Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Accuracy of Freehand versus Navigated Thoracolumbar Pedicle Screw Placement in Patients with Metastatic Tumors of the Spine

  • De La Garza Ramos, Rafael (Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine) ;
  • Echt, Murray (Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine) ;
  • Benton, Joshua A. (Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine) ;
  • Gelfand, Yaroslav (Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine) ;
  • Longo, Michael (Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine) ;
  • Yanamadala, Vijay (Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine) ;
  • Yassari, Reza (Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine)
  • Received : 2019.12.31
  • Accepted : 2020.03.25
  • Published : 2020.11.01
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Abstract

Objective : To compare the accuracy and breach rates of freehand (FH) versus navigated (NV) pedicle screws in the thoracic and lumbar spine in patients with metastatic spinal tumors. Methods : A retrospective review of adult patients who underwent pedicle screw fixation in the thoracic or lumbar spine for metastatic spinal tumors between 2012 and 2018 was conducted. Breaches were assessed based on the Gertzbein and Robbins classification and only screws placed >4 mm outside of the pedicle wall (lateral or medial) were considered breached. Results : A total of 62 patients received 547 pedicle screws (average 8 per patient) - 34 patients received 298 pedicle screws in the FH group and 28 patients received 249 screws in the NV group. There were 40/547 breaches, corresponding to a breach and accuracy rate of 7.3% and 92.7%, respectively. The breach rate was 9.7% in the FH group and 4.4% in the NV group (chi-squared test, p=0.017); this corresponded to an accuracy rate of 90.3% and 95.6%, respectively. Only one patient from the overall cohort (in the FH group) required revision surgery due to a medial breach abutting the spinal cord (1.6% of all patients; 2.9% of FH patients); no patient suffered organ, vessel, or neurological injury from screw breaches. Conclusion : Navigated pedicle screw placement in patients with metastatic spinal tumors has a significantly higher radiographic accuracy compared to the FH technique. However, the revision surgery was low and no patient suffered from clinically-relevant breach. Navigation also offers the advantage of real-time localization of spinal tumors and aids in targeting and resection of these lesions.

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References

  1. Arand M, Hartwig E, Kinzl L, Gebhard F : Spinal navigation in tumor surgery of the thoracic spine: first clinical results. Clin Orthop Relat Res (399) : 211-218, 2002
  2. Brasiliense LB, Theodore N, Lazaro BC, Sayed ZA, Deniz FE, Sonntag VK, et al. : Quantitative analysis of misplaced pedicle screws in the thoracic spine: how much pullout strength is lost?: presented at the 2009 Joint Spine Section Meeting. J Neurosurg Spine 12 : 503-508, 2010 https://doi.org/10.3171/2009.11.SPINE09408
  3. Cho W, Cho SK, Wu C : The biomechanics of pedicle screw-based instrumentation. J Bone Joint Surg Br 92 : 1061-1065, 2010
  4. duPleiss SJ, Hurlbert RJ : Pedicle screw fixation of the thoracic and lumbar spine in Dickman CA, Fehlings MG, Gokaslan ZL (eds) : Spinal Cord and Spinal Column Tumors. New York : Thieme, 2006, pp587-598
  5. Fourney DR, Abi-Said D, Lang FF, McCutcheon IE, Gokaslan ZL : Use of pedicle screw fixation in the management of malignant spinal disease: experience in 100 consecutive procedures. J Neurosurg 94(1 Suppl) : 25-37, 2001
  6. Gautschi OP, Schatlo B, Schaller K, Tessitore E : Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: a literature review of 35,630 pedicle screws. Neurosurg Focus 31 : E8, 2011
  7. Gelalis ID, Paschos NK, Pakos EE, Politis AN, Arnaoutoglou CM, Karageorgos AC, et al. : Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J 21 : 247-255, 2012 https://doi.org/10.1007/s00586-011-2011-3
  8. Gertzbein SD, Robbins SE : Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976) 15 : 11-14, 1990 https://doi.org/10.1097/00007632-199001000-00004
  9. Innocenzi G, Bistazzoni S, D'Ercole M, Cardarelli G, Ricciardi F : Does navigation improve pedicle screw placement accuracy? Comparison between navigated and non-navigated percutaneous and open fixations. Acta Neurochir Suppl 124 : 289-295, 2017 https://doi.org/10.1007/978-3-319-39546-3_42
  10. Kakkos SK, Shepard AD : Delayed presentation of aortic injury by pedicle screws: report of two cases and review of the literature. J Vasc Surg 47 : 1074-1082, 2008 https://doi.org/10.1016/j.jvs.2007.11.005
  11. Karapinar L, Erel N, Ozturk H, Altay T, Kaya A : Pedicle screw placement with a free hand technique in thoracolumbar spine: is it safe? J Spinal Disord Tech 21 : 63-67, 2008 https://doi.org/10.1097/BSD.0b013e3181453dc6
  12. 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) 29 : 333-342; discussion 342, 2004 https://doi.org/10.1097/01.BRS.0000109983.12113.9B
  13. Kosmopoulos V, Schizas C : Pedicle screw placement accuracy: a metaanalysis. Spine (Phila Pa 1976) 32 : E111-E120, 2007 https://doi.org/10.1097/01.brs.0000254048.79024.8b
  14. Kotil K, Bilge T : Accuracy of pedicle and mass screw placement in the spine without using fluoroscopy: a prospective clinical study. Spine J 8 : 591-596, 2008 https://doi.org/10.1016/j.spinee.2007.04.002
  15. Krag MH, Beynnon BD, Pope MH, Frymoyer JW, Haugh LD, Weaver DL : An internal fixator for posterior application to short segments of the thoracic, lumbar, or lumbosacral spine. Design and testing. Clin Orthop Relat Res (203) : 75-98, 1986
  16. Lehman RA Jr, Kang DG, Lenke LG, Gaume RE, Paik H : The ventral lamina and superior facet rule: a morphometric analysis for an ideal thoracic pedicle screw starting point. Spine J 14 : 137-144, 2014 https://doi.org/10.1016/j.spinee.2013.06.092
  17. Luther N, Iorgulescu JB, Geannette C, Gebhard H, Saleh T, Tsiouris AJ, et al. : Comparison of navigated versus non-navigated pedicle screw placement in 260 patients and 1434 screws: screw accuracy, screw size, and the complexity of surgery. J Spinal Disord Tech 28 : E298-E303, 2015 https://doi.org/10.1097/BSD.0b013e31828af33e
  18. Moussazadeh N, Rubin DG, McLaughlin L, Lis E, Bilsky MH, Laufer I : Short-segment percutaneous pedicle screw fixation with cement augmentation for tumor-induced spinal instability. Spine J 15 : 1609-1617, 2015 https://doi.org/10.1016/j.spinee.2015.03.037
  19. Nasser R, Drazin D, Nakhla J, Al-Khouja L, Brien E, Baron EM, et al. : Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis. Neurosurg Focus 41 : E15, 2016
  20. Parker SL, McGirt MJ, Farber SH, Amin AG, Rick AM, Suk I, et al. : Accuracy of free-hand pedicle screws in the thoracic and lumbar spine: analysis of 6816 consecutive screws. Neurosurgery 68 : 170-178; discussion 178, 2011 https://doi.org/10.1227/NEU.0b013e3181fdfaf4
  21. Rajasekaran S, Kamath V, Shetty AP : Intraoperative Iso-C three-dimensional navigation in excision of spinal osteoid osteomas. Spine (Phila Pa 1976) 33 : E25-E29, 2008 https://doi.org/10.1097/BRS.0b013e31815e6308
  22. Shin BJ, James AR, Njoku IU, Hartl R : Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computernavigated versus freehand insertion. J Neurosurg Spine 17 : 113-122, 2012 https://doi.org/10.3171/2012.5.SPINE11399