Reconstruction of Shattered Lumbo-Sacral Junction/Pelvis Utilizing Bilateral L4-Sacrum Fibula Strut Allograft And Double Iliac Screws Plus Routine Lumbar Pedicle Screw Fixation

Background: A traumatically shattered lumbosacral junction/pelvis may be difficult to repair. Here the authors offer a pelvic fixation technique utilizing routine pedicle screws, interbody lumbar fusions, bilateral iliac screws/ rods/crosslinks, and bilateral fibular strut allografts from the lumbar spine to the sacrum. Methods: A middle aged male sustained a multiple storey fall resulting in a left sacral fracture, and right sacroiliac joint (SI) dislocation. The patient had previously undergone attempted decompressions with routine pedicle screw L4-S1 fusions at outside institutions; these failed twice. When the patient was finally seen, he exhibited, on CT reconstructed images, MR, and X-rays, a left sacral fracture nonunion, and a right sacroiliac joint dislocation. Results: The patient underwent a bilateral pelvic reconstruction utilizing right L4, L5, S1 and left L4, L5 pedicle screws plus interbody fusions (L4-L5, and L5, S1), performed from the left. Unique to this fusion construct was the placement of bilateral double iliac screws plus the application of bilateral fibula allografts from L4-sacrum filled with bone morphogenetic protein (BMP). After rod/screw/connectors were applied, bone graft was placed over the fusion construct, including the decorticated edges of the left sacral fractures, and right SI joint dislocation. We additionally reviewed other pelvic fusion reconstruction methods. Conclusions: Here, we utilized a unique pelvic reconstruction technique utilizing pedicle screws/rods, double iliac screws/rods, and bilateral fibula strut grafts extending from the L4-sacrum filled with BMP.

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Reduction and Fixation of Sacroiliac Joint Dislocation by the Combined Use of S1 Pedicle Screws and an Iliac Rod

Advances in Spinal Fusion ◽

10.1201/9780203912935.ch1 ◽

2003 ◽

Author(s):

Kuniyoshi Abumi ◽

Manabu Ito ◽

Yoshihisa Kotani ◽

Michinori Saita

Keyword(s):

Sacroiliac Joint ◽

Pedicle Screws ◽

Joint Dislocation ◽

Combined Use

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Reduction and Fixation of Sacroiliac Joint Dislocation by the Combined Use of S1 Pedicle Screws and the Galveston Technique

Spine ◽

10.1097/00007632-200008010-00018 ◽

2000 ◽

Vol 25 (15) ◽

pp. 1977-1983 ◽

Cited By ~ 29

Author(s):

Kuniyoshi Abumi ◽

Michinori Saita ◽

Takahiro Iida ◽

Kiyoshi Kaneda

Keyword(s):

Sacroiliac Joint ◽

Pedicle Screws ◽

Joint Dislocation ◽

Combined Use ◽

Galveston Technique

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Spinal pelvic reconstruction after total sacrectomy for en bloc resection of a giant sacral chordoma

Journal of Neurosurgery Spine ◽

10.3171/spi.2005.3.6.0501 ◽

2005 ◽

Vol 3 (6) ◽

pp. 501-506 ◽

Cited By ~ 40

Author(s):

Gary L. Gallia ◽

Raqeeb Haque ◽

Ira Garonzik ◽

Timothy F. Witham ◽

Yevgeniy A. Khavkin ◽

...

Keyword(s):

Pelvic Ring ◽

Present Report ◽

Pedicle Screws ◽

Disease Free Survival ◽

Radical Resection ◽

Reconstruction Technique ◽

Pelvic Reconstruction ◽

En Bloc ◽

Sacral Chordoma ◽

Total Sacrectomy

✓ Although radical resection prolongs the disease-free survival period, surgical management of primary sacral tumors is challenging because of their location and often large size. Moreover, in cases of lesions for which a radical resection necessitates total sacrectomy, reconstruction is required. The authors have previously described a modified Galveston technique in which a liaison between the spine and pelvis is achieved using lumbar pedicle screws and Galveston rods embedded into the ilia; additionally, a transiliac bar reestablishes the pelvic ring. Although this reconstruction technique achieves stabilization, several biomechanical limitations exist. In the present report the authors present the case of a patient who underwent spinal pelvic reconstruction after a total sacrectomy was performed to remove a giant sacral chordoma. They describe a novel spinal pelvic reconstruction technique that addresses some of the biomechanical limitations.

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Image-Guided Spinal Surgery and Robotics in MIS: Where Are We Now?

Neurologico Spinale Medico Chirurgico ◽

10.15562/nsmc.v1i2.80 ◽

2018 ◽

Vol 1 (2) ◽

pp. 2

Author(s):

Chiung Chyi Shen

Keyword(s):

Pedicle Screw ◽

Spinal Surgery ◽

Surgical Navigation ◽

Improve Patient Safety ◽

Intraoperative Imaging ◽

Spinal Instrumentation ◽

Pedicle Screws ◽

Computer Assisted ◽

Navigation Systems ◽

Image Guided

Use of pedicle screws is widespread in spinal surgery for degenerative, traumatic, and oncological diseases. The conventional technique is based on the recognition of anatomic landmarks, preparation and palpation of cortices of the pedicle under control of an intraoperative C-arm (iC-arm) fluoroscopy. With these conventional methods, the median pedicle screw accuracy ranges from 86.7% to 93.8%, even if perforation rates range from 21.1% to 39.8%.The development of novel intraoperative navigational techniques, commonly referred to as image-guided surgery (IGS), provide simultaneous and multiplanar views of spinal anatomy. IGS technology can increase the accuracy of spinal instrumentation procedures and improve patient safety. These systems, such as fluoroscopy-based image guidance ("virtual fluoroscopy") and computed tomography (CT)-based computer-guidance systems, have sensibly minimized risk of pedicle screw misplacement, with overall perforation rates ranging from between 14.3% and 9.3%, respectively."Virtual fluoroscopy" allows simultaneous two-dimensional (2D) guidance in multiple planes, but does not provide any axial images; quality of images is directly dependent on the resolution of the acquired fluoroscopic projections. Furthermore, computer-assisted surgical navigation systems decrease the reliance on intraoperative imaging, thus reducing the use of intraprocedure ionizing radiation. The major limitation of this technique is related to the variation of the position of the patient from the preoperative CT scan, usually obtained before surgery in a supine position, and the operative position (prone). The next technological evolution is the use of an intraoperative CT (iCT) scan, which would allow us to solve the position-dependent changes, granting a higher accuracy in the navigation system.

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Augmented reality–assisted pedicle screw insertion: a cadaveric proof-of-concept study

Journal of Neurosurgery Spine ◽

10.3171/2018.12.spine181142 ◽

2019 ◽

Vol 31 (1) ◽

pp. 139-146 ◽

Cited By ~ 11

Author(s):

Camilo A. Molina ◽

Nicholas Theodore ◽

A. Karim Ahmed ◽

Erick M. Westbroek ◽

Yigal Mirovsky ◽

...

Keyword(s):

Augmented Reality ◽

Pedicle Screw ◽

User Experience ◽

Pedicle Screws ◽

Screw Insertion ◽

Pedicle Screw Insertion ◽

Insertion Method ◽

Comparative Accuracy ◽

Placement Accuracy ◽

Surgical Field

OBJECTIVEAugmented reality (AR) is a novel technology that has the potential to increase the technical feasibility, accuracy, and safety of conventional manual and robotic computer-navigated pedicle insertion methods. Visual data are directly projected to the operator’s retina and overlaid onto the surgical field, thereby removing the requirement to shift attention to a remote display. The objective of this study was to assess the comparative accuracy of AR-assisted pedicle screw insertion in comparison to conventional pedicle screw insertion methods.METHODSFive cadaveric male torsos were instrumented bilaterally from T6 to L5 for a total of 120 inserted pedicle screws. Postprocedural CT scans were obtained, and screw insertion accuracy was graded by 2 independent neuroradiologists using both the Gertzbein scale (GS) and a combination of that scale and the Heary classification, referred to in this paper as the Heary-Gertzbein scale (HGS). Non-inferiority analysis was performed, comparing the accuracy to freehand, manual computer-navigated, and robotics-assisted computer-navigated insertion accuracy rates reported in the literature. User experience analysis was conducted via a user experience questionnaire filled out by operators after the procedures.RESULTSThe overall screw placement accuracy achieved with the AR system was 96.7% based on the HGS and 94.6% based on the GS. Insertion accuracy was non-inferior to accuracy reported for manual computer-navigated pedicle insertion based on both the GS and the HGS scores. When compared to accuracy reported for robotics-assisted computer-navigated insertion, accuracy achieved with the AR system was found to be non-inferior when assessed with the GS, but superior when assessed with the HGS. Last, accuracy results achieved with the AR system were found to be superior to results obtained with freehand insertion based on both the HGS and the GS scores. Accuracy results were not found to be inferior in any comparison. User experience analysis yielded “excellent” usability classification.CONCLUSIONSAR-assisted pedicle screw insertion is a technically feasible and accurate insertion method.

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Minimally Invasive Techniques for Iliac Bolt Placement: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab001 ◽

2021 ◽

Vol 20 (4) ◽

pp. E292-E292

Author(s):

Travis Hamilton ◽

Mohamed Macki ◽

Thomas M Zervos ◽

Victor Chang

Keyword(s):

Minimally Invasive ◽

Imaging System ◽

Pedicle Screws ◽

Vertical Axis ◽

Spinal Diseases ◽

Open Approach ◽

Sagittal Vertical Axis ◽

Pelvic Fixation ◽

Iliac Screws ◽

Invasive Techniques

Abstract As the popularity of minimally invasive surgery (MIS) continues to grow, novel techniques are needed to meet the demands of multisegment fixation for advanced spinal diseases. In one such example, iliac bolts are often required to anchor large fusion constructs, but MIS technical notes are missing from the literature. A 67-yr-old female presented with a symptomatic coronal deformity: preoperative pelvic incidence = 47°, pelvic tilt = 19°, and lumbar lordosis = 29°, sagittal vertical axis = +5.4 cm with 30° of scoliosis. The operative plan included T10-ilium fusion with transforaminal interbody grafts at L2-3, L3-4, L4-5, and L5-S1. The intraoperative video is of minimally invasive placement of iliac bolts using the O-Arm Surgical Imaging System (Medtronic®). The patient consented to the procedure. A mini-open exposure that remains above the fascial planes allows for multilevel instrumentation with appropriate decompression at the interbody segments. After the placement of the pedicle screws under image-guidance, the direction is turned to the minimally invasive iliac bolts. Following the trajectory described in the standard open approach,1 the posterior superior iliac spine (PSIS) is identified with the navigation probe, which will guide the Bovie cautery through the fascia. This opening assists in the trajectory of the navigated-awl tap toward the anterior superior iliac spine (ASIS). Next, 8.5 mm x 90 mm iliac screws were placed in the cannulated bone under navigation. After intraoperative image confirmation of screw placement, the contoured rods are threaded under the fascia. The setscrews lock the rod in position. MIS approaches obviate cross-linking the rods, rendering pelvic fixation more facile. This technique allows for minimal dissection of the posterior pelvic soft tissue while maintaining adequate fixation.

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

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.139974 ◽

2014 ◽

Vol 05 (04) ◽

pp. 349-354 ◽

Cited By ~ 2

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.

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The accuracy of pedicle screw placement using intraoperative image guidance systems

Journal of Neurosurgery Spine ◽

10.3171/2013.11.spine13413 ◽

2014 ◽

Vol 20 (2) ◽

pp. 196-203 ◽

Cited By ~ 155

Author(s):

Alexander Mason ◽

Renee Paulsen ◽

Jason M. Babuska ◽

Sharad Rajpal ◽

Sigita Burneikiene ◽

...

Keyword(s):

Pedicle Screw ◽

Image Guidance ◽

Pedicle Screws ◽

Screw Placement ◽

Data Sets ◽

Pedicle Screw Placement ◽

Fluoroscopic Image ◽

Fluoroscopic Navigation ◽

Guidance Systems ◽

Accuracy Rates

Object Several retrospective studies have demonstrated higher accuracy rates and increased safety for navigated pedicle screw placement than for free-hand techniques; however, the accuracy differences between navigation systems has not been extensively studied. In some instances, 3D fluoroscopic navigation methods have been reported to not be more accurate than 2D navigation methods for pedicle screw placement. The authors of this study endeavored to identify if 3D fluoroscopic navigation methods resulted in a higher placement accuracy of pedicle screws. Methods A systematic analysis was conducted to examine pedicle screw insertion accuracy based on the use of 2D, 3D, and conventional fluoroscopic image guidance systems. A PubMed and MEDLINE database search was conducted to review the published literature that focused on the accuracy of pedicle screw placement using intraoperative, real-time fluoroscopic image guidance in spine fusion surgeries. The pedicle screw accuracy rates were segregated according to spinal level because each spinal region has individual anatomical and morphological variations. Descriptive statistics were used to compare the pedicle screw insertion accuracy rate differences among the navigation methods. Results A total of 30 studies were included in the analysis. The data were abstracted and analyzed for the following groups: 12 data sets that used conventional fluoroscopy, 8 data sets that used 2D fluoroscopic navigation, and 20 data sets that used 3D fluoroscopic navigation. These studies included 1973 patients in whom 9310 pedicle screws were inserted. With conventional fluoroscopy, 2532 of 3719 screws were inserted accurately (68.1% accuracy); with 2D fluoroscopic navigation, 1031 of 1223 screws were inserted accurately (84.3% accuracy); and with 3D fluoroscopic navigation, 4170 of 4368 screws were inserted accurately (95.5% accuracy). The accuracy rates when 3D was compared with 2D fluoroscopic navigation were also consistently higher throughout all individual spinal levels. Conclusions Three-dimensional fluoroscopic image guidance systems demonstrated a significantly higher pedicle screw placement accuracy than conventional fluoroscopy or 2D fluoroscopic image guidance methods.

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