Technique for drilling instrument monitoring electrical conductivity in pediatric cervical spine screw insertion: a preliminary report

Spine Surgery with Electronic Conductivity Device: A Prospectively Multicenter Randomized Clinical Trial and Literature Review

OBJECTIVE

Improving accuracy and safety of pedicle screw placement is of great clinical importance. Electronic conductivity device (ECD) can be a promising technique with features of affordability, portability, and real-time detection capabilities. This study aimed to validate the safety and effectiveness of a modified ECD.

METHODS

The ECD underwent a modification where six lamps of various colors, and it was utilized in a prospectively multicenter randomized controlled clinical trial involving 96 patients across three hospitals from June 2018 to December 2018. The trial incorporated a self-control randomization with an equal distribution of left or right side of vertebral pedicle among two groups: the free-hand group and the ECD group. A total of 496 pedicle screws were inserted, with 248 inserted in each group. The primary outcomes focused on the accuracy of pedicle screw placement and the frequency of intraoperative X-rays. Meanwhile, the secondary indicator measured the time required for pedicle screw placement. Results were presented as means ± SD. Paired samples t-test and χ2 -test were used for comparison. Furthermore, an updated review was conducted, which included studies published from 2006 onwards.

RESULTS

Baseline patient characteristics were recorded. The primary accuracy outcome revealed a 96.77% accuracy rate in the ECD group, compared to a 95.16% accuracy rate in the free-hand group, with no significant differences noted. In contrast, ECD demonstrated a significant reduction in radiation exposure frequency when compared to the free-hand group (1.11 ± 0.32 vs. 1.30 ± 0.53; p < 0.001), resulting in a 14.6% reduction. Moreover, ECD displayed a decrease of 30.38% in insertion time (70.88 ± 30.51 vs. 101.82 ± 54.00 s; p < 0.001). According to the results of the 21 studies, ECD has been utilized in various areas of the spine such as the atlas, thoracic and lumbar spine, as well as sacral 2-alar-iliac. The accuracy of ECD ranged from 85% to 100%.

CONCLUSION

The prospectively randomized trial and the review indicate that the use of ECD presents a secure and precise approach to the placement of pedicle screws, with the added benefit of reducing both procedure time and radiation exposure.

State-of-the-Art of Non-Radiative, Non-Visual Spine Sensing with a Focus on Sensing Forces, Vibrations and Bioelectrical Properties: A Systematic Review

In the research field of robotic spine surgery, there is a big upcoming momentum for surgeon-like autonomous behaviour and surgical accuracy in robotics which goes beyond the standard engineering notions such as geometric precision. The objective of this review is to present an overview of the state of the art in non-visual, non-radiative spine sensing for the enhancement of surgical techniques in robotic automation. It provides a vantage point that facilitates experimentation and guides new research projects to what has not been investigated or integrated in surgical robotics. Studies were identified, selected and processed according to the PRISMA guidelines. Relevant study characteristics that were searched for include the sensor type and measured feature, the surgical action, the tested sample, the method for data analysis and the system's accuracy of state identification. The 6DOF f/t sensor, the microphone and the electromyography probe were the most commonly used sensors in each category, respectively. The performance of the electromyography probe is unsatisfactory in terms of preventing nerve damage as it can only signal after the nerve is disturbed. Feature thresholding and artificial neural networks were the most common decision algorithms for state identification. The fusion of different sensor data in the decision algorithm improved the accuracy of state identification.

Improved Accuracy and Safety of Pedicle Screw Placement by Using a Probe with an Electrical Conductivity-Measuring Device during Severe Syndromic and Neuromuscular Scoliosis Spine Surgery

An electrical conductivity-measuring device (ECD) has recently been developed to support pedicle screw placement. However, no evidence exists regarding its efficacy for syndromic/neuromuscular scoliosis with extremely difficult screwing. We retrospectively reviewed 2010-2016 medical records of 21 consecutive syndromic/neuromuscular scoliosis patients undergoing free-hand segmental fixation surgery at our institution and compared the pedicle screw insertion accuracy and safety between 10 with a conventional non-ECD probe (2010-2013) and 11 with an ECD probe (2014-2016). We analyzed preoperative pedicle shape and postoperative screw placement in computed tomography. There were no significant differences between ECD and non-ECD groups in demographic, clinical, and treatment characteristics including scoliosis severity and pedicle diameter. The abandonment rate due to liquorrhea or perforation was lower in ECD (12.3%) than in non-ECD (26.7%) (p < 0.01). Acceptable insertion without perforation or <2-mm lateral/cranial position was more frequent in ECD (67.1%) than in non-ECD (56.9%) (p = 0.02). Critical ≥5-mm medial/caudal malposition was not seen in ECD (0.0%) but in non-ECD (2.4%) (p = 0.02). The perforation distance was shorter in ECD (2.2 ± 1.1 mm) than in non-ECD (2.6 ± 1.7 mm) (p = 0.01). Results involve small sample size, selection, performance, and learning curve biases; nevertheless, ECD could be useful for more accurate and safer pedicle screw placement in severe syndromic/neuromuscular scoliosis.

Accuracy of Pedicle Screw Placement Comparing an Electronic Conductivity Device and a Multi-axis Angiography Unit with C-arm Fluoroscopy in Lumbar Fixation Surgery for Safety

The aim of this study was to compare the accuracy, safety, and usefulness of percutaneous pedicle screw (PPS) placement for lumbar fixation using a multi-axis angiography unit (MAU) and an electronic conductivity device (ECD) with a cannulated Jamshidi needle with that using a conventional C-arm. Of 65 cases that underwent lumbar fixation (region between L1-S1) during April 2013 to March 2019, 57 cases that could be followed-up for more than 12 months after the procedure were included. Among them, 31 patients (150 screws) received treatment with MAU and ECD (MAU+ECD group) and 26 (117 screws) were treated with the conventional C-arm. We performed a retrospective study of the surgical techniques used in each group at our institute by assessing the accuracy of PPS using Gertzbin–Robbins classification and the Japanese Orthopedic Association (JOA) score for recovery. There was no significant difference in surgery outcome based on the JOA recovery rate. There was a significant difference between the two groups in terms of Accuracy-1 (Group A indicating accuracy and Groups B–E indicating inaccuracy), where the rates were 85.3% and 72.0% in the MAU+ECD group and C-arm group, respectively (P = 0.008). There was also a significant difference between the two groups in terms of Accuracy-2 (Groups A–B indicating accuracy; Groups C–E indicate inaccuracy), where the rates were 98.0% and 92.4% in the MAU+ECD and C-arm groups, respectively (P = 0.036). A combination of MAU and ECD is a safe and accurate method for inserting screws into the pedicle.

Reduced Puncture Time and Radiation Exposure of Percutaneous Transpedicular Puncture with Electronic Conductivity Device: A Randomized Clinical Trial

OBJECTIVES

The present study introduced an electronic conductivity device (ECD) to reduce time of percutaneous transpedicular puncture and frequency of patient valid radiation exposure in percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP).

METHODS

A randomized self-control clinical study was undertaken. Medical records of patients with vertebral compression fractures (VCFs) for bilateral PKP or PVP were collected, and each side was performed randomly with ECD or conventional trocar.

RESULTS

We enrolled 61 patients (44 women, 17 men) with 75 vertebras with VCF. Compared with the conventional fluoroscopy group, significant reductions in puncture time (504.33 ± 152.03 vs. 652.68 ± 167.60 seconds; P < 0.001) and fluoroscopy frequency (5.11 ± 1.23 vs. 8.15 ± 1.83; P < 0.001) for each percutaneous puncture were observed in the ECD group. When compared with the VCFs ≤50% group, the 2 indexes in the VCFs >50% group were significantly increased. And in the ECD group, the learning curve in the VCFs >50% group showed a steeper decreasing trend than that in the VCFs ≤50% group. No complications were observed in any patient.

CONCLUSIONS

ECD could reduce puncture time of percutaneous transpedicular puncture and exposure of radiation in PVP and PKP. ECD has more benefits in complicated transpedicular puncture in patients with vertebral compression >50%.

Usefulness of a New Electronic Conductivity Device with a Pedicle Probe and a Multi-axis Angiography Unit for Inserting a C1 Lateral Mass Screw Safely and Tightly: A Technical Note

The C1 lateral mass screw (LMS) is widely used as one of the screws for atlantoaxial fixation. Tight bicortical screwing from the posterior to anterior cortical margin of the atlas is recommended. However, important structures, such as the internal carotid artery, are located around this area so precision is required to avoid injuring them. We describe the usefulness of a new electronic conductivity device (ECD) with a pedicle probe and a multi-axis angiography unit for inserting the C1 LMS. Four consecutive patients who were treated with C1 and C2 posterior fixation using an ECD and a multi-axis angiography unit in the hybrid operating room were included. All patients were treated successfully. Seven of eight bicortical screws could be inserted into the perfectly ideal location. The median (interquartile range) distance from the anterior margin of the atlas to the tip of the screw was 0.81 mm (0.43, 1.21 mm). This study suggested that the ECD and multi-axis angiography unit are useful for inserting the C1 LMS safely and tightly.

Technical advances in pediatric craniovertebral junction surgery

Surgery for conditions in the craniovertebral junction in the pediatric population poses unique challenges. The posterior approach has emerged as the gold standard for arthrodesis in this region. Anterior fixation or decompression also may be indicated. Intraoperative image guidance and neurophysiological monitoring improve the safety and efficacy of these procedures. The specific technical advances in surgery of the craniovertebral junction that have improved patient outcomes are reviewed.

The contribution of an electronic conductivity device to the safety of pedicle screw insertion in scoliosis surgery

STUDY DESIGN

Retrospective, controlled clinical study.

OBJECTIVE

To evaluate the contribution of an electronic conductivity device (ECD) to the safety of pedicle screw insertion in pediatric scoliosis surgery.

SUMMARY OF BACKGROUND DATA

The implantation of pedicle screws in spinal deformity correction surgery has evolved into the currently predominant fixation technique. Methodologies for optimizing placement of pedicle screws are fluoroscopy, electromyography, and intraoperative image-based navigation. A hand-held ECD was recently introduced.

METHODS

Pedicle screw insertion was analyzed in 248 pediatric scoliosis patients (idiopathic, congenital, neuromuscular, syndromatic). Group I included 150 procedures without the aid of the ECD and group II included 98 ECD-aided procedures. The two groups were matched by age, sex, etiology, Cobb angle, and surgical criteria. Data on screw position and concomitant neuromonitoring alarms were compared. Group I consisted of patients operated with both the hybrid construct and pedicle screw instrumentation, while group II consisted of patients operated solely with pedicle screws. Both groups were operated on by a single surgeon with the same neurophysiologic methodology. Clinically relevant misplaced pedicle screws were established by intraoperative monitoring alarms concomitant with pedicle screw insertion.

RESULTS

A total of 1270 pedicle screw placements were analyzed in group I and compared with 1400 pedicle screw placements in group II. Neuromonitoring alarms concomitant with screw placement occurred in 10 procedures in group I (6.6%) compared with 3 in group II (3.0%). The contribution of the electronic device to reducing the number of neurophysiologic alarms was significant (P = 0.048, Fisher exact test). Nine of the 13 monitoring alarms (69%) were associated with implantation adjacent to the apex of the spinal curve.

CONCLUSION

The use of an ECD significantly reduced the incidence of clinically relevant misplaced screws in a variety of scoliosis patients, thereby increasing the safety of pedicle screw implantation.