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

Clinical article

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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.


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.


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.


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:

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.



  • 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.



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