Postoperative Low Back Pain after Posterior Lumbar Interbody Fusion Surgery Using Cortical Bone Trajectory Screws

Efficacy and Safety of Cortical Bone Trajectory Screws versus Pedicle Screws in Lumbar Fusion: A Systematic Review and Meta-Analysis

OBJECTIVE

A systematic review and meta-analysis was conducted to compare the efficacy and safety of cortical bone trajectory (CBT) screws and traditional pedicle screws in lumbar fusion.

METHODS

Randomized controlled studies and cohort studies on CBT versus pedicle screws in lumbar fusion were searched in China Biology Medicine, China National Knowledge Infrastructure, Wanfang, VIP Database for Chinese Technical and Science Periodicals, PubMed, Cochrane Library, and Web of Science databases. The search period spanned from the establishment of the databases to December 2023. The Cochrane bias risk assessment tool and Newcastle-Ottawa scale were applied to assess the quality of the literature included. Clinical and imaging data as well as surgical outcomes, recovery, and postoperative complications were extracted from the relevant literature.

RESULTS

A total of 6 randomized controlled trials and 26 cohort studies were included after screening by inclusion and exclusion criteria with a total of 2478 patients. The meta-analysis demonstrated significant discrepancies between the CBT and TPS groups in Japanese Orthopaedic Association score at 3 and 6 months and final follow-up. Moreover, the TPS group exhibited a higher Oswestry disability index at final follow-up, a greater VAS for low back pain at both 1 week and final follow-up, as well as a higher VAS for leg pain at 1 month. Differences were also noted in surgical and recovery outcomes. However, there was no significant difference between the 2 groups in postoperative complications.

CONCLUSIONS

CBT and TPS have analogous safety profiles when applied to lumbar fusion, but the clinical efficacy of CBT is superior to that of TPS to some extent, and the procedure is less invasive with faster recovery.

A Novel Two-Step Method for Converting Lumbar Cortical Screw to Pedicle Screw: A Case Report

The cortical bone trajectory (CBT) technique has emerged as a minimally invasive approach for lumbar fusion but may result in pseudoarthrosis and hardware failure. This report presents a case of successful pedicle screw revision in a patient with previous failed L2 and L3 fusion using a novel "two-step" technique, including (1) drilling a new trajectory with Medtronic EM800N Stealth MIDAS Navigated MR8 drill system (Medtronic, Dublin, Ireland) and (2) placement of Solera 4.75 ATS (awl-tapped screws) with navigated POWEREASE™ (Medtronic), described here for the first time. This method involves utilizing neuronavigation and specialized instruments to safely place pedicle screws through the path of the old cortical screw trajectory, addressing the challenges associated with CBT hardware failure.

The effect of the cortical bone trajectory screw fixation and traditional pedicle screw fixation on surgical site wound infection in posterior lumbar fusion wound: A meta-analysis

A meta-analysis investigation was performed to measure the influence of cortical bone trajectory screw fixation (CBTSF) and traditional pedicle screw fixation (TPSF) on surgical site wound infection (SSWI) in posterior lumbar fusion (PLF). A comprehensive literature inspection till February 2023 was applied and 1657 interrelated investigations were reviewed. The 13 chosen investigations enclosed 1195 individuals with PLF in the chosen investigations' starting point, 578 of them were using CBTSF, and 617 were using TPSF. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilised to compute the value of the effect of the CBTSF and TPSF on SSWI in PLF by the dichotomous approaches and a fixed or random model. No significant difference was found between individuals using CBTSF and TPSF in SSWI (OR, 0.68; 95% CI, 0.35-1.33, P = .26), superficial SSWI (OR, 0.62; 95% CI, 0.22-1.79, P = .38), and deep SSWI (OR, 0.30; 95% CI, 0.06-1.50, P = .14) in PLF. No significant difference was found between individuals using CBTSF and TPSF in SSWI, superficial SSWI, and deep SSWI in PLF. However, care must be exercised when dealing with its values because of the small sample sizes of several chosen investigations for this meta-analysis and the low number of selected investigations for a certain type of SSWI.

Complication, fusion, and revision rate in the lumbar cortical bone trajectory and pedicle screw fixation techniques: a systematic review and meta-analysis

BACKGROUND

To obtain the complication rate, fusion rate, and revision rate of the lumbar cortical bone trajectory technique and pedicle screw fixation technique in lumbar interbody fusion surgery by single-arm meta-analysis and lay a basis for orthopedic surgeons to select the fixation techniques and perioperative management.

METHODS

PubMed, Ovid Medline, Web of Science, CNKI, and Wanfang databases were searched comprehensively. Data extraction, content analysis, and quality assessment of the literature were performed by two independent reviewers according to the Cochrane Collaboration guidelines using R and STATA software for single-arm meta-analysis.

RESULTS

The total complication rate of the lumbar cortical bone trajectory technique was 6%, including a hardware complication rate of 2%, ASD (adjacent segment degeneration) rate of 1%, wound infection rate of 1%, dural damage rate of 1%, hematoma rate tending to 0%, fusion rate of 94%, and revision rate of 1%. Lumbar pedicle screw fixation techniques had a total complication rate of 9%, with a hardware complication rate of 2%, ASD rate of 3%, wound infection rate of 2%, dural damage rate of 1%, hematoma rate tending to 0%, fusion rate of 94%, and revision rate of 5%. This study was registered with PROSPERO, CRD42022354550.

CONCLUSION

Lumbar cortical bone trajectory was associated with a lower total complication rate, ASD rate, wound infection rate, and revision rate than pedicle screw fixation. The cortical bone trajectory technique reduces the incidence of intraoperative and postoperative complications and can be an alternative in lumbar interbody fusion surgery.

Comparative outcomes of cortical bone trajectory screw fixation and traditional pedicle screws in lumbar fusion: A meta-analysis

BACKGROUND

Pedicular screws (PS) is often used in lumbar fusion. Cortical bone trajectory (CBT) is a novel technology in lumbar fusion with less clinical outcomes evidence. So we conduct a meta-analysis to compare the efficacy and safety between cortical bone trajectory screw fixation and traditional pedicle screws in lumbar fusion surgery.

METHODS

Multiple databases were searched for the articles about comparison of cortical bone trajectory (CBT) and traditional pedicle screws (PS) in lumbar fusion surgeries. The Meta-analysis was conducted by Revman 5.3 software. The following indicators were abstracted: visual analog scale (VAS) scores for back and leg pain, Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA), surgical duration, complications, and blood loss. The quality of the articles was assessed by the Newcastle-Ottawa Scale or Cochrane Handbook.

RESULTS

25 studies were included involving a total of 1735 patients. There is no difference in preoperative VAS scores, JOA, ODI, postoperative VAS scores and fusion rates. Besides, postoperative JOA(MD = 0.78, P = 0.02), ODI (MD = -2.09, P＝0.03), surgical duration(MD = -26.90, P = 0.02), complications(MD = 0.70, P = 0.03), and blood loss(MD = -85.27, P＝0.0009) showed greater improvement trends in CBT group than PS group with significant difference.

CONCLUSION

CBT reduced the rate of complications, surgical duration, blood loss, postoperative ODI and JOA scores. CBT technique with better postoperative outcomes achieved similar fusion rates compared with PS technique.

Changes in Paraspinal Muscles and Facet Joints after Minimally Invasive Posterior Lumbar Interbody Fusion Using the Cortical Bone Trajectory Technique: A Prospective Study

In this prospective cohort study, we aimed to determine the surgical and adjacent segment changes in paraspinal muscles and facet joints in patients with lumbar spinal stenosis after minimally invasive posterior lumbar interbody fusion (PLIF) using the cortical bone trajectory (CBT) technique. We enrolled 30 consecutive patients who underwent the single-level CBT technique between October 2017 and October 2018. We evaluated preoperative and 1-month, 3-month, 6-month, and 1-year postoperative clinical data including Visual Analogue Scale (VAS) scores and Oswestry Disability Index (ODI). Magnetic resonance imaging (MRI) was performed a year after surgery. The erector spinae (ES) muscle area, volume, and fat infiltration (FI) on the surgical and adjacent segments were evaluated using the thresholding method, and the degree of adjacent facet joint degeneration was calculated using the Weishaupt scale. FI rate was graded using the Kjaer method. All patients underwent a 12-month follow-up. The VAS and ODI scores significantly improved after surgery in all patients. No patient showed degeneration of the adjacent facet joints (P > 0.05) during the 1-year follow-up postoperation. There was no significant difference in ES muscle volume, area, and FI on the surgical and adjacent segments (P > 0.05). The FI rate of the upper ES muscles increased postoperatively (P < 0.05); however, there were no significant changes in FI rate of the lower ES muscles. Patients with lumbar spinal stenosis could obtain satisfactory short-term clinical outcomes via minimally invasive PLIF using the CBT technique. Moreover, this technique may reduce the impact on the paravertebral muscles, especially the ES muscle, and the adjacent facet joints.