Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques (original) (raw)
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The Journal of Spinal Surgery, 2016
Introduction: The use of pedicle screws in stabilizing all three columns of the spine is a well-known but technically demanding procedure. Various assisted techniques like intraoperative fluoroscopy and stereotaxy-guided techniques have marginally increased placement accuracy along with increased radiation exposure to the surgeon and the patient, with an increased operative time. Over the last two decades, a detailed understanding of the anatomy of the thoracolumbar pedicles has led to the emergence of the "free-hand" technique. Objectives: To analyze the pedicle screw placement in thoracic, lumbar, and sacral spine over a 3-year period in terms of the intraoperative and immediate postoperative procedural results using navigation-guided and free hand techniques. Materials and methods: A retrospective study was done over a period of 3 years from November 2012 to December 2015 in a tertiary care center by a single surgeon, involving 118 cases that were done using the C-arm navigation and the free hand technique. Results: The study involved a total of 118 patients and 546 screws over a period of 3 years. The indications consisted of degenerative diseases (72%), infection (12.7%), trauma (12.7%), and malignancy (2.54%). The initial 77 cases were done by image guidance under C arm navigation and the later 41 cases with free hand techniques. Among these, there were eight breaches noted (6.72%), five (6.49%) in the image-guided technique vs three (7.3%) in the freehand technique. The direction of breach was lateral in one case (12.5%) and medial in seven cases (87.5%). Three patients (37.5%) with suboptimal screw placement underwent revision surgery. Four patients (3.36%) in the present study had postoperative neurological deficit in the form of foot drop and preoperative durotomies noted in nine patients (7.62%). Postoperative surgical site infections were noted in four cases (3.38%). Conclusion: Free hand pedicle screw placement based on external anatomy alone can be performed with acceptable safety and accuracy in experienced hands and allows avoidance of radiation exposure encountered in fluoroscopic techniques.
Asian spine journal, 2014
A retrospective cross-sectional study. The purpose of this study is to evaluate the accuracy and safety of free-hand pedicle screw insertion performed by a young surgeon. Few articles exist regarding the safety of the free-hand technique without inspection by an experienced spine surgeon. The index surgeon has performed spinal surgery for 2 years by himself. He performed fluoroscopy-assisted pedicle screw installation for his first year. Since then, he has used the free-hand technique. We retrospectively reviewed the records of all consecutive patients undergoing pedicle screw installation using the free-hand technique without fluoroscopy in the thoracic or lumbar spine by the index surgeon. Incidence and extent of cortical breach by misplaced pedicle screw was determined by a review of postoperative computed tomography (CT) images. A total of 36 patients received 306 free-hand placed pedicle screws in the thoracic or lumbar spine. A total of 12 screws (3.9%) were identified as brea...
Pedicle screw insertion: computed tomography versus fluoroscopic image guidance
International Orthopaedics, 2007
Computed tomography image-guided surgery (CTGS) clearly improves the accuracy of pedicle screw insertion. Recent reports claim that a fluoroscopy-guided system (FGS) offered high accuracy and easy application. However, the superiority of either technique remains unclear in clinical application. This study compares the accuracy of pedicle screws installed using CTGS with that of screws installed using FGS. Seventy-four screws inserted using FGS in 13 patients and 76 screws inserted using CTGS in 11 patients were compared. The study population included ten cases of vertebral fracture, five cases of degenerative spondylolisthesis, three cases of spondylolytic spondylolisthesis, two cases of tuberculous spondylitis, two cases of failed earlier back surgery and two case of ankylosing spondylitis with pseudarthrosis. The installed vertebral levels ranged from T8 to S1. Screw positions were assessed with postoperative radiographs and computed tomography. Sixty-nine (93.2%) screws were correctly placed in the FGS group, and seventy-three (96.1%) screws were correctly placed in the CTGS group (P=0.491). The results indicated that both image-guided systems offer high accuracy. However, the fluoroscope image-guided system could be considered the primary tool for lower thoracic and lumbosacral pedicle placement because it enables real-time navigation and does not require a preoperative CT scan. Résumé La chirurgie assistée par imagerie (CTGS) permet d'avoir une meilleure sécurité lors de l'implantation de vis pediculaires. Des articles récents montrent que le système avec amplificateur de brillance (fluoroscopie FGS) permet également cette implantation. Cependant, la supériorité d'une technique ou d'une autre n'apparaît pas clairement. Le but de cette étude est de comparer la bonne implantation des vis pediculaires en utilisant les deux systèmes. 74 vis ont été insérées avec le système FGS chez 13 patients et 66 vis avec le système CTGS chez 11 patients. Ces deux séries ont été comparées. Cette étude inclut 10 cas de fractures vertébrales, 5 cas de spondylolisthésis dégénératifs, 3 cas de spondylolisthésis avec spondylolyse, à 2 cas d'atteintes tuberculeuses, 2 cas d'échec de chirurgie par voie postérieure et 2 cas de spondylarthrite ankylosante avec pseudarthrose. Les niveaux d'instrumentation se sont échelonnés de T8 à S1. 69 (93.2%) vis ont été correctement mises en place dans le groupe FGS et, 73 (96.1%) avec le groupe CTGS (P=0.491). Les résultats montrent que le système d'images guidées CTGS offre beaucoup plus de sécurité dans l'implantation des vis tant au niveau lombaire qu'au niveau thoracique ou lombosacré ceci ne nécessite pas par ailleurs un scanner pré opératoire.
Journal of biomedical research, 2014
Computer-navigated pedicle screw insertion is applied to the thoracic and lumbar spine to attain high insertion accuracy and a low rate of screw-related complications. However, some in vivo and in vitro studies have shown that no advantages are gained with the use of navigation techniques compared to conventional techniques. Additionally, inconsistent conclusions have been drawn in various studies due to different population characteristics and methods used to assess the accuracy of screw placement. Moreover, it is not clear whether pedicle screw insertion with navigation techniques decreases the incidence of screw-related complications. Therefore, this study was sought to perform a meta-analysis of all available prospective evidence regarding pedicle screw insertion with or without navigation techniques in human thoracic and lumbar spine. We considered in vivo comparative studies that assessed the results of pedicle screw placement with or without navigation techniques. PubMed, Ovi...
Journal of Orthopaedics and Traumatology
Background Percutaneous pedicle screw (PPS) placement is a key step in several minimally invasive spinal surgery (MISS) procedures. Traditional technique for PPS makes use of C-arm fluoroscopy assistance (FA). More recently, newer intraoperative imaging techniques have been developed for PPS, including CT-guided navigation (CTNav). The aim of this study was to compare FA and CTNav techniques for PPS with regard to accuracy, complications, and radiation dosage. Materials and methods A total of 192 patients with degenerative lumbar spondylolisthesis and canal stenosis who underwent MISS posterior fusion ± interbody fusion through transforaminal approach (TLIF) were retrospectively reviewed. Pedicle screws were placed percutaneously using either standard C-arm fluoroscopy guidance (FA group) or CT navigation (CTNav group). Intraoperative effective dose (ED, mSv) was measured. Screw placement accuracy was assessed postoperatively on a CT scan using Gertzbein and Robbins classification (...
The Bone & Joint Journal, 2017
AimsWe aimed to retrospectively assess the accuracy and safety of CT navigated pedicle screws and to compare accuracy in the cervical and thoracic spine (C2-T8) with (COMB) and without (POST) prior anterior surgery (anterior cervical discectomy or corpectomy and fusion with ventral plating: ACDF/ACCF).Patients and MethodsA total of 592 pedicle screws, which were used in 107 consecutively operated patients (210 COMB, 382 POST), were analysed. The accuracy of positioning was determined according to the classification of Gertzbein and Robbins on post-operative CT scans.ResultsHigh accuracy was achieved in 524 screws (88.5%), 192 (87.7%) in the cervical spine and 332 (89%) in the thoracic spine, respectively. The results in the two surgical groups were compared and a logistic regression mixed model was performed to analyse the risk of low accuracy. Significantly lower accuracy was found in the COMB group with 82.9% versus 91.6% in the POST group (p = 0.036). There were no neurological c...
Biomed J, 2012
Background: Incorrect placement of pedicle screws may lead to neurovascular injury, so the position is important for the reduction of spinal fractures. CT-based image-guided surgery has been promoted as a means to theoretically improve the accuracy of pedicle screw placement. Patients who underwent CT-based navigation-assisted pedicle screw fixation for thoracic or lumbar fractures were reviewed to evaluate the accuracy of pedicle screw placement for spinal fracture cases.
Journal of neurosurgery, 2021
P edicle screw fixation is a widely used procedure in the thoracolumbar spine. It provides biomechanical support strong enough to achieve the needed fusion and stabilization. Conversely, pedicle screw insertion in the cervical spine is less widely adopted on account of the challenges brought on by the wide anatomical variance inherent to the subaxial spine in terms of pedicle location, dimension, and angulation. 1-4 The difficult anatomy, further compounded by the relative mobility of the cervical spine during surgery, invites a risk of major complications such as vertebral artery and nerve root injury. 5 Cervical pedicle screw (CPS) instrumentation is nevertheless recognized to confer superior biomechanical support compared to other methods of cervical posterior fixation, such as posterior wiring, lateral mass screws, and facet screws. 6,7 In current times, fluoroscopically guided CPS instrumentation remains the most widely adopted and published approach in the literature. The aim of this study was thus to address the comparative accuracy and safety of subaxial CPS insertion in which fluoroscopy and navigation techniques are used, by assessing the misplacement rate as well as complications, and in particular neurovascular injuries. Methods Search Strategy This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. 8 Several ABBREVIATIONS CP = complete perforation; CPS = cervical pedicle screw; PP = partial perforation.
Spinal Navigation for Cervical Pedicle Screws: Surgical Pearls and Pitfalls
Global Spine Journal, 2020
Study Design: Retrospective cohort study. Objective: We intend to evaluate the accuracy and safety of cervical pedicle screw (CPS) insertion under O-arm-based 3-dimensional (3D) navigation guidance. Methods: This is a retrospective study of patients who underwent CPS insertion under intraoperative O-arm-based 3D navigation during the years 2009 to 2018. The radiological accuracy of CPS placement was evaluated using their intraoperative scans. Results: A total of 297 CPSs were inserted under navigation. According to Gertzbein classification, 229 screws (77.1%) were placed without any pedicle breach (grade 0). Of the screws that did breach the pedicle, 51 screws (17.2%) had a minor breach of less than 2 mm (grade 1), 13 screws (4.4%) had a breach of between 2 and 4 mm (grade 2), and 4 screws (1.3%) had a complete breach of 4 mm or more (grade 3). Six screws were revised intraoperatively. There was no incidence of neurovascular injury in this series of patients. 59 of the 68 breaches (...