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      Freehand Juxtapedicular Screws Placed in the Apical Concavity of Adult Idiopathic Scoliosis Patients: Technique, Computed Tomography Confirmation, and Radiographic Results


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          The purpose of this study is to highlight our technique for freehand placement of juxtapedicular screws along with intraoperative computed tomography (CT) and radiographic results.


          Consecutive patients with adult idiopathic scoliosis undergoing primary surgery by the senior author were identified. All type D (absent/slit like channel) pedicles were identified on preoperative CT. Three-dimensional visualization software was used to measure screw angulation and purchase. Radiographs were measured by a fellowship trained spine surgeon. The freehand technique was used to place all screws in a juxtapedicular fashion without any fluoroscopic, radiographic, navigational or robotic assistance.


          Seventy-three juxtapedicular screws were analyzed. The most common level was T7 (9 screws) on the left and T5 (12 screws) on the right. The average medial angulation was 20.7° (range, 7.1°–36.3°), lateral vertebral body purchase was 13.4 mm (range, 0–28.9 mm), and medial vertebral body purchase was 21.1 mm (range, 8.9–31.8 mm). More than half (53.4%) of the screws had bicortical purchase. Two screws were lateral on CT scan, defined by the screw axis lateral to the lateral vertebral body cortex. No screws were medial. There was a difference in medial angulation between screws with (n = 58) and without (n = 15) lateral body purchase (22.0±4.9 vs. 15.5±4.5, p < 0.001). Three of 73 screws were repositioned after intraoperative CT. There were no neurovascular complications. The mean coronal cobb corrections for main thoracic and lumbar curves were 83.0% and 80.5%, respectively, at an average of 17.5 months postoperative.


          Freehand juxtapedicular screw placement is a safe technique for type D pedicles in adult idiopathic scoliosis patients.

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          Most cited references18

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          Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis.

          A retrospective matched cohort study. To comprehensively compare the 2-year postoperative results of posterior correction and fusion with segmental pedicle screw instrumentation versus those with hook constructs in adolescent idiopathic scoliosis (AIS) treated at a single institution. Despite the reports of satisfactory correction and maintenance of scoliotic curves by pedicle screw instrumentation compared to hook constructs, few reports on the comprehensive comparison of segmental pedicle screw instrumentation versus hook instrumentation exist. A total of 52 patients with AIS at a single institution who underwent a posterior spinal fusion with segmental pedicle screw (26) or hook (26) instrumentation were sorted and matched according to four criteria: similar age at surgery (14.8 years in pedicle screw group and 14.2 years in hook group), identical Lenke curve types, same number of fused vertebrae (11.7 in each group), and identical operative methods (18 posterior spinal fusions with thoracoplasty, 4 posterior spinal fusions with iliac crest bone graft, and 4 anterior and posterior spinal fusions in each group). Patients were evaluated before surgery, immediate after surgery, and at the 2-year follow-up according to radiographic changes in curve correction, pulmonary function tests, operative time, intraoperative blood loss, implant costs, and SRS-24 scores. After surgery, the average major curve correction was 76% in the screw group and 50% in the hook group (P 79% in screw group vs. 82%--> 74% in hook group, P = 0.0056; FEV-1, 73%--> 76% in screw group vs. 80%--> 79% in hook group, P = 0.017). Postoperative 2-year SRS-24 scores were similar in both groups (screw group [97] vs. hook group [101]) (P = 0.15). There were no neurologic or visceral complications related to hook or pedicle screw instrumentation. Pedicle screw instrumentation, although more expensive, offers a significantly better major and minor curve correction without neurologic problems and improved pulmonary function values in the operative treatment of AIS and enables a slightly shorter fusion length than segmental hook instrumentation.
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            Complications of thoracic pedicle screws in scoliosis treatment.

            A retrospective study. To analyze complications with thoracic pedicle screws in scoliosis treatment at our Department over a 3-year period (1999-2001). The use of pedicle screws remains controversial for thoracic scoliosis for fear of complications. A total of 115 consecutive patients who underwent posterior fusion using 1035 transpedicular thoracic screws were reviewed. All patients presented a main thoracic scoliosis with a mean Cobb angle of 75.4 degrees (range, 60 degrees -105 degrees ). For thoracic screw placement, a mini-laminotomy technique was used, inserting a spatula inside the vertebral canal to palpate the borders of the pedicle. Postoperative CT scan was used in 25 patients (21.7%) to study a total of 311 screws, when the screw position was questionable. An independent spine surgeon retrospectively reviewed medical records and radiographs of the patients, at a mean follow-up of 4 years. There were 18 screws misplaced (1.7%) in a total of 13 patients (11.3%). Screw malposition was symptomatic only in 1 patient (pleural effusion and fever) and asymptomatic in the other 12 cases (10.4%). Other complications included intraoperative pedicle fractures in 15 patients (13%), dural tears (without neurologic complications) in 14 cases (12.1%), and superficial wound infections in 2 (1.7%). Another operation for screw removal was performed in 5 patients (4.3%), due to pleural effusion (in 1 case), asymptomatic late lateral loosening of a malpositioned screw (in 1), and the possible future risks related the intrathoracic screw position despite the lack of any symptoms (in 3). Two cases (1.7%) were retreated due to wound infection, without removing instrumentation. There was no loss of correction at follow-up. The thoracic pedicle screw placement in scoliosis patients requires utmost caution. The mini-laminotomy technique was beneficial in increasing safety of the procedure with an acceptable incidence of complications.
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              Accuracy of free-hand pedicle screws in the thoracic and lumbar spine: analysis of 6816 consecutive screws.

              Pedicle screws are used to stabilize all 3 columns of the spine, but can be technically demanding to place. Although intraoperative fluoroscopy and stereotactic-guided techniques slightly increase placement accuracy, they are also associated with increased radiation exposure to patient and surgeon as well as increased operative time.

                Author and article information

                Korean Spinal Neurosurgery Society
                December 2022
                31 December 2022
                : 19
                : 4
                : 1116-1121
                [1 ]Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
                [2 ]Department of Orthopedic Surgery, Mount Sinai Hospital, New York, NY, USA
                [3 ]The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
                Author notes
                Corresponding Author James D. Lin Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, USA Email: james.lin@ 123456mountsinai.org
                Author information
                Copyright © 2022 by the Korean Spinal Neurosurgery Society

                This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 31 August 2022
                : 2 November 2022
                : 12 November 2022
                Original Article

                spine surgery,pedicle screw,thoracic instrumentation,lumbar instrumentation,juxtapedicular screw placement,extrapedicular screw placement


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