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Burger JA, Becker L, Li Z, Wang Z, Schmidt H, Pumberger M, Schömig F. In idiopathic scoliosis distances of spinal cord to thoracic pedicle are within 2 mm in a large region of the thoracic apex. Sci Rep 2024; 14:14340. [PMID: 38906927 PMCID: PMC11192752 DOI: 10.1038/s41598-024-64971-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/14/2024] [Indexed: 06/23/2024] Open
Abstract
Despite a 15% misplacement rate of screws in idiopathic scoliosis surgery, little is known about the relationship between pedicles and nerve structures in the entire thoracic curve. This study aimed to explore the spinal cord's proximity to the pedicle wall at each thoracic vertebra in the entire thoracic curve, while considering different anatomical changes. Spinal cord to medial pedicle distances were measured on magnetic resonance imaging in 73 patients who underwent posterior spinal fusion with pedicle screw instrumentation. Associations with different variables were examined. A total of 51 patients (69.9%) showed a distance within 2 mm at the apex vertebra on the concave side, more than 50% had a distance within 2 mm in the next thoracic vertebra level above and below, and more than 25% two levels above and below. Weak correlations were found between proximity of the spinal cord at the apex vertebra and vertebra's level and Cobb angle on the concave side (r = - 0.310, P = 0.008, r = 0.380, P = 0.001, respectively). These results emphasize the importance of thorough assessment when placing thoracic pedicle screws in idiopathic scoliosis patients. Further research is warranted to develop surgical strategies aimed at preventing potentially neurological complications resulting from screw misplacement.
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Affiliation(s)
- Joost A Burger
- Charité-Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany.
| | - Luis Becker
- Charité-Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
| | - Zhao Li
- Charité-Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
| | - Zhen Wang
- Charité-Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
| | - Hendrik Schmidt
- Julius Wolff Institute, Berlin Institute of Health at Charité-Universiätsmedizin Berlin, Berlin, Germany
| | - Matthias Pumberger
- Charité-Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
| | - Friederike Schömig
- Charité-Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
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Driver CJ, Nores VA, Thatcher H, Navarro-Carrillo M, Rose J. Accuracy and safety of freehand vs. end-on fluoroscopic guided drill-hole placement in canine cadaveric thoracic, lumbar and sacral vertebrae. Front Vet Sci 2024; 11:1419521. [PMID: 38938915 PMCID: PMC11210332 DOI: 10.3389/fvets.2024.1419521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/28/2024] [Indexed: 06/29/2024] Open
Abstract
Objective To develop and evaluate the safety and accuracy of an open, end-on fluoroscopic guided (EOFG) drill hole position technique in canine cadaveric spinal surgery, in comparison to a traditional free-hand (FH) drilling technique. Study design Cadaveric comparison study. Animals Canine cadaveric vertebral columns (n = 4). Methods Computed tomography (CT) scans were performed for in-silico planning. Ideal implant purchase depth and angulations were determined from previously published data. Plans for end-on fluoroscopic guided drill holes included angled reconstructions in thick slab mode to mimic fluoroscopic images. Following surgical preparation of T8 to S2, holes were drilled by one of two experienced surgeons randomized evenly by operated side, surgeon, and technique. C-arm fluoroscopy was utilized for the end-on technique. CT was repeated after the procedures. Safety was determined categorically using a modified Zdichavsky classification and "optimal" placement was compared between techniques. Continuous data for drill-hole accuracy was calculated as angle and depth deviations from the planned trajectories. Data sets were analyzed at both univariable and multivariable levels with logistic regression analysis. Results Drill hole safety was categorized as optimal (modified Zdichavsky classification 1) in 51/60 (85%) of drill holes using EOFG and 33/60 (55%) using FH (P < 0.001) techniques. There were no "unsafe" holes (modified Zdichavsky classification 3a). Optimal drill hole placement was significantly associated with the EOFG technique and use of the largest cadaver, and was significantly less likely within the thoracic region. Mean angle and depth deviations were significantly lower with the EOFG technique. Angle deviations were significantly lower for EOFG in the lumbar region, whereas bone purchase deviations were significantly lower for EOFG in both the thoracic and lumbar regions. The mean time taken to drill the hole was significantly longer for the EOFG technique. Conclusion Optimal drill hole placement was significantly more likely with the EOFG technique and improved the accuracy of bone purchase in the thoracic region. Clinical significance The EOFG technique shows promise for translation into a clinically setting, potentially improving implant purchase and therefore stabilizing construct strength, whilst potentially reducing the likelihood of neurovascular injury and need for surgical revision.
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Affiliation(s)
- Colin J. Driver
- Lumbry Park Veterinary Specialists, CVS Referrals, Alton, United Kingdom
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Bindels BJJ, Hovenier R, Groot OQ, Vincken KL, Rongen JJ, Smits MLJ, Verlaan JJ. Impact of intraoperative imaging on decision-making during spine surgery: a survey among spine surgeons using simulated intraoperative images. 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 2024; 33:2031-2042. [PMID: 38548932 DOI: 10.1007/s00586-024-08222-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE To assess whether the intention to intraoperatively reposition pedicle screws differs when spine surgeons evaluate the same screws with 2D imaging or 3D imaging. METHODS In this online survey study, 21 spine surgeons evaluated eight pedicle screws from patients who had undergone posterior spinal fixation. In a simulated intraoperative setting, surgeons had to decide if they would reposition a marked pedicle screw based on its position in the provided radiologic imaging. The eight assessed pedicle screws varied in radiologic position, including two screws positioned within the pedicle, two breaching the pedicle cortex < 2 mm, two breaching the pedicle cortex 2-4 mm, and two positioned completely outside the pedicle. Surgeons assessed each pedicle screw twice without knowing and in random order: once with a scrollable three-dimensional (3D) image and once with two oblique fluoroscopic two-dimensional (2D) images. RESULTS Almost all surgeons (19/21) intended to reposition more pedicle screws based on 3D imaging than on 2D imaging, with a mean number of pedicle screws to be repositioned of, respectively, 4.1 (± 1.3) and 2.0 (± 1.3; p < 0.001). Surgeons intended to reposition two screws placed completely outside the pedicle, one breaching 2-4mm, and one breaching < 2 mm more often based on 3D imaging. CONCLUSION When provided with 3D imaging, spine surgeons not only intend to intraoperatively reposition pedicle screws at risk of causing postoperative complications more often but also screws with acceptable positions. This study highlights the potential of intraoperative 3D imaging as well as the need for consensus on how to act on intraoperative 3D information.
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Affiliation(s)
- Bas J J Bindels
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Renée Hovenier
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Koen L Vincken
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jan J Rongen
- Philips Medical Systems International B.V., Veenpluis 6, 5684 PC, Best, The Netherlands
| | - Maarten L J Smits
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jorrit-Jan Verlaan
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Sakhrekar R, Shkumat N, Ertl-Wagner B, Lewis S, Lebel D, McVey MJ, Camp M. Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis. Spine Deform 2024; 12:739-746. [PMID: 38413472 DOI: 10.1007/s43390-024-00830-1] [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: 03/10/2023] [Accepted: 01/13/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. METHOD A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). RESULTS 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. CONCLUSION Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.
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Affiliation(s)
- Rajendra Sakhrekar
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Nicholas Shkumat
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Stephen Lewis
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - David Lebel
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - M J McVey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
| | - Mark Camp
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Miyazaki M, Abe T, Sako N, Kanezaki S, Tsumura H. Analysis of accuracy of pedicle screw placement in dysplastic pedicles in adolescent idiopathic scoliosis using the pedicle expansion technique with CT-based navigation. J Orthop Sci 2024; 29:741-748. [PMID: 37045687 DOI: 10.1016/j.jos.2023.03.019] [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: 12/05/2022] [Revised: 02/27/2023] [Accepted: 03/30/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND This study aimed to study the accuracy of pedicle screw (PS) insertion into dysplastic pedicles in adolescent idiopathic scoliosis (AIS) comparing cannulated screw using the pedicle expansion technique (PET) versus conventional technique. METHODS Forty-two AIS patients with 766 PSs were evaluated. In total, 236 screws were inserted into dysplastic pedicles: 138 and 98 screws were inserted using the PET (PET group) and standard technique (conventional group), respectively. Both methods used CT-based navigation to determine the insertion point. In the PET, a rigid ball tip feeler was tapped with a mallet to create an insertion route, a guide wire was passed through the tap, the pedicle was enlarged, and then a cannulated PS with a diameter of 4.35 mm was inserted. Postoperative CT was used to compare the accuracy of PS insertion. RESULTS In total, 23/236 (9.7%) perforations occurred. Regarding overall perforation, there were six (4.3%) and 17 (17.3%) cases in the PET and conventional group, respectively (P = 0.008). In terms of medial perforation, the PET group (n = 2, 1.4%) was significantly better than the conventional group (n = 7, 7.1%) (P = 0.021). In terms of lateral perforation, the PET group (n = 4, 2.9%) was significantly better than conventional group (n = 10, 10.2%) (P = 0.030). Only grade 1 perforation had occurred in the PET group, whereas grades 2 and 3 perforation occurred in the conventional group. CONCLUSION Use of the PET with CT-based navigation significantly increased the accuracy and safety of PS insertion in dysplastic pedicles in AIS.
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Affiliation(s)
- Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan.
| | - Tetsutaro Abe
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Noriaki Sako
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Shozo Kanezaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Hiroshi Tsumura
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
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Zhang J, Xu J, Xu C, Xie Y. Posterior endpoint determination of the lumbar pedicle central axis on the anterior-posterior fluoroscopic image for pedicle screw insertion. Sci Rep 2024; 14:9272. [PMID: 38653756 DOI: 10.1038/s41598-024-57349-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/18/2024] [Indexed: 04/25/2024] Open
Abstract
The transpedicular procedure has been widely used in spinal surgery. The determination of the best entry point is the key to perform a successful transpedicular procedure. Various techniques have been used to determine this point, but the results are variable. This study was carried out to determine the posterior endpoint of the lumbar pedicle central axis on the standard anterior-posterior (AP) fluoroscopic images. Computer-aided design technology was used to determine the pedicle central axis and the posterior endpoint of the pedicle central axis on the posterior aspect of the vertebra. The standard AP fluoroscopic image of the lumbar vertebral models by three-dimensional printing was achieved. The endpoint projection on the AP fluoroscopic image was determined in reference to the pedicle cortex projection by the measurements of the angle and distance on the established X-Y coordinate system of the radiologic image. The projection of posterior endpoint of the lumbar pedicle central axis were found to be superior to the X-axis of the established X-Y coordinate system and was located on the pedicle cortex projection on the standard AP fluoroscopic image of the vertebra. The projection point was distributed in different sectors in the coordinate system. It was located superior to the X-axis by 18° to 26° at L1, while they were located superior to the X-axis by 12° to 14° at L2 to L5. The projections of posterior endpoints of the lumbar pedicle central axis were located in different positions on the standard AP fluoroscopic image of the vertebra. The determination method of the projection point was helpful for selecting an entry point for a transpedicular procedure with a fluoroscopic technique.
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Affiliation(s)
- Jun Zhang
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Orthopaedic Surgery, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jiawei Xu
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chenyang Xu
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Youzhuan Xie
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
- Department of Orthopaedic Surgery, Quanzhou Taiwanese Investment Zone Hospital, Fujian, China.
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Vißmann S, Schöttes P, Topcuoglu F, Strohmann T, Stahl JP, Rohde S. [Precision and safety of positioning pedicle screws in the thoracic and lumbar spine using a hand-guided aiming sleeve : A CT control study]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:297-304. [PMID: 37989763 DOI: 10.1007/s00113-023-01392-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND For the implantation of pedicle screws, navigation-supported systems are nowadays used more and more to avoid screw misalignment by making the direction of the screw more predictable. OBJECTIVE Examination of the precision after instrumentation of the pedicle screw with the hand-guided aiming sleeve. The aim was to verify that the implementation of the pedicle screws is plannable and precise by using 2D X‑ray only. METHOD This retrospective study analyzed 27 consecutive trauma patients (17-84 years, 13f/14m) with vertebral body fractures. The position and precision of 108 screws, implanted using the hand-guided aiming sleeve was investigated. To determine the position the actual course of the screws was examined using the postoperative 3D CT data set (GE Optima 540, General Electric Company Boston, MA, USA; slice thickness 1.25 mm). The screws were then compared to the previously defined ideal position of the tip of the screw. In addition to the absolute and relative deviation from the ideal target point, the convergence angle and the parallelism to the cover plate were determined. RESULTS Of 108 implanted pedicle screws, 90 (83%) were within target. The remaining 18 (17%) represented a clinically irrelevant screw deviation: A lateral deviation was found in 17 pedicle screws (16%) and a medial deviation in 1 (1%). The average deviation from the ideal target point in the vertebral body was 2.3 mm ventrally with a standard deviation of ± 2.3 mm. No screw misalignment or pedicle perforation was found. CONCLUSION The transcutaneous implantation of pedicle screws with a hand-guided aiming sleeve in the thoracic and lumbar spine represents a safe and precise procedure. The risk of misalignment needing a revision is lower compared to other methods of navigated screw implantation reported in the literature [1-6]. A CT-based preliminary planning is not necessary. The method is economical, special technical equipment is not required.
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Affiliation(s)
- Silke Vißmann
- Klinik für Radiologie und Neuroradiologie, Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Dortmund, Deutschland.
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Münsterstraße 240, 44137, Dortmund, Deutschland.
| | - Philippus Schöttes
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Münsterstraße 240, 44137, Dortmund, Deutschland
| | - Fatma Topcuoglu
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Münsterstraße 240, 44137, Dortmund, Deutschland
| | - Thorsten Strohmann
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Münsterstraße 240, 44137, Dortmund, Deutschland
| | - Jens-Peter Stahl
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Münsterstraße 240, 44137, Dortmund, Deutschland
| | - Stefan Rohde
- Klinik für Radiologie und Neuroradiologie, Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Dortmund, Deutschland
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Larson AN, Polly DW, Sponseller PD, Kelly MP, Richards BS, Garg S, Parent S, Shah SA, Weinstein SL, Crawford CH, Sanders JO, Blakemore LC, Oetgen ME, Fletcher ND, Kremers WK, Marks MC, Brearley AM, Aubin CE, Sucato DJ, Labelle H, Erickson MA. The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial. J Bone Joint Surg Am 2024; 106:180-189. [PMID: 37973031 DOI: 10.2106/jbjs.23.00178] [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] [Indexed: 11/19/2023]
Abstract
BACKGROUND Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | - Sumeet Garg
- Children's Hospital of Colorado, Aurora, Colorado
| | | | | | | | | | | | | | | | | | | | - Michelle C Marks
- Harms Study Group/Setting Scoliosis Straight Foundation, El Cajon, California
| | | | - Carl-Eric Aubin
- Ecole Polytechnique, St. Justine Hospital, Montreal, Quebec, Canada
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Rosa Filezio M, Peiro-Garcia A, Parsons DL, Thomas K, Ferri-de-Barros F. Accuracy of imaging grading in comparison to open laminectomy to evaluate pedicle screws positioning. Ann Med Surg (Lond) 2024; 86:199-206. [PMID: 38222761 PMCID: PMC10783280 DOI: 10.1097/ms9.0000000000001515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/05/2023] [Indexed: 01/16/2024] Open
Abstract
Study design Prospective experimental study. Objective To compare the accuracy of O-Arm-acquired radiographic and computed tomography (CT) evaluation of thoracic pedicle screw placement with open laminectomy in a simulation laboratory. Summary of background data Improving surgical safety and procedural efficiency during thoracic posterior spine instrumentation is essential for decreasing complication rates and possible related risks. The most common way of verifying the position of pedicle screws during the surgical procedure and immediately postoperatively is to acquire intraoperative fluoroscopic images and plain radiographs of the spine, respectively. Laboratory simulated surgery is a valuable tool to evaluate the accuracy of those exams. Methods Twenty simulation models of scoliosis from T3 to T7 were instrumented by five spine fellows (total of 200 pedicle screws), followed by radiographic and CT images acquired with the assistance of the O-Arm which were evaluated by three independent raters. A fellowship-trained spine neurosurgeon performed laminectomies on the instrumented levels and assessed pedicle integrity (gold standard). Results Forty-eight breaches were identified in the axial direct view after laminectomy. Of those, eighteen breaches were classified as unacceptable. Regarding the sagittal direct view, four breaches were observed, three of which were classified as unacceptable. Overall, both O-arm radiographic and CT evaluations had a significantly high negative predicted value but a low positive predicted value to identify unacceptable breaches, especially in the sagittal plane. The frequency of missed breaches by all three examiners was high, particularly in the sagittal plane. Conclusion Postoperative evaluation of pedicle screws using O-arm-acquired radiographic or CT images may underdiagnose the presence of breaches. In our study, sagittal breaches were more difficult to diagnose than axial breaches. Although most breaches do not have clinical repercussions, this study suggests that this modality of postoperative radiographic assessment may be inaccurate. Level of evidence 4.
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10
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Vardiman AB, Wallace DJ, Booher GA, Toossi N, Bucklen BS. Decreasing the Pedicle Screw Misplacement Rate in the Thoracic Spine With Robot-guided Navigation. Clin Spine Surg 2023; 36:431-437. [PMID: 37348067 PMCID: PMC10681281 DOI: 10.1097/bsd.0000000000001474] [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: 12/08/2022] [Accepted: 05/17/2023] [Indexed: 06/24/2023]
Abstract
STUDY DESIGN A retrospective chart review. OBJECTIVE The aim of this study was to evaluate the screw accuracy of thoracic pedicle screws placed with a robot-guided navigation system. SUMMARY OF BACKGROUND DATA Thoracic pedicles are smaller in diameter than lumbar pedicles, making pedicle screw placement difficult. Misplaced pedicle screws may present complications including decreased construct stability, and increased risks of neurological deficits and blood vessel perforation. There is a dearth of knowledge on thoracic pedicle screw accuracy placed with a robot. MATERIALS AND METHODS A retrospective analysis of the robot-assisted placement of thoracic pedicle screws was performed. Preoperative and postoperative computed tomography (CT) scans of the implanted thoracic screws were collected to assess screw placement accuracy, pedicle breadth, and placement deviations. A CT-based Gertzbein and Robbins System was used to classify pedicle screw accuracy in 2 mm increments. A custom image overlay software was used to determine the deviations between the preoperatively planned trajectory of pedicle screws and final placement at screw entry (tail), and tip in addition to the angular deviation. RESULTS Seventy-five thoracic pedicle screws were implanted by navigated robotic guidance in 17 patients, only 1.3% (1/75) were repositioned intraoperatively. Average patient age and body mass index were 57.5 years and 25.9 kg/m 2 , respectively, with 52.9% female patients. Surgery diagnoses were degenerative disk disease (47.1%) and adjacent segment disease (17.6%). There were zero complications, with no returns to the operating room. According to the CT-based Gertzbein and Robbins pedicle screw breach classification system, 93.3% (70/75) screws were grade A or B, 6.6% (5/75) were grade C, and 0% were grade D or E. The average deviation from the preoperative plan to actual final placement was 1.8±1.3 mm for the screw tip, 1.6±0.9 mm for the tail, and 2.1±1.5 degrees of angulation. CONCLUSIONS The current investigation found a 93.3% accuracy of pedicle screw placement in the thoracic spine. Navigated robot assistance is a useful system for placing screws in the smaller pedicles of the thoracic spine. LEVEL OF EVIDENCE Level III-retrospective nonexperimental study.
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Affiliation(s)
- Arnold B. Vardiman
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - David J. Wallace
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Grant A. Booher
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Nader Toossi
- Musculoskeletal Education and Research Center (MERC), Audubon, PA
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Jeong S, Yang A, Dhodapkar MM, Jabbouri SS, Jonnalagadda A, Tuason D. 3D printed pedicle screw guides reduce the rate of intraoperative screw revision in adolescent idiopathic scoliosis surgery. Spine J 2023; 23:1894-1899. [PMID: 37553024 DOI: 10.1016/j.spinee.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/14/2023] [Accepted: 08/02/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND CONTEXT Pedicle screw fixation has become common in the treatment of adolescent idiopathic scoliosis (AIS). Malpositioned pedicle screws have significant complications and identifying surgical techniques to optimize screw placement accuracy is imperative. PURPOSE To compare the rate of intraoperative revision, replacement, or removal of pedicle screws placed utilizing 3D printed guides compared with pedicle screws placed utilizing a freehand technique. STUDY DESIGN/SETTING Retrospective cohort study/single academic center. PATIENT SAMPLE Thirty-two patients aged 10 to 18 with AIS. OUTCOME MEASURES Revision rate of pedicle screws and operative time between groups. METHODS A retrospective study was performed on patients 10 to 18 years of age who underwent posterior spinal instrumented fusion for AIS from February 2021 to July 2022. The study received an IRB exemption. Patient demographics, intraoperative measures, and outcome variables were recorded. Intraoperatively, all patients underwent a 3-dimensional fluoroscopic "check scan," which included axial, sagittal, and coronal images, to assess for screw accuracy. A secondary outcome of operative time was compared between groups. The p-values <.05 were considered significant. RESULTS A total of 32 patients were included in this study. There were 17 cases in the 3D guided and 15 cases in fluoroscopy-guided freehand cohort. There was a total of 254 pedicle screws using 3D guides and 402 screws using freehand technique. Between cohorts, there were no significant differences in a number of levels fused (p=.54) or length of surgery (p=.36). The total revision rate of 3D guided screw placement was 5.5% and that of the freehand technique was 8.5%. The freehand screw placement group had significantly higher revision rates per vertebral level compared with 3D guided (p=.0096). Notably, 3D printed guides had fewer screws that were removed/revised for being too anterior (7.1%) compared with freehand (23.5%). Surgical time was not significantly different between the 3D guided and freehand cohort (p=.35). CONCLUSIONS 3D printed guides reduce intraoperative revision rate compared with freehand techniques. Total operative time is comparable to freehand technique.
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Affiliation(s)
- Seongho Jeong
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Ally Yang
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Meera M Dhodapkar
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Sahir S Jabbouri
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Anshu Jonnalagadda
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Dominick Tuason
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA.
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12
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Nam Y, Chang DG, Kim HJ, Kim YH, Lee S, Yang JH, Suh SW. The Accuracy and Safety of a Pedicle Screw Using the Freehand Technique in Minimally Invasive Scoliosis Surgery. Neurospine 2023; 20:240-247. [PMID: 37016870 PMCID: PMC10080436 DOI: 10.14245/ns.2244646.323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/23/2022] [Indexed: 04/03/2023] Open
Abstract
Objective: The safety and clinical usefulness of minimally invasive scoliosis surgery (MISS) has been reported in various studies. However, freehand pedicle screwing in MISS remains technically challenging. The purpose of this study is to evaluate the accuracy and safety of pedicle screw placement using the freehand technique in adolescent idiopathic scoliosis (AIS) patients treated with MISS compared to conventional open scoliosis surgery (COSS).Methods: We included 76 patients who underwent deformity correction for AIS. Computed tomography scans were used to assess screw violations divided into 2 groups according to the surgical technique: MISS or COSS. Anterior violations were classified into grade 0, 1 (no contact with internal organs), and 2 (contact with internal organs). Medial and lateral violations were classified into grade 0, 1 ( < 2 mm), and 3 ( ≥ 2 mm). grade 2 were considered critical violations.Results: A total of 630 and 1,174 pedicle screws were inserted in the MISS and COSS groups, respectively. The overall critical violation rates of the MISS and COSS groups were 16.8% (106 screws) and 14.0% (165 screws) (p = 0.116). Medial critical violations on the left side in the middle thoracic region frequently occurred in the MISS group compared to the COSS group (p = 0.003). There were no statistical differences in the complications.Conclusion: Pedicle screw placement using the freehand technique in MISS for AIS patients provided similar accuracy and safety compared to COSS. Pedicle screws inserted on the left side of the middle thoracic region, exhibited more medial critical violations in the MISS group.
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Affiliation(s)
- Yunjin Nam
- Department of Orthopaedics, Korea University Guro Hospital, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopaedics, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Hong Jin Kim
- Department of Orthopaedics, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Young Ha Kim
- Department of Orthopaedics, Korea University Guro Hospital, Seoul, Korea
| | - Sangmin Lee
- Department of Orthopaedics, Korea University Guro Hospital, Seoul, Korea
| | - Jae Hyuk Yang
- Department of Orthopaedics, Korea University Anam Hospital, Seoul, Korea
| | - Seung Woo Suh
- Department of Orthopaedics, Korea University Guro Hospital, Seoul, Korea
- Corresponding Author Seung Woo Suh Department of Orthopaedics, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea
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13
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Jiang J, Chen X, Qiu Y, Wang B, Zhu ZZ, Yu Y. Accuracy of thoracic pedicle screw placement in adolescent idiopathic scoliosis patients using the entry point identified by new landmarks: a computed tomography study. BMC Surg 2022; 22:379. [PMID: 36333715 PMCID: PMC9636753 DOI: 10.1186/s12893-022-01827-1] [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: 06/08/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Although thoracic pedicle (TP) screw has gained increasingly popularity in the surgical treatment of adolescent idiopathic scoliosis (AIS) patients, questions remain about the accurate selection of entry point for TP screw placement in these patient. The main objective of the present study was to evaluate the accuracy of TP screw placement in AIS patients using the entry point identified by new landmarks. Methods Thirty-four thoracic AIS patients treated with posterior TP screw instrumentation were included. All these TP screws were inserted through the entry point identified by new landmarks with free-hand technique. Postoperative CT scans were obtained to evaluate the screw position. The perforations of the pedicle were classified as grade 0 (no perforation), grade 1 (≤ 2 mm), grade 2 (2.1–4 mm), grade 3 (4.1–6 mm) and grade 4 (6.1–8.0 mm). Screws in grade 0, displaced either medially or anteriorly in grade 1 and displaced laterally in grades 1 to 2 were considered acceptable. Results Of the 495 TP screws inserted, 34 (6.9%) screws were displaced with 7 screws (1.4%) displaced medially, 20 screws (4.1%) displaced laterally and 7 screws (1.4%) displaced anteriorly (P < 0.05). Among the 34 displaced screws, 11 screws (32.4%) were considered as grade 1, 14 screws (38.2%) as grade 2 and 9 screws (29.4%) as grade 3 (P < 0.05). The overall rate of acceptable screws was 97.8%. No screw-related complication was noted. Conclusion Our new method for selecting the entry point of TP screw in AIS patients is convenient and can achieve high accuracy of screw placement, which is worthy of being widely popularized.
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Affiliation(s)
- Jun Jiang
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| | - Xu Chen
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China ,grid.41156.370000 0001 2314 964XMedical School of Nanjing University, Nanjing, China
| | - Yong Qiu
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| | - Bin Wang
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| | - Ze-zhang Zhu
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| | - Yang Yu
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
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Tani Y, Saito T, Taniguchi S, Ishihara M, Paku M, Adachi T, Ando M. A new technique useful for lumbosacral percutaneous pedicle screw placement without fluoroscopy or computer-aided navigation systems. J Orthop Sci 2022; 27:1190-1196. [PMID: 34426052 DOI: 10.1016/j.jos.2021.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/05/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Percutaneous pedicle screw (PPS) placements in the lumbosacral spine generally rely on fluoroscopy at the expense of radiation exposure. Our accumulated experience in open PS placements without fluoroscopic guidance realized a consistent shift toward PPS insertion with newly developed devices, which require neither fluoroscopy nor navigation. We wish to report our new technique and evaluations of its accuracy. METHODS Our equipment consisted of a pedicle targeting tool to identify and escort the cannulated awl to the correct starting point for cortical bone perforation and a cannulated awl-probe system with a guidewire to maintain the optimal position throughout the subsequent surgical steps. The surgeon could advance the blunt-tipped probe searching for the cancellous bone track using tactile feedback as experienced in open techniques. A 2-year period of transition from a free-hand (1169 screws in 286 patients) to the new PPS technique (1933 screws in 413 patients) allowed accuracy comparison between the two procedures using postoperative CT scans. RESULTS Compared with the open-group, the PPS-group showed a lower rate of fully contained intrapedicular PS placements at L1 through S1, as a whole (90.7% vs 85.4%), but not at L4 through S1 (89.9% vs 90.2%). Less-accurate PPS placements at upper than lower lumbar spines in part reflect intended pedicle perforations laterally as a trade-off for avoiding facet violation immediately above the most cephalad screw. The PPS-group also had a higher incidence of PS-related transient nerve root complications (0% vs 1.7%). These values for the PPS-group, however, fell within those previously reported for free-hand or fluoroscopy techniques. CONCLUSIONS Our new PPS technique, although useful for eliminating the potential risk of repeated radiation exposure, fell short of reaching the accuracy of the free-hand technique. Nerve integrity monitoring with PS stimulation, which we currently use, will help further improve the technical precision. STUDY DESIGN Original Article. The study was approved by our institutional review boad (2,019,231).
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Affiliation(s)
- Yoichi Tani
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-city, Osaka, 573-1010, Japan.
| | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-city, Osaka, 573-1010, Japan
| | - Shinichiro Taniguchi
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-city, Osaka, 573-1010, Japan
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-city, Osaka, 573-1010, Japan
| | - Masaaki Paku
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-city, Osaka, 573-1010, Japan
| | - Takashi Adachi
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-city, Osaka, 573-1010, Japan
| | - Muneharu Ando
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-city, Osaka, 573-1010, Japan
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He J, Luo F, Wang H, Xu J, Zhang Z. SAP Principle Guided Free Hand Technique: A Secret for T1 to S1 Pedicle Screw Placement. Orthop Surg 2022; 14:2995-3002. [PMID: 36208012 DOI: 10.1111/os.13513] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/31/2022] [Accepted: 08/23/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Existing freehand techniques of screw placement mainly emphasized on various entry points and complex trajectory reference. The aim of this study is to illustrate a standardized and reliable freehand technique of pedicle screw insertion for open pedicle screw fixation with a universal entry point and a stereoscopic trajectory reference system and report the results from a single surgeon's clinical experience with the technique. METHOD In this study, the author respectively reviewed a total of 200 consecutive patients who had undergone open freehand pedicle screw fixation with Superior Articular Process (SAP) technique from January 2019 to May 2020. For accuracy and safety, all 200 cases had undergone postoperative X-ray while 33 cases including spinal deformity, infection, and tumor had received additional CT-scan. Screw accuracy was analyzed via a CT-based classification system with Student's t test. RESULTS A total of 1126 screws had been placed from T1-S1 with SAP-guided freehand technique and the majority had been confirmed safe in X-ray without the need of CT scan. A total of 316 screws in deformity or infectious or tumor cases had undergone additional CT scan with 95.5% (189 of 198 screws) accuracy in thoracic group and 94.9% (112 of 118 screws) in lumbar group. The accuracy had been 90.5% (114 of 126 screws) in deformity group and 95.8% (182 of 190 screws) in non-deformity group. All perforation cases had been rated Grade B (<2 mm) without significant difference between the medial and the lateral (p < 0.05). No cases had been detected with significant neurological deficiencies. The mean intraoperative X-ray shots were 0.73 per screw. CONCLUSION SAP-guidance is a reliable freehand technique for thoracic and lumbar pedicle screw instrument. It allows accurate and safe screw insertion in both non-deformity and deformity cases with less radiation exposure.
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Affiliation(s)
- Jinyue He
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Fei Luo
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Hao Wang
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jianzhong Xu
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - ZeHua Zhang
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
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16
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Gueziri HE, Georgiopoulos M, Santaguida C, Collins DL. Ultrasound-based navigated pedicle screw insertion without intraoperative radiation: feasibility study on porcine cadavers. Spine J 2022; 22:1408-1417. [PMID: 35523390 DOI: 10.1016/j.spinee.2022.04.014] [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] [Received: 12/02/2021] [Revised: 04/15/2022] [Accepted: 04/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Navigation systems for spinal fusion surgery rely on intraoperative computed tomography (CT) or fluoroscopy imaging. Both expose patient, surgeons and operating room staff to significant amounts of radiation. Alternative methods involving intraoperative ultrasound (iUS) imaging have recently shown promise for image-to-patient registration. Yet, the feasibility and safety of iUS navigation in spinal fusion have not been demonstrated. PURPOSE To evaluate the accuracy of pedicle screw insertion in lumbar and thoracolumbar spinal fusion using a fully automated iUS navigation system. STUDY DESIGN Prospective porcine cadaver study. METHODS Five porcine cadavers were used to instrument the lumbar and thoracolumbar spine using posterior open surgery. During the procedure, iUS images were acquired and used to establish automatic registration between the anatomy and preoperative CT images. Navigation was performed with the preoperative CT using tracked instruments. The accuracy of the system was measured as the distance of manually collected points to the preoperative CT vertebral surface and compared against fiducial-based registration. A postoperative CT was acquired, and screw placements were manually verified. We report breach rates, as well as axial and sagittal screw deviations. RESULTS A total of 56 screws were inserted (5.50 mm diameter n=50, and 6.50 mm diameter n=6). Fifty-two screws were inserted safely without breach. Four screws (7.14%) presented a medial breach with an average deviation of 1.35±0.37 mm (all <2 mm). Two breaches were caused by 6.50 mm diameter screws, and two by 5.50 mm screws. For vertebrae instrumented with 5.50 mm screws, the average axial diameter of the pedicle was 9.29 mm leaving a 1.89 mm margin in the left and right pedicle. For vertebrae instrumented with 6.50 mm screws, the average axial diameter of the pedicle was 8.99 mm leaving a 1.24 mm error margin in the left and right pedicle. The average distance to the vertebral surface was 0.96 mm using iUS registration and 0.97 mm using fiducial-based registration. CONCLUSIONS We successfully implanted all pedicle screws in the thoracolumbar spine using the ultrasound-based navigation system. All breaches recorded were minor (<2 mm) and the breach rate (7.14%) was comparable to existing literature. More investigation is needed to evaluate consistency, reproducibility, and performance in surgical context. CLINICAL SIGNIFICANCE Intraoperative US-based navigation is feasible and practical for pedicle screw insertion in a porcine model. It might be used as a low-cost and radiation-free alternative to intraoperative CT and fluoroscopy in the future.
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Affiliation(s)
- Houssem-Eddine Gueziri
- McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada.
| | - Miltiadis Georgiopoulos
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada
| | - D Louis Collins
- McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada
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17
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Intraoperative Cone Beam CT in Hybrid Operation Room for Pediatric Scoliosis Patients: Comparison of Pedicle Screw Violation Rate at Normal and Low Radiation Doses. Spine (Phila Pa 1976) 2022; 47:E507-E513. [PMID: 34545047 DOI: 10.1097/brs.0000000000004226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective observational study. OBJECTIVE This study aimed to determine the effect of reducing the radiation dose of intraoperative cone beam computed tomography (CBCT) during posterior spinal fusion (PSF) for pediatric scoliosis on the rate of pedicle screw (PS) violation. SUMMARY OF BACKGROUND DATA Intraoperative CBCT for pediatric scoliosis improves the accuracy of PS insertion in PSF. However, few reports have addressed the PS perforation rate from reduced radiation doses in hybrid navigation. METHODS We evaluated 855 PSs inserted into 58 pediatric scoliosis patients (11 male and 47 female, mean age: 16.6 yr) who underwent PSF using CBCT. A radiation dose of 1/3 or 1/5 of the normal dose (ND) was defined as a low dose (LD). After PS insertion, intraoperative CBCT images were reviewed to assess the degree of PS perforation. G2-3 (i.e., perforations of 4 mm or more) was defined as a violation. The PS violation rate was compared between the groups, and factors associated with violations were examined. RESULTS A total of 567 and 288 screws were inserted in the ND group and LD group, respectively. The PS violation rate was comparable at 1.8% in the ND group and 1.7% in the LD group. Multiple logistic regression analysis showed that distance from the upper instrumented vertebra (UIV) was an independently associated factor of PS violation (+1 vertebra, operation room 0.73, P = 0.038). In addition, the mean height of patients with PS violations (148.8 ± 3.6 cm) was significantly shorter than that of patients without violations (157.9 ± 1.2 cm) ( P = 0.034). CONCLUSION There was no increase in PS violation rate with lower doses of radiation for intraoperative navigation CBCT. Extra care is warranted for vertebrae close to the UIV and patients of shorter stature.Level of Evidence: 3.
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18
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Zhang Q, Fan MX, Han XG, Liu YJ, He D, Liu B, Tian W. Risk Factors of Unsatisfactory Robot-Assisted Pedicle Screw Placement: A Case-Control Study. Neurospine 2022; 18:839-844. [PMID: 35000338 PMCID: PMC8752688 DOI: 10.14245/ns.2142560.180] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/09/2021] [Indexed: 01/01/2023] Open
Abstract
Objective To identify potential risk factors of unsatisfactory screw position during robot-assisted pedicle screw fixation.
Methods A retrospective analysis of robot-assisted pedicle screw fixation performed in Beijing Jishuitan Hospital from March 2018 to March 2019 was conducted. Research data was collected from the medical record and imaging systems. Univariate tests were performed on the potential risk factors (patient’s characteristics and surgical factors) of unsatisfactory screw position during robot-assisted pedicle screw fixation. For statistically significant variables in univariate tests, a logistic regression test was used to identify independent risk factors for unsatisfactory screw position.
Results A total of 780 pedicle screws placed in 163 robot-assisted surgeries were analyzed. The rate of perfect screw positions was 93.08%, and the unsatisfactory rate was 6.92%. In patients with severe obesity (body mass index ≥ 30 kg/m2) (odds ratio [OR], 2.459; 95% confidence interval [CI], 1.199–5.044; p=0.014), osteoporosis (T ≤ -2.5) (OR, 1.857; 95% CI, 1.046–3.295; p=0.034), and the segments 3 levels away from the tracker (OR, 2.216; 95% CI, 1.119–4.387; p=0.022), robot-assisted pedicle screw placement has a higher risk of screw malposition.
Conclusion During robot-assisted pedicle screw placement for patients with severe obesity, osteoporosis, and segments 3 levels away from the tracker, vigilance should be maintained during surgery to avoid postoperative complications due to unsatisfactory screw position.
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Affiliation(s)
- Qi Zhang
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ming-Xing Fan
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Xiao-Guang Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ya-Jun Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Da He
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Bo Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
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Librianto D, Saleh I, Ipang F, Aprilya D. Freehand Pedicle Screw Insertion in Spondylitis Tuberculosis Kyphosis Correction Using Cantilever Method: A Breach Rate Analysis of 168 Consecutive Screws. Orthop Res Rev 2022; 14:17-24. [PMID: 35115848 PMCID: PMC8807407 DOI: 10.2147/orr.s349729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/14/2022] [Indexed: 11/24/2022] Open
Abstract
Background The cantilever method is a standard for two-dimensional deformity correction, as in spondylitis tuberculosis kyphotic deformity. An accurate and secured pedicle screw placement as part of the correction tools is essential to accommodate reduction while preventing screw-related complications. Many literatures have described the pedicle screw misplacement in cases with “normal” bone quality (ie, scoliosis, Scheuermann’s kyphosis, ankylosing spondylitis, trauma) or in the obviously abnormal bone such as osteoporosis. However, to our knowledge, the pedicle screw accuracy in cases of deformity correction of tuberculous kyphosis was not previously reported. Methods This is a retrospective study of 168 pedicle screws in 14 consecutive cases of spondylitis tuberculosis with kyphotic deformity. The cantilever reduction method with freehand screw insertion technique was done in all cases to correct the deformity. Postoperative computed tomography (CT) evaluation was done to evaluate screw position and breach rates. Results Among the 168 screws, accurate pedicle screw placement was accomplished in 39.3% screws (Gertzbein–Robbins Grade A). The overall breach rate was 61.9%, which was most commonly occurred on the segment proximal to the apex of the deformity (p=0.001). The lateral breach was more common than the medial breach (52.3% vs 7.7%). The pedicle screw on the thoracal region has a greater breach incidence than those on the lumbar region especially those on T9, T10, and T11. There was no injury to the surrounding neurovascular and pleural structures. No revision surgeries were required. Conclusion Freehand pedicle screw insertion in spondylitis tuberculosis kyphotic reduction has proved to be safe. However, the accuracy should be improved to prevent long-term screw-related complications.
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Affiliation(s)
- Didik Librianto
- Orthopedic Spine Surgery, Fatmawati General Hospital, Jakarta, Indonesia
| | - Ifran Saleh
- Department of Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Fachrisal Ipang
- Orthopedic Spine Surgery, Fatmawati General Hospital, Jakarta, Indonesia
| | - Dina Aprilya
- Department of Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Correspondence: Dina Aprilya, Department of Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Prof. Soelarto building, 1st floor, RS Fatmawati Street, Jakarta, 12430, Indonesia, Tel +62 89655106136, Fax +62 21-7660616, Email
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20
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Guzek RH, Mitchell SL, Krakow AR, Harshavardhana NS, Sarkissian EJ, Flynn JM. Morphometric analysis of the proximal thoracic pedicles in Lenke II and IV adolescent idiopathic scoliosis: an evaluation of the feasibility for pedicle screw insertion. Spine Deform 2021; 9:1541-1548. [PMID: 34453700 DOI: 10.1007/s43390-021-00377-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/13/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Pedicles on the concave side of the proximal thoracic (PT) curve in adolescent idiopathic scoliosis (AIS) patients with Lenke II and IV deformities tend to be narrow and dysplastic, making pedicle screw (PS) insertion challenging. The aim of this study was to evaluate the feasibility for PS placement in these patients using pedicle chord length, diameter, and channel morphology. METHODS In this retrospective study, 56 consecutive AIS patients with Lenke II or IV curves who underwent instrumented posterior spinal fusion (PSF) were studied. The mean age at surgery was 14.8 years and the mean PT curve measured 45°. Two independent investigators evaluated all visible pedicles from T1 to T6 vertebral levels using axial images from intraoperative computed tomography-guided navigation recording the pedicle: (1) maximum transverse diameter 'd' at the isthmus, (2) maximum chord length 'l', and (3) qualitative assessment of the channel morphology (types A-D). RESULTS Two hundred and sixty-eight concave and 264 convex pedicles were measured. The mean 'd' of the concave pedicles at T3 and T4 was < 3.0 mm, compared to > 5.0 mm for the convex counterparts (p < 0.001). Of all concave pedicle channels, 48% had morphology characteristics that were riskier for PS cannulation (type C or D) compared to 2% of all convex pedicle channels (type A or B) (p < 0.001). CONCLUSION Almost half of all concave pedicles have morphologic characteristics that make them too small to accommodate a PS. Though PSs could be inserted using an in-out-in technique in these patients, alternative fixation anchors may improve strength and safety.
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Affiliation(s)
- Ryan H Guzek
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stuart L Mitchell
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arielle R Krakow
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Eric J Sarkissian
- Orthopedic Surgery, Washington DC VA Medical Center, Washington, DC, USA
| | - John M Flynn
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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21
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Tachi H, Kato K, Abe Y, Kokabu T, Yamada K, Iwasaki N, Sudo H. Surgical Outcome Prediction Using a Four-Dimensional Planning Simulation System With Finite Element Analysis Incorporating Pre-bent Rods in Adolescent Idiopathic Scoliosis: Simulation for Spatiotemporal Anatomical Correction Technique. Front Bioeng Biotechnol 2021; 9:746902. [PMID: 34712654 PMCID: PMC8546212 DOI: 10.3389/fbioe.2021.746902] [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] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/09/2021] [Indexed: 01/15/2023] Open
Abstract
An optimal surgical strategy for adolescent idiopathic scoliosis (AIS) is to provide maximal deformity correction while preserving spinal mobile segments as much as possible and obtaining a balanced posture. From a spatiotemporal deformity correction standpoint, we recently showed that anatomical four-dimensional (4D) spinal correction could be accomplished by curving the rod. In the surgical procedure, two rods are bent identically to confirm spinal anatomical alignment without referring to the intraoperative alignment of the deformity. Therefore, anatomically designed rods have been developed as notch-free, pre-bent rods for easier anatomical reconstruction. In addition to providing the best spinal instrumentation configurations as pre-bent rods, prediction of surgical outcome along with its biomechanical impact can be obtained by simulation of the surgical procedures with computer modeling. However, an objective model that can simulate the surgical outcome in patients with AIS has not been completely elucidated. The present study aimed to compare simulated deformity corrections based on our newly developed spatiotemporal morphological 4D planning simulation system incorporating pre-bent rods and actual deformity corrections in patients with AIS. A consecutive series of 47 patients who underwent anatomical posterior correction for AIS curves were prospectively evaluated. After multilevel facetectomy, except for the lowest instrumented segment, 11 types of pre-bent rods were used. Patient demographic data, radiographic measurements, and sagittal rod angles were analyzed within 1 week of surgery. Our simulation system incorporating pre-bent rods showed a significant correlation with the actual postoperative spinal alignment. The present study demonstrated the feasibility of our simulation system and the ability to simulate the surgical procedure using the pre-bent rods. The simulation system can be used to minimize the differences between the optimal and possible outcomes related to the instrumentation levels and rod shapes. Preoperative assumption of rod shape and length can contribute to a reduction in operative time which decreases blood loss and risk of infection. The results of the finite element analysis in the simulation system measured for each individual patient would also provide a more realistic representation of the surgical procedures.
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Affiliation(s)
- Hiroyuki Tachi
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Orthopaedic Surgery, Eniwa Hospital, Eniwa, Japan
| | - Koji Kato
- Department of Systems Information Science, Future University Hakodate, Hakodate, Japan
| | - Yuichiro Abe
- Department of Orthopaedic Surgery, Eniwa Hospital, Eniwa, Japan
| | - Terufumi Kokabu
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Katsuhisa Yamada
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideki Sudo
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Advanced Medicine for Spine and Spinal Cord Disorders, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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22
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Skaggs DL, Compton E, Vitale MG, Garg S, Stone J, Fletcher ND, Illingworth KD, Kim HJ, Ball J, Kim EB, Keil L, Harris H, Shah SP, Andras LM. Power versus manual pedicle tract preparation: a multi-center study of early adopters. Spine Deform 2021; 9:1395-1402. [PMID: 33891296 DOI: 10.1007/s43390-021-00347-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
STUDY DESIGN Retrospective cohort, multicenter. A single surgeon study demonstrated that pedicle tract preparation with power tools was associated with lower fluoroscopy times and revision rates compared to manual tools, while maintaining patient safety. OBJECTIVE Our purpose was to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology. METHODS Retrospective review comparing patients that underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions between January 1, 2008 and August 31, 2019. The manual pedicle tract preparation used a pedicle awl. Power tract preparation used a flexible 2.0-2.4 mm drill bit, followed by a larger drill bit or a reamer. All screws were inserted with power technique. RESULTS In the manual tract preparation group, 9424 screws were placed in 585 cases. In the power tract preparation group, 22,209 screws were placed in 1367 cases. Seven patients (7/1952; 0.36%; 95% CI: 0.14-0.74%) had 11 mal-positioned screws (11/31,633; 0.03%; 95% CI: 0.017-0.062%). Seven screws (7/9424; 0.07%; 95% CI: 0.030-0.15%) were in the manual cohort and four (4/22,209; 0.02%; 95% CI: 0.0049-0.046%) were in the power cohort. There were significantly more revisions per screw in the manual cohort (p = 0.02). However, there were not significantly more revisions per patient in the manual cohort (manual: 0.5%, 3/585 vs. power: 0.3%, 4/1,367; p = 0.43). Of these seven, three patients (3/585; 0.5%; 95% CI: 0.1-1.5%) experienced neurologic injury or neuro-monitoring changes requiring screw removal in the manual cohort, and 1 patient (1/1,367, 0.07%; 95% CI: 0.002-0.4%) in the power cohort (p = 0.08). Three additional patients underwent revision in the power cohort: 1 for an asymptomatic lateral breech, 1 for a spinal headache/medial breech that developed after an MVA, and 1 for an iliac vein injury during pedicle tract preparation. CONCLUSION This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision. Equivalent patient safety was demonstrated compared to manual technique. LEVEL OF EVIDENCE III.
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Affiliation(s)
- David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA. .,Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
| | - Edward Compton
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Sumeet Garg
- Children's Hospital Colorado, Aurora, CO, USA
| | - Joseph Stone
- Department of Orthopaedics, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | | | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Jacob Ball
- Columbia University Medical Center, New York, NY, USA
| | - Eun Bi Kim
- Children's Hospital Colorado, Aurora, CO, USA
| | - Lukas Keil
- Department of Orthopaedics, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | - Hilary Harris
- Emory Orthopedics and Spine Center, Atlanta, GA, USA
| | - Sachin P Shah
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Abstract
BACKGROUND/INTRODUCTION Pedicle screws have long been part of the continued advancements in spine surgery. Despite the many techniques that have been devised for their safe placement, malposition of screws continues to occur. Studies have evaluated the possible safe limits of screw malposition, and have given some insight on anatomic variation in spinal deformity. Review of the literature reveals several cases of deleterious long-term sequelae of malpositioned screws. DISCUSSION With the current experience, proposed recommendations are provided to detect and avoid the potential long-term sequelae. Though the literature has helped to define possible concerning screws, there are no good studies predicting long-term risk. CONCLUSION Improvements in technology and techniques, advancements in intraoperative confirmation and postoperative surveillance, studies that assist risk stratification, and expert consensus evaluations will help guide surgeons in their decision for addressing misplaced screws.
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24
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Fu W, Tong J, Liu G, Zheng Y, Wang S, Abdelrahim MEA, Gong S. Robot-assisted technique vs conventional freehand technique in spine surgery: A meta-analysis. Int J Clin Pract 2021; 75:e13964. [PMID: 33370470 DOI: 10.1111/ijcp.13964] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The impact of robot-assisted techniques versus conventional freehand techniques in terms of the accuracy of pedicle screw placement remains conflicting. This meta-analysis was performed to evaluate this relationship. METHODS A systematic literature search up to July 2020 was performed and 15 studies were detected with 6041 pedicle screw placements with 2748 of them were using robot-assisted techniques and 3293 were conventional freehand techniques. They reported relationships between robot-assisted techniques and conventional freehand techniques in pedicle screw placement. Odds ratio (OR) or Mean differences (MD) with 95% confidence intervals (CIs) was calculated comparing the robot-assisted techniques to conventional freehand techniques in pedicle screw placement risks using the dichotomous and continuous method with a random or fixed-effect model. RESULTS Robot-assisted techniques had a significantly higher screw position grade A in Gertzbein-Robbins classification of the screw placement accuracy (OR, 2.43; 95% CI, 1.66-3.54, P < .001); shorter postoperative stay (MD, -0.67; 95% CI, -1.16 to -0.19, P < .001); lower intraoperative blood loss (MD, -91.64; 95% CI, -152.44 to -30.83, P = .003); fewer intraoperative radiation dose (MD, -23.52; 95% CI, -40.12 to -6.0.93, P = .005); and low proximal facet violations (MD, 0.08; 95% CI, 0.03-0.20, P < .001) compared with conventional freehand techniques. However, no significant difference was found between robot-assisted techniques and conventional freehand techniques in surgical time (OR, 11.71; 95% CI, 03.27-26.70, P = .13); visual analogue scale scores (MD, -0.15; 95% CI, -0.54 to 0.23, P = .44); and Oswestry disability index scores (MD, 0.21; 95% CI, -5.09-5.51, P = .94). CONCLUSIONS The extent of the improvement with robot-assisted techniques in screw position grade A in Gertzbein-Robbins classification of the screw placement accuracy, postoperative stay, intraoperative blood loss, intraoperative radiation dose, and proximal facet violations was significantly better than conventional freehand techniques. This relationship forces us to recommend robot-assisted techniques for pedicle screw placement to avoid any possible negative postoperative results.
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Affiliation(s)
- Weiguang Fu
- Department of Spinal Surgery, the 215 Hospital of shaanxi nuclear industry, Xianyang, China
| | - Jie Tong
- Department of Spinal Surgery, Affiliated Chenzhou Hospital, The First School of Clinical Medicine, Southern Medical University (The First People's Hospital of Chenzhou), Chenzhou, Hunan, 423000, China
| | - Gang Liu
- Department of Spinal Surgery, the 215 Hospital of shaanxi nuclear industry, Xianyang, China
| | - Yuxin Zheng
- Department of Orthopedics, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Shaolei Wang
- Department of Orthopaedic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Shaohua Gong
- Department of Spinal Surgery, Baoshan Branch, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Peeters CMM, van Houten L, Kempen DHR, Wapstra FH, Jutte PC, van den Akker-Scheek I, Faber C. Assessment of pedicle size in patients with scoliosis using EOS 2D imaging: a validity and reliability study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3473-3481. [PMID: 33895877 DOI: 10.1007/s00586-021-06839-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 12/30/2020] [Accepted: 04/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Free-hand pedicle screw insertion methods are widely used for screw insertion during scoliosis surgery. Preoperative knowledge about the pedicle size helps to maximize screw containment and minimize the risk of pedicle breach. Radiographs taken by a biplanar low-dose X-ray device (EOS) have no divergence in the vertical plane. The criterion validity and reliability of preoperative EOS images for pedicle size measurements in patients with idiopathic scoliosis (IS) was investigated in this study. METHODS Sixteen patients who underwent surgical treatment for IS were prospectively included. Intra- and extracortical pedicle height and width measurements on EOS images were compared with reconstructed intra-operative 3D images of the isthmus of included pedicles. Secondly, intra- and interobserver reliability of pedicle size measurements on EOS images was determined. RESULTS The total number of analyzed pedicles was 203. The correlation between the EOS and 3D scan measurements was very strong for the intra- and extracortical pedicle height and strong for the intra- and extracortical pedicle width. There are, however, significant, but likely clinically irrelevant differences (mean absolute differences < 0.43 mm) between the two measure methods for all four measurements except for extracortical pedicle height. For pedicles classified as Nash-Moe 0, no significant differences in intra- and extracortical pedicle width were observed. Both intra- and interobserver reliability was excellent for all pedicle size measurements on EOS images. CONCLUSION The results of this study indicate a good validity and reliability for pedicle size measurements on EOS radiographs. Therefore, EOS radiographs may be used for a preoperative estimation of pedicle size and subsequent screw diameter in patients with IS.
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Affiliation(s)
- C M M Peeters
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - L van Houten
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - D H R Kempen
- Department of Orthopaedics, OLVG, Amsterdam, The Netherlands
| | - F H Wapstra
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - P C Jutte
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - I van den Akker-Scheek
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - C Faber
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
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Zarei M, Ghadimi E, Bagheri N, Jamshidi SMMM, Moharrami A, Moosavi M, Baghdadi S. Posterior hemivertebra resection and short-segment fusion with lateral mass screws in congenital scoliosis: a novel strategy for the resource-limited setting. J Orthop Surg Res 2021; 16:271. [PMID: 33865419 PMCID: PMC8052735 DOI: 10.1186/s13018-021-02419-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/11/2021] [Indexed: 11/28/2022] Open
Abstract
Background Posterior hemivertebra resection and short-segment fusion with pedicle screws are an established treatment in congenital scoliosis, which require pediatric-specific instrumentation. The purpose of this study was to report the results of utilizing cervical lateral mass screws instead of pedicle screws in the treatment of congenital scoliosis in children younger than 5 years old. Methods In an IRB-approved retrospective chart review study, patients <5 years old with congenital scoliosis who underwent posterior hemivertebra resection and fusion with lateral mass screws from 2013 to 2017 were included. Demographic information, pre- and post-operative radiographs, complications, and outcomes were extracted from the charts. Results Twenty-three patients were included in the final analysis with a mean age of 40 months, of which 14 were female. Patients were followed for a mean of 51.3±13.2 months. The mean blood loss was 210ml, and patients were hospitalized for a mean of 4 days post-operatively. The correction rate of the main coronal curve, compensatory cranial curve, compensatory caudal curve, and segmental sagittal curve was 74.8%, 68%, 65.2%, and 68.9%, respectively. Three complications were observed: one intra-operative pedicle fracture, one case of implant failure, and one deep surgical-site infection, all of which were successfully managed. Conclusions Our findings suggest that adult lateral mass screws can be used for transpedicular fixation of the thoracic and lumbar vertebrae in low-resource settings where pediatric-specific pedicle instruments are not readily available. The correction rate, outcomes, and complications are similar and comparable to pediatric-specific pedicle screws, in addition to being low-profile and less bulky compared to adult implants.
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Affiliation(s)
- Mohammad Zarei
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
| | - Ehsan Ghadimi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
| | - Nima Bagheri
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
| | | | - Alireza Moharrami
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
| | - Mersad Moosavi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran
| | - Soroush Baghdadi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran, 1419733141, Iran. .,The Children's Hospital of Philadelphia, Division of Orthopaedics, Philadelphia, PA, USA.
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27
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Lonner B, Verma K, Roonprapunt C, Ren Y, Slattery CA, Alanay A, Kassin G, Castillo A, Bazerbashi M, Buehler MA, Kodigudla MK, Kelkar AV, Serhan H, Goel V. The Transverse Process Trajectory Technique: An Alternative for Thoracic Pedicle Screw Implantation-Radiographic and Biomechanical Analysis. Int J Spine Surg 2021; 15:315-323. [PMID: 33900989 PMCID: PMC8059387 DOI: 10.14444/8041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study evaluates the accuracy, biomechanical profile, and learning curve of the transverse process trajectory technique (TPT) compared to the straightforward (SF) and in-out-in (IOI) techniques. SF and IOI have been used for fixation in the thoracic spine. Although widely used, there are associated learning curves and symptomatic pedicular breaches. We have found the transverse process to be a reproducible pathway into the pedicle. METHODS Three surgeons with varying experience (experienced [E] with 20 years in practice, surgeon [S] with less than 10 years in practice, and senior resident trainee [T] with no experience with TPT) operated on 8 cadavers. In phase 1, each surgeon instrumented 2 cadavers, alternating between TPT and SF from T1 to T12 (n = 48 total levels). In phase 2, the E and T surgeons instrumented 1 cadaver each, alternating between TPT and IOI. Computed tomography scans were analyzed for accuracy of screw placement, defined as the percentage of placements without critical breaches. Axial pullout and derotational force testing were performed. Statistical analyses include paired t test and analysis of variance with Tukey correction. RESULTS Overall accuracy of screw placement was comparable between techniques (TPT: 92.7%; SF: 97.2%; IOI: 95.8%; P = .4151). Accuracy by technique did not differ for each individual surgeon (E: P = .7733; S: P = .3475; T: P = .4191) or by experience level by technique (TPT: P = .1127; FH: P = .5979; IOI: P = .5935). Pullout strength was comparable between TPT and SF (571 vs 442 N, P = .3164) but was greater for TPT versus IOI (454 vs 215 N, P = .0156). There was a trend toward improved derotational force for TPT versus SF (1.06 vs 0.93 Nm/degrees, P = .0728) but not for TPT versus IOI (1.36 vs 1.16 Nm/degrees, P = .74). Screw placement time was shortest for E and longest for T for TPT and SF and not different for IOI (TPT: P = .0349; SF: P < .0001; IOI: P = .1787) but did not vary by technique. CONCLUSIONS We describe the TPT, which uses the transverse process as a corridor through the pedicle. TPT is an accurate method of thoracic pedicle screw placement with potential biomechanical advantages and with acceptable learning curve characteristics. CLINICAL RELEVANCE This study provides the surgeon with a new trajectory for pedicle screw placement that can be used in clinical practice.
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Affiliation(s)
| | | | | | - Yuan Ren
- Mount Sinai Hospital, New York, New York
| | | | - Ahmet Alanay
- Department of Orthopaedics and Traumatology, Acibadem University School of Medicine, Istanbul, Turkey
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Guevar J, Bleedorn J, Cullum T, Hetzel S, Zlotnick J, Mariani CL. Accuracy and safety of three-dimensionally printed animal-specific drill guides for thoracolumbar vertebral column instrumentation in dogs: Bilateral and unilateral designs. Vet Surg 2020; 50:336-344. [PMID: 33340136 DOI: 10.1111/vsu.13558] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/04/2020] [Accepted: 11/26/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the safety and accuracy of a unilateral three-dimensionally printed animal-specific drill guide (3DASDG) design for unilateral stabilization in the thoracolumbar vertebral column of dogs compared to a bilateral design. STUDY DESIGN Cadaveric study. SAMPLE POPULATION Fifty-two corridors in one canine cadaver. METHODS Two 3DASDG designs with 2 drilling tubes each were created from T8 to L7 vertebrae. Fifty-two corridors were drilled on the right and the left sides by using unilateral and bilateral designs, respectively. Planned and postoperative trajectories (entry point, exit point, angle) were compared to establish the accuracy. Statistical analysis was used for accuracy comparison between designs. Safety was evaluated by using Zdichavsky classification. RESULTS Unilateral and bilateral drill guide designs were not different for entry point and angle deviations; however, they were different for the exit point deviations. Two corridors breached outside the vertebra. For all guides, mean entry and exit point deviations were less than 1 and 2 mm, respectively. The maximum entry or exit point deviation in both groups was 4.7 mm. The mean angle deviation was <3.5°, and the maximum angle deviation was 9.3°. CONCLUSION No difference was detected in accuracy of entry points and angle deviations between drill guide designs tested in normal vertebrae. The technique was classified as highly safe. CLINICAL SIGNIFICANCE A unilateral drill guide design may be a safe alternative to bilateral guides for unilateral stabilization of the thoracolumbar vertebral column in dogs.
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Affiliation(s)
- Julien Guevar
- Division of Clinical Neurology, Vetsuisse Faculty, University of Bern, Bern, Switzerland.,Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin- Madison, Madison, Wisconsin
| | - Jason Bleedorn
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin- Madison, Madison, Wisconsin
| | | | - Scott Hetzel
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin
| | - Josh Zlotnick
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Christopher L Mariani
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
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Uehara M, Kuraishi S, Ikegami S, Oba H, Takizawa T, Munakata R, Hatakenaka T, Koseki M, Takahashi J. Long-Term Surgical Results of Skip Pedicle Screw Fixation for Patients with Adolescent Idiopathic Scoliosis: A Minimum-Ten-Year Follow-Up Study. J Clin Med 2020; 9:E4002. [PMID: 33321984 PMCID: PMC7764638 DOI: 10.3390/jcm9124002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 11/20/2022] Open
Abstract
Skip pedicle screw fixation for adolescent idiopathic scoliosis (AIS) requires fewer screws and can reduce the risk of neurovascular injury as compared with segmental pedicle screw fixation. However, the long-term impact of screw number reduction on correction and clinical results is unclear. This study examined the 10-year post-operative outcomes of skip pedicle screw fixation for patients with AIS. We reviewed the outcomes of 30 patients who underwent skip pedicle screw fixation for AIS. Radiological and clinical findings were assessed before and immediately, 2 years, and 10 years after surgery in the remaining 25 patients. The mean Cobb angle of the main curve preoperatively and immediately, 2 years, and 10 years post-operatively was 59.4°, 23.4°, 25.8°, and 25.60°, respectively, and was significantly improved at all post-surgical time points (all p < 0.001). The mean correction rate immediately after surgery was 60.8%, and the correction loss rate at the observation end point was 4.8%. The Cobb angle of the lumbar curve was significantly improved immediately after surgery, and the correction persisted until 10 years post-operatively. Remarkable gains were observed for most Scoliosis Research Society-22 patient questionnaire sub-scores at the final follow-up versus preoperative assessments. In conclusion, good correction of the AIS deformity by skip pedicle screw fixation was well maintained over a long follow-up period of 10 years, with clinically meaningful gains in Society-22 patient questionnaire sub-scores.
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Affiliation(s)
- Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan; (S.K.); (S.I.); (H.O.); (T.T.); (R.M.); (T.H.); (J.T.)
| | - Shugo Kuraishi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan; (S.K.); (S.I.); (H.O.); (T.T.); (R.M.); (T.H.); (J.T.)
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan; (S.K.); (S.I.); (H.O.); (T.T.); (R.M.); (T.H.); (J.T.)
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan; (S.K.); (S.I.); (H.O.); (T.T.); (R.M.); (T.H.); (J.T.)
| | - Takashi Takizawa
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan; (S.K.); (S.I.); (H.O.); (T.T.); (R.M.); (T.H.); (J.T.)
| | - Ryo Munakata
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan; (S.K.); (S.I.); (H.O.); (T.T.); (R.M.); (T.H.); (J.T.)
| | - Terue Hatakenaka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan; (S.K.); (S.I.); (H.O.); (T.T.); (R.M.); (T.H.); (J.T.)
| | - Michihiko Koseki
- Department of Mechanical Engineering and Robotics, Faculty of Textile Science and Technology, Shinshu University, 3-15-1 Tokida, Ueda, Nagano 390-8621, Japan;
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan; (S.K.); (S.I.); (H.O.); (T.T.); (R.M.); (T.H.); (J.T.)
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Does Main Curve Flexibility Affect Screw Insertion Accuracy Using a CT-based Navigation System in Adolescent Idiopathic Scoliosis Surgery? Clin Spine Surg 2020; 33:E598-E600. [PMID: 32675685 DOI: 10.1097/bsd.0000000000001049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A retrospective single-center and single-surgeon study. OBJECTIVE This study investigated the screw perforation rate according to main curve flexibility in pedicle screw fixation using a computed tomography (CT) guidance for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND The authors have been using a CT-based navigation system during pedicle screw insertion for AIS to avoid serious neurovascular or visceral structure injury but suspect that high main curve flexibility may account for some breaches. DATA Seventy-two consecutive patients with AIS Lenke type 1 or 2 who had undergone pedicle screw fixation using a CT-based navigation system between February 2008 and April 2018 were retrospectively reviewed. MATERIALS AND METHODS The authors evaluated the perforation rate of pedicle screws inserted into the main thoracic curve between the upper-end and lower-end vertebrae for factors associated with screw violations using multivariate logistic regression mixed models. RESULTS A total of 723 pedicle screws were inserted into the T4-T12 vertebrae with the aid of CT-based navigation. The respective grade 3 perforation rates according to main curve flexibility were 0%-30%: 3.2%; 30%-55%: 1.1%; 55%-75%: 5.2%; and 75%-100%: 5.5%. Main curve flexibility of ≥55% was significantly associated with grade 3 screw perforations (P=0.02). CONCLUSIONS Main curve flexibility of ≥55% was significantly related to screw violation in AIS surgery. Greater care is thus advised for screw insertion using CT navigation in AIS with main curve flexibility ≥55%.
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Wang Y, Hao D, Qian L, He X, Meng Y, Wang B. Esophageal perforation following pedicle screw placement for the treatment of upper thoracic spinal tuberculosis: a case report and review of the literature. BMC Musculoskelet Disord 2020; 21:756. [PMID: 33208114 PMCID: PMC7672849 DOI: 10.1186/s12891-020-03783-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 11/10/2020] [Indexed: 12/22/2022] Open
Abstract
Background The technique of posterior pedicle screw fixation has already been widely applied in the treatment of upper thoracic spinal tuberculosis. However, lesions of tuberculosis directly invade the vertebrae and surrounding soft tissues, which increases the risk of esophageal perforation induced by the posterior pedicle screw placement. Herein, we report the first case of esophageal perforation following pedicle screw placement in the upper thoracic spinal tuberculosis, and describe the underlying causes, as well as the treatment and prognosis. Case presentation A 48-year-old female patient with upper thoracic spinal tuberculosis presented sputum-like secretions from the wound after she was treated with one-stage operation through the posterolateral approach. Endoscopy was immediately conducted, which confirmed that the patient complicated with postoperative esophageal perforation caused by screws. CT scan showed that the right screw perforated the anterior cortex of the vertebrae and the esophagus at the T4 level. Fortunately, mediastinal infection was not observed. The T4 screw was removed, Vacuum Sealing Drainage (VSD) was performed, and jejunum catheterization was used for enteral nutrition. After continuous treatment with sensitive antibiotics for 2.5 months and 5 times of VSD aspiration, the infected wound recovered gradually. With 18-month follow-up, the esophagus healed well, without symptoms of dysphagia and stomach discomfort, and CT scan showed that T2–4 had complete osseous fusion without sequestrum. Conclusion Tuberculosis increases the risk of postoperative esophageal perforation in a certain degree for patients with upper thoracic tuberculosis. The damages to esophagus during the operation should be prevented. The screws with the length no more than 30 mm should be selected. Moreover, close monitoring after operation should be conducted to help the early identification, diagnosis and treatment, which could help preventing the adverse effects induced by the delayed diagnosis and treatment of esophageal perforation.
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Affiliation(s)
- Yuhang Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China.,Xi'an Medical University, No. 74 Hanguang North Road, Xi'an, 710054, Shaanxi, China
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China
| | - Lixiong Qian
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China
| | - Xin He
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China
| | - Yibin Meng
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China
| | - Biao Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University College of Medicine, No. 76 Nanguo Road, Xi'an, 710054, Shaanxi, China.
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Perforation Rate of Pedicle Screws Using Hybrid Operating Room Combined With Intraoperative Computed Tomography Navigation for Adolescent Idiopathic Scoliosis: Impact of Distance From the Reference Frame and Other Risk Factors. Spine (Phila Pa 1976) 2020; 45:E1357-E1364. [PMID: 32890303 DOI: 10.1097/brs.0000000000003673] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Sundaram PPM, Oh JYL, Tan M, Nolan CP, Yu CS, Ling JM. Accuracy of Thoracolumbar Pedicle Screw Insertion Based on Routine Use of Intraoperative Imaging and Navigation. Asian Spine J 2020; 15:491-497. [PMID: 32951407 PMCID: PMC8377205 DOI: 10.31616/asj.2020.0068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/26/2020] [Indexed: 11/30/2022] Open
Abstract
Study Design Retrospective review. Purpose To determine the accuracy of thoracolumbar pedicle screw insertion with the routine use of three-dimensional (3D) intraoperative imaging and navigation over a large series of screws in an Asian population. Overview of Literature The use of 3D intraoperative imaging and navigation in spinal surgery is aimed at improving the accuracy of pedicle screw insertion. This study analyzed 2,240 pedicle screws inserted with the routine use of intraoperative navigation. It is one of very few studies done on an Asian population with a large series of screws. Methods Patients who had undergone thoracolumbar pedicle screws insertion using intraoperative imaging and navigation between 2009 and 2017 were retrospectively analyzed. Computed tomography (CT) images acquired after the insertion of pedicle screws were analyzed for breach of the pedicle wall. The pedicle screw breaches were graded according to the Gertzbein classification. The breach rate and revision rate were subsequently calculated. Results A total of 2,240 thoracolumbar pedicle screws inserted under the guidance of intraoperative navigation were analyzed, and the accuracy of the insertion was 97.41%. The overall breach rate was 2.59%, the major breach rate was 0.94%, and the intraoperative screw revision rate was 0.7%. There was no incidence of return to the operating theater for revision of screws. Conclusions The routine use of 3D navigation and intraoperative CT imaging resulted in consistently accurate pedicle screw placement. This improved the safety of spinal instrumentation and helped in avoiding revision surgery for malpositioned screws.
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Affiliation(s)
| | - Jacob Yoong-Leong Oh
- Spine Division, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Mark Tan
- Spine Division, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Chun Sing Yu
- Spine Division, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Ji Min Ling
- Department of Neurosurgery, National Neuroscience Institute, Singapore
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Ahmadzadeh Heshmati A, Ilka S. Accuracy Assessment of Freehand Pedicular Screw Placement. THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:519-523. [PMID: 32884973 DOI: 10.22038/abjs.2018.31503.1819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The purpose of this prospective study was to determine the accuracy of pedicular screw insertion without the use of fluoroscopy. Methods This study was conducted on patients with spinal diseases in need of pedicular screw fixation and fusion. The included patients suffered from such conditions as vertebral fracture, spinal stenosis, kyphosis, tumor, and pelvic fractures and were managed with triangular osteosynthesis fixation. However, those with scoliosis deformity were excluded from the study. A total of 760 pedicular screws were inserted in C7 to S1 vertebrae without using fluoroscopy. The locations of the screws were assessed by means of computed tomography scan after the surgery. The data were analyzed in SPSS software (version 22) using the Chi-square test. Results Out of 387 thoracic screws and 373 lumbar screws, 65 (16.8%) and 34 (9.1%) screws perforated the pedicle wall or vertebral body, respectively. The most frequent locations of perforation in the thoracic and lumbar spine were the anterior cortex of the vertebral body and medial wall of the pedicle, respectively. Except for the perforation of the anterior vertebral body (P=0.0001), there was no difference between the left and right sides or between thoracic and lumbar sites in terms of the preformation of the screw. No complication was observed due to screw perforation. Conclusion Our findings revealed the unnecessity of using fluoroscopy in spine surgeries for the insertion of pediculate screws. In this regard, the use of fluoroscopy for the placement of pedicular screw resulted in similar accuracy and complications, as compared to the free hand procedure.
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Affiliation(s)
| | - Shahab Ilka
- Bahonar Hospital, School of Medicine, Kerman University of Medcal Science, Kerman, Iran
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Clifton W, Damon A, Valero-Moreno F, Marenco-Hillembrand L, Nottmeier E, Tubbs RS, Fox WC, Pichelmann M. Investigation of the "Superior Facet Rule" Using 3D-Printed Thoracic Vertebrae With Simulated Corticocancellous Interface. World Neurosurg 2020; 143:e51-e59. [PMID: 32585384 DOI: 10.1016/j.wneu.2020.06.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pedicle screw placement is the most common method of fixation in the thoracic spine. Use of the "superior facet rule" allows the operator to locate the borders of the pedicle reliably using posterior landmarks alone. This study investigated the ability of 3-dimensionally (3D)-printed thoracic vertebrae, made from combined thermoplastic polymers, to demonstrate pedicle screw cannulation accurately using the superior facet as a reliable landmark. METHODS An anonymized computed tomography scan of the thoracic spine was obtained. The T1-T12 thoracic vertebrae were anatomically segmented and 3D-printed. The pedicle diameters and distance from the midpoint of the superior facet to the ventral lamina were recorded. A total of 120 thoracic pedicles in 60 thoracic vertebral models were instrumented using a freehand technique based only on posterior landmarks. The vertebral models were then coronally cut and examined for medial or lateral violations of the pedicle after screw placement. RESULTS A total of 120 pedicle screws were placed successfully within the 3D-printed thoracic vertebral models. Average measurements fell within 1 standard deviation of previous population studies. There were no pedicle wall violations using standard posterior element landmarks for instrumentation. There were 3 lateral violations of the vertebral body wall during screw placement, all attributable to the insertion technique. CONCLUSIONS 3D-printed thoracic vertebral models using combined thermoplastic polymers can accurately demonstrate the anatomical ultrastructure and posterior element relationships of the superior facet rule for safe thoracic pedicle screw placement. This method of vertebral model prototyping could prove useful for surgical education and demonstrating spinal anatomy.
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Affiliation(s)
- William Clifton
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA.
| | - Aaron Damon
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Fidel Valero-Moreno
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | - Eric Nottmeier
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - R Shane Tubbs
- Department of Neurosurgery and Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - W Christopher Fox
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Mark Pichelmann
- Department of Neurosurgery, Mayo Clinic Health Systems, Eau Claire, Wisconsin, USA
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Mirzashahi B, Moosavi M, Rostami M. Outcome of Posterior-Only Approach for Severe Rigid Scoliosis: A Retrospective Report. Int J Spine Surg 2020; 14:232-238. [PMID: 32355631 PMCID: PMC7188093 DOI: 10.14444/7032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The management of severe scoliosis may lead to significant complications, and adequate mobilization is a key step to achieve maximal correction, usually requiring extensive approaches. There is still no consensus on the management of these severe and rigid curves. In this study we evaluated the clinical and radiologic outcome of a posterior-only approach with multilevel asymmetric Ponte osteotomy with a minimum of 2 years' follow-up. METHODS In this retrospective study, 23 patients with severe and rigid adolescent idiopathic scoliosis who underwent surgery with a single-staged posterior-only approach were included. The surgical procedures in these patients were excision of posterior ligaments and spinous process, partial laminectomy in caudal part of lamina, excision of the ligamentum flavum, facetectomies, and multilevel asymmetric posterior column osteotomies (Ponte) followed by instrumented fusion. Clinical records-including demographic data; operating time; hospitalization time; blood loss; number of segments instrumented, fused, and osteotomized; functional improvement; follow-up duration; and complications-were recorded. RESULTS The mean preoperative Cobb angle of major curve in coronal plan was 97.5° (range, 82°-131°) with the mean flexibility of 21.4° (range, 10°-25°) on bending radiography. The mean immediate postoperative Cobb angle of major curve was 34.8° (range, 17°-61°), showing a 64.2% correction. The mean preoperative coronal and sagittal imbalances of 3.8 and 4.2 cm were improved to 1.0 and 1.3 cm at postoperative measurements, respectively. A mean of 6.1 (range, 5-9) vertebral segments were osteotomized. We experienced no major complications. CONCLUSIONS We found that a posterior-only procedure in patients with severe and rigid adolescent idiopathic scoliosis could provide correction rate, coronal and sagittal balance, and clinical outcomes comparable with other procedures. Using this technique can eliminate the need for the anterior release, with the associated complications related to anterior surgery, in the treatment of severe rigid scoliosis.
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Affiliation(s)
- Babak Mirzashahi
- Department of Orthopedic Surgery, Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mersad Moosavi
- Department of Orthopedic Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Rostami
- Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurosurgery, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
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Zhang W, Zhao J, Li L, Yu C, Zhao Y, Si H. Modelling tri-cortical pedicle screw fixation in thoracic vertebrae under osteoporotic condition: A finite element analysis based on computed tomography. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 187:105035. [PMID: 31443980 DOI: 10.1016/j.cmpb.2019.105035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/05/2019] [Accepted: 08/11/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE The technique of tri-cortical pedicle screw (TCPS) has been used to improve the anchoring strength in the sacral vertebrae. However, no studies have reported their application in the thoracic vertebrae. Our research is aimed to assess the stability and strength of the TCPS in thoracic vertebrae under osteoporotic condition by three dimensional (3D) finite element method on the basis of medical image reconstruction using computed tomography (CT), and verifying its effectiveness in clinical application. MATERIALS AND METHODS The 3D finite element models were constructed using Mimcs to transfer two dimensional CT images into 3D models by marching cubes algorithm of six-partition. Six physiological activities were simulated in 3D finite element models. Compared with the strength and stability of the uni-cortical pedicle screw (UCPS) and bi-cortical pedicle screw (BCPS), the effectiveness of TCPS was assessed. The stress distribution and maximum stress were measured to evaluate the strength. The maximum displacement and the range of motion were analysed to assessed the stability. EXPERIMENTAL RESULTS Four geometrically accurate and nonlinear T7-T9 finite element models were constructed successfully by 3D finite element method based on the CT images. Three kinds of internal fixation methods in the osteoporotic thoracic vertebral body can improved the maximum stress, decrease the maximum displacement and range of motion in six physiological activities. The range of motion and maximum displacement of TCPS decreased more significantly than that of UCPS and BCPS. The maximum von Mises stress of TCPS was minimum and UCPS was maximum under the condition of extension, right lateral bending, left rotation and right rotation. CONCLUSIONS Effectively, TCPS can provide better stability and strength than that of UCPS and BCPS techniques in the osteoporotic thoracic vertebrae. In practice, the technique of TCPS can be applied in the osteoporotic thoracic vertebral body to enhance the griping strength of the screws and reduce the risk of pedicle screw loosening. However, further cadaver experiments and more biomechanical analysis are necessary to confirmed our findings.
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Affiliation(s)
- Wencan Zhang
- Qilu Hospital, Shandong University, Jinan 250012, China
| | - Junyong Zhao
- College of Physics and Electronic Sciences, Shandong Normal University, Jinan 250000, China
| | - Le Li
- Qilu Hospital, Shandong University, Jinan 250012, China
| | - Chenxiao Yu
- Qilu Hospital, Shandong University, Jinan 250012, China
| | - Yuefeng Zhao
- College of Physics and Electronic Sciences, Shandong Normal University, Jinan 250000, China
| | - Haipeng Si
- Qilu Hospital, Shandong University, Jinan 250012, China.
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Accuracy of K-Wireless Insertion of Percutaneous Pedicle Screws Using Computer-Assisted Spinal Navigation: A Systematic Review and Single-Center Experience. World Neurosurg 2020; 138:e267-e274. [PMID: 32105880 DOI: 10.1016/j.wneu.2020.02.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study sought to 1) describe the use K-wireless pedicle screw insertion among adults (age ≥18 years) undergoing a minimally invasive fusion and 2) perform a systematic review (SR) of all studies that describe a navigated, K-wireless technique with 3-dimensional fluoroscopy. METHODS Patients undergoing a minimally invasive fusion requiring pedicle screw fixation for any indication were prospectively enrolled in the observational component of this study. An assessment of pedicle breach was performed independently and in duplicate based on a modification of the Belmont grading scale. Articles for the SR were identified from a structured search of Medline from inception to May 8, 2019, without restriction of language. RESULTS A total of 82 pedicle screws were placed in 20 patients who underwent surgery between January and June 2014. There was no significant difference in mean operative time between the cases included in this study and a matched cohort of 20 patients undergoing surgery with 2-dimensional fluoroscopy and K-wire-assisted pedicle screw placement (95 ± 13 vs. 87 ± 20 minutes, respectively; P > 0.05). There were 2 major pedicle breaches (Belmont grade 3) in a single patient, yielding a major breach rate of 2.44%. A total of 6 papers that described the placement of 700 pedicle screws in 160 patients between May 2011 and March 2017 were included in the SR. The overall breach rate was 7.00% (n = 37). CONCLUSIONS Percutaneous pedicle screws can be placed accurately and safely using 3-dimensional navigation without the use of K-wires and may confer benefits to patients and clinicians by reducing K-wire-associated complications and radiation exposure.
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Sarwahi V, Wendolowski SF, Lo Y, Thornhill B, Amaral T. End Vertebra Versus Apical Vertebra: Where Are We More Likely to Misplace in Spine Deformity? J Pediatr Orthop 2020; 40:53-59. [PMID: 31923163 DOI: 10.1097/bpo.0000000000001102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND DATA Pedicle screws placement remains technically demanding. The thoracic curve apex is considerably difficult due to its unique morphology and severe rotation. In comparison the upper end vertebrae have smaller pedicles and limited soft tissue exposure. This study seeks to evaluate the likelihood of screw misplacement at the end vertebra and apex. METHODS A retrospective review of preoperative and postoperative computed tomographic (CT) scans of spinal deformity patients who underwent posterior spinal fusion with pedicle screw constructs between 2004 and 2011 was performed. Pedicles located at the upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV), and the major and minor apices were evaluated. Pedicle morphology was studied on preoperative CT and screw placement on postoperative CT. RESULTS In total, 188 patients met the inclusion criteria, 172 had preoperative CT scans and 133 had postoperative CT scans. The UIV had a significantly lower percentage of normal pedicles (type A) compared with apex major, apex minor, or LIV (59.1% vs. 76.1% vs. 77.3% vs. 98.7%; P<0.001). UIV had significantly the lowest percentage of normal normally placed screws compared with LIV, apex major, or apex minor (69.4% vs. 97.3% vs. 87.6% vs. 92.1%; P<0.001). In a logistic regression adjusted for preoperative Cobb angles, UIV was more likely to have screws misplaced (odds ratio =7.56; 95% confidence interval, 4.01-14.30; P<0.001) and abnormal pedicles (odds ratio=2.81; 95% confidence interval, 1.52-5.19; P=0.001) compared with any other location studied. In abnormal pedicles, 41 (39.8%) of the 103 UIV screws were misplaced, whereas 10 (16.4%) of the 61 apex major, apex minor, or LIV screws were misplaced (P=0.007). CONCLUSIONS The UIV presents more of a risk for pedicle screw misplacement and abnormal morphology when compared with LIV and apical vertebra. We believe these findings can aid in the surgeon's preoperative and intraoperative management to ensure increased success in accurate and safe pedicle screw placement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Vishal Sarwahi
- Billie and George Ross center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen's Children Medical Center, Northwell Health System, Lake Success
| | - Stephen F Wendolowski
- Billie and George Ross center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen's Children Medical Center, Northwell Health System, Lake Success
| | - Yungtai Lo
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx
| | | | - Terry Amaral
- Billie and George Ross center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen's Children Medical Center, Northwell Health System, Lake Success
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40
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Brink RC, Homans JF, de Reuver S, van Stralen M, Schlösser TPC, Viergever MA, Chu WCW, Ng BKW, Castelein RM, Cheng JCY. A computed tomography-based spatial reference for pedicle screw placement in adolescent idiopathic scoliosis. Spine Deform 2020; 8:67-76. [PMID: 31981143 DOI: 10.1007/s43390-020-00032-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 07/14/2019] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Cross-sectional. OBJECTIVES To determine semiautomatically the 3D position of the pedicle axis in operative adolescent idiopathic scoliosis (AIS) patients relative to the operating table and the lamina, as orientation for pedicle screw placement for better understanding and reference of spine surgeons. Pedicle morphology is well described as the angle between the convex and concave pedicle. However, the pedicle angle as relative to the neutral anterior-posterior axis or to an easy-to-use intravertebral landmark, remained unknown. METHODS The pedicles of the apex and two adjacent vertebrae cranial and caudal to the apex of 86 right-sided primary thoracic AIS curves were evaluated using semiautomatic 3D software on high-resolution CT scans, in the same prone position as during surgery. Pedicle vectors were obtained and calculated as transverse and sagittal angles, as relative to the neutral axis (corresponding with an axis perpendicular to the operating table) and to an axis perpendicular to the lamina. RESULTS At the apex, the mean convex and concave transverse pedicle angles were 14.3º (95% confidence interval [95% CI]: 12.0-16.6) and 30.4º (95% CI: 28.1-32.8) to the right. The angles decreased toward the adjacent levels cranial and caudal to the apex (p < 0.001) and linearly increased with a higher Cobb angle (r ≥ 0.472; p < 0.001). The mean transverse pedicle-lamina angles, sagittal pedicle angles and the sagittal pedicle-lamina angles differed along the curve as well (p < 0.001). CONCLUSIONS Pedicle angulation differs between convex and concave and depends on the position of the vertebra relative to the apex, as well as the curve severity. The transverse and sagittal pedicle angles, as relative to the operating table and laminae, could provide useful reference for better understanding of the distorted 3D morphology, and the angles, as given in this study, could serve as an approximate guideline for the expected direction of the pedicle screw. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Rob C Brink
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Jelle F Homans
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Steven de Reuver
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Marijn van Stralen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tom P C Schlösser
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Max A Viergever
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Winnie C W Chu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bobby K W Ng
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - René M Castelein
- Department of Orthopaedic Surgery, G05.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Jack C Y Cheng
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Zhang Z. Freehand Pedicle Screw Placement Using a Universal Entry Point and Sagittal and Axial Trajectory for All Subaxial Cervical, Thoracic and Lumbosacral Spines. Orthop Surg 2020; 12:141-152. [PMID: 31828963 PMCID: PMC7031565 DOI: 10.1111/os.12599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/29/2019] [Accepted: 11/19/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Existing techniques of freehand pedicle screw placement primarily focus on various entry points with or without axial trajectory. The objective of this paper is to propose a universal entry point and sagittal and axial trajectory for all subaxial cervical, thoracic and lumbosacral spines freehand pedicle screw placements, and to report the results from a single-surgeon clinical experience with freehand pedicle screw placement. METHODS Two spine vertebrae specimens and 20 cases of three-dimensional (3D) reconstructions of spine CT images were used for observation of the entry point and sagittal and axial trajectory. The author retrospectively reviewed a total of 610 consecutive patients who underwent open, freehand pedicle screw fixation using a universal entry point and sagittal and axial trajectory for all subaxial cervical, thoracic and lumbosacral spine placements, during an 8-year period from January 2010 to December 2017. The junction of the lateral margin of the superior articulating process and the transverse process for the thoracic and lumbosacral spines, or lateral mass for the subaxial cervical spine, was determined. The entry point was chosen at 1 mm, 2 mm, and 3 mm (2 mm on average) caudally and medially to this junction for subaxial cervical, thoracic and lumbosacral spines placements, respectively. Both sagittal and axial trajectories were perpendicular to the sagittal and axial planes of the laminae of the isthmus. Among them, 68 patients underwent postoperative computed tomography (CT) scans, including 26 cervical cases, 19 scoliosis thoracic cases, 10 non-scoliosis thoracic cases, 8 lumbar cases, and 5 sacral cases. Placements of pedicle screws were assessed using CT data and outcome-based classifications systems. RESULTS After placing the iron scurf at the junction of the lateral margin of the superior articulating process and the transverse process, the present universal entry point was located at 1 o'clock or 11 o'clock of the pedicle's axial view. After inserting the 2.5 mm Gram needle or the pedicle virtual pin tracts according to the entry point and sagittal and axial trajectory described above, the presented trajectory was located in the pedicle's axial trajectory as in the described technique. A total of 766 pedicle screws were placed in 68 CT scan patients with a 99% accuracy rate in the non-kyphoscoliosis group and 92% in the kyphoscoliosis group. CONCLUSIONS Freehand pedicle screw placement based on the universal entry point and sagittal and axial trajectory for all subaxial cervical, thoracic and lumbosacral spines can be performed with acceptable safety and accuracy.
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Affiliation(s)
- Zheng‐feng Zhang
- Department of OrthopaedicsXinqiao Hospital, Third Military Medical UniversityChongqingChina
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Accuracy of Pedicle Screw Placement and Clinical Outcomes of Robot-assisted Technique Versus Conventional Freehand Technique in Spine Surgery From Nine Randomized Controlled Trials: A Meta-analysis. Spine (Phila Pa 1976) 2020; 45:E111-E119. [PMID: 31404053 DOI: 10.1097/brs.0000000000003193] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A meta-analysis. OBJECTIVE To investigate whether robot-assisted techniques are superior to conventional techniques in terms of the accuracy of pedicle screw placement and clinical indexes. SUMMARY OF BACKGROUND DATA Robot-assisted techniques are increasingly applied to spine surgery to reduce the rate of screw misplacement. However, controversy about the superiority of robot-assisted techniques over conventional freehand techniques remains. METHODS We conducted a comprehensive search of PubMed, EMBASE, and Cochrane Library for potentially eligible articles. The outcomes were evaluated in terms of risk ratio (RR) or standardized mean difference and the associated 95% confidence intervals (CIs). Meta-analysis was performed using the RevMan 5.3 software and subgroup analyses were performed based on the robot type for the accuracy of pedicle screw placement. RESULTS Nine randomized controlled trials with 696 patients were included in this meta-analysis. The results demonstrated that the robot-assisted technique was more accurate in pedicle screw placement than the freehand technique. Subgroup analyses showed that the TINAVI robot-assisted technique was more accurate in screw positions Grade A (RR, 1.10; 95% CI, 1.06-1.14), Grade B (RR, 0.46; 95% CI, 0.28-0.75), and Grades C + D + E (RR, 0.21; 95% CI, 0.09-0.45) than the freehand technique, whereas the Renaissance robot-assisted technique showed the same accuracy as the freehand technique in screw positions Grade A, Grade B, and Grades C + D + E. Furthermore, the robot-assisted techniques showed equivalent postoperative stay, visual analogue scale scores, and Oswestry disability index scores to those of the freehand technique and shorter intraoperative radiation exposure time, fewer radiation dose and proximal facet violations but longer surgical time than the freehand technique. CONCLUSION The robot-assisted technique is more accurate in pedicle screw placement than the freehand technique. And TINAVI robot-assisted pedicle screw placement is a more accurate alternative to conventional techniques and the Renaissance robot-assisted procedure. LEVEL OF EVIDENCE 1.
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43
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Nguyen NQ, Priola SM, Ramjist JM, Guha D, Dobashi Y, Lee K, Lu M, Androutsos D, Yang V. Machine vision augmented reality for pedicle screw insertion during spine surgery. J Clin Neurosci 2020; 72:350-356. [PMID: 31937502 DOI: 10.1016/j.jocn.2019.12.067] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/31/2019] [Indexed: 11/18/2022]
Abstract
Implementing pedicle safe zones with augmented reality has the potential to improve operating room workflow during pedicle screw insertion. These safe zones will allow for image guidance when tracked instruments are unavailable. Using the correct screw trajectory as a reference angle for a successful screw insertion, we will determine the angles which lead to medial, lateral, superior and inferior breaches. These breaches serve as the boundaries of the safe zones. Measuring safe zones from the view of the surgical site and comparing to the radiological view will further understand the visual relationship between the radiological scans and the surgical site. Safe zones were measured on a spine phantom and were then replicated on patients. It was found that the largest causes for variance was between each of the camera views and the radiological views. The differences between the left and right cameras were insignificant. Overall, the camera angles appeared to be larger than the radiological angles. The magnification effect found in the surgical site result in an increased level of angle sensitivity for pedicle screw insertion techniques. By designing a virtual road map on top of the surgical site directly using tracked tools, the magnification effect is already taken into consideration during surgery. Future initiatives include the use of an augmented reality headset.
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Affiliation(s)
- Nhu Q Nguyen
- Department of Electrical, Computer and Biomedical Engineering, Ryerson University, Toronto, ON, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Stefano M Priola
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Joel M Ramjist
- Department of Electrical, Computer and Biomedical Engineering, Ryerson University, Toronto, ON, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Daipayan Guha
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Yuta Dobashi
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kenneth Lee
- 7D Surgical Incorporated, Toronto, ON, Canada
| | - Michael Lu
- 7D Surgical Incorporated, Toronto, ON, Canada
| | - Dimitrios Androutsos
- Department of Electrical, Computer and Biomedical Engineering, Ryerson University, Toronto, ON, Canada
| | - Victor Yang
- Department of Electrical, Computer and Biomedical Engineering, Ryerson University, Toronto, ON, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; 7D Surgical Incorporated, Toronto, ON, Canada.
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Miyazaki M, Ishihara T, Abe T, Kanezaki S, Notani N, Kataoka M, Tsumura H. The position of the spinal cord relative to the vertebrae in adolescent idiopathic scoliosis. Medicine (Baltimore) 2019; 98:e18057. [PMID: 31764834 PMCID: PMC6882658 DOI: 10.1097/md.0000000000018057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We aimed to clarify the position of the spinal cord relative to the vertebra in patients with Lenke type 1 adolescent idiopathic scoliosis (AIS). In all, 35 patients with Lenke type 1 AIS who underwent posterior spinal fusion using a pedicle screw construct and preoperative computed tomography (CT) after myelography were recruited. The following radiological parameters were measured on preoperative CT myelography: spinal cord-vertebral (SV) angle, entry-spinal cord distance (ESD), ESD-X, ESD-Y, spinal cord-pedicle (SP) angle, and rotation angle (RAsag). The SV and SP angles were the smallest at T9 level, followed by T8 and T7 levels, and tended to increase cranially and caudally. The ESD was the shortest at T9 level, followed by T8 and T10 levels. The ESD-X was the smallest at T9 level, followed by T8 level, while the ESD-Y was the smallest at T10 level, followed by T9 and T8 levels. Mean RAsag increased from T4 to T9 levels and decreased from T9 to T12 levels. The ESD was significantly negatively correlated to RAsag. Among all apical vertebrae, the SV and SP angles were negatively correlated to Cobb angle. The RAsag was positively correlated while the ESD was negatively correlated to the Cobb angle. The spinal cord is close to the vertebrae in the apical vertebral region and far from the vertebrae at the upper and lower thoracic vertebral levels in AIS. Therefore, the potential risk of spinal cord injury by pedicle screw is the highest in the apical vertebral region.
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Affiliation(s)
| | | | - Tetsutaro Abe
- Department of Orthopaedic Surgery, Faculty of Medicine
| | | | - Naoki Notani
- Department of Orthopaedic Surgery, Faculty of Medicine
| | - Masashi Kataoka
- Physical Therapy Course of Study, Faculty of Welfare and Health Sciences, Oita University, Oita, Japan
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45
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Shepard N, Pham H, Natarajan V, Errico T, Rieger M. Use of a Novel Computerized Drill for Pedicle Screw Insertion in the Thoracic and Lumbar Spine: A Cadaveric Study. Int J Spine Surg 2019; 13:329-335. [PMID: 31534903 PMCID: PMC6727791 DOI: 10.14444/6045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND A variety of techniques have been utilized to improve the accuracy of pedicle screw instrumentation. Recently, a novel handheld computerized drill system, IntelliSense Drill Technology, has been used in orthopedic trauma to improve drilling accuracy and reduce radiation and iatrogenic injury. The specialized drill technology detects changes in cortical density to prevent inadvertent cortical violation. The aim of this study is to assess the ability of this system to identify pedicle trajectories in the thoracic and lumbar spine compared to a standard freehand technique. METHODS Two spine surgeons, including 1 senior-level and 1 junior-level attending drilled pedicle screw tracts using a freehand technique and computerized drill technology in 4 cadaveric spines from T2 to S1. A total of 134 pedicle screws were placed, including 70 by the senior surgeon and 64 by the junior surgeon. Cortical violations were assessed using computed tomography after instrumenting each pedicle tract, and procedure time for insertion of pedicle screws was recorded. RESULTS A total of 15 (22.4%) and 12 (18.2%) pedicle violations were noted using the freehand and computerized drill technique, respectively (P = .767). Perforations using the computerized drill decreased from 31.1% in the first attempt to 5.9% in the second attempt (P = .027). Mean drill time per pedicle using the freehand and computerized drill techniques were comparable (12.2 ± 8.4 versus 12.1 ± 13.2, P = .871), and both surgeons had an improvement in procedure time using the computerized drill (surgeon 1: 12.3 ± 13.7-5.7 ± 3.8 [SD], P = .059; surgeon 2: 20.3 ± 20.0-10.4 ± 5.6 [SD], P = .063). CONCLUSIONS We demonstrate the use of a novel drill technology for placement of pedicle screws in the thoracic and lumbar spine. After an initial learning curve, this technology is comparable to use of a freehand technique by both a senior-level and a junior-level attending surgeon in a cadaveric model. Further investigation is needed to identify the clinical role of this technology in spine surgery.
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Affiliation(s)
- Nicholas Shepard
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Hien Pham
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Vivek Natarajan
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Thomas Errico
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Mark Rieger
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
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Spyrantis A, Cattani A, Seifert V, Freiman TM, Setzer M. Minimally invasive percutaneous robotic thoracolumbar pedicle screw implantation combined with three-dimensional fluoroscopy can reduce radiation: A cadaver and phantom study. Int J Med Robot 2019; 15:e2022. [PMID: 31216120 DOI: 10.1002/rcs.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/26/2019] [Accepted: 06/04/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Andrea Spyrantis
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Adriano Cattani
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Matthias Setzer
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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Cinnella P, Rava A, Mahagna AA, Fusini F, Masse A, Girardo M. Over 70° thoracic idiopathic scoliosis: Results with screws or hybrid constructs. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2019; 10:108-113. [PMID: 31404131 PMCID: PMC6652256 DOI: 10.4103/jcvjs.jcvjs_39_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Adolescent idiopathic scoliosis is the most common type of scoliosis. High degrees curve can be treated with the anterior, posterior, or combined anterior-posterior approach. Contrarily to the anterior approach, the posterior one is widely used nowadays for its good correction outcomes and relatively low-complication rate. MATERIALS AND METHODS We evaluated retrospectively 27 patients, treated with posterior approach. Patients were divided into two groups, namely pedicle screws group (PSG) and hybrid group (pedicle screws + sublaminar bands). Radiographic measurements, including thoracic and lumbar Cobb° measurements of primary and secondary curves, coronal balance and sagittal balance, kyphosis and lordosis, curve flexibility, first and last vertebra included in the arthrodesis, and implant density were evaluated. Clinical patients' satisfaction was also evaluated with Scoliosis Research Society (SRS) 24 questionnaire. RESULTS Considering both groups, on preoperative X-rays, the average primary scoliotic curve angle was 83.56° ± 10.96° (range 70°-112°), whereas the global flexibility was 64° ± 7.63 (range 46°-72°). The curves were classified following the Lenke classification: 17 Type 1, 2 Type 2, and 8 Type 3. The primary curve resulted to be well corrected in both groups. In T0, the groups were homogeneous, but in T1 and follow-up, PSG stated a better mean value. No other significative differences can be found between groups for all other items (P > 0.05). Clinical results of SRS 24 were excellent in both groups. CONCLUSIONS The posterior approach proved to be an excellent technique for obtaining good clinical and radiographic results if the surgeon adopts the third-generation high-density implants. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Pasquale Cinnella
- Spine Surgery Unit, Orthopaedic and Trauma Centre, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Alessandro Rava
- Department of Orthopaedic and Traumatology, Orthopaedic and Trauma Centre, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Antonio Abed Mahagna
- Department of Orthopaedic and Traumatology, IRCCS Foundation, S. Matteo Hospital Institute, University of Pavia, Pavia, Italy
| | - Federico Fusini
- Department of Orthopaedic and Traumatology, Orthopaedic and Trauma Centre, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Alessandro Masse
- Department of Orthopaedic and Traumatology, Orthopaedic and Trauma Centre, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Massimo Girardo
- Spine Surgery Unit, Orthopaedic and Trauma Centre, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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How Much Surface Registration Accuracy is Required Using Ct-based Navigation System in Adolescent Idiopathic Scoliosis Surgery? Clin Spine Surg 2019; 32:E166-E170. [PMID: 30507639 DOI: 10.1097/bsd.0000000000000759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Retrospective, single-center, single-surgeon study. OBJECTIVE This study investigated screw perforation rate according to surface registration accuracy in pedicle screw fixation using a CT-based navigation system for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Posterior spinal fusion for scoliosis correction using pedicle screws is widely adopted but carries a risk of serious neurovascular or visceral structure events. To attempt to avoid these complications, we have been using a computed tomography (CT)-based navigation system during screw insertion, although insufficient surface registration accuracy may be a reason for some screw perforations. METHODS We evaluated 116 AIS patients (9 male and 107 females; mean±standard deviation age: 15.2±2.3 y) who had received pedicle screw fixation guided by a CT-based navigation system between August 2007 and December 2017. Screw perforation rate was evaluated in relation to surface registration accuracy and cut-off values were determined by receiver operating characteristic (ROC) curves. RESULTS A total of 1553 pedicle screws were inserted into T2-L4 vertebrae using CT-based navigation system. The respective overall perforation rates for grade 2 or 3 and grade 3 perforations by surface registration accuracy were 0.2 mm: 0% and 0%; 0.3 mm: 3.5% and 0%; 0.4 mm: 3.5% and 0.8%; 0.5 mm: 8.0% and 3.5%; 0.6 mm: 6.7% and 2.7%; 0.7 mm: 8.9% and 3.8%; 0.8 mm: 9.3% and 6.7%; and 0.9 mm: 9.3% and 4.7%. ROC curve analysis revealed a cut-off surface registration accuracy of 0.5 mm. The major screw perforation rate for a surface registration accuracy of ≥0.5 mm was significantly higher than that for <0.5 mm (P<0.01). CONCLUSIONS Analysis of screw perforation rate according to surface registration accuracy demonstrated a clinical cut-off of 0.5 mm. Thus, surface registration accuracy should optimally be <0.5 mm for scoliosis surgery with CT-based navigation system.
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Solitro GF, Whitlock K, Amirouche F, Mehta AI, McDonnell A. Currently Adopted Criteria for Pedicle Screw Diameter Selection. Int J Spine Surg 2019; 13:132-145. [PMID: 31131212 PMCID: PMC6510178 DOI: 10.14444/6018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Transpedicular screw insertion has become widely accepted for the correction of spinal deformity as well as degenerative and traumatic injury, but adoption of this technique has remained less widespread in the thoracic compared to the lumbar spine. This is thought to be associated with the relative technical difficulty of screw insertion into the narrower widths of the thoracic pedicles and the neurologic and mechanical risks associated with breach of the pedicle wall. The surgical decision making involves determining the appropriate sized screw for maximum fixation strength while simultaneously respecting the structural integrity of the vertebral pedicles to prevent a breach and provide better fixation. This paper presents a systematic review of criteria for thoracic pedicle screw diameter (SD) selection in order to orient inexperienced surgeons on the impact of this selection on pedicle breaching and fixation strength. METHODS We performed a systematic literature review focused on studies reporting SD selection in relation to pedicle dimensions, measures of fixation strength, and breach rate. RESULTS Twenty-nine articles that measured fixation strength, breach rate, and/or provided SD in relation to pedicle width were selected for inclusion. CONCLUSIONS A commonly accepted criteria for pedicle SD selection has not yet been proposed. Screw diameters approximately 80% of the pedicle width have been adopted, but this proportion is rarely reported in the midthoracic vertebrae for which smaller pedicles and inadequate hardware specificity result in higher breach rates. Depending upon the insertion technique adopted, greater specificity in diameter selection by vertebral level should be pursued in order to maximally target cortical bone purchase. CLINICAL RELEVANCE Based on this review of the literature, we believe that proper selection of the SD for individual vertebral level directly affects the insertion technique and the potential breach.
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Affiliation(s)
- Giovanni F Solitro
- Department of Orthopaedics, Louisiana State University Health Science Center, Shreveport, Louisiana
| | - Keith Whitlock
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Farid Amirouche
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Annie McDonnell
- Department of Mechanical Engineering, University of Illinois at Chicago, Chicago, Illinois
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Perdomo-Pantoja A, Ishida W, Zygourakis C, Holmes C, Iyer RR, Cottrill E, Theodore N, Witham TF, Lo SFL. Accuracy of Current Techniques for Placement of Pedicle Screws in the Spine: A Comprehensive Systematic Review and Meta-Analysis of 51,161 Screws. World Neurosurg 2019; 126:664-678.e3. [PMID: 30880208 DOI: 10.1016/j.wneu.2019.02.217] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pedicle screws (PSs) are routinely used for stabilization to enhance fusion in a variety of spinal diseases. Although the accuracy of different PS placement methods has been previously reported, most of these studies have been limited to 1 or 2 techniques. The purpose was to determine the current accuracy of PS placement among 4 modalities of PS insertion (freehand [FH], fluoroscopy-assisted [FA], computed tomography navigation-guided [CTNav], and robot-assisted [RA]) and analyze variables associated with screw misplacement. METHODS A systematic review was performed of peer-reviewed articles reporting PS accuracy of 1 technique from January 1990 to June 2018. Accuracy of PS placement, PS insertion technique, and pedicle breach (PB) data were collected. A meta-analysis was performed to estimate the overall pooled (OP) rates of PS accuracy as a primary outcome, stratified by screw insertion techniques. Potential determinants were analyzed via meta-regression analyses. RESULTS Seventy-eight studies with 7858 patients, 51,161 PSs, and 3614 cortical PBs were included. CTNav showed the highest PS placement accuracy compared with other techniques: OP accuracy rates were 95.5%, 93.1%, 91.5%, and 90.5%, via CTNav, FH, FA, and RA techniques, respectively. RA and CTNav were associated with the highest PS accuracy in the thoracic spine, compared with FH. CONCLUSIONS The OP data show that CTNav has the highest PS accuracy rates. Thoracic PSs were associated with lower accuracy rates; however, RA showed fewer breaches in the thoracic spine compared with FH and FA. Given the heterogeneity among studies, further standardized and comparative investigations are required to confirm our findings.
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Affiliation(s)
| | - Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Corinna Zygourakis
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christina Holmes
- Florida A&M University-Florida State University College of Engineering, Tallahassee, Florida, USA
| | - Rajiv R Iyer
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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