Clinical accuracy of 3D fluoroscopy–assisted cervical pedicle screw insertion

Ito, Yasuo; Sugimoto, Yukihiko; Tomioka, Masao; Hasegawa, Yasuhiro; Nakago, Kie; Yagata, Yukihisa

doi:10.3171/spi.2008.9.11.450

Cited by 118 publications

(74 citation statements)

References 16 publications

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“…Accordingly, reconstructions of most cervical disorders do not require CPS. But, of the current techniques, transpedicular anchorage provides highest stability [2,3,22,31,38,44,62], and in selected patients with advanced instability, CPS fixation is a sound treatment [12,21,28,62] with high accuracy rates in the hands of trained surgeons, particularly at C2 and C7 [1,9,25,29,62]. Our study offers new biomechanical data for the selective usage of CPS.…”

Section: Discussionmentioning

confidence: 86%

The stabilizing potential of anterior, posterior and combined techniques for the reconstruction of a 2-level cervical corpectomy model: biomechanical study and first results of ATPS prototyping

et al. 2010

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Clinical studies reported frequent failure with anterior instrumented multilevel cervical corpectomies. Hence, posterior augmentation was recommended but necessitates a second approach. Thus, an author group evaluated the feasibility, pull-out characteristics, and accuracy of anterior transpedicular screw (ATPS) fixation. Although first success with clinical application of ATPS has already been reported, no data exist on biomechanical characteristics of an ATPS-plate system enabling transpedicular end-level fixation in advanced instabilities. Therefore, we evaluated biomechanical qualities of an ATPS prototype C4-C7 for reduction of range of motion (ROM) and primary stability in a non-destructive setup among five constructs: anterior plate, posterior all-lateral mass screw construct, posterior construct with lateral mass screws C5 ? C6 and end-level fixation using pedicle screws unilaterally or bilaterally, and a 360°construct. 12 human spines C3-T1 were divided into two groups. Four constructs were tested in group 1 and three in group 2; the ATPS prototypes were tested in both groups. Specimens were subjected to flexibility test in a spine motion tester at intact state and after 2-level corpectomy C5-C6 with subsequent reconstruction using a distractable cage and one of the osteosynthesis mentioned above. ROM in flexionextension, axial rotation, and lateral bending was reported as normalized values. All instrumentations but the anterior plate showed significant reduction of ROM for all directions compared to the intact state. The 360°construct outperformed all others in terms of reducing ROM. While there were no significant differences between the 360°a nd posterior constructs in flexion-extension and lateral bending, the 360°constructs were significantly more stable in axial rotation. Concerning primary stability of ATPS prototypes, there were no significant differences compared to posterior-only constructs in flexion-extension and axial rotation. The 360°construct showed significant differences to the ATPS prototypes in flexionextension, while no significant differences existed in axial rotation. But in lateral bending, the ATPS prototype and the anterior plate performed significantly worse than the posterior constructs. ATPS was shown to confer increased primary stability compared to the anterior plate in flexion-extension and axial rotation with the latter yielding significance. We showed that primary stability after 2-level corpectomy reconstruction using ATPS prototypes compared favorably to posterior systems and superior to anterior plates. From the biomechanical point, the 360°i nstrumentation was shown the most efficient for reconstruction of 2-level corpectomies. Further studies will elucidate whether fatigue testing will enhance the benefit of transpedicular anchorage with posterior constructs and ATPS.

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Section: Discussionmentioning

confidence: 86%

The stabilizing potential of anterior, posterior and combined techniques for the reconstruction of a 2-level cervical corpectomy model: biomechanical study and first results of ATPS prototyping

et al. 2010

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“…Despite its biomechanically advantages, the method is technically demanding and iatrogenic damage to neurovascular structures are feared. While lateral mass screw placement show low incidents (0-4%) of neurovascular complications [7,25,36,46], recent reports concerning CPS are promising and clinical relevant complications do not occur frequently [2,9,11,15,18,24,26,29,47,48].…”

Section: Discussionmentioning

confidence: 99%

“…The correct screw placement in other studies was defined as no pedicle perforation [11,23,47,48] or perforations up to 1 mm [15,26,29]. Screw malposition was classified as minor breach, exposure or partial perforation if the cortical breach did not extend 1.75-2 mm or encroachment of the transversal foramen up to 25% [11,15,23,26,47,48]. Critical perforations of the pedicle was assumed if the violation measured more than 1.75 to 2 mm, with dural contact or narrowing of the transversal foramen [25%.…”

Section: Discussionmentioning

confidence: 99%

“…However, this technique has a potential risk of nerve root, spinal cord and vertebral artery injury due to a small corridor of safe screw placement [31,39,41], recent clinical studies demonstrate that relevant complications do not occur frequently [2,9,11,15,18,24,26,29,47,48]. The axis of the cervical pedicles to the sagittal midline plane vary between 25 and 60°and makes a wide exposure of the spine necessary [14].…”

Section: Introductionmentioning

confidence: 99%

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Percutaneous instrumentation of the cervical and cervico-thoracic spine using pedicle screws: preliminary clinical results and analysis of accuracy

et al. 2011

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The pedicle screw instrumentation represents the most rigid construct of the cervical and cervicothoracic spine and in spite of the risks to neurovascular structures clinical relevant complications do not occur frequently. The steep angles of the cervical pedicles result in a wide surgical exposure with extensive muscular trauma. The objective of this study was the evaluation of the accuracy of cervical pedicle screw insertion through a minimally invasive technique to reduce access-related muscular trauma. Therefore, percutaneous transpedicular instrumentation of the cervical and cervicothoracic spine was performed in 15 patients using fluoroscopy. All instrumentations from C2 to Th4 were inserted bilaterally through 2 to 3-cm skin and fascia incisions even in multilevel procedures and the rods were placed by blunt insertion through the incision. Thin-cut CT scan was used postoperatively to analyze pedicle violations. 76.4% of 72 screws were placed accurately. Most pedicle perforations were seen laterally towards the vertebral artery. Critical breaches [2 mm or narrowing of the transversal foramen occurred in 12.5% of screws; however, no revision surgery for screw displacement was needed in the absence of clinical symptoms. No conversion from percutaneous to open surgery was necessary. It was concluded that percutaneous transpedicular instrumentation of the cervical spine is a surgically demanding technique and should be reserved for experienced spine surgeons. The indications are limited to instrumentation-only procedures or in combination with anterior treatment, but with the potential to minimize access-related morbidity.

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“…Admittedly, there is a risk when using pedicle screws from C3 to C6, but cervical pedicle screw fixation has been shown to be the most stable form of cervical instrumentation fixation, obtaining a much more stable fixation than can be obtained by lateral mass screw and rod fixation [17]. With the improvement of the safety of the procedure using the pedicle axis-view method [29,30] or navigation system [13], the risk can be minimized and, in any case, the benefits of pedicle screw use are great.…”

Section: Discussionmentioning

confidence: 99%

Posterior approach for cervical fracture–dislocations with traumatic disc herniation

et al. 2010

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In the treatment algorithm for cervical spine fracture-dislocations, the recommended approach for treatment if there is a disc fragment in the canal is the anterior approach. The posterior approach is not common because of the disadvantage of potential neurological deterioration during reduction in traumatic cervical herniation patients. However, reports about the frequency of this deterioration and the behavior of disc fragments after reduction are scarce. Forty patients with traumatic disc herniation were observed. They represented 29.2% of 137 consecutive patients with subaxial cervical spine fracturedislocations. Surgical planning was performed according to our two-stage algorithm. In the first stage, they were treated with posterior open reduction and posterior spine arthrodesis. In the second stage, anterior surgery was added for cases where neurological deterioration attributed to nonreduced disc fragments on postoperative magnetic resonance imaging (MRI). Neurological deterioration after posterior open reduction was not observed. Furthermore, 25% of total cases and 75% of incomplete paralysis cases improved postoperatively by C1 grade in the American Spinal Injury Association impairment scale. Reduction or reversal of disc herniation was observed in all cases undergoing postoperative MRI. For local sagittal alignment, preoperative 9.4°kyphosis was corrected to 6.9°l ordosis postoperatively. The disc height ratio was 72.4% preoperatively and 106.3% postoperatively. The second stage of our plan was not required after the posterior approach in this series. The incidence of neurological deterioration after posterior open reduction was zero, even in cases with traumatic cervical disc herniation. Favorable clinical and radiological outcomes could be obtained by the first stage alone. Although preparations for prompt anterior surgery should always be made to cover any contingency, the need for them is minimal.

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Clinical accuracy of 3D fluoroscopy–assisted cervical pedicle screw insertion

Cited by 118 publications

References 16 publications

The stabilizing potential of anterior, posterior and combined techniques for the reconstruction of a 2-level cervical corpectomy model: biomechanical study and first results of ATPS prototyping

The stabilizing potential of anterior, posterior and combined techniques for the reconstruction of a 2-level cervical corpectomy model: biomechanical study and first results of ATPS prototyping

Percutaneous instrumentation of the cervical and cervico-thoracic spine using pedicle screws: preliminary clinical results and analysis of accuracy

Posterior approach for cervical fracture–dislocations with traumatic disc herniation

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