The Child’s Age and the Size of the Curvature Do Not Affect the Accuracy of Screw Placement with the Free-Hand Technique in Spinal Deformities in Children and Adolescents

Abstract

Background: The current method of treatment of spinal deformities would be almost impossible without pedicle screws (PS) placement. There are only a few studies evaluating the safety of PS placement and possible complications in children during growth. The present study was carried out to evaluate the safety and accuracy of PS placement in children with spinal deformities at any age using postoperative computed tomography (CT) scans. Methods: 318 patients (34 males and 284 females) who underwent 6358 PS fixations for pediatric spinal deformities were enrolled in this multi-center study. The patients were divided into three age groups: less than 10 years old, 11–13 years old, and 14–18 years old. These patients underwent postoperative CT scans and were analyzed for pedicle screw malposition (anterior, superior, inferior, medial, and lateral breaches). Results: The breach rate was 5.92% for all pedicles. There were 1.47% lateral and 3.12% medial breaches for all pedicles with tapping canals, and 2.66% lateral and 3.84% medial breaches for all pedicles without a tapping canal for the screw. Of the 6358 screws placed in the thoracic, lumbar, and sacral spine, 98% of the screws were accurately placed (grade 0, 1, and juxta pedicular). A total of 56 screws (0.88%) breached more than 4 mm (grade 3), and 17 (0.26%) screws were replaced. No new and permanent neurological, vascular, or visceral complications were encountered. Conclusions: The free-hand technique for pedicle screw placement in the acceptable and safety zone in pedicles and vertebral bodies was 98%. No complications associated with screw insertion in growth were noted. The free-hand technique for pedicle screw placement can be safely used in patients at any age. The screw accuracy does not depend on the child’s age nor the size of the deformity curve. Segmental instrumentation with posterior fixation in children with spinal deformities can be performed with a very low complication rate. Navigation of the robot is only an auxiliary tool in the hands of the surgeons, and the result of the work ultimately depends on the surgeons.

Influences of Increasing Pedicle Screw Diameter on Widening Vertebral Pedicle Size during Surgery in Spinal Deformities in Children and Adolescents without Higher Risk of Pedicle and Vertebral Breaches

“…Again, these results were consistent with the fact that the center wall is thicker and stronger than the side wall. Medial breaches are mostly observed in specific types of pedicles or severe and neglected spinal deformities [ 13 ]. However, care should be taken when using a screw that is too large.…”

“…Treatment of spinal deformities in children and adolescents is currently impossible without the use of pedicle screws [ 1 , 2 , 3 ]. The literature describes the morphology of pedicles and the frequency of occurrence of their types in the population, which has a significant impact on the safety of screw insertion and subsequent correction [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. Many scientific studies on the biomechanics of screws have proven that, in addition to the selection of appropriate screw parameters, increasing the diameter of the screw so that it optimally fills the pedicle will result in the best stability and resistance of the screw to the effect of pulling out and breaking [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ].…”

The Influence of Increased Pedicle Screw Diameter and Thicker Rods on Surgical Results in Adolescents Undergoing Posterior Spinal Fusion for Idiopathic Scoliosis

“…Also in this study, only 0.88% breached more than 4 mm vertebral walls and 0.26% of the screws were re-inserted. There were no new neurological, vascular, or visceral complications [60]. This was possible because the medial wall is 2-3 times thicker than the lateral wall at the thoracic level, which resists medial breaching [22,56].…”

“…Aside from correction, safety and accuracy remain top priorities in scoliotic instrumentation. Segmental screw placement in the upper-and mid-thoracic spine is technically challenging, with high misplacement rates [51,59,60]. In particular, increased screw diameters are often avoided for pediatric thoracic vertebrae, given their smaller pediatric pedicle size [22,59,61].…”

Radiological and Pulmonary Results of Surgical Treatment of Severe Idiopathic Scoliosis Using Preoperative Halo Gravity Traction Compared with Less Invasive Temporary Internal Distraction in Staged Surgery in Adolescents

“…Traction initiation commenced at 2-3 kg and was incrementally augmented to a maximum of 50% of the patient's body weight, mirroring protocols detailed in prior studies [4,10,20]. Subsequent to the completion of the HGT regimen, corrective measures for the spinal deformity were undertaken through a conventional posterior approach employing segmental screw instrumentation via a free-hand technique, alongside posterior column osteotomy, as documented in the pertinent literature [27][28][29][30][31]. A case illustration showcasing the management of severe idiopathic scoliosis with HGT and posterior spinal fusion (PSF) is delineated in Figure 1.…”