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      Treatment strategies for early neurological deficits related to malpositioned pedicle screws in the lumbosacral canal : A pilot study

      research-article
      Author(s): , MD 1 , , MD 1 , , MD 1 , , MD, PhD 1 ,
      Publication date (Electronic):
      Journal: Bone & Joint Research
      Keywords: pedicle screws, mispositioning, lumbar spine, neurological deficits, treatment

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          Abstract

          Objectives

          To employ a simple and fast method to evaluate those patients with neurological deficits and misplaced screws in relatively safe lumbosacral spine, and to determine if it is necessary to undertake revision surgery.

          Methods

          A total of 316 patients were treated by fixation of lumbar and lumbosacral transpedicle screws at our institution from January 2011 to December 2012. We designed the criteria for post-operative revision scores of pedicle screw malpositioning (PRSPSM) in the lumbosacral canal. We recommend the revision of the misplaced pedicle screw in patients with PRSPSM = 5′ as early as possible. However, patients with PRSPSM < 5′ need to follow the next consecutive assessment procedures. A total of 15 patients were included according to at least three-stage follow-up.

          Results

          Five patients with neurological complications (PRSPSM = 5′) underwent revision surgery at an early stage. The other ten patients with PRSPSM < 5′ were treated by conservative methods for seven days. At three-month follow-up, only one patient showed delayed onset of neurological complications (PRSPSM 7′) while refusing revision. Seven months later, PRSPSM decreased to 3′ with complete rehabilitation.

          Conclusions

          This study highlights the significance of consecutively dynamic assessments of PRSPSMs, which are unlike previous implementations based on purely anatomical assessment or early onset of neurological deficits.and also confirms our hypothesis that patients with early neurological complications may not need revision procedures in the relatively broad margin of the lumbosacral canal.

          Cite this article: X-J. Lin. Treatment strategies for early neurological deficits related to malpositioned pedicle screws in the lumbosacral canal: A pilot study. Bone Joint Res 2016;5:46–51. DOI: 10.1302/2046-3758.52.2000477.

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          Most cited references19

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          Accuracy of pedicular screw placement in vivo.

          Harlan S Robbins, S Gertzbein (1989)
          The accuracy of pedicular screw placement was assessed in 40 consecutive patients treated with the AO "Fixateur Interne." Postoperative CT scans were used to measure canal encroachment from the medial border of the pedicle, the angle of insertion and the point of entry. Eighty-one percent of the screws were placed within 2 mm of the medial border of the pedicle and 6% had 4-8 mm of canal encroachment with two patients developing minor neurological complications that spontaneously resolved. Four percent were inserted lateral to the pedicle. The parameters linked to satisfactory screw placement include entry point, angle of insertion and pedicular isthmus widths. Improvement in accuracy was noted in the latter 25% of screw insertions, reflecting the learning curve associated with this technique.
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            Pedicle screw placement accuracy: a meta-analysis.

            Victor Kosmopoulos, Constantin Schizas (2007)
            A meta-analysis of the published literature was conducted specifically looking at accuracy and the postoperative methods used for the assessment of pedicle screw placement in the human spine. This study specifically aimed to identify postoperative methods used for pedicle screw placement assessment, including the most common method, and to report cumulative pedicle screw placement study statistics from synthesis of the published literature. Safety concerns have driven specific interests in the accuracy and precision of pedicle screw placement. A large variation in reported accuracy may exist partly due to the lack of a standardized evaluation method and/or the lack of consensus to what, or in which range, is pedicle screw placement accuracy considered satisfactory. A MEDLINE search was executed covering the span from 1966 until 2006, and references from identified papers were reviewed. An extensive database was constructed for synthesis of the identified studies. Subgroups and descriptive statistics were determined based on the type of population, in vivo or cadaveric, and separated based on whether the assistance of navigation was employed. In total, we report on 130 studies resulting in 37,337 total pedicle screws implanted, of which 34,107 (91.3%) were identified as accurately placed for the combined in vivo and cadaveric populations. The most common assessment method identified pedicle screw violations simply as either present or absent. Overall, the median placement accuracy for the in vivo assisted navigation subgroup (95.2%) was higher than that of the subgroup without the use of navigation (90.3%). Navigation does indeed provide a higher accuracy in the placement of pedicle screws for most of the subgroups presented. However, an exception is found at the thoracic levels for both the in vivo and cadaveric populations, where no advantage in the use of navigation was found.
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              Complications of pedicle screw fixation in scoliosis surgery: a systematic review.

              Vincent Arlet, Amit Singla, F. Shen … (2010)
              Systematic review. To review the published literature on the use of pedicle screws in pediatric spinal deformity to quantify the risks and complications associated with pedicle screw instrumentation, particularly in the thoracic spine. The use of pedicle screws in adolescent scoliosis surgery is common. Although many reports have been published regarding the use of pedicle screws in pediatric patients, there has been no systematic review on the risks of complications. PubMed, Ovid Medline, and Cochrane databases were searched for studies reporting the use of thoracic pedicle screws in pediatric deformity. We excluded articles dealing with neuromuscular scoliosis or bone dysplasia to focus mostly on adolescent thoracic idiopathic scoliosis and the likes. We then searched for cases reports dealing with thoracic pedicle screws complications. This systematic review retrieved 21 studies with a total of 4570 pedicle screws in 1666 patients. The mean age of the patients was 17.6 years; 812 patients were women and 252 were men, and 5 studies did not identify sex. Overall, 518 (4.2%) screws were reported as malpositioned. However, in studies in which postoperative computed tomography scans were done systematically, the rate of screw malpositioning was as high as 15.7%. The reported percentage of patients with screw malpositioned is around 11%. Eleven patients underwent revision surgery for instrumentation malposition. Other complications reported include loss of curve correction, intraoperative pedicle fracture or loosening, dural laceration, deep infection, pseudarthrosis, and transient neurologic injury. There were no major vascular complications reported in these 21 studies. We could identify 9 case report articles dealing with complications of pedicle screws. Such complications were mostly either vascular (10 cases) or neurologic (4 cases), without any irreversible complications. Malposition is the most commonly reported complication of thoracic pedicle screw placement, at a rate of 15.7% per screw inserted with postoperative computed tomography scans. The use of pedicle screws in the thoracic spine for the treatment of pediatric deformity has been reported to be safe despite the high rate of patients with malpositioned screws (11%). Major complications, such as neurologic or vascular injury, were almost never reported in this literature review of case series. Cases reports on the other hand have started to identify such complications.
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                Author and article information

                Contributors
                J-Y. Du: Role: Orthopaedic Surgeon, Co-first author, The First Affiliated Hospital
                J-S. Wu: Role: Orthopaedic Surgeon, Co-first author, The First Affiliated Hospital
                Z-Q. Wen: Role: Orthopaedic Surgeon, The First Affiliated Hospital
                X-J. Lin: Role: Orthopaedic Surgeon, Professor, The First Affiliated Hospital
                Journal
                Journal ID (nlm-ta): Bone Joint Res
                Title: Bone & Joint Research
                ISSN (Electronic): 2046-3758
                Publication date Collection: February 2016
                Publication date (Electronic): 8 April 2016
                Volume: 5
                Issue: 2
                Pages: 46-51
                Affiliations
                [1 ]College of Medicine, Zhejiang University, No. 79 Oinchun Road,Hangzhou, China
                Author notes
                Article
                Publisher ID: 10.1302_2046-3758.52.2000477
                DOI: 10.1302/2046-3758.52.2000477
                PMC ID: 4852802
                PubMed ID: 26868892
                SO-VID: d95c916b-e923-4276-8864-6023f9716333
                Copyright © © 2016 X-J Lin et al.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attributions licence (CC-BY-NC), which permits unrestricted use, distribution, and reproduction in any medium, but not for commercial gain, provided the original author and source are credited.

                History
                Date received : 22 June 2015
                Date accepted : 27 October 2015
                Categories
                Subject: Spine
                Subject: 5
                Subject: Pedicle Screws
                Subject: Mispositioning
                Subject: Lumbar Spine
                Subject: Neurological Deficits
                Subject: Treatment

                Keywords: pedicle screws,mispositioning,lumbar spine,neurological deficits,treatment
                Data availability:
                Keywords: pedicle screws, mispositioning, lumbar spine, neurological deficits, treatment

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