Freehand screw insertion technique without image guidance for the cortical bone trajectory screw in posterior lumbar interbody fusion: what affects screw misplacement?

OBJECTIVE Cortical bone trajectory (CBT) screw insertion using a freehand technique is considered less feasible than guided techniques, due to the lack of readily identifiable visual landmarks. However, in posterior lumbar interbody fusion (PLIF), after resection of the posterior anatomy, the pedicles themselves, into which implantation is performed, are palpable from the spinal canal and neural foramen. With the help of pedicle wall probing, the authors have placed CBT screws using a freehand technique without image guidance in PLIF. This technique has advantages of no radiation exposure and no requirement for expensive devices, but the disadvantage of reduced accuracy in screw placement. To address the problem of symptomatic breaches with this freehand technique, variables related to unacceptable screw positioning and need for revisions were investigated. METHODS From 2014 to 2020, 182 of 426 patients with single-level PLIF were enrolled according to the combined criteria of L4–5 level, excluding cases of revision and isthmic spondylolisthesis; using screws 5.5 mm in diameter; and operated by right-handed surgeons. We studied the number of misplaced screws found and replaced during initial surgeries. Using multiplanar reconstruction CT postoperatively, 692 screw positions on images were classified using previously reported grading criteria. Details of pedicle breaches requiring revisions were studied. We conducted a statistical analysis of the relationship between unacceptable (perforations > 2 mm) misplacements and four variables: level, laterality, spinal deformity, and experiences of surgeons. RESULTS Three screws in L4 and another in L5 were revised during initial surgeries. The total rate of unacceptable screws on CT examinations was 3.3%. Three screws in L4 and another in L5 breached inferomedial pedicle walls in grade 3 and required revisions. The revision rate was 2.2%. The percentage of unacceptable screws was 5.2% in L4 and 1.7% in L5 (p < 0.05), whereas other variables showed no significant differences. CONCLUSIONS A freehand technique can be feasible for CBT screw insertion in PLIF, balancing the risks of 3.3% unacceptable misplacements and 2.2% revisions with the benefits of no radiation exposure and no need for expensive devices. Pedicle palpation in L4 is the key to safety, even though it requires deeper and more difficult probing. In the initial surgeries and revisions, 75% of revised screws were observed in L4, and unacceptable screw positions were more likely to be found in L4 than in L5.