A novel device to simplify intraoperative radiographic visualization of the cervical spine by producing transient caudal shoulder displacement: a 2-center case series of 80 patients

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Intraoperative radiographic localization within the cervical spine can be a challenge because of the anatomical relation of the musculoskeletal structures of the pectoral girdle. On standard cross-table lateral radiographs, these structures can produce shadowing that obscure the anatomical features of the cervical vertebrae, particularly at the caudal levels. Surgical guidelines recommend accurate intraoperative localization as a means to reduce wrong-level spine surgery, and unobstructed visualization is needed for fluoroscopy-guided placement of spinal instrumentation. In this article, the authors describe and evaluate a novel device designed to provide transient intraoperative caudal displacement of the shoulders to improve and simplify radiographic visualization of the cervical spine.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A 2-center prospective study was conducted to evaluate the device. The study included a total of 80 patients undergoing cervical spine surgery. The device was evaluated in a cohort of 50 patients undergoing elective single-level anterior discectomy and fusion and also in a second cohort of 30 patients at an independent institution. The patients in this second cohort were undergoing a variety of cervical spine procedures for multiple indications and were included in the study to allow the authors to assess the effectiveness of the device in a general neurosurgical practice. After the patients were anesthetized and positioned, consecutive standard cross-table lateral radiographs or intraoperative fluoroscopic were obtained before and after use of the device. The images were compared in order to determine the difference in lowest vertebral level visible.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>There was an average difference in cervical spine visualization of +2.8 ± 0.9 vertebral levels in the first cohort, while in the second the improvement was +1.2 ± 0.7 levels (p &lt; 0.0001 between cohorts, unpaired t-test). There was one complication, a minor shoulder abrasion, which required no specific management.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>This device is safe and effective for increasing the radiographic visualization of the cervical spine for intraoperative localization.</jats:p></jats:sec>

Enhanced Visualization of the Cervical Vertebra during Intraoperative Fluoroscopy Using a Shoulder Traction Device

“…Moreover, continuous traction throughout the surgical procedure is not necessary and will likely increase the risk of brachial plexus palsy. In 2013, Witiw et al [9] has proposed the use of a device called the Citow Cervical Visualizer, which is applied to the patient's acromion as needed. Moreover, Marangoz has reported an intraoperative traction device that is used to pull the shoulders [10].…”

“…Moreover, Marangoz has reported an intraoperative traction device that is used to pull the shoulders [10]. However, with the utilization of both devices, the user is exposed to increased radiation due to positioning [9,10]. Moreover, whether these two devices are more effective than tape traction in visualizing the lower cervical vertebrae on fluoroscopy is not elucidated.…”

Intrinsic Vertebral Markers for Spinal Level Localization in Anterior Cervical Spine Surgery: A Preliminary Report

“…The limitations of intraoperative radiography include inadequate radiological visualization, which is common in the lower cervical spine because of the anatomical relationship among the musculoskeletal structures of the pectoral girdle [2829]. Transient caudal shoulder displacement has been helpful for intraoperative radiographic visualization of the lower cervical spine [30]. Intrinsic markers can be very useful in situations where conventional radiographic methods fail to provide unequivocal results.…”

Intermittent Feet Dorsiflexion as a Simple Trick to Improve Cervical Fluoroscopic Visualization

“…These techniques are cumbersome, may dislodge catheters, interfere with monitoring devices, disrupt surgical field sterility and expose the person helping to direct radiation. 8 These disadvantages have been at least partly dealt with by various shoulder traction devices recently described. 8,9 However, they still include the risk of brachial plexopathy.…”

“…5,6 Established techniques to improve cervical fluoroscopic visualization include amongst others oblique rotation of the x-ray tube and caudal traction on the shoulders using tape, weights, manpower or special devices. 1,[7][8][9] We propose an extremely simple and convenient technique to increase the number of visualized cervical levels. We aim to measure the average change in fluoroscopically visualized levels when performing this maneuver.…”