Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2020 Mar;6(1):262-273.
doi: 10.21037/jss.2020.03.07.

Anatomic techniques for cervical pedicle screw placement

Kimberly-Anne Tan  1 , Shuxun Lin  1 , Brian Zhaojie Chin  1 , Vishaal Nanik Thadani  1 , Hwee Weng Dennis Hey  1
Affiliations
Review

Anatomic techniques for cervical pedicle screw placement

Kimberly-Anne Tan et al. J Spine Surg. 2020 Mar.

Abstract

Instrumentation of the cervical spine with cervical pedicle screws (CPS) is beneficial in patients with various types of spinal pathology. Despite posing greater technical challenges, CPS instrumentation confers better fixation outcomes when compared to lateral mass screws. While developments in technology have augmented the accuracy of CPS insertion, mastery in freehand CPS insertion allows the aforementioned technologies to reach their full potential in improving patient outcomes. The aim of this article is to discuss freehand CPS insertion techniques as established in the current literature while sharing our experience in this context. A comprehensive literature search was performed using the following electronic databases: PubMed, Medline, and EMBASE. Full-text articles focusing on clinical studies with description of freehand techniques were included. Articles which were on cadaveric studies, drill jig, navigation or robotic technology were excluded. Thirteen primary references comprising 1,480 patients were included in this review. Majority of studies reported utilizing the cranial margin of lamina for C2 level as a landmark for entry point, as well as lateral to centre of the articular mass, and just medial to the lateral border of the superior articular process for C3-7 levels. Method of tracking and facilitation of trajectory was reported in multiple studies, with use of instruments ranging from curved pedicle probes to high-speed burrs. Limited studies reported specific trajectories of CPS insertion. Most studies noted testing pedicle wall integrity at various checkpoints, with pedicle screw repositioning or conversion to lateral screw mass following detection of perforation or screw malpositioning. Success in CPS insertion rests on meticulous preoperative planning to identify the ideal screw entry point and trajectory. Patient-specific drill jigs, navigation and robotic technologies, while beneficial to progress in the field of cervical spine surgery and patient outcomes, should serve primarily to augment good expertise in freehand CPS insertion technique.

Keywords: Cervical spine; insertion; pedicle screw; technique.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: The series “Advanced Techniques in Complex Cervical Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
PRISMA flowchart of literature search.
Figure 2
Figure 2
Cervical entry point identification and screw insertion trajectory
Figure 3
Figure 3
Learning curves of CPS placement. CPS, cervical pedicle screw.
See this image and copyright information in PMC

References

    1. Heo Y, Lee SB, Lee BJ, et al. The Learning Curve of Subaxial Cervical Pedicle Screw Placement: How Can We Avoid Neurovascular Complications in the Initial Period? Oper Neurosurg (Hagerstown) 2019;17:603-7. 10.1093/ons/opz070 - DOI - PubMed
    1. Hojo Y, Ito M, Suda K, et al. A multicenter study on accuracy and complications of freehand placement of cervical pedicle screws under lateral fluoroscopy in different pathological conditions: CT-based evaluation of more than 1,000 screws. Eur Spine J 2014;23:2166-74. 10.1007/s00586-014-3470-0 - DOI - PubMed
    1. Abumi K, Shono Y, Ito M, et al. Complications of Pedicle Screw Fixation in Reconstructive Surgery of the Cervical Spine. Spine 2000;25:962-9. 10.1097/00007632-200004150-00011 - DOI - PubMed
    1. Neo M, Sakamoto T, Fujibayashi S, et al. The Clinical Risk of Vertebral Artery Injury From Cervical Pedicle Screws Inserted in Degenerative Vertebrae. Spine 2005;30:2800-5. 10.1097/01.brs.0000192297.07709.5d - DOI - PubMed
    1. Yoshimoto H, Sato S, Hyakumachi T, et al. Clinical accuracy of cervical pedicle screw insertion using lateral fluoroscopy: a radiographic analysis of the learning curve. Eur Spine J 2009;18:1326-34. 10.1007/s00586-009-1109-3 - DOI - PMC - PubMed