Park Y, Ha JW, Lee YT, et al. Cranial facet joint violations by percutaneously placed pedicle screws adjacent to a minimally invasive lumbar spinal fusion

Department of Orthopedic Surgery, Yonsei University College of Medicine, National Health Insurance Medical Center, 1232, Baekseok St, Ilsan district, Goyang City, Gyeonggi province, 410-719, Republic of Korea.
The spine journal: official journal of the North American Spine Society (Impact Factor: 2.43). 04/2011; 11(4):295-302. DOI: 10.1016/j.spinee.2011.02.007
Source: PubMed


Protecting cranial facet joint is a modifiable risk factor that may decrease the incidence of adjacent segment disease after lumbar spinal fusion. Percutaneously instrumented screws may more frequently violate cranial facet joints because of the potential limitation of screw entry site selection. To our knowledge, however, there is no study that has evaluated the cranial facet joint violations adjacent to minimally invasive lumbar fusion related to percutaneously placed pedicle screws.
We investigated the incidence and relating factors of cranial facet joint violations by percutaneous pedicle screws.
A retrospective study of prospectively collecting data.
The sample comprises 184 pedicle screws percutaneously placed at the cranial fusion segments in 92 patients who underwent minimally invasive lumbar spinal fusion.
The facet joint violations adjacent to a cranial fusion segment were examined on the postoperative computed tomography (CT) scans.
Two independent observers retrospectively examined all the postoperative CT images. A facet joint was considered violated if any of the following situations were encountered: pedicle screw clearly within the facet joint; pedicle screw head clearly within the facet joint; and pedicle screw and/or screw head within 1 mm from or abutting the facet joint, without clear joint involvement.
The incidence of the violations was 50% (46/92) of all patients and 31.5% (58/184) of all screws, which were significantly higher than the previously reported rates with the traditional open procedure (50% vs. 23.5% of all patients, p<.001; 31.5% vs. 15.2% of all screws, p<.001). The violations occurred approximately 3.3 times more frequently at the most cranial pedicle screws of L5 pedicle than at the other pedicles (70.8% vs. 42.6%, odds ratio [OR]=3.3, p=.021). Logistic regression analysis revealed a significant trend toward reducing the incidence of the violations as increasing the year of surgery (OR=0.7, p=.008). The incidence showed no significant relationships with patients' age, gender, body mass index, preoperative diagnosis, the number of fused segments, or the side of screw placement.
Our data raise a concern about the higher incidence of cranial facet joint violations by percutaneously placed pedicle screws than that previously reported rates by traditionally instrumented screws. Furthermore, more care should be taken to avoid cranial facet joint violations when the surgeon is a novice to percutaneous pedicle screw placement and/or minimally invasive fusion surgery is considered at the L5-S1 segment.

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    • "Fusion of lumbar motion segments performed for the treatment of intractable low back pain (LBP) from degenerative disc disease (DDD) without any deformities or instabilities are associated with a variety of negative side effects, including adjacent level pathologies, considerable complication and reoperation rates, symptomatic facet and sacroiliac joint complaints, cranial facet joint violations, adjacent segment stenosis, negatively altered sagittal alignment , pseudarthrosis, graft site morbidity, and others [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13]. "
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    ABSTRACT: The role of fusion of lumbar motion segments for the treatment of intractable low back pain (LBP) from degenerative disc disease (DDD) without deformities or instabilities remains controversially debated. Total lumbar disc replacement (TDR) has been used as an alternative in a highly selected patient cohort. However, the amount of long-term follow-up (FU) data on TDR is limited. In the United States, insurers have refused to reimburse surgeons for TDRs for fear of delayed complications, revisions, and unknown secondary costs, leading to a drastic decline in TDR numbers.
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    ABSTRACT: The authors sought to evaluate the feasibility and accuracy of three-dimensional (3D) fluoroscopic guidance for percutaneous placement of thoracic and lumbar pedicle screws in three cadaveric specimens. After attaching a percutaneous dynamic reference array to the surgical anatomy, an isocentric C-arm fluoroscope was used to obtain images of the region of interest. Light-emitting diodes attached to the C-arm unit were tracked using an electrooptical camera. The image data set was transferred to the image-guided workstation, which performed an automated registration. Using the workstation display, pedicle screw trajectories were planned. An image-guided drill guide was passed through a stab incision, and this was followed by sequential image-guided pedicle drilling, tapping, and screw placement. Pedicle screws of various diameters (range 4-6.5 mm) were placed in all pedicles greater than 4 mm in diameter. Postoperatively, thin-cut computerized tomography scans were obtained to determine the accuracy of screw placement. Eighty-nine (94.7%) of 94 percutaneous screws were placed completely within the cortical pedicle margins, including all 30 lumbar screws (100%) and 59 (92%) of 64 thoracic screws. The mean diameter of all thoracic pedicles was 6 mm (range 2.9-11 mm); the mean diameter of the five pedicles in which wall violations occurred was 4.6 mm (range 4.1-6.3 mm). Two of the violations were less than 2 mm beyond the cortex; the others were between 2 and 3 mm. Coupled with an image guidance system, 3D fluoroscopy allows highly accurate spinal navigation. Results of this study suggest that this technology will facilitate the application of minimally invasive techniques to the field of spine surgery.
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    ABSTRACT: The purpose of this study is to examine radiological adjacent segment degeneration (ASD) and clinical results after two levels percutaneous pedicle screw fixation.
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