Cortical bone trajectory technique’s outcomes and procedures for posterior lumbar fusion: A retrospective study (original) (raw)
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European Spine Journal, 2019
Purpose To compare the clinical efficacy and safety between cortical bone trajectory (CBT) and pedicle screw (PS) in posterior lumbar fusion surgery. Methods Five electronic databases were used to identify relevant studies comparing the clinical efficacy and safety between CBT and PS. The main outcomes were postoperative fusion rates and complication (especially in superior facet joint violations, symptomatic ASD, wound infection, dural tear, screw malposition and hematoma). The secondary results included operation time, intraoperative blood loss, length of hospital stay, incision length, ODI, VAS, JOA score, JOA recovery rate, patients' satisfaction and health-related quality of life. Results The outcomes showed that there was no significant difference in terms of fusion rate (p = 0.55), back and leg VAS score (p > 0.05), JOA score (p = 0.08) and incidence of reoperation (p = 0.07). However, CBT was superior to PS with Oswestry Disability Index (ODI) (p = 0.02), JOA recovery rate (p < 0.00001) and patients' satisfaction (p = 0.001). In addition, CBT was superior to PS with significantly lower incidence of superior facet joint violation and symptomatic ASD. However, there was no significant difference regarding wound infection (p > 0.05) and screw malposition (p > 0.05). CBT group required significant shorter operation time, less blood loss, shorter incision length and shorter length of hospital stay in comparison with PS group (p < 0.05). Conclusions Both CBT and PS achieve similar, fusion rate and revision surgery rate. Furthermore, CBT is superior to PS with lower incidence of complications, shorter operation time, less blood loss, shorter incision length and shorter length of hospital stay.
Journal of Neurological Surgery Part A: Central European Neurosurgery
Background Cortical bone trajectory (CBT) is a relatively new technique for pedicle screw insertion in the field of spine surgery. Previous studies have demonstrated the significantly better pullout and toggle characteristics the new method offers, and it appears to have certain advantages over the widely used traditional trajectory. The mechanism of the pullout and toggle characteristics still remains unknown. Purpose To report the medium- to long-term follow-up findings of patients who underwent posterior lumbar interbody fusion or posterior lumbar fusion (PLIF/PLF) at our institution and to discuss the ideal screw trajectory when using this technique. Study Design Retrospective radiologic study. Methods Fifty-five patients who underwent PLIF/PLF for lumbar spondylosis using the new technique between January 2011 and January 2016 were included. Clinical outcome was assessed using the Japanese Orthopaedic Association scores for low back pain and visual analog scale scores. Screw lo...
World Neurosurgery, 2015
Biomechanical studies demonstrate that cortical bone trajectory pedicle screws (CBTPS) have greater pullout strength than traditional pedicle screws with a lateral-medial trajectory. CBTPS start on the pars and angulate in a mediolateral-caudocranial direction. To our knowledge, no large series exists evaluating the perioperative outcomes and safety of CBTPS.-METHODS: We retrospectively reviewed all patients who received lumbar CBTPS at our institution. Data were collected regarding patient demographics, use of image guidance, operative blood loss, hospital stay, and postoperative complications.-RESULTS: A total of 79 patients undergoing CBTPS fusion for degenerative lumbosacral disease with back pain were included in the analysis (42 female, 37 male; October 2011eJanuary 2015). Twenty patients (25.3%) had previous lumbar spine surgery, 39 (49.4%) had a smoking history, and mean body mass index was 28.7. Mean length of stay was 3.5 days, and mean operative blood loss was 306.3 mL. Image guidance was used in 69 (87.3%) cases. A total of 66 (83.5%) fusions were single level, and 54 (68.4%) fusions were single level without previous surgery. There were 9 complications in 7 (8.9%) patients; these included hardware failure, pseudarthrosis, deep vein thrombosis, pulmonary embolism, epidural hematoma, and wound infection. No complications were caused by misplaced screws. Mean follow-up was 13.2 months.-CONCLUSIONS: As CBTPS becomes increasingly popular among spine surgeons performing lumbar fusion, this report provides an important evaluation of technique safety and acceptable perioperative outcomes.
Asian Spine Journal, 2019
A retrospective study of radiographic parameters of patients who underwent lumbar spinal pedicle screw insertion. Purpose: The optimal length of pedicle screws is often determined by the lateral radiograph during minimally invasive surgery (MIS). Compared with open techniques, measuring the precise length of screws or assessing the cortical breach is challenging. This study aims to ascertain the optimal pedicle screw lengths on intraoperative lateral radiographs for L1-L5. Overview of Literature: Research has revealed that optimal pedicle screw length is essential to optimize fixation, especially in osteoporotic patients; however, it must be balanced against unintentional breach of the anterior cortex, risking injury to adjacent neurovascular structures as demonstrated by case reports. Methods: We reviewed intra-and postoperative computed tomography scans of 225 patients who underwent lumbar pedicle screw insertion to ascertain which of the inserted screws were 'optimal screws.' The corresponding lengths of these screws were analyzed on postoperative lateral radiographs to ascertain the ideal position that a screw should attain (expressed as a percentage of the entire vertebral body length). Results: We reviewed 880 screws of which 771 were optimal screws. We noted a decreasing trend in average optimal percentages of insertion into the vertebral body for pedicle screws going from L1 (average=87.60%) to L5 (average=78.87%). The subgroup analysis revealed that there was an increasing percentage of screws directed in a straight trajectory from L1 to L5, compared to a medially directed trajectory. Conclusions: During MIS pedicle screw fixation, this study recommends that pedicle screws should not exceed 85% of the vertebral body length on the lateral view for L1, 80% for L2-L4, and 75% for L5; this will minimize the risk of anterior cortical breach yet maximize pedicle screw purchase for fixation stability.
Acta Neurochirurgica, 2017
Background The spatial and directional accuracy of the positioning of pedicle screws in the lumbosacral spine with conventional open surgery assessed by computed tomography (CT) has been published in several studies, systematic reviews and meta-analyses with a short-term follow-up. Inaccurate pedicle screw insertion may cause neurologic symptoms and weakens the construct. Methods The data of 147 patients operated on with transpedicular screw fixation based on anatomical landmarks, supported by fluoroscopy, by a senior neurosurgeon in our clinic between 2000 and 2010 were analyzed retrospectively. The accuracy of the pedicle screw position was assessed by using postoperative CT images and graded in 2-mm increments up to 6 mm by two independent surgeons and partly by an independent radiologist. Results A total of 837 lumbosacral pedicle screws were inserted in 147 randomly selected patients by a senior neurosurgeon. A mean accuracy of 85.7% of the screws being inside the pedicles was identified by the surgeon observers, with 3.3% being perforated 4 mm or more outside the pedicles. Postoperative neurologic symptoms were observed on the side corresponding to the breach in an average of 25.9% of patients with pedicle perforations, and 89.2% of the misplaced screws were either medially or inferiorly inserted. Conclusions Screw application reached a mean accuracy of 85.7% based on anatomical landmarks supported by fluoroscopy, warranting computer-assisted navigation for increased accuracy. Our results of 24 patients (16.3%) with the breached screws indicate that the direction of the breach may be more important than the absolute deviation in causing new neurologic symptoms.
Overview of literature: Potential complications of screw misplacement and pedicle wall violation have focused attention on screw placement techniques. Moreover, evaluation of any new postoperative pain or neurological deficit should rule out the causal relation between the screws and neurological complication. Purpose: The aim of the study is to evaluate the incidence and accuracy of pedicle screw placement comparing the conventional and percutaneous techniques of screw insertion. Study design: the study was done on 103 patients of both sexes and different ages. Patients are evaluated by postoperative C.T. scan with 2 mm axial slices with bone window performed. Methods: Data were collected from the Department of neurosurgery, Kasr Al-Ainy, Cairo University Hospital. The valid patient sample was collected (n0=103). In addition to the standard study protocol evaluation, patients were evaluated for the presence or absence of pedicle breach generally comparing both techniques (hypothesis 1), and comparing the degree of deviation between both techniques (hypothesis 2). Blinded several observers CT assessment was done. Results: Studying the presence of pedicle wall violation in general, there is no statistical difference between both techniques. However, at the S1 level, there is a statistical difference in favor of the percutaneous technique. Regarding the side of violation, there is a lower incidence of pedicle breach on the left side in favor of the percutaneous technique. Regarding the direction of pedicle breach, there is no statistically significant difference between both techniques. Studying the extent of pedicle breach in general, we found no effect of technique or level on the extent of pedicle breach. However, percutaneous technique had a lower amount of pedicle breach taking the side into consideration. The amount of medial deviation is smaller with the percutaneous technique. Conclusion: There is no statistical difference between open and percutaneous techniques, except at the S1 level, in favor of the percutaneous technique. Moreover, percutaneous technique had a lower amount of pedicle breach taking the side into consideration. The amount of medial deviation is smaller with the percutaneous technique.
Minimally Invasive Lumbar Pedicle Screw Fixation Using Cortical Bone Trajectory: Functional Outcomes
Cureus, 2018
Background Pedicle screw fixation is currently the mainstay technique for lumbar spinal fusion; however, more minimally invasive techniques are available such as cortical screw fixation. Numerous studies have proven biomechanical equivalence or superiority for cortical screws but few studies have examined clinical outcomes in patients. Our study aims to examine functional outcomes, as well as fusion rates, in patients who underwent pedicle screw fixation using a cortical trajectory. Methods We retrospectively reviewed prospectively collected functional outcomes data on 10 patients with a degenerative lumbar disease who underwent cortical screw placement by the senior author. Oswestry Disability Index (ODI) and Roland Morris (RM) scoring were calculated preoperatively, at six to 12 weeks and at six to eight months. The Kruskal-Wallis test and Dunn's multiple comparison were used to analyze differences in scores over time. Results We found that over time, cortical screw fixation r...
Medicine, 2020
This study aimed to verify the relationship between the number of fusion level and the risk of screw loosening by using cortical bone trajectory (CBT) screws in patients with lumbar degenerative disease. We retrospectively reviewed the serial plain radiograph images of lumbar degenerative disease patients who had undergone posterior fixation and fusion surgery with CBT from 2014. All included patients should have been followed-up with computed tomography scan or plain radiograph for at least 6 months after operation. We individually evaluated the prevalence of screw loosening according to each vertebral level. We also determined whether the number of screw fixation affected the prevalence of screw loosening and whether S1 fixation increased the risk of screw loosening. The screw-loosening rates were high at the S1 level. Moreover, although fixation involved to S1, the loosening rates evidently increased (Fisher exact test, P = .002 * *). The screw-loosening rate was 6.56% in 2 level fusion. However, it increased with the number of fusion levels (3 level: 25.00%, 4 level: 51.16%, and 5 level: 62.50%). To investigate if the number of fusion level affected the S1 screw loosening, we classified the cohort of patients into either involving S1 (S1+ group) or not (S1-group) according to different fusion levels (Table 3). The screw loosening between 2 group in 2 (5.56% vs 6.98%) and 3 fusion level (26.32% vs 22.73%) did not exhibit any significant difference. Interestingly, significantly high screw loosening was found in 4 fusion level (60.00% vs 15.38%), indicating that the higher fusion level (4 level) can directly increase the risk of S1 screw loosening. Our data confirmed that the screw-loosening rate increases rate when long segment CBT fixation involves to S1. Therefore, in case of long-segment fixation by using CBT screw, surgeons should be aware of the fusion level of S1. Abbreviations: CBT = cortical bone trajectory, EPS = endplate penetration screw, LDD = lumbar degenerative disease, MIDLF = midline interbody lumbar fusion, TPS = traditional pedicle screws.
Journal of spine surgery (Hong Kong), 2017
Fusion of the lumbosacral spine is a common surgical procedure to address a range of spinal pathologies. Fixation in lumbar fusion has traditionally been performed using pedicle screw (PS) augmentation. However, an alternative method of screw insertion via cortical bone trajectory (CBT) has been advocated as a less invasive approach which improves initial fixation and reduces neurovascular injury. There is a paucity of robust clinical evidence to support these claims, particularly in comparison to traditional pedicle screws. This study aims to review the available evidence to assess the merits of the CBT approach. Six electronic databases were searched for original published studies which compared CBT with traditional PS and their findings reviewed. Nine comparative studies were identified through a comprehensive literature search. Studies were classified as retrospective cohort, prospective cohort or case control studies with medium quality as assessed by the GRADE criteria. The av...