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Hasanain M, Englisch CN, Tschernig T, Saeed S, Lepschokov M, Ketter R, Oertel J. The Attallah screw: Where safety meets robustness in posterior subaxial cervical instrumentation. MEDICINE INTERNATIONAL 2024; 4:35. [PMID: 38756457 PMCID: PMC11097134 DOI: 10.3892/mi.2024.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/12/2024] [Indexed: 05/18/2024]
Abstract
Posterior fixation of the subaxial cervical spine (SCS) commonly relies on the application of lateral mass screws (LMS), with pedicle screws being a less prevalent alternative. The present study provides another option: A recently introduced novel approach, the Attallah screw, intended to ensure a safety profile comparable to that of LMS, combined with a strength profile similar to that of pedicle screws. The focus of the present study is the comparative analysis of peak insertion torques for these three screw types. Employing standard surgical techniques and instruments, Attallah screws were scheduled for insertion on the right side of the SCS in 15 cadavers, pedicle screws on the left side in 8 cadavers, and LMS on the left side in the remaining 7 cadavers. The peak insertion torque was recorded using an electronic torque screwdriver. The results revealed that the peak insertion torques were similar in the pedicle and the Attallah screw at C3, C4 and C7, but differed at C5 (mean ± SD; pedicle, 79.5±19.6 cNm; Attallah, 56.7±18.5 cNm; P=0.029) and C6 (pedicle, 85.4±28.7 cNm; Attallah, 49.8±17.9 cNm; P=0.004) in favor of the superior pedicle screw measurements. The peak insertion torques of the pedicle screw were superior to the corresponding data from the LMS from C4 to C7. By contrast, the peak insertion torques of the Attallah screw were only superior to those of the LMS at C7 (Attallah, 69.5±24.5 cNm; lateral mass, 40.5±21.4 cNm; P=0.030), although similar trends were observed at the other cervical levels. On the whole, the findings presented herein indicate the level-dependent superior robustness of the Attallah screw as a posterior cervical fixation method compared to the LMS. However, from a biomechanical perspective, the pedicle screw remains the preeminent choice for fixation within the C5-C6 range.
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Affiliation(s)
- Mohammed Hasanain
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
| | - Colya N. Englisch
- Institute for Anatomy and Cell Biology, Saarland University, D-66421 Homburg/Saar, Germany
| | - Thomas Tschernig
- Institute for Anatomy and Cell Biology, Saarland University, D-66421 Homburg/Saar, Germany
| | - Samah Saeed
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
| | - Magomed Lepschokov
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
| | - Ralf Ketter
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center, D-66421 Homburg/Saar, Germany
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Xu P, Lin J, Xiao H, Zheng J, Ji W. Feasibility of C2 Pedicle Screw Fixation With the "in-out-in" Technique for Patients With Basilar Invagination. Spine (Phila Pa 1976) 2024; 49:798-804. [PMID: 37339267 DOI: 10.1097/brs.0000000000004757] [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: 03/21/2023] [Accepted: 06/12/2023] [Indexed: 06/22/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To evaluate the feasibility of C2 pedicle screw fixation with the "in-out-in" technique in patients with basilar invagination (BI). SUMMARY OF BACKGROUND DATA The "in-out-in" technique is a fixation technique in which the screw enters the vertebrae through the parapedicle. The technique has been used in upper cervical spine fixation. However, anatomic parameters associated with the application of this technique in patients with BI are unclear. MATERIALS AND METHODS We measured the C2 pedicle width (PW), the distance between the vertebral artery (VA) and the transverse foramen (VATF), the safe zone, and the limit zone. The lateral safe zone is the distance from the medial/lateral cortex of the C2 pedicle to the VA (LPVA/MPVA), and the medial safe zone is the distance from the medial/lateral cortex of the C2 pedicle to the dura (MPD/LPD). The lateral limit zone is the sum of LPVA/MPVA and VATF (LPTF/MPTF), and the medial limit zone is the distance from the medial/lateral cortex of the C2 pedicle to the spinal cord (MPSC/LPSC). PW, LPVA, MPVA, and VATF were measured on the reconstructed CT angiography. PW, MPD, LPD, MPSC, and LPSC were measured on MRI. We define a width greater than 4 mm as safe for screw. The t -test was used to compare the parameters between male and female, left and right sides in all patients, and PW in CTA and MRI data in the same patient. For intrarater reliabilities, interclass correlation coefficients were calculated. RESULTS A total of 154 patients (49 CTA, 143 MRI) were included. The average PW, LPVA, MPVA, LPTF, MPTF, MPD, LPD, MPSC, and LPSC were 5.30 mm, 1.28 mm, 6.60 mm, 2.45 mm, 8.94 mm, 2.09 mm, 7.07 mm, 5.51 mm, and 10.48 mm, respectively. Furthermore, in patients with PW <4 mm, 53.6% of MPVA, 86.2% of LPTF, and all limit zones were larger than 4 mm. CONCLUSIONS In patients with BI, there is sufficient space medially and laterally to the C2 pedicle for partial screw encroachment to achieve "in-out-in" fixation, even if the pedicle is small. LEVEL OF EVIDENCE Level-4.
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Affiliation(s)
- Panjie Xu
- Division of Spine Surgery, Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junyu Lin
- Division of Spine Surgery, Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, China
| | - Hang Xiao
- Division of Spine Surgery, Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianying Zheng
- Division of Spine Surgery, Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei Ji
- Division of Spine Surgery, Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Orthopaedics, Yunfu People's Hospital
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Wu J, Fan M, He D, Wei Y, Duan F, Jiang X, Tian W. Accuracy and clinical characteristics of robot-assisted cervical spine surgery: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06179-4. [PMID: 38613575 DOI: 10.1007/s00264-024-06179-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/02/2024] [Indexed: 04/15/2024]
Abstract
PURPOSE To evaluate the accuracy and feasibility of robot-assisted cervical screw placement and factors that may affect the accuracy. METHODS A comprehensive search was made on PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang Med for the selection of potential eligible literature. The outcomes were evaluated in terms of the relative risk (RR) or standardized mean difference (MD) and corresponding 95% confidence interval (CI). Subgroup analyses of the accuracy of screw placement at different cervical segments and with different screw placement approaches were performed. A comparison was made between robotic navigation and conventional freehand cervical screw placement. RESULTS Six comparative cohort studies and five case series studies with 337 patients and 1342 cervical screws were included in this study. The perfect accuracy was 86% (95% CI, 82-89%) and the clinically acceptable rate was 98% (95% CI, 95-99%) in robot-assisted cervical screw placement. The perfect accuracy of robot-assisted C1 lateral mass screw placement was the highest (96%), followed by C6-7 pedicle screw placement (93%) and C2 pedicle screw placement (86%), and the lowest was C3-5 pedicle screw placement (75%). The open approach had a higher perfect accuracy than the percutaneous/intermuscular approach (91% vs 83%). Compared with conventional freehand cervical screw placement, robot-assisted cervical screw placement had a higher accuracy, a lower incidence of perioperative complications, and less intraoperative blood loss. CONCLUSION With good collaboration between the operator and the robot, robot-assisted cervical screw placement is accurate and feasible. Robot-assisted cervical screw placement has a promising prospect.
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Affiliation(s)
- Jiayuan Wu
- Spine Department, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Mingxing Fan
- Spine Department, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Da He
- Spine Department, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China.
| | - Yi Wei
- Spine Department, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Fangfang Duan
- Epidemiological Research Department, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Xieyuan Jiang
- Trauma Orthopedics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
- Beijing Jishuitan Orthopaedic Robot Engineering Research Center Co., Ltd, Beijing, 100035, China
| | - Wei Tian
- Spine Department, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China.
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Yamamoto Y, Fujishiro T, Hirai H, Hayama S, Nakaya Y, Usami Y, Neo M. Comparison of Cervical Pedicle Screw Placement Accuracy With Robotic Guidance System Versus Image Guidance System Using Propensity Score Matching. Clin Spine Surg 2024:01933606-990000000-00292. [PMID: 38637926 DOI: 10.1097/bsd.0000000000001616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/28/2024] [Indexed: 04/20/2024]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE To compare the accuracy of cervical pedicle screw (CPS) placement using a robotic guidance system (RGS) with that of using an image guidance system (IGS; navigation system) through propensity score matching. BACKGROUND The RGS may provide accurate CPS placement, which may outperform IGS. However, no study has directly compared the accuracy of CPS placement with the RGS to that with the IGS. PATIENTS AND METHODS We retrospectively reviewed the data of patients who had undergone cervical fusion surgery using CPS with the RGS or IGS. To adjust for potential confounders (patient demographic characteristics, disease etiology, and registration material), propensity score matching was performed, creating robotic guidance (RG) and matched image guidance (IG) groups. The accuracy of CPS placement from C2 to C6, where the vertebral artery runs, was evaluated on postoperative computed tomography images according to the Neo classification (grade 0 to grade 3). Furthermore, the intraoperative CPS revisions and related complications were examined. RESULTS Using propensity score matching, 22 patients were included in the RG and matched groups each, and a total of 95 and 105 CPSs, respectively, were included in the analysis. In both the axial and sagittal planes, the clinically acceptable rate (grades 0 + 1) of CPS placement did not differ between the RG and matched IG groups (97.9% vs 94.3% and 95.8% vs 96.2%, respectively). The incidence of CPS revision was similar between the groups (2.1% vs 2.9%), and no CPS-related complications were documented. Meanwhile, the incidence of lateral breach (grades 1 + 2 + 3) was significantly lower in the RG group than in the matched IG group (1.1% vs 7.7%, P= 0.037). CONCLUSION The RGS and IGS can equally aid in accurate and safe CPS placement in clinical settings. Nonetheless, RGS can further reduce the lateral breach, compared with IGS.
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Affiliation(s)
- Yuki Yamamoto
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
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Lyrtzis C, Stamati A, Tsitsopoulos PP, Piagkou M, Natsis K. Thickness Asymmetry of the Vertebral Artery Groove: A Dried Vertebrae Study. Cureus 2024; 16:e58206. [PMID: 38741812 PMCID: PMC11090258 DOI: 10.7759/cureus.58206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The vertebral artery groove (VAG), located on the posterior arch of the first cervical (atlas) vertebra plays a pivotal role in guiding the vertebral artery's (VA) third part (V3). Deviations in VAG morphology and morphometry (dimensions) can influence vascular dynamics and pose clinical implications. AIM The current study delves into the morphometric variants and explores the less-explored morphometric variable of the VAG thickness, highlighting possible laterality (asymmetry). METHODS A morphometric investigation was conducted on 141 dried atlas (73 male and 68 female) vertebrae from a Greek adult population. The VAG's minimum thickness was investigated by considering the laterality (sides' differences), gender, and age impact on it. Measurements were performed by two independent researchers, ensuring the data reliability. RESULTS A significant asymmetry was identified in the VAG thickness between the left (3.9 ± 0.9 mm) and right (4.1 ± 1.1 mm) (p=0.005) sides, with the left side having the mean minimum thickness. Gender had a significant impact on VAG thickness only on the left side, with females presenting a significantly thinner left-sided VAG (3.6 ± 0.9 mm) than males (4.10 ± 0.7 mm) (p=0.001). Age had no significant impact on the VAG thickness. Conclusion: The present study underscores the significance of asymmetry in the VAG thickness in craniocervical interventions. This less-explored morphometric variable warrants careful consideration by surgeons during preoperative planning to minimize potential complications. The current findings highlight the importance of understanding the VAG thickness asymmetry and its clinical implications, as this osseous variable may be an index of a different diameter of the VA by side. It is recommended that surgeons incorporate this variable into their preoperative assessments to improve the safety and efficacy of craniocervical interventions.
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Affiliation(s)
- Christos Lyrtzis
- Department of Anatomy and Surgical Anatomy, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Athina Stamati
- Department of Anatomy and Surgical Anatomy, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Maria Piagkou
- Department of Anatomy and Surgical Anatomy, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Konstantinos Natsis
- Department of Anatomy and Surgical Anatomy, Aristotle University of Thessaloniki, Thessaloniki, GRC
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Mao JZ, Soliman MA, Karamian BA, Khan A, Fritz AG, Avasthi N, DiMaria S, Levy BR, O’Connor TE, Schroeder G, Pollina J, Vaccaro AR, Mullin JP. Anatomical and Technical Considerations of Robot-Assisted Cervical Pedicle Screw Placement: A Cadaveric Study. Global Spine J 2023; 13:1992-2000. [PMID: 35195035 PMCID: PMC10556891 DOI: 10.1177/21925682211068410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Cadaver study. OBJECTIVES Assess the feasibility of robot-assisted cervical pedicle screw (RA-CPS) placement and understand the anatomical considerations of this technique. METHODS Four cadaver specimens free from bony pathology were acquired. Anatomical considerations, such as pedicle width (PW) and height (PH), transverse pedicle angle (TPA), and maximal screw length (MSL), were recorded from preoperative computational tomography (CT) scans. Intraoperative cone-beam CT was acquired and registered to the robotic system. After cervical levels were segmented, screw sizes and trajectories were planned, and RA-CPS were placed. Accuracy was assessed using Gertzbein and Robbin's classification on postoperative CT scans. RESULTS Thirty-five RA-CPS were placed. Major breaches (≥Grade C) occurred in 28.57% screws. Grade A or B accuracy was found in 71.43% of screws, with the most common direction of breach being medial (81.3%). The greatest proportion of breach per level occurred in the upper subaxial levels, (C3:71.4%, C4 66.6%, C5:50%) which had the smallest PW (C3: 4.34 ± .96 mm, C4: 4.48 ± .60, C5: 5.76 ± 1.11). PH was greatest at C2 (8.14 ± 1.89 mm) and ranged subaxial from 6.36 mm (C3) to 7.48 mm (C7). The mean PW was 5.37 mm and increased caudally from 4.34 mm (C3) to 6.31 mm (C7). The mean TPA was 39.9° and decreased moving caudally 46.9°) to C7 (34.4°). The MSL was 37.1 mm and increased from C2 (26.3 mm) to C7 (41.0 mm). CONCLUSION RA-CPS has the potential to be feasible, but technological and instrument modifications are necessary to increase the accuracy in the cervical region.
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Affiliation(s)
- Jennifer Z. Mao
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - Mohamed A.R. Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Brian A. Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Alexander G. Fritz
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Naval Avasthi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Stephen DiMaria
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - Bennett R. Levy
- George Washington University, School of Medicine and Health Sciences, Washington DC, USA
| | - Timothy E. O’Connor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Gregory Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia PA, USA
| | - Jeffrey P. Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY, USA
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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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Goldberg JL, Carnevale JA, Xia J, Sommer F, Gadjradj P, Medary B, Giantini-Larsen A, Navarro-Ramirez R, Tsiouris AJ, Chakravarthy V, Schwarz JT, McGrath LB, Virk MS, Fu KM, Riew KD, Hussain I, Härtl R. Variation in Cervical Pedicle Morphology: Important Considerations for Posterior Cervical Procedures. Oper Neurosurg (Hagerstown) 2023; 24:e85-e91. [PMID: 36637311 PMCID: PMC10158926 DOI: 10.1227/ons.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/30/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Safe posterior cervical spine surgery requires in-depth understanding of the surgical anatomy and common variations. The cervical pedicle attachment site to the vertebral body (VB) affects the location of exiting nerve roots and warrants preoperative evaluation. The relative site of attachment of the cervical pedicle has not been previously described. OBJECTIVE To describe the site of the pedicle attachment to the VB in the subaxial cervical spine. METHODS Cervical spine computed tomography scans without any structural, degenerative, or traumatic pathology as read by a board-certified neuroradiologist during 2021 were reviewed. Multiplanar reconstructions were created and cross-registered. The pedicle's attachment to the VB was measured relative to the VB height using a novel calculation system. RESULTS Fifty computed tomography scans met inclusion criteria yielding 600 total pedicles between C3-T1 (100 per level). The average patient age was 26 ± 5.3 years, and 21/50 (42%) were female. 468/600 (78%) pedicles attached in the cranial third of the VB, 132/600 (22%) attached in the middle third, and 0 attached to the caudal third. The highest prevalence of variant anatomy occurred at C3 (36/100 C3 pedicles; 36%). CONCLUSION In the subaxial cervical spine, pedicles frequently attach to the top third of the VB, but significant variation is observed. The rate of variation is highest at C3 and decreases linearly with caudal progression down the subaxial cervical spine to T1. This is the first report investigating this morphological phenomenon.
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Affiliation(s)
- Jacob L. Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Joseph A. Carnevale
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Jimmy Xia
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Fabian Sommer
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Pravesh Gadjradj
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Branden Medary
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - A. John Tsiouris
- Department of Radiology, Division of Neuroradiology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Vikram Chakravarthy
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Justin T. Schwarz
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Lynn B. McGrath
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Michael S. Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - K. Daniel Riew
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York, USA
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Coric D, Rossi V. Percutaneous Posterior Cervical Pedicle Instrumentation (C1 to C7) With Navigation Guidance: Early Series of 27 Cases. Global Spine J 2022; 12:27S-33S. [PMID: 35393883 PMCID: PMC8998482 DOI: 10.1177/21925682211029215] [Citation(s) in RCA: 2] [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] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN This is a technique paper describing minimally invasive, navigated, percutaneous pedicle screw fixation of the cervical spine. In addition, we include a retrospective feasibility analysis of our initial experience with 27 patients undergoing this procedure. OBJECTIVE The purpose of this study is to describe the technique of MIS navigated percutaneous cervical pedicle screw instrumentation and to report our initial experience. METHODS This is a retrospective review of 27 patients undergoing MIS navigated percutaneous posterior cervical pedicle screw fixation at 2 institutions. We describe the technique and report the radiographic outcomes and all intraoperative and postoperative complications. RESULTS A total of 27 patients underwent MIS navigated percutaneous pedicle screw fixation. Indications included odontoid fracture, subaxial fracture dislocations and burst fracture, pathological fracture, and degenerative spondylosis. There were no nerve root or vascular injuries. There were no spinal cord injuries. Two screws required repositioning intraoperatively, and 1 patient required reoperation for symptomatic malpositioned screw. CONCLUSIONS MIS navigated percutaneous posterior pedicle screw fixation can be performed safely. These constructs are biomechanically superior with neurovascular complication rates comparable to traditional lateral mass screw technique. While the current indications for this technique are relatively limited, the evolution of MIS cervical decompression techniques as well as navigation and robotics will provide an expanded role for percutaneous cervical pedicle screw instrumentation.
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Affiliation(s)
| | - Vincent Rossi
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
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Martin-Schutz GO, Amaral CAB, Labronici PJ, Pires LAS. MORPHOMETRIC STUDY OF THE C6 AND C7 PEDICLE: A COMPUTERIZED TOMOGRAPHY ANALYSIS. COLUNA/COLUMNA 2022. [DOI: 10.1590/s1808-185120222104262589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
ABSTRACT Objective: Measure the diameter and thickness of the C6 and C7 pedicles using computed tomography, to analyze the security of the act surgery and the difference between males and females. Methods: This is a retrospective study. Two hundred computerized tomography scans of the cervical spine, one hundred male and one hundred female, from the Hospital Santa Teresa Radiology sector were evaluated. The pedicle thickness was measured in the axial plane, and the height was measured in sagittal slices. The student’s t-test was used to compare differences between the sexes, and a p-value lower than 0.05 was considered significant. Results: The mean age of the individuals included in the sample was 35±9 years. The mean height of the C6 and C7 pedicles were 7.1±0.9 mm and 7.8±0.9 mm, respectively. The mean thickness of the C6 and C7 pedicles were 5.2±0.7 mm and 5.9±0.8 mm, respectively. The statistical test showed that the values were significantly lower for female patients. Conclusions: The present study demonstrated parameters that can be used and can be the rule for preoperative planning of transpedicular cervical fixation surgeries, both in C6 and C7. As it is a procedure that can cause iatrogenic damage to important structures, the screw size must be chosen with care in pre-operative planning to avoid vessel rupture or damage to adjacent nerves. Level of Evidence III; retrospective study.
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11
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Athari M, Golbakhsh MR, Mirbolook A, Athari M, Ahmadi A, Komlakh K, Azarhomayoun A, Paydarniya P. Posterior First and Second Cervical Vertebrae Fusion by Screw Fixation Technique using the Modern Pre-fabricated Template Method on Cadaver Samples. Malays Orthop J 2021; 15:58-64. [PMID: 34966496 PMCID: PMC8667244 DOI: 10.5704/moj.2111.009] [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] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 07/29/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction C1 lateral mass and C2 pedicular screws insertion are used for C1-C2 posterior fusion. Fluoroscopy Guided technique is routinely used for screw placement but it is associated with risk of injury to spinal cord and vertebral artery. 3D printing has developed rapidly in the fields of medicine. It is helpful in improving precise treatment and used for instrumentation in spine. We want to evaluate the accuracy of C1 lateral mass screws and C2 pedicle screws insertion by Pre-Fabricated Template made by three-dimensional (3D) printing. Materials and methods Five cervical samples were obtained from cadavers. Based on fine-cut CT scan 3D-images reconstructed and the path of the screws designed by special software. A template produced by 3D-printer from 3D images. After printing the templates, they were fixed on the relevant vertebra in the operation room and based on the template path, C1 lateral mass screw and C2 pedicular screws were inserted. Placement of the screws was evaluated using CT scans post-operatively. Results A total of 14 screws were inserted by above-mentioned method. After evaluation with CT scans none of the screws were entered in the spinal canal. Two screws had vertebral artery canal perforation with less than 50% breach. Violation was judged as noncritical and would probably not have resulted in injury to vertebral artery. Conclusions The accuracy of C1 lateral mass screw and C2 pedicle screw insertion is acceptable with pre-fabricated template and can provide a useful aid for screw placement.
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Affiliation(s)
- M Athari
- Department of Orthopaedics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M R Golbakhsh
- Department of Orthopaedics, Tehran University of Medical Sciences, Tehran, Iran
| | - A Mirbolook
- Department of Orthopaedics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Athari
- Department of Orthopaedics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Ahmadi
- Department of Orthopaedics, Tehran University of Medical Sciences, Tehran, Iran
| | - K Komlakh
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Azarhomayoun
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran, Iran
| | - P Paydarniya
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
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12
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Sandeep S, Dahapute AA, Balasubramanian SG, Nashikkar P, Marathe N, Sonavane SR. Evaluation of clinicoradiological outcomes of lateral vertebral notch referred pedicular screws entry point in subaxial cervical spine by freehand technique. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:240-247. [PMID: 34728990 PMCID: PMC8501819 DOI: 10.4103/jcvjs.jcvjs_28_21] [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: 02/28/2021] [Accepted: 06/07/2021] [Indexed: 11/04/2022] Open
Abstract
Purpose: Cervical pedicle screws (CPSs), though associated with complications and steep learning curve, have significantly increased strength and stability as compared to any other posterior instrumentation methods. Using anatomical referral techniques, pedicle screws can be inserted safely with a high accuracy rate obviating the need for anterior stabilization. Our present study aims to investigate the safety and outcomes of lateral vertebral notch (LVN) referred entry point for subaxial CPSs by freehand technique. Materials and Methods: We retrospectively studied 22 patients who underwent CPS fixation. Computed tomography (CT) scan with angiography was done in each case to know the anatomy, characteristics, and anomalies of each pedicle. Postoperative CT scan was done to look for any breach in cervical pedicles. We used free hand technique for insertion of subaxial cervical pedicles taking LVN as a reference point. The authors used the medial wall of the cervical pedicles as a safe guide for the probes that walked along it. Results: Eighty screws were inserted in total in the study group. Mean angle of screw with sagittal axis of vertebrae was 23.43° ± 9.279°. Range of angle used was 6°–40°. Perforation occurred in 11 pedicle screws: C3 (2 out of 8, 25%), c5 (3 out of 20, 15%), and c4 (4 of 22, 18%). Out of 11 perforations, four were complete and seven were partial perforations. One complete medial perforation was associated with radiculopathy that required revision. Conclusion: The technique described in the study can be considered relatively safe, easy, and reliable method of inserting cervical pedicle screws with high accuracy (86.25%) and low complication rates (1.25%). However, meticulous preoperative planning is required.
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Affiliation(s)
- Sonone Sandeep
- Department of Orthopaedics, KEM Hospital, Mumbai, Maharashtra, India
| | | | | | - Piyush Nashikkar
- Department of Orthopaedics, KEM Hospital, Mumbai, Maharashtra, India
| | - Nandan Marathe
- Department of Orthopaedics, KEM Hospital, Mumbai, Maharashtra, India
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13
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Hasanain MA, Englisch CN, Garner M, Tschernig T, Wagenpfeil S, Ketter R, Oertel J. Comparison of the maximum possible lengths of insertable screws in the Subaxial Cervical Spine. Ann Anat 2021; 239:151839. [PMID: 34634470 DOI: 10.1016/j.aanat.2021.151839] [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: 08/13/2021] [Revised: 10/01/2021] [Accepted: 10/02/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lateral mass screws are the most commonly used fixation technique in the Subaxial Cervical Spine (SCS), their main advantages being that they are easy to insert and safe in their application. Pedicle screws are significantly longer, are quite challenging to insert in most settings and are accompanied by the risk of serious complications such as vascular and neural injuries. We have therefore developed a new technique, which permits safe insertion of long screws in the SCS. METHODS A radiological evaluation was carried out to determine the maximum possible insertable screw length in the SCS when using the following techniques: pedicle, lateral mass (Magerl's) and "Attallah" screws. Scans of 66 cervical spines were analyzed to determine the maximum possible screw lengths of all three screw insertion techniques, based on the standard description through the vertebrae from C3 to C7. RESULTS The maximum possible length of the Attallah screw of 20.7 ± 2.5 mm (mean value ± SD) is only 2.4 mm shorter than the pedicle screw (23.1 ± 1.8 mm) along the SCS. The lateral mass screw is with 10.2 ± 1.3 mm full 12.9 mm shorter than the pedicle screw. CONCLUSIONS The maximum possible length of the Attallah screw is close to that of the pedicle screw and significantly greater than that of the lateral mass screw. We provide a fixation method comparable to the pedicle screw in its strength and to the lateral mass screw in its safety.
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Affiliation(s)
| | - Colya N Englisch
- Institute for Anatomy, Saarland University, Medical Campus, Homburg/Saar, Germany
| | - Malvina Garner
- Institute for Neuroradiology, Saarland University, Medical Campus, Homburg/Saar, Germany
| | - Thomas Tschernig
- Institute for Anatomy, Saarland University, Medical Campus, Homburg/Saar, Germany.
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Medical Campus, Homburg/Saar, Germany
| | - Ralf Ketter
- Neurosurgery Hospital, Saarland University, Medical Campus, Homburg/Saar, Germany
| | - Joachim Oertel
- Neurosurgery Hospital, Saarland University, Medical Campus, Homburg/Saar, Germany
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14
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Sharma D, Sawarkar DP, Singh PK, Kale SS, Joseph L, Garg A, Kumar A, Verma S, Doddamani R, Meena R, Chandra SP. Determination of Availability of Safety Margin for Placement of C3-C6 Pedicle Screw on CT Angiography. World Neurosurg 2021; 157:e22-e28. [PMID: 34555573 DOI: 10.1016/j.wneu.2021.09.057] [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: 06/28/2021] [Revised: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cervical pedicle screws (CPS) in the subaxial cervical spine (C3-C6) are faced with high incidence of perforating the lateral pedicular cortex endangering the vertebral artery (VA). The present study analyzes the pedicle width (PW) from C3 to C6 and defines the relation of VA with regard to pedicle and transverse foramen (TF) to determine the safety margin in cases of lateral pedicular breach. METHODS Computed tomography angiograms of 500 patients were retrospectively studied to identify the pedicle width (PW), VA area, TF area, and the lateral pedicle to vertebral artery distance (LPVA). Occupancy ratio (OR; the percentage area of transverse foramen occupied by VA) and safety margin (SM; permissible displacement of VA in TF), along with LPVA were considered to be protective parameters against VA injury if lateral pedicle breach happens. RESULTS PW was 4.7 mm at C3, 4.83 mm at C4, 5.26 mm at C5 and 5.41 mm at C6. Mean LPVA at different levels was between 0.97 mm and 1.15 mm, OR was around 20% at all levels, and mean SM was between 2.34 mm and 2.92 at various levels. Sex differences were statistically significant for PW but not for LPVA, SM, or OR. CONCLUSIONS This study gives us an idea about the various parameters in placement of cervical pedicle screw in subaxial cervical spine and the probable reasons there are few vertebral artery injuries despite high incidence of cervical pedicle breach. LPVA, safety margin, and OR may explain why even very significant CPS misplacement does not lead to vascular injury or neurologic deficit.
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Affiliation(s)
- Dhruv Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Pankaj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Leve Joseph
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Amandeep Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Satish Verma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Meena
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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15
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Agrawal M, Devarajan LJ, Dharanipathy S, Katiyar V, Singh PK, Garg A, Chandra PS, Kale SS. Morphometric Analysis of C2 Pedicle in 247 Patients and Proposal for Trajectory and Size of Pedicle Screw. Neurol India 2021; 69:925-930. [PMID: 34507414 DOI: 10.4103/0028-3886.325374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Screw diameters are currently available based on the literature available for the Western population. No data are available in such a large number of patients for the Indian population. Objective The aim of this study was to define the average pedicle size available and to determine the angulation for placement of screws for C2 pedicle in the Indian population. We also try to determine the pedicle screw diameter which can be used universally in most Indian patients, considering the pedicle dimensions. Material and Methods Retrospective morphometric analysis of CT scans of 247 patients (152 M, 95 F) was done to calculate the C2 pedicle width (PW), pedicle height (PH), pedicle length (PL), pedicle transverse angle (PTA) and the craniocaudal angulation (CCA) of the C2 pedicle. Results Mean PW in females was 5.3 mm and in males it was 5.9 mm. This difference was statistically significant. The mean PH in the study population was 8.9 mm, while the mean PL was 29.7 mm. The mean PTA was 40.0 degrees and the CCA was 28.4 degrees. Conclusion This is a morphometric analysis of the C2 pedicle which provides information for the surgeons to determine the safe site of entry and trajectory for the screw implantation. We conclude that a screw diameter of 2.7 mm can be safely implanted in a vast majority of the patient population.
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Affiliation(s)
- Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Leve J Devarajan
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Varidh Katiyar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj K Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank S Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Satake K, Kanemura T, Ito K, Tanaka S, Morita Y, Nakashima H, Ouchida J, Imagama S. Pedicle screw placement with use of a navigated surgical drill at subaxial cervical spine. J Clin Neurosci 2021; 88:28-33. [PMID: 33992198 DOI: 10.1016/j.jocn.2021.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/21/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE This study was performed to evaluate the accuracy of cervical pedicle screw (CPS) placement with use of a navigated surgical drill (ND) and to compare it with navigated manual probe (MP) at C3-C6. METHODS 47 consecutive patients (27 males and 20 females, 67.2 [33-91] years) underwent a posterior cervical fixation using CPSs under an intraoperative 3D - - CT based navigation system (total 207 CPSs). For initial probing, ND with 2.2-mm steel burr was used since Apr. 2017 (Group ND; 33 patients, 152 CPSs). MP was used earlier (Group MP; 14 patients, 55 CPSs). There were no other different procedures between the two groups. The accuracy of CPS placement was graded with postoperative CT and compared between the two groups. RESULTS There were no significant differences in the total perforation rates both in axial and sagittal planes between Groups ND and MP (axial; 7.2% vs. 14.5%, p = 0.25, sagittal; 10.5% vs. 14.5%, p = 0.46). However, the lateral and rostral perforation rates were significantly reduced in Group ND compared to Group MP (lateral: 36.4% vs. 87.5%, p = 0.04; rostral: 6.3% vs. 100%, p = 0.001). CONCLUSION Although ND did not decrease the total perforation rate significantly, it reduced the incidence of lateral and rostral perforation. ND is likely to make initial probing easier without a forcible manipulation which might cause vertebral rotation.
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Affiliation(s)
| | | | - Kenyu Ito
- Spine Center, Konan Kosei Hospital, Konan, Japan
| | | | | | | | - Jun Ouchida
- Department of Orthopedic Surgery, Nagoya University, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University, Nagoya, Japan
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17
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Gan G, Kaliya-Perumal AK, Yu CS, Nolan CP, Oh JYL. Spinal Navigation for Cervical Pedicle Screws: Surgical Pearls and Pitfalls. Global Spine J 2021; 11:196-202. [PMID: 32875902 PMCID: PMC7882822 DOI: 10.1177/2192568220902093] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE We intend to evaluate the accuracy and safety of cervical pedicle screw (CPS) insertion under O-arm-based 3-dimensional (3D) navigation guidance. METHODS This is a retrospective study of patients who underwent CPS insertion under intraoperative O-arm-based 3D navigation during the years 2009 to 2018. The radiological accuracy of CPS placement was evaluated using their intraoperative scans. RESULTS A total of 297 CPSs were inserted under navigation. According to Gertzbein classification, 229 screws (77.1%) were placed without any pedicle breach (grade 0). Of the screws that did breach the pedicle, 51 screws (17.2%) had a minor breach of less than 2 mm (grade 1), 13 screws (4.4%) had a breach of between 2 and 4 mm (grade 2), and 4 screws (1.3%) had a complete breach of 4 mm or more (grade 3). Six screws were revised intraoperatively. There was no incidence of neurovascular injury in this series of patients. 59 of the 68 breaches (86.8%) were found to perforate laterally, and the remaining 9 (13.2%) medially. It was noted that the C5 cervical level had the highest breach rate of 33.3%. CONCLUSIONS O-arm-based 3D navigation can improve the accuracy and safety of CPS insertion. The overall breach rate in this study was 22.9%. Despite these breaches, there was no incidence of neurovascular injury or need for revision surgery for screw malposition.
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Affiliation(s)
| | - Arun-Kumar Kaliya-Perumal
- Tan Tock Seng Hospital, Singapore,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | | | - Jacob Yoong-Leong Oh
- Tan Tock Seng Hospital, Singapore,Jacob Yoong-Leong Oh, Division of Spine, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433 Singapore.
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18
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Chiapparelli E, Okano I, Salzmann SN, Reisener MJ, Virk S, Winter F, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. C2 Pedicle Sclerosis Grading, More Than Diameter, Predicts Surgeons' Preoperative Assessment of Safe Screw Placement: A Novel Classification System. World Neurosurg 2021; 149:e576-e581. [PMID: 33549928 DOI: 10.1016/j.wneu.2021.01.132] [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: 12/21/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The preoperative assessment of C2 morphology is important for safe instrumentation. Sclerotic changes are often seen in C2 pedicles. Evaluating the diameter measurements solely might not accurately assess the safety of screw insertion. We have proposed a novel grading system of the C2 pedicle that includes sclerosis and evaluated the predictive value of this grading system with the surgeon's safety evaluation. METHODS We reviewed and measured the dimensional values in 220 cervical computed tomography angiograms. Additionally, we used a grading system that divides the findings into 5 grades according to the width measurement and degree of sclerosis in the C2 pedicle. Two spine surgeons independently classified the pedicles as follows: safe (minimal risk of pedicle violation), caution needed (caution to minimize pedicle violation), or dangerous (a high risk of pedicle violation). Finally, we compared the measurements and the surgeons' safety assessments. RESULTS A total of 411 pedicles of 203 patients (mean age, 69.5 years; 49.5% women) were included. Of the 411 C2 pedicles, 170 were classified as high risk by ≥1 surgeon. Between the dimensional measurements and grading system, the sclerotic grade showed the best predictive value. CONCLUSIONS We have introduced a novel tool to evaluate the safety of C2 pedicle screw placement. Our results suggest that our pedicle width-sclerosis grading system is reproducible and predicts the surgeon's assessment of safe screw placement better than C2 pedicle diametrical measurements alone.
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Affiliation(s)
- Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Stephan N Salzmann
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | | | - Sohrab Virk
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Fabian Winter
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA.
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Jung YG, Lee S, Jeong SK, Kim M, Park JH. Subaxial Cervical Pedicle Screw in Traumatic Spinal Surgery. Korean J Neurotrauma 2020; 16:18-27. [PMID: 32395448 PMCID: PMC7192805 DOI: 10.13004/kjnt.2020.16.e13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/13/2020] [Indexed: 01/19/2023] Open
Abstract
In cases of unstable cervical traumatic lesions, the biomechanical superiority of the cervical pedicle screw (CPS) allows the lesion to be stabilized effectively. In this study, we review and summarize the indications, technical guidelines, and potential neurovascular complications and their prevention of the use of the CPS for trauma. For patients with fractured lamina or lateral mass, a CPS is reliable for stabilization. In addition, the CPS can penetrate through a linear cervical spinal pedicle fracture gap and could stabilize three-column injury. CPS reduce the range of surgical approach and preserve the motion segment using short-segment fixation. Fluoroscopy-guided CPS insertion is popular and cost-effective. Image-guided navigation systems improve accuracy. Three-dimensional template-guided CPS placement is simple to use. Most spine surgeons can perform laminoforaminotomy easily. Freehand technique that can be performed quickly without heavy equipment is suitable for emergency situation. Possible complications due to screw misplacement are vertebral artery injury owing to a laterally misplaced screw, dural sac or spinal cord injury from a medially misplaced screw, and nerve root injury caused by a superiorly or inferiorly misplaced screw. To prevent neurovascular complications, meticulous preoperative anatomical evaluation and following the five steps are most important.
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Affiliation(s)
- Yoon Gyo Jung
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Subum Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Kyun Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myeongjong Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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20
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Jung YG, Jung SK, Lee BJ, Lee S, Jeong SK, Kim M, Park JH. The Subaxial Cervical Pedicle Screw for Cervical Spine Diseases: The Review of Technical Developments and Complication Avoidance. Neurol Med Chir (Tokyo) 2020; 60:231-243. [PMID: 32295984 PMCID: PMC7246229 DOI: 10.2176/nmc.ra.2019-0189] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This study aimed to review information on the subaxial cervical pedicle screw (CPS) including recent anatomical considerations, entry points, placement techniques, accuracy, learning curve, and complications. Relevant literatures were reviewed, and the authors’ experiences were summarized. The CPS is used for reconstruction of unstable cervical spine and achieves superior biomechanical stability compared to other fixation techniques. Various insertion and guidance techniques are established, among which, lateral fluoroscopy-assisted placement is the most common and cost-effective technique. Generally, placement under imaging guidance is more accurate than other techniques, and a three-dimensional template allows optimal trajectory for each pedicle regardless of intraoperative changes in spinal alignment. The free-hand technique using a curved pedicle probe without a funnel-like hole increases screw stability and reduces operation time, radiation exposure, and soft tissue injury. Compared to conventional lateral fluoroscopy-assisted placement, free-hand CPS placement by trained surgeons achieves superior accuracy comparable to that of image-guided navigation; in general, 30 training cases are sufficient for learning a safe and accurate technique for CPS placement. The complications of subaxial CPS are classified into three categories: complications due to screw misplacement, complications without screw misplacement, and others. Inexperienced surgeons may benefit from advanced techniques; however, the accuracy of CPS ultimately depends on the surgeon’s experience. Inexperienced surgeons should master the placement of the thoracolumbar pedicle screw in real practice and practice CPS insertion using cadavers. During the initial phase of the learning curve, careful preparation of surgery, reiterated identification, patterned safety steps, and supervision of the expert are necessary.
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Affiliation(s)
- Yoon Gyo Jung
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sang Ku Jung
- Department of Emergency Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine
| | - Byung Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Neuroscience and Radiosurgery Hybrid Research Center, College of Medicine
| | - Subum Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Seong Kyun Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Myeongjong Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine
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21
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Chytas D, Korres DS, Babis GC, Chronopoulos E, Kaseta MK, Markatos K, Nikolaou VS. Letter to the Editor Regarding "Proposal of a New Safety Margin for Placement of C2 Pedicle Screws on Computed Tomography Angiography". World Neurosurg 2020; 135:409. [PMID: 32143264 DOI: 10.1016/j.wneu.2019.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Dimitrios Chytas
- 2nd Orthopaedic Department, School of Medicine, National and Kapodistrian University of Athens, "Konstantopoulio-Patission" Hospital, Nea Ionia, Greece.
| | - Demetrios S Korres
- 2nd Orthopaedic Department, School of Medicine, National and Kapodistrian University of Athens, "Konstantopoulio-Patission" Hospital, Nea Ionia, Greece
| | - George C Babis
- 2nd Orthopaedic Department, School of Medicine, National and Kapodistrian University of Athens, "Konstantopoulio-Patission" Hospital, Nea Ionia, Greece
| | - Efstathios Chronopoulos
- 2nd Orthopaedic Department, School of Medicine, National and Kapodistrian University of Athens, "Konstantopoulio-Patission" Hospital, Nea Ionia, Greece
| | - Maria-Kyriaki Kaseta
- 2nd Orthopaedic Department, School of Medicine, National and Kapodistrian University of Athens, "Konstantopoulio-Patission" Hospital, Nea Ionia, Greece
| | | | - Vasileios S Nikolaou
- 2nd Orthopaedic Department, School of Medicine, National and Kapodistrian University of Athens, "Konstantopoulio-Patission" Hospital, Nea Ionia, Greece
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Tan KA, Lin S, Chin BZ, Thadani VN, Hey HWD. Anatomic techniques for cervical pedicle screw placement. JOURNAL OF SPINE SURGERY 2020; 6:262-273. [PMID: 32309664 DOI: 10.21037/jss.2020.03.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Instrumentation of the cervical spine with cervical pedicle screws (CPS) is beneficial in patients with various types of spinal pathology. Despite posing greater technical challenges, CPS instrumentation confers better fixation outcomes when compared to lateral mass screws. While developments in technology have augmented the accuracy of CPS insertion, mastery in freehand CPS insertion allows the aforementioned technologies to reach their full potential in improving patient outcomes. The aim of this article is to discuss freehand CPS insertion techniques as established in the current literature while sharing our experience in this context. A comprehensive literature search was performed using the following electronic databases: PubMed, Medline, and EMBASE. Full-text articles focusing on clinical studies with description of freehand techniques were included. Articles which were on cadaveric studies, drill jig, navigation or robotic technology were excluded. Thirteen primary references comprising 1,480 patients were included in this review. Majority of studies reported utilizing the cranial margin of lamina for C2 level as a landmark for entry point, as well as lateral to centre of the articular mass, and just medial to the lateral border of the superior articular process for C3-7 levels. Method of tracking and facilitation of trajectory was reported in multiple studies, with use of instruments ranging from curved pedicle probes to high-speed burrs. Limited studies reported specific trajectories of CPS insertion. Most studies noted testing pedicle wall integrity at various checkpoints, with pedicle screw repositioning or conversion to lateral screw mass following detection of perforation or screw malpositioning. Success in CPS insertion rests on meticulous preoperative planning to identify the ideal screw entry point and trajectory. Patient-specific drill jigs, navigation and robotic technologies, while beneficial to progress in the field of cervical spine surgery and patient outcomes, should serve primarily to augment good expertise in freehand CPS insertion technique.
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Affiliation(s)
- Kimberly-Anne Tan
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Shuxun Lin
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Brian Zhaojie Chin
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Vishaal Nanik Thadani
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Hwee Weng Dennis Hey
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
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Upendra B, Raghavendra R. Techniques of cervical pedicle screw insertion in lower cervical spine - A review. J Clin Orthop Trauma 2020; 11:794-801. [PMID: 32879566 PMCID: PMC7452216 DOI: 10.1016/j.jcot.2020.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 11/29/2022] Open
Abstract
Cervical pedicle screws (CPS) have been used for stabilization of lower cervical spine since its first description by Abumi et al., in 1994, but the usage has been limited due to the feared complications. Cadaveric studies have discouraged use of CPS in lower cervical spine due to high misplacement rates. On the contrary, clinical studies have shown limited complications due to screw misplacements and have highlighted the benefits of CPS with its superior biomechanical strength. Therefore surgeons have always tried to find a reliable, reproducible and safe CPS insertion technique to expand the usage of CPS with minimal complications. As of today Abumi et al. technique is the most popular free-hand technique used by surgeons, though many modifications have evolved to make the CPS insertions more safe and reproducible. The free hand technique should be considered as the cornerstone technique for CPS insertion and the navigation tools are essential to improve the safety of CPS in complex surgeries with altered cervical anatomy. The present review brings together the literature on the various aspects of cervical pedicle anatomy, the free-hand screw insertion techniques with their modifications, the screw misplacement rates and complications.
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Lin L, Zhu M, Peng P, Zhang X, Zhou X, Li J. Patient-specific drill template for C2 transoral pedicle insertion in complete reduction of atlantoaxial dislocation: cadaveric efficacy and accuracy assessments. J Orthop Surg Res 2019; 14:141. [PMID: 31096990 PMCID: PMC6524296 DOI: 10.1186/s13018-019-1189-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/03/2019] [Indexed: 11/29/2022] Open
Abstract
Background The transoral atlantoaxial reduction plate (TARP) is an effective advance in the treatment of atlantoaxial dislocation (AAD) and can enable the performance of anterior atlantoaxial release, reduction, decompression, and internal fixation in a one-stage operation. However, accurate transoral C2 pedicle insertion (C2TOPI) remains a challenge. The aim of this study is to develop a grouped patient-specific drill template (PDT) specifically for AAD with complete reduction and, furthermore, to compare its efficacy and accuracy in facilitating C2TOPI. Methods After CT scanning, ten cadaveric C2 specimens were randomly assigned to two groups (the PDT and freehand group). A grouped PDT specifically for AAD with complete reduction was designed and manufactured. C2TOPI was performed using the PDT or the fluoroscopy-guided freehand technique. Postoperative CT scans were subsequently performed to analyze the deviations at the centroid of the cross section at the midpoint of the pedicle. Screw position grades were also assessed in both groups. Results Compared to the freehand group, the PDT group had a significantly shorter surgery time (p < 0.001). Significant differences between the two groups were observed in the absolute value of the deviations at the centroid of the pedicle on either the axial or sagittal planes (p < 0.05). No significant difference was found in the screw positions between the two groups (p > 0.05); however, two unacceptable breaches (20%) occurred in the freehand group. Conclusion A specifically designed PDT could provide an accurate and easy-to-apply method for C2TOPI in AAD with complete reduction.
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Affiliation(s)
- Lijun Lin
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Street, Haizhu District, Guangzhou, Guangdong, China
| | - Meisong Zhu
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Street, Haizhu District, Guangzhou, Guangdong, China
| | - Peng Peng
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Xintao Zhang
- Department of Radiology, The Third Affiliated Hospital, Southern Medical University, 183 Zhongshandadao Xi, Tianhe District, Guangzhou, Guangdong, China
| | - Xiaoqi Zhou
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Street, Haizhu District, Guangzhou, Guangdong, China
| | - Jianyi Li
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China. .,Nanhai Hospital, Southern Medical University, 28 Liguan Road, Lishui Town, Nanhai District, Foshan, Guangdong, China.
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Kong G, Ji W, Lin J, Liu Q, Huang Z, Zhu Q. The Anatomic Study of Intracranial Structures Related to Clival Screw Placement. World Neurosurg 2019; 126:e1005-e1011. [PMID: 30877008 DOI: 10.1016/j.wneu.2019.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/02/2019] [Accepted: 03/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND A clival plate and screw fitted to the craniovertebral junction (CVJ) were developed in our previous studies. However, the anatomy of intracranial structures related to clival screw placement has not been studied. OBJECTIVE To measure the intracranial anatomic parameters delineating the basilar plexus and vertebrobasilar artery (VBA) course and to determine the relationship between brainstem and clivus for safer screw placement. METHODS Morphometric analysis of the VBA was conducted on 95 patients (48 men, 47 women) by CT angiography (CTA) and of the basilar plexus and brainstem on 80 patients (44 men, 36 women) by magnetic resonance imaging (MRI) The narrowest distance between the VBA and the intracranial clivus and the distance between the VBA and the median line of the skull were measured on the axial plane at different parts. The relative positions of point I (intersection of vertebral artery and basilar artery) and the pharyngeal tubercle were analyzed. The distance between the clivus and the brainstem was measured at different levels. RESULTS As the VBA ascended the distances to the intracranial clivus and the midline decreased. In 83.3% cases, point I was above the pharyngeal tubercle, and in only 9.5% cases was it located on the vertical line drawn from pharyngeal tubercle. The smallest safe space between the intracranial clivus and the brainstem was 7.46 mm at the lower part. CONCLUSION Appropriate screw size at the lower clivus and the pharyngeal tubercle may help avoiding inadvertent injury to the brainstem and the VBA. Preoperative CTA and MRI of the CVJ are suggested to guide the surgeon in this regard.
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Affiliation(s)
- Ganggang Kong
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Orthopaedic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Ji
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Junyu Lin
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qi Liu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zucheng Huang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingan Zhu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Proposal of a New Safety Margin for Placement of C2 Pedicle Screws on Computed Tomography Angiography. World Neurosurg 2018; 120:e282-e289. [DOI: 10.1016/j.wneu.2018.08.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/07/2018] [Accepted: 08/09/2018] [Indexed: 11/22/2022]
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Koller H, Ames C, Mehdian H, Bartels R, Ferch R, Deriven V, Toyone H, Shaffrey C, Smith J, Hitzl W, Schröder J, Robinson Y. Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project. 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; 28:324-344. [PMID: 30483961 DOI: 10.1007/s00586-018-5835-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/25/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND PURPOSE Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study. METHODS Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D). RESULTS Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001). CONCLUSIONS Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.
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Affiliation(s)
- H Koller
- Spine and Scoliosis Center, Schön Klinik Vogtareuth, Krankenhausstrasse 20, 83569, Vogtareuth, Germany. .,Department for Trauma and Sports Injuries, Paracelsus Medical University, Salzburg, Austria.
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Boyer DM, Harrington AR. New estimates of blood flow rates in the vertebral artery of euarchontans and their implications for encephalic blood flow scaling: A response to Seymour and Snelling (2018). J Hum Evol 2018; 128:93-98. [PMID: 30454907 DOI: 10.1016/j.jhevol.2018.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Doug M Boyer
- Department of Evolutionary Anthropology, Duke University, Durham, NC, 27708, USA.
| | - Arianna R Harrington
- Department of Evolutionary Anthropology, Duke University, Durham, NC, 27708, USA
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Jing L, Sun Z, Zhang P, Wang J, Wang G. Accuracy of Screw Placement and Clinical Outcomes After O-Arm–Navigated Occipitocervical Fusion. World Neurosurg 2018; 117:e653-e659. [DOI: 10.1016/j.wneu.2018.06.108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/29/2022]
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Zhang L, Luo Z, Wang H, Ren L, Yu F, Guan T, Fu S. An anatomical study of the spinous process of the seventh cervical vertebrae based on the three-dimensional computed tomography reconstruction. Exp Ther Med 2018; 16:511-516. [PMID: 30116309 PMCID: PMC6090245 DOI: 10.3892/etm.2018.6245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/26/2018] [Indexed: 11/06/2022] Open
Abstract
Palpation of the seventh cervical vertebra (C7) is important for the diagnosis and treatment of neck and chest conditions. However, the spinous process of C7 (C7-SP) displays an anatomical deviation among individuals. The present study aimed to clarify anatomic characteristics of C7-SP by using a three-dimensional (3D) computed tomographic (CT) reconstruction technique. A total of 245 subjects meeting the selection criteria were examined. After CT scanning, the images were reconstructed in 3D. All subjects were grouped according to their deviation of C7-SP: Deviating to the right (DR group), deviating to the left (DL group) and no deviation (ND group). Three distances and three angles were recorded on C7-SP. The vertical distances between the borders of the left and right transverse processes and the tip of the SP, were termed DLTS and DRTS, respectively. The length of the SP was also determined. The angle of the SP deviation was referred to as ∠α, the angle between the SP axis and the line crossing the tips of the transverse processes was referred to as ∠β and the angle between the vertebral body axis and the SP axis was referred to as ∠γ. Among the three groups, differences in ∠α and ∠β were statistically significant (P<0.05). Furthermore, the DLTS was significantly different between the DL and ND groups (P<0.05). In addition, a significant difference in the DRTS was identified between the DR and ND groups (P<0.05). 3D CT reconstruction was reliable for studying anatomic characteristics of C7-SP. Based on this, patients may be preliminarily grouped according to the deviation of their C7-SP and the measurement of the C7-SP may guide clinical diagnoses and treatments.
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Affiliation(s)
- Lei Zhang
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China.,Academician Workstation in Luzhou, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China
| | - Zidan Luo
- Academician Workstation in Luzhou, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China.,Department of Clinical Medicine, School of Clinical Medicine, Luzhou, Sichuan 646600, P.R. China
| | - Hao Wang
- The Key Laboratory of Molecular Biology, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Lin Ren
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China
| | - Fei Yu
- Department of Radiology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China
| | - Taiyuan Guan
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China.,Academician Workstation in Luzhou, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China
| | - Shijie Fu
- Department of Orthopedics, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China.,Academician Workstation in Luzhou, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 646600, P.R. China
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Peng P, Xu Y, Zhang X, Zhu M, Du B, Li W, Huang W, Song J, Li J. Is a patient-specific drill template via a cortical bone trajectory safe in cervical anterior transpedicular insertion? J Orthop Surg Res 2018; 13:91. [PMID: 29669577 PMCID: PMC5907449 DOI: 10.1186/s13018-018-0810-5] [Citation(s) in RCA: 5] [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: 02/06/2018] [Accepted: 04/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to develop patient-specific drill templates by computer numerical control or three-dimensional printing via two cortical bone trajectories (CBTs) and to evaluate their efficacies and accuracies in cervical anterior transpedicular insertion. METHODS Preoperative CT images of 20 cadaveric cervical vertebrae (C3-C7) were obtained. After image processing, patient-specific drill templates were randomly assigned to be constructed via two CBTs (CBT0 and CBT0.7) and manufactured by two methods (computer numerical control and three-dimensional printing). Guided by patient-specific drill templates, 3.5-mm-diameter screws were inserted into the pedicles. Postoperative CT scans were performed to evaluate the screw deviation in the entry point and midpoint of the pedicle. The screw positions were also graded. RESULTS Computer numerical control patient-specific drill templates had a significantly shorter manufacturing time compared to three-dimensional-printed patient-specific drill templates (p < 0.01). Absolute deviations at the entry point and midpoint of the pedicle had no significant differences on the transverse and sagittal planes (p > 0.05). There were no significant differences in screw positions (p = 0.3). However, three screw positions were in grade 3 in CBT0, while the others were in grade 1. CONCLUSIONS CBT0.7 appears to be a safe and feasible trajectory for cervical anterior transpedicular insertion. Bio-safe computer numerical control patient-specific drill templates can facilitate cervical anterior transpedicular insertion with good feasibility and accuracy.
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Affiliation(s)
- Peng Peng
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Yafei Xu
- Department of Orthopedics, Nanhai Hospital, Southern Medical University, 28 Liguan Road, Nanhai District, Foshan, Guangdong, China
| | - Xintao Zhang
- Department of Radiology, The Third Affiliated Hospital, Southern Medical University, 183 Zhongshandadao Xi, Tianhe District, Guangzhou, Guangdong, China
| | - Meisong Zhu
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, 253 Gongye Street, Haizhu District, Guangzhou, Guangdong, China
| | - Bingran Du
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Wenrui Li
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Wenhua Huang
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China
| | - Jun Song
- General Education Department, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China.
| | - Jianyi Li
- Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, 1063 Shatai Nan Road, Baiyun District, Guangzhou, Guangdong, China.
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Westermann L, Spemes C, Eysel P, Simons M, Scheyerer MJ, Siewe J, Baschera D. Computer tomography-based morphometric analysis of the cervical spine pedicles C3-C7. Acta Neurochir (Wien) 2018; 160:863-871. [PMID: 29411117 DOI: 10.1007/s00701-018-3481-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 01/25/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Our aim was to examine the specific dimensions of cervical pedicles in a large Caucasian cohort on high dissolving CT scans. METHODS A retrospective analysis of 100 cervical spine CT scans with a maximum slice thickness of 1 mm in axial, sagittal, and coronal reconstructions was performed. The pedicle axial length (PAL), inner and outer pedicle diameter (IPD/OPD), pedicle sagittal and transverse angle (PSA/PTA), pedicle height (PH), pedicle width (PW), and the cortical thickness (COT) at different margins were measured by two independent observers. A total of 1000 cervical pedicles (C3-C7) of 52 male (age 58 ± 17.47 years, height 177.97 ± 8.17 cm) and 48 female patients (age 57 ± 19.07 years, height 165.50 ± 7.44) were measured. RESULTS Cortical thickness at the medial limitation of the pedicle was 1.77 ± 0.43 and 0.90 ± 0.36 mm at the lateral limitation (p < 0.001). The mean PAL ranged from 30.5 mm at C4 level to 35.3 mm at C6 level. PW and PAL were smaller in the female than in the male patients. The smallest values for PW were at C3 with 29.17% of males and 52.88% of females < 4.5 mm. The percentage of patients with PW < 4.5 mm decreased caudally with less than 10% of pedicles below C4 in male participants and below C6 in female participants. Mean PTA ranged from 34.6° to 48.02° peaking at C4 and C5 levels. No gender-specific difference was found for PTA and PSA (p ≥ 0.13). IPD and OPD were larger in males (p < 0.001), and body height correlated significantly with IPW (p ≤ 0.019) and OPW (p ≤ 0.003). The interrater reliability was very good for PW, PH, and IPD (0.84-0.86), good for OPD, PTA, and PSA (0.64-0.79), and moderate for PAL (0.54) and cortical thickness (0.44). CONCLUSIONS Peculiarities of pedicle dimension of this central European cohort are comparable to morphometric studies in other ethnicities. Preoperative planning before cervical pedicle screw insertion on fine-cut CT scans demonstrates good interrater reliability for all important dimensions and angulations. More than half of female patients and almost a third of male patients had a PW of less than 4.5 mm at C3 level. Even though this percentage decreases caudally, pedicle screws might not be safe to insert in a noteworthy percentage of patients.
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Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? 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; 27:70-100. [PMID: 29290050 DOI: 10.1007/s00586-017-5421-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/07/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This article presents the current concepts of correction of spinal deformity in ankylosing spondylitis (AS) patients. Untreated AS can be a debilitating disease. In a few patients, disease progression results in severe spinal deformity affecting not only the thoracolumbar, but also the cervical spine. Surgery for correction in AS patients has a long history. With the advent of modern instrumentation, standardization of surgical and anesthesiologic techniques, surgical safety and corrective results could be improved and experiences from lumbar osteotomies could be transferred to the cervical spine. METHODS This article presents the current concepts of correction of spinal deformity in AS patients. In particular, questions regarding the localization and number of osteotomies, the optimal surgical target angle as well as planning and prediction of postoperative alignment are discussed. RESULTS Insight into recent technical developments, current challenges with correction and geometric analysis of center of rotation (COR) in cervical 3-column osteotomies (3CO) will be presented. CONCLUSION The article should encourage readers to improve surgical correction efficacy and provide a better understanding of correction geometry in 3CO for thoracolumbar and cervical spinal deformities.
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Affiliation(s)
- Heiko Koller
- Schön Klinik Nürnberg Fürth, Center for Spinal and Scoliosis Therapies, Europa-Allee 1, 90763, Fürth, Germany.
- Department for Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria.
| | - Juliane Koller
- Schön Klinik Nürnberg Fürth, Center for Spinal and Scoliosis Therapies, Europa-Allee 1, 90763, Fürth, Germany
| | - Michael Mayer
- Schön Klinik Nürnberg Fürth, Center for Spinal and Scoliosis Therapies, Europa-Allee 1, 90763, Fürth, Germany
- Department for Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Axel Hempfing
- Center for Spinal Surgery, Werner-Wicker-Clinic, Bad Wildungen, Germany
| | - Wolfgang Hitzl
- Research Office, Paracelsus Medical University Salzburg, Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Salzburg, Austria
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Accuracy of 3D fluoro-navigated anterior transpedicular screws in the subaxial cervical spine: an experimental study on human specimens. 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; 26:2934-2940. [DOI: 10.1007/s00586-017-5238-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 05/30/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022]
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Yu Z, Zhang G, Chen X, Chen X, Wu C, Lin Y, Huang W, Lin H. Application of a novel 3D drill template for cervical pedicle screw tunnel design: a 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; 26:2348-2356. [DOI: 10.1007/s00586-017-5118-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 12/23/2016] [Accepted: 05/01/2017] [Indexed: 11/28/2022]
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Kong G, Ji W, Huang Z, Liu J, Chen J, Zhu Q. The risk of translaminar screw fixation to the transverse foramen of the lower cervical spine: a computed tomography study. Sci Rep 2017; 7:46611. [PMID: 28429741 PMCID: PMC5399458 DOI: 10.1038/srep46611] [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: 10/11/2016] [Accepted: 03/21/2017] [Indexed: 11/17/2022] Open
Abstract
Translaminar screw fixation (TSF) of the axis is considered as an efficient, safe and simple surgical procedure, however the study of the potential risk of TSF to the transverse foramen in lower cervical spine is lacked. Head-neck CT images of 60 patients were included in this study. Maximum screw length, laminar thickness, the screw angle and the laminar height were measured. The feasibility of 3.5-mm diameter screw fixation and the potential risk of transverse foramen injury was analyzed. The TSF was safe at C3 and C4, but risky to the transverse foraman at a rate of 8.7% at C5 (0% on the left side and 20% on the right side), 33.3% at C6 (24.4% on the left side and 42.9% on the right side). C7 had the highest 77.8% rate (65.5% on the left side and 89.8% on the right side). The safe screw length was 27.7 mm at C3, 27.4 mm at C4, 28.0 mm at C5, 25.6 mm at C6 and 25.5 mm at C7, respectively. The present study showed that translaminar screw could place the transverse foramen of C5–C7 at risk. Preoperative CT scanning was necessary for safe screw placement.
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Affiliation(s)
- Ganggang Kong
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei Ji
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zucheng Huang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junhao Liu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianting Chen
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingan Zhu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Sangari SK, Heinneman TE, Conti MS, Dossous PMF, Dillon DJ, Tsiouris AJ, Pyo SY, Mtui EP, Härtl R. Quantitative Gross and CT measurements of Cadaveric Cervical Vertebrae (C3 - C6) as Guidelines for the Lateral mass screw fixation. Int J Spine Surg 2017; 10:43. [PMID: 28377857 DOI: 10.14444/3043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Lateral mass screw fixation is the treatment of choice for posterior cervical stabilization. Long or misdirected screws carry a risk of injury to spinal nerve roots or vertebral artery. This study was aimed to assess the gross anatomic and CT measurements of typical cervical vertebrae for the selection of lateral mass screws. METHODS Dimensions of the articular pillars were measured on 1) Dry cervical vertebrae with Vernier calipers and 2) Multiplanar reformations of CT scans of the same vertebrae with Viewer software package. The data was statistically evaluated. RESULTS The transverse diameter of the articular pillars with Vernier calipers varied from 6.0 to 15.4 mm (mean=10.5 mm ± 1.5) and on CT scans ranged from 8.2 - 16.1 mm (mean=11.6 mm ± 1.4). The antero-posterior diameter, an estimate of the screw length by Roy-Camille technique varied from 3.9 to 12.7 mm (mean=8.6 mm ± 1.6) by Vernier calipers and from 6.4 to 13.3 mm (mean=9.1 ± 1.2) on CT scans. The oblique AP diameter, an estimate of screw length by Magerl method varied from 10.8 to 20.3 mm (mean=14.9 mm ± 1.8) by Vernier calipers and from 11.4 to 19.3 mm (mean=14.5 mm ± 1.7) on CT. The CT measurements for height, transverse and AP diameter of the articular pillars were 0.5 - 1.0 mm larger than dimensions by Vernier calipers. No statistically significant difference was observed between the caliper and CT measurements for the oblique AP diameter. CONCLUSION CT measurements of the articular pillars may slightly overestimate the desired screw length selected by spine surgeons when compared to actual anatomy. Although means of the articular pillars correspond to the screw lengths used, substantial number of observations below 10 mm for Roy-Camille trajectory and below 14 mm for Magerl trajectory requires careful preoperative planning and intra-operative confirmation to avoid long/misdirected lateral mass screws.
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Affiliation(s)
- Santosh K Sangari
- Program in Anatomy and Body Visualization, Department of Radiology, Weill Cornell Medicine, New York, NY
| | - Thomas E Heinneman
- Weill Cornell Medical College, New York, NY; Otolaryngology - Head and Neck Surgery, UCLA Health, Los Angeles, CA
| | | | - Paul-Michel F Dossous
- Weill Cornell Medical College, New York, NY; Department of Orthopedic Surgery, Albany Medical Center Hospital, Albany, NY
| | | | - Apostolos J Tsiouris
- Department of Radiology, Neuroradiology section, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY
| | - Se Young Pyo
- Brain and Spine Center, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY; Department of Neurosurgery, College of Medicine, Inje University, Busan Paik Hospital, Busan Korea
| | - Estomih P Mtui
- Program in Anatomy and Body Visualization, Department of Radiology, Weill Cornell Medicine, New York, NY
| | - Roger Härtl
- Brain and Spine Center, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY
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Tubbs RS, Granger A, Fisahn C, Loukas M, Moisi M, Iwanaga J, Paulson D, Jeyamohan S, Chapman JR, Oskouian RJ. The Vertebral Artery Cave at C2: Anatomic Study with Application to C2 Pedicle Screw Placement. World Neurosurg 2016; 94:368-374. [DOI: 10.1016/j.wneu.2016.07.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/11/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
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Marques LMS, d'Almeida GN, Cabral J. "Two-step" technique with OsiriX™ to evaluate feasibility of C2 pedicle for surgical fixation. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2016; 7:75-81. [PMID: 27217652 PMCID: PMC4872566 DOI: 10.4103/0974-8237.181826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical treatment of craniovertebral junction pathology has evolved considerably in recent decades with the implementation of short atlanto-axial fixation techniques, notwhithstanding increasing neurovascular risks. Also, there is strong evidence that fixation of C2 anatomical pedicle has the best biomechanical profile of the entire cervical spine. However, it is often difficult and misleading, to evaluate anatomical bony and vascular anomalies using the three orthogonal planes (axial, coronal, and sagittal) of CT. OBJECTIVES The authors describe an innovative and simple technique to evaluate the feasibility of C2 pedicle for surgical screw fixation using preoperative planning with the free DICOM (Digital Imaging and Communications in Medicine) software OsiriX™. MATERIALS AND METHODS The authors report the applicatin of this novel technique in 5 cases (3 traumatic, 1 Os Odontoideum, and 1 complex congenital malformation) collected from our general case series of the Department in the last 5 years. RESULTS In this proof of concept study, the pre-operative analysis with the two-step tecnique was detrimental for choosing the surgical tecnique. Detailed post-operative analysis confirmed correct position of C2 screws without cortical breach. There were no complications or mortality reported. CONCLUSION This two-step technique is an easy and reliable way to determine the feasibility of C2 pedicle for surgical fixation. The detailed tridimensional radiological preoperative evaluation of craniovertebral junction anatomy is critical to the sucess and safety of this surgeries, and can avoid, to certain degree, expensive intra-operative tridimensional imaging facilities.
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Affiliation(s)
| | | | - José Cabral
- Department of Neurosurgery, Egas Moniz Hospital, Lisbon, Portugal
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Bredow J, Meyer C, Scheyerer MJ, Siedek F, Müller LP, Eysel P, Stein G. Accuracy of 3D fluoroscopy-navigated anterior transpedicular screw insertion in the cervical spine: an experimental 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 2016; 25:1683-9. [PMID: 26810977 DOI: 10.1007/s00586-016-4403-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 01/12/2016] [Accepted: 01/15/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE The technique of pedicle screw stabilization is finding increasing popularity for use in the cervical spine. Implementing anterior transpedicular screws (ATPS) in cervical spine offers theoretical advantages compared to posterior stabilization. The goal of the current study was the development of a new setting for navigated insertion of ATPS, combining the advantage of reduced invasiveness of an anterior approach with the technical advantages of navigation. METHODS 20 screws were implanted in levels C3 to C6 of four cervical spine models (SAWBONES(®) Cervical Vertebrae with Anterior Ligament) with the use of 3D fluoroscopy navigation system [Arcadis Orbic 3D, Siemens and VectorVision fluoro 3D trauma software (BrainLAB)]. The accuracy of inserted screws was analyzed according to postoperative CT scans and following the modified Gertzbein and Robbins classification. RESULTS 20 anterior pedicle screws were placed in four human cervical spine models. Of these, eight screws were placed in C3, two screws in C4, six screws in C5, and four screws in C6. 16 of 20 screws (80 %) reached a grade 1 level of accuracy according to the modified Gertzbein and Robbins Classification. Three screws (15 %) were grade 2, and one screw (5 %) was grade 3. Grade 4 and 5 positions were not evident. Summing grades 1 and 2 together as "good" positions, 95 % of the screws achieved this level. Only a single screw did not fulfill these criteria. CONCLUSION The setting introduced in this study for navigated insertion of ATPS into cervical spine bone models is well implemented and shows excellent results, with an accuracy of 95 % (Gertzbein and Robbins grade 2 or better). Thus, this preliminary study represents a prelude to larger studies with larger case numbers on human specimens.
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Affiliation(s)
- Jan Bredow
- Department of Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Carolin Meyer
- Department of Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Max Joseph Scheyerer
- Department of Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Florian Siedek
- Department of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Lars Peter Müller
- Department of Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Peer Eysel
- Department of Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Gregor Stein
- Department of Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
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Abstract
This article reviews the historical context, indications, techniques, and complications of four posterior fixation techniques to stabilize the subaxial cervical spine. Specifically, posterior wiring, laminar screw fixation, lateral mass fixation, and pedicle screw fixation are among the common methods of operative fixation of the subaxial cervical spine. While wiring and laminar screw fixation are now rarely used, both lateral mass and pedicle screw fixation are technically challenging and present the risk of significant complications if performed incorrectly. With a sound understanding of anatomy and rigorous preoperative evaluation of bony structures, both lateral mass and pedicle screw fixation provide a safe and reliable method for subaxial cervical spine fixation.
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Affiliation(s)
- Ahmer Ghori
- Orthopedic Surgery, Massachusetts General Hospital
| | - Hai V Le
- Orthopedic Surgery, Massachusetts General Hospital ; Orthopaedics, Brigham and Women's Hospital
| | - Heeren Makanji
- Orthopedic Surgery, Massachusetts General Hospital ; Orthopaedics, Brigham and Women's Hospital
| | - Thomas Cha
- Orthopedic Surgery, Massachusetts General Hospital
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Alicioglu B, Gulekon N, Akpinar S. Age-related morphologic changes of the vertebral artery in the transverse process. Analysis by multidetector computed tomography angiography. Spine J 2015; 15:1981-7. [PMID: 25931427 DOI: 10.1016/j.spinee.2015.04.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/27/2015] [Accepted: 04/20/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The V2 segment of the vertebral artery (VA) ascends and passes through the transverse foramen (TF) of the C6-C1 vertebrae. Atherosclerosis of the VA and degenerative changes in the cervical spine are likely to occur with aging, and subsequent morphologic changes may alter the normal anatomy. PURPOSE The aim was to determine the morphologic changes of TF and VA in relation to aging. STUDY DESIGN/SETTING This was a retrospective cross-sectional study. PATIENT SAMPLE One hundred ten consecutive patients who had undergone computed tomography angiography were included. METHODS The subjects were then divided into three groups according to age: Group A, less than 45 years; Group B, from 45 to 65 years; and Group C, older than 65 years. Cases with stenosis and dissection of the VA were excluded from the quantitative analysis. The areas of the VA and TF were measured, and the VA/TF occupation ratio (OR) was calculated accordingly. The presence of VAs tortuosity within the TF was also noted. RESULTS The TF was larger in the oldest group, but the difference was not statistically significant. There was also no significant statistical difference among the age groups in terms of the VA and VA/TF ORs (p>.05). In the Group C, the rate of overall tortuosity of the VA was 73%, and arterial tortuosity in the TF was 28.6%. In cases with tortuous VA, C6 and C4 TFs were found to be significantly larger. CONCLUSIONS Tortuous VAs tend to be associated with enlargement of C6 and C4 TFs. Knowledge of such changes in the anatomy is crucial during instrumentation used for cervical spine surgeries, to prevent serious complications in patients aged older than 65 years.
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Affiliation(s)
- Banu Alicioglu
- Department of Radiology, Near East University Medical Faculty, Nicosia / TRNC, Mersin 10 Turkey; Department of Anatomy, Gazi University Medical Faculty, Bahriye Üçok Caddesi Ankara/Çankaya, Turkey.
| | - Nadir Gulekon
- Department of Anatomy, Gazi University Medical Faculty, Bahriye Üçok Caddesi Ankara/Çankaya, Turkey
| | - Suha Akpinar
- Department of Radiology, Near East University Medical Faculty, Nicosia / TRNC, Mersin 10 Turkey
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Accuracy of fluoroscopy versus computer-assisted navigation for the placement of anterior cervical pedicle screws. Spine (Phila Pa 1976) 2015; 40:E404-10. [PMID: 25599290 DOI: 10.1097/brs.0000000000000786] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Randomized laboratory cadaver study. OBJECTIVE The objective of this study was to determine the accuracy of anterior transpedicular screw placement in the cervical spine using conventional fluoroscopy versus computer-assisted navigation. SUMMARY OF BACKGROUND DATA Traditionally, global cervical instability has required anterior and posterior fixation due to the superior biomechanical stability of circumferential constructs. Anterior transpedicular screws (ATPS) have recently been advocated as a single surgical approach. Current clinical publications report using fluoroscopic guidance for screw placement. Computer-assisted navigation (CAN) systems have demonstrated enhanced accuracy of pedicle screw placement at all spine levels but have not been assessed for ATPS. METHODS The anterior vertebrae of 9 fresh frozen cadaver cervical spines were exposed, preserving the lateral and posterior soft tissue envelope. Nine practicing spine surgeons placed 2.0-mm titanium anterior transpecidular Kirschner wires into the C3-T1 pedicles bilaterally using fluoroscopy or CAN guidance. Specimens were imaged by computed tomography and virtual screws were overlaid on the K-wires. Targeting accuracy was compared between the 2 techniques in all planes using a 5-level grading scale. RESULTS The percentage of acceptable screw placements for fluoroscopy and CAN was 42.6% and 66.7%, respectively (P = 0.012). Catastrophic screw placement (grade 3 or 4) was 33.3% for fluoroscopy and 16.7% for CAN. In the multivariable model, the accuracy rate was 67% lower for fluoroscopy than for CAN after controlling for other factors (odds ratio: 0.33, 95% confidence interval: 0.14-0.79). CONCLUSION The accuracy of CAN-guided placement of K-wires for ATPS was superior to placement under fluoroscopic guidance, demonstrating statistically more acceptable screw placements and significantly less catastrophic virtual screws. However, malposition was still high, with potential for vertebral artery and neurological injury in a clinical setting. Further advancement in current ATPS techniques is warranted prior to widespread implementation in a patient setting. LEVEL OF EVIDENCE N/A.
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Abumi K. Cervical spondylotic myelopathy: posterior decompression and pedicle screw fixation. 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 2015; 24 Suppl 2:186-96. [PMID: 25813005 DOI: 10.1007/s00586-015-3838-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 02/18/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Posterior decompression by laminoplasty and anterior decompression/fixation have been widely accepted, and they provide sufficient results for cervical spondylotic myelopathy. However, combined procedure of posterior decompression and reconstruction is favorable for some patients accompanying local kyphosis, segmental instability, previously operated conditions on the cervical spine, etc. DISCUSSION Among posterior cervical instrumentations, pedicle screw fixation is a strong tool of stabilization of unstable segment and correction of deformities in sagittal and/or coronal planes for the patient with cervical spondylotic myelopathy. On the other hand, neurovascular complications including injury to the vertebral artery and nerve root cannot be completely eliminated. Even after surgeons became familiar with placement of cervical pedicle screws, screw malposition rate by freehand technique is high for patients with severe spondylotic condition. Surgeons must especially be careful for inserting pedicle screw in the cervical spine associating marked degenerative changes by spondylosis, and must obtain preoperatively sufficient anatomical information of the pedicle and surrounding structures. CONCLUSION Combined procedure of posterior reconstructive surgery using a pedicle screw fixation provides better clinical outcomes than laminoplasty alone for cervical spondylotic myelopathy accompanying local kyphosis or segmental instability. Further development of supporting tools for cervical pedicle screw insertion including aiming device, navigation system and neuromonitoring procedure are expected for safer screw insertion.
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Affiliation(s)
- Kuniyoshi Abumi
- Sapporo Orthopaedic Hospital-Center for Spinal Disorders, 13-56, Hassam 13-4, Nishi-Ku, Sapporo, 063-0833, Japan,
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King NKK, Rajendra T, Ng I, Ng WH. A computed tomography morphometric study of occipital bone and C2 pedicle anatomy for occipital-cervical fusion. Surg Neurol Int 2014; 5:S380-3. [PMID: 25289166 PMCID: PMC4173205 DOI: 10.4103/2152-7806.139676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 06/06/2014] [Indexed: 11/30/2022] Open
Abstract
Background: Occipital-cervical fusion (OCF) has been used to treat instability of the occipito-cervical junction and to provide biomechanical stability after decompressive surgery. The specific areas that require detailed morphologic knowledge to prevent technical failures are the thickness of the occipital bone and diameter of the C2 pedicle, as the occipital midline bone and the C2 pedicle have structurally the strongest bone to provide the biomechanical purchase for cranio-cervical instrumentation. The aim of this study was to perform a quantitative morphometric analysis using computed tomography (CT) to determine the variability of the occipital bone thickness and C2 pedicle thickness to optimize screw placement for OCF in a South East Asian population. Methods: Thirty patients undergoing cranio-cervical junction instrumentation during the period 2008-2010 were included. The thickness of the occipital bone and the length and diameter of the C2 pedicle were measured based on CT. Results: The thickest point on the occipital bone was in the midline with a maximum thickness below the external occipital protuberance of 16.2 mm (±3.0 mm), which was thicker than in the Western population. The average C2 pedicle diameter was 5.3 mm (±2.0 mm). This was smaller than Western population pedicle diameters. The average length of the both pedicles to the midpoint of the C2 vertebral body was 23.5 mm (±3.3 mm on the left and ±2.3 mm on the right). Conclusions: The results of this first study in the South East Asian population should help guide and improve the safety in occipito-cervical region instrumentation. Thus reducing the risk of technical failures and neuro-vascular injury.
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Affiliation(s)
- Nicolas K K King
- Department of Neurosurgery, National Neuroscience Institute, Singapore General Hospital, Outram Road, Singapore 169608
| | - Tiruchelvarayan Rajendra
- National Neuroscience Institute, Singapore General Hospital, Outram Road, Singapore 169608 and Gleneagles Hospital, Napier Road, Singapore 258500
| | - Ivan Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore General Hospital, Outram Road, Singapore 169608
| | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore General Hospital, Outram Road, Singapore 169608
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Xiu P, Wang Q, Wang G, Wang S, Dai G, Lan Y. Morphological and clinical feasibility of C3 pedicle screw instrumentation in patients with congenital C2-3 fusion. 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 2014; 23:1730-6. [PMID: 24894411 DOI: 10.1007/s00586-014-3397-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 05/23/2014] [Accepted: 05/24/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Congenital C2-3 fusion (C2-3CF) is often involved in patients with atlantoaxial dislocation, and posterior occipitocervical fixation surgery is usually required. Hypoplasia of C2 pedicle is common in such patients, making C2 pedicle screws (PS) instrumentation inapplicable. Because of congenital fusion, C3PS instrumentation would be an ideal alternative for it will not sacrifice an additional motion segment; however, the morphological and clinical feasibility has not been previously reported. METHODS We included 42 C2-3CF patients to this study and evaluated pedicle trajectories of C2 and C3 using a three-dimensional CT. Clinical applications of C3PS instrumentation were evaluated and followed. RESULTS Among the 42 patients, 23 (54.8%) and 8 (19.0%) had C2 and C3 pedicle trajectory diameters <4.0 mm, respectively. The bisection line of the fused C2-3 lamina was used to represent the superior border of C3 articular mass; the entry point of C3 pedicle was located at 3 mm inferior to the assumed superior border and 3.2 mm medial to the lateral border. Bilateral C3PS instrumentations were successfully adopted in 22 patients. No spinal cord or vertebral artery injury occurred; postoperative CT showed a trajectory breach rate of 17.4% for C3PS. After mean of 3.6-year follow-up, no implant failure was documented. CONCLUSIONS C3PS instrumentation is morphologically and clinically feasible for a large proportion of patients with C2-3CF and can serve as another reliable alternative for C2PS instrumentation. Preoperative evaluation of pedicle trajectory of C2-3CF with three-dimensional CT is highly valuable in the choice of proper fixation methods.
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Affiliation(s)
- Peng Xiu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
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CT morphometric analysis to determine the anatomical basis for the use of transpedicular screws during reconstruction and fixations of anterior cervical vertebrae. PLoS One 2013; 8:e81159. [PMID: 24349038 PMCID: PMC3859485 DOI: 10.1371/journal.pone.0081159] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 10/18/2013] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Accurate placement of pedicle screw during Anterior Transpedicular Screw fixation (ATPS) in cervical spine depends on accurate anatomical knowledge of the vertebrae. However, little is known of the morphometric characteristics of cervical vertebrae in Chinese population. METHODS Three-dimensional reconstructions of CT images were performed for 80 cases. The anatomic data and screw fixation parameters for ATPS fixation were measured using the Mimics software. FINDINGS The overall mean OPW, OPH and PAL ranged from 5.81 to 7.49 mm, 7.77 to 8.69 mm, and 33.40 to 31.13 mm separately, and SPA was 93.54 to 109.36 degrees from C3 to C6, 104.99 degrees at C7, whereas, 49.00 to 32.26 degrees from C4 to C7, 46.79 degrees at C3 (TPA). Dl/rSIP had an increasing trend away from upper endplate with mean value from 1.87 to 5.83 mm. Dl/rTIP was located at the lateral portion of the anterior cortex of vertebrae for C3 to C5 and ipsilateral for C6 to C7 with mean value from -2.70 to -3.00 mm, and 0.17 to 3.18 mm. The entrance points for pedicular screw insertion for C3 to C5 and C6 to C7 were recommended -2∼-3 mm and 0-4 mm from the median sagittal plane, respectively, 1-4 mm and 5-6 mm from the upper endplate, with TPA being 46.79-49.00 degrees and 40.89-32.26 degrees, respectively, and SPA being 93.54-106.69 degrees and 109.36-104.99 degrees, respectively. The pedicle screw insertion diameter was recommended 3.5 mm (C3 and C4), 4.0 mm (C5 to C7), and the pedicle axial length was 21-24 mm for C3 to C7 for both genders. However, the ATPS insertion in C3 should be individualized given its relatively small anatomical dimensions. CONCLUSIONS The data provided a morphometric basis for the ATPS fixation technique in lower cervical fixation. It will help in preoperative planning and execution of this surgery.
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Wang Y, Xie J, Yang Z, Zhao Z, Zhang Y, Li T, Liu L. Computed tomography assessment of lateral pedicle wall perforation by free-hand subaxial cervical pedicle screw placement. Arch Orthop Trauma Surg 2013; 133:901-9. [PMID: 23632781 DOI: 10.1007/s00402-013-1752-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE To present the technique of free-hand subaxial cervical pedicle screw (CPS) placement without using intra-operative navigating devices, and to investigate the crucial factors for safe placement and avoidance of lateral pedicle wall perforation, by measuring and classifying perforations with postoperative computed tomography (CT) scan. The placement of CPS has generally been considered as technically demanding and associated with considerable lateral wall perforation rate. For surgeons without access to navigation systems, experience of safe free-hand technique for subaxial CPS placement is especially valuable. MATERIALS AND METHODS A total of 214 consecutive traumatic or degenerative patients with 1,024 CPS placement using the free-hand technique were enrolled. In the operative process, the lateral mass surface was decorticated. Then a small curette was used to identify the pedicle entrance by touching the cortical bone of the medial pedicle wall. It was crucial to keep the transverse angle and make appropriate adjustment with guidance of the resistance of the thick medial cortical bone. The hand drill should be redirected once soft tissue breach was palpated by a slim ball-tip prober. With proper trajectory, tapping, repeated palpation, the 26-30 mm screw could be placed. After the procedure, the transverse angle of CPS trajectory was measured, and perforation of the lateral wall was classified by CT scan: grade 1, perforation of pedicle wall by screw placement, with the external edge of screw deviating out of the lateral pedicle wall equal to or less than 2 mm and grade 2, critical perforation of pedicle wall by screw placement, large than 2 mm. RESULTS A total of 129 screws (12.64 %) were demonstrated as lateral pedicle wall perforation, of which 101 screws (9.86 %) were classified as grade 1, whereas 28 screws (2.73 %) as grade 2. Among the segments involved, C3 showed an obviously higher perforating rate than other (P < 0.05). The difference between the anatomical pedicle transverse angle and the screw trajectory angle was higher in patients of grade 2 perforation than the others. In the 28 screws of grade 2 perforation verified by axial CT, 26 screws had been palpated as abnormal during operation. However, only 19 out of the 101 screws of grade 1 perforation had shown palpation alarming signs during operation. The average follow-up was 36.8 months (range 5-65 months). There was no symptom and sign of neurovascular injuries. Two screws (0.20 %) were broken, and one screw (0.10 %) loosen. CONCLUSION Placement of screw through a correct trajectory may lead to grade 1 perforation, which suggests transversal expansion and breakage of the thinner lateral cortex, probably caused by mismatching of the diameter of 3.5 mm screws and the tiny cancellous bone cavity of pedicle. Grade 1 perforation is deemed as relatively safe to the vertebral artery. Grade 2 perforation means obvious deviation of the trajectory angle of hand drill, which directly penetrates into the transverse foramen, and the risk of vertebral artery injury (VAI) or development of thrombi caused by the irregular blood flow would be much greater compared to grade 1 perforation. Moreover, there are two crucial maneuvers for increasing accuracy of screw placement: identifying the precise entry point using a curette or hand drill to touch the true entrance of the canal after decortication, and guiding CPS trajectory on axial plane by the resistant of thick medial wall.
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Affiliation(s)
- Yingsong Wang
- Department of Orthopaedics, 2nd Affiliated Hospital of Kunming Medical University, No. 347 of Dianmian Street, Kunming, Yunnan Province 650101, People's Republic of China
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Cervical laminectomy and instrumented lateral mass fusion: techniques, pearls and pitfalls. 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 2013; 24 Suppl 2:168-85. [DOI: 10.1007/s00586-013-2838-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/01/2012] [Accepted: 05/12/2013] [Indexed: 10/26/2022]
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Fu M, Lin L, Kong X, Zhao W, Tang L, Li J, Ouyang J. Construction and accuracy assessment of patient-specific biocompatible drill template for cervical anterior transpedicular screw (ATPS) insertion: an in vitro study. PLoS One 2013; 8:e53580. [PMID: 23326461 PMCID: PMC3542371 DOI: 10.1371/journal.pone.0053580] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 12/03/2012] [Indexed: 11/20/2022] Open
Abstract
Background With the properties of three-column fixation and anterior-approach-only procedure, anterior transpedicular screw (ATPS) is ideal for severe multilevel traumatic cervical instabilities. However, the accurate insertion of ATPS remains challenging. Here we constructed a patient-specific biocompatible drill template and evaluated its accuracy in assisting ATPS insertion. Methods After ethical approval, 24 formalin-preserved cervical vertebrae (C2–C7) were CT scanned. 3D reconstruction models of cervical vertebra were obtained with 2-mm-diameter virtual pin tracts at the central pedicles. The 3D models were used for rapid prototyping (RP) printing. A 2-mm-diameter Kirschner wire was then inserted into the pin tract of the RP model before polymethylmethacrylate was used to construct the patient-specific biocompatible drill template. After removal of the anterior soft tissue, a 2-mm-diameter Kirschner wire was inserted into the cervical pedicle with the assistance of drill template. Cadaveric cervical spines with pin tracts were subsequently scanned using the same CT scanner. A 3D reconstruction was performed of the scanned spines to get 3D models of the vertebrae containing the actual pin tracts. The deviations were calculated between 3D models with virtual and actual pin tracts at the middle point of the cervical pedicle. 3D models of 3.5 mm-diameter screws were used in simulated insertion to grade the screw positions. Findings The patient-specific biocompatible drill template was constructed to assist ATPS insertion successfully. There were no significant differences between medial/lateral deviations (P = 0.797) or between superior/inferior deviations (P = 0.741). The absolute deviation values were 0.82±0.75 mm and 1.10±0.96 mm in axial and sagittal planes, respectively. In the simulated insertion, the screws in non-critical position were 44/48 (91.7%). Conclusions The patient-specific drill template is biocompatible, easy-to-apply and accurate in assisting ATPS insertion. Its clinical applications should be further researched.
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Affiliation(s)
- Maoqing Fu
- Department of Anatomy, Guangdong Provincial Key laboratory of Medical Biomechanics, School of Basic Medicine Science, Southern Medical University, Guangzhou, Guangdong, China
| | - Lijun Lin
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiangxue Kong
- Department of Anatomy, Guangdong Provincial Key laboratory of Medical Biomechanics, School of Basic Medicine Science, Southern Medical University, Guangzhou, Guangdong, China
| | - Weidong Zhao
- Department of Anatomy, Guangdong Provincial Key laboratory of Medical Biomechanics, School of Basic Medicine Science, Southern Medical University, Guangzhou, Guangdong, China
| | - Lei Tang
- Department of Anatomy, Guangdong Provincial Key laboratory of Medical Biomechanics, School of Basic Medicine Science, Southern Medical University, Guangzhou, Guangdong, China
| | - Jianyi Li
- Department of Anatomy, Guangdong Provincial Key laboratory of Medical Biomechanics, School of Basic Medicine Science, Southern Medical University, Guangzhou, Guangdong, China
- * E-mail:
| | - Jun Ouyang
- Department of Anatomy, Guangdong Provincial Key laboratory of Medical Biomechanics, School of Basic Medicine Science, Southern Medical University, Guangzhou, Guangdong, China
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