Skip to main content

Advertisement

SpringerLink
Log in

Are computer numerical control (CNC)-manufactured patient-specific metal templates available for posterior thoracic pedicle screw insertion? Feasibility and accuracy evaluation

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

Abstract

Purpose

Accurate and safe posterior thoracic pedicle insertion (PTPI) remains a challenge. Patient-specific drill templates (PDTs) created by rapid prototyping (RP) can assist in posterior thoracic pedicle insertion, but pose biocompatibility risks. The aims of this study were to develop alternative PDTs with computer numerical control (CNC) and assess their feasibility and accuracy in assisting PTPI.

Methods

Preoperative CT images of 31 cadaveric thoracic vertebras were obtained and then the optimal pedicle screw trajectories were planned. The PDTs with optimal screw trajectories were randomly assigned to be designed and manufactured by CNC or RP in each vertebra. With the guide of the CNC- or RP-manufactured PDTs, the appropriate screws were inserted into the pedicles. Postoperative CT scans were performed to analyze any deviations at entry point and midpoint of the pedicles.

Results

The CNC group was found to be significant manufacture-time-shortening, and cost-decreasing, when compared with the RP group (P < 0.01). The PDTs fitted the vertebral laminates well while all screws were being inserted into the pedicles. There were no significant differences in absolute deviations at entry point and midpoint of the pedicle on either axial or sagittal planes (P > 0.05). The screw positions were grade 0 in 90.3% and grade 1 in 9.7% of the cases in the CNC group and grade 0 in 93.5% and grade 1 in 6.5% of the cases in the RP group (P = 0.641).

Conclusion

CNC-manufactured PDTs are viable for assisting in PTPI with good feasibility and accuracy.

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
Fig. 6

Similar content being viewed by others

References

  1. Hicks JM, Singla A, Shen FH, Arlet V (2010) Complications of pedicle screw fixation in scoliosis surgery: a systematic review. Spine (Phila Pa 1976) 35:E465–E470. doi:10.1097/BRS.0b013e3181d1021a

    Article  Google Scholar 

  2. Di Silvestre M, Parisini P, Lolli F, Bakaloudis G (2007) Complications of thoracic pedicle screws in scoliosis treatment. Spine 32:1655–1661. doi:10.1097/BRS.0b013e318074d604

    Article  PubMed  Google Scholar 

  3. Hwang SW, Safain MG, King JJ, Kimball JS, Ames R, Betz RR, Cahill PJ, Samdani AF (2015) Management of spinal cord injury-related scoliosis using pedicle screw-only constructs. J Neurosurg Spine 22:185–191. doi:10.3171/2014.10.SPINE14185

    Article  PubMed  Google Scholar 

  4. Deng Y, Zhou Y, Lu G, Wang B, Li J, Kang Y, Lu C, Liu W, Ma Z (2009) Complication of thoracic pedicle screw fixation in spinal deformities. Zhong Nan Da Xue Xue Bao Yi Xue Ban 34:820–824

    PubMed  Google Scholar 

  5. Mattei T, Meneses M, Milano J, Ramina R (2009) Free-hand “technique for thoracolumbar pedicle screw instrumentation: critical appraisal of current” state-of-art. Neurol India 57:715. doi:10.4103/0028-3886.59465

    Article  PubMed  Google Scholar 

  6. Lekovic GP, Potts EA, Karahalios DG, Hall G (2007) A comparison of two techniques in image-guided thoracic pedicle screw placement: a retrospective study of 37 patients and 277 pedicle screws. J Neurosurg Spine 7:393–398. doi:10.3171/SPI-07/10/3933

    Article  PubMed  Google Scholar 

  7. Hyun SJ, Kim YJ, Cheh G, Yoon SH, Rhim SC (2012) Free hand pedicle screw placement in the thoracic spine without any radiographic guidance: technical note, a cadaveric study. J Korean Neurosurg Soc 51:66–70. doi:10.3340/jkns.2012.51.1.66

    Article  PubMed  PubMed Central  Google Scholar 

  8. Gang C, Haibo L, Fancai L, Weishan C, Qixin C (2012) Learning curve of thoracic pedicle screw placement using the free-hand technique in scoliosis: how many screws needed for an apprentice? Eur Spine J 21:1151–1156. doi:10.1007/s00586-011-2065-2

    Article  PubMed  Google Scholar 

  9. Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD (2004) Free hand pedicle screw placement in the thoracic spine: is it safe? Spine (Phila Pa 1976) 29:333–342

    Article  Google Scholar 

  10. Li J, Zhao H, Xie H, Yu L, Wei J, Zong M, Chen F, Zhu Z, Zhang N, Cao X (2014) A new free-hand pedicle screw placement technique with reference to the supraspinal ligament. J Biomed Res 28:64–70. doi:10.7555/JBR.27.20130051

    CAS  PubMed  Google Scholar 

  11. Braga BP, de Morais JV, Vilela MD (2010) Free-hand placement of high thoracic pedicle screws with the aid of fluoroscopy: evaluation of positioning by CT scans in a four-year consecutive series. Arq Neuropsiquiatr 68:390–395

    Article  PubMed  Google Scholar 

  12. Lee CH, Hyun SJ, Kim YJ, Kim KJ, Jahng TA, Kim HJ (2014) Accuracy of free hand pedicle screw installation in the thoracic and lumbar spine by a young surgeon: an analysis of the first consecutive 306 screws using computed tomography. Asian Spine J 8:237–243. doi:10.4184/asj.2014.8.3.237

    Article  PubMed  PubMed Central  Google Scholar 

  13. Austin MS, Vaccaro AR, Brislin B, Nachwalter R, Hilibrand AS, Albert TJ (2002) Image-guided spine surgery: a cadaver study comparing conventional open laminoforaminotomy and two image-guided techniques for pedicle screw placement in posterolateral fusion and nonfusion models. Spine (Phila Pa 1976) 27:2503–2508. doi:10.1097/01.BRS.0000031274.34509.1E

    Article  Google Scholar 

  14. Lee CY, Wu MH, Li YY, Cheng CC, Hsu CH, Huang TJ, Hsu RW (2015) Intraoperative computed tomography navigation for transpedicular screw fixation to treat unstable thoracic and lumbar spine fractures: clinical analysis of a case series (CARE-compliant). Medicine (Baltimore) 94:e757. doi:10.1097/MD.0000000000000757

    Article  Google Scholar 

  15. Rahmathulla G, Nottmeier EW, Pirris SM, Deen HG, Pichelmann MA (2014) Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance. Neurosurg Focus 36:E3. doi:10.3171/2014.1.FOCUS13516

    Article  PubMed  Google Scholar 

  16. Larson AN, Santos ER, Polly DJ, Ledonio CG, Sembrano JN, Mielke CH, Guidera KJ (2012) Pediatric pedicle screw placement using intraoperative computed tomography and 3-dimensional image-guided navigation. Spine (Phila Pa 1976) 37:E188–E194. doi:10.1097/BRS.0b013e31822a2e0a

    Article  Google Scholar 

  17. Rampersaud YR, Foley KT, Shen AC, Williams S, Solomito M (2000) Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976) 25:2637–2645

    Article  CAS  Google Scholar 

  18. Nyheim T, Staxrud LE, Jorgensen JJ, Jensen K, Olerud HM, Sandbaek G (2017) Radiation exposure in patients treated with endovascular aneurysm repair: what is the risk of cancer, and can we justify treating younger patients? Acta Radiol 58:323–330. doi:10.1177/0284185116651002

    Article  PubMed  Google Scholar 

  19. Mulconrey DS (2016) Fluoroscopic radiation exposure in spinal surgery. in vivo evaluation for operating room personnel. Clin Spine Surg 29:E331–E335. doi:10.1097/BSD.0b013e31828673c1

    PubMed  Google Scholar 

  20. Allam Y, Silbermann J, Riese F, Greiner-Perth R (2013) Computer tomography assessment of pedicle screw placement in thoracic spine: comparison between free hand and a generic 3D-based navigation techniques. Eur Spine J 22:648–653. doi:10.1007/s00586-012-2505-7

    Article  PubMed  Google Scholar 

  21. John PS, James C, Antony J, Tessamma T, Ananda R, Dinesh K (2007) A novel computer-assisted technique for pedicle screw insertion. Int J Med Robot 3:59–63. doi:10.1002/rcs.117

    Article  CAS  PubMed  Google Scholar 

  22. Lu S, Xu YQ, Chen GP, Zhang YZ, Lu D, Chen YB, Shi JH, Xu XM (2011) Efficacy and accuracy of a novel rapid prototyping drill template for cervical pedicle screw placement. Comput Aided Surg 16:240–248. doi:10.3109/10929088.2011.605173

    Article  PubMed  Google Scholar 

  23. Fu M, Lin L, Kong X, Zhao W, Tang L, Li J, Ouyang J (2013) Construction and accuracy assessment of patient-specific biocompatible drill template for cervical anterior transpedicular screw (ATPS) insertion: an in vitro study. PLoS One 8:e53580. doi:10.1371/journal.pone.0053580

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Ryken TC, Owen BD, Christensen GE, Reinhardt JM (2009) Image-based drill templates for cervical pedicle screw placement. J Neurosurg Spine 10:21–26. doi:10.3171/2008.9.SPI08229

    Article  PubMed  Google Scholar 

  25. Farshad M, Betz M, Farshad-Amacker NA, Moser M (2017) Accuracy of patient-specific template-guided vs. free-hand fluoroscopically controlled pedicle screw placement in the thoracic and lumbar spine: a randomized cadaveric study. Eur Spine J 26:738–749. doi:10.1007/s00586-016-4728-5

    Article  PubMed  Google Scholar 

  26. Lu S, Xu YQ, Zhang YZ, Li YB, Xie L, Shi JH, Guo H, Chen GP, Chen YB (2009) A novel computer-assisted drill guide template for lumbar pedicle screw placement: a cadaveric and clinical study. Int J Med Robot 5:184–191. doi:10.1002/rcs.249

    Article  PubMed  Google Scholar 

  27. Ma T, Xu YQ, Cheng YB, Jiang MY, Xu XM, Xie L, Lu S (2012) A novel computer-assisted drill guide template for thoracic pedicle screw placement: a cadaveric study. Arch Orthop Trauma Surg 132:65–72. doi:10.1007/s00402-011-1383-5

    Article  PubMed  Google Scholar 

  28. Lu S, Xu YQ, Zhang YZ, Xie L, Guo H, Li DP (2009) A novel computer-assisted drill guide template for placement of C2 laminar screws. Eur Spine J 18:1379–1385. doi:10.1007/s00586-009-1051-4

    Article  PubMed  PubMed Central  Google Scholar 

  29. Putzier M, Strube P, Cecchinato R, Lamartina C, Hoff EK (2017) 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 30:E430–E439. doi:10.1097/BSD.0000000000000220

    PubMed  Google Scholar 

  30. Takemoto M, Fujibayashi S, Ota E, Otsuki B, Kimura H, Sakamoto T, Kawai T, Futami T, Sasaki K, Matsushita T, Nakamura T, Neo M, Matsuda S (2015) Additive-manufactured patient-specific titanium templates for thoracic pedicle screw placement: novel design with reduced contact area. Eur Spine J. doi:10.1007/s00586-015-3908-z

    Google Scholar 

  31. Disegi JA, Eschbach L (2000) Stainless steel in bone surgery. Injury 31(Suppl 4):2–6

    Article  PubMed  Google Scholar 

  32. Shin MH, Ryu KS, Park CK (2012) Accuracy and safety in pedicle screw placement in the thoracic and lumbar spines: comparison study between conventional C-Arm fluoroscopy and navigation coupled with O-arm (R) guided methods. J Korean Neurosurg Soc 52:204–209. doi:10.3340/jkns.2012.52.3.204

    Article  PubMed  PubMed Central  Google Scholar 

  33. Amiot LP, Lang K, Putzier M, Zippel H, Labelle H (2000) Comparative results between conventional and computer-assisted pedicle screw installation in the thoracic, lumbar, and sacral spine. Spine (Phila Pa 1976) 25:606–614

    Article  CAS  Google Scholar 

  34. Samdani AF, Ranade A, Sciubba DM, Cahill PJ, Antonacci MD, Clements DH, Betz RR (2010) Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make? Eur Spine J 19:91–95. doi:10.1007/s00586-009-1183-6

    Article  PubMed  Google Scholar 

  35. Lu S, Zhang YZ, Wang Z, Shi JH, Chen YB, Xu XM, Xu YQ (2012) Accuracy and efficacy of thoracic pedicle screws in scoliosis with patient-specific drill template. Med Biol Eng Comput 50:751–758. doi:10.1007/s11517-012-0900-1

    Article  PubMed  Google Scholar 

  36. Wu ZX, Huang LY, Sang HX, Ma ZS, Wan SY, Cui G, Lei W (2011) Accuracy and safety assessment of pedicle screw placement using the rapid prototyping technique in severe congenital scoliosis. J Spinal Disord Tech 24:444–450. doi:10.1097/BSD.0b013e318201be2a

    Article  PubMed  Google Scholar 

  37. 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. doi:10.1007/s00402-013-1755-0

    PubMed  Google Scholar 

  38. Kaneyama S, Sugawara T, Sumi M (2015) Safe and accurate midcervical pedicle screw insertion procedure with the patient-specific screw guide template system. Spine (Phila Pa 1976) 40:E341–E348. doi:10.1097/BRS.0000000000000772

    Article  Google Scholar 

  39. Hu Y, Yuan ZS, Spiker WR, Albert TJ, Dong WX, Xie H, Yuan JB, Wang CT (2013) Deviation analysis of C2 translaminar screw placement assisted by a novel rapid prototyping drill template: a cadaveric study. Eur Spine J 22:2770–2776. doi:10.1007/s00586-013-2993-0

    Article  PubMed  PubMed Central  Google Scholar 

  40. Chung KJ, Suh SW, Desai S, Song HR (2008) Ideal entry point for the thoracic pedicle screw during the free hand technique. Int Orthop 32:657–662. doi:10.1007/s00264-007-0363-4

    Article  PubMed  Google Scholar 

  41. Yalniz E, Ciftdemir M, Eskin D, Dulger H (2009) The safety of pedicle screw fixation in the thoracic spine. Acta Orthop Traumatol Turc 43:522–527. doi:10.3944/AOTT.2009.522

    Article  PubMed  Google Scholar 

Download references

Author information

Author notes

  1. Xiangxue Kong and Lei Tang contributed equally to this work.

Authors and Affiliations

  1. Department of Anatomy, Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China

    Xiangxue Kong, Lei Tang, Wenhua Huang & Jianyi Li

  2. Department of Radiology, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China

    Qiang Ye

  3. Department of Orthopedics, Nanhai Hospital, Southern Medical University, Foshan, China

    Jianyi Li

Authors
  1. Xiangxue Kong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lei Tang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Qiang Ye
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Wenhua Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jianyi Li
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jianyi Li.

Ethics declarations

Funding source

This work was partly supported by the National Natural Science Foundation of China (NSFC) (61190122, 61190123) and Guangdong and Guangzhou provincial scientific and technique department (2014A020212200, 2015A040404022, 2015B010125006, 2015B010125005, 201704020129, 201704020069).

Conflict of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kong, X., Tang, L., Ye, Q. et al. Are computer numerical control (CNC)-manufactured patient-specific metal templates available for posterior thoracic pedicle screw insertion? Feasibility and accuracy evaluation. Eur Spine J 26, 2927–2933 (2017). https://doi.org/10.1007/s00586-017-5215-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-017-5215-3

Keywords

Search

Navigation