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Oki T, Lefor AK, Nakamura K, Higashi T, Oki I. Reduction in Radiation Exposure in Minimally Invasive Pedicle Screw Placement Using a Tubular Retractor: A Pilot Study. Tomography 2022; 9:12-24. [PMID: 36648989 PMCID: PMC9844279 DOI: 10.3390/tomography9010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Percutaneous pedicle screw (PPS) placement is a minimally invasive spinal procedure that has been rapidly adopted over the last decade. However, PPS placement has elicited fear of increased radiation exposure from some surgeons, medical staff, and patients. This is because PPS placement is performed using a K-wire, and the operator must perform K-wire insertion into the pedicle under fluoroscopy. In order to prevent erroneous insertion, there are many occasions when direct insertion is required during radiation exposure, and the amount of radiation exposure to hands and fingers in particular increases. Although these problems are being addressed by navigation systems, these systems are still expensive and not widely available. Attempts have been made to address this situation using instrumentation commonly used in spinal surgery. First, it was considered to visualize anatomical bone markers using a tubular retractor and a microscope. In addition, the use of a self-drilling pin was adopted to locate the pedicle in a narrower field of view. Based on these considerations, a minimally invasive and highly accurate pedicle screw placement technique was developed while avoiding direct radiation exposure. This study evaluated radiation exposure and accuracy of pedicle screw placement using this new procedure in one-level, minimally invasive, transforaminal lumbar interbody fusion (MIS-TLIF). MATERIALS AND METHODS Data were collected retrospectively to review pedicle screw placement in single-level MIS TLIFs using a tubular retractor under a microscope. The total fluoroscopy time, radiation dose, and screw placement accuracy were reviewed. Extension of operating time was also evaluated. RESULTS Twenty-four patients underwent single-level MIS TLIFs, with placement of 96 pedicle screws. There were 15 females and 9 males, with an average age of 64.8 years and a mean body mass index of 25.5 kg/m2. The mean operating time was 201.8 min. The mean fluoroscopic time was 26.8 s. The mean radiation dose of the area dose product was 0.0706 mGy∗m2. The mean radiation dose of air kerma was 6.0 mGy. The mean radiation dose of the entrance skin dose was 11.31 mGy. Postoperative computed tomography scans demonstrated 93 pedicle screws confined to the pedicle (97%) and three pedicle screw breaches (3.2%; two lateral, one medial). A patient with screw deviation of the medial pedicle wall developed right-foot numbness necessitating reoperation. There were no complications after reoperation. The average added time with this combined procedure was 39 min (range 16-69 min) per patient. CONCLUSIONS This novel pedicle screw insertion technique compares favorably with other reports in terms of radiation exposure reduction and accuracy and is also useful from the viewpoint of avoiding direct radiation exposure to hands and fingers. It is economical because it uses existing spinal surgical instrumentation.
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Affiliation(s)
- Takeshi Oki
- Department of Orthopedic Surgery, Yuki Hospital, 9629-1 Yuki, Yuki-City 307-0001, Ibaraki, Japan
- Correspondence: ; Tel.: +81-296334161
| | - Alan Kawarai Lefor
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-City 329-0498, Tochigi, Japan
| | - Kentaro Nakamura
- Department of Orthopedic Surgery, Yuki Hospital, 9629-1 Yuki, Yuki-City 307-0001, Ibaraki, Japan
| | - Takahiro Higashi
- Department of Orthopedic Surgery, Shin Oyama City Hospital, 2251-1 Hitotonoya, Oyama-City 323-0827, Tochigi, Japan
| | - Isao Oki
- Department of Orthopedic Surgery, Yuki Hospital, 9629-1 Yuki, Yuki-City 307-0001, Ibaraki, Japan
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Schmidt FA, Lekuya HM, Kirnaz S, Hernandez RN, Hussain I, Chang L, Navarro-Ramirez R, Wipplinger C, Rawanduzy C, Härtl R. Novel MIS 3D NAV Single Step Pedicle Screw System (SSPSS): Workflow, Accuracy and Initial Clinical Experience. Global Spine J 2022; 12:1098-1108. [PMID: 33430625 PMCID: PMC9210221 DOI: 10.1177/2192568220976393] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Prospective case series. OBJECTIVE SSPSS (single step pedicle screw system) was developed for minimally invasive spine surgery. We performed this study to report on safety, workflow, and our initial clinical experience with this novel technique. METHODS The prospective study was conducted on patients who underwent pedicle screw fixation between October 2017 and April 2018 using a novel single step 3D navigated pedicle screw system for MIS. Outcome measurements were obtained from intraoperative computerized tomography. The images were evaluated to determine pedicle wall penetration. We used a grading system to assess the severity of the pedicle wall penetration. Breaches were classified as grade 1 (<2 mm), grade 2 (2-4 mm), or grade 3 (<4 mm),1 and as cranial, caudal, medial, and lateral. RESULTS Our study includes 135 screws in 24 patients. SSPSS eliminated K-wires and multiple steps traditionally necessary for MIS pedicle screw insertion. The median time per screw was 2.45 minutes. 3 screws were corrected intraoperatively. Pedicle wall penetration occurred in 14 screws (10%). Grade 1 breaches occurred in 4 screws (3%) and grade 2 breaches occurred in 10 screws (7%). Lateral breaches were observed more often than medial breaches. The accuracy rate in our study was 90% (Grade 0 breach). No revision surgeries were needed and no complications occurred. CONCLUSIONS Our study suggests that SSPSS could be a safe, accurate, and efficient tool. Our accuracy rate is comparable to that found in the literature.
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Affiliation(s)
- Franziska A. Schmidt
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA.,Franziska A. Schmidt, Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, 525 East 68th Street, Box 99, New York, NY 10065, USA.
| | - Hervé M. Lekuya
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Sertac Kirnaz
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Robert Nick Hernandez
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Louis Chang
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Christoph Wipplinger
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Cameron Rawanduzy
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
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Huned D, Kumaran A, Lee LS, Tiwari RV. Case of flank pain from ureteral injury after lumbar laminectomy. BMJ Case Rep 2021; 14:14/4/e241170. [PMID: 33910802 PMCID: PMC8094358 DOI: 10.1136/bcr-2020-241170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of an iatrogenic complete left proximal ureteric injury after a lumbar 1 laminectomy and intradural tumour excision and lumbar 4/5 transforaminal lumbar interbody fusion. Initial management included a percutaneous nephrostomy for urinary diversion followed by definitive urinary reconstruction with an ileal ureter.
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BENITES VINICIUSDEMELDAU, SPARAPANI FABIOVEIGADECASTRO, IUNES EDUARDOAUGUSTO, ONISHI FRANZJOOJI, SALATI THIAGO, CAVALHEIRO SERGIO, PAZ DANIELDEARAÚJO. MINIMALLY INVASIVE LUMBAR ARTHRODESIS AND PERCUTANEOUS PEDICLE SCREWS: A SYSTEMATIC REVIEW. COLUNA/COLUMNA 2020. [DOI: 10.1590/s1808-185120201904228299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT A systematic review of the literature was performed in order to organize, evaluate, and select evidences available about the safety and efficacy of minimally invasive percutaneous arthrodesis with percutaneous pedicle screws in the treatment of patients with degenerative disc disease (and other spinal pathologies) as compared to conventional arthrodesis. PubMed, EMBASE and Cochrane Library databases were consulted to locate clinical trials and case reports/case series published in English between 2014 and 2019. After selection according to the inclusion/exclusion criteria, 21 of the 197 articles identified were chosen for a complete reading and used for the present review. Although the level of evidence of most of the studies included made the demonstration of efficacy and superiority among the surgical techniques reviewed difficult, the findings related to the minimally invasive procedure indicate a safe and reliable approach for the treatment of lumbar diseases. Level of evidence II; Systematic review of literature.
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Turgut M, Turgut AT, Dogra VS. Iatrogenic Ureteral Injury as a Complication of Posterior or Lateral Lumbar Spine Surgery: A Systematic Review of the Literature. World Neurosurg 2019; 135:280-296. [PMID: 31887462 DOI: 10.1016/j.wneu.2019.12.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/18/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Iatrogenic ureteral injury associated with lumbar spine surgery is an uncommon but devastating complication with associated medicolegal implications. METHODS We performed a systematic review of the English language literature published between 1954 and 2019, accessed through 4 popular databases. We found 44 articles (28 case reports, 9 case-based reviews, 4 case series, 1 original article, 1 case illustration, and 1 pictorial) containing 46 cases of ureteral injuries after posterior or lateral lumbar spine surgery. RESULTS Except for 5 cases with insufficient data, 24 of the remaining 41 patients were female and 17 were male, with ages ranging from 16 years to 83 years. Excluding 4 cases without enough information, initial diagnoses of lumbar disc herniation (n = 33) or lumbar spinal stenosis (n = 4), spondylolisthesis (n = 3), degenerative disc disease (n = 1), and failed back surgery syndrome (n = 1) were reported from 18 countries; 54% of patients were from the United States, Japan, or Turkey. The interval from spinal surgery to restorative surgery ranged from <24 hours to 1 month to 1 year; in 48% of patients, it was >1 week, and 90% of patients recovered completely. Initial surgery was combined with vascular injury in 15% of patients. CONCLUSIONS Ureteral injury associated with lumbar spine surgery is overreported in developed or developing countries. It should be considered in the differential diagnosis of any patient who presents with symptoms of acute abdomen after lumbar spine surgery, and patients who underwent restorative surgery had a good prognosis.
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Affiliation(s)
- Mehmet Turgut
- Department of Neurosurgery, Aydın Adnan Menderes University Faculty of Medicine, Efeler, Aydın, Turkey
| | - Ahmet Tuncay Turgut
- Department of Radiology, Yüksek İhtisas University Faculty of Medicine, Balgat, Ankara, Turkey.
| | - Vikram S Dogra
- Department of Imaging Sciences, University of Rochester Medical Center School of Medicine and Dentistry, Rochester, New York, USA
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Hong CH, Jung KJ, Soh JW, Won SH, Hong SJ, Kim CH, Lee HS, Wang SD, Lee WS, Kim WJ. Acute rib fracture caused by preoperative positioning for direct lateral interbody fusion: A case report. Medicine (Baltimore) 2019; 98:e14700. [PMID: 30813220 PMCID: PMC6407977 DOI: 10.1097/md.0000000000014700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE Degenerative spondylolisthesis is defined as forward slippage of a vertebra with respect to the underlying vertebra and is associated with the induction of lumbar canal stenosis. The use of anterior column support for degenerative lumbar conditions has been well documented. Direct lateral interbody fusion (DLIF) gains access via a lateral approach through the retroperitoneal fat and psoas muscle. It avoids many of the access-related complications yet comes with its own risks and limitations. The location of the iliac wing precludes exposure of the L5-S1 disc space and may make L4-5 surgery difficult. Therefore, accurate preoperative patient positioning is essential. PATIENT CONCERNS A 71-year-old female with a body mass index (BMI) of 39.2 kg/m (height 155.9 cm, weight 79.5 kg) presented with lumbar pain radiating to the left lower limb. She complained of neurologic claudication with more than 100 m ambulation. DIAGNOSIS Plain standing view on spine radiography revealed L4-5 spondylolisthesis and disc-space narrowing. Magnetic resonance imaging (MRI) revealed severe L4-5 bilateral foraminal stenosis. After the first surgery, simple rib cage radiography was performed to examine the source of her right-sided flank pain and it revealed acute fracture of the right ninth and tenth ribs. INTERVENTIONS The patient was laterally positioned on the table in an extreme bending position. The intervertebral cage was inserted in the L4-5 disc space and disc height was restored. With respect to the rib fracture, treatment was conservative. OUTCOMES The patient's radiating pain was immediately relieved and her lower back pain disappeared at 3 months after surgery. The patient reported right-sided flank pain after the first surgery. Simple rib cage radiography was performed and revealed fracture of the right ninth and tenth ribs. Follow-up assessments conducted 2 months later revealed complete bony union. LESSONS DLIF avoids many access-related complications. However, it is associated with other intraoperative complications, including injury to the lumbar nerve root and plexus. In addition, there are preoperative complications associated with improper patient placement on the table. In this case, the patient's obesity and strict positional requirements resulted in rib fracture. We suggest that surgeons consider this complication and exercise care in preoperative positioning.
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Affiliation(s)
- Chang Hwa Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
| | - Ki Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
| | - Jae Wan Soh
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
| | - Sung Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu
| | - Si John Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
| | - Chang Hyun Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
| | - Hong Seop Lee
- Department of Orthopaedic Surgery, Nowon Eulji Medical Center, Eulji University, Nowon-gu, Seoul, Korea
| | - Soon Do Wang
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
| | - Won Seok Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
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Lai CJ, Chang MY, Huang PC, Chu YC. Complete ureter avulsion causing a long defect as a complication of posterior spine fusion: a rare case treated with nonrobotic laparoscopic repair. Res Rep Urol 2019; 11:15-19. [PMID: 30697534 PMCID: PMC6342138 DOI: 10.2147/rru.s189259] [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] [Indexed: 11/23/2022] Open
Abstract
Purpose Ureter avulsion, a challenging urologic complication, has been rarely found in lumbar spine surgeries. Once ignored, the leaked urine usually leads to significant morbidity and also makes further repair more difficult. We present an unusual ureter injury causing a long defect which occurred in posterior spine fusion; immediate repair was performed with minimal invasion. Case presentation A 61-year-old female was receiving microscopic spine fusion (transforaminal lumbar interbody fusion) for her L3-L5 spondylosis. Ureter avulsion with one 3-cm defect occurred unexpectedly. We confirmed urine extravasation promptly, and performed end-to-end ureteroureterostomy with laparoscopy. Retrograde double-J stenting was indwelled. Her postoperative condition was uneventful. Conclusion This rare case with good outcome highlights the importance of early diagnosis and immediate repair for complete ureter avulsion. We prove that reanastomosis for ureter loss as much as 3 cm is feasible with laparoscopy in regional hospitals where a robot is not available. To deal with large gaps between stumps, adequate kidney mobilization is required before anastomosis.
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Affiliation(s)
- Chien-Jung Lai
- Division of Urology, Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan,
| | - Ming-Yuan Chang
- Division of Neurosurgery, Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Po-Chien Huang
- Division of Urology, Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan,
| | - Yuan-Chung Chu
- Division of Urology, Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan,
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