Abstract
PurposeThe violation of the cranial adjacent facet is a frequent complication in lumbar instrumentations and can induce local pain and adjacent segment disease. Minimally invasive screw implantation is often stated as risk factor in comparison with open approaches. Percutaneous pedicle screw placement (PPSP) can be performed using single X-ray images (fluoroscopy) or intraoperative 3D navigation. The study compares top-level screws in percutaneous lumbar instrumentations regarding facet violations and screw pedicle position using navigation or fluoroscopy.MethodsPatients after lumbar PPSP were retrospectively separated according to the intraoperative technique: navigation (NAV) or fluoroscopy (FLUORO). Two blinded investigators graded the top-level screws regarding facet violations and pedicle breach in postoperative CT scans. Subsequent matched cohort analysis was performed for comparable groups.ResultsEvaluating 768 screws, we assessed 70 (9.1%) facet violations. Overall, 186 (24.2%) screws were implanted using navigation. There was no significant difference in the rate of facet violations between both imaging groups (NAV 19/186, 10.2%, FLUORO 51/582, 8.8%, p = 0.55). Totally, 728 (94.8%) of all screws showed a correct pedicle position. Most of the 40 unfavorable pedicle positions were placed by fluoroscopy (NAV 4/186, 2.2%, FLUORO 36/582, 6.6%, p = 0.03). The matched cohorts verified these results (facet violations: NAV 19/186, 10.2%, FLUORO 18/186, 9.7%, p = 0.55; pedicle penetrations: NAV 4/186, 2.2%, FLUORO 12/186, 6.9%, p = 0.04).ConclusionsBoth intraoperative imaging techniques allow lumbar PPSP with low rates of cranial facet violations if the surgeon intends to preserve facet integrity. Navigation was superior concerning accurate pedicle screw position, but could not significantly prevent facet violations.
Highlights
The violation of the cranial adjacent facet joint is a frequent disregarded problem in patients receiving posterior lumbar instrumentations
In 93 (24.2%) of all patients, an intraoperative 3D scan and navigation was used (NAV group), which corresponds to 186 implanted screws
Percutaneous pedicle screw placement (PPSP) in dorsal lumbar instrumentations showed comparable low rates of facet violations as reported in open surgical techniques, whereas the intraoperative 3D navigation could not significantly reduce those facet injuries compared to conventional fluoroscopy
Summary
The violation of the cranial adjacent facet joint is a frequent disregarded problem in patients receiving posterior lumbar instrumentations. An injury to the cranial facet caused by the implants can induce local pain and adjacent segment. The rate is reported between 15% and 20% [10, 11]. European Spine Journal (2021) 30:88–96 spine surgery is increasingly used due to reduced muscle trauma and local back pain, less intraoperative blood loss, reduced wound healing disorders and a shorter hospital stay with accelerated recovery [12, 13]. A limitation of minimally invasive approaches is the absence of visual exposure of anatomic landmarks, possibly leading to increased rates of cranial facet violations. Due to oppositional results in several studies, this effect is discussed controversially [1, 6, 8, 14,15,16]
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