Agarwal Archit, Chauhan Vijendra, Singh Deepa, Shailendra Raghuvanshi, Maheshwari Rajesh, Juyal Anil
Department of Orthopaedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India.
Department of Anatomy, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India.
Indian J Orthop. 2016 May-Jun;50(3):243-9. doi: 10.4103/0019-5413.181779.
New and expensive technology such as three-dimensional computer assisted surgery is being used for pedicle screw fixation in dorsolumbar spine. Their availability, expenses and amount of radiation exposure are issues in a developing country. On the contrary, freehand technique of pedicle screw placement utilizes anatomic landmarks and tactile palpation without fluoroscopy or navigation to place pedicle screws. The purpose of this study was to analyze and compare the accuracy of freehand and image-assisted technique to place pedicle screws in the dorsolumbar spine of cadavers by an experienced surgeon and a resident. Evaluation was done using dissection of pedicle and computed tomography (CT) imaging.
Ten cadaveric dorsolumbar spines were exposed by a posterior approach. Titanium pedicle screws were inserted from D5 to L5 vertebrae by freehand and image-assisted technique on either side by an experienced surgeon and a resident. CT was obtained. A blinded radiologist reviewed the imaging. The spines were then dissected to do a macroscopic examination. Screws, having evidence of cortical perforation of more than 2 mm on CT, were considered to be a significant breach.
A total of 260 pedicle screws were placed. The surgeon and the resident placed 130 screws each. Out of 130 screws, both of them placed 65 screws each by freehand and image- assisted technique each. The resident had a rate of 7.69% significant medial and 10.76% significant lateral breach with freehand technique while with image-assisted had a rate of 3.07% significant medial and 9.23% significant lateral breach. The expert surgeon had a rate of 6.15% significant medial and 1.53% significant lateral breach with freehand technique while with image-assisted had a rate of 3.07% significant medial and 6.15% significant lateral breach on CT evaluation.
Freehand technique is as good as the image-assisted technique. Under appropriate supervision, residents can safely learn to place freehand pedicle screws with an acceptable violation rate.
诸如三维计算机辅助手术等新型且昂贵的技术正被用于胸腰椎椎弓根螺钉固定术。在发展中国家，这些技术的可及性、费用以及辐射暴露量都是问题。相反，徒手椎弓根螺钉置入技术利用解剖标志和触觉触诊，无需透视或导航即可置入椎弓根螺钉。本研究的目的是分析并比较经验丰富的外科医生和住院医师在尸体胸腰椎中徒手和图像辅助技术置入椎弓根螺钉的准确性。通过椎弓根解剖和计算机断层扫描（CT）成像进行评估。
通过后路暴露10个尸体胸腰椎。经验丰富的外科医生和住院医师分别通过徒手和图像辅助技术在两侧从D5至L5椎体插入钛椎弓根螺钉。获取CT图像。由一位不知情的放射科医生审查影像。然后解剖脊柱进行宏观检查。CT显示皮质穿孔超过2mm的螺钉被视为严重违规。
共置入260枚椎弓根螺钉。外科医生和住院医师各置入130枚螺钉。在130枚螺钉中，他们各自通过徒手和图像辅助技术各置入65枚螺钉。住院医师徒手技术的严重内侧违规率为7.69%，严重外侧违规率为10.76%，而图像辅助技术的严重内侧违规率为3.07%，严重外侧违规率为9.23%。在CT评估中，专家外科医生徒手技术的严重内侧违规率为6.15%，严重外侧违规率为1.53%，而图像辅助技术的严重内侧违规率为3.07%，严重外侧违规率为6.15%。
徒手技术与图像辅助技术一样好。在适当的监督下，住院医师可以安全地学习徒手置入椎弓根螺钉，且违规率可接受。
