European Spine Journal

, Volume 16, Issue 5, pp 613–617

Computer tomography assessment of pedicle screw insertion in percutaneous posterior transpedicular stabilization

  • Constantin Schizas
  • Jacky Michel
  • Victor Kosmopoulos
  • Nicolas Theumann
Original Article


Percutaneous insertion of cannulated pedicle screws has been recently developed as a minimally invasive alternative to the open technique during instrumented fusion procedures. Given the reported rate of screw misplacement using open techniques (up to 40%), we considered it important to analyze possible side effects of this new technique. Placement of 60 pedicle screws in 15 consecutive patients undergoing lumbar or lumbosacral fusion, mainly for spondylolisthesis, were analyzed. Axial, coronal, and sagittal reformatted computer tomography images were examined by three observers. Individual and consensus interpretation was obtained for each screw position. Along with frank penetration, we also looked at cortical encroachment of the pedicular wall by the screw. Thirteen percent of the patients (2/15) had severe frank penetration from the screws, while 80% of them (12/15) had some perforation. On axial images the incidence of severe frank pedicle penetration was 3.3% while the overall rate of screw perforation was 23%. In coronal images the overall screw perforation rate rose to 30% while the rate of severe frank pedicle penetration remained unchanged. One patient (6.6%) suffered S1 root symptoms due to a frankly medially misplaced screw, requiring re-operation. This study has shown that percutaneous insertion of cannulated pedicle screws in the lumbar spine is an acceptable procedure. The overall rate of perforation in axial images is below the higher rates reported in the literature but does remain important. Frank penetration of the pedicle was nevertheless low. It remains a demanding technique and has to be performed with extreme care to detail.


Lumbar spine Pedicle screws Minimally invasive surgery Radiological studies Complications 


  1. 1.
    Castro WH, Halm H, Jerosch J, Malms J, Steinbeck J, Blasius S (1996) Accuracy of pedicle screw placement in lumbar vertebrae. Spine 21:1320–1324PubMedCrossRefGoogle Scholar
  2. 2.
    Esses SI, Botsford DJ, Kostuik JP (1989) The role of external spinal skeletal fixation in the assessment of low-back disorders. Spine 14:594–601PubMedCrossRefGoogle Scholar
  3. 3.
    Farber GL, Place HM, Mazur RA, Jones DE, Damiano TR (1995) Accuracy of pedicle screw placement in lumbar fusions by plain radiographs and computed tomography. Spine 20:1494–1499PubMedCrossRefGoogle Scholar
  4. 4.
    Foley KT, Gupta SK (2002) Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg 97:7–12PubMedGoogle Scholar
  5. 5.
    Gertzbein SD, Robbins SE (1990) Accuracy of pedicular screw placement in vivo. Spine 15:11–14PubMedCrossRefGoogle Scholar
  6. 6.
    Holly LT, Foley KT (2003) Three-dimensional fluoroscopy-guided percutaneous thoracolumbar pedicle screw placement. Technical note. J Neurosurg 99:324–329PubMedGoogle Scholar
  7. 7.
    Khoo LT, Palmer S, Laich DT, Fessler RG (2002) Minimally invasive percutaneous posterior lumbar interbody fusion (see comment). Neurosurgery 51:S166–S171PubMedGoogle Scholar
  8. 8.
    Kim YJ, Lenke LG, Cheh G, Riew KD (2005) Evaluation of pedicle screw placement in the deformed spine using intraoperative plain radiographs: a comparison with computerized tomography. Spine 30:2084–2088PubMedCrossRefGoogle Scholar
  9. 9.
    Laine T, Lund T, Ylikoski M, Lohikoski J, Schlenzka D (2000) Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients (see comment). Eur Spine J 9:235–240PubMedCrossRefGoogle Scholar
  10. 10.
    Laine T, Makitalo K, Schlenzka D, Tallroth K, Poussa M, Alho A (1997) Accuracy of pedicle screw insertion: a prospective CT study in 30 low back patients. Eur Spine J 6:402–405PubMedCrossRefGoogle Scholar
  11. 11.
    Laine T, Schlenzka D, Makitalo K, Tallroth K, Nolte LP, Visarius H (1997) Improved accuracy of pedicle screw insertion with computer-assisted surgery A prospective clinical trial of 30 patients. Spine 22:1254–1258PubMedCrossRefGoogle Scholar
  12. 12.
    Learch TJ, Massie JB, Pathria MN, Ahlgren BA, Garfin SR (2004) Assessment of pedicle screw placement utilizing conventional radiography and computed tomography: a proposed systematic approach to improve accuracy of interpretation. Spine 29:767–773PubMedCrossRefGoogle Scholar
  13. 13.
    Magerl FP (1984) Stabilization of the lower thoracic and lumbar spine with external skeletal fixation. Clin Orthop Relat Res 189:125–141PubMedGoogle Scholar
  14. 14.
    Roy-Camille R, Saillant G, Mazel C (1986) Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res 203:7–17PubMedGoogle Scholar
  15. 15.
    Schulze CJ, Munzinger E, Weber U (1998) Clinical relevance of accuracy of pedicle screw placement. A computed tomographic-supported analysis. Spine 23:2215–2220PubMedCrossRefGoogle Scholar
  16. 16.
    Schwender JD, Holly LT, Rouben DP, Foley KT (2005) Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Techn 18(Suppl):S1–S6CrossRefGoogle Scholar
  17. 17.
    Wiesner L, Kothe R, Ruther W (1999) Anatomic evaluation of two different techniques for the percutaneous insertion of pedicle screws in the lumbar spine. Spine 24:1599–1603PubMedCrossRefGoogle Scholar
  18. 18.
    Wiesner L, Kothe R, Schulitz KP, Ruther W (2000) Clinical evaluation and computed tomography scan analysis of screw tracts after percutaneous insertion of pedicle screws in the lumbar spine. Spine 25:615–621PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Constantin Schizas
    • 1
  • Jacky Michel
    • 1
  • Victor Kosmopoulos
    • 1
  • Nicolas Theumann
    • 2
  1. 1.Hôpital Orthopédique de la Suisse Romande, OrthopaedicsLausanneSwitzerland
  2. 2.CHUV, RadiologyLausanneSwitzerland

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