Accuracy of Percutaneous Lumbosacral Pedicle Screw Placement Using the Oblique Fluoroscopic View Based on Computed Tomography Evaluations

Abstract

Study DesignRetrospective.PurposeThis study aims to investigate the accuracy of the oblique fluoroscopic view, based on preoperative computed tomography (CT) images for accurate placement of lumbosacral percutaneous pedicle screws (PPS).Overview of LiteratureAlthough PPS misplacement has been reported as one of the main complications in minimally invasive spine surgery, there is no comparative data on the misplacement rate among different fluoroscopic techniques, or comparing such techniques with open procedures.MethodsWe retrospectively selected 230 consecutive patients who underwent posterior spinal fusion with a pedicle screw construct for degenerative lumbar disease, and divided them into 3 groups, those who had undergone: minimally invasive percutaneous procedure using biplane (lateral and anterior-posterior views using a single C-arm) fluoroscope views (group M-1), minimally invasive percutaneous procedure using the oblique fluoroscopic view based on preoperative CT (group M-2), and conventional open procedure using a lateral fluoroscopic view (group O: controls). The relative position of the screw to the pedicle was graded for the pedicle breach as no breach, <2 mm, 2–4 mm, or >4 mm. Inaccuracy was calculated and assessed according to the spinal level, direction and neurological deficit. Inter-group radiation exposure was estimated using fluoroscopy time.ResultsInaccuracy involved an incline toward L5, causing medial or lateral perforation of pedicles in group M-1, but it was distributed relatively equally throughout multiple levels in groups M-2 and controls. The mean fluoroscopy time/case ranged from 1.6 to 3.9 minutes.ConclusionsMinimally invasive lumbosacral PPS placement using the conventional fluoroscopic technique carries an increased risk of inaccurate screw placement and resultant neurological deficits, compared with that of the open procedure. Inaccuracy tended to be distributed between medial and lateral perforations of the L5 pedicle, as a result of pedicle morphology and the PPS pathway. Oblique fluoroscopic views, based on CT measurement, may allow accurate PPS insertion with a shorter fluoroscopy time.

Accuracy of Percutaneous Pedicle Screw Placement after Single-Position versus Dual-Position Insertion for Lateral Interbody Fusion and Pedicle Screw Fixation Using Fluoroscopy

“…In general, inaccurate PPS placement can cause potential postoperative neurological deficits [6][7][8][9]. Previous reports have indicated 4.7%-15% rates of inaccurate PPS placement; however, PPS placement is reported to be an effective technique with no difference in perforation rate from the standard open free-hand technique [10][11][12].…”

Accuracy of pedicle screw insertion for unilateral open transforaminal lumbar interbody fusion: a side-by-side comparison of percutaneous and conventional open techniques in the same patients

“…Many authors have reported that MIS-TLIF can reduce tissue damage, blood loss, and postoperative pain compared with conventional TLIF [1][2][3][4]. In particular, PPS insertion can decrease damage not only to soft tissue but also to the superior facet joint because it is easier for surgeons to insert pedicle screws from the outside of the facet joint [14]. However, PPS insertion requires fluoroscopy or a navigation system.…”

Accuracy of fluoroscopic guidance with the coaxial view of the pedicle for percutaneous insertion of lumbar pedicle screws and risk factors for pedicle breach

“…However, only a few studies have described the accuracy of percutaneous lumbar pedicle screw placement, especially when using the coax-ial fluoroscopic view. [10][11][12][13] In addition, the factors affecting the accuracy of pedicle screw insertion are unclear.…”