Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results

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Object. Standard techniques for pedicle screw fixation of the lumbar spine involve open exposures and extensive muscle dissection. The purpose of this study was to report the initial clinical experience with a novel device for percutaneous posterior fixation of the lumbar spine.

Methods. An existing multiaxial lumbar pedicle screw system was modified to allow screws to be placed percutaneously by using an extension sleeve that permits remote manipulation of the polyaxial screw heads and remote engagement of the screw-locking mechanism. A unique rod-insertion device was developed that linked to the screw extension sleeves, allowing for a precut and -contoured rod to be placed through a small stab wound. Because the insertion device relies on the geometrical constraint of the rod pathway through the screw heads, minimal manipulation is required to place the rods in a standard submuscular position, there is essentially no muscle dissection, and the need for direct visual feedback is avoided. Twelve patients (six men and six women) who ranged in age from 23 to 68 years underwent pedicle screw fixation in which the rod-insertion device was used. Spondylolisthesis was present in 10 patients and osseous nonunion of a prior interbody fusion was present in two. All patients underwent successful percutaneous fixation. Ten patients underwent single-level fusions (six at L5—S1, three at L4–5, and one at L2–3), and two underwent two-level fusions (one from L3–5 and the other from L4—S1). The follow-up period ranged from 10 to 19 months (mean 13.8 months).

Conclusions. Although percutaneous lumbar pedicle screw placement has been described previously, longitudinal connector (rod or plate) insertion has been more problematic. The device used in this study allows for straightforward placement of lumbar pedicle screws and rods through percutaneous stab wounds. Paraspinous tissue trauma is minimized without compromising the quality of spinal fixation. Preliminary experience involving the use of this device has been promising.

Article Information

Address reprint requests to: Kevin T. Foley, M.D., Image-Guided Surgery Research Center, 220 South Claybrook, Suite 700, Memphis, Tennessee 38104. email: kfoley@usit.net.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Virtual fluoroscopic pedicle probe guidance. The virtual probe (black line) can be seen on the AP and lateral virtual fluoroscopic images. The probe's proposed trajectory is then extended (white line) to ensure that, as the probe reaches the base of the pedicle, it will lie safely within the pedicle cylinder on the AP and lateral views.

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    Photographs. Upper: A multiaxial screw head can be manipulated using the screw extenders even after the screw is inserted. The screw heads are manipulated (angulated and rotated) and aligned to accommodate the trajectory of the Sextant rod. This alignment occurs automatically when the screw extenders are connected. Center: The inserter—rod combination follows the curvilinear path connecting both screw head openings. The precontoured rod is seated in the screw heads in a reproducible, predictable fashion. Lower: The rod inserter pictured after the rod is in final position. The percutaneous reference array base (arrow) is also seen.

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    Intraoperative fluoroscopic image confirming the correct placement of the percutaneous rod.

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    Anteroposterior radiograph demonstrating acceptable screw placement and bilateral posterolateral fusion.

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    Photograph demonstrating that the small stab incisions are barely discernible (arrows). This patient's tattoo was preserved even though it was located in the lumbar midline, directly over the operative site.

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