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Wong CE, Lee PH, Chen CM, Huang CC, Hsu HH, Chen LY, Huang CY, Wang LC, Lee JS. Evaluation of the safety, radiographic and resident training results of thoracic pedicle screws placement using resection of the transverse process. Br J Neurosurg 2025; 39:210-216. [PMID: 37170634 DOI: 10.1080/02688697.2023.2211174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE This study aimed at the evaluation and assessment of a simple method, the transverse process resection (TPR) technique, for freehand thoracic pedicle screw placement and the learning curve for trainee surgeons. METHODS In the TPR technique, the tip of the thoracic transverse process (TP) is removed to create an entry point in the cancellous bone of the TP, and the thoracic pedicle is cannulated from the TP. We retrospectively evaluated the safety and radiographic results of the TPR technique and compared with that of conventional pedicle screws. The training performance of seven neurosurgical residents with TPR techniques were evaluated. RESULTS Among 46 patients, a total of 322 thoracic screws were analyzed, including 178 screws placed using the TPR technique and 144 screws using the conventional straight-forward (SF) technique. TPR screws had greater medial angulations in all levels from T2 to T12 compared to SF screws (p < 0.001). The incidence of pedicle breach was lower in the TPR screws compared to SF screws (6.2% vs. 21.5%, p < 0.001), especially for screws placed by residents (6.7% vs. 29.6%, p < 0.001). Residents had improved performance following a cadaveric training course on the TPR technique (p = 0.001). CONCLUSION This study demonstrated the safety of the TPR technique for thoracic pedicle screw placement and its short learning curve for trainee surgeons.
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Affiliation(s)
- Chia-En Wong
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Hsuan Lee
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan
- College of nursing and health sciences, Dayeh University, Taiwan
| | - Chi-Chen Huang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hao-Hsiang Hsu
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Liang-Yi Chen
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yuan Huang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Liang-Chao Wang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Shun Lee
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Wang K, Wang C, Si H, Zhang Y, Sang S, Zhang R, Zhang W, Chen J, Liu C, Li K, Hu B, Lin X, Feng Y, Fu Q, Kang Z, Xu M, Zhang D, Xu W, Li L. Relationship Between the Elastic Modulus of the Novel Pedicle Screw-Plate System and Biomechanical Properties Under Osteoporotic Condition: A Power-Law Regression Analysis Based on Parametric Finite Element Simulations. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2025; 265:108760. [PMID: 40179719 DOI: 10.1016/j.cmpb.2025.108760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Revised: 03/27/2025] [Accepted: 03/28/2025] [Indexed: 04/05/2025]
Abstract
BACKGROUND AND OBJECTIVE The novel pedicle screw-plate system (NPSPS) is a new internal fixation method for the thoracic spine that we proposed, which has demonstrated effectiveness through clinical practice and biomechanical testing. Nevertheless, the optimal elastic modulus of NPSPS (NPSPS-E) remains debated, particularly for osteoporosis patients. We propose a more efficient method to predict the biomechanical effects of NPSPS across varying elastic moduli in osteoporosis using parametric finite element (FE) analysis, establishing the regression relationship between NPSPS-E and biomechanical properties. METHODS An FE surgical model of NPSPS under osteoporotic conditions was developed. The NPSPS-E was linearly varied from 3.6 GPa (polyether ether ketone) to 110 GPa (titanium alloy). Using power-law regression analysis, a functional equation was established to correlate NPSPS-E with biomechanical properties under osteoporotic condition. RESULTS Power-law equations and regression models were successfully established between NPSPS-E and biomechanical prediction indices under osteoporotic condition (P<0.0001). As NPSPS-E increased, the range of motion (ROM) of the T8-T10 spinal segments decreased from 0.51°-4.06° to 0.24°-1.45°. The mean von Mises stress in the T8-T10 vertebrae declined from 1.36 MPa-2.03 MPa to 1.15 MPa-1.79 MPa. Concurrently, the stress shielding ratios and the total stress ratios of the NPSPS increased from 3.66%-48.07% and 13.96%-26.96% to 10.70%-56.20% and 52.62%-64.40%, respectively. CONCLUSION The functional equations derived from these models serve as a predictive tool to directly estimate the biomechanical effects of NPSPS across a range of elastic modulus under osteoporotic conditions, thereby facilitating the design and optimization of NPSPS materials.
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Affiliation(s)
- Kaibin Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Chongyi Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Haipeng Si
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China; Key Laboratory of Qingdao in Medicine and Engineering, Department of Orthopedics, Qilu Hospital (Qingdao) of Shandong University, Qingdao 266035, Shandong, China.
| | - Yanwei Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Shaowei Sang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Runtong Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Wencan Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Junfei Chen
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Chen Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Kunpeng Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Bingtao Hu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Xiangyu Lin
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Yunze Feng
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Qingyang Fu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Zhihao Kang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Mingyu Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Dingxin Zhang
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Wanlong Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
| | - Le Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China.
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Lei H, Zhou Z, Liu J, Cao H, Wu L, Song P, Yang B, Zhou W, Liu Y, Kong Q, Fan Y, Zhou C. Structural Optimization of 3D-Printed Porous Titanium Implants Promotes Bone Regeneration for Enhanced Biological Fixation. ACS APPLIED MATERIALS & INTERFACES 2025; 17:18059-18073. [PMID: 40067074 DOI: 10.1021/acsami.4c22401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2025]
Abstract
Structural defects and biological inertness significantly impair the integration of titanium alloy implants and bone tissues. In spinal internal fixation, the issue of pedicle screw loosening or fracture caused by poor integration urgently needs solving. In this study, we utilized 3D printing technology to custom fabricate a structurally optimized porous pedicle screw with the aim of enhancing bone regeneration and integration at the defect site, thereby enhancing the biological fixation of the implant in vivo. Results showed that the structurally optimized porous unit has superior mechanical properties and actively promotes cell adhesion and growth at the surface interface. The porous screw based on this optimized structure has immediate bonding strength and bending resistance comparable to clinical products and provides an optimal spatial structure for newly regenerated bone ingrowth and integration. Alkali-thermal activation constructed a bioactive sodium titanate coating on the screw surface, which promoted the proliferation, adhesion, and osteogenic differentiation of BMSCs. This further enhances the biological performance of the implant surface interface, highlighting the advantages of structurally optimization. In the beagle vertebrae, the structurally optimized bioactive screw promoted the regeneration of surrounding bone and the inward growth of newly regenerated bone, strengthening the osseointegration strength at the implant interface and inside, thus synergistically enhancing biological fixation. This study pioneers the introduction of porous structure into a pedicle screw through structural optimization, which provides an innovative strategy for the development of spinal internal fixation and improves the potential value for advancing the utilization of 3D-printed orthopedic implants.
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Affiliation(s)
- Haoyuan Lei
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu 610064, Sichuan, China
| | - Zhigang Zhou
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
- Department of Orthopaedics, Jiujiang First People's Hospital, Jiujiang 332000, Jiangxi, China
| | - Jia Liu
- Department of Orthopedics, Department of Operations Management and Business Development, The People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang, China
| | - Hongfu Cao
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu 610064, Sichuan, China
| | - Lina Wu
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu 610064, Sichuan, China
| | - Ping Song
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Bangcheng Yang
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu 610064, Sichuan, China
| | - Wenzheng Zhou
- Department of Orthopedics, Department of Operations Management and Business Development, The People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang, China
| | - Yongsheng Liu
- Chengdu Advanced Metal Materials Industry Technology Research Institute Co., Ltd., Chengdu 610300, Sichuan, China
| | - Qingquan Kong
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Yujiang Fan
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu 610064, Sichuan, China
| | - Changchun Zhou
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu 610064, Sichuan, China
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Sherif R, Spence EC, Smith J, McCarthy MJH. Intraoperative imaging adequacy and its impact on unplanned return-to-theatre rates in pedicle screw instrumentation. World J Orthop 2025; 16:103955. [PMID: 40124730 PMCID: PMC11924020 DOI: 10.5312/wjo.v16.i3.103955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Revised: 01/13/2025] [Accepted: 02/18/2025] [Indexed: 03/12/2025] Open
Abstract
BACKGROUND Pedicle screw instrumentation is a critical technique in spinal surgery, offering effective stabilization for various spinal conditions. However, the impact of intraoperative imaging quality-specifically the use of both anteroposterior (AP) and lateral views-on surgical outcomes remains insufficiently studied. Evaluating whether the adequacy of these imaging modalities affects the risk of unplanned returns to theatre (URTT) within 90 days due to screw malplacement is essential for refining surgical practices and improving patient care. AIM To evaluate how intraoperative imaging adequacy influences unplanned return-to-theatre rates, focusing on AP and lateral fluoroscopic views. METHODS This retrospective cohort study analyzed 1335 patients who underwent thoracolumbar and sacral pedicle screw instrumentation between January 2013 and December 2022. Data on intraoperative imaging adequacy, screw placement, and URTT events were collected and statistically analyzed using IBM SPSS v23. Imaging adequacy was assessed based on the presence of both AP and lateral views, and outcomes were compared between imaging groups. RESULTS A total of 9016 pedicle screws were inserted, with 82 screws identified as malplaced in 52 patients. Of these, 46 patients required URTT due to screw malplacement, with 37 returning within 90 days (URTT90). Patients with both AP and lateral imaging saved intraoperatively had significantly lower URTT90 rates compared to those with only lateral imaging saved, demonstrating the critical role of imaging adequacy in improving surgical outcomes. CONCLUSION This study underscores that comprehensive intraoperative imaging with both AP and lateral views reduces unplanned returns, improves outcomes, enhances precision, and offers a cost-effective approach for better spinal surgery results.
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Affiliation(s)
- Ramy Sherif
- Department of Spinal Surgery, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Ella Clifford Spence
- Department of Spinal Surgery, Cardiff University, Cardiff CF14 4XW, United Kingdom
| | - Jessica Smith
- Department of Spinal Surgery, Cardiff University, Cardiff CF14 4XW, United Kingdom
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Eif M, Forster T, Fleege C, Kilian F, Schmitt AD, Daentzer D. Lumbar fusion using a carbon-fiber PEEK pedicle screw system combined with a carbon-fiber PEEK TLIF cage: a prospective, multicenter study. BMC Musculoskelet Disord 2025; 26:224. [PMID: 40050812 PMCID: PMC11883982 DOI: 10.1186/s12891-025-08457-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/19/2025] [Indexed: 03/10/2025] Open
Abstract
BACKGROUND Carbon-fiber-reinforced polyether ether ketone (CF-PEEK) is a radiolucent, non-metallic implant material used for instrumented lumbar spondylodesis. Clinical studies of pedicle screw systems employing this material, especially for degenerative indications, are scant. METHODS We conducted a multicenter, prospective clinical study to assess clinical and radiographic outcomes in patients with symptomatic degenerative lumbar disk disease, including degenerative spondylolisthesis treated with a CF-PEEK pedicle screw and a transforaminal lumbar interbody fusion (TLIF) cage system. We followed up the participants for two years postoperatively to collect clinical data (via the Oswestry Disability Index, Core Outcome Measures Index, and Visual Analog Scale), radiographic parameters (functional X-rays) to assess fusion status, and any complications. RESULTS In total, 86 patients were recruited. During the study, 21 patients (24.4%) dropped out, including 5 (5.8%) who underwent explantation of the study device(s). At the final follow-up, the fusion rate was 98.6% (95% confidence interval, 92.7-100.0%). All clinical parameters improved significantly. There were no complications potentially attributed to the implant material. CONCLUSIONS The results demonstrate a fusion rate similar to that of metallic implant systems with the use of a CF-PEEK pedicle screw and a TLIF cage system. Further studies with larger samples are needed to substantiate this finding. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov (NCT02087267). Date of registration: March 12, 2014.
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Affiliation(s)
- Marcus Eif
- Städtisches Klinikum Görlitz gGmbH, Klinik für Neurochirurgie, Girbigsdorfer Straße 1-3, 02828, Görlitz, Germany
| | - Thomas Forster
- Kantonsspital St. Gallen, Ostschweizer Wirbelsäulenzentrum, Rorschacher Strasse 95, St. Gallen, 9007, Switzerland
| | - Christoph Fleege
- Orthopädische Universitätsklinik Friedrichsheim gGmbH, Marienburgstrasse 2, 60528, Frankfurt am Main, Germany
| | - Francis Kilian
- Katholisches Klinikum Brüderhaus Koblenz, Klinik für Wirbelsäulenchirurgie, Kardinal- Krementz-Str. 1-5, 56073, Koblenz, Germany
| | - Anne Dorothée Schmitt
- Klinik für Neurochirurgie, UK S-H, Campus Kiel, Arnold-Heller-Str. 3, Haus 41, 24105, Kiel, Germany
| | - Dorothea Daentzer
- Orthopedic Department, Spine Section, Hannover Medical School, DIAKOVERE Annastift, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany.
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Qiang Z, Zhou Q, Liu X, Zheng B. Efficacy and Safety of Low-Density Pedicle Screw versus High-Density Screw in Lenke I Scoliosis: A Systematic Review and Meta-Analysis. World Neurosurg 2025; 193:79-90. [PMID: 39414137 DOI: 10.1016/j.wneu.2024.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Revised: 10/07/2024] [Accepted: 10/08/2024] [Indexed: 10/18/2024]
Abstract
OBJECTIVE To evaluate the efficacy and safety of low-density versus high-density pedicle screw in patients with Lenke I adolescent idiopathic scoliosis through systematic review and meta-analysis. METHODS A comprehensive literature search was conducted in PubMed, Web of Science, and Embase databases. Studies comparing low-density and high-density pedicle screw in Lenke I adolescent idiopathic scoliosis were included. Two authors independently selected studies, assessed risk of bias, and extracted data. Meta-analysis was performed using systematic review software. RESULTS The meta-analysis included 11 studies comprising 697 patients (397 in low-density group and 300 in high-density group). No significant differences were found between low-density and high-density groups in terms of blood loss, operative time, complication rates, or revision rates. Radiographic outcomes, including major Cobb angle, curve correction, thoracic kyphosis, and coronal and sagittal balance, were also similar between the groups. However, low-density pedicle screw was associated with significantly lower costs. CONCLUSIONS This meta-analysis suggests that low-density pedicle screw can achieve similar clinical and radiographic outcomes compared with high-density constructs in patients with Lenke I adolescent idiopathic scoliosis, while potentially reducing costs, making it a more cost-effective option without compromising patient outcomes.
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Affiliation(s)
- Zhe Qiang
- Department of Orthopedics Surgery, 363 Hospital, Chengdu, China
| | - Qiang Zhou
- Department of Orthopedics Surgery, 363 Hospital, Chengdu, China
| | - Xuanwen Liu
- Department of Orthopedics Surgery, 363 Hospital, Chengdu, China
| | - Bin Zheng
- Spine surgery, Peking University People's Hospital, Beijing, China.
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Luo K, Zou X, Chen W, Cui S, Liu S, Chen L, Zhou L. Robotic assistance for upper cervical instrumentation: report on accuracy and safety. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2025; 34:105-117. [PMID: 39485543 DOI: 10.1007/s00586-024-08510-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 09/12/2024] [Accepted: 09/29/2024] [Indexed: 11/03/2024]
Abstract
PURPOSE This study aims to evaluate the accuracy and safety of C1 lateral mass and upper cervical pedicle screw placement assisted by the TiRobot II system. METHODS Ten patients who underwent cervical spine surgery assisted by the TiRobot II system were included. Screw accuracy was assessed using the Gertzbein-Robbins scale and by comparing the final screw positions with pre-planned trajectories. Deviations in screw tip, tail, and angle were recorded. Clinical data, including symptoms, surgical outcomes, and postoperative follow-up, were collected. Neurological improvement was evaluated using pre- and post-operative mJOA scores, with recovery rates calculated by Hirabayashi's method to assess outcomes 3 months after surgery. RESULTS A total of 30 screws were placed in 10 patients. All screws (30/30) were within the clinically acceptable range, with 93.33% (28 screws) classified as Grade A and 6.67% (2 screws) as Grade B. In the sagittal plane, the average tip deviation was 1.82 ± 0.79 mm, tail deviation 1.64 ± 0.60 mm, and angular deviation 1.92 ± 1.39°. In the axial plane, tip deviation was 1.96 ± 0.87 mm, tail deviation 1.92 ± 0.65 mm, and angular deviation 2.01 ± 1.07°. The average surgery time was 318.80 ± 66.07 min, with a mean EBL of 205.00 ± 55.03 mL. Postoperative mJOA scores significantly improved from 8.10 ± 1.97 to 12.60 ± 1.78 (p < 0.05), with a 52 ± 14% recovery rate. All patients showed significant symptom improvement. CONCLUSION The TiRobot II system demonstrates the capability to precisely execute pre-planned trajectories and improves the accuracy and safety of C1 lateral mass and upper cervical screw placement.
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Affiliation(s)
- Kaihang Luo
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Xuenong Zou
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Wei Chen
- Department of Ophthalmology, The University of Hong Kong Sheznhen Hospital, Shenzhen, Guangdong, China
| | - Shangbin Cui
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China.
| | - Shaoyu Liu
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Liuyun Chen
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Lin Zhou
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
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Sturgill D, How J, Blajda T, Davis Z, Ali M, O'Malley G, Patel NV, Khan MF, Goldstein I. Are the Clinical Outcomes and Cost-Effectiveness of Robot-Assisted Pedicle Screw Placement in Lumbar Fusion Surgery Superior to Computed Tomography Navigation and Freehand Fluoroscopy-Guided Techniques? A Systematic Review and Network Meta-Analysis. World Neurosurg 2024; 191:81-90. [PMID: 39127382 DOI: 10.1016/j.wneu.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 08/01/2024] [Accepted: 08/03/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE Spinal fusion surgery is known to be an expensive intervention. Although innovative technologies in the field aim at improving operative efficiency and outcomes, total costs must be considered. The authors hope to elucidate any differences between robot-assisted (RA) and computed tomography navigation (CT-nav) or freehand fluoroscopy-guided (FFG) pedicle screw placement in relation to patient outcomes and cost-effectiveness in lumbar fusion surgery (LFS). METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the authors performed a systematic review to identify studies comparing clinical outcomes between CT-nav or RA versus FFG in LFS patients. All included studies utilized bilateral pedicle screws. Statistical analysis was performed using R. RESULTS Of the 1162 identified studies, 5 were included in the analysis. Direct evidence showed that RA decreased hospital length of stay when compared to FFG (mean difference [MD]: -2.67 days; 95% confidence interval [CI]: -4.25 to -1.08; P < 0.01). Indirect evidence showed that RA decreased operative time when compared to CT-nav (MD: -65.57 minutes; 95% CI: -127.7 to -3.44; P < 0.05). For estimated blood loss, direct evidence showed that RA was superior to FFG (MD: -120.62 mL; 95% CI: -206.39 to -34.86; P < 0.01). However, no significant difference was found between RA and CT-nav for estimated blood loss (MD: 14.88 mL; 95% CI: -105.54 to 135.3; P > 0.05). There were no other significant differences in Oswestry Disability Index, visual analog scale, or complication or reoperation rates between RA and FFG or CT-nav. CONCLUSIONS This study shows that RA pedicle screw placement in LFS provides similar patient outcomes to CT-nav and FFG. Robot-assisted operations were found to give rise to cost savings via decreased length of stay when compared to both CT-nav and FFG techniques. Cost-savings of $4086-$4865/patient and $7317-$9654/patient could be achieved when utilizing RA over CT-nav and FFG, respectively. However, extra upfront and maintenance costs may impact full adoption of RA in LFS.
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Affiliation(s)
- Drew Sturgill
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.
| | - Justine How
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Timothy Blajda
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Zachary Davis
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Mir Ali
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Geoffrey O'Malley
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Nitesh V Patel
- Department of Neurosurgery, HMH-Jersey Shore University Medical Center, Neptune, New Jersey, USA
| | - Mohammed F Khan
- Department of Neurosurgery, Hackensack University Medical Center, Nutley, New Jersey, USA
| | - Ira Goldstein
- Department of Neurosurgery, Hackensack University Medical Center, Nutley, New Jersey, USA
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Nkwerem SP, Ohaegbulam SC, Mezue W, Emejulu JKC, Ndubuisi CA, Nkwerem GI. Lumbar Pedicle Dimensions Using CT Scan in Adults of South-Eastern Nigeria as Related to Transpedicular Fixation. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2024; 14:396-402. [PMID: 39309380 PMCID: PMC11412596 DOI: 10.4103/jwas.jwas_169_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/24/2024] [Indexed: 09/25/2024]
Abstract
Background Transpedicular fixation depends on accuracy of the entry points, angle of insertion and pedicular isthmus width for adequate screw insertion. Preoperative measurements of pedicle dimensions reduce the chances of failure during insertion. These pedicle dimensions (transverse diameter, longitudinal diameter, and maximum length of purchase [MLP]) vary with sex and race. Such data, from a large-scale study, are not available for our population. Objective The study aims to evaluate the dimensions of pedicle that are relevant for pedicle screw fixation in Southeast Nigerian population. Materials and Methods A prospective multi-slice CT based clinical anatomy study done at Memfys Hospital for Neurosurgery, Enugu. This study is on the lumbar pedicle dimensions that are related to transpedicular fixation (transverse and longitudinal diameters of the pedicle, MLP, pedicle transverse and longitudinal angles of inclination). Sample size (273) was calculated with the confidence interval formula based on the number of patients that present for images. Consent and ethical approval were obtained. Results The mean values are as follow: LD1 8.22 mm, LD2 7.73 mm, LD3 7.40 mm, LD4 7.16 mm, LD5 6.87 mm TD1 5.05 mm, TD2 5.31 mm, TD3 6.72 mm, TD4 8.27 mm, TD5 11.31 mm, MLP1 46.60 mm, MLP2 47.97 mm, MLP3 47.14 mm, MLP4 45.54 mm, MLP5 43.47 mm TA1 17.8°, TA2 19.34°, TA3 20.80°, TA4 22.00°, TA5 25.70° LA1 19.42°, LA2 18.61°, LA3 18.00°, LA4 17.09°, LA5 16.40°. Unlike transverse diameter, transverse angle, longitudinal dimension, longitudinal angle (LA), MLP there was significant correlation between age and mean LA. The mean values also correlated significantly with the gender. Conclusion The mean values varied with the different vertebral levels and was good correlations between some of the parameters with age and gender.
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Affiliation(s)
- Sunday Patrick Nkwerem
- Faculty of Medicine, Department of Surgery, Nnamdi Azikiwe University, Nnewi Campus, Awka, Nigeria
| | | | - Wilfred Mezue
- Department of Surgery, University of Nigeria, Enugu Campus, Nigeria
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Kanhangad MP, Srinivasa V, Thirugnanam B, Soni A, Kashyap A, Vidyadhara A, Rao SK. Robotic spine systems: overcoming surgeon experience in pedicle screw accuracy: a prospective study. Asian Spine J 2024; 18:663-672. [PMID: 39434223 PMCID: PMC11538820 DOI: 10.31616/asj.2024.0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/09/2024] [Accepted: 08/11/2024] [Indexed: 10/23/2024] Open
Abstract
STUDY DESIGN Prospective single-center study. PURPOSE To compare the accuracy of pedicle screws placed by freehand and under fluoroscopy and robotic assistance with intraoperative image acquisition. OVERVIEW OF LITERATURE Pedicle screws are the most commonly used spinal anchors owing to their ability to stabilize all three spinal columns. Various techniques such as freehand, fluoroscopy-assisted, and navigation-assisted pedicle screw placements have been used with varying degrees of accuracy. Most studies on robotic-assisted pedicle screw placement have utilized preoperatively acquired computed tomography scans. To our knowledge, this is the only study in the literature that compared freehand with fluoroscopy-guided and robotic-assisted pedicle screw insertion with freehand and fluoroscopy. METHODS In this prospective study, a total of 1,120 pedicle screws were placed in the freehand group (n=175), 1,250 in the fluoroscopyassisted group (n=172), and 1,225 in the robotic-assisted group (n=180). Surgical parameters and screw accuracy were analyzed between the three groups. The preoperative plan overlapped with the postoperative O-arm scan to determine if the screws were executed as planned. RESULTS The frequency of clinically acceptable screw placement (Gertzbein-Robbins grades A and B) in the freehand, fluoroscopy-assisted, and robotic-assisted groups were 97.7%, 98.6%, and 99.34%, respectively. With robotic assistance, an experience-neutralizing effect implied that surgeons with varying levels of experience achieved comparable pedicle screw accuracy, blood loss, O-arm time, robot time, and time per screw. No significant difference in these parameters was found between surgeries commencing before and after 2 PM. No significant differences were noted between the planned and executed screw trajectories in the robotic-assisted group irrespective of surgical experience. CONCLUSIONS The third-generation robotic-assisted pedicle screw placement system used in conjunction with intraoperative threedimensional O-arm imaging consistently demonstrates safe and accurate screw placement with an experience-neutralizing effect.
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Affiliation(s)
- Madhava Pai Kanhangad
- Manipal Institute of Robotic Spine Surgery, Manipal Comprehensive Spine Care Centre, Manipal Hospital, Bangalore,
India
- Department of Orthopaedics, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal,
India
| | - Vidyadhara Srinivasa
- Manipal Institute of Robotic Spine Surgery, Manipal Comprehensive Spine Care Centre, Manipal Hospital, Bangalore,
India
- Department of Orthopaedics, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal,
India
| | - Balamurugan Thirugnanam
- Manipal Institute of Robotic Spine Surgery, Manipal Comprehensive Spine Care Centre, Manipal Hospital, Bangalore,
India
| | - Abhishek Soni
- Manipal Institute of Robotic Spine Surgery, Manipal Comprehensive Spine Care Centre, Manipal Hospital, Bangalore,
India
| | - Anjana Kashyap
- Department of Spine Anesthesia, Manipal Comprehensive Spine Care Center, Manipal Hospital, Bangalore,
India
- Department of Anesthesiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal,
India
| | - Alia Vidyadhara
- Department of Spine Anesthesia, Manipal Comprehensive Spine Care Center, Manipal Hospital, Bangalore,
India
| | - Sharath Kumar Rao
- Department of Orthopaedics, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal,
India
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Beucler N, Cungi PJ, Dagain A, Joubert C. Accuracy and Safety of Freehand Placement of Upper Thoracic Pedicle Screws Supported Solely by Anteroposterior, i.e., Frontal, X-Ray Fluoroscopy (C-Arm): Technical Note Including 23 Patients. World Neurosurg 2024; 191:25-34. [PMID: 39111660 DOI: 10.1016/j.wneu.2024.07.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 07/28/2024] [Accepted: 07/30/2024] [Indexed: 09/02/2024]
Abstract
BACKGROUND Biomechanical resistance and surgical morbidity of spinal posterior pedicle screw fixation depend on the intraosseous position of the implants. Upper thoracic pedicle screws are particularly demanding given their convergence and thin character. We present our experience as military surgeons of freehand placement of upper thoracic pedicle screws supported solely by anteroposterior, i.e., frontal x-ray fluoroscopy. METHODS A single-center retrospective analysis was performed at Sainte-Anne Military Teaching Hospital between 2017 and 2024 of patients in whom upper thoracic pedicle screw (T1-T5) were placed with anteroposterior fluoroscopy guidance only. RESULTS Analysis included 23 patients (mean age 59; male/female ratio 3.6; 16 traumatic lesions and 7 neoplastic lesions) in whom 15 cervicothoracic junction fixation and 8 upper thoracic spine surgeries were performed. Of 124 screws inserted (T1-T5), 85% (106/124) were graded 0 (Gertzbein-Robbins scale), whereas 14.5% (18/124) displayed some degree of misplacement (grades 1-3). All T1 screws (22/22) were accurately placed compared with 83% (20/24) of T2 screws, 88% (30/34) of T3 screws, 85% (17/20) of T4 screws, and 71% (17/24) of T5 screws, with no clinical complications. There were 3 surgical revisions (1 asymptomatic misplaced screw, 2 mechanical failures in trauma). Finally, 92.7% (51/55) of the screws inserted during working hours were accurately placed compared with 79.7% (55/69) inserted during after-hours surgeries (P = 0.039). CONCLUSIONS Clinically, placement of upper thoracic pedicle screws supported solely by anteroposterior fluoroscopy appears to be safe. The surgical technique is simple enough to be used in settings with limited resources, such as a mobile field surgical team.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France.
| | | | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France; Val-de-Grâce Military Academy, Paris, France
| | - Christophe Joubert
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France
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12
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Chiu CK, Wang WJ, Lee YJ, Chung WH, Chan CYW, Kwan MK. The widths of the medial and lateral pedicle walls in adolescent idiopathic scoliosis with major thoracic curves. Spine J 2024; 24:1293-1301. [PMID: 38408520 DOI: 10.1016/j.spinee.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/18/2024] [Accepted: 02/19/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND CONTEXT The widths of medial and lateral pedicle walls in the normal spine of middle-aged and elderly adults have been investigated and these studies found that the medial pedicle wall was thicker than the lateral pedicle wall. However, none had evaluated the widths of medial and lateral pedicle walls on adolescent or young adult scoliotic spines. PURPOSE This study aims to identify the distribution and variation of medial and lateral pedicle wall widths throughout the different vertebral levels of the scoliotic spine and its differences according to age, gender, body mass index (BMI), maturity, curve types and curve severity in adolescent idiopathic scoliotic (AIS) patients with major thoracic curves. STUDY DESIGN Retrospective study. PATIENT SAMPLE A total of 6,230 pedicles (right: 3,064, left: 3,166) from 191 patients were included in this study, with 264 (right: 183, left: 81) fully corticalized pedicles excluded from analysis. OUTCOME MEASURES Demographic data were age, gender, height, weight, BMI, Risser grade, Lenke curve types and Cobb angles. The main outcome measures were medial and lateral pedicle wall widths. Associations between pedicle wall widths and demographic data were calculated. METHODS This was a subanalytical retrospective study done on the same patient population as the previously published study on pedicle grading. The data was obtained from the main computed tomography (CT) scan pedicle study dataset. Medial and lateral pedicle wall widths were measured in the axial slices of CT scans from T1 to L5 vertebrae. RESULTS A total of 6,230 pedicles (right: 3,064, left: 3,166) from 191 patients were included in this study with 264 (right: 183, left: 81) fully corticalized pedicles excluded from analysis. Right-sided medial pedicle wall widths were narrower from T4-T10 (0.75±0.23 mm) compared to T1-T3 (0.89±0.28 mm) and T11-L5 (0.92±0.30 mm). Left-sided medial pedicle wall widths were narrower from T4 to T7 (0.76±0.24 mm) compared to T1-T3 (0.88±0.26 mm) and T8-L5 (0.90±0.27 mm). Medial cortical wall widths were significantly thicker compared to lateral cortical wall widths for all vertebras from T1 to L5 (right medial 0.85±0.28 mm vs lateral 0.64±0.26 mm (p<.001), left medial 0.86±0.26 mm vs lateral 0.64±0.26 mm (p<.001)). The left medial pedicle wall widths were marginally significantly (p<.001) thicker than the right side (right medial 0.85±0.28 mm vs left 0.86±0.26 mm). The main notable significant differences were located at the periapical region of the thoracic curve between T7 to T10 with the left concave medial pedicle width being thicker than the right convex medial pedicle width. The thinnest medial pedicle walls were located at right concave T7 (0.73±0.24 mm) and T8 (0.73±0.23 mm). We generally found no significant associations between the medial and lateral pedicle wall widths with age, gender, BMI, Risser grade, Cobb angle and curve types. CONCLUSIONS Knowledge on the widths of medial and lateral pedicle walls, their distribution and differences in a scoliotic spine is important for pedicle screw fixation, especially during pedicle probing to find the pedicle channel. The medial pedicle wall widths were significantly thicker than the lateral pedicle wall widths in AIS patients with major thoracic curves. The right concave periapical region had the thinnest medial pedicle walls.
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Affiliation(s)
- Chee Kidd Chiu
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Wee Jieh Wang
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Yu Jie Lee
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Weng Hong Chung
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Chris Yin Wei Chan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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Sharma S, Sun Y, Bonyun J, Khadem M, Amadio J, Eskandari AH, Alambeigi F. A Biomechanics-Aware Robot-Assisted Steerable Drilling Framework for Minimally Invasive Spinal Fixation Procedures. IEEE Trans Biomed Eng 2024; 71:1810-1819. [PMID: 38206784 PMCID: PMC11168586 DOI: 10.1109/tbme.2024.3352607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
In this paper, we propose a novel biomechanics-aware robot-assisted steerable drilling framework with the goal of addressing common complications of spinal fixation procedures occurring due to the rigidity of drilling instruments and implants. This framework is composed of two main unique modules to design a robotic system including (i) a Patient-Specific Biomechanics-aware Trajectory Selection Module used to analyze the stress and strain distribution along an implanted pedicle screw in a generic drilling trajectory (linear and/or curved) and obtain an optimal trajectory; and (ii) a complementary semi-autonomous robotic drilling module that consists of a novel Concentric Tube Steerable Drilling Robot (CT-SDR) integrated with a seven degree-of-freedom robotic manipulator. This semi-autonomous robot-assisted steerable drilling system follows a multi-step drilling procedure to accurately and reliably execute the optimal hybrid drilling trajectory (HDT) obtained by the Trajectory Selection Module. Performance of the proposed framework has been thoroughly analyzed on simulated bone materials by drilling various trajectories obtained from the finite element-based Selection Module using Quantitative Computed Tomography (QCT) scans of a real patient's vertebra.
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Ryu S, Ha BJ, Yoon S, Lee CK, Shin DA, Kim KN, Yi S. Feasibility and safety report on robotic assistance for cervical pedicle screw fixation: a cadaveric study. Sci Rep 2024; 14:10881. [PMID: 38740762 DOI: 10.1038/s41598-024-60435-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
This cadaveric study aimed to evaluate the safety and usability of a novel robotic system for posterior cervical pedicle screw fixation. Three human cadaveric specimens and C2-T3 were included. Freshly frozen human cadaver specimens were prepared and subjected to robot-assisted posterior cervical pedicle screw fixation using the robotic system. The accuracy of screw placement, breach rate, and critical structure violations were evaluated. The results were statistically compared with those of previous studies that used different robotic systems for cervical pedicle screw fixation. The robotic system demonstrated a high accuracy rate in screw placement. A significant number of screws were placed within predetermined safe zones. The total entry offset was 1.08 ± 0.83 mm, the target offset was 1.86 ± 0.50 mm, and the angle offset was 2.14 ± 0.77°. Accuracy rates comparable with those of previous studies using different robotic systems were achieved. The system was also feasible, allowing precise navigation and real-time feedback during the procedure. This cadaveric study validated the safety and usability of the novel robotic system for posterior cervical pedicle screw fixation. The system exhibited high precision in screw placement, and the results support the extension of the indications for robot-assisted pedicle screw fixation from the lumbar spine to the cervical spine.
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Affiliation(s)
- Seungjun Ryu
- Department of Neurosurgery, Daejeon Eulji University Hospital, School of Medicine, Eulji University, Daejeon, South Korea
- IBS Center for Cognition and Sociality, Expo-ro, Doryong-dong, Yuseong-gu, Daejeon, South Korea
| | - Byeong-Jin Ha
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri, Gyeonggi-do, 11923, Republic of Korea
| | - Sunjin Yoon
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Chang Kyu Lee
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Keung-Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
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Sakhrekar R, Shkumat N, Ertl-Wagner B, Lewis S, Lebel D, McVey MJ, Camp M. Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis. Spine Deform 2024; 12:739-746. [PMID: 38413472 DOI: 10.1007/s43390-024-00830-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 01/13/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. METHOD A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). RESULTS 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. CONCLUSION Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.
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Affiliation(s)
- Rajendra Sakhrekar
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Nicholas Shkumat
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Stephen Lewis
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - David Lebel
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - M J McVey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
| | - Mark Camp
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Zhang J, Xu J, Xu C, Xie Y. Posterior endpoint determination of the lumbar pedicle central axis on the anterior-posterior fluoroscopic image for pedicle screw insertion. Sci Rep 2024; 14:9272. [PMID: 38653756 DOI: 10.1038/s41598-024-57349-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/18/2024] [Indexed: 04/25/2024] Open
Abstract
The transpedicular procedure has been widely used in spinal surgery. The determination of the best entry point is the key to perform a successful transpedicular procedure. Various techniques have been used to determine this point, but the results are variable. This study was carried out to determine the posterior endpoint of the lumbar pedicle central axis on the standard anterior-posterior (AP) fluoroscopic images. Computer-aided design technology was used to determine the pedicle central axis and the posterior endpoint of the pedicle central axis on the posterior aspect of the vertebra. The standard AP fluoroscopic image of the lumbar vertebral models by three-dimensional printing was achieved. The endpoint projection on the AP fluoroscopic image was determined in reference to the pedicle cortex projection by the measurements of the angle and distance on the established X-Y coordinate system of the radiologic image. The projection of posterior endpoint of the lumbar pedicle central axis were found to be superior to the X-axis of the established X-Y coordinate system and was located on the pedicle cortex projection on the standard AP fluoroscopic image of the vertebra. The projection point was distributed in different sectors in the coordinate system. It was located superior to the X-axis by 18° to 26° at L1, while they were located superior to the X-axis by 12° to 14° at L2 to L5. The projections of posterior endpoints of the lumbar pedicle central axis were located in different positions on the standard AP fluoroscopic image of the vertebra. The determination method of the projection point was helpful for selecting an entry point for a transpedicular procedure with a fluoroscopic technique.
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Affiliation(s)
- Jun Zhang
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Orthopaedic Surgery, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jiawei Xu
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chenyang Xu
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Youzhuan Xie
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
- Department of Orthopaedic Surgery, Quanzhou Taiwanese Investment Zone Hospital, Fujian, China.
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Wang P, Xin Y, Zhou S, Duan S, Bai D, Li B, Xu W. Efficacy of computer-assisted robotic based clinical training program for spinal oncology education on pedicle screw placement. J Robot Surg 2024; 18:150. [PMID: 38564025 PMCID: PMC10987351 DOI: 10.1007/s11701-023-01804-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 04/04/2024]
Abstract
Pedicle screw placement (PSP) is the fundamental surgical technique that requires high accuracy for novice orthopedists studying spinal oncology education. Therefore, we set forth to establish a computer-assisted robotic navigation training program for novice spinal oncology education. Novice orthopedists were involved in this study to evaluate the feasibility and safety of the computer-assisted robotic navigation (CARN) training program. In this research, trainees were randomly taught by the CARN training program and the traditional training program. We prospectively collected the clinical data of patients with spinal tumors from 1st May 2021 to 1st March 2022. The ability of PSP was evaluated by cumulative sum (CUSUM) analysis, learning curve, and accuracy of pedicle screws. The patients included in both groups had similar baseline characteristics. In the CUSUM analysis of the learning curve for accurate PSP, the turning point in the CARN group was lower than that in the traditional group (70th vs. 92nd pedicle screw). The LC-CUSUM test indicated competency for PSP at the 121st pedicle screw in the CARN group and the 138th pedicle screw in the traditional group. The accuracy of PSP was also significantly higher in the CARN group than in the traditional group (88.17% and 79.55%, P = 0.03 < 0.05). Furthermore, no major complications occurred in either group. We first described CARN in spinal oncology education and indicated the CARN training program as a novel, efficient and safe training program for surgeons.
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Affiliation(s)
- Pengru Wang
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Yingye Xin
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Shangbin Zhou
- Department of Orthopedics, Naval Medical Center, Naval Military Medical University, Shanghai, China
| | - Shujie Duan
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Danyang Bai
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Bo Li
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
| | - Wei Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China.
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Leblond L, Godio-Raboutet Y, Glard Y, La Greca R, Clement T, Evin M. Assessment of the tolerance angle for pedicle screw insertion. Med Biol Eng Comput 2024; 62:1265-1275. [PMID: 38177833 DOI: 10.1007/s11517-023-03002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024]
Abstract
Cannulation process intervenes before implantation of pedicle screw and depends on the surgeon's experience. A reliable experimental protocol has been developed for the characterization of the slipping behavior of the surgical tool on the cortical shell simulated by synthetic materials. Three types of synthetic foam samples with three different densities were tested using an MTS Acumen 3 A/T electrodynamic device with a tri-axis 3 kN Kistler load cell mounted on a surgical tool, moving at a constant rotational speed of 10° mm-1 and performing a three-step cannulation test. Cannulation angle varied between 10° and 30°. Synthetic samples were scanned after each tests, and cannulation coefficient associated to each perforation section was computed. Reproducibility tests resulted in an ICC for Sawbone samples of 0.979 (p < 0.001) and of 0.909 (p < 0.001) for Creaplast and Sawbone samples. Cannulation coefficient and maximum force in Z-axis are found the best descriptors of the perforation. Angular threshold for perforation prediction was found to be 17.5° with an area under the curve of the Receiver Operating Characteristic of 89.5%. This protocol characterizes the cannulation process before pedicle screw insertion and identifies the perforation tool angle until which the surgical tool slips on the cortical shell depending on bone quality.
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Affiliation(s)
- Lugdivine Leblond
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France
| | - Yves Godio-Raboutet
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France
| | - Yann Glard
- Department of Paediatric Orthopaedics, Saint Joseph Hospital, Marseille, France
| | - Raphael La Greca
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France
| | - Thomas Clement
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France
| | - Morgane Evin
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France.
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Hwang YH, Ha BJ, Kim HC, Lee BH, Park JY, Chin DK, Yi S. A Propensity Score-Matched Cohort Study Comparing 3 Different Spine Pedicle Screw Fixation Methods: Freehand, Fluoroscopy-Guided, and Robot-Assisted Techniques. Neurospine 2024; 21:83-94. [PMID: 38569633 PMCID: PMC10992644 DOI: 10.14245/ns.2448036.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/14/2024] [Accepted: 02/18/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE This study aimed to compare the accuracy of robotic spine surgery and conventional pedicle screw fixation in lumbar degenerative disease. We evaluated clinical and radiological outcomes to demonstrate the noninferiority of robotic surgery. METHODS This study employed propensity score matching and included 3 groups: robot-assisted mini-open posterior lumbar interbody fusion (PLIF) (robotic surgery, RS), c-arm guided minimally invasive surgery transforaminal lumbar interbody fusion (C-arm guidance, CG), and freehand open PLIF (free of guidance, FG) (54 patients each). The mean follow-up period was 2.2 years. The preoperative spine condition was considered. Accuracy was evaluated using the Gertzbein-Robbins scale (GRS score) and Babu classification (Babu score). Radiological outcomes included adjacent segmental disease (ASD) and mechanical failure. Clinical outcomes were assessed based on the visual analogue scale, Oswestry Disability Index, 36-item Short Form health survey, and clinical ASD rate. RESULTS Accuracy was higher in the RS group (p < 0.01) than in other groups. The GRS score was lower in the CG group, whereas the Babu score was lower in the FG group compared with the RS group. No significant differences were observed in radiological and clinical outcomes among the 3 groups. Regression analysis identified preoperative facet degeneration, GRS and Babu scores as significant variables for radiological and clinical ASD. Mechanical failure was influenced by the GRS score and patients' age. CONCLUSION This study showed the superior accuracy of robotic spine surgery compared with conventional techniques. When combined with minimally invasive surgery, robotic surgery is advantageous with reduced ligament and muscle damage associated with traditional open procedures.
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Affiliation(s)
- Yoon Ha Hwang
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong-Jin Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Hyung Cheol Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Byung Ho Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Kyu Chin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
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20
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Li Q, Zhao H, Yang J, Song S, Liu X. Optimization of Pedicle Screw Parameters for Enhancing Implant Stability Based on Finite Element Analysis. World Neurosurg 2024; 183:e345-e354. [PMID: 38151174 DOI: 10.1016/j.wneu.2023.12.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE To improve implant stability parameters, including pedicle screw (PS) outer diameter, thread depth, and pitch, by finite element analysis. METHODS Insertion and pullout of the PS were simulated by finite element analysis, and the precision of simulation was evaluated by comparison with mechanical tests. Influences of the parameters on the maximum insertion torque and maximum pullout force were analyzed by computational simulations, including single-factor analysis and orthogonal experiments. RESULTS The simulation results agreed with the mechanical test results. The order of parameters influencing insertion torque and pullout force was outer diameter > pitch > thread depth. When the pilot hole diameter is 0.1 mm larger than the inner diameter of the PS, the calculated Pearson correlation coefficient between the maximum insertion torque and maximum pullout force was r = 0.99. The optimized PS had a maximum insertion torque of 485.16 N·mm and a maximum pullout force of 1726.33 N, 23.9% and 9.1% higher, respectively, than the values of standard screws. CONCLUSIONS The presently used models are feasible for evaluating the implant stability of PSs. The maximum insertion torque and maximum pullout force of PSs are highly correlated and can be improved by increasing the outer diameter and decreasing pitch. Although with the parameters of the PS, pedicle size and bone mineral density are 2 additional factors to consider for better implant stability.
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Affiliation(s)
- Qiang Li
- School of Mechanical Engineering, University of Shanghai for Science and Technology, Shanghai, People's Republic of China; Shanghai Engineering Research Center of High-Performance Medical Device Materials, Shanghai, People's Republic of China.
| | - Hu Zhao
- School of Mechanical Engineering, University of Shanghai for Science and Technology, Shanghai, People's Republic of China
| | - Jinshuai Yang
- School of Mechanical Engineering, University of Shanghai for Science and Technology, Shanghai, People's Republic of China
| | - Shihong Song
- School of Mechanical Engineering, University of Shanghai for Science and Technology, Shanghai, People's Republic of China
| | - Xuyan Liu
- School of Mechanical Engineering, University of Shanghai for Science and Technology, Shanghai, People's Republic of China
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21
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Oberthür S, Roch PJ, Klockner F, Jäckle KB, Viezens L, Lehmann W, Sehmisch S, Weiser L. Can You Feel it? - Correlation Between Intraoperatively Perceived Bone Quality and Objectively Measured Bone Mineral Density. Global Spine J 2024; 14:631-638. [PMID: 35993490 PMCID: PMC10802517 DOI: 10.1177/21925682221120398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN clinical study. OBJECTIVES Loosening of pedicle screws is a frequent complication in patients with osteoporosis. The indication for additional stabilization, such as cement augmentation, is more often based on the subjective intraoperative feeling of the surgeon than on a preoperative bone mineral density (BMD) measurement. Aim was to evaluate the correlation of the intraoperative perceived bone quality in comparison to the objectively measured BMD. METHODS A total of 62 patients undergoing dorsal stabilization using pedicle screws at a level-1 trauma center were analyzed. The preoperative CT scan measured each instrumented vertebra's pedicle size and BMD. During the surgery, the perceived screw stability was graded by the respective surgeon for each screw. RESULTS 204 vertebral bodies were evaluated. Looking at all implanted screws a significant correlation between the measured BMD and the perceived screw stability was found (Resident r = .450; R2 = .202; P < .001/Attending r = .364; R2 = .133; P < .001), but there was no significant correlation in the osteoporotic patients (Resident P = .148 / Attending P = .907). The evaluation of the screws implanted in osteoporotic vertebrae showed that the surgeons considered a total of 31% of these screws to be sufficiently stable. CONCLUSIONS There was no significant correlation between the measured BMD and the perceived pedicle screw stability in the group with osteopenic / osteoporotic bone (<100 mg/cm³). The results indicate that it is not possible to reliably determine the bone quality and the resulting screw stability in patients with reduced BMD. The preoperative measurement of the BMD should become a crucial part of preoperative planning.
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Affiliation(s)
- Swantje Oberthür
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
- Department of Trauma Surgery, Medical School Hannover, Hannover, Germany
| | - Paul Jonathan Roch
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Friederike Klockner
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Katharina Blanka Jäckle
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Lennart Viezens
- Department of Trauma and Orthopaedic Surgery, Division of Spine Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Lehmann
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Stephan Sehmisch
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
- Department of Trauma Surgery, Medical School Hannover, Hannover, Germany
| | - Lukas Weiser
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
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22
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Li YD, Lai PL, Hsieh MK, Chen WP, Lee DM, Tsai TT, Tai CL. Influence of various pilot hole profiles on pedicle screw fixation strength in minimally invasive and traditional spinal surgery: a comparative biomechanical study. Front Bioeng Biotechnol 2024; 12:1359883. [PMID: 38380264 PMCID: PMC10877418 DOI: 10.3389/fbioe.2024.1359883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/25/2024] [Indexed: 02/22/2024] Open
Abstract
Despite advancements in pedicle screw design and surgical techniques, the standard steps for inserting pedicle screws still need to follow a set of fixed procedures. The first step, known as establishing a pilot hole, also referred to as a pre-drilled hole, is crucial for ensuring screw insertion accuracy. In different surgical approaches, such as minimally invasive or traditional surgery, the method of creating pilot holes varies, resulting in different pilot hole profiles, including variations in size and shape. The aim of this study is to evaluate the biomechanical properties of different pilot hole profiles corresponding to various surgical approaches. Commercially available synthetic L4 vertebrae with a density of 0.16 g/cc were utilized as substitutes for human bone. Four different pilot hole profiles were created using a 3.0 mm cylindrical bone biopsy needle, 3.6 mm cylindrical drill, 3.2-5.0 mm conical drill, and 3.2-5.0 mm conical curette for simulating various minimally invasive and traditional spinal surgeries. Two frequently employed screw shapes, namely, cylindrical and conical, were selected. Following specimen preparation, screw pullout tests were performed using a material test machine, and statistical analysis was applied to compare the mean maximal pullout strength of each configuration. Conical and cylindrical screws in these four pilot hole configurations showed similar trends, with the mean maximal pullout strength ranking from high to low as follows: 3.0 mm cylindrical biopsy needle, 3.6 mm cylindrical drill bit, 3.2-5.0 mm conical curette, and 3.2-5.0 mm conical drill bit. Conical screws generally exhibited a greater mean maximal pullout strength than cylindrical screws in three of the four different pilot hole configurations. In the groups with conical pilot holes, created with a 3.2-5.0 mm drill bit and 3.2-5.0 mm curette, both conical screws exhibited a greater mean maximal pullout strength than did cylindrical screws. The strength of this study lies in its comprehensive comparison of the impact of various pilot hole profiles commonly used in clinical procedures on screw fixation stability, a topic rarely reported in the literature. Our results demonstrated that pilot holes created for minimally invasive surgery using image-guided techniques exhibit superior pullout strength compared to those utilized in traditional surgery. Therefore, we recommend prioritizing minimally invasive surgery when screw implantation is anticipated to be difficult or there is a specific need for stronger screw fixation. When opting for traditional surgery, image-guided methods may help establish smaller pilot holes and increase screw fixation strength.
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Affiliation(s)
- Yun-Da Li
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Orthopedic Surgery, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Weng-Pin Chen
- Department of Mechanical Engineering, National Taipei University of Technology, Taipei, Taiwan
| | - De-Mei Lee
- Department of Mechanical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ching-Lung Tai
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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23
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Li Y, Wei X, Liang Y, Song G. Robot-assisted versus fluoroscopy-guided pedicle screw fixation of thoracolumbar compression fractures. Medicine (Baltimore) 2023; 102:e36430. [PMID: 38050284 PMCID: PMC10695527 DOI: 10.1097/md.0000000000036430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/10/2023] [Indexed: 12/06/2023] Open
Abstract
The aim of this study is to compare the clinical outcomes and accuracy of robot-assisted (RA) versus fluoroscopy-guided (FG) pedicle screw fixation of thoracolumbar compression fractures. We retrospectively enrolled 85 patients with surgically treated thoracolumbar compression fractures in our study (RA group, 45 patients; FG group, 40 patients). We analyzed the accuracy of pedicle screw placement by using the Gertzbein-Robbins classification, and calculated the one-time success rate (i.e., the rate of screws successfully inserted in the first attempt). We also evaluated volume of blood loss, operative time, visual analogue scale scores for pain, Cobb angle, and postoperative complications. The rates of grade A screw placement (96% vs 68.5%; P < .005), clinically acceptable screw placement (98.2% vs 86%; P < .005), and the one-time success rate (97.3% vs 82.5%; P < .005) were all significantly higher in the RA group than in the FG group. No differences were observed in sex, age, body mass index, volume of blood loss, operative time, visual analogue scale scores, Cobb angle, and postoperative complications between the 2 groups. Compared to FG surgery, RA surgery yielded greater accuracy and one-time success rates of pedicle screw fixation of thoracolumbar compression fractures, with comparable clinical outcomes.
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Affiliation(s)
- Yongjun Li
- Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Xing Wei
- Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Yonghui Liang
- Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Guangze Song
- Peking University Aerospace School of Clinical Medicine, Beijing, China
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24
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McCormick B, Asdourian PL, Johnson DC, Moatz BW, Duvall GT, Soda MT, Beaufort AR, Chotikul LG, McAfee PC. 100 Complex posterior spinal fusion cases performed with robotic instrumentation. J Robot Surg 2023; 17:2749-2756. [PMID: 37707742 DOI: 10.1007/s11701-023-01707-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
Robotic navigation has been shown to increase precision, accuracy, and safety during spinal reconstructive procedures. There is a paucity of literature describing the best techniques for robotic-assisted spine surgery for complex, multilevel cases or in cases of significant deformity correction. We present a case series of 100 consecutive multilevel posterior spinal fusion procedures performed for multilevel spinal disease and/or deformity correction. 100 consecutive posterior spinal fusions were performed for multilevel disease and/or deformity correction utilizing robotic-assisted placement of pedicle screws. The primary outcome was surgery-related failure, which was defined as hardware breakage or reoperation with removal of hardware. A total of 100 consecutive patients met inclusion criteria. Among cases included, 31 were revision surgeries with existing hardware in place. The mean number of levels fused was 5.6, the mean operative time was 303 min, and the mean estimated blood loss was 469 mL. 28 cases included robotic-assisted placement of S2 alar-iliac (S2AI) screws. In total, 1043 pedicle screws and 53 S2AI screws were placed with robotic-assistance. The failure rate using survivorship analysis was 18/1043 (1.7%) and the failure rate of S2AI screws using survivorship analysis was 3/53 (5.7%). Four patients developed postoperative wound infections requiring irrigation and debridement procedures. None of the 1043 pedicle screws nor the 53 S2AI screws required reoperation due to malpositioning or suboptimal placement. This case series of 100 multilevel posterior spinal fusion procedures demonstrates promising results with low failure rates. With 1043 pedicle screws and 53 S2AI screws, we report low failure rates of 1.7% and 5.7%, respectively with zero cases of screw malpositioning. Robotic screw placement allows for accurate screw placement with no increased rate of postoperative infection compared to historical controls. Level of evidence: IV, Retrospective review.
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25
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Mengesha MG, Meena J, Ramachandran K, Shetty AP, Thippeswamy PB, Kanna RM, Shanmuganathan R. Correlation Analysis Between Computed Tomography and Magnetic Resonance Imaging for Assessing Thoracic Pedicle Morphology. World Neurosurg 2023; 180:e599-e606. [PMID: 37793609 DOI: 10.1016/j.wneu.2023.09.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVE This study aimed to determine the accuracy and reliability of using magnetic resonance imaging (MRI) to characterize thoracic pedicle morphology in the normal population. METHODS Computed tomography (CT) and MRI datasets of 63 surgically treated patients were included in the study. Bilateral T3, T6, T9, and T12 vertebral levels were evaluated for the type of pedicle, pedicle chord length, and pedicle isthmic diameter on both MRI and CT scans. Pedicles were classified according to Sarwahi et al. into type A (normal pedicle), >4 mm cancellous channel; type B, 2-4 mm channel; type C, completely cortical channels >2 mm; and type D, <2 mm cortical bone channel. RESULTS Of 504 pedicles, 294 were classified as type A, 173 as type B, 24 as type C, and 13 as type D based on a CT scan. MRI had an overall accuracy rate of 92.86% for detecting type A, 96.53% for type B, and 100% for type C and type D compared with CT scans. Regarding the thoracic levels, MRI had an overall concordance of 97.98% at T3 level, 94.43% at T6 level, 98.11% at T9 level, and 99.3% at T12 level with CT readings. Comparing measurements between MRI and CT studies for pedicle isthmic diameter and pedicle chord length showed moderate to good reliability at all measured levels. CONCLUSIONS Pedicle measurements obtained by MRI may be used to estimate pedicle dimensions, allowing surgeons to preoperatively determine pedicle screw sizes based on MRI scans alone.
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Affiliation(s)
- Mengistu G Mengesha
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Jalaj Meena
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Karthik Ramachandran
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India.
| | | | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
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26
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Eastlack RK, Nunley PD, Poelstra KA, Vaccaro AR, Stone M, Miller LE, Legay P, Clin J, Agarwal A. Finite element analysis comparing a PEEK posterior fixation device versus pedicle screws for lumbar fusion. J Orthop Surg Res 2023; 18:855. [PMID: 37950318 PMCID: PMC10636999 DOI: 10.1186/s13018-023-04349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Pedicle screw loosening and breakage are common causes of revision surgery after lumbar fusion. Thus, there remains a continued need for supplemental fixation options that offer immediate stability without the associated failure modes. This finite element analysis compared the biomechanical properties of a novel cortico-pedicular posterior fixation (CPPF) device with those of a conventional pedicle screw system (PSS). METHODS The CPPF device is a polyetheretherketone strap providing circumferential cortical fixation for lumbar fusion procedures via an arcuate tunnel. Using a validated finite element model, we compared the stability and load transfer characteristics of CPPF to intact conditions under a 415 N follower load and PSS conditions under a 222 N preload. Depending on the instrumented levels, two different interbody devices were used: a lateral lumbar interbody device at L4-5 or an anterior lumbar interbody device at L5-S1. Primary outcomes included range of motion of the functional spinal units and anterior load transfer, defined as the total load through the disk and interbody device after functional motion and follower load application. RESULTS Across all combinations of interbody devices and lumbar levels evaluated, CPPF consistently demonstrated significant reductions in flexion (ranging from 90 to 98%), extension (ranging from 88 to 94%), lateral bending (ranging from 75 to 80%), and torsion (ranging from 77 to 86%) compared to the intact spine. Stability provided by the CPPF device was comparable to PSS in all simulations (range of motion within 0.5 degrees for flexion-extension, 0.6 degrees for lateral bending, and 0.5 degrees for torsion). The total anterior load transfer was higher with CPPF versus PSS, with differences across all tested conditions ranging from 128 to 258 N during flexion, 89-323 N during extension, 135-377 N during lateral bending, 95-258 N during torsion, and 82-250 N during standing. CONCLUSION Under the modeled conditions, cortico-pedicular fixation for supplementing anterior or lateral interbody devices between L4 and S1 resulted in comparable stability based on range of motion measures and less anterior column stress shielding based on total anterior load transfer measures compared to PSS. Clinical studies are needed to confirm these finite element analysis findings.
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Affiliation(s)
- Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA, USA
| | | | - Kornelis A Poelstra
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, LA, USA
| | - Larry E Miller
- Miller Scientific, 3101 Browns Mill Road, Ste 6, #311, Johnson City, TN, 37604, USA.
| | | | | | - Aakash Agarwal
- Departments of Bioengineering and Orthopaedic Surgery, University of Toledo, Toledo, OH, USA
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Mullins RA, Espinel Ruperéz J, Bleedorn J, Hoey S, Hetzel S, Ortega C, Kraus KH, Guevar J. Accuracy of pin placement in the canine thoracolumbar spine using a free-hand probing technique versus 3D-printed patient-specific drill guides: An ex-vivo study. Vet Surg 2023; 52:648-660. [PMID: 37071824 DOI: 10.1111/vsu.13958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/17/2023] [Accepted: 03/20/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVE To compare pin placement accuracy, intraoperative technique deviations, and duration of pin placement for pins placed by free-hand probing (FHP) or 3D-printed drill guide (3DPG) technique. SAMPLE POPULATION Four greyhound cadavers. METHODS Computed tomography (CT) examinations from T6-sacrum were obtained for determination of optimal pin placement and 3DPG creation. Two 3.2/2.4-mm positive profile pins were inserted per vertebra, one left and one right from T7-L7 (FHP [n = 56]; 3DPG [n = 56]) by one surgeon and removed for repeat CT. Duration of pin placement and intraoperative deviations (unanticipated deviations from planned technique) were recorded. Pin tracts were graded by two blinded observers using modified Zdichavsky classification. Descriptive statistics were used. RESULTS A total of 54/56 pins placed with 3DPGs were assigned grade I (optimal placement) compared with 49/56 pins using the FHP technique. A total of 2/56 pins placed with 3DPGs and 3/56 pins using the FHP technique were assigned grade IIa (partial medial violation). A total of 4/56 pins placed using the FHP technique were assigned grade IIIa (partial lateral violation). No pins were assigned grade IIb (full medial violation). Intraoperative technique deviations occurred with 6/56 pins placed using the FHP technique and no pins with 3DPGs. Overall, pins were placed faster (mean ± SD 2.6 [1.3] vs. 4.5 [1.8] min) with 3DPGs. CONCLUSIONS Both techniques were accurate for placement of spinal fixation pins. The 3DPG technique may decrease intraoperative deviations and duration of pin placement. CLINICAL RELEVANCE Both techniques allow accurate pin placement in the canine thoracolumbar spine. The FHP technique requires specific training and has learning curve, whereas 3DPG technique requires specific software and 3D printers.
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Affiliation(s)
- Ronan A Mullins
- Section of Small Animal Clinical Studies, University College Dublin, Dublin, Ireland
| | - Jorge Espinel Ruperéz
- Section of Small Animal Clinical Studies, University College Dublin, Dublin, Ireland
| | - Jason Bleedorn
- Department of Veterinary Clinical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Seamus Hoey
- Equine Clinical Studies, Diagnostic Imaging and Anaesthesia, School of Veterinary Medicine, University College Dublin, Dublin, Ireland
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Cristina Ortega
- Section of Small Animal Clinical Studies, University College Dublin, Dublin, Ireland
| | - Karl H Kraus
- Department of Clinical Sciences, College of Veterinary Medicine, Iowa State University, Iowa, USA
| | - Julien Guevar
- Division of Surgery, Department of Clinical Sciences, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Nunley PD, Eastlack RK, Miller LE, Poelstra KA, Cox JB, Shedden PM, Stone M. Metal-Free Cortico-Pedicular Device for Supplemental Fixation in Lumbar Interbody Fusion. World Neurosurg 2023; 174:4-10. [PMID: 36871655 DOI: 10.1016/j.wneu.2023.02.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Pedicle screw fixation is a commonly utilized adjunct for lumbar interbody fusion, yet risks include screw malposition, pullout, loosening, neurovascular injury, and stress transfers leading to adjacent segment degeneration. This report describes the preclinical and initial clinical results of a minimally invasive, metal-free cortico-pedicular fixation device used for supplemental posterior fixation in lumbar interbody fusion. METHODS Safety of arcuate tunnel creation was evaluated in cadaveric lumbar (L1-S1) specimens. A finite element analysis study evaluated clinical stability of the device to pedicular screw-rod fixation at L4-L5. Preliminary clinical results were assessed by analysis of Manufacturer and User Facility Device Experience database complications, and 6-month outcomes in 13 patients treated with the device. RESULTS Among 35 curved drill holes in 5 lumbar specimens, no breaches of the anterior cortex were identified. The mean minimum distance from the anterior surface of the hole to the spinal canal ranged from 5.1 mm at L1-L2 to 9.8 mm at L5-S1. In the finite element analysis study, the polyetheretherketone strap provided comparable clinical stability and reduced anterior stress shielding compared to the conventional screw-rod construct. The Manufacturer and User Facility Device Experience database identified 1 device fracture with no clinical sequelae among 227 procedures. Initial clinical experience showed a 53% decrease in pain severity (P = 0.009), a 50% decrease in Oswestry Disability Index (P < 0.001), and no device-related complications. CONCLUSIONS Cortico-pedicular fixation is a safe and reproducible procedure that may address limitations of pedicle screw fixation. Longer term clinical data in large clinical studies are recommended to confirm these promising early results.
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Affiliation(s)
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA, United States
| | | | - Kornelis A Poelstra
- The Robotic Spine Institute of Las Vegas at Nevada Spine Clinic, Las Vegas, NV, United States
| | - J Bridger Cox
- Neuroscience Specialists, Oklahoma City, OK, United States
| | - Peter M Shedden
- Greater Houston Neurosurgery Center, The Woodlands, TX, United States
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, LA, United States
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Li C, Song L, Xiao J, Wu W, Jiang Y, Zhou R, Dai F. Second-generation bone cement-injectable cannulated pedicle screws for osteoporosis: biomechanical and finite element analyses. J Orthop Surg Res 2023; 18:343. [PMID: 37161530 PMCID: PMC10170841 DOI: 10.1186/s13018-023-03752-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/24/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Biomechanical and finite element analyses were performed to investigate the efficacy of second-generation bone cement-injectable cannulated pedicle screws (CICPS) in osteoporosis. METHODS This study used the biomechanical test module of polyurethane to simulate osteoporotic cancellous bone. Polymethylmethacrylate (PMMA) bone cement was used to anchor the pedicle screws in the module. The specimens were divided into two groups for the mechanical tests: the experimental group (second-generation CICPS) and control group (first-generation CICPS). Safety was evaluated using maximum shear force, static bending, and dynamic bending tests. Biomechanical stability evaluations included the maximum axial pullout force and rotary torque tests. X-ray imaging and computed tomography were used to evaluate the distribution of bone cement 24 h after PMMA injection, and stress distribution at the screw fracture and screw-cement-bone interface was assessed using finite element analysis. RESULTS Mechanical testing revealed that the experimental group (349.8 ± 28.6 N) had a higher maximum axial pullout force than the control group (277.3 ± 8.6 N; P < 0.05). The bending moments of the experimental group (128.5 ± 9.08 N) were comparable to those of the control group (113.4 ± 20.9 N; P > 0.05). The screw-in and spin-out torques of the experimental group were higher than those of the control group (spin-in, 0.793 ± 0.015 vs. 0.577 ± 0.062 N, P < 0.01; spin-out, 0.764 ± 0.027 vs. 0.612 ± 0.049 N, P < 0.01). Bone cement was mainly distributed at the front three-fifths of the screw in both groups, but the distribution was more uniform in the experimental group than in the control group. After pullout, the bone cement was closely connected to the screw, without loosening or fragmentation. In the finite element analysis, stress on the second-generation CICPS was concentrated at the proximal screw outlet, whereas stress on the first-generation CICPS was concentrated at the screw neck, and the screw-bone cement-bone interface stress of the experimental group was smaller than that of the control group. CONCLUSION These findings suggest that second-generation CICPS have higher safety and stability than first-generation CICPS and may be a superior choice for the treatment of osteoporosis.
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Affiliation(s)
- Congcan Li
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng Street, Chongqing, 400038, China
| | - Lei Song
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng Street, Chongqing, 400038, China
| | - Jun Xiao
- Department of Special Service Physiological Training, Guangzhou Special Service Recuperation Center of PLA Rocket Force, Shantou, 515515, China
| | - Wenwen Wu
- Chinese People's Liberation Army 132U, Tunchang, 571627, China
| | - Yifan Jiang
- Fourth Department of Convalescence, Sanya Rehabilitation and Convalescent Center, Joint Logistics Support Force, Sanya, 572000, China
| | - Rui Zhou
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng Street, Chongqing, 400038, China.
| | - Fei Dai
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, No. 30 Gaotanyanzheng Street, Chongqing, 400038, China.
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Li YD, Hsieh MK, Chen WP, Lee DM, Tsai TT, Lai PL, Tai CL. Biomechanical evaluation of pedicle screw stability after 360-degree turnback from full insertion: effects of screw shape, pilot hole profile and bone density. Front Bioeng Biotechnol 2023; 11:1151627. [PMID: 37214307 PMCID: PMC10196264 DOI: 10.3389/fbioe.2023.1151627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/26/2023] [Indexed: 05/24/2023] Open
Abstract
Intraoperative pedicle screw depth adjustment after initial insertion, including both forward and backward adjustments, is sometimes necessary to facilitate rod application and ensure that the screw is in the correct position, which is determined by intraoperative fluoroscopy. Adjusting the screw with forward turns has no negative influence on the screw fixation stability; however, screw turnback may weaken the fixation stability. The aim of this study is to evaluate the biomechanical properties of screw turnback and demonstrate the reduction in the fixation stability after the screw is turned 360° from its full insertion position. Commercially available synthetic closed-cell polyurethane foams with three different densities simulating various degrees of bone density were utilized as substitutes for human bone. Two different screw shapes (cylindrical and conical) together with two different pilot hole profiles (cylindrical and conical) were tested. Following specimen preparation, screw pullout tests were conducted using a material test machine. The mean maximal pullout strength between full insertion and 360-degree turnback from full insertion in each setting was statistically analyzed. The mean maximal pullout strength after 360-degree turnback from full insertion was generally lower than that at full insertion. The reduced mean maximal pullout strength after turnback increased with decreasing bone density. Conical screws had significantly lower pullout strength after 360-degree turnback than cylindrical screws. The mean maximal pullout strength was reduced by up to approximately 27% after 360-degree turnback when using a conical screw in a low bone density specimen. Additionally, specimens treated with a conical pilot hole presented a less reduction in pullout strength after screw turnback as compared to those with a cylindrical pilot hole. The strength of our study was that we systematically investigated the effects of various bone densities and screw shapes on screw stability after turnback, which has rarely been reported in the literature. Our study suggests that pedicle screw turnback after full insertion should be reduced in spinal surgeries, particularly procedures that use conical screws in osteoporotic bone. Pedicle screw secured with a conical pilot hole might be beneficial for screw adjustment.
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Affiliation(s)
- Yun-Da Li
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, New Taipei Municipal TuCheng Hospital, Built and Operated by Chang Gung Medical Foundation, New TaipeiCity, Taiwan
| | - Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Weng-Pin Chen
- Department of Mechanical Engineering, National Taipei University of Technology, Taipei, Taiwan
| | - De-Mei Lee
- Department of Mechanical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ching-Lung Tai
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Egenolf P, Harland A, Weber M, Prescher A, Bratke G, Eysel P, Scheyerer MJ, Lenz M. Is human bone matrix a sufficient augmentation method revising loosened pedicle screws in osteoporotic bone? - A biomechanical evaluation of primary stability. Clin Biomech (Bristol, Avon) 2023; 103:105925. [PMID: 36863219 DOI: 10.1016/j.clinbiomech.2023.105925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION Despite good screw anchorage and safe screw trajectory, screw loosening occurs in several cases, especially in osteoporotic individuals. The aim of this biomechanical analysis was to evaluate the primary stability of revision screw placement in individuals with reduced bone quality. Therefore, revision via enlarged diameter screws was compared to the use of human bone matrix as augmentation to improve the bone stock and screw coverage. METHODS 11 lumbar vertebral bodies from cadaveric specimens with a mean age of 85.7 years (± 12.0 years) at death were used. 6.5 mm diameter pedicle screws were inserted in both pedicles and hereafter loosened using a fatigue protocol. Screws were revised inserting a larger diameter screw (8.5 mm) in one pedicle and a same diameter screw with human bone matrix augmentation in the other pedicle. The previous loosening protocol was then reapplied, comparing maximum load and cycles to failure between both revision techniques. Insertional torque was continuously measured during insertion of both revision screws. FINDINGS The number of cycles and the maximum load until failure were significantly greater in enlarged diameter screws than in augmented screws. The enlarged screws' insertional torque was also significantly higher than of the augmented screws. INTERPRETATION Human bone matrix augmentation does not reach the same ad-hoc fixation strength as enlarging the screw's diameter by 2 mm and is therefore biomechanically inferior. Regarding the immediate stability, a thicker screw should therefore be prioritised.
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Affiliation(s)
- Philipp Egenolf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedic and Trauma Surgery, Germany.
| | - Arne Harland
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedic and Trauma Surgery, Germany
| | - Maximilian Weber
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedic and Trauma Surgery, Germany
| | - Andreas Prescher
- University Hospital Aachen, Institute of Molecular and Cellular Anatomy, Germany
| | - Grischa Bratke
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Radiology, Germany
| | - Peer Eysel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedic and Trauma Surgery, Germany
| | - Max Joseph Scheyerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedic and Trauma Surgery, Germany
| | - Maximilian Lenz
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Orthopaedic and Trauma Surgery, Germany
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Dwarakanath LV, Sewell MD, Leung E, Knight T, Jones M, McKay G, Newton-Ede M, Marks D, Spilsbury J, Mehta J, Gardner A. Systematic Review and Meta-analysis: Does Anterior-Posterior Spinal Fusion Still have a Role in Severe Thoracic Adolescent Idiopathic Scoliosis? Indian J Orthop 2023; 57:167-176. [PMID: 36777133 PMCID: PMC9880087 DOI: 10.1007/s43465-022-00747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 09/06/2022] [Indexed: 02/14/2023]
Abstract
Background Debate exists as to whether anterior-posterior spinal fusion (APSF), rather than posterior-only spinal fusion (PSF), provides benefit for treating severe thoracic adolescent idiopathic scoliosis (AIS). This systematic review and meta-analysis compare (1) Cobb angle correction, (2) complication and reoperation rate, (3) pulmonary function, (4) number of fused segments, and 5) patient-reported outcome measures (PROMs) in both groups. Methods Electronic databases were searched to identify studies that met the following inclusion criteria: comparative studies (level 3 or above), severe thoracic curves (≥ 70°), age ≤ 16, AIS aetiology, Lenke 1-4 curves and follow-up ≥ 1 year for ≥ 95% of patient population. Literature was graded for quality and bias using GRADE and MINORS criteria. Results Eight studies were included, defined by GRADE as low or moderate level evidence. Three studies showed superior curve correction in the APSF group; however, the meta-analysis showed no significant difference in curve correction between groups (95% CI - 3.45-12.96, P = 0.26). There were more complications in the APSF group, without statistical significance (95% CI 0.53-3.39, P = 0.54; I 2 = 0%, P = 0.78). There were no re-operations in either group. Two studies reported pulmonary function; one showed better function in the APSF group, the other better function in the PSF group. One study showed fewer fused segments in the APSF group, however, no significance was observed in the meta-analysis (95%CI - 1.65-0.31, P = 0.18). Three studies reported PROMs with no differences reported between groups. Conclusions APSF and PSF have been found to have comparable results. The present evidence cannot support recommendations for guidelines on future practice with regards to effect on curve correction, complications, re-operations, pulmonary function or PROMs. Level of evidence Level III, Systematic review of Level-III studies.
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Affiliation(s)
| | | | - Enid Leung
- The Royal Orthopaedic Hospital, Northfield, Birmingham, B31 2AP, UK
| | - Timothy Knight
- The Royal Orthopaedic Hospital, Northfield, Birmingham, B31 2AP, UK
| | - Morgan Jones
- The Royal Orthopaedic Hospital, Northfield, Birmingham, B31 2AP, UK
| | - George McKay
- The Royal Orthopaedic Hospital, Northfield, Birmingham, B31 2AP, UK
| | | | - David Marks
- The Royal Orthopaedic Hospital, Northfield, Birmingham, B31 2AP, UK
| | | | - Jwalant Mehta
- The Royal Orthopaedic Hospital, Northfield, Birmingham, B31 2AP, UK
| | - Adrian Gardner
- The Royal Orthopaedic Hospital, Northfield, Birmingham, B31 2AP, UK
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Chiu YC, Yang SC, Kao YH, Tu YK. Percutaneous Sacroplasty for Symptomatic Sacral Pedicle Screw Loosening. Indian J Orthop 2023; 57:96-101. [PMID: 36660492 PMCID: PMC9789267 DOI: 10.1007/s43465-022-00773-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/07/2022] [Indexed: 11/25/2022]
Abstract
Background This study aimed to evaluate the efficacy of fluoroscopy-guided percutaneous sacroplasty in patients with sacral pedicle screws loosening after instrumented spinal fusion. Methods We retrospectively reviewed the medical records of 18 patients who underwent percutaneous sacroplasty to treat sacral pedicle screws loosening from January 2016 to December 2019. Imaging studies, visual analog scale (VAS), length of hospital stay, and complications were recorded. The clinical outcomes based on the Oswestry disability index (ODI) and the modified Brodsky's criteria (MBC) were also evaluated to determine the efficacy of percutaneous sacroplasty. Results All patients had undergone at least 1 year of follow-up in our institute (range, 12-24 months). The average VAS score was 5.6 (range, 4-7) before surgery and decreased to 1.7 (range, 1-3) at the final visit. All patients were discharged on the next day after surgery. No patients experienced complications, such as cement leakage, deep infection, or neurologic deterioration. All patients achieved good or excellent outcomes based on the MBC. The ODI scores improved from 51.8 preoperatively to 25.6 postoperatively. Conclusion Percutaneous sacroplasty was an effective treatment approach for relieving the patient's symptoms caused by sacral pedicle screws loosening and could be a valuable treatment alternative to extensive revision surgery. Level of clinical evidence IV.
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Affiliation(s)
- Yen-Chun Chiu
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, No. 1, E-Da Road, Kaohsiung City, 82445 Taiwan, ROC
| | - Shih-Chieh Yang
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, No. 1, E-Da Road, Kaohsiung City, 82445 Taiwan, ROC
| | - Yu-Hsien Kao
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, No. 1, E-Da Road, Kaohsiung City, 82445 Taiwan, ROC
| | - Yuan-Kun Tu
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, No. 1, E-Da Road, Kaohsiung City, 82445 Taiwan, ROC
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Chen S, Li B, Liu S, Zhao J, Zhou X, Zhai X, Gu X, Hou C, Shi Z, Bai Y, Li M, Mao N. Sagittal imaging study of the lumbar spine with the short rod technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3536-3543. [PMID: 36173555 DOI: 10.1007/s00586-022-07373-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 08/13/2022] [Accepted: 08/28/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The short rod technique (SRT) is a novel method for lumbar pedicle screw placement to reduce surgical trauma and avoid damage to the facet joint and articular surface. The core concept is to change the entry point and angle of the screw on the vertebrae at both ends in the sagittal plane to shorten the length of the longitudinal rods. The purpose of this study is to determine the sagittal screw angle (SSA) and its safe Maximum (MAX) value on each lumbar vertebra for the SRT and to observe the shortening effect on the longitudinal rods. METHODS A total of 152 healthy adults were investigated by measuring the lumbar spine lateral view images. The SSA and MAX-SSA were measured with SRT as reference to the conventional placement technique method. The distance between the entry points of the proximal and distal vertebrae was measured to compare the changes in the length of the longitudinal rods using the two screw placement techniques. RESULTS + SSA increased from L1 to L4, and -SSA increased from L2 to L5, in which the -SSA of L2, L3, and L4 were significantly greater than those of + SSA (P < 0.05). + MAX-SSA at L1-L4 was 23.26 ± 3.54°, 23.68 ± 3.37°, 24.12 ± 3.29°, and 24.26 ± 3.42°, respectively. -MAX-SSA at L2-L5 was 36.25 ± 3.26°, 38.26 ± 3.73°, 38.62 ± 3.63° and 37.33 ± 3.31°, respectively. Theoretical reductions by calculation for the 2-segment lumbar pedicles were: L1-2: 9 mm, L2-3: 9.29 mm, L3-4: 6.23 mm, and L4-5: 7.08 mm; And the 3-segment lumbar pedicles were: L1-3: 16.97 mm, L2-4: 16.73 mm, L3-5, and 18.24 mm, respectively. CONCLUSIONS The application of the SRT to lumbar pedicles is a safe screw placement method that can significantly shorten the length of the used longitudinal rods.
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Affiliation(s)
- Shaofeng Chen
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Bo Li
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Shu Liu
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jian Zhao
- Department of Neurology, The General Hospital of Western Theater Command, Chengdu, China
| | - Xiaoyi Zhou
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xiao Zhai
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xiaochuan Gu
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Canglong Hou
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zhicai Shi
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Yushu Bai
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Ming Li
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Ningfang Mao
- Department of Orthopaedic Surgery, Changhai Hospital, The Navy Military Medical University, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Amick M, Ottesen TD, O'Marr J, Frenkel MY, Callahan B, Grauer JN. Effects of anode position on pedicle screw testing during lumbosacral spinal fusion surgery. Spine J 2022; 22:2000-2005. [PMID: 35843532 DOI: 10.1016/j.spinee.2022.07.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/11/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
OF BACKGROUND DATA Pedicle screws are commonly placed with lumbar/lumbosacral fusions. Triggered electromyography (tEMG), which employs the application of electrical current between the screw and a complementary anode to determine thresholds of conduction, may be utilized to confirm the safe placement of such implants. While previous research has established clinical thresholds associated with safe screw placement, there is variability in clinical practice of anode placement which could lead to unreliable measurements. PURPOSE To determine the variance in pedicle screw stimulation thresholds when using four unique anode locations (ipsilateral/contralateral and paraspinal/gluteal relative to tested pedicle screws). STUDY DESIGN Prospective cohort study. Tertiary medical center. PATIENT SAMPLE Twenty patients undergoing lumbar/lumbosacral fusion with pedicle screws using tEMG OUTCOME MEASURES: tEMG stimulation return values are used to assess varied anode locations and reproducibility based on anode placement. METHODS Measurements were assessed across node placement in ipsilateral/contralateral and paraspinal/gluteal locations relative to the screw being assessed. R2 coefficients of correlation were determined, and variances were compared with F-tests. RESULTS A total of 94 lumbosacral pedicle screws from 20 patients were assessed. Repeatability was verified using two stimulations at each location for a subset of the screws with an R2 of 0.96. Comparisons between the four anode locations demonstrated R2 values ranging from 0.76 to 0.87. F-tests comparing thresholds between each anode site demonstrated all groups not to be statistically different. CONCLUSION The current study, a first-of-its-kind formal evaluation of anode location for pedicle screw tEMG testing, demonstrated very strong repeatability and strong correlation with different locations of anode placement. These results suggest that there is no need to change the side of the anode for testing of left versus right screws, further supporting that placing an anode electrode into gluteal muscle is sufficient and will avoid a sharp ground needle in the surgical field.
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Affiliation(s)
- Michael Amick
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA; Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA, 02114, USA
| | - Jamieson O'Marr
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Mikhail Y Frenkel
- Nuvasive Clinical Services 10275 Little Patuxent Pkwy Ste 300 Columbia, MD 21044, USA; UConn Main Campus 2131 Hillside Road, Unit 3088 Storrs, CT 06269-3088
| | - Brooke Callahan
- Nuvasive Clinical Services 10275 Little Patuxent Pkwy Ste 300 Columbia, MD 21044, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA.
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Robotic-assisted spine surgery allows for increased pedicle screw sizes while still improving safety as indicated by elevated triggered electromyographic thresholds. J Robot Surg 2022; 17:1007-1012. [DOI: 10.1007/s11701-022-01493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/12/2022] [Indexed: 12/02/2022]
Abstract
AbstractThe present study used triggered electromyographic (EMG) testing as a tool to determine the safety of pedicle screw placement. In this Institutional Review Board exempt review, data from 151 consecutive patients (100 robotic; 51 non-robotic) who had undergone instrumented spinal fusion surgery of the thoracic, lumbar, or sacral regions were analyzed. The sizes of implanted pedicle screws and EMG threshold data were compared between screws that were placed immediately before and after adoption of the robotic technique. The robotic group had significantly larger screws inserted that were wider (7 ± 0.7 vs 6.5 ± 0.3 mm; p < 0.001) and longer (47.8 ± 6.4 vs 45.7 ± 4.3 mm; p < 0.001). The robotic group also had significantly higher stimulation thresholds (34.0 ± 11.9 vs 30.2 ± 9.8 mA; p = 0.002) of the inserted screws. The robotic group stayed in the hospital postoperatively for fewer days (2.3 ± 1.2 vs 2.9 ± 2 days; p = 0.04), but had longer surgery times (174 ± 37.8 vs 146 ± 41.5 min; p < 0.001). This study demonstrated that the use of navigated, robot-assisted surgery allowed for placement of larger pedicle screws without compromising safety, as determined by pedicle screw stimulation thresholds. Future studies should investigate whether these effects become even stronger in a later cohort after surgeons have more experience with the robotic technique. It should also be evaluated whether the larger screw sizes allowed by the robotic technology actually translate into improved long-term clinical outcomes.
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Benech CA, Perez R, Benech F, Shirk T, Bucklen BS. A quantitative accuracy assessment of the use of a rigid robotic arm in navigated placement of 726 pedicle screws. BMC Surg 2022; 22:385. [DOI: 10.1186/s12893-022-01838-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/29/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Traditional minimally invasive fluoroscopy-based techniques for pedicle screw placement utilize guidance, which may require fluoroscopic shots. Computerized tomography (CT) navigation results in more accurate screw placement. Robotic surgery seeks to establish access and trajectory with greater accuracy.
Objective
This study evaluated the screw placement accuracy of a robotic platform.
Methods
Demographic data, preoperative/postoperative CT scans, and complication rates of 127 patients who underwent lumbosacral pedicle screw placement with minimally invasive navigated robotic guidance using preoperative CT were analyzed.
Results
On the GRS scale, 97.9% (711/726) of screws were graded A or B, 1.7% (12/726) of screws graded C, 0.4% (3/726) of screws graded D, and 0% graded E. Average offset from preoperative plan to final screw placement was 1.9 ± 1.5 mm from tip, 2.2 ± 1.4 mm from tail and 2.9 ± 2.3° of angulation.
Conclusions
Robotic-assisted surgery utilizing preoperative CT workflow with intraoperative fluoroscopy-based registration improves pedicle screw placement accuracy within a patient’s pedicles.
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Biomechanical Comparison of Salvage Pedicle Screw Augmentations Using Different Biomaterials. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12157792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Allograft bone particles, hydroxyapatite/β-hydroxyapatite-tricalcium phosphate (HA/β-TCP), calcium sulfate (CS), and polymethylmethacrylate (PMMA) bone cement are biomaterials clinically used to fill defective pedicles for pedicle screw augmentation. Few studies have systematically investigated the effects of various biomaterials utilized for salvage screw stabilization. The aim of this study was to evaluate the biomechanical properties of screws augmented with these four different materials and the effect of different pilot hole sizes and bone densities on screw fixation strength. Commercially available synthetic bones with three different densities (7.5 pcf, 15pcf, 30 pcf) simulating different degrees of bone density were utilized as substitutes for human bone. Two different pilot hole sizes (3.2 mm and 7.0 mm in diameter) were prepared on test blocks to simulate primary and revision pedicle screw fixation, respectively. Following separate specimen preparation with these four different filling biomaterials, a screw pullout test was conducted using a material test machine, and the average maximal screw pullout strength was compared among groups. The average maximal pullout strength of the materials, presented in descending order, was as follows: bone cement, calcium sulfate, HA/β-TCP, allograft bone chips and the control. In samples in both the 3.2 mm pilot-hole and 7.0 mm pilot-hole groups, the average maximal pullout strength of these four materials increased with increasing bone density. The average maximal pullout strength of the bone cement augmented salvage screw (7.0 mm) was apparently elevated in the 7.5 pcf test block. Salvage pedicle screw augmentation with allograft bone chips, HA/β-TCP, calcium sulfate, and bone cement are all feasible methods and can offer better pullout strength than materials in the non-augmentation group. Bone cement provides the most significantly augmented effect in each pilot hole size and bone density setting and could be considered preferentially to achieve larger initial stability during revision surgery, especially for bones with osteoporotic quality.
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Yan K, Zhang Q, Tian W. Comparison of accuracy and safety between second-generation TiRobot-assisted and free-hand thoracolumbar pedicle screw placement. BMC Surg 2022; 22:275. [PMID: 35840958 PMCID: PMC9288055 DOI: 10.1186/s12893-022-01723-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/11/2022] [Indexed: 01/02/2023] Open
Abstract
Background Robot-assisted spine surgery aims to improve the accuracy of screw placement. We compared the accuracy and safety between a novel robot and free hand in thoracolumbar pedicle screw placement. Methods Eighty patients scheduled to undergo robot-assisted (40 patients) and free-hand (40 patients) pedicle screw placement were included. The patients’ demographic characteristics, radiographic accuracy, and perioperative outcomes were compared. The accuracy of screw placement was based on cortical violation and screw deviation. Safety outcomes mainly included operative time, blood loss, revision, and complications. Results A total of 178 and 172 screws were placed in the robot-assisted and free-hand groups, respectively. The rate of perfect screw position (grade A) was higher in the robot-assisted group than in the free-hand group (91.0% vs. 75.6%; P < 0.001). The rate of clinically acceptable screw position (grades A and B) was also higher in the robot-assisted group than in the free-hand group (99.4% vs. 90.1%; P < 0.001). The robot-assisted group had significantly lower screw deviation than the free-hand group [1.46 (0.94, 1.95) mm vs. 2.48 (1.09, 3.74) mm, P < 0.001]. There was no robot abandonment in the robot-assisted group. No revision was required in any of the groups. Conclusions Robot-assisted pedicle screw placement is more accurate than free-hand placement. The second-generation TiRobot–assisted thoracolumbar pedicle screw placement is an accurate and safe procedure. Trial registration retrospectively registered
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Affiliation(s)
- Kai Yan
- Department of Spine Surgery, Beijing Jishuitan Hospital, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China.,Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, 100035, China
| | - Qi Zhang
- Department of Spine Surgery, Beijing Jishuitan Hospital, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China.,Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, 100035, China
| | - Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China. .,Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, 100035, China.
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Matsuoka A, Toyone T, Okano I, Kudo Y, Ishikawa K, Maruyama H, Ozawa T, Shirahata T, Inagaki K. Comparison of pedicle screw placement accuracy between two types of imaging support (Artis Zeego versus two-dimensional fluoroscopy): a cross-sectional observational study. BMC Musculoskelet Disord 2022; 23:644. [PMID: 35790951 PMCID: PMC9254419 DOI: 10.1186/s12891-022-05602-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/28/2022] [Indexed: 02/07/2023] Open
Abstract
Background The pedicle screw system is widely used in spine surgery, and it provides rigid fixation and leads to successful subsequent deformity correction and bony fusion. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. Artis Zeego is an emerging intraoperative imaging technique that can provide conventional two-dimensional fluoroscopic images and rapid three-dimensional fluoroscopic computed tomography reconstruction imaging. The aim of this study is to compare the insertion accuracies of PS placement using Artis Zeego and conventional 2D X-ray fluoroscopy. Methods In this study, we retrospectively reviewed the postoperative images of thoracolumbar fusion patients who underwent surgery using pedicle screws between 2013 and 2018. Pedicle screw malplacement was assessed using a four-grade classification by Rao et al. Misplacement rates were compared between pedicle screws assisted with Artis Zeego and two-dimensional fluoroscopy. Results A total of 1107 pedicle screws in 153 patients were inserted using Artis Zeego, and 427 pedicle screws in 80 patients were inserted using fluoroscopy. The overall perforation rate was 4.2% (46 perforations of 1106 pedicle screws) in the Artis Zeego group and 7.7% (33 perforations of 427 pedicle screws) in the fluoroscopy group. In the Artis Zeego group, 43 (3.9%) screws were classified as grade 1, and three (0.3%) screws were classified as grade 2. In the fluoroscopy group, 21 (4.9%) screws were classified as grade 1, 10 (2.3%) screws were classified as grade 2, and 2 (0.5%) screws were classified as grade 3. The use of Artis Zeego was associated with a significantly lower screw malplacement rate than was the use of fluoroscopy (p < 0.001). Conclusions Our results demonstrated that pedicle screw placement with Artis Zeego was associated with a lower malplacement rate than was conventional two-dimensional fluoroscopy. No severe malplacement was observed in the Artis Zeego group. Thus, Artis Zeego could be a good option for improving pedicle screw accuracy.
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Pijpker PAJ, Kuijlen JMA, Tamási K, Oterdoom DLM, Vergeer RA, Rijtema G, Coppes MH, Kraeima J, Groen RJM. The Accuracy of Patient-Specific Spinal Drill Guides Is Non-Inferior to Computer-Assisted Surgery: The Results of a Split-Spine Randomized Controlled Trial. J Pers Med 2022; 12:jpm12071084. [PMID: 35887581 PMCID: PMC9317516 DOI: 10.3390/jpm12071084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022] Open
Abstract
In recent years, patient-specific spinal drill guides (3DPGs) have gained widespread popularity. Several studies have shown that the accuracy of screw insertion with these guides is superior to that obtained using the freehand insertion technique, but there are no studies that make a comparison with computer-assisted surgery (CAS). The aim of this study was to determine whether the accuracy of insertion of spinal screws using 3DPGs is non-inferior to insertion via CAS. A randomized controlled split-spine study was performed in which 3DPG and CAS were randomly assigned to the left or right sides of the spines of patients undergoing fixation surgery. The 3D measured accuracy of screw insertion was the primary study outcome parameter. Sixty screws inserted in 10 patients who completed the study protocol were used for the non-inferiority analysis. The non-inferiority of 3DPG was demonstrated for entry-point accuracy, as the upper margin of the 95% CI (−1.01 mm−0.49 mm) for the difference between the means did not cross the predetermined non-inferiority margin of 1 mm (p < 0.05). We also demonstrated non-inferiority of 3D angular accuracy (p < 0.05), with a 95% CI for the true difference of −2.30°−1.35°, not crossing the predetermined non-inferiority margin of 3° (p < 0.05). The results of this randomized controlled trial (RCT) showed that 3DPGs provide a non-inferior alternative to CAS in terms of screw insertion accuracy and have considerable potential as a navigational technique in spinal fixation.
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Affiliation(s)
- Peter A. J. Pijpker
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
- 3D-Lab, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands;
- Correspondence:
| | - Jos M. A. Kuijlen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Katalin Tamási
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - D. L. Marinus Oterdoom
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Rob A. Vergeer
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Gijs Rijtema
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Maarten H. Coppes
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Joep Kraeima
- 3D-Lab, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands;
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Rob J. M. Groen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
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Yao GL, Xiao ZZ, Xiao T, Zhong NS, Huang SH, Liu JM, Liu ZL. Development and biomechanical test of a new pedicle screw for thoracolumbar spinal surgery. Med Eng Phys 2022; 104:103808. [DOI: 10.1016/j.medengphy.2022.103808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022]
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Ozaki T, Yamada K, Nakamura H. Usefulness of Preoperative Planning by Three-Dimensional Planning Software for Pedicle Screw Placement in Thoracolumbar Surgeries: <i>Misplacement Rate and Associated Risk Factors</i>. Spine Surg Relat Res 2022; 6:279-287. [PMID: 35800631 PMCID: PMC9200427 DOI: 10.22603/ssrr.2021-0185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/02/2021] [Indexed: 11/07/2022] Open
Abstract
Introduction A number of imaging technologies have been developed to reduce the risk of pedicle screw (PS) misplacement. For example, preoperative three-dimensional (3D) planning can reportedly enhance implant placement accuracy in some orthopedic surgeries. However, no study has investigated the effect of preoperative 3D planning on PS placement without intraoperative 3D navigation. Thus, in this study, we aim to examine the accuracy of PS placement and identify the risk factors for PS misplacement in thoracolumbar surgeries performed using preoperative 3D planning software with intraoperative fluoroscopic guidance in a retrospective study. Methods In total, 25 consecutive patients (197 PSs) underwent thoracic or lumbar spinal fusion surgeries using preoperative 3D planning with intraoperative fluoroscopic guidance. PS misplacement was graded based on the degree of perforation (Grade 0, no perforation; Grade 1, <2 mm; Grade 2, 2-4 mm; Grade 3, >4 mm) observed in postoperative computed tomography (CT). Deviations between planned and actual PSs were evaluated by matching preoperative and postoperative CT volume images for each vertebra. Results The overall PS misplacement rate was 6.6% (Grade 1: 4.0%, Grade 2: 1.5%, Grade 3: 1.0%). The median linear deviations of PS entry points between planned and actual locations were determined to be 3.3 mm and 3.3 mm for the horizontal and vertical axes, respectively. The median angular deviations of the PS axis were 6.2° and 4.5° for the transverse and sagittal planes, respectively. Multivariate analysis revealed that horizontal deviation of the PS entry point was the sole factor associated with Grade ≥1 PS misplacement (odds ratio=2.47, p<0.001). Conclusions Preoperative 3D planning software without intraoperative 3D navigation was able to achieve a relatively low PS misplacement ratio among the reported ratio of conventional techniques without navigation. Surgeons should carefully ensure that the entry point is consistent with preoperative planning, especially in the mediolateral direction to avoid misplacement in this method.
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Affiliation(s)
| | - Kentaro Yamada
- Department of Orthopaedic Surgery, Osaka Metropolitan University
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University
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A Comparison of Drill Guiding and Screw Guiding 3D-Printing Techniques for Intra- and Extrapedicular Screw Insertion. Spine (Phila Pa 1976) 2022; 47:E434-E441. [PMID: 34132234 DOI: 10.1097/brs.0000000000004147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Screw randomized cadaveric study. OBJECTIVE To compare the accuracy of three-dimensional (3D)-printed drill guides versus additional screw guiding techniques for challenging intra- and extrapedicular screw trajectories. SUMMARY OF BACKGROUND DATA Pedicle screw placement can be technically demanding, especially in syndromic scoliosis with limited bone stock. Recently, 3D-printing and virtual planning technology have become available as new tools to improve pedicle screw insertion. Differences in techniques exist, while some focus on guiding the drill, others also actively guide subsequent screws insertion. The accuracy of various 3D-printing-assisted techniques has been studied; however, direct comparative studies have yet to determine whether there is a benefit of additional screw guidance. METHODS Two cadaveric experiments were conducted to compare drill guides with two techniques that introduce additional screw guiding. The screw guiding consisted of either k-wire cannulated screws or modular guides, which were designed to guide the screw in addition to the drill bit. Screws were inserted intra- or extrapedicular using one of each methods according to a randomization scheme. Postoperative computed tomography scanning was performed and fused with the preoperative planning for detailed 3D screw deviation analysis. RESULTS For intrapedicular screw trajectories malpositioning was low (2%) and the modular guides revealed a statistically significant increase of accuracy (P = 0.05) compared with drill guides. All techniques showed accurate cervical screw insertion without breach. For the extrapedicular screw trajectories both additional screw guiding methods did not significantly (P = 0.09) improve accuracy and malpositioning rates remained high (24%). CONCLUSIONS In this cadaveric study it was found that the additional screw-guiding techniques are not superior to the regular 3D-printed drill guides for the technically demanding extrapedicular screw technique. For intrapedicular screw insertion, modular guides can improve insertion; however, at cervical levels regular 3D-printed drill guides already demonstrated very high accuracy and therefore there is no benefit from additional screw guiding techniques. LEVEL OF EVIDENCE 3.
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The effect of hydroxyapatite on titanium pedicle screw resistance: an electrical model. Spine J 2022; 22:869-876. [PMID: 34813959 DOI: 10.1016/j.spinee.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Intraoperative detection of a pedicle wall breach implicitly reduces surgical risk, but the reliability of intraoperative neuromonitoring has been contested. Hydroxyapatite (HA) has been promulgated to increase pedicle screw resistance and negatively influence the accuracy of electromyography. PURPOSE The primary purpose of this experiment is to evaluate the effect of HA on pedicle screw electrical resistance using a controlled laboratory model. STUDY DESIGN Controlled laboratory study. METHODS Stimulation of pedicle screws was performed in normal saline (0.9% NaCl). The experimental group included 8 HA coated (HAC) pedicle screws and matched manufacturer control pedicle screws without HAC (Ti6Al4V). All screws were stimulated at 5, 10-, 15-, 20-, and 25-mm submersion depths. Circuit current return was recorded, and pedicle screw electrical resistance was calculated according to Ohm's Law. Data were assessed for normality and variance. Mann-Whitney U and Kruskal-Wallis tests compared groups with Bonferroni correction for multiple testing. Effect size is reported with 95% confidence intervals (95CI). p values <.05 were considered significant. RESULTS Current return was detected for all screws (N=24) following subclinical 8.5 µA stimulation at 5, 10-, 15-, 20-, and 25-mm submersion depths (N=144). The effect estimate of HA on pedicle screw electrical resistance is -0.07 (-0.17 to 0.01 95CI). The estimated effect of HA on pedicle screw electrical resistance did not differ across manufacturers. Electrical resistance values were inversely related to submersion depth. Electrical resistance values were lower in the experimental group at 10 mm (p=.04), 15 mm (p=.04), and 25 mm (p=.02) submersion depths. The HA effect ranged from -0.03 to -0.08 as submersion depth varied. CONCLUSIONS We found no evidence that HA increased pedicle screw electrical resistance in a matched manufacturer control laboratory model. Electrical stimulation of pedicle screws may be reliable for pedicle breach detection in the presence of HA. Future research should investigate if laboratory findings translate to clinical practice and confirm that electrical stimulation of pedicle screws is a reliable method to detect pedicle breach in the presence of HA.
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Su XJ, Lv ZD, Chen Z, Wang K, Zhu C, Chen H, Han YC, Song QX, Lao LF, Zhang YH, Li Q, Shen HX. Comparison of Accuracy and Clinical Outcomes of Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Posterior Cervical Surgery. Global Spine J 2022; 12:620-626. [PMID: 32975454 PMCID: PMC9109572 DOI: 10.1177/2192568220960406] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
STUDY DESIGN This was a prospective controlled study. OBJECTIVE To compare the accuracy and clinical outcomes of robot-assisted (RA) and fluoroscopy-guided (FG) pedicle screw placement in posterior cervical surgery. METHODS This study included 58 patients. The primary outcome measures were the 1-time success rate and the accuracy of pedicle screw placement according to the Gertzbein-Robbins scales. The secondary outcome measures, including the operative time, intraoperative blood loss, hospital stay, cumulative radiation time, radiation dose, intraoperative advent events, and postoperative complications, were recorded and analyzed. The Japanese Orthopedics Association (JOA) scores and Neck Disability Index (NDI) were used to assess the neurological function of patients before and at 3 and 6 months after surgery. RESULTS The rate of grade A was significantly higher in the RA group than in the FG group (90.6% and 71.1%; P < .001). The clinically acceptable accuracy was 97.2% in the RA group and 90.7% in the FG group (P = .009). Moreover, the 1-time success rate was significantly higher in the RA group than in the FG group. The RA group had less radiation time (P < .001) and less radiation dose (P = .002) but longer operative time (P = .001). There were no significant differences in terms of intraoperative blood loss, hospital stay, intraoperative adverse events, postoperative complications, JOA scores, and NDI scores at each follow-up time point between the 2 groups. CONCLUSIONS The RA technique achieved higher accuracy and 1-time success rate of pedicle screw placement in posterior cervical surgery while achieving comparable clinical outcomes.
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Affiliation(s)
- Xin-Jin Su
- Shanghai Jiao Tong
University, Shanghai, China
| | | | - Zhi Chen
- Shanghai Jiao Tong
University, Shanghai, China
| | - Kun Wang
- Shanghai Jiao Tong
University, Shanghai, China
| | - Chao Zhu
- Shanghai Jiao Tong
University, Shanghai, China
| | - Hao Chen
- Shanghai Jiao Tong
University, Shanghai, China
| | | | | | - Li-Feng Lao
- Shanghai Jiao Tong
University, Shanghai, China
| | | | - Quan Li
- Shanghai Jiao Tong
University, Shanghai, China
| | - Hong-Xing Shen
- Shanghai Jiao Tong
University, Shanghai, China,Hong-Xing Shen, Department of Spine Surgery,
Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian
Road, Shanghai, 200127, China.
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47
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Zhang Q, Fan MX, Han XG, Liu YJ, He D, Liu B, Tian W. Risk Factors of Unsatisfactory Robot-Assisted Pedicle Screw Placement: A Case-Control Study. Neurospine 2022; 18:839-844. [PMID: 35000338 PMCID: PMC8752688 DOI: 10.14245/ns.2142560.180] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/09/2021] [Indexed: 01/01/2023] Open
Abstract
Objective To identify potential risk factors of unsatisfactory screw position during robot-assisted pedicle screw fixation.
Methods A retrospective analysis of robot-assisted pedicle screw fixation performed in Beijing Jishuitan Hospital from March 2018 to March 2019 was conducted. Research data was collected from the medical record and imaging systems. Univariate tests were performed on the potential risk factors (patient’s characteristics and surgical factors) of unsatisfactory screw position during robot-assisted pedicle screw fixation. For statistically significant variables in univariate tests, a logistic regression test was used to identify independent risk factors for unsatisfactory screw position.
Results A total of 780 pedicle screws placed in 163 robot-assisted surgeries were analyzed. The rate of perfect screw positions was 93.08%, and the unsatisfactory rate was 6.92%. In patients with severe obesity (body mass index ≥ 30 kg/m2) (odds ratio [OR], 2.459; 95% confidence interval [CI], 1.199–5.044; p=0.014), osteoporosis (T ≤ -2.5) (OR, 1.857; 95% CI, 1.046–3.295; p=0.034), and the segments 3 levels away from the tracker (OR, 2.216; 95% CI, 1.119–4.387; p=0.022), robot-assisted pedicle screw placement has a higher risk of screw malposition.
Conclusion During robot-assisted pedicle screw placement for patients with severe obesity, osteoporosis, and segments 3 levels away from the tracker, vigilance should be maintained during surgery to avoid postoperative complications due to unsatisfactory screw position.
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Affiliation(s)
- Qi Zhang
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ming-Xing Fan
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Xiao-Guang Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Ya-Jun Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Da He
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Bo Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
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Kumaraswamy P, Takhelmayum U, Singh L, Chirom D, Maku P, Lingaraju Y. Posterior instrumented stabilization in the management of unstable thoracolumbar spine fractures with minimum 2 years follow-up. JOURNAL OF ORTHOPAEDICS AND SPINE 2022. [DOI: 10.4103/joasp.joasp_19_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
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Li C, Li W, Gao S, Cao C, Li C, He L, Ma X, Li M. Comparison of accuracy and safety between robot-assisted and conventional fluoroscope assisted placement of pedicle screws in thoracolumbar spine: A meta-analysis. Medicine (Baltimore) 2021; 100:e27282. [PMID: 34559135 PMCID: PMC8462633 DOI: 10.1097/md.0000000000027282] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 09/01/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The purpose of this systematic review and meta-analysis is to explore the screw positioning accuracy, complications related to pedicle screw implantation, revision rate and radiation exposure between robot screw placement and traditional fluoroscopic screw placement. METHODS We searched several databases, including CNKI, Wanfang database, cqvip datebase, PubMed, Cochrane library and EMBASE, to identify articles that might meet the criteria. Meta-analysis was performed using Revman 5.3 software. RESULTS A total of 13 randomized controlled trial were included. The results showed that the pedicle screw accuracy of the robot assisted group was significantly better than that of the conventional freehand (FH) group (OR = 3.5, 95% confidence interval [CI] [2.75,4.45], P < .0001). There was no significant difference in the complications caused by pedicle screw implantation between the robot-assisted group and the conventional FH group [OR = 0.39, 95%CI (0.10,1.48), P = .17]. The rate of facet joint invasion in the robot-assisted group was significantly lower than that in the conventional FH group (OR = 0.06, 95%CI [0.01,0.29], P = .0006). The revision rate in the robot-assisted group was significantly lower than that in the conventional FH group (OR = 0.19, 95%CI [0.05,0.71], P = 0.0.01). There was no significant difference in the average radiation of pedicle screws implantation between the robot-assisted group and the conventional FH (mean difference = -7.94, 95%CI [-20.18,4.30], P = .20). CONCLUSION The robot-assisted group was significantly better than the conventional FH in the accuracy of pedicle screw placement and facet joint invasion rate and revision rate. There was no significant difference in the complication and fluoroscopy time between the two groups.
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Affiliation(s)
- Chuntao Li
- Hebei North University, Zhangjiakou, Hebei, China
| | - Wenyi Li
- Department of Orthopedics, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Shangju Gao
- Department of Orthopedics, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Can Cao
- Department of Orthopedics, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Changren Li
- Hebei North University, Zhangjiakou, Hebei, China
| | - Liang He
- Hebei North University, Zhangjiakou, Hebei, China
| | - Xu Ma
- Hebei North University, Zhangjiakou, Hebei, China
| | - Meng Li
- Hebei Medical University, Shijiazhuang, Hebei, China
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Dial BL, Esposito VR, Catanzano AA, Fitch RD, Lark RK. Implant Distribution Versus Implant Density in Lenke Type 1 Adolescent Idiopathic Scoliosis: Does the Position of the Screw Matter? Global Spine J 2021; 11:1076-1082. [PMID: 32799688 PMCID: PMC8351067 DOI: 10.1177/2192568220941456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Previous studies have demonstrated that increased implant density (ID) results in improved coronal deformity correction. However, low-density constructs with strategically placed fixation points may achieve similar coronal correction. The purpose of this study was to identify key zones along the spinal fusion where high ID statistically correlated to improved coronal deformity correction. Our hypothesis was that high ID within the periapical zone would not be associated with increased percent Cobb correction. METHODS We identified patients with Lenke type 1 curves with a minimum 2-year follow up. The instrumented vertebral levels were divided into 4 zones: (1) cephalad zone, (2) caudal zone, (3) apical zone, and (4) periapical zone. High and low percent Cobb correction groups were compared, high percent Cobb group was defined as percent correction >67%. Total ID, total concave ID, total convex ID, and ID within each zone of the curve were compared between the groups. A multivariable analysis was performed to identify independent predictors for coronal correction. Subsequently increased and decreased thoracic kyphosis (TK) groups were compared, increased TK was defined as post-operative TK being larger than preoperative TK and decreased TK was defined as post-operative TK being less than preoperative TK. RESULTS The cohort included 68 patients. The high percent Cobb group compared with the low percent Cobb group had significantly greater ID for the entire construct, the total concave side, the total convex side, the apical convex zone, the periapical zone, and the cephalad concave zone. The high percent Cobb group had greater pedicle screw density for the total construct, total convex side, and total concave side. In the multivariate model ID and pedicle screw density remained significant for percent Cobb correction. Ability to achieve coronal balance was not statistically correlated to ID (P = .78). CONCLUSIONS Increased ID for the entire construct, the entire convex side, the entire concave side, and within each spinal zone was associated with improved percent Cobb correction. The ability to achieve coronal balance was not statistically influence by ID. The results of this study support that increasing ID along the entire length of the construct improves percent Cobb correction.
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Affiliation(s)
| | | | | | | | - Robert K. Lark
- Duke University Medical Center, Durham, NC, USA,Robert K. Lark, Department of Orthopedic Surgery, Duke University Medical Center, 3000 Erwin Road, DUMC 2809, Durham, NC 27710, USA.
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