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At What Levels Are Freehand Pedicle Screws More Frequently Malpositioned in Children?

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Abstract

Study Design

Retrospective case series.

Background

Previous studies report that 5% to 17% of pedicle screws placed in children are malpositioned. Knowledge of the long-term effects of malpositioned screws is limited. We sought to further characterize risk factors for malpositioned pedicle screws in order to establish a more proactive role in limiting future complications.

Objective

We undertook this study to answer the following: 1) Is the rate of freehand pedicle screw malpositioning higher in children with spinal deformity, particularly at the apical concavity? 2) At what vertebral levels do freehand pedicle screws have the highest rates of malpositioning? 3) In which direction (medial or lateral) do freehand pedicle wall violations occur most often?

Methods

Incidental postoperative computed tomographic (CT) exams were retrospectively reviewed in 85 pediatric patients (605 screws) treated with posterior spinal fusion using freehand pedicle screw technique. Of the screws imaged, 355 were in patients without deformity and 250 in patients with deformity. Breaches were categorized as mild (<2 mm), moderate (2–4 mm), or severe (>4 mm).

Results

Screws in pediatric deformity patients were more frequently malpositioned by 2 mm or more than were screws in patients without deformity (26% vs. 19%, p =.02). In patients with deformity, no higher rate of screw malposition was detected at the apical region. Overall, the highest rates of severe screw malposition were between T3 and T8. Pedicle breaches were more commonly in a medial direction compared with lateral (74% vs. 26%, p <.0001). However, severe breaches within the T3–T8 region were more often directed lateral than medial (92% vs. 8%, p ≤.0001).

Conclusions

The clinical significance of asymptomatic pedicle screw breaches in children has not yet been determined. In this study, screws at the apical concavity were no more likely to be malpositioned than those at other sites. Efforts to reduce pedicle screw malposition would likely be most effective at the T3–T8 levels.

Level of Evidence

Level IV, Therapeutic Study. See the Guidelines for Authors for a complete description of the levels of evidence.

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References

  1. Manbachi A, Cobbold RS, Ginsberg HJ. Guided pedicle screw insertion: techniques and training. Spine J 2014;14:165–79.

    Article  Google Scholar 

  2. Rajasekaran S, Vidyadhara S, Ramesh P, Shetty AP. Randomized clinical study to compare the accuracy of navigated and nonnavigated thoracic pedicle screws in deformity correction surgeries. Spine (Phila Pa 1976) 2007;32:E3–64.

    Article  Google Scholar 

  3. Hicks JM, Singla A, Shen FH, Arlet V. Complications of pedicle screw fixation in scoliosis surgery: a systematic review. Spine (Phila Pa 1976) 2010;35:E3–70.

    Article  Google Scholar 

  4. Baghdadi YM, Larson AN, McIntosh AL, et al. Complications of pedicle screws in children 10 years or younger: a case control study. Spine (Phila Pa 1976) 2013;38:E3–93.

    Article  Google Scholar 

  5. Larson AN, Polly Jr DW, Guidera KJ, et al. The accuracy of navigation and 3D image-guided placement for the placement of pedicle screws in congenital spine deformity. J Pediatr Orthop 2012;32:e23–9.

    Article  Google Scholar 

  6. Polly Jr DW, Potter BK, Kuklo T, et al. Volumetric spinal canal intrusion: a comparison between thoracic pedicle screws and thoracic hooks. Spine (Phila Pa 1976) 2004;29:63–9.

    Article  Google Scholar 

  7. Suk SI, Lee CK, Kim WJ, et al. Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine (Phila Pa 1976) 1995;20:1399–405.

    Article  CAS  Google Scholar 

  8. Ledonio CG, Polly Jr DW, Vitale MG, et al. Pediatric pedicle screws: comparative effectiveness and safety: a systematic literature review from the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America task force. J Bone Joint Surg Am 2011;93:1227–34.

    Article  Google Scholar 

  9. Kuklo TR, Potter BK, Lenke LG, et al. Surgical revision rates of hooks versus hybrid versus screws versus combined anteroposterior spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2007;32:2258–64.

    Article  Google Scholar 

  10. Kim YJ, Lenke LG, Bridwell KH, et al. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine (Phila Pa 1976) 2004;29:333–42; discussion 42.

    Article  Google Scholar 

  11. Ayvaz M, Alanay A, Yazici M, et al. Safety and efficacy of posterior instrumentation for patients with congenital scoliosis and spinal dysraphism. J Pediatr Orthop 2007;27:380–6.

    Article  Google Scholar 

  12. Dede O, Ward WT, Bosch PP, et al. Using the free hand pedicle screw placement technique in adolescent idiopathic scoliosis surgery: what is the incidence of neurologic symptoms secondary to misplaced screws? Spine (Phila Pa 1976) 2014;39:286–90.

    Article  Google Scholar 

  13. Shin BJ, James AR, Njoku IU, Hartl R. Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. J Neurosurg Spine 2012;17:113–22.

    Article  Google Scholar 

  14. Hartl R, Lam KS, Wang J, et al. Worldwide survey on the use of navigation in spine surgery. World Neurosurg 2013;79:162–72.

    Article  Google Scholar 

  15. Ovadia D, Korn A, Fishkin M, et al. The contribution of an electronic conductivity device to the safety of pedicle screw insertion in scoliosis surgery. Spine 2011;36:E3–21.

    Article  Google Scholar 

  16. Papadopoulos EC, Girardi FP, Sama A, et al. Accuracy of singletime, multilevel registration in image-guided spinal surgery. Spine J 2005;5:263–7; discussion 8.

    Article  Google Scholar 

  17. Ul Haque M, Shufflebarger HL, O’Brien M, Macagno A. Radiation exposure during pedicle screw placement in adolescent idiopathic scoliosis: is fluoroscopy safe? Spine (Phila Pa 1976) 2006;31:2516–20.

    Article  Google Scholar 

  18. Abul-Kasim K, Ohlin A, Strombeck A, et al. Radiological and clinical outcome of screw placement in adolescent idiopathic scoliosis: evaluation with low-dose computed tomography. Eur Spine J 2010;19:96–104.

    Article  Google Scholar 

  19. Lehman Jr RA, Lenke LG, Keeler KA, et al. Computed tomography evaluation of pedicle screws placed in the pediatric deformed spine over an 8-year period. Spine 2007;32:2679–84.

    Article  Google Scholar 

  20. Ughwanogho E, Patel NM, Baldwin KD, et al. Computed tomography-guided navigation of thoracic pedicle screws for adolescent idiopathic scoliosis results in more accurate placement and less screw removal. Spine (Phila Pa 1976) 2012;37:E3–8.

    Article  Google Scholar 

  21. Larson AN, Santos ER, Polly Jr DW, et al. Pediatric pedicle screw placement using intraoperative CT and 3D image-guided navigation. Spine (Phila Pa 1976) 2012;37:e188–94.

    Article  Google Scholar 

  22. Ughwanogho E, Patel NM, Baldwin KD, et al. Computed tomography-guided navigation of thoracic pedicle screws for adolescent idiopathic scoliosis results in more accurate placement and less screw removal. Spine 2012;37:E3–8.

    Article  Google Scholar 

  23. Harimaya K, Lenke LG, Son-Hing JP, et al. Safety and accuracy of pedicle screws and constructs placed in infantile and juvenile patients. Spine 2011;36:1645–51.

    Article  Google Scholar 

  24. Mueller TL, Miller NH, Baulesh DM, et al. The safety of spinal pedicle screws in children ages 1 to 12. Spine J 2013;13:894–901.

    Article  Google Scholar 

  25. Zindrick MR, Knight GW, Sartori MJ, et al. Pedicle morphology of the immature thoracolumbar spine. Spine (Phila Pa 1976) 2000;25:2726–35.

    Article  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Mayo Medical School, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA

    Mark Heidenreich BS

  2. Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA

    Yaser M. K. Baghdadi MD, Amy L. McIntosh MD, William J. Shaughnessy MD, Anthony Stans MD & A. Noelle Larson MD

  3. The CORE Institute, 18444 North 25th Avenue Suite 320, Phoenix, AZ, 85023, USA

    Mark B. Dekutoski MD

Authors
  1. Mark Heidenreich BS
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  2. Yaser M. K. Baghdadi MD
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  3. Amy L. McIntosh MD
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  4. William J. Shaughnessy MD
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  5. Mark B. Dekutoski MD
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  6. Anthony Stans MD
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  7. A. Noelle Larson MD
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Corresponding author

Correspondence to A. Noelle Larson MD.

Additional information

Ethical Review Committee Statement: Institutional review board approval was obtained for all aspects of this study.

No external funding was used to conduct this study.

Author disclosures: MH (none); YMKB (none); ALM (none); WJS (none); MBD (none); AS (none); ANL (none).

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Heidenreich, M., Baghdadi, Y.M.K., McIntosh, A.L. et al. At What Levels Are Freehand Pedicle Screws More Frequently Malpositioned in Children?. Spine Deform 3, 332–337 (2015). https://doi.org/10.1016/j.jspd.2014.12.003

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  • DOI: https://doi.org/10.1016/j.jspd.2014.12.003

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