1
|
Meng X, Zhong J, Yang F, Peng J, Li J, Yuan Y. Percutaneous cement-augmented short-segment pedicle screw fixation plus percutaneous vertebroplasty for stage III Kummell's disease without neurological symptoms: A case report. Int J Surg Case Rep 2024; 118:109440. [PMID: 38581935 PMCID: PMC11015437 DOI: 10.1016/j.ijscr.2024.109440] [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: 01/17/2024] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 04/08/2024] Open
Abstract
INTRODUCTION The incidence of stage III Kummell's disease without neurological symptoms is increasing in elderly patients with osteoporotic thoracolumbar fractures. However, the surgical method is still controversial in this condition. This report presented a case of Kummell's disease in which percutaneous bone cement-augmented short-segment pedicle screw fixation combined with percutaneous vertebroplasty was performed, providing a reference for the surgical approach. CASE PRESENTATION The patient was a 72-year-old female who presented unexplained lower back pain accompanied with limited mobility for the past three months. Based on her medical history, physical examinations, and imaging studies, it was confirmed that she had Kummell's disease in stage III without neurological symptoms. We treated her with percutaneous bone cement-augmented short-segment pedicle screw fixation combined with percutaneous vertebroplasty on the symptomatic vertebrae. CLINICAL DISCUSSION The majority of patients with stage III Kummell's disease have severe osteoporosis, which result in failure of the internal fixation and a series of other complications. Maintaining the stability of the internal fixation system is crucial, especially after screwing and subsequent locking. When augmented with bone cement, the grip and pull-out resistance of the percutaneous pedicle screws enhance greatly. Simultaneously, percutaneous vertebroplasty on the symptomatic vertebrae can immediately support the spine unit's stability mechanically and maintain the shape of the vertebrae after reduction. CONCLUSIONS The percutaneous bone cement-augmented short-segment pedicle screw fixation combined with percutaneous vertebroplasty on the symptomatic vertebrae is an effective treatment for stage III Kummell's disease without neurological symptoms. It can effectively restore the vertebral height, correct the kyphotic deformities, improve spinal canal stenosis, and achieve satisfactory short-term clinical outcomes.
Collapse
Affiliation(s)
- Xudong Meng
- Orthopedics Department, Yueyang Hospital Affiliated to Hunan Normal University, Yueyang 414000, Hunan Province, China
| | - Jiongbiao Zhong
- Orthopedics Department, Yueyang Hospital Affiliated to Hunan Normal University, Yueyang 414000, Hunan Province, China.
| | - Fan Yang
- Orthopedics Department, Yueyang Hospital Affiliated to Hunan Normal University, Yueyang 414000, Hunan Province, China
| | - Jiarui Peng
- Orthopedics Department, Yueyang Hospital Affiliated to Hunan Normal University, Yueyang 414000, Hunan Province, China
| | - Jiafu Li
- Orthopedics Department, Yueyang Hospital Affiliated to Hunan Normal University, Yueyang 414000, Hunan Province, China
| | - Ye Yuan
- Orthopedics Department, Yueyang Hospital Affiliated to Hunan Normal University, Yueyang 414000, Hunan Province, China
| |
Collapse
|
2
|
Wang Y, Kahaer A, Maimaiti A, Guo H, Rexiti P. Complication, fusion, and revision rate in the lumbar cortical bone trajectory and pedicle screw fixation techniques: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:382. [PMID: 37226223 DOI: 10.1186/s13018-023-03820-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/02/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND To obtain the complication rate, fusion rate, and revision rate of the lumbar cortical bone trajectory technique and pedicle screw fixation technique in lumbar interbody fusion surgery by single-arm meta-analysis and lay a basis for orthopedic surgeons to select the fixation techniques and perioperative management. METHODS PubMed, Ovid Medline, Web of Science, CNKI, and Wanfang databases were searched comprehensively. Data extraction, content analysis, and quality assessment of the literature were performed by two independent reviewers according to the Cochrane Collaboration guidelines using R and STATA software for single-arm meta-analysis. RESULTS The total complication rate of the lumbar cortical bone trajectory technique was 6%, including a hardware complication rate of 2%, ASD (adjacent segment degeneration) rate of 1%, wound infection rate of 1%, dural damage rate of 1%, hematoma rate tending to 0%, fusion rate of 94%, and revision rate of 1%. Lumbar pedicle screw fixation techniques had a total complication rate of 9%, with a hardware complication rate of 2%, ASD rate of 3%, wound infection rate of 2%, dural damage rate of 1%, hematoma rate tending to 0%, fusion rate of 94%, and revision rate of 5%. This study was registered with PROSPERO, CRD42022354550. CONCLUSION Lumbar cortical bone trajectory was associated with a lower total complication rate, ASD rate, wound infection rate, and revision rate than pedicle screw fixation. The cortical bone trajectory technique reduces the incidence of intraoperative and postoperative complications and can be an alternative in lumbar interbody fusion surgery.
Collapse
Affiliation(s)
- Yixi Wang
- First Clinical Medical College, Xinjiang Medical University, Urumqi, China
| | - Alafate Kahaer
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Abulikemu Maimaiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Hailong Guo
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Paerhati Rexiti
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
- Key Laboratory of High Incidence Disease Research in Xingjiang (Xinjiang Medical University), China Ministry of Education, Urumqi, China.
- Xinjiang Clinical Research Center for Orthopedics, Xinjiang Medical University, Urumqi, China.
| |
Collapse
|
3
|
Zhang XN, Zhou LJ, Su QJ, Guan L, Li DY, Pei BQ, Pan AX, Yang HH, Ding HT, Liu YZ, Hai Y. Accuracy of cortical bone trajectory screw fixation guided by spinous process clamp guide in lumbosacral vertebrae: A cadaver study. Int J Med Robot 2023; 19:e2484. [PMID: 36413096 DOI: 10.1002/rcs.2484] [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: 08/17/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The purpose of this study was to access the accuracy of cortical bone trajectory screw placement guided by spinous process clamp (SPC). METHODS Eight formalin-treated cadaveric lumbar specimens with T12-S1 were used. A total of 96 screws were implanted in eight lumbar specimens. RESULTS In the freehand (FH) group, clinically acceptable placement (grade A and B) was 40 screws (83.3%), meanwhile 44 screws (91.7%) in the SPC guide group (p = 0.217). The grade A screws in the SPC guide group were much more than that in the FH group (n = 40 vs. n = 31, p = 0.036). The misplacement screws (grade C, D, and E) and proximal facet joint violation (FJV) in the SPC group was comparable to the FH group. CONCLUSIONS This cadaveric study demonstrate that implanting CBT screws guided by SPC guide was more accuracy and reduces severe deviations in important directions.
Collapse
Affiliation(s)
- Xi-Nuo Zhang
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Li-Jin Zhou
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Qing-Jun Su
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Li Guan
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Dong-Yue Li
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Bao-Qing Pei
- Beijing 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
| | - Ai-Xing Pan
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Hong-Hao Yang
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Hong-Tao Ding
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Yu-Zeng Liu
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
4
|
Zhang XN, Zhang YQ, Liu YZ, Su QJ, Guan L, Li DY, Pei BQ, Pan AX, Yang HH, Ding HT, Hai Y, Zhou LJ. Cortical screw placement with a spinous process clamp guide: a cadaver study accessing accuracy. BMC Surg 2022; 22:384. [PMID: 36348354 PMCID: PMC9644622 DOI: 10.1186/s12893-022-01829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
Background and objective The Cortical Bone Trajectory (CBT) technique provides an alternative method for fixation in the lumbar spine in patients with osteoporosis. An accuracy CBT screw placement could improve mechanical stability and reduce complication rates. Purpose The purpose of this study is to explore the accuracy of cortical screw placement with the application of implanted spinous process clip (SPC) guide. Methods and materials Four lumbar specimens with T12-S1 were used to access the accuracy of the cortical screw. The SPC-guided planning screws were compared to the actual inserted screws by superimposing the vertebrae and screws preoperative and postoperative CT scans. According to preoperative planning, the SPC guide was adjusted to the appropriate posture to allow the K-wire drilling along the planned trajectory. Pre and postoperative 3D-CT reconstructions was used to evaluate the screw accuracy according to Gertzbein and Robbins classification. Intraclass correlation coefficients (ICCs) and Bland–Altman plots were used to examine SPC-guided agreements for CBT screw placement. Results A total of 48 screws were documented in the study. Clinically acceptable trajectory (grades A and B) was accessed in 100% of 48 screws in the planning screws group, and 93.8% of 48 screws in the inserted screws group (p = 0.242). The incidence of proximal facet joint violation (FJV) in the planning screws group (2.1%) was comparable to the inserted screws group (6.3%) (p = 0.617). The lateral angle and cranial angle of the planned screws (9.2 ± 1.8° and 22.8 ± 5.6°) were similar to inserted screws (9.1 ± 1.7° and 23.0 ± 5.1°, p = 0.662 and p = 0.760). Reliability evaluated by intraclass correlation coefficients and Bland–Altman showed good consistency in cranial angle and excellent results in lateral angle and distance of screw tip. Conclusions Compared with preoperative planning screws and the actually inserted screws, the SPC guide could achieve reliable execution for cortical screw placement.
Collapse
|
5
|
Abstract
STUDY DESIGN Multicenter retrospective review. OBJECTIVE To calculate overall incidence of pedicle screw "plowing" in adolescent idiopathic scoliosis (AIS) patients who underwent posterior spinal fusion (PSF). To identify risk factors for pedicle screw plowing and associated postoperative outcomes, including loss of correction and revision rate. SUMMARY OF BACKGROUND DATA Curve correction of AIS generates perpendicular stresses that can cause pedicle screws to lose alignment and "plow" through pedicles craniocaudally. METHODS We reviewed records of 1057 patients who underwent PSF for AIS from 2002 to 2015. Preoperative and first postoperative erect radiographs were evaluated by two observers to determine (1) presence of plowing and (2) subsequent loss of correction (LOC). Plowing was defined as more than 25° sagittal angulation compared with pedicle axis or entry of the most dorsal part of the screw outside the pedicle projection. LOC was defined as postoperative change in focal angulation of an instrumented spinal level, when in consensus of both reviewers. Bivariate analyses were performed (alpha = 0.05). RESULTS Nineteen thousand five hundred sixty nine screws were assessed across our cohort of 1057 patients. Both observers agreed that 48 patients (4.5%) demonstrated plowing of more than or equal to one pedicle screw. For 72 screws (0.4%), both observers noted plowing, most commonly through the cranial cortex of the pedicle (65/72 screws) and at the lowest instrument vertebra (LIV) (17/72 screws). Factors associated with plowing included larger curves (P = 0.02); lower mean pedicle screw density (P = 0.0003); skeletal immaturity as measured by open triradiate cartilage (P = 0.04); and younger chronological age at time of surgery (P = 0.04). LOC occurred in 13 patients, most commonly at LIV (P < 0.0001). Revision rate for loss of screw fixation was higher in the plowing group (P = 0.003). CONCLUSION Pedicle screw plowing occurred in 4.5% of AIS patients, especially in those skeletally immature and with decreased implant density. Plowing commonly occurred in the cranial direction and was associated with LOC, particularly at the LIV.Level of Evidence: 3.
Collapse
|
6
|
Zhang L, Tian N, Yang J, Ni W, Jin L. Risk of pedicle and spinous process violation during cortical bone trajectory screw placement in the lumbar spine. BMC Musculoskelet Disord 2020; 21:536. [PMID: 32781995 PMCID: PMC7422524 DOI: 10.1186/s12891-020-03535-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/23/2020] [Indexed: 01/09/2023] Open
Abstract
Background Previous studies have confirmed the feasibility of the cortical bone trajectory (CBT) technique. However, there are few reports on spinous process violation and screw penetration during the screw insertion. The purpose of this study was to evaluate the incidence of spinous process violation and screw penetration through the pedicle during CBT screw insertion. Methods Computed tomography (CT) scans with normal lumbar structures were consecutively obtained and three-dimensional (3D) reconstructions of the lumbar spine were created. Bilateral CBT screw placement was simulated on each segment using a screw diameter of 4.5 mm, 5.0 mm, or 5.5 mm. Incidences of these complications were recorded and analyzed. Results A total of 90 patients were enrolled. Spinous process violation was observed in 68.3, 53.3, 25.5, 1.7, and 0% from L1 to L5, respectively, using 4.5 mm screws. A significant difference was found among the five segments but this was unconnected to gender or screw diameter. The incidence of screw penetration through the inner wall decreased from L1 to L4; in turn, L1 (16.7–35.5%), L2 (12.7–34.4%), L3 (2.8–23.8%) and L4 (1.1–6.7%). This trend was reversed in L5 (6.7–16.7%). Moreover, screw penetration through the outer wall was rare. The incidence of screw penetration varied with screw size as well as lumbar level, but not with gender. Conclusions There are more difficulties of CBT screw fixation in upper lumbar spine. The low rate of screw penetration, using 4.5 mm screws, suggests the safety for CBT fixation in the lumbar spine. Larger screws (5.0 mm or 5.5 mm) are more recommended for use in the lower lumbar spine. Moreover, CBT fixation in L5 deserves greater attention because of the unique morphology of the pedicle.
Collapse
Affiliation(s)
- Lilian Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Naifeng Tian
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Jian Yang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Wenfei Ni
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China
| | - Liya Jin
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang, China.
| |
Collapse
|
7
|
Zhang T, Ren X, Feng X, Diwan A, Luk KDK, Lu WW, Wong TM, Li C, Cheung JPY. Failure mechanisms of pedicle screws and cortical screws fixation under large displacement: A biomechanical and microstructural study based on a clinical case scenario. J Mech Behav Biomed Mater 2020; 104:103646. [DOI: 10.1016/j.jmbbm.2020.103646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
|
8
|
Nakajima N, Maenaka T, Kano H. Postoperative Low Back Pain after Posterior Lumbar Interbody Fusion Surgery Using Cortical Bone Trajectory Screws. Asian Spine J 2020; 14:655-662. [PMID: 32213798 PMCID: PMC7595813 DOI: 10.31616/asj.2019.0085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/23/2019] [Indexed: 12/25/2022] Open
Abstract
Study Design Retrospective analysis of a case series of prospectively collected data. Purpose To compare clinical and radiological outcomes between two posterior lumbar interbody fusion techniques: cortical bone trajectory (CBT) and traditional pedicle screw (PS). Overview of Literature Biomechanical studies have revealed the benefits of the CBT technique. However, clinical evidence obtained from the direct comparison of outcomes between CBT and PS is limited. Methods We retrospectively investigated 104 patients who had undergone posterior lumbar interbody fusion using CBT or PS. Clinical symptoms were evaluated and compared between CBT and PS using the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and Visual Analog Scale (VAS) before and 1 year after surgery. Spinal fusion status was assessed by multiplanar reconstruction computed tomography at 1 year after surgery. Results The CBT and PS techniques were performed on 36 and 68 patients, respectively. Both CBT- and PS-treated patients exhibited improvement in each subdomain of the JOABPEQ and in the VAS. With regard to postoperative improvement of low back pain, the treatment effect, as assessed by the JOABPEQ, was greater for PS than for CBT. The spinal fusion rate was slightly lower for CBT than for PS, although the difference between them was not significant. The effect of treatment on postoperative low back pain was smaller for CBT than for PS, regardless of whether rigid spinal fusion was achieved. Conclusions Clinical symptoms and spinal fusion efficiency were not significantly different between CBT and PS except for postoperative improvement in low back pain. The treatment effect on postoperative low back pain was smaller for CBT than for PS.
Collapse
Affiliation(s)
- Nozumu Nakajima
- Department of Orthopaedic Surgery, Osaka General Medical Center, Osaka, Japan
| | - Takahiro Maenaka
- Department of Orthopaedic Surgery, Osaka General Medical Center, Osaka, Japan
| | - Hiroki Kano
- Department of Orthopaedic Surgery, Osaka General Medical Center, Osaka, Japan
| |
Collapse
|
9
|
Cofano F, Marengo N, Ajello M, Penner F, Mammi M, Petrone S, Lavorato A, Zenga F, Garbossa D. The Era of Cortical Bone Trajectory Screws in Spine Surgery: A Qualitative Review with Rating of Evidence. World Neurosurg 2020; 134:14-24. [DOI: 10.1016/j.wneu.2019.10.079] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/11/2019] [Accepted: 10/13/2019] [Indexed: 12/14/2022]
|
10
|
Nomoto EK, Fogel GR, Rasouli A, Bundy JV, Turner AW. Biomechanical Analysis of Cortical Versus Pedicle Screw Fixation Stability in TLIF, PLIF, and XLIF Applications. Global Spine J 2019; 9:162-168. [PMID: 30984495 PMCID: PMC6448199 DOI: 10.1177/2192568218779991] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
STUDY DESIGN Cadaveric biomechanical study. OBJECTIVES Medial-to-lateral trajectory cortical screws are of clinical interest due to the ability to place them through a less disruptive, medialized exposure compared with conventional pedicle screws. In this study, cortical and pedicle screw trajectory stability was investigated in single-level transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and extreme lateral interbody fusion (XLIF) constructs. METHODS Eight lumbar spinal units were used for each interbody/screw trajectory combination. The following constructs were tested: TLIF + unilateral facetectomy (UF) + bilateral pedicle screws (BPS), TLIF + UF + bilateral cortical screws (BCS), PLIF + medial facetectomy (MF) + BPS, PLIF + bilateral facetectomy (BF) + BPS, PLIF + MF + BCS, PLIF + BF + BCS, XLIF + BPS, XLIF + BCS, and XLIF + bilateral laminotomy + BCS. Range of motion (ROM) in flexion-extension, lateral bending, and axial rotation was assessed using pure moments. RESULTS All instrumented constructs were significantly more rigid than intact (P < .05) in all test directions except TLIF + UF + BCS, PLIF + MF + BCS, and PLIF + BF + BCS in axial rotation. In general, XLIF and PLIF + MF constructs were more rigid (lowest ROM) than TLIF + UF and PLIF + BF constructs. In the presence of substantial iatrogenic destabilization (TLIF + UF and PLIF + BF), cortical screw constructs tended to be less rigid (higher ROM) than the same pedicle screw constructs in lateral bending and axial rotation; however, no statistically significant differences were found when comparing pedicle and cortical fixation for the same interbody procedures. CONCLUSIONS Both cortical and pedicle trajectory screw fixation provided stability to the 1-level interbody constructs. Constructs with the least iatrogenic destabilization were most rigid. The more destabilized constructs showed less lateral bending and axial rotation rigidity with cortical screws compared with pedicle screws. Further investigation is warranted to understand the clinical implications of differences between constructs.
Collapse
Affiliation(s)
- Edward K. Nomoto
- Cedars-Sinai Spine Center, Los Angeles, CA, USA,Edward K. Nomoto, Cedars-Sinai Spine Center, 444 S
San Vincente Boulevard #800, Los Angeles, CA 90048, USA.
| | | | | | | | | |
Collapse
|
11
|
Kaito T, Matsukawa K, Abe Y, Fiechter M, Zhu X, Fantigrossi A. Cortical pedicle screw placement in lumbar spinal surgery with a patient-matched targeting guide: A cadaveric study. J Orthop Sci 2018; 23:865-869. [PMID: 30042005 DOI: 10.1016/j.jos.2018.06.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/17/2018] [Accepted: 06/11/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cortical pedicle screw placement is an attractive technique in terms of both fixation strength and less invasiveness. However, to insert the screw with penetrating cortical bone on the ideal trajectory is technically demanding. The use of three-dimensional (3D) patient-matched guides may facilitate the use of this technique. PURPOSE To examine the accuracy of cortical screw placement using a patient-matched targeting guide with a cadaveric study assessing the accuracy. METHODS The 3D planning of the pedicle screw placement, including the location at which the screw would pass through the center of the pedicle, sagittal/transverse trajectory (angle), length, and diameter, was developed using 3D CAD design software. Three-dimensional guides based on the preoperative planning were created for three cadaveric specimens (L1 to S1, 36 pedicles). Screws (n = 18) and pins (n = 18) were placed using K-wire or drill-based guides, without X-ray exposure. Actual positioning was compared to the preoperative plan by superimposing the inserted screws/pins based on postoperative CT. The placement accuracy was graded based on the degree of perforation of the pedicle by the pedicle screw or pin using an acceptance criterion (no perforation; Grade A, 0-2 mm; Grade B, 2-4 mm; and Grade C, >4 mm). The mean deviation between the planned and inserted screw positions on the coronal plane at the midpoint of the pedicle was compared to the accuracy of screw guide for traditional pedicle screw trajectory (0.70 mm). RESULTS Of 35 evaluated screws and pins, 32 (91.4%) were inserted completely inside the pedicle. All pedicle perforation was within 2 mm. The mean deviation from the plan at the midpoint of pedicle was 0.66 mm; thus, the accuracy was within the predefined criteria. CONCLUSIONS Cortical pedicle screw placement using 3D-patient matched guides is accurate. Further clinical studies are required to confirm the radiographic and clinical effects.
Collapse
Affiliation(s)
- Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Japan.
| | - Keitaro Matsukawa
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Japan
| | - Yuichiro Abe
- Department of Orthopaedic Surgery, Wajokai Eniwa Hospital, Japan
| | | | - Xia Zhu
- Medacta International SA, Switzerland
| | | |
Collapse
|
12
|
Hayashi K, Toyoda H, Terai H, Hoshino M, Suzuki A, Takahashi S, Tamai K, Ohyama S, Hori Y, Yabu A, Nakamura H. Comparison of minimally invasive decompression and combined minimally invasive decompression and fusion in patients with degenerative spondylolisthesis with instability. J Clin Neurosci 2018; 57:79-85. [PMID: 30154001 DOI: 10.1016/j.jocn.2018.08.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/13/2018] [Indexed: 01/12/2023]
Abstract
Posterior lumbar interbody fusion with cortical bone trajectory (CBT-PLIF) is a form of minimally invasive decompression and fusion, whereas microendoscopic laminotomy (MEL) is a form of minimally invasive decompression surgery. No study has compared the clinical outcomes of the two methods for patients who have degenerative spondylolisthesis (DS) with instability. In this study, CBT-PLIF and MEL were both offered to 64 patients who met the inclusion criteria. Each patient then selected his or her preferred treatment. Twenty patients received CBT-PLIF. They were matched to 30 of the 44 patients receiving MEL based on age, sex, disease duration, and surgical levels. The 20 patients with CBT-PLIF formed the CBT group and the 30 matched patients with MEL formed the MEL group. At 2 years of follow-up, Japanese Orthopaedic Association scores improved to 72.6% and 70.5% in the CBT and MEL groups, respectively. The difference in scores was not statistically significant. Further, improvements in visual analogue scale scores for back and leg symptom did not differ significantly between the two groups. Regarding complications, 1 CBT-group patient (5%) had adjacent-segment degeneration and 7 MEL-group patients (23%) had same-segment degeneration. Three CBT-group patients (15%) and 5 MEL-group patients (16%) required reoperation within the follow-up period. In summary, among patients who had DS with instability, MEL and CBT-PLIF offered comparable clinical outcomes at 2 years of follow-up. Although the rate of segmental degeneration was relatively high in the MEL group, both groups had similar reoperation rates.
Collapse
Affiliation(s)
- Kazunori Hayashi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiromitsu Toyoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masatoshi Hoshino
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akinobu Suzuki
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinji Takahashi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koji Tamai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shoichiro Ohyama
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Hori
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akito Yabu
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
13
|
Sellin JN, Raskin JS, Staggers KA, Brayton A, Briceño V, Moreno AJ, Jea A. Feasibility and safety of using thoracic and lumbar cortical bone trajectory pedicle screws in spinal constructs in children: technical note. J Neurosurg Pediatr 2018; 21:190-196. [PMID: 29148922 DOI: 10.3171/2017.7.peds17240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Thoracic and lumbar cortical bone trajectory pedicle screws have been described in adult spine surgery. They have likewise been described in pediatric CT-based morphometric studies; however, clinical experience in the pediatric age group is limited. The authors here describe the use of cortical bone trajectory pedicle screws in posterior instrumented spinal fusions from the upper thoracic to the lumbar spine in 12 children. This dedicated study represents the initial use of cortical screws in pediatric spine surgery. The authors retrospectively reviewed the demographics and procedural data of patients who had undergone posterior instrumented fusion using thoracic, lumbar, and sacral cortical screws in children for the following indications: spondylolysis and/or spondylolisthesis (5 patients), unstable thoracolumbar spine trauma (3 patients), scoliosis (2 patients), and tumor (2 patients). Twelve pediatric patients, ranging in age from 11 to 18 years (mean 15.4 years), underwent posterior instrumented fusion. Seventy-six cortical bone trajectory pedicle screws were placed. There were 33 thoracic screws and 43 lumbar screws. Patients underwent surgery between April 29, 2015, and February 1, 2016. Seven (70%) of 10 patients with available imaging achieved a solid fusion, as assessed by CT. Mean follow-up time was 16.8 months (range 13-22 months). There were no intraoperative complications directly related to the cortical bone trajectory screws. One patient required hardware revision for caudal instrumentation failure and screw-head fracture at 3 months after surgery. Mean surgical time was 277 minutes (range 120-542 minutes). Nine of the 12 patients received either a 12- or 24-mg dose of recombinant human bone morphogenic protein 2. Average estimated blood loss was 283 ml (range 25-1100 ml). In our preliminary experience, the cortical bone trajectory pedicle screw technique seems to be a reasonable alternative to the traditional trajectory pedicle screw placement in children. Cortical screws seem to offer satisfactory clinical and radiographic outcomes, with a low complication profile.
Collapse
Affiliation(s)
- Jonathan N Sellin
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Jeffrey S Raskin
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Kristen A Staggers
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Alison Brayton
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Valentina Briceño
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Amee J Moreno
- 1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Andrew Jea
- 2Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurosurgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| |
Collapse
|
14
|
Matsukawa K, Yato Y. Lumbar pedicle screw fixation with cortical bone trajectory: A review from anatomical and biomechanical standpoints. Spine Surg Relat Res 2017; 1:164-173. [PMID: 31440629 PMCID: PMC6698564 DOI: 10.22603/ssrr.1.2017-0006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/06/2017] [Indexed: 12/14/2022] Open
Abstract
Over the past few decades, many attempts to enhance the integrity of the bone-screw interface have been made to prevent pedicle screw failure and to achieve a better clinical outcome when treating a variety of spinal disorders. Cortical bone trajectory (CBT) has been developed as an alternative to the traditional lumbar pedicle screw trajectory. Contrary to the traditional trajectory, which follows the anatomical axis of the pedicle from a lateral starting point, CBT starts at the lateral part of the pars interarticularis and follows a mediolateral and caudocranial screw path through the pedicle. By markedly altering the screw path, CBT has the advantage of achieving a higher level of thread contact with the cortical bone from the dorsal entry point to the vertebral body. Biomechanical studies demonstrated the superior anchoring ability of CBT over the traditional trajectory, even with a shorter and smaller CBT screw. Furthermore, screw insertion from a more medial and caudal starting point requires less exposure and minimizes the procedure-related morbidity, such as reducing damage to the paraspinal muscles, avoiding iatrogenic injury to the cranial facet joint, and maintaining neurovascular supply to the fused segment. Thus, the features of CBT, which enhance screw fixation with limited surgical exposure, have attracted the interest of surgeons as a new minimally invasive method for spinal fusion. The purpose of this study was: 1) to identify the features of the CBT technique by reviewing previous anatomical and biomechanical literature, and 2) to describe its clinical application with a focus on the indications, limitations, surgical technique, and clinical evidence.
Collapse
Affiliation(s)
- Keitaro Matsukawa
- Department of Orthopaedic Surgery, Self Defense Force Central Hospital, Tokyo, Japan
| | - Yoshiyuki Yato
- Department of Orthopaedic Surgery, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan
| |
Collapse
|
15
|
Review of Cortical Bone Trajectory: Evidence of a New Technique. Asian Spine J 2017; 11:817-831. [PMID: 29093793 PMCID: PMC5662866 DOI: 10.4184/asj.2017.11.5.817] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/06/2017] [Accepted: 03/01/2017] [Indexed: 12/26/2022] Open
Abstract
This article summarizes recent evidence on the cortical bone trajectory (CBT) obtained from published anatomical, biomechanical, and clinical studies. CBT was proposed by Santoni in 2009 as a new trajectory that can improve the fixation of pedicle screws in response to screw loosening in osteoporotic patients. Recently, research interest has been growing with increasing numbers of published series and frequent reports of new applications. We performed an online database search using the terms “cortical bone trajectory,” “pedicle screw,” “CBT spine,” “CBT fixation,” “MISS CBT,” and “traditional trajectory.” The search included the PubMed, Ovid MEDLINE, Cochrane, and Google Scholar databases, resulting in an analysis of 42 articles in total. These covered three aspects of CBT research: anatomical studies, biomechanical parameters, and clinical cases or series. Compared to the traditional trajectory, CBT improves pullout strength, provides greater stiffness in cephalocaudal and mediolateral loading, and shows superior resistance to flexion/extension; however, it is inferior in lateral bending and axial rotation. CBT seems to provide better immediate implant stability. In clinical studies, CBT has shown better perioperative results for blood loss, length of stay in hospital, and surgery time; similar or better clinical postoperative scores; and similar comorbidity, without any major fixation system complications due to instrumentation failure or screw misplacement. In addition, advantages such as less lateral exposure allow it to be used as a minimally invasive technique. However, most of the clinical studies were retrospective case series or case-control studies; prospective evidence on this technique is scarce, making a definitive comparison with the traditional trajectory difficult. Nevertheless, we can conclude that CBT is a safe technique that offers good clinical results with similar biomechanical and perioperative parameters to those of the traditional trajectory. In addition, new applications can improve its results and make it useful for additional pathologies.
Collapse
|
16
|
Pull-out strength of patient-specific template-guided vs. free-hand fluoroscopically controlled thoracolumbar pedicle screws: a biomechanical analysis of a randomized cadaveric study. 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 2017; 26:2865-2872. [DOI: 10.1007/s00586-017-5025-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/20/2016] [Accepted: 02/28/2017] [Indexed: 10/20/2022]
|