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González-González F, Aguilar-Chávez F, Martínez-Loya C, Marín-Castañeda LA, Arellanes-Chavez CA, Lee Á. Top 100 Most Cited Articles on Intraoperative Image-Guided Navigation in Spine Surgery. Cureus 2024; 16:e67950. [PMID: 39328685 PMCID: PMC11426548 DOI: 10.7759/cureus.67950] [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: 08/27/2024] [Indexed: 09/28/2024] Open
Abstract
Navigation technologies have become essential in spine surgery over the last decade, offering precise procedures and minimizing risks. To the best of our knowledge, this is the first bibliometric analysis on this topic, providing insights and trends on topics, authors, and journals. The study identifies and analyzes the 100 most cited articles related to navigation in spine surgery. A systematic search was performed in Scopus and Google Scholar to identify all articles related to navigation in spine surgery (38,057 articles). The 100 most cited were analyzed for citations, titles, abstracts, authors, affiliations, keywords, country and institute of origin, year of publication, and level of evidence. The search was conducted in October 2023. The 100 most cited articles were published between 1995 and 2019, with 2010 to 2019 being the most prolific decade (46%). The most cited article had 733 citations, and the paper with the most citations per year averaged 59.27 citations/year. The Spine Journal had the most articles (34%). The United States contributed the most articles (39%). Most publications were clinical research and reviews (94%), with an overall evidence grade of IV-V (63%). A positive trend was noted in the last decade for incorporating augmented reality. This bibliometric analysis offers valuable insights and trends in spine surgery navigation literature. The findings indicate that technological advancements have led to more articles with higher levels of evidence. These pivotal articles shape evidence-based medicine, future surgeons, and industry improvements in navigated spine surgery.
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Affiliation(s)
| | - Felipe Aguilar-Chávez
- Cisne Spine Academy, Star Medica Hospital, Autonomous University of Chihuahua, Chihuahua, MEX
| | - Carolina Martínez-Loya
- Research, Faculty of Medicine and Biomedical Sciences, Autonomous University of Chihuahua, Chihuahua, MEX
| | | | | | - Ángel Lee
- Research, Dr. Manuel Gea González General Hospital, Mexico City, MEX
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Steinmetz MP, Riggleman JR, Mahoney JM, Harris JA, Butler JB, Ferrick BJ, Bucklen BS. A Dual-Screw Technique for Vertebral Compression Fractures via Robotic Navigation in the Osteopenic Lumbar Spine: An In-Vitro Biomechanical Analysis. Global Spine J 2024; 14:1706-1713. [PMID: 36644787 PMCID: PMC11268308 DOI: 10.1177/21925682231152833] [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] [Indexed: 01/17/2023] Open
Abstract
STUDY DESIGN Biomechanical cadaveric study. OBJECTIVES Multi-rod constructs maximize posterior fixation, but most use a single pedicle screw (PS) anchor point to support multiple rods. Robotic navigation allows for insertion of PS and cortical screw (CS) within the same pedicle, providing 4 points of bony fixation per vertebra. Recent studies demonstrated radiographic feasibility for dual-screw constructs for posterior lumbar spinal fixation; however, biomechanical characterization of this technique is lacking. METHODS Fourteen cadaveric lumbar specimens (L1-L5) were divided into 2 groups (n = 7): PS, and PS + CS. VCF was simulated at L3. Bilateral posterior screws were placed from L2-L4. Load control (±7.5Nm) testing performed in flexion-extension (FE), lateral bending (LB), axial rotation (AR) to measure ROM of: (1) intact; (2) 2-rod construct; (3) 4-rod construct. Static compression testing of 4-rod construct performed at 5 mm/min to measure failure load, axial stiffness. RESULTS Four-rod construct was more rigid than 2-rod in FE (P < .001), LB (P < .001), AR (P < .001). Screw technique had no significant effect on FE (P = .516), LB (P = .477), or AR (P = .452). PS + CS 4-rod construct was significantly more stable than PS group (P = .032). Stiffness of PS + CS group (445.8 ± 79.3 N/mm) was significantly greater (P = .019) than PS (317.8 ± 79.8 N/mm). Similarly, failure load of PS + CS group (1824.9 ± 352.2 N) was significantly greater (P = .001) than PS (913.4 ± 309.8 N). CONCLUSIONS Dual-screw, 4-rod construct may be more stable than traditional rod-to-rod connectors, especially in axial rotation. Axial stiffness and ultimate strength of 4-rod, dual-screw construct were significantly greater than rod-to-rod. In this study, 4-rod construct was found to have potential biomechanical benefits of increased strength, stiffness, stability.
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Affiliation(s)
- Michael P. Steinmetz
- Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Center for Spine Health Neurologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica R. Riggleman
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, PA, USA
| | - Jonathan M. Mahoney
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, PA, USA
| | - Jonathan A. Harris
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, PA, USA
| | - John B. Butler
- Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Center for Spine Health Neurologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bryan J. Ferrick
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, USA
| | - Brandon S. Bucklen
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, PA, USA
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Shang Q, Luan H, Peng C, Song X. Comparative effectiveness of cortical bone trajectory screws and pedicle screws in the treatment of adjacent segment degeneration after lumbar fusion surgery: a systematic review and meta-analysis. J Orthop Surg Res 2024; 19:380. [PMID: 38943143 PMCID: PMC11212258 DOI: 10.1186/s13018-024-04865-y] [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: 02/07/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024] Open
Abstract
PURPOSE To compare the efficacy and safety of cortical bone trajectory (CBT) screw and pedicle screw (PS) internal fixation in the treatment of adjacent segment degeneration (ASD) after lumbar fusion. METHODS This study was registered on International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42023484937). We searched PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wan Fang Database, and Wei Pu Database by computer to collect controlled clinical studies on the efficacy and safety of cortical bone trajectory (CBT) screw and pedicle screw (PS) internal fixation in the treatment of adjacent segment degeneration (ASD) after lumbar fusion from database establishment to November 2023. Two researchers screened the literature, extracted data and evaluated the risk of bias of the included studies, recorded the authors, and sample size, and extracted the intraoperative blood loss, operation time, Oswestry disability index (ODI), Visual analogue scale (VAS), disc height (DH), hospital length stay and complications in each study. Meta-analysis was performed using Revman 5.4 software provided by Cochrane Library. RESULTS A total of 6 cohort studies (CS) and 1 randomized controlled study with a total of 420 patients were included in this study, including 188 patients in the CBT group and 232 patients in the PS group. The CBT group had lower intraoperative blood loss than the PS group [mean difference (MD) = -129.38, 95% CI (-177.22, -81.55), P < 0.00001] and operation time was shorter than that of the PS group [MD = -1.42, 95% CI (-2.63, -0.20), P = 0.02]. Early postoperative back and leg pain improved more significantly in the CBT group [MD = -0.77, 95% CI (-1.35, -0.19), P = 0.01; MD = -0.24, 95% CI (-0.37, -0.10), P = 0.0005]. CONCLUSION Compared with PS, CBT for adjacent segment degeneration after lumbar fusion has the advantages of less intraoperative blood loss, shorter operation time, and less back and leg pain in the early postoperative period.
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Affiliation(s)
- Qisong Shang
- Department of Spine Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, 830002, China
| | - Haopeng Luan
- Department of Spine Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, 830002, China
| | - Cong Peng
- Department of Spine Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, 830002, China
| | - Xinghua Song
- Department of Spine Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, 830002, China.
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Palmer R, Ton A, Robertson D, Liu KG, Liu JC, Wang JC, Hah RJ, Alluri RK. Top 25 Most Cited Articles on Intraoperative Computer Tomography-Guided Navigation in Spine Surgery. World Neurosurg 2024; 184:322-330.e1. [PMID: 38342177 DOI: 10.1016/j.wneu.2024.02.024] [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: 01/09/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND In recent years, the use of intraoperative computer tomography-guided (CT-guided) navigation has gained significant popularity among health care providers who perform minimally invasive spine surgery. This review aims to identify and analyze trends in the literature related to the widespread adoption of CT-guided navigation in spine surgery, emphasizing the shift from conventional fluoroscopy-based techniques to CT-guided navigation. METHODS Articles pertaining to this study were identified via a database review and were hierarchically organized based on the number of citations. An "advanced document search" was performed on September 28th, 2022, utilizing Boolean search operator terms. The 25 most referenced articles were combined into a primary list after sorting results in descending order based on the total number of citations. RESULTS The "Top 25" list for intraoperative CT-guided navigation in spine surgery cumulatively received a total of 2742 citations, with an average of 12 new citations annually. The number of citations ranged from 246 for the most cited article to 60 for the 25th most cited article. The most cited article was a paper by Siewerdsen et al., with 246 total citations, averaging 15 new citations per year. CONCLUSIONS Intraoperative CT-guided navigation is 1 of many technological advances that is used to increase surgical accuracy, and it has become an increasingly popular alternative to conventional fluoroscopy-based techniques. Given the increasing adoption of intraoperative CT-guided navigation in spine surgery, this review provides impactful evidence for its utility in spine surgery.
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Affiliation(s)
- Ryan Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine at The University of Southern California, Los Angeles, California, USA
| | - Andy Ton
- Department of Orthopaedic Surgery, Keck School of Medicine at The University of Southern California, Los Angeles, California, USA.
| | - Djani Robertson
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Kevin G Liu
- Department of Orthopaedic Surgery, Keck School of Medicine at The University of Southern California, Los Angeles, California, USA
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine at The University of Southern California, Los Angeles, California, USA
| | - Jeffrey C Wang
- Department of Neurological Surgery, Keck School of Medicine at The University of Southern California, Los Angeles, California, USA
| | - Raymond J Hah
- Department of Orthopaedic Surgery, Keck School of Medicine at The University of Southern California, Los Angeles, California, USA
| | - Ram K Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine at The University of Southern California, Los Angeles, California, USA
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Zhang XN, Su QJ, Pei BQ, Pan AX, Yang HH, Ding HT, Hai Y, Liu YZ. The accuracy of cortical bone trajectory screw placement guided by spinous process clamp hardware in lumbar spinal surgery: a retrospective study. Sci Rep 2023; 13:16447. [PMID: 37777594 PMCID: PMC10542810 DOI: 10.1038/s41598-023-43406-1] [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: 11/13/2022] [Accepted: 09/23/2023] [Indexed: 10/02/2023] Open
Abstract
This study aimed to assess the accuracy of cortical bone trajectory (CBT) screws placement guided by a spinous process clamp (SPC) guide. A total of 32 patients who received single-level midline lumbar fusion (MIDLF) surgery between June 2019 and January 2020 were retrospectively analyzed and divided into free-hand (FH) and SPC-guided groups according to the surgical approach. In the FH group, CBT screws was implanted with the assistance of fluoroscopy, while in the SPC group, CBT screws was implanted using the SPC navigator hardwire. A total of 128 screws were assessed in this study, with higher rates of clinically acceptable screw placement (grades A and B) and grade A screws in the SPC group than in the FH guide group (92.2% vs. 79.7%, P = 0.042 and 54.7% vs. 35.9%, P = 0.033, respectively). Misplacement screws (grades C, D, and E) occurred more often in the FH group than in the SPC guide group (20.3% vs. 7.8%, P = 0.042). The incidence of proximal facet joint violation (FJV) was higher in the FH group than in the SPC group (15.6% vs. 3.1%, P = 0.030). The radiation dose and time in the SPC guide group were comparable to those in the FH group (P = 0.063 and P = 0.078). The average operative time was significantly longer in the SPC guide group than in the FH group (267.8 ± 45.5 min vs. 210.9 ± 44.5 min, P = 0.001). Other clinical parameters, such as the average bone mineral density (BMD), intraoperative blood loss, and postoperative hospital stay, were not significantly different. Oswestry disability index (ODI) and back pain visual analogue scale (VAS) scores were significantly improved in both groups compared with preoperatively. SPC guided screw placement was more accurate than the fluoroscopy-assisted FH technique for single-level MIDLF at L4/5. Patients undergoing SPC-guided screw placement can achieve similar clinical outcomes as the fluoroscopy-assisted FH technique.
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Affiliation(s)
- Xi-Nuo Zhang
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Qing-Jun Su
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Bao-Qing Pei
- Beijing Key Laboratory for Design and Evaluation Technology of Advanced Implantable and Interventional Medical Devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Ai-Xing Pan
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Hong-Hao Yang
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Hong-Tao Ding
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Yu-Zeng Liu
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China.
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Han J, Guo J, Ma X, Zhang G, Han S, Zhang H, Liu H, Chen M, Wang Y. The Cortical Bone Trajectory Screw Technique Assisted by the Mazor Renaissance Robotic System as a Salvage Strategy for Failed Lumbar Spine Surgery: Technical Note and Case Series. J Pain Res 2023; 16:2971-2980. [PMID: 37664488 PMCID: PMC10474863 DOI: 10.2147/jpr.s423058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose The objective of this study was to describe the Mazor Renaissance robotic system-assisted CBT (cortical bone trajectory) screw technique as a salvage strategy for failed lumbar spine surgery. Patients and Methods Between January 2018 and June 2022, 7 patients underwent salvage surgery with the CBT screw fixation technique assisted by the Mazor Renaissance robot system in our institution. Intraoperative observations were recorded for blood loss, duration of operation, and fluoroscopy time. Complications related to CBT screws were also recorded. The accuracy of CBT screws was recorded in accordance with the modified Gertzbein-Robbins classification. The JOA (Japanese Orthopedic Association) score for low back pain was used to evaluate surgical outcomes. Results A total of 26 CBT screws were placed in 7 patients, including 4 females and 3 males. Three patients underwent ASD (adjacent segment disease) and four patients underwent lumbar union failure with loose or compromised PSs (pedicle screws). The mean operation time was 129.29 ± 32.97 minutes, the mean blood loss was 180 ± 52.60 mL, and the mean intraoperative fluoroscopy time was 14.29 ± 3.15 s. All screws were clinically acceptable according to the Gertzbein-Robbins classification. There were no complications related to CBT screws in any of the cases. The JOA scores for low back pain of all patients were significantly improved at the final follow-up. Conclusion The CBT screw fixation technique supplemented the traditional PS fixation technique, which can be performed as a salvage strategy for failed lumbar spine surgery and achieved good clinical results. The spinal robot was very helpful in evaluating pedicle size and determining CBT screw direction, especially in a previously instrumented lumbar pedicle.
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Affiliation(s)
- Jialuo Han
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
| | - Jianwei Guo
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
| | - Xuexiao Ma
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
| | - Guoqing Zhang
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
| | - Shuo Han
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
| | - Hao Zhang
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
| | - Houchen Liu
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
| | - Mingrui Chen
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
| | - Yan Wang
- Department of Spinal Surgery, the Affiliated Hospital of Qingdao University, Shandong, People’s Republic of China
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Yuan YF, Ren ZX, Zhang C, Li GJ, Liu BZ, Li XD, Miao J, Li JF. Multitrack and multianchor point screw technique combined with the Wiltse approach for lesion debridement for lumbar tuberculosis. World J Clin Cases 2023; 11:3167-3175. [PMID: 37274032 PMCID: PMC10237128 DOI: 10.12998/wjcc.v11.i14.3167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/01/2023] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND The incidence of lumbar tuberculosis is high worldwide, and effective treatment is a continuing problem.
AIM To study the safety and efficacy of the multitrack and multianchor point screw technique combined with the contralateral Wiltse approach for lesion debridement to treat lumbar tuberculosis.
METHODS The C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), visual analogue scale (VAS) score, oswestry disability index (ODI) and American Spinal Injury Association (ASIA) grade were recorded and analysed pre- and postoperatively.
RESULTS The CRP level and ESR returned to normal, and the VAS score and ODI were decreased at 3 mo postoperatively, with significant differences compared with the preoperative values (P < 0.01). Neurological dysfunction was relieved, and the ASIA grade increased, with no adverse events.
CONCLUSION The multitrack, multianchor point screw fixation technique combined with the contralateral Wiltse approach for debridement is an effective and safe method for the treatment of lumbar tuberculosis.
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Affiliation(s)
- Yu-Fei Yuan
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Zhi-Xin Ren
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Cun Zhang
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Guan-Jun Li
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Bing-Zhi Liu
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Xiao-Dong Li
- Department of Orthopadics, Handan Center Hospital, Handan 056001, Hebei Provence, China
| | - Jie Miao
- Department of Orthopedic Surgery, Handan Central Hospital, Handan 056001, Hebei Province, China
| | - Jian-Fei Li
- Department of CT, Handan Central Hospital, Handan 056001, Hebei Province, China
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Li Y, Wang S, Zhu Z, Chen L, Shi Z, Ye X, Xu W, Li Z. Biomechanical Analysis of Cortical Bone Trajectory Screw Versus Bone Cement Screw for Fixation in Porcine Spinal Low Bone Mass Model. Clin Spine Surg 2023; 36:E145-E152. [PMID: 36180974 PMCID: PMC10150626 DOI: 10.1097/bsd.0000000000001395] [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: 04/05/2022] [Accepted: 08/17/2022] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN A prospective study of in vitro animal. OBJECTION To compare the biomechanics of cortical bone trajectory screw (CBT) and bone cement screw (BC) in an isolated porcine spinal low bone mass model. SUMMARY OF BACKGROUND DATA The choice of spinal fixation in patients with osteoporosis remains controversial. Is CBT better than BC? Research on this issue is lacking. METHODS Ten porcine spines with 3 segments were treated with EDTA decalcification. After 8 weeks, all the models met the criteria of low bone mass. Ten specimens were randomly divided into groups, group was implanted with CBT screw (CBT group) and the other group was implanted with bone cement screw (BC group). The biomechanical material testing machine was used to compare the porcine spine activities of the two groups in flexion, extension, bending, and axial rotation, and then insertional torque, pull-out force, and anti-compression force of the 2 groups were compared. Independent sample t test was used for comparison between groups. RESULTS Ten 3 segments of porcine spine models with low bone mass were established, and the bone mineral density of all models was lower than 0.75 g/cm 2 . There is no difference between the CBT and BC groups in flexion, extension, bending, and axial rotation angle, P >0.05. However, there were significant differences between the 2 groups and the control group, with P <0.01. The 2 groups significantly differed between the insertional torque ( P =0.03) and the screw pull-out force ( P =0.021). The anti-compression forces between the 2 groups have no significant difference between the two groups ( P =0.946). CONCLUSIONS The insertional torque and pull-out force of the CBT were higher than those of the BC in the isolated low bone porcine spine model. The range of motion and anti-compression ability of the model was similar between the 2 fixation methods.
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Affiliation(s)
| | - Silian Wang
- Department of Imaging, Tongren Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Zhenbiao Zhu
- Department of Orthopaedics, Central South University Xiangya School of Medicine Affiliated Haikou Hospital, Haikou, Hainan, P.R.China
| | - Liwei Chen
- Department of Imaging, Tongren Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Zhangpeng Shi
- Shanghai Clinical College, Anhui Medical University, Shanghai
| | | | - Wei Xu
- Department of Orthopedics
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Tang YX, Peng SL, Chen YW, Huang HM, Shih CT. Evaluating the contact anatomy and contact bone volume of spinal screws using a novel drilled surface image. PLoS One 2023; 18:e0282737. [PMID: 37036863 PMCID: PMC10085035 DOI: 10.1371/journal.pone.0282737] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/21/2023] [Indexed: 04/11/2023] Open
Abstract
Intraoperative navigation systems have been widely applied in spinal fusion surgery to improve the implantation accuracy of spinal screws using orthogonal tomographic and surface-rendering imaging. However, these images contain limited anatomical information and no information on bone volume contact by the implanted screw, which has been proven to affect the stability of implanted screws. This study proposed a novel drilled surface imaging technique that displays anatomical integration properties to calculate the contact bone volume (CBV) of the screws implanted along an implantation trajectory. A cylinder was used to represent the area traversed by the screws, which was manually rotated and translated to a predetermined implantation trajectory according to a vertebra model obtained using computed tomography (CT) image volumes. The drilled surface image was reconstructed by interpolating the CT numbers at the predefined sampling points on the cylinder surface. The anatomical integration property and CBV of the screw implanted along the transpedicular trajectory (TT) and cortical bone trajectory (CBT) were evaluated and compared. The drilled surface image fully revealed the contact anatomical structure of the screw under the trajectories, improving the understanding of the anatomical integration of the screw and surrounding tissues. On average, the CBV of the CBT was 30% greater than that of the TT. The proposed drilled surface image may be applied in preoperative planning and integrated into intraoperative navigation systems to evaluate the anatomical integration and degree of bone contact of the screw implanted along a trajectory.
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Affiliation(s)
- Yun-Xuan Tang
- Department of Radiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Shin-Lei Peng
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
| | - Yi-Wen Chen
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
- x-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan
- 3D Printing Medical Research Institute, Asia University, Taichung, Taiwan
| | - Hsiang-Ming Huang
- Department of Neurosurgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Cheng-Ting Shih
- Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
- x-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan
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Peng SB, Yuan XC, Lu WZ, Yu KX. Application of the cortical bone trajectory technique in posterior lumbar fixation. World J Clin Cases 2023; 11:255-267. [PMID: 36686364 PMCID: PMC9850973 DOI: 10.12998/wjcc.v11.i2.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/29/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
The cortical bone trajectory (CBT) is a novel technique in lumbar fixation and fusion. The unique caudocephalad and medial-lateral screw trajectories endow it with excellent screw purchase for vertebral fixation via a minimally invasive method. The combined use of CBT screws with transforaminal or posterior lumbar interbody fusion can treat a variety of lumbar diseases, including spondylolisthesis or stenosis, and can also be used as a remedy for revision surgery when the pedicle screw fails. CBT has obvious advantages in terms of surgical trauma, postoperative recovery, prevention and treatment of adjacent vertebral disease, and the surgical treatment of obese and osteoporosis patients. However, the concept of CBT internal fixation technology appeared relatively recently; consequently, there are few relevant clinical studies, and the long-term clinical efficacy and related complications have not been reported. Therefore, large sample and prospective studies are needed to further reveal the long-term complications and fusion rate. As a supplement to the traditional pedicle trajectory fixation technique, the CBT technique is a good choice for the treatment of lumbar diseases with accurate screw placement and strict indications and is thus deserving of clinical recommendation.
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Affiliation(s)
- Shi-Bo Peng
- Department of Orthopedics, Chongqing Nanchuan Hospital of Traditional Chinese Medicine, Chongqing 408400, China
| | - Xi-Chuan Yuan
- Department of Orthopedics, Chongqing Nanchuan Hospital of Traditional Chinese Medicine, Chongqing 408400, China
| | - Wei-Zhong Lu
- Department of Orthopedics, Chongqing Hospital of Traditional Chinese Medicine, Chongqing 400021, China
| | - Ke-Xiao Yu
- Department of Orthopedics, Chongqing Hospital of Traditional Chinese Medicine, Chongqing 400021, China
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Guo S, Zhu K, Yan MJ, Li XH, Tan J. Cortical bone trajectory screws in the treatment of lumbar degenerative disc disease in patients with osteoporosis. World J Clin Cases 2022; 10:13179-13188. [PMID: 36683619 PMCID: PMC9850985 DOI: 10.12998/wjcc.v10.i36.13179] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/05/2022] [Accepted: 11/28/2022] [Indexed: 12/26/2022] Open
Abstract
Lumbar degenerative disc disease (DDD) in the elderly population remains a global health problem, especially in patients with osteoporosis. Osteoporosis in the elderly can cause failure of internal fixation. Cortical bone trajectory (CBT) is an effective, safe and minimally invasive technique for the treatment of lumbar DDD in patients with osteoporosis. In this review, we analyzed the anatomy, biomechanics, and advantages of the CBT technique in lumbar DDD and revision surgery. Additionally, the clinical trials and case reports, indications, advancements and limitations of this technique were further discussed and reviewed. Finally, we concluded that the CBT technique can be a practical, effective and safe alternative to traditional pedicle screw fixation, especially in DDD patients with osteoporosis.
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Affiliation(s)
- Song Guo
- Department of Orthopedics Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Kai Zhu
- Department of Orthopedics Ⅱ, Qingdao No. 8 People’s Hospital, Qingdao 266121, Shandong Province, China
| | - Mei-Jun Yan
- Department of Orthopedics Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Xin-Hua Li
- Department of Orthopedics Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Jun Tan
- Department of Orthopedics, United Family Healthcare, Shanghai 200336, China
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12
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Muacevic A, Adler JR, Torii Y, Umehara T, Iinuma M, Yoshida A, Tomochika K, Niki H. Accuracy and Screw Insertion Time of Robotic-Assisted Cortical Bone Trajectory Screw Placement for Posterior Lumbar Interbody Fusion: A Comparison of Early, Middle, and Late Phases. Cureus 2022; 14:e32574. [PMID: 36654567 PMCID: PMC9840449 DOI: 10.7759/cureus.32574] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction The purpose of this study was to evaluate robotic-assisted cortical bone trajectory (CBT) screw placement. Early, middle, and late phases of robotic-assisted CBT screw placement were compared for accuracy and screw insertion time by comparing time and accuracy in every phase. Methods A retrospective review was conducted on the initial 40 patients who underwent spinal fusion using CBT screws in one institution from September 2021 to September 2022 utilizing a spine surgery robot system (Mazor X Stealth Edition, Medtronic Inc., Dublin, Ireland). The inclusion criterion was one- or two-level posterior lumbar interbody fusion (PLIF). Exclusion criteria were 1) patients who underwent posterior-lateral fusion in other segments, 2) patients who underwent additional decompression in other segments, 3) patients who underwent reoperation, and 4) patients with spondylolysis. The deviation of the CBT screw was evaluated on computed tomography (CT) one week after surgery using the Gertzbein-Robbins grade system. The rate of Grade A was considered the perfect accuracy rate, and the rate of penetration of 2 mm or more (Grades C, D, and E) was calculated as the deviation rate. To assess the learning curve, patients were divided into three groups. The first 10 cases were in the early phase group, the subsequent 10 cases were in the middle phase group, and the last 10 cases were in the late phase group. We compared the perfect accuracy rate, deviation rate, operative time, operative time per segment, intraoperative blood loss, registration time, and screw insertion time among the three groups. Results Thirty patients met the criteria. Overall, the perfect accuracy (Grade A) rate of the screw was 95.3% and the deviation rate was 1.4%. The perfect accuracy rate was 90.4% in the early phase, 95.5% in the middle phase, and 100% in the late phase. The deviation rate was 3.8% in the early phase, 0% in the middle phase, and 0% in the late phase, and there was no statistically significant difference between the three groups. Among the three groups, the operative time, the operative time per segment, the intraoperative blood loss, and the registration time were not significantly different. There was no significant difference in the screw insertion time among the three groups, but it decreased with experience (early phase: 156.9 ± 54.7 sec, middle phase: 139.9 ± 41.6 sec, and late phase: 106.4 ± 39.9 sec, p=0.060). The screw insertion time of the late phase tended to be shorter than that of the early phase (p=0.052). Conclusions The deviation rate of robotic-assisted CBT screw placement with one- or two-level PLIF was 1.4%, which was highly accurate. The deviation rate was 3.8% in the early phase, 0% in the middle phase, and 0% in the late phase. Although the deviation rate was low even in the early period, the screw insertion time in the early 10 cases tended to be longer than that in the late 10 cases. After passing the experience of 10 cases, this study concluded that robotic-assisted CBT screw placement was proficient.
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13
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Kahaer A, Maimaiti X, Maitirouzi J, Wang S, Shi W, Abuduwaili N, Zhou Z, Liu D, Maimaiti A, Rexiti P. Biomechanical investigation of the hybrid modified cortical bone screw–pedicle screw fixation technique: Finite-element analysis. Front Surg 2022; 9:911742. [PMID: 35923441 PMCID: PMC9339714 DOI: 10.3389/fsurg.2022.911742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundHybrid fixation techniques including the both modified cortical bone trajectory (MCBT) and traditional trajectory (TT) at the L4 and L5 lumbar segment are firstly proposed by our team. Therefore, the purpose of this study is to evaluate and provide specific biomechanical data of the hybrid fixation techniques including the MCBT and TT.MethodsFour human cadaveric specimens were from the anatomy laboratory of Xinjiang Medical University. Four finite-element (FE) models of the L4–L5 lumbar spine were generated. For each of them, four implanted models with the following fixations were established: TT-TT (TT screw at the cranial and caudal level), MCBT-MCBT (MCBT screw at the cranial and caudal level), hybrid MCBT-TT (MCBT screw at the cranial level and TT screw at the caudal level), and TT-MCBT (TT screw at the cranial level and MCBT screw at the caudal level). A 400-N compressive load with 7.5 N/m moments was applied to simulate flexion, extension, lateral bending, and rotation, respectively. The range of motion (ROM) of the L4–L5 segment and the posterior fixation, the von Mises stress of the intervertebral disc, and the posterior fixation were compared.ResultsCompared to the TT-TT group, the MCBT-TT showed a significant lower ROM of the L4–L5 segment (p ≤ 0.009), lower ROM of the posterior fixation (p < 0.001), lower intervertebral disc stress (p < 0.001), and lower posterior fixation stress (p ≤ 0.041). TT-MCBT groups showed a significant lower ROM of the L4–L5 segment (p ≤ 0.012), lower ROM of the posterior fixation (p < 0.001), lower intervertebral disc stress (p < 0.001), and lower posterior fixation stress (p ≤ 0.038).ConclusionsThe biomechanical properties of the hybrid MCBT-TT and TT-MCBT techniques at the L4–L5 segment are superior to that of stability MCBT-MCBT and TT-TT techniques, and feasibility needs further cadaveric study to verify.
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Affiliation(s)
- Alafate Kahaer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xieraili Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Shuiquan Wang
- Department of Anatomy, College of Basic Medicine, Xinjiang Medical University, Urumqi, China
| | - Wenjie Shi
- First Clinical Medical College, Xinjiang Medical University, Urumqi, China
| | - Nueraihemaiti Abuduwaili
- Department of Imaging Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Zhihao Zhou
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Dongshan Liu
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Abulikemu Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Correspondence: Paerhati Rexiti
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14
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Controversies in Spine Surgery: Is a Cortical Bone Trajectory Superior to Traditional Pedicle Screw Trajectory? Clin Spine Surg 2022; 35:225-228. [PMID: 32205518 DOI: 10.1097/bsd.0000000000000965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Kim SJ, Mobbs RJ, Natarajan P, Fonseka RD, Walsh WR. Historical Note: The Evolution of Cortical Bone Trajectory and Associated Techniques. Spine Surg Relat Res 2022; 6:1-9. [PMID: 35224240 PMCID: PMC8842353 DOI: 10.22603/ssrr.2021-0059] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/15/2021] [Indexed: 11/17/2022] Open
Abstract
Cortical bone trajectory (CBT) for posterior fixation with pedicle screws is considered a relatively new alternative trajectory that travels in the medio-lateral direction in the transverse plane and in the caudo-cephalad path in the sagittal plane. Various biomechanical studies have already validated its superior pullout strength and mechanical stability over the traditional trajectory of convergent pedicle screws. Due to the relatively medial starting point of this trajectory, the CBT also poses the clinical advantage of requiring a smaller surgical field of exposure, thus minimizing tissue and muscle injury while reducing operative time and intraoperative blood loss. The evolution of CBT through time has closely been linked to the unwavering philosophy of prioritizing patient outcomes, advancements in neuronavigational technology, and the mounting biomechanical, morphometric, and clinical evidence. In this historical review, we provide a unique perspective on how CBT surgical technique has developed through time, highlighting key milestones and attempting to explain its explosive rise in popularity.
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Affiliation(s)
- Sihyong J. Kim
- Surgical Orthopaedics Research Laboratory, Prince of Wales Hospital
| | | | | | | | - William R. Walsh
- Surgical Orthopaedics Research Laboratory, Prince of Wales Hospital
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16
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Tan QC, Huang JF, Bai H, Liu ZX, Huang XY, Zhao X, Yang Z, Du CF, Lei W, Wu ZX. Effects of Revision Rod Position on Spinal Construct Stability in Lumbar Revision Surgery: A Finite Element Study. Front Bioeng Biotechnol 2022; 9:799727. [PMID: 35071208 PMCID: PMC8766337 DOI: 10.3389/fbioe.2021.799727] [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: 10/22/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022] Open
Abstract
Revision surgery (RS) is a necessary surgical intervention in clinical practice to treat spinal instrumentation–related symptomatic complications. Three constructs with different configurations have been applied in RS. One distinguishing characteristic of these configurations is that the revision rods connecting previous segments and revision segments are placed alongside, outside, or inside the previous rods at the level of facetectomy. Whether the position of the revision rod could generate mechanical disparities in revision constructs is unknown. The objective of this study was to assess the influence of the revision rod position on the construct after RS. A validated spinal finite element (FE) model was developed to simulate RS after previous instrumented fusion using a modified dual-rod construct (DRCm), satellite-rod construct (SRC), and cortical bone trajectory construct (CBTC). Thereafter, maximum von Mises stress (VMS) on the annulus fibrosus and cages and the ligament force of the interspinous ligament, supraspinous ligament, and ligamentum flavum under a pure moment load and a follower load in six directions were applied to assess the influence of the revision rod position on the revision construct. An approximately identical overall reducing tendency of VMS was observed among the three constructs. The changing tendency of the maximum VMS on the cages placed at L4-L5 was nearly equal among the three constructs. However, the changing tendency of the maximum VMS on the cage placed at L2-L3 was notable, especially in the CBTC under right bending and left axial rotation. The overall changing tendency of the ligament force in the DRCm, SRC, and CBTC was also approximately equal, while the ligament force of the CBTC was found to be significantly greater than that of the DRCm and SRC at L1-L2. The results indicated that the stiffness associated with the CBTC might be lower than that associated with the DRCm and SRC in RS. The results of the present study indicated that the DRCm, SRC, and CBTC could provide sufficient stabilization in RS. The CBTC was a less rigid construct. Rather than the revision rod position, the method of constructing spinal instrumentation played a role in influencing the biomechanics of revision.
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Affiliation(s)
- Quan-Chang Tan
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi'an, China.,Department of Orthopaedics, Air Force Hospital of Eastern Theater Command, Nanjing, China
| | - Jin-Feng Huang
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi'an, China
| | - Hao Bai
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi'an, China
| | - Zi-Xuan Liu
- Tianjin Key Laboratory for Advanced Mechatronic System Design and Intelligent Control, School of Mechanical Engineering, Tianjin University of Technology, Tianjin, China.,National Demonstration Center for Experimental Mechanical and Electrical Engineering Education, Tianjin University of Technology, Tianjin, China
| | - Xin-Yi Huang
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi'an, China
| | - Xiong Zhao
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi'an, China
| | - Zhao Yang
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi'an, China
| | - Cheng-Fei Du
- Tianjin Key Laboratory for Advanced Mechatronic System Design and Intelligent Control, School of Mechanical Engineering, Tianjin University of Technology, Tianjin, China.,National Demonstration Center for Experimental Mechanical and Electrical Engineering Education, Tianjin University of Technology, Tianjin, China
| | - Wei Lei
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi'an, China
| | - Zi-Xiang Wu
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, Xi'an, China
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17
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Placement of Unilateral Cortical Bone Trajectory Screws in Previously Instrumented Pedicle without Removal of Existing Hardware for Adjacent Segment Disease. Case Rep Orthop 2021; 2021:9994539. [PMID: 34796033 PMCID: PMC8595017 DOI: 10.1155/2021/9994539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
Adjacent segment disease (ASD) in the lumbar spine is a possible consequence in segments adjacent to a fusion. As the number of lumbar fusions in the United States increases, the rates of ASD will continue to climb. There are several treatment options for ASD with open decompression and extension of the fusion being common. However, need for exposure and removal of existing instrumentation can lead to increased operative times resulting in increasing blood loss and infection risk. The purpose of this paper is to describe a case report for unilateral cortical trajectory screw instrumentation, allowing for posterior instrumentation without having to remove the existing pedicle screws in the setting of ASD. Our technique can be done with standard c-arm fluoroscopy without the need for navigation.
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18
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Chen MM, Jia P, Tang H. Cortical bone trajectory fixation in cemented vertebrae in lumbar degenerative disease: A case report. World J Clin Cases 2021; 9:8609-8615. [PMID: 34754875 PMCID: PMC8554437 DOI: 10.12998/wjcc.v9.i28.8609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/27/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Percutaneous vertebroplasty (PVP) has been widely used in osteoporotic vertebral compression fracture (OVCF). Following surgery, the bone cement would be positioned permanently. However, in some cases of lumbar degenerative disease, the cemented vertebrae needs to be fixed after decompression and fusion procedure. It is difficult to implant traditional pedicle screws into the cemented vertebrae because of the bone cement filling. At present, the main treatment strategy is to skip the cemented vertebra and conduct a long segment fixation. This article presents a cortical bone trajectory (CBT) fixation technique for cemented vertebrae.
CASE SUMMARY PVP involving the L3 and L4 was performed in an 82-year-old man due to OVCF. During the surgery, bone cement leakage occurred, resulting in compression of the root of the right L3 nerve. We performed a partial facetectomy to retrieve the leaked bone cement and to relieve the patient’s neurological symptoms. After 3 mo, the patient developed lumbar disc herniation in L3/4, potentially due to instability caused by the previous surgery. Therefore, it was necessary to perform intervertebral fusion and fixation. It was difficult to implant traditional trajectory pedicle screws in L3 and L4 because of the bone cement filling. Hence, we implanted CBT screws in the L3 and L4 vertebrae. As a result, the patient’s symptoms resolved and he reported satisfaction with the surgery at follow-up after 8 mo.
CONCLUSION It is feasible to utilize CBT in cemented vertebrae for the treatment of lumbar degenerative disease.
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Affiliation(s)
- Meng-Meng Chen
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Pu Jia
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Hai Tang
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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19
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Rho K, OConnor TE, Lucas JM, Pollina J, Mullin J. Minimally Invasive Robot-Guided Dual Cortical Bone Trajectory for Adjacent Segment Disease. Cureus 2021; 13:e16822. [PMID: 34513418 PMCID: PMC8407417 DOI: 10.7759/cureus.16822] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/15/2022] Open
Abstract
Here we present a novel application of cortical bone trajectory (CBT) fixation utilizing robotic guidance in a previously instrumented spine with a traditional pedicle screw (PS), obviating the need for a larger posterior incision, reducing the risk of infection, muscular dissection, and likely decreasing hospital length of stay. A 60-year-old woman with prior left L3-L4 extreme lateral interbody fusion and unilateral percutaneous PS placed at L3 to L5 presented with progressive bilateral lower-extremity pain and diminished sensation in the S1 dermatome secondary to adjacent segment disease (ASD). The patient underwent an L5-S1 anterior lumbar interbody fusion for indirect decompression and restoration of segmental lordosis. After the first stage was completed, she was turned prone for posterior percutaneous instrumentation. Given prior instrumentation at L3-L5 on the left side, a robot planning software was used to plan a cortical bone screw on the left L5 pedicle. A left S1 PS was then planned with the screw head aligning with the left L5 cortical bone screw. Instrumentation was then placed percutaneously using the robot bilaterally without issue. Intraoperative fluoroscopic imaging demonstrated accurate placement of PS, and postoperative computed tomography demonstrated the excellent positioning of all PSs. This report is the first documented case of a robotically placed CBT screw placed in the same pedicle as a prior traditional PS for ASD. This method expands the surgical options for ASD to include robotic percutaneous placement of posterior instrumentation at the same level as previous instrumentation.
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Affiliation(s)
- Kyungduk Rho
- Neurological Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Timothy E OConnor
- Neurological Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Jean-Marc Lucas
- Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - John Pollina
- Neurological Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Jeffrey Mullin
- Neurological Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
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20
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He K, Dong C, Wei H, Yang F, Ma H, Tang X, Tan M, Yi P. A Minimally Invasive Technique Using Cortical Bone Trajectory Screws Assisted by 3D-Printed Navigation Templates in Lumbar Adjacent Segment Degeneration. Clin Interv Aging 2021; 16:1403-1413. [PMID: 34321872 PMCID: PMC8313433 DOI: 10.2147/cia.s318525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/25/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose Revision surgery for adjacent segment degeneration (ASD) commonly requires exposing and removing the original fixation. To minimize trauma and to reduce the operation time and blood loss, we introduced a minimally invasive lumbar revision technique using cortical bone trajectory (CBT) screws assisted by three-dimensional (3D)-printed navigation templates. Methods From April 2017 to October 2019, 18 patients with ASD underwent revision surgery with CBT screws assisted by 3D-printed templates in our hospital. All surgical data, including the operation time, blood loss, and incision length, were recorded. We evaluated the clinical efficacy using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and the Japanese Orthopedic Association (JOA) score. X-ray and computed tomography (CT) scans were used to evaluate the stability of CBT screw fixation, the accuracy of screws, and the fusion rate. Results The mean follow-up was 22.4±4.7 months (12–31 months). The VAS, ODI, and JOA scores were analyzed by SPSS 21.0 and showed significant improvement at 2 weeks and the last follow-up compared with preoperative data (P<0.05). Seventy-six CBT screws were inserted with navigation templates; 2 screws were Grade B, and the other screws were Grade 0 or A. Changes in intervertebral height showed good stability of CBT screw fixation (P>0.05). All the patients exhibited satisfactory fusion results. Conclusion Revision surgery for ASD with CBT screws assisted by 3D-printed navigation templates has satisfactory clinical efficacy with the advantages of a short operation time, a small incision, and less blood loss.
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Affiliation(s)
- Kun He
- Beijing University of Chinese Medicine, Beijing, 100029, People's Republic of China.,Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Chunke Dong
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, 100010, People's Republic of China
| | - Hongyu Wei
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Feng Yang
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Haoning Ma
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Xiangsheng Tang
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Mingsheng Tan
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Ping Yi
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
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21
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Wang L, Zhao YH, Cai XB, Liang JL, Luo HT, Ma YL, Xu YQ, Lu S. Feasibility of cortical bone trajectory screws for bridging fixation in revision surgery for lumbar adjacent segment degeneration. Medicine (Baltimore) 2021; 100:e26666. [PMID: 34260574 PMCID: PMC8284764 DOI: 10.1097/md.0000000000026666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/29/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To investigate the feasibility of using cortical bone trajectory (CBT) screws for bridging fixation in revision surgery for lumbar adjacent segment degeneration and to provide a reference for clinical practice. METHODS Computed tomography scans of the lumbar spines of 36 patients in our hospital were used. Sixteen males and 20 females with an average age of 65.5 ± 10.5 years (range: 46 to 83 years) were included. Three-dimensional reconstruction was performed using computer software. Screws with appropriate sizes were selected for the L1 to L5 vertebral segments, and traditional pedicle screws were placed using the standard method. After completing screw placement, simulated placement of CBT screws was performed separately. No overlap occurred between the two screws in the process of CBT screw placement, and the placement point and direction were adjusted until screw placement completion. After all screw placement simulations were complete, according to the contact area of the cortical bone of the screw trajectory and the screw puncture position and distance through the trajectory, the screw placement results were categorized as excellent, good, general, and failure. Excellent and good ratings were considered successful, while a general rating was regarded as acceptable. Then, the success rate and acceptable rate of each segment of the lumbar spine were calculated. RESULTS Three hundred and sixty screw placement simulations were performed in lumbar pedicles, and 72 CBT screws were implanted in each vertebral body of the lumbar spine. The success rates in the L1 to L5 segments were 73.6%, 80.6%, 83.3%, 88.9%, and 77.8%, respectively, and the acceptable rates were 91.7%, 97.2%, 97.2%, 100%, and 91.7%, respectively. The overall success rate and acceptable rate of CBT screw placement in the lumbar spine were 80.8% and 95.6%, respectively. CONCLUSION CBT screws are feasible for bridging fixation in lumbar adjacent segment degeneration revision surgery, and the accuracy of screw placement in different lumbar vertebrae varies.
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Affiliation(s)
- Long Wang
- Postgraduate College of Kunming Medical University, No. 1168 Chunrong Xi Road, Kunming, China
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Yong-Hui Zhao
- Department of Orthopedics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, The Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road, Kunming, China
| | - Xing-Bo Cai
- Postgraduate College of Kunming Medical University, No. 1168 Chunrong Xi Road, Kunming, China
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Jin-Long Liang
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Hao-Tian Luo
- Department of Orthopedics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, The Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road, Kunming, China
| | - Yu-Long Ma
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Yong-Qing Xu
- Department of Orthopedics, 920th Hospital of Joint Logistics Support Force, 212 Daguan Road, Kunming, China
| | - Sheng Lu
- Department of Orthopedics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, The Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road, Kunming, China
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22
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Kumar KK, Parikh B, Jabarkheel R, Dirlikov B, Singh H. Fluoroscopic versus CT-guided cortical bone trajectory pedicle screw fixation: Comparing trajectory related complications. J Clin Neurosci 2021; 89:354-359. [PMID: 34088578 DOI: 10.1016/j.jocn.2021.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/23/2021] [Accepted: 05/23/2021] [Indexed: 01/02/2023]
Abstract
Cortical bone trajectory (CBT) pedicle screw fixation is an emerging technique for treatment of degenerative spine disease which requires either intraoperative fluoroscopy or intraoperative CT guidance (iCT). To date, there has been no direct comparison of these two navigation modalities; here we compare fluoroscopic versus iCT navigation for CBT pedicle screw fixation. We retrospectively reviewed all patients who underwent CBT screw fixation with either fluoroscopic or iCT guidance for lumbar degenerative disease by the senior author. Trajectory-related complications such as medial or lateral breach were compared on postoperative CT, in addition to the incidence of trajectory-related dural tear. We also compared general surgical complications such as postoperative infection and decompression related durotomies. Thirty-eight patients (19 fluoroscopic, 19 CT-guided) who underwent placement of 182 cortical screws (88 fluoroscopic, 94 CT-guided) were identified. In terms of trajectory-related complications, the iCT cohort had fewer medial breaches (1/94) compared to the fluoroscopic cohort (6/88) (p = 0.05). Each group had one lateral breach (p = 0.73). There was one case of CSF leak from screw placement in the fluoroscopic cohort, but none in the iCT cohort (p = 0.48). Overall, there were eight trajectory-related complications in the fluoroscopic cohort versus two in the iCT cohort (p = 0.04). Our data suggests statistically significant decreased trajectory-related complications with iCT-guided CBT screw fixation as compared to fluoroscopically guided. In terms of general surgical complications, while we observed increased postoperative infections in our fluoroscopic cohort, there was no statistically significant difference.
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Affiliation(s)
- Kevin K Kumar
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Bhavya Parikh
- School of Medicine, Meharry Medical College, Nashville, TN, USA
| | - Rashad Jabarkheel
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin Dirlikov
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University, Stanford, CA, USA; Division of Neurosurgery, Santa Clara Valley Medical Center, San Jose, CA, USA.
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Cortical screw fixation using CT-navigation coupled with real-time electrophysiological monitoring of individual screw placement for unstable degenerative lumbar spondylolisthesis. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Xue YD, Ma C, Feng J, Dai WX, Zhang ZC. Investigation of clinical efficacy of screw fixation with cortical bone trajectory for adjacent segment disease after lumbar interbody fusion. EUR J INFLAMM 2021. [DOI: 10.1177/20587392211000561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To evaluate the clinical efficacy of screw fixation with cortical bone trajectory for adjacent segment disease after lumbar interbody fusion. A total of 14 patients with adjacent segment disease were enrolled, and a retrospective analysis was performed. All patients experienced posterior lumbar interbody fusion of the affected segments combined with internal fixation of cortical bone trajectory screw. Operation time, intraoperative blood loss, and complications were recorded. Clinical outcomes was evaluated by Visual Analogue Scale, Oswestry disability index, and Japanese Orthopaedic Association score. X-ray and computed tomography and sagittal reconstruction were used to check regularly during the follow-up. Bone graft fusion rate was evaluated by Brantigan classification. Preoperatively, Visual Analogue Scale, Oswestry Disability Index, and Japanese Orthopaedic Association scores were 7.0 ± 1.0, 72.2 ± 3.2, and 11.9 ± 1.3 points, respectively. At the 12th month after surgery, their scores were 1.9 ± 0.7, 28.6 ± 1.2, and 23.7 ± 0.9 points, respectively, which were significantly improved compared with those before surgery, and there were statistical significance in all differences (all p < 0.05). At the 12th month after surgery, X-ray and computed tomography showed there were no complications related to internal fixation, such as breakage and displacement. At the 12th month after surgery, according to the Brantigan classification, 10 patients were classified as Grade E, 3 as Grade D, and 1 as Grade C, with a fusion rate of 92.9%. At the final follow-up, clinical outcomes were assessed by the Stauffer-Coventry criteria: there were 10 patients with excellent outcomes, 1 with good outcomes, 3 with fair outcomes, and 0 with poor outcomes, with an excellent and good rate of 78.6%. The clinical outcomes of posterior lumbar interbody fusion combine with cortical bone trajectory screw for adjacent segment disease without removing the previous internal fixator were satisfactory, but further clinical researches were still required to explore its long-term outcome.
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Affiliation(s)
- You-Di Xue
- Department of Orthopaedic Surgery, Xuzhou Central Hospital, Xuzhou, Jiangsu Province, People’s Republic of China
| | - Chao Ma
- Department of Orthopaedic Surgery, Xuzhou Central Hospital, Xuzhou, Jiangsu Province, People’s Republic of China
| | - Jie Feng
- Department of Orthopaedic Surgery, Xuzhou Central Hospital, Xuzhou, Jiangsu Province, People’s Republic of China
| | - Wei-Xiang Dai
- Department of Orthopaedic Surgery, Xuzhou Central Hospital, Xuzhou, Jiangsu Province, People’s Republic of China
| | - Zhao-Chuan Zhang
- Department of Orthopaedic Surgery, Xuzhou Central Hospital, Xuzhou, Jiangsu Province, People’s Republic of China
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Zhao YH, Ma YL, Wang L, Liang JL, Luo HT, Xu YQ, Lu S. Anatomical study of the ideal cortical bone trajectory in the lumbar spine. Medicine (Baltimore) 2021; 100:e24099. [PMID: 33466177 PMCID: PMC7808538 DOI: 10.1097/md.0000000000024099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 12/08/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND To explore the ideal trajectory of lumbar cortical bone trajectory screws and provide the optimal placement scheme in clinical applications. METHODS Lumbar computed tomography (CT) data of 40 patients in our hospital were selected, and the cortical vertebral bone contour model was reconstructed in three dimensions (3D). Depending on the different regions of the screw through the entrance and exit of the pedicle, 9 trajectories were obtained through combinational design: T-Aa, T-Ab, T-Ac, T-Ba, T-Bb, T-Bc, T-Ca, T-Cb, and T-Cc. Cortical bone trajectory (CBT) screws with appropriate diameters were selected to simulate screw placement and measure the parameters corresponding to each trajectory (screw path diameter, screw trajectory length, cephalad angle, and lateral angle), and then determine the optimal screw according to the screw parameters and screw safety. Then, 23 patients in our hospital were selected, and the navigation template was designed based on the ideal trajectory before operation, CBT screws were placed during the operation to further verify the safety and feasibility of the ideal trajectory. RESULTS T-Bc and T-Bb are the ideal screw trajectories for L1-L2 and L3-L5, respectively. The screw placement point is located at the intersection of the inner 1/3 vertical line of the superior facet joint and the bottom 1/3 horizontal line of the outer crest of the vertebral lamina (i.e., 2-4 mm inward at the bottom 1/3 of the outer crest of the vertebral lamina). CBT screws were successfully placed based on the ideal screw trajectory in clinical practice. During the operation or the follow-up period, there were no adverse events. CONCLUSION CBT screw placement based on the ideal screw trajectory is a safe and reliable method for achieving effective fixation and satisfactory postoperative effects.
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Affiliation(s)
- Yong-Hui Zhao
- Department of Orthopedics, the First People's Hospital of Yunnan Province, the Affiliated Hospital of Kunming University of Science and Technology, the Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road
- Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force, 212 Daguan Road, Kunming, China
| | - Yu-Long Ma
- Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force, 212 Daguan Road, Kunming, China
| | - Long Wang
- Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force, 212 Daguan Road, Kunming, China
| | - Jin-Long Liang
- Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force, 212 Daguan Road, Kunming, China
| | - Hao-Tian Luo
- Department of Orthopedics, the First People's Hospital of Yunnan Province, the Affiliated Hospital of Kunming University of Science and Technology, the Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road
| | - Yong-Qing Xu
- Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force, 212 Daguan Road, Kunming, China
| | - Sheng Lu
- Department of Orthopedics, the First People's Hospital of Yunnan Province, the Affiliated Hospital of Kunming University of Science and Technology, the Key Laboratory of Digital Orthopedics of Yunnan Province, No. 157 Jinbi Road
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Kovalenko RA, Kashin VA, Cherebillo VY. Individual Navigation Templates for Subcortical Screw Placement in Lumbar Spine. Sovrem Tekhnologii Med 2021; 13:41-46. [PMID: 35265348 PMCID: PMC8858410 DOI: 10.17691/stm2021.13.5.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 12/04/2022] Open
Abstract
Subcortical screw placement is currently performed using frontal view fluoroscopy or intraoperative O-arm navigation system. The emergence of a novel technique for spinal navigation based on individual navigation templates created using 3D printing technology determines the need to study their safety and effectiveness in subcortical implantation. The aim of the study was to evaluate and compare the efficacy of subcortical implantation of pedicle screws in the lumbar spine using individual navigation templates versus intraoperative fluoroscopy.
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Affiliation(s)
- R A Kovalenko
- Assistant, Department of Neurosurgery Pavlov First Saint Petersburg State Medical University, 6-8 L'va Tolstogo St., Saint Petersburg, 197022, Russia
| | - V A Kashin
- PhD Student, Department of Neurosurgery Pavlov First Saint Petersburg State Medical University, 6-8 L'va Tolstogo St., Saint Petersburg, 197022, Russia
| | - V Yu Cherebillo
- Professor, Head of the Department of Neurosurgery Pavlov First Saint Petersburg State Medical University, 6-8 L'va Tolstogo St., Saint Petersburg, 197022, Russia
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Guidelines for cortical screw versus pedicle screw selection from a fatigued decompressive lumbar laminectomy model show similar stability and less bone mineral density dependency. Clin Biomech (Bristol, Avon) 2020; 80:105195. [PMID: 33128963 DOI: 10.1016/j.clinbiomech.2020.105195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traditional pedicle screws are the gold standard for lumbar spine fixation; however, cortical screws along the midline cortical bone trajectory may be advantageous when lumbar decompression is required. While biomechanic investigation of both techniques exists, cortical screw performance in a multi-level lumbar laminectomy and fusion model is unknown. Furthermore, longer-term viability of cortical screws following cyclic fatigue has not been investigated. METHODS Fourteen human specimens (L1-S1) were divided into cortical and pedicle screw treatment groups. Motion was captured for the following conditions: intact, bilateral posterior fixation (L3-L5), fixation with laminectomy at L3-L5, fixation with laminectomy and transforaminal lumbar interbody fusion at L3-L5 both prior to, and following, simulated in vivo fatigue. Following fatigue, screw pullout force was collected and "effective shear stress" [pullout force/screw surface area] (N/mm2) was calculated; comparisons and correlations were performed. FINDINGS In flexion-extension and lateral bending, all operative constructs significantly reduced motion compared to intact (P < 0.05), regardless of pedicle or cortical screws; only posterior fixation with and without laminectomy significantly reduced motion in axial rotation (P < 0.05). Pedicle screws significantly increased average pullout strength (944.2 N vs. 690.2 N, P < 0.05), but not the "effective shear stress" (1.01 N/mm2 vs. 1.1 N/mm2, P > 0.05). INTERPRETATION In a posterior laminectomy and fusion model, cortical screws provided equivalent stability to pedicle screw fixation, yet had significantly lower screw pullout force. No differences in "effective shear stress" warrant further investigation of the effect of screw length/diameter in the aforementioned screw trajectories.
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Rexiti P, Aierken A, Sadeer A, Wang S, Abuduwali N, Deng Q, Sheng WB, Guo HL. Anatomy and Imaging Studies on Cortical Bone Screw Freehand Placement Applying Anatomical Targeting Technology. Orthop Surg 2020; 12:1954-1962. [PMID: 32896100 PMCID: PMC7767784 DOI: 10.1111/os.12775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/11/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES A series of constant anatomical structures were used as guide targets for screw placement to improve the accuracy of cortical screw placement and reduce surgical injury and fluoroscopy radiation. The most commonly used angles and distances between the cortical bone screw insertion point and the lateral margins of the isthmus were selected as the contents of the questionnaire. METHODS A total of 40 physicians were selected to determine the specific values for each angle and distance. Screw placements were performed on four dry and six wet lumbar spine specimens according to the proposed anatomical target guidance technique. A total of 100 cortical bone trajectories were evaluated using X-ray and CT scanning of the specimens to verify the practicability, accuracy, and safety of the anatomical target guidance technique in screw placement. RESULTS The average deviation rates for angle and distance determination were 105.5% and 14.33%, respectively, indicating a significant difference between the estimated and actual values from other angles (P < 0.05). Based on visual inspection, probe penetration, X-ray, and CT examination of 100 cortical bone trajectories, the excellent rate of 40 trajectories on four dry specimens was 95%, while that of 60 trajectories on six wet specimens was 88.7%. CONCLUSION Use of lumbar constant anatomical structures as targeting guidance could assist cortical bone screw placement and reduce surgical damage.
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Affiliation(s)
- Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Ailixier Aierken
- Department of Spine Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Aierken Sadeer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Shuiquan Wang
- Department of Anatomy, College of Basic Medicine, Xinjiang Medical University, Ürümqi, China
| | - Nueraihemaiti Abuduwali
- Department of Imaging Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Qiang Deng
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Wei-Bin Sheng
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Hai-Long Guo
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
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Zhang L, Tian N, Yang J, Ni W, Jin L. Risk of pedicle and spinous process violation during cortical bone trajectory screw placement in the lumbar spine. BMC Musculoskelet Disord 2020; 21:536. [PMID: 32781995 PMCID: PMC7422524 DOI: 10.1186/s12891-020-03535-4] [Citation(s) in RCA: 3] [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: 03/09/2020] [Accepted: 07/23/2020] [Indexed: 01/09/2023] Open
Abstract
Background Previous studies have confirmed the feasibility of the cortical bone trajectory (CBT) technique. However, there are few reports on spinous process violation and screw penetration during the screw insertion. The purpose of this study was to evaluate the incidence of spinous process violation and screw penetration through the pedicle during CBT screw insertion. Methods Computed tomography (CT) scans with normal lumbar structures were consecutively obtained and three-dimensional (3D) reconstructions of the lumbar spine were created. Bilateral CBT screw placement was simulated on each segment using a screw diameter of 4.5 mm, 5.0 mm, or 5.5 mm. Incidences of these complications were recorded and analyzed. Results A total of 90 patients were enrolled. Spinous process violation was observed in 68.3, 53.3, 25.5, 1.7, and 0% from L1 to L5, respectively, using 4.5 mm screws. A significant difference was found among the five segments but this was unconnected to gender or screw diameter. The incidence of screw penetration through the inner wall decreased from L1 to L4; in turn, L1 (16.7–35.5%), L2 (12.7–34.4%), L3 (2.8–23.8%) and L4 (1.1–6.7%). This trend was reversed in L5 (6.7–16.7%). Moreover, screw penetration through the outer wall was rare. The incidence of screw penetration varied with screw size as well as lumbar level, but not with gender. Conclusions There are more difficulties of CBT screw fixation in upper lumbar spine. The low rate of screw penetration, using 4.5 mm screws, suggests the safety for CBT fixation in the lumbar spine. Larger screws (5.0 mm or 5.5 mm) are more recommended for use in the lower lumbar spine. Moreover, CBT fixation in L5 deserves greater attention because of the unique morphology of the pedicle.
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Affiliation(s)
- Lilian Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Naifeng Tian
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Jian Yang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Wenfei Ni
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Liya Jin
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China.
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Ver MLP, Gum JL, Crawford CH, Djurasovic M, Owens RK, Brown M, Steele P, Carreon LY. Index episode-of-care propensity-matched comparison of transforaminal lumbar interbody fusion (TLIF) techniques: open traditional TLIF versus midline lumbar interbody fusion (MIDLIF) versus robot-assisted MIDLIF. J Neurosurg Spine 2020; 32:741-747. [PMID: 31978884 DOI: 10.3171/2019.9.spine1932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 09/16/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF. METHODS A retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed. RESULTS Of 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors' first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF. CONCLUSIONS Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors' first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.
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Abstract
With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety. Cite this article: Bone Joint J 2020;102-B(3):371–375.
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Affiliation(s)
- Derek Cawley
- Department of Spine Surgery, Mater Private Hospital, Dublin, Republic of Ireland; Department of Spine Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Rakesh Dhokia
- Department of Spine Surgery, Royal Victoria Hospital, Belfast, UK
| | - James Sales
- Department of Spine Surgery, Royal Victoria Hospital, Belfast, UK
| | - Nagy Darwish
- Department of Spine Surgery, Royal Victoria Hospital, Belfast, UK
| | - Sean Molloy
- Department of Spine Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK,
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Cofano F, Marengo N, Ajello M, Penner F, Mammi M, Petrone S, Lavorato A, Zenga F, Garbossa D. The Era of Cortical Bone Trajectory Screws in Spine Surgery: A Qualitative Review with Rating of Evidence. World Neurosurg 2020; 134:14-24. [DOI: 10.1016/j.wneu.2019.10.079] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/11/2019] [Accepted: 10/13/2019] [Indexed: 12/14/2022]
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Midline lumbar interbody fusion (MIDLIF) with cortical screws: initial experience and learning curve. Acta Neurochir (Wien) 2019; 161:2415-2420. [PMID: 31650331 DOI: 10.1007/s00701-019-04079-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 09/17/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND A variety of surgical techniques can be used to achieve lumbar spinal fusion for management of degenerative conditions. Transforaminal lumbar interbody fusion (TLIF) is the most popular technique; however, midline lumbar interbody fusion (MIDLIF) is a valid alternative to the more traditional pedicle screw trajectory with potential advantages. The aim of this study is to evaluate the clinical outcomes from a cohort of patients submitted to MIDLIF in a single hospital during the surgical team's initial learning period. METHODS The first 30 consecutive patients who underwent single- or two-level MIDLIF surgery for lumbar degenerative disease were included in this retrospective study. Patients' demographics, surgical data, length of hospitalisation, and perioperative complications were analysed. Preoperative and postoperative radiographic parameters were obtained. Validated questionnaires, Core Outcome Measure Index for the back, Euro-QoL 5-Dimensional Questionnaire, and Oswestry Disability Index, were used for clinical assessment. RESULTS Mean surgery time was 278.53 ± 82.16 min and mean hospitalisation time was 6.17 ± 3.51 days. Six patients experienced complications, four of which being dural tears with no consequences, and two required reoperations during the mean follow-up of 25.23 ± 9.74 months. Preoperative and postoperative radiological parameters did not demonstrate significant differences. All clinical parameters significantly improved after surgery (p < 0.001). A complexity score was developed to more accurately compare the different procedures, and it strongly correlated with surgery duration (r = 0.719, p < 0.001). Furthermore, a moderate correlation was found between a developed Duration Index and the patient's order number (r = - 0.539, p = 0.002). CONCLUSIONS In our initial experience, MIDLIF showed to be effective in significantly improving the patients' functional status, pain scores, and quality of life. The technique seems safe, with an acceptably low complication rate. Hence, MIDLIF can be considered as a promising alternative to more traditional TLIF and PLIF techniques even at the beginning of the learning curve.
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Laratta JL, Shillingford JN, Pugely AJ, Gupta K, Gum JL, Djurasovic M, Crawford CH. Accuracy of cortical bone trajectory screw placement in midline lumbar fusion (MIDLF) with intraoperative cone beam navigation. JOURNAL OF SPINE SURGERY 2019; 5:443-450. [PMID: 32042994 DOI: 10.21037/jss.2019.09.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Cortical bone trajectory (CBT) screws have been recently described as a method of lumbosacral fixation. These screws are typically inserted under fluoroscopic guidance with a medial-to-lateral trajectory in the axial plane and a caudal-to-cephalad trajectory in the sagittal plane. In an effort to reduce surgeon radiation exposure and improve accuracy, CBT screws may be inserted under navigation with intraoperative cone beam computed tomography (CT). However, the accuracy of CBT screw placement under intraoperative navigation has yet to be assessed in the literature. The purpose of the study was to evaluate the accuracy of CBT screw placement using intraoperative cone beam CT navigation. Methods One hundred and thirty-four consecutive patients who underwent CBT fixation with 618 screws under intraoperative navigation were analyzed from May 2016 through May 2018. Screws were placed by one of three senior spine surgeons using the Medtronic O-Arm Stealth Navigation. Screw position and accuracy were assessed on intraoperative and postoperative CT scans using 2D and 3D reconstructions with VitreaCore software. Results The majority of surgeries were primary cases (73.1%). The mean age at the time of surgery was 61.5±10.0 years and the majority of patients were female (61.2%). Most patients underwent surgery for a diagnosis of degenerative spondylolisthesis (47.8%) followed by mechanical collapse with foraminal stenosis (22.4%). Ten violations of the vertebral cortex were noted with an average breach distance of 1.0±0.7 mm. Three breaches were lateral (0.5%) and seven were medial (1.1%). The overall navigated screw accuracy rate was 98.3%. The accuracy to within 1 mm of error was 99.2%. There were no intra-operative neurologic, vascular, or visceral complications related to the placement of the CBT screws. Conclusions CBT screw fixation under an intraoperative cone beam CT navigated insertion technique is safe and reliable. Despite five breaches greater than 1mm, there were no complications related to the placement of the CBT screws in this series.
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Affiliation(s)
- Joseph L Laratta
- Norton Leatherman Spine Center, Louisville, KY, USA.,University of Louisville Medical Center, Louisville, KY, USA
| | - Jamal N Shillingford
- Norton Leatherman Spine Center, Louisville, KY, USA.,University of Louisville Medical Center, Louisville, KY, USA
| | | | - Karishma Gupta
- Western Regional Center for Brain and Spine Surgery, Las Vegas, NV, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, KY, USA.,University of Louisville Medical Center, Louisville, KY, USA
| | - Mladen Djurasovic
- Norton Leatherman Spine Center, Louisville, KY, USA.,University of Louisville Medical Center, Louisville, KY, USA
| | - Charles H Crawford
- Norton Leatherman Spine Center, Louisville, KY, USA.,University of Louisville Medical Center, Louisville, KY, USA
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Zhang RJ, Li HM, Gao H, Jia CY, Xing T, Dong FL, Shen CL. Cortical bone trajectory screws used to save failed traditional trajectory screws in the osteoporotic lumbar spine and vice versa: a human cadaveric biomechanical study. J Neurosurg Spine 2019; 30:759-766. [PMID: 30849746 DOI: 10.3171/2018.12.spine18970] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/05/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Traditional trajectory (TT) screws are widely used in lumbar fixation. However, they may require revision surgery in some instances, especially in patients with osteoporotic spines. Cortical bone trajectory (CBT) screws may potentially be used to rescue a failed TT screw and vice versa in nonosteoporotic spines. This study aimed to investigate whether a CBT screw can salvage a compromised TT screw in osteoporotic lumbar spines and vice versa. METHODS A total of 42 vertebrae from 17 cadaveric lumbar spines were obtained. Bone mineral density was measured, and a CBT screw was randomly inserted into one side of each vertebra. A TT screw was then inserted into the contralateral side. The biomechanical properties of the screws were tested to determine their insertional torque, pullout strength, and fatigue performance. After checking the screws for the failure of each specimen, the failed screw track was salvaged with a screw of the opposite trajectory. The specimen was then subjected to the same mechanical tests, and results were recorded. A repeat pullout test on TT and CBT screws was also performed. RESULTS When CBT screws were used to rescue failed TT screws, the original torque increased by 50%, an average of 81% of the pullout strength of the initial TT screws was retained, and the fatigue performance was equal to that of the original screws, which were considerably stronger than the loose TT screws-that is, the TT repeat screws/TT screws were 33% of the pullout strength of the initial TT screws. When the TT screws were used to salvage the compromised CBT screws, the TT screws retained 51% of the original torque and 54% of the original pullout strength, and these screws were still stronger than the loose CBT screws-that is, the loose CBT screws retained 12% pullout strength of the initial CBT screws. Fatigue performance and the ratio of the pullout strength considerably decreased between the CBT rescue screws and the original CBT screws but slightly changed between the TT rescue screws and the original TT screws. CONCLUSIONS CBT and TT screws can be applied in a revision technique to salvage each other in osteoporotic lumbar spines. Additionally, CBT and TT screws each retain adequate insertional torque, pullout strength, and fatigue performance when used for revision in osteoporotic lumbar spines.
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Comparative clinical efficacy and safety of cortical bone trajectory screw fixation and traditional pedicle screw fixation in posterior lumbar fusion: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1678-1689. [DOI: 10.1007/s00586-019-05999-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 05/05/2019] [Indexed: 12/28/2022]
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Zhang R, Gao H, Li H, Xing T, Jia C, Zhang J, Dong F, Shen C. Differences in bone mineral density of trajectory between lumbar cortical and traditional pedicle screws. J Orthop Surg Res 2019; 14:128. [PMID: 31072395 PMCID: PMC6507139 DOI: 10.1186/s13018-019-1169-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/26/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cortical bone trajectory (CBT) has been well-known in spine surgery for obtaining improved fixation while minimizing soft tissue dissection. This study was designed to compare the bone mineral density (BMD) between the CBT and traditional trajectory (TT) by using Hounsfield unit (HU) values and identify the ideal decades of patients and the suitable lumbar segments using this CBT technology from a radiological standpoint. METHODS Patients were selected randomly from an institutional database based on age (evenly distributed by a decade of life) and gender. A total of 240 healthy patients had a computed tomography (CT) scan of the chest, abdomen, and pelvis. For each patient, axial slices of every vertebra were cut in two planes: one horizontal to the pedicle representing the plane wherein pedicle screws were inserted using the TT and the other in a caudocranial plane representing the plane wherein pedicle screws were inserted using the CBT. For each trajectory, a region of interest (ROI) was selected within the area wherein the screws were inserted. A CT number (HU values) was then calculated within each ROI to represent bone density. RESULTS HU values measured at the ROI of CBT were significantly greater than those of the traditional pedicle screw in all age groups, and the specific value (ratio of the HU values of CBT/the HU values of TT) between CBT and TT was 1.92. A significant difference was observed between male and female. The HU values of CBT and TT of males were generally higher than those of females (males: CBT/TT 1.89 ± 0.45; Females: CBT/TT 1.95 ± 0.47). The specific value in HU values significantly increased with increasing age (p = 0.000) and cauda lumbar level (p = 0.000) in males and females. CONCLUSION BMD, as measured by HU values for the ROI of the CBT screw, was significantly greater than that of the traditional pedicle screw, especially in old patients and cauda lumbar segments.
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Affiliation(s)
- Renjie Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China.,Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Hai Gao
- Department of Orthopedics, The First Affiliated Hospital of USTC (Anhui Provincial Hospital), Hefei, 230022, Anhui, China.,Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Huimin Li
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China.,Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Tao Xing
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China.,Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Chongyu Jia
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China.,Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Jianxiang Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China.,Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Fulong Dong
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China.,Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Cailiang Shen
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China. .,Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China.
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Sin DA, Heo DH. Comparative Finite Element Analysis of Lumbar Cortical Screws and Pedicle Screws in Transforaminal and Posterior Lumbar Interbody Fusion. Neurospine 2019; 16:298-304. [PMID: 31154694 PMCID: PMC6603848 DOI: 10.14245/ns.1836030.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 02/14/2019] [Indexed: 12/11/2022] Open
Abstract
Objective Lumbar cortical screw fixation (CSF), rather than pedicle screw fixation (PSF), has recently been attempted in lumbar interbody fusion. The purpose of our study was to evaluate the biomechanical stability of lumbar CSF using a finite element (FE) model.
Methods A 3-FE model, including the L1 to S1 levels, was designed to evaluate and compare the biomechanical stability of lumbar CSF and PSF in single-level lumbar interbody fusion at L4–5. Cortical or pedicle screws were inserted bilaterally, and posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) were modeled at L4–5, respectively. We compared the stability of CSF to that of PSF in these 2 different anatomic variations of PLIF, as well as in TLIF.
Results Lumbar CSF showed less stability than PSF in PLIF when the midline posterior ligaments were not preserved, but demonstrated similar stability when the ligaments were preserved. The range of motion (ROM) at the treated level in CSF was larger than that observed for PSF, in all PLIF and TLIF models. Furthermore, the ROM in the posterior ligament-sacrificing PLIF with CSF model was larger than the ROM in the posterior ligament-preserving PLIF with CSF or PSF model.
Conclusion Based on our FE analysis, the stability of CSF is comparable to that of PSF in PLIF and TLIF when the midline posterior ligaments are preserved.
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Affiliation(s)
- Dong Ah Sin
- Department of Neurosurgery, Spine and Spinal Cord Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hwa Heo
- Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon, Korea
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Using the cortical bone trajectory screw technique with vertebral column resection to treat an osteoporotic compression fracture in progressive thoracolumbar hyperkyphosis: A case report. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Kaye ID, Prasad SK, Vaccaro AR, Hilibrand AS. The Cortical Bone Trajectory for Pedicle Screw Insertion. JBJS Rev 2019; 5:e13. [PMID: 28857932 DOI: 10.2106/jbjs.rvw.16.00120] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- I David Kaye
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Alex R Vaccaro
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alan S Hilibrand
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Hoffman H, Verhave B, Jalal MS, Beutler T, Galgano MA, Chin LS. Comparison of Cortical Bone Trajectory Screw Placement Using the Midline Lumbar Fusion Technique to Traditional Pedicle Screws: A Case-Control Study. Int J Spine Surg 2019; 13:33-38. [PMID: 30805284 DOI: 10.14444/6005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Cortical bone trajectory (CBT) screws are an alternative to traditional pedicle screws (PS) for lumbar fixation. The proposed benefits of CBT screws include decreased approach-related morbidity and greater cortical bone contact to prevent screw pullout. Relatively little data is published on this technique. Here, we compare the midline lumbar fusion (MIDLF) approach for CBT screw placement to transforaminal lumbar interbody fusion (TLIF) for traditional PS placement. Methods A prospectively maintained institutional database was retrospectively reviewed for all patients undergoing lumbar spinal fusion using CBT screws over the past 5 years. Controls were identified from the same database as patients undergoing lumbar spinal fusion with traditional PS placement and matched based on age, sex, and number of levels fused. Exclusion criteria included prior lumbar instrumentation. The electronic health record was retrospectively reviewed for demographic, perioperative, and postoperative data. Results A total of 23 patients who underwent CBT screw placement and 35 controls who received traditional PS were included in the study. The median follow-up time was 52.5 months. The CBT screw group had significantly less mean estimated blood loss than the PS group (186 mL versus 414 mL respectively; P = .008). Both groups experienced significant improvements in preoperative Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for back and leg pain. However, there was no significant difference between the groups in regard to operative time and amount of improvement in VAS pain score or ODI. The CBT group was associated with a significantly shorter mean length of stay (LOS). There were 2 instances of screw pullout in each group. Conclusions The MIDLF approach with CBT screw placement is associated with less intraoperative blood loss and shorter LOS than traditional PS placement. There is no difference between the 2 techniques in regard to improvement in pain or disability.
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Affiliation(s)
- Haydn Hoffman
- State University of New York Upstate Department of Neurosurgery, Syracuse, New York
| | - Brendon Verhave
- State University of New York Upstate Department of Neurosurgery, Syracuse, New York
| | - Muhammad S Jalal
- State University of New York Upstate Department of Neurosurgery, Syracuse, New York
| | - Timothy Beutler
- State University of New York Upstate Department of Neurosurgery, Syracuse, New York
| | - Michael A Galgano
- State University of New York Upstate Department of Neurosurgery, Syracuse, New York
| | - Lawrence S Chin
- State University of New York Upstate Department of Neurosurgery, Syracuse, New York
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Three-Dimensional Patient-Specific Guides for Intraoperative Navigation for Cortical Screw Trajectory Pedicle Fixation. World Neurosurg 2019; 122:674-679. [DOI: 10.1016/j.wneu.2018.11.159] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/15/2018] [Accepted: 11/17/2018] [Indexed: 12/12/2022]
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Design and Application of Individualized, 3-Dimensional-Printed Navigation Template for Placing Cortical Bone Trajectory Screws in Middle-Upper Thoracic Spine: Cadaver Research Study. World Neurosurg 2019; 125:e348-e352. [PMID: 30703596 DOI: 10.1016/j.wneu.2019.01.076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/04/2019] [Accepted: 01/08/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the safety and accuracy of use of a 3-dimensional printed navigation template in the placement of a cortical bone trajectory (CBT) screw in the middle-upper thoracic spine. METHODS Ten human cadavers were included in the study. Sixty CBT screws were placed on 1 side, using the free-hand technique, and 60 CBT screws were placed on the other side, using the navigation template that was designed and printed using data from 10 cadavers. The safety and accuracy of use of the CBT screws were directly evaluated by radiography and computed tomography. RESULTS Computed tomography revealed that 2 and 3 of 60 screws, placed using the navigation template, were broken in the medial or lateral areas and in the superior or inferior pedicle wall, respectively. Furthermore, 8 screws were broken in the medial or lateral areas and 11 screws were broken in the superior or inferior pedicle wall when the free-hand technique was used. Radiography revealed that 3 screws in zone I, 55 screws in zone II, and 2 screws in zone III were placed using the navigation template. Furthermore, 7 screws in zone I, 45 screws in zone II, and 8 screws in zone III were placed using the free-hand technique. CONCLUSIONS In this cadaver study, insertion of the CBT screws in the middle-upper thoracic spine with the assistance of the navigation template was safe and convenient.
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Kotheeranurak V, Lin GX, Mahatthanatrakul A, Kim JS. Endoscope-Assisted Anterior Lumbar Interbody Fusion with Computed Tomography-Guided, Image-Navigated Unilateral Cortical Bone Trajectory Screw Fixation in Managing Adjacent Segment Disease in L5/S1: Technical Note. World Neurosurg 2018; 122:469-473. [PMID: 30321680 DOI: 10.1016/j.wneu.2018.10.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to describe a novel technique in managing a patient with adjacent segment disease at the L5/S1 level. METHODS We performed an endoscope-assisted anterior lumbar interbody fusion with computed tomography-guided, image-navigated unilateral cortical bone trajectory screw fixation to treat L5/S1 intervertebral disk pathology. RESULTS Patient was successfully treated by a direct endoscopic decompression through the anterior access, interbody fusion using an anterior lumbar interbody fusion cage, unilateral cortical bone trajectory instrumentation under computed tomography-guided image navigation. CONCLUSIONS This minimally invasive technique is effective in terms of decompression and fixation. It could be used as an alternative method to treat patients with L5/S1 adjacent segment disease.
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Affiliation(s)
- Vit Kotheeranurak
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Sriracha, Chonburi, Thailand
| | - Guang-Xun Lin
- Department of Neurosurgery, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | | | - Jin-Sung Kim
- Department of Neurosurgery, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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Wochna JC, Marciano R, Catanescu I, Katz J, Spalding MC, Narayan K. Cortical Trajectory Pedicle Screws for the Fixation of Traumatic Thoracolumbar Fractures. Cureus 2018; 10:e2891. [PMID: 30167347 PMCID: PMC6112911 DOI: 10.7759/cureus.2891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective Cortical bone trajectory pedicle screws (CBT) have a different trajectory compared to traditional pedicle screws (PS) and they may confer biomechanical advantages in some patient populations. We hypothesize that the placement of CBT in traumatic thoracolumbar fractures could be an alternative technique to the traditional utilization of PS. Methods Single surgeon, retrospective study was performed at a Level 1 Trauma Center from 2013 to 2017. All patients aged between 18 and 90 years with operative AO classification A, B, and C traumatic thoracolumbar fractures were included. Patients with pathological fractures, active spinal infections, or history of vertebral augmentation were excluded. Age, injury severity score (ISS), AO classification, operative time, estimated blood loss (EBL), length of stay (LOS), and presence of proximal junctional kyphosis (PJK) or construct failure were compared between CBT and PS groups. The PS group was further separated into open reduction internal fixation (ORIF) and minimally invasive spine (MIS) groups. All CBT and ORIF cases were completed via open incisions allowing arthrodesis of the involved lamina and facet joints whereas no arthrodesis was completed in the MIS patients. Choice of technique was at the attending surgeon’s discretion. Results The study included 71 patients, out of which 12 received CBT and 59 received PS. Of the 59 PS patients, 39 were ORIF and 20 were MIS. The average operative time was 22.9 minutes less in CBT compared to ORIF (p = 0.24). EBL was 337.50 mL for CBT, 184.33 mL for MIS, and 503.33 mL for ORIF (p = 0.01) demonstrating that MIS technique results in a significantly reduced blood loss. However, EBL was comparable for CBT versus MIS (p > 0.05). ISS was not significantly different between the three groups (p = 0.89). LOS was 4.06 days fewer for CBT patients compared to ORIF patients (p = 0.36). There was one case of construct failure as well as one case of incisional site infection in the PS group, but none were found in the CBT group. Instances of PJK complications were determined by the change in the Cobb angle over time and they were not statistically different between the three groups (p = 0.68). Conclusions CBT is noninferior to PS in the fixation of unstable adult traumatic thoracolumbar fractures. With the exception of EBL, CBT was not statistically different compared to MIS and ORIF. This study establishes a precedent to expand the application of this new technique and investigate with larger sample sizes.
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Affiliation(s)
- Jacob C Wochna
- Medical Student, Ohio University Heritage College of Osteopathic Medicine, Athens, USA
| | | | | | - Joel Katz
- Neurological Surgery, OhioHealth, Columbus, USA
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Lee GW, Shin JH. Comparative Study of Two Surgical Techniques for Proximal Adjacent Segment Pathology after Posterior Lumbar Interbody Fusion with Pedicle Screws: Fusion Extension using Conventional Pedicle Screw vs Cortical Bone Trajectory-Pedicle Screw (Cortical Screw). World Neurosurg 2018; 117:e154-e161. [PMID: 29883823 DOI: 10.1016/j.wneu.2018.05.218] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To present a minimally invasive surgical technique using cortical bone trajectory pedicle screws (cortical screws [CS]) for adjacent segment pathology (ASP) after lumbar fusion surgery, and to thoroughly compare postoperative outcomes of surgical techniques with either a CS or conventional pedicle screws (PS) for ASP at a 1-year follow-up. METHODS Among 59 patients who underwent surgical treatment for proximal ASP after lumbar fusion surgery, 53 patients who met the study criteria (group A, 31 patients with conventional technique using PS; group B, 22 patients with minimally invasive technique using CS) were enrolled in the study. The primary outcome measure was the fusion rate at 1 year after surgery, and secondary outcome measures included patient satisfaction, clinical outcomes, radiologic outcomes, and surgical outcomes and complications. RESULTS Fusion at 1 year postsurgery was achieved by 90% of the patients in group A with PS and 91% of those in group B with CS (P > 0.99). Patient satisfaction at 1 month postsurgery (P = 0.03) and pain intensity within 1 month postsurgery (P = 0.04) were significantly better in group B compared with group A. Regarding surgical outcomes, blood loss was significantly less, operation time and length of hospital stay were significantly shorter, and the incision was significantly shorter n group B than in group A. Other clinical parameters and outcomes were similar in the 2 groups. CONCLUSIONS We suggest that a minimally invasive surgical technique using CS for ASP can be a viable alternative to a conventional surgical technique using PS.
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Affiliation(s)
- Gun Woo Lee
- Spine Center and Department of Orthopedic Surgery, Yeungnam University College of Medicine, Yeungnam University Medical Center, Daegu, Korea.
| | - Ji-Hoon Shin
- Spine Center and Department of Orthopedic Surgery, Yeungnam University College of Medicine, Yeungnam University Medical Center, Daegu, Korea
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Shi S, Ying X, Zheng Q, Zhu B, Jin Y, Shen J, Zheng M, Hu S. Application of Cortical Bone Trajectory Screws in Elderly Patients with Lumbar Spinal Tuberculosis. World Neurosurg 2018; 117:e82-e89. [PMID: 29864561 DOI: 10.1016/j.wneu.2018.05.168] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To investigate the clinical efficacy of cortical bone trajectory (CBT) screws in the treatment of elderly patients with lumbar spinal tuberculosis. METHODS A total of 45 elderly patients with lumbar spinal tuberculosis were allocated to 1 groups based on different surgical methods: 22 patients in group A received posterior CBT screw fixation combined with anterior debridement with a small incision and bone grafting, and 23 patients in group B underwent posterior pedicle screw fixation combined with anterior debridement with a small incision and bone grafting. The intraoperative blood loss, postoperative drainage volumes, Cobb angles, visual analogue scale scores, erythrocyte sedimentation rates (ESRs), and Frankel grades before and after surgery were analyzed. The surgical complications and spinal fusion were also assessed. RESULTS After a 3-month follow-up, 2 patients in group A and 3 patients in group B experienced anterior psoas muscle abscesses, which were cured by a second surgery. The remaining patients were healed by the first surgery. Spinal fusion after bone graft required 3 to 8 months (average, 4.9 months). There were no significant differences in surgery time, blood loss, drainage volume, and hospital stay between the 2 groups. The visual analogue scale scores, Cobb angles, ESRs, and Frankel grades were significantly improved after surgery in both groups. CONCLUSION The CBT screws were not inferior to traditional pedicle screws. The application of CBT- screws fixation combined with anterior debridement with a small incision and bone grafting was an effective and safe method to treat elderly patients with lumbar spinal tuberculosis.
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Affiliation(s)
- Shiyuan Shi
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Xiaozhang Ying
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China.
| | - Qi Zheng
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Bo Zhu
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Yanghui Jin
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Jian Shen
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Mingfeng Zheng
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
| | - Shunping Hu
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, China
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Gu G, Wang C, Gu X, Zhang H, Zhao Y, He S. Percutaneous Transforaminal Endoscopic Discectomy for Adjacent Segment Disease After Lumbar Fusion in Elderly Patients Over 65 Years Old. World Neurosurg 2018; 112:e830-e836. [PMID: 29408425 DOI: 10.1016/j.wneu.2018.01.170] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
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Sellin JN, Raskin JS, Staggers KA, Brayton A, Briceño V, Moreno AJ, Jea A. Feasibility and safety of using thoracic and lumbar cortical bone trajectory pedicle screws in spinal constructs in children: technical note. J Neurosurg Pediatr 2018; 21:190-196. [PMID: 29148922 DOI: 10.3171/2017.7.peds17240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Thoracic and lumbar cortical bone trajectory pedicle screws have been described in adult spine surgery. They have likewise been described in pediatric CT-based morphometric studies; however, clinical experience in the pediatric age group is limited. The authors here describe the use of cortical bone trajectory pedicle screws in posterior instrumented spinal fusions from the upper thoracic to the lumbar spine in 12 children. This dedicated study represents the initial use of cortical screws in pediatric spine surgery. The authors retrospectively reviewed the demographics and procedural data of patients who had undergone posterior instrumented fusion using thoracic, lumbar, and sacral cortical screws in children for the following indications: spondylolysis and/or spondylolisthesis (5 patients), unstable thoracolumbar spine trauma (3 patients), scoliosis (2 patients), and tumor (2 patients). Twelve pediatric patients, ranging in age from 11 to 18 years (mean 15.4 years), underwent posterior instrumented fusion. Seventy-six cortical bone trajectory pedicle screws were placed. There were 33 thoracic screws and 43 lumbar screws. Patients underwent surgery between April 29, 2015, and February 1, 2016. Seven (70%) of 10 patients with available imaging achieved a solid fusion, as assessed by CT. Mean follow-up time was 16.8 months (range 13-22 months). There were no intraoperative complications directly related to the cortical bone trajectory screws. One patient required hardware revision for caudal instrumentation failure and screw-head fracture at 3 months after surgery. Mean surgical time was 277 minutes (range 120-542 minutes). Nine of the 12 patients received either a 12- or 24-mg dose of recombinant human bone morphogenic protein 2. Average estimated blood loss was 283 ml (range 25-1100 ml). In our preliminary experience, the cortical bone trajectory pedicle screw technique seems to be a reasonable alternative to the traditional trajectory pedicle screw placement in children. Cortical screws seem to offer satisfactory clinical and radiographic outcomes, with a low complication profile.
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Affiliation(s)
- Jonathan N Sellin
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Jeffrey S Raskin
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Kristen A Staggers
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Alison Brayton
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Valentina Briceño
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Amee J Moreno
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Andrew Jea
- 2Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurosurgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana
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Hussain I, Virk MS, Link TW, Tsiouris AJ, Elowitz E. Posterior Lumbar Interbody Fusion with 3D-Navigation Guided Cortical Bone Trajectory Screws for L4/5 Degenerative Spondylolisthesis: 1-Year Clinical and Radiographic Outcomes. World Neurosurg 2018; 110:e504-e513. [DOI: 10.1016/j.wneu.2017.11.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/05/2017] [Accepted: 11/07/2017] [Indexed: 01/16/2023]
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