Individual Navigation Templates for Subcortical Screw Placement in Lumbar Spine

Subcortical screw placement is currently performed using frontal view fluoroscopy or intraoperative O-arm navigation system. The emergence of a novel technique for spinal navigation based on individual navigation templates created using 3D printing technology determines the need to study their safety and effectiveness in subcortical implantation.

The aim of the study was to evaluate and compare the efficacy of subcortical implantation of pedicle screws in the lumbar spine using individual navigation templates versus intraoperative fluoroscopy.

Materials and Methods. The study was based on the analysis of treatment results in 39 patients who underwent surgery with subcortical implantation of 130 screws using the MidLIF technique. In group 1, navigation templates were used, in group 2 — intraoperative fluoroscopic control. Comparative analysis of implantation correctness and time, the total operation time, and radiation load was performed.

Results. The mean distance between the screw and the cortical plate recorded in the groups ranged within 1.20–3.97 mm, without statistically significant difference (p>0.05). The mean time of pedicle screw implantation was 137.0 [115.25; 161.50] s in group 1 and 314.0 [183.50; 403.25] s in group 2. The total operation time was reduced from 173.0 [155.0; 192.25] min in group 2 to 119.0 [108.0; 128.75] min in group 1. The average of 1.0 [1.0; 2.0] X-ray image was performed to place one screw in group 1, while it was 12.0 [10.0; 13.25] in group 2. The differences between the groups in terms of implantation time and radiation load were statistically significant (p<0.05).

Conclusion. Compared with intraoperative fluoroscopy, the use of individual navigation templates for subcortical implantation of pedicle screws provides their correct positioning with a significant reduction in both operation time and radiation load at similar safety.

1. Santoni B.G., Hynes R.A., McGilvray K.C., Rodriguez-Canessa G., Lyons A.S., Henson M.A., Womack W.J., Puttlitz C.M. Cortical bone trajectory for lumbar pedicle screws. Spine J 2009; 9(5): 366–373, https://doi.org/10.1016/j.spinee.2008.07.008.
2. Mobbs R.J. The “medio-latero-superior trajectory technique”: an alternative cortical trajectory for pedicle fixation. Orthop Surg 2013; 5(1): 56–59, https://doi.org/10.1111/os.12027.
3. Dabbous B., Brown D., Tsitlakidis A., Arzoglou V. Clinical outcomes during the learning curve of MIDline Lumbar Fusion (MIDLF®) using the cortical bone trajectory. Acta Neurochir (Wien) 2016; 158(7): 1413–1420, https://doi.org/10.1007/s00701-016-2810-8.
4. Khanna N., Deol G., Poulter G., Ahuja A. Medialized, muscle-splitting approach for posterior lumbar interbody fusion: technique and multicenter perioperative results. Spine (Phila Pa 1976) 2016; 41 (Suppl 8): S90–S96, https://doi.org/10.1097/brs.0000000000001475.
5. Lee G.W., Son J.H., Ahn M.W., Kim H.J., Yeom J.S. The comparison of pedicle screw and cortical screw in posterior lumbar interbody fusion: a prospective randomized noninferiority trial. Spine J 2015; 15(7): 1519–1526, https://doi.org/10.1016/j.spinee.2015.02.038.
6. Takenaka S., Mukai Y., Tateishi K., Hosono N., Fuji T., Kaito T. Clinical outcomes after posterior lumbar interbody fusion: comparison of cortical bone trajectory and conventional pedicle screw insertion. Clin Spine Surg 2017; 30(10): E1411–E1418, https://doi.org/10.1097/bsd.0000000000000514.
7. Matsukawa K., Yato Y., Imabayashi H., Hosogane N., Abe Y., Asazuma T., Chiba K. Biomechanical evaluation of fixation strength among different sizes of pedicle screws using the cortical bone trajectory: what is the ideal screw size for optimal fixation? Acta Neurochir (Wien) 2016; 158(3): 465–471, https://doi.org/10.1007/s00701-016-2705-8.
8. Kaito T., Matsukawa K., Abe Y., Fiechter M., Zhu X., Fantigrossi A. Cortical pedicle screw placement in lumbar spinal surgery with a patient-matched targeting guide: a cadaveric study. J Orthop Sci 2018; 23(6): 865–869, https://doi.org/10.1016/j.jos.2018.06.005.
9. Kim J., Rajadurai J., Choy W.J., Cassar L., Phan K., Harris L., Fiechter M., Mobbs R.J. Three-dimensional patient-specific guides for intraoperative navigation for cortical screw trajectory pedicle fixation. World Neurosurg 2019; 122: 674–679, https://doi.org/10.1016/j.wneu.2018.11.159.
10. Marengo N., Matsukawa K., Monticelli M., Ajello M., Pacca P., Cofano F., Penner F., Zenga F., Ducati A., Garbossa D. Cortical bone trajectory screw placement accuracy with a patient-matched 3-dimensional printed guide in lumbar spinal surgery: a clinical study. World Neurosurg 2019; 130: e98–e104, https://doi.org/10.1016/j.wneu.2019.05.241.
11. Phan K., Ramachandran V., Tran T.M., Shah K.P., Fadhil M., Lackey A., Chang N., Wu A.M., Mobbs R.J. Systematic review of cortical bone trajectory versus pedicle screw techniques for lumbosacral spine fusion. J Spine Surg 2017; 3(4): 679–688, https://doi.org/10.21037/jss.2017.11.03.
12. Phan K., Hogan J., Maharaj M., Mobbs R.J. Cortical bone trajectory for lumbar pedicle screw placement: a review of published reports. Orthop Surg 2015; 7(3): 213–221, https://doi.org/10.1111/os.12185.
13. Rodriguez A., Neal M.T., Liu A., Somasundaram A., Hsu W., Branch C.L. Jr. Novel placement of cortical bone trajectory screws in previously instrumented pedicles for adjacent-segment lumbar disease using CT image-guided navigation. Neurosurg Focus 2014; 36(3): E9, https://doi.org/10.3171/2014.1.focus13521.
14. Azimi P., Yazdanian T., Benzel E.C., Azimi A., Montazeri A. 3D-printed navigation template in cervical spine fusion: a systematic review and meta-analysis. Eur Spine J 2021; 30(2): 389–401, https://doi.org/10.1007/s00586-020-06601-6.
15. Elford J.H., Oxley B., Behr S. Accuracy of placement of pedicle screws in the thoracolumbar spine of dogs with spinal deformities with three-dimensionally printed patient-specific drill guides. Vet Surg 2020; 49(2): 347–353, https://doi.org/10.1111/vsu.13333.
16. Zhang M., Li J., Fang T., Zhao J., Pan W., Wang X., Xu J., Zhou Q. Evaluation of a three-dimensional printed guide and a polyoxymethylene thermoplastic regulator for percutaneous pedicle screw fixation in patients with thoracolumbar fracture. Med Sci Monit 2020; 26: e920578, https://doi.org/10.12659/msm.920578.
17. Burtsev A.V., Pavlova O.M., Ryabykh S.O., Gubin A.V. Computer 3D-modeling of patient-specific navigational template for cervical screw insertion. Hirurgia pozvonocnika 2018; 15(2): 33–38, https://doi.org/10.14531/ss2018.2.33-38.
18. Kosulin A.V., Elyakin D.V., Kornievskiy L.A., Darkovskaya A.M., Bulatova I.A., Pashko A.A. Application of three-level navigation template in surgery for hemivertebrae in adolescents. Hirurgia pozvonocnika 2020; 17(1): 54–60, https://doi.org/10.14531/ss2020.1.54-60.
19. Kosulin A.V., Elyakin D.V., Lebedeva K.D., Sukhomlinova A.E., Kozlova E.A., Orekhova A.E. Navigation template for vertebral pedicle passage in transpedicular screw fixation. Pediatr 2019; 10(3): 45–50, https://doi.org/10.17816/ped10345-50.
20. Merc M., Recnik G., Krajnc Z. Lumbar and sacral pedicle screw placement using a template does not improve the midterm pain and disability outcome in comparison with free-hand method. Eur J Orthop Surg Traumatol 2017; 27(5): 583–589, https://doi.org/10.1007/s00590-017-1904-1.
21. Lu S., Xu Y.Q., Zhang Y.Z., Li Y.B., Shi J.H., Chen G.P., Chen Y.B. Rapid prototyping drill guide template for lumbar pedicle screw placement. Chin J Traumatol 2009; 12(3): 177–180.
22. Merc M., Drstvensek I., Vogrin M., Brajlih T., Recnik G. A multi-level rapid prototyping drill guide template reduces the perforation risk of pedicle screw placement in the lumbar and sacral spine. Arch Orthop Trauma Surg 2013; 133(7): 893–839, https://doi.org/10.1007/s00402-013-1755-0.
23. Shao Z.X., Wang J.S., Lin Z.K., Ni W.F., Wang X.Y., Wu A.M. Improving the trajectory of transpedicular transdiscal lumbar screw fixation with a computer-assisted 3D-printed custom drill guide. PeerJ 2017; 5: e3564, https://doi.org/10.7717/peerj.3564.
24. Cao Y., Zhang W., Liang Y., Feng Z., Jiang C., Chen Z., Jiang X. Translaminar facet joint screw insertion with a rapid prototyping guide template: a cadaver study. Comput Assist Surg (Abingdon) 2019; 24(1): 1–6, https://doi.org/10.1080/24699322.2018.1542027.

Kovalenko R.A., Kashin V.A., Cherebillo V.Yu. Individual Navigation Templates for Subcortical Screw Placement in Lumbar Spine. Sovremennye tehnologii v medicine 2021; 13(5): 41, https://doi.org/10.17691/stm2021.13.5.05