Research ArticleNew technology

Technique, Safety, and Accuracy Assessment of Percutaneous Pedicle Screw Placement Utilizing Computer-Assisted Navigation in Lateral Decubitus Single-Position Surgery

Anna-Katharina Calek, Bettina Hochreiter and Aaron J. Buckland
International Journal of Spine Surgery July 2024, 8613; DOI: https://doi.org/10.14444/8613

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Intraoperative clinical photographs. (A) Lateral decubitus patient positioning with reference frame attached to the iliac crest. (B) Use of 3-dimensional computer-assisted navigation for placement of a percutaneous pedicle screw starting with the most proximal vertebra to be instrumented.

  • Figure 2
    Figure 2

    Intraoperative clinical photograph demonstrating the operating room setup. The anterior exposure of the disc space is performed by the vascular surgeon on the right side. Simultaneously, the spine surgeon performs the percutaneous pedicle screw placement with 3-dimensional computer-assisted navigation, seen in the background. Each surgeon has their own scrub nurse.

  • Figure 3
    Figure 3

    Frequency distribution of pedicle screws according to grading (Grades I–IV).

  • Figure 4
    Figure 4

    Illustrative case with axial (A) and coronal (B) postoperative computed tomography images demonstrating a Grade IV lateral breach (orange line: 4.8 mm) of the left L2 pedicle due to pedicle orientation. Had the “perfect” pedicle trajectory been followed (blue line), facet joint violation would have been inevitable. The coronal view (B) demonstrates a narrow “V-shaped” pedicle on the left side.

  • Figure 5
    Figure 5

    Pedicle screw breaches according to level.

  • Figure 6
    Figure 6

    Illustrative case with axial (A) and coronal (B) postoperative computed tomography images demonstrating a Grade II lateral breach of both L4 pedicles with hypertrophic facet joints at L3/4.

Tables

  • Table 1

    Demographics of study participants (N = 44).

    CharacteristicValue
    Gender, n (%) 
     Women28 (63.6)
     Men16 (36.4)
    Age, y, median (range)64.1 (17.3–86.3)
    Body mass index, mean (SD)27.62 (5.74)
    Smoking, n (%) 
     Never39 (88.6)
     Former2 (4.5)
     Unknown3 (6.8)
    Diabetes, n (%) 
     No40 (90.9)
     Yes4 (9.1)
    Osteoporosis, n (%) 
     No24 (54.5)
     Yes2 (4.5)
     Unknown18 (40.9)
    Charlson Comorbidity Index, median (range)2 (0–8)
  • Table 2

    Treatment and procedural outcome measures (N = 44).

    Outcome MeasureValue
    Indication for surgery, n (%)
     Degenerative spondylolisthesis24 (54.5)
     Degenerative disc disease12 (27.3)
     Foraminal stenosis with radiculopathy6 (13.6)
     Facet arthropathy1 (2.3)
     Spondylolysis/pedicle fracture1 (2.3)
    Prior surgery, n (%) 
     No36 (81.8)
     Yes8 (18.2)
    Levels fused, n (%) 
     126 (59.1)
     215 (34.1)
     33 (6.8)
     Median (range)1 (1–3)
    ALIF cage levels, n (%) 
     06 (13.6)
     124 (54.5)
     214 (31.8)
    LLIF cage levels, n (%) 
     034 (77.3)
     17 (15.9)
     23 (6.8)
    Cages, n (%) 
     ALIF only35 (79.5)
     LLIF only6 (13.6)
     Combination of ALIF and LLIF3 (6.8)
    Most commonly treated levels, n (%) 
     L5/S146.2%
     L4/536.9%
     L3/410.8%
     L2/36.2%
    Lateral position, n (%) 
     Left side up36 (81.8)
     Right side up8 (18.2)
    Neuromonitoring, n (%) 
     Yes44 (100.0)
    Operative time, min, median (range)110 (53–293)
    Fluoroscopy time, sec, median (range)98.5 (12.8–283)
    Estimated blood loss, mL, median (range)100 (100–1900)
    Length of stay, d2 (1–14)

    • Abbreviations: ALIF, anterior lumbar interbody fusion; EMG, electromyography; LLIF, lateral lumbar interbody fusion.

    • a EMG and free-running EMG.

  • Table 3

    Lateral breach location as a function of pedicle orientation during instrumentation.

    Pedicle Orientation n
    Down-side screw7
    Up-side screw4
    Total 11
  • Table 4

    Published rates of percutaneous pedicle screw accuracy in lateral decubitus single-position anterior-posterior surgery assessed by computed tomography.

    AuthorYearInsertion TechniqueNo. of ScrewsBreach RateBreach GradingBreach LateralityFacet Joint Violations
    Blizzard et al6 2018Fluoroscopy3005.1%Grade II: 84.6% Grade III: 15.4%Medial: 69.2%
    Lateral: 23.1%    		-
    Ouchida et al16 2020Computer-assisted navigation2281.8%Grade II: unknown
    Grade III: 100%    		--
    Okuda et al17 2023Computer-assisted navigation4534.6%Grade II: 52.4%
    Grade III: 27.3%Grade IV: 18.2%    		Medial: 14.3%
    Lateral: 85.7%    		-
    Hiyama et al24 2023Computer-assisted navigation7281.9%Grade II: 35.7%
    Grade III: 50% Grade IV: 14.3%    		--
    Present study2024Computer-assisted navigation2205%Grade II: 90%
    Grade III: 0%
    Grade IV: 10%    		Medial: 0 %
    Lateral: 100%    		None

    • a Grade II breaches were not reported in this study.

    • b Only screws in the lumbar spine were considered.

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Technique, Safety, and Accuracy Assessment of Percutaneous Pedicle Screw Placement Utilizing Computer-Assisted Navigation in Lateral Decubitus Single-Position Surgery
Anna-Katharina Calek, Bettina Hochreiter, Aaron J. Buckland
International Journal of Spine Surgery Jul 2024, 8613; DOI: 10.14444/8613
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