Free-hand thoracic pedicle screws placed by neurosurgery residents: A CT analysis

Department of Neurological Surgery, University of California, 505 Parnassus Ave., Box 0112, San Francisco, CA 94143-0112, USA.
European Spine Journal (Impact Factor: 2.07). 02/2010; 19(5):821-7. DOI: 10.1007/s00586-010-1293-1
Source: PubMed


Free-hand thoracic pedicle screw placement is becoming more prevalent within neurosurgery residency training programs. This technique implements anatomic landmarks and tactile palpation without fluoroscopy or navigation to place thoracic pedicle screws. Because this technique is performed by surgeons in training, we wished to analyze the rate at which these screws were properly placed by residents by retrospectively reviewing the accuracy of resident-placed free-hand thoracic pedicle screws using computed tomography imaging. A total of 268 resident-placed thoracic pedicle screws was analyzed using axial computed tomography by an independent attending neuroradiologist. Eighty-five percent of the screws were completely within the pedicle and that 15% of the screws violated the pedicle cortex. The majority of the breaches were lateral breaches between 2 and 4 mm (46%). There was no clinical evidence of neurovascular injury or injury to the esophagus. There were no re-operations for screw replacement. We concluded that under appropriate supervision, neurosurgery residents can safely place free-hand thoracic pedicle screws with an acceptable breach rate.

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    • "The accuracy and safety of the free-hand technique were addressed in several papers [14,15,16,17]. However, the free-hand technique was implemented by an experienced spine surgeon or under the guidance of an experienced surgeon in almost all previous studies. "
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    ABSTRACT: Study DesignA retrospective cross-sectional study.PurposeThe purpose of this study is to evaluate the accuracy and safety of free-hand pedicle screw insertion performed by a young surgeon.Overview of LiteratureFew articles exist regarding the safety of the free-hand technique without inspection by an experienced spine surgeon.MethodsThe index surgeon has performed spinal surgery for 2 years by himself. He performed fluoroscopy-assisted pedicle screw installation for his first year. Since then, he has used the free-hand technique. We retrospectively reviewed the records of all consecutive patients undergoing pedicle screw installation using the free-hand technique without fluoroscopy in the thoracic or lumbar spine by the index surgeon. Incidence and extent of cortical breach by misplaced pedicle screw was determined by a review of postoperative computed tomography (CT) images.ResultsA total of 36 patients received 306 free-hand placed pedicle screws in the thoracic or lumbar spine. A total of 12 screws (3.9%) were identified as breaching the pedicle in 9 patients. Upper thoracic spine was the most frequent location of screw breach (10.8%). Lateral breach (2.3%) was more frequent than any other direction. Screw breach on the right side (9 patients) was more common than that on the left side (3 patients) (p<0.01).ConclusionsAn analysis by CT scan shows that young spine surgeons who have trained under the supervision of an experienced surgeon can safely place free-hand pedicle screws with an acceptable breach rate through repetitive confirmatory steps.
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