Skip to main content
SpringerLink
Log in

Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques

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

Abstract

Introduction

With the advances and improvement of computer-assisted surgery devices, computer-guided pedicle screws insertion has been applied to the lumbar, thoracic and cervical spine. The purpose of the present study was to perform a systematic review of all available prospective evidence regarding pedicle screw insertion techniques in the thoracic and lumbar human spine.

Materials and methods

We considered all prospective in vivo clinical studies in the English literature that assessed the results of different pedicle screw placement techniques (free-hand technique, fluoroscopy guided, computed tomography (CT)-based navigation, fluoro-based navigation). MEDLINE, OVID, and Springer databases were used for the literature search covering the period from January 1950 until May 2010.

Results

26 prospective clinical studies were eventually included in the analysis. These studies included in total 1,105 patients in which 6,617 screws were inserted. In the studies using free-hand technique, the percentage of the screws fully contained in the pedicle ranged from 69 to 94%, with the aid of fluoroscopy from 28 to 85%, using CT navigation from 89 to 100% and using fluoroscopy-based navigation from 81 to 92%. The screws positioned with free-hand technique tended to perforate the cortex medially, whereas the screws placed with CT navigation guidance seemed to perforate more often laterally.

Conclusions

In conclusion, navigation does indeed exhibit higher accuracy and increased safety in pedicle screw placement than free-hand technique and use of fluoroscopy.

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

Similar content being viewed by others

References

  1. Slomczykowski M, Roberto M, Schneeberger P (1999) Radiation dose for pedicle screw insertion. Fluoroscopic method versus computer-assisted surgery. Spine 24:975–982

    Article  PubMed  CAS  Google Scholar 

  2. Ludwig SC, Kowalski JM, Edwards CC 2nd, Heller JG (2000) Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine 25:2675–2681

    Article  PubMed  CAS  Google Scholar 

  3. Sakai Y, Matsuyama Y, Nakamura H, Katayama Y, Imagama S, Ito Z, Ishiguro N (2008) Segmental pedicle screwing for idiopathic scoliosis using computer-assisted surgery. J Spinal Disord Tech 21:181–186

    Article  PubMed  Google Scholar 

  4. Laine T, Schlenzka D, Mäkitalo K, Tallroth K, Nolte LP, Visarius H (1997) Improved accuracy of pedicle screw insertion with computer-assisted surgery. A prospective clinical trial of 30 patients. Spine 22:1254–1258

    Article  PubMed  CAS  Google Scholar 

  5. 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 25:606–614

    Article  PubMed  CAS  Google Scholar 

  6. Castro WH, Halm H, Jerosch J, Malms J, Steinbeck J, Blasius S (1996) Accuracy of pedicle screw placement in lumbar vertebrae. Spine 21:1320–1324

    Article  PubMed  CAS  Google Scholar 

  7. Esses SI, Sachs BL, Dreyzin V (1993) Complications associated with the technique of pedicle screw fixation. A selected survey of ABS members. Spine 18:2231–2238

    Article  PubMed  CAS  Google Scholar 

  8. Schwarzenbach O, Berlemann U, Jost B, Visarius H, Arm E, Langlotz F, Nolte LP, Ozdoba C (1997) Accuracy of computer-assisted pedicle screw placement. An in vivo computed tomography analysis. Spine 22:452–458

    Article  PubMed  CAS  Google Scholar 

  9. Welch WC, Subach BR, Pollack IF, Jacobs GB (1997) Frameless stereotactic guidance for surgery of the upper cervical spine. Neurosurgery 40:958–963

    Article  PubMed  CAS  Google Scholar 

  10. Mirza SK, Wiggins GC, Kuntz IV Ch, York JE, Bellabarba C, Knonodi MA, Chapman JR, Shaffrey CI (2003) Accuracy of thoracic vertebral body screw placement using standard fluoroscopy, fluoroscopic image guidance, and computed tomographic image guidance. Spine 28:402–413

    PubMed  Google Scholar 

  11. Fisher CG, Sahajpal V, Keynan O, Boyd M, Graeb D, Bailey C, Panagiotopoulos K, Dvorak M (2006) Accuracy and safety of pedicle screw fixation in thoracic spine trauma. J Neurosurg Spine 5:520–526

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  13. Tian NF, Xu HZ (2009) Image-guided pedicle screw insertion accuracy: a meta-analysis. Int Orthop 33:895–903

    Article  PubMed  Google Scholar 

  14. Gertzbein SD, Robbins SE (1990) Accuracy of pedicular screw placement in vivo. Spine 15:11–14

    Article  PubMed  CAS  Google Scholar 

  15. Schizas C, Michel J, Kosmopoulos V, Theumann N (2007) Computer tomography assessment of pedicle screw insertion in percutaneous posterior transpedicular stabilization. Eur Spine J 16:613–617

    Article  PubMed  Google Scholar 

  16. Odgers CJ 4th, Vaccaro AR, Pollack ME, Cotler JM (1996) Accuracy of pedicle screw placement with the assistance of lateral plain radiography. J Spinal Disord 9:334–338

    Article  PubMed  Google Scholar 

  17. Sim E (1993) Location of transpedicular screws for fixation of the lower thoracic and lumbar spine. Computed tomography of 45 fracture cases. Acta Orthop Scand 64:28–32

    PubMed  CAS  Google Scholar 

  18. Rajan V, Kamath V, Shetty AP, Rajasekaran S (2010) Iso-C3D navigation assisted pedicle screw placement in deformities of the cervical and thoracic spine. Indian J orthop 44:163–168

    Article  Google Scholar 

  19. Modi H, Suh SW, Song HR, Yang JH (2009) Accuracy of thoracic pedicle screw placement in scoliosis using the ideal pedicle entry point during the freehand technique. Int Orthop 33:469–475

    Article  PubMed  Google Scholar 

  20. Beck M, Mittlmeier T, Gierer P, Harms C, Gradl G (2009) Benefit and accuracy of intraoperative 3D imaging after pedicle screw placement: a prospective study in stabilizing thoracolumbar fractures. Eur Spine J 18:1469–1477

    Article  PubMed  Google Scholar 

  21. Karapinar L, Erel N, Ozturk H, Altay T, Kaya A (2008) Pedicle screw placement with a free hand technique in thoracolumbar spine: is it safe? J Spinal Disord Tech 21:63–67

    Article  PubMed  Google Scholar 

  22. Wang HC, Yang YL, Lin WC, Chen WF, Yang TM, Lin YJ, Rau CS, Lee TC (2008) Computer-assisted pedicle screw placement for thoracolumbar spine fracture with separate spinal reference clamp placement and registration. Surg Neurol 69:597–601

    Article  PubMed  Google Scholar 

  23. Upendra BN, Meena D, Chowdhury B, Ahmad A, Jayaswal A (2008) Outcome-based classification for assessment of thoracic pedicular screw placement. Spine 33:384–390

    Article  PubMed  Google Scholar 

  24. Rampersaud YR, Lee KS (2007) Fluoroscopic computer-assisted pedicle screw placement through a mature fusion mass: an assessment of 24 consecutive cases with independent analysis of computed tomography and clinical data. Spine 32:217–222

    Article  PubMed  Google Scholar 

  25. Merloz P, Troccaz J, Vouaillat H, Vasile C, Tonetti J, Eid A, Plaweski S (2007) Fluoroscopy-based navigation system in spine surgery. Proc Inst Mech Eng H 221:813–820

    PubMed  CAS  Google Scholar 

  26. Rampersaud YR, Pik JH, Salonen D, Farooq S (2005) Clinical accuracy of fluoroscopic computer-assisted pedicle screw fixation: a CT analysis. Spine 30:183–190

    Article  Google Scholar 

  27. Vougioukas VI, Weber J, Scheufler KM (2005) Clinical and radiological results after parapedicular screw fixation of the thoracic spine. J Neurosurg Spine 3:283–287

    Article  PubMed  Google Scholar 

  28. Kuntz C 4th, Maher PC, Levine NB, Kurokawa R (2004) Prospective evaluation of thoracic pedicle screw placement using fluoroscopic imaging. J Spinal Disord Tech 17:206–214

    Article  PubMed  Google Scholar 

  29. Fu TS, Chen LH, Wong CB, Lai PL, Tsai TT, Niu CC, Chen WJ (2004) Computer-assisted fluoroscopic navigation of pedicle screw insertion: an in vivo feasibility study. Acta Orthop Scand 75:730–735

    Article  PubMed  Google Scholar 

  30. Halm H, Niemeyer T, Link T, Liljenqvist U (2000) Segmental pedicle screw instrumentation in idiopathic thoracolumbar and lumbar scoliosis. Eur Spine J 9:191–197

    Article  PubMed  CAS  Google Scholar 

  31. Carl AL, Khanuja HS, Gatto CA, Matsumoto M, vomLehn J, Schenck J, Rohling K, Lorensen W, Vosburgh K (2000) In vivo pedicle screw placement: image-guided virtual vision. J Spinal Disord 13:225–229

    Article  PubMed  CAS  Google Scholar 

  32. Laine T, Lund T, Ylikoski M, Lohikoski J, Schlenzka D (2000) Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients. Eur Spine J 9:235–240

    Article  PubMed  CAS  Google Scholar 

  33. Girardi FP, Cammisa FP Jr, Sandhu HS, Alvarez L (1999) The placement of lumbar pedicle screws using computerised stereotactic guidance. J Bone Joint Surg Br 81:825–829

    Article  PubMed  CAS  Google Scholar 

  34. Merloz P, Tonetti J, Pittet L, Coulomb M, Lavalleé S, Sautot P (1998) Pedicle screw placement using image guided techniques. Clin Orthop Relat Res 354:39–48

    Article  PubMed  Google Scholar 

  35. Laine T, Mäkitalo K, Schlenzka D, Tallroth K, Poussa M, Alho A (1997) Accuracy of pedicle screw insertion: a prospective CT study in 30 low back patients. Eur Spine J 6:402–405

    Article  PubMed  CAS  Google Scholar 

  36. Rajasekaran S, Vidyadhara S, Ramesh P, Shetty AP (2007) Randomized clinical study to compare the accuracy of navigated and non-navigated thoracic pedicle screws in deformity correction surgeries. Spine 32:56–64

    Article  Google Scholar 

  37. Barr SJ, Schuette AM, Emans JB (1997) Lumbar pedicle screws versus hooks. Results in double major curves in adolescent idiopathic scoliosis. Spine 22:1369–1379

    Article  PubMed  CAS  Google Scholar 

  38. Broom MJ, Banta JV, Renshaw TS (1989) Spinal fusion augmented by luque-rod segmental instrumentation for neuromuscular scoliosis. J Bone Joint Surg Am 71:32–44

    PubMed  CAS  Google Scholar 

  39. Hamill CL, Lenke LG, Bridwell KH, Chapman MP, Blanke K, Baldus C (1996) The use of pedicle screw fixation to improve correction in the lumbar spine of patients with idiopathic scoliosis. Is it warranted? Spine 21:1241–1249

    Article  PubMed  CAS  Google Scholar 

  40. Kosmopoulos V, Schizas C (2007) Pedicle screw placement accuracy: a meta-analysis. Spine 32:E111–E120

    Article  PubMed  Google Scholar 

  41. Verma R, Krishan S, Haendlmayer K, Mohsen A (2010) Functional outcome of computer-assisted spinal pedicle screw placement: a systematic review and meta-analysis of 23 studies including 5, 992 pedicle screws. Eur Spine J 19:370–375

    Article  PubMed  Google Scholar 

  42. West JL 3rd, Ogilvie JW, Bradford DS (1991) Complications of the variable screw plate pedicle screw fixation. Spine 16:576–579

    Article  PubMed  Google Scholar 

  43. Lonstein JE, Denis F, Perra JH, Pinto MR, Smith MD, Winter RB (1999) Complications associated with pedicle screws. J Bone Joint Surg Am 81:1519–1528

    PubMed  CAS  Google Scholar 

  44. Gaines RW Jr (2000) The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Joint Surg Am 82-A:1458–1476

    PubMed  Google Scholar 

  45. Weinstein JN, Spratt KF, Spengler D, Brick C, Reid S (1988) Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine 13:1012–1018

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

The authors have no conflict of interest to declare.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery and Traumatology, School of Medicine, University of Ioannina, Pantazidi Street 11, 45221, Ioannina, Epirus, Greece

    Ioannis D. Gelalis, Nikolaos K. Paschos, Emilios E. Pakos, Angelos N. Politis, Christina M. Arnaoutoglou, Athanasios C. Karageorgos, Avraam Ploumis & Theodoros A. Xenakis

Authors
  1. Ioannis D. Gelalis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nikolaos K. Paschos
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Emilios E. Pakos
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Angelos N. Politis
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christina M. Arnaoutoglou
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Athanasios C. Karageorgos
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Avraam Ploumis
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Theodoros A. Xenakis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ioannis D. Gelalis.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gelalis, I.D., Paschos, N.K., Pakos, E.E. et al. Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J 21, 247–255 (2012). https://doi.org/10.1007/s00586-011-2011-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-011-2011-3

Keywords

Search

Navigation