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Chiu CK, Wang WJ, Lee YJ, Chung WH, Chan CYW, Kwan MK. The widths of the medial and lateral pedicle walls in adolescent idiopathic scoliosis with major thoracic curves. Spine J 2024; 24:1293-1301. [PMID: 38408520 DOI: 10.1016/j.spinee.2024.02.014] [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: 09/25/2023] [Revised: 02/18/2024] [Accepted: 02/19/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND CONTEXT The widths of medial and lateral pedicle walls in the normal spine of middle-aged and elderly adults have been investigated and these studies found that the medial pedicle wall was thicker than the lateral pedicle wall. However, none had evaluated the widths of medial and lateral pedicle walls on adolescent or young adult scoliotic spines. PURPOSE This study aims to identify the distribution and variation of medial and lateral pedicle wall widths throughout the different vertebral levels of the scoliotic spine and its differences according to age, gender, body mass index (BMI), maturity, curve types and curve severity in adolescent idiopathic scoliotic (AIS) patients with major thoracic curves. STUDY DESIGN Retrospective study. PATIENT SAMPLE A total of 6,230 pedicles (right: 3,064, left: 3,166) from 191 patients were included in this study, with 264 (right: 183, left: 81) fully corticalized pedicles excluded from analysis. OUTCOME MEASURES Demographic data were age, gender, height, weight, BMI, Risser grade, Lenke curve types and Cobb angles. The main outcome measures were medial and lateral pedicle wall widths. Associations between pedicle wall widths and demographic data were calculated. METHODS This was a subanalytical retrospective study done on the same patient population as the previously published study on pedicle grading. The data was obtained from the main computed tomography (CT) scan pedicle study dataset. Medial and lateral pedicle wall widths were measured in the axial slices of CT scans from T1 to L5 vertebrae. RESULTS A total of 6,230 pedicles (right: 3,064, left: 3,166) from 191 patients were included in this study with 264 (right: 183, left: 81) fully corticalized pedicles excluded from analysis. Right-sided medial pedicle wall widths were narrower from T4-T10 (0.75±0.23 mm) compared to T1-T3 (0.89±0.28 mm) and T11-L5 (0.92±0.30 mm). Left-sided medial pedicle wall widths were narrower from T4 to T7 (0.76±0.24 mm) compared to T1-T3 (0.88±0.26 mm) and T8-L5 (0.90±0.27 mm). Medial cortical wall widths were significantly thicker compared to lateral cortical wall widths for all vertebras from T1 to L5 (right medial 0.85±0.28 mm vs lateral 0.64±0.26 mm (p<.001), left medial 0.86±0.26 mm vs lateral 0.64±0.26 mm (p<.001)). The left medial pedicle wall widths were marginally significantly (p<.001) thicker than the right side (right medial 0.85±0.28 mm vs left 0.86±0.26 mm). The main notable significant differences were located at the periapical region of the thoracic curve between T7 to T10 with the left concave medial pedicle width being thicker than the right convex medial pedicle width. The thinnest medial pedicle walls were located at right concave T7 (0.73±0.24 mm) and T8 (0.73±0.23 mm). We generally found no significant associations between the medial and lateral pedicle wall widths with age, gender, BMI, Risser grade, Cobb angle and curve types. CONCLUSIONS Knowledge on the widths of medial and lateral pedicle walls, their distribution and differences in a scoliotic spine is important for pedicle screw fixation, especially during pedicle probing to find the pedicle channel. The medial pedicle wall widths were significantly thicker than the lateral pedicle wall widths in AIS patients with major thoracic curves. The right concave periapical region had the thinnest medial pedicle walls.
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Affiliation(s)
- Chee Kidd Chiu
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Wee Jieh Wang
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Yu Jie Lee
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Weng Hong Chung
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Chris Yin Wei Chan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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Chiu CK, Wang WJ, Lee YJ, Chung WH, Chan CYW, Kwan MK. What is the prevalence and distribution of narrow dysplastic and fully corticalized pedicles in Asian adolescent idiopathic scoliosis patients with major main thoracic curves? A computed tomography scan analysis of 6,494 pedicles. Spine J 2023; 23:1700-1708. [PMID: 37453514 DOI: 10.1016/j.spinee.2023.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/04/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND CONTEXT Patients with adolescent idiopathic scoliosis (AIS) have higher prevalence of abnormal or dysplastic pedicles. PURPOSE To investigate the prevalence and distribution of narrow dysplastic and fully corticalized pedicles in Asian AIS patients with major main thoracic curves. DESIGN Retrospective study. PATIENT SAMPLE A total of 6,494 pedicles in 191 patients were measured and evaluated. OUTCOME MEASURES The primary outcomes measures were the pedicle width measurements (total transverse pedicle width, transverse cancellous width, total transverse cortical width) and classification of pedicles. Demographic data (age, gender, height, weight, body mass index), proximal thoracic Cobb angle, main thoracic Cobb angle and lumbar Cobb angle were also obtained. METHODS AIS patients with major (largest Cobb angle) main thoracic curves and had computed tomography (CT) scans prior to corrective spine surgery were reviewed. The pedicles were classified as Grade A: cancellous channel >4 mm; Grade B: cancellous channel 2 to 4 mm; Grade C: cancellous channel <2 mm or corticalized pedicle >4 mm; Grade D: corticalized pedicle ≤4 mm. Grades B, C, and D were dysplastic pedicles while grades C and D were narrow dysplastic pedicles. RESULTS The prevalence of dysplastic pedicles (grades B, C, and D) was 61.7%. There were 22.6% narrow dysplastic pedicles (grades C and D) and 4.1% fully corticalized pedicles (grade D). In the thoracolumbar region, there was a sharp transition from larger and less dysplastic pedicles at T11 and T12 to narrower and more dysplastic pedicles at L1 and L2 (narrow dysplastic pedicles at T11: 3.1%, T12: 3.1%, L1: 39.8% and L2: 23.6%). Higher prevalences of narrow dysplastic pedicles were located at right T3 to T5 (71.2%-83.7%) and left T7-T9 (51.3%-61.2%). Higher prevalences of fully corticalized pedicles were located at right T3 to T5 (20.9%-34.0%) and left T7 to T8 (11.0%-12.0%). These were the concave pedicles of proximal thoracic and main thoracic curves, respectively. CONCLUSION There were 95.9% pedicles with cancellous channels (grades A, B, and C) can allow pedicle screw fixation and only 4.1% fully corticalized pedicles (grade D) that require an alternative method of fixation. For grade C pedicles (18.5%), pedicle screws can still be attempted with caution. Precautions should also be observed at the L1 and L2 levels as there was a transition to narrower pedicles.
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Affiliation(s)
- Chee Kidd Chiu
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Wee Jieh Wang
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yu Jie Lee
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Weng Hong Chung
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chris Yin Wei Chan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Makhija N, Sharma A, Magoon R, Kumar A. Surgical-conundrum of a hiding 'Bullet': Echocardiographic artefact clues the concealed fact! Indian J Anaesth 2021; 65:412-413. [PMID: 34211202 PMCID: PMC8202800 DOI: 10.4103/ija.ija_1236_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/29/2020] [Accepted: 03/28/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Neeti Makhija
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, India
| | - Amita Sharma
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, India
| | - Abhinav Kumar
- Division of Trauma Surgery and Critical Care, Department of Surgical Discipline, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
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Alomari S, Planchard R, Lo SFL, Witham T, Bydon A. Aortic injury in spine surgery……What a spine surgeon needs to know. Neurosurg Rev 2021; 44:3189-3196. [PMID: 33851267 DOI: 10.1007/s10143-021-01527-z] [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: 01/12/2021] [Revised: 02/23/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
Aortic injury is a rare, yet underreported and underestimated complication of spine surgery. Anatomical relation between the aorta and the spine changes under physiological (positional) as well as pathological (deformity) conditions, which puts the aorta at risk of injury during spine surgery. Clinical presentation of aortic injury ranges from asymptomatic perforation of the aorta to acute fatal bleeding. Although several diagnostic methods have been reported, CT-angiography remains an important diagnostic study. Several advancements in the open and the endovascular surgical management have been reported to be successfully used in the management of aortic injury following spine surgery. Management approach of malpositioned screws abutting the aorta is still controversial. Anatomical knowledge and understanding of the previously reported mechanisms of aortic injury are important to be integrated in the preoperative planning process. If the complication occurs, time-to- recognition and to-appropriate-management are important factors for predicting mortality. If unrecognized and untreated in the acutely injured patients, mortality can approach 100%.
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Affiliation(s)
- Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan Planchard
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Neurological Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 5-109, Baltimore, MD, 21287, USA.
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Valič M, Žižek D, Špan M, Mihalič R, Mohar J. Malpositioned pedicle screw in spine deformity surgery endangering the aorta: report of two cases, review of literature, and proposed management algorithm. Spine Deform 2020; 8:809-817. [PMID: 32170660 DOI: 10.1007/s43390-020-00094-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 02/11/2020] [Indexed: 12/20/2022]
Abstract
STUDY DESIGN Case reports and review of the literature with a proposed management algorithm. OBJECTIVES To report two cases of a potential vascular complication due to an incorrectly placed pedicle screw (PS) during spine deformity surgery. Relevant literature regarding the management of vascular complications is reviewed, and an evidence-based management algorithm is proposed. Aortic lesions represent a rare but potentially life-threatening complications with spine deformity and revision surgery, significantly increasing the risk. A management algorithm for an aortic lesion in the case of a malpositioned PS has not yet been published. METHODS Case 1: An 18-year-old female with proximal thoracic spinal non-instrumented fusion underwent a revision corrective procedure due to a progressive right-sided thoracolumbar compensatory curve. However, postoperative computed tomography (CT) performed to evaluate the position of the PS revealed malposition of the left T9 PS, which was abutting the descending aorta with CT angiography excluding the perforation of the aorta. Case 2: A 17-year-old male was scheduled for correction of Lenke 3-C-N adolescent idiopathic scoliosis. Postoperative routine evaluation with low-dose CT revealed a left T9 PS paravertebral malposition, and subsequent CTA demonstrated that the thread of the PS was in contact with the descending thoracic aorta and an unlikely hemodynamically significant vessel injury. RESULTS Successful removal of both malpositioned PS was performed. In the first case, a cardiovascular surgeon attended the operation if an urgent thoracotomy was needed, and in the second case, additional video-assisted thoracoscopic control of the aorta was performed during PS removal. CONCLUSIONS Preoperative imaging in spinal surgery is essential to avoid major vascular and other complications when placing PS, especially in thoracic deformities. When a potential major vessel complication emerges, an interdisciplinary approach and an appropriate management algorithm are mandatory to make the best clinical decisions. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Matej Valič
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia
| | - David Žižek
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška cesta 7, 1000, Ljubljana, Slovenia
| | - Matjaž Špan
- International Center for Cardiovascular Diseases - MC Medicor, Polje 40, 6310, Izola, Slovenia
| | - René Mihalič
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia
| | - Janez Mohar
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska cesta 31, 6280, Ankaran, Slovenia. .,Chair of Orthopedics, Faculty of Medicine, University of Ljubljana, Zaloška cesta 9, 1000, Ljubljana, Slovenia.
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Safety of Pedicle Screws in Adolescent Idiopathic Scoliosis Surgery. Asian Spine J 2017; 11:998-1007. [PMID: 29279757 PMCID: PMC5738323 DOI: 10.4184/asj.2017.11.6.998] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 11/22/2022] Open
Abstract
To review existing publications on the safety of pedicle screw insertions in adolescent idiopathic scoliosis (AIS). Despite having increased risk for neurological and visceral injuries, the use of pedicle screws have led to increased correction rates in scoliosis surgery. A review was performed on topics pertinent to pedicle screw insertion in AIS, which included pedicle morphometry in AIS, structures at risk during pedicle screw insertion, and accuracy and safety of various pedicle screw insertion techniques. The importance of computer navigation and future research regarding pedicle screw placement in AIS were also briefly reviewed. Many authors have reported abnormal pedicle anatomy in AIS. Injury to the neural structures was highest over the apical region, whereas aortic injury was the highest at T5 and T10. In the proximal thoracic spine, the esophagus could be injured even with screws as short as 25 mm. Overall pedicle perforation rates for perforations >0 and >2 mm (assessed by computed tomography) ranged from 6.4% to 65.0% and 3.7% to 29.9%, respectively. The critical pedicle perforation (>2 mm excluding lateral thoracic) and anterior perforation (>0 mm) rates was reported to range from 1.5% to 14.5% and 0.0% to 16.1%, respectively. Pedicle perforation rates were lower with the use of computer navigation. The incidence of neurological adverse events after scoliosis surgery was 0.06%–1.9%. Aortic injury has only been observed in case reports. According to the available literature, pedicle screw insertion in AIS is considered safe with low rates of clinical adverse events. Moreover, the use of navigation technology has been shown to reduce pedicle perforation rates.
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Sevuk U, Mesut A, Kiraz I, Kose K, Ayaz F, Erkul A. Delayed Presentation of Aortic Injury by a Thoracic Pedicle Screw. J Card Surg 2016; 31:220-30. [PMID: 26864154 DOI: 10.1111/jocs.12718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Delayed presentation of a thoracic aortic injury is an extremely rare complication after spine surgery. We report a case of delayed presentation of a thoracic aortic injury with a vertebral pedicle screw after posterior spinal surgery without periaortic hematoma, hemorrhage or pseudoaneurysm formation and review the relevant literature.
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Affiliation(s)
- Utkan Sevuk
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Abdullah Mesut
- Department of Neurosurgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Ilker Kiraz
- Department of Neurosurgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Kaan Kose
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Firat Ayaz
- Department of Cardiovascular Surgery, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Aylin Erkul
- Department of Anesthesiology, Diyarbakir Obstetrics and Gynecology Hospital, Diyarbakir, Turkey
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Decker S, Omar M, Krettek C, Müller CW. Elective thoracotomy for pedicle screw removal to prevent severe aortic bleeding. World J Clin Cases 2014; 2:100-103. [PMID: 24749121 PMCID: PMC3985037 DOI: 10.12998/wjcc.v2.i4.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/24/2014] [Accepted: 02/18/2014] [Indexed: 02/05/2023] Open
Abstract
We present a case of a 33-year-old female who sustained multiple injuries of her spine, including spinous process fractures of C5 to C7 and a lamina fracture of C6 and C7. Her thoracic spine showed transverse process fractures of T4 to T10, a compression fracture and lamina fracture of T3, spinous process and transverse process fractures of T4 and T5, a rotation injury of T6, as well as a compression fracture of L1. Thirteen months after posterior thoracic spinal instrumentation, a pedicle screw was suspected to be in contact with the aorta, which was proved by computed tomography angiograms. Consequently, implant removal was planned with direct exposure of the aorta in order to allow for immediate repair if needed. So far, studies that compare different techniques to remove pedicle screws that are suspected to penetrate the aorta are missing. However, different techniques have been described in case reports, mainly minimally invasive endovascular techniques vs open techniques such as thoracotomy.
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