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Wu S, Liu S, Ling M, Huang M, Liu Z, Duan X. A novel method to evaluate the transverse pedicle angles of the lower lumbar vertebrae using digital radiography. PLoS One 2024; 19:e0295196. [PMID: 38870237 PMCID: PMC11175444 DOI: 10.1371/journal.pone.0295196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
To investigate a novel approach for establishing the transverse pedicle angle (TPA) of the lower lumbar spine using preoperative digital radiography (DR). Computed Tomography (CT) datasets of the lower lumbar were reconstructed using MIMICS 17.0 software and then imported into 3-matic software for surgical simulation and anatomical parameter measurement. A mathematical algorithm of TPA based on the Pythagorean theorem was established, and all obtained data were analyzed by SPSS software. The CT dataset from 66 samples was reconstructed as a digital model of the lower lumbar vertebrae (L3-L5), and the AP length/estimated lateral length for L3 between the right and left sides was statistically significant (P = 0.015, P = 0.005). The AP length of the right for L4 was smaller than that of the left after a paired t test was executed (P = 0.006). Both the width of the pedicle and the length of the pedicle (P2C1) were consistent with TPA (L3
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Affiliation(s)
- Shixun Wu
- Department of Orthopedics Surgery, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi, China
- Key Laboratory of Bone Joint Disease Basic and Clinical Translation of Shaanxi Province, Xi’an, Shaanxi, China
| | - Shizhang Liu
- Department of Orthopedics Surgery, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi, China
- Key Laboratory of Bone Joint Disease Basic and Clinical Translation of Shaanxi Province, Xi’an, Shaanxi, China
| | - Ming Ling
- Department of Orthopedics Surgery, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi, China
- Key Laboratory of Bone Joint Disease Basic and Clinical Translation of Shaanxi Province, Xi’an, Shaanxi, China
| | - Minggang Huang
- Department of Computed Tomography, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi, China
| | - Zhe Liu
- Department of Computed Tomography, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi, China
| | - Xianglong Duan
- Key Laboratory of Bone Joint Disease Basic and Clinical Translation of Shaanxi Province, Xi’an, Shaanxi, China
- Second Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi, China
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an Shaanxi, China
- Second Department of General Surgery, Third Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Peterson SL, Mounsef JB, Sebastian AS, Morrissey PB. Intraoperative Triggered Electromyography: Indispensable in Routine Lumbar Fusions? Clin Spine Surg 2022; 35:329-332. [PMID: 33872222 DOI: 10.1097/bsd.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Shian Liu Peterson
- Department of Orthopedic Surgery, Naval Medical Center San Diego, San Diego, CA
| | - Jad Bou Mounsef
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | - Patrick B Morrissey
- Department of Orthopedic Surgery, Naval Medical Center San Diego, San Diego, CA
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Zhang JK, Del Valle AJ, Alexopoulos G, Patel N, Van Nispen J, Patel M, Xu E, Mercier P, Kohn NA, Mattei TA. Malpractice litigation in elective lumbar spinal fusion: a comprehensive review of reported legal claims in the U.S. in the past 50 years. Spine J 2022; 22:1254-1264. [PMID: 35381361 DOI: 10.1016/j.spinee.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/08/2022] [Accepted: 03/28/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In the U.S., medical malpractice litigation is associated with significant financial costs and often leads to the practice of defensive medicine. Among medical subspecialities, spine surgery is disproportionately impacted by malpractice claims. PURPOSE To provide a comprehensive assessment of reported malpractice litigation claims involving elective lumbar spinal fusion (LSF) surgery during the modern era of spine surgery instrumentation in the U.S., to identify factors associated with verdict outcomes, and to compare malpractice claims characteristics between different approaches for LSF. STUDY DESIGN/SETTING A retrospective review. PATIENT SAMPLE Patients undergoing elective lumbar spinal fusion surgery. OUTCOME MEASURES The primary outcome measure was verdict outcome (defendant vs. plaintiff verdict). Secondary outcome measures included alleged malpractice, injury/damage claimed, and award payouts. METHODS The Westlaw legal database (Thomson Reuters, New York, NY, USA) was queried for verdict and settlement reports pertaining to elective LSF cases from 1970 to 2021. Data were collected regarding patient demographics, surgeon specialty, fellowship training, state/region, procedure, institutional setting (academic vs. community hospital), alleged malpractice, injury sustained, case outcomes, and monetary award. RESULTS A total of 310 cases were identified, yielding 67% (n=181) defendant and 24% (n=65) plaintiff verdicts, with 9% (n=26) settlements. Neurosurgeons and orthopedic spine surgeons were equally named as the defendant (45% vs. 51% respectively, p=0.59). When adjusted for inflation, the median final award for plaintiff verdicts was $1,241,286 (95% CI: $884,850-$2,311,706) while the median settlement award was $925,000 (95% CI: $574,800-$1,787,130), with no stastistically significant differences between verdict and reported settlement payouts (p=0.49). The Northeast region displayed significantly higher award payouts compared to other U.S. regions (p=0.02). There were no associations in awards outcomes when comparing alleged malpractice, alleged injuries/damages, institutional setting, surgical procedures, and surgeon specialty or fellowship training. The most common claims were intraoperative error (28%, n=107) followed by failure to obtain informed consent (24%, n=94). In the analyzed cohort, the most common injuries leading to litigation were refractory pain and suffering (37%, n=149) followed by permanent neurological deficits (26%, n=106). There were no differences in alleged malpractice or injury sustained between cases in which the outcome was favorable to defendant versus plaintiff. Anterior lumbar interbody fusion (ALIF) cases were 2.75 times more likely to be cited for excessive or inappropriate surgery (OR: 2.75 [95% CI: 1.14, 6.86], p=0.02) when compared to posterior surgical approaches. CONCLUSION The results of our analysis of reported claims suggest that medical malpractice litigation involving elective LSF is associated with jury verdicts over $1 million per case, with the most common alleged malpractice being intraoperative error and failure to obtain informed consent. Surgeon specialty, fellowship training, procedure type, and institution type were not associated with greater litigation risks; however, ALIF surgery had a significantly higher risk of involving claims of excessive or inappropriate surgery compared to posterior approaches for lumbar fusion. In addition, claims were significantly higher in the Northeast compared to other U.S. regions. Efforts to improve patient education through shared-decision making and proactive strategies to avoid, detect, and mitigate intra-operative procedural errors may decrease the risk of litigation in elective LSF.
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Affiliation(s)
- Justin K Zhang
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Armando J Del Valle
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Georgios Alexopoulos
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Niel Patel
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Johan Van Nispen
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Mayur Patel
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Evan Xu
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Philippe Mercier
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Nina A Kohn
- David M. Levy Professor of Law, Syracuse University College of Law, Syracuse, NY, USA
| | - Tobias A Mattei
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA.
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Simulation on synthetic bone: A tool for teaching thoracolumbar pedicle screw placement. Orthop Traumatol Surg Res 2021; 107:103056. [PMID: 34536595 DOI: 10.1016/j.otsr.2021.103056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/11/2020] [Accepted: 01/11/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Simulation workshops for surgical training of residents are becoming popular. The gold standard for teaching thoracolumbar pedicle screw placement are cadaver labs; however, the availability of human bodies is limited. The primary objective of this study was to determine if training on a synthetic bone model improves the apprenticeship of accurate pedicle screw placement. The secondary objective was to check the influence of residents' previous experience in spine surgery. HYPOTHESIS The main hypothesis was that theoretical learning with practical application on synthetic bone was superior to theoretical learning alone. METHODS Twenty-three orthopedic residents were taught about free-hand pedicle screw placement using a theoretical presentation. Six residents had previous experience with screwing techniques. After randomization in two groups, 11 residents (group 1) participated in a workshop on synthetic bone, whereas 12 residents received only theoretical instruction (group 2). Each resident was asked to place two thoracic screws (T7-T11) and two lumbar screws (L1-L5) on a cadaver. Screw placement accuracy was analyzed using the Gertzbein classification on computed tomography (grades 0 and 1=accurate positioning; grades 2 and 3=malposition>2mm). RESULTS Rates of accurate screw positioning were 64.0% and 62.5% for thoracic levels, and 72.7% and 66.6% for lumbar levels in group 1 and 2, respectively. There was no significant difference in malposition rates on cadavers between the groups (p=0.1809). A resident who was first trained by simulation had a chance of decreasing the Gertzbein score with an odds-ratio of 1.7714 [0.7710-4.1515]. The odds ratio was 4.5188 [0.0456-0.8451] when comparing residents with previous experience in spinal surgery to novice residents. DISCUSSION Theoretical teaching associated with a simulation model is relevant for learning a surgical technique. A single simulation workshop on synthetic bone seems insufficient to improve pedicle screw placement accuracy compared to theoretical teaching alone. Progressive experience and the repetition of technical gestures during hands-on supervised learning in spine surgery with a senior surgeon had an influence on the accuracy of pedicle screw placement. LEVEL OF EVIDENCE II.
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Guide wire displacement in robot-assisted spinal pedicle screw implantation. Wideochir Inne Tech Maloinwazyjne 2021; 16:526-535. [PMID: 34691302 PMCID: PMC8512515 DOI: 10.5114/wiitm.2021.103952] [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: 09/11/2020] [Accepted: 11/19/2020] [Indexed: 01/02/2023] Open
Abstract
Aim Guide wire displacement in spinal pedicle screw implantation was analyzed in order to reduce or avoid the occurrence of this phenomenon and to reduce the complications associated with robot-assisted pedicle screw implantation surgery. Material and methods From April 2017 to December 2019, a retrospective study was conducted with 398 patients who underwent robot-assisted spinal pedicle screw implantation. The causes of guide wire displacement in 60 punctures were analyzed. Results There were 2,408 robot-assisted wire punctures of the pedicle, of which 2,348 wire punctures were located well within the pedicle, and 60 wire displacements occurred during robot-assisted wire puncture, with a displacement rate of 2.49%. There was 1 case of thoracic segmental artery injury and 1 case of spinal cord incomplete injury. Conclusions As it is a rare phenomenon in robot-assisted spinal pedicle screw implantation, guide wire displacement should be avoided as much as possible to improve the accuracy of screw placement and reduce surgical complications during the operation.
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Li J, Huang L, Zhou W, Wang Z, Li Z, Zeng L, Liu Z, Shen H, Cai Z, Gu H, Yang X, Zhang R, Hu W, Yu M, Chen J. Evaluation of a new spinal surgical robotic system of Kirschner wire placement for lumbar fusion: A multi-centre, randomised controlled clinical study. Int J Med Robot 2020; 17:e2207. [PMID: 33205847 DOI: 10.1002/rcs.2207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/19/2020] [Accepted: 11/16/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND To introduce a novel robotic system 'Orthbot' that has been developed and tested as a surgical assistant for auto-placement of the K-wire in lumbar fusion. METHODS This is a multi-centre, randomized controlled clinical study that includes 56 patients (robot group, RG: 27, free-hand group, FG: 29). Following the pre-operative planning and intra-operative fluoroscopic images, the 'Orthbot' automatically completed registration and K-wire placement under the supervision of the surgeon. Deviation distance (DD) and deviation angle (DA) were used as the primary parameters to evaluate the accuracy of the robotic system. RESULTS The average DD was 0.95 ± 0.377 mm and 4.35 ± 2.01 mm, respectively in the RG and FG (p < 0.001). The average DA of the K-wire in the coronal plane and the sagittal plane in X-Ray was respectively 6.80 ± 7.79° and 1.27 ± 2.32° in the RG (p < 0.001), and 22.22 ± 16.85° and 4.57 ± 3.86° in the FG (p < 0.001), which showed a higher accuracy rate in the robotic-assisted cases compared to the free-hand cases. CONCLUSIONS The novel robotic system could achieve accurate K-wire insertions as indicated by the radiological results.
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Affiliation(s)
- Junyu Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Lin Huang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Wenyu Zhou
- Department of Orthopedics, Shenzhen Second People's Hospital, Shenzhen, China
| | - Zizhen Wang
- Peking University Health Science Center, Beijing, China
| | - Zongze Li
- Department of Orthopedics, Southern Medical University Nanfang Hospital, Guangzhou, China
| | - Lin Zeng
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Zhongjun Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Huiyong Shen
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Zhaopeng Cai
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Hongsheng Gu
- Department of Orthopedics, Shenzhen Second People's Hospital, Shenzhen, China
| | - Xinjian Yang
- Department of Orthopedics, Shenzhen Second People's Hospital, Shenzhen, China
| | - Rui Zhang
- Department of Orthopedics, Shenzhen Second People's Hospital, Shenzhen, China
| | - Wanheng Hu
- Department of Science and Technology Studies, Cornell University, Ithaca, New York, USA
| | - Miao Yu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Jianting Chen
- Department of Orthopedics, Southern Medical University Nanfang Hospital, Guangzhou, China
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Patil ND, Dahapute A. A Novel Intraoperative Technique to Determine Cranio-Caudal Angulation of Pedicle Screws in Thoracolumbar Spine: A Prospective Computerized Tomography-Based Analysis of 428 Screws. Int J Spine Surg 2020; 14:722-730. [PMID: 33077436 DOI: 10.14444/7104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We report a novel technique of directing the sagittal profile of thoracic and lumbar pedicle screws using a freehand technique without the use of intraoperative monitoring. METHODS This is a prospective computerized tomography (CT)-based evaluation of pedicle screw insertion in the thoracic and lumbar spine of 64 patients operated upon for varied etiologies. All the patients were operated upon independently by 2 young surgeons with 1 year of spinal-fellowship experience. Intraoperatively, a right-angle retractor was positioned to determine the sagittal inclination of the pedicle screw. Postoperatively, sagittal CT scans were analyzed for the sagittal profile of the screw. The vertebral bodies were divided into 3 equidistant zones (A, B, and C) from the superior to inferior endplates, and the positions of the screw tips were noted. RESULTS There were 41 men and 23 women (mean age = 45.5 years). A total of 428 screws were inserted. There were 2 cases of superior pedicle wall violation in D1 and D5. The majority (96.97%) of the pedicle screws were inserted into zones A and B. CONCLUSIONS We introduced a simple, accurate, and safe method of directing the sagittal inclination of the pedicle screw in the thoracic and lumbar spine without intraoperative image guidance.
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Affiliation(s)
- Nirmal D Patil
- Department of Spine surgery, Queens Medical Centre, Nottingham, UK
| | - Aditya Dahapute
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, India
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Floccari LV, Poppino KF, Mundluru SN, McIntosh AL, Rathjen KE, Sucato DJ. Two AIS spine surgeries on the same day by the same surgeon: is performance and outcome the same for the second patient? Spine Deform 2020; 8:977-981. [PMID: 32447574 DOI: 10.1007/s43390-020-00136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/11/2020] [Indexed: 11/24/2022]
Abstract
STUDY DESIGN Retrospective case-controlled study. OBJECTIVES To analyze the overall performance and outcome of two-a-day surgery days for adolescent idiopathic scoliosis (AIS). As a method to improve efficiency and operating room utilization, some surgeons are now performing two surgeries for AIS in a single day. METHODS A prospectively collected series of AIS patients who underwent posterior spinal fusion on the same day as a second AIS patient by the same surgeon and surgical team were retrospectively reviewed. Patients who underwent same-day surgery (SD) were grouped according to whether they were the first (SD1) or second (SD2) case of the day and were matched (M1 and M2) by surgeon, curve magnitude, Lenke classification, and fusion levels. Comparisons were made: SD1 vs. SD2, SD1 vs. M1, and SD2 vs. M2. RESULTS There were 56 patients, with no differences between groups in age, gender, BMI, or curve magnitude (66° vs. 62° vs. 65° vs. 63°). Surgical time was shorter for the SD1 group (17.2 min/level) compared to M1 (20.5 min/level) for a 15% operative time reduction of 44 min (p = 0.008). There were no differences between the groups in curve correction (65.8% vs. 62.8% vs. 66.1% vs. 58.5%), estimated blood loss (EBL), length of stay, or complication rate. One SD2 patient had a malpositioned screw that required revision. There were no other complications. CONCLUSIONS When performing two AIS surgeries on the same day, surgical time was reduced by 44 min, or 15%, on the first case compared to a matched control. This may be a reflection of the team moving along more efficiently, given the full operative day scheduled. The performance measures of curve correction, EBL, complications, and length of stay did not decline in this new model, and no increased incidence of complications was seen.
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Affiliation(s)
- Lorena V Floccari
- Akron Children's Hospital, Akron, OH, USA.,Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Kiley F Poppino
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Surya N Mundluru
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA.,University of Texas Houston McGovern School of Medicine, Houston, TX, USA
| | - Amy L McIntosh
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Karl E Rathjen
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA
| | - Daniel J Sucato
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, 2222 Welborn St., Dallas, TX, 75219, USA.
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Wang R, Li C, Yi X, Lu H, Wang Y, Li H. Causes of lower extremity weaknesses after posterior lumbar spine fusion surgery and therapeutic effects of active surgical exploration. J Orthop Surg Res 2020; 15:435. [PMID: 32962720 PMCID: PMC7510092 DOI: 10.1186/s13018-020-01948-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 09/07/2020] [Indexed: 11/11/2022] Open
Abstract
Background This study was aimed at investigating the causes of lower extremity weaknesses after posterior lumbar spine fusion surgery and looking at subsequent treatment strategies. Methods Patients who underwent posterior lumbar spine fusion surgery in the Peking University First Hospital between January 2009 and December 2018 were counted. Those who needed secondary surgery because of subsequent lower extremity weaknesses were selected. CT scans and MRIs were used to evaluate the reasons for weaknesses before secondary surgery. Muscle strength was evaluated after surgery. Results Thirty patients (30/4078, 0.74%) required a secondary surgery because of lower extremity weaknesses after posterior lumbar spine fusion surgery. The main causes of weakness were (1) internal fixation malposition and loosening (11 patients, 36%), (2) epidural hematomas (9 patients, 30%), (3) insufficient decompression (5 patients, 17%), and (4) nerve root edemas (5 patients, 17%). Weakness occurred on average 2.9 days after surgery (1–9 days). Twenty-seven patients (90%) got improved muscle strength after their secondary surgery. Conclusions Iatrogenic neurologic deficits and lower extremity weaknesses were rare complications after posterior lumbar spine fusion surgeries, but important to recognize and manage. The main causes of weakness were internal fixation malposition and loosening, epidural hematomas, insufficient decompression, or root edemas. There may be positive, therapeutic effects to subsequent, active surgical exploration.
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Affiliation(s)
- Rui Wang
- Department of Orthopaedics, Peking University First Hospital, No.8 of Xishiku Street, Xicheng District, Beijing, China
| | - Chunde Li
- Department of Orthopaedics, Peking University First Hospital, No.8 of Xishiku Street, Xicheng District, Beijing, China
| | - Xiaodong Yi
- Department of Orthopaedics, Peking University First Hospital, No.8 of Xishiku Street, Xicheng District, Beijing, China
| | - Hailin Lu
- Department of Orthopaedics, Peking University First Hospital, No.8 of Xishiku Street, Xicheng District, Beijing, China
| | - Yu Wang
- Department of Orthopaedics, Peking University First Hospital, No.8 of Xishiku Street, Xicheng District, Beijing, China
| | - Hong Li
- Department of Orthopaedics, Peking University First Hospital, No.8 of Xishiku Street, Xicheng District, Beijing, China.
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Ding B, Zhou T, Zhao J. A novel system for accurate lumbar spine pedicle screw placement based on three-dimensional computed tomography reconstruction. J Orthop Translat 2020; 23:101-106. [PMID: 32642424 PMCID: PMC7322241 DOI: 10.1016/j.jot.2020.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 03/23/2020] [Indexed: 12/04/2022] Open
Abstract
Objectives The accuracy of pedicle screw placement strongly affects the outcome of spinal surgery and has mainly relied on the surgeons’ experience. There is no simple, low-cost, and effective pedicle screw placement system to assist new spinal surgeons with less experience. Methods We designed a localization system with six parameters (starting point height [SP-H], starting point length [SP-L], transverse section angle, sagittal section angle [SSA], pedicle width [W] and height [H]) based on preoperative computed tomography reconstruction and combined it with the Roussouly classification to guide lumbar spine pedicle screw placement and analysed the change patterns of the six parameters in 50 participants. Results Based on the system, we confirmed that combining SP-H and SP-L can localize the entrance of the pedicle screw. Furthermore, we considered that SP-L and transverse section angle would be a new standard for determination of the transverse orientation of the pedicle screw. More importantly, the linear regression equations between H and W and SP-H and H were concealed. In addition, H and W can guide the appropriate selection of pedicle screw. Moreover, change patterns of SSA combined with the Roussouly classification indicate that SSA of L3 can be used as a benchmark to guide the establishment of sagittal alignment of the lumbar spine. Conclusions Understanding and applying the six-parameter localization system are essential for achieving accuracy in lumbar spine pedicle screw placement, and the system is a useful guide in the establishment of sagittal alignment. The translational potential of this article This study provides a new pedicle-screw placement system for accurate lumbar spine pedicle screw placement based on three-dimensional CT reconstruction, requiring six parameters to guide the system.
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Affiliation(s)
- Baozhi Ding
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, PR China
| | - Tangjun Zhou
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, PR China
| | - Jie Zhao
- Shanghai Key Laboratory of Orthopedic Implants, Department of Orthopedics, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, PR China
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Lee S, Jung SK, Keshen SG, Lewis SJ, Park JH. A distal start point facilitates safer insertion of S2-alar-iliac screws fixation. J Clin Neurosci 2020; 72:102-107. [DOI: 10.1016/j.jocn.2019.12.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/12/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
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Lee S, Jung SK, Keshen SG, Lewis SJ, Park JH. Accuracy Analysis of Iliac Screw Using Freehand Technique in Spinal Surgery : Relation between Screw Breach and Revision Surgery. J Korean Neurosurg Soc 2020; 63:210-217. [PMID: 31931555 PMCID: PMC7054120 DOI: 10.3340/jkns.2019.0090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/12/2019] [Indexed: 11/27/2022] Open
Abstract
Objective To analyze the accuracy of iliac screws using freehand technique performed by the same surgeon. We also analyzed how the breach of iliac screws was related to the clinical symptoms resulting in revision surgery.
Methods From January 2009 to November 2015, 100 patients (193 iliac screws) were analyzed using postoperative computed tomography scans. The breaches were classified based on the superior, inferior, lateral, and medial iliac wall violation by the screw. According to the length of screw extrusion, the classification grades were as follows : grade 1, screw extrusion <1 cm; grade II, 1 cm ≤ screw extrusion <2 cm; grade III, 2 cm ≤ screw extrusion <3 cm; and grade IV, 3 cm ≤ screw extrusion. We also reviewed the revision surgery associated with iliac screw misplacement.
Results Of the 193 inserted screws, 169 were correctly located and 24 were misplaced screws. There were eight grade I, six grade II, six grade III, and four grade IV screw breaches, and 11, 8, 2, and 3 screws violated the medial, lateral, superior, and inferior walls, respectively. Four revision surgeries were performed for the grade III or IV iliac screw breaches in the lateral or inferior direction with respect to its related symptoms.
Conclusion In iliac screw placement, 12.4% breaches developed. Although most breaches were not problematic, symptomatic violations (2.1%) could result in revision surgery. Notably, the surgeon should keep in mind that lateral or inferior wall breaches longer than 2 cm can be risky and should be avoided.
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Affiliation(s)
- Subum Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ku Jung
- Department of Emergency Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sam G Keshen
- Division of Orthopaedic Surgery, University Health Network, Toronto Western Hospital, Toronto, Canada
| | - Stephen J Lewis
- Division of Orthopaedic Surgery, University Health Network, Toronto Western Hospital, Toronto, Canada
| | - Jin Hoon Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Jung JM, Hyun SJ, Kim KJ, Jahng TA, Kim HJ, Choi Y. Anatomic Trajectory Screw Fixation at Upper Instrumented Vertebra Is a Substantial Risk Factor for Proximal Junctional Kyphosis. World Neurosurg 2019; 129:e522-e529. [PMID: 31152888 DOI: 10.1016/j.wneu.2019.05.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/23/2019] [Accepted: 05/23/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aimed to investigate the risk of proximal junction kyphosis (PJK) and proximal junction failure (PJF) associated with screw trajectory (straightforward vs. mixed vs. anatomic) at upper instrumented vertebra (UIV). METHODS A single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥4 levels (the UIV of the thoracolumbar spine, T9-L2, and the lower instrumented vertebra at the sacrum or pelvis) was retrospectively reviewed. Patients were divided into 3 groups according to UIV screw trajectory: group S, 2 straightforward screws; group M, 1 straightforward screw and 1 anatomic trajectory screw; and group A, 2 anatomic trajectory screws. RESULTS A total of 83 patients were included in this study, including 51 in group S, 16 in group M, and 16 in group A. The incidence of PJK in group S (12 patients, 23.5%), group M (7 patients, 43.8%), and group A (9 patients, 56.3%) significantly increased in sequence by group (P = 0.044). Anatomic trajectory screw fixation increased the risk for PJF requiring revision surgery compared with straightforward screw fixation (3 patients [18.8%] vs. 1 patient [2.0%]; P = 0.040). Multivariable analysis identified that anatomic trajectory screw fixation was a significant risk factor for PJK (P = 0.008; adjusted odds ratio = 7.591; 95% confidence interval, 1.69-34.093). CONCLUSION Anatomic trajectory screw fixation at the UIV is a substantial risk factor for PJK and PJF. To reduce PJK and PJF, straightforward screw fixation at the UIV is recommended in adult spinal deformity correction surgery.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea.
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Perdomo-Pantoja A, Ishida W, Zygourakis C, Holmes C, Iyer RR, Cottrill E, Theodore N, Witham TF, Lo SFL. Accuracy of Current Techniques for Placement of Pedicle Screws in the Spine: A Comprehensive Systematic Review and Meta-Analysis of 51,161 Screws. World Neurosurg 2019; 126:664-678.e3. [PMID: 30880208 DOI: 10.1016/j.wneu.2019.02.217] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pedicle screws (PSs) are routinely used for stabilization to enhance fusion in a variety of spinal diseases. Although the accuracy of different PS placement methods has been previously reported, most of these studies have been limited to 1 or 2 techniques. The purpose was to determine the current accuracy of PS placement among 4 modalities of PS insertion (freehand [FH], fluoroscopy-assisted [FA], computed tomography navigation-guided [CTNav], and robot-assisted [RA]) and analyze variables associated with screw misplacement. METHODS A systematic review was performed of peer-reviewed articles reporting PS accuracy of 1 technique from January 1990 to June 2018. Accuracy of PS placement, PS insertion technique, and pedicle breach (PB) data were collected. A meta-analysis was performed to estimate the overall pooled (OP) rates of PS accuracy as a primary outcome, stratified by screw insertion techniques. Potential determinants were analyzed via meta-regression analyses. RESULTS Seventy-eight studies with 7858 patients, 51,161 PSs, and 3614 cortical PBs were included. CTNav showed the highest PS placement accuracy compared with other techniques: OP accuracy rates were 95.5%, 93.1%, 91.5%, and 90.5%, via CTNav, FH, FA, and RA techniques, respectively. RA and CTNav were associated with the highest PS accuracy in the thoracic spine, compared with FH. CONCLUSIONS The OP data show that CTNav has the highest PS accuracy rates. Thoracic PSs were associated with lower accuracy rates; however, RA showed fewer breaches in the thoracic spine compared with FH and FA. Given the heterogeneity among studies, further standardized and comparative investigations are required to confirm our findings.
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Affiliation(s)
| | - Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Corinna Zygourakis
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christina Holmes
- Florida A&M University-Florida State University College of Engineering, Tallahassee, Florida, USA
| | - Rajiv R Iyer
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Park SM, Shen F, Kim HJ, Kim H, Chang BS, Lee CK, Yeom JS. How Many Screws Are Necessary to Be Considered an Experienced Surgeon for Freehand Placement of Thoracolumbar Pedicle Screws?: Analysis Using the Cumulative Summation Test for Learning Curve. World Neurosurg 2018; 118:e550-e556. [DOI: 10.1016/j.wneu.2018.06.236] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/27/2018] [Accepted: 06/28/2018] [Indexed: 11/29/2022]
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Accuracy of Freehand Pedicle Screw Placement in Surgical Correction of Thoracolumbar Kyphosis Secondary to Ankylosing Spondylitis: A Computed Tomography Investigation of 2314 Consecutive Screws. World Neurosurg 2018; 116:e850-e855. [PMID: 29807178 DOI: 10.1016/j.wneu.2018.05.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the accuracy and safety of freehand pedicle screw placement in surgical correction for thoracolumbar kyphosis caused by ankylosing spondylitis (AS). METHODS We retrospectively reviewed 266 consecutive patients with AS who underwent osteotomy for kyphosis correction with freehand screw insertion from January 1998 to April 2015 at our institution. A total of 2314 pedicle screws in 158 patients with AS with postoperative computed tomography scans were included in the study. Postoperative computed tomography was performed to classify accuracy of screws, using the established Gertbein classification (grade 0: no perforation, grade 1: perforation <2 mm, grade 2: perforation between 2 and 4 mm, and grade 3: perforation >4 mm). Patients were divided into 2 groups according to coronal Cobb angle: group A (n = 21, Cobb angle ≥10°), group B (n = 137, Cobb angle <10°). RESULTS Among the 2314 pedicle screws, 2168 pedicle screw placements were categorized as grade 0, 71 were grade 1, 51 were grade 2, and 24 were grade 3. Breaches occurred more frequently in L1-S1 than the thoracic spine (7.1% and 5.4%, respectively). T5 (25.0%) and S1 (17.7%) experienced the greatest breach rate, whereas T8, L1, and L3 had the lowest breach rate. The breach rate of group A was greater than that of group B (7.9% vs. 6.1%). None of the breaches resulted in either neurologic deficits or vascular complications. CONCLUSIONS Freehand pedicle screw placement can be performed safely with acceptable breach rate in patients with AS and thoracolumbar kyphosis.
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Park HJ, Wang C, Choi KH, Kim HN. Use of a life-size three-dimensional-printed spine model for pedicle screw instrumentation training. J Orthop Surg Res 2018; 13:86. [PMID: 29661210 PMCID: PMC5902859 DOI: 10.1186/s13018-018-0788-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/28/2018] [Indexed: 11/30/2022] Open
Abstract
Background Training beginners of the pedicle screw instrumentation technique in the operating room is limited because of issues related to patient safety and surgical efficiency. Three-dimensional (3D) printing enables training or simulation surgery on a real-size replica of deformed spine, which is difficult to perform in the usual cadaver or surrogate plastic models. The purpose of this study was to evaluate the educational effect of using a real-size 3D-printed spine model for training beginners of the free-hand pedicle screw instrumentation technique. We asked whether the use of a 3D spine model can improve (1) screw instrumentation accuracy and (2) length of procedure. Methods Twenty life-size 3D-printed lumbar spine models were made from 10 volunteers (two models for each volunteer). Two novice surgeons who had no experience of free-hand pedicle screw instrumentation technique were instructed by an experienced surgeon, and each surgeon inserted 10 pedicle screws for each lumbar spine model. Computed tomography scans of the spine models were obtained to evaluate screw instrumentation accuracy. The length of time in completing the procedure was recorded. The results of the latter 10 spine models were compared with those of the former 10 models to evaluate learning effect. Results A total of 37/200 screws (18.5%) perforated the pedicle cortex with a mean of 1.7 mm (range, 1.2–3.3 mm). However, the latter half of the models had significantly less violation than the former half (10/100 vs. 27/100, p < 0.001). The mean length of time to complete 10 pedicle screw instrumentations in a spine model was 42.8 ± 5.3 min for the former 10 spine models and 35.6 ± 2.9 min for the latter 10 spine models. The latter 10 spine models had significantly less time than the former 10 models (p < 0.001). Conclusion A life-size 3D-printed spine model can be an excellent tool for training beginners of the free-hand pedicle screw instrumentation.
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Affiliation(s)
- Hyun Jin Park
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul, 150-950, South Korea
| | - Chenyu Wang
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul, 150-950, South Korea
| | - Kyung Ho Choi
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul, 150-950, South Korea
| | - Hyong Nyun Kim
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul, 150-950, South Korea.
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Are computer numerical control (CNC)-manufactured patient-specific metal templates available for posterior thoracic pedicle screw insertion? Feasibility and accuracy evaluation. 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 2017; 26:2927-2933. [PMID: 28718167 DOI: 10.1007/s00586-017-5215-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 06/28/2017] [Accepted: 07/07/2017] [Indexed: 01/18/2023]
Abstract
PURPOSE Accurate and safe posterior thoracic pedicle insertion (PTPI) remains a challenge. Patient-specific drill templates (PDTs) created by rapid prototyping (RP) can assist in posterior thoracic pedicle insertion, but pose biocompatibility risks. The aims of this study were to develop alternative PDTs with computer numerical control (CNC) and assess their feasibility and accuracy in assisting PTPI. METHODS Preoperative CT images of 31 cadaveric thoracic vertebras were obtained and then the optimal pedicle screw trajectories were planned. The PDTs with optimal screw trajectories were randomly assigned to be designed and manufactured by CNC or RP in each vertebra. With the guide of the CNC- or RP-manufactured PDTs, the appropriate screws were inserted into the pedicles. Postoperative CT scans were performed to analyze any deviations at entry point and midpoint of the pedicles. RESULTS The CNC group was found to be significant manufacture-time-shortening, and cost-decreasing, when compared with the RP group (P < 0.01). The PDTs fitted the vertebral laminates well while all screws were being inserted into the pedicles. There were no significant differences in absolute deviations at entry point and midpoint of the pedicle on either axial or sagittal planes (P > 0.05). The screw positions were grade 0 in 90.3% and grade 1 in 9.7% of the cases in the CNC group and grade 0 in 93.5% and grade 1 in 6.5% of the cases in the RP group (P = 0.641). CONCLUSION CNC-manufactured PDTs are viable for assisting in PTPI with good feasibility and accuracy.
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Kaliya-Perumal AK, Charng JR, Niu CC, Tsai TT, Lai PL, Chen LH, Chen WJ. Intraoperative electromyographic monitoring to optimize safe lumbar pedicle screw placement - a retrospective analysis. BMC Musculoskelet Disord 2017; 18:229. [PMID: 28558816 PMCID: PMC5450215 DOI: 10.1186/s12891-017-1594-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/22/2017] [Indexed: 12/16/2022] Open
Abstract
Background The foremost concern of a surgeon during pedicle screw fixation is safety. Assistive modalities, especially intraoperative electromyographic monitoring (EMG) can function as an essential tool to recognize screw malposition that compromise neural integrity, so that the screws can be repositioned immediately rather than later. We intend to study the efficacy of intraoperative EMG monitoring to detect potential pedicle breach and evaluate whether reoperation rates were significantly reduced. Methods Retrospectively, patients who underwent posterior stabilization with pedicle screws for various pathologies were analysed and those with screws among L1-S1 levels were shortlisted. They were divided into two groups. Group 1 included patients in whom trigger EMG (t-EMG) was used to confirm appropriate screw placement and Group 2 included those in whom it was not used. Responses to t-EMG and corresponding stimulation thresholds were recorded for Group 1 patients. The sensitivity and specificity of the test was calculated. Reoperation rates due to postoperative neurologic compromise caused by malpositioned screws were compared between both the groups. Results A total of 518 patients had 3112 pedicle screws between L1-S1 levels. Among Group 1 [n = 296; Screws = 1856], 145 screws (7.8%) showed a positive response for t-EMG at stimulation thresholds ranging between 2.6 to 19.8 mA. The sensitivity and specificity of t-EMG to diagnose potential pedicle breach was found to be 93.33% and 92.88% respectively. Only one patient among Group 1 required reoperation. However, among Group 2 [n = 222; screws = 1256], six patients required reoperation. This indicated a significant decrease in the number of malpositioned screws that caused neurological compromise [p = 0.02], leading to subsequent decrease in reoperation rates [p = 0.04] among Group 1 patients. Conclusions Trigger EMG is well efficient in detecting potential pedicle screw breaches that might endanger neural integrity. In combination with palpatory and radiographic assessment, it will certainly aid safe and secure pedicle screw placement. It can also efficiently reduce reoperation rates due to neurologic compromise provoked by a malpositioned screw.
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Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan.,Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
| | - Jiun-Ran Charng
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Chi-Chien Niu
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan.
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Lih-Huei Chen
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
| | - Wen-Jer Chen
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan
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How High Are Radiation-related Risks in Minimally Invasive Transforaminal Lumbar Interbody Fusion Compared With Traditional Open Surgery?: A Meta-analysis and Dose Estimates of Ionizing Radiation. Clin Spine Surg 2016; 29:52-9. [PMID: 26889987 DOI: 10.1097/bsd.0000000000000351] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Meta-analysis and dose estimation. OBJECTIVE The aim of this study was to estimate radiation dose during minimally invasive transforaminal lumbar interbody fusion (MiTLIF) compared with open transforaminal lumbar interbody fusion (OTLIF) and evaluate the risk of radiation-related disease. SUMMARY OF BACKGROUND DATA MiTLIF was introduced to reduce soft tissue injury and shows favorable perioperative outcomes. However, the disadvantage of MiTLIF is that, compared with OTLIF, it involves high radiation exposure because MiTLIF usually depends on a fluoroscopic guide. The additional cancer risk due to medical radiation exposure during the MiTLIF procedure has not yet been assessed. METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials in June 2014 for studies directly comparing MiTLIF and OTLIF. Patient demographics, fluoroscopy time, intraoperative bleeding, and hospitalization period were extracted. The effective dose was converted from fluoroscopy time using formulas from prior studies. RESULTS Eight cohort studies with a total of 619 patients were identified. Mean fluoroscopy time was 39.42 seconds [95% confidence interval (CI), 38.01-40.83] during OTLIF and 94.21 seconds (95% CI, 91.51-96.91) during MiTLIF according to the meta-analysis. The pooled data revealed that patients who underwent MiTLIF were exposed to 2.4-fold more radiation than those who underwent OTLIF. Patients who underwent OTLIF and MiTLIF were exposed to 0.66 mSv (95% CI, 0.64-0.69) and 1.58 mSv (95% CI, 1.54-1.63) during the surgery, respectively. The lifetime risk of cancer was theoretically increased by 36.4×10 and 87.0×10 after OTLIF and MiTLIF, respectively. The risk of detrimental hereditary disorders associated with OTLIF and MiTLIF is 1.32×10 and 3.16×10, respectively. CONCLUSIONS Patients who underwent MiTLIF were exposed to 2.4-fold more radiation than those who underwent OTLIF. Although the theoretical cancer risk associated with radiation exposure may be tolerable, stochastic effects should not be disregarded.
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Agarwal A, Chauhan V, Singh D, Shailendra R, Maheshwari R, Juyal A. A comparative study of pedicle screw fixation in dorsolumbar spine by freehand versus image-assisted technique: A cadaveric study. Indian J Orthop 2016; 50:243-9. [PMID: 27293283 PMCID: PMC4885291 DOI: 10.4103/0019-5413.181779] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND New and expensive technology such as three-dimensional computer assisted surgery is being used for pedicle screw fixation in dorsolumbar spine. Their availability, expenses and amount of radiation exposure are issues in a developing country. On the contrary, freehand technique of pedicle screw placement utilizes anatomic landmarks and tactile palpation without fluoroscopy or navigation to place pedicle screws. The purpose of this study was to analyze and compare the accuracy of freehand and image-assisted technique to place pedicle screws in the dorsolumbar spine of cadavers by an experienced surgeon and a resident. Evaluation was done using dissection of pedicle and computed tomography (CT) imaging. MATERIALS AND METHODS Ten cadaveric dorsolumbar spines were exposed by a posterior approach. Titanium pedicle screws were inserted from D5 to L5 vertebrae by freehand and image-assisted technique on either side by an experienced surgeon and a resident. CT was obtained. A blinded radiologist reviewed the imaging. The spines were then dissected to do a macroscopic examination. Screws, having evidence of cortical perforation of more than 2 mm on CT, were considered to be a significant breach. RESULTS A total of 260 pedicle screws were placed. The surgeon and the resident placed 130 screws each. Out of 130 screws, both of them placed 65 screws each by freehand and image- assisted technique each. The resident had a rate of 7.69% significant medial and 10.76% significant lateral breach with freehand technique while with image-assisted had a rate of 3.07% significant medial and 9.23% significant lateral breach. The expert surgeon had a rate of 6.15% significant medial and 1.53% significant lateral breach with freehand technique while with image-assisted had a rate of 3.07% significant medial and 6.15% significant lateral breach on CT evaluation. CONCLUSION Freehand technique is as good as the image-assisted technique. Under appropriate supervision, residents can safely learn to place freehand pedicle screws with an acceptable violation rate.
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Affiliation(s)
- Archit Agarwal
- Department of Orthopaedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Vijendra Chauhan
- Department of Orthopaedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India,Address for correspondence: Dr. Vijendra Chauhan, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun - 248 140, Uttarakhand, India. E-mail:
| | - Deepa Singh
- Department of Anatomy, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Raghuvanshi Shailendra
- Department of Radio-diagnosis and Imaging, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Rajesh Maheshwari
- Department of Orthopaedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Anil Juyal
- Department of Orthopaedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
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Iatrogenic neurologic deficit after lumbar spine surgery: A review. Clin Neurol Neurosurg 2015; 139:76-80. [DOI: 10.1016/j.clineuro.2015.08.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 08/21/2015] [Accepted: 08/23/2015] [Indexed: 11/21/2022]
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Hyun SJ, Kim WB, Park YS, Kim KJ, Jahng TA, Kim YJ. Adolescent Idiopathic Scoliosis Treatment by a Korean Neurosurgeon: The Changing Role for Neurosurgeons. J Korean Neurosurg Soc 2015; 58:50-3. [PMID: 26279813 PMCID: PMC4534739 DOI: 10.3340/jkns.2015.58.1.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/02/2015] [Accepted: 04/20/2015] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this study was to evaluate radiographic/clinical outcomes of adolescent idiopathic scoliosis (AIS) patients treated by a Korean neurosurgeon. Methods Ten AIS patients were treated by a single neurosurgeon between January 2011 and September 2013 utilizing segmental instrumentation with pedicle screws. Basic demographic information, curve pattern by Lenke classification, number of levels treated, amount of correction achieved, radiographic/clinical outcomes [by Scolisis Resarch Society (SRS-22r) questionnaire] and complications were evaluated to determine the surgical results. Pulmonary function test was utilized to assess forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) before and after surgery. Results The average percentage of correction of the major structural curve was 73.6% (ranged from 64% to 81.5%). Preoperative and final postoperative absolute FVC averaged 3.03 L and 3.76 L (0.73 L increase, p=0.046), and absolute FEV1 averaged 2.63 L and 3.49 L (0.86 L increase, p=0.021). Preoperative and final postoperative average self-image and function scores of SRS-22r were, 2.6±0.5, 3.3±0.1, 4.0±0.5, and 4.6±0.0, respectively. There was a significant improvement of the self-image and function scores of SRS-22r questionnaires before and after surgery (p<0.05). There was no case of neurological deficit, infection and revision for screw malposition. One patient underwent a fusion extension surgery for shoulder asymmetry. Conclusion Radiographic/clinical outcomes of AIS patients treated by a Korean neurosurgeon were acceptable. Fundamental understanding of pediatric spinal deformity is essential for the practice of AIS surgery.
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Affiliation(s)
- Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Woong-Beom Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young-Seop Park
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yongjung J Kim
- Department of Orthopaedic Surgery, Spine Service, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Hyun SJ, Kim YJ, Rhim SC, Cheh G, Cho SK. Pedicle Screw Placement in the Thoracolumbar Spine Using a Novel, Simple, Safe, and Effective Guide-Pin : A Computerized Tomography Analysis. J Korean Neurosurg Soc 2015; 58:9-13. [PMID: 26279807 PMCID: PMC4534748 DOI: 10.3340/jkns.2015.58.1.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 03/18/2015] [Accepted: 04/08/2015] [Indexed: 11/27/2022] Open
Abstract
Objective To improve pedicle screw placement accuracy with minimal radiation and low cost, we developed specially designed K-wire with a marker. To evaluate the accuracy of thoracolumbar pedicle screws placed using the novel guide-pin and portable X-rays. Methods Observational cohort study with computerized tomography (CT) analysis of in vivo and in vitro pedicle screw placement. Postoperative CT scans of 183 titanium pedicle screws (85 lumbar and 98 thoracic from T1 to L5) placed into 2 cadavers and 18 patients were assessed. A specially designed guide-pin with a marker was inserted into the pedicle to identify the correct starting point (2 mm lateral to the center of the pedicle) and aiming point (center of the pedicle isthmus) in posteroanterior and lateral X-rays. After radiographically confirming the exact starting and aiming points desired, a gearshift was inserted into the pedicle from the starting point into the vertebral body through the center of pedicle isthmus. Results Ninety-nine percent (181/183) of screws were contained within the pedicle (total 183 pedicle screws : 98 thoracic pedicle screws and 85 lumbar screws). Only two of 183 (1.0%) thoracic pedicle screws demonstrated breach (1 lateral in a patient and 1 medial in a cadaver specimen). None of the pedicle breaches were associated with neurologic or other clinical sequelae. Conclusion A simple, specially designed guide-pin with portable X-rays can provide correct starting and aiming points and allows for accurate pedicle screw placement without preoperative CT scan and intraoperative fluoroscopic assistance.
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Affiliation(s)
- Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yongjung J Kim
- Department of Orthopaedic Surgery, Spine Service, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Seung-Chul Rhim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gene Cheh
- Department of Orthopedic Surgery, Wooridul Spine Hospital, Seoul, Korea
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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