An Extrapedicular Approach to the Placement of Screws in the Thoracic Spine: An Anatomic and Radiographic Assessment

Husted, Daniel S.; Yue, James J.; Fairchild, Todd A.; Haims, Andrew

doi:10.1097/01.brs.0000085361.32600.63

Cited by 34 publications

(25 citation statements)

References 31 publications

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“…However, pedicle violation resulted from malpositioned screw leading to potential harm to nearby vital structures, which prompted surgeons to search for the perfect strategy. Though alternative methods (e.g., transarticular screw [2], lateral mass [3], extrapedicular screw fixation [4,5]) were developed for better surgical outcome, surgeons were more prone to improve the pedicle screw insertion accuracy by trying various supporting methods (e.g., intraoperative monitoring [6,7], anatomical markers [13,24,26,47]). Nevertheless, none of the conventional methods was considered as the perfect intraoperative assisting method.…”

Section: Introductionmentioning

confidence: 99%

Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies

et al. 2010

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Studies revealed that navigation systems that provided intraoperative assistance might improve pedicle screw insertion accuracy, and also implied that different systems provided different pedicle screw insertion accuracy. A systematic review and meta-analysis was conducted to focus on the pedicle screw insertion accuracy with or without the assistance of image-guided system, and the variance among the different navigation systems. Comparative studies were searched on pedicle screw insertion accuracy between conventional and navigated method, and among different navigation systems. A total of 43 papers, including 28 clinical, 14 cadaveric and 1 model studies, were included in the current study. For clinical articles, there were 3 randomized clinical trials, 4 prospective comparative studies and 21 retrospective comparative studies. The incidence of pedicle violation among computer tomography-based navigation method group was statistically significantly less than that observed among the conventional group (OR 95% CI, in vivo: 0.32-0.60; in vitro: 0.24-0.75 P \ 0.01). Two-dimensional fluoroscopybased navigation system (OR 95% CI, in vivo: 0.27-0.48; in vitro: 0.43-0.88 P \ 0.01) and three-dimension fluoroscopy-based navigation system (OR 95% CI, in vivo: 0.09-0.38; in vitro: 0.09-0.36 P \ 0.01) also obtained significant reduced screw deviation rate over traditional methods. Between navigated approaches, statistically insignificant individual and pooled RR values were observed for all in vivo subgroups. Pooled estimate of in vitro studies show that computer tomography-based and three-dimension fluoroscopy-based navigation system provided more accurate pedicle screw insertion over two-dimension fluoroscopy-based navigation system. Our review showed that navigation provided a higher accuracy in the placement of pedicle screws compared with conventional methods. The superiority of navigation systems was obvious when they were applied to abnormal spinal structure. Although no strong in vivo evidence has detected significantly different pedicle screw placement accuracy among the three major navigation systems, meta-analysis revealed the variance in pedicle screw insertion accuracy with different navigation methods.

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Section: Introductionmentioning

confidence: 99%

Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies

et al. 2010

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“…Between the pedicle and the dural sac, Uğur reported no distance from T3 to T6 and only 0.5 and 0.2 mm of distance at T1 and T2, respectively 3 . Attempting to bypass the challenges of narrow pedicle screw fixation in the thoracic spine, an extrapedicular technique has been described by Husted 1 . In fact, we used this technique in two children, allowing the use of 5.5 mm screws in the pedicles of T3 through T5.…”

Section: Discussionmentioning

confidence: 99%

“…Biomechanical advantages include three-column support [1][2][3][4] , possibility of instrumentation in the absence of posterior column integrity [1][2][3][4] and greater rotational stability in the transverse axis 5,6 . An additional benefit from a screwrod construct is the use of cross-links, forming a triangle in the transverse plane, which significantly improves screw pullout strength and rotational and lateral bending stiffness 17,18 .…”

Section: Discussionmentioning

confidence: 99%

“…Theoretical advantages of pedicle screw fixation include three-column support [1][2][3][4] greater rotational stability 5,6 , possibility of instrumentation in the absence of posterior column integrity [1][2][3][4] , avoidance of neural canal dissection, decreased operative time 3,5,7 and decreased blood loss 7 . More recently, superior efficacy of thoracic pedicle screws over other systems has been demonstrated [5][6][7][8][9] .…”

Section: Introductionmentioning

confidence: 99%

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Free-hand placement of high thoracic pedicle screws with the aid of fluoroscopy: evaluation of positioning by CT scans in a four-year consecutive series

Braga

Morais²,

Vilela

2010

Arq. Neuro-Psiquiatr.

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Objective: To evaluate the feasibility, safety and accuracy of pedicle screw placement in the upper thoracic spine using the free-hand technique with the aid of fluoroscopy; to analyze the methods used to verify correct screw positioning intra and postoperatively. Method: All patients with instability of the cervicothoracic or upper thoracic spine and at least one screw placed in the segment T1-T6 as part of a posterior construct entered the study. Only C-arm intraoperative fluoroscopy was used to guide screw placement. Results: We obtained excellent positioning in 98.07% of the screws. CT scans precisely demonstrated pedicle wall and anterolateral body violations. There was no hardware failure, no neurological or vascular injury and no loss of alignment during the follow-up period. Conclusion: Pedicle screws can be safely placed in the upper thoracic spine when strict technical principles are followed. Only a CT scan can precisely demonstrate vertebral body and medial pedicle cortical violations. Key words: pedicle screws, transpedicular fixation, thoracic spine, cervicothoracic junction, spinal instability.Colocação de parafusos pediculares na coluna torácica alta utilizando fluoroscopia: avaliação do posicionamento dos parafusos por tomografia computadorizada em uma série de casos durante quatro anos RESUMO Objetivo: Avaliar a factibilidade, segurança e eficácia da colocação de parafusos pediculares na coluna torácia alta utilizando apenas a fluoroscopia; analisar os métodos intra e pós-operatórios de verficação do posicionamento de parafusos. Método: Todos os pacientes com instabilidade da coluna cervico-torácica ou torácica alta e pelo menos um parafuso colocado no segmento T1-T6 foram incluídos no estudo. Apenas fluoroscopia intra-operatória foi utilizada para guiar a colocação dos parafusos. Resultados: Obtivemos excelente posicionamento em 98,07% dos parafusos. TC axial mostrou precisamente violações pediculares e da parede anterolateral do corpo vertebral. Não houve falência do instrumental, lesões neurológicas ou vasculares, ou perda do alinhamento sagital no período de seguimento. Conclusão: Os parafusos pediculares podem ser colocados com segurança na coluna torácica alta desde que técnicas operatórias precisas sejam executadas. Somente a TC pode demonstrar precisamente violações do corpo vertebral e da parede pedicular. Palavras-chave: parafusos pediculares, fixação transpedicular, coluna torácica alta, junção cervico-torácica, instabilidade espinhal.

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“…If the pedicle is too narrow for screw placement, alternative fixation techniques such as an extrapedicular approach to screw placement in the thoracic spine or the use of pedicle hooks should be considered. 45 Underlying cord diseases such as syringomyelia, tethered cord, or an associated Chiari malformation must be recognized prior to deformity correction. On clinical examination of apparent idiopathic scoliosis patients with neurological signs, patients younger than 11 years of age, with a left thoracic scoliosis, or significant neck or back pain should be further investigated with MR imaging.…”

Section: Surgical Causes Of Posci In the Thoracic Spinementioning

confidence: 99%

Prevention, identification, and treatment of perioperative spinal cord injury

Ahn¹,

Fehlings

2008

FOC

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Object In this report, the authors suggest evidence-based approaches to minimize the chance of perioperative spinal cord injury (POSCI) and optimize outcome in the event of a POSCI. Methods A systematic review of the basic science and clinical literature is presented. Results Authors of clinical studies have assessed intraoperative monitoring to minimize the chance of POSCI. Furthermore, preoperative factors and intraoperative issues that place patients at increased risk of POSCI have been identified, including developmental stenosis, ankylosing spondylitis, preexisting myelopathy, and severe deformity with spinal cord compromise. However, no studies have assessed methods to optimize outcomes specifically after POSCIs. There are a number of studies focussed on the pathophysiology of SCI and the minimization of secondary damage. These basic science and clinical studies are reviewed, and treatment options outlined in this article. Conclusions There are a number of treatment options, including maintenance of mean arterial blood pressure > 80 mm Hg, starting methylprednisolone treatment preoperatively, and multimodality monitoring to help prevent POSCI occurrence, minimize secondary damage, and potentially improve the clinical outcome of after a POSCI. Further prospective cohort studies are needed to delineate incidence rate, current practice patterns for preventing injury and minimizing the clinical consequences of POSCI, factors that may increase the risk of POSCI, and determinants of clinical outcome in the event of a POSCI.

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An Extrapedicular Approach to the Placement of Screws in the Thoracic Spine: An Anatomic and Radiographic Assessment

Abstract: This study, although only introductory, indicates the potential for extrapedicular vertebral body fixation in the thoracic spine. Biomechanical evaluations are presently being conducted to evaluate the use of extrapedicular thoracic screw fixation.

Cited by 34 publications

References 31 publications

Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies

Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies

Free-hand placement of high thoracic pedicle screws with the aid of fluoroscopy: evaluation of positioning by CT scans in a four-year consecutive series

Prevention, identification, and treatment of perioperative spinal cord injury

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