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Ono K, Murata S, Matsushita M, Shimizu Y, Nakamura Y, Yabe T, Ito H. Accuracy of Cervical Pedicle Screw Insertion With and Without a Navigation-Linked High-Speed Drill: A Retrospective Clinical Study. Cureus 2024; 16:e68558. [PMID: 39364480 PMCID: PMC11449457 DOI: 10.7759/cureus.68558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2024] [Indexed: 10/05/2024] Open
Abstract
INTRODUCTION Cervical pedicle screw (CPS) fixation provides high stability but poses a risk of nerve and vascular injury. Although useful for reducing CPS deviation rates, navigation systems cannot completely eliminate deviation. This study aimed to compare two methods for creating insertion paths, one using a navigation-linked high-speed drill (NAVI drill) and the other using conventional manual probing. METHODS Our study comprised 104 patients with 509 CPSs at the C3-6 level who were treated at our institution between 2017 and 2023. CPS deviations were graded according to the Neo classification system, and the deviation direction (medial, lateral, cranial, or caudal) was assessed. Complications associated with CPS deviation were also investigated. We compared cases that used the NAVI drill (Group M) with those that used manual probing (Group N). RESULTS Group M included 45 cases (252 screws), and Group N included 59 cases (257 screws). The CPS deviation rate was grade 1 or higher in 14.7% and 17.1% of cases in Groups M and N, respectively (p = 0.469). It was grade 2 or higher in 1.2% and 4.3% of cases in Groups M and N, respectively (p = 0.222). The medial, lateral, caudal, and cranial deviation direction rates were 56.8%, 2.7%, 40.5%, and 0% in Group M and 13.6%, 72.7%, 11.4%, and 2.3% in Group N, respectively (p < 0.001). In one case in Group N, a grade 3 lateral deviation resulted in vertebral artery injury (VAI). CONCLUSIONS The use of the NAVI drill was associated with a slightly lower, albeit insignificant, CPS deviation rate. However, it significantly lowered the proportion of lateral deviations. Therefore, the NAVI drill is a useful tool for preventing VAI.
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Affiliation(s)
- Kosei Ono
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, JPN
| | - Sohei Murata
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, JPN
| | - Mutsumi Matsushita
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, JPN
| | - Yu Shimizu
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, JPN
| | - Yusuke Nakamura
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, JPN
| | - Taisuke Yabe
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, JPN
| | - Hiromu Ito
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, JPN
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Ryu S, Ha BJ, Yoon S, Lee CK, Shin DA, Kim KN, Yi S. Feasibility and safety report on robotic assistance for cervical pedicle screw fixation: a cadaveric study. Sci Rep 2024; 14:10881. [PMID: 38740762 DOI: 10.1038/s41598-024-60435-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
This cadaveric study aimed to evaluate the safety and usability of a novel robotic system for posterior cervical pedicle screw fixation. Three human cadaveric specimens and C2-T3 were included. Freshly frozen human cadaver specimens were prepared and subjected to robot-assisted posterior cervical pedicle screw fixation using the robotic system. The accuracy of screw placement, breach rate, and critical structure violations were evaluated. The results were statistically compared with those of previous studies that used different robotic systems for cervical pedicle screw fixation. The robotic system demonstrated a high accuracy rate in screw placement. A significant number of screws were placed within predetermined safe zones. The total entry offset was 1.08 ± 0.83 mm, the target offset was 1.86 ± 0.50 mm, and the angle offset was 2.14 ± 0.77°. Accuracy rates comparable with those of previous studies using different robotic systems were achieved. The system was also feasible, allowing precise navigation and real-time feedback during the procedure. This cadaveric study validated the safety and usability of the novel robotic system for posterior cervical pedicle screw fixation. The system exhibited high precision in screw placement, and the results support the extension of the indications for robot-assisted pedicle screw fixation from the lumbar spine to the cervical spine.
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Affiliation(s)
- Seungjun Ryu
- Department of Neurosurgery, Daejeon Eulji University Hospital, School of Medicine, Eulji University, Daejeon, South Korea
- IBS Center for Cognition and Sociality, Expo-ro, Doryong-dong, Yuseong-gu, Daejeon, South Korea
| | - Byeong-Jin Ha
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri, Gyeonggi-do, 11923, Republic of Korea
| | - Sunjin Yoon
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Chang Kyu Lee
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Keung-Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
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Chen Z, Lv G, Zhang O, Li Y, Wang X, He H, Yuan H, Pan C, Kuang L. Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF). BMC Musculoskelet Disord 2024; 25:1. [PMID: 38166792 PMCID: PMC10759594 DOI: 10.1186/s12891-023-07116-z] [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: 04/29/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND For patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for symptom relief. However, hardware failure is not rare and results in neck pain or even permanent neurological lesions. There are no in-depth studies of hardware-related complications following laminectomy and PCF with instrumentation. METHODS The present study was a retrospective, single centre, observational study. Patients who underwent laminectomy and PCF with instrumentation in a single institution between January 2019 and January 2021 were included. Patients were divided into hardware failure and no hardware failure group according to whether there was a hardware failure. Data, including sex, age, screw density, end vertebra (C7 or T1), cervical sagittal alignment parameters (C2-C7 cervical lordosis, C2-C7 sagittal vertical axis, T1 slope, Cervical lordosis correction), regional Hounsfield units (HU) of the screw trajectory and osteoporosis status, were collected and compared between the two groups. RESULTS We analysed the clinical data of 56 patients in total. The mean overall follow-up duration was 20.6 months (range, 12-30 months). Patients were divided into the hardware failure group (n = 14) and no hardware failure group (n = 42). There were no significant differences in the general information (age, sex, follow-up period) of patients between the two groups. The differences in fusion rate, fixation levels, and screw density between the two groups were not statistically significant (p > 0.05). The failure rate of fixation ending at T1 was lower than that at C7 (9% vs. 36.3%) (p = 0.019). The regional HU values of the pedicle screw (PS) and lateral mass screw (LMS) in the failure group were lower than those in the no failure group (PS: 267 ± 45 vs. 368 ± 43, p = 0.001; LMS: 308 ± 53 vs. 412 ± 41, p = 0.001). The sagittal alignment parameters did not show significant differences between the two groups before surgery or at the final follow-up (p > 0.05). The hardware failure rate in patients without osteoporosis was lower than that in patients with osteoporosis (14.3% vs. 57.1%) (p = 0.001). CONCLUSIONS Osteoporosis, fixation ending at C7, and low regional HU value of the screw trajectory were the independent risk factors of hardware failure after laminectomy and PCF. Future studies should illuminate if preventive measures targeting these factors can help reduce hardware failure and identified more risk factors, and perform long-term follow-up.
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Affiliation(s)
- Zejun Chen
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Guohua Lv
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Ou Zhang
- California University of Science and Medicine, Colton, CA, USA
| | - Yunchao Li
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Xiaoxiao Wang
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Haoyu He
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Hui Yuan
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Changyu Pan
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Lei Kuang
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China.
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Canyang H, Weidong C, Zhiping H, Xiuhua W, Minghui Z, Haihong H, Qingan Z, Dongbin Q. A Novel Semi-Cannulated Screw Enhanced Bone Cement Augmentation and Pullout Strength in Posterior Cervical Lateral Mass Screw Fixations: An In Vitro Biomechanical and Morphological Study. Orthop Surg 2023; 15:2927-2936. [PMID: 37712328 PMCID: PMC10622296 DOI: 10.1111/os.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE To develop a novel semi-cannulated lateral mass screw (SC-LMS) for cervical posterior fixations and compare the fixation stability and safety of SC-LMS with regular solid lateral mass screw (S-LMS) in bone cement augmentation and pullout strength using fresh cadaveric cervical vertebrae. METHODS The conventional multiaxial screw for cervical lateral mass fixation was modified to a cannulated screw with two lateral holes, used for bone cement injection in situ. Eight fresh human cervical vertebrae (C3, C4, and C5) were collected and used. μCT scan was performed to evaluate the bone quality of the lateral masses, including bone mineral density (BMD), trabecular thickness (Tb.Th), and trabecular separation (Tb.Sp). SCLMS or S-LMS were randomly inserted into the paired cervical vertebrae and pulled out as a screw loosening model. These screws were reinserted in with bone cement augmentation, scanned by μCT to obtain the bone cement distribution along the screws, and pulled out to test the screw purchase strength. RESULTS Fmax values exhibited strong positive correlations with the local BMD (𝑟 = 0.8640, p < 0.0001) and Tb.Th (𝑟 = 0.6795, p = 0.0038), whereas a negative correlation with Tb.Sp (𝑟 = -0.5567, p = 0.0251). A significant difference was observed between the Fmax before and after PMMA injection on the SC-LMS side (p = 0.019). The SC-LMS exhibited lower risk of cement leakage than S-LMS after PMMA injection, and a positive correlation was observed between 𝐹max and the distribution volumes on the SC-LMS side. CONCLUSION The novel SC-LMS provides more robust fixation stability and is safer than the S-LMS for PMMA augmentation, which may be related to the cement-screw-cement-bone complex formation.
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Affiliation(s)
- Huang Canyang
- Division of Spine Surgery, Department of OrthopaedicsNanfang Hospital, Southern Medical UniversityGuangzhouChina
- Division of Spine Surgery, Department of OrthopaedicsQuanzhou First Hospital Affiliated to Fujian Medical University and Quanzhou First Hospital FujianQuanzhouChina
| | - Chen Weidong
- Division of Spine Surgery, Department of OrthopaedicsNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Huang Zhiping
- Division of Spine Surgery, Department of OrthopaedicsNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Wu Xiuhua
- Division of Spine Surgery, Department of OrthopaedicsNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Zheng Minghui
- Division of Spine Surgery, Department of OrthopaedicsNanfang Hospital, Southern Medical UniversityGuangzhouChina
- Department of OrthopaedicsZengcheng Branch of Nanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Huang Haihong
- Division of Spine Surgery, Department of OrthopaedicsNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Zhu Qingan
- Division of Spine Surgery, Department of OrthopaedicsNanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Qu Dongbin
- Division of Spine Surgery, Department of OrthopaedicsNanfang Hospital, Southern Medical UniversityGuangzhouChina
- Department of OrthopaedicsZengcheng Branch of Nanfang Hospital, Southern Medical UniversityGuangzhouChina
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Couch BK, Patel SS, Talentino SE, Buldo-Licciardi M, Evashwick-Rogler TW, Oyekan AA, Gannon EJ, Shaw JD, Donaldson WF, Lee JY. To Cross the Cervicothoracic Junction? Terminating Posterior Cervical Fusion Constructs Proximal to the Cervicothoracic Junction Does Not Impart Increased Risk of Reoperation in Patients With Cervical Spondylotic Myelopathy. Global Spine J 2023; 13:2379-2386. [PMID: 35285337 PMCID: PMC10538346 DOI: 10.1177/21925682221083926] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To evaluate the effect of caudal instrumentation level on revision rates following posterior cervical laminectomy and fusion. METHODS A retrospective review of a prospectively collected database was performed. Minimum follow-up was one year. Patients were divided into two groups based on the caudal level of their index fusion construct (Group 1-cervical and Group 2- thoracic). Reoperation rates were compared between the two groups, and preoperative demographics and radiographic parameters were compared between patients who required revision and those who did not. Multivariate binomial regression analysis was performed to determine independent risk factors for revision surgery. RESULTS One hundred thirty-seven (137/204) patients received fusion constructs that terminated at C7 (Group 1), while 67 (67/204) received fusion constructs that terminated at T1 or T2 (Group 2). The revision rate was 8.33% in the combined cohort, 7.3% in Group 1, and 10.4% in Group 2. There was no significant difference in revision rates between the 2 groups (P = .43). Multivariate regression analysis did not identify any independent risk factors for revision surgery. CONCLUSION This study shows no evidence of increased risk of revision in patients with fusion constructs terminating in the cervical spine when compared to patients with constructs crossing the cervicothoracic junction. These findings support terminating the fusion construct proximal to the cervicothoracic junction when indicated. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Brandon K. Couch
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stuti S. Patel
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | - Anthony A. Oyekan
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emmett J. Gannon
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeremy D. Shaw
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William F. Donaldson
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joon Y. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Zeng Y, Huang Z, Huang Z, Cheng Y, Zhu Q, Ji W, Jiang H. Ipsilateral Fixation and Reconstruction of the Cervical Spine after Resection of a Dumbbell Tumor Via a Unilateral Posterior Approach: A Case Report and Biomechanical Study. Orthop Surg 2023; 15:2435-2444. [PMID: 37431728 PMCID: PMC10475664 DOI: 10.1111/os.13798] [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: 02/01/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 07/12/2023] Open
Abstract
OBJECTIVE There is lack of an internal fixation following resection of a dumbbell tumor by hemi-laminectomy and facetectomy that achieves adequate stability with less trauma. Unilateral fixation and reconstruction (unilateral pedicle screw and contralateral lamina screw fixation combined with lateral mass reconstruction, UPS + CLS + LM) may be an ideal technique to address this problem. A biomechanical comparison and a case report were designed to evaluate its spinal stability and clinical effect. METHODS Seven fresh-frozen human subcervical specimens were used for the biomechanical testing. The conditions tested were: (1) intact; (2) injured (single-level hemi-laminectomy and facetectomy); (3) unilateral pedicle screw (UPS) fixation; (4) UPS fixation combined with lateral mass (LM) reconstruction (UPS + LM); (5) UPS fixation and contralateral lamina screw fixation (UPS + CLS); (6) UPS + CLS + LM; (7) UPS fixation and contralateral transarticular screw fixation (UPS + CTAS); (8) bilateral pedicle screw (BPS) fixation. Range of motion (ROM) and neutral zone (NZ) were obtained at C5-C7 segment under eight conditions. In addition, we report the case of a patient with a C7-T1 dumbbell tumor that was treated by UPS + CLS + LM technique. RESULTS Except left/right lateral bending and right axial rotation (all, p < 0.05), ROM of UPS + CLS + LM condition in other directions was similar to that of BPS condition (all, p > 0.05). There was no significant difference between UPS + CLS + LM and the UPS + CTAS condition in other directions of ROM (all, p > 0.05), except in left/right axial rotation (both, p < 0.05). Compared to UPS + CLS condition, left/right lateral bending ROM of UPS + CLS + LM condition were significantly reduced (both, p < 0.05). UPS + CLS + LM condition significantly reduced ROM in all directions compared to UPS and UPS + LM condition (all, p < 0.05). Similarly, except lateral bending (p < 0.05), there was no difference in NZ in other directions between UPS + CLS + LM and BPS condition (both, p > 0.05). There was no significant difference between UPS + CLS + LM and UPS + CTAS condition in NZ in all directions (all, p > 0.05). Axial rotation NZ of UPS + CLS + LM condition was significantly reduced compared to UPS + CLS condition (p < 0.05). Compared to UPS and UPS + LM condition, NZ of UPS + CLS + LM condition was significantly reduced in all directions (all, p < 0.05). The patient's imaging examination at 3 months postoperatively indicated that the internal fixation did not move and the graft bone was seen with fusion. CONCLUSION After resection of a dumbbell tumor in the cervical spine, UPS + CLS + LM technique is a reliable internal fixation method to provide sufficient immediate stability and promote postoperative bone fusion.
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Affiliation(s)
- Yongqiang Zeng
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Zhiping Huang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Zucheng Huang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Yongquan Cheng
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Qing'an Zhu
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Wei Ji
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
| | - Hui Jiang
- Division of Spine Surgery, Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouPeople's Republic of China
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Li C, Song L, Xiao J, Wu W, Jiang Y, Zhou R, Dai F. Second-generation bone cement-injectable cannulated pedicle screws for osteoporosis: biomechanical and finite element analyses. J Orthop Surg Res 2023; 18:343. [PMID: 37161530 PMCID: PMC10170841 DOI: 10.1186/s13018-023-03752-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/24/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Biomechanical and finite element analyses were performed to investigate the efficacy of second-generation bone cement-injectable cannulated pedicle screws (CICPS) in osteoporosis. METHODS This study used the biomechanical test module of polyurethane to simulate osteoporotic cancellous bone. Polymethylmethacrylate (PMMA) bone cement was used to anchor the pedicle screws in the module. The specimens were divided into two groups for the mechanical tests: the experimental group (second-generation CICPS) and control group (first-generation CICPS). Safety was evaluated using maximum shear force, static bending, and dynamic bending tests. Biomechanical stability evaluations included the maximum axial pullout force and rotary torque tests. X-ray imaging and computed tomography were used to evaluate the distribution of bone cement 24 h after PMMA injection, and stress distribution at the screw fracture and screw-cement-bone interface was assessed using finite element analysis. RESULTS Mechanical testing revealed that the experimental group (349.8 ± 28.6 N) had a higher maximum axial pullout force than the control group (277.3 ± 8.6 N; P < 0.05). The bending moments of the experimental group (128.5 ± 9.08 N) were comparable to those of the control group (113.4 ± 20.9 N; P > 0.05). The screw-in and spin-out torques of the experimental group were higher than those of the control group (spin-in, 0.793 ± 0.015 vs. 0.577 ± 0.062 N, P < 0.01; spin-out, 0.764 ± 0.027 vs. 0.612 ± 0.049 N, P < 0.01). Bone cement was mainly distributed at the front three-fifths of the screw in both groups, but the distribution was more uniform in the experimental group than in the control group. After pullout, the bone cement was closely connected to the screw, without loosening or fragmentation. In the finite element analysis, stress on the second-generation CICPS was concentrated at the proximal screw outlet, whereas stress on the first-generation CICPS was concentrated at the screw neck, and the screw-bone cement-bone interface stress of the experimental group was smaller than that of the control group. CONCLUSION These findings suggest that second-generation CICPS have higher safety and stability than first-generation CICPS and may be a superior choice for the treatment of osteoporosis.
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Affiliation(s)
- Congcan Li
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng Street, Chongqing, 400038, China
| | - Lei Song
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng Street, Chongqing, 400038, China
| | - Jun Xiao
- Department of Special Service Physiological Training, Guangzhou Special Service Recuperation Center of PLA Rocket Force, Shantou, 515515, China
| | - Wenwen Wu
- Chinese People's Liberation Army 132U, Tunchang, 571627, China
| | - Yifan Jiang
- Fourth Department of Convalescence, Sanya Rehabilitation and Convalescent Center, Joint Logistics Support Force, Sanya, 572000, China
| | - Rui Zhou
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng Street, Chongqing, 400038, China.
| | - Fei Dai
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng Street, Chongqing, 400038, China.
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Soliman MAR, Aguirre AO, Khan S, Kuo CC, Ruggiero N, Mariotti BL, Fritz AG, Sharma S, Nezha A, Levy BR, Khan A, Salem AA, Jowdy PK, Zeeshan Q, Ghannam MM, Starling RV, Rho K, Pollina J, Mullin JP. Complications associated with subaxial placement of pedicle screws versus lateral mass screws in the cervical spine (C2-T1): systematic review and meta-analysis comprising 4,165 patients and 16,669 screws. Neurosurg Rev 2023; 46:61. [PMID: 36849823 DOI: 10.1007/s10143-023-01968-8] [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: 01/11/2023] [Revised: 02/09/2023] [Accepted: 02/19/2023] [Indexed: 03/01/2023]
Abstract
Lateral mass screw (LMS) and cervical pedicle screw (CPS) fixation are among the most popular techniques for posterior fusion of the cervical spine. Early research prioritized the LMS approach as the trajectory resulted in fewer neurovascular complications; however, with the incorporation of navigation assistance, the CPS approach should be re-evaluated. Our objective was to report the findings of a meta-analysis focused on comparing the LMS and CPS techniques in terms of rate of various complications with inclusion of all levels from C2 to T1. We conducted a systematic review of PubMed and EMBASE databases with final inclusion criteria focused on identifying studies that reported outcomes and complications for either the CPS or LMS technique. These studies were then pooled, and statistical analyses were performed from the cumulative data. A total of 60 studies comprising 4165 participants and 16,669 screws placed within the C2-T1 levels were identified. Within these studies, the LMS group had a significantly increased odds for lateral mass fractures (odds ratio [OR] = 43.2, 95% confidence interval [CI] = 2.62-711.42), additional cervical surgeries (OR = 5.56, 95%CI = 2.95-10.48), and surgical site infections (SSI) (OR = 5.47, 95%CI = 1.65-18.16). No other significant differences between groups in terms of complications were identified. Within the subgroup analysis of navigation versus non-navigation-guided CPS placement, no significant differences were identified for individual complications, although collectively significantly fewer complications occurred with navigation (OR = 5.29, 95%CI = 2.03-13.78). The CPS group had significantly fewer lateral mass fractures, cervical revision surgeries, and SSIs. Furthermore, navigation-assisted CPS placement was associated with a significant reduction in complications overall.
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Affiliation(s)
- Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Slah Khan
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Brandon L Mariotti
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Alexander G Fritz
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Siddharth Sharma
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Anxhela Nezha
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Bennett R Levy
- School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Amany A Salem
- Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Patrick K Jowdy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Qazi Zeeshan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Moleca M Ghannam
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Robert V Starling
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Kyungduk Rho
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA.
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.
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9
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Goldberg JL, Carnevale JA, Xia J, Sommer F, Gadjradj P, Medary B, Giantini-Larsen A, Navarro-Ramirez R, Tsiouris AJ, Chakravarthy V, Schwarz JT, McGrath LB, Virk MS, Fu KM, Riew KD, Hussain I, Härtl R. Variation in Cervical Pedicle Morphology: Important Considerations for Posterior Cervical Procedures. Oper Neurosurg (Hagerstown) 2023; 24:e85-e91. [PMID: 36637311 PMCID: PMC10158926 DOI: 10.1227/ons.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/30/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Safe posterior cervical spine surgery requires in-depth understanding of the surgical anatomy and common variations. The cervical pedicle attachment site to the vertebral body (VB) affects the location of exiting nerve roots and warrants preoperative evaluation. The relative site of attachment of the cervical pedicle has not been previously described. OBJECTIVE To describe the site of the pedicle attachment to the VB in the subaxial cervical spine. METHODS Cervical spine computed tomography scans without any structural, degenerative, or traumatic pathology as read by a board-certified neuroradiologist during 2021 were reviewed. Multiplanar reconstructions were created and cross-registered. The pedicle's attachment to the VB was measured relative to the VB height using a novel calculation system. RESULTS Fifty computed tomography scans met inclusion criteria yielding 600 total pedicles between C3-T1 (100 per level). The average patient age was 26 ± 5.3 years, and 21/50 (42%) were female. 468/600 (78%) pedicles attached in the cranial third of the VB, 132/600 (22%) attached in the middle third, and 0 attached to the caudal third. The highest prevalence of variant anatomy occurred at C3 (36/100 C3 pedicles; 36%). CONCLUSION In the subaxial cervical spine, pedicles frequently attach to the top third of the VB, but significant variation is observed. The rate of variation is highest at C3 and decreases linearly with caudal progression down the subaxial cervical spine to T1. This is the first report investigating this morphological phenomenon.
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Affiliation(s)
- Jacob L. Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Joseph A. Carnevale
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Jimmy Xia
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Fabian Sommer
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Pravesh Gadjradj
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Branden Medary
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - A. John Tsiouris
- Department of Radiology, Division of Neuroradiology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Vikram Chakravarthy
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Justin T. Schwarz
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Lynn B. McGrath
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Michael S. Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - K. Daniel Riew
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
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10
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Wiguna IA, Suyasa IK, Nugraha HK. Pedicle Screw Fixation for Hemiplegia and Bilateral Hypoesthesia Due to C2-C3 Spinal Fracture Dislocation: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00049. [PMID: 36867717 DOI: 10.2106/jbjs.cc.22.00337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
CASE A 48-year-old man fell from a tree and presented to the emergency department with right-sided full hemiplegia and C3 bilateral hypoesthesia. Imaging was remarkable for a C2-C3 fracture-dislocation. The patient was effectively managed surgically with a posterior decompression and 4-level posterior cervical fixation/fusion that included pedicle screws in the axis fixation and lateral mass screws. The reduction/fixation remained stable, and the patient regained full lower extremity function and demonstrated functional upper-extremity recovery at three-year follow-up. CONCLUSIONS C2-C3 fracture-dislocation is a rare but potentially fatal injury due to concomitant spinal cord injury, and its surgical management can be challenging because of the proximity of vascular and nerve structures. Posterior cervical fixation that includes axis pedicle screws can be an effective fixation option in select patients with this condition.
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Affiliation(s)
- Iglna Artha Wiguna
- Department of Orthopedic and Traumatology, Faculty of Medicine Udayana University / Sanglah General Hospital, Bali, Indonesia
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11
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Vickery JW, Varas EE, Abtahi AM. Crossing the Cervicothoracic Junction: A Review of the Current Literature. Clin Spine Surg 2022; 35:451-457. [PMID: 36447350 DOI: 10.1097/bsd.0000000000001411] [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: 09/06/2022] [Accepted: 10/03/2022] [Indexed: 12/05/2022]
Abstract
ABSTRACT The cervicothoracic junction (CTJ) is the site of transition in biomechanical, osseous, and alignment properties of the spine. The interface between the highly mobile, lordotic cervical spine and the rigid, kyphotic thoracic spine results increased the biomechanical stress experienced at this junction. The concentration of stress at this level has led to high rates of failure when instrumenting near or across the CTJ. The changes in osseous anatomy from the cervical spine to the thoracic spine present additional challenges in construct planning. For these reasons, a thorough understanding of the complexity of the cervicothoracic junction is necessary when operating near or across the CTJ. There are multiple options for cervical fixation, including lateral mass screws, pedicle screws, and laminar screws, each with its own advantages and risks. Instrumentation at C7 is controversial, and there is data supporting both its inclusion in constructs and no risk when this level is skipped. Thoracic pedicle screws are the preferred method of fixation in this region of the spine; however, the connection between cervical and thoracic screws can be challenging due to differences in alignment. Transitional rods and rod connectors mitigate some of the difficulties with this transition and have shown to be effective options. Recently, more investigation has looked into the failure of posterior cervical constructs which end at or near the CTJ. The trend in data has favored fixation to T1 or T2 rather than ending a construct at C7 due to the decreased rates of distal junction kyphosis. Although data on patient-reported outcomes with a length of constructs and the lowest instrumented vertebra is scarce, preliminary reports show no difference at this time. As posterior cervical instrumentation continues to increase in frequency, the CTJ will continue to be an area of difficulty in navigation and instrumentation. A thorough understanding of this region is necessary and continued research is needed to improve outcomes. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
| | | | - Amir M Abtahi
- Department of Orthopaedic Surgery
- Center for Musculoskeletal Research
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
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12
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He YX, Shang QS, Feng L, Li HB, Han L, Zhou D, Jiang YQ. Comparison of the Safety and Efficacy of Three-Dimensional Guiding Templates and Free Hand Technique for Cervical Pedicle Screw Fixation: A Retrospective Study. Surg Innov 2022; 29:652-661. [DOI: 10.1177/15533506221127381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim. To compare the safety and efficacy of computed tomography (CT)-assisted three-dimensional guiding templates (3DGTs) and free-hand (FH) technique for posterior cervical pedicle screw fixation in cervical spondylotic myelopathy (CSM) treatment. Methods. Thirty-five patients (216 screws) with CSM and developmental cervical stenosis were randomly divided into groups A (FH) and B (3DGTs). All patients underwent modified posterior surgery with cervical pedicle screw insertion (C1-7). Preoperative, postoperative, and intergroup comparisons of efficacy were evaluated using the visual analog scale (VAS), Japanese Orthopaedic Association (JOA), and Short Form 12 (SF-12) scores and JOA score improvement rate. Incidence of intra- and postoperative complications was analyzed. Postoperative cervical spine CT was performed to evaluate (i) the pedicle screws’ deviation angle from the optimal path (sagittal deviation, α; coronal deviation angle, β), screw insertion point’s deviation distance (d), and screw accuracy and (ii) the deviation angle and distance of screw entrance point of pedicle screws from the optimal channel. Results. All patients successfully completed the procedures. Groups A and B did not significantly differ in age, sex ratio, body mass index, operative time, or intraoperative blood loss amount. Postoperative VAS, JOA, and SF-12 scores improved in both groups. VAS, JOA, or SF-12 scores did not significantly differ between the 2 groups. The α, β, and d scores were lower in group B, but accuracy was higher in group B. Conclusions. 3DGTs and FH technique show comparable outcomes with respect to neurological improvement and safety.
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Affiliation(s)
- Yan-xing He
- Department of Orthopedics, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou City, Jiangsu Province
| | - Qi-song Shang
- Department of Orthopedics, Third Affiliated Hospital School of Medicine College, Shihezi City, Xinjiang Province
| | - Lin Feng
- Department of Orthopedics, Wuqia People’s Hospital, The Kirgiz Autonomous Prefecture of Kizilsu, Xinjiang Uygur Autonomous Region
| | - Hai-bo Li
- Department of Orthopedics, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou City, Jiangsu Province
| | - Long Han
- Department of Orthopedics, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou City, Jiangsu Province
| | - Dong Zhou
- Department of Orthopedics, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou City, Jiangsu Province
- Department of Orthopedics, Wuqia People’s Hospital, The Kirgiz Autonomous Prefecture of Kizilsu, Xinjiang Uygur Autonomous Region
| | - Yu-qing Jiang
- Department of Orthopedics, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou City, Jiangsu Province
- Department of Orthopedics, Wuqia People’s Hospital, The Kirgiz Autonomous Prefecture of Kizilsu, Xinjiang Uygur Autonomous Region
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13
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Biomechanical Comparison of Salvage Pedicle Screw Augmentations Using Different Biomaterials. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12157792] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Allograft bone particles, hydroxyapatite/β-hydroxyapatite-tricalcium phosphate (HA/β-TCP), calcium sulfate (CS), and polymethylmethacrylate (PMMA) bone cement are biomaterials clinically used to fill defective pedicles for pedicle screw augmentation. Few studies have systematically investigated the effects of various biomaterials utilized for salvage screw stabilization. The aim of this study was to evaluate the biomechanical properties of screws augmented with these four different materials and the effect of different pilot hole sizes and bone densities on screw fixation strength. Commercially available synthetic bones with three different densities (7.5 pcf, 15pcf, 30 pcf) simulating different degrees of bone density were utilized as substitutes for human bone. Two different pilot hole sizes (3.2 mm and 7.0 mm in diameter) were prepared on test blocks to simulate primary and revision pedicle screw fixation, respectively. Following separate specimen preparation with these four different filling biomaterials, a screw pullout test was conducted using a material test machine, and the average maximal screw pullout strength was compared among groups. The average maximal pullout strength of the materials, presented in descending order, was as follows: bone cement, calcium sulfate, HA/β-TCP, allograft bone chips and the control. In samples in both the 3.2 mm pilot-hole and 7.0 mm pilot-hole groups, the average maximal pullout strength of these four materials increased with increasing bone density. The average maximal pullout strength of the bone cement augmented salvage screw (7.0 mm) was apparently elevated in the 7.5 pcf test block. Salvage pedicle screw augmentation with allograft bone chips, HA/β-TCP, calcium sulfate, and bone cement are all feasible methods and can offer better pullout strength than materials in the non-augmentation group. Bone cement provides the most significantly augmented effect in each pilot hole size and bone density setting and could be considered preferentially to achieve larger initial stability during revision surgery, especially for bones with osteoporotic quality.
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14
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Tsuda K, Tagami A, Yamada S, Yokota K, Chiba K, Yonekura A, Tomita M, Osaki M. Computed tomographic evaluation of three types of screw trajectories for posterior cervical spine fixation: Cervical pedicle screw, lateral mass screw, and paravertebral foramen screw. Medicine (Baltimore) 2022; 101:e29857. [PMID: 35839061 PMCID: PMC11132321 DOI: 10.1097/md.0000000000029857] [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: 01/10/2022] [Accepted: 06/06/2022] [Indexed: 11/26/2022] Open
Abstract
Computed tomography (CT) attenuation values of cervical spine were evaluated in vivo using a clinically relevant group. To compare CT attenuation values between cervical pedicle screw (CPS), lateral mass screw (LMS), and paravertebral foramen screw (PVFS) trajectories. CPS and LMS are commonly used for posterior fixation of the cervical spine. The PVFS method has been reported as a new method. CT attenuation values along the screw trajectory are reportedly associated with screw stability. We identified 45 patients who had undergone whole-body CT for trauma with no injury to the cervical spine. Regions of interest (ROIs) were designated along the trajectories that would be used for CPS, LMS, and PVFS through vertebral pedicles and lateral masses of the C3-C6 vertebrae. CT attenuation values of each ROI were measured and compared between each screw trajectories at each cervical vertebral level. Participants were divided into Group I (age, 20-39 years; n = 12), Group II (age, 40-59 years; n = 17), and Group III (age, 60-79 years; n = 16). CT attenuation values of ROIs were compared between each age group. PVFS trajectories showed higher CT attenuation values than LMS trajectories at every vertebral level and also higher values than CPS trajectories at C5 and C6 levels. CT attenuation values at C3 were lower than those at C4 in the LMS trajectory and lower than those at C5 and C6 in the PVFS trajectory. CT attenuation values were lower in the elder group (>60 years old) than in the other 2 groups for all screw trajectories. CT attenuation values suggested that the PVFS technique may be useful for posterior fixation of the cervical spine in elder patients who require more secure fixation.
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Affiliation(s)
- Keiichi Tsuda
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Atsushi Tagami
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shuta Yamada
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuaki Yokota
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ko Chiba
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Yonekura
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masato Tomita
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Makoto Osaki
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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15
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Zhang K, Chen H, Chen K, Yang P, Yang H, Mao H. O-Arm Navigated Cervical Pedicle Screw Fixation in the Treatment of Lower Cervical Fracture-Dislocation. Orthop Surg 2022; 14:1135-1142. [PMID: 35524652 PMCID: PMC9163967 DOI: 10.1111/os.13227] [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: 06/07/2020] [Revised: 01/12/2022] [Accepted: 01/19/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of cervical pedicle screw (CPS) placement with O-arm navigation in the treatment of lower cervical fracture-dislocation. METHODS A retrospective clinical study was performed involving 42 consecutive patients with lower cervical spine fracture-dislocation who underwent CPS fixation surgery with O-arm navigation (CPS group) or received conventional lateral mass screw (LMS) fixation surgery (LMS group) between August 2015 and August 2019. Accuracy of CPS position was evaluated by postoperative CT. The clinical parameters including preoperative and final follow-up Japanese Orthopaedic Association (JOA) score and American Spinal Injury Association (ASIA) Impairment Scale, preoperative Sub-axial Injury Classification (SLIC) score, number of fixation segments, operation time, intraoperative blood loss, injury mechanism, injury location, surgical complications were also assessed between the two groups. RESULTS In LMS group, the preoperative SLIC score was 7.5 ± 0.9, ASIA score improvement was 0.8 ± 0.5, JOA score improvement was 3.0 ± 1.8, mean operation time was 204 ± 89 min, intraoperative blood loss was 311 ± 127 ml. In CPS group, the preoperative SLIC score was 7.3 ± 1.2, ASIA score improvement was 0.9 ± 0.5, JOA score improvement was 3.2 ± 2.4, mean operation time is 241 ± 85 min, intraoperative blood loss is about 327 ± 120 ml. There was no significant difference in terms of above clinical parameters between the two groups (P > 0.05), the fixation segments in CPS group (3.5 ± 1.1) were less than that in LMS group (4.2 ± 0.7) (P = 0.037). The accuracy of CPS insertion was evaluated based on postoperative CT. Of all the 118 CPSs, 83 (70.3%) were defined as Grade 0; 27 (22.9%) as Grade 1; eight (6.8%) as Grade 2; and none as Grade 3. CPS malposition rate in this study was 6.8%. In this study, there was no direct intraoperative or postoperative complication caused by CPS or LMS insertion. All the operations were successfully completed in two groups. One of the patients in LMS group presented cerebrospinal fluid leak caused by bone fragment broken of the dural sac, which led to delayed incision healing. CPS group and LMS group both had two patients who suffered pulmonary infection after surgery. A total of 78.6% of the patients showed evidence of neurologic recovery. Satisfactory reduction was achieved in all cases and maintained throughout the follow-up duration. CONCLUSION In the treatment of lower cervical spine fracture-dislocation, cervical pedicle screw insertion with O-arm navigation is a safe and effective method for posterior fixation.
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Affiliation(s)
- Kai Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hao Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Yangzhou University, Yangzhou, China.,Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou, China
| | - Kangwu Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peng Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Huilin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haiqing Mao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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16
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Liu H, Zhou ZY, Wei JX, Zhang M, Bai M, Huang AB. Comprehensive analysis of pedicle screw implantation in the C7 vertebra using computed tomography-based three-dimensional models. BMC Surg 2022; 22:96. [PMID: 35287657 PMCID: PMC8922919 DOI: 10.1186/s12893-022-01548-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background From a biomechanical point of view, pedicle screws (PS) are better than other kinds of screws for implantation in the seventh cervical vertebra (C7). However, the application of PS is limited because of the high risk of severe complications. It is essential to define the optimal entry point and trajectory. The aim of this study was to comprehensively analyze the starting point and trajectory for C7 PS insertion using three dimensional (3D) models. Methods Overall, 60 subjects aged 18 to 67 years old were included. All CT images were used to construct 3D computer models of the C7 vertebrae. A new coordinate system was established for the next evaluation. The pedicle axis was calculated with respect to the entire pedicle; then, the ideal entry point, screw diameter and length, sagittal angle and lateral angle were assessed. Results All the ideal entry points were located at the medial superior to lateral notch (LN), and the mean distance between the entry point and LN was 5.86 ± 1.67 mm in the horizontal direction and 3.47 ± 1.57 mm in the vertical direction. The mean distance between the entry point and the middle point of the inferior edge of the C6 articular process (MP) was 0.74 ± 1.83 mm in the horizontal direction. The mean sagittal angle of the pedicle axis was 90.42°, and the mean pedicle transverse angle was 30.70°. The average diameter and length of the PS were 6.51 ± 0.76 mm and 31.58 ± 4.40 mm, respectively. Conclusions This study provided a novel method to calculate the ideal starting point and trajectory for C7 PS insertion. These measurements may be helpful for preoperative planning. It is recommended that 3D CT imaging is used preoperatively to carefully evaluate the anatomy of each individual.
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Affiliation(s)
- Huan Liu
- Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Zhi-Yong Zhou
- Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Jia-Xu Wei
- Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Ming Zhang
- Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Meng Bai
- Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Ai-Bing Huang
- Department of Orthopedics, Hospital Affiliated 5 to Nantong University (Taizhou People's Hospital), Taizhou, 225300, Jiangsu, China. .,Postgraduate School, Dalian Medical University, Dalian, 116000, Liaoning, China.
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17
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Willemsen K, Magré J, Mol J, Noordmans HJ, Weinans H, Hekman EEG, Kruyt MC. Vital Role of In-House 3D Lab to Create Unprecedented Solutions for Challenges in Spinal Surgery, Practical Guidelines and Clinical Case Series. J Pers Med 2022; 12:395. [PMID: 35330395 PMCID: PMC8951204 DOI: 10.3390/jpm12030395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022] Open
Abstract
For decades, the advantages of rapid prototyping for clinical use have been recognized. However, demonstrations of potential solutions to treat spinal problems that cannot be solved otherwise are scarce. In this paper, we describe the development, regulatory process, and clinical application of two types of patient specific 3D-printed devices that were developed at an in-house 3D point-of-care facility. This 3D lab made it possible to elegantly treat patients with spinal problems that could not have been treated in a conventional manner. The first device, applied in three patients, is a printed nylon drill guide, with such accuracy that it can be used for insertion of cervical pedicle screws in very young children, which has been applied even in semi-acute settings. The other is a 3D-printed titanium spinal column prosthesis that was used to treat progressive and severe deformities due to lysis of the anterior column in three patients. The unique opportunity to control size, shape, and material characteristics allowed a relatively easy solution for these patients, who were developing paraplegia. In this paper, we discuss the pathway toward the design and final application, including technical file creation for dossier building and challenges within a point-of-care lab.
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Affiliation(s)
- Koen Willemsen
- Department of Orthopedics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.); (J.M.); (H.W.); (M.C.K.)
- 3D Lab, Division of Surgical Specialties, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Joëll Magré
- Department of Orthopedics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.); (J.M.); (H.W.); (M.C.K.)
- 3D Lab, Division of Surgical Specialties, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Jeroen Mol
- Department of Orthopedics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.); (J.M.); (H.W.); (M.C.K.)
| | - Herke Jan Noordmans
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Harrie Weinans
- Department of Orthopedics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.); (J.M.); (H.W.); (M.C.K.)
- Department Biomechanical Engineering, Delft University of Technology, 2628 CD Delft, The Netherlands
| | - Edsko E. G. Hekman
- Department of Biomechanical Engineering, Twente University, 7522 NB Enschede, The Netherlands;
| | - Moyo C. Kruyt
- Department of Orthopedics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.); (J.M.); (H.W.); (M.C.K.)
- Department of Biomechanical Engineering, Twente University, 7522 NB Enschede, The Netherlands;
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18
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Soliman MAR, Khan A, Pollina J, Mullin JP. Letter to the Editor. Meta-analysis of fluoroscopic and navigation-based cervical pedicle screw placement. J Neurosurg Spine 2022; 36:522-523. [PMID: 34624838 DOI: 10.3171/2021.6.spine21859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mohamed A R Soliman
- 1Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY
- 2Buffalo General Medical Center, Kaleida Health, Buffalo, NY
- 3Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Asham Khan
- 1Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY
- 2Buffalo General Medical Center, Kaleida Health, Buffalo, NY
| | - John Pollina
- 1Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY
- 2Buffalo General Medical Center, Kaleida Health, Buffalo, NY
| | - Jeffrey P Mullin
- 1Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY
- 2Buffalo General Medical Center, Kaleida Health, Buffalo, NY
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Nakashima H, Imagama S, Yoshii T, Egawa S, Sakai K, Kusano K, Nakagawa Y, Hirai T, Wada K, Katsumi K, Fujii K, Kimura A, Furuya T, Kanchiku T, Nagamoto Y, Oshima Y, Nagoshi N, Ando K, Takahata M, Mori K, Nakajima H, Murata K, Matsunaga S, Kaito T, Yamada K, Kobayashi S, Kato S, Ohba T, Inami S, Fujibayashi S, Katoh H, Kanno H, Li Y, Yatsuya H, Koda M, Kawaguchi Y, Takeshita K, Matsumoto M, Yamazaki M, Okawa A. Comparison of laminoplasty and posterior fusion surgery for cervical ossification of posterior longitudinal ligament. Sci Rep 2022; 12:748. [PMID: 35031694 PMCID: PMC8760337 DOI: 10.1038/s41598-021-04727-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
This prospective multicenter study, established by the Japanese Ministry of Health, Labour and Welfare and involving 27 institutions, aimed to compare postoperative outcomes between laminoplasty (LM) and posterior fusion (PF) for cervical ossification of the posterior longitudinal ligament (OPLL), in order to address the controversy surrounding the role of instrumented fusion in cases of posterior surgical decompression for OPLL. 478 patients were considered for participation in the study; from among them, 189 (137 and 52 patients with LM and PF, respectively) were included and evaluated using the Japanese Orthopaedic Association (JOA) scores, the JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), and radiographical measurements. Basic demographic and radiographical data were reviewed, and the propensity to choose a surgical procedure was calculated. Preoperatively, there were no significant differences among the participants in terms of patient backgrounds, radiographical measurements (K-line or cervical alignment on X-ray, OPLL occupation ratio on computed tomography, increased signal intensity change on magnetic resonance imaging), or clinical status (JOA score and JOACMEQ) after adjustments. The overall risk of perioperative complications was found to be lower with LM (odds ratio [OR] 0.40, p = 0.006), and the rate of C5 palsy occurrence was significantly lower with LM (OR 0.11, p = 0.0002) than with PF. The range of motion (20.91° ± 1.05° and 9.38° ± 1.24°, p < 0.0001) in patients who had PF was significantly smaller than in those who had LM. However, multivariable logistic regression analysis showed no significant difference among the participants in JOA score, JOA recovery rate, or JOACMEQ improvement at two years. In contrast, OPLL progression was greater in the LM group than in the PF group (OR 2.73, p = 0.0002). Both LM and PF for cervical myelopathy due to OPLL had resulted in comparable postoperative outcomes at 2 years after surgery.
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Affiliation(s)
- Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan.
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
| | - Satoru Egawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
| | - Kenichiro Sakai
- Department of Orthopaedic Surgery, Saiseikai Kawaguchi General Hospital, 5-11-5 Nishikawaguchi, Kawaguchishi, Saitama, 332-8558, Japan
| | - Kazuo Kusano
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudanminami, Chiyodaku, 102-0074, Japan
| | - Yukihiro Nakagawa
- Department of Orthopaedic Surgery, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Itogun, Wakayama, 649-7113, Japan
| | - Takashi Hirai
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
| | - Kanichiro Wada
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan
| | - Keiichi Katsumi
- Department of Orthopaedic Surgery, Niigata University Medicine and Dental General Hospital, 1-754 Asahimachidori, Chuo Ward, Niigata, Niigata, 951-8520, Japan
| | - Kengo Fujii
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Atsushi Kimura
- Department of Orthoaedics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo Ward, Chiba, Chiba, 260-8670, Japan
| | - Tsukasa Kanchiku
- Department of Orthopaedic Surgery, Yamaguchi University School of Medicine, 111 Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Yukitaka Nagamoto
- Department of Orthopaedic Surgery, Osaka Rosai Hospital, 1179-3 Nagasonecho, Sakaishi, Osaka, 591-8025, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku Ward, Tokyo, 160-8582, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Sapporo, 060-8638, Japan
| | - Kanji Mori
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Kazuma Murata
- Department of Orthopaedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Shunji Matsunaga
- Department of Orthopaedic Surgery, Imakiire General Hospital, 4-16 Shimotatsuocho, Kagoshimashi, 892-8502, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Kei Yamada
- Department of Orthopaedic Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, 830-0011, Japan
| | - Sho Kobayashi
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3125, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo Ward, Yamanashi, 409-3898, Japan
| | - Satoshi Inami
- Department of Orthopaedic Surgery, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotsuga-gun, Tochigi, 321-0293, Japan
| | - Shunsuke Fujibayashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Haruo Kanno
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryomachi, Aoba Ward, Sendai, Miyagi, 980-8574, Japan
| | - Yuanying Li
- Department of Public Health, Fujita Health University School of Medicine, Aichi, Japan
| | - Hiroshi Yatsuya
- Department of Public Health, Fujita Health University School of Medicine, Aichi, Japan.,Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masao Koda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Katsushi Takeshita
- Department of Orthoaedics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku Ward, Tokyo, 160-8582, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Atsushi Okawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
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Kwon JW, Arreza EO, Suguitan AA, Lee SB, Sung S, Park Y, Ha JW, Kim TH, Moon SH, Lee BH. Medial Pedicle Pivot Point Using Preoperative Computed Tomography Morphometric Measurements for Cervical Pedicle Screw Insertion: A Novel Technique and Case Series. J Clin Med 2022; 11:jcm11020396. [PMID: 35054092 PMCID: PMC8779533 DOI: 10.3390/jcm11020396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/29/2021] [Accepted: 01/01/2022] [Indexed: 02/04/2023] Open
Abstract
This study describes a new and safe freehand cervical pedicle screw insertion technique using preoperative computed tomography (CT) morphometric measurements as a guide and a medial pedicle pivot point (MPPP) during the procedure. This study included 271 pedicles at 216 cervical spine levels (mean: 4.75 pedicles per patient). A pedicle diameter (PD) ≥ 3.5 mm was the cut-off for pedicle screw fixation. The presence and grade of perforation were detected using postoperative CT scans, where perforations were graded as follows: 0, no perforation; 1, perforation < 0.875 mm; 2, perforation 0.875-1.75 mm; and 3, perforation > 1.75 mm. The surgical technique involved the use of an MPPP, which was the point at which the lines representing the depth of the lateral mass and total length of the pedicle intersected, deep in the lateral mass. The overall success rate was 96.3% (261/271, Grade 0 or 1 perforations). In total, 54 perforations occurred, among which 44 (81.5%) were Grade 1 and 10 (18.5%) were Grade 2. The most common perforation direction was medial (39/54, 72.2%). The freehand technique for cervical pedicle screw fixation using the MPPP may allow for a safe and accurate procedure in patients with a PD ≥3.5 mm.
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Affiliation(s)
- Ji-Won Kwon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Edward O. Arreza
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Anthony A. Suguitan
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Soo-Bin Lee
- Department of Orthopedic Surgery, Catholic-Kwandong University, Incheon 22711, Korea;
| | - Sahyun Sung
- Department of Orthopedic Surgery, Ewha Womans University College of Medicine, Seoul 07804, Korea;
| | - Yung Park
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang 10444, Korea; (Y.P.); (J.-W.H.)
| | - Joong-Won Ha
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang 10444, Korea; (Y.P.); (J.-W.H.)
| | - Tae Hyung Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Byung Ho Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
- Correspondence:
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21
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Sharma D, Sawarkar DP, Singh PK, Kale SS, Joseph L, Garg A, Kumar A, Verma S, Doddamani R, Meena R, Chandra SP. Determination of Availability of Safety Margin for Placement of C3-C6 Pedicle Screw on CT Angiography. World Neurosurg 2021; 157:e22-e28. [PMID: 34555573 DOI: 10.1016/j.wneu.2021.09.057] [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: 06/28/2021] [Revised: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cervical pedicle screws (CPS) in the subaxial cervical spine (C3-C6) are faced with high incidence of perforating the lateral pedicular cortex endangering the vertebral artery (VA). The present study analyzes the pedicle width (PW) from C3 to C6 and defines the relation of VA with regard to pedicle and transverse foramen (TF) to determine the safety margin in cases of lateral pedicular breach. METHODS Computed tomography angiograms of 500 patients were retrospectively studied to identify the pedicle width (PW), VA area, TF area, and the lateral pedicle to vertebral artery distance (LPVA). Occupancy ratio (OR; the percentage area of transverse foramen occupied by VA) and safety margin (SM; permissible displacement of VA in TF), along with LPVA were considered to be protective parameters against VA injury if lateral pedicle breach happens. RESULTS PW was 4.7 mm at C3, 4.83 mm at C4, 5.26 mm at C5 and 5.41 mm at C6. Mean LPVA at different levels was between 0.97 mm and 1.15 mm, OR was around 20% at all levels, and mean SM was between 2.34 mm and 2.92 at various levels. Sex differences were statistically significant for PW but not for LPVA, SM, or OR. CONCLUSIONS This study gives us an idea about the various parameters in placement of cervical pedicle screw in subaxial cervical spine and the probable reasons there are few vertebral artery injuries despite high incidence of cervical pedicle breach. LPVA, safety margin, and OR may explain why even very significant CPS misplacement does not lead to vascular injury or neurologic deficit.
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Affiliation(s)
- Dhruv Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Pankaj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Leve Joseph
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Amandeep Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Satish Verma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Meena
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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22
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Spinous Process Screw Fixation: A Salvage Technique in Subaxial Cervical Spinal Instrumentation. World Neurosurg 2021; 154:e458-e464. [PMID: 34293522 DOI: 10.1016/j.wneu.2021.07.059] [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: 05/03/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We sought to evaluate the feasibility and efficacy of spinous process screws in subaxial cervical fixation. METHODS A retrospective study was conducted on 7 patients receiving posterior cervical instrumentation for subaxial fracture dislocation or atlantoaxial dislocation from 2014 to 2015. In addition, a biomechanical test was performed on 7 fresh-frozen cadaveric spine samples (from the occiput to C7) from healthy human subjects with no history of spinal trauma. And lastly, the potential trajectories of cervical spinous process screws of 100 adults were measured through axial computed tomography in order to establish the general rule for applicability of this technique. RESULTS Rigid fixation and solid fusion were achieved in all 7 patients included in the study. Biomechanical test results revealed no significant difference between bilateral lateral mass screw fixation and the hybrid lateral mass and spinous process screw fixation constructs. Measurement of the potential trajectory suggested that spinous process screw fixation was a viable technique in the subaxial cervical spine in the general population. CONCLUSIONS The spinous process screw fixation technique in the subaxial cervical spine is a viable and effective salvage option for patients in whom conventional posterior fixations were not sufficient and salvage, supplementary techniques were required.
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23
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Park JH, Lee JY, Lee BH, Jeon HJ, Park SW. Free-Hand Cervical Pedicle Screw Placement by Using Para-articular Minilaminotomy: Its Feasibility and Novice Neurosurgeons' Experience. Global Spine J 2021; 11:662-668. [PMID: 32875896 PMCID: PMC8165935 DOI: 10.1177/2192568220919089] [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] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN. Retrospective study. OBJECTIVE. Cervical pedicle screw (CPS) placement is technically demanding because of the great variation in pedicle size, dimension, and angulations between cervical levels and patients and the lack of anatomical landmarks. This retrospective study was conducted to analyze novice neurosurgeons' experience of CPS placement by using the technique with direct exposure of pedicle via para-articular minilaminotomy. METHODS. We retrospectively reviewed 78 CPSs in 22 consecutive patients performed by 2 surgeons. All pedicle screws were inserted under the direct visualization of the pedicle by using para-articular minilaminotomy without any fluoroscopic guidance. We analyzed the direction and grade of pedicle perforation on the postoperative computed tomography scan. The degree of perforation was classified as grade 0 to 3. Grades 0 and 1 were classified as the correct position and the others, as the incorrect position. RESULTS. In total, the correct position (grade 0 and 1) was found in 72 (92.3%) screws and the incorrect position (grade 2 and 3) in 6 (7.7%). Among the 16 pedicle perforations (grade 1, 2, and 3 perforations), the directions were lateral in 15 (93.8%) and superior in 1 (6.2%). There were no neurovascular complications related to CPS insertion. CONCLUSION. Free-hand CPS placement by using para-articular minilaminotomy seems to be feasible and reproducible.
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Affiliation(s)
- Jong-Hwa Park
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Kangwon National University, Gangwon-do, Republic of Korea
| | - Jong Young Lee
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Jong Young Lee, Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea 150, Seongan-ro, Gangdong-gu, Seoul, Republic of Korea.
| | - Byoung Hun Lee
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Kangwon National University, Gangwon-do, Republic of Korea
| | - Hong Jun Jeon
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Seung-Woo Park
- Kangwon National University, Gangwon-do, Republic of Korea
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Alsaleh K, Essbaiheen F, Aldosari K, Alsubei B, Alabdulkareeem M. Morphometric Analysis of Subaxial Cervical Spine Pedicles in a Middle Eastern Population. Int J Spine Surg 2021; 15:413-417. [PMID: 33963031 DOI: 10.14444/8061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pedicle screw instrumentation of the posterior cervical spine is the most secure form of fixation available to surgeons. It has not achieved widespread use yet in the Middle East, mostly due to concerns regarding its feasibility in the target population. A detailed morphometric analysis of the lower cervical spine pedicles using computerized tomography (CT) was proposed to address this issue. METHODS Two hundred and seventy patients were enrolled in the study. CT scans were reviewed by two experienced assessors, and measurements of pedicle width (PW), height (PH), and transverse angle (TA) were recorded for all patients. Interobserver and intraobserver reliability were calculated using the kappa statistic. Sex differences were also recorded and analyzed. The t test was used to assess for any significant differences in measurements due to sex (P < .05). RESULTS The mean PW varied from 4.4 mm in C3 to 6.1 mm in C7. The mean PH was 6.4 mm in C3 and 6.8 mm in C7. Pedicle TA varied from 42 to 51 degrees between the different levels. Sex differences were observed and were statistically significant for PW and PH. Interobserver reliability was high for PW and PH, but was low for TA. Intraobserver reliability was 0.99 for both assessors. CONCLUSION This study provides reliable PW and PH measurements and demonstrates that cervical pedicle screw instrumentation is feasible in our local population. Significant variability exists, however, and each patient must be addressed individually for best results. LEVEL OF EVIDENCE 3. CLINICAL RELEVANCE This study shows that the morphology of the subaxial cervical pedicle permits instrumentation in a majority of cases of our target population.
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Affiliation(s)
- Khalid Alsaleh
- Department or Orthopedics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Essbaiheen
- Department of Radiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Bandar Alsubei
- Department or Orthopedics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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25
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İştemen İ, Arslan A, Olguner SK, Afşer KA, Açık V, Arslan B, Ökten Aİ, Gezercan Y. Significance of Preoperative Prone Position Computed Tomography in Free Hand Subaxial Cervical Pedicular Screwing. J Korean Neurosurg Soc 2021; 64:247-254. [PMID: 33715326 PMCID: PMC7969039 DOI: 10.3340/jkns.2020.0252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/28/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The subaxial cervical pedicle screwing technique shows powerful biomechanical properties for posterior cervical fusion. When applying a pedicle screw using the freehand technique, it is essential to analyse cervical computed tomography and plan the surgery accordingly. Normal cervical computed tomography is usually performed in the supine position, whereas during surgery, the patient lies in a prone position. This fact leads us to suppose that radiological evaluations may yield misleading results. Our study aimed to investigate whether there is any superiority between preoperative preparation on computed tomography performed in the prone position and that performed in the supine position. METHODS This study included 17 patients (132 pedicle screws) who were recently operated on with cervical vertebral computed tomography in the prone position and 17 patients (136 pedicle screws) who were operated on by conventional cervical vertebral computed tomography as the control group. The patients in both groups were compared in terms of age, gender, pathological diagnosis, screw malposition and complications. A screw malposition evaluation was made according to the Gertzbein-Robbins scale. RESULTS No statistically significant difference was observed between the two groups regarding age, gender and pathological diagnosis. The screw malposition rate (from 11.1% to 6.9%, p<0.05), mean malposition distance (from 2.18 mm to 1.86 mm, p <0.05), and complications statistically significantly decreased in the prone position computed tomography group. CONCLUSION Preoperative surgical planning by performing cervical vertebral computed tomography in the prone position reduces screw malposition and complications. Our surgical success increased with a simple modification that can be applied by all clinicians without creating additional radiation exposure or additional costs.
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Affiliation(s)
- İismail İştemen
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Ali Arslan
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Semih Kıvanç Olguner
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Kemal Alper Afşer
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Vedat Açık
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Barış Arslan
- Department of Anesthesia and Intensive Care, Adana City Education and Research Hospital, Adana, Turkey
| | - Ali İhsan Ökten
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
| | - Yurdal Gezercan
- Department of Neurosurgery, Adana City Education and Research Hospital, Adana, Turkey
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26
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Xue X, Wang Y, Ji J, Han Y, Sun Q, Miao J. [Clinical application of cervical pedicle screw implantation technique under regional method]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1515-1520. [PMID: 33319528 DOI: 10.7507/1002-1892.202004128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of cervical pedicle screw implantation technique under regional method. Methods The clinical data of 85 patients who met the selection criteria between April 2010 and May 2018 were retrospectively analyzed. There were 57 males and 28 females, aged 35-68 years, with an average of 57.6 years. Among them, there were 10 cases of ossification of posterior longitudinal ligament, 68 cases of cervical spondylosis with multilevel stenosis, 3 cases of cervical tumor, 1 case of congenital malformation, and 3 cases of cervical trauma; the lower cervical spine lesions involved C 3-C 7. Preoperative Frankel spinal cord injury grading: 2 cases of grade C, 51 cases of grade D, and 32 cases of grade E. Cervical pedicle screw implantation technique under regional method was performed with a total of 618 pedicle screws. Postoperative changes in neurological symptoms were observed; cervical mouth opening anteroposterior and lateral X-ray films and cervical CT examinations were performed to evaluate the pedicle screws position. Results The operation time was 2.5-4.0 hours, with an average of 3.0 hours. The intraoperative blood loss was 180-550 mL, with an average of 345 mL. No intraoperative vascular or nerve injury occurred. The patients with neurological symptoms were relieved to varying degrees. There were 2 cases of superficial incision infection after operation, the wound healed after enhanced dressing change. The postoperative hospital stay was 5-14 days, with an average of 8.4 days. At discharge, Frankel neurological grading was grade D in 26 patients and grade E in 59 patients. All the patients were followed up 6-24 months, with an average of 13 months. At last follow-up, cervical X-ray films showed the good pedicle screw fixation without loosening. Cervical CT evaluated the position of pedicle screws: 523 pedicle screws (84.7%) in grade Ⅰ, 80 (12.9%) in grade Ⅱ, and 15 (2.4%) in grade Ⅲ; the accuracy rate of the screw position was 97.6%. Conclusion Cervical pedicle screw implantation technique under regional method can significantly improve the success rate of screw implantation. It is easy to operate, does not destroy the bone cortex, and has stable fixation.
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Affiliation(s)
- Xiaobei Xue
- Graduate School of Tianjin Medical University, Tianjin, 300350, P.R.China
| | - Yubing Wang
- Department of Orthopedics, the Seventh People's Hospital of Hebei Province, Baoding Hebei, 071000, P.R.China
| | - Jingtao Ji
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, 300350, P.R.China
| | - Yue Han
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, 300350, P.R.China
| | - Quan Sun
- Department of Orthopedics, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou Guangdong, 510120, P.R.China
| | - Jun Miao
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, 300350, P.R.China
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Shi H, Zhu L, Ma J, Zhu YC, Wu XT. The accuracy of a novel pedicle screw insertion technique assisted by a special angular scale in the subaxial cervical spine using lateral mass as a reference marker. J Orthop Surg Res 2020; 15:551. [PMID: 33228707 PMCID: PMC7681976 DOI: 10.1186/s13018-020-02054-1] [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: 09/02/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022] Open
Abstract
Background Posterior cervical pedicle screw (CPS) internal fixation has better biomechanical stability than other posterior cervical fixation methods. However, this technique is limited in clinical practice due to the complex anatomical structure and the adjacent relationship of the cervical pedicle, and the high risk of neurovascular injury. The purpose of this study was to describe a novel subaxial CPS insertion technique assisted by a special angular scale using lateral mass as a reference marker and to evaluate the accuracy of CPS placement and the distribution characteristics of CPS misplacement. Methods A total of 36 patients with subaxial cervical spine diseases who underwent posterior CPS fixation were consecutively selected. The optimal entry point on the posterior surface of the lateral mass was identified on the three-dimensional cervical model reconstructed from preoperative computed tomography (CT) images. The pedicle transverse angle (PTA) and pedicle-lateral mass angle (PLMA) were measured on the transverse and sagittal CT images respectively. The pedicle screws were inserted according to the preoperatively planned entry point and angles. We analysed the postoperative CT images for CPS misplacement rates and perforation directions following the Lee classification. Results Overall, 177 pedicle screws were inserted, of which 119 (67.2%) were classified as grade 0, 43 (24.3%) as grade 1, 12 (6.8%) as grade 2 and 3 (1.7%) as grade 3 by the postoperative CT images. The accuracy rate of CPS placement was 91.5%. Of the 15 misplaced pedicle screws (grades 2 and 3), 11 were lateral pedicle perforations, 3 were superior perforations and 1 was an inferior perforation. There were no neurovascular injuries related to CPS misplacement. Conclusions With our technique, the optimal entry point and two angles (PTA and PLMA) were identified for CPS insertion. The novel CPS insertion technique assisted by a special angular scale provides high accuracy and few complications.
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Affiliation(s)
- Hang Shi
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Lei Zhu
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Jun Ma
- The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China
| | - Yu-Cheng Zhu
- The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China
| | - Xiao-Tao Wu
- Department of Spine Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
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Yoshii T, Egawa S, Chikuda H, Wakao N, Furuya T, Kanchiku T, Nagoshi N, Fujiwara Y, Yoshida M, Taguchi T, Watanabe M. Comparison of anterior decompression with fusion and posterior decompression with fusion for cervical spondylotic myelopathy-A systematic review and meta-analysis. J Orthop Sci 2020; 25:938-945. [PMID: 32008876 DOI: 10.1016/j.jos.2019.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/21/2019] [Accepted: 12/03/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND The optimal surgical procedure for the treatment of cervical spondylotic myelopathy (CSM) remains controversial. Recently, laminectomy/laminoplasty with instrumented fusion (LAMF) has been increasingly applied to treat CSM. However, few comprehensive studies have compared anterior decompression with fusion (ADF) and LAMF. Therefore, we conducted a meta-analysis to evaluate the evidence in the literature and to compare the surgical outcomes between the 2 procedures. Since the surgical outcomes and risks differ between patients with CSM and ossification of the posterior longitudinal ligament (OPLL) and between only posterior decompression and decompression with fusion treatments, we excluded patients with OPLL and patients with only posterior decompression in this review. METHODS An extensive literature search was performed using PubMed, Embase, and the Cochrane Library to identify comparative studies of ADF and LAMF for the treatment of CSM. The language was restricted to English, and the publication period was from January 2001 to July 2019. We only included studies about CSM and excluded studies that involved patients with ossification of the posterior longitudinal ligament and with the treatment of posterior decompression without fusion. We extracted outcomes from the studies, such as preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, neck disability index (NDI) scores, cervical alignment data, and surgical complications. Then, a meta-analysis was performed on these surgical outcomes. RESULTS Eleven studies were obtained, and the quality of the studies was acceptable. In the meta-analysis, the pre- and postoperative JOA scores were similar between the ADF and LAMF groups. The ADF group exhibited more favorable results than the LAMF group in terms of postoperative cervical alignment and the NDI. Overall complications were similar between the ADF and LAMF groups; however, C5 palsy was more frequently observed in the LAMF group than in the ADF group. CONCLUSIONS While the ADF and LAMF groups demonstrated similar results in terms of neurological recovery, postoperative cervical lordosis and NDI scores were more favorable with ADF than with LAMF. The overall complication rate was similar between the ADF and LAMF groups. Surgeons should understand the merits and shortcomings of both procedures when deciding on a surgical procedure.
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Affiliation(s)
- Toshitaka Yoshii
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo, 113-8511, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan.
| | - Satroru Egawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo, 113-8511, Japan
| | - Hirotaka Chikuda
- Department of Orthopedic Surgery, Gunma University School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma, 371-8513, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
| | - Norimitsu Wakao
- Department of Orthopedic Surgery, National Center for Geriatrics and Gerontology, Moriokacho 7-430, Obu, Aichi, 474-8511, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
| | - Tsukasa Kanchiku
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, 1315-4, Oaza-Onoda, Onoda, Yamaguchi, 756-0095, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
| | - Yasushi Fujiwara
- Department of Orthopedic Surgery, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakitaku, Hiroshima, 731-0293, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
| | - Masahiro Yoshida
- Department of Surgery, International University of Health and Welfare Ichikawa Hospital, Konodai 6-1-14, Ichikawashi, Chiba, 272-0827, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
| | - Toshihiko Taguchi
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, 1315-4, Oaza-Onoda, Onoda, Yamaguchi, 756-0095, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan; Guideline Committee of Ossification of the Spinal Ligament, Japanese Orthopaedic Association, Japan
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Defining an Algorithm of Treatment for Severe Cervical Deformity Using Surgeon Survey and Treatment Patterns. World Neurosurg 2020; 139:e541-e547. [DOI: 10.1016/j.wneu.2020.04.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/08/2020] [Indexed: 11/21/2022]
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Liu B, Liu X, Shen X, Wang G, Chen Y. The "slide technique"-a novel free-hand method of subaxial cervical pedicle screw placement. BMC Musculoskelet Disord 2020; 21:399. [PMID: 32576178 PMCID: PMC7313203 DOI: 10.1186/s12891-020-03420-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 06/15/2020] [Indexed: 12/30/2022] Open
Abstract
Background Cervical Pedicle Screw (CPS) placement is a challenging work due to the high risk of neurovascular complications. Although there have been several different free-hand or navigation assisted techniques for CPS placement, perforations may occur during screw insertion, especially lateral perforation. The objective of this manuscript is to describe a novel free-hand technique for subaxial CPS placement (C3–C7) and to evaluate if it decreases the chances of perforation. Methods Thirty-two patients undergoing surgery with CPS instrumentation (C3–C7) at our institute between June 2017 and December 2018 were included in this study. All the patients had cervical trauma, and pedicle screw insertion was performed according to the free-hand “slide technique”. The lamina, lateral mass and facet joint of the target area were exposed and the optimal entry point was found on the lateral mass posterior surface. A pedicular probe was then inserted and gently advanced. During the pedicle probe insertion, the cortex of the medial margin of the pedicle acted as a slide to permit the safe insertion of the screw. If the pedicle screw pathway was intact, the screw of the appropriate size was carefully placed. Three-dimensional (3D) CT imaging reconstruction was performed in all the patients after surgery, and screw perforations were graded with the Gertzbein-Robbins classification. Results Thirty-two patients who met the inclusion criteria were included in this study. A total of 257 CPSs (C3–7) were inserted, of which 41 CPSs were in C3, 61 CPSs were in C4, 55 CPSs were in C5, 53 CPSs were in C6, and 47 CPSs were in C7. The diameter and length of CPSs were 3.5 mm and 22–26 mm respectively. According to the Gertzbein-Robbins classification, grade 0, 231 screws; grade 1, 19 screws; and grade 2, 7 screws. No neurovascular complications occurred stemming from malpositioning of pedicle screws. Among perforated screws (26 screws), there were 16 lateral perforations, 5 medical perforations, and 4 inferior perforations. Conclusions The initial usage result shows the “slide technique” is a safe, effective and cost-effective technique for pedicle screw placement in the cervical spine. This is the first report of such a technique, and further studies are needed.
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Affiliation(s)
- Bin Liu
- Department of Spine Surgery, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Xiangyang Liu
- Department of Spine Surgery, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Xiongjie Shen
- Department of Spine Surgery, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Guoping Wang
- Department of Spine Surgery, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
| | - Yixin Chen
- Department of Rehabilitation, Xiangya Hospital of Central South University, Changsha, Hunan, China.
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Raasck K, Khoury J, Aoude A, Beland B, Munteanu A, Weber MH, Golan J. The Effect of Thoracolumbar Pedicle Isthmus on Pedicle Screw Accuracy. Global Spine J 2020; 10:393-398. [PMID: 32435557 PMCID: PMC7222685 DOI: 10.1177/2192568219850143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVES Aberrant pedicle screws can cause serious neurovascular complications. We propose that a predominant factor of pedicle screw breach is the vertebral anatomy at a given spinal level. We aim to investigate the inverse correlation between breach incidence and vertebral isthmus width. METHODS The computed tomography scans of patients undergoing thoracolumbar surgery were retrospectively reviewed. Breaches were categorized as minor (<2 mm) or major (>2 mm). Breach incidence was stratified by spinal level. Average isthmus width was then compared to the collected breach incidences. A regression analysis and Pearson's correlation were performed. RESULTS A total of 656 pedicle screws were placed in 91 patients with 233 detected breaches. Incidence of major breach was 6.3%. Four patients developed post-operative radiculopathy due to breach. Breach incidence was higher in the thoracic than lumbar spine (Fisher's exact test, P < .0001). The 2 spinal levels with the thinnest isthmus width (T4 and T5) were breached most often (73.7% and 73.9%, respectively). The 2 spinal levels with the thickest isthmus width (L4 and L5) were breached least often (20.5% and 11.8%). Breach incidence and isthmus width were shown to have a significant inverse correlation (Pearson's correlation, R 2 = 0.7, P < .0001). CONCLUSIONS Thinner vertebral isthmus width increases pedicle screw breach incidence. Image-guided assistance may be most useful where breach incidence is highest and isthmus width is lowest (T2 to T6). Despite high incidence of cortical bone violation, there was little correlation with clinical symptoms. A breach is not automatically a clinical problem, provided the screw is structurally sound and the patient is symptomless.
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Affiliation(s)
- Kyle Raasck
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada,Kyle Raasck, Division of Orthopaedic Surgery, McGill Faculty of Medicine, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.
| | - Jason Khoury
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ahmed Aoude
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Benjamin Beland
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexander Munteanu
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael H. Weber
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jeff Golan
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Jung YG, Jung SK, Lee BJ, Lee S, Jeong SK, Kim M, Park JH. The Subaxial Cervical Pedicle Screw for Cervical Spine Diseases: The Review of Technical Developments and Complication Avoidance. Neurol Med Chir (Tokyo) 2020; 60:231-243. [PMID: 32295984 PMCID: PMC7246229 DOI: 10.2176/nmc.ra.2019-0189] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This study aimed to review information on the subaxial cervical pedicle screw (CPS) including recent anatomical considerations, entry points, placement techniques, accuracy, learning curve, and complications. Relevant literatures were reviewed, and the authors’ experiences were summarized. The CPS is used for reconstruction of unstable cervical spine and achieves superior biomechanical stability compared to other fixation techniques. Various insertion and guidance techniques are established, among which, lateral fluoroscopy-assisted placement is the most common and cost-effective technique. Generally, placement under imaging guidance is more accurate than other techniques, and a three-dimensional template allows optimal trajectory for each pedicle regardless of intraoperative changes in spinal alignment. The free-hand technique using a curved pedicle probe without a funnel-like hole increases screw stability and reduces operation time, radiation exposure, and soft tissue injury. Compared to conventional lateral fluoroscopy-assisted placement, free-hand CPS placement by trained surgeons achieves superior accuracy comparable to that of image-guided navigation; in general, 30 training cases are sufficient for learning a safe and accurate technique for CPS placement. The complications of subaxial CPS are classified into three categories: complications due to screw misplacement, complications without screw misplacement, and others. Inexperienced surgeons may benefit from advanced techniques; however, the accuracy of CPS ultimately depends on the surgeon’s experience. Inexperienced surgeons should master the placement of the thoracolumbar pedicle screw in real practice and practice CPS insertion using cadavers. During the initial phase of the learning curve, careful preparation of surgery, reiterated identification, patterned safety steps, and supervision of the expert are necessary.
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Affiliation(s)
- Yoon Gyo Jung
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sang Ku Jung
- Department of Emergency Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine
| | - Byung Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Neuroscience and Radiosurgery Hybrid Research Center, College of Medicine
| | - Subum Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Seong Kyun Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Myeongjong Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
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Sonone S, Dahapute AA, Bhaladhare SM, Marathe NA, Balasubramanian SG, George PK. Posterior Cervical Interbody Fusion - Single-Stage Approach of Anterior Reconstruction and Posterior Stabilization: A Case Report and Review of Literature. Asian J Neurosurg 2020; 15:222-224. [PMID: 32181208 PMCID: PMC7057898 DOI: 10.4103/ajns.ajns_189_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/25/2019] [Indexed: 11/12/2022] Open
Abstract
The success and popularity of the transforaminal approach in the lumbar spine have been made possible by the routine use of pedicle screws in the lumbar spine. Transforaminal approach in the cervical spine can give access to the disc and the vertebral body anteriorly and avoid an additional anterior approach in certain clinical situations. A case of cervical spine trauma was managed by this approach. Technical details and difficulties faced were analyzed in this article. Transforaminal approach in the lower cervical spine, though has a learning curve, seems to be a feasible technique along with the use of cervical pedicle screws. The safety and reproducibility of the approach need to be substantiated with a larger study. Further, this procedure can avoid additional anterior surgery in certain situations in the cervical spine.
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Affiliation(s)
- Sandeep Sonone
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Aditya A Dahapute
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Nandan Amrit Marathe
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Prakash Kieron George
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Mahesh B, Upendra B, Raghavendra R. Acceptable errors with evaluation of 577 cervical pedicle screw placements. 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 2020; 29:1043-1051. [PMID: 32152697 DOI: 10.1007/s00586-020-06359-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/12/2019] [Accepted: 02/26/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Cadaveric studies have discouraged the use of cervical pedicle screws (CPS) with high misplacement rates. However, the clinical results show minimal screw-related complications and have highlighted the advantages of using CPS. We introduce "acceptable errors classification" in the placement of cervical pedicle screws to bridge the gap between the high radiological perforation rates and low clinical complications. METHODS Ninety-nine patients with average age of 49 years were operated between December 2011 and June 2017 using CPS. Sixty-one patients had trauma, 33 had CSM, 3 had tumors and 2 patients had fracture with ankylosing spondylitis. The screws were inserted using the medial cortical pedicle screw technique. Axial and sagittal CT reconstructed images along the axis of the inserted screws were evaluated for screw placements both in the medio-lateral and supero-inferior directions. RESULTS A total of 577 pedicle screw placements (C3 to C7) were assessed in 99 patients using the conventional grading of screw perforations and acceptable errors classification in both medio-lateral and supero-inferior directions. There were 25.64% (148/577) screw perforations and 74.35% (429/577) screw placements within the pedicle using the conventional perforation grading system. The same set of screws, assessed using the "Acceptable errors classification", showed 529 screws (91.68%) having acceptable placements and 48 screws (8.31%) having unacceptable placements. CONCLUSION The acceptable errors classification in placement of CPS seems to bridge the gap between the high radiological perforation rates and the low clinical complications. The present study reinforces studies reporting minimal clinical complications with high rates of screw misplacements. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Bijjawara Mahesh
- Vitus Spine Care And Research, Department of Spine Surgery, Bhagwan Mahaveer Jain Hospital, Vasanth Nagar, Bangalore, 560052, India
| | - Bidre Upendra
- Vitus Spine Care And Research, Department of Spine Surgery, Bhagwan Mahaveer Jain Hospital, Vasanth Nagar, Bangalore, 560052, India.
| | - Rao Raghavendra
- Vitus Spine Care And Research, Department of Spine Surgery, Bhagwan Mahaveer Jain Hospital, Vasanth Nagar, Bangalore, 560052, India
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Design and application of a novel patient-specific 3D printed drill navigational guiding template in percutaneous thoracolumbar pedicle screw fixation: A cadaveric study. J Clin Neurosci 2020; 73:294-298. [DOI: 10.1016/j.jocn.2020.01.083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/12/2020] [Accepted: 01/27/2020] [Indexed: 12/17/2022]
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Liu MY, Tsai TT, Lai PL, Hsieh MK, Chen LH, Tai CL. Biomechanical comparison of pedicle screw fixation strength in synthetic bones: Effects of screw shape, core/thread profile and cement augmentation. PLoS One 2020; 15:e0229328. [PMID: 32084219 PMCID: PMC7034823 DOI: 10.1371/journal.pone.0229328] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/04/2020] [Indexed: 12/02/2022] Open
Abstract
Pedicle screw loosening resulting from insufficient bone-screw interfacial holding power is not uncommon. The screw shape and thread profile are considered important factors of the screw fixation strength. This work investigated the difference in pullout strength between conical and cylindrical screws with three different thread designs. The effects of the thread profiles on the screw fixation strength of cannulated screws with or without cement augmentation in osteoporotic bone were also evaluated. Commercially available artificial standard L4 vertebrae and low-density polyurethane foam blocks were used as substitutes for healthy vertebrae and osteoporotic bones, respectively. The screw pullout strengths of nine screw systems were investigated (six in each). These systems included the combination of three different screw shapes (solid/cylindrical, solid/conical and cannulated/cylindrical) with three different thread profiles (fine-thread, coarse-thread and dual-core/dual-thread). Solid screws were designed for the cementless screw fixation of vertebrae using the standard samples, whereas cannulated screws were designed for the cemented screw fixation of osteoporotic bone using low-density test blocks. Following specimen preparation, a screw pullout test was conducted using a material test machine, and the maximal screw pullout strength was compared among the groups. This study demonstrated that, in healthy vertebrae, both the conical and dual-core/dual-thread designs can improve pullout strength. A combination of the conical and dual-core/dual-thread designs may achieve optimal postoperative screw stability. However, in osteoporotic bone, the thread profile have little impact on the screw fixation strength when pedicle screws are fixed with cement augmentation. Cement augmentation is the most important factor contributing to screw pullout fixation strength as compared to screw designs.
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Affiliation(s)
- Mu-Yi Liu
- Ph.D. Program in Biomedical Engineering, Collage of Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Lih-Huei Chen
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
- * E-mail: (CLT); (LHC)
| | - Ching-Lung Tai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Graduate Institute of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
- * E-mail: (CLT); (LHC)
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Upendra B, Raghavendra R. Techniques of cervical pedicle screw insertion in lower cervical spine - A review. J Clin Orthop Trauma 2020; 11:794-801. [PMID: 32879566 PMCID: PMC7452216 DOI: 10.1016/j.jcot.2020.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 11/29/2022] Open
Abstract
Cervical pedicle screws (CPS) have been used for stabilization of lower cervical spine since its first description by Abumi et al., in 1994, but the usage has been limited due to the feared complications. Cadaveric studies have discouraged use of CPS in lower cervical spine due to high misplacement rates. On the contrary, clinical studies have shown limited complications due to screw misplacements and have highlighted the benefits of CPS with its superior biomechanical strength. Therefore surgeons have always tried to find a reliable, reproducible and safe CPS insertion technique to expand the usage of CPS with minimal complications. As of today Abumi et al. technique is the most popular free-hand technique used by surgeons, though many modifications have evolved to make the CPS insertions more safe and reproducible. The free hand technique should be considered as the cornerstone technique for CPS insertion and the navigation tools are essential to improve the safety of CPS in complex surgeries with altered cervical anatomy. The present review brings together the literature on the various aspects of cervical pedicle anatomy, the free-hand screw insertion techniques with their modifications, the screw misplacement rates and complications.
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Kuo JR, Zheng HX, Lee YL, Wang CC. Utilization of the 3-D image and printed model as a surgical plan: An experience of a multi-level cervical spine fracture. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_80_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Does an Uninstrumented Level Increase the Rate of Revision Surgery in a Multilevel Posterior Cervical Decompression and Fusion? Clin Spine Surg 2019; 32:E416-E419. [PMID: 31789896 DOI: 10.1097/bsd.0000000000000910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The goal of this study is to determine if skipping a single level affects the revision rate for patients undergoing multilevel posterior cervical decompression and fusion (PCDF). SUMMARY OF BACKGROUND DATA A multilevel PCDF is a common procedure for patients with cervical spondylotic myelopathy. With advanced pathology, it can be difficult to safely place screw instrumentation at every level increasing the risk of intraoperative and perioperative morbidity. It is unclear whether skipping a level during PCDF affects fusion and revision rates. PATIENTS AND METHODS A cervical spine surgeries database at a single institution was used to identify patients who underwent ≥3 levels of PCDF. Inclusion criteria consisted of patients who had screws placed at every level or if they had a single level without screws bilaterally. Patients were excluded if the surgery was performed for tumor, trauma, or infection, and age below 18 years, or if there was <1 year of follow-up. RESULTS A total of 157 patients met inclusion criteria, with 86 undergoing a PCDF with instrumentation at all levels and 71 that had a single uninstrumented level. Overall mean follow-up was 46.5±22.8 months. In patients with or without a skipped level, the revision rate was 25% and 26%, respectively (P<1.00). Univariate regression analysis demonstrated that proximal fixation level in the upper cervical region, having the fusion end at C7, prior surgery, and myelopathy were significant predictors of revision. Skipping a single level, however, was not predictive of revision. CONCLUSIONS When performing a multilevel PCDF, there is no increase in the rate of revision surgery if a single level is uninstrumented. Conversely, other surgical factors, including the cranial and caudal levels, affect revision rates. In contrast to other reports, the C2 sagittal vertical axis did not affect reoperation rates. LEVEL OF EVIDENCE Level IV.
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Crossing the Cervicothoracic Junction in Posterior Cervical Decompression and Fusion: A Cohort Analysis. World Neurosurg 2019; 131:e514-e520. [DOI: 10.1016/j.wneu.2019.07.219] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/28/2019] [Accepted: 07/29/2019] [Indexed: 11/21/2022]
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Implant failure of pedicle screws in long-segment posterior cervical fusion is likely to occur at C7 and is avoidable by concomitant C6 or T1 buttress pedicle screws. J Clin Neurosci 2019; 63:106-109. [DOI: 10.1016/j.jocn.2019.01.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/20/2018] [Accepted: 01/18/2019] [Indexed: 11/18/2022]
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Tukkapuram VR, Kuniyoshi A, Ito M. A Review of the Historical Evolution, Biomechanical Advantage, Clinical Applications, and Safe Insertion Techniques of Cervical Pedicle Screw Fixation. Spine Surg Relat Res 2019; 3:126-135. [PMID: 31435564 PMCID: PMC6690082 DOI: 10.22603/ssrr.2018-0055] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 08/30/2018] [Indexed: 12/02/2022] Open
Abstract
Cervical spine instrumentation is evolving with an aim of stabilizing traumatic and non-traumatic cases of the cervical spine with a beneficial reduction, better biomechanical strength, and a strong construct with minimal intraoperative, as well as immediate and late postoperative complications. The evolution from interspinous wiring till cervical pedicle screws has changed the outlook in treating the cervical spine pathologies with maximum 3D stability, decreasing the duration of postoperative immobilization and hospital stay. Some complications associated with the use of cervical pedicle screw can be catastrophic. This review article discusses the morphometry of cervical pedicle; indications, biomechanical superiority, tricks, and pitfalls of cervical pedicle screw; complications and technical advancements in targeting safe surgery; and future directions of cervical pedicle screw instrumentation.
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Affiliation(s)
| | - Abumi Kuniyoshi
- Department of orthopaedics, Sapporo Orthopaedic Hospital, Sapporo, Japan
| | - Manabu Ito
- Department of orthopaedics, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
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Miyamoto H, Ikeda T, Akagi M. Radiologic analysis of pedicle marker for the cervical spine. J Orthop Sci 2019; 24:24-29. [PMID: 30316658 DOI: 10.1016/j.jos.2018.08.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To elucidate the usefulness of the pedicle marker (PM) for more accurate insertion of cervical pedicle screws (CPSs). METHODS Artificial bone study. Fifty pedicles of five artificial bone specimens were examined. PMs were inserted in five different positions (confirmed by computed tomography (CT)); (1) insertion angle correct, insertion point too medial, (2) both insertion angle and insertion point correct, (3) insertion angle correct, insertion point too lateral, (4) insertion point correct, insertion angle too big, and (5) insertion point correct, insertion angle too small. Oblique radiographs were taken to assess the relationships between the pedicle and the PM as IN and OUT. Clinical series. A total of 228 CPSs were inserted in 59 consecutive patients using either CT cutout technique or navigation. During surgery, PMs were inserted, and the locations were confirmed on oblique fluoroscopic views in CT cutout technique and intraoperative CT in navigation. Intraoperative misplaced PM and postoperative misplaced CPS were assessed. RESULTS Artificial bone study. Evaluation found 67% of Types 1 and 100% of Type 5 seemed to be IN on the oblique views at 10, 20, and 30° because the pedicle and PM overlapped. All cases of Type 2 were IN at any angles. Almost all Types 3 and 4 were OUT at any angle. Clinical series. The route was modified under the recognition of misplaced PM during surgery in 3.7% (all Type 4) of CT cutout and 4.2% (four Type 4 and one Type 5) of navigation. One CPS was malpositioned (0.9%, Type 1) in CT cutout and none in navigation by postoperative CT. CONCLUSIONS By applying PM, lateral displacement is easier to recognize in fluoroscopy. Medial misplacement should be aware because the PM and the rim of the pedicle overlap. Even after launching navigation, PM helped to indicate the wrong route before inserting the CPS during surgery.
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Affiliation(s)
- Hiroshi Miyamoto
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka-Sayama, Japan.
| | - Terumasa Ikeda
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka-Sayama, Japan
| | - Masao Akagi
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka-Sayama, Japan
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Srivastava A, Nanda G, Mahajan R, Nanda A, Batra S, Mishra N, Pandita N, Chhabra HS. Feasibility of Sub-Axial Cervical Laminar Screws, Including C7, in the Indian Population: A Study on 50 Patients Using Computed Tomography-Based Morphometry Measurements. Asian Spine J 2018; 13:7-12. [PMID: 30326693 PMCID: PMC6365788 DOI: 10.31616/asj.2018.0110] [Citation(s) in RCA: 4] [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: 05/10/2018] [Accepted: 07/01/2018] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Observational study of computed tomography (CT) data. PURPOSE We performed a CT-based radiographic analysis of sub-axial cervical lamina in the Indian population to assess the feasibility of laminar screws. OVERVIEW OF LITERATURE Morphometric studies have been performed for populations of various ethnic groups, but none exist for Indian populations. METHODS Cervical spine CT scans of 50 adults with a minimum slice thickness of <2 mm (0.5-2 mm) were obtained from the database of a single center in northern India. Measurements (e.g., length, thickness, and height) were taken in millimeters along the axial, coronal, and sagittal planes. Three measurements were made to assess laminar anatomy, namely, the translaminar/screw length, laminar thickness, and sagittal laminar height. RESULTS The final sample comprised 500 laminae in 50 patients, resulting in 1,500 measurements. The mean translaminar lengths of the C3, C4, C5, C6, and C7 laminae were 19.48 mm, 19.60 mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 19.60 , 19.60 mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 19.61 , 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 20.49 , 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, and 22.85 mm, respectively. The mean thick- , and 22.85 mm, respectively. The mean thick , and 22.85 mm, respectively. The mean thicknesses of these cervical laminae were 3.12 mm, 2.62 mm, 2.56 mm, 3.47 mm, and 5.20 mm, respectively. The mean sagittal heights of these laminae were 9.38 mm, 9.80 mm, 10.12 mm, 11.31 mm, and 13.84 mm, respectively. Except for the C7 vertebrae, all other levels had a success rate of <10% in the Indian population using the criteria of a laminar height of at least 9 mm and thickness of 4.5 mm. Limited success was achieved at the C5, C6, and C3 levels. CONCLUSIONS To the best of our knowledge, the present study is the only series on the feasibility of laminar screws in the sub-axial cervical spine in the Indian population. We found that Indian patients have smaller anatomical dimensions and thus, are not suitable for laminar screws in the sub-axial cervical spine, barring C7, which is contrary to findings for populations in western and south Asian countries.
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Affiliation(s)
| | - Geetanjali Nanda
- Department of Radiodiagnosis, Mahajan Imaging Centre, New Delhi, India
| | - Rajat Mahajan
- Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India
| | - Ankur Nanda
- Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India
| | - Sahil Batra
- Department of Spine Services, Caremax Superspeciality Hospital, Jalandhar, India
| | | | - Naveen Pandita
- Department of Spine Services, Primus Hospital, New Delhi, India
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Posterior cervical spine crisscross fixation: Biomechanical evaluation. Clin Biomech (Bristol, Avon) 2018; 55:18-22. [PMID: 29635141 DOI: 10.1016/j.clinbiomech.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/30/2018] [Accepted: 04/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biomechanical/anatomic limitations may limit the successful implantation, maintenance, and risk acceptance of posterior cervical plate/rod fixation for one stage decompression-fusion. A method of posterior fixation (crisscross) that resolves biomechanical deficiencies of previous facet wiring techniques and not reliant upon screw implantation has been devised. The biomechanical performance of the new method of facet fixation was compared to the traditional lateral mass plate/screw fixation method. METHODS Thirteen human cadaver spine segments (C2-T1) were tested under flexion-compression loading and four were evaluated additionally under pure-moment load. Preparations were evaluated in a sequence of surgical alterations with intact, laminectomy, lateral mass plate/screw fixation, and crisscross facet fixation using forces, displacements and kinematics. FINDINGS Combined loading demonstrated significantly lower bending stiffness (p < 0.05) between laminectomy compared to crisscross and lateral mass plate/screw preparations. Crisscross fixation showed a comparative tendency for increased stiffness. The increased overall motion induced by laminectomy was resolved by both fixation techniques, with crisscross fixation demonstrating a comparatively more uniform change in segmental motions. INTERPRETATION The crisscross technique of facet fixation offers immediate mechanical stability with resolution of increased flexural rotations induced by multi-level laminectomy. Many of the anatomic limitations and potentially deleterious variables that may be associated with multi-level screw fixation are not associated with facet wire passage, and the subsequent fixation using a pattern of wire connection crossing each facet joint exhibits a comparatively more uniform load distribution. Crisscross wire fixation is a valuable addition to the surgical armamentarium for extensive posterior cervical single-stage decompression-fixation.
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Peng P, Xu Y, Zhang X, Zhu M, Du B, Li W, Huang W, Song J, Li J. Is a patient-specific drill template via a cortical bone trajectory safe in cervical anterior transpedicular insertion? J Orthop Surg Res 2018; 13:91. [PMID: 29669577 PMCID: PMC5907449 DOI: 10.1186/s13018-018-0810-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to develop patient-specific drill templates by computer numerical control or three-dimensional printing via two cortical bone trajectories (CBTs) and to evaluate their efficacies and accuracies in cervical anterior transpedicular insertion. METHODS Preoperative CT images of 20 cadaveric cervical vertebrae (C3-C7) were obtained. After image processing, patient-specific drill templates were randomly assigned to be constructed via two CBTs (CBT0 and CBT0.7) and manufactured by two methods (computer numerical control and three-dimensional printing). Guided by patient-specific drill templates, 3.5-mm-diameter screws were inserted into the pedicles. Postoperative CT scans were performed to evaluate the screw deviation in the entry point and midpoint of the pedicle. The screw positions were also graded. RESULTS Computer numerical control patient-specific drill templates had a significantly shorter manufacturing time compared to three-dimensional-printed patient-specific drill templates (p < 0.01). Absolute deviations at the entry point and midpoint of the pedicle had no significant differences on the transverse and sagittal planes (p > 0.05). There were no significant differences in screw positions (p = 0.3). However, three screw positions were in grade 3 in CBT0, while the others were in grade 1. CONCLUSIONS CBT0.7 appears to be a safe and feasible trajectory for cervical anterior transpedicular insertion. Bio-safe computer numerical control patient-specific drill templates can facilitate cervical anterior transpedicular insertion with good feasibility and accuracy.
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Affiliation(s)
- Peng Peng
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Yafei Xu
- Department of Orthopedics, Nanhai Hospital, Southern Medical University, 28 Liguan Road, Nanhai District, Foshan, Guangdong, China
| | - Xintao Zhang
- Department of Radiology, The Third Affiliated Hospital, Southern Medical University, 183 Zhongshandadao Xi, Tianhe District, Guangzhou, Guangdong, China
| | - Meisong Zhu
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Street, Haizhu District, Guangzhou, Guangdong, China
| | - Bingran Du
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Wenrui Li
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Wenhua Huang
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Jun Song
- General Education Department, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China.
| | - Jianyi Li
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China.
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Cervical pedicle screw instrumentation is more reliable with O-arm-based 3D navigation: analysis of cervical pedicle screw placement accuracy with O-arm-based 3D navigation. 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 2018; 27:2729-2736. [DOI: 10.1007/s00586-018-5585-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 03/05/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
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Unexpected Late Complication Causing Dysphagia. Dysphagia 2018; 33:481-483. [PMID: 29623425 DOI: 10.1007/s00455-018-9893-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
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Westermann L, Spemes C, Eysel P, Simons M, Scheyerer MJ, Siewe J, Baschera D. Computer tomography-based morphometric analysis of the cervical spine pedicles C3-C7. Acta Neurochir (Wien) 2018; 160:863-871. [PMID: 29411117 DOI: 10.1007/s00701-018-3481-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 01/25/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Our aim was to examine the specific dimensions of cervical pedicles in a large Caucasian cohort on high dissolving CT scans. METHODS A retrospective analysis of 100 cervical spine CT scans with a maximum slice thickness of 1 mm in axial, sagittal, and coronal reconstructions was performed. The pedicle axial length (PAL), inner and outer pedicle diameter (IPD/OPD), pedicle sagittal and transverse angle (PSA/PTA), pedicle height (PH), pedicle width (PW), and the cortical thickness (COT) at different margins were measured by two independent observers. A total of 1000 cervical pedicles (C3-C7) of 52 male (age 58 ± 17.47 years, height 177.97 ± 8.17 cm) and 48 female patients (age 57 ± 19.07 years, height 165.50 ± 7.44) were measured. RESULTS Cortical thickness at the medial limitation of the pedicle was 1.77 ± 0.43 and 0.90 ± 0.36 mm at the lateral limitation (p < 0.001). The mean PAL ranged from 30.5 mm at C4 level to 35.3 mm at C6 level. PW and PAL were smaller in the female than in the male patients. The smallest values for PW were at C3 with 29.17% of males and 52.88% of females < 4.5 mm. The percentage of patients with PW < 4.5 mm decreased caudally with less than 10% of pedicles below C4 in male participants and below C6 in female participants. Mean PTA ranged from 34.6° to 48.02° peaking at C4 and C5 levels. No gender-specific difference was found for PTA and PSA (p ≥ 0.13). IPD and OPD were larger in males (p < 0.001), and body height correlated significantly with IPW (p ≤ 0.019) and OPW (p ≤ 0.003). The interrater reliability was very good for PW, PH, and IPD (0.84-0.86), good for OPD, PTA, and PSA (0.64-0.79), and moderate for PAL (0.54) and cortical thickness (0.44). CONCLUSIONS Peculiarities of pedicle dimension of this central European cohort are comparable to morphometric studies in other ethnicities. Preoperative planning before cervical pedicle screw insertion on fine-cut CT scans demonstrates good interrater reliability for all important dimensions and angulations. More than half of female patients and almost a third of male patients had a PW of less than 4.5 mm at C3 level. Even though this percentage decreases caudally, pedicle screws might not be safe to insert in a noteworthy percentage of patients.
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Kim JY, Kwon JY, Kim MS, Lee JJ, Kim IS, Hong JT. Comparison of Morphological Characteristics of the Subaxial Cervical Spine between Athetoid Cerebral Palsy and Normal Control. J Korean Neurosurg Soc 2018. [PMID: 29526068 PMCID: PMC5853193 DOI: 10.3340/jkns.2017.0303.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective To compare the morphometry of subaxial cervical spine between cerebral palsy (CP) and normal control. Methods We retrospectively analyzed 72 patients with CP, as well as 72 patients from normal population. The two groups were matched for age, sex, and body mass index. Pedicle, lateral mass (LM), and vertebral foramen were evaluated using computed tomography (CT) imaging. Pedicle diameter, LM height, thickness, width and vertebral foramen asymmetry (VFA) were measured and compared between the two groups. Cervical dynamic motion, disc and facet joint degeneration were investigated. Additionally, we compared the morphology of LM between convex side and concave side with cervical scoliotic CP patients. Results LM height was smaller in CP group. LM thickness and width were larger in CP group at mid-cervical level. In 40 CP patients with cervical scoliosis, there were no height and width differences between convex and concave side. Pedicle outer diameter was not statistically different between two groups. Pedicle inner diameter was significantly smaller in CP group. Pedicle sclerosis was more frequent in CP patients. VFA was larger in CP group at C3, C4, and C5. Disc/facet degeneration grade was higher in the CP group. Cervical motion of CP group was smaller than those of the control group. Conclusion LM morphology of CP patients was different from normal population. Sclerotic pedicles and vertebral foramen asymmetry were more commonly identified in CP patients. CP patients were more likely to demonstrate progressive disc/facet degeneration. This data may provide useful information on cervical posterior instrumentation in CP patients.
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Affiliation(s)
- Jun Young Kim
- Department of Neurosurgery, Wiltse Memorial Hospital, Suwon, Korea
| | - Jae Yeol Kwon
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Moon Seok Kim
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jeong Jae Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Il Sup Kim
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jae Taek Hong
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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