. 2015 May 28:10:79.

doi: 10.1186/s13018-015-0225-5.

Lumbosacral pedicle screw placement using a fluoroscopic pedicle axis view and a cannulated tapping device

Toshitaka Yoshii^{1

2}, Takashi Hirai^{3

4}, Tsuyoshi Yamada^{5

6}, Satoshi Sumiya⁷, Renpei Mastumoto^{8

9}, Tsuyoshi Kato¹⁰, Mitsuhiro Enomoto^{11

12}, Hiroyuki Inose^{13

14}, Shigenori Kawabata¹⁵, Kenichi Shinomiya^{16

17}, Atsushi Okawa^{18

19}

Affiliations

¹ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. yoshii.orth@tmd.ac.jp.
² Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. yoshii.orth@tmd.ac.jp.
³ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. hirai.orth@tmd.ac.jp.
⁴ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. hirai.orth@tmd.ac.jp.
⁵ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. yamada.orth@tmd.ac.jp.
⁶ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. yamada.orth@tmd.ac.jp.
⁷ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. sumiya.orth@tmd.ac.jp.
⁸ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. matsumoto.orth@tmd.ac.jp.
⁹ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. matsumoto.orth@tmd.ac.jp.
¹⁰ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. kato.orth@tmd.ac.jp.
¹¹ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. enomoto.orth@tmd.ac.jp.
¹² Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. enomoto.orth@tmd.ac.jp.
¹³ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. inose.orth@tmd.ac.jp.
¹⁴ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. inose.orth@tmd.ac.jp.
¹⁵ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. kawabata.orth@tmd.ac.jp.
¹⁶ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. shinomiya.orth@tmd.ac.jp.
¹⁷ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. shinomiya.orth@tmd.ac.jp.
¹⁸ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. okawa.orth@tmd.ac.jp.
¹⁹ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. okawa.orth@tmd.ac.jp.

PMID: 26016564
PMCID: PMC4450829
DOI: 10.1186/s13018-015-0225-5

Lumbosacral pedicle screw placement using a fluoroscopic pedicle axis view and a cannulated tapping device

Toshitaka Yoshii et al. J Orthop Surg Res. 2015.

. 2015 May 28:10:79.

doi: 10.1186/s13018-015-0225-5.

Authors

Affiliations

¹ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. yoshii.orth@tmd.ac.jp.
² Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. yoshii.orth@tmd.ac.jp.
³ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. hirai.orth@tmd.ac.jp.
⁴ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. hirai.orth@tmd.ac.jp.
⁵ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. yamada.orth@tmd.ac.jp.
⁶ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. yamada.orth@tmd.ac.jp.
⁷ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. sumiya.orth@tmd.ac.jp.
⁸ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. matsumoto.orth@tmd.ac.jp.
⁹ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. matsumoto.orth@tmd.ac.jp.
¹⁰ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. kato.orth@tmd.ac.jp.
¹¹ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. enomoto.orth@tmd.ac.jp.
¹² Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. enomoto.orth@tmd.ac.jp.
¹³ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. inose.orth@tmd.ac.jp.
¹⁴ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. inose.orth@tmd.ac.jp.
¹⁵ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. kawabata.orth@tmd.ac.jp.
¹⁶ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. shinomiya.orth@tmd.ac.jp.
¹⁷ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. shinomiya.orth@tmd.ac.jp.
¹⁸ Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. okawa.orth@tmd.ac.jp.
¹⁹ Section of Regenerative Therapeutics for Spine and Spinal Cord, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. okawa.orth@tmd.ac.jp.

PMID: 26016564
PMCID: PMC4450829
DOI: 10.1186/s13018-015-0225-5

Abstract

Background: Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. However, the misplacement of pedicle screws can lead to disastrous complications. Inaccurate pedicle screw placement is relatively common even when placement is performed under fluoroscopic control. In order to improve the accuracy of the screw placement, we applied a technique using guide wires and a cannulated tapping device with the assistance of a fluoroscopic pedicle axis view.

Methods: From 2006 to 2011, 854 pedicle screws were placed in 176 patients in lumbosacral spinal fusion surgeries. The accuracy of screw placement was evaluated using postoperative reconstructed computed tomography images. Screw misplacement was classified as minor (cortical perforation <3 mm), moderate (cortical perforation 3-6 mm), or severe (cortical perforation >6 mm). Using logistic regression analysis, we also investigated the potential risk factors associated with screw misplacement.

Results: Pedicle screw misplacement was observed in 37 screws (4.3%) in 34 patients. In the sub-classification analysis, 28 screws (3.3%) were determined to be minor perforations, 7 screws (0.8%) were considered to be moderate perforations, and 2 screws (0.2%) was judged to be a severe perforation (cortical perforation >6 mm). None of the 28 screws that were considered to be minor perforations were associated with any significant symptoms in the patients. However, 2 of the 9 screws that were determined to be moderate or severe perforations caused neurological symptoms (1 of which required revision). No significant differences were observed in the incidence of screw misplacement among the vertebral levels. Significant risk factors for screw misplacement were obesity and degenerative scoliosis. The odds ratios of these significant risk factors were 3.593 (95% confidence interval (CI), 1.061-12.175) for obesity and 8.893 for degenerative scoliosis (95% CI, 1.200-76.220).

Conclusions: A modified fluoroscopic technique using a pedicle axis view and a cannulated tapping instrument can achieve safe and accurate pedicle screw placement. In addition, obesity and degenerative scoliosis were identified as significant risk factors for screw misplacement.

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Figures

**Fig. 1**
a Fluoroscopic pedicle axis view. The C-arm was rotated in the anterior-posterior (AP)/lateral direction (arrow) to ensure that the pedicle cortex wall could be clearly visualized. b Guide wires (1.5 mm) were placed in the pilot holes (arrows). c A cannulated tapping device. The arrow: the guide wire can be visualized in the cannulated tap to ensure that the wire does not penetrate the anterior wall

**Fig. 2**
a Fluoroscopic pedicle axis view; (b) fluoroscopic lateral view

**Fig. 3**
The pedicle screws judged as misplacement. a Medial minor perforation, (b) inferior minor perforation, (c) medial moderate perforation, and (d) lateral severe perforation

See this image and copyright information in PMC

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Lumbosacral pedicle screw placement using a fluoroscopic pedicle axis view and a cannulated tapping device

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Lumbosacral pedicle screw placement using a fluoroscopic pedicle axis view and a cannulated tapping device

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