Детская хирургия. Журнал им. Ю.Ф. Исакова. 2022; 26: 261-266
Ширина корня дуги позвонка как предиктор успешной транспедикулярной имплантации у детей
https://doi.org/10.55308/1560-9510-2022-26-5-261-266Аннотация
Введение. В ряде исследований констатирована связь мальпозиции транспедикулярных винтов с малыми значениями тех или иных морфометрических параметров корня дуги. Определение критических для имплантации размерных характеристик является актуальной проблемой.
Материал и методы. В исследование включены 29 пациентов в возрасте 3-17 лет с врожденными и приобретенными деформациями позвоночника, которым выполнялась задняя инструментальная фиксация с установкой транспедикулярных винтов в грудные и поясничные позвонки без использования навигационного оборудования (методика free hand). На предоперационной компьютерной томографии в аксиальной плоскости производились измерения наружной ширины корня дуги, внутренней ширины корня дуги, вычислялась доля спонгиозного вещества. На послеоперационных томограммах выполнялась оценка корректности стояния транспедикулярных винтов. Для определения зависимости вероятности корректной имплантации от морфометрических параметров корня дуги применялась бинарная логистическая регрессия с построением ROC-кривых и вычислением AUC (Area under Curve).
Результаты. По методике free hand 29 пациентам было установлено 233 транспедикулярных винта. При послеоперационном обследовании было подтверждено корректное стояние 191 (82%) винта. При построении логистической модели каждый морфометрический параметр оказался значимым (p < 0,001). Наружная ширина корня дуги обладала наибольшим предиктивным значением. Статистические показатели прогностической модели были определены для значений ширины корня дуги 3,5; 6,0; 7,5 мм.
При пороговой величине наружной ширины корня дуги 3,5 мм вероятность корректной имплантации близка к 50%, метод высокочувствителен, общая точность максимальна. Данная морфометрическая характеристика представляет собой технический предел неассистированной имплантации. Предложены рекомендации по выбору техники установки винтов в зависимости от ширины корня дуги.
Заключение. Наружная ширина корня дуги позвонка 3,5 мм является критическим параметром для имплантации по методике free hand.
Список литературы
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2. Gonzalvo A., Fitt G., Liew S., et al. Correlation between pedicle size and the rate of pedicle screw misplacement in the treatment of thoracic fractures: Can we predict how difficult the task will be? Br J Neurosurg. 2015; 29(4): 508-12. https://doi.org/10.3109/02688697.2015.1019414
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4. Aoude A.A., Fortin M., Figueiredo R., et al. Methods to determine pedicle screw placement accuracy in spine surgery: a systematic review. Eur Spine J. 2015; 24(5): 990-1004. https://doi.org/10.1007/s00586-015-3853-x
5. Perdomo-Pantoja A., Ishida W., Zygourakis C., et al. Accuracy of Current Techniques for Placement of Pedicle Screws in the Spine: A Comprehensive Systematic Review and Meta-Analysis of 51,161 Screws. World Neurosurg. 2019; 126: 664-678.e3. https://doi.org/10.1016/j.wneu.2019.02.217
6. Amaral T.D., Hasan S., Galina J., et al. Screw Malposition: Are There Longterm Repercussions to Malposition of Pedicle Screws? J Pediatr Orthop. 2021; 41(Suppl 1): S80-6. https://doi.org/1097/BPO.0000000000001828
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9. Mac-Thiong J.M., Parent S., Poitras B., et al. Neurological outcome and management of pedicle screws misplaced totally within the spinal canal. Spine (Phila Pa 1976). 2013; 38(3): 229-37. https://doi.org/10.1097/BRS.0b013e31826980a9
10. Kakkos S.K., Shepard A.D. Delayed presentation of aortic injury by pedicle screws: report of two cases and review of the literature. J Vasc Surg. 2008; 47(5): 1074-82. https://doi.org/10.1016/j.jvs.2007.11.005
11. Wegener B., Birkenmaier C., Fottner A., et al. Delayed perforation of the aorta by a thoracic pedicle screw. Eur Spine J. 2008; 17(Suppl. 2): 351-4. https://doi.org/10.1007/s00586-008-0715-9
12. Koktekir E., Ceylan D., Tatarli N., et al. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. Spine J. 2014; 14(8): 1702-8. https://doi.org/10.1016/j.spinee.2014.03.044
13. Виссарионов С.В., Шредер Дж.Е., Новиков С.Н., Кокушин Д.Н., Белянчиков С.М., Каплан Л. Применение трехмерной навигации в хирургическом лечении детей с идиопатическим сколиозом. Хирургия позвоночника. 2015; 12(1): 14-20. https://doi.org/10.14531/ss2015.1.14-20.
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19. Bratschitsch G., Leitner L., Stucklschweiger G., et al. Radiation Exposure of Patient and Operating Room Personnel by Fluoroscopy and Navigation during Spinal Surgery. Sci Rep. 2019; 9(1): 7652. https://doi.org/10.1038/s41598-019-53472-z
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24. Akazawa T., Kotani T., Sakuma T., et al. Evaluation of pedicle screw placement by pedicle channel grade in adolescent idiopathic scoliosis: should we challenge narrow pedicles? J Orthop Sci. 2015; 20(5): 818-22. https://doi.org/10.1007/s00776-015-0746-0
25. Zhang Y., Xie J., Wang Y., et al. Thoracic pedicle classification determined by inner cortical width of pedicles on computed tomography images: its clinical significance for posterior vertebral column resection to treat rigid and severe spinal deformities-a retrospective review of cases. BMC Musculoskelet Disord. 2014; (15): 278. https://doi.org/10.1186/1471-2474-15-278
26. Gao B., Gao W., Chen C., et al. What is the Difference in Morphologic Features of the Thoracic Pedicle Between Patients With Adolescent Idiopathic Scoliosis and Healthy Subjects? A CT-based Casecontrol Study. Clin Orthop Relat Res. 2017; 475(11): 2765-74. https://doi.org/10.1007/s11999-017-5448-9
27. Sarwahi V., Sugarman E.P., Wollowick A.L., et al. Prevalence, Distribution, and Surgical Relevance of Abnormal Pedicles in Spines with Adolescent Idiopathic Scoliosis vs. No Deformity: A CT-Based Study. J Bone Joint Surg Am. 2014; 96(11): e92. https://doi.org/10.2106/JBJS.M.01058
28. Jeswani S., Drazin D., Hsieh J.C., et al. Instrumenting the small thoracic pedicle: the role of intraoperative computed tomography image-guided surgery. Neurosurg Focus. 2014; 36(3): E6. https://doi.org/10.3171/2014.1.FOCUS13527
29. Fardy J.M, Barrett B.J. Evaluation of Diagnostic Tests. Parfrey P.S., Barrett B.J., eds. Clinical Epidemiology: Practice and Methods. New-York: Springer Science+Business Media, 2015. https://doi.org/10.1007/978-1-4939-2428-8_17
Russian Journal of Pediatric Surgery. 2022; 26: 261-266
The pedicle width predicts an accurate screw insertion
https://doi.org/10.55308/1560-9510-2022-26-5-261-266Abstract
Introduction. Correlation between pedicle screw malposition and small values of pedicle morphometric parameters has been confirmed in numerous studies. Definition of critical pedicle size for screw insertion is an actual problem for pediatric spinal surgery.
Material and methods. 29 patients, aged 3-17, with congenital or acquired spinal deformities were included in the study. All the patients had posterior surgery with pedicle screw implantation. All the screws were inserted by free hand technique. On preoperative CT, external pedicle width, internal pedicle width, and spongiosa proportion were measured. On postoperative CT, pedicle screw accuracy was evaluated. The binomial logistic regression was used to define dependence of pedicle screw accuracy on pedicle morphometric parameter values. ROC-curves were graphed, and AUC were calculated.
Results. 233 pedicle screws were implanted to 29 patients by free hand technique. On postoperative CT, 191 (82%) screws were confirmed to be accurately inserted. The logistic model confirmed significance of all the examined morphometric parameters (p<0.001). The external pedicle width possessed the maximal predictive value. Statistical indices for the prognostic model (sensitivity, specificity, and accuracy) were calculated for pedicle width 3.5; 6.0; 7.5 mm.
In the cut-off value of external pedicle width 3.5 mm, probability of accurate screw insertion is about 50%; this technique has been highly sensitive and maximally accurate. This morphometric feature is a technical limit of free hand pedicle screw insertion. Recommendations for selecting an implantation technique in different pedicle width are proposed.
Conclusion. The external pedicle width 3.5 mm is a critical one for pedicle screw insertion by the free hand technique.
References
1. Raasck K., Khoury J., Aoude A., et al. The Effect of Thoracolumbar Pedicle Isthmus on Pedicle Screw Accuracy. Global Spine J. 2020; 10(4): 393-8. https://doi.org/10.1177/2192568219850143
2. Gonzalvo A., Fitt G., Liew S., et al. Correlation between pedicle size and the rate of pedicle screw misplacement in the treatment of thoracic fractures: Can we predict how difficult the task will be? Br J Neurosurg. 2015; 29(4): 508-12. https://doi.org/10.3109/02688697.2015.1019414
3. Marks D.S., Qaimkhani S.A. The natural history of congenital scoliosis and kyphosis. Spine (Phila Pa 1976). 2009; 34(17): 1751-5. https://doi.org/10.1097/BRS.0b013e3181af1caf
4. Aoude A.A., Fortin M., Figueiredo R., et al. Methods to determine pedicle screw placement accuracy in spine surgery: a systematic review. Eur Spine J. 2015; 24(5): 990-1004. https://doi.org/10.1007/s00586-015-3853-x
5. Perdomo-Pantoja A., Ishida W., Zygourakis C., et al. Accuracy of Current Techniques for Placement of Pedicle Screws in the Spine: A Comprehensive Systematic Review and Meta-Analysis of 51,161 Screws. World Neurosurg. 2019; 126: 664-678.e3. https://doi.org/10.1016/j.wneu.2019.02.217
6. Amaral T.D., Hasan S., Galina J., et al. Screw Malposition: Are There Longterm Repercussions to Malposition of Pedicle Screws? J Pediatr Orthop. 2021; 41(Suppl 1): S80-6. https://doi.org/1097/BPO.0000000000001828
7. Delank K.S., Delank H.W., Konig D.P., et al. Iatrogenic paraplegia in spinal surgery. Arch Orthop Trauma Surg. 2005; 125(1): 33-41. https://doi.org/10.1007/s00402-004-0763-5
8. Leroy A., Kabbaj R., Dubory A., et al. The Indian Basket Trick: a case of delayed paraplegia with complete recovery, caused by misplaced thoracic pedicle screw. Springerplus. 2016; 5(1): 944. https://doi.org/10.1186/s40064-016-2334-y
9. Mac-Thiong J.M., Parent S., Poitras B., et al. Neurological outcome and management of pedicle screws misplaced totally within the spinal canal. Spine (Phila Pa 1976). 2013; 38(3): 229-37. https://doi.org/10.1097/BRS.0b013e31826980a9
10. Kakkos S.K., Shepard A.D. Delayed presentation of aortic injury by pedicle screws: report of two cases and review of the literature. J Vasc Surg. 2008; 47(5): 1074-82. https://doi.org/10.1016/j.jvs.2007.11.005
11. Wegener B., Birkenmaier C., Fottner A., et al. Delayed perforation of the aorta by a thoracic pedicle screw. Eur Spine J. 2008; 17(Suppl. 2): 351-4. https://doi.org/10.1007/s00586-008-0715-9
12. Koktekir E., Ceylan D., Tatarli N., et al. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. Spine J. 2014; 14(8): 1702-8. https://doi.org/10.1016/j.spinee.2014.03.044
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14. Rivkin M.A, Yocom S.S. Thoracolumbar instrumentation with CT-guided navigation (O-arm) in 270 consecutive patients: accuracy rates and lessons learned. Neurosurg Focus. 2014; 36(3): E7. https://doi.org/10.3171/2014.1.FOCUS13499
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18. Liang W., Han B., Hai J.J., et al. 3D-printed drill guide template, a promising tool to improve pedicle screw placement accuracy in spinal deformity surgery: A systematic review and meta-analysis. Eur Spine J. 2021; 30(5): 1173-83. https://doi.org/10.1007/s00586-021-06739-x
19. Bratschitsch G., Leitner L., Stucklschweiger G., et al. Radiation Exposure of Patient and Operating Room Personnel by Fluoroscopy and Navigation during Spinal Surgery. Sci Rep. 2019; 9(1): 7652. https://doi.org/10.1038/s41598-019-53472-z
20. Hartl R., Lam K.S., Wang J., et al. Worldwide survey on the use of navigation in spine surgery. World Neurosurg. 2013; 79(1): 162-72. https://doi/org/10.1016/j.wneu.2012.03.011
21. D'Souza M., Gendreau J., Feng A., et al. Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends. Robot Surg. 2019; (6): 9-23. https://doi.org/10.2147/RSRR.S190720
22. Pan Y., Lu G.H., Kuang L., et al. Accuracy of thoracic pedicle screw placement in adolescent patients with severe spinal deformities: a retrospective study comparing drill guide template with free-hand technique. Eur Spine J. 2018; 27(2): 319-26. https://doi.org/10.1007/s00586-017-5410-2
23. Liu K, Zhang Q, Li X, et al. Preliminary application of a multilevel 3D printing drill guide template for pedicle screw placement in severe and rigid scoliosis. Eur Spine J. 2017; 26(6): 1684-9. https://doi.org/10.1007/s00586-016-4926-1
24. Akazawa T., Kotani T., Sakuma T., et al. Evaluation of pedicle screw placement by pedicle channel grade in adolescent idiopathic scoliosis: should we challenge narrow pedicles? J Orthop Sci. 2015; 20(5): 818-22. https://doi.org/10.1007/s00776-015-0746-0
25. Zhang Y., Xie J., Wang Y., et al. Thoracic pedicle classification determined by inner cortical width of pedicles on computed tomography images: its clinical significance for posterior vertebral column resection to treat rigid and severe spinal deformities-a retrospective review of cases. BMC Musculoskelet Disord. 2014; (15): 278. https://doi.org/10.1186/1471-2474-15-278
26. Gao B., Gao W., Chen C., et al. What is the Difference in Morphologic Features of the Thoracic Pedicle Between Patients With Adolescent Idiopathic Scoliosis and Healthy Subjects? A CT-based Casecontrol Study. Clin Orthop Relat Res. 2017; 475(11): 2765-74. https://doi.org/10.1007/s11999-017-5448-9
27. Sarwahi V., Sugarman E.P., Wollowick A.L., et al. Prevalence, Distribution, and Surgical Relevance of Abnormal Pedicles in Spines with Adolescent Idiopathic Scoliosis vs. No Deformity: A CT-Based Study. J Bone Joint Surg Am. 2014; 96(11): e92. https://doi.org/10.2106/JBJS.M.01058
28. Jeswani S., Drazin D., Hsieh J.C., et al. Instrumenting the small thoracic pedicle: the role of intraoperative computed tomography image-guided surgery. Neurosurg Focus. 2014; 36(3): E6. https://doi.org/10.3171/2014.1.FOCUS13527
29. Fardy J.M, Barrett B.J. Evaluation of Diagnostic Tests. Parfrey P.S., Barrett B.J., eds. Clinical Epidemiology: Practice and Methods. New-York: Springer Science+Business Media, 2015. https://doi.org/10.1007/978-1-4939-2428-8_17
