Abstract
Introduction
The treatment of spinal deformities has rapidly changed during the past decade. The advent of new surgical techniques, particularly thoracic pedicle screws and spinal osteotomies, allow more aggressive deformity correction, and require an increased focus on safety.
Materials and methods
Review of the navigation systems and neuromonitoring techniques currently available.
Conclusion
Navigation systems today are where intraoperative neuromonitoring was 20 years ago: new, under investigation, not widely accepted, with concerns for cost, safety and efficiency. Navigation enhances the accuracy of pedicle screws placement in deformed spines, reducing the rate of misplaced screws and potential complications. With further use and investigation, navigation, like neuromonitoring, will soon become standard at major spine centers throughout the world.
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References
Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB (1995) Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine 20(12):1399–4052
Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER (2001) Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine 26(18):2049–2057
Dobbs MB, Lenke LG, Kim YJ, Kamath G, Peelle MW, Bridwell KH (2006) Selective posterior thoracic fusions for adolescent idiopathic scoliosis: comparison of hooks versus pedicle screws. Spine 31(20):2400–2404
Lehman RA Jr, Lenke LG, Keeler KA, Kim YJ, Buchowski JM, Cheh G et al (2008) Operative treatment of adolescent idiopathic scoliosis with posterior pedicle screw-only constructs: minimum three-year follow-up of one hundred fourteen cases. Spine 33(14):1598–1604
Liljenqvist U, Lepsien U, Hackenberg L, Niemeyer T, Halm H (2002) Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis. Eur Spine J 11(4):336–343
Lenke LG, Kuklo TR, Ondra S, Polly DW Jr (2008) Rationale behind the current state-of-the-art treatment of scoliosis (in the pedicle screw era). Spine 33(10):1051–1054
Ledonio CG, Polly DW Jr, Vitale MG, Wang Q, Richards BS (2011) Pediatric pedicle screws: comparative effectiveness and safety: a systematic literature review from the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America task force. J Bone Joint Surg Am 93(13):1227–1234
Luhmann SJ, Lenke LG, Kim YJ, Bridwell KH, Schootman M (2005) Thoracic adolescent idiopathic scoliosis curves between 70 degrees and 100 degrees: is anterior release necessary? Spine 30(18):2061–2067
Kuklo TR, Lenke LG, O’Brien MF, Lehman RA Jr, Polly DW Jr, Schroeder TM (2005) Accuracy and efficacy of thoracic pedicle screws in curves more than 90 degrees. Spine 30(2):222–226
Odgers CJt, Vaccaro AR, Pollack ME, Cotler JM (1996) Accuracy of pedicle screw placement with the assistance of lateral plain radiography. J Spinal Disord 9(4):334–338
Coe JD, Arlet V, Donaldson W, Berven S, Hanson DS, Mudiyam R et al (2006) Complications in spinal fusion for adolescent idiopathic scoliosis in the new millennium. A report of the Scoliosis Research Society Morbidity and Mortality Committee. Spine 31(3):345–349
Di Silvestre M, Parisini P, Lolli F, Bakaloudis G (2007) Complications of thoracic pedicle screws in scoliosis treatment. Spine 32(15):1655–1661
Lonstein JE, Denis F, Perra JH, Pinto MR, Smith MD, Winter RB (1999) Complications associated with pedicle screws. J Bone Joint Surg Am 81(11):1519–1528
Minor ME, Morrissey NJ, Peress R, Carroccio A, Ellozy S, Agarwal G et al (2004) Endovascular treatment of an iatrogenic thoracic aortic injury after spinal instrumentation: case report. J Vasc Surg 39(4):893–896
Kakkos SK, Shepard AD (2008) Delayed presentation of aortic injury by pedicle screws: report of two cases and review of the literature. J Vasc Surg 47(5):1074–1082
Choi JB, Han JO, Jeong JW (2001) False aneurysm of the thoracic aorta associated with an aorto-chest wall fistula after spinal instrumentation. J Trauma 50(1):140–143
Wegener B, Birkenmaier C, Fottner A, Jansson V, Durr HR (2008) Delayed perforation of the aorta by a thoracic pedicle screw. Eur Spine J 17(Suppl 2):S351–S354
Harimaya K, Lenke LG, Son-Hing JP, Bridwell KH, Schwend RM, Luhmann SJ et al (2011) Safety and accuracy of pedicle screws and constructs placed in infantile and juvenile patients. Spine 36(20):1645–1651
Misenhimer GR, Peek RD, Wiltse LL, Rothman SL, Widell EH Jr (1989) Anatomic analysis of pedicle cortical and cancellous diameter as related to screw size. Spine 14(4):367–372
Sjostrom L, Jacobsson O, Karlstrom G, Pech P, Rauschning W (1993) CT analysis of pedicles and screw tracts after implant removal in thoracolumbar fractures. J Spinal Disord 6(3):225–231
Gang C, Haibo L, Fancai L, Weishan C, Qixin C (2011) Learning curve of thoracic pedicle screw placement using the free-hand technique in scoliosis: how many screws needed for an apprentice? Eur Spine J Epub 2011/11/15
Gonzalvo A, Fitt G, Liew S, de la Harpe D, Turner P, Ton L et al (2009) The learning curve of pedicle screw placement: how many screws are enough? Spine 34(21):E761–E765
Lonner BS, Auerbach JD, Estreicher MB, Kean KE (2009) Thoracic pedicle screw instrumentation: the learning curve and evolution in technique in the treatment of adolescent idiopathic scoliosis. Spine 34(20):2158–2164
Samdani AF, Ranade A, Saldanha V, Yondorf MZ (2010) Learning curve for placement of thoracic pedicle screws in the deformed spine. Neurosurgery 66(2):290–294 (discussion 4–5)
Lehman RA Jr, Lenke LG, Keeler KA, Kim YJ, Cheh G (2007) Computed tomography evaluation of pedicle screws placed in the pediatric deformed spine over an 8-year period. Spine 32(24):2679–2684
Smorgick Y, Millgram MA, Anekstein Y, Floman Y, Mirovsky Y (2005) Accuracy and safety of thoracic pedicle screw placement in spinal deformities. J Spinal Disord Tech 18(6):522–526
Sarlak AY, Tosun B, Atmaca H, Sarisoy HT, Buluc L (2009) Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosis. Eur Spine J 18(12):1892–1897
Amaral TD, Wollowick AL, Kulkarni PM, Thornhill B, Suggs W, Sugarman EP, et al (2011) How commonly are pedicle screws adjacent to the great vessels or viscera? A study of 2,295 pedicle screws. Presented at the 46th Annual Meeting of the Scoliosis Research Society
Ughwanogho E, Patel NM, Baldwin KD, Sampson NR, Flynn J (2012) CT-guided navigation of thoracic pedicle screws for AIS results in more accurate placement and less screw removal. Spine
Ughwanogho E, Patel NM, Baldwin KD, Sampson NR, Flynn JM. CT-guided navigation of thoracic pedicle screws for AIS results in more accurate placement and less screw removal. Presented at the 46th Annual Meeting of the Scoliosis Research Society
Eggspuehler A, Sutter MA, Grob D, Jeszenszky D, Dvorak J (2007) Multimodal intraoperative monitoring during surgery of spinal deformities in 217 patients. Eur Spine J 16(Suppl 2):S188–S196
Perot PL Jr (1973) Chapter 28. The clinical use of somatosensory evoked potentials in spinal cord injury. Clin Neurosurg 20:367–381
Engler GL, Spielholz NJ, Bernhard WN, Danziger F, Merkin H, Wolff T (1978) Somatosensory evoked potentials during Harrington instrumentation for scoliosis. J Bone Joint Surg Am 60(4):528–532
Gavaret M, Trebuchon A, Aubert S, Jacopin S, Blondel B, Glard Y et al (2011) Intraoperative monitoring in pediatric orthopedic spinal surgery: three hundred consecutive monitoring cases of which 10 % of patients were younger than 4 years of age. Spine 36(22):1855–1863
Calancie B, Lebwohl N, Madsen P, Klose KJ (1992) Intraoperative evoked EMG monitoring in an animal model. A new technique for evaluating pedicle screw placement. Spine 17(10):1229–1235
Calancie B, Madsen P, Lebwohl N (1994) Stimulus-evoked EMG monitoring during transpedicular lumbosacral spine instrumentation. Initial clinical results. Spine 19(24):2780–2786
Maguire J, Wallace S, Madiga R, Leppanen R, Draper V (1995) Evaluation of intrapedicular screw position using intraoperative evoked electromyography. Spine 20(9):1068–1074
Clements DH, Morledge DE, Martin WH, Betz RR (1996) Evoked and spontaneous electromyography to evaluate lumbosacral pedicle screw placement. Spine 21(5):600–604
Gertzbein SD, Robbins SE (1990) Accuracy of pedicular screw placement in vivo. Spine 15(1):11–14
Shi YB, Binette M, Martin WH, Pearson JM, Hart RA (2003) Electrical stimulation for intraoperative evaluation of thoracic pedicle screw placement. Spine 28(6):595–601
Eggspuehler A, Sutter MA, Grob D, Porchet F, Jeszenszky D, Dvorak J (2007) Multimodal intraoperative monitoring (MIOM) during surgical decompression of thoracic spinal stenosis in 36 patients. Eur Spine J 16(Suppl 2):S216–S220
Lenke LG, O’Leary PT, Bridwell KH, Sides BA, Koester LA, Blanke KM (2009) Posterior vertebral column resection for severe pediatric deformity: minimum two-year follow-up of thirty-five consecutive patients. Spine (Phila Pa 1976) 34(20):2213–2221
Lenke LG, Sides BA, Koester LA, Hensley M, Blanke KM (2010) Vertebral column resection for the treatment of severe spinal deformity. Clin Orthop Relat Res 468(3):687–699
Suk SI, Chung ER, Lee SM, Lee JH, Kim SS, Kim JH (2005) Posterior vertebral column resection in fixed lumbosacral deformity. Spine (Phila Pa 1976) 30(23):E703–E710
Suk SI, Chung ER, Kim JH, Kim SS, Lee JS, Choi WK (2005) Posterior vertebral column resection for severe rigid scoliosis. Spine (Phila Pa 1976) 30(14):1682–1687
Eggspuehler A, Sutter MA, Grob D, Jeszenszky D, Porchet F, Dvorak J (2007) Multimodal intraoperative monitoring (MIOM) during cervical spine surgical procedures in 246 patients. Eur Spine J 16(Suppl 2):S209–S215
Nash CL Jr, Lorig RA, Schatzinger LA, Brown RH (1977) Spinal cord monitoring during operative treatment of the spine. Clin Orthop Relat Res 126:100–105
Spielholz NI, Benjamin MV, Engler GL, Ransohoff J (1979) Somatosensory evoked potentials during decompression and stabilization of the spine. Methods and findings. Spine 4(6):500–505
Brown RH, Nash CL Jr (1984) Cortical evoked potential monitoring. A system for intraoperative monitoring of spinal cord function. Spine 9(3):256–261
Mostegl A, Bauer R (1984) The application of somatosensory-evoked potentials in orthopedic spine surgery. Arch Orthop Trauma Surg 103(3):179–184
Keim HA, Hajdu M, Gonzalez EG, Brand L, Balasubramanian E (1985) Somatosensory evoked potentials as an aid in the diagnosis and intraoperative management of spinal stenosis. Spine 10(4):338–344
Yang J, Huang Z, Shu H, Chen Y, Sun X, Liu W, et al (2012) Improving successful rate of transcranial electrical motor-evoked potentials monitoring during spinal surgery in young children. Eur Spine J 21(5):980–984
Lenke LG, Padberg AM, Russo MH, Bridwell KH, Gelb DE (1995) Triggered electromyographic threshold for accuracy of pedicle screw placement. An animal model and clinical correlation. Spine (Phila Pa 1976) 20(14):1585–1591
Dvorak J, Sutter M, Eggspuehler A, Szpalski M, Aebi M (2007) Multimodal intraoperative monitoring: towards a routine use in surgical treatment of severe spinal disorders. Eur Spine J 16(Suppl 2):S113–S114
Sutter M, Deletis V, Dvorak J, Eggspuehler A, Grob D, Macdonald D et al (2007) Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries. Eur Spine J 16(Suppl 2):S232–S237
Pajewski TN, Arlet V, Phillips LH (2007) Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. Eur Spine J 16(Suppl 2):S115–S129
Dawson EG, Sherman JE, Kanim LE, Nuwer MR (1991) Spinal cord monitoring. Results of the Scoliosis Research Society and the European Spinal Deformity Society survey. Spine 16(8 Suppl):S361–S364
Nuwer MR, Dawson EG, Carlson LG, Kanim LE, Sherman JE (1995) Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: results of a large multicenter survey. Electroencephalogr Clin Neurophysiol 96(1):6–11
Tabaraud F, Boulesteix JM, Moulies D, Longis B, Lansade A, Terrier G et al (1993) Monitoring of the motor pathway during spinal surgery. Spine 18(5):546–550
Boyd SG, Rothwell JC, Cowan JM, Webb PJ, Morley T, Asselman P et al (1986) A method of monitoring function in corticospinal pathways during scoliosis surgery with a note on motor conduction velocities. J Neurol Neurosurg Psychiatry 49(3):251–257
Deletis V (2007) Basic methodological principles of multimodal intraoperative monitoring during spine surgeries. Eur Spine J 16(Suppl 2):S147–S152
Pastorelli F, Di Silvestre M, Plasmati R, Michelucci R, Greggi T, Morigi A et al (2011) The prevention of neural complications in the surgical treatment of scoliosis: the role of the neurophysiological intraoperative monitoring. Eur Spine J 20(Suppl 1):S105–S114
Macdonald DB (2007) Four-limb muscle motor evoked potential and optimized somatosensory evoked potential monitoring with decussation assessment: results in 206 thoracolumbar spine surgeries. Eur Spine J 16(Suppl 2):S171–S187
Sutter M, Eggspuehler A, Grob D, Jeszenszky D, Benini A, Porchet F et al (2007) The diagnostic value of multimodal intraoperative monitoring (MIOM) during spine surgery: a prospective study of 1,017 patients. Eur Spine J 16(Suppl 2):S162–S170
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Flynn, J.M., Sakai, D.S. Improving safety in spinal deformity surgery: advances in navigation and neurologic monitoring. Eur Spine J 22 (Suppl 2), 131–137 (2013). https://doi.org/10.1007/s00586-012-2360-6
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DOI: https://doi.org/10.1007/s00586-012-2360-6