Skip to main content
SpringerLink
Log in

Acceptable errors with evaluation of 577 cervical pedicle screw placements

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

Abstract

Purpose

Cadaveric studies have discouraged the use of cervical pedicle screws (CPS) with high misplacement rates. However, the clinical results show minimal screw-related complications and have highlighted the advantages of using CPS. We introduce “acceptable errors classification” in the placement of cervical pedicle screws to bridge the gap between the high radiological perforation rates and low clinical complications.

Methods

Ninety-nine patients with average age of 49 years were operated between December 2011 and June 2017 using CPS. Sixty-one patients had trauma, 33 had CSM, 3 had tumors and 2 patients had fracture with ankylosing spondylitis. The screws were inserted using the medial cortical pedicle screw technique. Axial and sagittal CT reconstructed images along the axis of the inserted screws were evaluated for screw placements both in the medio-lateral and supero-inferior directions.

Results

A total of 577 pedicle screw placements (C3 to C7) were assessed in 99 patients using the conventional grading of screw perforations and acceptable errors classification in both medio-lateral and supero-inferior directions. There were 25.64% (148/577) screw perforations and 74.35% (429/577) screw placements within the pedicle using the conventional perforation grading system. The same set of screws, assessed using the “Acceptable errors classification”, showed 529 screws (91.68%) having acceptable placements and 48 screws (8.31%) having unacceptable placements.

Conclusion

The acceptable errors classification in placement of CPS seems to bridge the gap between the high radiological perforation rates and the low clinical complications. The present study reinforces studies reporting minimal clinical complications with high rates of screw misplacements.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

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

Similar content being viewed by others

References

  1. Anderson O, Davis R, Hanna GB, Vincent CA (2013) Surgical adverse events: a systematic review. Am J Surg 206(2):253–262. https://doi.org/10.1016/j.amjsurg.2012.11.009

    Article  PubMed  Google Scholar 

  2. Howell AM, Panesar SS, Burns EM, Donaldson LJ, Darzi A (2014) Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Ann Surg 259(4):630–641. https://doi.org/10.1097/SLA.0000000000000371

    Article  PubMed  Google Scholar 

  3. Jones EL, Heller JG, Silcox DH et al (1997) Cervical pedicle screws versus lateral mass screws: anatomic feasibility and biomechanical comparison. Spine 22:977–982

    Article  CAS  PubMed  Google Scholar 

  4. Karaikovic EE, Yingsakmongkol W, Gaines RW (2001) Accuracy of cervical pedicle screw placement using the funnel technique. Spine 26:2456–2462

    Article  CAS  PubMed  Google Scholar 

  5. Ludwig SC, Kramer DL, Balderston RA et al (2000) Placement of pedicle screws in the human cadaveric cervical spine. Comp Accuracy Three Techn Spine 25:1655–1667

    CAS  Google Scholar 

  6. Miller RM, Ebraheim NA, Xu R et al (1996) Anatomic consideration of transpedicular screw placement in the cervical spine: an analysis of two approaches. Spine 21:2317–2322

    Article  CAS  PubMed  Google Scholar 

  7. 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 (Phila Pa 1976) 25:962–969

    Article  CAS  Google Scholar 

  8. Yukawa Y, Kato F, Yoshihara H, Yanase M, Ito K (2006) Cervical pedicle screw fixation for 100 cases of unstable cervical injuries using pedicle axis views by fluoroscopy. J Neurosurg Spine 5(6):488–493

    Article  PubMed  Google Scholar 

  9. 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 

  10. Kotani Y, Cunningham BW, Abumi K, McAfee PC (1994) Biomechanical analysis of cervical stabilization systems: an assessment of transpedicular screw fixation in the cervical spine. Spine 19:2529–2539

    Article  CAS  PubMed  Google Scholar 

  11. Abumi K, Shono Y, Taneichi T et al (1999) Correction of cervical kyphosis using pedicle screw fixation systems. Spine 24:2389–2396

    Article  CAS  PubMed  Google Scholar 

  12. Mahesh B, Upendra B, Vijay S, Arun K, Srinivas R (2016) Addressing stretch myelopathy in multilevel cervical kyphosis with posterior surgery using cervical pedicle screws. Asian Spine J10(6):1–11. https://doi.org/10.4184/asj.2016.10.6.1

    Article  Google Scholar 

  13. Mahesh B, Upendra B, Vijay S, ArunG C, Srinivas R (2017) Perforations and Angulations of 324 cervical medial cortical pedicle screws: a possible guide to avoid lateral perforations with use of pedicle screws in lower cervical spine. Spine J 17(3):457–465. https://doi.org/10.1016/j.spinee.2016.11.011

    Article  PubMed  Google Scholar 

  14. Mahesh B, Upendra B, Mahan RS (2014) The medial cortical pedicle screw-a new technique for cervical pedicle screw placement with partial drilling of medial cortex. Spine J 14(2):371–380

    Article  PubMed  Google Scholar 

  15. 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. https://doi.org/10.3171/2011.11.SPINE11102

    Article  PubMed  Google Scholar 

  16. Karaikovic EE, Daubs MD, Madsen RW, Gaines RW Jr (1997) Morphologic characteristics of human cervical pedicles. Spine (Phila Pa 1976) 22(5):493–500

    Article  CAS  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  18. Abumi K, Ito H, Taneichi H, Kaneda K (1994) Transpedicular screw fixations for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report. J Spinal Disord 7:19–28

    Article  CAS  PubMed  Google Scholar 

  19. Uehara M, Takahashi J, Hirabayashi H, Hashidate H, Ogihara N, Mukaiyama K, Ikegami S, Kato H (2010) Perforation rates of cervical pedicle screw insertion by disease and vertebral level. Open Orthop J 4(4):142–146

    Article  PubMed  PubMed Central  Google Scholar 

  20. Park JH, Jeon SR, Roh SW, Kim JH, Rhim SC (2014) The safety and accuracy of freehand pedicle screw placement in the subaxial cervical spine: a series of 45 consecutive patients. Spine (Phila Pa 1976) 39(4):280–5. https://doi.org/10.1097/BRS.0000000000000133

    Article  Google Scholar 

  21. Huang D, Du K, Zeng S, Gao W, Huang L, Su P (2011) The security analysis of transpedicular screw fixation in the lower cervical spine and a case report. Spine 36(26):E1702–E1708

    Article  PubMed  Google Scholar 

  22. Daniels DL, Hyde JS, Kneeland J et al (1986) The cervical nerves and foramina: local-coil MRI imaging. Am J Neuroradiol 7:129–133

    CAS  PubMed  PubMed Central  Google Scholar 

  23. 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 (Phila Pa 1976) 30(24):2800–5

    Article  Google Scholar 

  24. Onishi E, Sekimoto Y, Fukumitsu R, Yamagata S, Matsushita M (2010) Cerebral infarction due to an embolism after cervical pedicle screw fixation. Spine (Phila Pa 1976) 35(2):E63–E66

    Article  Google Scholar 

  25. Uehara M, Takahashi J, Ikegami S, Mukaiyama K, Kuraishi S, Shimizu M, Futatsugi T, Ogihara N, Hashidate H, Hirabayashi H, Kato H (2014) Screw perforation features in 129 consecutive patients performed computer-guided cervical pedicle screw insertion. Eur Spine J 23(10):2189–2195

    Article  PubMed  Google Scholar 

  26. Hojo Y, Ito M, Suda K, Oda I, Yoshimoto H, Abumi K (2014) 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(10):2166–2174. https://doi.org/10.1007/s00586-014-3470-0

    Article  PubMed  Google Scholar 

  27. 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. https://doi.org/10.1007/s00402-013-1752-3

    Article  PubMed  Google Scholar 

  28. Bidre Upendra MS, Devkant Meena MS, Buddhadev Chowdhury MS, Abrar Ahmed MS, Arvind Jayaswal MS (2008) Outcome based classification for assessment of thoracic pedicular screw placement. Spine 33(4):384–390

    Article  PubMed  Google Scholar 

Download references

Funding

This study was not funded by any individual or organization.

Author information

Authors and Affiliations

  1. Vitus Spine Care And Research, Department of Spine Surgery, Bhagwan Mahaveer Jain Hospital, Vasanth Nagar, Bangalore, 560052, India

    Bijjawara Mahesh, Bidre Upendra & Rao Raghavendra

Authors
  1. Bijjawara Mahesh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bidre Upendra
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rao Raghavendra
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bidre Upendra.

Ethics declarations

Conflict of interest

The first two authors had grants from Medtronic, outside the scope of submitted work. The third author has nothing to disclose.

Ethical standards

There was no objection from the institutional ethical committee for the above study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (PPT 293 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mahesh, B., Upendra, B. & Raghavendra, R. Acceptable errors with evaluation of 577 cervical pedicle screw placements. Eur Spine J 29, 1043–1051 (2020). https://doi.org/10.1007/s00586-020-06359-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-020-06359-x

Keywords

Search

Navigation