Yoshida Go, Sato Koji, Kanemura Tokumi, Iwase Toshiki, Togawa Daisuke, Matsuyama Yukihiro
Department of Orthopedic Surgery, Hamamatsu Medical Center, Hamamatsu, Japan.
Department of Orthopedic Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
Asian Spine J. 2016 Aug;10(4):630-8. doi: 10.4184/asj.2016.10.4.630. Epub 2016 Aug 16.
Retrospective.
This study aims to investigate the accuracy of the oblique fluoroscopic view, based on preoperative computed tomography (CT) images for accurate placement of lumbosacral percutaneous pedicle screws (PPS).
Although PPS misplacement has been reported as one of the main complications in minimally invasive spine surgery, there is no comparative data on the misplacement rate among different fluoroscopic techniques, or comparing such techniques with open procedures.
We retrospectively selected 230 consecutive patients who underwent posterior spinal fusion with a pedicle screw construct for degenerative lumbar disease, and divided them into 3 groups, those who had undergone: minimally invasive percutaneous procedure using biplane (lateral and anterior-posterior views using a single C-arm) fluoroscope views (group M-1), minimally invasive percutaneous procedure using the oblique fluoroscopic view based on preoperative CT (group M-2), and conventional open procedure using a lateral fluoroscopic view (group O: controls). The relative position of the screw to the pedicle was graded for the pedicle breach as no breach, <2 mm, 2-4 mm, or >4 mm. Inaccuracy was calculated and assessed according to the spinal level, direction and neurological deficit. Inter-group radiation exposure was estimated using fluoroscopy time.
Inaccuracy involved an incline toward L5, causing medial or lateral perforation of pedicles in group M-1, but it was distributed relatively equally throughout multiple levels in groups M-2 and controls. The mean fluoroscopy time/case ranged from 1.6 to 3.9 minutes.
Minimally invasive lumbosacral PPS placement using the conventional fluoroscopic technique carries an increased risk of inaccurate screw placement and resultant neurological deficits, compared with that of the open procedure. Inaccuracy tended to be distributed between medial and lateral perforations of the L5 pedicle, as a result of pedicle morphology and the PPS pathway. Oblique fluoroscopic views, based on CT measurement, may allow accurate PPS insertion with a shorter fluoroscopy time.
回顾性研究。
本研究旨在基于术前计算机断层扫描（CT）图像，探讨斜位透视对于准确置入腰骶部经皮椎弓根螺钉（PPS）的准确性。
尽管PPS置入不当已被报道为微创脊柱手术的主要并发症之一，但关于不同透视技术之间的置入不当率，或此类技术与开放手术比较的对比数据尚无。
我们回顾性选择了230例连续接受后路脊柱融合并采用椎弓根螺钉结构治疗退行性腰椎疾病的患者，并将他们分为3组，即接受以下手术的患者：使用双平面（使用单C形臂的侧位和前后位视图）透视的微创经皮手术（M-1组）、基于术前CT的斜位透视的微创经皮手术（M-2组）以及使用侧位透视的传统开放手术（O组：对照组）。将螺钉相对于椎弓根的相对位置根据椎弓根破裂情况分为无破裂、<2mm、2 - 4mm或>4mm。根据脊柱节段、方向和神经功能缺损计算并评估不准确情况。使用透视时间估计组间辐射暴露量。
M-1组不准确情况表现为向L5倾斜，导致椎弓根内侧或外侧穿孔，但在M-2组和对照组中不准确情况在多个节段分布相对均匀。平均透视时间/病例为1.6至3.9分钟。
与开放手术相比，使用传统透视技术进行微创腰骶部PPS置入时，螺钉置入不准确及由此导致神经功能缺损的风险增加。由于椎弓根形态和PPS路径，不准确情况倾向于分布在L5椎弓根的内侧和外侧穿孔之间。基于CT测量的斜位透视可能允许以更短的透视时间准确插入PPS。
