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Accurate placement of cervical pedicle screws using 3D-printed navigational templates

An improved technique with continuous image registration

Genaue Platzierung zervikaler Pedikelschrauben mittels Navigationsschablone aus dem 3‑D-Drucker

Verbessertes Verfahren mit kontinuierlicher Bildregistrierung

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Abstract

Objective

Accurate placement of cervical pedicle screws remains a surgical challenge. This study aimed to test the feasibility of using a novel three-dimensional (3D-)printed navigational template to overcome this challenge.

Methods

Cervical spines were scanned using computed tomography (CT). A 3D model of the cervical spines was created. The screw trajectory was designed to pass through the central axis of the pedicle. Thereafter, a navigational template was designed by removing the soft tissue from the bony surface in the 3D model. A 3D printer was used to print the navigational template. The screws were then placed in the cadavers following CT scanning. The 3D model of the designed trajectory and the placed screws were registered. The coordinates of the entry and exit points of the designed trajectory and the actual trajectory were recorded. The numbers of qualified points that met the different degrees of accuracy were compared using a χ2 test.

Results

A total of 158 screws were placed. Five screws breached the pedicle cortex with a distance <2 mm. There was no significant difference between the pre- and postoperative entry points with a degree of accuracy ≥1.7 mm (P = 0.131). Meanwhile, there was no significant difference between the pre- and postoperative exit points with degrees of accuracy ≥6.4 mm (P = 0.071).

Conclusion

A navigational template can be designed by removing the soft tissue from the bony surface in a CT-generated 3D model. This guiding tool may effectively prevent intraoperative drifting and accurately places cervical pedicle screws.

Zusammenfassung

Ziel der Arbeit

Die genaue Platzierung zervikaler Pedikelschrauben bleibt eine chirurgische Herausforderung. Die vorliegende Studie hatte zum Ziel, die Eignung einer neuartigen Navigationsschablone zu testen, die mit dem dreidimensionalen (3-D-)Drucker hergestellt wurde, um dieses Problem zu lösen.

Methoden

Es wurden Aufnahmen der Halswirbelsäule (HWS) mittels Computertomographie (CT) angefertig. Dann wurde ein 3‑D-Modell der HWS erzeugt. Der Weg der Schraube wurde so geplant, dass er durch die Zentralachse des Pedikels verlaufen sollte. Danach wurde eine Navigationsschablone hergestellt, indem die Weichteile von der knöchernen Oberfläche im 3‑D-Modell entfernt wurden. Ein 3‑D-Drucker wurde zur Herstellung der Navigationsschablone verwendet. Nach Erstellung der CT-Aufnahmen wurden die Schrauben dann in die Leichenpräparate gesetzt. Das 3‑D-Modell des geplanten Verlaufs und die Platzierung der Schrauben wurden dokumentiert. Die Koordinaten der Ein- und Austrittspunkte des geplanten Verlaufs und der tatsächliche Verlauf wurden aufgezeichnet. Unter Verwendung eines χ2-Tests wurde die Anzahl qualifizierter Punkte verglichen, die den verschiedenen Graden an Genauigkeit entsprachen.

Ergebnisse

Insgesamt wurden 158 Schrauben platziert. Fünf Schrauben perforierten die Pedikelkortikalis um <2 mm. Es bestand kein signifikanter Unterschied zwischen prä- und postoperativen Eintrittspunkten bei einem Grad der Genauigkeit ≥1,7 mm (p = 0,131). Auch lag kein signifikanter Unterschied zwischen den prä- und postoperativen Austrittspunkten bei einem Grad der Genauigkeit ≥6,4 mm (p = 0,071) vor.

Schlussfolgerung

Eine Navigationsschablone kann durch Entfernung der Weichteile von der knöchernen Oberfläche in einem CT-basierten 3‑D-Modell hergestellt werden. Diese Leitschiene ermöglicht, dass eine intraoperative Verschiebung wirksam verhindert wird und die zervikalen Pedikelschrauben genau gesetzt werden.

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Abbreviations

3D:

Three-dimensional

CT:

Computed tomography

DICOM:

Digital Imaging and Communications in Medicine

HU:

Hounsfield unit

K-wire:

Kirschner wire

STL:

Stereolithography

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Funding

This study was supported by grants from the Fujian Provincial Nature Science Foundation (2016J01607, 2015J01507), the Fujian Province Health and Family Planning Commission (2012-CX-34, 2015-2-32) and the Educational Department of Fujian Province (JA14274).

Author contributions

G. Zhang, Z. Yu, X. Chen and H. Lin designed the study. Z. Yu and X. Chen collected and analysed the data. Z. Yu, X. Chen, C. Wu and Y. Lin contributed sample collection and intellectual input. G. Zhang and Z. Yu drafted and wrote the manuscript. H. Lin critically revised the manuscript for intellectual content. All authors gave intellectual input to the study and approved the final version of the manuscript.

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Authors and Affiliations

  1. Department of Orthopedics, Affiliated Hospital of Putian University Teaching Hospital of Fujian Medical University, Affiliated Putian Hospital of Southern Medical University, Affiliated Hospital of Putian University, 351100, Putian, Fujian, China

    Guodong Zhang, Zhengxi Yu, Xuanhuang Chen, Xu Chen, Changfu Wu, Yijun Lin & Haibin Lin

  2. Department of Human Anatomy, Southern Medical University School of Basic Medical Sciences, 510515, Guangzhou, China

    Guodong Zhang & Wenhua Huang

Authors
  1. Guodong Zhang
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  2. Zhengxi Yu
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  3. Xuanhuang Chen
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  4. Xu Chen
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  5. Changfu Wu
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  6. Yijun Lin
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  7. Wenhua Huang
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  8. Haibin Lin
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Corresponding authors

Correspondence to Wenhua Huang or Haibin Lin.

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Conflict of interest

G. Zhang, Z. Yu, X. Chen, X. Chen, C. Wu, Y. Lin, W. Huang and H. Lin declare that they have no competing interests.

This study was approved by the Ethics Committee of Putian College Affiliated Hospital. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

G. Zhang, Z. Yu and X. Chen contributed equally to this work.

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Zhang, G., Yu, Z., Chen, X. et al. Accurate placement of cervical pedicle screws using 3D-printed navigational templates. Orthopäde 47, 428–436 (2018). https://doi.org/10.1007/s00132-017-3515-2

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