Inserting pedicle screws in the upper thoracic spine without the use of fluoroscopy or image guidance. Is it safe?

Abstract

Several studies have looked at accuracy of thoracic pedicle screw placement using fluoroscopy, image guidance, and anatomical landmarks. To our knowledge the upper thoracic spine (T1-T6) has not been specifically studied in the context of screw insertion and placement accuracy without the use of either image guidance or fluoroscopy. Our objective was to study the accuracy of upper thoracic screw placement without the use of fluoroscopy or image guidance, and report on implant related complications. A single surgeon inserted 60 screws in 13 consecutive non-scoliotic spine patients. These were the first 60 screws placed in the high thoracic spine in our institution. The most common diagnosis in our patient population was trauma. All screws were inserted using a modified RoyCamille technique. Post-operative axial computed tomography (CT) images were obtained for each patient and analyzed by an independent senior radiologist for placement accuracy. Implant related complications were prospectively noted. No pedicle screw misplacement was found in 61.5% of the patients. In the remaining 38.5% of patients some misplacements were noted. Fifty-three screws out of the total 60 implanted were placed correctly within all the pedicle margins. The overall pedicle screw placement accuracy was 88.3% using our modified Roy-Camille technique. Five medial and two lateral violations were noted in the seven misplaced screws. One of the seven misplaced screws was considered to be questionable in terms of pedicle perforation. No implant related complications were noted. We found that inserting pedicle screws in the upper thoracic spine based solely on anatomical landmarks was safe with an accuracy comparable to that of published studies using imageguided navigation at the thoracic level.

Benefit and accuracy of intraoperative 3D-imaging after pedicle screw placement: a prospective study in stabilizing thoracolumbar fractures

“…Several authors favour the exclusive implantation of the screws on the basis of anatomical landmarks both in the upper area of the thoracic spine and for spines with scoliotic deformations [19,25]. Schizas reports of a rate of 11.7% falsely positioned screws in the area T1-T6, but with no need for operative revision [25].…”

“…Schizas reports of a rate of 11.7% falsely positioned screws in the area T1-T6, but with no need for operative revision [25]. Of 1,009 manually inserted pedicle screws in cases of scoliosis, 73% were intrapedicular, 20.3% penetrated the pedicle limits in an acceptable false position and 6.7% of the screws were classified as requiring revision [19].…”

CT-navigation versus fluoroscopy-guided placement of pedicle screws at the thoracolumbar spine: single center experience of 4,500 screws

“…When dealing with conventional, namely fluoroscopic, support for pedicle screw insertion into the thoracic spine, the reported misplacement rates are considerably higher in comparison to screws placed under navigation, especially 3D-navigation techniques like O-arm [19][20][21]. Only a few publications are available regarding placement accuracy of non-navigated pedicle screws in upper thoracic levels.…”

Accuracy of pedicle screw placement in thoracolumbar spine with conventional open technique

“…These concerns are mainly about the safety of the procedure. No matter how your technique is perfect and you use solely anatomical landmarks (22). The application of pedicle screws is ultimately a blind procedure even if you use sophisticated technical resources (16,23) or even robots (13) to assist the surgery.…”