Novel technique for preoperative pedicle localization in spinal surgery with challenging anatomy

Abstract

T he ability to localize an intraoperative spinal level and correlate that level with the pathology observed on preoperative imaging is of paramount importance. In certain patients it is difficult to precisely define the level with existing imaging technology. C-arm fluoroscopy and conventional radiography have a limited field of view. These technologies are accurate for the rostral and caudal ends of the spine, but defining the intervening levels requires moving the frame of reference while counting. This has an inherent potential for error and often requires extended surgical time and increased radiation exposure to the patient and to the operating room personnel.Wrong-level spine surgery remains a prevalent problem, with nearly 50% of surgeons having performed a wrong-level surgery at least once during their career, according to a recent survey by the American Association of Neurological Surgeons. 4 Such an error fails to resolve the pathological condition and alleviate the patient's symptoms.Identifying the correct spinal level intraoperatively is critical to optimizing the patient's surgical outcome, thereby eliminating any adverse consequences associated with wrong-level spine surgery. Multiple factors can increase the difficulty of spinal localization, including osteoporosis, obesity, scapular/humeral shadow, anatomical variations in the number of vertebrae, and ribs. 11Although various techniques have been proposed to facilitate intraoperative localization of the vertebral level, none has achieved widespread use.In this paper a new technique to localize pathology within the thoracic spine is presented. We propose the placement of a radiopaque marker, in a separate preoperative stage, with postplacement confirmation of the level with either CT or MRI, depending on the spinal pathology. This approach ensures confident localization of the defined pathology while causing minimal discomfort to the patient, minimizes the intraoperative radiation exposure to the patient and to the operating room personnel, and provides a safe, effective method of preventing a wrong-level surgery. Methods A patient presented with symptoms of progressive myelopathy referable to an MRI-documented thoracicNovel technique for preoperative pedicle localization in spinal surgery with challenging anatomy Department of Neurological Surgery, George Washington University Medical Center, Washington, DCAccurately localizing a spine level in the thoracic spine is often not easily achieved with the existing imaging modalities available in the operating room. The coordination of the preoperative imaging pathology with intraoperative imaging is even more difficult in patients with challenging anatomy. Using standard percutaneous techniques, the authors placed a radiopaque embolization coil into the pedicle of interest under biplanar fluoroscopy in 1 patient. Thoracic spine MRI along with scout MRI was then performed to confirm coil marker placement in relation to the actual spine pathology prior to surgical intervention. No complications were ...

A Novel Localization Method in Minimally Invasive Spine Surgery: Localization Membrane

“…Some novel localization methods have been designed and applied, mainly including invasive and noninvasive operations. Invasive operations include preoperative percutaneous ducial metallic marker placement 3 , preoperative metallic coil placement 4,5 , preoperative percutaneous placement of a marking wire 6 , preoperative percutaneous placement of polymethyl-methacrylate 7 and preoperative percutaneous injection of methylene blue 8 . Non-invasive operations include intraoperative spinal navigation 13 , arti cial intelligence and the spinal locator.…”

“…Some novel localization methods have been designed and applied, mainly including invasive and noninvasive operations. Invasive operations mainly refer to preoperative percutaneous marker placement [3][4][5][6][7][8] , which do enable accurate positioning and shorten the positioning time, however, may carry the risk of infection and displacement. Non-invasive operations have garnered broader support and popularity, which include spinal navigation, arti cial intelligence and the spinal locator 9 .…”

Pre- and intraoperative thoracic spine localization techniques: a systematic review

“…19 Young et al described a similar technique using an embolization coil, but they deployed the coil directly into the pedicle of interest rather than detaching above. 20 Expanding on this technique, Maduri et al proposed removing a small cylindrical bone fragment from the pedicle before inserting the embolization coils. 21 The authors suggest that using this technique locks the coils in place and minimizes the risk for coil migration.…”

Pearls: Wrong-level Surgery Prevention

“…Several localization techniques have been described and can be generally divided into those that place markers in the soft tissue, and those that place them in the bone itself [1,3,[5][6][7][8]. In these challenging patients, I firmly believe that there is no role for soft-tissue markers.…”