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TO THE EDITOR: We read with great interest the recent article by Husain et al.2 on the comparison of open versus percutaneous transfacet fixation of the posterior cervical spine (Husain A, Akpolat YT, Palmer DK, et al: A comparison of open versus percutaneous cervical transfacet fixation. J Neurosurg Spine 25:430–435, October 2016). The authors found a higher incidence of screw misplacement in the percutaneous technique compared to the open technique. The authors mention in their introduction that they were unable to find any descriptions of percutaneous cervical transfacet screw placement techniques in the literature.
We would like to point out our paper published in 2012 on exactly this topic that Husain et al. failed to notice: “Percutaneous trans-facet screws for supplemental posterior cervical fixation.”1 In that report we described an initial clinical experience with cervical transfacet screws, which we found to be a technically feasible option in the subaxial cervical spine for truly percutaneous spinal fixation. Surgery was successfully performed in 3 cases by using small fragment screws that are commonly used in orthopedic trauma surgery. We also described our percutaneous surgical technique with illustrative pictures and radiographs.
Transfacet open screw placement is a good bailout option if lateral mass fixation fails. It also can be used as an intermediate fixation option in long cervical constructs. For percutaneous screws, the use is limited to supplemental fixation after an anterior fusion procedure, due to limitations of current percutaneous posterior fusion options.
1 1Kaiser Foundation Hospitals, Fontana, CA; and 2School of Medicine, Loma Linda University, Loma Linda, CA
The letter to the editor that was submitted by Ahmad and Wang is greatly appreciated. In response to their statement, we were unable to find any technique descriptions of percutaneous cervical transfacet screw placement in the literature at the time our manuscript was submitted. However, the article by Ahmad et al. titled “Percutaneous trans-facet screws for supplemental posterior cervical fixation”1 was published in World Neurosurgery in 2012—prior to the submission and publication of our manuscript. With apologies, we did not have knowledge of this paper and thus did not reference it in our manuscript.
We read the paper by Ahmad et al.1 with great interest. It is well written and provides an introduction for percutaneous transfacet fixation of the posterior cervical spine. They include an informative description of their surgical technique of percutaneous transfacet screws for supplemental posterior cervical fixation and describe their initial clinical experience with this technique. The paper notes that “future areas of development will include validation of the safety and efficacy of this technique.”1
Our study is therefore an appropriate segue; it compares the percutaneous to the open technique of transfacet fixation of posterior cervical spine in regard to the accuracy of facet capture (efficacy) and the potential of placing neurovascular structures at risk (safety). We describe the use of percutaneous techniques as an alternative to open transfacet fixation. Despite the potential risk of a higher incidence of misplacement with the percutaneous technique compared with the open technique, our results show that the distances from the screw to the neurovascular structures were statistically similar and the accuracies of facet capture were not statistically different. It is with great pleasure and enthusiasm that we see that two separate surgical teams can independently design a novel technique with so many similarities. This shows promise for the idea, the technique, and the potential for its use as a minimally invasive approach to treatment of the cervical spine.