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Groisser BN, Thakur A, Hillstrom HJ, Adhiyaman A, Zucker C, Du J, Cunningham M, Hresko MT, Haddas R, Blanco J, Potter HG, Mintz DN, Breighner RE, Heyer JH, Widmann RF. Fully automated determination of robotic pedicle screw accuracy and precision utilizing computer vision algorithms. J Robot Surg 2024; 18:278. [PMID: 38960985 PMCID: PMC11222209 DOI: 10.1007/s11701-024-02001-w] [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: 04/27/2024] [Accepted: 05/27/2024] [Indexed: 07/05/2024]
Abstract
Historically, pedicle screw accuracy measurements have relied on CT and expert visual assessment of the position of pedicle screws relative to preoperative plans. Proper pedicle screw placement is necessary to avoid complications, cost and morbidity of revision procedures. The aim of this study was to determine accuracy and precision of pedicle screw insertion via a novel computer vision algorithm using preoperative and postoperative computed tomography (CT) scans. Three cadaveric specimens were utilized. Screw placement planning on preoperative CT was performed according to standard clinical practice. Two experienced surgeons performed bilateral T2-L4 instrumentation using robotic-assisted navigation. Postoperative CT scans of the instrumented levels were obtained. Automated segmentation and computer vision techniques were employed to align each preoperative vertebra with its postoperative counterpart and then compare screw positions along all three axes. Registration accuracy was assessed by preoperatively embedding spherical markers (tantalum beads) to measure discrepancies in landmark alignment. Eighty-eight pedicle screws were placed in 3 cadavers' spines. Automated registrations between pre- and postoperative CT achieved sub-voxel accuracy. For the screw tip and tail, the mean three-dimensional errors were 1.67 mm and 1.78 mm, respectively. Mean angular deviation of screw axes from plan was 1.58°. For screw mid-pedicular accuracy, mean absolute error in the medial-lateral and superior-inferior directions were 0.75 mm and 0.60 mm, respectively. This study introduces automated algorithms for determining accuracy and precision of planned pedicle screws. Our accuracy outcomes are comparable or superior to recent robotic-assisted in vivo and cadaver studies. This computerized workflow establishes a standardized protocol for assessing pedicle screw placement accuracy and precision and provides detailed 3D translational and angular accuracy and precision for baseline comparison.
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Affiliation(s)
- Benjamin N Groisser
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ankush Thakur
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Howard J Hillstrom
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Akshitha Adhiyaman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Colson Zucker
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jerry Du
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Matthew Cunningham
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | | | - Ram Haddas
- University of Rochester Medical Center, Rochester, NY, USA
| | - John Blanco
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Hollis G Potter
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Douglas N Mintz
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ryan E Breighner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jessica H Heyer
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Roger F Widmann
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Yang JH, Kim HJ, Chang TY, Suh SW, Chang DG. Comparative Analysis of Monoaxial and Polyaxial Pedicle Screws in the Surgical Correction of Adolescent Idiopathic Scoliosis. J Clin Med 2024; 13:2689. [PMID: 38731218 PMCID: PMC11084419 DOI: 10.3390/jcm13092689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/21/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Although several biomechanical studies have been reported, few clinical studies have compared the efficacy of monoaxial and polyaxial pedicle screws in the surgical treatment of adolescent idiopathic scoliosis (AIS). This study aims to compare the radiological and clinical outcomes of mono- and polyaxial pedicle screws in the surgical treatment of AIS. Methods: A total of 46 AIS patients who underwent surgery to treat scoliosis using pedicle screw instrumentation (PSI) and rod derotation (RD) were divided into two groups according to the use of pedicle screws: the monoaxial group (n = 23) and polyaxial group (n = 23). Results: The correction rate of the main Cobb's angle was higher in the monoaxial group (70.2%) than in the polyaxial group (65.3%) (p = 0.040). No differences in the rotational correction of the apical vertebra were evident between the two groups. SRS-22 scores showed no significant differences according to the type of pedicle screws used. Conclusions: The use of polyaxial pedicle screws resulted in coronal, sagittal, and rotational correction outcomes comparable to those associated with the use of monoaxial pedicle screws for surgical treatment using PSI and RD to treat moderate cases of AIS.
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Affiliation(s)
- Jae Hyuk Yang
- Department of Orthopaedic Surgery, Korea University Anam Hospital, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (J.H.Y.); (T.Y.C.)
| | - Hong Jin Kim
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul 01757, Republic of Korea;
| | - Tae Yeong Chang
- Department of Orthopaedic Surgery, Korea University Anam Hospital, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (J.H.Y.); (T.Y.C.)
| | - Seung Woo Suh
- Department of Orthopedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, Seoul 08308, Republic of Korea;
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul 01757, Republic of Korea;
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Sakhrekar R, Shkumat N, Ertl-Wagner B, Lewis S, Lebel D, McVey MJ, Camp M. Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis. Spine Deform 2024; 12:739-746. [PMID: 38413472 DOI: 10.1007/s43390-024-00830-1] [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: 03/10/2023] [Accepted: 01/13/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. METHOD A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). RESULTS 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. CONCLUSION Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.
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Affiliation(s)
- Rajendra Sakhrekar
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Nicholas Shkumat
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Stephen Lewis
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - David Lebel
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - M J McVey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
| | - Mark Camp
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Grabala P, Kowalski P, Grabala M. The Influence of Increased Pedicle Screw Diameter and Thicker Rods on Surgical Results in Adolescents Undergoing Posterior Spinal Fusion for Idiopathic Scoliosis. J Clin Med 2024; 13:2174. [PMID: 38673447 PMCID: PMC11051082 DOI: 10.3390/jcm13082174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Modern surgical techniques allow for the correction of spinal deformity, stopping its progression and improving pain relief and social and physical functioning. These instruments have different implant designs, screws, and rod diameters and can be composed of different metal alloys with different hardnesses, which can have a significant impact on the effect of correcting spinal deformities. We designed a retrospective cohort study based on the same surgical technique and spine system using different implant sizes, and compared the results across them. Methods: This is a retrospective review of adolescent idiopathic scoliosis (AIS) patients who underwent posterior spinal fusion (PSF) between 2016 and 2022 with a minimum two-year follow-up (FU) using two spinal implant systems: 5.5 and 6.0 mm diameter screws with double 5.5 mm titanium rods (Group 1 (G1)), and 6.0 and 6.5 mm diameter pedicle screws with double 6.0 mm cobalt-chromium rods (Group 2 (G2)). The evaluated data were as follows: preoperative personal data, radiographic outcomes, complications, and health-related quality of life questionnaire (HRQoL). The parameters were reviewed preoperatively, after the final fusion, and during the FU. Results: The mean age of all 260 patients at surgery was 14.8 years. The average BMI was also similar in both groups and was noted as 21. The mean levels of fusion and screw density were similar in both groups. The mean preoperative major curves (MCs) were 57.6° and 62.5° in G1 and G2, respectively. The mean flexibility of the curves was noted as 35% in G1 and 33% in G2. After definitive surgery, the mean percentage correction of the MC was better in G2 vs. G1, with 74.5% vs. 69.8%, respectively (p < 0.001). At the final FU, the average loss of correction was 5.9° for G1 and 3.2° for G2 (p < 0.001). The mean preoperative (TK) thoracic kyphosis (T2-T5) was 12.2° in G1 and 10.8° in G2. It was corrected to 15.2° in G1 and to 13° in G2. At the FFU, we noted a significant difference in the TK (T2-T5) between the groups, with 16.7° vs. 9.6° for G1 vs. G2, respectively (p < 0.001). Statistical significance was observed between the preoperative sagittal balance and the final follow-up for both groups (p < 0.001). Conclusions: AIS patients surgically treated with screws with a larger diameter and thicker and stiffer rods showed greater correction and postoperative thoracic kyphosis without implant failure. The complication rates, implant density, and clinical outcomes remained similar. The radiographic benefits reported in this cohort study suggest that large-sized screws and stiffer rods for the correction of pediatric spinal deformities are safe and very effective.
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Affiliation(s)
- Pawel Grabala
- Department of Pediatric Orthopedic Surgery and Traumatology, Medical University of Bialystok and Medical University of Bialystok Children’s Clinical Hospital, ul. Waszyngtona 17, 15-274 Bialystok, Poland
- Paley European Institute, Al. Rzeczypospolitej 1, 02-972 Warsaw, Poland
- Department of Neurosurgery with Department of Interventional Neurology, Medical University of Bialystok and Medical University of Bialystok Clinical Hospital, ul. M. Sklodowskiej-Curie 24A, 15-276 Bialystok, Poland
| | - Piotr Kowalski
- Department of Neurosurgery, Regional Specialized Hospital, ul. Dekerta 1, 66-400 Gorzow, Poland;
| | - Michal Grabala
- 2nd Clinical Department of General and Gastroenterogical Surgery, Medical University of Bialystok and Medical University of Bialystok Clinical Hospital, ul. M. Skłodowskiej-Curie 24A, 15-276 Bialystok, Poland;
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Sullivan MH, Yu L, Schueler BA, Nassr A, Guerin J, Milbrandt TA, Larson AN. Radiation exposure in navigated techniques for AIS: is there a difference between pre-operative CT and intraoperative CT? Spine Deform 2024; 12:349-356. [PMID: 37870680 DOI: 10.1007/s43390-023-00772-0] [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: 08/08/2023] [Accepted: 09/23/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE Utilization of navigation improves pedicle screw accuracy in adolescent idiopathic scoliosis (AIS). Our center switched from intraoperative CT (ICT) to an optical navigation system that utilizes pre-operative CT (PCT). We aim to evaluate the radiation dose and operative time for low-dose ICT compared to standard and low-dose PCT used for optical navigation in AIS patients undergoing posterior spinal fusion. METHODS A single-center matched-control cohort study of 38 patients was conducted. Nineteen patients underwent ICT navigation (O-arm) and were matched by sex, age, and weight to 19 patients who underwent PCT for use with an optical-guided navigation (7D, Seaspine). A total of 418 levels were instrumented and reviewed. PCT was either a standard dose (N = 7) or a low dose (N = 12). The mean volume CT dose index, dose-length product, overall effective dose (ED), ED per level instrumented, and operative time per level were compared. RESULTS ED per level instrumented was 0.061 ± 0.029 mSv in low-dose PCT and 0.14 ± 0.05 mSv in low-dose ICT (p < 0.0001). ED per level instrumented was significantly higher in standard PCT (1.46 ± 0.39 vs. 0.14 ± 0.03 mSv; p < 0.0001). Mean operative time per level was 31 ± 7 min for ICT and 33 ± 3 min for PCT (p = 0.628). CONCLUSION Low-dose PCT resulted in 0.70 mSv exposure per case and 31 min per level, standard-dose was 16.95 mSv, while ICT resulted in 1.34-1.62 mSv and a similar operative time. Use of a standard-dose PCT involves radiation exposure about 9 times higher than ICT and 23 times higher than low-dose PCT per level instrumented. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Mikaela H Sullivan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Lifeng Yu
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Julie Guerin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Todd A Milbrandt
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Larson AN, Polly DW, Sponseller PD, Kelly MP, Richards BS, Garg S, Parent S, Shah SA, Weinstein SL, Crawford CH, Sanders JO, Blakemore LC, Oetgen ME, Fletcher ND, Kremers WK, Marks MC, Brearley AM, Aubin CE, Sucato DJ, Labelle H, Erickson MA. The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial. J Bone Joint Surg Am 2024; 106:180-189. [PMID: 37973031 DOI: 10.2106/jbjs.23.00178] [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] [Indexed: 11/19/2023]
Abstract
BACKGROUND Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | - Sumeet Garg
- Children's Hospital of Colorado, Aurora, Colorado
| | | | | | | | | | | | | | | | | | | | - Michelle C Marks
- Harms Study Group/Setting Scoliosis Straight Foundation, El Cajon, California
| | | | - Carl-Eric Aubin
- Ecole Polytechnique, St. Justine Hospital, Montreal, Quebec, Canada
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Sarwahi V, Hasan S, Koutsogiannis P, Visahan K, Rao H, Patil A, Lo Y, Amaral T, DiMauro JP. Effect of Pedicle Screw Size on Surgical Outcomes Following Surgery for 412 Adolescent Idiopathic Scoliosis Patients. Spine (Phila Pa 1976) 2023; 48:1544-1551. [PMID: 37134132 DOI: 10.1097/brs.0000000000004700] [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: 01/18/2023] [Accepted: 04/12/2023] [Indexed: 05/04/2023]
Abstract
STUDY DESIGN Retrospective Review. OBJECTIVE The objective of this study was to determine differences in surgical and post-operative outcomes in AIS patients undergoing spinal deformity correction surgery using standard or large pedicle screw size. SUMMARY OF BACKGROUND Use of pedicle screw fixation in spinal deformity correction surgery is considered safe and effective. Still, the small size of the pedicle and the complex 3D anatomy of the thoracic spine makes screw placement challenging, with improper pedicle screw fixation leading to catastrophic complications including injuries to nerve roots, spinal cord, and major vessels. Thus, insertion of larger diameter screw sizes has raised concerns amongst surgeons, especially in the pediatric population. MATERIALS AND METHODS AIS patients undergoing PSF between 2013 and 2019 were included. Demographic, radiographic, and operative outcomes collected. Patients in the large screw size group (GpI) received 6.5 mm diameter screw sizes at all levels while standard screw size group (GpII) received 5.0 to 5.5 mm diameter screw sizes at all levels. Kruskall-Wallis and Fisher's exact test performed for continuous and categorical variables respectively.Subanalyses included (1) screw accuracy in patients with available CT scans, (2) stratified analysis of large- and standard-screw patients with ≥60% flexibility rate, (3) stratified analysis of large- and standard-screw patients with <60% flexibility rate, and (4) matched analysis of large- and standard-screw patients by surgeon and year of surgery. RESULTS GpI patients experienced significantly higher overall curve correction ( P <0.001), with 87.6% experiencing at least one grade reduction of apical vertebral rotation from preoperative to postoperative visit( P =0.008).Patients with larger screws displayed higher postoperative kyphosis. No patient experienced medial breaching. CONCLUSION Large screw sizes have similar safety profiles to standard screws without negatively impacting surgical and perioperative outcomes in AIS patients undergoing PSF. Additionally, coronal, sagittal, and rotational correction is superior for larger-diameter screws in AIS patients.
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Affiliation(s)
- Vishal Sarwahi
- Department of Pediatric Orthopaedics, Cohen Children's Medical Center, New Hyde Park, NY
| | - Sayyida Hasan
- Department of Pediatric Orthopaedics, Cohen Children's Medical Center, New Hyde Park, NY
| | - Petros Koutsogiannis
- Department of Pediatric Orthopaedics, Cohen Children's Medical Center, New Hyde Park, NY
| | - Keshin Visahan
- Department of Pediatric Orthopaedics, Cohen Children's Medical Center, New Hyde Park, NY
| | - Himanshu Rao
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
| | - Aravind Patil
- Department of Pediatric Orthopaedics, Cohen Children's Medical Center, New Hyde Park, NY
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Terry Amaral
- Department of Pediatric Orthopaedics, Cohen Children's Medical Center, New Hyde Park, NY
| | - Jon-Paul DiMauro
- Department of Pediatric Orthopaedics, Cohen Children's Medical Center, New Hyde Park, NY
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Wang X, Larson AN, Polly DW, Aubin CE. Biomechanical Computational Study of Pedicle Screw Position and Density in Adolescent Idiopathic Scoliosis Instrumentation. Spine (Phila Pa 1976) 2023; 48:1436-1445. [PMID: 37294810 DOI: 10.1097/brs.0000000000004742] [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: 02/25/2023] [Accepted: 05/23/2023] [Indexed: 06/11/2023]
Abstract
STUDY DESIGN Computer simulation of adolescent idiopathic scoliosis instrumentation. OBJECTIVE To test the hypothesis that different screw densities would result in different apical vertebral rotation (AVR) corrections and bone-screw forces in adolescent idiopathic scoliosis instrumentation. SUMMARY OF BACKGROUND DATA The "Minimize Implants Maximize Outcomes" Clinical Trial revealed that the use of more versus fewer screws resulted in similar coronal plane correction for Lenke 1A curves. However, the biomechanical impact of screw density on transverse plane correction is still unclear. Further investigation is needed to determine if and how transverse plane correction is correlated with screw density. PATIENTS AND METHODS We simulated apical vertebral derotation after segmental translation using patient-specific computer models of 30 patients from the "Minimize Implants Maximize Outcomes" Trial. For each case, 10 alternative screw patterns were tested with overall densities ranging between 1.2 and 2 screws per level fused, and local density at the 3 apical levels ranging between 0.7 and 2 (total: 600 simulations). Main thoracic (MT) Cobb angle, thoracic kyphosis (TK), AVR, and bone-screw forces were computed and compared. RESULTS The presenting MT (62 ± 11°; range: 45° to 86°), TK (27 ± 20°; -5° to 81°), and AVR (14±7°; -2° to 25°) were corrected through segmental translation to 22 ± 7° (10° to 41°), 26 ± 5° (18° to 45°), and 14 ± 7° (-4° to 26°). After apical vertebral derotation, they became 16 ± 8° (1° to 41°), 24 ± 4° (13° to 40°), and 4 ± 5° (-12° to 18°). There was no significant difference in MT among screw patterns; higher screw density had lower bone-screw forces ( P < 0.05). The apical vertebral derotation maneuver reduced AVR by an average of 70%, positively correlated with apical screw density ( r = 0.825, P < 0.05). There was no significant difference in TK. CONCLUSION Screw density had no significant effect on 3-dimensional correction through the primary segmental translation maneuver. Transverse plane correction through subsequent apical vertebral derotation was positively correlated with screw density at the apical levels ( r = 0.825, P < 0.05). Bone-screw forces were negatively correlated with overall screw density ( P < 0.05).
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Affiliation(s)
- Xiaoyu Wang
- Department of Mechanical Engineering, Polytechnique Montreal (Quebec), Canada
- Research Center, Sainte-Justine University Hospital Center, Montreal (Quebec), Canada
| | | | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN
| | - Carl-Eric Aubin
- Department of Mechanical Engineering, Polytechnique Montreal (Quebec), Canada
- Research Center, Sainte-Justine University Hospital Center, Montreal (Quebec), Canada
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Grabala P, Helenius IJ, Grabala M, Shah SA. Influences of Increasing Pedicle Screw Diameter on Widening Vertebral Pedicle Size during Surgery in Spinal Deformities in Children and Adolescents without Higher Risk of Pedicle and Vertebral Breaches. J Clin Med 2023; 12:5368. [PMID: 37629410 PMCID: PMC10455094 DOI: 10.3390/jcm12165368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND A very common technique for treating spinal deformities in children and adolescents is the use of segmental screws. In order to obtain proper stability and the best possible correction, the screws must first be precisely inserted. Additional factors influencing the quality and success of the operation are the size and quality of the bone, the skills of the surgeon, and biomechanical factors, i.e., the width and length of the screws used during surgery. Our study was focused on evaluating the effect of increasing the diameter of the instrumented pedicles by pedicle screws and assessing the safety of expanding these pedicles with screws of various sizes in children with spinal deformities during the growth period, using preoperative magnetic resonance imaging and postoperative computed tomography (CT) to assess and compare preoperative size measurements from MRI to postoperative CT measurements. METHODS We obtained data for evaluation from the available medical records and treatment histories of patients aged 2 to 18 who underwent surgical treatment of spinal deformities in the years 2016-2023. In 230 patients (28 male and 202 female), 7954 vertebral bodies were scanned by preoperative MRI, and 5080 pedicle screws were inserted during surgery, which were then assessed by postoperative CT scan. For the most accurate assessment, patients were classified into three age groups: 2-5 years (Group 1), 6-10 years (Group 2), and 11-18 years (Group 3). In addition, we studied implant subgroups: vertebral bodies with inserted pedicles of screw sizes 5.0 mm and 5.5 mm (Group S), and pedicles of screw sizes 6.0 mm, 6.5 mm, and 7.0 mm (Group L). RESULTS The morphology of pedicles (Lenke classification) analyzed before surgery using MRI was 55.2% type A, 33.8% type B, 4.7% type C, and 6.3% type D. The postoperative lateral and medial breaches were noted, and these did not cause any complications requiring revision surgery. The mean pedicle diameter before surgery for T1-L5 vertebral pedicles was between 3.79 (1.44) mm and 5.68 (1.64) mm. The mean expanding diameter of pedicles after surgery for T1-L5 vertebral pedicles ranged from 1.90 (0.39) mm to 2.92 (0.28) mm, which corresponds to the extension of the pedicle diameter in the mean range of 47% (4.1)-71% (3.0). We noted that the mean vertebral pedicle expansion was 49% in Group 1, 52% in Group 2, and 62% in Group 3 (N.S.), and the mean expansion for 7.0 mm screw pedicles was 78%. CONCLUSIONS Our study confirms that there is a wide range of expansion of the vertebral pedicle during screw insertion (up to 78%) with a low risk of lateral or medial breaches and without an increased risk of complications. The larger the diameter of the screw inserted into the pedicle, the more the pedicle expands. Pedicle measurements by preoperative MRI may be helpful for sufficient reliability in preoperative planning.
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Affiliation(s)
- Pawel Grabala
- Department of Pediatric Orthopedic Surgery and Traumatology, University Children’s Hospital, Waszyngtona 17, 15-274 Bialystok, Poland
| | - Ilkka J. Helenius
- Department of Orthopedics and Traumatology, Helsinki University Hospital, 00260 Helsinki, Finland;
| | - Michal Grabala
- 2nd Clinical Department of General and Gastroenterogical Surgery, Medical University of Bialystok, ul. M. Skłodowskiej-Curie 24a, 15-276 Bialystok, Poland;
| | - Suken A. Shah
- Department of Orthopaedic Surgery, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803, USA;
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Ansorge A, Sarwahi V, Bazin L, Vazquez O, De Marco G, Dayer R. Accuracy and Safety of Pedicle Screw Placement for Treating Adolescent Idiopathic Scoliosis: A Narrative Review Comparing Available Techniques. Diagnostics (Basel) 2023; 13:2402. [PMID: 37510146 PMCID: PMC10378125 DOI: 10.3390/diagnostics13142402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/15/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
Posterior spinal fusion and segmental spinal instrumentation using pedicle screws (PS) is the most used procedure to correct adolescent idiopathic scoliosis. Computed navigation, robotic navigation, and patient-specific drill templates are available, besides the first described free-hand technique. None of these techniques are recognized as the gold standard. This review compares the PS placement accuracy and misplacement-related complication rates achieved with the techniques mentioned above. It further reports PS accuracy classifications and anatomic PS misplacement risk factors. The literature suggests a higher PS placement accuracy for robotic relative to computed navigation and for the latter relative to the free-hand technique (misplacement rates: 0.4-7.2% versus 1.9-11% versus 1.5-50.7%) using variable accuracy classifications. The reported PS-misplacement-related complication rates are, however, uniformly low (0-1.4%) for every technique, while robotic and computed navigation induce a roughly fourfold increase in the patient's intraoperative radiation exposure relative to the free-hand technique with fluoroscopic implant positioning control. The authors, therefore, recommend dedicating robotic and computed navigation for complex deformities or revisions with altered landmarks, underline the need for a generally accepted PS accuracy classification, and advise against PS placement in grade 4 pedicles yielding higher misplacement rates (22.2-31.5%).
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Affiliation(s)
- Alexandre Ansorge
- Department of Spine Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
| | - Vishal Sarwahi
- Department of Pediatric Orthopedics, Cohen Children's Medical Center, Northwell Health System, New Hyde Park, NY 11040, USA
| | - Ludmilla Bazin
- Pediatric Orthopedic Unit, Geneva University Hospital, 1211 Geneva, Switzerland
| | - Oscar Vazquez
- Pediatric Orthopedic Unit, Geneva University Hospital, 1211 Geneva, Switzerland
| | - Giacomo De Marco
- Pediatric Orthopedic Unit, Geneva University Hospital, 1211 Geneva, Switzerland
| | - Romain Dayer
- Pediatric Orthopedic Unit, Geneva University Hospital, 1211 Geneva, Switzerland
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11
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Grabala P, Helenius IJ, Kowalski P, Grabala M, Zacha S, Deszczynski JM, Albrewczynski T, Galgano MA, Buchowski JM, Chamberlin K, Shah SA. The Child's Age and the Size of the Curvature Do Not Affect the Accuracy of Screw Placement with the Free-Hand Technique in Spinal Deformities in Children and Adolescents. J Clin Med 2023; 12:3954. [PMID: 37373646 DOI: 10.3390/jcm12123954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The current method of treatment of spinal deformities would be almost impossible without pedicle screws (PS) placement. There are only a few studies evaluating the safety of PS placement and possible complications in children during growth. The present study was carried out to evaluate the safety and accuracy of PS placement in children with spinal deformities at any age using postoperative computed tomography (CT) scans. METHODS 318 patients (34 males and 284 females) who underwent 6358 PS fixations for pediatric spinal deformities were enrolled in this multi-center study. The patients were divided into three age groups: less than 10 years old, 11-13 years old, and 14-18 years old. These patients underwent postoperative CT scans and were analyzed for pedicle screw malposition (anterior, superior, inferior, medial, and lateral breaches). RESULTS The breach rate was 5.92% for all pedicles. There were 1.47% lateral and 3.12% medial breaches for all pedicles with tapping canals, and 2.66% lateral and 3.84% medial breaches for all pedicles without a tapping canal for the screw. Of the 6358 screws placed in the thoracic, lumbar, and sacral spine, 98% of the screws were accurately placed (grade 0, 1, and juxta pedicular). A total of 56 screws (0.88%) breached more than 4 mm (grade 3), and 17 (0.26%) screws were replaced. No new and permanent neurological, vascular, or visceral complications were encountered. CONCLUSIONS The free-hand technique for pedicle screw placement in the acceptable and safety zone in pedicles and vertebral bodies was 98%. No complications associated with screw insertion in growth were noted. The free-hand technique for pedicle screw placement can be safely used in patients at any age. The screw accuracy does not depend on the child's age nor the size of the deformity curve. Segmental instrumentation with posterior fixation in children with spinal deformities can be performed with a very low complication rate. Navigation of the robot is only an auxiliary tool in the hands of the surgeons, and the result of the work ultimately depends on the surgeons.
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Affiliation(s)
- Pawel Grabala
- Department of Pediatric Orthopedic Surgery and Traumatology, University Children's Hospital, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland
- Paley European Institute, Al. Rzeczypospolitej 1, 02-972 Warsaw, Poland
| | - Ilkka J Helenius
- Department of Orthopedics and Traumatology, Helsinki University Hospital, 00260 Helsinki, Finland
| | - Piotr Kowalski
- Department of Neurosurgery, Regional Specialized Hospital, Ul. Dekerta 1, 66-400 Gorzow Wielkopolski, Poland
| | - Michal Grabala
- 2nd Clinical Department of General and Gastroenterogical Surgery, Medical University of Bialystok, Ul. Marii Skłodowskiej-Curie 24a, 15-276 Bialystok, Poland
| | - Slawomir Zacha
- Department of Pediatric Orthopedics and Oncology of the Musculoskeletal System, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Jaroslaw M Deszczynski
- Paley European Institute, Al. Rzeczypospolitej 1, 02-972 Warsaw, Poland
- Department of Orthopedics and Rehabilitation, Warsaw Medical University, 02-091 Warsaw, Poland
| | | | - Michael A Galgano
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC 27516, USA
| | - Jacob M Buchowski
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 S Euclid Ave., St. Louis, MO 63110, USA
| | - Kelly Chamberlin
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC 27516, USA
| | - Suken A Shah
- Department of Orthopaedic Surgery, Nemours Children's Health, Delaware Valley,1600 Rockland Road, Wilmington, DE 19803, USA
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12
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Salunke P, Karthigeyan M, Uniyal P, Mishra K, Gupta T, Kumar N. A Novel Pedicle Screw Design with Variable Thread Geometry: Biomechanical Cadaveric Study with Finite Element Analysis. World Neurosurg 2023; 172:e144-e150. [PMID: 36587893 DOI: 10.1016/j.wneu.2022.12.120] [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: 10/20/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pedicle screw fixation provides one of the most stable spinal constructs. Their designs together with osseous characteristics have been known to influence the screw-bone interplay during surgical maneuvers and thereafter the fusion process. Various technical modifications to enhance screw performance have been suggested. This study evaluated the pull-out strength and axial stiffness of a novel pedicle screw design with variable thread geometry and pitch. METHODS The newly designed triple threaded pedicle screw is tapered, and has unique out-turned flanges to hold the cancellous bone and a finer pitch at its distal and proximal end to engage the cortical bone. Five lumbar and 4 lower thoracic cadaveric vertebrae were divided into hemivertebrae. A standard cancellous pedicle screw and the newly designed pedicle screw were inserted into each hemivertebra. Axial stiffness and peak pull-out force between the screw types were compared; a finite element analysis was also performed to additionally compare the pull out under toggle forces. RESULTS In cadaveric study, the axial stiffness of the new screw was significantly better than that of the standard screw. However, the peak load between the screws was not statistically different. Finite element analyses suggested lesser stress at bone-implant interface for the new screw along with better axial stiffness under both co-axial and toggle forces. CONCLUSIONS Our novel pedicle screw design with variable thread geometry demonstrates greater axial stiffness compared with the standard screws, and therefore is likely to withstand a greater surgical manipulation.
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Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Madhivanan Karthigeyan
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.
| | - Piyush Uniyal
- Department of Mechanical Engineering, Indian Institute of Technology (IIT), Ropar, Punjab, India
| | - Keshav Mishra
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Tulika Gupta
- Department of Anatomy, PGIMER, Chandigarh, India
| | - Navin Kumar
- Department of Mechanical Engineering, Indian Institute of Technology (IIT), Ropar, Punjab, India
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13
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Chotigavanichaya C, Adulkasem N, Pisutbenya J, Ruangchainikom M, Luksanapruksa P, Wilartratsami S, Ariyawatkul T, Korwutthikulrangsri E. Comparative effectiveness of different pedicle screw density patterns in spinal deformity correction of small and flexible operative adolescent idiopathic scoliosis: inverse probability of treatment weighting analysis. 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 2023:10.1007/s00586-023-07615-6. [PMID: 36995418 DOI: 10.1007/s00586-023-07615-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 01/30/2023] [Accepted: 02/18/2023] [Indexed: 03/31/2023]
Abstract
PURPOSES An optimal pedicle screw density for spinal deformity correction in adolescent idiopathic scoliosis (AIS) remains poorly defined. We compared radiographic correction, operative time, estimated blood loss, and implant cost among different screw density patterns in operatively treated AIS patients. METHODS A retrospective observational cohort study of AIS patients who underwent posterior spinal fusion using all-pedicle screw instrumentation was conducted from January 2012 to December 2018. All patients were categorized into three different pedicle screw density groups: the very low density (VLD), the low density (LD), and the high density (HD) group. The comparative effectiveness between each pairwise comparison was performed under the inverse probability of the treatment weighting method to minimize the possible confounders imbalance among treatment groups. The primary endpoints in this study were the degrees of correction and deformity progression at 2 years postoperatively. RESULTS A total of 174 AIS patients were included in this study. The adjusted treatment effects demonstrated similar degrees of deformity correction after 2 years in the three treatment groups. However, the VLD and LD group slightly increased the curve progression at 2 years compared to the HD group by 3.9° (p = 0.005) and 3.2° (p = 0.044), respectively. Nevertheless, the limited screw density patterns (VLD and LD) significantly reduced the operative time, estimated blood loss, and implant cost per operated level. CONCLUSION The limited pedicle screw pattern (VLD and LD) in relatively flexible AIS spinal deformity correction results in similar coronal and sagittal radiological outcomes while reducing operative time, estimated blood loss, and implant cost compared to the high-density pedicle screw instrumentation.
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Affiliation(s)
- Chatupon Chotigavanichaya
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Nath Adulkasem
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Jirachai Pisutbenya
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Monchai Ruangchainikom
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Panya Luksanapruksa
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Sirichai Wilartratsami
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Thanase Ariyawatkul
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Ekkapoj Korwutthikulrangsri
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
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14
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Mohar J, Valič M, Podovšovnik E, Mihalič R. Pedicle screw placement safety with the aid of patient-specific guides in a case series of patients with thoracic scoliosis. 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 2022; 31:3544-3550. [PMID: 36308545 DOI: 10.1007/s00586-022-07427-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 09/21/2022] [Accepted: 10/11/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Pedicle screw (PS) placement in thoracic scoliotic deformities can be challenging due to altered vertebral anatomy; malposition can result in severe functional disability or inferior construct stability. Three-dimensional (3D) printed patient-specific guides (PSGs) have been recently used to supplement other PS placement techniques. We conducted a single-center, retrospective observational study to assess the accuracy of PS placement using PSGs in a consecutive case series of pediatric and adult patients with thoracic scoliosis. METHODS We analyzed the data of patients with thoracic scoliosis who underwent PS placement using 3D-printed PSG as a vertebral cannulation aid between June 2013 and July 2018. PS positions were determined via Gertzbein-Robbins (GR) and Heary classifications on computed tomography images. We determined the concordance of actual and preoperatively planned PS positions and defined the technique learning curve using a receiver-operating characteristic (ROC) curve. RESULTS We performed 362 thoracic PS placement procedures in 39 consecutive patients. We classified 352 (97.2%), 2 (0.6%), and 8 (2.2%) screws as GR grades 0 (optimal placement), I, and II, respectively. The average instrumented PS entry point offsets on the X- and Y-axes were both 0.8 mm, and the average differences in trajectory between the planned and the actual screw placements on the oblique sagittal and oblique transverse planes were 2.0° and 2.4°, respectively. The learning process was ongoing until the first 12 PSs were placed. CONCLUSIONS The accuracy of PS placement using patient-specific 3D templates in our case series exceeds the accuracies of established thoracic PS placement techniques.
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Affiliation(s)
- Janez Mohar
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska C. 31, 6280, Ankaran, Europe, Slovenia.
- Chair of Orthopedics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
| | - Matej Valič
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska C. 31, 6280, Ankaran, Europe, Slovenia
| | - Eva Podovšovnik
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska C. 31, 6280, Ankaran, Europe, Slovenia
| | - Rene Mihalič
- Department of Spine Surgery, Valdoltra Orthopedic Hospital, Jadranska C. 31, 6280, Ankaran, Europe, Slovenia
- Chair of Orthopedics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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15
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Zhao J, Jiang H, Zhuge Y, Gao R, Wang C, Ma J, Zhou X. Risk Factors for the Drift Phenomenon in O-arm Navigation-Assisted Pedicle Screw Placement during Spinal Deformity Surgery. Orthop Surg 2022; 15:118-123. [PMID: 36394161 PMCID: PMC9837212 DOI: 10.1111/os.13557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 09/10/2022] [Accepted: 09/16/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Intraoperative O-arm navigation systems improve the accuracy of spinal instrumentation placement. However, deviation of the pedicle screw from the guide line might occur. The aim of the present study was to explore the causes of and countermeasures for the drift phenomenon during pedicle screw implantation with the aid of an O-arm three-dimensional navigation system in spinal deformity surgery. METHODS This was a retrospective analysis of 341 patients with spinal deformity who underwent O-arm navigation system-assisted pedicle screw placement from July 2015 to June 2019. The patient's general condition, Cobb angle, apical vertebra position, softness index, spinal release status, fixed reference frame position, and distance between the navigation vertebral body and the reference frame were collected and compared by independent-samples t test or Pearson's chi-square analysis. The potential risk factors for the drift phenomenon were identified using binary logistic regression analysis. RESULTS The drift phenomenon occurred in 57 patients during the first navigation-assisted pedicle screw placement, for an incidence of 16.7% (57/341). There were significant differences in factors such as the apical vertebra position, softness index, spinal release status, and distance between the vertebral body and the reference frame when the drift phenomenon occurred (P < 0.05). Binary logistic regression analysis showed that the softness index, spinal release status, and distance between the vertebral body and the reference frame when drifting occurred were independent risk factors for the drift phenomenon during O-arm navigation-assisted pedicle screw placement. CONCLUSION During the use of an O-arm navigation system to assist with pedicle screw placement, pedicle screws should not be placed away from the reference frame, and spinal osteotomy and release should be performed after pedicle screw placement. In addition, the accuracy of O-arm navigation-assisted pedicle screw placement will be affected more in those with larger softness indices.
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Affiliation(s)
- Jianquan Zhao
- Present address:
Department of Orthopaedic Surgery, Shanghai Changzheng HospitalSecond Military Medical UniversityShanghaiChina
| | - Heng Jiang
- Present address:
Department of Orthopaedic Surgery, Shanghai Changzheng HospitalSecond Military Medical UniversityShanghaiChina
| | - Yingjie Zhuge
- Present address:
Department of Orthopaedic Surgery, Shanghai Changzheng HospitalSecond Military Medical UniversityShanghaiChina,Department of Orthopaedic SurgeryShanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong UniversityShanghaiChina
| | - Rui Gao
- Present address:
Department of Orthopaedic Surgery, Shanghai Changzheng HospitalSecond Military Medical UniversityShanghaiChina
| | - Ce Wang
- Present address:
Department of Orthopaedic Surgery, Shanghai Changzheng HospitalSecond Military Medical UniversityShanghaiChina
| | - Jun Ma
- Present address:
Department of Orthopaedic Surgery, Shanghai Changzheng HospitalSecond Military Medical UniversityShanghaiChina
| | - Xuhui Zhou
- Present address:
Department of Orthopaedic Surgery, Shanghai Changzheng HospitalSecond Military Medical UniversityShanghaiChina
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16
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Suominen EN, Saarinen AJ, Syvänen J, Ahonen M, Helenius L, Helenius IJ. Beam-Like rods do not Provide Additional Improvement to Thoracic Kyphosis Restoration when Compared to Sagittal Reinforced rods in Adolescents Undergoing Spinal Fusion with Pedicle Screw Instrumentation for Idiopathic Scoliosis. World Neurosurg 2022; 168:e555-e561. [DOI: 10.1016/j.wneu.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/07/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022]
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17
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Helenius L, Gerdhem P, Ahonen M, Syvänen J, Jalkanen J, Charalampidis A, Nietosvaara Y, Helenius I. Postoperative outcomes of pedicle screw instrumentation for adolescent idiopathic scoliosis with and without a subfascial wound drain: a multicentre randomized controlled trial. Bone Joint J 2022; 104-B:1067-1072. [PMID: 36047026 DOI: 10.1302/0301-620x.104b9.bjj-2022-0391.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption. METHODS Adolescents (aged between 10 and 21 years) with an idiopathic scoliosis (major curve ≥ 45°) were eligible for inclusion in this randomized controlled noninferiority trial (n = 125). A total of 90 adolescents who had undergone segmental pedicle screw instrumentation were randomized into no-drain or drain groups at the time of wound closure using the sealed envelope technique (1:1). The primary outcome was a drop in the haemoglobin level during first three postoperative days. Secondary outcomes were 48-hour postoperative oxycodone consumption and surgical complications. RESULTS All 90 patients were included in the primary outcome analysis (no drain = 43; drain = 47). The mean total postoperative blood loss (intraoperative and drain output) was significantly higher in the group with a subfascial drain than in the no-drain group (1,008 ml (SD 520) vs 631 ml (SD 518); p < 0.001). The drop in haemoglobin level did not differ between the study groups over the postoperative timepoints (p = 0.290). The 48-hour opioid consumption was significantly higher in the no-drain group (2.0 mg/kg (SD 0.9) vs 1.4 (SD 0.6); p = 0.005). Two patients in the no-drain and one patient in the drain group developed a surgical site infection. CONCLUSION Leaving the subfascial drain out after pedicle screw instrumentation for AIS is not associated with higher postoperative haemoglobin levels. Patients treated without a subfascial drain needed 30% more opioids during the first 48 hours than those who had a drain.Cite this article: Bone Joint J 2022;104-B(9):1067-1072.
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Affiliation(s)
- Linda Helenius
- Department of Anaesthesia and Intensive Care, University of Turku and Turku University Hospital, Turku, Finland.,Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul Gerdhem
- Department of Clinical Science, Intervention, and Technology, Karolinska Institute and Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden.,Department of Orthopaedics, Uppsala University Hospital and Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Matti Ahonen
- Department of Paediatric Surgery and Orthopaedics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Johanna Syvänen
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Jenni Jalkanen
- Department of Paediatric Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Anastasios Charalampidis
- Department of Clinical Science, Intervention, and Technology, Karolinska Institute and Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Yrjänä Nietosvaara
- Department of Paediatric Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Ilkka Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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18
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Saarinen AJ, Suominen EN, Helenius L, Syvänen J, Raitio A, Helenius I. Intraoperative 3D Imaging Reduces Pedicle Screw Related Complications and Reoperations in Adolescents Undergoing Posterior Spinal Fusion for Idiopathic Scoliosis: A Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9081129. [PMID: 36010020 PMCID: PMC9406950 DOI: 10.3390/children9081129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 01/18/2023]
Abstract
Widely used surgical treatment for adolescent idiopathic scoliosis (AIS) is posterior spinal fusion using pedicle screw instrumentation (PSI). Two-dimensional (2D) or three-dimensional (3D) navigation is used to track the screw positioning during surgery. In this study, we evaluated the screw misplacement, complications, and need for reoperations of intraoperative 3D as compared to 2D imaging in AIS patients. There were 198 adolescents, of which 101 (51%) were evaluated with 2D imaging and 97 (49%) with 3D imaging. Outcome parameters included radiographic correction, health-related quality of life (HRQOL), complications, and reoperations. The mean age was 15.5 (SD 2.1) years at the time of the surgery. Forty-four (45%) patients in the 3D group and 13 (13%) patients in the 2D group had at least one pedicle screw repositioned in the index operation (p < 0.001). Six (6%) patients in the 2D group, and none in the 3D group had a neurological complication (p = 0.015). Five (5%) patients in the 2D group and none in the 3D group required reoperation (p = 0.009). There were no significant differences in HRQOL score at two-year follow-up between the groups. In conclusion, intraoperative 3D imaging reduced pedicle screw-related complications and reoperations in AIS patients undergoing PSI as compared with 2D imaging.
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Affiliation(s)
- Antti J. Saarinen
- Department of Pediatric Orthopedic Surgery, Turku University Hospital, 20521 Turku, Finland; (A.J.S.); (E.N.S.); (J.S.); (A.R.)
- Department of Orthopedics and Traumatology, Helsinki University Hospital, 00260 Helsinki, Finland
| | - Eetu N. Suominen
- Department of Pediatric Orthopedic Surgery, Turku University Hospital, 20521 Turku, Finland; (A.J.S.); (E.N.S.); (J.S.); (A.R.)
- Department of Orthopedics and Traumatology, Helsinki University Hospital, 00260 Helsinki, Finland
| | - Linda Helenius
- Department of Anesthesia and Intensive Care, Turku University Hospital, 20521 Turku, Finland;
| | - Johanna Syvänen
- Department of Pediatric Orthopedic Surgery, Turku University Hospital, 20521 Turku, Finland; (A.J.S.); (E.N.S.); (J.S.); (A.R.)
| | - Arimatias Raitio
- Department of Pediatric Orthopedic Surgery, Turku University Hospital, 20521 Turku, Finland; (A.J.S.); (E.N.S.); (J.S.); (A.R.)
| | - Ilkka Helenius
- Department of Orthopedics and Traumatology, Helsinki University Hospital, 00260 Helsinki, Finland
- Correspondence:
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Pedicle Screw Placement in Adolescent Idiopathic Scoliosis: A Comparison between Robotics Coupled with Navigation versus the Freehand Technique. SENSORS 2022; 22:s22145204. [PMID: 35890882 PMCID: PMC9316760 DOI: 10.3390/s22145204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 02/01/2023]
Abstract
(1) Background: Robotics coupled with navigation (RAN) is a modern surgical platform shown to increase screw placement accuracy during pediatric scoliosis surgery. Our institution uses a technique which combines the RAN platform for apical pedicle screw placement and the freehand (FH) technique for terminal pedicle screw placement during scoliosis surgery (termed hybrid technique). We question if the complementary use of the RAN technology affects intraoperative outcomes, relative to the FH-only approach. (2) Methods: 60 adolescent idiopathic scoliosis (AIS) patients, ages 11−19 at surgery, who were operated on from 2019 through 2020 by a single surgeon, were retrospectively reviewed. Patients were separated by surgery type (hybrid RAN or FH), matched on demographic and surgical factors, and their intraoperative outcomes were compared statistically. (3) Results: Hybrid RAN patients had more screws placed (p = 0.01) and were of a higher BMI percentile (p = 0.005). Controlling for the number of screws placed, BMI%, and initial curve magnitude, there were no statistical differences in estimated blood loss per screw (p = 0.51), curve correction (p = 0.69), complications (p = 0.52), or fluoroscopy time (p = 0.88), between groups. However, operative time was two minutes longer per screw for hybrid RAN patients (p < 0.001). (4) Conclusions: Hybrid RAN surgeries took longer than FH, but yielded comparable effectiveness and safety as the FH technique during the initial RAN adoption phase.
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Boachie-Adjei O, Duah HO, Sackeyfio A, Yankey KP, Lenke LG, Sponseller PD, Samdani AF, Sucato DJ, Sides BA, Newton PO, Shah SA, Akoto H, Gupta MC. Surgical outcomes of severe spinal deformities exceeding 100° or treated by vertebral column resection (VCR). Does implant density matter?: an observational study of deformity groupings. Spine Deform 2022; 10:595-606. [PMID: 35305251 DOI: 10.1007/s43390-021-00460-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/11/2021] [Indexed: 11/29/2022]
Abstract
STUDY DESIGN Prospective multicenter international observational study. OBJECTIVE To investigate the effect of implant density on clinical outcomes in complex pediatric spine reconstruction. Implant density in spine deformity surgery has been a subject of much debate with some authors advocating higher density for better correction. Few studies have looked at the effect of implant density on severe curves > 100 deg or treated with vertebral column resection (VCR). METHODS 250/311 pts with 2-year f/u enrolled in the FOX pediatric database from 17 international sites were queried for the impact of implant density and surgical outcomes. Patients were grouped into three implant density categories for comparative analysis Group 1 (density ≤ 1), Group 2 (1 < density < 1.5) and Group 3 (density; 1.5-2). RESULTS 250 pts: 47 (Grp1)/99 (Grp2) /104 (Grp3); Pre-op age and etiology and curve types were similar in all groups, but body mass index (BMI) was higher in Grp3. Grps 1 and 2 had significantly higher sagittal deformity angular ratio (S-DAR) compared to Grp 3 (p < 0.001). Pre-op Halo Gravity Traction (HGT) was used in 55.3%/44.4%/31.7%, p = 0.017; Grp1/Grp2/Grp3, respectively. Average duration of surgery (min) was higher in Grp3 relative to Grp1 only: 352.5/456.5/515.0, p = 0.0029. Blood loss was similar in all Grps. Rate of VCR, PSO and SPO was similar in all Grps. Pre-op Coronal Cobb avg 96.1/83.6/88.6, p = 0.2342, attained similar correction after HGT (24.6%/27.2%/23.2%, p = 0.4864. Coronal Cobb corrections at 2-year follow-up (FU) were (37.1%/40.3%/53.5%, p = 0.0004). Pre-op sagittal Cobb was (105.4/101.9/75.9, p < 0.01.), achieved similar %correction in HGT (19.1%/22.3%/22.5%, p = 0.6851) and at 2-year FU (39.6%/41.4%/29.8%, p = 0.1916). After adjusting for C-DAR, S-DAR, pre-op coronal and sagittal Cobb, etiology, curve types, age, BMI and number of rods in multivariate analysis, the odds of developing post-operative implant complication was 11 times greater in group 1 compared to group 3 (OR = 11.17,95% CI 2.34-53.32). There was significant improvement in SRS scores in all Grps at 2-year FU. CONCLUSION Although higher implant density was observed to be associated with greater curve correction and lower rates of post-operative implant-related complication and revision in heterogeneous case groups, the results may not imply causality of implant density on the outcomes in severe pediatric spine reconstruction.
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Affiliation(s)
| | - Henry Ofori Duah
- FOCOS Orthopaedic Hospital, No 8 Teshie Street Pantang, Accra, Ghana
| | - Arthur Sackeyfio
- FOCOS Orthopaedic Hospital, No 8 Teshie Street Pantang, Accra, Ghana
| | | | | | | | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, Philadelphia, PA, USA
| | | | - Brenda A Sides
- Department of Orthopedics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Suken A Shah
- Spine and Scoliosis Center, Nemours/Alfred I. du Pont Pediatrics, Wilmington, DE, USA
| | | | - Munish C Gupta
- Department of Orthopedics, Washington University School of Medicine, St. Louis, MO, USA
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Swany L, Larson AN, Garg S, Hedequist D, Newton P, Sponseller P. 0.4% incidence of return to OR due to screw malposition in a large prospective adolescent idiopathic scoliosis database. Spine Deform 2022; 10:361-367. [PMID: 34746979 DOI: 10.1007/s43390-021-00434-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/17/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE In contrast to infection and curve progression, return to OR for implant malposition is potentially within the surgeon's control. With increasing surgeon familiarity with freehand/fluoroscopic pedicle screw placement, rates of return to OR due to malposition may have decreased over time. We sought to document the incidence and risk factors for return to OR due to screw malposition in a large cohort of patients with idiopathic scoliosis. METHODS AIS patients enrolled in a multicenter prospective registry with minimum 2-year follow-up undergoing PSF between 2003 and 2017 were included. Surgeries with the use of intraoperative CT-guided navigation were excluded. Return to OR due to screw malposition over time was tabulated. Lenke class, age at surgery, year of surgery, height, weight, surgeon and site were evaluated. RESULTS 2435 patients underwent PSF with non-navigated open pedicle screw instrumentation. Mean age was 14.6 years, mean thoracic curve magnitude was 53°, and mean lumbar was 40°. Patients did not routinely undergo intraoperative or postoperative CT evaluation. There were 10 returns to OR for screw malposition at a mean of 0.83 years postoperatively (range 0.1-3.4 years), for an overall incidence of 0.4%. Of the 14 screws, 10 were thoracic, 7 were left-sided. No association was found between screw malposition and curve size, enrolling site, surgeon, BMI, Lenke class, or age. Five patients had radiculopathy which improved after screw revision. Return to OR for screw malposition changed from 2003 to 2017 (1-0.2%) but this did not reach statistical significance. CONCLUSION Although the incidence of asymptomatic malpositioned screws is unknown, the rate of return to the OR for implant malposition overall in this registry was 1 in 250 patients. Recent data suggest the rate has decreased to 1 in 500 patients. Further work may determine whether enabling technologies can reduce the rate, ideally to a "never event".
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Affiliation(s)
- Lauren Swany
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, USA.
| | - Sumeet Garg
- Pediatric Orthopaedics and Spine Surgery Center, Children's Hospital Colorado, Aurora, CO, USA
| | - Daniel Hedequist
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Peter Newton
- Department of Orthopedics and Scoliosis, Rady Children's Hospital, San Diego, CA, USA
| | - Paul Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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22
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Li J, Hu Z, Qian Z, Tang Z, Qiu Y, Zhu Z, Liu Z. The prognosis and recovery of major postoperative neurological deficits after corrective surgery for scoliosis : an analysis of 65 cases at a single institution. Bone Joint J 2022; 104-B:103-111. [PMID: 34969290 DOI: 10.1302/0301-620x.104b1.bjj-2021-0772.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years. METHODS A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up. RESULTS The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher's exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model. CONCLUSION For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103-111.
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Affiliation(s)
- Jie Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zongshan Hu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhikai Qian
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Ziyang Tang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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23
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Pushpa BT, Rajasekaran S, Anand KSSV, Shetty AP, Kanna RM. Anatomical changes in vertebra in dystrophic scoliosis due to neurofibromatosis and its implications on surgical safety. Spine Deform 2022; 10:159-167. [PMID: 34309821 DOI: 10.1007/s43390-021-00392-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/17/2021] [Indexed: 12/24/2022]
Abstract
STUDY DESIGN Detailed radiological analysis by multimodality imaging. OBJECTIVE To document anatomical changes jeopardizing instrumentation safety in Neurofibromatosis deformity correction surgeries. MATERIALS AND METHODS The apical and 3 adjacent vertebral segments above and below amounting to 70 segments in 10 NF scoliosis were studied by radiographs, CT and MRI. The changes in lamina, pedicle and vertebral body that could jeopardize pedicle screw and sublaminar wire placement were documented and changes were appropriately classified. RESULTS Extensive anatomical changes were noted. These changes were more severe at the apex and independent of the curve severity. Both laminae were normal in only 36 (Type 1), rest had either gross asymmetry in length and shape (Type 2; 21) or also in sloping (Type 3; 13). Of the 140 pedicles, normal pedicles were found only in 48 (Type 1); while they were divergent (Type 2; 4) or abnormally elongated with only thinning (Type 3a; 26); or with sclerosis (3b; 34); or very curved and wavy (3c; 23) and even fractured or indistinct (Type 4; 5). It was notable that 92 of the 140 pedicles were unsuitable for pedicle screws. A unique phenomenon of body drift was identified in 29 segments which could jeopardize screw placement and rib dislocation into the canal was found in 18 segments. CONCLUSION Gross anatomical changes jeopardizing both sublaminar wire strength and trajectory of pedicle screws were common in NF and independent of curve severity. Therefore, detailed preoperative assessment and planning by a 3D CT are essential.
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Affiliation(s)
- B T Pushpa
- Department of Radiodiagnosis, Ganga Medical Centre and Hospitals Pvt Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - S Rajasekaran
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt Ltd, 313, Mettupalayam Road, Coimbatore, India.
| | - K S Sri Vijay Anand
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt Ltd, 313, Mettupalayam Road, Coimbatore, India
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You C, Zhou Y, Han J. Loss of correction in cubitus varus deformity after osteotomy. Medicine (Baltimore) 2021; 100:e27848. [PMID: 34889234 PMCID: PMC8663885 DOI: 10.1097/md.0000000000027848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 11/02/2021] [Indexed: 11/26/2022] Open
Abstract
We aimed to investigate the rate of loss of correction and the factors thereof in pediatric patients undergoing osteotomy for treatment of cubitus varus deformity.Between July 2008 and July 2017, we treated 30 patients who underwent osteotomy for cubital varus. We compared the preoperative and postoperative clinical and imaging findings, including the H-Cobb and Baumman angles, in all patients. Postoperative evaluation was performed by telephonic interviews.Our patients consisted of 17 males and 13 females. The mean age was 75 months. At the first follow-up, approximately 80% of patients had experienced a loss of correction of the humerus-cobb angle (H-Cobb angle); at the second follow-up, the incidence was 83%. Meanwhile, 57% and 43% of patients experienced a loss of correction of the Baumman angle at the first and second follow-ups, respectively. The average interval between the first and second follow-ups was 24 days, and the mean loss in the H-Cobb angle was 2.4°. There was a significant difference between the H-Cobb angles as measured before and after surgery (P < .05). There was no significant difference between the H-Cobb angles of the affected side and the contralateral healthy elbow at the third postoperative follow-up; however, there was a significant difference between the Baumman angle between before and after surgery (P < .05). The Baumman angles as measured at the second and third postoperative follow-ups differed significantly from those of the contralateral healthy elbow joint. According to the survival curve analysis, the median survival times of the H-Cobb and Baumman angles were 27 and 34 months, respectively.The postoperative loss of the 2 angles occurred mainly during the first and second follow-up periods. Therefore, patient follow-up is particularly important in the period directly following the operation. Additional measures may be necessary to avoid rapid angle loss.
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25
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Cao J, Zhang X, Liu H, Yao Z, Bai Y, Guo D, Feng L. 3D printed templates improve the accuracy and safety of pedicle screw placement in the treatment of pediatric congenital scoliosis. BMC Musculoskelet Disord 2021; 22:1014. [PMID: 34863150 PMCID: PMC8645104 DOI: 10.1186/s12891-021-04892-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/19/2021] [Indexed: 12/17/2022] Open
Abstract
Background Three-dimensional (3-D) printed guidance templates are being increasingly used in spine surgery. The purpose of this study was to determine if 3D printed navigation templates can improve the accuracy of pedicle screw placement and decrease the complication rate compared to freehand screw placement in the treatment of children with congenital scoliosis. Methods The records of pediatric patients with congenital scoliosis treated at our hospital from January 2017 to January 2019 were retrospectively reviewed. Patients were divided into those where a 3D printed guidance templated was used and those in which the freehand method was used for pedicle screw placement. The accuracy rate of pedicle screw placement, surgical outcomes, and complications were compared between groups. Results A total of 67 children with congenital scoliosis were included (43 males and 24 females; mean age of 4.13 ± 2.66 years; range, 2–15 years). There were 34 children in the template-assisted group and 33 in the freehand group. The excellent accuracy rate of pedicle screw placement was significantly higher in the template-assisted group (96.10% vs. 88.64%, P = 0.007). The main Cobb angle and kyphosis angle were similar between the 2 groups preoperatively and postoperatively (all, P > 0.05), and in both groups both angles were significantly decreased after surgery as compared to the preoperative values (all, P < 0.001). The degree of change of the Cobb angle of the main curve and kyphosis angle were not significantly different between the 2 groups. There were no postoperative complications in the template group and 4 in the freehand group (0% vs. 12.12%; P = 0.009). All 4 patients with complications required revision surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04892-4.
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Affiliation(s)
- Jun Cao
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, #56 Nan Li Shi Road, Xi Cheng District, Beijing, 100045, China
| | - Xuejun Zhang
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, #56 Nan Li Shi Road, Xi Cheng District, Beijing, 100045, China.
| | - Haonan Liu
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, #56 Nan Li Shi Road, Xi Cheng District, Beijing, 100045, China
| | - Ziming Yao
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, #56 Nan Li Shi Road, Xi Cheng District, Beijing, 100045, China
| | - Yunsong Bai
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, #56 Nan Li Shi Road, Xi Cheng District, Beijing, 100045, China
| | - Dong Guo
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, #56 Nan Li Shi Road, Xi Cheng District, Beijing, 100045, China
| | - Lei Feng
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, #56 Nan Li Shi Road, Xi Cheng District, Beijing, 100045, China
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26
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Linden GS, Birch CM, Hresko MT, Cook D, Hedequist DJ. Intraoperative Use of Robotics With Navigation for Pedicle Screw Placement in Treatment of Pediatric High-grade Spondylolisthesis: A Preliminary Report. J Pediatr Orthop 2021; 41:591-596. [PMID: 34516471 DOI: 10.1097/bpo.0000000000001947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Accurate pedicle screw placement is critical to surgically correct pediatric high-grade spondylolisthesis (HGS). The recent advent of robotics coupled with computer-assisted navigation (RAN) may represent a novel option to improve surgical outcomes of HGS, secondary to enhanced pedicle screw placement safety. This series presents the HGS-RAN technique adopted by our site, describing its surgical outcomes and feasibility. METHODS Consecutive patients with a diagnosis of HGS (Meyerding grade III to V), operated on using RAN from 2019 to 2020 at a single-center were reviewed. Demographics, screw accuracy, sagittal L5-S1 parameters, complications, and perioperative outcomes were described. All patients were treated with instrumentation, decompression, posterior lumbar interbody fusion, and reduction. Robotic time included anatomic registration to end of screw placement. Screw accuracy-defined as a screw placed safely within the planned intrapedicular trajectory-was characterized by the Gertzbein-Robbins system for patients with additional 3-dimensional imaging. RESULTS Ten HGS patients, with an average age of 13.7 years old, were included in the series. All 62 screws were placed without neurological deficit or complication. Seven patients had additional 3-dimensional imaging to assess screw accuracy (42 of 62 screws). One hundred percent of screws were placed safely with no pedicle breaches (Gertzbein-Robbins-grade A). Thirty screws (48%) were placed through separate incisions that were percutaneous/transmuscular and 32 screws (52%) were inserted through the main incision. There were statistically significant improvements in L5 slippage (P=0.002) and lumbosacral angle (P=0.002), reflecting successful HGS correction. The total median operative time was 324 minutes with the robotic usage time consuming a median of 72 minutes. Median estimated blood loss was 150 mL, and length-of-stay was a median 3 days. CONCLUSIONS This case-series demonstrates that RAN represents a viable option for HGS repair, indicated by high screw placement accuracy, safety, and L5-S1 slippage correction. Surgeons looking to adopt an emerging technique to enhance safety and correction of pediatric HGS should consider the RAN platform. LEVEL OF EVIDENCE Level IV-therapeutic study.
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Affiliation(s)
| | - Craig M Birch
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - M Timothy Hresko
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Danielle Cook
- Department of Orthopaedic Surgery, Boston Children's Hospital
| | - Daniel J Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
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27
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Charalampidis A, Möller H, Gerdhem P. Anterior versus posterior fusion surgery in idiopathic scoliosis: a comparison of health-related quality of life and radiographic outcomes in Lenke 5C curves - results from the Swedish spine registry. J Child Orthop 2021; 15:464-471. [PMID: 34858533 PMCID: PMC8582605 DOI: 10.1302/1863-2548.15.210049] [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: 03/02/2021] [Accepted: 09/07/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To compare health-related quality of life and radiographic outcomes in patients treated with either anterior or posterior fusion surgery for Lenke 5C type idiopathic scoliosis. METHODS We used data from the Swedish spine registry and identified 59 patients with idiopathic scoliosis treated with fusion for Lenke 5C type curves; 27 patients underwent anterior surgery and 32 underwent posterior surgery. All patients had pre- and postoperative radiographic data and postoperative clinical data at a minimum of two years after surgery. Patient-reported outcomes measures included the Scoliosis Research Society (SRS)-22r, EuroQoL 5 dimensions 3 levels (EQ-5D-3L), EQ-visual analogue scale (VAS) and VAS for back pain. Radiographic assessment included measurement of the angle of the major curve, disc angulation below the lowest instrumented vertebra, curve flexibility, rate of curve correction, differences in sagittal parameters, number of fused vertebrae and length of fusion. RESULTS The mean age at surgery was 16 years in both groups. The mean follow-up time was 3.8 years. There were no significant differences in the SRS-22r score and EQ-5D-3L index at follow-up (all p ≥ 0.2). Postoperatively, both the anterior and posterior fusion group demonstrated a significant correction of the major curve (p ≤ 0.001) with no significant difference of the correction rate between the groups (p = 0.4). The posterior fusion group had shorter operative time (p < 0.001) and higher perioperative blood loss (p = 0.004) while the anterior group had lower number of fused vertebrae ( p< 0.001). CONCLUSION The type of surgical approach for Lenke 5C curves is not associated with differences in health-related quality of life, despite the lower number of fused vertebrae after anterior surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anastasios Charalampidis
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden,Correspondence should be sent to Anastasios Charalampidis, MD, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, 141 86 Stockholm, Sweden. E-mail:
| | - Hans Möller
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet,Stockholm Center for Spine Surgery, Stockholm, Sweden
| | - Paul Gerdhem
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
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Sawires AN, Birch CM, Hedequist D. The Use of Robotics Coupled With Navigation for Pediatric Congenital Spine Deformity. HSS J 2021; 17:289-293. [PMID: 34539269 PMCID: PMC8436341 DOI: 10.1177/15563316211027166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/01/2021] [Accepted: 06/04/2021] [Indexed: 11/16/2022]
Abstract
Background: Spinal instrumentation in children with congenital spine deformity poses challenges to the surgeon, given the small patient size and the anomalous anatomy often encountered. Purpose: We aimed to investigate the accuracy of screw placement when robotics coupled with real-time navigation was used for surgical treatment of pediatric congenital spine deformity at 1 institution. Methods: We conducted a retrospective search of our institution's database for all patients younger than 18 years of age with congenital spine deformity who were treated with the robotics surgical platform coupled with navigation between June 2019 and December 2020. We recorded data on demographics, location and type of anomaly, procedure performed, and intraoperative variables related to robotics and navigation. We reviewed the images of patients who had intraoperative 3-dimensional imaging or postoperative computed tomographic scans to determine the accuracy of screw placement using the Gertzbein-Robbins scale. Results: In 14 patients identified, a total of 95 screws were attempted, with 94 successfully placed using robotics coupled with navigation. There were no noted screw-related complications (neurologic or visceral) and no return to the operating room for screw malposition. Conclusion: Patients with congenital spine deformity present potentially unique challenges due to variant anatomy. This retrospective series suggests that robotics coupled with navigation for congenital spine deformity correction in the pediatric population may aid in accurate screw placement and reduce complication rates. More rigorous study is warranted.
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Affiliation(s)
- Andrew N. Sawires
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Craig M. Birch
- Department of Orthopedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Hedequist
- Department of Orthopedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Gigliotti MJ, Farou N, Savaliya S, Rizk E. Nonaccidental Trauma Managed with Open Spinal Fixation and Instrumentation and a Review of the Literature. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1732792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractNonaccidental trauma (NAT), causing spinal injury is rare and occurs in up to 3% of cases. Management of these injuries is typically conservative, and thus surgical management is not widely reported in the literature. In this case report, we presented three patients to review the effectiveness of spinal instrumentation and posterior fusion in pediatric patients due to NAT. All patients recovered well and were neurologically intact at last follow-up with no postprocedural complications noted. Spinal arthrodesis is a safe, effective way to manage spinal injuries due to NAT in cases of fracture-dislocation, distraction injuries, as well as cases involving neurologic compromise.
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Affiliation(s)
- Michael J. Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Noa Farou
- School of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Sandip Savaliya
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Elias Rizk
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
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Abstract
BACKGROUND/INTRODUCTION Pedicle screws have long been part of the continued advancements in spine surgery. Despite the many techniques that have been devised for their safe placement, malposition of screws continues to occur. Studies have evaluated the possible safe limits of screw malposition, and have given some insight on anatomic variation in spinal deformity. Review of the literature reveals several cases of deleterious long-term sequelae of malpositioned screws. DISCUSSION With the current experience, proposed recommendations are provided to detect and avoid the potential long-term sequelae. Though the literature has helped to define possible concerning screws, there are no good studies predicting long-term risk. CONCLUSION Improvements in technology and techniques, advancements in intraoperative confirmation and postoperative surveillance, studies that assist risk stratification, and expert consensus evaluations will help guide surgeons in their decision for addressing misplaced screws.
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Zaher A, El Youssef K, Decourtivron B, Bergerault F, Bonnard C, Odent T. Efficacy of polyester bands placed under the transverse vertebral process for the correction of adolescent idiopathic scoliosis : A case series of 105 patients with a minimum of 24 months follow-up. 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; 30:1959-1964. [PMID: 33881643 DOI: 10.1007/s00586-021-06841-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/02/2021] [Accepted: 04/07/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To report an original technique for the surgical correction of adolescent idiopathic scoliosis (AIS) based on hybrid construct using polyester bands placed under the thoracic transverse processes. METHODS We reviewed 105 patients operated between 2013 to 2017 for AIS with a minimum of 2 years follow-up. Clinical and radiological data, including 2D measurements of scoliosis parameters preoperatively, and at 3- and 24-months postoperatively were analyzed. Radiological analysis was performed by two independent observers using KEOPS (Smaio, Lyon-France, CE 2014) database. RESULTS Mean age was 14.6 ± 2 years. Mean follow-up was 23.7 ± 1.2 months. Most curves were classified as Lenke-1 (78%). The average number of vertebra involved in the construct was 10.9 ± 1.3 (range 7-13). A mean of 12.8 implants were used per construct (mean implant density 0.59). The number of subtransverse bands placed averaged 3 (range 1-5 bands). The mean frontal Cobb angle decreased from 57.9 to 21.2 ° (p < 0.05) postoperatively. The average T4-T12 kyphosis increased from 20.2°to 32.4° (p < 0.05) postoperatively and no loss of correction was observed at 2 years follow-up. We encountered one case of transverse process fracture intraoperativley. No neurological complications were observed. In the postoperative period, 4 cases were diagnosed with distal junctional failure, three of which required an extension of the construct, while the fourth case was treated by bracing. CONCLUSIONS The use of subtransverse band is an efficient and safe method for the surgical correction of AIS. This technique incorporates technical ease (minimal risk of neurological injury), provides good frontal correction and restores thoracic kyphosis. Results are maintained over a two-year period.
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Affiliation(s)
- Abdullah Zaher
- Service de Chirurgie Orthopédique Pédiatrique, Hôpital Gatien de Clocheville, CHRU de Tours, Tours, 37044 Tours Cedex 9, France.
- Université François Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France.
| | - Khaled El Youssef
- Service de Chirurgie Orthopédique Pédiatrique, Hôpital Gatien de Clocheville, CHRU de Tours, Tours, 37044 Tours Cedex 9, France
- Université François Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
| | - Benoit Decourtivron
- Service de Chirurgie Orthopédique Pédiatrique, Hôpital Gatien de Clocheville, CHRU de Tours, Tours, 37044 Tours Cedex 9, France
- Université François Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
| | - Francois Bergerault
- Service de Chirurgie Orthopédique Pédiatrique, Hôpital Gatien de Clocheville, CHRU de Tours, Tours, 37044 Tours Cedex 9, France
- Université François Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
| | - Chistian Bonnard
- Service de Chirurgie Orthopédique Pédiatrique, Hôpital Gatien de Clocheville, CHRU de Tours, Tours, 37044 Tours Cedex 9, France
- Université François Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
| | - Thierry Odent
- Service de Chirurgie Orthopédique Pédiatrique, Hôpital Gatien de Clocheville, CHRU de Tours, Tours, 37044 Tours Cedex 9, France
- Université François Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
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Skalak TJ, Gagnier J, Caird MS, Farley FA, Li Y. Higher pedicle screw density does not improve curve correction in Lenke 2 adolescent idiopathic scoliosis. J Orthop Surg Res 2021; 16:276. [PMID: 33882975 PMCID: PMC8061215 DOI: 10.1186/s13018-021-02415-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/07/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose Higher pedicle screw density posterior spinal fusion (PSF) constructs have not been shown to result in improved curve correction in Lenke 1 and 5 adolescent idiopathic scoliosis (AIS) but do increase cost. The purpose of this study questioned whether higher screw density constructs improved curve correction and maintenance of correction in Lenke 2 AIS. Secondary goals were to identify predictive factors for correction and postoperative magnitude of curves in Lenke 2 AIS. Methods We identified patients 11 to 17 years old who underwent primary PSF for Lenke 2 AIS between 2007 and 2017 who had minimum follow-up of 2 years. Demographic and radiographic data were collected to perform regression and elimination analysis. Results Thirty patients (21 females, 9 males) were analyzed. Average age and SD at time of surgery was 14.0 ± 1.8 years (range, 11–17 years), and median follow-up was 2.8 years (IQR 2.1–4.0 years). Implant density did not predict final postoperative curve magnitude. Predictors of final postoperative curve magnitude were sex and preoperative curve magnitude. Predictors of percentage of correction of major curve were sex and age at the time of surgery. Predictors of final postoperative thoracic kyphosis were sex and percent flexibility preop. Females had lower final postoperative major curve magnitude, a higher percent curve correction, and lower postoperative thoracic kyphosis. Conclusions Increased implant density is not predictive of postoperative curve magnitude in Lenke 2 AIS. Predictors of postoperative curve magnitude are sex and preoperative curve magnitude. Level of evidence Level III, retrospective observational
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Affiliation(s)
- Timothy J Skalak
- Nationwide Children's Hospital, Columbus, OH, USA. .,, Columbus, USA.
| | - Joel Gagnier
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michelle S Caird
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Frances A Farley
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ying Li
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
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Use of intraoperative navigation for posterior spinal fusion in adolescent idiopathic scoliosis surgery is safe to consider. Spine Deform 2021; 9:403-410. [PMID: 33025389 DOI: 10.1007/s43390-020-00218-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/21/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE The use of image-guided stereotactic navigation is increasing in use in treating AIS; however, no studies have investigated perioperative outcomes and short-term adverse events compared with non-navigated procedures. The aim of the present study is to use a large national pediatric database to assess the rate of utilization of intraoperative navigation in pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) and to compare thirty-day outcomes of navigated vs. non-navigated surgery. METHODS The NSQIP-Pediatric database was queried for cases of posterior fusion for AIS. Patients were stratified by whether or not a concurrent code for stereotactic navigation was used (CPT 61,783). Year of procedure, demographics, comorbidities, operative variables and perioperative adverse outcomes were abstracted and assessed using univariate and multivariate analysis. RESULTS Overall, 12,739 non-navigated patients and 340 navigated patients were identified. The use of navigation increased from 0.5% of cases in 2012 to 5.2% of cases in 2018. Demographics, comorbidities, and number of levels fused did not differ between navigated and non-navigated patients. Navigated cases were on average 41 min longer than non-navigated cases (268.6 vs. 309.6 min p < 0.001), with 9.84% more cases requiring transfusion (65.0% vs 75.6%, p < 0.001). Hospital stay for navigated cases was an average of 0.4 days shorter (3.9 days vs 4.3 days, p = 0.001). On multivariate analysis, navigated cases had higher odds of prolonged surgery (OR = 2.13, p < 0.001) and lower odds of prolonged length of stay (OR = 0.28, p < 0.001). CONCLUSION Although the use of navigation for AIS posterior fusion was associated with longer operative time, post-operative hospital stay was shorter and other perioperative adverse outcomes were not significantly different between groups.
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Kaya I, Cingöz ID, Şahin MC, Bozoğlan E. Investigation of the Effects of Three-Dimensional Modeling Techniques on Degenerative Rotoscoliosis Surgery. Cureus 2021; 13:e13075. [PMID: 33643748 PMCID: PMC7885741 DOI: 10.7759/cureus.13075] [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] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 11/26/2022] Open
Abstract
Objectives The present study aimed to compare patients in whom an operation plan was prepared before surgery using the three-dimensional (3D) modeling technology with the application of freehand screws using magnetic resonance imaging (MRI) and computed tomography (CT) scan images. Methods The printings and modelings were established in the Training and Research Center. Of 40 patients, 20 underwent surgery with 3D printing (Group 1) and 20 with the freehand technique (Group 2). The surgeries were performed by the same surgeons. Moreover, 5-mm pedicle screws were located in 122 vertebrae in 20 patients in whom 3D modeling was used and in 124 vertebrae in 20 patients in whom this modeling technique was not used. Results The mean time of screw insertion was 2.9 ± 1.2 minutes in the experimental group and 4.7 ± 2.3 minutes in the control group. While the mean amount of bleeding was 7.4 ± 4.1 ml in the experimental group, it was found to be 39.6 ± 14.2 ml in the control group. When the locations of the screws in the experimental group were evaluated, it was seen that 106 (86.9%) screws were 'excellent' and 16 (13.1%) screws were 'good.' When the placement of 124 pedicle screws in the control group was evaluated, it was found that 100 (80.6%) screws were 'excellent,' 20 (17.8%) screws were 'good,' and two (1.6%) screws were 'poor.' Conclusion The use of the improved 3D technology in the neurosurgery field is advantageous for surgeons, as it decreases the preoperative preparation phase, length of operation, and risk of complications.
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Affiliation(s)
- Ismail Kaya
- Neurosurgery, Kutahya Health Sciences University, Kutahya, TUR
| | | | | | - Emirhan Bozoğlan
- Bioengineering, Kutahya Health Sciences University, Kutahya, TUR
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Floccari LV, Poppino KF, Mundluru SN, McIntosh AL, Rathjen KE, Sucato DJ. Two AIS spine surgeries on the same day by the same surgeon: is performance and outcome the same for the second patient? Spine Deform 2020; 8:977-981. [PMID: 32447574 DOI: 10.1007/s43390-020-00136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/11/2020] [Indexed: 11/24/2022]
Abstract
STUDY DESIGN Retrospective case-controlled study. OBJECTIVES To analyze the overall performance and outcome of two-a-day surgery days for adolescent idiopathic scoliosis (AIS). As a method to improve efficiency and operating room utilization, some surgeons are now performing two surgeries for AIS in a single day. METHODS A prospectively collected series of AIS patients who underwent posterior spinal fusion on the same day as a second AIS patient by the same surgeon and surgical team were retrospectively reviewed. Patients who underwent same-day surgery (SD) were grouped according to whether they were the first (SD1) or second (SD2) case of the day and were matched (M1 and M2) by surgeon, curve magnitude, Lenke classification, and fusion levels. Comparisons were made: SD1 vs. SD2, SD1 vs. M1, and SD2 vs. M2. RESULTS There were 56 patients, with no differences between groups in age, gender, BMI, or curve magnitude (66° vs. 62° vs. 65° vs. 63°). Surgical time was shorter for the SD1 group (17.2 min/level) compared to M1 (20.5 min/level) for a 15% operative time reduction of 44 min (p = 0.008). There were no differences between the groups in curve correction (65.8% vs. 62.8% vs. 66.1% vs. 58.5%), estimated blood loss (EBL), length of stay, or complication rate. One SD2 patient had a malpositioned screw that required revision. There were no other complications. CONCLUSIONS When performing two AIS surgeries on the same day, surgical time was reduced by 44 min, or 15%, on the first case compared to a matched control. This may be a reflection of the team moving along more efficiently, given the full operative day scheduled. The performance measures of curve correction, EBL, complications, and length of stay did not decline in this new model, and no increased incidence of complications was seen.
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Affiliation(s)
- Lorena V Floccari
- Akron Children's Hospital, Akron, OH, USA.,Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Kiley F Poppino
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Surya N Mundluru
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA.,University of Texas Houston McGovern School of Medicine, Houston, TX, USA
| | - Amy L McIntosh
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Karl E Rathjen
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Daniel J Sucato
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA.
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Larson AN, Floccari LV, Garg S, Erickson MA, Sponseller PD, Brito JP, Aubin CE, Polly DW. Willingness to enroll in a surgical randomized controlled trial: patient and parent preferences regarding implant density for adolescent idiopathic scoliosis fusion. Spine Deform 2020; 8:957-963. [PMID: 32495208 DOI: 10.1007/s43390-020-00143-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/16/2020] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN Prospective survey of adolescent idiopathic scoliosis (AIS) patients/parents with surgical magnitude curves. OBJECTIVE We hypothesized that patients and families considering fusion surgery would be willing to enroll in a randomized controlled trial (RCT) evaluating the effect of number of implants on curve correction. Surgical RCTs are infrequently performed, particularly in a pediatric population. Parental willingness to enroll affects both study design and trial feasibility. The Minimize Implants Maximize Outcomes (MIMO) Clinical Trial proposes to randomize patients to more versus fewer screws (high or low density) for Lenke 1A curve patterns, but it is unclear whether families and patients are willing to enroll in such a trial. METHODS This study was undertaken at 4 of the 14 sites participating in the MIMO Clinical Trial. AIS patients with Cobb > 45° were included. Implant density is defined as screws per level fused. Patients and families reviewed the MIMO education module describing proposed advantages and disadvantages of high (> 1.8) vs. low (< 1.4) density screw constructs and completed a custom survey regarding their preferences about the trial. RESULTS 159 individuals were surveyed (78 families), including 82 parents/guardians, and 77 patients. Of those surveyed, 95% mostly or completely understood the trial (range 47-78%), and 63% agreed to enroll. Parents and patients who completely understood the trial were significantly more likely to enroll. CONCLUSION Randomization in the MIMO Trial was acceptable to the majority (63%) of patients and parents. Clear patient and parent education materials and access to the surgeon may facilitate enrollment in the trial. Parents afforded the child much autonomy when considering enrollment, although most families agree both child and parent should be in agreement before entering the trial. LEVEL OF EVIDENCE II.
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Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Lorena V Floccari
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sumeet Garg
- Children's Hospital Colorado, Aurora, CO, USA
| | | | | | - Juan P Brito
- Mayo Clinic Shared Decision Making National Resource Center, Mayo Clinic, Rochester, USA.,Department of Endocrinology, Mayo Clinic, Rochester, USA
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Senkoylu A, Cetinkaya M, Daldal I, Necefov E, Eren A, Samartzis D. Personalized Three-Dimensional Printing Pedicle Screw Guide Innovation for the Surgical Management of Patients with Adolescent Idiopathic Scoliosis. World Neurosurg 2020; 144:e513-e522. [PMID: 32891830 DOI: 10.1016/j.wneu.2020.08.212] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of patient-specific three-dimensional (3D) rapid-prototype printing technology for pedicle screw insertion in patients with adolescent idiopathic scoliosis (AIS). METHODS The 3D pedicle screw guides were produced after selecting the fixation points for all individual levels to be used intraoperatively. Preoperative computed tomography images recreated 3D bone models of each vertebra specific to each patient. Safe pedicle trajectories were determined in all 3 planes on these models. 3D printed guides were modeled according to these trajectories and manufactured with a biocompatible material. Postoperatively, all screws were evaluated and scored with computed tomography as class 1 (accurate), class 2 (inaccurate), or class 3 (deviated). The mean angle between the inserted pedicle screw and the intended trajectory, and the mean distance between the central longitudinal axis of a screw and pedicle were also measured. RESULTS A total of 134 screws were inserted. On the concave and convex sides, the mean medial malposition was 0.5 ± 0.8 and 0.4 ± 0.6 mm, the mean lateral malposition was 1.4 ± 2.3 and 0.8 ± 1.3 mm, angle between the inserted pedicle screw and the intended trajectory was 4.2 ± 4.6 and 4.3° ± 6.0°, and distance between the central longitudinal axis of a screw and pedicle was 1.5 ± 2.1 and 0.9 ± 1.2 mm, respectively. A total of 117 screws were regarded as class 1, 14 as class 2, and 3 as class 3. Of all screws inserted, 92.5% achieved positional accuracy. There were no screw-related complications. CONCLUSIONS This is one of the initial reports to note the novel design and implementation of patient-specific 3D pedicle screw guides for adolescent idiopathic scoliosis surgery. Our pilot study shows that the use of these low-cost personalized 3D guides is completely safe and effective in both convex and concave sides of the curves.
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Affiliation(s)
- Alpaslan Senkoylu
- Gazi University School of Medicine, Department of Orthopaedics and Traumatology, Ankara, Turkey.
| | - Mehmet Cetinkaya
- Stellenbosch University Faculty of Medicine and Health Sciences, Department of Orthopaedics, Spinal Unit, Western Cape, South Africa
| | - Ismail Daldal
- Lokman Hekim University, Akay Hospital, Department of Orthopaedics and Traumatology, Ankara, Turkey
| | - Elsan Necefov
- Nakhchivan Government Hospital, Department of Orthopaedics and Traumatology, Nakhchivan, Azerbaijan
| | - Ali Eren
- Gumushane Kelkit Government Hospital, Department of Orthopaedics and Traumatology, Gumushane, Turkey
| | - Dino Samartzis
- Rush University Department of Orthopaedic Surgery, Department of Orthopaedic Surgery, Chicago, Illinois, USA
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Helenius IJ. Standard and magnetically controlled growing rods for the treatment of early onset scoliosis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:26. [PMID: 32055617 DOI: 10.21037/atm.2019.09.72] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Distraction based spinal instrumentation represents the most common and standard surgical technique to correct early onset scoliosis (EOS), i.e., scoliosis which has been diagnosed before the age of 10 years. Surgical treatment of EOS aims at controlling spinal deformity while maintaining spinal growth which is mandatory for the development of normal lung capacity. To achieve these goals the spinal instrumentation needs to be distracted to facilitate spinal growth during treatment. Distraction can be obtained by repeated surgical lengthenings (traditional growing rods, TGRs) or using magnetically controlled growing rods (MCGRs), which can be lengthened using external remote controller on an outpatient basis. The outcomes of TGR instrumentation for EOS are well described with follow-up until skeletal maturity: normal spinal growth can be maintained, 40-50% of the scoliosis can be corrected, but there is an over 50% risk of complications including deep wound infection, rod failure, and instrumentation pull-out. MCGR instrumentation may reduce the risk of wound related complications, provides similar deformity correction, but may not provide as much spinal growth. Metallosis around the instrumentation necessitates MCGR removal and definitive final instrumented fusion at the end of growth friendly management. Even severe EOS can be treated using distraction based spinal instrumentation.
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Affiliation(s)
- Ilkka J Helenius
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
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Mukhametzhanov K, Mukhametzhanov DZ, Karibaev BM, Bulekbaev SA, Bekarisov OS, Кusainova KK, Dyusenbaev NN. Using an intraoperative computed tomography scanner with a navigation station for spinal surgery. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2019. [DOI: 10.29333/ejgm/115859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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The Accuracy of 3D Printing Assistance in the Spinal Deformity Surgery. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7196528. [PMID: 31828123 PMCID: PMC6885147 DOI: 10.1155/2019/7196528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/21/2019] [Accepted: 10/05/2019] [Indexed: 12/25/2022]
Abstract
Background The pedicle screw is one of the main tools used in spinal deformity correction surgery. Robotic and navigated surgeries are usually used, and they provide superior accuracy in pedicle screw placement than free-hand and fluoroscopy-guided techniques. However, their high cost and space limitation are problematic. We provide a new solution using 3D printing technology to facilitate spinal deformity surgery. Methods A workflow was developed to assist spinal deformity surgery using 3D printing technology. The trajectory and profile of pedicle screws were determined on the image system by the surgical team. The engineering team designed drill templates based on the bony surface anatomy and the trajectory of pedicle screws. Their effectiveness and safety were evaluated during a preoperative simulation surgery. The surgery consisted in making a pilot hole through the drill template on a computed tomography- (CT-) based, full-scale 3D spine model for every planned segment. Somatosensory evoke potential (SSEP) and motor evoke potential (MEP) were used for intraoperative neurophysiological monitoring. Postoperative CT was obtained 6 months after the correction surgery to confirm the screw accuracy. Results From July 2015 to November 2016, we performed 10 spinal deformity surgeries with 3D printing technology assistance. In total, 173 pedicle screws were implanted using drill templates. No notable change in SSEP and MEP or neurologic deficit was noted. Based on postoperative CT scans, the acceptable rate was 97.1% (168/173). We recorded twelve pedicle screws with medial breach, six with lateral breach, and five with inferior breach. Medial breach (12/23) was the main type of penetration. Lateral breach occurred mostly in the concave side (5/6). Most penetrations occurred above the T8 level (69.6%, 16/23). Conclusion 3D printing technology provides an effective alternative for spinal deformity surgery when expensive medical equipment, such as intraoperative navigation and robotic systems, is unavailable.
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Yeh YC, Niu CC, Chen LH, Chen WJ, Lai PL. The correlations between the anchor density and the curve correction of adolescent idiopathic scoliosis surgery. BMC Musculoskelet Disord 2019; 20:497. [PMID: 31656190 PMCID: PMC6816219 DOI: 10.1186/s12891-019-2844-1] [Citation(s) in RCA: 7] [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: 03/21/2019] [Accepted: 09/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background The optimal anchor density in adolescent idiopathic scoliosis (AIS) surgery to achieve good curve correction remains unclear. The purpose of the study is to analyze the correlations between three-dimensional curve correction and anchor density in the pedicle screw-based posterior fusion of AIS. Methods One hundred and twenty-seven AIS patients receiving primary posterior fusion with pedicle screw instrumentation were retrospectively reviewed. Anchor density (AD) was defined as the screws number per fused spinal segment. The correlations between three-dimensional curve correction radiographic parameters and anchor density were analyzed with subgroup analysis based on different curve types, curve magnitudes, and curve flexibilities. The differences of curve correction parameters between the low-density (AD ≤1.4), middle-density (1.4 < AD ≤1.7) and high-density (AD > 1.7) groups were also calculated. Independent t-test, analysis of variance (ANOVA), and Pearson’s correlation coefficient were used for statistical analysis. Results There were no correlations between the anchor density and the coronal curve correction or apical vertebral rotation (AVR) correction. In the sagittal plane, mild positive correlations existed between anchor density and thoracic kyphosis correction in all patients (r = 0.27, p = 0.002). Subgroup analysis revealed similar mild positive correlations in Lenke 1 (r = 0.31, p = 0.02), Lenke 1–3 (r = 0.27, p = 0.01), small curves (40°-60°, r = 0.38, p < 0.001), and flexible curves (flexibility > 40%, r = 0.34, p = 0.01). There were no differences between low-density (mean 1.31), middle-density (mean 1.55), and high-density (mean 1.83) in terms of coronal or axial curve correction parameters. Low-density group has longer fused level (mean difference 2.14, p = 0.001) and smaller thoracic kyphosis correction (mean difference 9.25°, p = 0.004) than high-density group. Conclusion In our study, the anchor density was not related to coronal or axial curve corrections. Mild positive correlations with anchor density were found in thoracic kyphosis correction, especially in patients with smaller and flexible curves. Low anchor density with longer fusion level achieves similar curve corrections with middle or high anchor density in adolescent idiopathic scoliosis surgery.
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Affiliation(s)
- Yu-Cheng Yeh
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist.,, 33305, Taoyuan, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Chien Niu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist.,, 33305, Taoyuan, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lih-Huei Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist.,, 33305, Taoyuan, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Jer Chen
- Department of Orthopedic Surgery, Chung Shan Hospital, Taipei, Taiwan
| | - Po-Liang Lai
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist.,, 33305, Taoyuan, Taiwan. .,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Helenius L, Diarbakerli E, Grauers A, Lastikka M, Oksanen H, Pajulo O, Löyttyniemi E, Manner T, Gerdhem P, Helenius I. Back Pain and Quality of Life After Surgical Treatment for Adolescent Idiopathic Scoliosis at 5-Year Follow-up: Comparison with Healthy Controls and Patients with Untreated Idiopathic Scoliosis. J Bone Joint Surg Am 2019; 101:1460-1466. [PMID: 31436653 DOI: 10.2106/jbjs.18.01370] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Posterior spinal fusion with pedicle screws is the gold-standard treatment for adolescent idiopathic scoliosis (AIS); however, it is unclear whether this procedure results in improved long-term back pain and health-related quality of life compared with patients not surgically treated for AIS. The aim of the present study was to evaluate back pain and quality of life in surgically managed patients with a minimum follow-up of 5 years compared with patients with untreated AIS and a healthy control group. METHODS Fifty-five consecutive adolescent patients who underwent posterior pedicle screw instrumentation for AIS by a single orthopaedic surgeon were prospectively enrolled. At a minimum of 5 years postoperatively, 49 patients completed Scoliosis Research Society (SRS)-24 questionnaires, and data on reoperation were collected. Pain and quality-of-life parameters were compared with those of 49 age and sex-matched patients with untreated AIS and 49 healthy controls. RESULTS The major curve averaged 53° preoperatively and 12° at 2 years postoperatively. One reoperation (pedicle screw removal) was needed because of a new neurological deficit (transient). The SRS-24 pain, function, and total scores improved significantly from preoperatively to 5 years postoperatively (all p ≤ 0.016), with pain scores improving from 4.0 to 4.3 (p = 0.003). There was no association between pain scores and the preoperative major curve, instrumentation below L1, or postoperative rib hump. The surgical treatment group had significantly better pain, activity, and self-image domain scores at 5 years postoperatively compared with the untreated AIS group (all p ≤ 0.014), and similar pain, self-image, and activity domain scores compared with the healthy control group; however, function scores were significantly lower among patients in the surgical treatment group (p < 0.001). CONCLUSIONS Patients who underwent posterior spinal fusion with pedicle screws experienced improved back pain and health-related quality of life compared with patients with untreated AIS. Patients in the surgical treatment group had similar health-related quality of life to that of the healthy control group, except for function, which was significantly lower. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Linda Helenius
- Departments of Anaesthesia and Intensive Care (L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.H., M.L., H.O., O.P., and I.H.), University of Turku and Turku University Hospital, Turku, Finland
| | - Elias Diarbakerli
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Grauers
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Orthopaedics, Sundsvall and Härnösand County Hospital, Sundsvall, Sweden
| | - Markus Lastikka
- Departments of Anaesthesia and Intensive Care (L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.H., M.L., H.O., O.P., and I.H.), University of Turku and Turku University Hospital, Turku, Finland
| | - Hanna Oksanen
- Departments of Anaesthesia and Intensive Care (L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.H., M.L., H.O., O.P., and I.H.), University of Turku and Turku University Hospital, Turku, Finland
| | - Olli Pajulo
- Departments of Anaesthesia and Intensive Care (L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.H., M.L., H.O., O.P., and I.H.), University of Turku and Turku University Hospital, Turku, Finland
| | | | - Tuula Manner
- Departments of Anaesthesia and Intensive Care (L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.H., M.L., H.O., O.P., and I.H.), University of Turku and Turku University Hospital, Turku, Finland
| | - Paul Gerdhem
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Ilkka Helenius
- Departments of Anaesthesia and Intensive Care (L.H. and T.M.) and Paediatric Orthopaedic Surgery (L.H., M.L., H.O., O.P., and I.H.), University of Turku and Turku University Hospital, Turku, Finland
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CORR Insights®: Does Three-dimensional Printing Plus Pedicle Guider Technology in Severe Congenital Scoliosis Facilitate Accurate and Efficient Pedicle Screw Placement? Clin Orthop Relat Res 2019; 477:1913-1914. [PMID: 31169623 PMCID: PMC7000006 DOI: 10.1097/corr.0000000000000835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Does Three-dimensional Printing Plus Pedicle Guider Technology in Severe Congenital Scoliosis Facilitate Accurate and Efficient Pedicle Screw Placement? Clin Orthop Relat Res 2019; 477:1904-1912. [PMID: 31107327 PMCID: PMC6999999 DOI: 10.1097/corr.0000000000000739] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Three-dimensional (3-D) printing offers the opportunity to create patient-specific guides for pedicle screw placement based on CT-generated models. This technology might allow for more-accurate placement of pedicle screws in patients with severe congenital scoliosis who have rotated vertebrae and small pedicles, but to our knowledge, this premise has not been tested. QUESTIONS/PURPOSES (1) Is the use of 3-D printing and pedicle guider technology as or more accurate than the use of the freehand technique for pedicle-screw placement in patients with severe congenital scoliosis? (2) Does surgical time differ with the use of these guiders? (3) Are complications less common in patients treated with this new approach to pedicle-screw placement? METHODS A prospective controlled study was conducted of patients with severe congenital scoliosis (major curve ≥ 90°) from June 2016 to June 2018. During this period, we treated 93 patients with congenital scoliosis; 32 had severe scoliosis with a major curve ≥ 90°. The patients were divided into a pedicle guider group (n = 15) and a control group (n = 17) based on their willingness to use pedicle guider technology, which was considered a research technology. With the numbers available, there were no between-group differences in terms of age, sex, BMI, or parameters related to curve severity or flexibility, and all patients in both groups had severe curves. Preoperative and postoperative low-dose CT scans were performed in the two groups. In the pedicle guider group, custom software was used to design the pedicle guider, and a 3-D printer was used to print a physical spinal model and pedicle guiders. The pedicle guiders were tested on the surface of the physical spinal model before surgery to ensure proper fit, and then used to assist pedicle screw placement during surgery. A total of 244 screws were implanted with the help of 127 pedicle guiders (254 guiding tunnels) during surgery in the PG group. Five predesigned pedicle guiders were abandoned due to an unstable match, and the success rate of assisted screw placement using a pedicle guider was 96% (244 of 254). The freehand technique was used in the control group, which relied on anatomic localization to place pedicle screws. The accuracy of pedicle screw placement was evaluated with CT scans, which revealed whether screws had broken through the pedicle cortex. We compared the groups in terms of accuracy (defined as unanticipated breaches less than 2 mm), surgical time, time to place pedicle screws, and screw-related complications. RESULTS A higher proportion of the screws placed using pedicle guider technology were positioned accurately than were in the control group (93% [227 of 244] versus 78% [228 of 291]; odds ratio, 3.69 [95% CI, 2.09-6.50]; p<0.001). With pedicle guider use, operative time (296 ± 56 versus 360 ± 74; 95% CI, -111 to -17; p = 0.010), time to place all screws (92 ± 17 versus 118 ± 21; 95% CI, -39 to -12; p = 0.001), and mean time to place one screw (6 ± 1 versus 7 ± 1; 95% CI, -2 to 0; p = 0.011) decreased. One patient in the pedicle guider group and four in the control group experienced screw-related complications; the sample sizes and small number of complications precluded statistical comparisons. CONCLUSIONS In this small, preliminary study, we showed that the accuracy of the surgical technique using spinal 3-D printing combined with pedicle guider technology in patients with severe congenital scoliosis was higher than the accuracy of the freehand technique. In addition, the technique using pedicle guider technology appeared to shorten operative time. If these findings are confirmed in a larger study, pedicle guider technology may be helpful for situations in which intraoperative CT or O-arm navigation is not available. LEVEL OF EVIDENCE Level II, therapeutic study.
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Vardiman AB, Wallace DJ, Crawford NR, Riggleman JR, Ahrendtsen LA, Ledonio CG. Pedicle screw accuracy in clinical utilization of minimally invasive navigated robot-assisted spine surgery. J Robot Surg 2019; 14:409-413. [PMID: 31321615 PMCID: PMC7237509 DOI: 10.1007/s11701-019-00994-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/20/2019] [Indexed: 12/19/2022]
Abstract
In the emerging field of robot-assisted spine surgery, the radiographic evaluation of pedicle screw accuracy in clinical application is an area of high interest. This study describes the pedicle screw accuracy of the first 56 consecutive cases in which navigated robotic assistance was used in a private practice clinical setting. A retrospective, Institutional Review Board-exempt review of the first 56 navigated robot-assisted spine surgery cases was performed. Pedicle screw malposition, reposition, and return to operating room (OR) rates were collected. A CT-based Gertzbein and Robbins system (GRS) was used to classify pedicle screw accuracy. In the first 56 robotic cases, 356 total pedicle screws were placed. Eight screws were placed without the robot due to surgeon discretion. Of the 348 pedicle screws inserted by navigated robotic guidance, only 2.6% (9/348) were repositioned, resulting in a 97.4% (339/348) successful screw placement rate. The average age was 64, and 48% were female. Average body mass index was 31 kg/m2. Based on the GRS CT-based grading, 97.7% (340/348) were graded A or B, 1.7% (6/348) screws were graded C, and only 0.6% (2/348) of screws were graded D. Two complications, explantation of interbody and vacuum-assisted wound closure, were reported as requiring a return to the OR, but these were not related to robotic guidance or pedicle screws. This study demonstrated a high level of accuracy (97.7%) in the first 56 cases using navigated, robot-assisted surgery based on the GRS. There were two non-screw-related complications requiring return to the operating room.
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Affiliation(s)
- Arnold B Vardiman
- Department of Neurosurgery, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX, 78229-3900, USA.
| | - David J Wallace
- Department of Neurosurgery, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX, 78229-3900, USA
| | - Neil R Crawford
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc, 2560 General Armistead Avenue, Audubon, PA, 19403, USA
| | - Jessica R Riggleman
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc, 2560 General Armistead Avenue, Audubon, PA, 19403, USA
| | - Leigh A Ahrendtsen
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc, 2560 General Armistead Avenue, Audubon, PA, 19403, USA
| | - Charles G Ledonio
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc, 2560 General Armistead Avenue, Audubon, PA, 19403, USA
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Baky FJ, Milbrandt T, Echternacht S, Stans AA, Shaughnessy WJ, Larson AN. Intraoperative Computed Tomography-Guided Navigation for Pediatric Spine Patients Reduced Return to Operating Room for Screw Malposition Compared With Freehand/Fluoroscopic Techniques. Spine Deform 2019; 7:577-581. [PMID: 31202374 PMCID: PMC6578871 DOI: 10.1016/j.jspd.2018.11.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 11/16/2018] [Accepted: 11/20/2018] [Indexed: 10/26/2022]
Abstract
PURPOSE Placement of pedicle screws can be performed using freehand/fluoroscopic technique or intraoperative computed tomography (CT)-guided navigation. We sought to compare screw malposition and return to operating room (OR) for pedicle screw malposition for screws placed with and without CT-guided navigation. METHODS This study was a single-center retrospective comparative study. All patients younger than 18 years with minimum two-year follow-up who underwent pedicle screw instrumentation between 2009 and 2015 were included. Institutional review board approval was obtained and patient charts were reviewed for patient demographics and surgical outcomes. If available, incidental CTs following the index surgery were reviewed to assess screw position. RESULTS A total of 217 patients underwent spinal instrumentation. Overall, 112 patients had pedicle screws placed using fluoroscopic guidance, whereas 105 patients had screws placed using low-dose intraoperative CT-guided navigation (O-arm; Medtronics). Of the total cohort, 107 (49.3%) patients had adolescent idiopathic scoliosis, and the remainder had neuromuscular, tumor, congenital, or other diagnoses. Patients in each group had a similar number of levels fused (fluoroscopic = 10.9 vs. CT navigation = 9.8, p = .06). There was no difference in total estimated blood loss (1,127 vs. 1,179 mL, p = .63) or in blood loss per level fused (133.7 vs. 146.6 mL, p = .47). Patients with screws placed using fluoroscopic guidance had a shorter total operative time (441 vs. 468 minutes, p = .04); however, there was no difference when controlling for number of levels fused (58.3 vs. 61.5 minutes/level, p = .63). Postoperative CTs were available in 51 patients representing 526 imaged screws, which showed a significantly higher rate of severely malpositioned (>4 mm) screws in the fluoroscopic group than the CT navigation group (3.3% vs. 1.0%, p = .027). There was a 3.6% rate of return to OR for pedicle screw malposition in the freehand/fluoroscopic group compared with 0% in the CT-guided navigation group (p = .048). Including patients with less than two-year follow-up (169 fluoroscopy, 220 CT guidance) also found higher rates of screw malposition (13.5% vs. 7.1%, p = .004), severe screw malposition (3.0% vs. 0.50%, p = .04), and return to OR due to screw malposition (2.4% vs. 0%, p = .02) in patients with screws placed using fluoroscopic guidance. CONCLUSION Patients with pedicle screws placed with CT-guided navigation had a lower rate of severely malpositioned screws and unplanned returns to the OR. There was no significant difference in blood loss or operative time when controlling for number of levels fused. SIGNIFICANCE In the era of health care "never-events," return to OR for screw malposition could certainly be deemed unacceptable. Use of intraoperative CT-guided navigation thus far eliminated return to OR for screw malposition in a complex cohort of pediatric spinal deformity patients, without measurable increase in operative time or blood loss.
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Affiliation(s)
- Fady J Baky
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Todd Milbrandt
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Scott Echternacht
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642, USA
| | - Anthony A Stans
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - William J Shaughnessy
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
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Biomechanical analysis of pedicle screw density in posterior spine instrumentation. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mitchell A, Upasani VV, Bartley CE, Newton PO, Yaszay B. Rigid segmental cervical spine instrumentation is safe and efficacious in younger children. Childs Nerv Syst 2019; 35:985-990. [PMID: 30941509 DOI: 10.1007/s00381-019-04130-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/18/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The utilization of cervical spine instrumentation in the young pediatric patient is not well reported. This study presents outcomes and complications of cervical spine instrumentation in patients who underwent cervical spine fusion surgery before age 10. METHODS Radiographic and clinical data were collected on all patients who underwent cervical spine surgery with instrumentation at a single institution between January 1, 2006, and March 31, 2015. Patients were ≤ 10 years of age at the time of surgery with any cervical spine deformity/injury diagnosis. Patient demographics, details on cervical spine diagnosis, procedural data, imaging data, and postoperative follow-up data were collected. RESULTS Twenty children met the criteria and were included in the study with a mean follow-up of 10.6 months (3 months-2 years). Initial indication for cervical spine correction surgery included deformity (7 cases), trauma (6 cases), instability (3 cases), stenosis (2 cases), rotary subluxation (1 case), and infection (1 case). Fifteen cases were treated with adult 3.5-mm cervical spine instrumentation, 3 with wiring (1 sublaminar and 2 spinous process), and 2 with cannulated screws. Postoperative immobilization included 16 halo fixation, 3 collars, and 1 CTO. Overall, there were five complications related to the surgery. Two patients who had wiring (1 sublaminar and 1 spinous process) developed a non-union and required revision surgery (1 with cannulated screws and 1 with 3.5-mm segmental cervical spine instrumentation). One patient developed a postoperative infection that required incision and drainage. Five patients developed superficial pin infections for their halo. Two deformity patients experienced neurological complications that were likely unrelated to the cervical instrumentation. CONCLUSIONS Rigid segmental fixation can be safe and efficacious when used in pediatric cervical spine patients. Whether used with halo or orthosis, patients experience minimal to no complications from the instrumentation and achieve successful fusion. Cervical spine wiring had a high risk of non-union requiring revision surgery. The incidence of wound infection was low with one in 20 cases.
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Affiliation(s)
- Ana Mitchell
- University of California San Diego, San Diego, CA, USA
| | - Vidyadhar V Upasani
- University of California San Diego, San Diego, CA, USA
- Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Carrie E Bartley
- Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Peter O Newton
- University of California San Diego, San Diego, CA, USA
- Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Burt Yaszay
- University of California San Diego, San Diego, CA, USA.
- Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.
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Huntsman KT, Ahrendtsen LA, Riggleman JR, Ledonio CG. Robotic-assisted navigated minimally invasive pedicle screw placement in the first 100 cases at a single institution. J Robot Surg 2019; 14:199-203. [PMID: 31016575 PMCID: PMC7000538 DOI: 10.1007/s11701-019-00959-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/09/2019] [Indexed: 11/28/2022]
Abstract
Proper pedicle screw placement is an integral part of spine fusion requiring expertly trained spine surgeons. Advances in medical imaging guidance have improved accuracy. There is high interest in the emerging field of robot-assisted spine surgery; however, safety and accuracy studies are needed. This study describes the pedicle screw placement of the first 100 cases in which navigated robotic assistance was used in a private practice clinical setting. A single-surgeon, single-site retrospective Institutional Review Board-exempt review of the first 100 navigated robot-assisted spine surgery cases was performed. An orthopaedic surgeon evaluated screw placement using plain film radiographs. In addition, pedicle screw malposition, reposition, and return to operating room (OR) rates were collected. Results demonstrated a high level (99%) of successful surgeon assessed pedicle screw placement in minimally invasive navigated robot-assisted spine surgery, with no malpositions requiring return to the OR.
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Affiliation(s)
- Kade T Huntsman
- Salt Lake Orthopaedic Clinic, Suite 500, 1160 East 3900 South, Salt Lake City, UT, 84124, USA
| | - Leigh A Ahrendtsen
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA, 19403, USA.
| | - Jessica R Riggleman
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA, 19403, USA
| | - Charles G Ledonio
- Musculoskeletal Education and Research Center (MERC), A Division of Globus Medical, Inc., 2560 General Armistead Avenue, Audubon, PA, 19403, USA
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Urbanski W. Response to comment from Dr. Yassari et al. JOURNAL OF SPINE SURGERY (HONG KONG) 2019; 5:180-181. [PMID: 31032456 PMCID: PMC6465458 DOI: 10.21037/jss.2018.12.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/04/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Wiktor Urbanski
- Department of Orthopaedics and Traumatology, Wroclaw Medical University, Wroclaw, Poland
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