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Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis

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Abstract

Introduction

Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion.

Method

A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2–4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0).

Results

25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48–120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries.

Conclusion

Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

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Authors and Affiliations

  1. Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada

    Rajendra Sakhrekar, Stephen Lewis, David Lebel & Mark Camp

  2. Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada

    Nicholas Shkumat & Birgit Ertl-Wagner

  3. Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada

    M. J. McVey

  4. Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada

    M. J. McVey

  5. Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada

    M. J. McVey

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  1. Rajendra Sakhrekar
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  4. Stephen Lewis
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  6. M. J. McVey
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  7. Mark Camp
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Contributions

All authors contributed to the study's conception and design. Material preparation, data collection and analysis were performed by [Rajendra Sakhrekar], [Mark Camp], [M.J.McVey], [David Lebel], [Nicholas Shkumat], [Birgit Ertl-Wagner]and [Stephen Lewis]. The first draft of the manuscript was written by [Rajendra Sakhrekar], and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Rajendra Sakhrekar, Nicholas Shkumat, Birgit Ertl-Wagner, David Lebel, Stephen Lewis, Mark Camp: made substantial contributions to the conception and design of the work; the acquisition, analysis, interpretation of data. M.J. McVey: made substantial contributions to the acquisition, analysis, and interpretation of data related to blood loss and % estimated blood loss.

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Correspondence to Rajendra Sakhrekar.

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Conflict of interest

Dr. Mark Camp is a consultant for OrthoPediatrics Inc. and 7D Surgical Inc. (SeaSpine)

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Approval was obtained from the ethics committee of The Hospital for Sick Children. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

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Sakhrekar, R., Shkumat, N., Ertl-Wagner, B. et al. Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis. Spine Deform 12, 739–746 (2024). https://doi.org/10.1007/s43390-024-00830-1

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