Delayed presentation of aortic injury by pedicle screws: Report of two cases and review of the literature

Kakkos, Stavros K.; Shepard, Alexander D.

doi:10.1016/j.jvs.2007.11.005

Cited by 132 publications

(80 citation statements)

References 53 publications

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“…These were detected by postoperative CT and the contour deformation confirmed with an aortogram as described by Sucato et al [28]. The potentially dire implications of these screws were confirmed by the recent report by Kakkos et al [6]. In this report, the authors describe the formation of aortic pseudoaneurysm in two patients several months following the placement of thoracic pedicle screws.…”

Section: Discussionsupporting

confidence: 73%

Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make?

et al. 2009

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The use of thoracic pedicle screws for the treatment of adolescent idiopathic scoliosis (AIS) has gained widespread popularity. However, the placement of pedicle screws in the deformed spine poses unique challenges, and surgeons experience a learning curve. The in vivo accuracy as determined by computed tomography (CT) of placement of thoracic pedicle screws in the deformed spine as a function of surgeon experience is unknown. We undertook a retrospective review to determine the effect of surgeon experience on the accuracy of thoracic pedicle screw placement in AIS. In 2005, we started to obtain routine postoperative CT scans on patients undergoing a spinal fusion. From a database of these patients, we selected AIS patients, who underwent a posterior spinal fusion. Fifteen consecutive patients for each of the following three groups stratified by attending surgeon experience were selected (N = 45): A) less than 20 cases of all pedicle screw constructs for AIS (surgeons \2 years of practice), B) 20-50 cases (surgeons 2-5 years of practice), and C) greater than 50 cases (surgeons greater than 5 years of practice). Intraoperative evaluation of all screws included probing of the pedicle screw tract, neurophysiologic monitoring, and fluoroscopic confirmation. A total of 856 thoracic pedicle screws were studied. Postoperative CT scans were evaluated by two spine surgeons and a consensus read established as follows: (1) In: intraosseous placement or B2-mm breach, (2) Out: [2-mm breach, either medial or lateral. Of the 856 screws, 104 demonstrated a [2-mm breach, for an overall rate of 12.1% (medial = 55, lateral = 49, P = 0.67). When the breach rates were stratified by surgeon experience, there was a trend toward decreased rate of breach for the most experienced surgeons, although this did not attain statistical significance (Group A: 12.7%, Group B: 12.9%, Group C: 10.8%, P = 0.58). However, the most experienced group (C) had a markedly decreased rate of medial breaches (3.5 vs. 7.4% and 8.4% for groups A and B, respectively, P \ 0.01). The breach rate for the concave periapical screws was not statistically different from the overall breach rate (13.0% vs. 12.1%, P = 0.93). In conclusion, the overall accuracy of placement of pedicle screws in the deformed spine was 87.9%, with no neurologic, vascular, or visceral complications. Meticulous technique allows spine surgeons with a range of surgical experience to accurately and safely place thoracic pedicle screws in the deformed spine. The most experienced surgeons demonstrated the lowest rate of medial breaches.

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Section: Discussionsupporting

confidence: 73%

Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make?

et al. 2009

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“…Although the rate of neurovascular complications associated with screw misplacement in scoliosis surgery usually reported to be almost 0% [3,[5][6][7], reports on serious complications associated with screw misplacement have been published since the introduction of this procedure [8][9][10][11]. As segmental pedicle screw fixation has become a widely used method in scoliosis corrective surgery, the knowledge about the pedicle morphometry has become increasingly essential.…”

Section: Introductionmentioning

confidence: 99%

Patients with adolescent idiopathic scoliosis of Lenke type-1 curve exhibit specific pedicle width pattern

Abul-Kasim

Ohlin

2011

Eur Spine J

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Introduction Study aim was to find out if patients with Lenke type 1 curve exhibit smaller pedicles and specific pedicle width pattern compared with individuals with no scoliosis. Materials and methods 4,828 pedicle width measurements (T1-L5) in 61 consecutive patients with adolescent idiopathic scoliosis of Lenke type 1 curve, 61 control subjects, and 20 patients with Lenke type 5 curve, were retrospectively performed by an experienced neuroradiologist. Results Among patients with Lenke type 1 curve, the differences between the width of right and left upper thoracic pedicles were statistically significant; smallest at right T4 (2.6 mm). At scoliotic apex, the pedicles on the concave (left) side were significantly smaller than those on the convex (right) side; smallest at left T7 (3.2 mm). Among patients with Lenke type 1 curve, 97% had pedicle width \4 mm. Conclusions Our study showed that patients with Lenke type 1 curve exhibit smaller pedicles and asymmetric pedicle width compared with control subjects.

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“…This was detected by routine postoperative CT, and the patient has not sustained any sequelae attributable to the screw. Generally, our protocol for screws suspected of aortic impingement on routine CT involves obtaining an aortogram to determine contour deformation, as described by Sucato et al 37 Kaccos et al 38 recently described the formation of aortic pseudoaneurysm in 2 patients several months after placement of thoracic pedicle screws, and others have described similar occurrences. 39 The concave periapical pedicles constitute the most deformed and difficult to cannulate in the deformed spine.…”

Section: Discussionmentioning

confidence: 99%

Learning Curve for Placement of Thoracic Pedicle Screws in the Deformed Spine

et al. 2010

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OBJECTIVE The placement of thoracic pedicle screws, particularly in the deformed spine, poses unique challenges, and a learning curve. We measured the in vivo accuracy of placement of thoracic pedicle screws by computed tomography in the deformed spine by a single surgeon over time. METHODS After obtaining institutional review board approval, we retrospectively selected the first 30 consecutive patients who had undergone a posterior spinal fusion using a pedicle screw construct for adolescent idiopathic scoliosis by a single surgeon. The average patient age was 14 years, and their preoperative thoracic Cobb angle was, on average, 62.6 degrees. Patients were divided into 3 groups: group A, patients 1 to 10; group B, patients 11 to 20; and group C, patients 21 to 30. Intraoperative evaluation of all pedicle screws included probing of the pedicle screw tract, neurophysiologic monitoring, and fluoroscopic confirmation. Postoperative computed tomographic scans were evaluated by 2 spine surgeons, and a consensus read was established, as previously described (Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine. 2004;29(3):333–342), as (1) “in,” axis of pedicle screw within the confines of the pedicle; or (2) “out,” axis of pedicle screw outside the confines of the pedicle. RESULTS A total of 553 thoracic pedicle screws were studied (group A, n = 181; group B, n = 189; group C, n = 183) with 64 graded as out (medial, 35; lateral, 29), for an overall breach rate of 11.6%. When the breach rates were stratified by the surgeon's evolving experience, there was a temporal decrease in the breach rate (group A, 15.5%; group B, 10.6%; group C, 8.7%; P < .05). This decreased breach rate was reflected in fewer medial breaches over time (group A, 9.4%; group B, 5.8%; group C, 3.8%; P < .05). Similar trends were observed for the concave periapical screws, although statistical significance was not attained (group A, 21.2%; group B, 16.2%; group C, 10.5%). CONCLUSION The overall accuracy of placement of thoracic pedicle screws in the deformed spine was 88.4%, with no neurologic or visceral complications. One patient from group A returned to the operating room on postoperative day 2 for removal of an asymptomatic left T7 thoracic pedicle screw abutting the aorta. As surgeon experience increased, there was an overall decreased breach rate, which was mainly reflected in fewer medial breaches.

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Delayed presentation of aortic injury by pedicle screws: Report of two cases and review of the literature

Cited by 132 publications

References 53 publications

Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make?

Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make?

Patients with adolescent idiopathic scoliosis of Lenke type-1 curve exhibit specific pedicle width pattern

Learning Curve for Placement of Thoracic Pedicle Screws in the Deformed Spine

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