At What Levels Are Freehand Pedicle Screws More Frequently Malpositioned in Children?

Heidenreich, Mark J.; Baghdadi, Yaser M. K.; McIntosh, Amy L.; Shaughnessy, William J.; Dekutoski, Mark B.; Stans, Anthony A.; Larson, A. Noelle

doi:10.1016/j.jspd.2014.12.003

Cited by 12 publications

(7 citation statements)

References 25 publications

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“…Lehman et al found 10.5% screws placed using the freehand technique were malpositioned on CT imaging 16 . Baghdadi et al found 9% of screws placed in children with freehand technique had more than a 4 mm breach, and up to 20% may have a 2 mm breach 17,18 . Samdani et al also found that 12% of freehand screws had a > 2 mm breach, with no statistical correlation based on surgeon experience 19 .…”

Section: Discussionmentioning

confidence: 99%

Intraoperative Computed Tomography–Guided Navigation for Pediatric Spine Patients Reduced Return to Operating Room for Screw Malposition Compared With Freehand/Fluoroscopic Techniques

et al. 2019

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Purpose: Placement of pedicle screws can be performed using freehand/fluoroscopic technique or intra-operative CT guided navigation. We sought to compare screw malposition and return to OR for pedicle screw malposition for screws placed with and without CT-guided navigation. Methods: This study was a single center retrospective comparative study. All patients under the age of 18 with minimum 2-year follow-up who underwent pedicle screw instrumentation between 2009-2015 were included. IRB-approval was obtained and patient charts were reviewed for patient demographics and surgical outcomes. If available, incidental CTs following the index surgery were reviewed to assess screw position. Results: 217 patients underwent spinal instrumentation. 112 patients had pedicle screws placed using fluoroscopic guidance, while 105 patients had screws placed using lowdose intraoperative CT-guided navigation (O-arm, Medtronics). Of the total cohort, 107 (49.3 %) patients had adolescent idiopathic scoliosis, and the remainder had neuromuscular, tumor, congenital, or other diagnoses. Patients in each group had a similar number of levels fused (fluoroscopic = 10.9 vs. CT navigation = 9.8, p = 0.06). There was no difference in total estimated blood loss (1127 vs. 1179 mL, p = 0.63), or in blood loss per level fused (133.7 vs. 146.6 mL, p = 0.47). Patients with screws placed using fluoroscopic guidance had a shorter total operative time (441 vs. 468 minutes, p = 0.04); however, there was no difference when controlling for number of levels fused (58.3 vs. 61.5 minutes/level, p = 0.63). Postoperative CTs were available in 51 patients representing 526 imaged screws, which showed a significantly higher rate of severely malpositioned (>4mm) screws in the fluoroscopic group than the CT navigation group (3.3% vs. 1.0%, p = 0.027). There was a 3.6% rate of return to OR for pedicle screw malposition in the freehand/fluoroscopic group compared to 0% in the CT-guided navigation group (p=0.048). Including patients with less than 2-year follow

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Section: Discussionmentioning

confidence: 99%

Intraoperative Computed Tomography–Guided Navigation for Pediatric Spine Patients Reduced Return to Operating Room for Screw Malposition Compared With Freehand/Fluoroscopic Techniques

et al. 2019

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“…While with the screw related complications, image guided approach did not show much advantage over free-hand technique [29] . Also, prior studies have reported that 5–17% pedicle screws are malpositioned, but these studies were not purely focused on children with younger age groups(12 years and less) [30] .…”

Section: Discussionmentioning

confidence: 99%

Assessment of pedicle screw malposition in uniplanar versus multiplanar spinal deformities in children

Sarathy

Dhawale

Rokade

et al. 2021

North American Spine Society Journal (NASSJ)

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Background: Spinal deformities can either be uniplanar or multiplanar. The current study aims to compare malpositioned pedicle screw assessment on radiographs versus CT in children < 12 years with multiplanar and uniplanar spinal deformities.Methods: A cohort of 15 children, mean age 10.1 years, who underwent posterior spinal fusion using free-hand pedicle screw insertion for multiplanar (M) or uniplanar (U) deformities with post-operative radiograph and CT evaluation of 154 screws. The outcome measures included the assessment of malpositions detected on plain radiographs versus CT scans in U and M deformities. The overall breaches in post-operative plain radiographs and CT in each group were compared and analyzed by two independent observers. The mal-positioned screws were graded on extent of cortical breach on CT. Inter and intra-observer variability was calculated with Kappa(k) method. Sensitivity, Specificity and Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated by comparing breaches on radiographs versus CT considered the gold standard.Results: In total,154 pedicle screws were analyzed, 65 in U group and 89 in M group. There were 23 (14.9%) malpositioned screws identified on plain radiographs and 43 (27.9%) on CT ( p = 0.008). There were 17/154 (11.03%) Grade 1 breaches, 16/154 (10.38%) Grade 2 breaches and 10/154(6.49%) Grade III breaches. Among the 43 CT breaches, 12/65 (18.46%) were in U group, 31/89 (34.83%) were in M group ( p = 0.013).The overall Sensitivity, Specificity and PPV of plain radiographs compared to CT in detecting malpositions were 32.56%, 91.89% and 60.87% respectively. Conclusions:There was a significant discrepancy in identification of pedicle screw malposition based on plain radiographic versus CT based assessment, more so in multiplanar deformities. The ability to detect a breach on plain radiographs is lesser in multiplanar versus uniplanar deformities.

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“…Three of these leaks occurred at the upper end of the construct and were all at the right upper thoracic area, which is known to have a high occurrence of small (type C and D) pedicles and highest rate of screw malposition (23, 24). Interestingly, the presentation was delayed.…”

Section: Discussionmentioning

confidence: 99%

Delayed Dural Leak Following Posterior Spinal Fusion for Idiopathic Scoliosis Using All Posterior Pedicle Screw Technique

Floccari¹,

Larson²,

Stans³

et al. 2017

Journal of Pediatric Orthopaedics

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Background In pediatric patients, pedicle screws are malpositioned 5–15% of the time. Complications associated with malpositioned screws are infrequently reported in the literature. We present a series of adolescent idiopathic scoliosis patients who presented in a delayed fashion with positional headache and chronic dural leak adjacent to the pedicle screw tract. Methods Scoliosis databases at two centers were reviewed, and cases of delayed positional headaches following posterior spinal fusion for adolescent idiopathic scoliosis were identified. Demographic and clinical data were collected. Results Out of 322 patients, four patients presented with positional headaches at a mean of 12.8 weeks following posterior spinal fusion surgery for AIS, with an interval time to diagnosis of 5 months. CT myelogram demonstrated severe pedicle screw malposition in one patient, and minimal malposition in three patients (less than 2mm violation). The patients had delayed presentation with positional headaches secondary to dural leak. All patients successfully underwent revision surgery with repair of the dural leak. At the time of latest follow-up, all patients are asymptomatic. Conclusion Pedicle screw malposition can result in dural leaks. Patients may present in a delayed fashion with positional headaches and an acquired Chiari malformation. Clinical suspicion should prompt imaging of the brain or cervical spine followed by CT myelogram to determine site of leak. This is a rare complication from pedicle screw malposition.

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At What Levels Are Freehand Pedicle Screws More Frequently Malpositioned in Children?

Abstract: Level IV, Therapeutic Study. See the Guidelines for Authors for a complete description of the levels of evidence.

Cited by 12 publications

References 25 publications

Intraoperative Computed Tomography–Guided Navigation for Pediatric Spine Patients Reduced Return to Operating Room for Screw Malposition Compared With Freehand/Fluoroscopic Techniques

Intraoperative Computed Tomography–Guided Navigation for Pediatric Spine Patients Reduced Return to Operating Room for Screw Malposition Compared With Freehand/Fluoroscopic Techniques

Assessment of pedicle screw malposition in uniplanar versus multiplanar spinal deformities in children

Delayed Dural Leak Following Posterior Spinal Fusion for Idiopathic Scoliosis Using All Posterior Pedicle Screw Technique

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