J Korean Neurosurg Soc.  2012 Nov;52(5):459-465. 10.3340/jkns.2012.52.5.459.

Cervical Pedicle Screw Insertion Using the Technique with Direct Exposure of the Pedicle by Laminoforaminotomy

• Jo DJ
• Seo EM
• Kim KT
• Kim SM
• Lee SH

• KMID: 2018252
• DOI: http://doi.org/10.3340/jkns.2012.52.5.459

Abstract

OBJECTIVE
To present the accuracy and safety of cervical pedicle screw insertion using the technique with direct exposure of the pedicle by laminoforaminotomy.
METHODS
We retrospectively reviewed 12 consecutive patients. A total of 104 subaxial cervical pedicle screws in 12 patients had been inserted. We also assessed the clinical and radiological outcomes and analyzed the direction and grade of pedicle perforation (grade 0: no perforation, 1: <25%, 2: 20% to 50%, 3: >50% of screw diameter) on the postoperative vascular-enhanced computed tomography scans. Grade 2 and 3 were considered as incorrect position.
RESULTS
The correct position was found in 95 screws (91.3%); grade 0-75 screws, grade 1-20 screws and the incorrect position in 9 screws (8.7%); grade 2-6 screws, grade 3-3 screws. There was no neurovascular complication related with cervical pedicle screw insertion.
CONCLUSION
This technique (technique with direct exposure of the pedicle by laminoforaminotomy) could be considered relatively safe and easy method to insert cervical pedicle screw.

Keyword

Cervical pedicle screw; Laminoforaminotomy; Pedicle perforation

MeSH Terms

Humans
Retrospective Studies

Figure

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  Fig. 1 A : 3 mm cutting burr is used to remove the outer cortex of the lateral mass over the pedicle entrance. B : the inferior aspect of the superior lamina and the superior aspect of the inferior lamina for the laminoforaminotomy.

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  Fig. 2 A : A laminoforaminotomy provides visual identification of the medial and superior walls of the pedicle. B : The pedicle is probed as close to the medial wall as possible by gentle manual pressure using a 15-degree, 2 mm-diameter curved gear shift probe.

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  Fig. 3 Preoperative and postoperative axial CT images on same cervical spine showing the diameter (arrow) and the convergence angle of the pedicle (A), and the convergence angle of the screw (B).

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  Fig. 4 Grading system of pedicle perforation. Grade 0 : the screw is located within the pedicle. Grade 1 : perforation less than 25% of the screw diameter. Grade 2 : 25% to 50% of the screw diameter. Grade 3 : over 50%.

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  Fig. 5 Preoperative sagittal MRI image (A) of a 71-year-old female myelopathic patient showing severe cervical cord compression. Posterior decompression with pedicle screw fixation from C3 to C7 was performed (B and C). Postoperative axial CT images show all grade 0 screw position without pedicle perforation (D).

Reference

1. Abumi K, Itoh H, Taneichi H, Kaneda K. Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine : description of the techniques and preliminary report. J Spinal Disord. 1994; 7:19–28. PMID: 8186585.

2. Abumi K, Kaneda K. Pedicle screw fixation for nontraumatic lesions of the cervical spine. Spine (Phila Pa 1976). 1997; 22:1853–1863. PMID: 9280021.

3. Abumi K, Kaneda K, Shono Y, Fujiya M. One-stage posterior decompression and reconstruction of the cervical spine by using pedicle screw fixation systems. J Neurosurg. 1999; 90:19–26. PMID: 10413121.

4. Abumi K, Shono Y, Ito M, Taneichi H, Kotani Y, Kaneda K. Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine (Phila Pa 1976). 2000; 25:962–969. PMID: 10767809.

5. Albert TJ, Klein GR, Joffe D, Vaccaro AR. Use of cervicothoracic junction pedicle screws for reconstruction of complex cervical spine pathology. Spine (Phila Pa 1976). 1998; 23:1596–1599. PMID: 9682316.

6. Barrey C, Cotton F, Jund J, Mertens P, Perrin G. Transpedicular screwing of the seventh cervical vertebra : anatomical considerations and surgical technique. Surg Radiol Anat. 2003; 25:354–360. PMID: 12955478.

7. Ebraheim NA, Xu R, Knight T, Yeasting RA. Morphometric evaluation of lower cervical pedicle and its projection. Spine (Phila Pa 1976). 1997; 22:1–6. PMID: 9122772.

8. Hardy RW Jr. The posterior surgical approach to the cervical spine. Neuroimaging Clin N Am. 1995; 5:481–490. PMID: 7551581.

9. Ishikawa Y, Kanemura T, Yoshida G, Ito Z, Muramoto A, Ohno S. Clinical accuracy of three-dimensional fluoroscopy-based computer-assisted cervical pedicle screw placement : a retrospective comparative study of conventional versus computer-assisted cervical pedicle screw placement. J Neurosurg Spine. 2010; 13:606–611. PMID: 21039152.

10. Ito Y, Sugimoto Y, Tomioka M, Hasegawa Y, Nakago K, Yagata Y. Clinical accuracy of 3D fluoroscopy-assisted cervical pedicle screw insertion. J Neurosurg Spine. 2008; 9:450–453. PMID: 18976176.

11. Jang WY, Kim IS, Lee HJ, Sung JH, Lee SW, Hong JT. A computed tomography-based anatomic comparison of three different types of c7 posterior fixation techniques : pedicle, intralaminar, and lateral mass screws. J Korean Neurosurg Soc. 2011; 50:166–172. PMID: 22102943.

12. Johnston TL, Karaikovic EE, Lautenschlager EP, Marcu D. Cervical pedicle screws vs. lateral mass screws : uniplanar fatigue analysis and residual pullout strengths. Spine J. 2006; 6:667–672. PMID: 17088197.

13. Jones EL, Heller JG, Silcox DH, Hutton WC. Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine (Phila Pa 1976). 1997; 22:977–982. PMID: 9152447.

14. Karaikovic EE, Daubs MD, Madsen RW, Gaines RW Jr. Morphologic characteristics of human cervical pedicles. Spine (Phila Pa 1976). 1997; 22:493–500. PMID: 9076880.

15. Karaikovic EE, Kunakornsawat S, Daubs MD, Madsen TW, Gaines RW Jr. Surgical anatomy of the cervical pedicles : landmarks for posterior cervical pedicle entrance localization. J Spinal Disord. 2000; 13:63–72. PMID: 10710153.

16. Karaikovic EE, Yingsakmongkol W, Gaines RW Jr. Accuracy of cervical pedicle screw placement using the funnel technique. Spine (Phila Pa 1976). 2001; 26:2456–2462. PMID: 11707710.

17. Kast E, Mohr K, Richter HP, Börm W. Complications of transpedicular screw fixation in the cervical spine. Eur Spine J. 2006; 15:327–334. PMID: 15912352.

18. Kotani Y, Abumi K, Ito M, Minami A. Improved accuracy of computer-assisted cervical pedicle screw insertion. J Neurosurg. 2003; 99:257–263. PMID: 14563142.

19. Kothe R, Rüther W, Schneider E, Linke B. Biomechanical analysis of transpedicular screw fixation in the subaxial cervical spine. Spine (Phila Pa 1976). 2004; 29:1869–1875. PMID: 15534407.

20. Kowalski JM, Ludwig SC, Hutton WC, Heller JG. Cervical spine pedicle screws : a biomechanical comparison of two insertion techniques. Spine (Phila Pa 1976). 2000; 25:2865–2867. PMID: 11074671.

21. Ludwig SC, Kramer DL, Balderston RA, Vaccaro AR, Foley KF, Albert TJ. Placement of pedicle screws in the human cadaveric cervical spine : comparative accuracy of three techniques. Spine (Phila Pa 1976). 2000; 25:1655–1667. PMID: 10870141.

22. Ludwig SC, Kramer DL, Vaccaro AR, Albert TJ. Transpedicle screw fixation of the cervical spine. Clin Orthop Relat Res. 1999; 77–88. PMID: 10078131.

23. Miller RM, Ebraheim NA, Xu R, Yeasting RA. Anatomic consideration of transpedicular screw placement in the cervical spine. An analysis of two approaches. Spine (Phila Pa 1976). 1996; 21:2317–2322. PMID: 8915065.

24. Neo M, Sakamoto T, Fujibayashi S, Nakamura T. The clinical risk of vertebral artery injury from cervical pedicle screws inserted in degenerative vertebrae. Spine (Phila Pa 1976). 2005; 30:2800–2805. PMID: 16371908.

25. Onibokun A, Khoo LT, Bistazzoni S, Chen NF, Sassi M. Anatomical considerations for cervical pedicle screw insertion : the use of multiplanar computerized tomography measurements in 122 consecutive clinical cases. Spine J. 2009; 9:729–734. PMID: 19699462.

26. Panjabi MM, Duranceau J, Goel V, Oxland T, Takata K. Cervical human vertebrae. Quantitative three-dimensional anatomy of the middle and lower regions. Spine (Phila Pa 1976). 1991; 16:861–869. PMID: 1948369.

27. Panjabi MM, Shin EK, Chen NC, Wang JL. Internal morphology of human cervical pedicles. Spine (Phila Pa 1976). 2000; 25:1197–1205. PMID: 10806495.

28. Reinhold M, Bach C, Audigé L, Bale R, Attal R, Blauth M, et al. Comparison of two novel fluoroscopy-based stereotactic methods for cervical pedicle screw placement and review of the literature. Eur Spine J. 2008; 17:564–575. PMID: 18210169.

29. Reinhold M, Magerl F, Rieger M, Blauth M. Cervical pedicle screw placement : feasibility and accuracy of two new insertion techniques based on morphometric data. Eur Spine J. 2007; 16:47–56. PMID: 16628443.

30. Rhee JM, Kraiwattanapong C, Hutton WC. A comparison of pedicle and lateral mass screw construct stiffnesses at the cervicothoracic junction : a biomechanical study. Spine (Phila Pa 1976). 2005; 30:E636–E640. PMID: 16261101.

31. Richter M, Amiot LP, Neller S, Kluger P, Puhl W. Computer-assisted surgery in posterior instrumentation of the cervical spine : an in-vitro feasibility study. Eur Spine J. 2000; 9(Suppl 1):S65–S70. PMID: 10766060.

32. Richter M, Cakir B, Schmidt R. Cervical pedicle screws : conventional versus computer-assisted placement of cannulated screws. Spine (Phila Pa 1976). 2005; 30:2280–2287. PMID: 16227890.

33. Richter M, Mattes T, Cakir B. Computer-assisted posterior instrumentation of the cervical and cervico-thoracic spine. Eur Spine J. 2004; 13:50–59. PMID: 14634850.

34. Schmidt R, Wilke HJ, Claes L, Puhl W, Richter M. Pedicle screws enhance primary stability in multilevel cervical corpectomies : biomechanical in vitro comparison of different implants including constrained and nonconstrained posterior instumentations. Spine (Phila Pa 1976). 2003; 28:1821–1828. PMID: 12923469.

35. Shin EK, Panjabi MM, Chen NC, Wang JL. The anatomic variability of human cervical pedicles : considerations for transpedicular screw fixation in the middle and lower cervical spine. Eur Spine J. 2000; 9:61–66. PMID: 10766079.

36. Yoshimoto H, Sato S, Hyakumachi T, Yanagibashi Y, Masuda T. Spinal reconstruction using a cervical pedicle screw system. Clin Orthop Relat Res. 2005; 431:111–119. PMID: 15685063.

37. Yukawa Y, Kato F, Ito K, Horie Y, Hida T, Nakashima H, et al. Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope. Eur Spine J. 2009; 18:1293–1299. PMID: 19488794.

38. Zheng X, Chaudhari R, Wu C, Mehbod AA, Transfeldt EE. Subaxial cervical pedicle screw insertion with newly defined entry point and trajectory : accuracy evaluation in cadavers. Eur Spine J. 2010; 19:105–112. PMID: 19916031.