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Xia H, Zhou C, Wang Y, Zheng Y. Design of a new detachable pedicle screw based on medical optical imaging inspection to improve osteoporosis and enhance vertebral body revision effect. Med Eng Phys 2024; 125:104137. [PMID: 38508790 DOI: 10.1016/j.medengphy.2024.104137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/19/2024] [Accepted: 02/25/2024] [Indexed: 03/22/2024]
Abstract
Osteoporosis is a common bone disease that often leads to difficulty in vertebrae revision. Traditional pedicle screws are often complicated to operate and have poor visibility during implantation. A new detachable pedicle screw is needed to improve the revision effect. The aim of this study was to design a new detachable pedicle screw based on medical optical imaging to improve the outcome of vertebral revision in osteoporosis, and to improve operational feasibility and visibility. In this study, the parameters related to the degree of osteoporosis were obtained by optical imaging detection of the osteoporotic vertebral body. Then a new detachable pedicle screw was designed according to the test results to improve the effect of vertebral body revision. By preparing and optimizing the material and structure of the screw, it is ensured that it has sufficient mechanical strength and stability. Finally, the visibility and operability of the improved screw during implantation were verified by medical optical imaging. Compared with traditional screws, the new detachable pedicle screw can improve the vertebral body revision in the case of osteoporosis. The optical imaging test results show that the new screw has good visibility and maneuverability, providing more accurate guidance and positioning for the vertebral body revision operation.
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Affiliation(s)
- Haipeng Xia
- Department of Spine Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, Shandong Province, China
| | - Chao Zhou
- Department of Spine Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, Shandong Province, China
| | - Yanguo Wang
- Department of Spine Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, Shandong Province, China
| | - Yanping Zheng
- Department of Spine Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, Shandong Province, China.
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Brunken F, Mandelka E, Bullert B, Gruetzner PA, Vetter SY, Gierse J. Comparison of 3D-navigation and fluoroscopic guidance in percutaneous pedicle screw placement for traumatic fractures of the thoracolumbar junction. BRAIN & SPINE 2024; 4:102769. [PMID: 38510605 PMCID: PMC10951758 DOI: 10.1016/j.bas.2024.102769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/29/2024] [Accepted: 02/16/2024] [Indexed: 03/22/2024]
Abstract
Introduction Fractures of the thoracolumbar junction are the most common vertebral fractures and can require surgical treatment. Several studies have shown that the accuracy of pedicle screw placement can be improved by the use of 3D-navigation. Still only few studies have focused on the use of navigation in traumatic spine injuries. Research question The aim of this study was to compare the screw placement accuracy and radiation exposure for 3D-navigated and fluoroscopy-guided percutaneous pedicle screw placement in traumatic fractures of the thoracolumbar junction. Materials and methods In this single-center study 25 patients undergoing 3D-navigated percutaneous pedicle screw placement for traumatic fractures of the thoracolumbar junction (T12-L2) were compared to a control group of 25 patients using fluoroscopy. Screw accuracy was determined in postoperative CT-scans using the Gertzbein-Robbins classification system. Additionally, duration of surgery, dose area product, fluoroscopy time and intraoperative complications were compared between the groups. Results The accuracy of 3D-navigated percutaneous pedicle screw placement was 92.66 % while an accuracy of 88.08 % was achieved using standard fluoroscopy (p = 0.19). The fluoroscopy time was significantly less in the navigation group compared to the control group (p = 0.0002). There were no significant differences in radiation exposure, duration of surgery or intraoperative complications between the groups. Discussion and conclusion The results suggest that 3D-navigation facilitates higher accuracy in percutaneous pedicle screw placement of traumatic fractures of the thoracolumbar junction, although limitations should be considered. In this study 3D-navigation did not increase fluoroscopy time, while radiation exposure and surgery time were comparable.
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Affiliation(s)
- Fenna Brunken
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117 Heidelberg, Germany
| | - Eric Mandelka
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117 Heidelberg, Germany
| | - Benno Bullert
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117 Heidelberg, Germany
| | - Paul Alfred Gruetzner
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117 Heidelberg, Germany
| | - Sven Y. Vetter
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117 Heidelberg, Germany
| | - Jula Gierse
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Heidelberg University, Grabengasse 1, 69117 Heidelberg, Germany
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LeRoy TE, Smith IC, Kim DH, Golenbock SW, Baker KC, Arnold PM, Sasso RC, Park DK, Fischgrund JS, Zaidi QH, Hwang RW. Clinical Significance of Lateral Pedicle Screw Malposition in Lumbar Spine Fusion. Clin Spine Surg 2023; 36:E258-E262. [PMID: 36823702 DOI: 10.1097/bsd.0000000000001440] [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: 02/13/2022] [Accepted: 12/13/2022] [Indexed: 02/25/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Our objective was to determine whether lateral pedicle screw breach affects fusion rates and patient-reported outcomes in lumbar fusion surgery. SUMMARY OF BACKGROUND DATA Although lateral pedicle screw malposition is considered relatively benign, few studies have focused specifically on clinical outcomes or fusion rates associated with lateral screw malposition. METHODS Twelve-month postoperative computed tomography scans were reviewed for lateral breach, severity of breach, and fusion status. Patients with lateral breach were compared with patients with no breach. Outcome measures included Numerical Pain Rating Scale for back and leg pain, Oswestry Disability Index, and SF-36 physical function (SF-36 PF). Multivariable linear and logistic regression and were adjusted for age, procedure, level, and/or baseline pain score. RESULTS Forty-five patients (31%) demonstrated 1 or more lateral breaches as compared with 99 patients without breach. After adjusting for baseline scores and fusion level, patients with 2 or more screw breaches experienced SF-36 PF score improvements that were 3.43 points less ( P =0.016) than patients with no lateral breach. After adjusting for baseline Numerical Pain Rating Scale, there was also a significant decrease in the odds of achieving minimally clinical important difference in back pain relief in these patients. There was no observed effect of lateral breach on the odds of successful fusion. CONCLUSIONS The current study did not observe an association between laterally malpositioned pedicle screws and nonunion. However, results are consistent with a negative effect on SF-36 PF scores and self-reported back pain at 12 months.
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Affiliation(s)
- Taryn E LeRoy
- Department of Orthopaedic Surgery, Tufts Medical Center
| | - Isabel C Smith
- Department of Orthopaedic Surgery, New England Baptist Hospital
- Department of Research, New England Baptist Hospital
| | - David H Kim
- Department of Orthopaedic Surgery, New England Baptist Hospital
- Tufts University School of Medicine, Boston, MA
| | | | - Kevin C Baker
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI
| | | | | | - Daniel K Park
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI
| | | | - Qasim H Zaidi
- Department of Orthopaedic Surgery, New England Baptist Hospital
| | - Raymond W Hwang
- Department of Orthopaedic Surgery, New England Baptist Hospital
- Tufts University School of Medicine, Boston, MA
- Boston Orthopaedic and Spine, Chestnut Hill, MA
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Du SY, Dai J, Zhou ZT, Shan BC, Jiang FX, Yang JY, Cao L, Zhou XZ. Size selection and placement of pedicle screws using robot-assisted versus fluoroscopy-guided techniques for thoracolumbar fractures: possible implications for the screw loosening rate. BMC Surg 2022; 22:365. [PMID: 36273170 PMCID: PMC9587613 DOI: 10.1186/s12893-022-01814-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background There has been increased development of robotic technologies for the accuracy of percutaneous pedicle screw placement. However, it remains unclear whether the robot really optimize the selection of screw sizes and enhance screw stability. The purpose of this study is to compare the sizes (diameter and length), placement accuracy and the loosening rate of pedicle screws using robotic-assisted versus conventional fluoroscopy approaches for thoracolumbar fractures. Methods A retrospective cohort study was conducted to evaluate 70 consecutive patients [34 cases of robot-assisted percutaneous pedicle screw fixation (RAF) and 36 of conventional fluoroscopy-guided percutaneous pedicle screw fixation (FGF)]. Demographics, clinical characteristics, and radiological features were recorded. Pedicle screw length, diameter, and pedicle screw placement accuracy were assessed. The patients’ sagittal kyphosis Cobb angles (KCA), anterior vertebral height ratios (VHA), and screw loosening rate were evaluated by radiographic data 1 year after surgery. Results There was no significant difference in the mean computed tomography (CT) Hounsfield unit (HU) values, operation duration, or length of hospital stay between the groups. Compared with the FGF group, the RAF group had a lower fluoroscopy frequency [14 (12–18) vs. 21 (16–25), P < 0.001] and a higher “grade A + B” pedicle screw placement rate (96.5% vs. 89.4%, P < 0.05). The mean screw diameter was 6.04 ± 0.55 mm in the RAF group and 5.78 ± 0.50 mm in the FGF group (P < 0.001). The mean screw length was 50.45 ± 4.37 mm in the RAF group and 48.63 ± 3.86 mm in the FGF group (P < 0.001). The correction loss of the KCA and VHR of the RAF group was less than that of the FGT group at the 1-year follow-up [(3.8 ± 1.8° vs. 4.9 ± 4.2°) and (5.5 ± 4.9% vs. 6.4 ± 5.7%)], and screw loosening occurred in 2 out of 34 patients (5.9%) in the RAF group, and 6 out of 36 patients (16.7%) in the FGF group, but there were no significant differences (P > 0.05). Conclusion Compared with the fluoroscopy-guided technique, robotic-assisted spine surgery decreased radiation exposure and optimizes screw trajectories and dimensions intraoperatively. Although not statistically significant, the loosening rate of the RAF group was lower that of than the FGT group.
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Affiliation(s)
- Sheng-Yang Du
- Department of Orthopaedics, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu, China.,Department of Orthopaedics, First People's Hospital of Xuzhou, 269 Daxue Road, Xuzhou, Jiangsu, China
| | - Jun Dai
- Department of Orthopaedics, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu, China
| | - Zhen-Tao Zhou
- Department of Orthopaedics, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu, China
| | - Bing-Chen Shan
- Department of Orthopaedics, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu, China
| | - Feng-Xian Jiang
- Department of Orthopaedics, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu, China
| | - Jing-Yan Yang
- Institute for Social and Economic Research and Policy, Graduate School of Arts and Sciences, Columbia University, New York, NY, USA.
| | - Lei Cao
- Department of Orthopaedics, First People's Hospital of Xuzhou, 269 Daxue Road, Xuzhou, Jiangsu, China.
| | - Xiao-Zhong Zhou
- Department of Orthopaedics, Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, Jiangsu, China.
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Novel Dual-Threaded Pedicle Screws Provide Fixation Stability That Is Comparable to That of Traditional Screws with Relative Bone Preservation: An In Vitro Biomechanical Study. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12126172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Replacement with larger diameter screws is always used in pedicle screw loosening but carries a risk of pedicle wall violation. A pedicle screw with more preserved bone stock is the preferred primary fixation choice. The purpose of this study was to evaluate whether a newly designed proximal-conical dual-thread screw with less bone occupancy provides fixation strength comparable to that of a traditional screw. Six types of pedicle screws based on three different shapes (cylindrical, conical, and proximal-conical) and two thread profiles (single-thread and dual-thread) were grouped. Conical and proximal-conical screws differed mainly in the slope of the outer diameter from the hub to the tip. Conical screws had an outer diameter (6.5 mm) that differed from the hub and tapered by 30% to an outer diameter (4.5 mm) at the tip and proximal-conical screws had the same outer diameter from the hub and tapered by 30% (4.5 mm) at 20 mm from the hub and then maintained the outer diameter (45 mm) to the tip. A total of 36 L4 Sawbones® vertebrae were used in the study and six trials for each screw group. The results of the imaging, screw volume in bone, insertion torque, and pullout force were analyzed. For screws with the same shape, insertion torque and pullout force were significantly higher for those in the dual-thread groups than for those in the single-thread groups (p < 0.05). For screws with the same thread profile, there was no significant difference in either biomechanical test between the different screw shapes (p > 0.05). Our results demonstrated that these proximal-conical dual-thread screws, with the property of relative bone stock preservation, display a comparable biomechanical performance to traditional dual-thread screws and a better performance than single-thread screws. This screw design could serve as the primary pedicle screw choice to reduce revision difficulty.
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Kanawati A, Constantinidis A, Williams Z, O'Brien R, Reynolds T. Generating patient-matched 3D-printed pedicle screw and laminectomy drill guides from Cone Beam CT images: Studies in ovine and porcine cadavers. Med Phys 2022; 49:4642-4652. [PMID: 35445429 PMCID: PMC9544846 DOI: 10.1002/mp.15681] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/05/2022] [Accepted: 04/17/2022] [Indexed: 11/22/2022] Open
Abstract
Background The emergence of robotic Cone Beam Computed Tomography (CBCT) imaging systems in trauma departments has enabled 3D anatomical assessment of musculoskeletal injuries, supplementing conventional 2D fluoroscopic imaging for examination, diagnosis, and treatment planning. To date, the primary focus has been on trauma sites in the extremities. Purpose To determine if CBCT images can be used during the treatment planning process in spinal instrumentation and laminectomy procedures, allowing accurate 3D‐printed pedicle screw and laminectomy drill guides to be generated for the cervical and thoracic spine. Methods The accuracy of drill guides generated from CBCT images was assessed using animal cadavers (ovine and porcine). Preoperative scans were acquired using a robotic CBCT C‐arm system, the Siemens ARTIS pheno (Siemens Healthcare, GmbH, Germany). The CBCT images were imported into 3D‐Slicer version 4.10.2 (www.slicer.org) where vertebral models and specific guides were developed and subsequently 3D‐printed. In the ovine cadaver, 11 pedicle screw guides from the T1–T5 and T7–T12 vertebra and six laminectomy guides from the C2–C7 vertebra were planned and printed. In the porcine cadaver, nine pedicle screw guides from the C3–T4 vertebra were planned and printed. For the pedicle screw guides, accuracy was assessed by three observers according to pedicle breach via the Gertzbein–Robbins grading system as well as measured mean axial and sagittal screw error via postoperative CBCT and CT scans. For the laminectomies, the guides were designed to leave 1 mm of lamina. The average thickness of the lamina at the mid‐point was used to assess the accuracy of the guides, measured via postoperative CBCT and CT scans from three observers. For all measurements, the intraclass correlation coefficient (ICC) was calculated to determine observer reliability. Results Compared with the planned screw angles for both the ovine and porcine procedures (n = 32), the mean axial and sagittal screw error measured on the postoperative CBCT scans from three observers were 3.9 ± 1.9° and 1.8 ± 0.8°, respectively. The ICC among the observes was 0.855 and 0.849 for the axial and sagittal measurements, respectively, indicating good reliability. In the ovine cadaver, directly comparing the measured axial and sagittal screw angle of the visible screws (n = 14) in the postoperative CBCT and conventional CT scans from three observers revealed an average difference 1.9 ± 1.0° in axial angle and 1.8 ± 1.0° in the sagittal angle. The average thickness of the lamina at the middle of each vertebra, as measured on‐screen in the postoperative CBCT scans by three observes was 1.6 ± 0.2 mm. The ICC among observers was 0.693, indicating moderate reliability. No lamina breaches were observed in the postoperative images. Conclusion Here, CBCT images have been used to generate accurate 3D‐printed pedicle screw and laminectomy drill guides for use in the cervical and thoracic spine. The results demonstrate sufficient precision compared with those previously reported, generated from standard preoperative CT and MRI scans, potentially expanding the treatment planning capabilities of robotic CBCT imaging systems in trauma departments and operating rooms.
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Affiliation(s)
| | | | - Zoe Williams
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
| | - Ricky O'Brien
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
| | - Tess Reynolds
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
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Augmented reality-navigated pedicle screw placement: a cadaveric pilot 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; 30:3731-3737. [PMID: 34350487 DOI: 10.1007/s00586-021-06950-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/04/2020] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Augmented reality (AR) is an emerging technology with great potential for surgical navigation through its ability to provide 3D holographic projection of otherwise hidden anatomical information. This pilot cadaver study investigated the feasibility and accuracy of one of the first holographic navigation techniques for lumbar pedicle screw placement. METHODS Lumbar computer tomography scans (CT) of two cadaver specimens and their reconstructed 3D models were used for pedicle screw trajectory planning. Planned trajectories and 3D models were subsequently uploaded to an AR head-mounted device. Randomly, k-wires were placed either into the left or the right pedicle of a vertebra (L1-5) with or without AR-navigation (by holographic projection of the planned trajectory). CT-scans were subsequently performed to assess accuracy of both techniques. RESULTS A total of 18 k-wires could be placed (8 navigated, 10 free hand) by two experienced spine surgeons. In two vertebrae, the AR-navigation was aborted because the registration of the preoperative plan with the intraoperative anatomy was imprecise due to a technical failure. The average differences of the screw entry points between planning and execution were 4.74 ± 2.37 mm in the freehand technique and 5.99 ± 3.60 mm in the AR-navigated technique (p = 0.39). The average deviation from the planned trajectories was 11.21° ± 7.64° in the freehand technique and 5.88° ± 3.69° in the AR-navigated technique (p = 0.09). CONCLUSION This pilot study demonstrates improved angular precision in one of the first AR-navigated pedicle screw placement studies worldwide. Technical shortcomings need to be eliminated before potential clinical applications.
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Chen X, Song Q, Wang K, Chen Z, Han Y, Shen H, Li Q. Robot-assisted minimally invasive transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion: a retrospective matched-control analysis for clinical and quality-of-life outcomes. J Comp Eff Res 2021; 10:845-856. [PMID: 33906371 DOI: 10.2217/cer-2021-0078] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aim: To compare the screw accuracy and clinical outcomes between robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA MIS-TLIF) and open TLIF in the treatment of one-level lumbar degenerative disease. Materials & methods: From May 2018 to December 2019, a consecutive series of patients undergoing robot-assisted minimally invasive one-level lumbar fusion procedures were retrospectively compared with matched controls who underwent one-level open TLIF procedures for clinical and quality-of-life outcomes. Results: A total of 52 patients underwent RA MIS-TLIF procedures (robot-assisted [RA] group) and 52 matched controls received freehand open TLIF procedures (open [OP] group). The RA group had more grade A screws with 96.2% one-time success rate of screw placement (p < 0.05). Besides, the RA group experienced less intraoperative blood loss and shorter length of hospital stay, while the OP group had shorter operative duration and cumulative radiation time (p < 0.001). What is more, the average VAS score for low back pain and ODI score in the RA group were lower than that in the OP group 1 month after operation (p < 0.05). Conclusion: The use of real-time, image-guided robot system may further expand the advantages of MIS-TLIF technique in terms of accuracy and safety.
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Affiliation(s)
- Xiuyuan Chen
- Department of Spine Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qingxin Song
- Department of Spine Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Kun Wang
- Department of Spine Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi Chen
- Department of Spine Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yingchao Han
- Department of Spine Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hongxing Shen
- Department of Spine Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Quan Li
- Department of Spine Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Retrospective Review of Revision Surgery After Image-guided Instrumented Spinal Surgery Compared With Traditional Instrumented Spinal Surgery. Clin Spine Surg 2020; 33:E317-E321. [PMID: 32049676 DOI: 10.1097/bsd.0000000000000949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
STUDY DESIGN Retrospective cohort series. OBJECTIVE The objective of this study was to determine if the use of image-guided navigation offers a clinically significant advantage over fluoroscopy-assisted pedicle screw and non-navigated screw placement in reducing the risk of revision surgery for malpositioned screws in instrumented spinal surgery. SUMMARY OF BACKGROUND DATA Use image-guided navigation has become increasingly commonplace in instrumented spine surgery, but there is a lack of information regarding differences in the rates of clinically relevant screw malposition with image-guided compared with non-navigated screw placement. MATERIALS AND METHODS This is a retrospective cohort series of consecutive patients who underwent instrumented spinal surgery by the senior authors at 2 academic tertiary care centers in New York. RESULTS A total of 663 instrumented spinal surgeries were analyzed, including 271 instances with image-guided navigation. For the image-guided navigation cohort, 110 of the patients underwent screw placement using O-Arm image-guidance, yielding data on 1115 screws. The remaining 161 surgeries utilizing image-guided screw placement were performed using Brainlab Spine Navigation, for a total of 1001 screws. A fluoroscopy-assisted technique or freehand technique was used in 419 instances, with a total of 3689 screws. Of the non-navigated cohort, 10 patients required a surgical revision of screw placement, for a total of 15 malpositioned screws. Amongst the image-guided navigation cohort, 1 patient in the O-Arm group and 2 in the Brainlab group required revision surgery, with 3 malpositioned screws in total. The rate of revision surgery for a malpositioned screw placed via non-navigated techniques was 2.39%. This risk was decreased to 1.11% with the use of the intraoperative image-guided navigation. However, no comparisons between non-navigated and image-guided screw placement reached statistical significance. CONCLUSION Although not reaching statistical significance, these data suggest there may be an advantage offered by image-guided screw placement in instrumented spinal surgery.
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Buell TJ, Yener U, Wang TR, Buchholz AL, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS. Sacral insufficiency fractures after lumbosacral arthrodesis: salvage lumbopelvic fixation and a proposed management algorithm. J Neurosurg Spine 2020; 33:225-236. [PMID: 32217798 DOI: 10.3171/2019.12.spine191148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors' operative experience managing this complication, review pertinent literature, and propose a treatment algorithm. METHODS The authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication. RESULTS Nine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8-96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score -1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8-90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to-lumbar lordosis (LL) mismatch. CONCLUSIONS A high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5-S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.
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Affiliation(s)
- Thomas J Buell
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ulas Yener
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Tony R Wang
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Avery L Buchholz
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Chun-Po Yen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Mark E Shaffrey
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Christopher I Shaffrey
- 2Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
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Huang X, Huang Z, Xu L, Liang D, Zhang M, Zhang H. Pullout strength of reinserted pedicle screws using the previous entry point and trajectory. J Orthop Surg Res 2019; 14:205. [PMID: 31272476 PMCID: PMC6611027 DOI: 10.1186/s13018-019-1240-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/13/2019] [Indexed: 11/10/2022] Open
Abstract
PURPOSE This study compared the biomechanics of reinserted pedicle screws using the previous entry point and trajectory with those of correctly inserted pedicle screws. METHODS The study used 18 lumbar vertebrae (L1-6) from three fresh calf spines to insert 6.5 × 40-mm pedicle screws. A control screw was inserted correctly along the axis of one pedicle, while an experimental screw was reinserted completely using the previous entry point and trajectory in the other pedicle. The experimental screw was removed after being completely inserted in group A and after 80% of the total trajectory inserted in group B. And the experimental screw was removed after 60% of the total trajectory was reached in group C. The biomechanical values of the pedicle screws were measured. RESULTS There were no significant differences in pedicle screw axial pullout strength between reinserted screws and correct screws in the 3 groups (PA = 0.463, PB = 0.753, PC = 0.753). Stiffness measurement increased for the reinserted screw compared with that of the control screw. Fracturing was observed between the vertebral body and pedicle. CONCLUSION Theoretically, a surgeon can remove the pedicle screw when necessary, inspect the trajectory, and reinsert the screw using the previous entry point and trajectory.
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Affiliation(s)
- Xuanwu Huang
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, No. 253, Gongye Road, Haizhu District, Guangzhou, 510282, China
| | - Zixiang Huang
- Department of Spine Surgery, Guangdong Second Provincial General Hospital, No. 466, Xingang Road, Haizhu District, Guangzhou, 510317, China
| | - Liwei Xu
- The Second School of Clinical Medicine, Southern Medical University, No. 253, Gongye Road, Haizhu District, Guangzhou, 510282, China.,Department of Spine Surgery, Guangdong Second Provincial General Hospital, No. 466, Xingang Road, Haizhu District, Guangzhou, 510317, China
| | - Dongzhu Liang
- Guangdong Provincial Key Laboratory of Medical Biomechanics, Department of Anatomy, Southern Medical University, Guangzhou, China
| | - Meichao Zhang
- Guangdong Provincial Key Laboratory of Medical Biomechanics, Department of Anatomy, Southern Medical University, Guangzhou, China
| | - Hui Zhang
- The Second School of Clinical Medicine, Southern Medical University, No. 253, Gongye Road, Haizhu District, Guangzhou, 510282, China. .,Department of Spine Surgery, Guangdong Second Provincial General Hospital, No. 466, Xingang Road, Haizhu District, Guangzhou, 510317, China.
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