scholarly journals Triggered Electromyography is a Useful Intraoperative Adjunct to Predict Postoperative Neurological Deficit Following Lumbar Pedicle Screw Instrumentation

2021 ◽  
pp. 219256822110184
Author(s):  
Rajiv P. Reddy ◽  
Robert Chang ◽  
Dominic V. Coutinho ◽  
Justin W. Meinert ◽  
Katherine M. Anetakis ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Pedicle Screw ◽  
Neurological Deficit ◽  
Meta Analysis ◽  
Pedicle Screws ◽  
Neurological Deficits ◽  
Lumbar Spine Surgery ◽  
Postoperative Neurological Deficit ◽  
Alarm Threshold ◽  
Lumbar Pedicle

Study Design: Systematic review and meta-analysis. Objectives: Malposition of pedicle screws during instrumentation in the lumbar spine is associated with complications secondary to spinal cord or nerve root injury. Intraoperative triggered electromyographic monitoring (t-EMG) may be used during instrumentation for early detection of malposition. The association between lumbar pedicle screws stimulated at low EMG thresholds and postoperative neurological deficits, however, remains unknown. The purpose of this study is to assess whether a low threshold t-EMG response to lumbar pedicle screw stimulation can serve as a predictive tool for postoperative neurological deficit. Methods: The present study is a meta-analysis of the literature from PubMed, Web of Science, and Embase identifying prospective/retrospective studies with outcomes of patients who underwent lumbar spinal fusion with t-EMG testing. Results: The total study cohort consisted of 2,236 patients and the total postoperative neurological deficit rate was 3.04%. 10.78% of the patients incurred at least 1 pedicle screw that was stimulated below the respective EMG alarm threshold intraoperatively. The incidence of postoperative neurological deficits in patients with a lumbar pedicle screw stimulated below EMG alarm threshold during placement was 13.28%, while only 1.80% in the patients without. The pooled DOR was 10.14. Sensitivity was 49% while specificity was 88%. Conclusions: Electrically activated lumbar pedicle screws resulting in low t-EMG alarm thresholds are highly specific but weakly sensitive for new postoperative neurological deficits. Patients with new postoperative neurological deficits after lumbar spine surgery were 10 times more likely to have had a lumbar pedicle screw stimulated at a low EMG threshold.

scholarly journals Confirmation of accuracy/inaccuracy of lumbar pedicle screw placement using postoperative computed tomography

2021 ◽  
Vol 12 ◽  
pp. 518
Author(s):  
Mohamed M. Arnaout ◽  
Magdy O. ElSheikh ◽  
Mansour A. Makia
Keyword(s):  
Computed Tomography ◽  
Lumbar Spine ◽  
Pedicle Screw ◽  
Pedicle Screws ◽  
Operative Intervention ◽  
Screw Placement ◽  
Lumbar Spine Surgery ◽  
Pedicle Screw Placement ◽  
Lumbar Pedicle ◽  
Ct Studies

Background: Transpedicular screws are extensively utilized in lumbar spine surgery. The placement of these screws is typically guided by anatomical landmarks and intraoperative fluoroscopy. Here, we utilized 2-week postoperative computed tomography (CT) studies to confirm the accuracy/inaccuracy of lumbar pedicle screw placement in 145 patients and correlated these findings with clinical outcomes. Methods: Over 6 months, we prospectively evaluated the location of 612 pedicle screws placed in 145 patients undergoing instrumented lumbar fusions addressing diverse pathology with instability. Routine anteroposterior and lateral plain radiographs were obtained 48 h after the surgery, while CT scans were obtained at 2 postoperative weeks (i.e., ideally these should have been performed intraoperatively or within 24–48 h of surgery). Results: Of the 612 screws, minor misplacement of screws (≤2 mm) was seen in 104 patients, moderate misplacement in 34 patients (2–4 mm), and severe misplacement in 7 patients (>4 mm). Notably, all the latter 7 (4.8% of the 145) patients required repeated operative intervention. Conclusion: Transpedicular screw insertion in the lumbar spine carries the risks of pedicle medial/lateral violation that is best confirmed on CT rather than X-rays/fluoroscopy alone. Here, we additional found 7 patients (4.8%) who with severe medial/lateral pedicle breach who warranting repeated operative intervention. In the future, CT studies should be performed intraoperatively or within 24–48 h of surgery to confirm the location of pedicle screws and rule in our out medial or lateral pedicle breaches.

scholarly journals Percutaneous Pedicle Screw and Rod Insertion for the Treatment of Thoracic and Lumbar Spine Fracture

2013 ◽  
Vol 3 (1) ◽  
pp. 23-27
Author(s):  
Pashupati Chaudhary ◽  
Navin Kumar Karn ◽  
Bikram Prasad Shrestha ◽  
Guru Prasad Khanal ◽  
Raju Rijal
Keyword(s):  
Lumbar Spine ◽  
Pedicle Screw ◽  
Neurological Deficit ◽  
Lumbar Fusion ◽  
Operation Time ◽  
Spine Fracture ◽  
Percutaneous Pedicle Screw ◽  
Traumatic Fracture ◽  
Thoracic And Lumbar Spine ◽  
Lumbar Pedicle

Introduction: Standard techniques for lumbar pedicle screw and rod fixation involve open exposure and extensive muscle dissection. Percutaneous pedicle screw system minimises the morbidity associated with traditional open approaches without compromising the quality of spinal fixation. A preliminary experience with this device has been encouraging. The purpose of this study was to demonstrate operative techniques and experiences with percutaneous lumbar pedicle screw and rod insertion for internal fixation of the lumbar spine without use of Zig. Methods: It was hospital based retrospective interventional study done at the department of Orthopaedics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal over a period of 2 and half years. The study enrolled 30 patients aged 18-55 years who had presented with traumatic fracture of thoracic and lumbar spine. All thirty patients underwent percutaneous pedicle screw and rod fixation and successful percutaneous single/two level fusions. The follow up period ranged from 6 to 24 months. Results: The study comprised of 25 males and 5 females. Average patient’s age was 36.5 years (range 18-55 years). The common mode of injury was fall from height, road traffic accident, physical assault followed by sports related injury. All patients were having unstable spine fracture without neurological deficit. Operation time, loss of blood, post operative pain was less in percutaneous method. Post operative rehabilitation was easier. Spinal fusion was achieved in all patients in 6 months to 1 year time. There was no post-operative neurological deficit, infection, implant failure. Conclusion: Our early experience suggests that Minimally invasive approaches for performing lumbar fusion, is able to achieve the same clinical results as conventional open procedures. DOI: http://dx.doi.org/10.3126/noaj.v3i1.9322   Nepal Orthopedic Association Journal 2013 Vol.3(1): 23-27

Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results

2002 ◽  
Vol 97 (1) ◽  
pp. 7-12 ◽  
Author(s):  
Kevin T. Foley ◽  
Sanjay K. Gupta
Keyword(s):  
Lumbar Spine ◽  
Pedicle Screw ◽  
Screw Fixation ◽  
Pedicle Screws ◽  
Pedicle Screw Fixation ◽  
Posterior Fixation ◽  
Content Type ◽  
Insertion Device ◽  
Lumbar Pedicle ◽  
Fine Print

Object. Standard techniques for pedicle screw fixation of the lumbar spine involve open exposures and extensive muscle dissection. The purpose of this study was to report the initial clinical experience with a novel device for percutaneous posterior fixation of the lumbar spine. Methods. An existing multiaxial lumbar pedicle screw system was modified to allow screws to be placed percutaneously by using an extension sleeve that permits remote manipulation of the polyaxial screw heads and remote engagement of the screw-locking mechanism. A unique rod-insertion device was developed that linked to the screw extension sleeves, allowing for a precut and -contoured rod to be placed through a small stab wound. Because the insertion device relies on the geometrical constraint of the rod pathway through the screw heads, minimal manipulation is required to place the rods in a standard submuscular position, there is essentially no muscle dissection, and the need for direct visual feedback is avoided. Twelve patients (six men and six women) who ranged in age from 23 to 68 years underwent pedicle screw fixation in which the rod-insertion device was used. Spondylolisthesis was present in 10 patients and osseous nonunion of a prior interbody fusion was present in two. All patients underwent successful percutaneous fixation. Ten patients underwent single-level fusions (six at L5—S1, three at L4–5, and one at L2–3), and two underwent two-level fusions (one from L3–5 and the other from L4—S1). The follow-up period ranged from 10 to 19 months (mean 13.8 months). Conclusions. Although percutaneous lumbar pedicle screw placement has been described previously, longitudinal connector (rod or plate) insertion has been more problematic. The device used in this study allows for straightforward placement of lumbar pedicle screws and rods through percutaneous stab wounds. Paraspinous tissue trauma is minimized without compromising the quality of spinal fixation. Preliminary experience involving the use of this device has been promising.

scholarly journals Application of a Novel Attachable Magnetic Nerve Stimulating Probe in Intraoperative Lumbar Pedicle Screw Placement: A Porcine Model Study

2021 ◽  
Vol 11 (17) ◽  
pp. 7801
Author(s):  
Tae Sik Goh ◽  
Sung-Chan Shin ◽  
Hyun-Keun Kwon ◽  
Eui-Suk Sung ◽  
Se Bin Jun ◽  
...  
Keyword(s):  
Pedicle Screw ◽  
Porcine Model ◽  
Lumbar Vertebrae ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Lumbar Spine Surgery ◽  
Pedicle Screw Placement ◽  
Significant Difference ◽  
Screw Malpositioning ◽  
Lumbar Pedicle

Pedicle screw instrumentation is a fundamental technique in lumbar spine surgery. However, several complications could occur when placing a pedicle screw, the most serious being damage to the neural structures. We developed an attachable magnetic nerve stimulating probe used for triggered electromyography (t-EMG) to avoid these. This study aimed to investigate the efficacy of this probe for intraoperative neuromonitoring (ION) during lumbar pedicle screw placement in a porcine model. Forty pedicle screws were inserted bilaterally into the pedicles of the fourth and fifth lumbar vertebrae of five pigs; 20 were inserted typically into the pedicle without nerve damage (Group A), and the other 20 were inserted through the broken medial wall of the pedicle to permit contact with the neural structures (Group B). We measured the triggered threshold for pedicle screw placement through the conventional nerve probe and our newly developed magnetic probe. There was no significant difference in the triggered threshold between the two instruments (p = 0.828). Our newly developed magnetic stimulating probe can be attached to a screwdriver, thus preventing real-time screw malpositioning and making it practical and equally safe. This probe could become indispensable in revision spine surgeries with severe adhesions or endoscopic spine surgeries.

scholarly journals Cortical Bone Trajectory Screw Fixation of Lumbar Spine in Adult Patients with Degenerative and Traumatic Spine Disorders

QJM ◽  
2020 ◽  
Vol 113 (Supplement_1) ◽  
Author(s):  
A M Elbadrawy ◽  
T M S Elkhateeb ◽  
E M M A Hassan
Keyword(s):  
Lumbar Spine ◽  
Random Effects ◽  
Screw Fixation ◽  
Meta Analysis ◽  
Pedicle Screws ◽  
Fusion Rate ◽  
Random Effects Models ◽  
Fixed And Random Effects ◽  
Spine Disorders ◽  
Lumbar Pedicle

Abstract Background the CBT for placing lumbar pedicle screws is a technique used to improve fixation during instrumented fusion of the lumbar spine. In comparison with traditional trajectory (TT) for pedicle screws, CBT screws (otherwise known as pars screws or cortical screws) have a more medial starting point and are aimed in a medial to lateral, caudal to cranial direction. First reported in 2009 as a method to increase the purchase of lumbar pedicle screws within bone.(1) Aim of the Work to perform a systematic review and meta-analysis to determine whether traditional Pedicles Screw Fixation (PS Fx) or Cortical Bone Trajectory Screw Fixation (CBT Fx); has been successful for the treatment and fixation of lumbar spine in adult patients with degenerative and traumatic spine disorders; and to compare the 2 techniques to identify risk factor for unfavorable outcome through the recent researches about that issue. Methodology this review was done using standard methodology outlined in the Cochrane Handbook and reported the findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines. Results meta-analysis study showed that; Successful fusion rate in fixed and random-effects models were (92.24% respectively); in SP group.Successful fusion rate in fixed and random-effects models were (92.44% respectively); in CBT group.Fixed and random-effects models showed non-significant difference in successful fusion rate; between the 2 groups of studies (p > 0.05). We calculated safety for each technique through post-operative (failed fusion rate). Conclusion Although there were insignificant p-values in the most of the comparative items but the CBT showed lower average of intraoperative blood loss, operation time and higher average of decrease in VAS & increase in ODI, slightly higher fusion rate in comparison with PS. So we recommend, the use of CBT as an acceptable alternative of PS in lumbar spine fixation.

scholarly journals Percutaneous pedicle screw fixation of the lumbar spine

2001 ◽  
Vol 10 (4) ◽  
pp. 1-9 ◽  
Author(s):  
Kevin T. Foley ◽  
Sanjay K. Gupta ◽  
Jeff R. Justis ◽  
Michael C. Sherman
Keyword(s):  
Lumbar Spine ◽  
Pedicle Screw ◽  
Screw Fixation ◽  
Pedicle Screws ◽  
Pedicle Screw Fixation ◽  
Posterior Fixation ◽  
Insertion Device ◽  
Locking Mechanism ◽  
Percutaneous Pedicle Screw ◽  
Lumbar Pedicle

Object Standard techniques for lumbar pedicle screw fixation involve open exposures and extensive muscle dissection. The purpose of this study was to report the initial clinical experience with a novel device for percutaneous posterior fixation of the lumbar spine. Methods An existing multiaxial lumbar pedicle screw system was modified so that screws could be placed percutaneously by using an extension sleeve that would allow for remote manipulation of the polyaxial screw heads and remote engagement of the screw locking mechanism. A unique rod insertion device was developed that linked to the screw extension sleeves, allowing for a precut, precontoured rod to be placed through a small stab wound. Because the insertion device relies on geometrical constraint of the rod pathway through the screw heads, rods can be placed in a standard submuscular position with minimal manipulation, essentially no muscle dissection, and without the need for direct visual feedback. Twelve patients (six men and six women who ranged in age from 23–68 years) underwent pedicle screw fixation in which the rod insertion device was used. Spondylolisthesis was present in 10 patients and nonunion of a prior interbody fusion was present in two. All patients underwent successful percutaneous fixation. Ten patients underwent single-level fusions (six at L5–S1, three at L4–5, and one at L2–3), and two underwent two-level fusions (one from L–3 to L–5 and the other from L–4 to S–1). The follow-up period ranged from 3 to 12 months (mean 6.8 months). Conclusions Although percutaneous lumbar pedicle screw placement has been described previously, longitudinal connector (rod or plate) insertion has been more problematic. The device used in this study allows for straightforward placement of lumbar pedicle screws and rods through percutaneous stab wounds. Paraspinous tissue trauma is minimized without compromising the quality of spinal fixation. Preliminary experience with this device has been promising.

Diagnostic Accuracy of SSEP Changes during Lumbar Spine Surgery for Predicting Postoperative Neurological Deficit

Spine ◽  
2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Robert Chang ◽  
Rajiv P. Reddy ◽  
Dominic V. Coutinho ◽  
Yue-Fang Chang ◽  
Katherine M. Anetakis ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Diagnostic Accuracy ◽  
Spine Surgery ◽  
Neurological Deficit ◽  
Lumbar Spine Surgery ◽  
Postoperative Neurological Deficit

scholarly journals Novel free-hand T1 pedicle screw method: Review of 44 consecutive cases

2014 ◽  
Vol 05 (04) ◽  
pp. 349-354 ◽  
Author(s):  
Mark A. Rivkin ◽  
Jessica F. Okun ◽  
Steven S. Yocom
Keyword(s):  
Pedicle Screw ◽  
Thoracic Spine ◽  
Pedicle Screws ◽  
High Rate ◽  
Imaging Modalities ◽  
Neurological Deficits ◽  
Upper Thoracic Spine ◽  
Starting Point ◽  
Grade 3 ◽  
Upper Thoracic

ABSTRACT Summary of Background Data: Multilevel posterior cervical instrumented fusions are becoming more prevalent in current practice. Biomechanical characteristics of the cervicothoracic junction may necessitate extending the construct to upper thoracic segments. However, fixation in upper thoracic spine can be technically demanding owing to transitional anatomy while suboptimal placement facilitates vascular and neurologic complications. Thoracic instrumentation methods include free-hand, fluoroscopic guidance, and CT-based image guidance. However, fluoroscopy of upper thoracic spine is challenging secondary to vertebral geometry and patient positioning, while image-guided systems present substantial financial commitment and are not readily available at most centers. Additionally, imaging modalities increase radiation exposure to the patient and surgeon while potentially lengthening surgical time. Materials and Methods: Retrospective review of 44 consecutive patients undergoing a cervicothoracic fusion by a single surgeon using the novel free-hand T1 pedicle screw technique between June 2009 and November 2012. A starting point medial and cephalad to classic entry as well as new trajectory were utilized. No imaging modalities were employed during screw insertion. Postoperative CT scans were obtained on day 1. Screw accuracy was independently evaluated according to the Heary classification. Results: In total, 87 pedicle screws placed were at T1. Grade 1 placement occurred in 72 (82.8%) screws, Grade 2 in 4 (4.6%) screws and Grade 3 in 9 (10.3%) screws. All Grade 2 and 3 breaches were <2 mm except one Grade 3 screw breaching 2-4 mm laterally. Only two screws (2.3%) were noted to be Grade 4, both breaching medially by less than 2 mm. No new neurological deficits or returns to operating room took place postoperatively. Conclusions: This modification of the traditional starting point and trajectory at T1 is safe and effective. It attenuates additional bone removal or imaging modalities while maintaining a high rate of successful screw placement compared to historical controls.

scholarly journals Percutaneous placement of lumbar pedicle screws via intraoperative CT image–based augmented reality–guided technology

2020 ◽  
Vol 32 (4) ◽  
pp. 542-547 ◽  
Author(s):  
Huan Liu ◽  
Junlong Wu ◽  
Yu Tang ◽  
Haiyin Li ◽  
Wenkai Wang ◽  
...  
Keyword(s):  
Augmented Reality ◽  
Pedicle Screw ◽  
Pedicle Screws ◽  
Clinical Situation ◽  
Ct Image ◽  
Alignment Method ◽  
Intraoperative Ct ◽  
Screw Perforation ◽  
Automatic Alignment ◽  
Lumbar Pedicle

OBJECTIVEThe authors aimed to assess, in a bone-agar experimental setting, the feasibility and accuracy of percutaneous lumbar pedicle screw placements using an intraoperative CT image–based augmented reality (AR)–guided method compared to placements using a radiograph-guided method. They also compared two AR hologram alignment methods.METHODSTwelve lumbar spine sawbones were completely embedded in hardened opaque agar, and a cubic marker was fixed on each phantom. After intraoperative CT, a 3D model of each phantom was generated, and a specialized application was deployed into an AR headset (Microsoft HoloLens). One hundred twenty pedicle screws, simulated by Kirschner wires (K-wires), were placed by two experienced surgeons, who each placed a total of 60 screws: 20 placed with a radiograph-guided technique, 20 with an AR technique in which the hologram was manually aligned, and 20 with an AR technique in which the hologram was automatically aligned. For each K-wire, the insertion path was expanded to a 6.5-mm diameter to simulate a lumbar pedicle screw. CT imaging of each phantom was performed after all K-wire placements, and the operative time required for each K-wire placement was recorded. An independent radiologist rated all images of K-wire placements. Outcomes were classified as grade I (no pedicle perforation), grade II (screw perforation of the cortex by up to 2 mm), or grade III (screw perforation of the cortex by > 2 mm). In a clinical situation, placements scored as grade I or II would be acceptable and safe for patients.RESULTSAmong all screw placements, 75 (94%) of 80 AR-guided placements and 40 (100%) of 40 radiograph-guided placements were acceptable (i.e., grade I or II; p = 0.106). Radiograph-guided placements had more grade I outcomes than the AR-guided method (p < 0.0001). The accuracy of the two AR alignment methods (p = 0.526) was not statistically significantly different, and neither was it different between the AR and radiograph groups (p < 0.0001). AR-guided placements required less time than the radiograph-guided placements (mean ± standard deviation, 131.76 ± 24.57 vs 181.43 ± 15.82 seconds, p < 0.0001). Placements performed using the automatic-alignment method required less time than those using the manual-alignment method (124.20 ± 23.80 vs 139.33 ± 23.21 seconds, p = 0.0081).CONCLUSIONSIn bone-agar experimental settings, AR-guided percutaneous lumbar pedicle screw placements were acceptable and more efficient than radiograph-guided placements. In a comparison of the two AR-guided placements, the automatic-alignment method was as accurate as the manual method but more efficient. Because of some limitations, the AR-guided system cannot be recommended in a clinical setting until there is significant improvement of this technology.

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