Minimally invasive screw fixation of fractures in the thoracic spine: CT-controlled pre-surgical guidewire implantation in routine clinical practice

Accuracy and Safety Assessment of Subaxial Cervical Pedicle Screw Instrumentation: A Systematic Review

BACKGROUND CONTEXT

Given increasing use of both cervical pedicle screw (CPS) fixation in the subaxial cervical spine (C3-C7) and emerging navigation technologies, a quantitative profile of safety and accuracy remains wanting. Compared with lateral mass instrumentation of this region, CPS fixation shows superior biomechanical properties but poses higher risk of complications because of the narrow cervical pedicle width and proximity to neurovascular structures.

PURPOSE

This systematic review quantifies the accuracy and safety of all types of subaxial CPS insertion, with or without navigation or template-based methods, to weigh the strengths and limitations of each technique.

STUDY DESIGN

Systematic review according to PRISMA guidelines.

PATIENT SAMPLE

Patients who underwent CPS instrumentation since its introduction.

OUTCOME MEASURES

Primary and secondary outcomes in our review included pedicle screw breach in the subaxial cervical spine determined on intra- or postoperative imaging, and screw-related operative complications, respectively.

METHODS

Following the PRISMA guidelines, our literature search of PubMed, Cochrane, and Scopus databases identified 3,312 clinical studies (1980-2024) using subaxial CPS that assessed for screw accuracy. After full-text analysis, data extracted included number of CPS, level of placement, number of patients, indications, insertion techniques, accuracy assessment method, classification of accuracy, breach rate, complication rate, and study origin.

RESULTS

The 73 studies included in final analysis from Asia (80%), Europe (12%) and North America (8%) yielded 14,118 CPS in 3,342 patients (1999-2024). Accuracy rates were 85.3% for 10,108 CPS placed with non-navigated techniques (free-hand and fluoroscopy), 82.7% for 3,067 with navigation techniques, and 96.3% for 943 CPS placed using 3D templates. Complication rates were 1.1%, 2.1%, and zero, respectively.

CONCLUSION

Our comprehensive review of more than 14,000 subaxial CPSs inserted found rates of high 84% overall accuracy and low 1.2% perioperative complications (i.e., attributed to a misplaced screw). With biomechanical advantages superior to lateral mass screws, our quantitative findings support consideration for CPS instrumentation in select patients by experienced surgeons.

Biomechanics and clinical outcome after posterior stabilization of mid-thoracic vertebral body fractures: a systematic literature review

PURPOSE

The aim of this review is to systematically screen the literature for clinical and biomechanical studies dealing with posterior stabilization of acute traumatic mid-thoracic vertebral fractures in patients with normal bone quality.

METHODS

This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications up to December 2018 dealing with the posterior stabilization of fractures of the mid-thoracic spine.

RESULTS

Altogether, 1012 articles were retrieved from the literature search. A total of 960 articles were excluded. A total of 16 articles were dealing with the timing of surgery in polytraumatized patients, patients suffering of neurologic deficits after midthoracic fractures, and the impact of concomitant thoracic injuries and were excluded. Thus, 36 remaining original articles were included in this systematic review depicting the topics biomechanics, screw insertion, and outcome after posterior stabilization. The overall level of evidence of the vast majority of studies is low.

CONCLUSION

High quality studies are lacking. Long-segmental stabilization is indicated in unstable midthoracic fractures with concomitant sternal fractures. Generally, long-segmental constructs seem to be the safer treatment strategy considering the relative high penetration rate of pedicle screws in this region. Thereby, navigated insertion techniques and intraoperative 3D-imaging help to improve pedicle screw placement accuracy.