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Sucu HK, Sevin İE, Gürkan G. Modified Tap-drilling Technique for Mid-cervical Pedicle Screw Placement: A Case Series of 473 Consecutive Screws. Clin Spine Surg 2024; 37:E269-E277. [PMID: 38490975 DOI: 10.1097/bsd.0000000000001577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 11/29/2023] [Indexed: 03/18/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTION To report our modified tap-drilling technique for mid-cervical pedicle screw placement and to evaluate its safety and accuracy. SUMMARY OF BACKGROUND DATA Cervical pedicle screw fixation, which provides a strong stabilization, has been a major concern due to the potential risks to neurovascular structures despite its increasing use. Several insertion techniques have been described so far to improve the cervical pedicle screw placement accuracy. METHODS This study retrospectively reviewed patients who underwent mid-cervical (C3-C6) pedicle screw fixation between September 2005 and September 2020. Laminectomy, laminoforaminotomy, or notch-referred anatomic landmark methods were used to adjust the entry point and the direction of the screws. After the cortical bone was removed at the entry point with a diamond burr, the cancellous bone was slowly drilled with a hand drill starting from 8 to 10 millimeters in length. Then, all of the bone walls were checked with a ball-tip probe to determine if there was any breach. The procedure was repeated several times. After completing the drilling, the screw was inserted without tapping. The breach rate of pedicle screws was analyzed on postoperative computed tomography scans. RESULTS A total of 473 mid-cervical pedicle screws were placed in 122 consecutive patients. No navigation or computer-assisted system was used, and the first 2 authors inserted all of the screws. All patients completed the surgery, and no evident intraoperative complications occurred. Postoperative CT scans were obtained for 405 screws. Although deviation was observed for 131 pedicle screws, a critical deviation was observed for only 25 pedicle screws. CONCLUSIONS Cervical pedicle screw insertion is a risky but applicable technique. Checking all of the bone walls with a ball-tip probe before gradually advancing the hand drill in small amounts, as presented in this article, may lead to the safe and effective placement of cervical pedicle screws.
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Affiliation(s)
- Hasan Kâmil Sucu
- Department of Neurosurgery, İzmir Kâtip Çelebi University, Atatürk Research and Training Hospital
| | - İsmail Ertan Sevin
- Department of Neurosurgery, İzmir Kâtip Çelebi University, Atatürk Research and Training Hospital
| | - Gökhan Gürkan
- Department of Neurosurgery, İzmir Atatürk Research and Training Hospital, İzmir, Turkey
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Pereira-Duarte M, Gagliardi M, Carazzo CA, Camino-Willhuber G, Gotfryd A, Rogers M, Guiroy A. Comparison of complication rates between anterior versus posterior approaches for treating unstable Hangman's fracture. A systematic review and meta-analysis. World Neurosurg X 2024; 21:100245. [PMID: 38221952 PMCID: PMC10787285 DOI: 10.1016/j.wnsx.2023.100245] [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: 09/27/2023] [Accepted: 10/05/2023] [Indexed: 01/16/2024] Open
Abstract
Study design Systematic Review and Meta-analysis. Objective To compare the complication rates associated with anterior and posterior approaches for the surgical treatment of unstable hangman's fractures. Methods A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in PubMed, Web of Science, and Scopus databases to identify comparative studies reporting complications of anterior versus posterior approaches for the treatment of unstable hangman's fractures. Results The search yielded 1163 papers from which 5 studies were fully included. One hundred fifteen (115) patients were operated on using an anterior approach versus 65 through a posterior approach. The average complication rates for the anterior and posterior approaches were 26.1 % and 13.8 %, respectively. No complications following the anterior approach required pharmacological or surgical intervention (Clavien-Dindo, Grade 1), while 88.9 % of complications following the posterior approach did (Clavien-Dindo, Grade 2). Conclusion No significant differences in the complication rates were found when comparing anterior versus posterior surgery for treating a C2 traumatic spondylolisthesis. However, most of the complications presented in the posterior surgery group were more severe.
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Affiliation(s)
- Matias Pereira-Duarte
- Adult Spine Unit, Hospital Italiano de Buenos Aires, Pte. Peron st. 4190, ZC 1199, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | - Gaston Camino-Willhuber
- Adult Spine Unit, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Alberto Gotfryd
- Santa Casa of São Paulo Medical School and Hospitals, Sao Paulo, Brazil
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Zeng Y, Huang Z, Huang Z, Cheng Y, Zhu Q, Ji W, Jiang H. Ipsilateral Fixation and Reconstruction of the Cervical Spine after Resection of a Dumbbell Tumor Via a Unilateral Posterior Approach: A Case Report and Biomechanical Study. Orthop Surg 2023; 15:2435-2444. [PMID: 37431728 PMCID: PMC10475664 DOI: 10.1111/os.13798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 07/12/2023] Open
Abstract
OBJECTIVE There is lack of an internal fixation following resection of a dumbbell tumor by hemi-laminectomy and facetectomy that achieves adequate stability with less trauma. Unilateral fixation and reconstruction (unilateral pedicle screw and contralateral lamina screw fixation combined with lateral mass reconstruction, UPS + CLS + LM) may be an ideal technique to address this problem. A biomechanical comparison and a case report were designed to evaluate its spinal stability and clinical effect. METHODS Seven fresh-frozen human subcervical specimens were used for the biomechanical testing. The conditions tested were: (1) intact; (2) injured (single-level hemi-laminectomy and facetectomy); (3) unilateral pedicle screw (UPS) fixation; (4) UPS fixation combined with lateral mass (LM) reconstruction (UPS + LM); (5) UPS fixation and contralateral lamina screw fixation (UPS + CLS); (6) UPS + CLS + LM; (7) UPS fixation and contralateral transarticular screw fixation (UPS + CTAS); (8) bilateral pedicle screw (BPS) fixation. Range of motion (ROM) and neutral zone (NZ) were obtained at C5-C7 segment under eight conditions. In addition, we report the case of a patient with a C7-T1 dumbbell tumor that was treated by UPS + CLS + LM technique. RESULTS Except left/right lateral bending and right axial rotation (all, p < 0.05), ROM of UPS + CLS + LM condition in other directions was similar to that of BPS condition (all, p > 0.05). There was no significant difference between UPS + CLS + LM and the UPS + CTAS condition in other directions of ROM (all, p > 0.05), except in left/right axial rotation (both, p < 0.05). Compared to UPS + CLS condition, left/right lateral bending ROM of UPS + CLS + LM condition were significantly reduced (both, p < 0.05). UPS + CLS + LM condition significantly reduced ROM in all directions compared to UPS and UPS + LM condition (all, p < 0.05). Similarly, except lateral bending (p < 0.05), there was no difference in NZ in other directions between UPS + CLS + LM and BPS condition (both, p > 0.05). There was no significant difference between UPS + CLS + LM and UPS + CTAS condition in NZ in all directions (all, p > 0.05). Axial rotation NZ of UPS + CLS + LM condition was significantly reduced compared to UPS + CLS condition (p < 0.05). Compared to UPS and UPS + LM condition, NZ of UPS + CLS + LM condition was significantly reduced in all directions (all, p < 0.05). The patient's imaging examination at 3 months postoperatively indicated that the internal fixation did not move and the graft bone was seen with fusion. CONCLUSION After resection of a dumbbell tumor in the cervical spine, UPS + CLS + LM technique is a reliable internal fixation method to provide sufficient immediate stability and promote postoperative bone fusion.
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Affiliation(s)
- Yongqiang Zeng
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Zhiping Huang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Zucheng Huang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Yongquan Cheng
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Qing'an Zhu
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Wei Ji
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Hui Jiang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
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Lee SH, Park JH, Lee JB, Lee HJ, Kim IS, Hur JW, Hong JT. Safety and Efficacy of Intraoperative Doppler Sonography-Assisted Cervical Pedicle Screw Fixation-A Retrospective Comparison with Conventional Pedicle Screw Implantation. Global Spine J 2023; 13:1592-1601. [PMID: 35193407 PMCID: PMC10448084 DOI: 10.1177/21925682211041965] [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 A Retrospective Cohort Study. OBJECTIVE To introduce a new Doppler sonography-assisted pedicle screw fixation technique that enables vertebral artery (VA) monitoring during surgery and compares the accuracies of Doppler sonography-assisted cervical pedicle screw fixation and the conventional technique. METHODS This retrospective study was performed on 164 consecutive patients that underwent pedicle-based screw fixation from C2 to C6 between January 2013 and August 2020. Surgery was performed without intraoperative Doppler sonography in 84 cases (the Control group) or with intraoperative Doppler sonography in 80 cases (the Doppler group). Proper positioning of pedicle screws was graded, and the incidences of VA injury and screw breach in the Control and Doppler groups were compared. RESULTS Three hundred and ninety-nine screws were placed in the 164 patients (Doppler, 186 screws; Control, 213 screws). The percentages of well-positioned screws in the two groups were significantly different (Doppler, 97.8%; Control, 85.0%). There were two cases of VA injury in the Control group, an incidence of 2.4%, but no case in the Doppler group. CONCLUSION Doppler sonography can be used intraoperatively to help guide the trajectory of the cervical pedicle screw insertion. It can detect the VA inside the screw trajectory and may reduce the risk of VA injury during cervical pedicle screw fixation.
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Affiliation(s)
- Sang Hyo Lee
- Department of Neurosurgery, The Catholic University of Korea Eunpyeong St Mary’s Hospital, Eunpyeong-gu, Korea
| | - Jong-Hyeok Park
- Department of Neurosurgery, The Catholic University of Korea Incheon St Mary’s Hospital, Incheon, Korea
| | - Jong Beom Lee
- Department of Neurosurgery, Chungbuk National University, Cheongju, Korea
| | - Ho Jin Lee
- Department of Neurosurgery, The Catholic University of Korea St Vincent’s Hospital, Suwon, Korea
| | - Il Sup Kim
- Department of Neurosurgery, The Catholic University of Korea St Vincent’s Hospital, Suwon, Korea
| | - Jeong Woo Hur
- Department of Neurosurgery, The Catholic University of Korea Eunpyeong St Mary’s Hospital, Eunpyeong-gu, Korea
| | - Jae Taek Hong
- Department of Neurosurgery, The Catholic University of Korea Eunpyeong St Mary’s Hospital, Eunpyeong-gu, Korea
- Department of Neurosurgery, The Catholic University of Korea St Vincent’s Hospital, Suwon, Korea
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Richter M. [Spinal navigation with preoperative computed tomography]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:3-16. [PMID: 36446936 DOI: 10.1007/s00064-022-00791-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/13/2022] [Accepted: 06/26/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Safe placement of posterior cervical-sacral pedicle screws, S2-Ala-iliac screws, iliac screws, transarticular screws C1/2, translaminar screws C2 or cervical lateral mass screws under the guidance of spinal navigation. INDICATIONS All posterior spinal instrumentations with screws: instabilities and deformities of rheumatic, traumatic, neoplastic, infectious, iatrogenic or congenital origin; multilevel cervical spinal stenosis with degenerative instability or kyphosis of the affected spinal segment. CONTRAINDICATIONS There are no absolute contraindications for spinal navigation. SURGICAL TECHNIQUE Cervical spine: Prone position on a gel mattress, rigid head fixation, e.g., with Mayfield tongs; if appropriate, closed reduction under lateral image intensification; thoracic + lumbar spine: prone position on a cushioned frame; midline posterior surgical approach at the level of the segments to be instrumented; if necessary, open reduction; insertion of the cervical/upper thoracic screws under the guidance of spinal navigation; if necessary, posterior decompression; instrumentation longitudinal rods; if fusion is to be obtained, decortication of the posterior bone elements with a high-speed burr and onlay of cancellous bone or bone substitutes. POSTOPERATIVE MANAGEMENT In stable instrumentations, no postoperative immobilization with orthosis is necessary, removal of drains (if used) 2-3 days postoperatively (postop), removal of the sutures 14 days postop, clinical and x‑ray controls 3 and 12 months postop or in case of clinical or neurological deterioration. RESULTS Numerous studies showed that the use of spinal navigation significantly reduces implant malplacement rates, complications, and revision surgery. Furthermore, intraoperative radiation exposure to the operation team can be reduced by up to 90%.
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Affiliation(s)
- Marcus Richter
- Wirbelsäulenzentrum, St. Josefs-Hospital GmbH, Beethovenstr. 20, 65189, Wiesbaden, Deutschland.
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Bohl MA, Farber SH, Kakarla UK, Mirzadeh Z, Turner JD. Technical Feasibility of Subaxial Cervical Pedicle Screws for Distal Anchoring of Occipitocervical Fixation Constructs in the Mid-Cervical Spine: Early Clinical Experience. Cureus 2022; 14:e25964. [PMID: 35855245 PMCID: PMC9285641 DOI: 10.7759/cureus.25964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 11/05/2022] Open
Abstract
Occipitocervical fixation and fusion (OCF) is performed for patients who have destabilizing traumatic injuries or pathologies affecting the complex bony and ligamentous structures of the occipitoatlantal and atlantoaxial joint structures. Distal fixation failure and pseudoarthrosis are known risks of these constructs, especially for those constructs ending in the mid-cervical spine. We present the technical feasibility of using cervical pedicle screws (CPSs) as distal fixation anchors to strengthen OCF constructs ending in the mid-cervical spine and present a case series describing our early clinical experience with this technique. We used a freehand technique to place subaxial pedicle screws in the mid-cervical spine as the distal fixation point in OCF constructs. This technique involves performing a laminotomy to provide direct visualization of the pedicle borders to safely guide freehand pedicle screw placement. Our early clinical experience with this technique is presented. Three patients received OCF constructs ending in the mid-cervical subaxial spine between C3 and C6. CPSs were placed at the distal vertebra in each construct. Stable instrumentation and arthrodesis were confirmed postoperatively in all patients. This freehand technique uses direct visualization of the pedicle to aid in safe and accurate subaxial pedicle screw placement. CPS placement is clinically feasible and increases the robustness of OCF constructs in appropriately selected patients. Larger case series are needed to further validate the safety and effectiveness of this technique.
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Zhang K, Chen H, Chen K, Yang P, Yang H, Mao H. O-Arm Navigated Cervical Pedicle Screw Fixation in the Treatment of Lower Cervical Fracture-Dislocation. Orthop Surg 2022; 14:1135-1142. [PMID: 35524652 PMCID: PMC9163967 DOI: 10.1111/os.13227] [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] [Received: 06/07/2020] [Revised: 01/12/2022] [Accepted: 01/19/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of cervical pedicle screw (CPS) placement with O-arm navigation in the treatment of lower cervical fracture-dislocation. METHODS A retrospective clinical study was performed involving 42 consecutive patients with lower cervical spine fracture-dislocation who underwent CPS fixation surgery with O-arm navigation (CPS group) or received conventional lateral mass screw (LMS) fixation surgery (LMS group) between August 2015 and August 2019. Accuracy of CPS position was evaluated by postoperative CT. The clinical parameters including preoperative and final follow-up Japanese Orthopaedic Association (JOA) score and American Spinal Injury Association (ASIA) Impairment Scale, preoperative Sub-axial Injury Classification (SLIC) score, number of fixation segments, operation time, intraoperative blood loss, injury mechanism, injury location, surgical complications were also assessed between the two groups. RESULTS In LMS group, the preoperative SLIC score was 7.5 ± 0.9, ASIA score improvement was 0.8 ± 0.5, JOA score improvement was 3.0 ± 1.8, mean operation time was 204 ± 89 min, intraoperative blood loss was 311 ± 127 ml. In CPS group, the preoperative SLIC score was 7.3 ± 1.2, ASIA score improvement was 0.9 ± 0.5, JOA score improvement was 3.2 ± 2.4, mean operation time is 241 ± 85 min, intraoperative blood loss is about 327 ± 120 ml. There was no significant difference in terms of above clinical parameters between the two groups (P > 0.05), the fixation segments in CPS group (3.5 ± 1.1) were less than that in LMS group (4.2 ± 0.7) (P = 0.037). The accuracy of CPS insertion was evaluated based on postoperative CT. Of all the 118 CPSs, 83 (70.3%) were defined as Grade 0; 27 (22.9%) as Grade 1; eight (6.8%) as Grade 2; and none as Grade 3. CPS malposition rate in this study was 6.8%. In this study, there was no direct intraoperative or postoperative complication caused by CPS or LMS insertion. All the operations were successfully completed in two groups. One of the patients in LMS group presented cerebrospinal fluid leak caused by bone fragment broken of the dural sac, which led to delayed incision healing. CPS group and LMS group both had two patients who suffered pulmonary infection after surgery. A total of 78.6% of the patients showed evidence of neurologic recovery. Satisfactory reduction was achieved in all cases and maintained throughout the follow-up duration. CONCLUSION In the treatment of lower cervical spine fracture-dislocation, cervical pedicle screw insertion with O-arm navigation is a safe and effective method for posterior fixation.
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Affiliation(s)
- Kai Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hao Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Yangzhou University, Yangzhou, China.,Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou, China
| | - Kangwu Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peng Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Huilin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haiqing Mao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Simulation Training in Spine Surgery. J Am Acad Orthop Surg 2022; 30:400-408. [PMID: 35446299 DOI: 10.5435/jaaos-d-21-00756] [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] [Received: 07/18/2021] [Accepted: 01/19/2022] [Indexed: 02/01/2023] Open
Abstract
Simulated surgery is part of a growing paradigm shift in surgical education as a whole. Various modalities from cadaver models to virtual reality have been developed and studied within the context of surgical education. Simulation training in spine surgery has an immense potential to improve education and ultimately improve patient safety. This is due to the inherent risk of operating the spine and the technical difficulty of modern techniques. Common procedures in the modern orthopaedic armamentarium, such as pedicle screw placement, can be simulated, and proficiency is rapidly achieved before application in patients. Furthermore, complications such as dural tears can be simulated and effectively managed in a safe environment with simulation. New techniques with steeper learning curves, such as minimally invasive techniques, can now be safely simulated. Hence, augmenting surgical education through simulation has great potential to benefit trainees and practicing orthopaedic surgeons in modern spine surgery techniques. Additional work will aim to improve access to such technologies and integrate them into the current orthopaedic training curriculum.
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Malikov A, Secen AE, Divanlioglu D, Gunerhan G, Ocal O, Gunduz UK. The feasibility of creating Image-Based Patient-Specific Drill Guides for the Atlantoaxial Instabilities using open-source CAD software and desktop 3D printers. World Neurosurg 2022; 163:e377-e383. [PMID: 35390495 DOI: 10.1016/j.wneu.2022.03.137] [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: 01/22/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE C1/2 cervical pedicle screw fixation is a well-known procedure for treating severely damaged and unstable C1/2 fractures. On the other hand, C1/C2 screw fixation is not safe and can lead to potentially disastrous consequences. The importance of personalized 3D printed navigational guides in avoiding these consequences cannot be overstated. MATERIALS AND METHODS We retrospectively reviewed the neuroimaging data of 16 patients who had undergone fixation for treatment of C1/2 diseases. We created patient-specific C1/2 models and drill guide models using open-source 3D editing software and a desktop 3D printer. The drill guides were then placed over the respective vertebrae models and fixated with 3.5 mm screws. Following fixation, the parts were scanned with a thin-slice (01 mm) CT scan, and the screw trajectories in the transverse and sagittal planes were measured at each level. RESULTS Of the total of 62 screws, 58 were type I (93.54%), 4 were type II (6.45%), and no screws were type III (Tab 2). The results showed that there was no significant deviation in the screw trajectories and the accuracy of the drill guides was 93.54% (Table 3). In our study, type I and type II screws were deemed acceptable, and the acceptable rates of C1/2 screw fixation were 100%. CONCLUSIONS In this preclinical study, we demonstrated that it is possible to create patient-specific pedicle drill guides using open source editing software and a commercially available desktop PLA printer, resulting in high accuracy rates in pedicle screw placement in C1/2 patient models.
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Affiliation(s)
- Azad Malikov
- Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey.
| | - Ahmet Eren Secen
- Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey
| | | | - Goksal Gunerhan
- Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey
| | - Ozgur Ocal
- Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey
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Oberkircher L, Riemenschneider J, Bäumlein M, Knauf T, Bliemel C, Ruchholtz S, Krüger A. Impact of 2 different posterior screw fixation techniques on primary stability in a cervical translational injury model: A biomechanical evaluation. Medicine (Baltimore) 2022; 101:e28866. [PMID: 35363191 PMCID: PMC9282136 DOI: 10.1097/md.0000000000028866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/31/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In case of injuries to the subaxial cervical spine, especially in osteoporotic bone, the question of the most stable operative technique arises. There are several techniques of screw fixation available regarding dorsal stabilization. This study investigates 2 techniques (lateral mass screws (LMS) vs cervical pedicle screws (CPS)) in the subaxial cervical spine regarding primary stability in a biomechanical testing using a translational injury model. METHODS A total of 10 human formalin fixed and 10 human fresh-frozen specimens (C 4 - T 1) were investigated. Specimens were randomized in 2 groups. Fracture generation of a luxation injury between C 5 and C 6 was created by a transection of all ligamentous structures as well as the intervertebral disc and a resection of the facet joints.Dorsal stabilization of C 4/C 5 to C 6/C 7 was performed in group A by lateral mass screws, in group B by pedicle screws. In the biomechanical testing, the specimens were loaded at 2 N/s in translation direction until implant failure. RESULTS Formalin fixed specimen: Mean load failure was 513.8 (±86.74) Newton (N) for group A (LMS) and 570.4 (±156.5) N for group B (CPS). There was no significant difference (P = .6905).Fresh frozen specimen: Mean load failure was 402.3 (±96.4) N for group A (LMS) and 500.7 (±190.3) N for group B (CPS). There was no significant difference (P = .4206). CONCLUSION In our loading model respecting the translational injury pattern and a flexion movement we could not verify statistically significant differences between lateral mass screws and cervical pedicle screws. Mean loading failure was slightly higher in the CPS group though.
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Affiliation(s)
- Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Location Marburg, Germany
| | - Julia Riemenschneider
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Location Marburg, Germany
| | - Martin Bäumlein
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Location Marburg, Germany
| | - Tom Knauf
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Location Marburg, Germany
| | - Christopher Bliemel
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Location Marburg, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Location Marburg, Germany
| | - Antonio Krüger
- Department of Trauma Surgery, Orthopaedics, Spine Surgery and Pediatric Trauma Surgery, Asklepios Hospital Lich, Lich, Germany
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Cho W, Le JT, Shimer AL, Werner BC, Glaser JA, Shen FH. The Feasibility of Translaminar Screws in the Subaxial Cervical Spine: Computed Tomography and Cadaveric Validation. Clin Orthop Surg 2022; 14:105-111. [PMID: 35251547 PMCID: PMC8858891 DOI: 10.4055/cios21059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/28/2021] [Accepted: 10/14/2021] [Indexed: 11/11/2022] Open
Abstract
Background The use of translaminar screws may serve as a viable salvage method for complicated cases. To our understanding, the study of the feasibility of translaminar screw insertion in the actual entire subaxial cervical spine has not been carried out yet. The purpose of this study was to report the feasibility of translaminar screw insertion in the entire subaxial cervical spine. Methods Eighteen cadaveric spines were harvested from C3 to C7 and 1-mm computed tomography (CT) scans and three-dimensional reconstructions were created to exclude any bony anomaly. Thirty anatomically intact segments were collected (C3, 2; C4, 3; C5, 3; C6, 8; and C7, 14), and randomly arranged. Twenty-one segments were physically separated at each vertebral level (group S), while 9 segments were not separated from the vertebral column and left in situ (group N–S). CT measurement of lamina thickness was done for both group S and group N–S, and manual measurement of various length and angle was done for group S only. Using the trajectory proposed by the previous studies, translaminar screws were placed at each level. Screw diameter was the same or 0.5 mm larger than the proposed diameter based on CT measurement. Post-insertion CT was performed. Cortical breakage was checked either visually or by CT. Results When 1° and 2° screws of the same size were used, medial cortex breakage was found 13% and 33% of the time, respectively. C7 was relatively safer than the other levels. With larger-sized screws, medial cortex breakage was found in 47% and 46% of 1° and 2° screws, respectively. There were no facet injuries due to the screws in group N–S. Conclusions Translaminar screw insertion in the subaxial cervical spine is feasible only when the lamina is thick enough to avoid any breakage that could lead to further complications. The authors do not recommend inserting translaminar screws in the subaxial cervical spine except in some salvage cases in the presence of a thick lamina.
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Affiliation(s)
- Woojin Cho
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, New York, NY, USA
| | - Jason T. Le
- Department of Orthopaedic Surgery, Banner Estrella Medical Center, Phoenix, AZ, USA
| | - Adam L. Shimer
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John A. Glaser
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Francis H. Shen
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
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12
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Jin C, Wang Z, Liu P, Liu Y, Wang Z, Xie N. A biomechanical analysis of anterior cervical discectomy and fusion alone or combined cervical fixations in treating compression-extension injury with unilateral facet joint fracture: a finite element study. BMC Musculoskelet Disord 2021; 22:938. [PMID: 34758793 PMCID: PMC8582196 DOI: 10.1186/s12891-021-04814-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/21/2021] [Indexed: 11/12/2022] Open
Abstract
Background Compression-extension injury with unilateral facet joint fracture is one of the most devastating injuries of subaxial cervical spine. However, it is not yet clear which fixation technique represents the optimal choice in surgical management. This study aims to assess the construct stability at the operative level (C4/C5 cervical spine) following anterior cervical discectomy and fusion (ACDF) alone and combined fixation techniques (posterior-anterior fixations). Methods A previously validated three-dimensional C2-T1 finite element model were modified to simulate surgical procedures via the anterior-only approach (ACDF) and combined cervical approach [(transarticular screw, lateral mass screw, unilateral pedicle screw, bilateral pedicle screw) + ACDF, respectively] for treating compression-extension injury with unilateral facet joint fracture at C4/C5 level. Construct stability (range of rotation, axial compression displacement and anterior shear displacement) at the operative level was comparatively analyzed. Results In comparison with combined fixation techniques, a wider range of motion and a higher maximum von Mises stress was found in single ACDF. There was no obvious difference in range of motion among transarticular screw and other posterior fixations in the presence of anterior fixation. In addition, the screws inserted by transarticular screw technique had high stress concentration at the middle part of the screw but much less than 500 MPa under different conditions. Furthermore, the variability of von Mises stress in the transarticular screw fixation device was significantly lower than ACDF but no obvious difference compared with other posterior fixations. Conclusions Of the five fixation techniques, ACDF has proven poor stability and high structural stress. Compared with lateral and pedicle screw, transarticular screw technique was not worse biomechanically and less technically demanding to acquire in clinical practice. Therefore, our study suggested that combined fixation technique (transarticular screw + ACDF) would be a reasonable treatment option to acquire an immediate stabilization in the management of compression-extension injury with unilateral facet joint fracture. However, clinical aspects must also be regarded when choosing a reconstruction method for a specific patient.
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Affiliation(s)
- Chen Jin
- Division of Spine Surgery, Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Zhong Wang
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, China
| | - Peng Liu
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, China.,State Key Laboratory of Trauma: Burns & Combined Wound, Institute for Traffic Medicine of Army Medical University, Chongqing, China
| | - Yaoyao Liu
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, China
| | - Zhanwei Wang
- Division of Spine Surgery, Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Ning Xie
- Division of Spine Surgery, Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China.
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13
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Sandeep S, Dahapute AA, Balasubramanian SG, Nashikkar P, Marathe N, Sonavane SR. Evaluation of clinicoradiological outcomes of lateral vertebral notch referred pedicular screws entry point in subaxial cervical spine by freehand technique. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:240-247. [PMID: 34728990 PMCID: PMC8501819 DOI: 10.4103/jcvjs.jcvjs_28_21] [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: 02/28/2021] [Accepted: 06/07/2021] [Indexed: 11/04/2022] Open
Abstract
Purpose: Cervical pedicle screws (CPSs), though associated with complications and steep learning curve, have significantly increased strength and stability as compared to any other posterior instrumentation methods. Using anatomical referral techniques, pedicle screws can be inserted safely with a high accuracy rate obviating the need for anterior stabilization. Our present study aims to investigate the safety and outcomes of lateral vertebral notch (LVN) referred entry point for subaxial CPSs by freehand technique. Materials and Methods: We retrospectively studied 22 patients who underwent CPS fixation. Computed tomography (CT) scan with angiography was done in each case to know the anatomy, characteristics, and anomalies of each pedicle. Postoperative CT scan was done to look for any breach in cervical pedicles. We used free hand technique for insertion of subaxial cervical pedicles taking LVN as a reference point. The authors used the medial wall of the cervical pedicles as a safe guide for the probes that walked along it. Results: Eighty screws were inserted in total in the study group. Mean angle of screw with sagittal axis of vertebrae was 23.43° ± 9.279°. Range of angle used was 6°–40°. Perforation occurred in 11 pedicle screws: C3 (2 out of 8, 25%), c5 (3 out of 20, 15%), and c4 (4 of 22, 18%). Out of 11 perforations, four were complete and seven were partial perforations. One complete medial perforation was associated with radiculopathy that required revision. Conclusion: The technique described in the study can be considered relatively safe, easy, and reliable method of inserting cervical pedicle screws with high accuracy (86.25%) and low complication rates (1.25%). However, meticulous preoperative planning is required.
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Affiliation(s)
- Sonone Sandeep
- Department of Orthopaedics, KEM Hospital, Mumbai, Maharashtra, India
| | | | | | - Piyush Nashikkar
- Department of Orthopaedics, KEM Hospital, Mumbai, Maharashtra, India
| | - Nandan Marathe
- Department of Orthopaedics, KEM Hospital, Mumbai, Maharashtra, India
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14
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Asuzu DT, Buchholz AL. MAZOR-X robotic-navigated percutaneous C2 screw placement for hangman's fracture: a case report. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:439-444. [PMID: 34734148 PMCID: PMC8511574 DOI: 10.21037/jss-20-676] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 04/25/2021] [Indexed: 05/26/2023]
Abstract
Robotic-navigated screw placement has potential for higher precision and accuracy. Robotic assistance is well-described in the lumbar spine, however only few studies have evaluated its use in the cervical spine. Surgical treatment for hangman's fractures after nonunion typically involves C2-3 anterior fusion or posterior occipito-cervical fusion. However, occipito-cervical fusion involves loss of mobility in the cervical spine with associated morbidity. We have previously described a minimally invasive approach using percutaneous screw fixation with X-ray navigation. Robotic assistance is ideally suited for cervical fusion given smaller bony anatomy and adjacent critical structures. We describe a young healthy patient who presented with a hangman's fracture initially managed conservatively with immobilization. She presented with nonunion and persistent symptoms. Surgical options considered included anterior cervical discectomy and fusion, or posterior cervical fusion with or without extension to the occiput. These options would have involved some loss of flexion/extension and rotational motion with associated morbidity. We performed percutaneous screw fixation of the hangman's fracture using MAZOR-X robotic navigation and achieved good radiographic fracture reduction with accurate screw placement. To our knowledge this is the first case of a robotic-assisted percutaneous screw fixation for a hangman's fracture. Robotic-navigated screw placement can be used safely and accurately for cervical spine fractures.
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Affiliation(s)
- David T. Asuzu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
- Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Avery L. Buchholz
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
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15
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Satake K, Kanemura T, Ito K, Tanaka S, Morita Y, Nakashima H, Ouchida J, Imagama S. Pedicle screw placement with use of a navigated surgical drill at subaxial cervical spine. J Clin Neurosci 2021; 88:28-33. [PMID: 33992198 DOI: 10.1016/j.jocn.2021.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/21/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE This study was performed to evaluate the accuracy of cervical pedicle screw (CPS) placement with use of a navigated surgical drill (ND) and to compare it with navigated manual probe (MP) at C3-C6. METHODS 47 consecutive patients (27 males and 20 females, 67.2 [33-91] years) underwent a posterior cervical fixation using CPSs under an intraoperative 3D - - CT based navigation system (total 207 CPSs). For initial probing, ND with 2.2-mm steel burr was used since Apr. 2017 (Group ND; 33 patients, 152 CPSs). MP was used earlier (Group MP; 14 patients, 55 CPSs). There were no other different procedures between the two groups. The accuracy of CPS placement was graded with postoperative CT and compared between the two groups. RESULTS There were no significant differences in the total perforation rates both in axial and sagittal planes between Groups ND and MP (axial; 7.2% vs. 14.5%, p = 0.25, sagittal; 10.5% vs. 14.5%, p = 0.46). However, the lateral and rostral perforation rates were significantly reduced in Group ND compared to Group MP (lateral: 36.4% vs. 87.5%, p = 0.04; rostral: 6.3% vs. 100%, p = 0.001). CONCLUSION Although ND did not decrease the total perforation rate significantly, it reduced the incidence of lateral and rostral perforation. ND is likely to make initial probing easier without a forcible manipulation which might cause vertebral rotation.
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Affiliation(s)
| | | | - Kenyu Ito
- Spine Center, Konan Kosei Hospital, Konan, Japan
| | | | | | | | - Jun Ouchida
- Department of Orthopedic Surgery, Nagoya University, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University, Nagoya, Japan
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16
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Bertram U, Schmidt TP, Clusmann H, Albanna W, Herren C, Riabikin A, Mueller CA, Blume C. Intraoperative Computed Tomography-Assisted Spinal Navigation in Dorsal Cervical Instrumentation: A Prospective Study on Accuracy Regarding Different Pathologies and Screw Types. World Neurosurg 2021; 149:e378-e385. [PMID: 33578024 DOI: 10.1016/j.wneu.2021.02.014] [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: 12/03/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intraoperative computed tomography (iCT) navigated dorsal instrumentation has been successfully introduced as a new clinical standard. The proximity of vital anatomic structures makes cervical spine instrumentation an especially delicate task. Therefore, navigated approaches might prove to be beneficial. In this study, the accuracy of conventional instrumentation was compared with iCT navigated dorsal cervical spine instrumentation with focus on cervical pedicle screws (CPSs) versus lateral mass screws (LMSs) and pathologies. METHODS We analyzed a prospective consecutive series of patients undergoing cervical dorsal instrumentation with iCT and spinal navigation and retrospectively analyzed a cohort that received conventional cervical instrumentation with C-arm fluoroscopy (control group). Accuracy was assessed with a modified Gertzbein-Robbins classification. Underlying pathologies were taken into account regarding accuracy in different entities. RESULTS Fifty-nine patients were treated using iCT (357 screws: 238 CPSs, 119 LMSs), and 98 patients underwent conventional instrumentation (632 screws: 69 CPSs, 563 LMSs). We achieved an initial accuracy of 93.28% (n = 220 screws) in the iCT group and 80.9% (n = 511 screws) in the control group (P < 0.001). Significant differences were found regarding the accuracy of CPS placement in cases of degenerative disorders (iCT vs. control; 94% vs. 63%; P < 0.001) and trauma (iCT vs. control; 88% vs. 72%; P < 0.05). iCT yielded favorable precision rates in regard to LMS placement (iCT vs. control; 94.2% vs. 82%; P < 0.05). CONCLUSIONS Accuracy of iCT navigated instrumentation was significantly higher than conventional instrumentation. An overall tendency toward the use of CPSs with iCT navigation is evident, increasing the mechanical properties of the construct. iCT appears to be especially beneficial in elective surgery cases of degenerative spinal disorders.
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Affiliation(s)
- Ulf Bertram
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Christian Herren
- Department of Orthopedic Trauma and Reconstructive Surgery, RWTH Aachen University, Aachen, Germany
| | | | | | - Christian Blume
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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17
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Hore N, Lücking H, Schmitt H, Buchfelder M, Brandner S. Pedicle Screw Instrumentation of the Cervicothoracic Junction in the Sitting Position using CT-guided Navigation: Application and Technical Aspects. J Neurol Surg A Cent Eur Neurosurg 2021; 82:176-181. [PMID: 33540455 DOI: 10.1055/s-0040-1718409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND We evaluate the feasibility and potential advantages of spinal CT navigation in the placement of pedicle screws at the cervicothoracic junction in the sitting position to counteract the anatomy-related limitations of 2D fluoroscopy. METHODS We retrospectively analyze the data from 15 patients who underwent CT-based navigation-guided placement of a total of 36 pedicle screws at the cervicothoracic junction in the sitting position. RESULTS CT-based spinal navigation is a useful method in increasing accuracy of pedicle screw instrumentation in the sitting position, successfully counteracting the anatomy-related limitations of 2D fluoroscopy at the cervicothoracic junction. CONCLUSION CT-based navigation-guided placement of pedicle screws at the cervicothoracic junction in the sitting position proved to be an accurate, safe, and user-friendly method.
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Affiliation(s)
- Nirjhar Hore
- Department of Neurosurgery, University of Erlangen, Erlangen, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen, Erlangen, Germany
| | - Hubert Schmitt
- Department of Anesthesiology, University of Erlangen, Erlangen, Germany
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18
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Faux I, Hall JL, Schwarz T, Clements DN, Ryan J. Comparing the accuracy of freehand, fluoroscopically guided and aiming device-assisted drilling in veterinary orthopaedic surgery. Vet Rec 2020; 187:e126. [PMID: 33033104 DOI: 10.1136/vr.105834] [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: 01/08/2020] [Revised: 07/15/2020] [Accepted: 08/06/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Drilling accuracy is essential in the correct positioning of implants and avoidance of iatrogenic damage to surrounding tissues. The use of augmented drilling methods has been documented as an approach to improving the accuracy of drilling. The aim of this study was to compare the accuracy of two augmented drilling methods (fluoroscopically guided and aiming device) to freehand (FH) drilling. METHODS Three experienced specialist surgeons and three veterinary surgeons without primary orthopaedic experience drilled into synthetic bone towards a target using the three different methods at three different angles (0°, 10° and 20°). The duration of drilling was recorded, and the accuracy of drilling was measured using photographs before and after drilling. RESULTS The two augmented methods were more accurate than FH drilling in synthetic bone, with the aiming device producing the greatest accuracy. Increased angulation of drilling decreased the drilling accuracy. Surgeon experience did not impact on drilling accuracy. Surgeon inexperience and augmented drilling methods both increased the time taken to drill. CONCLUSION The use of augmented drilling methods improved the accuracy of drilling, and surgeons should consider their use when drilling in anatomical regions where the margin of error is small.
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Affiliation(s)
- Ian Faux
- R(D)SVS, The University of Edinburgh, Edinburgh, UK
| | - Jon L Hall
- VetEd Specialists, VetEd Specialists Ltd, Quothquan, South Lanarkshire, UK
| | - Tobias Schwarz
- Clinical Veterinary Studies, The University of Edinburgh, Roslin, UK
| | | | - John Ryan
- R(D)SVS, The University of Edinburgh, Edinburgh, UK
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19
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Jung YG, Lee S, Jeong SK, Kim M, Park JH. Subaxial Cervical Pedicle Screw in Traumatic Spinal Surgery. Korean J Neurotrauma 2020; 16:18-27. [PMID: 32395448 PMCID: PMC7192805 DOI: 10.13004/kjnt.2020.16.e13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/13/2020] [Indexed: 01/19/2023] Open
Abstract
In cases of unstable cervical traumatic lesions, the biomechanical superiority of the cervical pedicle screw (CPS) allows the lesion to be stabilized effectively. In this study, we review and summarize the indications, technical guidelines, and potential neurovascular complications and their prevention of the use of the CPS for trauma. For patients with fractured lamina or lateral mass, a CPS is reliable for stabilization. In addition, the CPS can penetrate through a linear cervical spinal pedicle fracture gap and could stabilize three-column injury. CPS reduce the range of surgical approach and preserve the motion segment using short-segment fixation. Fluoroscopy-guided CPS insertion is popular and cost-effective. Image-guided navigation systems improve accuracy. Three-dimensional template-guided CPS placement is simple to use. Most spine surgeons can perform laminoforaminotomy easily. Freehand technique that can be performed quickly without heavy equipment is suitable for emergency situation. Possible complications due to screw misplacement are vertebral artery injury owing to a laterally misplaced screw, dural sac or spinal cord injury from a medially misplaced screw, and nerve root injury caused by a superiorly or inferiorly misplaced screw. To prevent neurovascular complications, meticulous preoperative anatomical evaluation and following the five steps are most important.
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Affiliation(s)
- Yoon Gyo Jung
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Subum Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Kyun Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myeongjong Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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20
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Jung YG, Jung SK, Lee BJ, Lee S, Jeong SK, Kim M, Park JH. The Subaxial Cervical Pedicle Screw for Cervical Spine Diseases: The Review of Technical Developments and Complication Avoidance. Neurol Med Chir (Tokyo) 2020; 60:231-243. [PMID: 32295984 PMCID: PMC7246229 DOI: 10.2176/nmc.ra.2019-0189] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This study aimed to review information on the subaxial cervical pedicle screw (CPS) including recent anatomical considerations, entry points, placement techniques, accuracy, learning curve, and complications. Relevant literatures were reviewed, and the authors’ experiences were summarized. The CPS is used for reconstruction of unstable cervical spine and achieves superior biomechanical stability compared to other fixation techniques. Various insertion and guidance techniques are established, among which, lateral fluoroscopy-assisted placement is the most common and cost-effective technique. Generally, placement under imaging guidance is more accurate than other techniques, and a three-dimensional template allows optimal trajectory for each pedicle regardless of intraoperative changes in spinal alignment. The free-hand technique using a curved pedicle probe without a funnel-like hole increases screw stability and reduces operation time, radiation exposure, and soft tissue injury. Compared to conventional lateral fluoroscopy-assisted placement, free-hand CPS placement by trained surgeons achieves superior accuracy comparable to that of image-guided navigation; in general, 30 training cases are sufficient for learning a safe and accurate technique for CPS placement. The complications of subaxial CPS are classified into three categories: complications due to screw misplacement, complications without screw misplacement, and others. Inexperienced surgeons may benefit from advanced techniques; however, the accuracy of CPS ultimately depends on the surgeon’s experience. Inexperienced surgeons should master the placement of the thoracolumbar pedicle screw in real practice and practice CPS insertion using cadavers. During the initial phase of the learning curve, careful preparation of surgery, reiterated identification, patterned safety steps, and supervision of the expert are necessary.
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Affiliation(s)
- Yoon Gyo Jung
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sang Ku Jung
- Department of Emergency Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine
| | - Byung Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Neuroscience and Radiosurgery Hybrid Research Center, College of Medicine
| | - Subum Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Seong Kyun Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Myeongjong Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
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Patel JYK, Kundnani VG, Kuriya S, Raut S, Meena M. Unstable Hangman's fracture: Anterior or posterior surgery? JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 10:210-215. [PMID: 32089613 PMCID: PMC7008659 DOI: 10.4103/jcvjs.jcvjs_112_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/18/2019] [Indexed: 12/03/2022] Open
Abstract
Context: Literature evaluating the efficacy and long-term clinico-radiological outcomes of anterior cervical discectomy and fusion (ACDF) and posterior fixation at C2–C3 for the treatment of unstable hangman's fractures is scanty. Aims: The aim of this study is to compare the efficacy, clinical-radiological outcomes, and complications of ACDF and posterior fixation techniques performed for unstable hangman's fractures. Settings and Design: The study design involves retrospective comparative study. Subjects and Methods: This study conducted from 2012 to 2018 included 21 patients with unstable hangman's fracture (Levine and Edwards Type II, IIa and III). All patients were divided into two groups based on the approach taken for fracture fixation (Group A-anterior approach and Group B-posterior approach). Peri-operative clinical, radiological parameters, postoperative complications, and outcomes were evaluated and compared in both the groups. Statistical Analysis Used: Chi-square test and Student's t-test were used. Results: The mean age was 39.8 ± 4.5 years in-group A and 41.3 ± 6.7 years in-group B. The male patients outnumbered the female patients and road traffic accident was the most common cause of unstable fractures. There were statistical significant differences in surgical time (P = 0.15), operative blood loss, pain-free status postsurgery, and hospital stay (P = 0.15) between two groups. No statistically significant differences noted in clinic-radiological outcomes in the form of visual analog scale and fusion rate at final follow-up between two groups at final follow-up. Conclusions: The unstable hangman's fractures can be effectively managed with both anterior and posterior approaches with comparable clinico-radiological outcome. A minimally invasive nature, earlier pain-free status, early mobilization with reduced hospitalization make the ACDF efficacious, particularly in cases with no medullary canal in C2 pedicles and traumatic C2–3 disc herniation with listhesis compressing the spinal cord.
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Affiliation(s)
| | - Vishal G Kundnani
- Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Suraj Kuriya
- Department of Spine, Mumbai Institute of Spine Surgery, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Saijyot Raut
- Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Mohit Meena
- Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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22
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Upendra B, Raghavendra R. Techniques of cervical pedicle screw insertion in lower cervical spine - A review. J Clin Orthop Trauma 2020; 11:794-801. [PMID: 32879566 PMCID: PMC7452216 DOI: 10.1016/j.jcot.2020.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 11/29/2022] Open
Abstract
Cervical pedicle screws (CPS) have been used for stabilization of lower cervical spine since its first description by Abumi et al., in 1994, but the usage has been limited due to the feared complications. Cadaveric studies have discouraged use of CPS in lower cervical spine due to high misplacement rates. On the contrary, clinical studies have shown limited complications due to screw misplacements and have highlighted the benefits of CPS with its superior biomechanical strength. Therefore surgeons have always tried to find a reliable, reproducible and safe CPS insertion technique to expand the usage of CPS with minimal complications. As of today Abumi et al. technique is the most popular free-hand technique used by surgeons, though many modifications have evolved to make the CPS insertions more safe and reproducible. The free hand technique should be considered as the cornerstone technique for CPS insertion and the navigation tools are essential to improve the safety of CPS in complex surgeries with altered cervical anatomy. The present review brings together the literature on the various aspects of cervical pedicle anatomy, the free-hand screw insertion techniques with their modifications, the screw misplacement rates and complications.
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23
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Obeidat M, Tan Z, Finkelstein JA. Cortical Bone Trajectory Screws for Fixation Across the Cervicothoracic Junction: Surgical Technique and Outcomes. Global Spine J 2019; 9:859-865. [PMID: 31819852 PMCID: PMC6882086 DOI: 10.1177/2192568219838822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Clinical case series describing a novel surgical technique. OBJECTIVE Stabilization across the cervicothoracic junction (CTJ) poses technical difficulties which make this procedure challenging. The transition from cervical lordosis to thoracic kyphosis and the orientation of the lateral masses of the cervical spine compared with the pedicles of the thoracic spine create the need to accommodate for 2 planes of alignment when placing instrumentation. A novel surgical technique for instrumentation across the cervicothoracic junction is described. METHODS The use of cortical bone trajectory (CBT) technique for pedicle fixation in the upper thoracic spine is described in combination with cervical lateral mass or pedicle screws. The application in our first 12 patients for stabilization across the CTJ is described. Two case presentations illustrate the technique. RESULTS All the patients had rod screw constructs without the need to skip levels, there was no requirement for transverse connectors and only 1 plane of contouring was required. CONCLUSIONS The use of CBT technique has not been described for the upper thoracic spine. This technique avoids many technical problems associated with posterior instrumentation of the CTJ. The facility of their use in this application arises from the similar coronal plane entry points as the cervical lateral mass screws compared with the more lateral starting point of traditional thoracic pedicle screws. The technique has clinical equipoise to traditional thoracic pedicle screw insertion but with the benefits of an easier ability to perform the instrumentation and saving levels of fusion.
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Affiliation(s)
- Mohammad Obeidat
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Zachary Tan
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Joel A. Finkelstein
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Joel A. Finkelstein, Feldberg Chair in Spinal Research Division of Orthopaedic Surgery, Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Room MG361, Toronto, Ontario, M4N 3M5, Canada.
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Sallent A, Ramírez M, Catalá J, Rodríguez-Baeza A, Bagó J, de Albert M, Vélez R. Precision and safety of Multilevel Cervical Transpedicular Screw Fixation with 3D Patient-Specific Guides; A Cadaveric Study. Sci Rep 2019; 9:15686. [PMID: 31666550 PMCID: PMC6821841 DOI: 10.1038/s41598-019-51936-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 10/02/2019] [Indexed: 11/09/2022] Open
Abstract
The aim is to design a patient-specific instrument (PSI) for multilevel cervical pedicle screw placement from C2 to C7, as well as verifying reliability and reproducibility. Computed tomography (CT) scans were obtained from 7 cadaveric cervical spines. Using Mimics software, semiautomatic segmentation was performed for each cervical spine, designing a 3D cervical spine bone model in order to plan transpedicular screw fixation. A PSI was designed according to the previously cited with two cannulated chimneys to guide the drill. The guides were 3D printed and surgeries performed at the laboratory. Postoperative scans were obtained to study screw placement. Sixty-eight transpedicular screws were available for study. 61.8% of all screws were within the pedicle or partially breached <4 mm. No differences were observed between cervical levels. None of these screws had neurovascular injury. Of the 27 screws with a grade 3 (screw outside the pedicle; 39.7%), only 2 had perforation of the transverse foramen and none of them would have caused a neural injury. In conclusion, multilevel PSI for cervical pedicle screw is a promising technology that despite showing improvements regarding free-hand technique requires further studies to improve the positioning of the PSI and their accuracy.
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Affiliation(s)
- Andrea Sallent
- Orthopaedic Department, Hospital Vall d'Hebron. Universitat Autónoma de Barcelona, Barcelona, Spain. .,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain.
| | - Manuel Ramírez
- Orthopaedic Department, Hospital Vall d'Hebron. Universitat Autónoma de Barcelona, Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain
| | - Jordi Catalá
- Radiology Department, Institut Guirado, Barcelona, Spain
| | | | - Joan Bagó
- Orthopaedic Department, Hospital Vall d'Hebron. Universitat Autónoma de Barcelona, Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain
| | - Matías de Albert
- Radiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Roberto Vélez
- Orthopaedic Department, Hospital Vall d'Hebron. Universitat Autónoma de Barcelona, Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain
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Wu X, Liu R, Xu S, Yang C, Yang S, Shao Z, Li S, Ye Z. Feasibility of mixed reality-based intraoperative three-dimensional image-guided navigation for atlanto-axial pedicle screw placement. Proc Inst Mech Eng H 2019; 233:1310-1317. [PMID: 31617820 DOI: 10.1177/0954411919881255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study aimed to evaluate the safety and accuracy of mixed reality-based intraoperative three-dimensional navigated pedicle screws in three-dimensional printed model of fractured upper cervical spine. A total of 27 cervical model from patients of upper cervical spine fractures formed the study group. All the C1 and C2 pedicle screws were inserted under mixed reality-based intraoperative three-dimensional image-guided navigation system. The accuracy and safety of the pedicle screw placement were evaluated on the basis of postoperative computerized tomography scans. A total of 108 pedicle screws were properly inserted into the cervical three-dimensional models under mixed reality-based navigation, including 54 C1 pedicle screws and 54 C2 pedicle screws. Analysis of the dimensional parameters of each pedicle at C1/C2 level showed no statistically significant differences in the ideal and the actual entry points, inclined angles, and tailed angles. No screw was misplaced outside the pedicle of the three-dimensional printed model, and no ionizing X-ray radiation was used during screw placement under navigation. It is easy and safe to place C1/C2 pedicle screws under MR surgical navigation. Mixed reality-based navigation is feasible within upper cervical spinal fractures with improved safety and accuracy of C1/C2 pedicle screw insertion.
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Affiliation(s)
- Xinghuo Wu
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Liu
- Department of Orthopaedic Surgery, Puren Hospital of Wuhan, Wuhan University of Science and Technology, Wuhan, China
| | - Song Xu
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cao Yang
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuhua Yang
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zengwu Shao
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suyun Li
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhewei Ye
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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[Relevance of spinal navigation in reconstructive surgery of the cervical spine]. DER ORTHOPADE 2019; 47:518-525. [PMID: 29663038 DOI: 10.1007/s00132-018-3568-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Spinal navigation has made significant advances in the last two decades. After initial experiences with pedicle screws in the thoracic and lumbar spine, technological improvements have resulted in their increased application in the cervical spine. Instrumentation techniques like cervical pedicle screws, lateral mass screws in C1 and transarticular screws C1/C2 have become standard due to the application of image guidance. TECHNIQUE Different navigation techniques can be distinguished based on the type of imaging. In the cervical spine, the preoperative computer tomography (CT) scan that requires intraoperative matching is still the standard of care due to the high image quality. 3D fluoroscopy navigation techniques are currently widely used in the lumbar spine, but the reduced image quality obviates the application in the more sophisticated cervical anatomy or the cervicothoracic region. The future availability of intraoperative CT scans (iCT) combines the advantages of high image quality with those of intraoperative image acquisition. This will lead to a wider use of image guidance in the cervical spine and will enable the surgeon to apply minimally invasive techniques with higher accuracy. APPLICATION The successful application of spinal navigation is based on the technical knowledge of navigation systems and its exercise in daily routine. Only the sufficient experience of the clinical staff makes it possible to standardize operational procedures to increase patient safety, reduce radiation dose and shorten operation time.
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Huh J, Hyun JH, Park HG, Kwak HY. Three Dimensional Measurement of Ideal Trajectory of Pedicle Screws of Subaxial Cervical Spine Using the Algorithm Could Be Applied for Robotic Screw Insertion. J Korean Neurosurg Soc 2019; 62:376-381. [PMID: 31290294 PMCID: PMC6616986 DOI: 10.3340/jkns.2018.0176] [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: 09/03/2018] [Accepted: 12/24/2018] [Indexed: 12/03/2022] Open
Abstract
Objective To define optimal method that calculate the safe direction of cervical pedicle screw placement using computed tomography (CT) image based three dimensional (3D) cortical shell model of human cervical spine.
Methods Cortical shell model of cervical spine from C3 to C6 was made after segmentation of in vivo CT image data of 44 volunteers. Three dimensional Cartesian coordinate of all points constituting surface of whole vertebra, bilateral pedicle and posterior wall were acquired. The ideal trajectory of pedicle screw insertion was defined as viewing direction at which the inner area of pedicle become largest when we see through the biconcave tubular pedicle. The ideal trajectory of 352 pedicles (eight pedicles for each of 44 subjects) were calculated using custom made program and were changed from global coordinate to local coordinate according to the three dimensional position of posterior wall of each vertebral body. The transverse and sagittal angle of trajectory were defined as the angle between ideal trajectory line and perpendicular line of posterior wall in the horizontal and sagittal plane. The averages and standard deviations of all measurements were calculated.
Results The average transverse angles were 50.60º±6.22º at C3, 51.42º ±7.44º at C4, 47.79º ±7.61º at C5, and 41.24º ±7.76º at C6. The transverse angle becomes more steep from C3 to C6. The mean sagittal angles were 9.72º ±6.73º downward at C3, 5.09º±6.39º downward at C4, 0.08º ±6.06º downward at C5, and 1.67º ±6.06º upward at C6. The sagittal angle changes from caudad to cephalad from C3 to C6.
Conclusion The absolute values of transverse and sagittal angle in our study were not same but the trend of changes were similar to previous studies. Because we know 3D address of all points constituting cortical shell of cervical vertebrae. we can easily reconstruct 3D model and manage it freely using computer program. More creative measurement of morphological characteristics could be carried out than direct inspection of raw bone. Furthermore this concept of measurement could be used for the computing program of automated robotic screw insertion.
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Affiliation(s)
- Jisoon Huh
- Department of Neurosurgery, Jeju National University School of Medicine, Jeju, Korea
| | - Jae Hwan Hyun
- Department of Neurosurgery, Jeju National University School of Medicine, Jeju, Korea
| | - Hyeong Geon Park
- Department of Neurosurgery, Jeju National University School of Medicine, Jeju, Korea
| | - Ho-Young Kwak
- Department of Computer Engineering, Jeju National University College of Engineering, Jeju, Korea
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Richter M, Ploux D. [Spinal navigation for posterior cervical and cervicothoracic instrumentation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:263-274. [PMID: 31197402 DOI: 10.1007/s00064-019-0610-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/02/2019] [Accepted: 03/06/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Safe placement of posterior cervical or high-thoracic pedicle screws, transarticular screws C1/2, translaminar screws C2 or cervical lateral mass screws under the guidance of spinal navigation. INDICATIONS All posterior cervical and cervicothoracic instrumentation with screws: instabilities and deformities of rheumatoid, traumatic, neoplastic, infectious, iatrogenic or congenital origin; multilevel cervical spinal stenosis with degenerative instability or kyphosis of the affected spinal segment. CONTRAINDICATIONS There are no absolute contraindications. SURGICAL TECHNIQUE Prone position on a gel mattress, rigid head fixation, e.g., with Mayfield tongs; if appropriate, closed reduction under lateral image intensification; midline posterior surgical approach at the level of the segments to be instrumented; if necessary, open reduction; insertion of the cervical/upper thoracic screws under the guidance of spinal navigation; if necessary, posterior decompression; instrumentation longitudinal rods; if a fusion is to be obtained, decortication of the posterior bone elements with a high-speed burr and onlay of cancellous bone or bone substitutes. POSTOPERATIVE MANAGEMENT In stable instrumentation, no postoperative immobilization with cervical collar is necessary. Drain removal on postoperative day 2-3, suture removal on postoperative day 14, clinical and x‑ray control 3 and 12 months after surgery or in case of clinical or neurological deterioration. RESULTS Numerous studies showed that the use of spinal navigation reduces implant malplacement rates significantly. Furthermore, it allows a reduction of the radiation dose for the operation team up to 90%.
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Affiliation(s)
- M Richter
- Wirbelsäulenzentrum, St.-Josefs Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Deutschland.
| | - D Ploux
- Wirbelsäulenzentrum, St.-Josefs Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Deutschland
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Tukkapuram VR, Kuniyoshi A, Ito M. A Review of the Historical Evolution, Biomechanical Advantage, Clinical Applications, and Safe Insertion Techniques of Cervical Pedicle Screw Fixation. Spine Surg Relat Res 2019; 3:126-135. [PMID: 31435564 PMCID: PMC6690082 DOI: 10.22603/ssrr.2018-0055] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 08/30/2018] [Indexed: 12/02/2022] Open
Abstract
Cervical spine instrumentation is evolving with an aim of stabilizing traumatic and non-traumatic cases of the cervical spine with a beneficial reduction, better biomechanical strength, and a strong construct with minimal intraoperative, as well as immediate and late postoperative complications. The evolution from interspinous wiring till cervical pedicle screws has changed the outlook in treating the cervical spine pathologies with maximum 3D stability, decreasing the duration of postoperative immobilization and hospital stay. Some complications associated with the use of cervical pedicle screw can be catastrophic. This review article discusses the morphometry of cervical pedicle; indications, biomechanical superiority, tricks, and pitfalls of cervical pedicle screw; complications and technical advancements in targeting safe surgery; and future directions of cervical pedicle screw instrumentation.
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Affiliation(s)
| | - Abumi Kuniyoshi
- Department of orthopaedics, Sapporo Orthopaedic Hospital, Sapporo, Japan
| | - Manabu Ito
- Department of orthopaedics, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
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Biomechanical Comparison of C1 Lateral Mass-C2 Short Pedicle Screw-C3 Lateral Mass Screw-Rod Construct Versus Goel-Harms Fixation for Atlantoaxial Instability. Spine (Phila Pa 1976) 2019; 44:E393-E399. [PMID: 30234804 DOI: 10.1097/brs.0000000000002868] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A biomechanical in vitro study using human cadaveric spines. OBJECTIVE The aim of this study was to compare atlantoaxial stability and stiffness of a C1 lateral mass - C2 short pedicle - C3 lateral mass screw-rod construct versus C1 lateral mass - C2 pedicle screw-rod construct. SUMMARY OF BACKGROUND DATA The C1 lateral mass - C2 pedicle screw-rod construct provides excellent atlantoaxial fixation, but C2 pedicle screw placement is associated with risk of vertebral artery injury. The use of shorter C2 pedicle screws may mitigate the risk of vascular injury but may result in reduced C1-C2 stabilization. Extending C1 lateral mass - C2 short pedicle screw-rod construct with C3 lateral mass screws may mitigate the risk of vascular injury without compromising C1-C2 fixation. METHODS Seven cervical spines were tested with internal control experimental design in the following sequence: intact state, and following creation of type II odontoid fracture, the specimen was instrumented with C1 lateral mass - C2 pedicle screw fixation (C2PED), C1 lateral mass - C2 short pedicle screw fixation (C2SPED), and C1 lateral mass - C2 short pedicle - C3 lateral mass screw fixation (C2SPED-C3LM). For each condition, the angular stiffness and range of motion (ROM) with 1.5-Nm load in flexion/extension (FE), lateral bending (LB), and right/left axial rotation (RAR/LAR) were quantified. RESULTS Instrumented conditions demonstrated significantly lower C1-C2 angular ROM and greater stiffness than the intact state. Compared with C2PED, C2SPED-C3LM demonstrated significantly lower C1-C2 ROM during FE and LB, significantly greater C1-C2 stiffness in flexion and right/left LB, similar C1-C2 ROM and stiffness in RAR/LAR, and similar stiffness in extension. C2SPED-C3LM demonstrated significantly greater atlantoaxial stabilization in the sagittal and coronal planes than C2PED construct. CONCLUSION Compared with C2PED, C2SPED-C3LM may be a suitable alternative surgical strategy for atlantoaxial instability that provides superior atlantoaxial fixation. LEVEL OF EVIDENCE N/A.
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31
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Bishop ES, Hall JL, Handel I, Clements DN, Ryan J. Sequential drilling and drill angulation reduce the accuracy of drill hole start location in a synthetic bone model. Vet Rec 2019; 184:383. [DOI: 10.1136/vr.104897] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 11/13/2018] [Accepted: 12/28/2018] [Indexed: 11/03/2022]
Affiliation(s)
| | - Jon L Hall
- Hospital for Small Animals, University of Edinburgh; Edinburgh UK
| | - Ian Handel
- Royal Dick School of Veterinary Studies, University of Edinburgh; Edinburgh UK
| | | | - John Ryan
- Hospital for Small Animals, University of Edinburgh; Edinburgh UK
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32
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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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Smith LGF, Hoang N, Shaikhouni A, Viljoen S. Sublaminar polyester bands as a salvage fixation method in the cervical spine: novel application in two patients. J Neurosurg Spine 2019; 30:772-776. [PMID: 30835703 DOI: 10.3171/2018.12.spine181147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/21/2018] [Indexed: 11/06/2022]
Abstract
Pedicle and lateral mass screws are the most common means of rigid fixation in posterior cervical spine fusions. Various other techniques such as translaminar screw placement, paravertebral foramen screw fixation, sublaminar and spinous process wiring, cement augmentation, and others have been developed for primary fixation or as salvage methods. Use of these techniques can be limited by a prior history of osteotomies, poor bone density, destruction of the bone-screw interface, and unfavorable vascular and osseous anatomy.Here, the authors report on the novel application of cervical sublaminar polyester bands as an adjunct salvage method or additional fixation point used with traditional methods in the revision of prior constructs. While sublaminar polyester bands have been used for decades in pediatric scoliosis surgery in the thoracolumbar spine, they have yet to be utilized as a method of fixation in the cervical spine. In both cases described here, sublaminar banding proved crucial for fixation points where traditional fixation techniques would have been less than ideal. Further study is required to determine the full application of sublaminar polyester bands in the cervical spine as well as its outcomes.
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Affiliation(s)
- Luke G F Smith
- 1Department of Neurological Surgery, Ohio State University, Wexner Medical Center; and
| | - Nguyen Hoang
- 1Department of Neurological Surgery, Ohio State University, Wexner Medical Center; and
| | - Ammar Shaikhouni
- 2Division of Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Stephanus Viljoen
- 1Department of Neurological Surgery, Ohio State University, Wexner Medical Center; and
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Celikoglu E, Borekci A, Ramazanoglu AF, Cecen DA, Karakoc A, Bektasoglu PK. Posterior Transpedicular Screw Fixation of Subaxial Vertebrae: Accuracy Rates and Safety of Mini-laminotomy Technique. Asian J Neurosurg 2019; 14:58-62. [PMID: 30937009 PMCID: PMC6417301 DOI: 10.4103/ajns.ajns_178_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Aim: Posterior cervical transpedicular screw fixation has the strongest resistance to pullout forces compared with other posterior fixation systems. Here, we present a case on the use of this technique combined with a mini-laminotomy technique, which serves as a guide for accurate insertion of posterior cervical transpedicular screws. Materials and Methods: We retrospectively analyzed data from 40 patients who underwent this procedure in our clinic between January 2014 and March 2017. Results: The study population comprised 27 males (67.5%) and 13 females (32.5%) aged 15–80 years (median, 51.5 years). Surgical indications included trauma (n = 18, 45%), degenerative disease (n = 19, 47.5%), spinal infection (n = 2, 5%), and basilar invagination due to systemic rheumatoid disease (n = 1, 2.5%). In the 18 trauma patients, 14 short-segment (1–2 levels) and 4 long-segment (≥3 levels) posterior cervical instrumentation and fusion procedures were performed. The mini-laminotomy technique was used in all patients to insert, direct, and achieve exact screw fixation in the pedicles. Pedicle perforations were classified as medial or lateral and were also graded. Among the 227 cervical pedicle fixations performed, 48 were at the C3 level, 49 at C4, 60 at C5, 50 at C6, and 20 at C7. Axial computed tomography scan measurements showed that 205 of 227 (90.3%, Grade 0 and 1) screws were accurately placed, whereas 22 (9.69%, Grade 2 and 3) were misplaced. However, no additional neurological injury due to misplacement was observed. Conclusion: As negligible complications were observed when performed by experienced surgeons, the mini-laminotomy technique can be safely used for posterior transpedicular screw fixation in the subaxial vertebrae for single-staged fusion.
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Affiliation(s)
- Erhan Celikoglu
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Ali Borekci
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Ali Fatih Ramazanoglu
- Department of Neurosurgery, Umraniye Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Dilber Aycicek Cecen
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Abdullah Karakoc
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Pinar Kuru Bektasoglu
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey.,Department of Physiology, Marmara University School of Medicine, Istanbul, Turkey
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Accuracy and revision rate of intraoperative computed tomography point-to-point navigation for lateral mass and pedicle screw placement: 11-year single-center experience in 1054 patients. Neurosurg Rev 2018; 42:895-905. [PMID: 30569212 DOI: 10.1007/s10143-018-01067-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/07/2018] [Accepted: 12/06/2018] [Indexed: 10/27/2022]
Abstract
High accuracy in intraoperative computed tomography (iCT) navigation utilizing an intraoperatively acquired dataset for screw placement in the spine has been reported in the literature. To further improve the accuracy and counteract any intraoperative movement of predefined registration points, we introduce an iCT point-to-point navigation, where marker screws are inserted intraoperatively to increase patient safety. In all, 1054 patients who underwent iCT point-to-point navigation for lateral mass and pedicle screw placement were retrospectively analyzed between 09/2005 and 09/2016. Implant-related complications such as screw misplacement, screw loosening, and revision rate were determined. Furthermore, we investigated the rate of complications and the clinical outcome. In total, 6059 screws were inserted in 1054 patients. There were 553 (52.5%) female and 501 (47.5%) male patients. Average age was 63.5 years, mean BMI 27.5 (SD 13.9). Here, 1427 (23.5%) screws were inserted in the cervical, 995 (16.4%) in the thoracic, 3167 (52.3%) in the lumbar, and 470 (7.8%) in the sacral spine. Eight patients required a revision procedure for screw misplacement (0.8%). Total screw misplacement rate was 0.3% (16/6059). With the use of reference markers in iCT-based, spinal, point-to-point navigation, we achieved a high accuracy of screw placement with a low revision rate (0.8%) and a total screw misplacement rate of 0.3%.
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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) 2018; 17:52-60. [DOI: 10.1093/ons/opy233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 07/27/2018] [Indexed: 11/13/2022] Open
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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Farooque K, Yadav R, Chowdhury B, Gamanagatti S, Kumar A, Meena PK. Computerized Tomography-Based Morphometric Analysis of Subaxial Cervical Spine Pedicle in Asymptomatic Indian Population. Int J Spine Surg 2018; 12:112-120. [PMID: 30276069 DOI: 10.14444/5017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The purpose of this study was to analyze morphometry of the subaxial cervical spine pedicles in an Indian population based on computed tomography (CT), and thus assess the safety and feasibility of cervical pedicle screw in the subaxial cervical spine. Methods CT scans of 500 subaxial cervical spine vertebrae were analyzed from 100 patients presenting to our institution and undergoing cervical spine CT scan for an unrelated cause as part of ATLS protocol. Pedicle width (PW), pedicle axis length (PAL), pedicle transverse angulation (PTA), and lateral pedicle distance (LPD) were calculated on axial CT scans, and pedicle height (PH), pedicle length (PL), superior pedicle distance (SPD), and pedicle sagittal angulation (PSA) were calculated on sagittal CT scans. Results The mean PW ranged from 4.3 mm at C3 to 5.7 mm at C7. Mean PH ranged from 5.5 mm at C3 to 6.1 mm at C7. Mean PTA ranged from 44.5° at C3 to 37.1° at C7. PSA ranged from 16.65° at C3 to 3.29° at C7. Mean LPD ranged from 1.6 mm at C3 to 3.4 mm at C6. Mean SPD ranged from 3.5 mm at C3 to 1.15 mm at C7. Mean PAL ranged from 29.6 mm at C3 to 33.04 mm at C7. Mean PL ranged from 5.2 mm at C3 to 5.78 mm at C7. Conclusions Our CT-based morphometric study confirms that cervical pedicle screw placement is possible in most of the Indian population except at C3 in females. A thorough understanding of pedicle anatomy with proper CT-based preoperative planning can mitigate the risk associated with pedicle screw placement in subaxial cervical spine.
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Affiliation(s)
- Kamran Farooque
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Buddhadev Chowdhury
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Shivanand Gamanagatti
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Pradeep Kumar Meena
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Hou Y, Shi J, Lin Y, Chen H, Yuan W. Virtual surgery simulation versus traditional approaches in training of residents in cervical pedicle screw placement. Arch Orthop Trauma Surg 2018; 138:777-782. [PMID: 29497839 DOI: 10.1007/s00402-018-2906-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The cervical screw placement is one of the most difficult procedures in spine surgery, which often needs a long period of repeated practices and could cause screw placement-related complications. We performed this cadaver study to investigate the effectiveness of virtual surgical training system (VSTS) on cervical pedicle screw instrumentation for residents. MATERIALS AND METHODS A total of ten novice residents were randomly assigned to two groups: the simulation training (ST) group (n = 5) and control group (n = 5). The ST group received a surgical training of cervical pedicle screw placement on VSTS and the control group was given an introductory teaching session before cadaver test. Ten fresh adult spine specimens including 6 males and 4 females were collected, and were randomly allocated to the two groups. The bilateral C3-C6 pedicle screw instrumentation was performed in the specimens of the two groups, respectively. After instrumentation, screw positions of the two groups were evaluated by image examinations. RESULTS There was significantly statistical difference in screw penetration rates between the ST (10%) and control group (62.5%, P < 0.05). The acceptable rates of screws were 100 and 50% in the ST and control groups with significant difference between each other (P < 0.05). In addition, the average screw penetration distance in the ST group (1.12 ± 0.47 mm) was significantly lower than the control group (2.08 ± 0.39 mm, P < 0.05). CONCLUSIONS This study demonstrated that the VSTS as an advanced training tool exhibited promising effects on improving performance of novice residents in cervical pedicle screw placement compared with the traditional teaching methods.
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Affiliation(s)
- Yang Hou
- Department of Orthopaedic Surgery, Changzheng Hospital, Second Military Medical University, No. 415 Fengyang Rd, Shanghai, 200003, China
| | - Jiangang Shi
- Department of Orthopaedic Surgery, Changzheng Hospital, Second Military Medical University, No. 415 Fengyang Rd, Shanghai, 200003, China
| | - Yanping Lin
- School of Mechanical Engineering, State Key Laboratory of Mechanical System and Vibration, Institute of Biomedical Manufacturing and Life Quality Engineering, Shanghai, 200240, China
| | - Huajiang Chen
- Department of Orthopaedic Surgery, Changzheng Hospital, Second Military Medical University, No. 415 Fengyang Rd, Shanghai, 200003, China
| | - Wen Yuan
- Department of Orthopaedic Surgery, Changzheng Hospital, Second Military Medical University, No. 415 Fengyang Rd, Shanghai, 200003, China.
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Cervical pedicle screw instrumentation is more reliable with O-arm-based 3D navigation: analysis of cervical pedicle screw placement accuracy with O-arm-based 3D navigation. 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 2018; 27:2729-2736. [DOI: 10.1007/s00586-018-5585-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 03/05/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
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Westermann L, Spemes C, Eysel P, Simons M, Scheyerer MJ, Siewe J, Baschera D. Computer tomography-based morphometric analysis of the cervical spine pedicles C3-C7. Acta Neurochir (Wien) 2018; 160:863-871. [PMID: 29411117 DOI: 10.1007/s00701-018-3481-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 01/25/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Our aim was to examine the specific dimensions of cervical pedicles in a large Caucasian cohort on high dissolving CT scans. METHODS A retrospective analysis of 100 cervical spine CT scans with a maximum slice thickness of 1 mm in axial, sagittal, and coronal reconstructions was performed. The pedicle axial length (PAL), inner and outer pedicle diameter (IPD/OPD), pedicle sagittal and transverse angle (PSA/PTA), pedicle height (PH), pedicle width (PW), and the cortical thickness (COT) at different margins were measured by two independent observers. A total of 1000 cervical pedicles (C3-C7) of 52 male (age 58 ± 17.47 years, height 177.97 ± 8.17 cm) and 48 female patients (age 57 ± 19.07 years, height 165.50 ± 7.44) were measured. RESULTS Cortical thickness at the medial limitation of the pedicle was 1.77 ± 0.43 and 0.90 ± 0.36 mm at the lateral limitation (p < 0.001). The mean PAL ranged from 30.5 mm at C4 level to 35.3 mm at C6 level. PW and PAL were smaller in the female than in the male patients. The smallest values for PW were at C3 with 29.17% of males and 52.88% of females < 4.5 mm. The percentage of patients with PW < 4.5 mm decreased caudally with less than 10% of pedicles below C4 in male participants and below C6 in female participants. Mean PTA ranged from 34.6° to 48.02° peaking at C4 and C5 levels. No gender-specific difference was found for PTA and PSA (p ≥ 0.13). IPD and OPD were larger in males (p < 0.001), and body height correlated significantly with IPW (p ≤ 0.019) and OPW (p ≤ 0.003). The interrater reliability was very good for PW, PH, and IPD (0.84-0.86), good for OPD, PTA, and PSA (0.64-0.79), and moderate for PAL (0.54) and cortical thickness (0.44). CONCLUSIONS Peculiarities of pedicle dimension of this central European cohort are comparable to morphometric studies in other ethnicities. Preoperative planning before cervical pedicle screw insertion on fine-cut CT scans demonstrates good interrater reliability for all important dimensions and angulations. More than half of female patients and almost a third of male patients had a PW of less than 4.5 mm at C3 level. Even though this percentage decreases caudally, pedicle screws might not be safe to insert in a noteworthy percentage of patients.
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Wilson PJ, Selby MD. C7 intra-laminar screws for complex cervicothoracic spine surgery-a case series. JOURNAL OF SPINE SURGERY 2018; 3:561-566. [PMID: 29354732 DOI: 10.21037/jss.2017.10.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background C7 has relatively unique anatomy compared to the remainder of the subaxial cervical spine (C3-C6) and upper thoracic spine. The C7 laminar has been previously reported in feasibility and biomechanical studies as an adequate fixation point in contrast to the lateral mass or pedicles, with few reports of its use in clinical practice. The purpose of this study was to review the safety and efficacy of using the C7 laminar as a fixation point in constructs involving the cervical spine and cervicothoracic junction. Methods Between February 2013 and July 2016, 10 patients (6 males, 4 females) had 19 C7 intra-laminar screws sited (bilateral in 9 patients, unilateral in 1 patient). Six patients had trauma as an underlying etiology, 2 of which had pseudoarthrosis from prior surgery. Three patients had cervical myelopathy from degenerative disease, 2 of which required anterior and posterior instrumentation for correction of deformity and 1 which had stand-alone posterior fixation. One patient had stabilization for an underlying malignancy. Results One patient died 2 weeks following their high cervical injury secondary to complications of respiratory failure. None of the remaining 9 patients were noted to have construct failure at a median follow up of 1 year (range, 6 months to 4 years) and all were noted to have satisfactory positioning of the instrumentation on post-operative imaging. The patient with malignancy died 6 months later from extra-spinal disease, there was one wound breakdown requiring debridement without infection in a revision case, and one patient required laminectomy for post-traumatic syrinx formation. Conclusions The C7 laminar provides an alternative fixation point for constructs involving the subaxial cervical spine and cervicothoracic junction, with excellent safety and efficacy in this small series. Larger series are required to more clarify the risk profile of this technique.
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Affiliation(s)
- Peter John Wilson
- Department of Neurosurgery, Prince of Wales Public and Private Hospitals, Sydney, Australia
| | - Michael Derrick Selby
- Department of Orthopaedics, Royal Adelaide Hospital, Adelaide, Australia.,Women's and Children's Hospital, Adelaide, Australia.,Queen Elizabeth Hospital, Adelaide, Australia.,Calvary-Wakefield Hospital, Adelaide, Australia.,St Andrew's Hospital, Adelaide, Australia.,Memorial Hospital, Adelaide, Australia
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Kashyap A, Kadur S, Mishra A, Agarwal G, Meena A, Maini L. Cervical pedicle screw guiding jig, an innovative solution. J Clin Orthop Trauma 2018; 9:226-229. [PMID: 30202153 PMCID: PMC6128793 DOI: 10.1016/j.jcot.2018.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 07/14/2018] [Indexed: 11/25/2022] Open
Abstract
Pedicle screws are one the commonest used modality in spinal instrumentation. However, the method of pedicle screw fixation in cervical spine as compared to thoracic and lumbar spine is still technically demanding because it carries the risk of catastrophic damage to the surrounding neurovascular structures We have utilized virtual planning and 3D (3-dimension) printing to develop a patient specific jig to guide the accurate placement of pedicle screws. A patient with bifacetal dislocation C7 over D1 classified as flexion-distraction injury type 3 who was planned for decompression and fusion by posterior instrumentation at C6, C7, D1 and D2 was selected. A CT scan with 1 mm cuts was used to produce DICOM images of the same. Using these DICOM images virtual planning was done on MIMICS and 3 MATICS software to create patient specific jigs. These jigs were then 3D printed using a 3D printer and used for accurate placement of pedicle screws intra-operatively after adequate sterilization. Our procedure is low cost but high technology based. It is simple, accurate, and very cost effective. The technology transfer is very easy and can be adopted easily.
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Affiliation(s)
- Abhishek Kashyap
- Department of Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Shreesh Kadur
- Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India,Corresponding author. #52, flat no: 202, Saathwik Residency, Ramanjaneya Nagar, Chikkalsandra, Banagalore, 560061, India.
| | - Abhishek Mishra
- Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Gaurang Agarwal
- Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Abhay Meena
- Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Lalit Maini
- Department of Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
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Chen W, Fang XM, Qian PY, Sanjeev Kumar PS, Chen HW, Xiao-Yun HU. Evaluation of Multi-Slice Spiral Computed Tomography in In vivo Simulation of Individualized Cervical Pedicle Screw Placement at C3-C7 in Chinese Healthy Population. Indian J Orthop 2018; 52:651-656. [PMID: 30532307 PMCID: PMC6241050 DOI: 10.4103/ortho.ijortho_3_17] [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: 02/04/2023]
Abstract
BACKGROUND Cervical pedicle screw fixation through posterior approach has shown greater cervical stability advantage. The cervical pedicle screw fixation technique through posterior approach is demanding. The key to the technique is the choice of point and angle of screw entrance. The angle of screw placement is variable. Morphometric measurements of the cervical pedicle are a prerequisite for individualized screw. CT imaging has become the most reliable and important means to obtain cervical pedicle's measurement data and morphology in vivo. This study explores the feasibility and application of precise in vivo measurements by multi-slice computed tomography (MSCT) for individualized cervical transpedicular screw placement at C3-C7 in Chinese healthy population. MATERIALS AND METHODS 80 adults who underwent cervical examination by enhanced and nonenhanced computed tomography angiography, respectively, were selected and submitted to bone algorithm reconstruction for slice thickness and interval of 0.75 mm to acquire clear images and detailed bone structures. Simulation of individualized screw placement was performed with a 4.0 mm diameter screw with the help of postprocessing workstation. Pedicle transverse angle (PTA) and sagittal angle (PSA) were measured using the single- and double-line methods (analog nailing, 4.0 mm in diameter) in 160 pairs of C3-C7 pedicles, setting positive and negative values for cranial direction and foot side PSAs, respectively. Comparison of the measured change scope in PTA and PSA between the two methods was carried out; the range was defined as the error range. RESULTS Significantly, different results (P < 0.05) were obtained between the single- and double-line methods in the error ranges of PTA and PSA in C3-C7 pedicles. Interestingly, the double-line method was better in simulating the actual needs of individualized nailing. The mean values of PTA and PSA were 42.9°, 45.5°, 42.4°, 37.1°, 29.0° and 8.4°, 5.0°, -4.0°, and -7.8°, -8.1°, respectively, with the double-line method. CONCLUSION MSCT reconstruction techniques can determine the direction and required parameters for individualized screw placement. In addition, accurate in vivo measurements of PTA and PSA, particularly PSA, provide the orthopedic surgeon with theoretical guidance and reliable basis in screw placement.
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Affiliation(s)
- Wei Chen
- Department of Intervention Radiology, Huai’an First People's Hospital, Nanjing Medical University, Jiangsu Province, China
| | - Xiang-Ming Fang
- Imaging Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Jiangsu Province, China
| | - Ping-Yan Qian
- Imaging Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Jiangsu Province, China
| | - PS Sanjeev Kumar
- Department of Medical Imaging, Parexel International Pvt Ltd, Hyderabad, Telangana, India
| | - Hong-wei Chen
- Imaging Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Jiangsu Province, China
| | - HU Xiao-Yun
- Imaging Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Jiangsu Province, China,Address for correspondence: Dr. Xiao-Yun HU, Imaging Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, No. 299, Qingyang Road, Wuxi 214023, Jiangsu Province, China. E-mail:
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Rienmüller A, Buchmann N, Kirschke JS, Meyer EL, Gempt J, Lehmberg J, Meyer B, Ryang YM. Accuracy of CT-navigated pedicle screw positioning in the cervical and upper thoracic region with and without prior anterior surgery and ventral plating. Bone Joint J 2017; 99-B:1373-1380. [PMID: 28963160 DOI: 10.1302/0301-620x.99b10.bjj-2016-1283.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/03/2017] [Indexed: 11/05/2022]
Abstract
AIMS We aimed to retrospectively assess the accuracy and safety of CT navigated pedicle screws and to compare accuracy in the cervical and thoracic spine (C2-T8) with (COMB) and without (POST) prior anterior surgery (anterior cervical discectomy or corpectomy and fusion with ventral plating: ACDF/ACCF). PATIENTS AND METHODS A total of 592 pedicle screws, which were used in 107 consecutively operated patients (210 COMB, 382 POST), were analysed. The accuracy of positioning was determined according to the classification of Gertzbein and Robbins on post-operative CT scans. RESULTS High accuracy was achieved in 524 screws (88.5%), 192 (87.7%) in the cervical spine and 332 (89%) in the thoracic spine, respectively. The results in the two surgical groups were compared and a logistic regression mixed model was performed to analyse the risk of low accuracy. Significantly lower accuracy was found in the COMB group with 82.9% versus 91.6% in the POST group (p = 0.036). There were no neurological complications, but two vertebral artery lesions were recorded. Three patients underwent revision surgery for malpositioning of a screw. Although the risk of malpositioning of a screw after primary anterior surgery was estimated to be 2.4-times higher than with posterior surgery alone, the overall rates of complication and revision were low. CONCLUSION We therefore conclude that CT navigated pedicle screws can be positioned safely although greater caution must be taken in patients who have previously undergone anterior surgery. Cite this article: Bone Joint J 2017;99-B:1373-80.
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Affiliation(s)
- A Rienmüller
- Medical University Vienna General Hospital, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - N Buchmann
- Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - J S Kirschke
- Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - E L Meyer
- Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - J Gempt
- Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - J Lehmberg
- Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - B Meyer
- Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - Y M Ryang
- Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
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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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Anatomy of Lamina in the Subaxial Cervical Spine With the Special Reference to Translaminar Screws: CT and Cadaveric Analysis With Screw Trajectory Simulation. Clin Spine Surg 2017; 30:E535-E539. [PMID: 28525474 DOI: 10.1097/bsd.0000000000000159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A cadaveric study. SUMMARY OF BACKGROUND DATA Translaminar screws were initially developed for C2 fixation. Since then, their usage has expanded to include the subaxial cervical spine, and thoracic and lumbar spine. To the best of our knowledge, special anatomy for inserting translaminar screws in the subaxial cervical spine has not been studied. OBJECTIVE To report the special anatomy for inserting translaminar screws in the subaxial cervical spine. METHODS A total of 18 cadaveric spines were harvested from C3 to C7 and 1 mm computed tomography (CT) scans and 3D reconstructions were obtained. Bilateral translaminar screw entry points and trajectories were simulated at each level from C3 to C7 utilizing Kodak Carestream/Pacs Ver 10.2. Constructs were selected to achieve maximal bony purchase with 1 screw, designated the "primary screw." The contralateral screw, designated the "secondary screw," was selected to achieve the optimal allowable diameter possible while avoiding a simulated cortical breach, which was not always necessarily the "best purchase" diameter. Initial screw diameters selected were 3.5 mm; however, in the event that a narrower portion was encountered, then a 3.0 mm diameter screw was utilized instead. The crossing area of both screws were calculated geometrically. Maximal thickness of the lamina was considered in determining the diameter of screws. Whenever possible, 3.5 mm screws were selected in both lamina (3.5/3.5 mm); however, if a 3.5 mm screw was utilized as the primary screw, but the permissible range (P) for the secondary screw was <3.5 mm, then a hybrid construct was utilized (3.5/3.0 mm). In cases where P was <3 mm, then both screws were studied at 3 mm (3.0/3.0 mm). Screw diameters that optimized trajectory and bony purchase, while remaining within the permissible range, were analyzed, tabulated, and recorded. On CT, along the trajectory of the screws, the image was cut and measured in terms of screw length, the narrowest portion of the lamina, vertical angle, and horizontal angle in both primary and secondary screws. On the individually separated cervical spine segments in cadavers (11 of 18), we performed caliper measurements on the same portions that were measured on CT. It could not be exactly the same portions, however, due to the 3-dimensional characteristics of the specimens. RESULTS For C3, only 1 specimen allowed 2 screws (3/3 mm), while the remaining specimens permitted a unilateral primary screw (3.5 or 3 mm) only. For C4, 37% of specimens allowed 2 screws (3.5/3 mm or 3/3 mm), but the rest allowed only a unilateral primary screw (3.5 or 3 mm). For C5, 58% allowed 2 screws (3.5/3.5, 3.5/3, or 3/3 mm). For C6, 89% of specimen allowed 2 screws (3.5/3.5, 3.5/3, or 3/3 mm). For C7, all levels allowed 2 screws (3.5/3.5, 3.5/3, 4/4, 4/3, 4.5/3, 4.5/3.5, or 4/3.5 mm). On CT, the average lengths of the 1- and 2-degree screws were 26.14 and 24.01 mm, respectively. The average vertical and horizontal angles were 22.26 and 40.66 degrees for the 1-degree screw, and 3.45 and 45.59 degrees for the 2-degree screw. On cadavers, the average lengths of the 1- and the 2-degree screws were 22.58 and 23.44 mm, respectively. The average vertical and horizontal angles were 23.67 and 54.44 degrees for the 1-degree screw, and 2.28 and 54.89 degrees for the 2-degree screw. CONCLUSIONS This is a report of the anatomy of the lamina in the subaxial cervical spine with the special reference to translaminar screws. It was analyzed with CT and cadaveric spines along with simulated screw trajectories. For the 1-degree translaminar screw, the entry point is the distance of the diameter of desired screw superior to the inferior margin of lamina-spinous process junction. The trajectory should be targeted toward the most superomedial corner of lateral mass. For the 2-degree translaminar screw, the entry point is the distance of the diameter of desired screw below the superior margin of lamina-spinous process junction, and the target is the most superolateral corner of lateral mass, which is typically horizontal. Further studies are needed to assess the feasibility of translaminar screw insertion in the actual subaxial cervical spine.
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Li G, Wang Q, Liu H. CT analysis of anatomical variation and injury affecting posterior pedicle screw fixation for unstable Hangman fractures. Medicine (Baltimore) 2017; 96:e6847. [PMID: 28489773 PMCID: PMC5428607 DOI: 10.1097/md.0000000000006847] [Citation(s) in RCA: 3] [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: 02/05/2023] Open
Abstract
The aim of this study was to evaluate the anatomical variations and injuries in patients with unstable Hangman fractures that affected the posterior pedicle screw placement of C2 to C3 and retrospectively review our experience with management of these fractures. Clinical data were reviewed in 72 patients with unstable Hangman fractures, especially using 3-dimensional computed tomography (3D-CT) scan to identify the presence of anatomical variations or injuries and analyzing the treatment strategies we used. Twenty-two patients (22/72, 30.6%) with 39 (C2 or C3) risk factors were not fit for safe C2 to C3 pedicle screw placement, due to factors such as small pedicle size of C2 or C3, high-riding vertebral arteries, fractured fragments encased into vertebral canal, or transverse process foramen of C2, sclerotic pedicles and pedicle fractures of C3. One or more than one of these risk factors could pose more risks of arterial or neural structures damages to pedicle screw fixation for unstable Hangman fractures. Individualized treatment plans were made to minimize the risks of surgery for the 22 patients. There is a high incidence of anatomical variations and injuries in the C2 to C3 region in patients with unstable Hangman fractures that affect the pedicle screw placement. Preoperative evaluation of these conditions using 3D-CT scans is of paramount importance to avoid and decrease operative complications and to choose appropriate surgical techniques.
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Affiliation(s)
- Guangzhou Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Qing Wang
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Hao Liu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu
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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: 4] [Impact Index Per Article: 0.6] [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: 11] [Impact Index Per Article: 1.6] [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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