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Shima K, Fujibayashi S, Otsuki B, Murata K, Shimizu T, Sono T, Matsuda S. S2 Alar Screw Insertion Accuracy and Factors Associated With Screw Loosening and Lumbosacral Nonunion. World Neurosurg 2024; 184:e129-e136. [PMID: 38253180 DOI: 10.1016/j.wneu.2024.01.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/12/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To investigate S2 alar screw (S2AS) accuracy and factors associated with S2AS loosening and lumbosacral nonunion. METHODS We retrospectively reviewed patients who underwent lumbosacral fusion surgery with S2AS addition under fluoroscopy. S2AS loosening and lumbosacral nonunion were analyzed using a 1-year postoperative computed tomography. S2AS insertion accuracy was originally classified as accurate, short, anterior perforation, lateral perforation, and sacroiliac joint (SIJ) deviation among lateral perforation. Clinical data including sex, age, body mass index, fused segments, fusion procedure, primary or revision surgery, Japanese Orthopedic Association scores and complications were collected. Factors associated with S2AS loosening and lumbosacral nonunion were analyzed. RESULTS A total of 37 patients (74 screws, age: 63.78 ± 13.57 years, female/male: 14/23 patients, body mass index: 23.11 ± 2.53, fused segments: 1-4 levels, revision: 38%) were included. S2AS loosening and lumbosacral nonunion were observed in 18 screws (13%) and 8 patients (22%) respectively. Only 35 screws (47%) were inserted accurately in our classification. Short, lateral perforation, and anterior perforation were observed in 14 screws (19%), 22 screws (30%), and 3 screws (4.1%). SIJ deviation was seen in 15 screws (20%) Factors associated with S2AS loosening were older age (P = 0.038), fusion levels (P = 0.011), and SIJ deviation (P < 0.001). S2AS loosening affects S1 pedicle screw (S1PS) loosening (P = 0.001). Furthermore, S2AS loosening is a risk factor for lumbosacral nonunion (P = 0.046). CONCLUSIONS S2AS insertion under fluoroscopy is inaccurate. S2AS loosening induces S1PS loosening and lumbosacral nonunion. Surgeons should avoid deviating to SIJ, especially in older patients and relatively longer fusion.
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Affiliation(s)
- Koichiro Shima
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | | | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichi Murata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takayoshi Shimizu
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Sono
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Pan A, Yang H, Hai Y, Liu Y, Zhang X, Ding H, Li Y, Lu H, Ding Z, Xu Y, Pei B. Adding sacral anchors through an S1 alar screw and multirod construct as a strategy for lumbosacral junction augmentation: an in vitro comparison to S1 pedicle screws alone with sacroiliac fixation. J Neurosurg Spine 2023; 38:107-114. [PMID: 36029265 DOI: 10.3171/2022.6.spine22424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/28/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Achieving solid fusion of the lumbosacral junction continues to be a challenge in long-segment instrumentation to the sacrum. The purpose of this study was to test the condition of adding sacral anchors through an S1 alar screw (S1AS) and multirod construct relative to using S1 pedicle screws (S1PSs) alone with sacroiliac fixation in lumbosacral junction augmentation. METHODS Seven fresh-frozen human lumbar-pelvic spine cadaveric specimens were tested under nondestructive moments (7.5 Nm). The ranges of motion (ROMs) in extension, flexion, left and right lateral bending (LB), and axial rotation (AR) of instrumented segments (L3-S1); the lumbosacral region (L5-S1); and the adjacent segment (L2-3) were measured, and the axial construct stiffness (ACS) was recorded. The testing conditions were 1) intact; 2) bilateral pedicle screw (BPS) fixation at L3-S1 (S1PS alone); 3) BPS and unilateral S2 alar iliac screw (U-S2AIS) fixation; 4) BPS and unilateral S1AS (U-S1AS) fixation; 5) BPS and bilateral S2AIS (B-S2AIS) fixation; and 6) BPS and bilateral S1AS (B-S1AS) fixation. Accessory rods were used in testing conditions 3-6. RESULTS In all directions, the ROMs of L5-S1 and L3-S1 were significantly reduced in B-S1AS and B-S2AIS conditions, compared with intact and S1PS alone. There was no significant difference in reduction of the ROMs of L5-S1 between B-S1ASs and B-S2AISs. Greater decreased ROMs of L3-S1 in extension and AR were detected with B-S2AISs than with B-S1ASs. Both B-S1ASs and B-S2AISs significantly increased the ACS compared with S1PSs alone. The ACS of B-S2AISs was significantly greater than that of B-S1ASs, but with greater increased ROMs of L2-3 in extension. CONCLUSIONS Adding sacral anchors through S1ASs and a multirod construct was as effective as sacropelvic fixation in lumbosacral junction augmentation. The ACS was less than the sacropelvic fixation but with lower ROMs of the adjacent segment. The biomechanical effects of using S1ASs in the control of long-instrumented segments were moderate (better than S1PSs alone but worse than sacropelvic fixation). This strategy is appropriate for patients requiring advanced lumbosacral fixation, and the risk of sacroiliac joint violation can be avoided.
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Affiliation(s)
- Aixing Pan
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Honghao Yang
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Yong Hai
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Yuzeng Liu
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Xinuo Zhang
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Hongtao Ding
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Yue Li
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Hongyi Lu
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Zihao Ding
- 1Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University
| | - Yangyang Xu
- 2Beijing Key Laboratory for Design and Evaluation Technology of Advanced Implantable & Interventional Medical Devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Baoqing Pei
- 2Beijing Key Laboratory for Design and Evaluation Technology of Advanced Implantable & Interventional Medical Devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
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Watanabe N, Takigawa T, Uotani K, Oda Y, Misawa H, Tanaka M, Ozaki T. Three-Dimensional Analysis of the Ideal Entry Point for Sacral Alar Iliac Screws. Asian Spine J 2022; 16:874-881. [PMID: 35184519 PMCID: PMC9827214 DOI: 10.31616/asj.2021.0268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/17/2021] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN This is a virtual three-dimensional (3D) imaging study examining computed tomography (CT) data to investigate instrumentation placement. PURPOSE In this study, we aim to clarify the ideal entry point and trajectory of the sacral alar iliac (SAI) screw in relationship to the dorsal foramen at S1 and the respective nerve root. OVERVIEW OF LITERATURE To the best of our knowledge, there is yet no detailed 3D imaging study on the ideal entry point of the SAI screw. Despite the evidence suggesting that the dorsal foramen at S1 is a landmark on the sacrum, the S1 nerve root disruption is a general concern during the insertion of SAI screws. No other study has been published examining the nerve root location at the S1and SAI screw insertions. METHODS Preoperative CT data from 26 patients pertaining to adult spinal deformities were investigated in this study. We applied a 3D image processing method for a detailed investigation. Virtual cylinders were used to mimic SAI screws. These were placed to penetrate the sacral iliac joint without violating the other cortex. We then assessed the trajectory of the longest SAI screw and the ideal entry point of SAI using a color mapping method on the surface of the sacrum. We measured the location of the nerve root at S1 in relation to the foramen at S1 and the sacral surface. RESULTS As per the results of our color mapping, it was determined that areas that received high scores are located medially and caudally to the dorsal foramen of S1. The mean angle between a horizontal line and a line connecting the medial edge of the foramen and nerve root at S1 was 93.5°. The mean distances from the dorsal medial edge of the foramen and sacral surface to S1 nerve root were 21.8 mm and 13.9 mm, respectively. CONCLUSIONS The ideal entry point of the SAI screw is located medially and caudally to the S1 dorsal foramen based on 3D digital mapping. It is also shown that this entry point spares the S1 nerve root from possible iatrogenic injuries.
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Affiliation(s)
- Noriyuki Watanabe
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama,
Japan,Department of Orthopaedic Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi,
Japan
| | - Tomoyuki Takigawa
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama,
Japan,Department of Orthopaedic Surgery, Kobe Red Cross Hospital, Kobe,
Japan
| | - Koji Uotani
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama,
Japan,Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama,
Japan
| | - Yoshiaki Oda
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama,
Japan
| | - Haruo Misawa
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama,
Japan
| | - Masato Tanaka
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama,
Japan,Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama,
Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama,
Japan
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The lateral entry point S2 alar-iliac (L-S2AI) screw: a preoperative computed tomography analysis of adult spinal deformity patients. Spine Deform 2022; 10:669-678. [PMID: 35088384 DOI: 10.1007/s43390-021-00462-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To radiographically compare lateral entry point S2-alar-iliac (L-S2AI) screw with conventional S2AI (C-S2AI) and conventional iliac screw (CIS) lengths and trajectories. METHODS Twenty-five preoperative CT scans of consecutive patients undergoing adult spinal deformity realignment surgery over a random 2-year period were analysed. Maximum in-bone length, caudal and lateral trajectories of CIS, C-S2AI, and L-S2AI screws were measured and compared using One-way ANOVA with Tukey's post hoc tests. Multivariate logistic regression was performed to identify predictors of high screw length discrepancy between C-S2AI and L-S2AI. RESULTS Potential screw length was longest for CIS, followed by L-S2AI, then C-S2AI (114.5 ± 8.3 mm vs 101.4 ± 9.6 mm vs 80.6 ± 5.9 mm, respectively) in all patients (p < 0.001). Actual screw lengths found both CIS and L-S2AI to be longer than C-S2AI (95.3 ± 8.5 mm and 93.4 ± 7.5 mm vs 82.1 ± 7.3 mm; p = 0.008 and 0.003). Potential lateral angulation was smallest for CIS, followed by L-S2AI, then C-S2AI (21.9 ± 7.0° vs 31.9 ± 7.1° vs 40.9 ± 6.7°, respectively) in all patients (p < 0.001). L-S2AI and C-S2AI had the same caudal angulation (24.9 ± 6.8°), which was smaller than CIS (30.8 ± 5.8°) in all patients (p < 0.001). Univariate, but not multivariate analysis, revealed that lumbar lordosis > 40° (OR 7.2, p = 0.041), diagnosis of degenerative spondylolisthesis (OR 10.5, p = 0.017), and > 7 instrumented levels (OR 2.6, p = 0.049) were significantly associated with high screw discrepancies. CONCLUSION The L-S2AI screw combines advantages of CIS and C-S2AI screws, which includes increased screw length, reduced lateral angulation, a low-profile screw head, ease of connection to proximal hardware, and the biomechanical advantage of a quadcortical purchase.
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Funao H, Yamanouchi K, Fujita N, Kado Y, Kato S, Otomo N, Isogai N, Sasao Y, Ebata S, Kitagawa Y, Watanabe K, Obara H, Ishii K. Comparative Study of S2-Alar-Iliac Screw Trajectories between Males and Females Using Three-Dimensional Computed Tomography Analysis: The True Lateral Angulation of the S2-Alar-Iliac Screw in the Axial Plane. J Clin Med 2022; 11:jcm11092511. [PMID: 35566635 PMCID: PMC9104294 DOI: 10.3390/jcm11092511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
The S2 alar-iliac screw (S2AIS) is commonly used for long spinal fusion as a rigid distal foundation in spinal deformity surgeries, and it is also used in percutaneous sacropelvic fixation for providing an in-line connection to the proximal spinal constructs without using offset connectors. Although the pelvic shape is different between males and females, reports on S2AIS trajectories according to gender have been scarce in the literature. In this paper, S2AIS trajectories are compared between males and females using pelvic three-dimensional computed tomography (3D-CT) in a normal Japanese population. After resetting the caudal angulation in CT-imaging plane manipulation, the angulation of S2AIS was more lateral in the axial plane and more horizontal in the coronal plane in females. Mean distances from the midline to starting points of S2AIS tended to be shorter in females, whereas mean distances from the midline to the posterior superior iliac spine was significantly longer in females. We also found that there were positive correlations between the patients’ height and the maximal lengths of S2AISs, and the patients’ height and minimal areas of S2AIS pathways. Our results are useful not only for conventional open spinal surgery, but also for minimally invasive spine surgery.
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Affiliation(s)
- Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Narita 286-8520, Japan;
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan
- Correspondence: (H.F.); (K.I.); Tel.: +81-476-35-5600 (H.F. & K.I.)
| | - Kento Yamanouchi
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Narita 286-8520, Japan;
| | - Naruhito Fujita
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Narita 286-8520, Japan;
| | - Yukihiro Kado
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Narita 286-8520, Japan;
| | - Shuzo Kato
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan
| | - Nao Otomo
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan
| | - Norihiro Isogai
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan
| | - Yutaka Sasao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan
| | - Shigeto Ebata
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Narita 286-8520, Japan;
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.K.); (H.O.)
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan;
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan; (Y.K.); (H.O.)
| | - Ken Ishii
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita 286-0048, Japan; (K.Y.); (N.F.); (S.K.); (N.O.); (N.I.); (Y.S.); (S.E.)
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Narita 286-8520, Japan;
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan;
- Correspondence: (H.F.); (K.I.); Tel.: +81-476-35-5600 (H.F. & K.I.)
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Computed Tomography-Based Navigation System in Current Spine Surgery: A Narrative Review. Medicina (B Aires) 2022; 58:medicina58020241. [PMID: 35208565 PMCID: PMC8880580 DOI: 10.3390/medicina58020241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 02/03/2022] [Indexed: 11/26/2022] Open
Abstract
The number of spine surgeries using instrumentation has been increasing with recent advances in surgical techniques and spinal implants. Navigation systems have been attracting attention since the 1990s in order to perform spine surgeries safely and effectively, and they enable us to perform complex spine surgeries that have been difficult to perform in the past. Navigation systems are also contributing to the improvement of minimally invasive spine stabilization (MISt) surgery, which is becoming popular due to aging populations. Conventional navigation systems were based on reconstructions obtained by preoperative computed tomography (CT) images and did not always accurately reproduce the intraoperative patient positioning, which could lead to problems involving inaccurate positional information and time loss associated with registration. Since 2006, an intraoperative CT-based navigation system has been introduced as a solution to these problems, and it is now becoming the mainstay of navigated spine surgery. Here, we highlighted the use of intraoperative CT-based navigation systems in current spine surgery, as well as future issues and prospects.
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Matsukawa K, Abe Y, Mobbs RJ. Novel Technique for Sacral-Alar-Iliac Screw Placement Using Three-Dimensional Patient-Specific Template Guide. Spine Surg Relat Res 2021; 5:418-424. [PMID: 34966869 PMCID: PMC8668215 DOI: 10.22603/ssrr.2020-0221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/27/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction The sacral-alar-iliac (SAI) screw technique is becoming popular for sacropelvic fixation. However, appropriately placing SAI screws is technically demanding because of a narrow safe corridor and the risk of neurovascular/visceral injuries. Recently, a three-dimensional patient-specific template guiding technique for pedicle screw placement has been considered a promising method to improve accuracy and safety. The objective of the present study was to investigate the accuracy of SAI screw placement with a patient-specific template guide using cadaveric and prospective clinical pilot studies. Methods Three-dimensional planning of SAI screw placement, including entry point, screw trajectory, length, and diameter, was performed using a computer simulation software. Then, three-dimensional printed patient-specific template guides were created based on the plan. Firstly, a total of 12 SAI screws were placed for 6 cadaveric specimens using the guides. Next, in a prospective clinical trial, a total of 20 SAI screws were placed for 10 consecutively enrolled patients. The safety and accuracy of screw placement were analyzed using postoperative computed tomography by the evaluation of any cortical breach and measurement of screw deviations between the planned and actual screw positions. Results All the screws showed no perforation. In the cadaveric study, the mean horizontal and vertical deviations from the planned screw position at the entry point were 1.40±1.21 mm and 1.34±1.09 mm, respectively. The mean angular deviations in the sagittal and transverse planes were 1.68°±1.24° and 1.53°±1.06°, respectively. The results of the clinical study showed comparable accuracy with those of the cadaveric study, except for the vertical deviation at the entry point (p=0.048). Conclusions This is the first study to evaluate the feasibility and accuracy of using a patient-specific template guide for SAI screw placement. This technique could become an effective solution to achieve accurate screw placement.
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Affiliation(s)
- Keitaro Matsukawa
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Tokyo, Japan
| | - Yuichiro Abe
- Department of Orthopaedic Surgery, Wajokai Eniwa Hospital, Eniwa, Japan
| | - Ralph Jasper Mobbs
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, Sydney, Australia.,NeuroSpine Surgery Research Group (NSURG), Level 7, Prince of Wales Private Hospital, Sydney, Australia
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de Sousa Pontes MD, Ismael LK, Francisco LA, Herrero CFPDS. Description of the Sacropelvic Parameters Measurement Method for S2-alar iliac Screw Insertion. Rev Bras Ortop 2020; 55:702-707. [PMID: 33364647 PMCID: PMC7748935 DOI: 10.1055/s-0040-1713163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 02/20/2020] [Indexed: 10/25/2022] Open
Abstract
Objective Description of the sacropelvic parameters measurement method for S2-alar iliac (S2AI) screw insertion. Methods Descriptive study of the method for measuring sacropelvic parameters for the insertion of the S2AI screw using computed tomography (CT). The data evaluated in multiplanar reconstructions were the parameters of the screw trajectory, including length, diameter and angles of the trajectory in the axial and sagittal planes. Results From the sagittal reconstruction, the axis of the series of axial slices is angled three-dimensionally so that it is possible to visualize the S2 vertebra, the screw entry point, and the anteroinferior iliac spine (AIIS) in the same plane. The entry point is demarcated at the midpoint between the dorsal foramina of S1 and S2. To measure the length of the screw, lines are drawn tangent to the inner and outer cortices of the iliac. The diameter is determined by the shortest distance between the inner and outer iliac faces minus half of the diameter of the screw chosen medially and laterally. The path angle in the axial plane is formed by the anteroposterior midline of the sacrum and the line of the screw length. The craniocaudal inclination angle in relation to the S1 plateau corresponds to the degree of inclination made in the sagittal plane to find the image in which the entry point and the AIIS are seen in the same plane. Conclusion It was possible to adequately assess, through multiplanar CT reconstructions, the sacropelvic parameters necessary for the safe insertion of the S2AI screw.
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Affiliation(s)
- Mariana Demétrio de Sousa Pontes
- Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor System, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Lucas Klarosk Ismael
- Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor System, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Lucas Américo Francisco
- Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor System, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Carlos Fernando Pereira da Silva Herrero
- Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor System, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Florio M, Capasso L, Olivi A, Vitiello C, Leone A, Liuzza F. 3D - Navigated percutaneous screw fixation of pelvic ring injuries - a pilot study. Injury 2020; 51 Suppl 3:S28-S33. [PMID: 32723529 DOI: 10.1016/j.injury.2020.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/02/2020] [Accepted: 07/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Screw fixation of pelvic ring fractures is a common, but demanding procedure and navigation techniques were introduced to increase the precision of screw placement. The purpose of this case series is to demonstrate a lower screw malposition rate using percutaneous fixation of pelvic ring fractures and sacroiliac dislocations guided by navigation system based on 3D-fluoroscopic images compared to traditional imaging techniques and to evaluate the functional outcomes of this innovative procedure. PATIENT AND METHODS 10 cases of disrupted pelvic ring lesions treated in our hospital from February 2018 to December 2018 were included for closed reduction and percutaneous screw fixation of using with O-Arm and the acquisition by the Navigator. Preoperative assessment was performed on the patients by means of X Ray imaging and CT scan. Routine CT was carried out on third postoperative day to evaluate screw placement. Measures of radiation exposure were extracted directly from reports provided by system. Quality of life was evaluated by SF 36-questionnaire 6 months after surgery. RESULTS 12 iliosacral- and 2 ramus pubic-screws were inserted. In post-operative CT-scans the screw position was assessed and graded using the score described by Smith. No wound infection or iatrogenic neurovascular damage were observed. No re-operations were performed. The exposure to radiation is, for the patient, slightly greater than that resulting from the use of traditional fluoroscopic systems, while it is naught for the surgical team, which at the time of image acquisition is located outside the room. DISCUSSION AND CONCLUSION The execution of an intraoperative 3D-fluoroscopic scan can on its own suffice as a post-operative control examination since its accuracy is similar to that of the post-operative CT. The use of a navigated 3d fluoroscopy exposes the patient to an amount of radiation slightly greater than that of traditional fluoroscopy, but the dose is lower than a CT examination. For the operating team, exposure to radiation is naught. 3D-fluoroscopic navigation is a safe tool providing high accuracy of percutaneous screw placement for pelvic ring fractures. Finally, despite the small cohort of patients studied, the excellent results obtained regarding the patients' quality of life and the absence of complications allow us to look positively at the future of this technique, which needs further studies and improvement.
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Affiliation(s)
- Michela Florio
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy
| | - Luigi Capasso
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy.
| | - Alessandro Olivi
- Department of Neurosurgery A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy
| | - Carla Vitiello
- Department of Radiology, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy
| | - Antonio Leone
- Department of Radiology, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy
| | - Francesco Liuzza
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy
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10
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Radley JM, Hill BW, Nicolaou DA, Huebner SB, Napier KB, Salazar DH. Bone density of first and second segments of normal and dysmorphic sacra. J Orthop Traumatol 2020; 21:6. [PMID: 32451838 PMCID: PMC7248149 DOI: 10.1186/s10195-020-00545-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 04/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background Iliosacral screw fixation is safe and effective but can be complicated by loss of fixation, particularly in patients with osteopenic bone. Sacral morphology dictates where iliosacral screws may be placed when stabilizing pelvic ring injuries. In dysmorphic sacra, the safe osseous corridor of the upper sacral segment (S1) is smaller and lacks a transsacral corridor, increasing the need for fixation in the second sacral segment (S2). Previous evidence suggests that S2 is less dense than S1. The aim of this cross-sectional study is to further evaluate bone mineral density (BMD) of the S1 and S2 iliosacral osseous pathways through morphology stratification into normal and dysmorphic sacra. Materials and methods Pelvic computed tomography scans of 50 consecutive trauma patients, aged 18 to 50 years, from a level 1 trauma center were analyzed prospectively. Five radiographic features (upper sacral segment not recessed in the pelvis, mammillary bodies, acute alar slope, residual S1 disk, and misshapen sacral foramen) were used to identify dysmorphic characteristics, and sacra with four or five features were classified as dysmorphic. Hounsfield unit values were used to estimate the regional BMD of S1 and S2. Student’s t-test was utilized to compare the mean values at each segment, with statistical significance being set at p < 0.05. No change in clinical management occurred as a result of inclusion in this study. Results A statistical difference in BMD was appreciated between S1 and S2 in both normal and dysmorphic sacra (p < 0.0001), with 28.4% lower density in S2 than S1. Further, S1 in dysmorphic sacra tended to be 4% less dense than S1 in normal sacra (p = 0.047). No difference in density was appreciated at S2 based on morphology. Conclusions Our results would indicate that, based on BMD alone, fixation should be maximized in S1 prior to fixation in S2. In cases where S2 fixation is required, we recommend that transsacral fixation should be strongly considered if possible to bypass the S2 body and achieve fixation in the cortical bone of the ilium and sacrum. Level of evidence Level III.
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Affiliation(s)
- Joseph M Radley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center-Hamot, 201 State Street, Erie, PA, 16550, USA.
| | - Brian W Hill
- Department of Orthopaedic Surgery, Saint Louis University Medical School, 3635 Vista Ave, Saint Louis, MO, 63110, USA
| | - Daemeon A Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University Medical School, 3635 Vista Ave, Saint Louis, MO, 63110, USA
| | - Stephen B Huebner
- Department of Radiology, Saint Louis University Medical School, 3635 Vista Ave, Saint Louis, MO, 63110, USA
| | - Kelby B Napier
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University, 510 S Kingshighway Blvd, Saint Louis, MO, 63110, USA
| | - Dane H Salazar
- Department of Orthopaedics, Loyola University, Chicago, 2160 S 1st Ave, Maywood, IL, 60153, USA
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11
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Kochanski RB, Lombardi JM, Laratta JL, Lehman RA, O'Toole JE. Image-Guided Navigation and Robotics in Spine Surgery. Neurosurgery 2020; 84:1179-1189. [PMID: 30615160 DOI: 10.1093/neuros/nyy630] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/04/2018] [Indexed: 01/27/2023] Open
Abstract
Image guidance (IG) and robotics systems are becoming more widespread in their utilization and can be invaluable intraoperative adjuncts during spine surgery. Both are highly reliant upon stereotaxy and either pre- or intraoperative radiographic imaging. While user-operated IG systems have been commercially available longer and subsequently are more widely utilized across centers, robotics systems provide unique theoretical advantages over freehand and IG techniques for placing instrumentation within the spine. While there is a growing plethora of data showing that IG and robotic systems decrease the incidence of malpositioned screws, less is known about their impact on clinical outcomes. Both robotics and IG may be of particular value in cases of substantial deformity or complex anatomy. Indications for the use of these systems continue to expand with an increasing body of literature justifying their use in not only guiding thoracolumbar pedicle screw placement, but also in cases of cervical and pelvic instrumentation as well as spinal tumor resection. Both techniques also offer the potential benefit of reducing occupational exposures to ionizing radiation for the operating room staff, the surgeon, and the patient. As the use of IG and robotics in spine surgery continues to expand, these systems' value in improving surgical accuracy and clinical outcomes must be weighed against concerns over cost and workflow. As newer systems incorporating both real-time IG and robotics become more utilized, further research is necessary to better elucidate situations where these systems may be particularly beneficial in spine surgery.
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Affiliation(s)
- Ryan B Kochanski
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Joseph M Lombardi
- Department of Orthopedic Surgery, Columbia University, New York, New York
| | - Joseph L Laratta
- Department of Orthopedic Surgery, Columbia University, New York, New York
| | - Ronald A Lehman
- Department of Orthopedic Surgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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12
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Morphometric measurement and applicable feature analysis of sacral alar-iliac screw fixation using forward engineering. Arch Orthop Trauma Surg 2020; 140:177-186. [PMID: 31538234 DOI: 10.1007/s00402-019-03257-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate S1AI-S4AI screw channels with three-dimensional digital technology simulation analysis and to study the feasibility and applicable features of sacral alar-iliac screw fixation in adults. MATERIALS AND METHODS Forty (20 men and 20 women) normal adult's pelvic CT scan data sets were selected to reconstruct the three-dimensional pelvic model. The ideal S1AI-S4AI screw channels were simulated, followed by precise measurement of their parameters. RESULTS The results showed that there were no significant differences in the transverse angles, sagittal angles, radiuses of the maximal inscribed circles, or lengths of the screw channels in S1AI-S2AI screws between genders (P > 0.05). In contrast, the radiuses of the maximal inscribed circles on the left and right, respectively, were 5.93 ± 1.02 mm and 5.92 ± 1.04 mm in males and 4.64 ± 0.98 mm and 4.59 ± 0.95 mm in females, and there was a significant difference in S3AI screws between genders (P < 0.05). With a radius of 2.50 mm considered to be standard, there were 25 cases (62.5%) with an S4AI screw channel radius ≤ 2.50 mm in 40 adults, and 15 cases (37.5%; 9 males and 6 females) with a radius > 2.50 mm. Furthermore, the transverse angles, the sagittal angles, the lengths of the screw channels, and the radiuses of the maximal inscribed circles were significantly different between genders in 15 cases (P < 0.05). CONCLUSION Only one maximum ideal screw can be placed on one side at a time. With a radius of 2.50 mm considered to be standard, it is feasible to place S1AI-S3AI screws with a radius > 2.50 mm in the entire adult population and S4AI screws with a radius > 2.50 mm in some of the adult population. Furthermore, preoperative three-dimensional reconstruction and three-matic research software can effectively simulate the sacral alar-iliac screw channels, and they can provide accurate data for clinical applications.
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13
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Tavares-Júnior MCM, Sanchez FB, Iturralde JDU, Fernandes RJR, Marcon RM, Cristante AF, de Barros-Filho TEP, Letaif OB. Comparative tomographic study of the iliac screw and the S2-alar-iliac screw in children. Clinics (Sao Paulo) 2020; 75:e1824. [PMID: 32935824 PMCID: PMC7470428 DOI: 10.6061/clinics/2020/e1824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/15/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The recent advancements in spine fixation aid in the treatment of complex spinal pathologies. Both the iliac screw (IS) and the S2-alar-iliac (S2AI) screw provide adequate stability in the fixation of complex lumbosacral spine pathologies, leading to a significant increased rate of using these techniques in the daily practice of the spine surgeons. This study aims to analyze, describe, and compare the insertion and positioning parameters of the S2AI screw and IS techniques in children without spinal deformities. METHODS An observational retrospective study was conducted at a university hospital in 2018, with 25 computed tomography (CT) images selected continuously. Mann-Whitney-Shapiro-Wilk tests were performed. The reliability of the data was assessed using the intraclass correlation. The data were stratified by age group only for Pearson's correlation analysis. RESULTS The mean age was 11.7 years (4.5 SD). The mean IS length was 106.63 mm (4.59 SD). The mean length of the S2AI screw was 104.13 mm (4.22 SD). The mean skin distance from the IS entry point was 28.13 mm (4.27 SD) and that for the S2AI screw was 39.96 mm (4.54 SD). CONCLUSIONS Through CT, the S2AI screw trajectory was observed to have a greater bone thickness and skin distance than the IS. There was a linear correlation between age and screw length for both techniques. A similar relationship was observed between skin distance and age for the S2AI screw technique. In children, the S2AI screw technique presents advantages such as greater cutaneous coverage and implant thickness than the IS technique.
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Affiliation(s)
- Mauro Costa Morais Tavares-Júnior
- Departamento de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Fernando Barbosa Sanchez
- Departamento de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Jaime David Uquillas Iturralde
- Departamento de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Renan Jose Rodrigues Fernandes
- Departamento de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Raphael Martus Marcon
- Departamento de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alexandre Fogaça Cristante
- Departamento de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Tarcisio Eloy Pessoa de Barros-Filho
- Departamento de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Olavo Biraghi Letaif
- Grupo de Coluna, Departamento de Ortopedia e Traumatologia, Instituto de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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14
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Nakashima H, Kanemura T, Satake K, Ito K, Ishikawa Y, Ouchida J, Segi N, Yamaguchi H, Imagama S. The Prevalence and Risk Factors for S2 Alar-Iliac Screw Loosening with a Minimum 2-Year Follow-up. Asian Spine J 2019; 14:177-184. [PMID: 31679321 PMCID: PMC7113458 DOI: 10.31616/asj.2019.0127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/25/2019] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN A retrospective cohort study. PURPOSE The purpose of this study was to investigate the prevalence and risk factors for S2 alar-iliac (SAI) screw loosening following lumbosacral fixation, with a minimum 2-year follow-up. OVERVIEW OF LITERATURE Although SAI screws allow surgeons to perform lumbosacral fixation with a low profile and enhanced biomechanical strength, screw loosening following surgery can occur in some cases. However, few studies have investigated the prevalence and risk factors for SAI screw loosening. METHODS This retrospective study included 35 patients (mean age, 72.8±8.0 years; male, 10; female, 25) who underwent lumbosacral fixation using SAI screws with at least 2 years of follow-up. SAI screw loosening and L5-S bony fusion were assessed using computed tomography. The period for which the screws appeared loose and the risk factors for SAI screw loosening were investigated 2 years after surgery. RESULTS A total of 70 SAI screws and 70 S1 pedicle screws were inserted. Loosening was observed 0.5, 1, and 2 years after surgery in 17 (24.3%), 35 (50.0%), and 35 (50.0%) SAI screws, respectively. Bony fusion rate at L5-S was significantly lower in patients with SAI screw loosening than in those without screw loosening (65.0% vs. 93.3%, p =0.048). The score for SAI screw contact with the iliac cortical bone and the bony fusion rate at L5-S were significantly lower in the loosening group than in the non-loosening group (1.8±0.5 vs. 2.2±0.3, p <0.001, respectively). Postoperative pelvic incidence-lumbar lordosis was significantly higher in the loosening group than in the non-loosening group (7.9°±15.4° vs. 0.5°±8.7°, p =0.02, respectively). CONCLUSIONS SAI screw loosening is closely correlated with pseudoarthrosis at L5-S. Appropriate screw insertion and optimal lumbar lordosis restoration are important to prevent postoperative complications related to SAI screws.
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Affiliation(s)
- Hiroaki Nakashima
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Tokumi Kanemura
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Kotaro Satake
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Kenyu Ito
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | | | - Jun Ouchida
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetoshi Yamaguchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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15
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Cunningham BW, Sponseller PD, Murgatroyd AA, Kikkawa J, Tortolani PJ. A comprehensive biomechanical analysis of sacral alar iliac fixation: an in vitro human cadaveric model. J Neurosurg Spine 2019; 30:367-375. [PMID: 30611149 DOI: 10.3171/2018.8.spine18328] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 08/27/2018] [Indexed: 11/06/2022]
Abstract
In BriefIn this in vitro investigation, we compared the multidirectional flexibility properties of sacral alar iliac fixation with conventional methods of sacral and sacroiliac fixation using nondestructive and destructive investigative methods. The study demonstrated that S1-2 sacral fixation alone significantly increases sacroiliac motion under all loading modalities, while sacral alar iliac fixation reduced motion in axial rotation at the sacroiliac joint and offers potential advantages of a lower instrumentation profile and ease of assembly compared to conventional sacroiliac screw instrumentation.
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Affiliation(s)
- Bryan W Cunningham
- 1MedStar Musculoskeletal Education and Research Institute, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital
| | - Paul D Sponseller
- 2Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Ashley A Murgatroyd
- 1MedStar Musculoskeletal Education and Research Institute, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital
| | - Jun Kikkawa
- 3Department of Orthopedic Surgery, Saitama Medical University, Saitama, Japan
| | - P Justin Tortolani
- 1MedStar Musculoskeletal Education and Research Institute, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital
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16
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Galetta MS, Leider JD, Divi SN, Goyal DKC, Schroeder GD. Robotics in spinal surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S165. [PMID: 31624731 DOI: 10.21037/atm.2019.07.93] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Although the da Vinci robot system has garnered much attention in the realm of surgery over the past few decades, several new surgical robotic systems have been developed for spinal surgery with varying levels of robot autonomy and surgeon-specified input. These devices are currently being considered as potential avenues for increasing the precision of any surgical intervention. The following review will attempt to provide an overview of robotics in modern spine surgery and how these devices will continue to be employed in various sectors across the field.
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Affiliation(s)
- Matthew S Galetta
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph D Leider
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Srikanth N Divi
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dhruv K C Goyal
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
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17
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Xu Y, Lin FY, Lin X, Yin XM. Second Sacral Alar Screw Fixation: Anatomic Study of Three-Dimensional Computed Tomography and Case Report. World Neurosurg 2019; 126:e1542-e1548. [PMID: 30928580 DOI: 10.1016/j.wneu.2019.03.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE S2 alar screw would be an alternative choice without breaking the sacroiliac joint. The aim of this study was to measure radiographic parameters for optimal placement of posterior S2 alar screw for instrumentation and fusion. METHODS Three-dimensional computed tomography scans of the pelvis of 60 normal adults were used to map the S2 alar screw. Entry point was typically chosen lateral and superior to the S2 dorsal foramen. Ideal S2 alar screw trajectories were explored by rotating the three-dimensional pelvis, while ensuring trajectories were of maximum length and width. After identification of an optimal trajectory, related linear anatomic parameters and sagittal and transverse angles were determined. RESULTS Ideal S2 alar screw trajectories were identified in each computed tomography scan. According to this morphometric study, trajectories for female patients were more lateral in the transverse plane (female 33.73 ± 5.99° vs. male 29.82 ± 4.11°, P < 0.001). Maximal length of trajectory in male patients was significantly longer than in female patients (female 40.82 ± 4.29 mm vs. male 43.42 ± 4.02 mm, P = 0.001). Fourteen S2 alar screws were used in 7 patients with high-grade spondylolisthesis, scoliosis, or nonunion at lumbosacral site. No complications occurred during S2 alar screw placement. One S2 screw failed owing to severe local osteoporosis. No patient developed local pain or wound-related problems. CONCLUSIONS S2 alar screw is an alternative sacral fixation point to provide additional biomechanical stability of lumbosacral constructs. A trajectory with maximum length through the S2 ala can be determined using three-dimensional computed tomography.
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Affiliation(s)
- Yang Xu
- Department of Orthopedics, FuJian Provincial Hospital, Fu Zhou, China
| | - Fei-Yue Lin
- Department of Orthopedics, FuJian Provincial Hospital, Fu Zhou, China
| | - Xi Lin
- Department of Orthopedics, FuJian Provincial Hospital, Fu Zhou, China.
| | - Xiao-Ming Yin
- Department of Orthopedics, FuJian Provincial Hospital, Fu Zhou, China
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18
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Tavares Junior MCM, de Souza JPV, Araujo TPF, Marcon RM, Cristante AF, de Barros Filho TEP, Letaif OB. Comparative tomographic study of the S2-alar-iliac screw versus the iliac screw. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:855-862. [PMID: 30382431 DOI: 10.1007/s00586-018-5806-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 10/24/2018] [Indexed: 11/27/2022]
Abstract
AIMS Iliac screws and S2-alar-iliac screws provide adequate mechanical stability for the fixation of lumbosacral spine pathologies, which has led to a significant increase in the use of these techniques in the routine practice of spine surgeons. However, studies on the ideal technical positioning for both techniques are limited. STUDY DESIGN This is an observational, retrospective, analytical descriptive study. OBJECTIVE To analyze, describe and compare the insertion and positioning parameters of the S2-alar-iliac and iliac screw techniques in adult patients without spinal deformities. METHODS The present study comprises a retrospective analysis of lumbosacral computed tomography images selected continuously in 2016 from 25 patients at a university hospital. Mann-Whitney-Shapiro-Wilk tests were performed. Data reliability was assessed using intraclass correlation. RESULTS The mean length of the iliac screw was greater than that of the S2-alar-iliac screw, and the S2-alar-iliac screw sat 20.5 mm deeper than the iliac screw. The mean of the greatest bone thickness for the iliac screw was 20.72 mm; that of the S2-alar-iliac screw was 23.24 mm. The mean distance from the iliac screw entry point to the skin was 32.46 mm, and the mean distance from the S2-alar-iliac screw entry point to the skin was 52.87 mm. CONCLUSION The trajectory of the S2-alar-iliac screws studied via computed tomography was greater in terms of bone thickness and deeper relative to the skin compared with the iliac screws. The S2-alar-iliac technique may have desirable clinical advantages in terms of the diameter of the screws and reduced protrusion when used in adults. These slides can be retrieved from Electronic supplementary material.
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Affiliation(s)
| | - João Paço Vaz de Souza
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | | | - Raphael Martus Marcon
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | - Alexandre Fogaça Cristante
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | | | - Olavo Biraghi Letaif
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
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19
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Novel Procedure for Designing and 3D Printing a Customized Surgical Template for Arthrodesis Surgery on the Sacrum. Symmetry (Basel) 2018. [DOI: 10.3390/sym10080334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In this article, the authors propose a novel procedure for designing a customized 3D-printed surgical template to guide surgeons in inserting screws into the sacral zone during arthrodesis surgeries. The template is characterized by two cylindrical guides defined by means of trajectories identified, based on standard procedure, via an appropriate Computer-Aided-Design (CAD)-based procedure. The procedure is based on the definition of the insertion direction by means of anatomical landmarks that enable the screws to take advantage of the maximum available bone path. After 3D printing, the template adheres perfectly to the bone surface, showing univocal positioning by exploiting the foramina of the sacrum, great maneuverability due to the presence of an ergonomic handle, as well as a break system for the two independent guides. These features make the product innovative. Thanks to its small size and the easy anchoring, the surgeon can simply position the template on the insertion area and directly insert the screws, without alterations to standard surgical procedures. This has the effect of reducing the overall duration of the surgery and the patient’s exposure to X-rays, and increasing both the safety of the intervention and the quality of the results.
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20
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Zhang N, Yu B. [Application of second sacral alar-iliac screw technique for reconstruction of spinopelvic stability]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:764-768. [PMID: 29905058 DOI: 10.7507/1002-1892.201711124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To summarize the current research progress of second sacral alar-iliac (S 2AI) screw technique for reconstruction of spinopelvic stability. Methods The recent original literature concerning development, clinical applications, anatomy, imageology, and biomechanics of S 2AI screw technique in reconstruction of spinopelvic stability was reviewed and analyzed. Results As a common clinical strategy for the reconstruction of spinopelvic stability, S 2AI screws achieve satisfactory effectiveness of lumbosacral fixation without complications which were found during the application of traditional iliac screws technique. S 2AI screw technique is more difficult to place screws by hand because of its narrow screw trajectory. Although the S 2AI screws trajectory pass through 3 layers of bone cortex, the biomechanical cadaveric study demonstrate that no statistical difference in stiffness was found between the traditional iliac and S 2AI screw in a spinopelvic fixation model. Conclusion S 2AI screw technique should be a safe and feasible method for reconstruction of spinopelvic stability in place of the traditional iliac screw technique.
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Affiliation(s)
- Nanwei Zhang
- Shantou University Medical College, Shantou Guangdong, 515041, P.R.China;Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen Guangdong, 518036, P.R.China
| | - Binsheng Yu
- Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen Guangdong, 518036, P.R.China;Shenzhen Key Laboratory of Spine Surgery, Orthopaedic Research Center, Peking University Shenzhen Hospital, Shenzhen Guangdong, 518036,
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21
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Yamada K, Abe Y, Satoh S. Safe insertion of S-2 alar iliac screws: radiological comparison between 2 insertion points using computed tomography and 3D analysis software. J Neurosurg Spine 2018; 28:536-542. [PMID: 29451435 DOI: 10.3171/2017.8.spine17735] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE S-2 alar iliac (S2AI) screws are commonly used as anchors for lumbosacral fixation. A serious potential complication of screw insertion is major vascular injury due to anterior or caudal screw deviation. To avoid screw deviation, the pelvic inlet view on intraoperative fluoroscopy images is recommended. However, there has been no detailed investigation of optimal fluoroscopic incline with the pelvic inlet view. The purpose of this study was to investigate the safety margins and to optimize fluoroscopic settings to avoid screw deviation with 2 reported insertion techniques using 3D analysis software and CT. METHODS The study included 50 patients (25 men and 25 women) who underwent abdominal-pelvic CT. With the use of software, the ideal S2AI screws were set from 2 entry points: A) the midpoint between the S-1 dorsal foramen and the S-2 dorsal foramen where they meet the lateral sacral crest, and B) 1 mm inferior and 1 mm lateral to the S-1 dorsal foramen. Anteriorly or caudally deviated screws were defined as deviation of a half thread of the ideal screw by rotation anteriorly or caudally from the entry point. The angular safety margins were compared between the 2 entry points, and patients with small safety margins were investigated. Subsequently, fluoroscopic images were virtualized on ray sum-rendered images. Conditions that provided proper recognition of screw deviation were investigated via lateral and anteroposterior views with the beam tilted caudally. RESULTS The safety margins of S2AI screws were smaller in the anterior direction than in the caudal direction and by entry point A than by entry point B (A: 9.1° ± 1.6° and B: 9.7° ± 1.5° in the anterior direction; A: 10.9° ± 3.8° and B: 13.9° ± 4.1° in the caudal direction). In contrast, patients with a deep-seated L-5 vertebral body tended to have smaller safety margins in the caudal direction. All anteriorly deviated screws were recognized with a 60°-70° inlet view from the S-1 slope. The caudally deviated screws were all recognized on the lateral view, but 31% of screws at entry point A and 21% of screws at entry point B were not recognized on the pelvic inlet view. CONCLUSIONS S2AI screws should be carefully placed to avoid anterior deviation compared with caudal deviation in terms of the safety margin, except in patients with a deep-seated L-5. The difference in safety margins between entry points A and B was negligible. Intraoperative fluoroscopy is recommended with a pelvic inlet view tilted 60°-70° from the S-1 slope to avoid anterior screw deviation. The lateral view is recommended to confirm that the screw is not deviated caudally.
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Affiliation(s)
- Kentaro Yamada
- 1Department of Orthopaedic Surgery, Wajokai Eniwa Hospital, Eniwa, Hokkaido; and.,2Department of Orthopaedic Surgery, Osaka City University, Osaka, Japan
| | - Yuichiro Abe
- 1Department of Orthopaedic Surgery, Wajokai Eniwa Hospital, Eniwa, Hokkaido; and
| | - Shigenobu Satoh
- 1Department of Orthopaedic Surgery, Wajokai Eniwa Hospital, Eniwa, Hokkaido; and
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Smith EJ, Kyhos J, Dolitsky R, Yu W, O'Brien J. S2 Alar Iliac Fixation in Long Segment Constructs, a Two- to Five-Year Follow-up. Spine Deform 2018; 6:72-78. [PMID: 29287821 DOI: 10.1016/j.jspd.2017.05.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 04/18/2017] [Accepted: 05/21/2017] [Indexed: 11/17/2022]
Abstract
STUDY DESIGN Retrospective review of patients having undergone S2 alar-iliac (S2AI) fixation for long fusions with a minimum two-year follow-up. OBJECTIVES To report on fusion rates, complications, technique-specific complications of patients having undergone S2AI fixation. SUMMARY OF BACKGROUND DATA Sacropelvic fixation continues to be a challenge when performing long fusions to the pelvis. S2AI screws have been found to provide solid biomechanical fixation and have been found to have good clinical results in short-term follow-up for pediatric and adult patients. METHODS Cases were retrospectively reviewed in patients who had placement of S2AI screws for long fusions with at least a two-year follow-up. Demographic data, complications, and reoperations were reviewed. Complications were broken into minor and major categories similar to previous series on pelvic fixation. RESULTS There were 86 cases identified. Minor and major complications occurred in 29% and 24% of patients, respectively, with the majority of minor complications being intraoperative dural tears. Revision surgery for all causes was performed in 23% of the cohort. Fusion rate at L5-S1 for patients without preoperative pseudarthrosis was 95.3%. Preoperative L5-S1 pseudoarthrosis was identified in 20 patients, 17 (95%) of these went onto fusion after one surgery. There was evidence of S2AI screw lucency in 10.4% of cases. However, the majority of these were asymptomatic. CONCLUSIONS Sacropelvic fixation using the S2AI technique provides safe, durable fixation with low rates of technique-specific complications and limited need for hardware removal. Complication rates in this series were similar to other series on long fusions to the pelvis. Additionally, fusion rates were high at L5-S1 for both patients with and without preoperative L5-S1 pseudarthrosis. It appears that the S2AI technique is a powerful option for patients with previous L5-S1 pseudarthrosis. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Evan J Smith
- Department of Orthopedic Surgery, George Washington University, 2300 M St. NW 5th Fl., Washington, DC 20037, USA.
| | - Justin Kyhos
- Department of Orthopedic Surgery, Northwestern University, 633 Clark St, Evanston, IL 60208, USA
| | - Robert Dolitsky
- Department of Orthopedic Surgery, Northwell Health, Great Neck, NY, USA
| | - Warren Yu
- Department of Orthopedic Surgery, George Washington University, 2300 M St. NW 5th Fl., Washington, DC 20037, USA
| | - Joseph O'Brien
- Department of Orthopedic Surgery, George Washington University, 2300 M St. NW 5th Fl., Washington, DC 20037, USA
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The efficacy of posterior hemivertebra resection with lumbosacral fixation and fusion in the treatment of congenital scoliosis: A more than 2-year follow-up study. Clin Neurol Neurosurg 2018; 164:154-159. [DOI: 10.1016/j.clineuro.2017.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/14/2017] [Accepted: 12/02/2017] [Indexed: 11/17/2022]
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Choi HY, Hyun SJ, Kim KJ, Jahng TA, Kim HJ. Freehand S2 Alar-Iliac Screw Placement Using K-Wire and Cannulated Screw : Technical Case Series. J Korean Neurosurg Soc 2017; 61:75-80. [PMID: 29354238 PMCID: PMC5769852 DOI: 10.3340/jkns.2016.1212.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/23/2017] [Accepted: 04/11/2017] [Indexed: 01/11/2023] Open
Abstract
Objective Among the various sacropelvic fixation methods, S2 alar-iliac (S2AI) screw fixation has several advantages compared to conventional iliac wing screw. However, the placement of S2AI screw still remains a challenge. The purpose of this study was to describe a novel technique of free hand S2AI screw insertion using a K-wire and cannulated screw, and to evaluate the accuracy of the technique. Methods S2AI screw was inserted by free hand technique in sixteen consecutive patients without any fluoroscopic guidance. The gearshift was advanced to make a pilot hole passing through the sacroiliac joint and directing the anterior inferior iliac spine. A K-wire was placed through the pilot hole. After introducing a cannulated tapper along with the K-wire, a cannulated S2AI screw was installed over the K-wire. Results Thirty-three S2AI screws were placed in sixteen consecutive patients. Thirty-two screws were cannulated screws, and one screw was a conventional non-cannulated screw. Thirty out of 32 (93.8%) cannulated screws were accurately positioned, whereas two cannulated screws and one non-cannulated screw violated lateral cortex of the ilium. Conclusion The technique using K-wire and cannulated screw can provide accurate placement of free hand S2AI screw.
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Affiliation(s)
- Ho Yong Choi
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Takeba J, Umakoshi K, Kikuchi S, Matsumoto H, Annen S, Moriyama N, Nakabayashi Y, Sato N, Aibiki M. Accuracy of screw fixation using the O-arm ® and StealthStation ® navigation system for unstable pelvic ring fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:431-438. [PMID: 29124339 DOI: 10.1007/s00590-017-2075-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/03/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Screw fixation for unstable pelvic ring fractures is generally performed using the C-arm. However, some studies reported erroneous piercing with screws, nerve injuries, and vessel injuries. Recent studies have reported the efficacy of screw fixations using navigation systems. The purpose of this retrospective study was to investigate the accuracy of screw fixation using the O-arm® imaging system and StealthStation® navigation system for unstable pelvic ring fractures. METHODS The participants were 10 patients with unstable pelvic ring fractures, who underwent screw fixations using the O-arm StealthStation navigation system (nine cases with iliosacral screw and one case with lateral compression screw). We investigated operation duration, bleeding during operation, the presence of complications during operation, and the presence of cortical bone perforation by the screws based on postoperative CT scan images. We also measured the difference in screw tip positions between intraoperative navigation screen shot images and postoperative CT scan images. RESULTS The average operation duration was 71 min, average bleeding was 12 ml, and there were no nerve or vessel injuries during the operation. There was no cortical bone perforation by the screws. The average difference between intraoperative navigation images and postoperative CT images was 2.5 ± 0.9 mm, for all 18 screws used in this study. CONCLUSION Our results suggest that the O-arm StealthStation navigation system provides accurate screw fixation for unstable pelvic ring fractures.
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Affiliation(s)
- Jun Takeba
- Department of Emergency Medicine and Critical Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Kensuke Umakoshi
- Department of Emergency Medicine and Critical Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Satoshi Kikuchi
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Hironori Matsumoto
- Department of Emergency Medicine and Critical Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Suguru Annen
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Naoki Moriyama
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yuki Nakabayashi
- Department of Emergency Medicine and Critical Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Norio Sato
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mayuki Aibiki
- Department of Emergency Medicine and Critical Care, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
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Abstract
STUDY DESIGN A retrospective cohort study of patients who underwent S2-alar-iliac (S2AI) screw insertion using robotic guidance in long constructs for spinal deformity correction extending to the sacrum performed at a single institution. OBJECTIVE To assess and evaluate the feasibility and accuracy of robotic guidance for S2AI screw insertion. SUMMARY OF BACKGROUND DATA Pelvic fixation has become a common adjunct to long fusions extending to the sacrum. The S2AI method possesses advantages over the traditional Galveston technique. S2AI involves finding a pathway from S2 across the sacral ala and the sacroiliac joint into the ilium. Robotic guidance is a new modality for implant insertion that has shown high accuracy. METHODS We identified all patients who underwent robotic-guided S2AI screw insertion in long constructs extending to the sacrum. Cortical breaches and protrusions, assessed on postoperative imaging, and complications were recorded. RESULTS Fourteen patients (31 screws) underwent S2AI screw insertion using robotic guidance and free-hand probing. Average screw length was 80 mm (range, 65-90 mm). All trajectories were confirmed as accurate (no proximal breaches). Screw insertion, performed manually, resulted in 10 protrusions <2 mm, 1 by 2-4 mm, and 6 by ≥4 mm. No screw was intrapelvic or risked any visceral or neurovascular structures and none required removal or revision. Longer screws (>80 mm) were associated with distal protrusion. CONCLUSIONS Robotic-guided S2AI screws are accurate and a feasible option. Although no complications from protrusion were identified, larger studies and instrumentation modifications are required to assess the clinical acceptance of robotic guidance in sacropelvic fixation.
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Liu Z, Qiu Y, Yan H, Hu ZS, Zhu F, Qiao J, Xu LL, Wang B, Yu Y, Qian BP, Zhu ZZ. S2 Alar-iliac Fixation: A Powerful Procedure for the Treatment of Kyphoscoliosis. Orthop Surg 2017; 8:81-4. [PMID: 27028385 DOI: 10.1111/os.12227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 12/10/2015] [Indexed: 11/27/2022] Open
Abstract
The purpose of this study was to introduce a powerful technique for the treatment of kyphoscoliosis. There are currently multiple techniques for sacropelvic fixation, including trans-iliac bars and iliac and iliosacral screws. Several studies have documented the use of these instrumentation techniques; however, a ubiquitous problematic issue concerns the need for separate incisions for the use of offset connectors, which add to surgical time and morbidity. Any additional dissection of the skin, subcutaneous tissue or muscle in this area is believed to increase the incidence of complications of wound healing. However, as stated above, the above-mentioned techniques require separate incisions for the use of offset connectors, which add to surgical time and morbidity. The novel technique of S2 alar-iliac (S2AI) pelvic fixation has been developed to address some of these issues. However, a technique for achieving correction of kyphoscoliosis with pelvic obliquity in adult patients with spinal deformity has not previously been described. Our entry point is based on the S1 foramen and is typically up to 5 mm caudal and 2 to 3 mm lateral to that foramen. Once the S1 foramen has been identified, a blunt instrument can be used to probe the alar ridge. The screw trajectory is 40°-50° from horizontal and 20°-30° caudal, aimed toward the greater trochanter and rostral to the sciatic notch. A 36-year-old female patient presented with a 3-year history of low back pain, and progressive thoracolumbar kyphoscoliosis. In this typical case, we performed S2AI fixation with transforaminal lumbar interbody fusion and hemivertebra resection technique to treat her lumbosacral kyphoscoliosis. Satisfactory improvement in her preoperative lumbar kyphoscoliosis was found at 3-month follow-up.
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Affiliation(s)
- Zhen Liu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong Qiu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Huang Yan
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zong-shan Hu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Feng Zhu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jun Qiao
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lei-lei Xu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Bin Wang
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang Yu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Bang-ping Qian
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ze-zhang Zhu
- Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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Salazar D, Lannon S, Pasternak O, Schiff A, Lomasney L, Mitchell E, Stover M. Investigation of bone quality of the first and second sacral segments amongst trauma patients: concerns about iliosacral screw fixation. J Orthop Traumatol 2015; 16:301-8. [PMID: 26018428 PMCID: PMC4633427 DOI: 10.1007/s10195-015-0354-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 05/10/2015] [Indexed: 11/27/2022] Open
Abstract
Background Iliosacral screw fixation has become a common method for surgical stabilization of acute disruptions of the pelvic ring. Placement of iliosacral screws into the first sacral (S1) body is the preferred method of fixation, but size limitations and sacral dysmorphism may preclude S1 fixation. In these clinical situations, fixation into the second sacral (S2) body has been recommended. The objective of this study was to evaluate the bone quality of the S1 compared to S2 in the described “safe zone” of iliosacral screw fixation in trauma patients. Materials and methods The pelvic computed tomography scans of 25 consecutive trauma patients, ages 18–49, at a level 1 trauma center were prospectively analyzed. Hounsfield units, a standardized computed tomography attenuation coefficient, was utilized to measure regional cancellous bone mineral density of the S1 and S2. No change in the clinical protocol or treatment occurred as a consequence of inclusion in this study. Results A statically significant difference in bone quality was found when comparing the first and second sacral segment (p = 0.0001). Age, gender, or smoking status did not independently affect bone quality. Conclusion In relatively young, otherwise healthy trauma patients there is a statistically significant difference in the bone density of the first sacral segment compared to the second sacral segment. This study highlights the need for future biomechanical studies to investigate whether this difference is clinically relevant. Due to the relative osteopenia in the second sacral segment, which may impact the quality of fixation, we feel this technique should be used with caution. Level of evidence III
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Affiliation(s)
- Dane Salazar
- The Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, 2160 South First Avenue, Maywood, IL, 60153, USA.
| | - Sean Lannon
- The Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, 2160 South First Avenue, Maywood, IL, 60153, USA
| | - Olga Pasternak
- The Department of Radiology, Loyola University Health System, 2160 South First Avenue, Maywood, IL, 60153, USA
| | - Adam Schiff
- The Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, 2160 South First Avenue, Maywood, IL, 60153, USA
| | - Laurie Lomasney
- The Department of Radiology, Loyola University Health System, 2160 South First Avenue, Maywood, IL, 60153, USA
| | - Erika Mitchell
- The Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, 2160 South First Avenue, Maywood, IL, 60153, USA
| | - Michael Stover
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair, Suite 1350, Chicago, IL, 60611, USA
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Biomechanical evaluation of S2 alar-iliac screws: effect of length and quad-cortical purchase as compared with iliac fixation. Spine (Phila Pa 1976) 2013; 38:E1250-5. [PMID: 23759811 DOI: 10.1097/brs.0b013e31829e17ff] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A biomechanical study conducted on cadaveric specimens. OBJECTIVE (1) To compare the biomechanical strength of the S2 alar-iliac (S2AI) screw to traditional iliac fixation and (2) to examine the effect of length and trajectory on the S2AI screw. SUMMARY OF BACKGROUND DATA A recent technique to attain spinal fixation distal to S1 pedicle screws is the S2AI screw using either an open or a percutaneous approach with an altered S2 alar screw trajectory to obtain purchase in the ilium. A novel modification of the S2AI screw is placement with bicortical purchase in the ilium (quad-cortical screw). This may allow for a shorter-length screw with equivalent biomechanics. METHODS Seven human cadaveric spines (L2-Pelvis) were fixed at L2 proximally and the pubis distally. Pedicle screws were placed from L3-S1 with S2AI screw lengths of 65-mm, 80-mm, or 90-mm iliac screws. S2AI screws were tested with and without quad-cortical purchase. Each specimen was tested on the 6 degrees of freedom spine simulator. A load control protocol with an unconstrained pure moment of 10 Nm was used in flexion-extension, lateral bending, and axial rotation for a total of 3 load/unload cycles. The range of motion was normalized to the intact cadaveric spine (100%). RESULTS All the instrumented constructs significantly reduced range of motion compared with the intact spine. The L3-S1 construct was statistically significantly less stable than all instrumented constructs in flexion-extension. There was statistically no significant difference between the S2AI screws of all lengths and the iliac screw constructs with offset connectors. CONCLUSION S2AI screws are biomechanically as stable as the test constructs using iliac screws in all loading modes. Sixty-five-millimeter S2AI screws were biomechanically equivalent to 90-mm iliac screws and 80-mm S2AI screws. Quad-cortical purchase did not statistically significantly improve the biomechanical strength of S2AI screws. LEVEL OF EVIDENCE N/A.
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Yoshihara H. Surgical options for lumbosacral fusion: biomechanical stability, advantage, disadvantage and affecting factors in selecting options. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24 Suppl 1:S73-82. [DOI: 10.1007/s00590-013-1282-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 07/06/2013] [Indexed: 10/26/2022]
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Liu J, Li Y, Wu Y, Zhu Q. An anatomic study on the placement of the second sacral screw and its clinical applications. Arch Orthop Trauma Surg 2013; 133:911-20. [PMID: 23636318 DOI: 10.1007/s00402-013-1753-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND The fixation of lumbosacral and sacral pelvis can be performed on the ilium and the Second Sacrum Vertebrae (S2). Although several studies on the anatomical and biomechanical features of S2 screw fixation have been published, little clinical application has been reported, especially combination of anatomical investigation and clinical study. This study was performed to design and optimize the method of pedicle screw placement for S2. MATERIALS AND METHODS Fifteen adult dry sacrum specimens were prepared and truncated from the S1-S2 and S2-S3 vertebral fusion remnants, and the morphology of the S2 vertebral body was observed from this section. The intersection of the horizontal line through the lowest point of the inferior edge of the first posterior sacral foramen and the lateral sacral crest was the entry point (Point X). The screws were inserted anterolaterally or anteromedially at Point X in 10 cadavers, with all of the screws penetrating the sacrum. Finally, the S2 sacral screw fixation technique was applied to a total of 13 patients with lumbosacral lesions, and the clinical outcome was evaluated at a minimum follow-up of 1 year. RESULTS Two S2 sacral screw placement methods were developed, i.e., the anterolateral and anteromedial insertions. Seven patients had complete preoperative, postoperative, and follow-up data. In all cases, the bilateral S2 screws were placed in good position and the fixation was firm. There was no surgical wound infection or internal fixation loosening. All the patients achieved partial bone graft healing, which was verified by computed tomography. CONCLUSIONS The intersection of the horizontal line through the lowest point of the inferior edge of the first posterior sacral foramen and the lateral sacral crest can be used as the entry point for S2 sacral screw fixation. The S2 pedicle screw fixation shows good clinical effectiveness and safety for stable reconstruction of lumbosacral lesions.
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Affiliation(s)
- Jingchen Liu
- Department of Spine Surgery, The First Bethune Hospital, Jilin University, No. 71 Xinmin Street, Changchun 130021, China
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Ray WZ, Ravindra VM, Schmidt MH, Dailey AT. Stereotactic navigation with the O-arm for placement of S-2 alar iliac screws in pelvic lumbar fixation. J Neurosurg Spine 2013; 18:490-5. [DOI: 10.3171/2013.2.spine12813] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Pelvic fixation is a crucial adjunct to many lumbar fusions to avoid L5–S1 pseudarthrosis. It is useful for treatment of kyphoscoliosis, high-grade spondylolisthesis, L5–S1 pseudarthrosis, sacral tumors, lumbosacral dislocations, and osteomyelitis. The most popular method, iliac fixation, has drawbacks including hardware prominence, extensive muscle dissection, and the need for connection devices. S-2 alar iliac fixation provides a useful primary or salvage alternative. The authors describe their techniques for using stereotactic navigation for screw placement.
Methods
The O-arm Surgical Imaging System allowed for CT-quality multiplanar reconstructions of the pelvis, and registration to a StealthStation Treon provided intraoperative guidance. The authors describe their technique for performing computer-assisted S-2 alar iliac fixation for various indications in 18 patients during an 18-month period.
Results
All patients underwent successful bilateral placement of screws 80–100 mm in length. All placements were confirmed with a second multiplanar reconstruction. One screw was moved because of apparent anterior breach of the ilium. There were no immediate neurological or vascular complications due to screw placement. The screw length required additional instruments including a longer pedicle finder and tap.
Conclusions
Stereotactic guidance to navigate the placement of distal pelvic fixation with bilateral S-2 alar iliac fixation can be safely performed in patients with a variety of pathological conditions. Crossing the sacroiliac joint, choosing trajectory, and ensuring adequate screw length can all be enhanced with 3D image guidance. Long-term outcome studies are underway, specifically evaluating the sacroiliac joint.
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Affiliation(s)
- Wilson Z. Ray
- 1Department of Neurosurgery, Clinical Neurosciences Center; and
| | | | - Meic H. Schmidt
- 1Department of Neurosurgery, Clinical Neurosciences Center; and
- 2Spinal Oncology Service, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Andrew T. Dailey
- 1Department of Neurosurgery, Clinical Neurosciences Center; and
- 2Spinal Oncology Service, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Reinforcement of lumbosacral instrumentation using S1–pedicle screws combined with S2–alar screws. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2013; 25:294-314. [DOI: 10.1007/s00064-012-0160-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Estimating the effective radiation dose imparted to patients by intraoperative cone-beam computed tomography in thoracolumbar spinal surgery. Spine (Phila Pa 1976) 2013; 38:E306-12. [PMID: 23238490 DOI: 10.1097/brs.0b013e318281d70b] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational. OBJECTIVE To estimate the radiation dose imparted to patients during typical thoracolumbar spinal surgical scenarios. SUMMARY OF BACKGROUND DATA Minimally invasive techniques continue to become more common in spine surgery. Computer-assisted navigation systems coupled with intraoperative cone-beam computed tomography (CT) represent one such method used to aid in instrumented spinal procedures. Some studies indicate that cone-beam CT technology delivers a relatively low dose of radiation to patients compared with other x-ray-based imaging modalities. The goal of this study was to estimate the radiation exposure to the patient imparted during typical posterior thoracolumbar instrumented spinal procedures, using intraoperative cone-beam CT and to place these values in the context of standard CT doses. METHODS Cone-beam CT scans were obtained using Medtronic O-arm (Medtronic, Minneapolis, MN). Thermoluminescence dosimeters were placed in a linear array on a foam-plastic thoracolumbar spine model centered above the radiation source for O-arm presets of lumbar scans for small or large patients. In-air dosimeter measurements were converted to skin surface measurements, using published conversion factors. Dose-length product was calculated from these values. Effective dose was estimated using published effective dose to dose-length product conversion factors. RESULTS Calculated dosages for many full-length procedures using the small-patient setting fell within the range of published effective doses of abdominal CT scans (1-31 mSv). Calculated dosages for many full-length procedures using the large-patient setting fell within the range of published effective doses of abdominal CT scans when the number of scans did not exceed 3. CONCLUSION We have demonstrated that single cone-beam CT scans and most full-length posterior instrumented spinal procedures using O-arm in standard mode would likely impart a radiation dose within the range of those imparted by a single standard CT scan of the abdomen. Radiation dose increases with patient size, and the radiation dose received by larger patients as a result of more than 3 O-arm scans in standard mode may exceed the dose received during standard CT of the abdomen. Understanding radiation imparted to patients by cone-beam CT is important for assessing risks and benefits of this technology, especially when spinal surgical procedures require multiple intraoperative scans.
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Schouten R, Lee R, Boyd M, Paquette S, Dvorak M, Kwon BK, Fisher C, Street J. Intra-operative cone-beam CT (O-arm) and stereotactic navigation in acute spinal trauma surgery. J Clin Neurosci 2012; 19:1137-43. [PMID: 22721892 DOI: 10.1016/j.jocn.2012.01.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 01/29/2012] [Indexed: 01/05/2023]
Abstract
The purpose of this ambispective cohort study is to describe the emerging role of intra-operative cone-beam CT (O-arm®, Medtronic, Minneapolis, MN, USA), frequently coupled with stereotactic navigation (StealthStation®, Medtronic), in the surgical management of acute spinal trauma. All patients with acute spinal trauma between May 2009 and May 2011 who were treated with the use of the O-arm were identified from a prospectively collected spine database and retrospectively analyzed to characterize indications and outcomes. Over the two-year period, the O-arm was used in 183 spinal operations; 27 of these (15%) involved acute spinal trauma. Within the trauma cohort, 14 injuries were in the cervical spine, nine at the cervicothoracic junction, and four were in the thoracolumbar spine. In 12 patients (44%) pre-existing aberrant and challenging anatomy, commonly ankylosing conditions, were present. Surgical techniques included transarticular atlantoaxial fixation and direct osteosynthesis of a Hangman's fracture performed entirely percutaneously (via two stab incisions) using O-arm assisted stereotactic navigation. No trauma cases using O-arm assisted navigation had iatrogenic neurovascular injury and none required subsequent revision surgery for implant malposition, compared with a revision rate of 1.2% of patients with non-navigated acute spinal trauma during the same interval. Technical factors associated with successful application of this technology in the setting of acute spinal trauma were detailed. O-arm assisted navigation can overcome anatomical challenges and broaden the available stabilization options in the management of acute spinal trauma. Other advantages include protecting the surgical team from cumulative fluoroscopic radiation exposure and patients from repeat surgery due to implant malposition.
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Affiliation(s)
- Rowan Schouten
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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Nottmeier EW, Bowman C, Nelson KL. Surgeon radiation exposure in cone beam computed tomography-based, image-guided spinal surgery. Int J Med Robot 2011; 8:196-200. [DOI: 10.1002/rcs.450] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2011] [Indexed: 11/10/2022]
Affiliation(s)
| | - Cammi Bowman
- Department of Neurosurgery; Mayo Clinic; Jacksonville Florida USA
| | - Kevin L. Nelson
- Department of Radiology; Mayo Clinic; Jacksonville Florida USA
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Garrido BJ, Wood KE. Navigated placement of iliac bolts: description of a new technique. Spine J 2011; 11:331-5. [PMID: 21474085 DOI: 10.1016/j.spinee.2011.03.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 01/02/2011] [Accepted: 03/05/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Image navigation has improved the safety and ability to perform complex spinal procedures where visibility is not optimal or anatomic deformity is present. Numerous published studies are available demonstrating its effectiveness in improved pedicle screw placement in complex multiplanar deformities. Studies have also demonstrated image navigation technology versatility; however, stabilization of the lumbopelvic junction with navigated iliac bolt fixation has not been reported. PURPOSE To describe an innovative versatile application of image navigation technology in spine surgery. We examine the safety, accuracy, and effectiveness of navigated iliac bolt placement while minimizing challenges associated with current techniques. STUDY DESIGN Case series. PATIENT SAMPLE Five patients requiring lumbopelvic fixation for multiple indications, including lumbosacral pseudoarthrosis, complex sacral fracture patterns, compromised revision sacral fixation, and as an adjunct to degenerative deformity with multilevel fusion, underwent navigated iliac bolt placement. OUTCOME MEASURES Accurate placement was verified using intraoperative computed tomography (CT) imaging using O-ARM (Medtronic, Inc.) after placement. METHODS Five patients requiring lumbopelvic fixation have undergone navigated iliac bolt placement using Medtronic Stealth Station Treon in conjunction with the O-ARM (Medtronic, Inc.). A right percutaneous posterior superior iliac spine (PSIS) reference frame was placed at the superior lateral margin of the PSIS, and bilateral iliac bolts were placed via navigation using both the anatomic and traditional surgical techniques. Both techniques were performed without direct notch palpation and minimal soft-tissue exposure. Postplacement intraoperative CT imaging was obtained to confirm position and trajectory of the bolts using O-ARM (Medtronic, Inc.). RESULTS Ten iliac bolts were successfully placed in five patients. Intraoperative CT demonstrated ideal iliac screw bone placement projecting within 2 cm over sciatic notch, between pelvic tables. With image navigation, both anatomic and traditional iliac bolt placement techniques were performed with less surgical exposure, no radiation exposure, and complete accuracy using image navigation techniques with a percutaneous reference frame. The percutaneous reference frame placed in the superior lateral PSIS did not cause any interference with our navigated trajectory or bolt. CONCLUSIONS Image-navigated iliac fixation allows for safe and accurate placement of bilateral iliac bolts without PSIS percutaneous reference frame interference. Image guidance eliminates fluoroscopic radiation exposure and extensive soft-tissue dissection and facilitates both traditional and anatomic iliac bolt placement techniques.
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Affiliation(s)
- Ben J Garrido
- Lake Norman Orthopedic Spine Center, 170 Medical Park Rd, Suite 102, Mooresville, NC 28117, USA.
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Abul-Kasim K, Ohlin A. The rate of screw misplacement in segmental pedicle screw fixation in adolescent idiopathic scoliosis. Acta Orthop 2011; 82:50-5. [PMID: 21189100 PMCID: PMC3229997 DOI: 10.3109/17453674.2010.548032] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There are no reports in the literature on the influence of learning on the pedicle screw insertion. We studied the effect of learning on the rate of screw misplacement in patients with adolescent idiopathic scoliosis treated with segmental pedicle screw fixation. METHOD We retrospectively evaluated low-dose spine computed tomography of 116 consecutive patients (aged 16 (12-24) years, 94 females) who were operated during 4 periods over 2005-2009 (group 1: patients operated autumn 2005-2006; group 2: 2007; group 3: 2008; and group 4: 2009). 5 types of misplacement were recorded: medial cortical perforation, lateral cortical perforation, anterior cortical perforation of the vertebral body, endplate perforation, and perforation of the neural foramen. RESULTS 2,201 pedicle screws were evaluated, with an average of 19 screws per patient. The rate of screw misplacement for the whole study was 14%. The rate of lateral and medial cortical perforation was 7% and 5%. There was an inverse correlation between the occurrence of misplacement and the patient number, i.e. the date of operation (r = -0.35; p < 0.001). The skillfulness of screw insertion improved with reduction of the rate of screw misplacement from 20% in 2005-2006 to 11% in 2009, with a breakpoint at the end of the first study period (34 patients). INTERPRETATION We found a substantial learning curve; cumulative experience may have contributed to continued reduction of misplacement rate.
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Affiliation(s)
- Kasim Abul-Kasim
- Division of Neuroradiology, Lund University, Diagnostic Centre for Imaging and Functional Medicine, Skåne University Hospital
| | - Acke Ohlin
- Department of Orthopaedic Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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