Skip to main content
SpringerLink
Log in

The accuracy of 3D fluoroscopy-navigated screw insertion in the upper and subaxial cervical spine

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Purpose

Due to better primary stability and repositioning options, pedicle screws are increasingly used during posterior stabilization of the cervical spine. However, the serious risks generally associated with the insertion of screws in the cervical spine remain. The purpose of this study is to examine the accuracy of pedicle screw insertion with the use of 3D fluoroscopy navigation systems, also accounting for various spine levels.

Methods

Data of 64 patients were collected during and after screw implantation (axial and subaxial) in the cervical spine. 207 screws were implanted from C1 to C7 and analyzed for placement accuracy according to postoperative CT scans and following the modified Gertzbein and Robbins classification.

Results

The accuracy of most of the inserted screws was assessed as grade 2 according to the modified Gertzbein and Robbins classification. 93.9 % of the screws implanted at C1 or C2, and 78.51 % of the screws implanted at levels C3–C7 showed placement accuracy grade 2 or better, indicating pedicle wall perforation of <2 mm. Overall, seven complications were observed. In three cases, the vertebral artery was affected, leading to one fatality. Surgical revision was necessary once because of Magerl screw misplacement and three times due to impaired wound healing. No radicular symptoms resulted from screw malposition.

Conclusion

Axial and subaxial screws can be inserted with a high grade of accuracy using 3D fluoroscopy-based navigation systems. Nevertheless, while this useful innovation helps to minimize the risks of misplacement, the surgery is still a challenge, as arising complications remain severe.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Abumi K, Itoh 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(1):19–28

    Article  CAS  PubMed  Google Scholar 

  2. Abumi K, Kaneda K (1997) Pedicle screw fixation for nontraumatic lesions of the cervical spine. Spine 22(16):1853–1863

    Article  CAS  PubMed  Google Scholar 

  3. Abumi K, Shono Y, Ito M, Taneichi H, Kotani Y, Kaneda K (2000) Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine 25(8):962–969

    Article  CAS  PubMed  Google Scholar 

  4. Barnes AH, Eguizabal JA, Acosta FL Jr, Lotz JC, Buckley JM, Ames CP (2009) Biomechanical pullout strength and stability of the cervical artificial pedicle screw. Spine 34(1):E16–E20. doi:10.1097/BRS.0b013e3181891772

    Article  PubMed  Google Scholar 

  5. Blauth M, Richter M, Lange U (1999) Trans-articular screw fixation of C1/C2 in atlanto-axial instability. Comparison between percutaneous and open procedures. Der Orthopade 28(8):651–661

    CAS  PubMed  Google Scholar 

  6. Dunlap BJ, Karaikovic EE, Park HS, Sokolowski MJ, Zhang LQ (2010) Load sharing properties of cervical pedicle screw-rod constructs versus lateral mass screw-rod constructs. Eur Spine J 19(5):803–808. doi:10.1007/s00586-010-1278-0

    Article  PubMed Central  PubMed  Google Scholar 

  7. Ebraheim NA, Xu R, Knight T, Yeasting RA (1997) Morphometric evaluation of lower cervical pedicle and its projection. Spine 22(1):1–6

    Article  CAS  PubMed  Google Scholar 

  8. Gebauer M, Barvencik F, Briem D, Kolb JP, Seitz S, Rueger JM, Puschel K, Amling M (2010) Evaluation of anatomic landmarks and safe zones for screw placement in the atlas via the posterior arch. Eur Spine J 19(1):85–90. doi:10.1007/s00586-009-1181-8

    Article  PubMed Central  PubMed  Google Scholar 

  9. Gelalis ID, Paschos NK, Pakos EE, Politis AN, Arnaoutoglou CM, Karageorgos AC, Ploumis A, Xenakis TA (2012) Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J 21(2):247–255. doi:10.1007/s00586-011-2011-3

    Article  PubMed Central  PubMed  Google Scholar 

  10. Gertzbein SD, Robbins SE (1990) Accuracy of pedicular screw placement in vivo. Spine 15(1):11–14

    Article  CAS  PubMed  Google Scholar 

  11. Glossop ND, Hu RW, Randle JA (1996) Computer-aided pedicle screw placement using frameless stereotaxis. Spine 21(17):2026–2034

    Article  CAS  PubMed  Google Scholar 

  12. Haid RW Jr (2001) C1–C2 transarticular screw fixation: technical aspects. Neurosurgery 49(1):71–74

    PubMed  Google Scholar 

  13. Ishikawa Y, Kanemura T, Yoshida G, Ito Z, Muramoto A, Ohno S (2010) Clinical accuracy of three-dimensional fluoroscopy-based computer-assisted cervical pedicle screw placement: a retrospective comparative study of conventional versus computer-assisted cervical pedicle screw placement. J Neurosurg Spine 13(5):606–611. doi:10.3171/2010.5.SPINE09993

    Article  PubMed  Google Scholar 

  14. 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(5):472–478. doi:10.3171/2011.6.SPINE10809

    Article  PubMed  Google Scholar 

  15. Kantelhardt SR, Keric N, Giese A (2012) Management of C2 fractures using Iso-C(3D) guidance: a single institution’s experience. Acta Neurochir (Wien) 154(10):1781–1787. doi:10.1007/s00701-012-1443-9

    Article  Google Scholar 

  16. Karaikovic EE, Kunakornsawat S, Daubs MD, Madsen TW, Gaines RW Jr (2000) Surgical anatomy of the cervical pedicles: landmarks for posterior cervical pedicle entrance localization. J Spinal Disord 13(1):63–72

    Article  CAS  PubMed  Google Scholar 

  17. Kosmopoulos V, Schizas C (2007) Pedicle screw placement accuracy: a meta-analysis. Spine 32(3):E111–E120. doi:10.1097/01.brs.0000254048.79024.8b

    Article  PubMed  Google Scholar 

  18. Lee DH, Lee SW, Kang SJ, Hwang CJ, Kim NH, Bae JY, Kim YT, Lee CS, Daniel Riew K (2011) Optimal entry points and trajectories for cervical pedicle screw placement into subaxial cervical vertebrae. Eur Spine J 20(6):905–911. doi:10.1007/s00586-010-1655-8

    Article  PubMed Central  PubMed  Google Scholar 

  19. Liu YJ, Tian W, Liu B, Li Q, Hu L, Li ZY, Yuan Q, Lu YW, Sun YZ (2010) Comparison of the clinical accuracy of cervical (C2–C7) pedicle screw insertion assisted by fluoroscopy, computed tomography-based navigation, and intraoperative three-dimensional C-arm navigation. Chin Med J 123(21):2995–2998

    PubMed  Google Scholar 

  20. Ludwig SC, Kramer DL, Vaccaro AR, Albert TJ (1999) Transpedicle screw fixation of the cervical spine. Clin Orthop Relat Res 359:77–88

    Article  PubMed  Google Scholar 

  21. Luther N, Iorgulescu JB, Geannette C, Gebhard H, Saleh T, Tsiouris AJ, Hartl R (2013) Comparison of navigated versus non-navigated pedicle screw placement in 260 patients and 1434 screws: screw accuracy, screw size, and the complexity of surgery. J Spinal Disord Tech. doi:10.1097/BSD.0b013e31828af33e

    Google Scholar 

  22. Mueller CA, Roesseler L, Podlogar M, Kovacs A, Kristof RA (2010) Accuracy and complications of transpedicular C2 screw placement without the use of spinal navigation. Eur Spine J 19(5):809–814. doi:10.1007/s00586-010-1291-3

    Article  PubMed Central  PubMed  Google Scholar 

  23. 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(3):238–247. doi:10.3171/2011.11.SPINE11102

    Article  PubMed  Google Scholar 

  24. Panjabi MM, Shin EK, Chen NC, Wang JL (2000) Internal morphology of human cervical pedicles. Spine 25(10):1197–1205

    Article  CAS  PubMed  Google Scholar 

  25. Richter M, Cakir B, Schmidt R (2005) Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws. Spine 30(20):2280–2287

    Article  PubMed  Google Scholar 

  26. Richter M, Mattes T, Cakir B (2004) Computer-assisted posterior instrumentation of the cervical and cervico-thoracic spine. Eur Spine J 13(1):50–59. doi:10.1007/s00586-003-0604-1

    Article  PubMed Central  PubMed  Google Scholar 

  27. Richter M, Schmidt R, Claes L, Puhl W, Wilke HJ (2002) Posterior atlantoaxial fixation: biomechanical in vitro comparison of six different techniques. Spine 27(16):1724–1732

    Article  PubMed  Google Scholar 

  28. Roy-Camille R, Saillant G, Laville C, Benazet JP (1992) Treatment of lower cervical spinal injuries—C3 to C7. Spine 17(10 Suppl):S442–S446

    Article  CAS  PubMed  Google Scholar 

  29. Sakamoto T, Neo M, Nakamura T (2004) Transpedicular screw placement evaluated by axial computed tomography of the cervical pedicle. Spine 29(22):2510–2514 discussion 2515

    Article  PubMed  Google Scholar 

  30. Schmidt R, Wilke HJ, Claes L, Puhl W, Richter M (2003) Pedicle screws enhance primary stability in multilevel cervical corpectomies: biomechanical in vitro comparison of different implants including constrained and nonconstrained posterior instrumentations. Spine 28(16):1821–1828. doi:10.1097/01.BRS.0000083287.23521.48

    Article  PubMed  Google Scholar 

  31. Tian W, Liu Y, Zheng S, Lv Y (2013) Accuracy of lower cervical pedicle screw placement with assistance of distinct navigation systems: a human cadaveric study. Eur Spine J 22(1):148–155. doi:10.1007/s00586-012-2494-6

    Article  PubMed Central  PubMed  Google Scholar 

  32. Wang Y, Xie J, Yang Z, Zhao Z, Zhang Y, Li T, Liu L (2013) Computed tomography assessment of lateral pedicle wall perforation by free-hand subaxial cervical pedicle screw placement. Arch Orthop Trauma Surg 133(7):901–909. doi:10.1007/s00402-013-1752-3

    Article  PubMed  Google Scholar 

  33. Weinstein JN, Spratt KF, Spengler D, Brick C, Reid S (1988) Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine 13(9):1012–1018

    Article  CAS  PubMed  Google Scholar 

  34. Xu R, Ebraheim NA, Skie M (2008) Pedicle screw fixation in the cervical spine. Am J Orthop 37(8):403–408 discussion 408

    PubMed  Google Scholar 

  35. Yukawa Y, Kato F, Ito K, Nakashima H, Machino M (2009) Anterior cervical pedicle screw and plate fixation using fluoroscope-assisted pedicle axis view imaging: a preliminary report of a new cervical reconstruction technique. Eur Spine J 18(6):911–916. doi:10.1007/s00586-009-0949-1

    Article  PubMed Central  PubMed  Google Scholar 

  36. Zhang HL, Zhou DS, Jiang ZS (2011) Analysis of accuracy of computer-assisted navigation in cervical pedicle screw installation. Orthop Surg 3(1):52–56. doi:10.1111/j.1757-7861.2010.00110.x

    Article  CAS  PubMed  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no competing interests. We have no personal or financial conflicts of interest related to the preparation and publication of this manuscript.

Author information

Authors and Affiliations

  1. Department of Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany

    J. Bredow, J. Oppermann & P. Eysel

  2. Department of Orthopedics, Medical Center City Aachen GmBH, Wuerselen, Germany

    R. Sobottke

  3. Department of Radiology, University Hospital of Cologne, Cologne, Germany

    B. Kraus

  4. Institute of Medical Statistics, Informatics and Epidemiology, University Hospital of Cologne, Cologne, Germany

    P. Schiller

  5. Department of Trauma, Orthopedic and Hand Surgery, Vinzenz-Pallotti Hospital, Bergisch Gladbach, Germany

    G. Schiffer

  6. Department of Spine Surgery, KLINIK am RING, Cologne, Germany

    T. Koy

Authors
  1. J. Bredow
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Oppermann
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. B. Kraus
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. P. Schiller
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. G. Schiffer
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. R. Sobottke
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. P. Eysel
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. T. Koy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. Bredow.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bredow, J., Oppermann, J., Kraus, B. et al. The accuracy of 3D fluoroscopy-navigated screw insertion in the upper and subaxial cervical spine. Eur Spine J 24, 2967–2976 (2015). https://doi.org/10.1007/s00586-015-3974-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-015-3974-2

Keywords

Search

Navigation