Kumar Naresh, Hui Si Jian, Zaw Aye Sander, Leow Gabriel Zihui, Hallinan James Thomas Patrick Decourcy, Joshua K, Tan Jonathan Jiong Hao, Wong Hee-Kit
National University Health System, Singapore, Singapore.
Eur Spine J. 2025 Apr 23. doi: 10.1007/s00586-025-08870-5.
Plain radiography remains the standard for intra- and post-operative assessment of pedicle screw placement in spine surgery. While newer technologies like intraoperative CT and navigation have been introduced, they do not consistently improve thoracic pedicle screw accuracy. The aim of this study was to evaluate the accuracy of anteroposterior (AP) alone versus orthogonal (AP and lateral) radiographs in assessing thoracic pedicle screw position across different observer experience levels and to determine the reliability of traditional fluoroscopy as compared to newer modalities.
23 disarticulated adult thoracic vertebrae were instrumented with pedicle screws placed either intra-osseous or with deliberate medial or lateral cortical violations. True AP and lateral radiographs were independently reviewed by two spine surgeons, two trainees, and two radiologists, blinded to actual screw positions. They categorized screws as "inside pedicle," "out laterally," "out medially," or "unsure." Assessments were compared to confirmed positions using axial views and direct visualization.
Orthogonal radiographs had 74.3% accuracy in screw position assessment and 77.3% accuracy in detecting cortical breaches, outperforming AP-only views. Lateral breaches were most easily identified, while intra-osseous placement was most often misclassified. Notably, 20.5% of medial breaches were incorrectly identified as intra-osseous, most commonly by radiologists. Surgeons were more accurate and cautious than both trainees and radiologists in reporting screw placement.
Orthogonal radiography remains a viable tool for thoracic pedicle screw assessment if used judiciously. Surgical experience enhances interpretation accuracy, particularly in identifying medial breaches, which carry a notable risk of being reported as intra-osseous.
在脊柱手术中，普通X线摄影仍然是评估椎弓根螺钉置入情况的术中及术后标准方法。虽然已经引入了诸如术中CT和导航等新技术，但它们并不能持续提高胸椎椎弓根螺钉的置入准确性。本研究的目的是评估在不同观察者经验水平下，仅使用前后位（AP）X线片与使用正交位（AP和侧位）X线片评估胸椎椎弓根螺钉位置的准确性，并确定传统荧光透视与更新技术相比的可靠性。
对23个离体成人胸椎椎体进行椎弓根螺钉置入，置入方式包括骨内置入或故意造成内侧或外侧皮质骨破坏。由两名脊柱外科医生、两名实习医生和两名放射科医生独立审查真实的前后位和侧位X线片，他们对实际螺钉位置不知情。他们将螺钉分类为“在椎弓根内”、“外侧穿出”、“内侧穿出”或“不确定”。使用轴向视图和直接可视化将评估结果与确认的位置进行比较。
正交位X线片在螺钉位置评估中的准确率为74.3%，在检测皮质骨破坏方面的准确率为77.3%，优于仅使用前后位视图。外侧皮质骨破坏最容易识别，而骨内置入最常被错误分类。值得注意的是，20.5%的内侧皮质骨破坏被错误地识别为骨内置入，最常见于放射科医生。在报告螺钉置入情况时，外科医生比实习医生和放射科医生更准确、更谨慎。
如果谨慎使用，正交位X线摄影仍然是评估胸椎椎弓根螺钉的可行工具。手术经验可提高解读准确性，尤其是在识别内侧皮质骨破坏方面，内侧皮质骨破坏被报告为骨内置入的风险显著。
