Pedicle Screw Accuracy Placed with Assistance of Machine Vision Technology in Patients with Neuromuscular Scoliosis

Overview

Journal Spine Deform

Publisher Springer Nature

Date 2024 Feb 27

PMID 38413472

Authors

Rajendra Sakhrekar

Nicholas Shkumat

Birgit Ertl-Wagner

Stephen Lewis

David Lebel

M J McVey

Mark Camp

Affiliations

Soon will be listed here.

Abstract

Introduction: Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion.

Method: A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0).

Results: 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries.

Conclusion: Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

Citing Articles

"Ultralow-dose" CT Without Sedation in Pediatric Patients With Neuromuscular Scoliosis.

Yee N, Iorio C, Shkumat N, Rocos B, Lebel D, Camp M J Pediatr Orthop. 2024; 45(1):e43-e48.

PMID: 39169901 PMC: 11627314. DOI: 10.1097/BPO.0000000000002786.

References

Cotrel Y, Dubousset J, GUILLAUMAT M . New universal instrumentation in spinal surgery. Clin Orthop Relat Res. 1988; 227:10-23. View

Gaines Jr R . The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Joint Surg Am. 2000; 82(10):1458-76. DOI: 10.2106/00004623-200010000-00013. View

Lenke L, Kuklo T, Ondra S, Polly Jr D . Rationale behind the current state-of-the-art treatment of scoliosis (in the pedicle screw era). Spine (Phila Pa 1976). 2008; 33(10):1051-4. DOI: 10.1097/BRS.0b013e31816f2865. View

Winter R . Lessons from the past: pathways to the future. J Orthop Sci. 2009; 14(1):121-7. PMC: 2779376. DOI: 10.1007/s00776-008-1297-4. View

Ledonio C, Polly Jr D, Vitale M, Wang Q, Richards B . Pediatric pedicle screws: comparative effectiveness and safety: a systematic literature review from the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America task force. J Bone Joint Surg Am. 2011; 93(13):1227-34. DOI: 10.2106/JBJS.J.00678. View

Lehman Jr R, Lenke L, Keeler K, Kim Y, Cheh G . Computed tomography evaluation of pedicle screws placed in the pediatric deformed spine over an 8-year period. Spine (Phila Pa 1976). 2007; 32(24):2679-84. DOI: 10.1097/BRS.0b013e31815a7f13. View

Mason A, Paulsen R, Babuska J, Rajpal S, Burneikiene S, Nelson E . The accuracy of pedicle screw placement using intraoperative image guidance systems. J Neurosurg Spine. 2013; 20(2):196-203. DOI: 10.3171/2013.11.SPINE13413. View

Kotani Y, Abumi K, Ito M, Takahata M, Sudo H, Ohshima S . Accuracy analysis of pedicle screw placement in posterior scoliosis surgery: comparison between conventional fluoroscopic and computer-assisted technique. Spine (Phila Pa 1976). 2007; 32(14):1543-50. DOI: 10.1097/BRS.0b013e318068661e. View

Kotani T, Akazawa T, Sakuma T, Koyama K, Nemoto T, Nawata K . Accuracy of Pedicle Screw Placement in Scoliosis Surgery: A Comparison between Conventional Computed Tomography-Based and O-Arm-Based Navigation Techniques. Asian Spine J. 2014; 8(3):331-8. PMC: 4068853. DOI: 10.4184/asj.2014.8.3.331. View

10.

Weinstein J, Claverie W, Gibson S . The pain of discography. Spine (Phila Pa 1976). 1988; 13(12):1344-8. DOI: 10.1097/00007632-198812000-00002. View

11.

Halm H, Niemeyer T, Link T, Liljenqvist U . Segmental pedicle screw instrumentation in idiopathic thoracolumbar and lumbar scoliosis. Eur Spine J. 2000; 9(3):191-7. PMC: 3611403. DOI: 10.1007/s005860000139. View

12.

Jin M, Liu Z, Liu X, Yan H, Han X, Qiu Y . Does intraoperative navigation improve the accuracy of pedicle screw placement in the apical region of dystrophic scoliosis secondary to neurofibromatosis type I: comparison between O-arm navigation and free-hand technique. Eur Spine J. 2015; 25(6):1729-37. DOI: 10.1007/s00586-015-4012-0. View

13.

Brown C, Lenke L, Bridwell K, Geideman W, Hasan S, Blanke K . Complications of pediatric thoracolumbar and lumbar pedicle screws. Spine (Phila Pa 1976). 1998; 23(14):1566-71. DOI: 10.1097/00007632-199807150-00012. View

14.

Watanabe K, Yamazaki A, Hirano T, Izumi T, Sano A, Morita O . Descending aortic injury by a thoracic pedicle screw during posterior reconstructive surgery: a case report. Spine (Phila Pa 1976). 2010; 35(20):E1064-8. DOI: 10.1097/BRS.0b013e3181ed29c1. View

15.

Esses S, Sachs B, Dreyzin V . Complications associated with the technique of pedicle screw fixation. A selected survey of ABS members. Spine (Phila Pa 1976). 1993; 18(15):2231-8; discussion 2238-9. DOI: 10.1097/00007632-199311000-00015. View

16.

Acikbas S, Arslan F, Tuncer M . The effect of transpedicular screw misplacement on late spinal stability. Acta Neurochir (Wien). 2003; 145(11):949-54. DOI: 10.1007/s00701-003-0116-0. View

17.

Fichtner J, Hofmann N, Rienmuller A, Buchmann N, Gempt J, Kirschke J . Revision Rate of Misplaced Pedicle Screws of the Thoracolumbar Spine-Comparison of Three-Dimensional Fluoroscopy Navigation with Freehand Placement: A Systematic Analysis and Review of the Literature. World Neurosurg. 2017; 109:e24-e32. DOI: 10.1016/j.wneu.2017.09.091. View

18.

Odate S, Fujibayashi S, Otsuki B, Shikata J, Tsubouchi N, Tsutsumi R . Reoperation for Misplaced Pedicle Screws: A Multicenter Retrospective Study. Spine (Phila Pa 1976). 2022; 47(21):1525-1531. DOI: 10.1097/BRS.0000000000004398. View

19.

Miyanji F, Nasto L, Sponseller P, Shah S, Samdani A, Lonner B . Assessing the Risk-Benefit Ratio of Scoliosis Surgery in Cerebral Palsy: Surgery Is Worth It. J Bone Joint Surg Am. 2018; 100(7):556-563. DOI: 10.2106/JBJS.17.00621. View

20.

Modi H, Suh S, Hong J, Cho J, Park J, Yang J . Treatment and complications in flaccid neuromuscular scoliosis (Duchenne muscular dystrophy and spinal muscular atrophy) with posterior-only pedicle screw instrumentation. Eur Spine J. 2009; 19(3):384-93. PMC: 2899771. DOI: 10.1007/s00586-009-1198-z. View