Lonstein J E, Denis F, Perra J H, Pinto M R, Smith M D, Winter R B
Twin Cities Spine Center, Minneapolis, Minnesota 55404, USA.
J Bone Joint Surg Am. 1999 Nov;81(11):1519-28. doi: 10.2106/00004623-199911000-00003.
The safety and the effectiveness of pedicle-screw instrumentation in the spine have been questioned despite its use worldwide to enhance stabilization of the spine. This review was performed to answer questions about the technique of insertion and the nature and etiology of complications directly attributable to the screws.
We performed a retrospective review of all of the pedicle-screw procedures that were done by us from January 1, 1984, to December 31, 1993. We inserted 4790 screws during 915 operative procedures on 875 patients; 668 (76.3 percent) of the patients had a lumbosacral arthrodesis. The mean duration of follow-up was three years (range, two to five years). The accuracy of screw placement was assessed on intraoperative, immediate postoperative, and follow-up radiographs with use of a technique that was developed by one of us (F. D.); this technique has yet to be validated to determine the prevalence of various types of error.
Of the 4790 screws, 4548 (94.9 percent) had been inserted within the pedicle and the vertebral body. One hundred and thirty-four (2.8 percent) of the screws had perforated the anterior cortex, and this was the most common type of perforation. One hundred and fifteen (2.4 percent) of the screws were associated with complications that could be ascribed to the use of pedicle screws. The most common problem was late-onset discomfort or pain related to a pseudarthrosis or perhaps to the screws; this problem was associated with 1102 (23.0 percent) of the screws, used in 222 (24.3 percent) of the procedures. The symptoms necessitated removal of the instrumentation with or without repair of the pseudarthrosis. A pseudarthrosis was found during forty-six (20.7 percent) of the 222 procedures. Irritation of a nerve root occurred after nine procedures (1.0 percent) and was caused by eleven screws (0.2 percent); it was more commonly caused by medially placed screws. Three patients had residual neurological weakness despite removal of the screws. Twenty-five screws (0.5 percent), used in twenty procedures (2.2 percent), broke. The screws that broke were of an early design. A pseudarthrosis was found in thirteen of twenty patients who had broken screws. Sixteen of the twenty patients had an exploration; three of them were found to have a solid fusion, and thirteen were found to have a pseudarthrosis. The remaining four patients had evidence of a solid fusion on radiographs and had no pain.
There are few problems associated with the insertion of screws, provided that the surgeon is experienced and adheres to the principles and details of the operative technique. Our review revealed a low rate of postoperative complications related to pedicle screws. The problem of late-onset pain may be related to the implants or to the stiffness of the construct; however, it is difficult to accurately identify its exact etiology.
尽管椎弓根螺钉内固定术在全球范围内被用于增强脊柱稳定性，但其安全性和有效性一直受到质疑。本综述旨在回答有关螺钉植入技术以及直接归因于螺钉的并发症的性质和病因等问题。
我们对1984年1月1日至1993年12月31日期间我们所做的所有椎弓根螺钉手术进行了回顾性研究。我们在对875例患者实施的915例手术中植入了4790枚螺钉；668例（76.3%）患者进行了腰骶部关节融合术。平均随访时间为3年（范围为2至5年）。使用我们其中一人（F.D.）开发的一种技术，在术中、术后即刻和随访X线片上评估螺钉置入的准确性；该技术尚未经过验证以确定各种类型错误的发生率。
在4790枚螺钉中，4548枚（94.9%）被植入椎弓根和椎体内。134枚（2.8%）螺钉穿出椎体前皮质，这是最常见的穿孔类型。115枚（2.4%）螺钉出现了可归因于椎弓根螺钉使用的并发症。最常见的问题是与假关节或可能与螺钉相关的迟发性不适或疼痛；这个问题与1102枚（23.0%）螺钉有关，这些螺钉用于222例（24.3%）手术中。这些症状需要取出内固定装置，无论是否修复假关节。在222例手术中的46例（20.7%）发现了假关节。9例手术（1.0%）后出现神经根刺激，由11枚螺钉（0.2%）引起；更常见于内侧置入的螺钉。3例患者尽管取出了螺钉仍有残留神经功能障碍。25枚（0.5%）螺钉在20例手术（2.2%）中发生断裂。断裂的螺钉为早期设计。在20例螺钉断裂的患者中，13例发现有假关节。20例患者中有16例进行了探查；其中3例发现有牢固融合，13例发现有假关节。其余4例患者X线片显示有牢固融合且无疼痛。
只要外科医生经验丰富并遵循手术技术的原则和细节，螺钉植入很少出现问题。我们的综述显示与椎弓根螺钉相关的术后并发症发生率较低。迟发性疼痛问题可能与植入物或固定结构的僵硬程度有关；然而，很难准确确定其确切病因。
