Abstract
Aim: Fennell et al. describe a simple, effective freehand technique for thoracic pedicle screw insertion. In this study, we aimed to compare the patients undergoing upper thoracic pedicle screw insertion with the Fennell technique simulated on Pedicle Screw Simulator (PSS) and those recruited to the same procedure utilizing C-arm fluoroscopy.
Material and Method: First, we uploaded pre-operative CT images of 12 patients to the PSS module, which was used in our study to calculate the screw angle and visualize the pedicle screw entry point and trajectories. Then, we created three-dimensional vertebral models of the patients to simulate screw placement using visualization tool kit (VTK), open-source software for 3D computer graphics and visualization, available free of charge as part of 3D Slicer. Next, we placed pedicle screws through pre-determined anatomic regions. C-arm fluoroscopy-guided pedicle screws were placed in the patients in the control group. The amount of bleeding, operation times and correct screw placement data were recorded in both groups.
Results: 24 patients were included in the study. The mean age of the patients was 32.3±4.1 years. We applied 80 pedicle screws to Group 1 and 72 to Group 2. According to the malposition classification by Rao et al. on postoperative CTs, 68 patients in Group 1 were classified as Grade 0, 8 as Grade 1, 4 as Grade 2. Yet, there were no statistical differences between the groups by Rao et al.’s classification (p>0.05). While the mean operation time of Group 1 was 138±34 minutes, it was 162±44 minutes in Group 2. The groups significantly differed by operation time (p<0.05).
Conclusion: Overall, pre-operative simulation on PSS may allow more efficient and easier thoracic pedicle screw application. In addition, the simulator may contribute to the training of surgeons on upper thoracic pedicle screw application and increase the accuracy of pedicular screw placement.
Supporting Institution
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Project Number
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References
- Cho W, Cho SK, Wu C. The biomechanics of pedicle screw-based instrumentation. J Bone Joint Surg Br 2010; 92: 1061-5.
- Dede O, Ward WT, Bosch P, Bowles AJ, Roach JW. Using the freehand pedicle screw placement technique in adolescent idiopathic scoliosis surgery: what is the incidence of neurological symptoms secondary to misplaced screws? Spine (Phila Pa 1976) 2014; 39: 286-90.
- Park SM, Shen F, Kim HJ, et al. How many screws are necessary to be considered an experienced surgeon for freehand placement of thoracolumbar pedicle screws?: analysis using the cumulative summation test for learning curve. World neurosurgery 2018; 118: e550-e6.
- Perna F, Borghi R, Pilla F, Stefanini N, Mazzotti A, Chehrassan M. Pedicle screw insertion techniques: an update and review of the literature. Musculoskeletal Surg 2016; 100: 165-9.
- Esses SI, Sachs BL, Dreyzin V. Complications associated with the technique of pedicle screw fixation. A selected survey of ABS members. Spine (Phila Pa 1976) 1993; 18: 2231-8.
- Cui G, Wang Y, Kao TH, et al. Application of intraoperative computed tomography with or without navigation system in surgical correction of spinal deformity: a preliminary result of 59 consecutive human cases. Spine (Phila Pa 1976) 2012; 37: 891-900.
- Xiang L, Zhou Y, Wang H, et al. Significance of preoperative planning simulator for junior surgeons' training of pedicle screw insertion. J Spinal Disord Tech 2015; 28: E25-9.
- Song G BH, Zhao Y, Han J, Liu Preoperative planning and simulation for pedicle screw insertion using computed tomography-based patient specific volume rendering combined with projection fluoroscopy. Int Robot Autom J 2017; 2: 25-9.
- Park SK, Yeom JS, Won JH, et al. C1-2 fixation using polyaxial screws and rods assisted by computer simulation for revision of failed posterior fusion: a technical report. jkoa 2017; 40: 778-81.
- Fedorov A, Beichel R, Kalpathy-Cramer J, et al. 3D slicer as an image computing platform for the quantitative imaging network. Magn Reson Imaging 2012; 30: 1323-41.
- Muralidharan V, Swaminathan G, Devadhas D, Joseph BV. Patient-specific interactive software module for virtual preoperative planning and visualization of pedicle screw entry point and trajectories in spine surgery. Neurol India 2018; 66: 1766-70.
- Fennell VS, Palejwala S, Skoch J, Stidd DA, Baaj AA. Freehand thoracic pedicle screw technique using a uniform entry point and sagittal trajectory for all levels: preliminary clinical experience. J Neurosurg Spine 2014; 21: 778-84.
- Rao G, Brodke DS, Rondina M, Dailey AT. Comparison of computerized tomography and direct visualization in thoracic pedicle screw placement. J Neurosurg 2002; 97: 223-6.
- Mattei TA, Meneses MS, Milano JB, Ramina R. "Free-hand" technique for thoracolumbar pedicle screw instrumentation: critical appraisal of current "state-of-art". Neurol India 2009; 57: 715-21.
- Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine (Phila Pa 1976) 2004; 29: 333-42; discussion 42.
- Shin BJ, James AR, Njoku IU, Hartl R. Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. J Neurosurg Spine 2012; 17: 113-22.
- Rampersaud YR, Foley KT, Shen AC, Williams S, Solomito M. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976) 2000; 25: 2637-45.
- Swaminathan G, Muralidharan V, Devakumar D, Joseph BV. Accuracy of the freehand (fennell) technique using a uniform entry point and sagittal trajectory for insertion of thoracic pedicle screws: A computed tomography-based virtual simulation study. Neurol India 2020; 68: 468-71.
- Guzey FK, Emel E, Hakan Seyithanoglu M, et al. Accuracy of pedicle screw placement for upper and middle thoracic pathologies without coronal plane spinal deformity using conventional methods. J Spinal Disord Tech 2006; 19: 436-41.
- Vaccaro AR, Rizzolo SJ, Balderston RA, et al. Placement of pedicle screws in the thoracic spine. Part II: An anatomical and radiographic assessment. J Bone Joint Surg Am 1995; 77: 1200-6.
- Wi W, Park SM, Shin BS. Computed tomography-based preoperative simulation system for pedicle screw fixation in spinal surgery. J Korean Med Sci 2020; 35: e125.
Abstract
Project Number
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References
- Cho W, Cho SK, Wu C. The biomechanics of pedicle screw-based instrumentation. J Bone Joint Surg Br 2010; 92: 1061-5.
- Dede O, Ward WT, Bosch P, Bowles AJ, Roach JW. Using the freehand pedicle screw placement technique in adolescent idiopathic scoliosis surgery: what is the incidence of neurological symptoms secondary to misplaced screws? Spine (Phila Pa 1976) 2014; 39: 286-90.
- Park SM, Shen F, Kim HJ, et al. How many screws are necessary to be considered an experienced surgeon for freehand placement of thoracolumbar pedicle screws?: analysis using the cumulative summation test for learning curve. World neurosurgery 2018; 118: e550-e6.
- Perna F, Borghi R, Pilla F, Stefanini N, Mazzotti A, Chehrassan M. Pedicle screw insertion techniques: an update and review of the literature. Musculoskeletal Surg 2016; 100: 165-9.
- Esses SI, Sachs BL, Dreyzin V. Complications associated with the technique of pedicle screw fixation. A selected survey of ABS members. Spine (Phila Pa 1976) 1993; 18: 2231-8.
- Cui G, Wang Y, Kao TH, et al. Application of intraoperative computed tomography with or without navigation system in surgical correction of spinal deformity: a preliminary result of 59 consecutive human cases. Spine (Phila Pa 1976) 2012; 37: 891-900.
- Xiang L, Zhou Y, Wang H, et al. Significance of preoperative planning simulator for junior surgeons' training of pedicle screw insertion. J Spinal Disord Tech 2015; 28: E25-9.
- Song G BH, Zhao Y, Han J, Liu Preoperative planning and simulation for pedicle screw insertion using computed tomography-based patient specific volume rendering combined with projection fluoroscopy. Int Robot Autom J 2017; 2: 25-9.
- Park SK, Yeom JS, Won JH, et al. C1-2 fixation using polyaxial screws and rods assisted by computer simulation for revision of failed posterior fusion: a technical report. jkoa 2017; 40: 778-81.
- Fedorov A, Beichel R, Kalpathy-Cramer J, et al. 3D slicer as an image computing platform for the quantitative imaging network. Magn Reson Imaging 2012; 30: 1323-41.
- Muralidharan V, Swaminathan G, Devadhas D, Joseph BV. Patient-specific interactive software module for virtual preoperative planning and visualization of pedicle screw entry point and trajectories in spine surgery. Neurol India 2018; 66: 1766-70.
- Fennell VS, Palejwala S, Skoch J, Stidd DA, Baaj AA. Freehand thoracic pedicle screw technique using a uniform entry point and sagittal trajectory for all levels: preliminary clinical experience. J Neurosurg Spine 2014; 21: 778-84.
- Rao G, Brodke DS, Rondina M, Dailey AT. Comparison of computerized tomography and direct visualization in thoracic pedicle screw placement. J Neurosurg 2002; 97: 223-6.
- Mattei TA, Meneses MS, Milano JB, Ramina R. "Free-hand" technique for thoracolumbar pedicle screw instrumentation: critical appraisal of current "state-of-art". Neurol India 2009; 57: 715-21.
- Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine (Phila Pa 1976) 2004; 29: 333-42; discussion 42.
- Shin BJ, James AR, Njoku IU, Hartl R. Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. J Neurosurg Spine 2012; 17: 113-22.
- Rampersaud YR, Foley KT, Shen AC, Williams S, Solomito M. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976) 2000; 25: 2637-45.
- Swaminathan G, Muralidharan V, Devakumar D, Joseph BV. Accuracy of the freehand (fennell) technique using a uniform entry point and sagittal trajectory for insertion of thoracic pedicle screws: A computed tomography-based virtual simulation study. Neurol India 2020; 68: 468-71.
- Guzey FK, Emel E, Hakan Seyithanoglu M, et al. Accuracy of pedicle screw placement for upper and middle thoracic pathologies without coronal plane spinal deformity using conventional methods. J Spinal Disord Tech 2006; 19: 436-41.
- Vaccaro AR, Rizzolo SJ, Balderston RA, et al. Placement of pedicle screws in the thoracic spine. Part II: An anatomical and radiographic assessment. J Bone Joint Surg Am 1995; 77: 1200-6.
- Wi W, Park SM, Shin BS. Computed tomography-based preoperative simulation system for pedicle screw fixation in spinal surgery. J Korean Med Sci 2020; 35: e125.
Details
| Primary Language | English |
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| Subjects | Health Care Administration |
| Journal Section | Original Article |
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| Project Number | - |
| Publication Date | January 17, 2022 |
| Published in Issue | Year 2022 Volume: 5 Issue: 1 |
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