Is in vivo manual palpation for thoracic pedicle screw instrumentation reliable?

Donohue, Miriam L; Moquin, Ross R.; Singla, Amit; Calancie, Blair

doi:10.3171/2014.1.spine13197

Cited by 12 publications

(5 citation statements)

References 17 publications

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“…In a separate report originating from this study, 15 we found poor agreement between the in vivo accuracy of manual palpation of a pedicle wall and the position of the screw placed within that pedicle track. One reason for this poor agreement is that in some cases the original pedicle track was contained within the bony margins of the pedicle, but the larger-diameter screw placed along that track breached the medial wall of the pedicle.…”

Section: Resultsmentioning

confidence: 51%

“…First, we recently showed that manual palpation of the pedicle alone in an operating room setting-even by a fellowship-trained spine surgeon-often fails to detect misdirected pedicle tracks that will lead to a medially malpositioned screw. 15 Similarly, we must emphasize that an inexperienced neuromonitoring team will probably not achieve the level of accuracy in preventing medially malpositioned screws that is possible with close adherence to the protocol described in these two companion papers. Of course, this concern applies across the spectrum of neuromonitoring techniques now employed in the operating room, as has been pointed out by numerous authors.…”

Section: Is Each Step Of the Protocol Necessary?mentioning

confidence: 99%

See 1 more Smart Citation

Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 2. The role of feedback

Calancie¹,

Donohue

Moquin³

2014

SPI

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Object The authors have reported in Part 1 of this study on a novel neuromonitoring test for the prevention of medial malpositioning of thoracic pedicle screws. In the present paper they examine the impact of providing the results of the test as intraoperative feedback to the surgical team. Methods This is the second part of a 2-part report of a prospective, blinded and randomized neuromonitoring study designed to lower the incidence of medially malpositioned thoracic pedicle screws. Details of the neuromonitoring technique and data supporting the alarm criteria used are contained in the companion article (Part 1). For the majority of pedicle screw placements, intraoperative test results were withheld from the study team (that is, the team members were blinded to the test results). However, for a limited number of pedicle sites the authors provided one of 2 forms of testing feedback to the surgical team: 1) “break the blind” feedback, if testing suggested that screw placement would result in direct contact between screw and the dura mater; and 2) “planned” feedback, beginning during the later stages of the study and provided for 50% of pedicle sites. Feedback gave the surgeon the opportunity to adjust the trajectory that the screw would ultimately take within the pedicle. The final screw position relative to the pedicle's medial wall for all sites in which feedback was withheld from the surgical team was compared with the screw position for those sites in which either form of feedback (“break the blind” or “planned”) was provided to and acted upon by the surgical team. Results Of the 820 pedicle tracks tested among the 71 surgical cases included in this study, a total of 684 were operated upon without any form of feedback. Planned feedback was provided for an additional 107 pedicle tracks, of which 15 triggered an intraoperative alarm (evoked electromyogram response in leg muscles to stimulus intensity ≤ 10 mA) leading to a warning to the surgical team of a medially biased pedicle track. Finally, the blind was broken 29 times, in each case when testing revealed a particularly low threshold (≤ 4 mA) for evoked responses in leg muscles when stimulating along the pedicle track with the ball-tipped probe. As detailed in the companion paper to this one, there were 32 screws with threads lying at least 2 mm medial to the pedicle wall. In all 32 instances (100%), either these screws were in the “no feedback” category (n = 29) or they were in a feedback category but the surgeon elected to not revise the pedicle-track trajectory. Two patients returned to the operating room for revision of screw placements because the screws were encroaching upon the central canal; the pedicle tracks for these screws had been in the “no feedback” category. Conclusions This is the first blinded and randomized study to prove that implementing a novel neuromonitoring strategy during placement of thoracic pedicle screws can significantly reduce the incidence of clinically relevant thoracic pedicle screw medial malpositioning.

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Section: Resultsmentioning

confidence: 51%

Section: Is Each Step Of the Protocol Necessary?mentioning

confidence: 99%

Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 2. The role of feedback

Calancie¹,

Donohue

Moquin³

2014

SPI

Self Cite

View full text Add to dashboard Cite

show abstract

“…Manual pedicle palpation with a ball-tip probe has low accuracy 25,26 and the potential for inadvertent neurological injury with the probe. 27 Even stereotactic image guidance cannot entirely prevent pedicle perforations.…”

Section: Discussionmentioning

confidence: 99%

Feasibility of Endoscopic Inspection of Pedicle Wall Integrity in a Live Surgery Model

et al. 2018

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Background: Perforations of the pedicle wall during cannulation can occur with experienced surgeons. Direct endoscopic visualization has not been used to inspect pedicles previously due to bone bleeding obscuring the camera visualization. The hypothesis of this study was that endoscopic visualization of pedicle wall integrity was technically feasible and would enable identification of clinically significant pedicle breaches.Methods: A live porcine model was used. Eight lumbar pedicles were cannulated. Clinically significant breaches were created. An endoscope was introduced and was used to inspect the pedicles.Results: All lumbar pedicles were endoscopically visible at a systolic pressure of 100 mm Hg. Clinically relevant anatomic structures and iatrogenic pathology, such as medial, lateral, and anterior breaches, were identified. There were no untoward events resulting from endoscopic inspection of the pedicle endosteal canal.Conclusions: Endoscopic inspection of lumbar pedicles was safe and effective. The findings on endoscopic inspection corresponded with the ball-tip probe palpation techniques. Additional techniques, such as selection between 2 tracts, was possible with the endoscopic technique.

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“…Generally, PS placement is attempted following careful preoperative planning, direct visualization, and pedicle probing. 8,9 Nevertheless, detection of pedicle breaches remains challenging.…”

Section: Introductionmentioning

confidence: 99%

Low Radiation Protocol for Intraoperative Robotic C-Arm Can Enhance Adolescent Idiopathic Scoliosis Deformity Correction Accuracy and Safety

Tanaka

Schol

Sakai

et al. 2023

Global Spine Journal

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Study design Retrospective case-series study Objectives To assess (1) low cone beam CT (CBCT) mediated intraoperative navigation to limit radiation exposure without compromising surgical accuracy, and (2) the potential of intraoperative C-arm CBCT navigation to augment pedicle screw (PS) placement accuracy in AIS surgery compared to pre-surgery CT-based planning. Methods The first part involved a prospective phantom study, comparing radiation doses for conventional CT, and standard (6sDCT) and a low dose (5sDCT) Artis Zeego®-imaging. Next, 5sDCT- and 6sDCT-navigation were compared on PS accuracy and radiation exposure during AIS correction. The final part compared surgical AIS deformity correction through intraoperative 5sDCT navigation to a matched cohort treated using conventional pre-surgery CT-scans for navigation. Outcome parameters included operation time, skin dose (SD), dose area product (DAP), intraoperative blood loss, postoperative complications, and PS deviation rates. Results The phantom study demonstrated a reduction in radiation for the 5sDCT protocol. Moreover, 5sDCT-imaged patients (n = 15) showed a significantly lower SD (-27.41%) and DAP (-30.92%), without compromising PS accuracy compared with 6sDCT-settings (n = 15). Finally, AIS correction through intraoperative CBCT C-arm navigation (n = 27) significantly reduced screw deviation rates (6.83% versus 10.75%, P = .016) without increasing operation times, compared with conventional CT (n = 37). Conclusions Intraoperative navigation using a CBCT C-arm system improved the accuracy of PS insertion and reduced surgery time. Moreover, it reduced radiation exposure compared with conventional CT, which was further curtailed by adapting the low-dose 5sDCT protocol. In short, our study highlights the benefits of intraoperative CBCT navigation for PS placement in AIS surgery.

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Is in vivo manual palpation for thoracic pedicle screw instrumentation reliable?

Cited by 12 publications

References 17 publications

Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 2. The role of feedback

Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 2. The role of feedback

Feasibility of Endoscopic Inspection of Pedicle Wall Integrity in a Live Surgery Model

Low Radiation Protocol for Intraoperative Robotic C-Arm Can Enhance Adolescent Idiopathic Scoliosis Deformity Correction Accuracy and Safety

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