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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

Clinical article

Yoshimoto Ishikawa, Tokumi Kanemura, Go Yoshida, Zenya Ito, Akio Muramoto, and Shuichiro Ohno

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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Intraoperative, full-rotation, three-dimensional image (O-arm)–based navigation system for cervical pedicle screw insertion

Clinical article

Yoshimoto Ishikawa, Tokumi Kanemura, Go Yoshida, Akiyuki Matsumoto, Zenya Ito, Ryoji Tauchi, Akio Muramoto, Shuichiro Ohno, and Yusuke Nishimura

Object

The aim of this study was to retrospectively evaluate the reliability and accuracy of cervical pedicle screw (CPS) placement using an intraoperative, full-rotation, 3D image (O-arm)–based navigation system and to assess the advantages and disadvantages of the system.

Methods

The study involved 21 consecutive patients undergoing posterior stabilization surgery of the cervical spine between April and December 2009. The patients, in whom 108 CPSs had been inserted, underwent screw placement based on intraoperative 3D imaging and navigation using the O-arm system. Cervical pedicle screw positions were classified into 4 grades, according to pedicle-wall perforations, by using postoperative CT.

Results

Of the 108 CPSs, 96 (88.9%) were classified as Grade 0 (no perforation), 9 (8.3%) as Grade 1 (perforations < 2 mm, CPS exposed, and < 50% of screw diameter outside the pedicle), and 3 (2.8%) as Grade 2 (perforations between ≥ 2 and < 4 mm, CPS breached the pedicle wall, and > 50% of screw diameter outside the pedicle). No screw was classified as Grade 3 (perforation > 4 mm, complete perforation). No neurovascular complications occurred because of CPS placement.

Conclusions

The O-arm offers high-resolution 2D or 3D images, facilitates accurate and safe CPS insertion with high-quality navigation, and provides other substantial benefits for cervical spinal instrumentation. Even with current optimized technology, however, CPS perforation cannot be completely prevented, with 8.3% instances of minor violations, which do not cause significant complications, and 2.8% instances of major pedicle violations, which may cause catastrophic complications. Therefore, a combination of intraoperative 3D image–based navigation with other techniques may result in more accurate CPS placement.

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Subaxial sagittal alignment and adjacent-segment degeneration after atlantoaxial fixation performed using C-1 lateral mass and C-2 pedicle screws or transarticular screws

Clinical article

Go Yoshida, Mituhiro Kamiya, Hisatake Yoshihara, Tokumi Kanemura, Fumihiko Kato, Yasutugu Yukawa, Keigo Ito, Yukihiro Matsuyama, and Yoshihito Sakai

Object

The purpose of this study was to evaluate the effect of a fixed atlantoaxial angle on subaxial sagittal alignment, and that of atlantoaxial fixation on adjacent-segment motion and degeneration.

Methods

The authors retrospectively reviewed 65 patients in whom atlantoaxial instability was treated with atlantoaxial fixation by C-1 lateral mass and C-2 pedicle screw fixation (30 patients, Goel-Harms [GH] group) or a combination of transarticular screw fixation and posterior wiring (35 patients, Magerl-Brooks [MB] group). Angles of Oc–C1, C1–2, C2–3, and C2–7 were determined based on an upright lateral radiograph in flexion, neutral, and extension positions. The range of motion (ROM) at Oc–C1 and C2–3 was also determined. All patients were examined before and 2 years after surgery.

Results

The mean preoperative atlantoaxial angles in the GH and MB groups were 20.9 ± 8.3° and 18.3 ± 7.2°, respectively, and the mean postoperative atlantoaxial angles in the same groups were 23.5 ± 5.6° and 29.7 ± 6.3°, respectively, with a statistically significant difference between the 2 groups (p < 0.05). The mean preoperative angles of C2–7 in the GH and MB groups were 15.4 ± 7.8° and 13.7 ± 9.5°, respectively, and after surgery, the angles were 11.8 ± 12° and 2.48 ± 12°, respectively, with a statistically significant difference between the 2 groups (p < 0.05). The postoperative angle of C1–2 showed a negative correlation with the extent of change observed in the C2–7 angle preand postoperatively in each of these 2 surgical procedures. The Oc–C1 ROM increased after surgery in both groups, but the difference was not statistically significant (p = 0.38). The C2–3 ROM decreased after surgery in both groups, and the difference was statistically significant (p < 0.05).

Conclusions

Atlantoaxial fixation in a hyperlordotic position produced kyphotic sagittal alignment after surgery in both GH and MB groups. Reduction of the atlantoaxial joint can be easily achieved through screw fixation at an optimal angle, thereby ameliorating the risk for subsequent subaxial kyphosis. Degeneration of lower adjacent segments appeared to be less with this procedure compared with using a combination of transarticular screw fixation and posterior wiring.

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Effect of position on lumbar lordosis in patients with adult spinal deformity

Tatsuya Yasuda, Tomohiko Hasegawa, Yu Yamato, Daisuke Togawa, Sho Kobayashi, Go Yoshida, Tomohiro Banno, Hideyuki Arima, Shin Oe, and Yukihiro Matsuyama

OBJECTIVE

The purpose of this study was to evaluate the effect of position on lumbar lordosis (LL) in adult spinal deformity (ASD) patients.

METHODS

The authors evaluated the radiographic data of ASD patients who underwent posterior corrective fusion surgery from the thoracic spine to L5, S1, or the ilium for the treatment of ASD of the lumbar spine. The spinopelvic parameters were measured in the standing position preoperatively. LL was also evaluated in the supine position preoperatively and in the prone position on the surgical frame. Changes in LL were compared between groups.

RESULTS

Eighty-five patients were included. The average LL in standing, supine, and prone positions was 11.8°, 24.3°, and 24.0°, respectively. LL increased significantly from standing to supine or prone position (p < 0.001). In 80 patients (94.1%), the difference between supine LL and prone LL was within 5°. Change in LL from standing to prone position was significantly higher in the severe deformity group.

CONCLUSIONS

The lordotic effect of intraoperative prone positioning was remarkable in patients with severe deformities. LL in the supine position was approximately the same as that in the prone position. Therefore, assessing preoperative supine lateral lumbar radiographs enables one to plan corrective spinal surgeries in ASD patients.

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Treatment strategy for rod fractures following corrective fusion surgery in adult spinal deformity depends on symptoms and local alignment change

Yu Yamato, Tomohiko Hasegawa, Sho Kobayashi, Tatsuya Yasuda, Daisuke Togawa, Go Yoshida, Tomohiro Banno, Shin Oe, Yuki Mihara, and Yukihiro Matsuyama

OBJECTIVE

Despite the significant incidence of rod fractures (RFs) following long-segment corrective fusion surgery, little is known about the optimal treatment strategy. The objectives of this study were to investigate the time course of clinical symptoms and treatments in patients with RFs following adult spinal deformity (ASD) surgery and to establish treatment recommendations.

METHODS

This study was a retrospective case series of patients with RFs whose data were retrieved from a prospectively collected single-center database. The authors reviewed the cases of 304 patients (mean age 62.9 years) who underwent ASD surgery. Primary symptoms, time course of symptoms, and treatments were investigated by reviewing medical records. Standing whole-spine radiographs obtained before and after RF development and at last follow-up were evaluated. Osseous union was assessed using CT scans and intraoperative findings.

RESULTS

There were 54 RFs in 53 patients (mean age 68.5 years [range 41–84 years]) occurring at a mean of 21 months (range 6–47 months) after surgery. In 1 patient RF occurred twice, with each case at a different time and level, and the symptoms and treatments for these 2 RFs were analyzed separately (1 case of revision surgery and 1 case of nonoperative treatment). The overall rate of RF observed on radiographs after a minimum follow-up of 1 year was 18.0% (54 of 300 cases). The clinical symptoms at the time of RF were pain in 77.8% (42 of 54 cases) and no onset of new symptoms in 20.5% (11 of 54 cases). The pain was temporary and had subsided in 19 of 42 cases (45%) within 2 weeks. In 36 of the 54 cases (66.7%) (including the first RF in the patient with 2 RFs), patients underwent revision surgery at a mean of 116 days (range 5–888 days) after diagnosis. In 18 cases patients received only nonoperative treatment as of the last follow-up, including 17 cases in which the patients experienced no pain and no remarkable progression of deformity (mean 18.5 months after RF development).

CONCLUSIONS

This analysis of 54 RFs in 53 patients following corrective fusion surgery for ASD demonstrates a relationship between symptoms and alignment change. Revision surgeries were performed in a total of 36 cases. Nonoperative care was offered in 18 (33.3%) of 54 cases at the last follow-up, with no additional symptoms in 17 of the 18 cases. These data offer useful information regarding informed decision making for patients in whom an RF occurs after ASD surgery.

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Should L3 be selected as the lowest instrumented vertebra in patients with Lenke type 5C adolescent idiopathic scoliosis whose lowest end vertebra is L4?

Tomohiro Banno, Yu Yamato, Hiroki Oba, Tetsuro Ohba, Tomohiko Hasegawa, Go Yoshida, Hideyuki Arima, Shin Oe, Yuki Mihara, Hiroki Ushirozako, Jun Takahashi, Hirotaka Haro, and Yukihiro Matsuyama

OBJECTIVE

L3 is most often selected as the lowest instrumented vertebra (LIV) to conserve mobile segments in fusion surgery; however, in cases with the lowest end vertebra (LEV) at L4, LIV selection as L3 could have a potential risk of correction loss and coronal decompensation. This study aimed to compare the clinical and radiographic outcomes depending on the LEV in adolescent idiopathic scoliosis (AIS) patients with Lenke type 5C curves.

METHODS

Data from 49 AIS patients with Lenke type 5C curves who underwent selective thoracolumbar/lumbar (TL/L) fusion to L3 as the LIV were retrospectively analyzed. The patients were classified according to their LEVs into L3 and L4 groups. In the L4 group, subanalysis was performed according to the upper instrumented vertebra (UIV) level toward the upper end vertebra (UEV and 1 level above the UEV [UEV+1] subgroups). Radiographic parameters and clinical outcomes were compared between these groups.

RESULTS

Among 49 patients, 32 and 17 were in the L3 and L4 groups, respectively. The L4 group showed a lower TL/L curve correction rate and a higher subjacent disc angle postoperatively than the L3 group. Although no intergroup difference was observed in coronal balance (CB), the L4 group showed a significantly higher main thoracic (MT) and TL/L curve progression during the postoperative follow-up period than the L3 group. In the L4 group, the UEV+1 subgroup showed a higher absolute value of CB at 2 years than the UEV subgroup.

CONCLUSIONS

In Lenke type 5C AIS patients with posterior selective TL/L fusion to L3 as the LIV, patients with their LEVs at L4 showed postoperative MT and TL/L curve progression; however, no significant differences were observed in global alignment and clinical outcome.

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Complications of cervical pedicle screw fixation for nontraumatic lesions: a multicenter study of 84 patients

Clinical article

Hiroaki Nakashima, Yasutsugu Yukawa, Shiro Imagama, Tokumi Kanemura, Mitsuhiro Kamiya, Makoto Yanase, Keigo Ito, Masaaki Machino, Go Yoshida, Yoshimoto Ishikawa, Yukihiro Matsuyama, Naoki Ishiguro, and Fumihiko Kato

Object

The cervical pedicle screw (PS) provides strong stabilization but poses a potential risk to the neurovascular system, which may be catastrophic. In particular, vertebrae with degenerative changes complicate the process of screw insertion, and PS misplacement and subsequent complications are more frequent. The purpose of this study was to evaluate the peri- and postoperative complications of PS fixation for nontraumatic lesions and to determine the risk factors of each complication.

Methods

Eighty-four patients who underwent cervical PS fixation for nontraumatic lesions were independently reviewed to identify associated complications. The mean age of the patients was 60.1 years, and the mean follow-up period was 4.1 years (range 6–168 months). Pedicle screw malpositioning was classified on postoperative CT scans as Grade I (< 50% of the screw outside the pedicle) or Grade II (≥ 50% of the screw outside the pedicle). Risk factors of each complication were evaluated using a multivariate analysis.

Results

Three hundred ninety cervical PSs and 24 lateral mass screws were inserted. The incidence of PS misplacement was 19.5% (76 screws); in terms of malpositioning, 60 screws (15.4%) were classified as Grade I and 16 (4.1%) as Grade II. In total, 33 complications were observed. These included postoperative neurological complications in 11 patients in whom there was no evidence of screw misplacement (C-5 palsy in 10 and C-7 palsy in 1), implant failure in 11 patients (screw loosening in 5, broken screws in 4, and loss of reduction in 2), complications directly attributable to screw insertion in 5 patients (nerve root injury by PS in 3 and vertebral artery injury in 2), and other complications in 6 patients (pseudarthrosis in 2, infection in 1, transient dyspnea in 1, transient dysphagia in 1, and adjacent-segment degeneration in 1). The multivariate analysis showed that a primary diagnosis of cerebral palsy was a risk factor for postoperative implant failure (HR 10.91, p = 0.03) and that the presence of preoperative cervical spinal instability was a risk factor for both Grade I and Grade II screw misplacement (RR 2.12, p = 0.03), while there were no statistically significant risk factors for postoperative neurological complications in the absence of evidence of screw misplacement or complications directly attributable to screw insertion.

Conclusions

In the present study, misplacement of cervical PSs and associated complications occurred more often than in previous studies. The rates of screw-related neurovascular complications and neurological deterioration unrelated to PSs were high. Insertion of a PS for nontraumatic lesions is surgically more challenging than that for trauma; consequently, experienced surgeons should use PS fixation for nontraumatic cervical lesions only after thorough preoperative evaluation of each patient's cervical anatomy and after considering the risk factors specified in the present study.

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Multivariate analysis of C-5 palsy incidence after cervical posterior fusion with instrumentation

Clinical article

Hiroaki Nakashima, Shiro Imagama, Yasutsugu Yukawa, Tokumi Kanemura, Mitsuhiro Kamiya, Makoto Yanase, Keigo Ito, Masaaki Machino, Go Yoshida, Yoshimoto Ishikawa, Yukihiro Matsuyama, Nobuyuki Hamajima, Naoki Ishiguro, and Fumihiko Kato

Object

Postoperative C-5 palsy is a significant complication resulting from cervical decompression procedures. Moreover, when cervical degenerative diseases are treated with a combination of decompression and posterior instrumented fusion, patients are at increased risk for C-5 palsy. However, the clinical and radiological features of this condition remain unclear. Therefore, the purpose of this study was to clarify the risk factors for developing postoperative C-5 palsy.

Methods

Eighty-four patients (mean age 60.1 years) who had undergone posterior instrumented fusion using cervical pedicle screws to treat nontraumatic lesions were independently reviewed. The authors analyzed the medical records of some of these patients who developed postoperative C-5 palsy, paying particular attention to their plain radiographs, MRI studies, and CT scans. Risk factors for postoperative C-5 palsy were assessed using multivariate logistic regression analysis. The cutoff values for the pre- and postoperative width of the intervertebral foramen (C4–5) were determined by receiver operating characteristic curve analysis.

Results

Ten (11.9%) of 84 patients developed postoperative C-5 palsy. Seven patients recovered fully from the neurological complications. The pre- and postoperative C4–5 angles showed significant kyphosis in the C-5 palsy group. The pre- and postoperative diameters of the C4–5 foramen on the palsy side were significantly smaller than those on the opposite side in the C-5 palsy group and those bilaterally in the non–C5 palsy group. Risk factors identified by multivariate logistic regression analysis were as follows: 1) ossification of the posterior longitudinal ligament (relative risk [RR] 7.22 [95% CI 1.03–50.55]); 2) posterior shift of the spinal cord (C4–5) (RR 1.73 [95% CI 1.00–2.98]); and 3) postoperative width of the C-5 intervertebral foramen (RR 0.33 [95% CI 0.14–0.79]). The cutoff values of the pre- and postoperative widths of the C-5 intervertebral foramen for C-5 palsy were 2.2 and 2.3 mm, respectively.

Conclusions

Patients with preoperative foraminal stenosis, posterior shift of the spinal cord, and additional iatrogenic foraminal stenosis due to cervical alignment correction were more likely to develop postoperative C-5 palsy after posterior instrumentation with fusion. Prophylactic foraminotomy at C4–5 might be useful when preoperative foraminal stenosis is present on CT. Furthermore, it might be useful for treating postoperative C-5 palsy. To prevent excessive posterior shift of the spinal cord, the authors recommend that appropriate kyphosis reduction should be considered carefully.

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Medical complications following adult spinal deformity correction in patients with autoimmune disease

Rina Therese R. Madelar, Shin Oe, Yu Yamato, Tomohiko Hasegawa, Go Yoshida, Tomohiro Banno, Hideyuki Arima, Koichiro Ide, Tomohiro Yamada, Kenta Kurosu, Keiichi Nakai, and Yukihiro Matsuyama

OBJECTIVE

An aberrant inflammatory response, which plays a role in the development of postoperative complications, is observed in autoimmune diseases, Yet, there is a paucity of literature regarding the effects of autoimmune diseases after adult spinal deformity (ASD) surgery. The goal of this study was to determine the effects of autoimmune diseases (rheumatoid arthritis, systemic lupus erythematosus) on postoperative medical complications, patient-reported outcome measures (PROMs), and radiographic alignment in patients who underwent ASD surgery.

METHODS

Propensity-score matching for age and sex was performed for patients with autoimmune disease (group A) and nonautoimmune patients (group NA1). Postoperative medical complications, preoperative and 2-year follow-up PROMs, and preoperative, immediate postoperative, and 2-year follow-up radiographic alignment were evaluated.

RESULTS

Among 386 patients (27 in group A and 359 in group NA1), autoimmune patients had a higher incidence of respiratory complications (11.1% vs 2.2%, p = 0.036), gastrointestinal complications (14.8% vs 3.1%, p = 0.016), urinary tract infections (14.8% vs 3.1%, p = 0.016), cholecystitis (7.4% vs 0%, p = 0.005), and fever of unknown origin (14.8% vs 0%, p < 0.001). Autoimmune patients had worse preoperative ODI (54.2 vs 44.7, p = 0.004) and 2-year follow-up Scoliosis Research Society 22-item Questionnaire (SRS-22) scores (3.1 vs 3.5, p = 0.039), with higher preoperative sacral slope (23.4° vs 17.8°, p = 0.020). Propensity-score matching for age and sex yielded 27 pairs (group A and group NA2). Having at least one medical complication (group A 74.1% vs group NA2 22.2%, p < 0.001), total complications per person (1.3 vs 0.3, p = 0.010), prognostic nutrition index (44.8 vs 48.6, p = 0.034), steroid use (51.9% vs 0%, p < 0.001), immunosuppressant use (48.1% vs 0%, p < 0.001), length of hospital stay (38 vs 27 days, p = 0.018), and discharge to care facility (29.6% vs 7.4%, p = 0.036) were higher in group A. Preoperative ODI (54.2 vs 43.2, p = 0.011) and 2-year follow-up SRS-22 scores (3.1 vs 3.6 p = 0.019) were worse in group A. No differences were observed in radiographic alignment.

CONCLUSIONS

Patients with autoimmune disease had higher complication rates and worse PROMs following ASD surgery in this study. There was no difference in spinal alignment compared with controls. Multidisciplinary planning and full disclosure of possible adverse effects should be completed prior to correction of ASD in patients with autoimmune disease.

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Risk factors and clinical impact of persistent coronal imbalance after posterior spinal fusion in thoracolumbar/lumbar idiopathic scoliosis

Tomohiro Banno, Yu Yamato, Hiroki Oba, Tetsuro Ohba, Tomohiko Hasegawa, Go Yoshida, Hideyuki Arima, Shin Oe, Koichiro Ide, Tomohiro Yamada, Jun Takahashi, Hirotaka Haro, and Yukihiro Matsuyama

OBJECTIVE

Persistent coronal imbalance (PCI) can develop postoperatively. In this study, the authors aimed to clarify the risk factors and clinical impact of PCI after posterior spinal fusion (PSF) in idiopathic scoliosis (IS) patients with a major thoracolumbar/lumbar (TL/L) curve.

METHODS

Data on 108 patients with Lenke type 5C or 6C IS who underwent PSF with a minimum of 2 years of follow-up were retrospectively analyzed. PCI was defined as coronal imbalance persisting 2 years after surgery. Radiographic parameters and clinical outcomes were compared between the PCI (+) and PCI (−) groups. Multivariate regression analyses of associated factors were performed to determine the risk factors for PCI.

RESULTS

Of the 108 patients, 48 (44%) had immediate postoperative coronal imbalance, and 10 of these patients (9%) had coronal imbalance persisting 2 years after surgery. The PCI (+) group had significantly worse postoperative subtotal and satisfaction scores than the PCI (−) group. Preoperative apical vertebral translation (AVT) of the TL/L curve (AVT-TL/L) and postoperative coronal balance (CB) were identified as independent risk factors for PCI. The cutoff values of preoperative AVT-TL/L at 49.5 mm (area under the curve [AUC] 0.835, p = 0.001, 95% CI 0.728–0.941, sensitivity 70.0%, specificity 72.4%) and those of postoperative CB at −27.5 mm (AUC 0.837, p < 0.001, 95% CI 0.729–0.945, sensitivity 78.6%, specificity 70.0%) were used to predict PCI. In selective fusion cases, older age (OR 2.110, 95% CI 1.159–3.842, p = 0.015), greater preoperative AVT-TL/L (OR 1.199, 95% CI 1.029–1.398, p = 0.020), and less postoperative CB (OR 0.855, 95% CI 0.743–0.983, p = 0.027) were independent risk factors for PCI.

CONCLUSIONS

Preoperative AVT-TL/L and postoperative CB are important parameters for predicting PCI. PCI adversely affects postoperative clinical outcomes. In selective fusion surgery, PCI tends to occur in older patients due to reduced flexibility and compensatory abilities.