Abstract
Purpose
To conduct a retrospective multicenter study to investigate the accuracy of pedicle screw (PS) placement in the cervical spine by freehand technique and the related complications in various pathological conditions including trauma, rheumatoid arthritis, degenerative conditions and others.
Methods
283 patients with 1,065 PSs in the cervical spine who were treated at eight spine centers and finished postoperative CT scan were enrolled. The numbers of placed PSs were 608 for trauma, 180 for rheumatoid arthritis (RA), 199 for spondylosis, and 78 for others. Malposition grades on CT image in the axial plane were defined as grade 0 (G-0) correct placement, grade 1 (G-1): malposition by less than half screw diameter, grade 2 (G-2): malposition by more than half screw diameter. The direction of malposition was classified into four categories: medial, lateral, superior and inferior.
Results
Overall malposition rate was 14.8 % (9.6 % in G-1 and 5.3 % in G-2). The highest malposition rate was 26.7 % for RA, followed by 16.6 % for spondylosis, and 11.2 % for trauma. The malposition rate for RA was significantly higher than those for other pathologies. 79.7 % of the malpositioned screws were placed laterally. Though intraoperative vertebral artery injury was observed in two patients with RA, there were no serious complications during a minimal 2-year follow-up.
Conclusions
Malposition rate of PS placement in the cervical spine by freehand technique was high in rheumatoid patients even when being performed by experienced spine surgeons. Any guidance tools including navigation systems are recommended for placement of cervical PSs in patients with RA.
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References
Abumi K, Ito H, Taneichi H, Kaneda K (1994) Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine. Description of the techniques and preliminary report. J Spinal Disord 7:19–28
Abumi K, Takada T, Shono Y, Kaneda K, Fujiya M (1999) Posterior occipitocervical reconstruction using cervical pedicle screws and plate-rod systems. Spine 24:1425–1434
Sudo H, Ito M, Abumi K, Kotani Y, Takeuchi T, Yasui K, Minami A (2006) Long-term follow up of surgical outcomes in patients with cervical disorders undergoing hemodialysis. J Neurosurg Spine 5:313–319
Oda I, Abumi K, Ito M, Kotani Y, Oya T, Hasegawa K, Minami A (2006) Palliative spinal reconstruction using cervical pedicle screws for metastatic lesions of the spine: a retrospective analysis of 32 cases. Spine 31:1439–1444
Hasegawa K, Hirano T, Shimoda H, Homma T, Morita O (2008) Indications for cervical pedicle screw instrumentation in nontraumatic lesions. Spine 33:2284–2289
Kothe R, Rüther W, Schneider E, Linke B (2004) Biomechanical analysis of transpedicular screw fixation in the subaxial cervical spine. Spine 29:1869–1875
Abumi K, Shono Y, Ito M, Taneichi T, Kotani Y, Kaneda K (2000) Complication of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine 25:962–969
Neo M, Sakamoto T, Fujibayashi S, Nakamura T (2005) The clinical risk of vertebral artery injury from cervical pedicle screws inserted in degenerative vertebrae. Spine 30:2800–2805
Onishi E, Sekimoto Y, Fukumitsu R, Yamagata S, Matsushita M (2010) Cerebral infraction due to an embolism after cervical pedicle screw fixation. Spine 35:E63–E66
Ishikawa Y, Kanemura T, Yoshida G, Matsumoto A, Ito Z, Tauchi R, Muramoto A, Ohno S, Nishimura Y (2011) Intraoperative, full-rotation, three-dimensional image (O-arm)-based navigation system for cervical pedicle screw insertion. J Neurosurg Spine 15:472–478
Ito Y, Sugimoto Y, Tomioka M, Hasegawa Y, Nakago K, Yagata Y (2008) Clinical accuracy of 3D fluoroscopy-assisted cervical pedicle screw insertion. J Neurosurg Spine 9:450–453
Nakashima H, Yukawa Y, Imagama S, Kanemura T, Kamiya M, Yanase M, Ito K, Machino M, Yoshida G, Ishikawa Y, Matsuyama Y, Ishiguro N, Kato F (2012) Complications of cervical pedicle screw fixation for nontraumatic lesions: a multicenter study of 84 patients. J Neurosurg Spine 16:238–247
Kosmopoulous V, Schizas C (2007) Pedicle screw placement accuracy: a meta-analysis. Spine 32:E111–E120
Hojo Y, Ito M, Abumi K, Kotani Y, Sudo H, Takahata M, Minami A (2011) A late neurological complication following posterior correction surgery of severe cervical kyphosis. Eur Spine J 20:890–898
Miyata M, Neo M, Ito H, Yoshida M, Fujibashi S, Nakamura T (2008) Rheumatoid arthritis as a risk factor for a narrow C-2 pedicle: 3D analysis of the C2 pedicle screw trajectory. J Neurosurg Spine 9:17–21
Yoshimoto H, Sato S, Hyakumachi T, Yanagibashi Y, Kanno T, Masuda T (2009) Clinical accuracy of cervical pedicle screw insertion using lateral fluoroscopy: a radiographic analysis of the learning curve. Eur Spine J 18:1326–1334
Gonzalvo A, Fitt G, Liew S, de la Harpe D, Turner P, Ton L, Rogers MA, Wilde PH (2009) The learning curve of pedicle screw placement; how many screws are enough? Spine 34:E761–E765
Yukawa Y, Kato F, Yoshihara H, Yanase M, Ito K (2006) Cervical pedicle screw fixation in 100 cases of unstable cervical injuries: pedicle axis views obtained using fluoroscopy. J Neurosurg Spine 5:488–493
Yukawa Y, Kato F, Ito K, Horie Y, Hida T, Nakashima H, Machino M (2009) Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope. Eur Spine J 18:1293–1299
Ryken TC, Owen BD, Christensen GE, Reinhardt JM (2009) Image-based drill templates for cervical pedicle screw placement. J Neurosurg Spine 10:21–26
Kim HS, Heller JG, Hudgins PA, Fountain JA (2003) The accuracy of computed tomography in assessing cervical pedicle screw placement. Spine 28:2441–2446
Ludwig SC, Kowalski JM, Edwards CC II, Heller JG (2000) Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine 25:2675–2681
Richter M, Cakir B, Schmidt R (2005) Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws. Spine 30:2280–2287
Rath SA, Moszko S, Schäffner PM, Cantone G, Braun V, Richter HP, Antoniadis G (2008) Accuracy of pedicle screw insertion in the cervical spine for internal fixation using frameless stereotactic guidance. J Neurosurg Spine 8:234–245
Shin EK, Panjabi MM, Chen NC, Wang JL (2000) The anatomic variability of human cervical pedicles: consideration for transpedicular screw fixation in the middle and lower cervical spine. Eur Spine J 9:61–66
Kast E, Mohr K, Richter HP, Börm W (2006) Complications of transpedicular screw fixation in the cervical spine. Eur Spine J 15:327–334
Acknowledgement
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000(5). Informed consent was obtained from all patients for being included in the study. The authors thank Hitoshi Haba, MD, Takashi Ishida, MD, Keigo Yasui, MD, and Tatsuto Takeuchi, MD, for their support in data collection. Also thanks to Mr. Mason Mark for his support in English language editing.
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Hojo, Y., Ito, M., Suda, K. et al. A multicenter study on accuracy and complications of freehand placement of cervical pedicle screws under lateral fluoroscopy in different pathological conditions: CT-based evaluation of more than 1,000 screws. Eur Spine J 23, 2166–2174 (2014). https://doi.org/10.1007/s00586-014-3470-0
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DOI: https://doi.org/10.1007/s00586-014-3470-0