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Intraoperative CT Scan Verification of Pedicle Screw Placement in AIS to Prevent Malpositioned Screws: Safety Benefit and Cost

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Abstract

Study Design

Prospective database review.

Objectives

Determine if use of intraoperative 3D imaging of pedicle screw position provides clinical and cost benefit.

Summary of Background

Injury or reoperation from malpositioned pedicle screws in adolescent idiopathic scoliosis (AIS) surgery occurs but is increasingly considered to be a never-event. To avoid complications, intraoperative 3D imaging of screw position may be obtained.

Methods

A prospective, consecutive AIS database at a high-volume pediatric spine center was examined three years before and after implementation of an intraoperative low-dose computed tomographic (CT) scan protocol. All screws were placed via freehand technique and corrected if found to be outside optimal trajectory on the postplacement CT scan. Demographic and outcome data were compared between cohorts, along with number, location, and reason for screw change. Cost analysis was based on the average cost of revision surgery for screw malposition versus intraoperative CT use.

Results

There were 153 patients in the pre-CT and 153 in the post-CT cohorts with a minimum 2-year follow-up. Two reoperations were needed for revision of improper screw placement in the pre-CT group and none in the post-CT group. Number of patients needed to harm was 76 (absolute risk increase = 1.31% [–0.49%, 3.11%]). Of those who had intraoperative CT scans, 80 (52.3%) needed on average 1.75 screw trajectories/lengths changed. Forty-three percent were medial breaches; of these, 39% were in the concavity. There were no differences between patients who did and did not need screw repositioning with regard to body mass index (BMI), age, curve size, surgeon/trainee side, screw density, or preoperative and one-year postoperative Scoliosis Research Society–22 patient questionnaire (SRS-22) scores. The average cost of reoperation for malposition was $4,900, whereas the cost of a single intraoperative CT was $232.

Conclusion

Intraoperative CT is an effective tool to prevent reoperation in AIS surgery for incorrect screw placement. Despite high volume, experience, and specialty training, incorrect trajectories occur and systems should be in place for preventable error.

Level of Evidence

Level II.

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Author information

Authors and Affiliations

  1. Seattle Children’s Hospital, 4800 Sand Point Way NE, 98105, Seattle, WA, USA

    Jennifer M. Bauer MD, MS

  2. Seton Hall University, 400 S Orange Ave, 07079, South Orange, NJ, USA

    Jeffrey A. Moore MD

  3. Nemours/AI duPont Hospital for Children, 1600 Rockland Rd, 19803, Wilmington, DE, USA

    Rajiv Rangarajan BSISE, Brian S. Gibbs BA, Petya K. Yorgova MS, Geraldine I. Neiss PhD, Kenneth Rogers PhD, Peter G. Gabos MD & Suken A. Shah MD

Authors
  1. Jennifer M. Bauer MD, MS
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  2. Jeffrey A. Moore MD
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  3. Rajiv Rangarajan BSISE
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  5. Petya K. Yorgova MS
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  6. Geraldine I. Neiss PhD
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  9. Suken A. Shah MD
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Corresponding author

Correspondence to Jennifer M. Bauer MD, MS.

Additional information

Author disclosures: JMB (none), JAM (none), RR (none), BSG (none), PKY (none), GIN (none), KR (none), PGG (personal fees from DePuy, A Johnson & Johnson company, outside the submitted work), SAS (grants from Setting Scoliosis Straight Foundation; personal fees and nonfinancial support from DePuy Synthes Spine, Inc.; personal fees from NuVasive, Inc., outside the submitted work).

Funding: none.

Institutional review board approval was obtained from the Nemours IRB.

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Bauer, J.M., Moore, J.A., Rangarajan, R. et al. Intraoperative CT Scan Verification of Pedicle Screw Placement in AIS to Prevent Malpositioned Screws: Safety Benefit and Cost. Spine Deform 6, 662–668 (2018). https://doi.org/10.1016/j.jspd.2018.04.010

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  • DOI: https://doi.org/10.1016/j.jspd.2018.04.010

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