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Hagan MJ, Syed S, Leary OP, Persad-Paisley EM, Lin Y, Zheng B, Shao B, Abdulrazeq H, Yu JYH, Telfeian AE, Gokaslan ZL, Fridley JS, Oyelese AA. Pedicle Screw Placement Using Intraoperative Computed Tomography and Computer-Aided Spinal Navigation Improves Screw Accuracy and Avoids Postoperative Revisions: Single-Center Analysis of 1400 Pedicle Screws. World Neurosurg 2022; 160:e169-e179. [PMID: 34990843 DOI: 10.1016/j.wneu.2021.12.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Intraoperative computed tomography and navigation (iCT-Nav) is increasingly used to aid spinal instrumentation. We aimed to document the accuracy and revision rate of pedicle screw placement across many screws placed using iCT-Nav. We also assess patient-level factors predictive of high-grade pedicle breach. METHODS Medical records of patients who underwent iCT-Nav pedicle screw placement between 2015 and 2017 at a single center were retrospectively reviewed. Screw placement accuracy was individually assessed for each screw using the 2-mm incremental grading system for pedicle breach. Predictors of high-grade (>2 mm) breach were identified using multiple logistic regression. RESULTS In total, 1400 pedicle screws were placed in 208 patients undergoing cervicothoracic (29; 13.9%), thoracic (30; 14.4), thoracolumbar (19; 9.1%) and lumbar (130; 62.5%) surgeries. iCT-Nav afforded high-accuracy screw placement, with 1356 of 1400 screws (96.9%) being placed accurately. In total, 37 pedicle screws (2.64%) were revised intraoperatively during the index surgery across 31 patients, with no subsequent returns to the operating room because of screw malpositioning. After correcting for potential confounders, males were less likely to have a high-grade breach (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.10-0.59, P = 0.003) whereas lateral (OR 6.21; 95% CI 2.47-15.52, P < 0.001) or anterior (OR 5.79; 95% CI2.11-15.88, P = 0.001) breach location were predictive of a high-grade breach. CONCLUSIONS iCT-Nav with postinstrumentation intraoperative imaging is associated with a reduced need for costly postoperative return to the operating room for screw revision. In comparison with studies of navigation without iCT where 1.5%-1.7% of patients returned for a second surgery, we report 0 revision surgeries due to screw malpositioning.
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Affiliation(s)
- Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Sohail Syed
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Owen P Leary
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Yang Lin
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Belinda Shao
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Hael Abdulrazeq
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - James Y H Yu
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Albert E Telfeian
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA.
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Abstract
As robotics in spine surgery has progressed over the past 2 decades, studies have shown mixed results on its clinical outcomes and economic impact. In this review, we highlight the evolution of robotic technology over the past 30 years, discussing early limitations and failures. We provide an overview of the history and evolution of currently available spinal robotic platforms and compare and contrast the available features of each. We conclude by summarizing the literature on robotic instrumentation accuracy in pedicle screw placement and clinical outcomes such as complication rates and briefly discuss the future of robotic spine surgery.
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Affiliation(s)
| | | | | | | | - Darren R. Lebl
- Weill Cornell Medicine, New York, NY, USA
- Hospital for Special Surgery, New York, NY, USA
| | - Sheeraz A. Qureshi
- Weill Cornell Medicine, New York, NY, USA
- Hospital for Special Surgery, New York, NY, USA
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3
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Luo Y, Li Z, Jiang S, Hu L, Liu W, Li W. A novel fluoroscopy-based robot system for pedicle screw fixation surgery. Int J Med Robot 2020; 16:1-8. [PMID: 32949442 DOI: 10.1002/rcs.2171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/01/2020] [Accepted: 09/17/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Robot-assisted pedicle screw insertion has gained popularity in the spinal surgery field. Due to high cost, these spinal robots are not extensively applied in clinical surgeries. Developing an effective robot system with low cost and high clinical acceptability is one of the future trends. METHODS We developed a novel fluoroscopy-based robot system for pedicle screw insertion. Four live pigs were conducted with percutaneous pedicle screw insertion. Robot-assisted surgery was performed on the left side of pedicle, while the right opposite side is placed by freehand. The respect accuracy, surgical time and fluoroscopy time were recorded. RESULTS Robot-assisted group achieved 100% (23/23) accuracy. The average times (6.4 ± 1.7) for intraoperative fluoroscopy usage per procedure were lesser than freehand group (12.5 ± 3.6), and the surgical time (6.8 ± 2.1 min) per screw was reduced compared with freehand group (12.1 ± 4.8 min). CONCLUSIONS Our robot system is cost-effective and feasible for pedicle screw placement. Low economic cost makes it easier for extensive application in primary hospitals.
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Affiliation(s)
- Yanzhong Luo
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Zhuofu Li
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Shuai Jiang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Lei Hu
- School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Wenyong Liu
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China.,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China
| | - Weishi Li
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
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Elfiky TA, Patil ND, Luk KD, Faheem ME, Samartzis D. The Concept of Lamina-Pedicle Perpendicularity: Part 2: Thoracic Spine. Asian Spine J 2020; 15:252-260. [PMID: 32521949 PMCID: PMC8055461 DOI: 10.31616/asj.2019.0334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/16/2019] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective radiographic study. PURPOSE The hypothesis of this study was that the pedicle axis (PA) is almost perpendicular to the interlaminar line (ILL) in the sagittal plane of the thoracic vertebrae. The objective of the current study was to define the thoracic lamina-PA inclination in order to verify the right-angle concept and to estimate the safety zones for sagittal inclination during pedicle screw insertion. The authors, to the best of their knowledge, are unaware of previous similar studies. OVERVIEW OF LITERATURE Based on the study's observations of different spinal disorders, including deformities, it was noted that following a sagittal cranial-caudal trajectory perpendicular to the ILL and joining the two adjacent thoracic vertebrae would work well at most vertebral levels. METHODS This was a retrospective study on the computed tomography (CT) chest scans of patients with no spinal pathologies. The ILL-PA, superior and inferior safe angles of the pedicle screw trajectories, and the exit zone of the screw perpendicular to the ILL were reviewed by two observers via three-dimensional multiplanar reconstruction mode of the Horos DICOM software (https://horosproject.org/). RESULTS The CT chest images of 30 consecutive patients (20 males and 10 females) with a mean age of 49.87±15.48 years (range, 24-74 years) were evaluated. The mean ILL-PA angle was almost orthogonal for all levels. This angle ranged between 86.21°±3.01° at D5 and 90.59°±2.72° at D10. The safety zones of the sagittal inclination of the pedicle screws were demonstrated. The results revealed that the least safe angle was when the screw was directed cranially along the middle part of the pedicle between 4.43°±0.75° at D8 and 6.94°±1.19° at D11. CONCLUSIONS The results of this study confirmed the ILL-PA angle perpendicularity in the thoracic spine at all levels. The ILL is a useful guide for pedicle screw sagittal inclination.
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Affiliation(s)
| | | | - Keith Dk Luk
- Department of Orthopaedics & Traumatology, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | | | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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5
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Kochanski RB, Lombardi JM, Laratta JL, Lehman RA, O'Toole JE. Image-Guided Navigation and Robotics in Spine Surgery. Neurosurgery 2020; 84:1179-1189. [PMID: 30615160 DOI: 10.1093/neuros/nyy630] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/04/2018] [Indexed: 01/27/2023] Open
Abstract
Image guidance (IG) and robotics systems are becoming more widespread in their utilization and can be invaluable intraoperative adjuncts during spine surgery. Both are highly reliant upon stereotaxy and either pre- or intraoperative radiographic imaging. While user-operated IG systems have been commercially available longer and subsequently are more widely utilized across centers, robotics systems provide unique theoretical advantages over freehand and IG techniques for placing instrumentation within the spine. While there is a growing plethora of data showing that IG and robotic systems decrease the incidence of malpositioned screws, less is known about their impact on clinical outcomes. Both robotics and IG may be of particular value in cases of substantial deformity or complex anatomy. Indications for the use of these systems continue to expand with an increasing body of literature justifying their use in not only guiding thoracolumbar pedicle screw placement, but also in cases of cervical and pelvic instrumentation as well as spinal tumor resection. Both techniques also offer the potential benefit of reducing occupational exposures to ionizing radiation for the operating room staff, the surgeon, and the patient. As the use of IG and robotics in spine surgery continues to expand, these systems' value in improving surgical accuracy and clinical outcomes must be weighed against concerns over cost and workflow. As newer systems incorporating both real-time IG and robotics become more utilized, further research is necessary to better elucidate situations where these systems may be particularly beneficial in spine surgery.
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Affiliation(s)
- Ryan B Kochanski
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Joseph M Lombardi
- Department of Orthopedic Surgery, Columbia University, New York, New York
| | - Joseph L Laratta
- Department of Orthopedic Surgery, Columbia University, New York, New York
| | - Ronald A Lehman
- Department of Orthopedic Surgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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Elfiky TA, Patil ND, Luk KD, Faheem ME, Samartzis D. The Concept of Lamina-Pedicle Perpendicularity: Part 1. Lumbar Spine. Asian Spine J 2020; 15:81-88. [PMID: 32050312 PMCID: PMC7904482 DOI: 10.31616/asj.2019.0114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 10/13/2019] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective radiographic study. Purpose We hypothesized that the pedicle is almost perpendicular to the interlaminar line in the sagittal plane of the lumbar vertebrae. The current study aimed to define the lumbar lamina–pedicle inclination to verify the right-angle concept and to estimate the safety zones of sagittal inclination during pedicle screw insertion. To the best of our knowledge there are no previous similar studies. Overview of Literature Based on our observations in different spinal disorders including deformities, we noted that following a sagittal (cranial–caudal) trajectory perpendicular to the interlaminar line joining the two adjacent vertebrae would work well in most of the vertebral levels. Methods This was a retrospective study on normal lumbar spine lateral radiographs of patients who presented with low back pain and were reviewed by two observers. Different inclination angles were constructed to estimate the safety zones of the pedicle screws’ sagittal inclination. Results Radiographs of 30 consecutive patients, 25 females and five males, with a mean age of 39.43±11.18 years, were studied. The mean angle of the interlaminar line and the pedicle axis was almost orthogonal at all the levels, with a range of 89.16°–94.63°, which was not affected by the lumbar sagittal profile. The safety zones of the pedicle screws were measured, and they revealed a safe sagittal range of 19.73°–24.40° if the screw was inserted from the pedicle axis, 21.03°–22.59° if inserted from the most cephalic part, and 13.31°–17.03° if inserted from the most caudal part. Conclusions Our results confirmed the perpendicularity of the interlaminar line with the pedicle axis in the lumbar spine at all the levels. The interlaminar line is a useful guide for pedicle screw sagittal inclination.
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Affiliation(s)
| | | | - Keith Dk Luk
- Department of Orthopaedics & Traumatology, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | | | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Junaid M, Afzal A, Kalsoom A, Bukhari SS. Freehand pedicle screw fixation: A safe recipe for dorsal, lumbar and sacral spine. Pak J Med Sci 2019; 35:680-684. [PMID: 31258575 PMCID: PMC6572961 DOI: 10.12669/pjms.35.3.981] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To determine outcome of freehand pedicle screw fixation for dorsal, lumbar and sacral fractures at a tertiary care centre in the developing world. Methods: A retrospective review was performed of 150 consecutive patients who underwent pedicle screw fixation from January 1, 2012 to 31st December 2017. A total of 751 pedicle screws were placed. Incidence and extent of cortical breach by misplaced pedicle screw was determined by review of intra-operative and post-operative radiographs and/or computed tomography. Results: Among the total 751 free hand placed pedicle screws, four screws (0.53%) were repositioned due to a misdirected trajectory towards the disc space. six screws (0.79%) were identified to have cause moderate breach while four screws (0.53%) cause severe breach. There was no occurrence of iatrogenic nerve root damage or violation of the spinal canal. Conclusion: Free hand pedicle screw placement based on external landmarks showed remarkable safety and accuracy in our center. The authors conclude that assiduous adherence to technique and preoperative planning is vital to success.
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Affiliation(s)
- Muhammad Junaid
- Dr. Muhammad Junaid, FCPS IFAANS, Department of Neurosurgery, PNS Shifa Hospital, Karachi, Pakistan
| | - Ali Afzal
- Dr. Ali Afzal, FCPS, Department of Neurosurgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Anisa Kalsoom
- Dr. Anisa Kalsoom, FCPS, Department of Radiology, Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Syed Sarmad Bukhari
- Dr. Syed Sarmad Bukhari, MBBS, Department of Neurological Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Abstract
Robots have been successfully used in commercial industry and have enabled humans to perform tasks which are repetitive, dangerous and requiring extreme force. Their role has evolved and now includes many aspects of surgery to improve safety and precision. Orthopaedic surgery is largely performed on bones which are rigid immobile structures which can easily be performed by robots with great precision. Robots have been designed for use in orthopaedic surgery including joint arthroplasty and spine surgery. Experimental studies have been published evaluating the role of robots in arthroscopy and trauma surgery. In this article, we will review the incorporation of robots in orthopaedic surgery looking into the evidence in their use.
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Avila MJ, Baaj AA. Freehand Thoracic Pedicle Screw Placement: Review of Existing Strategies and a Step-by-Step Guide Using Uniform Landmarks for All Levels. Cureus 2016; 8:e501. [PMID: 27014535 PMCID: PMC4803536 DOI: 10.7759/cureus.501] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pedicle screw fixation in the thoracic spine presents certain challenges due to the critical regional neurovascular anatomy as well as the narrow pedicular corridor that typically exists. With increased awareness of the dangers of intraoperative radiation, the ability to place pedicle screws with anatomic landmarks alone is paramount. In this study, we reviewed the literature from 1990 to 2015 for studies that included freehand pedicle screw placement in the thoracic spine with special emphasis on entry points and the trajectories of the screws. We excluded studies that used fluoroscopy guidance, navigation techniques, cadaveric and biomechanical articles, case reports, and experimental studies on animals. The search retrieved 40 articles, and after careful selection, seven articles were analyzed. Over 8,000 screws were placed in the different studies. The mean accuracy for placement of the thoracic screws was 93.3%. However, there is little consensus between studies in entry points, sagittal, and axial trajectories of the screws. We complete this review by presenting our step-by-step technique for the placement of freehand pedicle screws in the thoracic spine.
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Affiliation(s)
| | - Ali A Baaj
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical College
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Liu Y, Zeng C, Fan M, Hu L, Ma C, Tian W. Assessment of respiration-induced vertebral motion in prone-positioned patients during general anaesthesia. Int J Med Robot 2015; 12:214-8. [PMID: 26147226 DOI: 10.1002/rcs.1676] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/13/2015] [Accepted: 05/16/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Yajun Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, People's Republic of China
| | - Cheng Zeng
- Department of Spine Surgery, Beijing Jishuitan Hospital, People's Republic of China
| | - Mingxing Fan
- Department of Spine Surgery, Beijing Jishuitan Hospital, People's Republic of China
| | - Lin Hu
- Department of Spine Surgery, Beijing Jishuitan Hospital, People's Republic of China
| | - Chi Ma
- Department of Spine Surgery, Beijing Jishuitan Hospital, People's Republic of China
| | - Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, People's Republic of China
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Fennell VS, Palejwala S, Skoch J, Stidd DA, Baaj AA. Freehand thoracic pedicle screw technique using a uniform entry point and sagittal trajectory for all levels: preliminary clinical experience. J Neurosurg Spine 2014; 21:778-84. [DOI: 10.3171/2014.7.spine1489] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Experience with freehand thoracic pedicle screw placement is well described in the literature. Published techniques rely on various starting points and trajectories for each level or segment of the thoracic spine. Furthermore, few studies provide specific guidance on sagittal and axial trajectories. The goal of this study was to propose a uniform entry point and sagittal trajectory for all thoracic levels during freehand pedicle screw placement and determine the accuracy of this technique.
Methods
The authors retrospectively reviewed postoperative CT scans of 33 consecutive patients who underwent open, freehand thoracic pedicle-screw fixation using a uniform entry point and sagittal trajectory for all levels. The same entry point for each level was defined as a point 3 mm caudal to the junction of the transverse process and the lateral margin of the superior articulating process, and the sagittal trajectory was always orthogonal to the dorsal curvature of the spine at that level. The medial angulation (axial trajectory) was approximately 30° at T-1 and T-2, and 20° from T-3 to T-12. Breach was defined as greater than 25% of the screw diameter residing outside of the pedicle or vertebral body.
Results
A total of 219 thoracic pedicle screws were placed with a 96% accuracy rate. There were no medial breaches and 9 minor lateral breaches (4.1%). None of the screws had to be repositioned postoperatively, and there were no neurovascular complications associated with the breaches.
Conclusions
It is feasible to place freehand thoracic pedicle screws using a uniform entry point and sagittal trajectory for all levels. The entry point does not have to be adjusted for each level as reported in existing studies, although this technique was not tested in severe scoliotic spines. While other techniques are effective and widely used, this particular method provides more specific parameters and may be easier to learn, teach, and adopt.
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