Lumbar and sacral pedicle screw placement using a template does not improve the midterm pain and disability outcome in comparison with free-hand method

  • Matjaz MercEmail author
  • Gregor Recnik
  • Zmago Krajnc



The free-hand technique carries a higher risk of pedicle weakening and neurovascular injuries in comparison with pedicle screw placement using a drill guide. Due to this evidence and because of some variances in the surgical method, different outcome can be expected. The objective of the study was to evaluate the disability, the back and leg pain before and at least 3 years after the surgery between examined groups.

Materials and methods

Eleven patients in drill guide and 13 in control group were randomly assigned for vertebral fusion in the lumbar and first sacral regions. Pre- and post-operative CT scans, Oswestry disability index (ODI) and visual analogue scale (VAS) for back and leg pain were taken. Post-operative evaluations of cortex perforation and statistical analysis between studied groups have been performed.


Seventy-two screws were inserted in each group. All patients completed a 3-year follow-up. Comparing groups, there was no statistical significant difference in VAS and ODI before or after surgery. Cortex perforation incidence in drill guide group was 6 and in free-hand group 29 (p < 0.05). In each group, pain and disability were significantly lower as before the procedure.


The application of a drill guide template for pedicle screw placement is not more effective in reducing pain and disability after midterm follow-up in comparison with the free-hand technique. However, it reduces the cortex perforation incidence. Concerning this evidence, a drill guide is still an additional tool that could in the future potentially compete with other screw placement techniques.


Follow-up Perforation ODI VAS Drill guide 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

Experiments comply with the current law of the country in which they were performed.


  1. 1.
    Mattei TA, Meneses MS, Milano JB, Ramina R (2009) Free-hand” technique for thoracolumbar pedicle screw instrumentation: critical appraisal of current “state-of-art. Neurol India 57(6):715–721CrossRefPubMedGoogle Scholar
  2. 2.
    Karapinar L, Erel N, Ozturk H, Altay T, Kaya A (2008) Pedicle screw placement with a free hand technique in thoracolumbar spine: is it safe? J Spinal Disord Tech 21(1):63–67CrossRefPubMedGoogle Scholar
  3. 3.
    Richards PJ, Kurta IC, Jasani V, Jones CH, Rahmatalla A, Mackenzie G et al (2007) Assessment of CAOS as a training model in spinal surgery: a randomised study. Eur Spine J 16:239–244CrossRefPubMedGoogle Scholar
  4. 4.
    Hughes SP, Anderson FM (1999) Infection in the operating room. J Bone Jt Surg Br 81(5):754–755CrossRefGoogle Scholar
  5. 5.
    Birnbaum K, Schkommodau E, Decker N, Prescher A, Klapper U, Radermacher K (2001) Computer-assisted orthopedic surgery with individual templates and comparison to conventional operation method. Spine 26(4):365–370CrossRefPubMedGoogle Scholar
  6. 6.
    Radermacher K, Portheine F, Anton M, Zimolong A, Kaspers G, Rau G et al (1998) Computer assisted orthopaedic surgery with image based individual templates. Clin Orthop 354:28–38CrossRefGoogle Scholar
  7. 7.
    Van Brussel K, Vander S, Van Audekercke R, Swaelens B, Van den Berghe L, Fabry G (1998) A medical image based template for pedicle screw insertion. Comput Method Biomech Biomed 2:347–354Google Scholar
  8. 8.
    Berry E, Cuppone M, Porada S, Millner PA, Rao A, Chiverton N et al (2005) Personalised image-based templates for intra-operative guidance. Proc Inst Mech Eng [H] 219(2):111–118CrossRefGoogle Scholar
  9. 9.
    Goffin J, Van Brussel K, Martens K, Vander Sloten J, Van Audekercke R, Smet MH (2001) Three-dimensional computed tomography-based, personalized drill guide for posterior cervical stabilization at C1–C2. Spine 26(12):1343–1347CrossRefPubMedGoogle Scholar
  10. 10.
    Owen BD, Christensen GE, Reinhardt JM, Ryken TC (2007) Rapid prototype patient-specific drill template for cervical pedicle screw placement. Comput Aided Surg Off J Int Soc Comput Aided Surg 12(5):303–308CrossRefGoogle Scholar
  11. 11.
    Lu S, Xu YQ, Zhang YZ, Li YB, Xie L, Shi JH et al (2009) A novel computer-assisted drill guide template for lumbar pedicle screw placement: a cadaveric and clinical study. Int J Med Robot Comput Assist Surg MRCAS 5(2):184–191CrossRefGoogle Scholar
  12. 12.
    Lu S, Xu Y-Q, Zhang Y-Z, Li Y-B, Shi J-H, Chen G-P et al (2009) Rapid prototyping drill guide template for lumbar pedicle screw placement. Chin J Traumatol Zhonghua Chuang Shang Za Zhi Chin Med Assoc 12(3):177–180Google Scholar
  13. 13.
    Ma T, Xu Y-Q, Cheng Y-B, Jiang M-Y, Xu X-M, Xie L et al (2012) A novel computer-assisted drill guide template for thoracic pedicle screw placement: a cadaveric study. Arch Orthop Trauma Surg 132(1):65–72CrossRefPubMedGoogle Scholar
  14. 14.
    Hu Y, Yuan Z, Spiker WR, Albert TJ, Dong W, Xie H et al (2013) Deviation analysis of C2 translaminar screw placement assisted by a novel rapid prototyping drill template: a cadaveric study. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 22(12):2770–2776CrossRefGoogle Scholar
  15. 15.
    Ferrari V, Parchi P, Condino S, Carbone M, Baluganti A, Ferrari M et al (2013) An optimal design for patient-specific templates for pedicle spine screws placement. Int J Med Robot Comput Assist Surg MRCAS 9(3):298–304CrossRefGoogle Scholar
  16. 16.
    Wu Z-X, Huang L-Y, Sang H-X, Ma Z-S, Wan S-Y, Cui G et al (2011) Accuracy and safety assessment of pedicle screw placement using the rapid prototyping technique in severe congenital scoliosis. J Spinal Disord Tech 24(7):444–450CrossRefPubMedGoogle Scholar
  17. 17.
    Kaneyama S, Sugawara T, Sumi M (2015) Safe and accurate midcervical pedicle screw insertion procedure with the patient-specific screw guide template system. Spine 40(6):E341–E348CrossRefPubMedGoogle Scholar
  18. 18.
    Merc M, Drstvensek I, Vogrin M, Brajlih T, Recnik G (2013) A multi-level rapid prototyping drill guide template reduces the perforation risk of pedicle screw placement in the lumbar and sacral spine. Arch Orthop Trauma Surg 133(7):893–899CrossRefPubMedGoogle Scholar
  19. 19.
    Putzier M, Strube P, Cecchinato R, Lamartina C, Hoff E (2016) A new navigational tool for pedicle screw placement in patients with severe scoliosis: a pilot study to prove feasibility, accuracy, and identify operative challenges. Clin Spine Surg. doi: 10.1097/BSD.0000000000000220 Google Scholar
  20. 20.
    Hu Y, Yuan Z-S, Kepler CK, Albert TJ, Xie H, Yuan J-B et al (2014) Deviation analysis of atlantoaxial pedicle screws assisted by a drill template. Orthopedics 37(5):e420–e427CrossRefPubMedGoogle Scholar
  21. 21.
    Sugawara T, Higashiyama N, Kaneyama S, Takabatake M, Watanabe N, Uchida F, Sumi M, Mizoi K (2013) Multistep pedicle screw insertion procedure with patient-specific lamina fit-and-lock templates for the thoracic spine: clinical article. J Neurosurg Spine 19(2):85–90CrossRefGoogle Scholar
  22. 22.
    Inoue G, Miyagi M, Takaso M (2016) Surgical and nonsurgical treatments for lumbar spinal stenosis. Eur J Orthop Surg Traumatol 26(7):695–704CrossRefPubMedGoogle Scholar
  23. 23.
    Drstvensek I, Hren NI, Strojnik T, Brajlih T, Valentan B, Pogacar V et al (2008) Applications of rapid prototyping in cranio-maxilofacial surgery procedures. Int J Biol Biomed Eng 1:29–38Google Scholar
  24. 24.
    Fairbank JC, Couper J, Davies JB, O’Brien JP (1980) The Oswestry low back pain disability questionnaire. Physiotherapy 66(8):271–273PubMedGoogle Scholar
  25. 25.
    Huskisson EC (1974) Measurement of pain. Lancet Lond Engl 2(7889):1127–1131CrossRefGoogle Scholar
  26. 26.
    Waschke A, Walter J, Duenisch P, Reichart R, Kalff R, Ewald C (2013) CT-navigation versus fluoroscopy-guided placement of pedicle screws at the thoracolumbar spine: single center experience of 4,500 screws. Eur Spine J 22(3):654–660CrossRefPubMedGoogle Scholar
  27. 27.
    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):247–255CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France 2017

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryUKC MariborMariborSlovenia

Personalised recommendations