Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.
J Neurosurg Spine. 2014 Nov;21(5):826-32. doi: 10.3171/2014.7.SPINE13846. Epub 2014 Aug 29.
Over the past decade percutaneous pedicle screws have become popular for the minimally invasive treatment of spinal disorders. However, until the last 5 years the presence of a significant spinal deformity was regarded as a relative contraindication for percutaneous instrumentation. Recent advances in surgical technique and intraoperative technology have made percutaneous fixation in complex spinal pathologies more commonplace. The authors report their experience using a parsimonious method for uniplanar fluoroscopic targeting of pedicles in challenging cases.
The authors performed a retrospective analysis of patients with adult spinal deformity who underwent percutaneous pedicle screw instrumentation from 2008 to 2013. Cases were included if a spiral slice postoperative CT scan was obtained. All cases had a minimum of 10° of axial rotation and typically had additional accompanying anatomical abnormalities. Screws were assessed for any pedicle violations as well as any impingement of the surrounding facet joints.
A total of 410 pedicle screws were placed in 36 patients with an average 6.4 levels of instrumentation per patient. The mean age was 67 years (range 44-86 years) and there were 25 females. Of the 410 screws, 29 (7.1%) had some medial or lateral pedicle violation. Of these, 15 (3.7%) were Grade 1, 6 (1.4%) were Grade 2, and 8 (2.0%) were Grade 3 violations. Of the Grade 3 violations, 2 each were at the L-4, L-5, and S-1 levels, and 1 each was at the T-10 and L-1 levels. Two of the patients had symptoms and both underwent screw repositioning, one during the same admission and the other in a delayed fashion. Both were at the L-5 and S-1 levels with anatomically highly medialized pedicles. There were no motor deficits, and both removals were for numbness. Of the 72 screws at the proximal end of the construct, there were 6 facet violations (8.3%). Four (5.6%) of these were Grade 1, 1 (1.4%) was Grade 2, and 1 (1.4%) was Grade 3.
The anteroposterior fluoroscopic technique can be effectively used by spinal surgeons to cannulate the pedicles in patients with rotational deformities. The complication rate in this challenging population is acceptable and is in accordance with the existing literature. However, caution should be used at L-5 and S-1 when the pedicle is narrow and highly medialized, rendering an indistinct medial wall on anteroposterior imaging.
在过去的十年中，经皮椎弓根螺钉已成为治疗脊柱疾病的微创治疗的热门选择。但是，直到最近 5 年，明显的脊柱畸形才被认为是经皮器械的相对禁忌症。手术技术和术中技术的最新进展使复杂脊柱病变的经皮固定更为常见。作者报告了他们在具有挑战性的病例中使用简化的单平面透视靶向椎弓根的经验。
作者对 2008 年至 2013 年接受经皮椎弓根螺钉固定的成人脊柱畸形患者进行了回顾性分析。如果获得螺旋切片术后 CT 扫描，则纳入病例。所有病例均至少有 10°的轴向旋转，通常还伴有其他伴随的解剖异常。评估了所有椎弓根螺钉的任何椎弓根侵犯情况以及周围关节突关节的任何撞击情况。
在 36 例患者中总共放置了 410 个椎弓根螺钉，每个患者平均有 6.4 个节段的器械。平均年龄为 67 岁（范围 44-86 岁），有 25 名女性。在 410 个椎弓根螺钉中，有 29 个（7.1％）存在内侧或外侧椎弓根侵犯。其中，15 个（3.7％）为 1 级，6 个（1.4％）为 2 级，8 个（2.0％）为 3 级侵犯。在 3 级侵犯中，L-4、L-5 和 S-1 各有 2 个，T-10 和 L-1 各有 1 个。有 2 位患者出现症状，均进行了螺钉重新定位，1 位在同一次住院期间，另一位则是延迟进行。两者均位于 L-5 和 S-1，椎弓根高度向内侧化。没有运动功能障碍，两者的移除均因麻木而引起。在近端结构的 72 个螺钉中，有 6 个关节突侵犯（8.3％）。其中 4 个（5.6％）为 1 级，1 个（1.4％）为 2 级，1 个（1.4％）为 3 级。
脊柱外科医生可以有效地使用前后位透视技术为旋转畸形患者进行椎弓根穿刺。在这种具有挑战性的人群中，并发症发生率是可以接受的，并且与现有文献一致。但是，当椎弓根狭窄且高度向内侧化时，在 L-5 和 S-1 处应谨慎操作，前后成像上的内侧壁不明显。
