Fayaz Mohsin, Chibber Sarabjit Singh, Singh Kaushal Deep, Tyngkam Lamkordor, Hela Amir, Chaurasia Bipin
Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India.
Neurosurgery Clinic, Birgunj, Nepal.
J Craniovertebr Junction Spine. 2024 Jul-Sep;15(3):326-330. doi: 10.4103/jcvjs.jcvjs_56_24. Epub 2024 Sep 12.
Pedicle screw placement plays a crucial role in treating various cases such as fractures, scoliosis, degenerative spine issues, and kyphosis, reinforcing all three spinal columns simultaneously. While three-dimensional navigation-assisted pedicle screw placement is considered superior, the freehand technique relies on anatomical landmarks and tactile feedback, with observed low complication rates.
This was a prospective single-center study conducted over a period of 3 years. It included all patients of dorsal, lumbar, and sacral spinal instability of myriad etiology. Previously operated patients and sick obtunded patients were excluded from the study.
In our study, we included 102 patients including 62 (60.7%) males and 40 (39.2%) females. More than half of patients were young in the age group of 20-50 years. Our study population had a varied etiology with 43.1% of patients having vertebral column instability due to trauma. The other etiologies were spondylolisthesis and lumbar canal stenosis (39.2%), Pott's spine (11.7%), tumors (2.9%), and osteoporotic fractures (2.9%). Majority of patients (44.1%) presented with lower backache with radiculopathy. All the transpedicular screws inserted were evaluated by C-arm to assess for screw fixation. In the first year of our study, an average of 4 anteroposterior (AP) and 4 lateral C-arm X-ray shots were taken per screw placement. In the next year, an average of 3 AP and 3 lateral shots and finally in the last year of our study only 2 AP and 2 lateral C-arm X-ray shots were taken per screw placement. Out of 650 screws placed, 4 screws were identified to cause breach with maximum breaches in the lumbar spine fixation. In dorsal spine fixation, there was 1 lateral breach at D10. In lumbar spine fixation, there were 3 breaches: two medial one each at L4 and L5 and one anterior at L2 level. The various complications include wound infection, temporary and permanent neurological deficit, screw breakage, screw misplacement, cerebrospinal fluid leaks, nonunion, and spinal epidural hematoma.
Our study has provided strong encouragement to persist with the freehand technique in transpedicular fixation surgeries after a certain number of cases given the minimal breaches and complications observed. There are subtle technical nuances as we increase the number of cases with less exposure of anatomical landmarks and X-rays. Success hinges on experience, adherence to technique, and thorough preoperative planning. Further research and extended follow-up periods are necessary to firmly establish this technique as the gold standard.
椎弓根螺钉置入在治疗多种病症（如骨折、脊柱侧弯、退行性脊柱疾病和驼背）中起着关键作用，可同时加固脊柱的三个柱体。虽然三维导航辅助椎弓根螺钉置入被认为更具优势，但徒手技术依靠解剖标志和触觉反馈，且观察到的并发症发生率较低。
这是一项为期3年的前瞻性单中心研究。研究对象包括各种病因导致的胸、腰和骶部脊柱不稳定的所有患者。曾接受过手术的患者和病情严重的昏迷患者被排除在研究之外。
在我们的研究中，纳入了102例患者，其中男性62例（60.7%），女性40例（39.2%）。超过一半的患者年龄在20至50岁之间。我们的研究人群病因多样，43.1%的患者因创伤导致脊柱不稳定。其他病因包括腰椎滑脱和腰椎管狭窄（39.2%）、结核性脊柱炎（11.7%）、肿瘤（2.9%）和骨质疏松性骨折（2.9%）。大多数患者（44.1%）表现为下背痛伴神经根病。所有置入的椎弓根螺钉均通过C形臂进行评估以确定螺钉固定情况。在我们研究的第一年，每次螺钉置入平均拍摄4张前后位（AP）和4张侧位C形臂X线片。在第二年，平均拍摄3张AP和3张侧位片，最后在研究的最后一年，每次螺钉置入仅拍摄2张AP和2张侧位C形臂X线片。在置入的650枚螺钉中，有4枚被确定出现突破，其中腰椎固定的突破最多。在胸椎固定中，D10处有1例侧方突破。在腰椎固定中，有3例突破：L4和L5各有1例内侧突破，L2水平有1例前方突破。各种并发症包括伤口感染、暂时性和永久性神经功能缺损、螺钉断裂、螺钉误置、脑脊液漏、骨不连和脊柱硬膜外血肿。
我们的研究有力地支持了在完成一定数量的病例后，鉴于观察到的突破和并发症极少，在椎弓根固定手术中继续采用徒手技术。随着病例数量的增加，解剖标志和X线暴露减少，存在一些细微的技术差异。成功取决于经验、对技术的坚持和全面的术前规划。需要进一步的研究和更长的随访期来将该技术牢固地确立为金标准。
