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      Learning curve of thoracic pedicle screw placement using the free-hand technique in scoliosis: how many screws needed for an apprentice?

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          Abstract

          Purpose

          The purpose of this study is to evaluate the learning curve of thoracic pedicle screw (TPS) placement of an inexperienced apprentice in scoliosis with the free-hand technique.

          Methods

          The patients with scoliosis who underwent TPS inserted with the free-hand technique by the apprentice under the direction of a chief surgeon were included in this study. The TPS placement by the apprentice was evaluated by examining the assessed position in chronological subgroups of 30 screws. The TPS position was assessed on the postoperative computed tomography (CT) scan images using Zdichavsky grading evaluation system and pedicle breach. The rates of good and dangerous screw placement and the rates of pedicle breaches in each apprentice subgroup were compared with those in the chief surgeon group.

          Results

          Thirty-eight patients with 311 TPS were retrospectively analyzed in our study. Of all screws, 154 pedicle screws were inserted by the apprentice, and were divided chronologically into five subgroups. The rates of dangerous placement performed by the apprentice in the first two subgroups were 26.7 and 23.3%, respectively, and were significantly higher than 9.1% by the chief surgeon ( P < 0.05). Meanwhile, the breach rate was 46.6% in subgroup 1 and 50.0% in subgroup 2, and was significantly higher than 29.3% in chief surgeon ( P < 0.05). Furthermore, after the first 60 TPS placements, the assessed rates in apprentice reached to a stable level, and no significant difference could be found among the subgroups (subgroup 3, 4 and 5) and the chief surgeon group ( P > 0.05).

          Conclusions

          For an apprentice, an experience of at least 60 screw placements under the direction of an experienced surgeon is needed for inserting the TPS in scoliosis using the free-hand technique independently.

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          Most cited references28

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          Free hand pedicle screw placement in the thoracic spine: is it safe?

          A retrospective study. To evaluate the safety of a free hand technique of pedicle screw placement in the thoracic spine at a single institution over a 10-year experience. Thoracic pedicle screw fixation techniques are still controversial for thoracic deformities because of possible complications including neurologic. Three hundred ninety-four consecutive patients who underwent posterior stabilization utilizing 3204 transpedicular thoracic screws by 2 surgeons from 1992 to 2002 were analyzed. The mean age was 27 + 10 years (range 5 + 3-87 + 0 years) at the time of surgery. Etiologic diagnoses were: scoliosis in 273, kyphosis in 53, other spinal disease in 68. Pedicle screws were inserted using a free hand technique similar to that used in the lumbar spine in which anatomic landmarks and specific entry sites were used to guide the surgeon. A 2-mm tip pedicle probe was carefully advanced free hand down the pedicle into the body. Careful palpation of all bony borders (floor and four pedicle walls) was performed before and after tapping. Next, the screw was placed, followed by neurophysiologic (screw stimulation with rectus abdominus muscle recording) and radiographic (anteroposterior and lateral) confirmation. An independent spine surgeon using medical records and roentgenograms taken during treatment and follow-up reviewed all the patients. The number of the screws inserted at each level were as follows (total n = 3204): T1, n = 13; T2, n = 60; T3, n = 192; T4, n = 275; T5, n = 279; T6, n = 240; T7, n = 230; T8, n = 253; T9, n = 259; T10, n = 341; T11, n = 488; T12, n = 572. Five hundred seventy-seven screws inserted into the deformed thoracic spine were randomly evaluated by thoracic computed tomography scan to assess for screw position. Thirty-six screws (6.2%) were inserted with moderate cortical perforation, which meant the central line of the pedicle screw was out of the outer cortex of the pedicle wall and included 10 screws (1.7%) that violated the medial wall. There were no screws (out of the entire study group of 3204) with any neurologic, vascular, or visceral complications with up to 10 years follow-up. The free hand technique of thoracic pedicle screw placement performed in a step-wise, consistent, and compulsive manner is an accurate, reliable, and safe method of insertion to treat a variety of spinal disorders, including spinal deformity.
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            Internal fixation of the lumbar spine with pedicle screw plating.

            The results and complications of pedicle screw plate (PSP) stabilizations were investigated in lumbar fresh fractures, malunions, lumbar metastases, primary tumors, lumbosacral fusions, and highgrade spondylolisthesis. The low incidence of neurologic complications of PSP is noteworthy, and a reason for recommending the method.
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              Thoracic pedicle screw fixation in spinal deformities: are they really safe?

              A retrospective study. To determine the safety of pedicle screw fixation in thoracic deformity correction. Pedicle screw fixation enables enhanced correction of spinal deformities. However, the technique is still not widely applied for thoracic deformities for fear of neurologic complications. A total of 462 patients subjected to thoracic pedicle screw fixation for spinal deformities were analyzed after a minimum follow-up of 2 years. Etiologic diagnoses were idiopathic scoliosis in 330, congenital kyphoscoliosis in 68, kyphosis in 50, and others in 14. They were reviewed using the medical records and preoperative, intraoperative, and postoperative roentgenograms. Computed tomography was performed when screw position was questionable. A total of 4604 thoracic pedicle screws were inserted (10.1 screws/patient). There were 67 screw malpositions (1.5%) in 48 patients (10.4%). The malpositions were inferior in 33, lateral in 18, superior in 12, and medial in 4. Screw-related neurologic complications occurred in four patients (0.8%); these comprised a transient paraparesis and three dural tears. Other complications comprised 11 intraoperative pedicle fractures, 35 screw loosenings, 9 postoperative infections, and 1 pneumothorax. There were no significant screw-related neurologic or visceral complications that adversely affected the long-term result. The deformity correction was 69.9% for idiopathic scoliosis and 60.7% for congenital scoliosis. The sagittal plane deformity correction was 47 degrees for kyphosis. Thoracic pedicle screw fixation is a reliable method of treating spinal deformities, with an excellent deformity correction and a high margin of safety.
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                Author and article information

                Contributors
                86-571-87783543 , 86-571-87784556 , bertpumc@yahoo.com
                Journal
                Eur Spine J
                Eur Spine J
                European Spine Journal
                Springer-Verlag (Berlin/Heidelberg )
                0940-6719
                1432-0932
                12 November 2011
                12 November 2011
                June 2012
                : 21
                : 6
                : 1151-1156
                Affiliations
                Department of Orthopedic Surgery, The 2nd Affiliated Hospital of Medical College of Zhejiang University, 88 Jiefang Road, Hangzhou, 310009 Zhejiang China
                Article
                2065
                10.1007/s00586-011-2065-2
                3366127
                22081239
                b3a70f41-c8ca-424f-9cac-c4d7e0c6e60b
                © The Author(s) 2011
                History
                : 31 January 2011
                : 25 October 2011
                : 3 November 2011
                Categories
                Chinese Section
                Custom metadata
                © Springer-Verlag 2012

                Orthopedics
                learning curve,free-hand technique,thoracic pedicle screw,scoliosis
                Orthopedics
                learning curve, free-hand technique, thoracic pedicle screw, scoliosis

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