Pedicle screw insertion: computed tomography versus fluoroscopic image guidance (original) (raw)
2007, International Orthopaedics
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.
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European Spine Journal, 2012
Introduction With the advances and improvement of computer-assisted surgery devices, computer-guided pedicle screws insertion has been applied to the lumbar, thoracic and cervical spine. The purpose of the present study was to perform a systematic review of all available prospective evidence regarding pedicle screw insertion techniques in the thoracic and lumbar human spine. Materials and methods We considered all prospective in vivo clinical studies in the English literature that assessed the results of different pedicle screw placement techniques (free-hand technique, fluoroscopy guided, computed tomography (CT)-based navigation, fluoro-based navigation). MEDLINE, OVID, and Springer databases were used for the literature search covering the period from January 1950 until May 2010.
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.
Comparison of computerized tomography and direct visualization in thoracic pedicle screw placement
Journal of Neurosurgery: Spine, 2002
Object. To validate computerized tomography (CT) scanning as a tool to assess the accuracy of thoracic pedicle screw placement, the authors compared its accuracy with that of direct visualization in instrumented cadaveric spine specimens. Methods. A grading scale was devised to score the placement of the pedicle screw. The grades ranged from 0 to 3 depending on the extent to which the pedicle had been violated. One hundred fifty-five pedicles were fitted with instrumentation in eight cadaveric spines. A single observer graded the appearance of the screw based on CT scans (3-mm axial sections with 1-mm overlap) and direct visualization of the specimen. The authors arrived at a Kappa value of 0.51, which suggested only moderate agreement between the two measurement techniques. Whereas CT had a positive predictive value of 95%, it had a negative predictive value of 62%. Conclusions. The authors thus conclude that although CT scanning is the most valid tool to assess the accuracy of tho...
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.
Accuracy of upper thoracic pedicle screw placement using three-dimensional image guidance
The Spine Journal, 2009
BACKGROUND CONTEXT: Pedicle screw malposition rates using conventional techniques have been reported to occur with a frequency of 6% to 41%. The upper thoracic spine (T1-T3) is a challenging area for pedicle screw placement secondary to the small size of the pedicles, the inability to visualize this area with lateral fluoroscopy, and significant consequences for malpositioned screws. We describe our experience placing 150 pedicle screws in the T1-T3 levels using three-dimensional (3D) image guidance. PURPOSE: The aim of this study was to assess the accuracy of 3D image guidance for placing pedicle screws in the first three thoracic vertebrae. STUDY DESIGN: The accuracy of pedicle screw placement in the first three thoracic vertebrae was evaluated using postoperative thin-section computed tomography (CT) scans of the cervicothoracic region. PATIENT SAMPLE: Thirty-four patients who underwent cervicothoracic fusion were included. OUTCOME MEASURES: Radiological investigation with CT scans was performed during the postoperative period. METHODS: Thirty-four consecutive patients underwent cervicothoracic instrumentation and fusion for a total of 150 pedicle screws placed in the first three thoracic vertebrae. All screws were placed using 3D image guidance. Medical records and postoperative imaging of the cervicothoracic junction for each patient were retrospectively reviewed. An independent radiologist reviewed the placement of the pedicle screws and assessed for pedicle breach. All cortical violations were reported as Grade 1, 0 to 2 mm; Grade 2, 2 to 4 mm; and Grade 3, greater than 4 mm. RESULTS: Overall, 140 (93.3%) out of 150 screws were contained solely in the desired pedicle. All 10 pedicle violations were Grade 1. The direction of pedicle violation included three medial, four inferior, two superior, and one minor anterolateral vertebral body. No complication occurred as a result of screw placement or the use of image guidance. CONCLUSIONS: Upper thoracic pedicle screw placement is technically demanding as a result of variable pedicle anatomy and difficulty with two-dimensional visualization. This study demonstrates the accuracy and reliability of 3D image guidance when placing pedicle screws in this region. Advantages of this technology in our practice include safe and accurate placement of spinal instrumentation with little to no radiation exposure to the surgeon and operating room staff. Ó
Journal of spine surgery (Hong Kong), 2017
In the literature, there is a large variation in the reported misplacement rates of pedicle screws. The use of minimally invasive surgical techniques is increasing and as such there has only been a small amount of data to look at the misplacement rate of percutaneously inserted thoracic and lumbar pedicle screws. A retrospective analysis of post-operative computed tomography (CT) scans were performed on 108 patients who underwent minimally invasive percutaneously inserted thoracic and lumbar pedicle screws by a single surgeon. Analysis of the screw trajectory using strict guidelines was performed using multiplanar reconstruction CT scan data to determine the accuracy of the pedicle screws. A total of 614 screws were inserted in vertebral levels T2 to S1. Twenty-five (4.07%) screws were considered misplaced having breached the pedicular cortex. Thoracic pedicle screws had a statistically higher misplacement rate than lumbar pedicle screws (14.67% vs. 2.60% respectively, P<0.001). ...
Asian Spine Journal, 2021
Study DesignRetrospective review.PurposeTo determine the accuracy of thoracolumbar pedicle screw insertion with the routine use of three-dimensional (3D) intraoperative imaging and navigation over a large series of screws in an Asian population.Overview of LiteratureThe use of 3D intraoperative imaging and navigation in spinal surgery is aimed at improving the accuracy of pedicle screw insertion. This study analyzed 2,240 pedicle screws inserted with the routine use of intraoperative navigation. It is one of very few studies done on an Asian population with a large series of screws.MethodsPatients who had undergone thoracolumbar pedicle screws insertion using intraoperative imaging and navigation between 2009 and 2017 were retrospectively analyzed. Computed tomography (CT) images acquired after the insertion of pedicle screws were analyzed for breach of the pedicle wall. The pedicle screw breaches were graded according to the Gertzbein classification. The breach rate and revision ra...
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...
Journal of Korean Neurosurgical Society, 2015
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. 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. Ninety-nine percent (181/18...
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