Cervical Spine Pedicle Screw Accuracy in Fluoroscopic, Navigated and Template Guided Systems—A Systematic Review

Background: Pedicle screws provide excellent fixation for a wide range of indications. However, their adoption in the cervical spine has been slower than in the thoracic and lumbar spine, which is largely due to the smaller pedicle sizes and the proximity to the neurovascular structures in the neck. In recent years, technology has been developed to improve the accuracy and thereby the safety of cervical pedicle screw placement over traditional fluoroscopic techniques, including intraoperative 3D navigation, computer-assisted Systems and 3D template moulds. We have performed a systematic review into the accuracy rates of the various systems. Methods: The PubMed and Cochrane Library databases were searched for eligible papers; 9 valid papers involving 1427 screws were found. Results: fluoroscopic methods achieved an 80.6% accuracy and navigation methods produced 91.4% and 96.7% accuracy for templates. Conclusion: Navigation methods are significantly more accurate than fluoroscopy, they reduce radiation exposure to the surgical team, and improvements in technology are speeding up operating times. Significantly superior results for templates over fluoroscopy and navigation are complemented by reduced radiation exposure to patient and surgeon; however, the technology requires a more invasive approach, prolonged pre-operative planning and the development of an infrastructure to allow for their rapid production and delivery. We affirm the superiority of navigation over other methods for providing the most accurate and the safest cervical pedicle screw instrumentation, as it is more accurate than fluoroscopy and lacks the limitations of templates.

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The comparative accuracy and safety of fluoroscopic and navigation-based techniques in cervical pedicle screw fixation: systematic review and meta-analysis

Journal of Neurosurgery Spine ◽

10.3171/2020.11.spine201877 ◽

2021 ◽

pp. 1-8

Author(s):

Ahmad M. Tarawneh ◽

Shahnawaz Haleem ◽

Daniel D’Aquino ◽

Nasir Quraishi

Keyword(s):

Systematic Review ◽

Pedicle Screw ◽

Meta Analysis ◽

Pedicle Screw Fixation ◽

Cochrane Library ◽

Complication Rates ◽

Ct Guided ◽

Cervical Pedicle Screw ◽

Comparative Accuracy ◽

Cervical Pedicle

OBJECTIVE The goal of this study was to evaluate the comparative accuracy and safety of navigation-based approaches for cervical pedicle screw (CPS) placement over fluoroscopic techniques. METHODS A systematic search of the literature published between January 2006 and December 2019 relating to CPS instrumentation and the comparative accuracy and safety of fluoroscopic and intraoperative computer-based navigation techniques was conducted. Several databases, including the Cochrane Library, PubMed, and EMBASE, were systematically searched to identify potentially eligible studies. Data relating to CPS insertion accuracy and associated complications, in particular neurovascular complications, were extrapolated from the included studies and summarized for analysis. RESULTS A total of 17 studies were identified from the search methodology. Eleven studies evaluated CPS placement under traditional fluoroscopic guidance and 6 studies addressed outcomes following navigation-assisted placement (3D C-arm or CT-guided placement). Overall, a total of 4278 screws were placed in 1065 patients. Misplacement rates of CPS were significantly lower (p < 0.0001) in navigation-assisted techniques (12.51% [range 2.5%–20.5%]) compared to fluoroscopy-guided techniques (18.8% [range 0%–43.5%]). Fluoroscopy-guided CPS insertion was associated with a significantly higher incidence of postoperative complications relating to neurovascular injuries (p < 0.038), with a mean incidence of 1.9% compared with 0.3% in navigation-assisted techniques. CONCLUSIONS This systematic review supports a logical conclusion that navigation-based techniques confer a statistically significantly more accurate screw placement and resultant lower complication rates.

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Cervical Pedicle Screw Insertion: Assessment of Safety and Accuracy with Computer-Assisted Image Guidance

Journal of Spinal Disorders ◽

10.1097/00002517-200008000-00001 ◽

2000 ◽

Vol 13 (4) ◽

pp. 275 ◽

Cited By ~ 3

Author(s):

John G. Heller

Keyword(s):

Pedicle Screw ◽

Image Guidance ◽

Computer Assisted ◽

Cervical Pedicle Screw ◽

Screw Insertion ◽

Pedicle Screw Insertion ◽

Cervical Pedicle ◽

Computer Assisted Image

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Clinical accuracy of three-dimensional fluoroscopy-based computer-assisted cervical pedicle screw placement: a retrospective comparative study of conventional versus computer-assisted cervical pedicle screw placement

Journal of Neurosurgery Spine ◽

10.3171/2010.5.spine09993 ◽

2010 ◽

Vol 13 (5) ◽

pp. 606-611 ◽

Cited By ~ 75

Author(s):

Yoshimoto Ishikawa ◽

Tokumi Kanemura ◽

Go Yoshida ◽

Zenya Ito ◽

Akio Muramoto ◽

...

Keyword(s):

Pedicle Screw ◽

Three Dimensional ◽

Screw Placement ◽

Computer Assisted ◽

Pedicle Screw Placement ◽

Cervical Pedicle Screw ◽

Retrospective Clinical Study ◽

Significant Difference ◽

Cervical Pedicle ◽

Grade 3

Object The authors performed a retrospective clinical study to evaluate the feasibility and accuracy of cervical pedicle screw (CPS) placement using 3D fluoroscopy-based navigation (3D FN). Methods The study involved 62 consecutive patients undergoing posterior stabilization of the cervical spine between 2003 and 2008. Thirty patients (126 screws) were treated using conventional techniques (CVTs) with a lateral fluoroscopic view, whereas 32 patients (150 screws) were treated using 3D FN. Screw positions were classified into 4 grades based on the pedicle wall perforations observed on postoperative CT. Results The prevalence of perforations in the CVT group was 27% (34 screws): 92 (73.0%), 12 (9.5%), 6 (4.8%), and 16 (12.7%) for Grade 0 (no perforation), Grade 1 (perforation < 1 mm), Grade 2 (perforation ≥ 1 and < 2 mm), and Grade 3 (perforation ≥ 2 mm), respectively. In the 3D FN group, the prevalence of perforations was 18.7% (28 screws): 122 (81.3%), 17 (11.3%), 6 (4%), and 5 (3.3%) for Grades 0, 1, 2, and 3, respectively. Statistical analysis showed no significant difference in the prevalence of Grade 1 or higher perforations between the CVT and 3D FN groups. A higher prevalence of malpositioned CPSs was seen in Grade 2 or higher (17.5% vs 7.3%, p < 0.05) in the 3D FN group and Grade 3 (12.7% vs 7.3%, p < 0.05) perforations in the CVT group. The ORs for CPS malpositioning in the CVT group were 2.72 (95% CI 1.16–6.39) in Grade 2 or higher perforations and 3.89 (95% CI 1.26–12.02) in Grade 3 perforations. Conclusions Three-dimensional fluoroscopy-based navigation can improve the accuracy of CPS insertion; however, severe CPS malpositioning that causes injury to the vertebral artery or neurological complications can occur even with 3D FN. Advanced techniques for the insertion of CPSs and the use of modified insertion devices can reduce the risk of a malpositioned CPS and provide increased safety.

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Improved accuracy of computer-assisted cervical pedicle screw insertion

Journal of Neurosurgery Spine ◽

10.3171/spi.2003.99.3.0257 ◽

2003 ◽

Vol 99 (3) ◽

pp. 257-263 ◽

Cited By ~ 44

Author(s):

Yoshihisa Kotani ◽

Kuniyoshi Abumi ◽

Manabu Ito ◽

Akio Minami

Keyword(s):

Real Time ◽

Pedicle Screw ◽

Computer Assisted ◽

Insertion Technique ◽

Content Type ◽

Cervical Pedicle Screw ◽

Screw Insertion ◽

Pedicle Screw Insertion ◽

Cervical Pedicle ◽

Fine Print

Object. The authors introduce a unique computer-assisted cervical pedicle screw (CPS) insertion technique used in conjunction with specially modified original pedicle screw insertion instruments. The accuracy of screw placement as well as surgery-related outcome and complication rates were compared between two groups of patients: those in whom a computer-assisted and those in whom a conventional manual insertion technique was used. Methods. The screw insertion guiding system consisted of a modified awl, probe, tap and a screwdriver specially designed for a computer-assisted CPS insertion. Using this system, real-time instrument/screw tip information was three dimensionally identified in each step of screw insertion. Seventeen patients underwent CPS fixation in which a computer-assisted surgical navigation system was used. The cervical disorders consisted of spondylotic myelopathy with segmental instability or kyphosis, metastatic spinal tumor, rheumatoid spine, and postlaminectomy kyphosis. The rate of pedicle wall perforation was significantly lower in the computer-assisted group than that in the other group (1.2 and 6.7%, respectively; p < 0.05). The screw trajectory in the horizontal plane was significantly closer to the anatomical pedicle axis in the computer-assisted group compared with the manual insertion group (p < 0.05). This factor significantly reduced the incidence of screw perforation laterally. Complications such as neural damage or vascular injury were not demonstrated in the computer-assisted group (compared with 2% in the manual insertion treatment group). The overall surgery-related outcome was satisfactory. Conclusions. In contrast to the previously reported computer-assisted technique, our CPS insertion technique provides real-time three-dimensional instrument/screw tip information. This serves as a powerful tool for safe and accurate pedicle screw placement in the cervical spine.

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Subaxial cervical pedicle screw fixation: safe zone for screw placement—a systematic review

The Spine Journal ◽

10.1016/j.spinee.2016.12.044 ◽

2017 ◽

Vol 17 (3) ◽

pp. S14

Author(s):

Shahnawaz Haleem ◽

Muzaffar Malik ◽

N.A. Quraishi

Keyword(s):

Systematic Review ◽

Pedicle Screw ◽

Screw Fixation ◽

Safe Zone ◽

Pedicle Screw Fixation ◽

Screw Placement ◽

Cervical Pedicle Screw ◽

Cervical Pedicle

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Mid-Term Results of Computer-Assisted Cervical Pedicle Screw Fixation

Asian Spine Journal ◽

10.4184/asj.2014.8.6.759 ◽

2014 ◽

Vol 8 (6) ◽

pp. 759 ◽

Cited By ~ 4

Author(s):

Masashi Uehara ◽

Jun Takahashi ◽

Keijiro Mukaiyama ◽

Shugo Kuraishi ◽

Masayuki Shimizu ◽

...

Keyword(s):

Pedicle Screw ◽

Screw Fixation ◽

Pedicle Screw Fixation ◽

Computer Assisted ◽

Cervical Pedicle Screw ◽

Cervical Pedicle ◽

Mid Term Results

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Development and Biomechanical Analysis of a New Anterior Cervical Pedicle Screw Fixation System

10.21203/rs.3.rs-150237/v1 ◽

2021 ◽

Author(s):

Maji Sun ◽

Qiuan Wang ◽

Xingchen Zhang ◽

Rui Zhao ◽

Kaijin Guo ◽

...

Keyword(s):

Cervical Spine ◽

Pedicle Screw ◽

Screw Fixation ◽

Pedicle Screw Fixation ◽

Cervical Pedicle Screw ◽

Cervical Pedicle ◽

Group B ◽

Group D ◽

Fixation System ◽

Better Than

Abstract ObjectiveA new anterior cervical pedicle screw fixation system was developed based on the relevant anatomical structure of the cervical spine, and its biomechanical properties were evaluated on fresh cadaver cervical spine specimens to provide a basis for preliminary clinical application. MethodsThree-dimensional parameters of the new nail plate system were obtained from the anatomical data of cervical spine specimens, and the system was produced by 3D printing technology. Fresh adult cadaver cervical spine specimens were used to measure biomechanical stability in the intact state (group A: complete group) and to establish a C5-7 instability model in which fixation with the traditional cervical anterior nail plate system was performed (group B). Anterior cervical spine displacement, strength, stiffness, torsion torque, etc. were measured under the fixed state when 4 screws were used for fixation with the pedicle screw system (group C) and 6 screws were used for the anterior cervical pedicle screw system (group D). ResultsIn terms of the load-displacement relationship, the results showed that the average displacement difference between group D and group C after the test was 25%, that between group D and group B was 30%, that between groups C and B was 18%, and the differences were statistically significant (P <0.05). In terms of the axial stiffness of the cervical spine, that of group D was 20% higher than that of group C and 40% higher than that of group B, that of group C was 20% higher than that of group B when fixed, and those of group D and C were both better than that of group A, the blank control group; all the differences were statistically significant (P<0.05). In terms of torsion mechanical properties of the cervical spine, the experimental results showed that that of group D was higher than that of group C by 21% and higher than that of group B by 40%, that of group C was higher than that of group B by 30%, and the differences were statistically significant (P<0.05). The biomechanical tests showed that in terms of load-displacement, axial stiffness and torsional mechanical properties, the anterior cervical pedicle locking and guiding internal fixation system was slightly better than the complete method. The 6 nail fixation method was better than the 4 nail fixation method. ConclusionThe new anterior cervical pedicle screw fixation system conforms to the anatomy of Chinese individuals and has better mechanical stability than do traditional fixation methods. It is a new, reliable anterior cervical pedicle internal fixation system for clinical practice.List of Abbreviations: ACPS: anterior cervical pedicle screw.

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Techniques of cervical pedicle screw insertion in lower cervical spine - A review

Journal of Clinical Orthopaedics and Trauma ◽

10.1016/j.jcot.2020.06.040 ◽

2020 ◽

Vol 11 (5) ◽

pp. 794-801

Author(s):

Bidre Upendra ◽

Rao Raghavendra

Keyword(s):

Cervical Spine ◽

Pedicle Screw ◽

Lower Cervical Spine ◽

Cervical Pedicle Screw ◽

Screw Insertion ◽

Pedicle Screw Insertion ◽

Cervical Pedicle

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Precision and safety of Multilevel Cervical Transpedicular Screw Fixation with 3D Patient-Specific Guides; A Cadaveric Study

Scientific Reports ◽

10.1038/s41598-019-51936-w ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 1

Author(s):

Andrea Sallent ◽

Manuel Ramírez ◽

Jordi Catalá ◽

Alfonso Rodríguez-Baeza ◽

Joan Bagó ◽

...

Keyword(s):

Cervical Spine ◽

Pedicle Screw ◽

Screw Fixation ◽

Screw Placement ◽

Patient Specific ◽

Transverse Foramen ◽

Cervical Pedicle Screw ◽

Transpedicular Screw ◽

Cervical Pedicle ◽

Transpedicular Screw Fixation

Abstract The aim is to design a patient-specific instrument (PSI) for multilevel cervical pedicle screw placement from C2 to C7, as well as verifying reliability and reproducibility. Computed tomography (CT) scans were obtained from 7 cadaveric cervical spines. Using Mimics software, semiautomatic segmentation was performed for each cervical spine, designing a 3D cervical spine bone model in order to plan transpedicular screw fixation. A PSI was designed according to the previously cited with two cannulated chimneys to guide the drill. The guides were 3D printed and surgeries performed at the laboratory. Postoperative scans were obtained to study screw placement. Sixty-eight transpedicular screws were available for study. 61.8% of all screws were within the pedicle or partially breached <4 mm. No differences were observed between cervical levels. None of these screws had neurovascular injury. Of the 27 screws with a grade 3 (screw outside the pedicle; 39.7%), only 2 had perforation of the transverse foramen and none of them would have caused a neural injury. In conclusion, multilevel PSI for cervical pedicle screw is a promising technology that despite showing improvements regarding free-hand technique requires further studies to improve the positioning of the PSI and their accuracy.

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