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      In vitro study of accuracy of subaxial cervical pedicle screw insertion using calipers based on the gravity line

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          Abstract

          Object

          There is a high probability of iatrogenic perforation of the vertebral pedicle wall during the application of subaxial cervical pedicle screw (CPS). The goal of this study was to evaluate the accuracy of CPS insertion at C3-C7 in vitro using novel calipers based on the gravity line.

          Methods

          Nine cadaveric cervical spines underwent computed tomography scanning and preoperative design. A lateral fluoroscopic view was taken to measure the intra-operative sagittal angle by C-arm with hanging cross structured K-wires. By referring to the gravity line, caliper A was used to locate the entry point, while caliper B was employed to guide the screw insertion. Postoperative CT scans were performed to assess the accuracy of the screw placements, according to the Neo classification.

          Results

          Overall, 78 (88.6%) of the 88 pedicle screw placements were classified as grade 0 (correct position), 4 (4.5%) were grade 1 (non-critical perforation), 4 (4.5%) were grade 2 (critical perforation), and 2 (2.3%) were grade 3 (critical perforation).

          Conclusions

          Using our novel calipers and referring to the gravity line was helpful for locating and guiding individual cervical pedicle screw insertions.

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          Most cited references 28

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          Complications of pedicle screw fixation in reconstructive surgery of the cervical spine.

          Retrospective evaluation of complications in 180 consecutive patients with cervical disorders who had been treated by using pedicle screw fixation systems. To determine the risks associated with pedicle screw fixation in the cervical spine and to emphasize the importance of preoperative planning and surgical techniques in reducing the risks of this procedure. Generally, pedicle screw fixation in the cervical spine has been considered too risky for the neurovascular structures. There have been several reports describing the complications of lateral mass screw-plate fixation. However, no studies have examined in detail the complications associated with cervical pedicle screw fixation. One hundred eighty patients who underwent cervical reconstructive surgery using cervical pedicle screw fixation were reviewed to clarify the complications associated with the pedicle screw fixation procedure. Cervical disorders were spinal injuries in 70 patients and nontraumatic lesions in 110 patients. Seven hundred twelve screws were inserted into the cervical pedicles, and the locations of 669 screws were radiologically evaluated. Injury of the vertebral artery occurred in one patient. The bleeding was stopped by bone wax, and no neurologic complication developed after surgery. On computed tomographic (CT) scan, 45 screws (6.7%) were found to penetrate the pedicle, and 2 of 45 screws caused radiculopathy. Besides these three neurovascular complications directly attributed to screw insertion, radiculopathy caused by iatrogenic foraminal stenosis from excessive reduction of the translational deformity was observed in one patient. The incidence of the clinically significant complications caused by pedicle screw insertion was low. Complications associated with cervical pedicle screw fixation can be minimized by sufficient preoperative imaging studies of the pedicles and strict control of screw insertion. Pedicle screw fixation is a useful procedure for reconstruction of the cervical spine in various kinds of disorders and can be performed safely.
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            Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report.

            Thirteen patients with fractures and/or dislocations of the middle and lower cervical spine were treated by transpedicular screw fixation using the Steffee variable screw placement system. Postoperative immobilization was either not used or simplified to short-term use of a soft neck collar. Recovery of nerve function and correction of kyphotic and/or translational deformities were satisfactory. All patients had solid fusion without loss of correction at the latest follow-up. There were no neurovascular complications. It was concluded that transpedicular screw fixation is as strong a fixation procedure for the cervical spine as it is for the thoracic and lumbar spine. This surgical procedure is associated with some risks of major neurovascular injuries; however, safety is adequate if the procedure is performed by experienced surgeons using meticulous surgical techniques.
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              The clinical risk of vertebral artery injury from cervical pedicle screws inserted in degenerative vertebrae.

              Postoperative outcomes of cervical pedicle screw (CPS) placement were evaluated. The screws were inserted in degenerative vertebrae using anatomic landmarks. To evaluate the risks of this procedure caused by misplacements and subsequent complications. The CPS gives superior vertebral fixation but risks causing vertebral artery and spinal cord injury. However, few clinical reports have been published concerning CPS misplacement and subsequent complications. Therefore, the risk of this procedure is still unclear. There were 18 consecutive patients, who submitted to CPS fixation of degenerative vertebrae C2-C6, evaluated using computerized tomography (CT). In 5 of 9 patients in whom the screw critically violated the transverse foramen, viability of the vertebral artery was evaluated using multi-detector row CT angiography. There were no intraoperative vertebral artery or spinal cord injuries and no serious postoperative complications. A total of 86 screws were inserted, and 25 (29%) breached the pedicle cortex. Of them, 84% deviated laterally and violated the transverse foramen. There were 13 screws (15%) that deviated more than 2 mm. However, multi-detector row CT angiography showed the continuity of the vertebral artery in all cases. The deviation rate of CPS placement using anatomic landmarks was higher than anticipated, although no serious complications were encountered. Refinement of the technique (e.g., using a computer-assisted navigation system) is strongly recommended.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                20 July 2017
                2017
                : 12
                : 7
                Affiliations
                Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, PR China
                Harvard Medical School/BIDMC, UNITED STATES
                Author notes

                Competing Interests: The first author (Xiang Yao) is the patent owner of the calipers used in this study. The rest of the authors have no competing interest to declare.

                • Conceptualization: XY SL.

                • Data curation: XY SL.

                • Formal analysis: XY.

                • Investigation: XY SL.

                • Methodology: XY SL.

                • Project administration: SL.

                • Resources: XY SL.

                • Software: XY SL.

                • Supervision: SL.

                • Validation: XY SL.

                • Visualization: SL.

                • Writing – original draft: XY SL.

                • Writing – review & editing: SL.

                Article
                PONE-D-16-37344
                10.1371/journal.pone.0181324
                5519080
                28727778
                © 2017 Yao, Liu

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 6, Tables: 2, Pages: 14
                Product
                Funding
                The author(s) received no specific funding for this work.
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