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Percutaneous instrumentation of the cervical and cervico-thoracic spine using pedicle screws: preliminary clinical results and analysis of accuracy

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Abstract

The pedicle screw instrumentation represents the most rigid construct of the cervical and cervicothoracic spine and in spite of the risks to neurovascular structures clinical relevant complications do not occur frequently. The steep angles of the cervical pedicles result in a wide surgical exposure with extensive muscular trauma. The objective of this study was the evaluation of the accuracy of cervical pedicle screw insertion through a minimally invasive technique to reduce access-related muscular trauma. Therefore, percutaneous transpedicular instrumentation of the cervical and cervicothoracic spine was performed in 15 patients using fluoroscopy. All instrumentations from C2 to Th4 were inserted bilaterally through 2 to 3-cm skin and fascia incisions even in multilevel procedures and the rods were placed by blunt insertion through the incision. Thin-cut CT scan was used postoperatively to analyze pedicle violations. 76.4% of 72 screws were placed accurately. Most pedicle perforations were seen laterally towards the vertebral artery. Critical breaches >2 mm or narrowing of the transversal foramen occurred in 12.5% of screws; however, no revision surgery for screw displacement was needed in the absence of clinical symptoms. No conversion from percutaneous to open surgery was necessary. It was concluded that percutaneous transpedicular instrumentation of the cervical spine is a surgically demanding technique and should be reserved for experienced spine surgeons. The indications are limited to instrumentation-only procedures or in combination with anterior treatment, but with the potential to minimize access-related morbidity.

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Conflict of interest

N. Hansen Algenstaedt worked as a consultant of Stryker spine.

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Authors and Affiliations

  1. Orthopaedic Spine Surgery, Spine Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany

    Christian Schaefer, Ina Fuhrhop, Malte Schroeder, Lennart Viezens, Lothar Wiesner & Nils Hansen-Algenstaedt

  2. Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany

    Phillip Begemann

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  1. Christian Schaefer
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Correspondence to Nils Hansen-Algenstaedt.

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Online Resource Fig 1 A, The patients were placed in a prone position, the fluoroscope was checked for collision and whether the necessary fluoroscopic views are of sufficient quality. B, The skin entry point was determined by positioning a spinal needle and the correct trajectories were controlled by fluoroscopy pedicle axis (C) and lateral view (D).

Online Resource Fig 2 Surgical approach with skin incision of 2-3 cm (A) and subsequent muscle split in fiber course until the lateral mass was identified (B).

Online Resource Fig 3 After the surgical approach a trokar with blunt tip was positioned and a bone awl was inserted (A). The bone awl was positioned below the lower margin of the upper articular surface and lateral to the midline of the lateral mass. The correct position was controlled by lateral (B) and true a.p. fluoroscopic view (C) as well as oblique views perpendicular to the pedicle axis (not shown). The inclination of the bone awl from the mid-sagittal plane was chosen according to preoperative CT scan and controlled by fluoroscopy using the pedicle axis view (D). The pedicle axis view was achieved by rotation the fluoroscope until the pedicle appears approximately circular. The awl should be positioned in line between the medial and lateral boundaries of the pedicles and the cortical wall was opened.

Online Resource Fig 4 Process of automatic drilling with corresponding fluoroscopic views. Automatic drilling was performed after securing the entry point with the trokar (A). During drilling process, the correct trajectories of the drill were controlled by fluoroscopy using lateral, a.p. and pedicle axis views. If the drill reaches the vertebral body in oblique or lateral view (B), it should not cross the medial or lateral boundaries of the pedicle in a.p. view (C) and pedicle axis view (D). The correct inclination to the mid-sagittal plane was determined again using the preoperative CT scan and the pedicle axis view (D). Position of the drill at the end of the drilling process in fluoroscopic views in lateral (E), a.p. (F) and pedicle axis (G) direction.

Online Resource Fig 5 After drilling a 3.5 mm screw was inserted into the vertebra. During the insertion of the screw the position was checked by lateral (A + D), a.p. (B + E) and pedicle axis (C) fluoroscopy. Screw position can be seen on intraoperative image (F).

Online Resource Fig 6 After screw positioning the rod was inserted through the most caudal incision close to the bone and beyond the fascia and muscle (A) and fixed with blocker nuts (B). Intraoperative image (C) and intraoperative fluoroscopic views in a.p. (D) and oblique direction (E, perpendicular to the pedicle axis) demonstrating the fixed screw rod construct.

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Schaefer, C., Begemann, P., Fuhrhop, I. et al. Percutaneous instrumentation of the cervical and cervico-thoracic spine using pedicle screws: preliminary clinical results and analysis of accuracy. Eur Spine J 20, 977–985 (2011). https://doi.org/10.1007/s00586-011-1775-9

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  • DOI: https://doi.org/10.1007/s00586-011-1775-9

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