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Zeng Y, Huang Z, Huang Z, Cheng Y, Zhu Q, Ji W, Jiang H. Ipsilateral Fixation and Reconstruction of the Cervical Spine after Resection of a Dumbbell Tumor Via a Unilateral Posterior Approach: A Case Report and Biomechanical Study. Orthop Surg 2023; 15:2435-2444. [PMID: 37431728 PMCID: PMC10475664 DOI: 10.1111/os.13798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 07/12/2023] Open
Abstract
OBJECTIVE There is lack of an internal fixation following resection of a dumbbell tumor by hemi-laminectomy and facetectomy that achieves adequate stability with less trauma. Unilateral fixation and reconstruction (unilateral pedicle screw and contralateral lamina screw fixation combined with lateral mass reconstruction, UPS + CLS + LM) may be an ideal technique to address this problem. A biomechanical comparison and a case report were designed to evaluate its spinal stability and clinical effect. METHODS Seven fresh-frozen human subcervical specimens were used for the biomechanical testing. The conditions tested were: (1) intact; (2) injured (single-level hemi-laminectomy and facetectomy); (3) unilateral pedicle screw (UPS) fixation; (4) UPS fixation combined with lateral mass (LM) reconstruction (UPS + LM); (5) UPS fixation and contralateral lamina screw fixation (UPS + CLS); (6) UPS + CLS + LM; (7) UPS fixation and contralateral transarticular screw fixation (UPS + CTAS); (8) bilateral pedicle screw (BPS) fixation. Range of motion (ROM) and neutral zone (NZ) were obtained at C5-C7 segment under eight conditions. In addition, we report the case of a patient with a C7-T1 dumbbell tumor that was treated by UPS + CLS + LM technique. RESULTS Except left/right lateral bending and right axial rotation (all, p < 0.05), ROM of UPS + CLS + LM condition in other directions was similar to that of BPS condition (all, p > 0.05). There was no significant difference between UPS + CLS + LM and the UPS + CTAS condition in other directions of ROM (all, p > 0.05), except in left/right axial rotation (both, p < 0.05). Compared to UPS + CLS condition, left/right lateral bending ROM of UPS + CLS + LM condition were significantly reduced (both, p < 0.05). UPS + CLS + LM condition significantly reduced ROM in all directions compared to UPS and UPS + LM condition (all, p < 0.05). Similarly, except lateral bending (p < 0.05), there was no difference in NZ in other directions between UPS + CLS + LM and BPS condition (both, p > 0.05). There was no significant difference between UPS + CLS + LM and UPS + CTAS condition in NZ in all directions (all, p > 0.05). Axial rotation NZ of UPS + CLS + LM condition was significantly reduced compared to UPS + CLS condition (p < 0.05). Compared to UPS and UPS + LM condition, NZ of UPS + CLS + LM condition was significantly reduced in all directions (all, p < 0.05). The patient's imaging examination at 3 months postoperatively indicated that the internal fixation did not move and the graft bone was seen with fusion. CONCLUSION After resection of a dumbbell tumor in the cervical spine, UPS + CLS + LM technique is a reliable internal fixation method to provide sufficient immediate stability and promote postoperative bone fusion.
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Affiliation(s)
- Yongqiang Zeng
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Zhiping Huang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Zucheng Huang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Yongquan Cheng
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Qing'an Zhu
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Wei Ji
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Hui Jiang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
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Vickery JW, Varas EE, Abtahi AM. Crossing the Cervicothoracic Junction: A Review of the Current Literature. Clin Spine Surg 2022; 35:451-457. [PMID: 36447350 DOI: 10.1097/bsd.0000000000001411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/03/2022] [Indexed: 12/05/2022]
Abstract
ABSTRACT The cervicothoracic junction (CTJ) is the site of transition in biomechanical, osseous, and alignment properties of the spine. The interface between the highly mobile, lordotic cervical spine and the rigid, kyphotic thoracic spine results increased the biomechanical stress experienced at this junction. The concentration of stress at this level has led to high rates of failure when instrumenting near or across the CTJ. The changes in osseous anatomy from the cervical spine to the thoracic spine present additional challenges in construct planning. For these reasons, a thorough understanding of the complexity of the cervicothoracic junction is necessary when operating near or across the CTJ. There are multiple options for cervical fixation, including lateral mass screws, pedicle screws, and laminar screws, each with its own advantages and risks. Instrumentation at C7 is controversial, and there is data supporting both its inclusion in constructs and no risk when this level is skipped. Thoracic pedicle screws are the preferred method of fixation in this region of the spine; however, the connection between cervical and thoracic screws can be challenging due to differences in alignment. Transitional rods and rod connectors mitigate some of the difficulties with this transition and have shown to be effective options. Recently, more investigation has looked into the failure of posterior cervical constructs which end at or near the CTJ. The trend in data has favored fixation to T1 or T2 rather than ending a construct at C7 due to the decreased rates of distal junction kyphosis. Although data on patient-reported outcomes with a length of constructs and the lowest instrumented vertebra is scarce, preliminary reports show no difference at this time. As posterior cervical instrumentation continues to increase in frequency, the CTJ will continue to be an area of difficulty in navigation and instrumentation. A thorough understanding of this region is necessary and continued research is needed to improve outcomes. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
| | | | - Amir M Abtahi
- Department of Orthopaedic Surgery
- Center for Musculoskeletal Research
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
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Jin C, Xie N, Wang J, Ren Y, Guo Q, Jia L, Cheng L. Clinical and Radiographic Outcomes of Combined Posterior Transfacet Screw Fixation and Anterior Cervical Discectomy and Fusion Surgery for Unilateral Cervical Facet Fracture with Traumatic Disc Herniation: A Retrospective Cohort Study. Pain Ther 2022; 11:225-240. [PMID: 35066860 PMCID: PMC8861222 DOI: 10.1007/s40122-021-00349-7] [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: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Combined lateral mass screw-rod (LMSR) fixation and anterior cervical discectomy and fusion (ACDF) surgery is currently the most widely described and accepted procedure for subaxial cervical facet fracture with traumatic disc herniation. Recent biomechanical studies have demonstrated that the use of transfacet screw (TFS) can be considered as a simple alternative method to LMSR. However, to date, little is known about the feasibility and effectiveness of TFS in the combined approach. The aim of this study was to compare the clinical and radiographic results of TFS + ACDF surgery and LMSR + ACDF surgery, and to provide a less invasive alternative technique for spine surgeons. Method We retrospectively reviewed patients with unilateral cervical facet fracture with traumatic disc herniation who had undergone TFS + ACDF (N = 36) or LMSR + ACDF (N = 34) with a minimum 2-year follow-up. Clinical assessments, which included American Spinal Injury Association impairment scale (AIS), visual analog scale for neck pain (VASSNP) score and patient satisfaction, were made before surgery and at follow-up. For the radiographic outcomes, the instability parameters of segmental kyphosis and sagittal translation were measured. Results The demographic characteristics of the two groups of patients were similar. In terms of clinical outcomes, both two groups were associated with significant improvements at the final follow-up. There were no significant between-group differences in VASSNP score or patient satisfaction (both P > 0.05). The LMSR + ACDF group suffered more blood loss and had longer operative time (mean 206.0 ml; mean 274.4 min, respectively) than in the TFS + ACDF group (mean 110.0 ml; mean 142.8 min, respectively) (P < 0.001 for both comparisons). For the radiographic results, the segmental kyphosis and sagittal translation were significantly corrected after surgery in both groups (P < 0.001 for both groups), and no significant differences were found between groups at the last follow-up (P > 0.05). Conclusion In the absence of any self-evident clinical and radiographic benefits of one technique over the other (TFS + ACDF vs. LMSR + ACDF), we recommend combined TFS + ACDF surgery as a safe and less invasive alternative treatment for unilateral cervical facet fractures with traumatic disc herniation, as it was associated with a shorter duration of surgery and lower estimated blood loss than LMSR + ACDF surgery.
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Affiliation(s)
- Chen Jin
- Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Ning Xie
- Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China.
| | - Jianjie Wang
- Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Yilong Ren
- Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Qunfeng Guo
- Department of Orthopedics, Shanghai Changzheng Hospital, Shanghai, 200003, China
| | - Lianshun Jia
- Department of Orthopedics, Shanghai Changzheng Hospital, Shanghai, 200003, China
| | - Liming Cheng
- Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China
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Goel A, Biswas C, Shah A, Rai S, Dandpat S, Bhambere S. Report of an eight-year experience with Camille's transarticular technique of cervical spinal stabilization. J Clin Neurosci 2021; 95:9-19. [PMID: 34929658 DOI: 10.1016/j.jocn.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 10/10/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
We present our experience with Camille's cervical transarticular screw fixation technique. During the period June 2012 to April 2020, 2422 screws were implanted in 321 patients by Camille's transarticular cervical spinal screw fixation technique. The indications of screw implantation were radiculopathy/myelopathy related to cervical spondylosis in 258 cases, cervical OPLL in 54 cases and Hirayama disease in 9 cases. The follow-up ranged from 6 to 92 months. In the entire series, there were no nerve or vessel injury or any other intraoperative 'complications' related to screw implantation. There was no instance of screw pull out or screw failure. There was no metal implant related infection. Satisfactory arthrodesis of all the treated spinal segments was observed on investigations done at a minimum follow-up of 6 months. Camille's transarticular screw fixation technique is a relatively simple surgical procedure and provides a safe, strong and reliable arthrodesis at the fulcrum of spinal movements.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India; Department of Neurosurgery, Lilavati Hospital and Research Centre, Bandra, Mumbai, India.
| | - Chandrima Biswas
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
| | - Abhidha Shah
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
| | - Survendra Rai
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
| | - Saswat Dandpat
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
| | - Sagar Bhambere
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
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Jin C, Wang Z, Liu P, Liu Y, Wang Z, Xie N. A biomechanical analysis of anterior cervical discectomy and fusion alone or combined cervical fixations in treating compression-extension injury with unilateral facet joint fracture: a finite element study. BMC Musculoskelet Disord 2021; 22:938. [PMID: 34758793 PMCID: PMC8582196 DOI: 10.1186/s12891-021-04814-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/21/2021] [Indexed: 11/12/2022] Open
Abstract
Background Compression-extension injury with unilateral facet joint fracture is one of the most devastating injuries of subaxial cervical spine. However, it is not yet clear which fixation technique represents the optimal choice in surgical management. This study aims to assess the construct stability at the operative level (C4/C5 cervical spine) following anterior cervical discectomy and fusion (ACDF) alone and combined fixation techniques (posterior-anterior fixations). Methods A previously validated three-dimensional C2-T1 finite element model were modified to simulate surgical procedures via the anterior-only approach (ACDF) and combined cervical approach [(transarticular screw, lateral mass screw, unilateral pedicle screw, bilateral pedicle screw) + ACDF, respectively] for treating compression-extension injury with unilateral facet joint fracture at C4/C5 level. Construct stability (range of rotation, axial compression displacement and anterior shear displacement) at the operative level was comparatively analyzed. Results In comparison with combined fixation techniques, a wider range of motion and a higher maximum von Mises stress was found in single ACDF. There was no obvious difference in range of motion among transarticular screw and other posterior fixations in the presence of anterior fixation. In addition, the screws inserted by transarticular screw technique had high stress concentration at the middle part of the screw but much less than 500 MPa under different conditions. Furthermore, the variability of von Mises stress in the transarticular screw fixation device was significantly lower than ACDF but no obvious difference compared with other posterior fixations. Conclusions Of the five fixation techniques, ACDF has proven poor stability and high structural stress. Compared with lateral and pedicle screw, transarticular screw technique was not worse biomechanically and less technically demanding to acquire in clinical practice. Therefore, our study suggested that combined fixation technique (transarticular screw + ACDF) would be a reasonable treatment option to acquire an immediate stabilization in the management of compression-extension injury with unilateral facet joint fracture. However, clinical aspects must also be regarded when choosing a reconstruction method for a specific patient.
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Affiliation(s)
- Chen Jin
- Division of Spine Surgery, Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Zhong Wang
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, China
| | - Peng Liu
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, China.,State Key Laboratory of Trauma: Burns & Combined Wound, Institute for Traffic Medicine of Army Medical University, Chongqing, China
| | - Yaoyao Liu
- Division of Spine Surgery, Department of Orthopedics, Daping Hospital of Army Medical University, Chongqing, China
| | - Zhanwei Wang
- Division of Spine Surgery, Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Ning Xie
- Division of Spine Surgery, Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, Putuo District, Shanghai, 200065, China.
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Balestrino A, Gondar R, Jannelli G, Zona G, Tessitore E. Surgical challenges in posterior cervicothoracic junction instrumentation. Neurosurg Rev 2021; 44:3447-3458. [PMID: 33754193 DOI: 10.1007/s10143-021-01520-6] [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: 12/01/2020] [Revised: 02/08/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
The cervicothoracic junction (CTJ) is a region of the spine submitted to significant mechanical stress. The peculiar anatomical and biomechanical characteristics make posterior surgical stabilization of this area particularly challenging. We present and discuss our surgical series highlighting the specific surgical challenges provided by this region of the spine. We have analyzed and reported retrospective data from patients who underwent a posterior cervicothoracic instrumentation between 2011 and 2019 at the Neurosurgical Department of the Geneva University Hospitals. We have discussed C7 and Th1 instrumentation techniques, rods design, extension of constructs, and spinal navigation. Thirty-six patients were enrolled. We have preferentially used lateral mass (LM) screws in the subaxial spine and pedicle screws (PS) in C7, Th1, and upper thoracic spine. We have found no superiority of 3D navigation techniques over 2D fluoroscopy guidance in PS placement accuracy, probably due to the relatively small case series. Surgical site infection was the most frequent complication, significantly associated with tumor as diagnosis. When technically feasible, PS represent the technique of choice for C7 and Th1 instrumentation although other safe techniques are available. Different rod constructs are described although significant differences in biomechanical stability still need to be clarified. Spinal navigation should be used whenever available even though 2D fluoroscopy is still a safe option. Posterior instrumentation of the CTJ is a challenging procedure, but with correct surgical planning and technique, it is safe and effective.
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Affiliation(s)
- Alberto Balestrino
- Department of Neurosurgery, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy. .,Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS San Martino Polyclinic Hospital, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
| | - Renato Gondar
- Neurosurgical Unit, Geneva University Hospitals, Geneva, Switzerland
| | | | - Gianluigi Zona
- Department of Neurosurgery, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
| | - Enrico Tessitore
- Neurosurgical Unit, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Wang QA, Guo C, Sun MJ, Yuan F. Three-dimensional spiral CT observation of the facet joints of the lower cervical spine and its clinical significance. 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; 30:1536-1541. [PMID: 33515102 DOI: 10.1007/s00586-021-06743-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/17/2020] [Accepted: 01/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE By observing the 3D anatomy of normal adult cervical facet joints, using the picture archiving and communication system to measure its 3D parameters and discussing its clinical significance, the aim of this study was to provide a reliable morphological basis for the design and manufacture of lower cervical facet joint interface distractors. METHODS We selected 200 patients who underwent cervical spine 3D spiral computed tomography (CT) examination in the imaging department of our hospital from September 2019 to May 2020 and whose spiral CT images showed no cervical spinal canal stenosis, cervical disc herniation, obvious bone hyperplasia, or infection. The anterior and posterior diameters of the facet joints on both sides of the cervical spine, the space between the joints, and the left and right diameters were measured on the sagittal, cross-sectional and coronal planes after reconstruction with 3D spiral CT. RESULTS The anterior and posterior diameters of the facet joints of the cervical spine, the space between the joints, and the left and right diameters all increased from top to bottom along the cervical spine. The 3D parameters of the C2-3~C6-7 segments were significantly different between the male and female groups. CONCLUSION The anteroposterior diameter, joint space interval, and left and right diameter of cervical facet joints are different in each segment and between the sexes. The lower cervical facet joint interface fusion device designed according to the measurement results can fully meet the needs of most patients.
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Affiliation(s)
- Qiu An Wang
- Xuzhou Medical University Affiliated Hospital, Xuzhou, China
| | - Chong Guo
- Xuzhou Medical University Affiliated Hospital, Xuzhou, China
| | - Ma Ji Sun
- Xuzhou Medical University Affiliated Hospital, Xuzhou, China
| | - Feng Yuan
- Xuzhou Medical University Affiliated Hospital, Xuzhou, China.
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Joaquim AF, Tan L, Riew KD. Posterior screw fixation in the subaxial cervical spine: a technique and literature review. JOURNAL OF SPINE SURGERY 2020; 6:252-261. [PMID: 32309663 DOI: 10.21037/jss.2019.09.28] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior cervical spine fixation is a key component in achieving spinal arthrodesis for treating various cervical spine pathologies including neoplastic, inflammatory, traumatic and degenerative diseases. Historically, various wiring techniques had played major roles in posterior cervical spine fixation. Today, posterior cervical screw fixation is utilized by most spine surgeons instead of wiring for its superior biomechanical strength. A review of lateral mass, pedicle, intralaminar and transfacet screw fixation techniques in the subaxial cervical spine is presented in a detailed fashion. A comparison among different posterior cervical subaxial fixation techniques is also included. Although the safety of freehand techniques was demonstrated in the majority of the existing studies, real-time navigation is becoming increasingly utilized for cervical screw insertion, especially for cervical pedicle screws, where the freehand technique is technically demanding and may carry a higher risk of neurovascular injury. Several different posterior screw fixation techniques exist for the subaxial cervical spine with generally low complication rate. Spine surgeons should be familiar with these techniques and choose the optimal technique based on each patient's individual anatomy and surgical needs.
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Affiliation(s)
- Andrei Fernandes Joaquim
- Department of Neurology, Discipline of Neurosurgery, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Lee Tan
- University of California, UCSF, San Francisco, CA, USA
| | - K Daniel Riew
- Columbia University Medical Center, New York, NY, USA
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Abstract
STUDY DESIGN A narrative literature review. OBJECTIVES To review the surgical techniques of posterior screw fixation in the subaxial cervical spine. METHODS A broad literature review on the most common screw fixation techniques including lateral mass, pedicle, intralaminar and transfacet screws was performed on PubMed. The techniques and surgical nuances are summarized. RESULTS The following techniques were described in detail and presented with illustrative figures, including (1) lateral mass screw insertion: by Roy-Camille, Louis, Magerl, Anderson, An, Riew techniques and also a modified technique for C7 lateral mass fixation; (2) pedicle screw fixation technique as described by Abumi and also a freehand technique description; (3) intralaminar screw fixation; and finally, (4) transfacet screw fixation, as described by Takayasu, DalCanto, Klekamp, and Miyanji. CONCLUSIONS Many different techniques of subaxial screw fixation were described and are available. To know the nuances of each one allows surgeons to choose the best option for each patient, improving the success of the fixation and decrease complications.
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Affiliation(s)
- Andrei Fernandes Joaquim
- University of Campinas (UNICAMP), Campinas, São Paulo, Brazil,Andrei Fernandes Joaquim, Department of
Neurology, Discipline of Neurosurgery, University of Campinas (UNICAMP),
Campinas, São Paulo, Brazil.
| | | | - Lee A. Tan
- Department of Neurosurgery, UCSF Medical Center, San Francisco, CA,
USA
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10
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Bayoumi AB, Efe IE, Berk S, Kasper EM, Toktas ZO, Konya D. Posterior Rigid Instrumentation of C7: Surgical Considerations and Biomechanics at the Cervicothoracic Junction. A Review of the Literature. World Neurosurg 2017; 111:216-226. [PMID: 29253696 DOI: 10.1016/j.wneu.2017.12.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 12/02/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The cervicothoracic junction is a challenging anatomic transition in spine surgery. It is commonly affected by different types of diseases that may significantly impair stability in this region. The seventh cervical vertebra (C7) is an atypical cervical vertebra with unique anatomic features compared to subaxial cervical spine (C3 to C6). C7 has relatively broader laminae, larger pedicles, smaller lateral masses, and a long nonbifid spinous process. These features allow a variety of surgical methods for performing posterior rigid instrumentation in the form of different types of screws, such as lateral mass screws, pedicle screws, transfacet screws, and intralaminar screws. Many biomechanical studies on cadavers have evaluated and compared different types of implants at C7. METHODS We reviewed PubMed/Medline by using specific combinations of keywords to summarize previously published articles that examined C7 posterior rigid instrumentation thoroughly in an experimental fashion on patients or cadavers with additional descriptive radiologic parameters for evaluation of the optimum surgical technique for each type. RESULTS A total of 44 articles were reported, including 22 articles that discussed anatomic considerations (entry points, sagittal and axial trajectories, and features of screws) and another 22 articles that discussed the relevant biomechanical testing at this transitional region if C7 was directly involved in terms of receiving posterior rigid implants. CONCLUSIONS C7 can accommodate different types of screws, which can provide additional benefits and risks based on availability of bony purchase, awareness of surgical technique, biomechanics, and anatomic considerations.
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Affiliation(s)
- Ahmed B Bayoumi
- Department of Neurosurgery, Medical Park Goztepe Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey.
| | - Ibrahim E Efe
- Department of Neurosurgery, Medical Park Goztepe Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey; Department of Neurosurgery, Charite-University Medicine Berlin, Berlin, Germany
| | - Selim Berk
- Department of Neurosurgery, Medical Park Goztepe Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Ekkehard M Kasper
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Zafer Orkun Toktas
- Department of Neurosurgery, Medical Park Goztepe Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Deniz Konya
- Department of Neurosurgery, Medical Park Goztepe Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey
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11
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Husain A, Akpolat YT, Palmer DK, Rios D, Criswell KR, Cheng WK. A comparison of open versus percutaneous cervical transfacet fixation. J Neurosurg Spine 2016; 25:430-435. [PMID: 27176112 DOI: 10.3171/2016.2.spine151334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study is to describe a technique for percutaneous cervical transfacet screw placement and compare this technique to the open technique with regard to the accuracy of facet capture and the potential of placing neurovascular structures at risk. METHODS Eight cadaveric cervical spines were harvested. One side of each spine was assigned to the percutaneous group, and the other side to the open group. The spines were instrumented from C-3 to T-1 (80 screws). The distance to the spinal canal, foramen transversarium, and neural foramen were measured to determine the likelihood of placing neurovascular structures at risk. The percentage of the facet joint captured and the angle of screw trajectory compared with the ideal trajectory were used to determine the accuracy. RESULTS There were, in total, 11 misplacements of screws: 2 screws using the open technique and 9 screws using the percutaneous technique (p = 0.006). From a neurovascular point of view, 3 percutaneous screws violated the foramen transversarium. Two of these percutaneous screws violated the neural foramen. No neurovascular foramina were violated using the open technique. The open technique resulted in a significantly greater distance from the screw to the spinal canal (p < 0.001). The distance from the screw to the foramen transversarium (p = 0.015), as well as the distance from the screw to the neural foramen (p = 0.012), did not demonstrate statistical difference when using either technique. As for the accuracy of facet capture, 8 screws exhibited less than 15% purchase of the facet joint. Six of these screws were placed using the percutaneous technique, and 2 screws were placed using the open technique. CONCLUSIONS There is a higher incidence of screw misplacement using the percutaneous transfacet in comparison to the open transfacet technique. The accuracies of facet capture using the 2 techniques were not statistically different. Surgeons will need to understand the potential risk of using the percutaneous technique as an alternative to open transfacet fixation.
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Affiliation(s)
| | | | - Daniel K Palmer
- Loma Linda University School of Medicine, Loma Linda, California
| | - David Rios
- Loma Linda University School of Medicine, Loma Linda, California
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Tong J, Ji W, Zhou R, Huang Z, Liu S, Zhu Q. Biomechanical comparison of transfacet screws to lateral mass screw-rod constructs in the lower cervical spine. 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 2015; 25:1787-93. [PMID: 26530298 DOI: 10.1007/s00586-015-4305-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Transfacet screws have been used as an alternative posterior fixation in the cervical spine. There is lack of spinal stability of the transfacet screws either as stand-along constructs or combined with anterior plate. This study was designed to evaluate spinal stability of transfacet screws following posterior ligamentous injury and combined with anterior plate, respectively, and compare transfacet screws to lateral mass screw-rod constructs. METHODS Flexibility tests were conducted on eight cadaveric specimens in an intact and injury, and instrumented with the transfacet screw fixation and lateral mass screw-rod construct at C5-C7 levels either after section of the posterior ligamentous complex or combined with an anterior plate and a mesh cage for C6 corpectomy reconstruction. A pure moment of ±2.0 Nm was applied to the specimen in flexion-extension, lateral bending, and axial rotation. Ranges of motion (ROM) were calculated for the C5-C7 segment. RESULTS ROM with the transfacet screws was 22 % of intact in flexion-extension, 9 % in lateral bending and 11 % in axial rotation, while ROM with the lateral mass screw-rod construct was 9 % in flexion-extension, 8 % in lateral bending and 22 % in axial rotation. The only significant difference between two constructs was seen in flexion-extension (5.8 ± 4.2° vs. 2.4 ± 1.2°, P = 0.002). When combined with an anterior plate and mesh cage, the transfacet screw fixation reduced ROM to 3.0° in flexion-extension, 1.2° in lateral bending, and 1.1° in axial rotation, which was similar to the lateral mass screw-rod construct. CONCLUSIONS This study identified the transfacet screw fixation, as stand-alone posterior fixation, was equivalent to the lateral mass screw-rod constructs in axial rotation and lateral bending except in flexion-extension. When combined with an anterior plate, the transfacet screw fixation was similar to the lateral mass screw-rod construct in motion constraint. The results suggested the transfacet screw fixation a biomechanically effective way as supplementation of anterior fixation.
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Affiliation(s)
- Jie Tong
- Department of Spine Surgery, Nanfang Hospital, Southern Medical University, 1838 N. Guangzhou Ave, Guangzhou, 510515, Guangdong, People's Republic of China.,Department of Spine Surgery, The First People's Hospital of Chenzhou, Chenzhou, Hunan, People's Republic of China
| | - Wei Ji
- Department of Spine Surgery, Nanfang Hospital, Southern Medical University, 1838 N. Guangzhou Ave, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Ruozhou Zhou
- Department of Spine Surgery, Nanfang Hospital, Southern Medical University, 1838 N. Guangzhou Ave, Guangzhou, 510515, Guangdong, People's Republic of China.,Department of Spine Surgery, The First People's Hospital of Chenzhou, Chenzhou, Hunan, People's Republic of China
| | - Zhiping Huang
- Department of Spine Surgery, Nanfang Hospital, Southern Medical University, 1838 N. Guangzhou Ave, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Sheting Liu
- Department of Spine Surgery, The First People's Hospital of Chenzhou, Chenzhou, Hunan, People's Republic of China
| | - Qingan Zhu
- Department of Spine Surgery, Nanfang Hospital, Southern Medical University, 1838 N. Guangzhou Ave, Guangzhou, 510515, Guangdong, People's Republic of China.
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Zileli M, Sharif S, Qadeer M. Does Trauma Have a Major Role in Ossified Posterior Longitudinal Ligament and Should We Perform Fusion in Every Case? World Neurosurg 2015; 84:1517-9. [PMID: 26145827 DOI: 10.1016/j.wneu.2015.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 06/27/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | - Salman Sharif
- Liaquat National Hospital & Medical College, Karachi, Pakistan.
| | - Mohsin Qadeer
- Liaquat National Hospital & Medical College, Karachi, Pakistan
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Yi S, Rim DC, Nam KS, Keem SH, Murovic JA, Lim J, Park J. Biomechanical Comparison of Cervical Fixation via Transarticular Facet Screws without Rods versus Lateral Mass Screws with Rods. World Neurosurg 2015; 83:548-52. [DOI: 10.1016/j.wneu.2014.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 07/14/2014] [Accepted: 12/08/2014] [Indexed: 10/24/2022]
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Finite element analysis of posterior cervical fixation. Orthop Traumatol Surg Res 2015; 101:23-9. [PMID: 25576521 DOI: 10.1016/j.otsr.2014.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Revised: 05/25/2014] [Accepted: 11/21/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND CONTEXT Despite largely, used in the past, biomechanical test, to investigate the fixation techniques of subaxial cervical spine, information is lacking about the internal structural response to external loading. It is not yet clear which technique represents the best choice and whether stabilization devices can be efficient and beneficial for three-column injuries (TCI). HYPOTHESIS The different posterior cervical fixation techniques (pedicle screw PS, lateral mass screw LS, and transarticular screw TS) have respective indications. MATERIALS AND METHODS A detailed, geometrically accurate, nonlinear C3-C7 finite element model (FEM) had been successfully developed and validated. Then three FEMs were reconstructed from different fixation techniques after C4-C6 TCI. A compressive preload of 74N combined with a pure moment of 1.8 Nm in flexion, extension, left-right lateral bending, and left-right axial rotation was applied to the FEMs. RESULTS The ROM results showed that there were obvious significant differences when comparing the different fixation techniques. PS and TS techniques can provide better immediate stabilization, compared to LS technique. The stress results showed that the variability of von Mises stress in the TS fixation device was minimum and LS fixation device was maximum. Furthermore, the screws inserted by TS technique had high stress concentration at the middle part of the screws. Screw inserted by PS and LS techniques had higher stress concentration at the actual cap-rod-screw interface. CONCLUSIONS The research considers that spinal surgeon should first consider using the TS technique to treat cervical TCI. If PS technique is used, we should eventually prolong the need for external bracing in order to reduce the higher risk of fracture on fixation devices. If LS technique is used, we should add anterior cervical operation for acquire a better immediate stabilization.
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Leasure JM, Buckley J. Biomechanical evaluation of an interfacet joint decompression and stabilization system. J Biomech Eng 2014; 136:1812592. [PMID: 24389961 DOI: 10.1115/1.4026363] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 12/30/2013] [Indexed: 11/08/2022]
Abstract
A majority of the middle-aged population exhibit cervical spondylosis that may require decompression and fusion of the affected level. Minimally invasive cervical fusion is an attractive option for decreasing operative time, morbidity, and mortality rates. A novel interfacet joint spacer (DTRAX facet screw system, Providence Medical) promises minimally invasive deployment resulting in decompression of the neuroforamen and interfacet fusion. The present study investigates the effectiveness of the device in minimizing intervertebral motion to promote fusion, decompression of the nerve root during bending activity, and performance of the implant to adhere to anatomy during repeated bending loads. We observed flexion, extension, lateral bending, and axial rotation resonant overshoot mode (ROM) in cadaver models of c-spine treated with the interfacet joint spacer (FJ spacer) as stand-alone and supplementing anterior plating. The FJ spacer was deployed bilaterally at single levels. Specimens were placed at the limit of ROM in flexion, extension, axial bending, and lateral bending. 3D images of the foramen were taken and postprocessed to quantify changes in foraminal area. Stand-alone spacer specimens were subjected to 30,000 cycles at 2 Hz of nonsimultaneous flexion-extension and lateral bending under compressive load and X-ray imaged at regular cycle intervals for quantitative measurements of device loosening. The stand-alone FJ spacer increased specimen stiffness in all directions except extension. 86% of all deployments resulted in some level of foraminal distraction. The rate of effective distraction was maintained in flexed, extended, and axially rotated postures. Two specimens demonstrated no detectable implant loosening (<0.25 mm). Three showed unilateral subclinical loosening (0.4 mm maximum), and one had subclinical loosening bilaterally (0.5 mm maximum). Results of our study are comparable to previous investigations into the stiffness of other stand-alone minimally invasive technologies. The FJ spacer system effectively increased stiffness of the affected level comparable to predicate systems. Results of this study indicate the FJ spacer increases foraminal area in the cervical spine, and decompression is maintained during bending activities. Clinical studies will be necessary to determine whether the magnitude of decompression observed in this cadaveric study will effectively treat cervical radiculopathy; however, results of this study, taken in context of successful decompression treatments in the lumbar spine, are promising for the continued development of this product. Results of this biomechanical study are encouraging for the continued investigation of this device in animal and clinical trials, as they suggest the device is well fixated and mechanically competent.
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Ray WZ, Ravindra VM, Jost GF, Bisson EF, Schmidt MH. Cost effectiveness of subaxial fusion--lateral mass screws versus transarticular facet screws. Neurosurg Focus 2013; 33:E14. [PMID: 22746231 DOI: 10.3171/2012.4.focus1289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As health care reform continues to evolve, demonstrating the cost effectiveness of spinal fusion procedures will be of critical value. Posterior subaxial cervical fusion with lateral mass screw and rod instrumentation is a well-established fixation technique. Subaxial transarticular facet fixation is a lesser known fusion technique that has been shown to be biomechanically equivalent to lateral mass screws for short constructs. Although there has not been a widespread adoption of transarticular facet screws, the screws potentially represent a cost-effective alternative to lateral mass rod and screw constructs. In this review, the authors describe an institutional experience with the use of lateral mass screws and provide a theoretical cost comparison with the use of transarticular facet screws.
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Affiliation(s)
- Wilson Z Ray
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Kim K, Isu T, Omura T, Morimoto D, Kobayashi S, Teramoto A. Transarticular fixation with a bioabsorptive screw for cervical spondylolisthesis. World Neurosurg 2013; 81:843.e5-9. [PMID: 23313236 DOI: 10.1016/j.wneu.2013.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 09/05/2012] [Accepted: 01/05/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patients with cervical instability and intramedullary signal intensity changes on preoperative magnetic resonance imaging scans may benefit from not only cervical decompression but also from fusion surgery. Transarticular screw (TAS) fixation is a useful technique for posterior fixation. We first report treating a patient with cervical spondylosis and instability by cervical laminoplasty with TAS fixation using a bioabsorptive screw. METHODS A 66-year-old woman who had undergone surgery for carcinoma of the tongue via the anterior approach experienced cervical myelopathy. Radiologic findings showed severe cervical canal stenosis with myelomalacia and spondylolisthesis at C4/C5 with instability. RESULTS We performed laminoplasty of C3 to C7 and TAS fixation of C4/C5 using a bioabsorptive poly-L-lactide screw that contained hydroxyapatite. Her postoperative course was uneventful, and at 1 year after treatment we confirmed C4/C5 fusion. CONCLUSIONS Our method has advantages over metal instrumentation. The treated area can be evaluated with the use of magnetic resonance imaging, and the space left after screw absorption is filled by newly formed bone. Because our screw contains hydroxyapatite, it is osteoconductive. This may increase the fusion rate and induce substitution with new bone. To our knowledge this is the first patient treated by cervical posterior TAS fixation via the use of a bioabsorptive screw. Our method is safe and economical and free of the complications elicited by the use of metal parts. TAS fixation with a bioabsorptive screw may be appropriate for one fixation in patients without severe instability.
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Affiliation(s)
- Kyongsong Kim
- Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School, Chiba, Japan.
| | - Toyohiko Isu
- Department of Neurosurgery, Kushiro Rosai Hospital, Hokkaido, Japan
| | - Tomoko Omura
- Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School, Chiba, Japan
| | - Daijiro Morimoto
- Department of Neurosurgery, Shin-Midori General Hospital, Kanagawa, Japan
| | - Shiro Kobayashi
- Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School, Chiba, Japan
| | - Akira Teramoto
- Department of Neurosurgery, Nippon Medical School, Tokyo, Japan
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Liu G, Ma W, Xu R, Godinsky R, Sun S, Feng J, Zhao L, Hu Y, Zhou L, Liu J. Clinical application of combined fixation in the cervical spine using posterior transfacet screws and pedicle screws. J Clin Neurosci 2012; 20:560-4. [PMID: 23232101 DOI: 10.1016/j.jocn.2012.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 04/19/2012] [Accepted: 04/22/2012] [Indexed: 11/18/2022]
Abstract
The aim of the present study was to describe the clinical application of combined fixation in the cervical spine using posterior transfacet and pedicle screws. Ten patients with cervical disorders requiring stabilization were treated from May 2006 to December 2008. The operative details varied depending on indication, the need for decompression, and the number of levels to be included in the spinal construct. Radiographic analysis of the fusion was performed after surgery. A total of 23 transfacet screws were inserted at or caudal to the C4/5 facet. A total of 21 pedicle screws were placed. All patients underwent operative treatment without neurovascular complications. Fusion was achieved in all patients. When performed appropriately, the method of using posterior transfacet screws in the caudal cervical joints combined with pedicle screw fixation in the cephalic cervical spine is reliable and deserves more widespread use.
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Affiliation(s)
- Guanyi Liu
- Department of Orthopaedic Surgery, Ningbo Sixth Hospital, 1059 Zhongshan East Road, Ningbo, Zhejiang 315040, China
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20
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Jackson DM, Karp JE, O'Brien JR, Anderson DG, Gelb DE, Ludwig SC. A novel radiographic targeting guide for percutaneous placement of transfacet screws in the cervical spine with limited fluoroscopy: A cadaveric feasibility study. Int J Spine Surg 2012; 6:62-70. [PMID: 25694873 PMCID: PMC4300881 DOI: 10.1016/j.ijsp.2011.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background We describe a technique for percutaneous transfacet screw placement in the cervical spine without the need for lateral-view fluoroscopy. Methods Previously established articular pillar morphometry was used to define the ideal trajectory for transfacet screw placement in the subaxial cervical spine. A unique targeting guide was developed to allow placement of Kirschner wires across the facet joint at 90° without the guidance of lateral-view fluoroscopy. Kirschner wires and cannulated screws were placed percutaneously in 7 cadaveric specimens. Placement of instrumentation was performed entirely under modified anteroposterior-view fluoroscopy. All specimens were assessed for acceptable screw placement by 2 fellowship-trained orthopaedic spine surgeons using computed tomography. Open dissection was used to confirm radiographic interpretation. Acceptable placement was defined as a screw crossing the facet joint, achieving purchase in the inferior and superior articular processes, and not violating critical structures. Malposition was defined as a violation of the transverse foramen, spinal canal, or nerve root or inadequate fixation. Results A total of 48 screws were placed. Placement of 45 screws was acceptable. The 3 instances of screw malposition included a facet fracture, a facet distraction, and a C6-7 screw contacting the C7 nerve root in a specimen with a small C7 superior articular process. Conclusions Our data show that with the appropriate radiographic technique and a targeting guide, percutaneous transfacet screws can be safely placed at C3-7 without the need for lateral-view fluoroscopy during the targeting phase. Because of the variable morphometry of the C7 lateral mass, however, care must be taken when placing a transfacet screw at C6-7. Clinical Relevance This study describes a technique that has the potential to provide a less invasive strategy for posterior instrumentation of the cervical spine. Further investigation is needed before this technique can be applied clinically.
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Affiliation(s)
- David M Jackson
- Department of Orthopaedics, University of Maryland, Baltimore, MD
| | | | - Joseph R O'Brien
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, DC
| | - D Greg Anderson
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Daniel E Gelb
- Department of Orthopaedics, University of Maryland, Baltimore, MD
| | - Steven C Ludwig
- Department of Orthopaedics, University of Maryland, Baltimore, MD
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Percutaneous Trans-Facet Screws for Supplemental Posterior Cervical Fixation. World Neurosurg 2012; 78:716.e1-4. [DOI: 10.1016/j.wneu.2011.12.092] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 12/21/2011] [Indexed: 11/20/2022]
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22
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Kim DY, Kim JY, Yoon SH, Park HC, Park CO. Radiological Efficacy of Cervical Lateral Mass Screw Insertion and Rod Fixation by Modified Magerl's Method (Yoon's Method) with Minimum 2 Years of Follow-up. KOREAN JOURNAL OF SPINE 2012; 9:137-41. [PMID: 25983804 PMCID: PMC4430991 DOI: 10.14245/kjs.2012.9.3.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 09/04/2012] [Accepted: 09/26/2012] [Indexed: 12/01/2022]
Abstract
Objective Cervical lateral mass screw insertion and rod fixation is a useful method for stabilizing the cervical disease, so various modified techniques were present. Many surgeons had reported the biomechanical safety according to the screw positioning method in the cervical spine, but the modified Magerl's method (Yoon's method) was not well studied. So, this study assessed the radiological efficacy of the modified Magerl's method with long-term follow-up. Methods This study retrospectively reviewed 323 lateral mass screws of 50 patients who had followed-up at least 2 years. Radiologic data were analyzed as parameters of complications after operation, including kyphotic or lordotic change, bone fusion, pull-out or malposition of screw, foraminal stenosis, adjacent disc degeneration or aggravation, pseudoarthrosis, and vertebral artery injury. Results The mean follow-up period was 32 (24 to 52) months. There were kyphotic changes in 4.0%(2 of 50 cases). Unsuccessful bone fusion occurred in 4.0%(2 of 50 cases). Among the 323 screws, screw pull-out (4.0%. 2 of 50cases, 3 of 323 screws), foraminal invasion (1.2% of total screws), and facet injury (0.6% of total screws) occurred. Conclusion The lateral mass screw insertion and rod fixation by the modified Magerl's method (Yoon's method) is a safe and reliable technique with low rate of complication related to instruments in minimum 2 years follow-up.
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Affiliation(s)
- Do Yeon Kim
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Ji Yong Kim
- Department of Neurosurgery, The Armed Forces Hospital of Pusan, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Hyung Chun Park
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Chong Oon Park
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
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The study on comparison of 3 techniques for transarticular screw placement in the lower cervical spine. Spine (Phila Pa 1976) 2012; 37:E468-72. [PMID: 21971134 DOI: 10.1097/brs.0b013e318237aae4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective comparative study. OBJECTIVE To compare 3 techniques for transarticular screw placement in the lower cervical spine. SUMMARY OF BACKGROUND DATA The transarticular screw is found to have satisfactory biomechanical stability. According to current studies, there are several techniques for the placement of transarticular screws in the lower cervical spine. Although several techniques are available for transarticular screw implantation in the lower cervical spine, only a few studies in the literature have been carried out to compare these techniques. METHODS The techniques of transarticular screw placement used by Takayasu (group A), Dalcanto (group B), and Klekamp (group C) were applied in 24 cervical specimens. The facet fractures, the encroachment of the cervical anterior branches of nerve roots and vertebral arteries and the failure of the screws to go through the facets were observed and analyzed. RESULTS One hundred ninety-two transarticular screws were implanted on both sides in 24 cervical cadavers, 64 for each group. There were 25 splits of inferior facets in group B, 2 splits in group C, and none in group A. Thirty-six screws encroached the vertebral arteries in group A, none in groups B and C. Forty anterior branches of lower cervical nerve roots were involved in group A, 5 in group B, and 3 in group C. Although all screws went through facets in the study except for 5 in group A, there were no significant differences between each group (χ(AB)2 = 3.33, P > 0.05; χ(AC)2 = 3.33, P > 0.05). CONCLUSION There is a high risk of injury to the anterior branch of the cervical nerve roots and vertebral artery if the screws were too long, and the Takayasu technique was used. However, the rate of facet splitting is high if the Dalcanto technique was applied. Klekamp's technique is recommended.
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Jost GF, Bisson EF, Schmidt MH. Computed tomography–based determination of a safe trajectory for placement of transarticular facet screws in the subaxial cervical spine. J Neurosurg Spine 2012; 16:334-9. [DOI: 10.3171/2011.12.spine11141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Placement of transarticular facet screws is one option for stabilization of the subaxial cervical spine. Small clinical series and biomechanical data support their role as a substitute for other posterior stabilization techniques; however, the application of transarticular facet screws in the subaxial cervical spine has not been widely adopted, possibly because of surgeon unfamiliarity with the trajectory. In this study, the authors' objective is to define insertion points and angles of safe trajectory for transarticular facet screw placement in the subaxial cervical spine.
Methods
Thirty fine-cut CT scans of cervical spines were reconstructed in the multiplanar mode and evaluated for safe transarticular screw placement in the subaxial cervical spine (C2–3, C3–4, C4–5, C5–6, C6–7). As in placement of lateral mass screws, the vertebral artery and exiting nerve root were bypassed posterolaterally. The entry point was set 1 mm medial and 1 mm caudal to the center of the lateral mass. From this entry point, the sagittal angulation was set to traverse the facet joint plane approximately perpendicularly. For the axial angulation, the exit point was set posterolaterally to the transverse process. After ideal insertion angles and screw lengths were identified, the trajectory was simulated on CT scans of 20 different cervical spines to confirm safe screw placement.
Results
The mean optimal mediolateral insertion angles (± SD) were as follows: 23° ± 5° at C2–3; 24° ± 4° at C3–4; 25° ± 5° at C4–5; 25° ± 4° at C5–6; and 33° ± 6° at C6–7. The mean sagittal insertion angles measured to the sagittal projection of the facet joint space were as follows: 77° ± 10° at C2–3; 77° ± 10° at C3–4; 80° ± 11° at C4–5; 81°± 8° at C5–6; and 100° ± 11° at C6–7. The mean trajectory lengths were 15 ± 2 mm at C2–3; 14 ± 1 mm at C3–4; 15 ± 1 mm at C4–5; 16 ± 2 mm at C5–6; and 23 ± 4 mm at C6–7. Simulation of these insertion angles on 20 different cervical spine CTs yielded a safe trajectory in 85%–95% of spines for C2–3, C3–4, C4–5, C5–6, and C6–7.
Conclusions
The calculated optimal insertion angles and lengths for each level may guide the safe placement of subaxial cervical transfacet screws.
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Reconstruction of the subaxial cervical spine using lateral mass and facet screw instrumentation. Spine (Phila Pa 1976) 2012; 37:E335-41. [PMID: 22218298 DOI: 10.1097/brs.0b013e31824442eb] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Review article. OBJECTIVE To review the indications, technical details, and complications of lateral mass and transfacet mass fixation methods. SUMMARY OF BACKGROUND DATA Potential advantages of rigid fixation in subaxial cervical spine have been defined as early mobilization, faster healing and fusion, and increased fusion rates. Lateral mass screw fixation has been the most popular fixation technique for posterior instrumentation. Transfacet screw fixation, on the other hand, is an alternative method less commonly used. METHODS Narrative and review of the literature. RESULTS Several different techniques aiming for the most safe and secure lateral mass screw fixation have been described by several different authors. Lateral mass screws provide rigid fixation and high fusion rates in patients with healthy bone. Complications are rare when patients' anatomy is well documented and proper technique is used. Transfacet screw fixation is another method less commonly used and with better biomechanical stability. CONCLUSION Lateral mass screw provides excellent 3-dimensional fixations from C3 to C7, and currently it is also the most commonly performed posterior fixation method.
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Posterior cervical fixation following laminectomy: a stress analysis of three techniques. 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 2011; 20:1552-9. [PMID: 21318278 DOI: 10.1007/s00586-011-1711-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 12/24/2010] [Accepted: 01/28/2011] [Indexed: 10/18/2022]
Abstract
The aim of this study was to compare the following three main fixation techniques: pedicle screw (PS) technique, lateral mass screw (LS) technique, and transarticular screw (TS) technique. A detailed, geometrically accurate, nonlinear C3-C7 FE model had been successfully developed and validated. Then three finite element (FE) models were reconstructed by different fixation techniques following C4-C6 level laminectomy. A compressive preload of 74 N combined with a pure moment of 1.8 Nm in flexion, extension, left-right lateral bending, and left-right axial rotation was applied to the models. The results showed that maximum von Mises stress on the fixation devices was much higher in the FE models of TS technique, compared with the models of PS and LS techniques. Furthermore, the screws inserted by TS technique had high stress concentration at the middle part of the screws. Screw inserted by PS and LS techniques had high stress concentration at the actual cap-rod-screw interface. The highest level of maximal stress was obtained with the fixation device of the TS technique. TS technique induces noticeable differences in the stress compared to the posterior cervical fixation technique, regarding the higher stress level on fixation devices.
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27
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Liu G, Xu R, Ma W, Sun S, Feng J. Anatomical considerations for the placement of cervical transarticular screws. J Neurosurg Spine 2011; 14:114-21. [DOI: 10.3171/2010.9.spine1066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The object of this study was to determine the safe screw placement technique for cervical transarticular screw fixation.
Methods
Twenty cadaveric adult cervical spines were studied. All soft tissues surrounding the cervical spinal nerves from C-2 to T-1 were dissected carefully to expose the lateral mass, facet joint, transverse process, vertebral artery (VA), and spinal nerves (ventral and dorsal rami). After the proper entrance and exit points for the transarticular screws were determined, posterior transarticular screw implantation was performed under direct visualization from C2–3 to C5–6. A CT scan was performed to check the screw placement. The angle and length of the transarticular screw trajectory, the distance between the tip of the screw and the VA, and the sagittal safety angle were measured on the CT scan. Statistical analysis was performed using ANOVA (p < 0.05). Sagittal and axial orientations of transarticular screws were carefully analyzed.
Results
There was no nerve or artery impingement or penetration. The average caudal angle of the screws in the sagittal plane was 37.3° ± 5.0° and the lateral angle in the axial plane was 16.6° ± 4.6°. The average distance between the tip of the screw and the VA (the posterior border of the VA foramen) was 5.8 ± 1.5 mm. The average sagittal safety angle was 41.9° ± 5.6°. No difference was observed according to the vertebral level. The average bone purchase was 18.7 ± 1.4 mm. Bone purchase was significantly greater at C2–3 (23.2 ± 1.6 mm) than at C3–4 through C5–6 (17.2 ± 1.3 mm, p < 0.05).
Conclusions
This study establishes anatomical guidelines to allow for safe cervical transarticular screw insertion. The starting point of transarticular screws should be 1 mm medial to the midpoint of the lateral mass. The “ideal” drilling angle is approximately 37° in the inferior direction and 16° in the lateral direction for the C2–3 through the C5–6 levels. The screw should be directed as laterally as possible in the axial plane without causing the lateral mass to fracture and as caudally as the occipital bone permits in the sagittal plane. The ideal screw size would be 3.5 mm in diameter and 18 mm in length.
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Xu R, Zhao L, Chai B, Ma W, Xia H, Wang G, Jiang W. Lateral radiological evaluation of transarticular screw placement in the lower cervical spine. 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 2009; 18:392-7. [PMID: 19130097 DOI: 10.1007/s00586-008-0861-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 11/18/2008] [Accepted: 12/14/2008] [Indexed: 10/21/2022]
Abstract
This study assessed the ideal district of lateral radiograph in evaluation of transarticular screw placement in the lower cervical spine. To assess the ideal zone of lateral radiographs in determining the safe or hazardous locations of the screw tips during transarticular screw implantation in the lower cervical spine. Transarticular screw in the lower cervical spine had been used as an alternative technique to achieve posterior cervical spine stability. Injury to the spinal nerves caused by transarticular screws which are too long must be identified quickly to minimize the neurologic complication. No previous radiological study regarding evaluation of the transarticular screw placement using lateral radiographs has been reported. Twelve cervical spines were removed from embalmed cadavers. Four transarticular screw placements with Dalcanto's technique under direct visualization, including placement of the screw tip staying the ventral cortex, 2, 4 and 6 mm over-penetration of the ventral cortex, were performed on each specimen. Following each placement, a lateral radiograph was taken. Each vertebral body was divided vertically into four equal zones, and another equal zone posterior to the posterior border of the vertebral body was defined as Zone pre-1. The numbers of screw tips seen in each zone were quantified for each placement. Partitions of chi (2) method was used to evaluate the ideal zone on lateral radiograph for transarticular screw insertion. At C34 and C45, no significant difference was found between Zone pre-1 and Zone 1 (chi(2) = 0.18, P > 0.50), while there was significant difference between Zones 1 and 2 (chi(2) = 73.6, P < 0.005), as well as Zones 2 and 3 (chi(2) = 13.2, P < 0.005). At C56 and C67, No significant difference was found between Zones 2 and 3 (chi(2) = 0.25, P > 0.50), while there was significant difference between Zone pre-1 and Zone 1 (chi(2) = 66.2, P < 0.005), as well as Zones 1 and 2 (chi(2) = 10.5, P < 0.005). Ideal screw tip positions on lateral radiograph for transarticular screw by Dalcanto's technique should be in Zone 1 at C34 and C45, in Zone pre-1 at C56 and C67. If the screw tip was in Zones 3 and 4, the safe rate will be decreased significantly and it might be too deep and be dangerous.
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Affiliation(s)
- Rongming Xu
- Department of Orthopaedic Surgery, Ningbo 6th Hospital, 315040, Ningbo, ZheJiang, People's Republic of China
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Biomechanical differences between transfacet and lateral mass screw-rod constructs for multilevel posterior cervical spine stabilization. Spine (Phila Pa 1976) 2008; 33:E865-9. [PMID: 18978579 DOI: 10.1097/brs.0b013e318184ace8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN In vitro biomechanical investigation using human cadaveric cervical spines. OBJECTIVE Evaluate differences in biomechanical stability between typical lateral mass screw + rod constructs compared to transfacet screw fixation with and without rods. SUMMARY OF BACKGROUND DATA Lateral mass screw + rod constructs have reported efficacious arthrodesis rates/quality but risk damaging the lateral neurovascular structures. Transfacet screw fixation has been studied in the lumbar spine, but little data exists regarding its potential utility in the cervical spine. METHODS Sixteen human cadaveric cervical spines were stripped of soft tissue leaving the occiput and ligamentous structures intact. Spines were randomized to lateral mass or transfacet groups (n = 8/group). Spines were prepared in typical surgical fashion and instrumented with the appropriate devices. In the case of the transfacet constructs, the occiput was left intact to simulate the potential surgical difficulty of screw insertion. The transfacet screw group was initially instrumented with rods. Once instrumented (C3-C6) for each group, spines were further dissected to isolate the instrumented levels. End vertebral bodies were rigidly fixed and constructs biomechanically tested in flexion/extension, lateral bending, and axial torsion between +/-2 Nm. After testing for the transfacet screw + rod group, rods were removed and spines retested. All instrumentation was then removed and spines tested in their destabilized state as would occur with surgical preparation. Stiffness data were calculated for each test direction for all groups. Raw and normalized data were each compared across techniques with a 1-way ANOVA (P < 0.05). RESULTS The transfacet screw groups (with and without rods) were found to have statistically similar biomechanical stability to lateral mass screw + rod constructs for each test direction. CONCLUSION Transfacet screws (without rods) were found to have similar biomechanical stability compared to typical lateral mass screw + rod constructs. However, transfacet fixation eliminates the risk to the neurovascular structures and lowers the overall implant profile.
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