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Hasanain M, Englisch CN, Tschernig T, Saeed S, Lepschokov M, Ketter R, Oertel J. The Attallah screw: Where safety meets robustness in posterior subaxial cervical instrumentation. MEDICINE INTERNATIONAL 2024; 4:35. [PMID: 38756457 PMCID: PMC11097134 DOI: 10.3892/mi.2024.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/12/2024] [Indexed: 05/18/2024]
Abstract
Posterior fixation of the subaxial cervical spine (SCS) commonly relies on the application of lateral mass screws (LMS), with pedicle screws being a less prevalent alternative. The present study provides another option: A recently introduced novel approach, the Attallah screw, intended to ensure a safety profile comparable to that of LMS, combined with a strength profile similar to that of pedicle screws. The focus of the present study is the comparative analysis of peak insertion torques for these three screw types. Employing standard surgical techniques and instruments, Attallah screws were scheduled for insertion on the right side of the SCS in 15 cadavers, pedicle screws on the left side in 8 cadavers, and LMS on the left side in the remaining 7 cadavers. The peak insertion torque was recorded using an electronic torque screwdriver. The results revealed that the peak insertion torques were similar in the pedicle and the Attallah screw at C3, C4 and C7, but differed at C5 (mean ± SD; pedicle, 79.5±19.6 cNm; Attallah, 56.7±18.5 cNm; P=0.029) and C6 (pedicle, 85.4±28.7 cNm; Attallah, 49.8±17.9 cNm; P=0.004) in favor of the superior pedicle screw measurements. The peak insertion torques of the pedicle screw were superior to the corresponding data from the LMS from C4 to C7. By contrast, the peak insertion torques of the Attallah screw were only superior to those of the LMS at C7 (Attallah, 69.5±24.5 cNm; lateral mass, 40.5±21.4 cNm; P=0.030), although similar trends were observed at the other cervical levels. On the whole, the findings presented herein indicate the level-dependent superior robustness of the Attallah screw as a posterior cervical fixation method compared to the LMS. However, from a biomechanical perspective, the pedicle screw remains the preeminent choice for fixation within the C5-C6 range.
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Affiliation(s)
- Mohammed Hasanain
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
| | - Colya N. Englisch
- Institute for Anatomy and Cell Biology, Saarland University, D-66421 Homburg/Saar, Germany
| | - Thomas Tschernig
- Institute for Anatomy and Cell Biology, Saarland University, D-66421 Homburg/Saar, Germany
| | - Samah Saeed
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
| | - Magomed Lepschokov
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
| | - Ralf Ketter
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
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Mao JZ, Soliman MA, Karamian BA, Khan A, Fritz AG, Avasthi N, DiMaria S, Levy BR, O’Connor TE, Schroeder G, Pollina J, Vaccaro AR, Mullin JP. Anatomical and Technical Considerations of Robot-Assisted Cervical Pedicle Screw Placement: A Cadaveric Study. Global Spine J 2023; 13:1992-2000. [PMID: 35195035 PMCID: PMC10556891 DOI: 10.1177/21925682211068410] [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: 11/17/2022] Open
Abstract
STUDY DESIGN Cadaver study. OBJECTIVES Assess the feasibility of robot-assisted cervical pedicle screw (RA-CPS) placement and understand the anatomical considerations of this technique. METHODS Four cadaver specimens free from bony pathology were acquired. Anatomical considerations, such as pedicle width (PW) and height (PH), transverse pedicle angle (TPA), and maximal screw length (MSL), were recorded from preoperative computational tomography (CT) scans. Intraoperative cone-beam CT was acquired and registered to the robotic system. After cervical levels were segmented, screw sizes and trajectories were planned, and RA-CPS were placed. Accuracy was assessed using Gertzbein and Robbin's classification on postoperative CT scans. RESULTS Thirty-five RA-CPS were placed. Major breaches (≥Grade C) occurred in 28.57% screws. Grade A or B accuracy was found in 71.43% of screws, with the most common direction of breach being medial (81.3%). The greatest proportion of breach per level occurred in the upper subaxial levels, (C3:71.4%, C4 66.6%, C5:50%) which had the smallest PW (C3: 4.34 ± .96 mm, C4: 4.48 ± .60, C5: 5.76 ± 1.11). PH was greatest at C2 (8.14 ± 1.89 mm) and ranged subaxial from 6.36 mm (C3) to 7.48 mm (C7). The mean PW was 5.37 mm and increased caudally from 4.34 mm (C3) to 6.31 mm (C7). The mean TPA was 39.9° and decreased moving caudally 46.9°) to C7 (34.4°). The MSL was 37.1 mm and increased from C2 (26.3 mm) to C7 (41.0 mm). CONCLUSION RA-CPS has the potential to be feasible, but technological and instrument modifications are necessary to increase the accuracy in the cervical region.
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Affiliation(s)
- Jennifer Z. Mao
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - Mohamed A.R. Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Brian A. Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Alexander G. Fritz
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Naval Avasthi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Stephen DiMaria
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - Bennett R. Levy
- George Washington University, School of Medicine and Health Sciences, Washington DC, USA
| | - Timothy E. O’Connor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Gregory Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - Jeffrey P. Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
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Kim SH, Kim JH, Kwon JW, Kim HS, Moon SH, Suk KS, Lee BH. Assessment of Biomechanical Advantages in Combined Anterior-Posterior Cervical Spine Surgery by Radiological Outcomes: Pedicle Screws over Lateral Mass Screws. J Clin Med 2023; 12:jcm12093201. [PMID: 37176646 PMCID: PMC10179026 DOI: 10.3390/jcm12093201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/10/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The combined anterior-posterior approach has shown good clinical outcomes for multilevel cervical diseases. This work describes the biomechanical advantage of cervical-pedicle-screw fixation over lateral-mass-screw fixation in combined anterior-posterior cases. METHOD Seventy-six patients who received combined cervical surgery from June 2013 to December 2020 were included. The patients were divided into two groups: the lateral-mass-screw group (LMS) and the pedicle-screw group (PPS). Radiological outcomes were assessed with lateral cervical spine X-rays for evaluating sagittal alignment, subsidence, and bone remodeling. RESULTS At 1 year postoperatively, the numbers of patients whose C2-C7 cervical lordosis was less than 20 degrees decreased by more in the PPS group (p-value = 0.001). The amount of vertical-length change from immediately to 1 year postsurgery was less in the PPS group than in the LMS group (p-value = 0.030). The mean vertebral-body-width change was larger in the PPS group than in the LMS group during 3 months to 1 year postsurgery (p-value = 0.000). CONCLUSIONS In combined anterior-posterior cervical surgery cases, maintenance of cervical lordosis and protection of the vertebral body from subsidence were better with the pedicle-screw fixation. More bone remodeling occurred when using the pedicle-screw fixation method.
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Affiliation(s)
- Sang-Ho Kim
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
| | - Ji-Hyeon Kim
- Department of Orthopedic Surgery, Dangjin 9988 Hospital, Dangjin-si 31784, Republic of Korea
| | - Ji-Won Kwon
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
| | - Hak-Sun Kim
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
| | - Seong-Hwan Moon
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
| | - Kyung-Soo Suk
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
| | - Byung-Ho Lee
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
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Kisinde S, Hu X, Hesselbacher S, Satin AM, Lieberman IH. Robotic-guided placement of cervical pedicle screws: feasibility and accuracy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:693-701. [PMID: 35020080 DOI: 10.1007/s00586-022-07110-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/22/2021] [Accepted: 01/04/2022] [Indexed: 01/02/2023]
Abstract
INTRODUCTION It has been shown that pedicle screw instrumentation in the cervical spine has superior biomechanical pullout strength and stability. However, due to the complex and variable anatomy of the cervical pedicles and the risk of catastrophic complications, cervical pedicle screw placement is not widely utilized. STUDY DESIGN A retrospective, consecutive patient review. OBJECTIVE To review and report our experience with robotic guided cervical pedicle screw placement. METHODS We retrospectively reviewed preoperative and postoperative CT scans of 12 consecutive patients who underwent cervical pedicle screw fixation with robotic guidance. Screw placement and deviation from the preoperative plan were assessed using the robotic system's planning software by fusing the preoperative CT (with the planned cervical pedicle screws) to the post-op CT. This process was carried out by manually aligning the anatomical landmarks on the two CTs. Once a satisfactory fusion was achieved, the software's measurement tool was used manually to compare the planned vs. actual screw placements in the axial, sagittal and coronal planes within the instrumented pedicle in a resolution of 0.1 mm. Medical charts were reviewed for technical issues and intra-operative complications. RESULTS Eighty-eight cervical pedicle screws were reviewed in 12 patients; mean age = 65 years, M:F = 2:1, and mean BMI = 27.99. No intra-operative complications related to the cervical pedicle screw placement were reported. Robotic guidance was successful in all 88 screws: eight in C2, 14 in C3, 16 in each of C4 and C5, 19 in C6, and 15 at C7. There were 14 pedicle screw breaches (15.9%); all were medial, less than 1 mm, and with no clinical consequences. In the axial plane, the screws deviated from the preoperative plan by 1.32 ± 1.17 mm and in the sagittal plane by 1.27 ± 1.00 mm. In the trajectory view, the overall deviation was 2.20 ± 1.17 mm. Although differences were observed in screw deviation from the pre-op plan between the right and left sides, they were not statistically significant (p > 0.05). CONCLUSION This study indicates that robotic-guided cervical pedicle screw placement is feasible and safe. The medial breaches did not result in any clinical consequences.
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Affiliation(s)
- Stanley Kisinde
- Scoliosis and Spine Tumor Center, Texas Back Institute/HCA, 6020 West Parker Road, Suite 200A, Plano, TX, 75093, USA
| | - Xiaobang Hu
- University of Texas South Western Medical Center, Dallas, TX, 75390, USA
| | - Shea Hesselbacher
- Scoliosis and Spine Tumor Center, Texas Back Institute/HCA, 6020 West Parker Road, Suite 200A, Plano, TX, 75093, USA
| | - Alexander M Satin
- Scoliosis and Spine Tumor Center, Texas Back Institute/HCA, 6020 West Parker Road, Suite 200A, Plano, TX, 75093, USA
| | - Isador H Lieberman
- Scoliosis and Spine Tumor Center, Texas Back Institute/HCA, 6020 West Parker Road, Suite 200A, Plano, TX, 75093, USA.
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Kwon JW, Arreza EO, Suguitan AA, Lee SB, Sung S, Park Y, Ha JW, Kim TH, Moon SH, Lee BH. Medial Pedicle Pivot Point Using Preoperative Computed Tomography Morphometric Measurements for Cervical Pedicle Screw Insertion: A Novel Technique and Case Series. J Clin Med 2022; 11:jcm11020396. [PMID: 35054092 PMCID: PMC8779533 DOI: 10.3390/jcm11020396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/29/2021] [Accepted: 01/01/2022] [Indexed: 02/04/2023] Open
Abstract
This study describes a new and safe freehand cervical pedicle screw insertion technique using preoperative computed tomography (CT) morphometric measurements as a guide and a medial pedicle pivot point (MPPP) during the procedure. This study included 271 pedicles at 216 cervical spine levels (mean: 4.75 pedicles per patient). A pedicle diameter (PD) ≥ 3.5 mm was the cut-off for pedicle screw fixation. The presence and grade of perforation were detected using postoperative CT scans, where perforations were graded as follows: 0, no perforation; 1, perforation < 0.875 mm; 2, perforation 0.875-1.75 mm; and 3, perforation > 1.75 mm. The surgical technique involved the use of an MPPP, which was the point at which the lines representing the depth of the lateral mass and total length of the pedicle intersected, deep in the lateral mass. The overall success rate was 96.3% (261/271, Grade 0 or 1 perforations). In total, 54 perforations occurred, among which 44 (81.5%) were Grade 1 and 10 (18.5%) were Grade 2. The most common perforation direction was medial (39/54, 72.2%). The freehand technique for cervical pedicle screw fixation using the MPPP may allow for a safe and accurate procedure in patients with a PD ≥3.5 mm.
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Affiliation(s)
- Ji-Won Kwon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Edward O. Arreza
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Anthony A. Suguitan
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Soo-Bin Lee
- Department of Orthopedic Surgery, Catholic-Kwandong University, Incheon 22711, Korea;
| | - Sahyun Sung
- Department of Orthopedic Surgery, Ewha Womans University College of Medicine, Seoul 07804, Korea;
| | - Yung Park
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang 10444, Korea; (Y.P.); (J.-W.H.)
| | - Joong-Won Ha
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang 10444, Korea; (Y.P.); (J.-W.H.)
| | - Tae Hyung Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
| | - Byung Ho Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.-W.K.); (E.O.A.); (A.A.S.); (T.H.K.); (S.-H.M.)
- Correspondence:
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Hasanain MA, Englisch CN, Garner M, Tschernig T, Wagenpfeil S, Ketter R, Oertel J. Comparison of the maximum possible lengths of insertable screws in the Subaxial Cervical Spine. Ann Anat 2021; 239:151839. [PMID: 34634470 DOI: 10.1016/j.aanat.2021.151839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/01/2021] [Accepted: 10/02/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lateral mass screws are the most commonly used fixation technique in the Subaxial Cervical Spine (SCS), their main advantages being that they are easy to insert and safe in their application. Pedicle screws are significantly longer, are quite challenging to insert in most settings and are accompanied by the risk of serious complications such as vascular and neural injuries. We have therefore developed a new technique, which permits safe insertion of long screws in the SCS. METHODS A radiological evaluation was carried out to determine the maximum possible insertable screw length in the SCS when using the following techniques: pedicle, lateral mass (Magerl's) and "Attallah" screws. Scans of 66 cervical spines were analyzed to determine the maximum possible screw lengths of all three screw insertion techniques, based on the standard description through the vertebrae from C3 to C7. RESULTS The maximum possible length of the Attallah screw of 20.7 ± 2.5 mm (mean value ± SD) is only 2.4 mm shorter than the pedicle screw (23.1 ± 1.8 mm) along the SCS. The lateral mass screw is with 10.2 ± 1.3 mm full 12.9 mm shorter than the pedicle screw. CONCLUSIONS The maximum possible length of the Attallah screw is close to that of the pedicle screw and significantly greater than that of the lateral mass screw. We provide a fixation method comparable to the pedicle screw in its strength and to the lateral mass screw in its safety.
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Affiliation(s)
| | - Colya N Englisch
- Institute for Anatomy, Saarland University, Medical Campus, Homburg/Saar, Germany
| | - Malvina Garner
- Institute for Neuroradiology, Saarland University, Medical Campus, Homburg/Saar, Germany
| | - Thomas Tschernig
- Institute for Anatomy, Saarland University, Medical Campus, Homburg/Saar, Germany.
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Medical Campus, Homburg/Saar, Germany
| | - Ralf Ketter
- Neurosurgery Hospital, Saarland University, Medical Campus, Homburg/Saar, Germany
| | - Joachim Oertel
- Neurosurgery Hospital, Saarland University, Medical Campus, Homburg/Saar, Germany
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Kim MK, Lee JJ, Cho SH, Kwak DS. Versatile Usage of the Modified Lateral Mass Screw as an Alternative to Cervical Pedicle Screw Fixation. J Neurol Surg A Cent Eur Neurosurg 2021; 83:231-235. [PMID: 34192784 DOI: 10.1055/s-0041-1728767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Posterior subaxial cervical screw fixation is commonly performed using the cervical pedicle screws (CPS) and lateral mass screws (LMS); however, their compatibility is low. Modified lateral mass screws (mLMS, also called paravertebral foramen screw) fixation was introduced as a salvage technique for LMS fixation and has features of both LMS and CPS techniques. In the present study, the use of mLMS as an alternative to CPS was analyzed based on clinical results. METHODS Seventy-eight screws (38 CPSs and 40 mLMSs) were inserted into 12 patients. The misplacement of the screws was evaluated by computed tomography (CT). The failure of instrumentation and instability were evaluated using plain radiographs. RESULTS The total number of CPS misplacements was 3 (10.5%); however, neurologic complications were not observed. mLMSs were used in the middle segments of the fusion in 10 patients and 2 patients had mLMS fixation for single-level fusion. An additional bridging implant was not required for connecting both CPSs and mLMSs. Instability was not observed during the observation period (4-51 months). Complete fusion was seen in 10 patients. CONCLUSIONS The alternative mLMS fixation can decrease the risk of screw misplacement compared with CPS fixation alone and achieves adequate stability leading to fusion.
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Affiliation(s)
- Moon-Kyu Kim
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Jung-Jae Lee
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Su-Hee Cho
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Dai-Soon Kwak
- Catholic Institute for Applied Anatomy / Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Park JH, Lee JY, Lee BH, Jeon HJ, Park SW. Free-Hand Cervical Pedicle Screw Placement by Using Para-articular Minilaminotomy: Its Feasibility and Novice Neurosurgeons' Experience. Global Spine J 2021; 11:662-668. [PMID: 32875896 PMCID: PMC8165935 DOI: 10.1177/2192568220919089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN. Retrospective study. OBJECTIVE. Cervical pedicle screw (CPS) placement is technically demanding because of the great variation in pedicle size, dimension, and angulations between cervical levels and patients and the lack of anatomical landmarks. This retrospective study was conducted to analyze novice neurosurgeons' experience of CPS placement by using the technique with direct exposure of pedicle via para-articular minilaminotomy. METHODS. We retrospectively reviewed 78 CPSs in 22 consecutive patients performed by 2 surgeons. All pedicle screws were inserted under the direct visualization of the pedicle by using para-articular minilaminotomy without any fluoroscopic guidance. We analyzed the direction and grade of pedicle perforation on the postoperative computed tomography scan. The degree of perforation was classified as grade 0 to 3. Grades 0 and 1 were classified as the correct position and the others, as the incorrect position. RESULTS. In total, the correct position (grade 0 and 1) was found in 72 (92.3%) screws and the incorrect position (grade 2 and 3) in 6 (7.7%). Among the 16 pedicle perforations (grade 1, 2, and 3 perforations), the directions were lateral in 15 (93.8%) and superior in 1 (6.2%). There were no neurovascular complications related to CPS insertion. CONCLUSION. Free-hand CPS placement by using para-articular minilaminotomy seems to be feasible and reproducible.
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Affiliation(s)
- Jong-Hwa Park
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Kangwon National University, Gangwon-do, Republic of Korea
| | - Jong Young Lee
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Jong Young Lee, Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea 150, Seongan-ro, Gangdong-gu, Seoul, Republic of Korea.
| | - Byoung Hun Lee
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea,Kangwon National University, Gangwon-do, Republic of Korea
| | - Hong Jun Jeon
- Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Seung-Woo Park
- Kangwon National University, Gangwon-do, Republic of Korea
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Safety and Feasibility of Cervical Pedicle Screw Insertion in Pediatric Subaxial Cervical Spine Without Navigation: A Retrospective Cohort Study. J Pediatr Orthop 2021; 41:119-126. [PMID: 33027234 DOI: 10.1097/bpo.0000000000001694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of cervical pedicle screws (CPSs) in pediatric subaxial cervical spine has been scarcely reported in the literature. The biomechanical superiority of CPS over other methods of fixation is beneficial in surgery for correcting severe, rigid cervical/cervicothoracic deformity. Our study aims to assess the safety, efficacy, and feasibility of CPS fixation in pediatric subaxial cervical spine without intraoperative navigation. METHODS Eight pediatric patients requiring rigid subaxial cervical spine fixation for complex cervical deformities were operated at a single center between 2014 and 2016. Their hospital records and imaging were retrospectively studied. The feasibility of inserting CPS was assessed by studying pedicle morphometry on preoperative computed tomography (CT) scans. Aberrant vertebral artery anatomy was ruled out using CT angiography. CPS were inserted into selected pedicles without navigation. Postoperative CT scans were studied to look for screw containment within pedicles. Complications were noted and clinicoradiologic follow-up was for a minimum of 36 months. RESULTS Thirty-seven CPS were inserted in 8 pediatric patients with a mean age of 9.2 years (range: 5 to 13 y). Surgery was done for complex cervical deformities due to various causes-neglected cervical spine trauma (n=3), posttubercular kyphosis (n=2), cervicothoracic scoliosis (n=2), and cervicothoracic osteoblastoma (n=1). The level-wise distribution of the inserted CPS was: C3=4, C4=6, C5=10, C6=10, and C7=7. Postoperative CT scans showed grade-1 medial cortical breach in 5/37 screws and grade-2 medial cortical breach in a single screw (16%). No perioperative complications were noted. At a mean follow-up of 3.6 years (range: 3 to 4.33 y), no patient had implant failure or deformity progression. CONCLUSIONS CPS insertion in pediatric subaxial cervical spine without neuronavigation is safe, feasible, and effective in carefully selected cases. Biomechanical advantages of CPS can be extended to the pediatric subaxial cervical spine. LEVEL OF EVIDENCE Level IV-retrospective cohort.
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Kovalenko RA, Rudenko VV, Kashin VA, Cherebillo VY, Ptashnikov DA. [Assessment of the safety and accuracy of implantation of screws into the C2 vertebra using individual 3D-navigation matrices]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:42-50. [PMID: 32412193 DOI: 10.17116/neiro20208402142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Individual 3D-navigation matrices are valuable to increase the safety of screw implantation into the axis. Objective To analyze safety and accuracy of screw deployment into the axis using individual 3D-navigation matrices compared to free hand technique. Material and methods A retrospective analysis included 23 patients (group 1) who underwent implantation of 44 screws into the axis using the «free hand» technique. The screws were installed along the transpedicular or pars trajectory. A prospective analysis enrolled 17 patients (group 2) who underwent installation of 34 screws using individual navigation matrices. 3D-printing technology was applied for manufacturing these matrices. Implantation results were evaluated considering postoperative CT data and SGT (Screw Guide Template) system. Results In the 1st group («free hand»), grade 0 and 1 (no malposition or less than 50% of screw diameter) were recorded for 29 (65.91%) screws, grade 2 - for 13 (29.55%) screws, grade 3 - for 2 (4.45%) screws. Intraoperative injury of the vertebral artery without postoperative neurological deficit occurred in 4 (8.89%) patients. In the 2nd group, 97% of screws were implanted in accordance with grades 1 and 2. Deviation grade 2 was registered in 11 cases (32.35%). Mean deviation was 1.8 ± 1.0 mm. In the 2nd group, 28 (82.35%) out of 34 screws were completely within the bone structures (grade 0), 4 (11.76%) screws perforated pedicles for less than 50% of their diameter (grade 1). There were 2 cases of malposition grade 2 and 3 without vertebral artery injury. Conclusion Individual 3D navigation matrix is an effective method for screw installation into the axis. This approach exceeds fluoroscopy-assisted "free hand" technique in terms of safety of implantation.
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Affiliation(s)
- R A Kovalenko
- V.A. Almazov Medical Research Center, Saint Petersburg, Russia
| | - V V Rudenko
- R.R. Vreden Russian Scientific Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia
| | - V A Kashin
- V.A. Almazov Medical Research Center, Saint Petersburg, Russia
| | - V Yu Cherebillo
- V.A. Almazov Medical Research Center, Saint Petersburg, Russia
| | - D A Ptashnikov
- R.R. Vreden Russian Scientific Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia
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Jung YG, Jung SK, Lee BJ, Lee S, Jeong SK, Kim M, Park JH. The Subaxial Cervical Pedicle Screw for Cervical Spine Diseases: The Review of Technical Developments and Complication Avoidance. Neurol Med Chir (Tokyo) 2020; 60:231-243. [PMID: 32295984 PMCID: PMC7246229 DOI: 10.2176/nmc.ra.2019-0189] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This study aimed to review information on the subaxial cervical pedicle screw (CPS) including recent anatomical considerations, entry points, placement techniques, accuracy, learning curve, and complications. Relevant literatures were reviewed, and the authors’ experiences were summarized. The CPS is used for reconstruction of unstable cervical spine and achieves superior biomechanical stability compared to other fixation techniques. Various insertion and guidance techniques are established, among which, lateral fluoroscopy-assisted placement is the most common and cost-effective technique. Generally, placement under imaging guidance is more accurate than other techniques, and a three-dimensional template allows optimal trajectory for each pedicle regardless of intraoperative changes in spinal alignment. The free-hand technique using a curved pedicle probe without a funnel-like hole increases screw stability and reduces operation time, radiation exposure, and soft tissue injury. Compared to conventional lateral fluoroscopy-assisted placement, free-hand CPS placement by trained surgeons achieves superior accuracy comparable to that of image-guided navigation; in general, 30 training cases are sufficient for learning a safe and accurate technique for CPS placement. The complications of subaxial CPS are classified into three categories: complications due to screw misplacement, complications without screw misplacement, and others. Inexperienced surgeons may benefit from advanced techniques; however, the accuracy of CPS ultimately depends on the surgeon’s experience. Inexperienced surgeons should master the placement of the thoracolumbar pedicle screw in real practice and practice CPS insertion using cadavers. During the initial phase of the learning curve, careful preparation of surgery, reiterated identification, patterned safety steps, and supervision of the expert are necessary.
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Affiliation(s)
- Yoon Gyo Jung
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sang Ku Jung
- Department of Emergency Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine
| | - Byung Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Neuroscience and Radiosurgery Hybrid Research Center, College of Medicine
| | - Subum Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Seong Kyun Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Myeongjong Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
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Upendra B, Raghavendra R. Techniques of cervical pedicle screw insertion in lower cervical spine - A review. J Clin Orthop Trauma 2020; 11:794-801. [PMID: 32879566 PMCID: PMC7452216 DOI: 10.1016/j.jcot.2020.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 11/29/2022] Open
Abstract
Cervical pedicle screws (CPS) have been used for stabilization of lower cervical spine since its first description by Abumi et al., in 1994, but the usage has been limited due to the feared complications. Cadaveric studies have discouraged use of CPS in lower cervical spine due to high misplacement rates. On the contrary, clinical studies have shown limited complications due to screw misplacements and have highlighted the benefits of CPS with its superior biomechanical strength. Therefore surgeons have always tried to find a reliable, reproducible and safe CPS insertion technique to expand the usage of CPS with minimal complications. As of today Abumi et al. technique is the most popular free-hand technique used by surgeons, though many modifications have evolved to make the CPS insertions more safe and reproducible. The free hand technique should be considered as the cornerstone technique for CPS insertion and the navigation tools are essential to improve the safety of CPS in complex surgeries with altered cervical anatomy. The present review brings together the literature on the various aspects of cervical pedicle anatomy, the free-hand screw insertion techniques with their modifications, the screw misplacement rates and complications.
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13
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Kim MK, Cho HJ, Kwak DS. A new anatomical approach of cervical lateral mass for cervical pedicle screw and paravertebral foramen screw insertion. PLoS One 2019; 14:e0219119. [PMID: 31318904 PMCID: PMC6638838 DOI: 10.1371/journal.pone.0219119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 06/17/2019] [Indexed: 01/01/2023] Open
Abstract
Thus far, anatomical studies have reported data on the cervical pedicle, with the focus remaining on the pedicle itself. It was necessary to obtain more comprehensive data about the relationships between the lateral mass, pedicle, and transverse foramen for cervical pedicle screwing (CPS) and paravertebral foramen screwing (PVFS), a new technique. The purpose of this study was to describe the relationships between the lateral mass, pedicle, and transverse foramen. This study analyzed computed tomography images from 77 patients (42 female, 35 male; mean age: 63.95 years). The anatomical pedicle transverse angle (PTA) and linear parameters of the lateral mass were measured, and the relationship between the calculated angles and the anatomical PTA was investigated. θp was defined as the convergence angle from the posterolateral edge of the lateral mass to the pedicle, and θc was defined as the convergence angle from the posterolateral edge of the lateral mass to the anterolateral corner of the vertebral foramen. The thickness of the cortical bone of the medial wall of the lateral mass (cT) and the medial (mT) and lateral (lT) walls of the pedicle at C3-7 were also measured. The PTA was similar to θp and θc at C3-6, but different at C7. In all cases, the transverse foramen was located more anterior to the posterior wall of the cervical body at C3-6, but not at C7. mT and cT were significantly thicker than lT at all levels. Lateral fluoroscopic images show that when the probe is inserted along θc, it meets the counter corner of the lateral mass at C3-6 without invasion of the transverse foramen if it does not cross the posterior wall of the vertebral body. This can be significant when performing CPS and PVFS.
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Affiliation(s)
- Moon-Kyu Kim
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Ho-Jung Cho
- Catholic Institute for Applied Anatomy / Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dai-Soon Kwak
- Catholic Institute for Applied Anatomy / Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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Huh J, Hyun JH, Park HG, Kwak HY. Three Dimensional Measurement of Ideal Trajectory of Pedicle Screws of Subaxial Cervical Spine Using the Algorithm Could Be Applied for Robotic Screw Insertion. J Korean Neurosurg Soc 2019; 62:376-381. [PMID: 31290294 PMCID: PMC6616986 DOI: 10.3340/jkns.2018.0176] [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: 09/03/2018] [Accepted: 12/24/2018] [Indexed: 12/03/2022] Open
Abstract
Objective To define optimal method that calculate the safe direction of cervical pedicle screw placement using computed tomography (CT) image based three dimensional (3D) cortical shell model of human cervical spine.
Methods Cortical shell model of cervical spine from C3 to C6 was made after segmentation of in vivo CT image data of 44 volunteers. Three dimensional Cartesian coordinate of all points constituting surface of whole vertebra, bilateral pedicle and posterior wall were acquired. The ideal trajectory of pedicle screw insertion was defined as viewing direction at which the inner area of pedicle become largest when we see through the biconcave tubular pedicle. The ideal trajectory of 352 pedicles (eight pedicles for each of 44 subjects) were calculated using custom made program and were changed from global coordinate to local coordinate according to the three dimensional position of posterior wall of each vertebral body. The transverse and sagittal angle of trajectory were defined as the angle between ideal trajectory line and perpendicular line of posterior wall in the horizontal and sagittal plane. The averages and standard deviations of all measurements were calculated.
Results The average transverse angles were 50.60º±6.22º at C3, 51.42º ±7.44º at C4, 47.79º ±7.61º at C5, and 41.24º ±7.76º at C6. The transverse angle becomes more steep from C3 to C6. The mean sagittal angles were 9.72º ±6.73º downward at C3, 5.09º±6.39º downward at C4, 0.08º ±6.06º downward at C5, and 1.67º ±6.06º upward at C6. The sagittal angle changes from caudad to cephalad from C3 to C6.
Conclusion The absolute values of transverse and sagittal angle in our study were not same but the trend of changes were similar to previous studies. Because we know 3D address of all points constituting cortical shell of cervical vertebrae. we can easily reconstruct 3D model and manage it freely using computer program. More creative measurement of morphological characteristics could be carried out than direct inspection of raw bone. Furthermore this concept of measurement could be used for the computing program of automated robotic screw insertion.
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Affiliation(s)
- Jisoon Huh
- Department of Neurosurgery, Jeju National University School of Medicine, Jeju, Korea
| | - Jae Hwan Hyun
- Department of Neurosurgery, Jeju National University School of Medicine, Jeju, Korea
| | - Hyeong Geon Park
- Department of Neurosurgery, Jeju National University School of Medicine, Jeju, Korea
| | - Ho-Young Kwak
- Department of Computer Engineering, Jeju National University College of Engineering, Jeju, Korea
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Kovalenko RA, Rudenko VV, Kashin VA, Cherebillo VY, Ptashnikov DA. Application of patient-specific 3D navigation templates for pedicle screw fixation of subaxial and upper thoracic vertebrae. HIRURGIÂ POZVONOČNIKA (SPINE SURGERY) 2019. [DOI: 10.14531/ss2019.2.35-41] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective. To analyze the safety and accuracy of pedicle screw placement in the subaxial cervical and upper thoracic spine using patient-specific 3D navigation templates.Material and Methods. The study included 16 patients who underwent transpedicular implantation of screws in the subaxial cervical and upper thoracic vertebrae using patient-specific 3D navigation templates. A total of 88 screws were installed. All patients underwent preoperative CT angiography to assess visualization of the vertebral artery. Customized vertebral models and navigation templates were created using 3D printing technology. Models and templates were sterilized and used during surgery. The results of screw implantation, as well as the safety and accuracy of the placement, were assessed by postoperative CT.Results. The average deviation from the planned trajectory was 1.8 ± 0.9 mm. Deviation was estimated as class 1 (<2 mm) for 57 (64.77 %) screws, class 2 (2–4 mm) for 29 (32.95 %), and class 3 for two (2.27 %). The safety of screw implantation of grade 0 (the screw is completely inside the bone structure) was in 79 (89.77 %) cases, of grade 1 (<50 % of the screw diameter perforates the bone) – in 5 (5.68 %), and of grade 3 – in 2 (2.27 %).Conclusion. Using 3D navigation templates is an affordable and safe method of installing pedicle screws in the cervical and upper thoracic spine. The method can be used as an alternative to intraoperative CT navigation.
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Affiliation(s)
| | - V. V. Rudenko
- Russian Scientific Research Institute of Traumatology and Orthopedics n.a. R.R. Vreden
| | | | | | - D. A. Ptashnikov
- Russian Scientific Research Institute of Traumatology and Orthopedics n.a. R.R. Vreden
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16
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Tukkapuram VR, Kuniyoshi A, Ito M. A Review of the Historical Evolution, Biomechanical Advantage, Clinical Applications, and Safe Insertion Techniques of Cervical Pedicle Screw Fixation. Spine Surg Relat Res 2019; 3:126-135. [PMID: 31435564 PMCID: PMC6690082 DOI: 10.22603/ssrr.2018-0055] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 08/30/2018] [Indexed: 12/02/2022] Open
Abstract
Cervical spine instrumentation is evolving with an aim of stabilizing traumatic and non-traumatic cases of the cervical spine with a beneficial reduction, better biomechanical strength, and a strong construct with minimal intraoperative, as well as immediate and late postoperative complications. The evolution from interspinous wiring till cervical pedicle screws has changed the outlook in treating the cervical spine pathologies with maximum 3D stability, decreasing the duration of postoperative immobilization and hospital stay. Some complications associated with the use of cervical pedicle screw can be catastrophic. This review article discusses the morphometry of cervical pedicle; indications, biomechanical superiority, tricks, and pitfalls of cervical pedicle screw; complications and technical advancements in targeting safe surgery; and future directions of cervical pedicle screw instrumentation.
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Affiliation(s)
| | - Abumi Kuniyoshi
- Department of orthopaedics, Sapporo Orthopaedic Hospital, Sapporo, Japan
| | - Manabu Ito
- Department of orthopaedics, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
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Celikoglu E, Borekci A, Ramazanoglu AF, Cecen DA, Karakoc A, Bektasoglu PK. Posterior Transpedicular Screw Fixation of Subaxial Vertebrae: Accuracy Rates and Safety of Mini-laminotomy Technique. Asian J Neurosurg 2019; 14:58-62. [PMID: 30937009 PMCID: PMC6417301 DOI: 10.4103/ajns.ajns_178_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Aim: Posterior cervical transpedicular screw fixation has the strongest resistance to pullout forces compared with other posterior fixation systems. Here, we present a case on the use of this technique combined with a mini-laminotomy technique, which serves as a guide for accurate insertion of posterior cervical transpedicular screws. Materials and Methods: We retrospectively analyzed data from 40 patients who underwent this procedure in our clinic between January 2014 and March 2017. Results: The study population comprised 27 males (67.5%) and 13 females (32.5%) aged 15–80 years (median, 51.5 years). Surgical indications included trauma (n = 18, 45%), degenerative disease (n = 19, 47.5%), spinal infection (n = 2, 5%), and basilar invagination due to systemic rheumatoid disease (n = 1, 2.5%). In the 18 trauma patients, 14 short-segment (1–2 levels) and 4 long-segment (≥3 levels) posterior cervical instrumentation and fusion procedures were performed. The mini-laminotomy technique was used in all patients to insert, direct, and achieve exact screw fixation in the pedicles. Pedicle perforations were classified as medial or lateral and were also graded. Among the 227 cervical pedicle fixations performed, 48 were at the C3 level, 49 at C4, 60 at C5, 50 at C6, and 20 at C7. Axial computed tomography scan measurements showed that 205 of 227 (90.3%, Grade 0 and 1) screws were accurately placed, whereas 22 (9.69%, Grade 2 and 3) were misplaced. However, no additional neurological injury due to misplacement was observed. Conclusion: As negligible complications were observed when performed by experienced surgeons, the mini-laminotomy technique can be safely used for posterior transpedicular screw fixation in the subaxial vertebrae for single-staged fusion.
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Affiliation(s)
- Erhan Celikoglu
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Ali Borekci
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Ali Fatih Ramazanoglu
- Department of Neurosurgery, Umraniye Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Dilber Aycicek Cecen
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Abdullah Karakoc
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey
| | - Pinar Kuru Bektasoglu
- Department of Neurosurgery, Fatih Sultan Mehmet Education and Research Hospital, Turkish Ministry of Health, University of Health Sciences, Istanbul, Turkey.,Department of Physiology, Marmara University School of Medicine, Istanbul, Turkey
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18
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Pan Z, Zhong J, Xie S, Yu L, Wu C, Ha Y, Kim KN, Zhang Y, Cao K. Accuracy and Safety of Lateral Vertebral Notch-Referred Technique Used in Subaxial Cervical Pedicle Screw Placement. Oper Neurosurg (Hagerstown) 2018; 17:52-60. [DOI: 10.1093/ons/opy233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 07/27/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zhimin Pan
- Department of Orthopaedics, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Junlong Zhong
- Department of Orthopaedics, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shiming Xie
- Department of Orthopaedics, Mianyang Orthopaedic Hospital, Mianyang, China
| | - Limin Yu
- Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen, China
| | - Chunyang Wu
- Department of Orthopaedics, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Youshan Zhang
- Computer of Science Engineering, Lehigh University, Bethlehem, Pennsylvania
| | - Kai Cao
- Department of Orthopaedics, the Second Affiliated Hospital of Nanchang University, Nanchang, China
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Abstract
STUDY DESIGN A prospective case-series study and a retrospective analysis of historical patients for comparison of data. OBJECTIVE To compare accuracy and limitations of intraoperative computed tomography (iCT)- versus 3D C-arm-based spinal navigation for posterior pedicle screw implantation. SUMMARY OF BACKGROUND DATA Despite the higher accuracy of navigated compared to non-navigated pedicle screw implantation, it remains a matter of debate whether the use of iCT imaging may further benefit navigated spinal instrumentation compared to more commonly used isocentric 3D C-arm imaging. METHODS Between 2013 and 2016, 1527 pedicle screws were implanted in 260 patients with iCT (1219 screws) or 3D C-arm (308 screws)-based spinal navigation. Screw positioning was intraoperatively assessed by a second iCT or 3D C-arm (intraoperative accuracy). If necessary, immediate intraoperative screw revision was performed. Thereafter, a third iCT or 3D C-arm scan was performed to confirm repositioning (final accuracy). Clinical and patient data, intraoperative screw assessability, and accuracy rates were retrospectively reviewed and analyzed by an independent observer. RESULTS Intraoperative CT permitted immediate intraoperative assessment of each implanted screw. In contrast, 39 of the screws visualized with 3D C-arm imaging were intraoperatively not clearly assessable. Regarding the overall precision, iCT and 3D C-arm navigation yielded a comparable intraoperative accuracy (iCT 94.7% vs 3D C-arm 89.4%) and immediate correction of misplaced screws was feasible with both modalities (final accuracy: iCT 95.4% vs 3D C-arm 91.6%). Regarding the region specific performance, however, iCT-based navigation yielded significantly higher final accuracy rates in the cervical (iCT 99.5% vs 3D C-arm 88.9%, P < 0.01) and thoracic (iCT 97.7% vs 3D C-arm 88.8%, P < 0.001) regions. CONCLUSION Both iCT and 3D C-arm-based spinal navigation provides high pedicle screw accuracy rates. Immediate screw assessability and placement accuracy in the cervical-thoracic spine, however, appear to be limited with intraoperative 3D C-arm imaging alone. LEVEL OF EVIDENCE 3.
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20
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Kim MK, Cho HJ, Kwak DS, You SH. Characteristics of regional bone quality in cervical vertebrae considering BMD: Determining a safe trajectory for cervical pedicle screw fixation. J Orthop Res 2018. [PMID: 28621468 DOI: 10.1002/jor.23633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study aimed to report the mechanical strength and characteristics of the lateral mass and pedicle considering BMD for the safe insertion of pedicle screws in the subaxial cervical level. We evaluated BMD and Hounsfield unit (HU) values of cortical bones at the lateral mass and pedicle of C3-7 from CT images in 99 patients. Patients were divided into three groups (Group A, T-score ≥ -1; Group B, -2.5 < T-score < -1.0; Group C, T-score ≤ -2.5). The HU numbers of cortical bone in the vertebral canal (medial wall of the lateral mass; cHU), posterior wall of the transverse foramen (fHU), and medial wall, lateral wall, and trabecular area of the pedicle (mHU, lHU, and pHU, respectively) were measured on the CT images in the middle of the pedicle. A mechanical study was also performed to measure cortical bone strength using 10 fresh cadavers. The cHU and mHU values in Group C were higher than lHU and fHU in Groups A and B, and there was a wide gap between the pHU value and other areas. The penetrating force also had a close correlation with HU number. The mean penetrating force of the medial wall of the lateral mass and the posterior wall of the transverse foramen were 210.08 ± 110.46 and 50.51 ± 46.09 N, respectively. The cortical bones in the vertebral canal and medial wall of the pedicle were stronger than the lateral wall and the trabecular area. The cHU and mHU in the osteoporotic group were higher than fHU and pHU in the normal group. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:217-223, 2018.
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Affiliation(s)
- Moon-Kyu Kim
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Ho-Jung Cho
- Catholic Institute for Applied Anatomy/Department of Anatomy, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-goo, Seoul 06591, Korea
| | - Dai-Soon Kwak
- Catholic Institute for Applied Anatomy/Department of Anatomy, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-goo, Seoul 06591, Korea
| | - Seung-Hoon You
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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Lee JH, Choi BK, Han IH, Choi WG, Nam KH, Kim HS. Cervical Pedicle Screw Placement Using Medial Funnel Technique. KOREAN JOURNAL OF SPINE 2017; 14:84-88. [PMID: 29017302 PMCID: PMC5642088 DOI: 10.14245/kjs.2017.14.3.84] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/24/2017] [Accepted: 08/27/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Cervical pedicle screw (CPS) placement is very challenging due to high risk of neurovascular complications. We devised a new technique (medial funnel technique) to improve the accuracy and feasibility of CPS placement. METHODS We reviewed 28 consecutive patients undergoing CPS instrumentation using the medial funnel technique. Their mean age was 51.4 years (range, 30-81 years). Preoperative diagnosis included degenerative disease (n=5), trauma (n=22), and infection (n=1). Screw perforations were graded with the following criteria: grade 0 having no perforation, grade 1 having <25%, grade 2 having 25%-50% and grade 3 having >50% of screw diameter. Grades 0 and 1 were considered as correct position. The degree of perforation was determined by 2 junior neurosurgeons and 1 senior neurosurgeon. RESULTS A total of 88 CPSs were inserted. The rate of correct placement was 94.3%; grade 0, 54 screws; grade 1, 29 screws; grade 2, 4 screws; and grade 3, 1 screw. No neurovascular complications or failure of instrumentation occurred. In perforated screws (34 screws), lateral perforations were 4 and medial perforations were 30. CONCLUSION We performed CPS insertion using medial funnel technique and achieved 94.3% (83 of 88) of correct placement. And it can decrease lateral perforation.
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Affiliation(s)
- Jung Hwan Lee
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - Byung Kwan Choi
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - In Ho Han
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - Won Gyu Choi
- Department of Neurosurgery, Asan Chungmoo Hospital, Asan, Korea
| | - Kyoung Hyup Nam
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - Hwan Soo Kim
- Department of Neurosurgery, Busan Himchan Hospital, Busan, Korea
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Yao X, Liu S. In vitro study of accuracy of subaxial cervical pedicle screw insertion using calipers based on the gravity line. PLoS One 2017; 12:e0181324. [PMID: 28727778 PMCID: PMC5519080 DOI: 10.1371/journal.pone.0181324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 06/29/2017] [Indexed: 11/23/2022] Open
Abstract
Object There is a high probability of iatrogenic perforation of the vertebral pedicle wall during the application of subaxial cervical pedicle screw (CPS). The goal of this study was to evaluate the accuracy of CPS insertion at C3-C7 in vitro using novel calipers based on the gravity line. Methods Nine cadaveric cervical spines underwent computed tomography scanning and preoperative design. A lateral fluoroscopic view was taken to measure the intra-operative sagittal angle by C-arm with hanging cross structured K-wires. By referring to the gravity line, caliper A was used to locate the entry point, while caliper B was employed to guide the screw insertion. Postoperative CT scans were performed to assess the accuracy of the screw placements, according to the Neo classification. Results Overall, 78 (88.6%) of the 88 pedicle screw placements were classified as grade 0 (correct position), 4 (4.5%) were grade 1 (non-critical perforation), 4 (4.5%) were grade 2 (critical perforation), and 2 (2.3%) were grade 3 (critical perforation). Conclusions Using our novel calipers and referring to the gravity line was helpful for locating and guiding individual cervical pedicle screw insertions.
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Affiliation(s)
- Xiang Yao
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, PR China
| | - Shiqing Liu
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, PR China
- * E-mail:
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23
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Li W, Liu Y, Sun H, Pan Y, Qian Z. Monitoring reduced scattering coefficient in pedicle screw insertion trajectory using near-infrared spectroscopy. Med Biol Eng Comput 2015; 54:1533-9. [PMID: 26695814 DOI: 10.1007/s11517-015-1428-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 12/07/2015] [Indexed: 11/30/2022]
Abstract
Pedicle screw (PS) implantation is an ideal treatment for severe multilevel vertebra instabilities. The accuracy of fixating PS is a key factor of spinal surgery. We developed a near-infrared spectroscopy device with a needlelike optical fiber probe to monitor optical parameters (reduced scattering coefficient) of vertebra models in real time. The fresh-frozen cadaver, cats and porcine vertebras were first studied in the experiments. Moreover, the reduced scattering coefficient (μ' s) along the different trajectories of PS insertion was obtained. In the fresh-frozen cadavera experiment, μ' s values could be used to distinguish the different compositions of the thoracic vertebra. In cat vertebra experiment, μ' s values of vertebrae bones, including cortical bone (15.30 ± 0.18 cm(-1)), cancellous bone (7.84 ± 1.11 cm(-1)) and spinal cord (19.46 ± 0.21 cm(-1)), were different in vivo. In the pig vertebrae experiment, there were obvious differences between the normal and abnormal PS puncture curves based on μ' s values. Thus, μ' s values measured by using the proposed device could be used as the pattern factor in spinal fusion surgery. Our studies demonstrate that near-infrared spectroscopy method may be potentially used for assisting the PS insertion.
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Affiliation(s)
- Weitao Li
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China.
| | - Yangyang Liu
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China
| | - Haixiang Sun
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China
| | - Yue Pan
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China
| | - Zhiyu Qian
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China
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Hybrid Technique for Cervical Pedicle Screw Placement: Combination of Miniopen Surgery and Use of a Percutaneous Cannula System-Pilot Study. Spine (Phila Pa 1976) 2015; 40:1181-6. [PMID: 25996541 DOI: 10.1097/brs.0000000000000986] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaver study and clinical application; a pilot study. OBJECTIVE To minimize muscle dissection and enhance accuracy of cervical pedicle screw (CPS) placement by using a percutaneous cannula system. SUMMARY OF BACKGROUND DATA Many studies have reported that the most frequent misplacement of CPSs is breach of the lateral wall; thus, an easy technique for securing medial convergence is required. We developed a percutaneous cannula system for this purpose and report the results of a cadaver study and its clinical application. METHODS A cadaver study was conducted to confirm the possibility of this percutaneous technique in 5 specimens (50 CPSs, C3-C7). Then, the technique was applied in 8 patients (40 CPSs, C3-C7). The surgical technique was a hybrid of miniopen surgery and the use of percutaneous cannula system under lateral fluoroscopic guidance. Entry holes were made in the open field and a cannula was used for tapping and insertion of CPSs. A stiff pedicle probe through the cannula was used to locate the pedicle in the lateral mass. RESULTS In the cadaver study, there were 12 (24%) misplacements among 50 CPSs used. The hybrid technique was applied clinically in 4 traumatic, 2 degenerative, and 2 failed back surgery lesions. Thirty CPSs were inserted using the percutaneous cannula system and 10 were inserted using a cannula as a retractor. Misplacement occurred in 6.7% (n = 2) and 20% (n = 2) pedicles, respectively, and there were no symptomatic complications (total incidence, 10%). An additional incision for the cannula system can be made for 2-level CPS insertions. CONCLUSION Use of the percutaneous cannula system facilitated a secure convergence angle for CPS insertion without extending muscle dissection or shifting cervical alignment because of muscle retraction. Moreover, this system can be used for CPS insertion in bull-necked patients. LEVEL OF EVIDENCE 3.
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Abumi K. Cervical spondylotic myelopathy: posterior decompression and pedicle screw fixation. 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 2015; 24 Suppl 2:186-96. [PMID: 25813005 DOI: 10.1007/s00586-015-3838-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 02/18/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Posterior decompression by laminoplasty and anterior decompression/fixation have been widely accepted, and they provide sufficient results for cervical spondylotic myelopathy. However, combined procedure of posterior decompression and reconstruction is favorable for some patients accompanying local kyphosis, segmental instability, previously operated conditions on the cervical spine, etc. DISCUSSION Among posterior cervical instrumentations, pedicle screw fixation is a strong tool of stabilization of unstable segment and correction of deformities in sagittal and/or coronal planes for the patient with cervical spondylotic myelopathy. On the other hand, neurovascular complications including injury to the vertebral artery and nerve root cannot be completely eliminated. Even after surgeons became familiar with placement of cervical pedicle screws, screw malposition rate by freehand technique is high for patients with severe spondylotic condition. Surgeons must especially be careful for inserting pedicle screw in the cervical spine associating marked degenerative changes by spondylosis, and must obtain preoperatively sufficient anatomical information of the pedicle and surrounding structures. CONCLUSION Combined procedure of posterior reconstructive surgery using a pedicle screw fixation provides better clinical outcomes than laminoplasty alone for cervical spondylotic myelopathy accompanying local kyphosis or segmental instability. Further development of supporting tools for cervical pedicle screw insertion including aiming device, navigation system and neuromonitoring procedure are expected for safer screw insertion.
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Affiliation(s)
- Kuniyoshi Abumi
- Sapporo Orthopaedic Hospital-Center for Spinal Disorders, 13-56, Hassam 13-4, Nishi-Ku, Sapporo, 063-0833, Japan,
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Uehara M, Takahashi J, Ikegami S, Mukaiyama K, Kuraishi S, Shimizu M, Futatsugi T, Ogihara N, Hashidate H, Hirabayashi H, Kato H. Screw perforation features in 129 consecutive patients performed computer-guided cervical pedicle screw insertion. 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 2014; 23:2189-95. [DOI: 10.1007/s00586-014-3502-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 10/24/2022]
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Cervical Pedicle Screw Placement in Sawbone Models and Unstable Cervical Traumatic Lesions by Using Para-Articular Mini-Laminotomy: A Novice Neurosurgeon's Experience. Korean J Neurotrauma 2013. [DOI: 10.13004/kjnt.2013.9.2.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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