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Lee SH, Park JH, Lee JB, Lee HJ, Kim IS, Hur JW, Hong JT. Safety and Efficacy of Intraoperative Doppler Sonography-Assisted Cervical Pedicle Screw Fixation-A Retrospective Comparison with Conventional Pedicle Screw Implantation. Global Spine J 2023; 13:1592-1601. [PMID: 35193407 PMCID: PMC10448084 DOI: 10.1177/21925682211041965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN A Retrospective Cohort Study. OBJECTIVE To introduce a new Doppler sonography-assisted pedicle screw fixation technique that enables vertebral artery (VA) monitoring during surgery and compares the accuracies of Doppler sonography-assisted cervical pedicle screw fixation and the conventional technique. METHODS This retrospective study was performed on 164 consecutive patients that underwent pedicle-based screw fixation from C2 to C6 between January 2013 and August 2020. Surgery was performed without intraoperative Doppler sonography in 84 cases (the Control group) or with intraoperative Doppler sonography in 80 cases (the Doppler group). Proper positioning of pedicle screws was graded, and the incidences of VA injury and screw breach in the Control and Doppler groups were compared. RESULTS Three hundred and ninety-nine screws were placed in the 164 patients (Doppler, 186 screws; Control, 213 screws). The percentages of well-positioned screws in the two groups were significantly different (Doppler, 97.8%; Control, 85.0%). There were two cases of VA injury in the Control group, an incidence of 2.4%, but no case in the Doppler group. CONCLUSION Doppler sonography can be used intraoperatively to help guide the trajectory of the cervical pedicle screw insertion. It can detect the VA inside the screw trajectory and may reduce the risk of VA injury during cervical pedicle screw fixation.
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Affiliation(s)
- Sang Hyo Lee
- Department of Neurosurgery, The Catholic University of Korea Eunpyeong St Mary’s Hospital, Eunpyeong-gu, Korea
| | - Jong-Hyeok Park
- Department of Neurosurgery, The Catholic University of Korea Incheon St Mary’s Hospital, Incheon, Korea
| | - Jong Beom Lee
- Department of Neurosurgery, Chungbuk National University, Cheongju, Korea
| | - Ho Jin Lee
- Department of Neurosurgery, The Catholic University of Korea St Vincent’s Hospital, Suwon, Korea
| | - Il Sup Kim
- Department of Neurosurgery, The Catholic University of Korea St Vincent’s Hospital, Suwon, Korea
| | - Jeong Woo Hur
- Department of Neurosurgery, The Catholic University of Korea Eunpyeong St Mary’s Hospital, Eunpyeong-gu, Korea
| | - Jae Taek Hong
- Department of Neurosurgery, The Catholic University of Korea Eunpyeong St Mary’s Hospital, Eunpyeong-gu, Korea
- Department of Neurosurgery, The Catholic University of Korea St Vincent’s Hospital, Suwon, Korea
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Malikov A, Secen AE, Ocal O, Divanlioglu D, Belen AD, Dalgic A. Accuracy of Axis Drill Guides in the Cases of Atlantoaxial Instabilities Associated With High-Riding Vertebral Arteries, Narrow Pedicles, and Complex Deformities: Comparison of 3 Fixation Methods. World Neurosurg 2022; 168:e336-e343. [DOI: 10.1016/j.wneu.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 12/15/2022]
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Zileli M, Akıntürk N. Commentary: Transarticular Fixation Following Mobilization of "High-Riding" Vertebral Artery. Oper Neurosurg (Hagerstown) 2021; 21:E61-E62. [PMID: 33822138 DOI: 10.1093/ons/opab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/31/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mehmet Zileli
- Ege University Neurosurgery Department, Izmir, Turkey
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Shimizu T, Koda M, Abe T, Shibao Y, Kono M, Eto F, Miura K, Mataki K, Noguchi H, Takahashi H, Funayama T, Yamazaki M. Correlation between osteoarthritis of the atlantoaxial facet joint and a high-riding vertebral artery. BMC Musculoskelet Disord 2021; 22:406. [PMID: 33941142 PMCID: PMC8091766 DOI: 10.1186/s12891-021-04275-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A high-riding vertebral artery (HRVA) is an intraosseous anomaly that narrows the trajectory for C2 pedicle screws. The prevalence of a HRVA is high in patients who need surgery at the craniovertebral junction, but reports about HRVAs in subaxial cervical spine disorders are limited. We sought to determine the prevalence of HRVAs among patients with subaxial cervical spine disorders to elucidate the potential risk for VA injury in subaxial cervical spine surgery. METHODS We included 215 patients, 94 were with a main lesion from C3 to C7 (subaxial group) and 121 were with a main lesion from T1 to L5 (thoracolumbar group). A HRVA was defined as a maximum C2 pedicle diameter of < 3.5 mm on axial CT. The sex, age of patients, body mass index (BMI), osteoarthritis of the atlantoaxial (C1-2) facet joints, and prevalence of a HRVA in the 2 groups were compared and logistic regression was used to identify the factors correlated with a HRVA. RESULTS The patients in the subaxial group were younger than those in the thoracolumbar group, but their sex and BMI did not differ significantly between the 2 groups. The mean osteoarthritis grade of the C1-2 facet joints of patients in the subaxial group was significantly higher than that in those in the thoracolumbar group. A HRVA was found in 26 patients of 94 (27.7 %) in the subaxial group and in 19 of 121 (15.7 %) in the thoracolumbar group. The prevalence of a HRVA in the subaxial group was significantly higher and osteoarthritis of C1-2 facet joints correlated significantly with a HRVA. CONCLUSIONS The prevalence of a HRVA in patients with subaxial cervical spine disorders is higher than in those without and osteoarthritis of the C1-2 facet joints is correlated with a HRVA.
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Affiliation(s)
- Tomoaki Shimizu
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan.
| | - Masao Koda
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Tetsuya Abe
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Yosuke Shibao
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Mamoru Kono
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Fumihiko Eto
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Kousei Miura
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Kentaro Mataki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Hiroshi Noguchi
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Toru Funayama
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
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Hong JT, Koller H, Abumi K, Yuan W, Falavigna A, Lee HJ, Lee JB, Le Huec JC, Park JH, Kim IS. A new nomenclature system for the surgical treatment of cervical spine deformity, developing, and validation of SOF system. 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 2021; 30:1670-1680. [PMID: 33547943 DOI: 10.1007/s00586-021-06751-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 12/08/2020] [Accepted: 01/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To develop and assess the reliability of new nomenclature system that systematically organizes osteotomy techniques and briefly describes the surgical approach, the surgical sequence, and the fixation technique for cervical spine deformity (CSD). METHODS We developed a new classification system (SOF system) for CSD surgery that describes the sequence of surgical approach (S), the grade of osteotomy (O), and the information of fixation (F) using alphanumeric codes. Twenty CSD osteotomies (8 anterior osteotomies, 12 posterior osteotomies) were included in this study to evaluate the inter- and intra-observer agreement based on operation records. Six observers performed independent evaluations of the operation records in random order. Each observer described 20 CSD surgeries using the SOF system twice (> 30 days between assessments) based on operation records to validate SOF system. RESULTS Overall agreement (among all six observers at the initial assessment) on the anterior and posterior osteotomy was ICC = 0.96 and ICC = 0.91, respectively. Overall agreement (repeat observations after at least 30 days) on the anterior and posterior osteotomy was ICC = 0.96 and ICC = 0.91, respectively. This data showed that both inter- and intra-observer agreement revealed 'excellent'. CONCLUSION This study introduces the SOF system of the CSD surgery to understand the surgical sequence, the type of osteotomy and the fixation techniques. The investigation of the inter- and intra-observer agreement revealed 'excellent agreement' for both anterior and posterior osteotomies. Thus, SOF system can provide a consistent description of the various CSD surgeries and its use will provide a common frame for CSD surgery and help communicate between surgeons.
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Affiliation(s)
- Jae Taek Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.
| | - Heiko Koller
- Department of Neurosurgery, Technical University of Munich, Munich, Germany
| | - Kuniyoshi Abumi
- Department of Orthopedic Surgery, Sapporo Orthopedic Hospital, Sapporo, Japan
| | - Wen Yuan
- Department of Orthopedic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Asdrubal Falavigna
- Department of Neurosurgery, University of Caxias Do Sul, Caxias Do Sul, RS, Brazil
| | - Ho Jin Lee
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Jong Beom Lee
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jean-Charles Le Huec
- Department of Orthopedic Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Jong-Hyeok Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Il Sup Kim
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
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Guo Q, Zhou X, Guo X, Han Z, Chen F, Zhu J, Lu X, Ni B. C2 partial transpedicular screw technique for atlantoaxial dislocation with high-riding vertebral artery: A technique note with case series. Clin Neurol Neurosurg 2020; 200:106403. [PMID: 33338827 DOI: 10.1016/j.clineuro.2020.106403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although the C2 pedicle screw (C2PS) is currently the most biomechanically robust option for C2 fixation, the high-riding vertebral artery (HRVA) precludes safe C2PS placement. However, unintentional partial C2 pedicle perforation and vertebral foramen violation due to C2PS placement without neurovascular complications occurred frequently in clinic. Therefore, we have attempted to apply C2 partial transpedicular screw (C2PTS) in patients with HRVA with satisfactory preliminary outcomes. The aim of the present study is to introduce the C2PTS technique and report the preliminary radiological and clinical outcomes of application of C2PTS. PATIENTS AND METHODS The data of 15 patients with atlantoaxial dislocation underwent atlantoaxial arthrodesis with posterior screw-rod construct were retrospectively reviewed. All patients had unilateral or bilateral HRVA that precluded safe C2PS placement and C2PTS was used as an alternative. In this technique, a Penfield dissector was used to properly mobilize the HRVA inferiorly to preclude vertebral artery injury and pave the way for C2PTS placement. The C2PTS travelled under the superior border of the isthmus and toward the ipsilateral atlantoaxial articulation. The implant position and atlantoaxial reduction were evaluated using computed tomography (CT) scans and vertebral artery (VA) was assessed using CT angiography postoperatively. RESULTS Satisfactory C2PTS placement and atlantoaxial reduction were achieved in all patients. Postoperatively, no vertebral artery injury and implant failure were observed, and bone fusion was achieved in all the patients. Additionally, there were no VA occlusion or stenosis due to screws demonstrated on VA CT angiography. CONCLUSION C2PTS can achieve three-column fixation of axis and is an efficient alternative to C2PS which is prohibited due to HRVA; also, gently mobilizing the HRVA inferiorly is mandatory to prevent vertebral artery injury during C2PTS placement.
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Affiliation(s)
- Qunfeng Guo
- From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China
| | - Xin Zhou
- From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China
| | - Xiang Guo
- From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China
| | - Zhao Han
- From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China
| | - Fei Chen
- From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China
| | - Jingyu Zhu
- From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China
| | - Xuhua Lu
- From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China
| | - Bin Ni
- From the Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China.
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Hong JT, Koller H, Abumi K, Yuan W, Falavigna A, Lee HJ, Lee JB, Le Huec JC, Park JH, Kim IS. SOF System; A New Nomenclature System for the Surgical Techniques of Cervical Spine Deformity. Neurospine 2020; 17:505-512. [PMID: 33022155 PMCID: PMC7538365 DOI: 10.14245/ns.2040472.236] [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: 08/03/2020] [Accepted: 08/25/2020] [Indexed: 12/05/2022] Open
Abstract
Although cervical spinal deformity (CSD) can have a profoundly negative impact on an individual’s quality of life and there have been many advances in surgical treatment of CSD in recent years, there exists no comprehensive classification system of surgical treatment that categorizes anterior and posterior surgery separately according to the grade of surgery. The objective of this study is to introduce the new classification system of various surgical treatments for CSD. We developed a new classification system (SOF system) for CSD surgery that describes the sequence of surgical approach (S), the grade of osteotomy (O), and the information of fixation (F) using alphanumeric codes. This new classification system can provide a consistent description of the various osteotomies performed in CSD surgery. Especially, regarding research, there has been a clear benefit to this classification. Having a standardized classification that allows for common frame for cervical deformity correction surgery, communication between surgeons and the evaluation of the CSD surgeries make it possible to conduct global comparative research about surgical outcome.
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Affiliation(s)
- Jae Taek Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Heiko Koller
- Department of Neurosurgery, Technical University of Munich, Munich, Germany
| | - Kuniyoshi Abumi
- Department of Orthopedic Surgery, Sapporo Orthopedic Hospital, Sapporo, Japan
| | - Wen Yuan
- Department of Orthopedic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Asdrubal Falavigna
- Department of Neurosurgery, University of Caxias do Sul, Caxias do Sul, RS, Brazil
| | - Ho Jin Lee
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Jong Beom Lee
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jean-Charles Le Huec
- Department of Orthopedic Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Jong Hyuk Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Il Sup Kim
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
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Klepinowski T, Pala B, Cembik J, Sagan L. Prevalence of High-Riding Vertebral Artery: A Meta-Analysis of the Anatomical Variant Affecting Choice of Craniocervical Fusion Method and Its Outcome. World Neurosurg 2020; 143:e474-e481. [PMID: 32750514 DOI: 10.1016/j.wneu.2020.07.182] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A high-riding vertebral artery (HRVA) has been defined as a C2 isthmus height of ≤5 mm and/or internal height of ≤2 mm measured 3 mm lateral to the border of the spinal canal. Its reported prevalence has varied widely. If overlooked during the approach for craniocervical fusion, injury to the vertebral arteries can occur, affecting the outcome. The present meta-analysis aimed to provide the pooled prevalence of HRVAs. METHODS A comprehensive database search was conducted by 3 of us. Peer-reviewed studies that had followed the strict definition for HRVAs and had reported its prevalence were included. The risk of bias was assessed using the anatomical quality assessment tool. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. The pooled prevalence was calculated using a random effects model. RESULTS The data from 20 studies with 3126 subjects (7496 sides) were analyzed. The overall pooled prevalence of ≥1 HRVA was 25.3% (95% confidence interval [CI], 19.6%-31.5%). The prevalence in those without the most important confounding factor, rheumatoid arthritis (RA), was 20.9% (95% CI, 16.5%-25.8%). Patients with RA had a prevalence of 42.9% (95% CI, 23.8%-63.1%). The difference between the non-RA and RA groups was statistically significant (P < 0.001, test of homogeneity, χ2). No geographical differences were noted (P = 0.20, test of homogeneity, χ2). Among those with HRVA, unilateral HRVA was present in 70.3% (95% CI, 65.2%-75.2%) and bilateral in 29.7% (95% CI, 24.8%-34.8%). No left or right side predilection was found (left, 50.8%; 95% CI, 33.8%-67.6%; right, 49.2%; 95% CI, 32.4%-66.2%). CONCLUSIONS Craniocervical fusion should be preceded by examination of the vertebral arteries at the level of C2 because the presence of HRVAs is common and might preclude the safe insertion of transarticular or transpedicular screws.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Public Clinical Hospital No. 1, Pomeranian Medical University, Szczecin, Poland.
| | - Bartłomiej Pala
- Department of Neurosurgery, Public Clinical Hospital No. 1, Pomeranian Medical University, Szczecin, Poland
| | | | - Leszek Sagan
- Department of Neurosurgery, Public Clinical Hospital No. 1, Pomeranian Medical University, Szczecin, Poland
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Azimi P, Yazdanian T, Benzel EC, Aghaei HN, Azhari S, Sadeghi S, Montazeri A. Accuracy and safety of C2 pedicle or pars screw placement: a systematic review and meta-analysis. J Orthop Surg Res 2020; 15:272. [PMID: 32690035 PMCID: PMC7372824 DOI: 10.1186/s13018-020-01798-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/14/2020] [Indexed: 11/25/2022] Open
Abstract
Study design Systematic review and meta-analysis. Aim The purpose of this study was to compare the safety and accuracy of the C2 pedicle versus C2 pars screws placement and free-hand technique versus navigation for upper cervical fusion patients. Methods Databases searched included PubMed, Scopus, Web of Science, and Cochrane Library to identify all papers published up to April 2020 that have evaluated C2 pedicle/pars screws placement accuracy. Two authors individually screened the literature according to the inclusion and exclusion criteria. The accuracy rates associated with C2 pedicle/pars were extracted. The pooled accuracy rate estimated was performed by the CMA software. A funnel plot based on accuracy rate estimate was used to evaluate publication bias. Results From 1123 potentially relevant studies, 142 full-text publications were screened. We analyzed data from 79 studies involving 4431 patients with 6026 C2 pedicle or pars screw placement. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Overall, funnel plot and Begg’s test did not indicate obvious publication bias. The pooled analysis reveals that the accuracy rates were 93.8% for C2 pedicle screw free-hand, 93.7% for pars screw free-hand, 92.2% for navigated C2 pedicle screw, and 86.2% for navigated C2 pars screw (all, P value < 0.001). No statistically significant differences were observed between the accuracy of placement C2 pedicle versus C2 pars screws with the free-hand technique and the free-hand C2 pedicle group versus the navigated C2 pedicle group (all, P value > 0.05). Conclusion Overall, there was no difference in the safety and accuracy between the free-hand and navigated techniques. Further well-conducted studies with detailed stratification are needed to complement our findings.
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Affiliation(s)
- Parisa Azimi
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Arabi Ave, Daneshjoo Blvd, Velenjak, Tehran, 19839-63113, Iran.
| | | | - Edward C Benzel
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Hossein Nayeb Aghaei
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Arabi Ave, Daneshjoo Blvd, Velenjak, Tehran, 19839-63113, Iran
| | - Shirzad Azhari
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Arabi Ave, Daneshjoo Blvd, Velenjak, Tehran, 19839-63113, Iran
| | - Sohrab Sadeghi
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Arabi Ave, Daneshjoo Blvd, Velenjak, Tehran, 19839-63113, Iran
| | - Ali Montazeri
- Population Health Research Group, Mental Health Research Group, Health Metrics Research Centre, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran
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