Multistep pedicle screw insertion procedure with patient-specific lamina fit-and-lock templates for the thoracic spine

Clinical article

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Object

Pedicle screw fixation is a standard procedure of spinal instrumentation, but accurate screw placement is essential to avoid injury to the adjacent structures, such as the vessels, nerves, and viscera. The authors recently developed an intraoperative screw guiding method in which patient-specific laminar templates were used, and verified the accuracy of the multistep procedure in the thoracic spine.

Methods

Preoperative bone images of the CT scans were analyzed using 3D/multiplanar imaging software and the trajectories of the screws were planned. Plastic templates with screw guiding structures were created for each lamina by using 3D design and printing technology. Three types of templates were made for precise multistep guidance, and all templates were specially designed to fit and lock on the lamina during the procedure. Plastic vertebra models were also generated and preoperative screw insertion simulation was performed. Surgery was performed using this patient-specific screw guide template system, and the placement of screws was postoperatively evaluated using CT scanning.

Results

Ten patients with thoracic or cervicothoracic pathological entities were selected to verify this novel procedure. Fifty-eight pedicle screws were placed using the screw guide template system. Preoperatively, each template was found to fit exactly and to lock on the lamina of the vertebra models, and screw insertion simulation was successfully performed. Intraoperatively the templates also fit and locked on the patient lamina, and screw insertion was completed successfully. Postoperative CT scans confirmed that no screws violated the cortex of the pedicles, and the mean deviation of the screws from the planned trajectories was 0.87 ± 0.34 mm at the coronal midpoint section of the pedicles.

Conclusions

The multistep, patient-specific screw guide template system is useful for intraoperative pedicle screw navigation in the thoracic spine. This simple and economical method can improve the accuracy of pedicle screw insertion and reduce the operating time and radiation exposure of spinal fixation surgery.

Abbreviation used in this paper:OPLL = ossification of the posterior longitudinal ligament.

Article Information

Address correspondence to: Taku Sugawara, M.D., Department of Neurosurgery, Akita University School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan. email: taku@nsg.med.akita-u.ac.jp.

Please include this information when citing this paper: published online May 24, 2013; DOI: 10.3171/2013.4.SPINE121059.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Schematic drawings showing the multistep thoracic pedicle screw insertion guidance system.

  • View in gallery

    Three types of templates. Location templates mark the screw entry points on the lamina, drill guide templates control the screw trajectory before screw insertion, and screw guide templates control screw insertion.

  • View in gallery

    Postprocedure CT scans of the plastic vertebra models after T2–4 screw insertion simulation. Scans include a 3D image (A), axial view at the T-3 level (B), and coronal view at the midpoint of the pedicles (C).

  • View in gallery

    Measurement of screw deviation. Distance from the planned trajectory to the center of the placed screw was measured on 3D/multiplanar software.

  • View in gallery

    Preoperative (A–C) and postoperative (D–F) CT scans obtained in a patient with OPLL. Axial views (A and D) at the T-3 level, sagittal views of the screw trajectory (B and E), and coronal views at the midpoint of the pedicles (C and F) show accurate screw insertion.

References

1

Abul-Kasim KSöderberg MSelariu EGunnarsson MKherad MOhlin A: Optimization of radiation exposure and image quality of the cone-beam O-arm intraoperative imaging system in spinal surgery. J Spinal Disord Tech 25:52582012

2

Abumi KKaneda K: Pedicle screw fixation for nontraumatic lesions of the cervical spine. Spine (Phila Pa 1976) 22:185318631997

3

Belmont PJ JrKlemme WRDhawan APolly DW Jr: In vivo accuracy of thoracic pedicle screws. Spine (Phila Pa 1976) 26:234023462001

4

Berry ECuppone MPorada SMillner PARao AChiverton N: Personalised image-based templates for intra-operative guidance. Proc Inst Mech Eng H 219:1111182005

5

Cinotti GGumina SRipani MPostacchini F: Pedicle instrumentation in the thoracic spine: a morphometric and cadaveric study for placement of screws. Spine (Phila Pa 1976) 24:1141191999

6

Costa FCardia AOrtolina AFabio GZerbi AFornari M: Spinal navigation: standard preoperative versus intraoperative computed tomography data set acquisition for computer-guidance system: radiological and clinical study in 100 consecutive patients. Spine (Phila Pa 1976) 36:209420982011

7

Ebraheim NAXu RAhmad MYeasting RA: Projection of the thoracic pedicle and its morphometric analysis. Spine (Phila Pa 1976) 22:2332381997

8

Gelalis IDPaschos NKPakos EEPolitis ANArnaoutoglou CMKarageorgos AC: Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J 21:2472552012

9

Kothe RO'Holleran JDLiu WPanjabi MM: Internal architecture of the thoracic pedicle. An anatomic study. Spine (Phila Pa 1976) 21:2642701996

10

Liljenqvist UHackenberg LLink THalm H: Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Acta Orthop Belg 67:1571632001

11

Liljenqvist URHalm HFLink TM: Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine (Phila Pa 1976) 22:223922451997

12

Lu SXu YQChen GPZhang YZLu DChen YB: Efficacy and accuracy of a novel rapid prototyping drill template for cervical pedicle screw placement. Comput Aided Surg 16:2402482011

13

Lu SXu YQLu WWNi GXLi YBShi JH: A novel patient-specific navigational template for cervical pedicle screw placement. Spine (Phila Pa 1976) 34:E959E9662009

14

Lu SZhang YZWang ZShi JHChen YBXu XM: Accuracy and efficacy of thoracic pedicle screws in scoliosis with patient-specific drill template. Med Biol Eng Comput 50:7517582012

15

Ma TXu YQCheng YBJiang MYXu XMXie L: A novel computer-assisted drill guide template for thoracic pedicle screw placement: a cadaveric study. Arch Orthop Trauma Surg 132:65722012

16

Magerl FP: Stabilization of the lower thoracic and lumbar spine with external skeletal fixation. Clin Orthop Relat Res 1891251411984

17

Nottmeier EWSeemer WYoung PM: Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort. Clinical article. J Neurosurg Spine 10:33392009

18

Oertel MFHobart JStein MSchreiber VScharbrodt W: Clinical and methodological precision of spinal navigation assisted by 3D intraoperative O-arm radiographic imaging. Technical note. J Neurosurg Spine 14:5325362011

19

Owen BDChristensen GEReinhardt JMRyken TC: Rapid prototype patient-specific drill template for cervical pedicle screw placement. Comput Aided Surg 12:3033082007

20

Papin PArlet VMarchesi DRosenblatt BAebi M: Unusual presentation of spinal cord compression related to misplaced pedicle screws in thoracic scoliosis. Eur Spine J 8:1561591999

21

Roy-Camille RSaillant GMazel C: Plating of thoracic, thoracolumbar, and lumbar injuries with pedicle screw plates. Orthop Clin North Am 17:1471591986

22

Ryken TCOwen BDChristensen GEReinhardt JM: Imagebased drill templates for cervical pedicle screw placement. Laboratory investigation. J Neurosurg Spine 10:21262009

23

Shin BJJames ARNjoku IUHärtl R: Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. A review. J Neurosurg Spine 17:1131222012

24

Vaccaro ARRizzolo SJBalderston RAAllardyce TJGarfin SRDolinskas C: Placement of pedicle screws in the thoracic spine. Part II: An anatomical and radiographic assessment. J Bone Joint Surg Am 77:120012061995

25

Xu REbraheim NAOu YYeasting RA: Anatomic considerations of pedicle screw placement in the thoracic spine. Roy-Camille technique versus open-lamina technique. Spine (Phila Pa 1976) 23:106510681998

26

Youkilis ASQuint DJMcGillicuddy JEPapadopoulos SM: Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery 48:7717792001

27

Zindrick MRWiltse LLDoornik AWidell EHKnight GWPatwardhan AG: Analysis of the morphometric characteristics of the thoracic and lumbar pedicles. Spine (Phila Pa 1976) 12:1601661987

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