Comparison of Superior-Level Facet Joint Violations During Open and Percutaneous Pedicle Screw Placement

Abstract

Background Superior-level facet joint violation by pedicle screws may result in increased stress to the level above the instrumentation and may contribute to adjacent segment disease (ASD). Previous studies have evaluated facet joint violations in open or percutaneous screw cases, but there are no reports describing a direct institutional comparison. Objective To compare the incidence of superior-level facet violation for open versus percutaneous pedicle screws, and evaluate patient and surgical factors that impact this outcome. Methods We reviewed 279 consecutive patients who underwent an index instrumented lumbar fusion from 2007 to 2011 for degenerative spine disease with stenosis with or without spondylolisthesis. We used a CT grading system which represents progressively increasing grades of facet joint violation. Patient and surgical factors were evaluated to determine their impact on facet violation. Results Our cohort consisted of 126 open and 153 percutaneous cases. Percutaneous procedures had a higher overall violation grade (p=0.018) and greater incidence of high-grade violations (p=0.0059) compared to open procedures. Bivariate analysis showed significantly greater violations in percutaneous cases for age<65, obesity, pedicle screws at L4, and 1- and 2-level surgeries. Multivariate analysis showed the percutaneous approach and depth of the spine to be independent risk factors for high-grade violations. Conclusion This study demonstrates greater facet violations for percutaneously placed pedicle screws compared to open.

Comparison of Cranial Facet Joint Violation Rate Between Percutaneous and Open Pedicle Screw Placement

“…The details of literature search and selection are displayed in Figure 1 . After detailed evaluation, 4 independent retrospective trials 21 – 24 with a cumulative sample size of 881 patients and 1755 cranial pedicle screws were included in the overall meta-analysis. For the quality assessment of the 4 studies, the Newcastle–Ottawa Quality Assessment Scale grades were 6 to 8 stars, which were regarded as high quality of the studies.…”

“…All the 4 articles 21 – 24 presented the number of pedicle screw suffering from facet joint violation. There are 847 pedicle screws in percutaneous insertion group and 908 in open technique group.…”

Treatment of Symptomatic Lumbar Disc Degeneration with the VariLift-L Interbody Fusion System: Retrospective Review of 470 Cases

“…However, supplemental fixation methods are more technically demanding and increase operative time, blood loss and complications such as nerve root injury and violation of the adjacent facet joints. 5,6 This method of instrumented fusion may also be associated with an increased risk of symptomatic adjacent segment disease. 7 The VariLift®-L interbody fusion system was developed as a stand-alone expandable fusion device that does not require supplemental fixation.…”

The VariLift&reg; Interbody Fusion System: expandable, standalone interbody fusion

“… 29 These drawbacks have led to the recent trend of adding supplemental fixation such as pedicle screw systems to interbody fusion, despite the well-known risks of pedicle screw placement. 10 – 13 …”

“… 9 While such supplemental fixation provides a biomechanically stable construct in benchtop testing, pedicle screw placement is associated with significant morbidities, including increased operative time, blood loss, reoperation rate, and significant risk of nerve root injury. 10 Violation of the facet joint at the cephalad segment is also common during pedicle screw placement, 11 – 13 and may be associated with symptomatic adjacent segment degeneration (ASD), a common sequela of instrumented fusion. 14 In the cervical spine, anterior cervical discectomy and fusion (ACDF) utilizing autologous iliac crest bone graft (ICBG) remains a common procedure for interbody fusion due to the high fusion rate achieved with this technique; the addition of an interbody cage to ACDF has demonstrated lower complication rates compared to ACDF with ICBG.…”