Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: a literature review of 35,630 pedicle screws

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The technique of pedicle screw insertion is a mainstay of spinal instrumentation. Some of its potential complications are clinically relevant and may require reoperation or further postoperative care.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A literature search was performed using MEDLINE (between 1999 and June 2011) for studies on pedicle screw placement in thoracolumbar surgery. The authors included randomized controlled trials, case-control studies, and case series (≥ 20 patients) from the English-, German-, and French-language literature. The authors assessed study type, the number of patients, the anatomical area, the number of pedicle screws, duration of follow-up, type of pedicle screw placement, incidence of complications, and type of complication. The management of specific complications is discussed.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Thirty-nine articles with 46 patient groups were reviewed with a total of 35,630 pedicle screws. One study was a randomized controlled trial, 8 were case-control studies, and the remaining articles were case series. Dural lesions and irritation of nerve roots were reported in a mean of 0.18% and 0.19% per pedicle screws, respectively. Thirty-two patients in 10 studies (of 5654 patients from all 39 studies) required further revision surgeries for misplaced pedicle screws causing neurological problems. None of the analyzed studies reported vascular complications, and only 2 studies reported visceral complications of clinical significance.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Pedicle screw placement in the thoracolumbar region is a safe procedure with an overall high accuracy and a very low rate of clinically relevant complications.</jats:p></jats:sec>

The accuracy of pedicle screw placement using intraoperative image guidance systems

“…Many surgeons consider the majority of cortical violations to be clinically silent depending on the location and the length of penetration. 4,11,13 However, even those initially silent violations may be responsible for instability of the biomechanical construct, 1 of utmost importance; however, misplacement rates have been reported to range from 5% to 41% in the lumbar spine and from 3% to 55% in the thoracic spine when using conventional techniques.…”

Robotic versus fluoroscopy-guided pedicle screw insertion for metastatic spinal disease: a matched-cohort comparison

“…Consequently, manifestations of screw malposition include instability, fractures, injury to dura, vessels, or nervous structures. 6 In contrast to mere malposition on imaging, the incidence of neurological complications of pedicle screw placement in the literature is extremely low. In this study, we present data assessing the utility and feasibility of robot-assisted insertion of pedicle screws in patients with metastatic spinal disease.…”

“…2 Malposition rates with conventional screw placement can be significant. 6 However, the term "malposition" is not well defined and depends on the various grading systems, which are available to evaluate screw position. The majority of pedicle screws with minor breach of pedicle cortex may still have excellent biomechanical properties.…”

Reliability of the Planned Pedicle Screw Trajectory versus the Actual Pedicle Screw Trajectory using Intra-operative 3D CT and Image Guidance

“…[46][47][48] Serious complications such vascular, visceral, and neurologic injury are rare, however screw malposition is a more common complication, with a cited incidence of 0-42%. [46][47][48][49][50] It is also necessary to provide a strong stable construct by minimizing screw pullout, breakage, and late spinal instability. 51,52 Each of these indications is directly related to the accuracy of pedicle screw placement.…”