Abstract
Today, posterior stabilization of the cervical spine is most frequently performed by lateral mass screws or spinous process wiring. These techniques do not always provide sufficient stability, and anterior fusion procedures are added secondarily. Recently, transpedicular screw fixation of the cervical spine has been introduced to provide a one-stage stable posterior fixation. The aim of the present prospective study is to examine if cervical pedicle screw fixation can be done by low risk and to identify potential risk factors associated with this technique. All patients stabilized by cervical transpedicular screw fixation between 1999 and 2002 were included. Cervical disorders included multisegmental degenerative instability with cervical myelopathy in 16 patients, segmental instability caused by rheumatoid arthritis in three, trauma in five and instability caused by infection in two patients. In most cases additional decompression of the spinal cord and bone graft placement were performed. Pre-operative and post-operative CT-scans (2-mm cuts) and plain X-rays served to determine changes in alignment and the position of the screws. Clinical outcome was assessed in all cases. Ninety-four cervical pedicle screws were implanted in 26 patients, most frequently at the C3 (26 screws) and C4 levels (19 screws). Radiologically 66 screws (70%) were placed correctly (maximal breach 1 mm) whereas 20 screws (21%) were misplaced with reduction of mechanical strength, slight narrowing of the vertebral artery canal (<25%) or the lateral recess without compression of neural structures. However, these misplacements were asymptomatic in all cases. Another eight screws (9%) had a critical breach. Four of them showed a narrowing of the vertebral artery canal of more then 25%, in all cases without vascular problems. Three screws passed through the intervertebral foramen, causing temporary paresis in one case and a new sensory loss in another. In the latter patient revision surgery was performed. The screw was loosened and had to be corrected. The only statistically significant risk factor was the level of surgery: all critical breaches were seen from C3 to C5. Percutaneous application of the screws reduced the risk for misplacement, although this finding was not statistically significant. There was also a remarkable learning curve. Instrumentation with cervical transpedicular screws results in very stable fixation. However, with the use of new techniques like percutaneous screw application or computerized image guidance there remains a risk for damaging nerve roots or the vertebral artery. This technique should be reserved for highly selected patients with clear indications and to highly experienced spine surgeons.
Similar content being viewed by others
References
Abumi K, Shono Y, Ito M, Taneichi H, Kotani Y, Kaneda K (2000) Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine 25:962–969
Abumi K, Shono Y, Kotani Y, Kaneda K (2000) Indirect posterior reduction and fusion of the traumatic herniated disc by using a cervical pedicle screw system. J Neurosurg (Spine 1) 92:30–37
Abumi K, Kaneda K (1997) Pedicle screw fixation for nontraumatic lesions of the cervical spine. Spine 22:1853–1863
Albert TJ, Vacarro A (1998) Postlaminectomy kyphosis. Spine 23:2738–2745
Heller JG, Silcox DH, Sutterlin CE (1995) Complications of posterior cervical plating. Spine 20:2442–2448
Jones EL, Heller JG, Silcox DH, Hutton WC (1997) Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine 22:977–982
Judet J, Roy-Camille R, Joillant G (1970) Actualités de chirurgie orthopédique de l‘Hôspital Raymond Poincarré, No VIII Fractures du rachis cervical. Masson, Paris, pp 174–195
Kamimura M, Ebara S, Itoh H, Tateiwa Y, Kinoshita T, Takaoka K (2000) Cervical pedicle screw insertion: assessment of safety and accuracy with computer assisted image guidance. J Spinal Disord 13:218–224
Karaikovic EE, Daubs MD, Madsen RW, Gaines RW (1997) Morphologic characteristics of human cervical pedicles. Spine 22:493–500
Kowalski JM, Ludwig SC, Hutton WC, Heller JG (2000) Cervical spine pedicle screws, a biomechanical comparison of two insertion techniques. Spine 25:2865–2867
Ludwig SC, Kowaslki JM, Edwards CC, Heller JG (2000) Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine 25:2675–2681
Ludwig SC, Kramer DL, Balderston RA, Vaccaro AR, Foley KF, Albert TJ (2000) Placement of pedicle screws in the human cadaveric cervical spine. Spine 25:1655–1667
Levine AM, Mazel C, Roy-Camille R (1992) Management of fracture separations of the articular mass using posterior cervical plating. Spine 17 (Suppl):S447–S454
Panjabi MM, Shin EK, Chen NC, Wang JL (2000) Internal morphology of human cervical pedicles. Spine 25:1197–1205
Richter M, Wilke HJ, Kluger P, Neller S, Claes L, Puhl W (2000) Biomechanical evaluation of a new modular rod-screw implant system for posterior instrumentation of the occipitocervical spine: in-vitro comparison with two established implant systems. Eur Spine J. 9:417–442
Roy-Camille R, Salient G, Mazel C (1989) Internal fixation of the unstable cervical spine by a posterior osteosynthesis with plates and screws. In: The cervical spine, 2nd edn. Lippincott, Philadelphia, pp 390–403
Tanaka N, Fujimoto Y, An HS, Ikuta Y, Yasuda M (2000) The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine. Spine 25:286–291
Ugur HC, Attar A, Tekdemir I, Egemen N, Caglar S, Genc Y (2000) Surgical anatomic evaluation of the cervical pedicle and adjacent neural structures. Neurosurgery 47:1162–1168
Veras LM, Pedraza-Gutiérrez S, Castellanos J, Capellades J, Casamitjana J, Rovira-Cañellas A (2000) Vertebral artery occlusion after acute cervical spine trauma. Spine 25:1171–1177
Yamazaki T, Yanaka K, Sato H, Uemura K, Tsukada A, Nose T (2003) Cervical spondylotic myelopathy: surgical results and factors affecting outcome with special reference to age differences. Neurosurgery 52:122–126
Acknowledgements
The studies comply with the current laws of the country in which they were performed inclusive of ethics approval.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Kast, E., Mohr, K., Richter, HP. et al. Complications of transpedicular screw fixation in the cervical spine. Eur Spine J 15, 327–334 (2006). https://doi.org/10.1007/s00586-004-0861-7
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-004-0861-7