The present study aimed to evaluate the effect of using one-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion in the treatment of unstable hangman’s fracture. A total of 13 patients with unstable hangman’s fractures underwent C2 and C3 pedicle screw fixation, lamina interbody fusion or combined anterior C2-C3 fusion and imaging examinations to evaluate the fracture fixation and healing condition at three days and three months following surgery. Postoperative X-ray and computed tomography (CT) results showed high fracture reduction, good internal fixation position and reliable fracture fixation. The three-month postoperative CT showed good vertebral fracture healing. C2 and C3 pedicle screw fixation has a good curative effect in the treatment of unstable hangman’s fracture. The direct fixation of the fracture enables early ambulation by the patients.
hangman’s fracture; C2; C3; pedicle screw; instability
The purpose of this study was to assess the efficacy and accuracy of posterior screw fixation for unstable Hangman’s fracture using intraoperative 3D fluoroscopy-based navigation.
14 patients with unstable Hangman’s fractures (11 males and 3 females), ranging in age from 21 to 59 years, received posterior fixation assisted by an intraoperative 3D fluoroscopy-based navigation system: 11 Levine–Edwards type II and three type IIA cases. The American Spine Injury Association grade was D in 2 and E in 12 cases.
Operation time was 110 min (range 90–140 min). Hospital stay was 7.6 days (range 5–12 days). All the patients were observed for an average of 28.8 months (range 15–50 months). No screw-related injury to nerve, or vertebral artery was observed intraoperatively. An average of four screws/patient were inserted. Pedicle screws were placed into C2 and C3, and 5 screws were into the lateral mass of C3. Screw placement accuracy was evaluated using postoperative CT, according to the modified classification of Gertzbein and Robbins; one screw was grade 2 in C2, and three screws were grade 2 in the pedicle of C3. No grade 3 misplacement or clinical deficits were noted. C3 lateral mass screws were successfully inserted. Neck pain was relieved in each case. Neurologic status improved from D to E in 2 cases. Solid fusion was demonstrated in all the cases by static and dynamic films during the final follow-up.
This case series demonstrates that intraoperative 3D fluoroscopy-based navigation is a safe, accurate, and effective tool for screw placement in patients with unstable Hangman’s fracture.
Three-dimensional fluoroscopy; Hangman’s fracture; Screw fixation; Intraoperative navigation; Traumatic spondylolisthesis of the axis
Opinions have varied regarding the optimal treatment of an unstable Hangman’s fracture. C2 pedicle screw instrumentation is a biomechanically strong fixation which although done through a simple posterior approach, is a technically demanding procedure. This prospective, non-randomized multicentre study included 15 consecutive patients with displaced type II traumatic spondylolisthesis of the axis. There were nine males and six females with a mean age of 37 years at surgery. The cause of injury was a road traffic accident in 11 patients and a fall from height in 4 patients. All patients had a single stage reduction and direct transpedicular screw fixation through the C2 pedicles. During follow-up, clinical evaluation and plain X-rays were performed at each visit; at 6-month follow-up, additional dynamic lateral flexion/extension views and a CT scan were performed. The average follow-up period was 32 months (range 25–56 months). At final follow-up, all patients were asymptomatic and regained a good functional outcome with no limitation of range of motion; all the patients showed solid union with no implant failure. There were no neurological complications. At 6-month follow-up, CT evaluation showed fusion in all patients and an adequate position of 28 screws. Two pedicle screws (6.6%) showed minimal (defined as <2 mm) intrusion; one into the spinal canal and the other into the vertebral foreamen. Transpedicular screw fixation through the C2 pedicles is a safe and effective method in treating type II traumatic spondylolisthesis of the axis resulting in good clinical and radiological outcomes. Adequate reduction was achieved and motion segments were preserved with its use.
Hangman’s fracture; Transpedicular screw; Motion preservation; Cervical spine
This study describes a percutaneous technique for C2 transpedicular screw fixation and evaluates its safety and efficacy in the treatment of patients with hangman’s fracture.
Ten patients with hangman’s fracture were treated by percutaneous C2 transpedicular screw fixation. There are six males and four females, who were, based on the classification of Levine and Edwards, sorted as follows: type I fracture, three cases; type II, five cases; type IIa, two cases. The causes of injury were road traffic accident in six patients and falling injury in four patients. Other associated lesions included rib fractures (7 patients), head injuries (4 patients), and fractures of extremities (6 patients).
The new technique was performed successfully in all cases. The average operation time was 98 min (range 60–130 min) and the estimated blood loss was 25 ml (range 15–40 ml). No complications such as vascular or neural structures injuries were found intraoperatively. Postoperative CT scans demonstrated that 17 (85 %) of 20 screws were placed satisfactorily, and 3 (15 %) screws showed perforations of the pedicle wall (<2 mm). These patients were asymptomatic and no further intervention was required postoperatively. After 8–25 months follow-up (mean 15.3 months), solid fusion was demonstrated by computed tomography. All cases got well-sagittal alignment and no angulation or dislocation was found at the segment of C2–C3. There was no loss of fixation. Clinical examination showed a full range of motion in the neck in all patients.
The fluoroscopically assisted percutaneous C2 transpedicular screw fixation method is a technically feasible and minimally invasive technique for hangman’s fracture.
Hangman’s fracture; Transpedicular screw; Percutaneous; Minimal invasive; Cervical spine
Most hangman’s fractures are treated conservatively. If surgery is indicated, an anterior approach using a C2/C3 graft and plate fusion is usually preferred. Another surgical method according to Judet is direct transpedicular osteosynthesis by the dorsal approach. This surgery is frequently rejected because of the high risk of spinal cord damage or vertebral artery tear. Direct transpedicular osteosynthesis of hangman’s fracture according to Judet is a “physiological operation” that does not cause fusion and creates anatomical conditions. This procedure enables appropriate reduction, compression of fragments and immediate stabilization of the C2 segment. A new aspect of Judet’s method of internal fixation of a hangman’s fracture is now proposed. Computed tomographic (CT) guidance is used to ensure safe and exact introduction of two screws from the posterior approach. This method of CT-guided internal fixation of hangman’s fracture allows, preoperatively, for an accurate assessment of the pattern and course of fracture line, selection of the anatomically safest screw path and determination of an appropriate screw length. The procedure also allows for accurate intraoperative control of instrument and implant placement, screw tightening, fracture reduction and anchoring of the screw tip in the contralateral cortex, using repeated CT scans. The procedure is performed in a CT unit under sterile conditions. This method was used in the treatment of eight male and two female patients aged 21–71 years. All treated patients were without neurological deficit. Follow-up ranged from 12 to 57 months (mean 33.3 months). No intraoperative or early or late postoperative complications were apparent. This new aspect of the surgical procedure ensures highly accurate screw placement and minimal risks, and fully achieves the “physiological” internal fixation.
Key words Axis pedicle; Hangman’s fracture; CT-guided ¶surgery; Internal fixation
The aim of this study was to assess the effectiveness and feasibility of anterior C3 corpectomy and fusion with screw-plate fixation of C2–4 for the treatment of Hangman’s fracture in which spinal cord compression comes from the posterosuperior part of C3 vertebral body and the intervertebral disc injury at the C2–3 level.
From August 2000 to December 2005, 11 patients (eight males and three females) with traumatic spondylolisthesis of the axis underwent the above surgery. Neurological status was evaluated by the Japanese Orthopaedic Association Score (JOA score). The fusion of the graft, healing of the fracture, and range of motion of the whole cervical spine were examined according to X-ray imaging.
No patient received blood transfusion. There was no deterioration of the neurological function in any case postoperatively. The mean JOA score was significantly improved from 9.1 ± 2.3 preoperatively to 14.8 ± 1.2 at the 12-month postoperative visit. All patients were relieved of axial pain. Imaging evaluation confirmed a high fusion rate and healing rate in all patients. No patient complained of limited mobility of the cervical spine in flexion, extension and rotation. No graft or plate-related complication was observed in any patients during the whole follow-up period. The only postoperative complication was trouble in swallowing liquids in two cases which resolved three months after surgery without any treatment.
Anterior C3 corpectomy and fusion may prove to be safe and applicable for the treatment of complex Hangman’s fractures.
During the past 30 years various treatment protocols for hangman’s fractures have been attempted. In order to guide the management of hangman’s fractures, different classifications have been introduced. However, opinions on operative or nonoperative treatment have not yet been solidified. To evaluate both conservative and operative management of hangman’s fractures in the published literature and to provide appropriate guidelines for treatment of hangman’s fractures, a systematic review of the literature regarding the management of hangman’s fractures was performed. An English literature search from January 1966 to January 2004 was completed with reference to treatment of hangman’s fractures. The classification for treatment guidance from the literature was also reviewed. Regarding a primary therapy for hangman’s fractures, there were 20 papers (62.5%) that advocated for a conservative treatment and 11 of the remaining 12 papers suggested that conservative treatment was suitable for some stable fractures. The classification of Effendi et al. modified by Levine and Edwards was used widely. Most hangman’s fractures could be managed successfully with traction and external immobilization, especially in Effendi Type I, Type II and Levine-Edwards Type II fractures. It is necessary for Levine-Edwards Type IIa and III fractures to be treated with rigid immobilization. Only for some stable Type I and Levine-Edwards Type II injuries, nonrigid external fixation alone was sufficient. Rigid immobilization alone was necessary for most cases. Surgical stabilization is recommended in unstable cases when there is the possibility of later instability, such as Levine-Edwards Type IIa and III fractures with significant dislocation. The classification system proposed by Effendi et al. and modified by Levine and Edwards provided a clinically reasonable guideline for successful management of hangman’s fractures.
Hangman’s fracture; Traumatic spondylolisthesis of C2; Management; Systematic review
Between 1999 and 2004, 28 patients (average age: 41, range: 18–70 years) with unstable hangman’s fracture underwent anterior discectomy and fusion with internal fixation at our unit. According to the Levine-Edwards classification, all cases were unstable with type II (10 cases), type IIA (17 cases) and type III (1 case). An average follow-up of 15 months was achieved (range: 3–48 months). The average operative time was 107 min (80–131 min). No patient received blood transfusion. No patient experienced worsening neurological function postoperatively. No other intra- or postoperative complication was observed. All patients were relieved from axial pain. Neurological status improved postoperatively in all four cases with neurological deficit. Each patient showed evidence of a solid anterior C2–3 interbody fusion after six months. No bone graft or plate screws complication was observed in any of the cases during the follow-up period. In our experience the anterior approach with primary internal stabilisation may be a feasible and safe method to treat unstable hangman’s fracture.
Transpedicular screw fixation has been accepted worldwide since Harrington et al. first placed pedicle screws through the isthmus. In vivo and in vitro studies indicated that pedicle screw insertion accuracy could be significantly improved with image-assisted systems compared with conventional approaches. The O-arm is a new generation intraoperative imaging system designed without compromise to address the needs of a modern OR like no other system currently available. The aim of our study was to check the accuracy of O-arm based and S7-navigated pedicle screw implants in comparison to free-hand technique described by Roy-Camille at the lumbar and sacral spine using CT scans. The material of this study was divided into two groups, free-hand group (group I) (30 patients; 152 screws) and O-arm group (37 patients; 187 screws). The patients were operated upon from January to September 2009. Screw implantation was performed during PLIF or TLIF mainly for spondylolisthesis, osteochondritis and post-laminectomy syndrome. The accuracy rate in our work was 94.1% in the free-hand group compared to 99% in the O-arm navigated group. Thus it was concluded that free-hand technique will only be safe and accurate when it is in the hands of an experienced surgeon and the accuracy of screw placement with O-arm can reach 100%.
Pedicle screws; Image-guided surgery; Spine navigation; O-arm
Pedicle screw fixation is the most preferred method of stabilizing unstable spinal fractures. Pedicle screw placement may be difficult in presence of fractured posterior elements, deformed spine, gross instability and spinal pathology. Challenging spine-fracture fixation is defined as the presence of one or more of the following: 1) obscured topographical landmarks as in ankylosing spondylitis, 2) fractures in occipitocervical or cervicothoracic regions and 3) preexisting altered spinal alignment. We report a series of pedicle screw insertion with guidance of navigation in difficult fixation problems..
Materials and Methods:
Fourteen patients [hangman's fracture (n=3), odontoid fracture (n=4), C1C2 fracture (n=1) and spinal fracture with coexistent ankylosing spondylitis (n=6)] underwent posterior stabilization. Intraoperatively after surgical exposure, images were acquired by Iso-C 3D C-arm and transferred to navigation system. Instrumentation was performed with navigational assistance. Postoperatively, placements of pedicle screws were evaluated with radiographs and CT scan.
Sixty-seven pedicle screws (cervical, n=33; thoracic, n=6; lumbar, n=26; sacral n=2) and 15 lateral mass screws were inserted with navigation guidance. The average time of image data acquisition by Iso-C 3D C-arm and its transfer to workstation was 4 minutes (range, 2-6 minutes). Postoperative CT scan revealed ideal placement of screws in 63 pedicles (94%), grade 1 cortical breaches (<2 mm) in 3 pedicles (4.5%) and grade 2 cortical breach (2-4 mm) in one pedicle (1.5%). There were no neurovascular complications. Deep infection was encountered in one case, which settled with debridement.
Intraoperative Iso-C 3D C-arm based navigation is a useful adjunct while stabilizing challenging spinal trauma, rendering feasibility, accuracy and safety of pedicle screw placement even in difficult situations.
Computer-assisted surgery; neuronavigation; pedicle screw; spine fracture; challenging spinal trauma
Hangman's fractures, also known as traumatic spondylolisthesis of axis, can be managed either conservatively with immobilization or by surgery. Surgery is usually indicated in cases with instability or failure of conservative treatment. Different surgical approaches, both anterior and posterior, have been described for treating Hangman's fracture. We report two patients, one with type IIa and another with type III Hangman's fracture treated with C1-C3 lateral mass fusion and discuss the advantages and limitations of this technique when compared to other techniques for fusion in patients with Hangman's fracture.
Axis fracture; C1-C3 fusion; cervical spine; Hangman's fracture; pars; pedicle; spinal fusion; traumatic spondylolisthesis of axis
A retrospective analysis of 7 patients with traumatic rotatory atlanto-axial subluxation.
Overview of Literature
Cases of traumatic rotatory atlantoaxial subluxation in children are difficult to be stabilized. Surgical challenges include: narrow pedicles, medial vertebral arteries, vertebral artery anomalies, fractured pedicles or lateral masses, and fixed subluxation. The use of O-arm and computer-assisted navigation are still tested as aiding tools in such operative modalities.
Report of clinical series for evaluation of the safety of use of the O-arm and computed assisted-navigation in screw fixation in children with traumatic rotatory atlantoaxial subluxation.
In the present study, 7 cases of rotatory atlantoaxial traumatic subluxation were operated between December 2009 and March 2011. All patient-cases had undergone open reduction and instrumentation using atlas lateral mass and axis pedicle screws with intraoperative O-arm with computer-assisted navigation.
All hardware was safely placed in the planned trajectories in all the 7 cases. Intraoperative O-arm and computer assisted-navigation were useful in securing neural and vascular tissues safety with tough-bony purchases of the hardware from the first and only trial of application with sufficient reduction of the subluxation.
Successful surgery is possible with using the intraoperative O-arm and computer-assisted navigation in safe and proper placement of difficult atlas lateral mass and axis pedicle screws for rotatory atlantoaxial subluxation in children.
Atlantoaxial joint fusion; Intraoperative computer-assisted 3D navigation; Computer-assisted three-dimensional imaging
A cadaveric study to determine the accuracy of percutaneous screw placement in the thoracic spine using standard fluoroscopic guidance.
Summary of Background Data:
While use of percutaneous pedicle screws in the lumbar spine has increased rapidly, its acceptance in the thoracic spine has been slower. As indications for pedicle screw fixation increase in the thoracic spine so will the need to perform accurate and safe placement of percutaneous screws with or without image navigation. To date, no study has determined the accuracy of percutaneous thoracic pedicle screw placement without use of stereotactic imaging guidance.
Materials and Methods:
Eighty-six thoracic pedicle screw placements were performed in four cadaveric thoracic spines from T1 to T12. At each level, Ferguson anterior–posterior fluoroscopy was used to localize the pedicle and define the entry point. Screw placement was attempted unless the borders of the pedicle could not be delineated solely using intraoperative fluoroscopic guidance. The cadavers were assessed using pre- and postprocedural computed tomography (CT) scans as well as dissected and visually inspected in order to determine the medial breach rate.
Ninety pedicles were attempted and 86 screws were placed. CT analysis of screw placement accuracy revealed that only one screw (1.2%) breached the medial aspect of the pedicle by more than 2 mm. A total of four screws (4.7%) were found to have breached medially by visual inspection (three Grade 1 and one Grade 2). One (1.2%) lateral breach was greater than 2 mm and no screw violated the neural foramen. The correlation coefficient of pedicle screw violations and pedicle diameter was found to be 0.96.
This cadaveric study shows that percutaneous pedicle screw placement can be performed in the thoracic spine without a significant increase in the pedicle breach rate as compared with standard open techniques. A small percentage (4.4%) of pedicles, especially high in the thoracic spine, may not be safely visualized.
Minimally invasive surgery; pedicle screw; thoracic spine
To reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions, the authors have been using C1/2 transarticular and cervical pedicle screw fixations. Pedicle screw fixation and C1/2 transarticular screw fixation are biomechanically superior to other fixation techniques for RA patients. However, due to severe spinal deformity and small anatomical size of the vertebra, including the lateral mass and pedicle, in the most RA cervical lesions, these screw fixation procedures are technically demanding and pose the potential risk of neurovascular injuries. The purpose of this study was to evaluate the accuracy and safety of cervical pedicle screw insertion to the deformed, fragile, and small RA spine lesions using computer-assisted image-guidance systems. A frameless, stereotactic image-guidance system that is CT-based, and optoelectronic was used for correct screw placement. A total of 21 patients (16 females, 5 males) with cervical disorders due to RA were surgically treated using the image-guidance system. Postoperative computerized tomography and plane X-ray was used to determine the accuracy of the screw placement. Neural and vascular complications associated with screw insertion and postoperative neural recovery were evaluated. Postoperative radiological evaluations revealed that only 1 (2.1%; C4) of 48 screws inserted into the cervical pedicle had perforated the vertebral artery canal more than 25% (critical breach). However, no neurovascular complications were observed. According to Ranawat’s classification, 9 patients remained the same, and 12 patients showed improvement. Instrumentation failure, loss of reduction, or nonunion was not observed at the final follow-up (average 49.5 months; range 24–96 months). In this study, the authors demonstrated that image-guidance systems could be applied safely to the cervical lesions caused by RA. Image-guidance systems are useful tools in preoperative planning and in transarticular or transpedicular screw placement in the cervical spine of RA patients.
Cervical spine; Image guidance; Rheumatoid arthritis; Cervical pedicle screw; Transarticular screw
CT navigation has been shown to improve component positioning in total shoulder arthroplasty. The technique can be useful in achieving strong initial fixation of the metal backed glenoid in reverse shoulder arthroplasty. We report a 61 years male patient who underwent reverse shoulder arthroplasty for rotator cuff arthropathy. CT navigation was used intraoperatively to identify best possible glenoid bone and to maximize the depth of the fixation screws that anchor the metaglene portion of the metal backed glenoid component. Satisfactory positioning of screws and component was achieved without any perforation or iatrogenic fracture in the scapula. CT navigation can help in maximizing the purchase of the fixation screws that dictate the initial stability of the glenoid component in reverse shoulder arthroplasty. The technique can be extended to improve glenoid component position [version and tilt] with the availability of appropriate software.
Computer-assisted surgery; CT navigation; reverse shoulder arthroplasty; rotator cuff arthropathy
Despite potential advantages of three-dimensional fluoroscopy-based navigation, there still remain a lot of controversies about the indications of this technology, especially whether it is worthy of being used in placement of pedicle screws in lumbar spine. However, according to the inconsistent conclusions reported in the literature and our experiences, the traditional method relying on anatomical landmarks and fluoroscopic views to guide lumbar pedicle screw insertion is unable to meet the requirement of precise screw placement. Based on our observation, screw malposition seems to occur concomitant with vertebral axial rotation which is a ubiquitous phenomenon. Three-dimensional fluoroscopy-based navigation can provide the most valuable axial images in real-time, so it may be useful for placement of pedicle screws in lumbar spine. This study was intended to evaluate the effect of axial rotation of lumbar vertebrae on the accuracy of pedicle screw placement using the traditional method, as well as assess the value of three-dimensional fluoroscopy-based navigation in improving the accuracy. Sixteen lumbar simulation models at different degrees of axial rotation (0°, 5°, 10°, and 20°), with every four assigned the same degree, were equally divided into two groups (traditional method group and three-dimensional fluoroscopy-based navigation group). Random placement of pedicle screws was carried out, followed by CT scan postoperatively. Then the outer pedicle cortex contours were depicted from reconstructed sectional pedicle images using Photoshop. The accuracy of pedicle screw placement was evaluated by determining the interrelationship between screw trajectory and pedicle cortex (quality), and measuring the shortest distance from pedicle screw axis to outer cortex of the pedicle (quantity). Eighty pedicle screws were implanted, respectively, in each group. In traditional method group, statistical difference existed in the accuracy of pedicle screw placement at different axial rotational degrees (P < 0.05). With degrees increasing, the accuracy declined. The accuracy of three-dimensional fluoroscopy-based navigation group was higher than traditional method group in vertebrae with axial rotation (P < 0.01). In qualitative evaluation, the accuracy of the two methods had statistical difference when the degree was 20°, and in quantitative evaluation, statistical difference existed in 5°, 10°, and 20° of vertebral axial rotation.
Lumbar spine; Pedicle screw; Vertebral rotation; Three-dimensional fluoroscopy-based navigation; Accuracy
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.
Computed tomography; Free-hand; Pedicle screw; Resident; Thoracic
Intra-articular screw penetration is one complication of volar plate fixation of distal radius fractures. This study was designed to determine the most utilized imaging techniques and views during volar plating of distal radius fractures and to evaluate surgeons’ ability to detect intra-articular screw placement on static fluoroscopic images and rotational fluoroscopy.
Active members of The American Society for Surgery of the Hand were polled regarding preferred imaging techniques (fluoroscopic versus cassette radiographs) and views (rotational fluoroscopy, static orthogonal/anatomic tilt/semi-pronated imaging) during volar plating of distal radius fractures. Following the survey, volar locking plates were applied to 30 cadaveric distal radii. A single screw intentionally penetrated the radiocarpal joint in half of the specimens (15 arms) and intentionally did not penetrate the radiocarpal joint in the other half. Imaging (standard posterior-anterior (PA) and lateral views, 11° tilt PA and 22° tilt lateral views, and two 360° fluoroscopy movies) was performed utilizing a custom jig. Five blinded surgeons reviewed randomized image sets evaluating for intra-articular screw placement. Receiver operating characteristic curves were constructed to compare the reliability of each fluoroscopic projection/movie.
Among 696 survey respondents, 88% exclusively utilized fluoroscopic imaging (without cassette radiographs) and nearly 66% preferred either tilt images or rotational fluoroscopy to detect intra-articular screw penetration. In our cadaveric model, rotational fluoroscopy provided the highest sensitivity (93%) and specificity (96%) for the detection of intra-articular screw penetration. Rotational fluoroscopy was significantly more reliable (p<0.01) than most images (standard lateral, 11° PA, 22° lateral, paired PA/lateral) and trended strongly toward better reliability for all remaining images (standard PA [p=0.07], paired 11° PA/22° lateral [p=0.08], 22° tilt fluoroscopy movie [p=0.11]).
Rotational fluoroscopy improves the surgeon’s ability to detect intra-articular screw penetration during volar plating of the distal radius. No combination of imaging allowed detection of all intra-articular screws. A high level of suspicion for intra-articular screw penetration should be maintained during volar plating of distal radial fractures.
Level of evidence
Unable to be determined according to guidelines
complication; distal radius; fracture; fluoroscopy; volar plate
Internal fixation is the established dorsal standard procedure for the treatment of thoracolumbar fractures. The main problem of the procedure is the false positioning of the pedicle screws. The exact determination of pedicle screws has up to now only been possible through postoperative computed tomography. This study was intended to clarify the diagnostic value of intraoperative 3D scans after pedicle screw implantation in thoracolumbar spine surgery. The direct intraoperative consequences of the 3D scans are reported and the results of the 3D scans are compared with the postoperative computed tomography images. Intraoperative 3D scans were prospectively carried out from June 2006 to October 2008 on 95 patients with fractures of the thoracolumbar spine that have been treated with internal fixation. Screws positions were categorised intraoperatively, screws in relevant malposition were repositioned immediately. A computed tomography of the involved spinal section was carried out postoperatively for all patients. The positions of the pedicle screws were determined and compared in the axial reconstructions of both procedures. Four hundred and fourteen pedicles with enclosed screws were evaluated by the 3D scans. The time needed for carrying out the 3D scan amounts to an average of 8.2 min. Eleven screws (2.7%) in ten patients were primarily intraoperatively repositioned on the basis of the 3D scan evaluation. Two of 95 patients had to have false positions of the screws revised secondarily following evaluation of the computed tomographies. The secondary postoperative revision rate of the patients amounts to 2.1%. In relation to the number of screws, this is a revision rate of 0.5%. The postoperative computed tomographies showed 323 pedicles without cortical penetration by the screws (78.0%). Ninety-one screws penetrated the pedicle wall (22%). It was possible to postoperatively compare the position classifications of 406 pedicle screws. The CT showed 378 correct screw positions, while 28 screws were positioned falsely. On the basis of the 3D scans, 376 of 378 correct positions were correctly assessed. Twenty-one of 28 false positions could be correctly classified. The sensitivity of all 3D scans reached 91.3% and the specificity 98.2%. The position of 97.8% of the pedicle screws was correctly recognised by the intraoperative 3D scan. Nine screws were classified falsely (2.2%). The comparison of the classification results showed significantly higher error findings by the 3D scan in the spinal section T1–10 (P = 0.014). The image quality of the 3D scan correlates significantly with the width of the scanned pedicle, with the body mass index, the scanned spinal section and the extent of the fixation assembly. 3D scans showed a high accuracy in predicting pedicle screw position. Primary false placement of screws and primary neurovascular damage cannot be avoided. But intraoperative evaluation of the 3D scans resulted in a primary revision rate of 2.7% of the pedicle screws and we could lower the secondary revision rate to 0.5%.
Three-dimensional fluoroscopy; Intraoperative 3D-imaging; Pedicle screws; Thoracolumbar fracture; Spine
The management of odontoid fracture has evolved but controversy persists as to the best method for Type II odontoid fractures with or without atlantoaxial (AA) instability. The anterior odontoid screw fixation can be associated with significant morbidity while delayed odontoid screw fixation has shown to be associated with reasonable good fusion rates. We conducted a retrospective analysis to evaluate the outcome of a trial of conservative management in type II odontoid fractures without atlantoaxial instability (Group A) followed by delayed odontoid screw fixation in cases in which fusion was not achieved by conservative treatment. The outcome of type II odontoid fracture with AA subluxation (Group B) was also analysed where closed reduction on traction could be achieved and in those atlantoaxial subluxations that were irreducible an intraoperative reduction was done.
Materials and Methods:
A retrospective evaluation of 53 cases of odontoid fractures treated over a 9-year period is being reported. All odontoid fractures without AA instability (n=29) were initially managed conservatively. Three patients who did not achieve union with conservative management were treated with delayed anterior screw fixation. Twenty-four cases of odontoid fractures were associated with AA instability; 17 of them could be reduced with skeletal traction and were managed with posterior fusion and fixation. Of the seven cases that were irreducible, the initial three cases were treated by odontoid excision followed by posterior fusion and fixation; however, in the later four cases, intra operative reduction was achieved by a manipulation procedure, and posterior fusion and fixation was performed.
Twenty-six of 29 cases of odontoid fracture without AA instability achieved fracture union with conservative management whereas the remaining three patients achieved union following delayed anterior odontoid screw fixation. 17 out of 24 odontoid fracture with atlantoaxial dislocation could be reduced on traction and these patients underwent posterior fusion and fixation. Optimal or near optimal reduction was achieved by on table manipulation in four cases which were irreducible with skeletal traction. Atlantoaxial stability was achieved in all cases. All cases were noted to be stable on evaluation with x-rays at six months.
The initial conservative management and use of odontoid screw fixation only in cases where conservative management for 6–12 weeks has failed to provide fracture union have shown good outcome in type II odontoid fracture without AA instability rates. Intraoperative manipulation and reduction in patients where AA subluxation failed to reduce on skeletal traction followed by posterior fusion obviates the need for transoral odontoid excision.
Atlantoaxial dislocation; cervical spine injuries; odontoid fractures
Different navigation procedures (based on 2D-, 3D-fluoroscopy or CT modalities) with their respective limitations are established in orthopedic surgery. The hypothesis is that intraoperative matching of different modalities (fluoro and CT) increases the precision of navigated screw placement and reduces the fluoroscopy time. Vertical unstable pelvic ring fractures of 12 patients were treated with vertebro-pelvic fixations (6 in the standard technique and 6 using the fluoro-CT navigation). An optimal osseous corridor could be determined by the navigation procedure increasing the overall precision of screw placement (no misplacement in the second group as compared to one malplaced pedicle screw in the standard group). The achieved screw lengths were [(mean ± SE) 78 ± 5 vs. 53 ± 4 mm, p < 0.001). Less invasive open approaches and a reduction of fluoroscopy time (time per screw in seconds: 121 vs. 62 s) were observed. CT-fluoro-matched navigation improves the intraoperative visualization of osseous structures and increases the precision of screw placement with less radiation exposure.
Computer-assisted surgery; CT-fluoro matching; Navigation; Spino-pelvic dissociation; Pelvic fracture; Vertebro-pelvic fixation
Technical errors during navigation-assisted bone tumor resection may occur by: (1) incorrect registration of images and corresponding anatomic points of bone sent to the navigation system; and (2) incorrect fusion of two or more images that have been transported to the navigation system.
We investigated new methods of navigation surgery to minimize technical errors during the registration and image fusion processes and specifically asked whether a navigated cannula probe would reduce unnecessary soft tissue dissection, and allow percutaneous registration and implantation of a reference base tracker in the margin of bone to be resected.
We performed direct MRI-guided navigation surgery without image fusion on a patient with osteosarcoma using absorbable pins as temporary implanted bone markers that prevent artifacts on MR images.
Direct MRI-guided navigation surgery was possible using bone markers. A navigated cannula probe allowed percutaneous registration and a navigated blade-shaped probe provided a real-time check on the narrow osteotomy gap. The surgical procedure was facilitated by implantation of a reference base tracker on the margin of bone to be resected.
Our modified technique of MRI-guided navigation surgery for patients with a malignant bone tumor may reduce processing errors by increased accuracy and be helpful for joint preserving surgery.
Medial femoral neck fractures are common, and closed reduction and internal fixation by three cannulated screws is an accepted method for the surgical treatment. Computer navigation for screw placement may reduce fluoroscopy time, the number of guidewire passes and optimise screw placement.
In the context of a sawbone study, a computer-assisted planning and navigation system based on 3D-imaging for guidewire placement in the femoral neck was tested to improve screw placement. Three screws were inserted into 12, intact, femoral sawbones using the conventional technique and into 12, intact, femoral sawbones guided by the computer-based navigation system. Guidewire and subsequent screw placement in the femoral neck were evaluated.
Use of the navigation system resulted in a significant reduction of the number of drilling attempts (p ≤ 0.05) and achieved optimised accuracy of implant placement by attaining significantly better screw parallelism (p ≤ 0.05) and significantly enlarged neck-width coverage by the three screws (p ≤ 0.0001). Computer assistance significantly increased the number of fluoroscopic images (p ≤ 0.001) and the operation time (p ≤ 0.0001).
Three-dimensional computer-assisted navigation improves accuracy of cannulated screw placement in femoral neck while increasing the number of fluoroscopic images and operation time. Additional studies including fractured sawbones and cadaver models with the goal of reducing operation time are indispensable before introduction of this navigation system into clinical practice.