Q, Miao J. [Clinical application of cervical pedicle screw implantation technique under regional method]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1515-1520. [PMID: 33319528 DOI: 10.7507/1002-1892.202004128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of cervical pedicle screw implantation technique under regional method. Methods The clinical data of 85 patients who met the selection criteria between April 2010 and May 2018 were retrospectively analyzed. There were 57 males and 28 females, aged 35-68 years, with an average of 57.6 years. Among them, there were 10 cases of ossification of posterior longitudinal ligament, 68 cases of cervical spondylosis with multilevel stenosis, 3 cases of cervical tumor, 1 case of congenital malformation, and 3 cases of cervical trauma; the lower cervical spine lesions involved C 3-C 7. Preoperative Frankel spinal cord injury grading: 2 cases of grade C, 51 cases of grade D, and 32 cases of grade E. Cervical pedicle screw implantation technique under regional method was performed with a total of 618 pedicle screws. Postoperative changes in neurological symptoms were observed; cervical mouth opening anteroposterior and lateral X-ray films and cervical CT examinations were performed to evaluate the pedicle screws position. Results The operation time was 2.5-4.0 hours, with an average of 3.0 hours. The intraoperative blood loss was 180-550 mL, with an average of 345 mL. No intraoperative vascular or nerve injury occurred. The patients with neurological symptoms were relieved to varying degrees. There were 2 cases of superficial incision infection after operation, the wound healed after enhanced dressing change. The postoperative hospital stay was 5-14 days, with an average of 8.4 days. At discharge, Frankel neurological grading was grade D in 26 patients and grade E in 59 patients. All the patients were followed up 6-24 months, with an average of 13 months. At last follow-up, cervical X-ray films showed the good pedicle screw fixation without loosening. Cervical CT evaluated the position of pedicle screws: 523 pedicle screws (84.7%) in grade Ⅰ, 80 (12.9%) in grade Ⅱ, and 15 (2.4%) in grade Ⅲ; the accuracy rate of the screw position was 97.6%. Conclusion Cervical pedicle screw implantation technique under regional method can significantly improve the success rate of screw implantation. It is easy to operate, does not destroy the bone cortex, and has stable fixation.
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Affiliation(s)
- Xiaobei Xue
- Graduate School of Tianjin Medical University, Tianjin, 300350, P.R.China
| | - Yubing Wang
- Department of Orthopedics, the Seventh People's Hospital of Hebei Province, Baoding Hebei, 071000, P.R.China
| | - Jingtao Ji
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, 300350, P.R.China
| | - Yue Han
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, 300350, P.R.China
| | - Quan Sun
- Department of Orthopedics, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou Guangdong, 510120, P.R.China
| | - Jun Miao
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, 300350, P.R.China
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Tan KA, Lin S, Chin BZ, Thadani VN, Hey HWD. Anatomic techniques for cervical pedicle screw placement. JOURNAL OF SPINE SURGERY 2020; 6:262-273. [PMID: 32309664 DOI: 10.21037/jss.2020.03.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Instrumentation of the cervical spine with cervical pedicle screws (CPS) is beneficial in patients with various types of spinal pathology. Despite posing greater technical challenges, CPS instrumentation confers better fixation outcomes when compared to lateral mass screws. While developments in technology have augmented the accuracy of CPS insertion, mastery in freehand CPS insertion allows the aforementioned technologies to reach their full potential in improving patient outcomes. The aim of this article is to discuss freehand CPS insertion techniques as established in the current literature while sharing our experience in this context. A comprehensive literature search was performed using the following electronic databases: PubMed, Medline, and EMBASE. Full-text articles focusing on clinical studies with description of freehand techniques were included. Articles which were on cadaveric studies, drill jig, navigation or robotic technology were excluded. Thirteen primary references comprising 1,480 patients were included in this review. Majority of studies reported utilizing the cranial margin of lamina for C2 level as a landmark for entry point, as well as lateral to centre of the articular mass, and just medial to the lateral border of the superior articular process for C3-7 levels. Method of tracking and facilitation of trajectory was reported in multiple studies, with use of instruments ranging from curved pedicle probes to high-speed burrs. Limited studies reported specific trajectories of CPS insertion. Most studies noted testing pedicle wall integrity at various checkpoints, with pedicle screw repositioning or conversion to lateral screw mass following detection of perforation or screw malpositioning. Success in CPS insertion rests on meticulous preoperative planning to identify the ideal screw entry point and trajectory. Patient-specific drill jigs, navigation and robotic technologies, while beneficial to progress in the field of cervical spine surgery and patient outcomes, should serve primarily to augment good expertise in freehand CPS insertion technique.
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Affiliation(s)
- Kimberly-Anne Tan
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Shuxun Lin
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Brian Zhaojie Chin
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Vishaal Nanik Thadani
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Hwee Weng Dennis Hey
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
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Kim MK, Cho HJ, Kwak DS. A new anatomical approach of cervical lateral mass for cervical pedicle screw and paravertebral foramen screw insertion. PLoS One 2019; 14:e0219119. [PMID: 31318904 PMCID: PMC6638838 DOI: 10.1371/journal.pone.0219119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 06/17/2019] [Indexed: 01/01/2023] Open
Abstract
Thus far, anatomical studies have reported data on the cervical pedicle, with the focus remaining on the pedicle itself. It was necessary to obtain more comprehensive data about the relationships between the lateral mass, pedicle, and transverse foramen for cervical pedicle screwing (CPS) and paravertebral foramen screwing (PVFS), a new technique. The purpose of this study was to describe the relationships between the lateral mass, pedicle, and transverse foramen. This study analyzed computed tomography images from 77 patients (42 female, 35 male; mean age: 63.95 years). The anatomical pedicle transverse angle (PTA) and linear parameters of the lateral mass were measured, and the relationship between the calculated angles and the anatomical PTA was investigated. θp was defined as the convergence angle from the posterolateral edge of the lateral mass to the pedicle, and θc was defined as the convergence angle from the posterolateral edge of the lateral mass to the anterolateral corner of the vertebral foramen. The thickness of the cortical bone of the medial wall of the lateral mass (cT) and the medial (mT) and lateral (lT) walls of the pedicle at C3-7 were also measured. The PTA was similar to θp and θc at C3-6, but different at C7. In all cases, the transverse foramen was located more anterior to the posterior wall of the cervical body at C3-6, but not at C7. mT and cT were significantly thicker than lT at all levels. Lateral fluoroscopic images show that when the probe is inserted along θc, it meets the counter corner of the lateral mass at C3-6 without invasion of the transverse foramen if it does not cross the posterior wall of the vertebral body. This can be significant when performing CPS and PVFS.
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Affiliation(s)
- Moon-Kyu Kim
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Ho-Jung Cho
- Catholic Institute for Applied Anatomy / Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dai-Soon Kwak
- Catholic Institute for Applied Anatomy / Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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Pan Z, Zhong J, Xie S, Yu L, Wu C, Ha Y, Kim KN, Zhang Y, Cao K. Accuracy and Safety of Lateral Vertebral Notch-Referred Technique Used in Subaxial Cervical Pedicle Screw Placement. Oper Neurosurg (Hagerstown) 2019; 17:52-60. [PMID: 30189031 DOI: 10.1093/ons/opy233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 07/27/2018] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Biomechanical studies revealed that pedicle screw instrumentation has a superior stabilizing effect compared with other internal fixations in reconstructing the subaxial cervical spine. However, severe neurovascular risks preclude surgeons from routinely conducting pedicle screw manipulation in cervical spine. OBJECTIVE To evaluate the accuracy and safety of the lateral vertebral notch (LVN)-referred technique used in subaxial cervical pedicle screw (CPS) placement. METHODS One hundred thirty-five consecutive retrospective patients with cervical disorders underwent the LVN-referred technique for CPS placements in 3 spine centers. Postoperative pedicle perforations were confirmed by CT scans to assess the technical accuracy. Neurovascular complications derived from CPS misplacements were recorded to evaluate the technical safety. RESULTS A total of 718 CPSs were inserted into subaxial cervical spine. Postoperative CT scans revealed that the accuracy of CPS placement was superior. Neither vertebral artery injury nor spinal cord injury occurred. One radiculopathy was from a unilateral C6 nerve root compression. A screw-related neurovascular injury rate of 0.7% occurred in this cohort. Additionally, there was no significant difference in the accuracy of CPS placement among 3 surgeons (H = 1.460, P = .482). The relative standard deviation values revealed that technical reproducibility was acceptable. Furthermore, there was no significant difference between the patients' pedicle transverse angles and inserted CPS transverse angles from C3 to C7 (all P > .05). CONCLUSION The LVN is a reliable and consistent anatomic landmark for CPS placement. The accuracy and safety of subaxial CPS placement by using LVN-referred technique are highly acceptable, which may endow this technique to be practicably performed in selected patients.
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Affiliation(s)
- Zhimin Pan
- Department of Orthopaedics, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Junlong Zhong
- Department of Orthopaedics, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shiming Xie
- Department of Orthopaedics, Mianyang Orthopaedic Hospital, Mianyang, China
| | - Limin Yu
- Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen, China
| | - Chunyang Wu
- Department of Orthopaedics, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Youshan Zhang
- Computer of Science Engineering, Lehigh University, Bethlehem, Pennsylvania
| | - Kai Cao
- Department of Orthopaedics, the Second Affiliated Hospital of Nanchang University, Nanchang, China
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Moser M, Farshad M, Farshad-Amacker NA, Betz M, Spirig JM. Accuracy of Patient-Specific Template-Guided Versus Freehand Cervical Pedicle Screw Placement from C2 to C7: A Randomized Cadaveric Study. World Neurosurg 2019; 126:e803-e813. [PMID: 30862583 DOI: 10.1016/j.wneu.2019.02.152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dorsal spinal instrumentation with cervical pedicle screws (CPS) and rod constructs is performed for numerous pathologies of the cervical spine, although technically demanding. Screw misplacement is biomechanically disadvantageous and carries the risk of neurovascular sequelae. The aim of this study was to assess the accuracy of patient-specific, template-guided CPS placement from C2 to C7 compared with the freehand technique. METHODS Patient-specific targeting guides were used for placement of 3.5 mm CPS from C2 to C7 in 4 cadaveric specimens. Template-guided instrumentation was randomized for each cervical level and side and the contralateral side instrumented likewise but with the freehand technique. No fluoroscopy was used at all, and the spinal canal was not opened for the freehand technique. Accuracy was assessed by computed tomography, grading perforations using a 2-mm increment method, and time efficiency was compared between the 2 techniques. RESULTS In total, 48 screws were inserted with an equal distribution of 24 screws (50%) in each of the 2 groups. Outer pedicle width averaged 5.1 ± 1.0 mm (range 2.7-7.8); 66.7% (n = 16) of template-guided versus 20.8% (n = 5) of freehand CPS were fully contained within the pedicle (P = 0.001), whereas 91.7% (n = 22) versus 50% (n = 12) were within the <2 mm "safe" zone (P = 0.001). The mean time for instrumentation per level and side was 03:09 ± 01:37 minutes for the template-guided versus 02:32 ± 01:04 minutes for the freehand technique (P = 0.132). CONCLUSIONS In a cadaver model, template-guided CPS placement has a significantly greater accuracy than the freehand technique. This accuracy is comparable with navigated techniques reported in the literature.
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Affiliation(s)
- Manuel Moser
- Spine Division, Department of Orthopedics, Balgrist University Hospital Zurich, Zurich, Switzerland; Department of Spine Surgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland.
| | - Mazda Farshad
- Spine Division, Department of Orthopedics, Balgrist University Hospital Zurich, Zurich, Switzerland
| | | | - Michael Betz
- Spine Division, Department of Orthopedics, Balgrist University Hospital Zurich, Zurich, Switzerland
| | - José Miguel Spirig
- Spine Division, Department of Orthopedics, Balgrist University Hospital Zurich, Zurich, Switzerland
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Kim MK, Cho HJ, Kwak DS, You SH. Characteristics of regional bone quality in cervical vertebrae considering BMD: Determining a safe trajectory for cervical pedicle screw fixation. J Orthop Res 2018. [PMID: 28621468 DOI: 10.1002/jor.23633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study aimed to report the mechanical strength and characteristics of the lateral mass and pedicle considering BMD for the safe insertion of pedicle screws in the subaxial cervical level. We evaluated BMD and Hounsfield unit (HU) values of cortical bones at the lateral mass and pedicle of C3-7 from CT images in 99 patients. Patients were divided into three groups (Group A, T-score ≥ -1; Group B, -2.5 < T-score < -1.0; Group C, T-score ≤ -2.5). The HU numbers of cortical bone in the vertebral canal (medial wall of the lateral mass; cHU), posterior wall of the transverse foramen (fHU), and medial wall, lateral wall, and trabecular area of the pedicle (mHU, lHU, and pHU, respectively) were measured on the CT images in the middle of the pedicle. A mechanical study was also performed to measure cortical bone strength using 10 fresh cadavers. The cHU and mHU values in Group C were higher than lHU and fHU in Groups A and B, and there was a wide gap between the pHU value and other areas. The penetrating force also had a close correlation with HU number. The mean penetrating force of the medial wall of the lateral mass and the posterior wall of the transverse foramen were 210.08 ± 110.46 and 50.51 ± 46.09 N, respectively. The cortical bones in the vertebral canal and medial wall of the pedicle were stronger than the lateral wall and the trabecular area. The cHU and mHU in the osteoporotic group were higher than fHU and pHU in the normal group. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:217-223, 2018.
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Affiliation(s)
- Moon-Kyu Kim
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Ho-Jung Cho
- Catholic Institute for Applied Anatomy/Department of Anatomy, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-goo, Seoul 06591, Korea
| | - Dai-Soon Kwak
- Catholic Institute for Applied Anatomy/Department of Anatomy, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-goo, Seoul 06591, Korea
| | - Seung-Hoon You
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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Lee JH, Choi BK, Han IH, Choi WG, Nam KH, Kim HS. Cervical Pedicle Screw Placement Using Medial Funnel Technique. KOREAN JOURNAL OF SPINE 2017; 14:84-88. [PMID: 29017302 PMCID: PMC5642088 DOI: 10.14245/kjs.2017.14.3.84] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/24/2017] [Accepted: 08/27/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Cervical pedicle screw (CPS) placement is very challenging due to high risk of neurovascular complications. We devised a new technique (medial funnel technique) to improve the accuracy and feasibility of CPS placement. METHODS We reviewed 28 consecutive patients undergoing CPS instrumentation using the medial funnel technique. Their mean age was 51.4 years (range, 30-81 years). Preoperative diagnosis included degenerative disease (n=5), trauma (n=22), and infection (n=1). Screw perforations were graded with the following criteria: grade 0 having no perforation, grade 1 having <25%, grade 2 having 25%-50% and grade 3 having >50% of screw diameter. Grades 0 and 1 were considered as correct position. The degree of perforation was determined by 2 junior neurosurgeons and 1 senior neurosurgeon. RESULTS A total of 88 CPSs were inserted. The rate of correct placement was 94.3%; grade 0, 54 screws; grade 1, 29 screws; grade 2, 4 screws; and grade 3, 1 screw. No neurovascular complications or failure of instrumentation occurred. In perforated screws (34 screws), lateral perforations were 4 and medial perforations were 30. CONCLUSION We performed CPS insertion using medial funnel technique and achieved 94.3% (83 of 88) of correct placement. And it can decrease lateral perforation.
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Affiliation(s)
- Jung Hwan Lee
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - Byung Kwan Choi
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - In Ho Han
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - Won Gyu Choi
- Department of Neurosurgery, Asan Chungmoo Hospital, Asan, Korea
| | - Kyoung Hyup Nam
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - Hwan Soo Kim
- Department of Neurosurgery, Busan Himchan Hospital, Busan, Korea
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Yao X, Liu S. In vitro study of accuracy of subaxial cervical pedicle screw insertion using calipers based on the gravity line. PLoS One 2017; 12:e0181324. [PMID: 28727778 PMCID: PMC5519080 DOI: 10.1371/journal.pone.0181324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 06/29/2017] [Indexed: 11/23/2022] Open
Abstract
Object There is a high probability of iatrogenic perforation of the vertebral pedicle wall during the application of subaxial cervical pedicle screw (CPS). The goal of this study was to evaluate the accuracy of CPS insertion at C3-C7 in vitro using novel calipers based on the gravity line. Methods Nine cadaveric cervical spines underwent computed tomography scanning and preoperative design. A lateral fluoroscopic view was taken to measure the intra-operative sagittal angle by C-arm with hanging cross structured K-wires. By referring to the gravity line, caliper A was used to locate the entry point, while caliper B was employed to guide the screw insertion. Postoperative CT scans were performed to assess the accuracy of the screw placements, according to the Neo classification. Results Overall, 78 (88.6%) of the 88 pedicle screw placements were classified as grade 0 (correct position), 4 (4.5%) were grade 1 (non-critical perforation), 4 (4.5%) were grade 2 (critical perforation), and 2 (2.3%) were grade 3 (critical perforation). Conclusions Using our novel calipers and referring to the gravity line was helpful for locating and guiding individual cervical pedicle screw insertions.
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Affiliation(s)
- Xiang Yao
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, PR China
| | - Shiqing Liu
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, PR China
- * E-mail:
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Yu Z, Zhang G, Chen X, Chen X, Wu C, Lin Y, Huang W, Lin H. Application of a novel 3D drill template for cervical pedicle screw tunnel design: a cadaveric 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 2017; 26:2348-2356. [DOI: 10.1007/s00586-017-5118-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 12/23/2016] [Accepted: 05/01/2017] [Indexed: 11/28/2022]
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Wu C, Huang Z, Pan Z, Luo J, Li Z, Zhong J, Chen Y, Han Z, Abumi K, Ha Y, Cao K. Coronal Multiplane Reconstructed Computed Tomography Image Determining Lateral Vertebral Notch-Referred Pedicle Screw Entry Point in Subaxial Cervical Spine: A Preclinical Study. World Neurosurg 2017; 103:322-329. [PMID: 28434954 DOI: 10.1016/j.wneu.2017.04.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 04/05/2017] [Accepted: 04/07/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate feasibility of computed tomography (CT) coronal multiplane reconstruction image (CMRI) to determine subaxial cervical pedicle screw (PS) entry point and guide lateral vertebral notch (LVN)-referred technique for subaxial cervical PS insertion. METHODS Cervical CT scans were performed in 40 volunteers. PS entry point was determined by quantitating PS entry point related to LVN on CMRI. Pedicle mediolateral angle (α) and cephalocaudad angle (β) were also measured to guide the trajectory of PS insertion. Based on these quantitations, 12 human cadaveric subaxial cervical pedicles were inserted with PS referring to LVN. Cortical integrity of each pedicle was evaluated after dissecting the cadaveric vertebrae one by one and confirmed by radiography and CT. The cortical penetration and PS position were classified into 4 grades: 0 (excellent position), I (good position), II (fair position), and III (poor position). RESULTS On CT CMRI, PS entry point was consistently located approximately 2.2 mm medial to LVN from C3 to C7 and approximately 1.4 mm lower to LVN from C3 to C6, but 1.2 mm higher at C7. Bilateral α angle and β angle showed substantial decrease from cranial to caudal. Cortical integrity of PS positions was excellent and good in 88.33%, fair in 8.33%, and poor in 3.33%. CONCLUSIONS CMRI is reliable for determining subaxial cervical PS entry point. LVN is a consistent landmark for the notch-referred technique, which is a practical and easy to master technique for subaxial cervical spine PS insertion.
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Affiliation(s)
- Chunyang Wu
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Zhongren Huang
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Zhimin Pan
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Jiangxi, China; Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jiaquan Luo
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Zhiyun Li
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Junlong Zhong
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Yiwei Chen
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Zhimin Han
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Kuniyoshi Abumi
- Center for Spinal Disorders, Sapporo Orthopaedic Hospital, Sapporo, Japan
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea.
| | - Kai Cao
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Jiangxi, China.
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Luo J, Wu C, Huang Z, Pan Z, Li Z, Zhong J, Chen Y, Han Z, Cao K. The accuracy of the lateral vertebral notch-referred pedicle screw insertion technique in subaxial cervical spine: a human cadaver study. Arch Orthop Trauma Surg 2017; 137:517-522. [PMID: 28236185 DOI: 10.1007/s00402-017-2647-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Indexed: 11/29/2022]
Abstract
STUDY DESIGN This is a cadaver specimen study to confirm new pedicle screw (PS) entry point and trajectory for subaxial cervical PS insertion. OBJECTIVE To assess the accuracy of the lateral vertebral notch-referred PS insertion technique in subaxial cervical spine in cadaver cervical spine. BACKGROUNDS Reported morphometric landmarks used to guide the surgeon in PS insertion show significant variability. In the previous study, we proposed a new technique (as called "notch-referred" technique) primarily based on coronal multiplane reconstruction images (CMRI) and cortical integrity after PS insertion in cadavers. However, the PS position in cadaveric cervical segment was not confirmed radiologically. Therefore, the difference between the pedicle trajectory and the PS trajectory using the notch-referred technique needs to be illuminated. METHODS Twelve cadaveric cervical spines were conducted with PS insertion using the lateral vertebral notch-referred technique. The guideline for entry point and trajectory for each vertebra was established based on the morphometric data from our previous study. After 3.5-mm diameter screw insertion, each vertebra was dissected and inspected for pedicle trajectory by CT scan. The pedicle trajectory and PS trajectory were measured and compared in axial plane. The perforation rate was assessed radiologically and was graded from ideal to unacceptable: Grade 0 = screw in pedicle; Grade I = perforation of pedicle wall less than one-fourth of the screw diameter; Grade II = perforation more than one-fourth of the screw diameter but less than one-second; Grade III = perforation more than one-second outside of the screw diameter. In addition, pedicle width between the acceptable and unacceptable screws was compared. RESULTS A total of 120 pedicle screws were inserted. The perforation rate of pedicle screws was 78.3% in grade 0 (excellent PS position), 10.0% in grade I (good PS position), 8.3% in grade II (fair PS position), and 3.3% in grade III (poor PS position). The overall accepted accuracy of pedicle screws was 96.7% (Grade 0 + Grade I + Grade II), and only 3.3% had critical breach. There was no statistical difference between the pedicle trajectory and PS trajectory (p > 0.05). Compared to the pedicle width (4.4 ± 0.7 mm) in acceptably inserted screw, the unacceptably screw is 3.2 ± 0.3 mm which was statistically different (p < 0.05). CONCLUSION The accuracy of the notch-referred PS insertion in cadaveric subaxial cervical spine is satisfactory.
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Affiliation(s)
- Jiaquan Luo
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Chunyang Wu
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Zhongren Huang
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Zhimin Pan
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Zhiyun Li
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Junlong Zhong
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Yiwei Chen
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Zhimin Han
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China
| | - Kai Cao
- Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, China.
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Burcev AV, Pavlova OM, Diachkov KA, Diachkova GV, Ryabykh SO, Gubin AV. Easy method to simplify "freehand" subaxial cervical pedicle screw insertion. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:390-395. [PMID: 29403258 PMCID: PMC5763603 DOI: 10.4103/jcvjs.jcvjs_92_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Study Design: Technical note. Objectives: The objective of this study is to check out safety and rationality of standardized and fast tricks to select trajectory of subaxial cervical pedicle screw (SCPS) insertion, based on simple angles to bony landmarks. Materials and Methods: Stage 1 – Computed tomography (CT)-morphometric analysis of C3–C7 vertebrae of ten patients with cervical degenerative diseases. Stage 2 – SCPS insertion in 6 cadavers, according to the developed technique (59 pedicle screws). Stage 3 – SCPS insertion in 6 patients, according to the developed technique (32 pedicle screws). Results: CT-morphometric analysis showed that the average length of C3–C7 pedicle channels was 32 mm, the average angle between a pedicle axis and an axis of contralateral lamina - 180°, the average angle between a pedicle axis and plane of a posterior surface of a lateral mass amounted to 90° and the coordinates of an optimal entry point – 2 mm from a lateral edge and 2 mm from an upper edge of the lateral mass posterior surface. During the cadaveric study, 39 screws had a satisfactory position (66.1%), 7 screws permissible (11.9%), and 13 screws unacceptable (22%). During the clinical study, 26 screws (81.25%) had satisfactory position, 4 (12.5%) had permissible position, and 2 (6.25%) unacceptable position. Conclusion: Developed and clinically approved a method for simplicity SCPS insertion is relatively safe and cheap. No doubt, it requires further investigation, but the results of primary analysis allow us to recommend it to wide practical application.
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Affiliation(s)
| | | | | | | | - Sergey O Ryabykh
- Division Spine Pathology and Rare Diseases, Russian Ilizarov Scientific Center, Kurgan, Russian
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Chen H, Li H, Deng Y, Rong X, Gong Q, Li T, Song Y, Liu H. Optimal area of lateral mass mini-screws implanted in plated cervical laminoplasty: a radiography anatomy 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; 26:1140-1148. [PMID: 27671282 DOI: 10.1007/s00586-016-4785-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 08/28/2016] [Accepted: 09/16/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE Lateral mass mini-screws used in plated cervical laminoplasty might penetrate into facet joints. The objective is to observe this complication incidence and to identify the optimal areas for 5- and 7-mm-long mini-screws to implant on lateral mass. METHODS 47 patients who underwent plated cervical laminoplasty were included. The optimal area for mini-screws implanting was set according to pre-operative 3D CT reconstruction data. Then, each posterior-lateral mass surface was divided into three regions: 7-mm region, 5-mm region, and dangerous area. The mini-screw implanted region was recorded. Post-operative CT images were used to identify whether the mini-screws penetrated into facet joints. RESULTS 235 mini-plates and 470 lateral mass mini-screws were used in the study. 117 (24.9%) mini-screws penetrated 88 (37.4%) facet joints. The 5-mm-long mini-screw optimal area occupied the upper 72, 65, 65, 64, and 65 % area of the posterior-lateral mass surface for C3-7, while the 7-mm-long mini-screw optimal area encompassed the upper 54, 39, 40, 33, and 32 %. Only 7-mm-long mini-screws were used to fix the plate to the lateral mass. 4 of 240 mini-screws in 7-mm region, 67 of the 179 mini-screws in 5-mm region, and 46 of the 51 mini-screws in dangerous region penetrated into the facet joint. The differences in the rate of facet joint penetration related to region were statistically significant (P < 0.001). CONCLUSIONS The facet joint destruction by mini-screws was not a rare complication in plated cervical laminoplasty. The optimal areas we proposed may help guide the mini-screw implantation positions.
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Affiliation(s)
- Hua Chen
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu Sichuan, 610041, China
| | - Huibo Li
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu Sichuan, 610041, China
| | - Yuxiao Deng
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu Sichuan, 610041, China
| | - Xin Rong
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu Sichuan, 610041, China
| | - Quan Gong
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu Sichuan, 610041, China
| | - Tao Li
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu Sichuan, 610041, China
| | - Yueming Song
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu Sichuan, 610041, China
| | - Hao Liu
- Department of Orthopedics, West China Hospital, Sichuan University, 37# Guoxue Lane, Chengdu Sichuan, 610041, China.
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Herrera Palacios C, Ramos Guerrero AF, Casas Martínez G, Moheno Gallardo AJ, Fuentes Figueroa S. LEVEL OF EVIDENCE IN THE PLACEMENT OF TRANSPEDICULAR SCREWS IN SUBAXIAL CERVICAL SPINE. COLUNA/COLUMNA 2016. [DOI: 10.1590/s1808-185120161502155441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT The high-energy trauma mainly involves vertebral lesions and 6% occur in the cervical region. This poses a challenge to spine surgeons in surgical decision-making, both in terms of approach as the instrumentation. International recommendations establish that the procedures performed are reproducible, safe, and effective. The techniques for placement of pedicle screws are complicated and have been based on intraoperative navigation (limited by cost) and fluoroscopy (greater exposure of health care professionals and patients to radiation). Therefore, the freehand technique is an option. The goal was to identify the level of evidence and grade of recommendation in the medical literature regarding the safety and efficacy of pedicle screw instrumentation with freehand technique in subaxial cervical spine. To this end, we carried out a systematic review with the following MeSH terms: safety, efficacy, vertebral artery. Articles were evaluated twice in a standardized and blind way by two observers skilled in systematic analysis, after CLEIS 3401 authorization in November 2014. Due to the nature of the study and the variables, articles with a high level of evidence and grade of recommendation were not found. Level of Evidence obtained on safety and efficacy in the placement of pedicle screws in subaxial column with freehand technique: 2b. Degree of Recommendation obtained on safety and efficacy in the placement of pedicle screws in subaxial column with freehand technique: B, favorable recommendation.
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Vialle E, Herrera L, Vialle LR, Gomes L. FREE-HAND PLACEMENT OF C7 PEDICLE SCREWS: A CADAVERIC STUDY. COLUNA/COLUMNA 2015. [DOI: 10.1590/s1808-185120151404152743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective : To evaluate the accuracy of free-hand pedicle screws placement at the seventh cervical vertebra. Methods : The authors have exposed the cervicothoracic junction of 9 adult cadavers (7 male and 2 female) preserved in formalin from the Faculty of Medicine of the Universidad Andina Néstor Cáceres Velásquez, city of Juliaca, Puno - Peru, locating the C7 vertebra based on anatomical parameters. According to previous publications, the entry point for the C7 pedicle was determined as 3-4mm lateral and 5-6mm superior to the center of the lateral mass, and the pedicle was drilled manually and instrumented with 3.5mm screws. After the screws placement, the C7 vertebrae were removed for radiographic analysis. Results : The authors were able to adequately locate the C7 entry point in 12 pedicles (66.6% accuracy), finding a great variability both laterally (2-5mm) and cranially (3-10mm). The angulation in the coronal plane was correct in 13 pedicles (72.3%), despite the incorrect location of the entry point. Angle values in the coronal plane ranged from 38 to 62 degrees. In the sagittal plane angulation, 2 screws were placed in the C6-C7 disc. The midtransversal diameter of the 18 pedicles ranged from 4 to 7mm. Conclusions : The location of the entry point for placement of C7 pedicle screws with pure free-hand technique is very variable due to anatomical differences and the authors recommend some type of guidance for increased safety and accuracy.
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Hybrid Technique for Cervical Pedicle Screw Placement: Combination of Miniopen Surgery and Use of a Percutaneous Cannula System-Pilot Study. Spine (Phila Pa 1976) 2015; 40:1181-6. [PMID: 25996541 DOI: 10.1097/brs.0000000000000986] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaver study and clinical application; a pilot study. OBJECTIVE To minimize muscle dissection and enhance accuracy of cervical pedicle screw (CPS) placement by using a percutaneous cannula system. SUMMARY OF BACKGROUND DATA Many studies have reported that the most frequent misplacement of CPSs is breach of the lateral wall; thus, an easy technique for securing medial convergence is required. We developed a percutaneous cannula system for this purpose and report the results of a cadaver study and its clinical application. METHODS A cadaver study was conducted to confirm the possibility of this percutaneous technique in 5 specimens (50 CPSs, C3-C7). Then, the technique was applied in 8 patients (40 CPSs, C3-C7). The surgical technique was a hybrid of miniopen surgery and the use of percutaneous cannula system under lateral fluoroscopic guidance. Entry holes were made in the open field and a cannula was used for tapping and insertion of CPSs. A stiff pedicle probe through the cannula was used to locate the pedicle in the lateral mass. RESULTS In the cadaver study, there were 12 (24%) misplacements among 50 CPSs used. The hybrid technique was applied clinically in 4 traumatic, 2 degenerative, and 2 failed back surgery lesions. Thirty CPSs were inserted using the percutaneous cannula system and 10 were inserted using a cannula as a retractor. Misplacement occurred in 6.7% (n = 2) and 20% (n = 2) pedicles, respectively, and there were no symptomatic complications (total incidence, 10%). An additional incision for the cannula system can be made for 2-level CPS insertions. CONCLUSION Use of the percutaneous cannula system facilitated a secure convergence angle for CPS insertion without extending muscle dissection or shifting cervical alignment because of muscle retraction. Moreover, this system can be used for CPS insertion in bull-necked patients. LEVEL OF EVIDENCE 3.
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Mid-term results of computer-assisted cervical pedicle screw fixation. Asian Spine J 2014; 8:759-67. [PMID: 25558318 PMCID: PMC4278981 DOI: 10.4184/asj.2014.8.6.759] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 01/29/2014] [Accepted: 02/04/2014] [Indexed: 11/19/2022] Open
Abstract
Study Design A retrospective study. Purpose The present study aimed to evaluate mid-term results of cervical pedicle screw (CPS) fixation for cervical instability. Overview of Literature CPS fixation has widely used in the treatment of cervical spinal instability from various causes; however, there are few reports on mid-term surgical results of CPS fixation. Methods Record of 19 patients who underwent cervical and/or upper thoracic (C2-T1) pedicle screw fixation for cervical instability was reviewed. The mean observation period was 90.2 months. Evaluated items included Japanese Orthopaedic Association (JOA) score and C2-7 lordotic angle before surgery and at 5 years after surgery. Postoperative computerized tomography was used to determine the accuracy of screw placement. Visual analog scale (VAS) for neck pain and radiological evidence of adjacent segment degeneration (ASD) at the 5-year follow-up were also evaluated. Results Mean JOA score was significantly improved from 9.0 points before surgery to 12.8 at 5 years after surgery (p=0.001). The C2-7 lordotic angle of the neutral position improved from 6.4° to 7.8° at 5 years after surgery, but this was not significant. The major perforation rate was 5.0%. There were no clinically significant complications such as vertebral artery injury, spinal cord injury, or nerve root injury caused by any screw perforation. Mean VAS for neck pain was 49.4 at 5 years after surgery. The rate of ASD was 21.1%. Conclusions Our mid-term results showed that CPS fixation was useful for treating cervical instability. Severe complications were prevented with the assistance of a computed tomography-based navigation system.
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The safety and accuracy of freehand pedicle screw placement in the subaxial cervical spine: a series of 45 consecutive patients. Spine (Phila Pa 1976) 2014; 39:280-5. [PMID: 24299725 DOI: 10.1097/brs.0000000000000133] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To assess the safety and accuracy of subaxial cervical pedicle screw placement with freehand technique and to report the technical nuances. SUMMARY OF BACKGROUND DATA Although the efficacy and safety of freehand screw fixation in thoracic and lumbar vertebrae is proven, reports on this technique of screw insertion in the subaxial cervical spine are lacking. METHODS From March 2012 to September 2013, 45 consecutive patients underwent posterior cervical fusion. The diagnoses were trauma (22 patients), degenerative disease (18 patients), discitis/osteomyelitis (2 patients), pathological fracture (2 patients), and postlaminoplasty kyphosis (1 patient). Preoperative computed tomography (CT) was performed in all patients. We included patients whose outer diameter of the pedicle was greater than 3.0 mm. The standard entry points were modified according to the CT anatomy of each patient. A small pilot hole was fashioned at a predetermined entry point. Then, a 2.5-mm diameter curved pedicle probe was slowly inserted with a medial trajectory into the pedicle. After ball-tip probing and tapping, the screw was inserted. If ball-tip probing was suggestive of risk to neurovascular structures, conversion to a lateral mass screw was performed. Postoperatively, a CT scan was performed in all patients and the conversion rate from pedicle to lateral mass screw was recorded. The breech rate of pedicle screws was also analyzed. RESULTS There were 256 planned pedicle screws and 20 incidences (7.8%) of conversion to lateral mass screws. Lateral wall violation was observed in 14 pedicle screws (accuracy rate: 94.1%) on the postoperative CT scan. No medial, superior, and inferior pedicle wall violations were observed. There was no patient who developed symptoms related to vertebral artery stenosis. CONCLUSION Adherence to the surgical tips presented in this article may lead to safe and effective freehand placement of cervical pedicle screws. LEVEL OF EVIDENCE 3.
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Yoshihara H, Passias PG, Errico TJ. Screw-related complications in the subaxial cervical spine with the use of lateral mass versus cervical pedicle screws. J Neurosurg Spine 2013; 19:614-23. [DOI: 10.3171/2013.8.spine13136] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Lateral mass screws (LMS) have been used extensively with a low complication rate in the subaxial spine. Recently, cervical pedicle screws (CPS) have been introduced, and are thought to provide more optimal stabilization of the subaxial spine in certain circumstances. However, because of the concern for neurovascular injury, the routine use of CPS in this location remains controversial. Despite this controversy, however, there are no articles directly comparing screw-related complications of each procedure in the subaxial cervical spine. The purpose of this study was to evaluate screw-related complications of LMS and CPS in the subaxial cervical spine.
Methods
A PubMed/MEDLINE and Cochrane Collaboration Library search was executed, using the key words “lateral mass screw” and “cervical pedicle screw.” Clinical studies evaluating surgical procedures of the subaxial cervical spine in which either LMS or CPS were used and complications were reported were included. Studies in which the number of patients who had subaxial cervical spine surgery and the number of screws placed from C-3 to C-7 could not be specified were excluded. Data on screw-related complications of each study were recorded and compared.
Results
Ten studies of LMS and 12 studies of CPS were included in the analysis. Vertebral artery injuries were slightly but statistically significantly higher with the use of CPS relative to LMS in the subaxial cervical spine. Although the use of LMS was associated with a higher rate of screw loosening, screw pullout, loss of reduction, pseudarthrosis, and revision surgery, this finding was not statistically significant.
Conclusions
Based on the available literature, it appears that perioperative neurological and late biomechanical complication rates, including pseudarthrosis, are similarly low for both LMS and CPS techniques. In contrast, vertebral artery injuries, although statistically significantly more common when using CPS, are extremely rare with both techniques, which may justify their nonroutine use in select cases. Given the paucity of well-designed studies available, this recommendation may be a reflection of deficiencies in the available studies. Surgeons using either technique should have intimate knowledge of cervical anatomy and an adequate preoperative evaluation for each patient, with the final selection based on individual case requirements and anatomical limitations.
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Distractive flexion injuries of the subaxial cervical spine treated with a posterior procedure using cervical pedicle screws or a combined anterior and posterior procedure. J Clin Neurosci 2013; 20:697-701. [PMID: 23313522 DOI: 10.1016/j.jocn.2012.03.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 03/27/2012] [Accepted: 03/28/2012] [Indexed: 11/22/2022]
Abstract
The purpose of this study was to compare the clinical and radiographic outcomes of patients with distractive flexion (DF) injuries of the subaxial cervical spine who had undergone a posterior procedure using cervical pedicle screw (CPS) fixation with those who had undergone a combined anterior and posterior procedure. Recommendations for the surgical treatment of DF injuries of the subaxial cervical spine remain controversial. There are few clinical reports of posterior CPS fixation for DF injuries. We retrospectively reviewed the clinical records and radiographs of 50 consecutive patients with DF injuries of the subaxial cervical spine treated at the Imakiire General Hospital. Group 1 consisted of 24 patients who underwent posterior wiring fixation and fusion with additional anterior decompression and fusion. Group 2 consisted of 26 patients who underwent posterior decompression and fusion with CPS fixation. Group 1 had a significantly longer operation time (295.4 minutes) than Group 2 (163.3 minutes). Group 1 had significantly higher blood loss (689.1g) than Group 2 (313.7 g). No patient in Group 1 or 2 developed postoperative neurological worsening. The mean loss of kyphotic correction was 1.6° and 0.1° in Groups 1 and 2, respectively, and the loss of kyphotic correction in Group 2 was significantly less than that of Group 1. We suggest that posterior procedures with CPS fixation are reasonable for the management of cervical DF injuries.
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Cervical Pedicle Screw Placement in Sawbone Models and Unstable Cervical Traumatic Lesions by Using Para-Articular Mini-Laminotomy: A Novice Neurosurgeon's Experience. Korean J Neurotrauma 2013. [DOI: 10.13004/kjnt.2013.9.2.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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