Percutaneous Lumbar and Thoracic Pedicle Screws

Abstract

Retrospective case study. Percutaneous pedicle screw (PPS) techniques do not allow direct visualization and may lead to erroneous screw placement. A technique utilizing only fluoroscopy is described. Verification of its accuracy and morphometric validation are presented. Minimally invasive spine surgical techniques, particularly PPS placement, have been growing in popularity. The purported benefits of minimally invasive spine surgical stated may be even more advantageous in the trauma setting. Jamshidi needles were docked in the typical starting position verified with posterior-anterior image. Jamshidi needle (20 mm) was advanced ensuring that the tip remained lateral to the medial pedicle wall. A Kirschner (K-wire) was placed through the needle. Once all the K-wires were placed, a lateral image was taken confirming the correct trajectory and that the wire passed the posterior vertebral body wall. Patients with PPS fixation were retrospectively studied with postoperative computed tomography to verify screw accuracy. Screw grade was assessed as grade I when completely within the pedicle, II <2 mm, III 2-4 mm, and IV >4 mm outside the pedicle. Morphometrically, 40 thoracic and lumbar computed tomography scans of patients (<40 y) without spine fractures were reviewed. The pedicle length was defined as the distance from the dorsal cortical margin to the posterior vertebral body in the pedicle's midaxis. A total of 172 screws were placed. Eighteen percent were found to have cortical breach, but only 2.9% were found to have >grade II breach. The morphometric study demonstrated the pedicle length to range from 14.4 to 22.1 mm. The shortest was in the upper thoracic and the longest at L1-L2. The morphometric study demonstrates if a K-wire is placed 20 mm into the bone and remains lateral to the medial pedicle wall and the tip just engages the vertebral body, the screw trajectory is safe particularly in the lower thoracic and upper lumbar spine. A smaller distance may be utilized in the upper thoracic. Breach rates are similar to other reports using other techniques; none were clinically significant. The advantage of this technique is the use of only PA fluoroscopy for placing all the wires percutaneously.