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    Correction: Individualized 3D printing navigation template for pedicle screw fixation in upper cervical spine. PloS one [This corrects the article DOI: 10.1371/journal.pone.0171509.]. 10.1371/journal.pone.0212213
    A Review of the Historical Evolution, Biomechanical Advantage, Clinical Applications, and Safe Insertion Techniques of Cervical Pedicle Screw Fixation. Tukkapuram Venkata Ramakrishna,Kuniyoshi Abumi,Ito Manabu Spine surgery and related research Cervical spine instrumentation is evolving with an aim of stabilizing traumatic and non-traumatic cases of the cervical spine with a beneficial reduction, better biomechanical strength, and a strong construct with minimal intraoperative, as well as immediate and late postoperative complications. The evolution from interspinous wiring till cervical pedicle screws has changed the outlook in treating the cervical spine pathologies with maximum 3D stability, decreasing the duration of postoperative immobilization and hospital stay. Some complications associated with the use of cervical pedicle screw can be catastrophic. This review article discusses the morphometry of cervical pedicle; indications, biomechanical superiority, tricks, and pitfalls of cervical pedicle screw; complications and technical advancements in targeting safe surgery; and future directions of cervical pedicle screw instrumentation. 10.22603/ssrr.2018-0055
    Digitoxin metabolism by rat liver microsomes. Schmoldt A,Benthe H F,Haberland G Biochemical pharmacology
    Anterior Transdiscal Axial Screw Fixation for Subaxial Cervical Spine: A Biomechanical Study. Zheng Minghui,Ji Wei,Zou Lin,Huang Zhiping,Zhu Qingan,Qu Dongbin World neurosurgery OBJECTIVE:To evaluate stability of anterior transdiscal axial screw (ATAS) fixation for anterior instrumentation and to compare with standard anterior cervical decompression and fusion and plate (ACDFP) fixation in human subaxial cervical spine. METHODS:Flexibility tests were conducted on 7 cadaveric specimens (C5-T1) in an intact and injured state and instrumented with ACDFP fixation, ATAS fixation, and ACDFP plus ATAS fixation at the C6-7 segment after section of the anterior and posterior longitudinal ligaments and discectomy. A pure moment of ±2.0 N-m was applied to the specimen in flexion-extension, lateral bending, and axial rotation. Range of motion (ROM) and neutral zone were calculated for the C6-7 segment. RESULTS:ROM was reduced significantly compared with the intact or injured condition for 3 configurations under all motions. ATAS fixation resulted in similar ROM in C6-7 compared with ACDFP fixation in flexion (2.7° vs. 2.6°, P = 0.419), extension (2.7° vs. 2.1°, P = 0.152), and lateral bending (4.6° vs. 4.2°, P = 0.295) but larger ROM in axial rotation (6.1° vs. 5.3°, P = 0.014). When combined with an anterior plate, ATAS fixation reduced ROM to 1.2° in flexion, 1.1° in extension, 3.3° in lateral bending, and 3.8° in axial rotation, which were significantly smaller than ACDFP or ATAS fixation alone. CONCLUSIONS:ATAS fixation is a biomechanically effective alternative or supplemental method of anterior fixation in subaxial cervical spine. 10.1016/j.wneu.2017.11.008
    Cervical pedicle screw placement using intraoperative computed tomography imaging with a mobile scanner gantry. Yoshii Toshitaka,Hirai Takashi,Sakai Kenichiro,Inose Hiroyuki,Kato Tsuyoshi,Okawa Atsushi European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society PURPOSE:A multi-detector computed tomography (CT) imaging system with a mobile scanner gantry in the operating room can provide intraoperative reconstructed images with a high resolution. We devised a technique for cervical pedicle screw (CPS) placement using the mobile CT system and evaluated the accuracy of this technique. METHODS:Forty-eight patients who underwent cervical fixation using CPSs were prospectively enrolled in this study. Initial pedicle probing was performed approximately to the depth of the posterior aspect of the vertebral body using fluoroscopic lateral view, and a marking pin was put in place. Intraoperative CT images were obtained to confirm whether the position of the marking pin was accurate. After adequate modification of the trajectory was performed, an appropriately sized CPS was inserted. The accuracy of the CPS was evaluated using postoperative reconstructed CT images, and compared with a historical control group of 22 patients (CPS insertion using only fluoroscopy). RESULTS:A total of 193 CPSs were inserted. Intraoperative CT images demonstrated that 12.4 % of the initial probings were not accurate, and modification of the trajectory was required. On postoperative CT, 92.7 % of the CPSs were found to be placed accurately: the accuracy was significantly higher than the control group (80.9 %). In the cases using intraoperative CT images, only 1.0 % of the screws were judged to show grade 2 screw misplacement; no neurovascular complications associated with screw placement were observed. CONCLUSIONS:The technique of CPS placement using mobile CT was shown to be safe and effective in preventing catastrophic complications associated with CPS insertion. 10.1007/s00586-016-4508-2
    Is It "In" or "Out"? The Optimal Fluoroscopic Views for Intraoperative Determination of Proper Lateral Mass Screw Placement. Kim Sang Bum,Rhee John M,Oh Byung Hak,Won You Gun,Jung Yousun,Park Kun Young,Hutton William C,Kim Chulmin Spine STUDY DESIGN:Cadaveric. OBJECTIVE:Determine optimal fluoroscopic views for detecting cervical lateral mass screw (LMS) violations. SUMMARY OF BACKGROUND DATA:Single plane intraoperative x-rays are commonly used but frequently inadequate due to its complex trajectory. Fluoroscopy can be taken in multiple planes, but the ideal fluoroscopic view to assess malposition is not known: depending on the view, any given screw may look "in" or "out." METHODS:C3-6 LMS were inserted in three cadavers. To evaluate neuroforaminal violation, LMS were inserted into the foramen with the tip penetrating the anterior cortex by 0, 2, and 4 mm. To assess facet joint violation, LMS were inserted toward the subjacent facet joint with the tip penetrating the anterior cortex by 0 and 2 mm. Fluoroscopic views were taken 0°, 10°, 20°, 30°, and 40° to the lateral plane. Views were independently evaluated by three blinded spine surgeons. RESULTS:Twenty-degree oblique view correctly identified a 2 mm penetration into the neuroforamen in 79%, and a 4 mm penetration in 86%, for a sensitivity of 83% and specificity of 90%. Thirty-degree view had lower sensitivity (76%) but slightly higher specificity (93%). Twenty-degree and 30° views were significantly more sensitive than the other views. Zero-degree view correctly identified a 2 mm penetration into the facet joint in 93%, for a sensitivity of 93% and specificity of 92%. Ten-degree view had lower sensitivity (72%) but higher specificity (100%). The 0° view was significantly more sensitive than the other views. CONCLUSION:Twenty-degree and 30° oblique views significantly provided the most sensitive assessment of LMS potentially violating the neuroforamen, whereas the 0° neutral lateral view significantly provided the most sensitive assessment of facet violations. The specificities were also high (in the 90% range) for these views. We recommend the use of these views intraoperatively when assessing proper placement of LMS fluoroscopically. LEVEL OF EVIDENCE:N/A. 10.1097/BRS.0000000000001985
    Bicortical facet screws as a new option for posterior C2 fixation: anatomical study and clinical experience. Rusconi Angelo,Freitas-Olim E,Coloma P,Messerer R,Barrey C European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society PURPOSE:C2 fixation is a demanding procedure, particularly in patients with variants of C1-C2 anatomy. The inferior articular process (IAP) of the axis can be an alternative for screw placement. We report the results of a CT study of C2 IAP anatomy and we present the clinical experience of 28 patients operated with this technique. METHODS:Anatomical study: 50 CT angiographies of the vertebral arteries (VA) were used for this study and, therefore, 100 IAPs were considered. We measured on the axial and sagittal planes the length, height and width of the facet, the distance between the anterior cortex and the VA and the distance between the screw entry point and the VA. We also measured the angle between the sagittal plane and the external tangent line of the VA. CLINICAL REPORT:28 patients were treated with C2 IAP screws at the Spine Surgery Department of the University Hospital in Lyon, France, from January 2014 to January 2016. RESULTS:Anatomical study: the mean length of C2 IAP was 12 ± 2 mm, the mean distance between the anterior cortical layer and the VA was 5.2 ± 1.4 mm, and the mean angle we found was 0.2° ± 5.3°. CLINICAL REPORT:16 of the 28 patients presented post-traumatic C1-C2 instability, 8 patients presented degenerative disease, 1 patient was treated for pseudoarthrosis, 1 for tumour, 1 for OPLL and 1 for rheumatoid arthritis. All the screws were correctly positioned and there was no VA injury. CONCLUSION:IAP screws can represent a safe alternative option for C2 fixation. 10.1007/s00586-017-4997-7
    Free hand technique of cervical lateral mass screw fixation. Eldin Mohamed Mohi,Hassan Ahmed Salah Aldin Journal of craniovertebral junction & spine STUDY DESIGN:We introduce a simple free hand technique with great ease of application, without angles, measures or degrees, and without any fluoroscopic guidance. It is a safe and reproducible technique. We present our preliminary experience with the use this technique, with inimitable simplicity. PURPOSE:The primary aim of the procedure was to achieve adequate screw trajectory in an apparent challenging ease which is reproducible with a good outcome. OVERVIEW OF LITERATURE:Lateral mass screw fixation is used for posterior subaxial cervical fixation. It was described by Louis and Magerl, then by Anderson, An, and Ebraheim . Each one described the procedure with a unique screw entrance point and trajectory. TECHNICAL NOTE:This study is a prospective case study of 45 patients who underwent subaxial cervical lateral mass screw fixation. The screws were inserted using a free hand method. The described free hand technique was found to minimize the morbidity associated with other techniques without compromising the quality of fixation. CONCLUSIONS:Surgical experiences with this technique found it equally safe, rapid, easy, and reproducible. 10.4103/jcvjs.JCVJS_43_17
    Accuracy and Safety of Lateral Vertebral Notch-Referred Technique Used in Subaxial Cervical Pedicle Screw Placement. Pan Zhimin,Zhong Junlong,Xie Shiming,Yu Limin,Wu Chunyang,Ha Yoon,Kim Keung Nyun,Zhang Youshan,Cao Kai Operative neurosurgery (Hagerstown, Md.) BACKGROUND:Biomechanical studies revealed that pedicle screw instrumentation has a superior stabilizing effect compared with other internal fixations in reconstructing the subaxial cervical spine. However, severe neurovascular risks preclude surgeons from routinely conducting pedicle screw manipulation in cervical spine. OBJECTIVE:To evaluate the accuracy and safety of the lateral vertebral notch (LVN)-referred technique used in subaxial cervical pedicle screw (CPS) placement. METHODS:One hundred thirty-five consecutive retrospective patients with cervical disorders underwent the LVN-referred technique for CPS placements in 3 spine centers. Postoperative pedicle perforations were confirmed by CT scans to assess the technical accuracy. Neurovascular complications derived from CPS misplacements were recorded to evaluate the technical safety. RESULTS:A total of 718 CPSs were inserted into subaxial cervical spine. Postoperative CT scans revealed that the accuracy of CPS placement was superior. Neither vertebral artery injury nor spinal cord injury occurred. One radiculopathy was from a unilateral C6 nerve root compression. A screw-related neurovascular injury rate of 0.7% occurred in this cohort. Additionally, there was no significant difference in the accuracy of CPS placement among 3 surgeons (H = 1.460, P = .482). The relative standard deviation values revealed that technical reproducibility was acceptable. Furthermore, there was no significant difference between the patients' pedicle transverse angles and inserted CPS transverse angles from C3 to C7 (all P > .05). CONCLUSION:The LVN is a reliable and consistent anatomic landmark for CPS placement. The accuracy and safety of subaxial CPS placement by using LVN-referred technique are highly acceptable, which may endow this technique to be practicably performed in selected patients. 10.1093/ons/opy233
    A new anatomical approach of cervical lateral mass for cervical pedicle screw and paravertebral foramen screw insertion. Kim Moon-Kyu,Cho Ho-Jung,Kwak Dai-Soon PloS one Thus far, anatomical studies have reported data on the cervical pedicle, with the focus remaining on the pedicle itself. It was necessary to obtain more comprehensive data about the relationships between the lateral mass, pedicle, and transverse foramen for cervical pedicle screwing (CPS) and paravertebral foramen screwing (PVFS), a new technique. The purpose of this study was to describe the relationships between the lateral mass, pedicle, and transverse foramen. This study analyzed computed tomography images from 77 patients (42 female, 35 male; mean age: 63.95 years). The anatomical pedicle transverse angle (PTA) and linear parameters of the lateral mass were measured, and the relationship between the calculated angles and the anatomical PTA was investigated. θp was defined as the convergence angle from the posterolateral edge of the lateral mass to the pedicle, and θc was defined as the convergence angle from the posterolateral edge of the lateral mass to the anterolateral corner of the vertebral foramen. The thickness of the cortical bone of the medial wall of the lateral mass (cT) and the medial (mT) and lateral (lT) walls of the pedicle at C3-7 were also measured. The PTA was similar to θp and θc at C3-6, but different at C7. In all cases, the transverse foramen was located more anterior to the posterior wall of the cervical body at C3-6, but not at C7. mT and cT were significantly thicker than lT at all levels. Lateral fluoroscopic images show that when the probe is inserted along θc, it meets the counter corner of the lateral mass at C3-6 without invasion of the transverse foramen if it does not cross the posterior wall of the vertebral body. This can be significant when performing CPS and PVFS. 10.1371/journal.pone.0219119
    Safe placement of lateral mass screw in the subaxial cervical spine: a case series. Zhang Di,Gao Xianda,Jiang Jiang,Kong Fanlong,Shen Yong,Ding Wenyuan,Hao Xiufang,Cui Huixian International orthopaedics PURPOSE:Laminectomy with lateral mass screw fixation has been proven to be an effective method to treat the multilevel cervical degenerative myelopathy and severe cervical spondylosis. However, accurate and safe insertion of the lateral mass screw is technically demanding due to the individual variations of the anatomy of the lateral mass of the subaxial cervical spine. Misplaced lateral mass screw is not uncommon, and operation-related complications still beset the surgeons, which may impair the clinical outcomes. This study aimed to introduce a novel strategy for safe and accurate insertion of lateral mass screw in the subaxial cervical spine. METHODS:From July 2014 to March 2015, 24 patients with multilevel cervical degenerative myelopathy at C3-C6 levels received laminectomy. Before the operation, the screw insertion technique depended on the pre-operative imaging and operative exploration. Following this strategy, the lateral mass screws were inserted into the subaxial cervical spines. Post-operative radiograph was performed to observe the locations of the lateral mass screws and the cervical curvature. Patients were followed up, and the functional neurological recovery was evaluated by the modified Japanese Orthopedic Association (JOA) disability scale, the Neck Disability Index (NDI) and NDI ranking system. RESULTS:All screws were inserted into the lateral mass of C3-C6 cervical vertebrae following the current technique. Post-operative CT scans confirmed all screws inserted into the safe zone and relative safe zone of the lateral mass without any screw placed into the transverse foramen. The angle between the lateral mass screw and the vertical line was 40.49 ± 5.44 degrees on the axial CT images. Twenty-four patients were followed up for an average of 25.79 months (range, 20-30 months), and 22 cases evaluated as no or mild disability. According to the JOA score, NDI score and NDI ranking system, the postoperative function of the patients was significantly better when compared with their preoperative corresponding data (all p < 0.001) CONCLUSION: Inserting lateral mass screw following this new strategy is safe and easy to perform without any screw-related neurovascular complications, which contribute to the rigid fixation of the subaxial cervical spine and the satisfactory functional recovery. 10.1007/s00264-017-3423-4
    Optimal area of lateral mass mini-screws implanted in plated cervical laminoplasty: a radiography anatomy study. Chen Hua,Li Huibo,Deng Yuxiao,Rong Xin,Gong Quan,Li Tao,Song Yueming,Liu Hao European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society PURPOSE:Lateral mass mini-screws used in plated cervical laminoplasty might penetrate into facet joints. The objective is to observe this complication incidence and to identify the optimal areas for 5- and 7-mm-long mini-screws to implant on lateral mass. METHODS:47 patients who underwent plated cervical laminoplasty were included. The optimal area for mini-screws implanting was set according to pre-operative 3D CT reconstruction data. Then, each posterior-lateral mass surface was divided into three regions: 7-mm region, 5-mm region, and dangerous area. The mini-screw implanted region was recorded. Post-operative CT images were used to identify whether the mini-screws penetrated into facet joints. RESULTS:235 mini-plates and 470 lateral mass mini-screws were used in the study. 117 (24.9%) mini-screws penetrated 88 (37.4%) facet joints. The 5-mm-long mini-screw optimal area occupied the upper 72, 65, 65, 64, and 65 % area of the posterior-lateral mass surface for C3-7, while the 7-mm-long mini-screw optimal area encompassed the upper 54, 39, 40, 33, and 32 %. Only 7-mm-long mini-screws were used to fix the plate to the lateral mass. 4 of 240 mini-screws in 7-mm region, 67 of the 179 mini-screws in 5-mm region, and 46 of the 51 mini-screws in dangerous region penetrated into the facet joint. The differences in the rate of facet joint penetration related to region were statistically significant (P < 0.001). CONCLUSIONS:The facet joint destruction by mini-screws was not a rare complication in plated cervical laminoplasty. The optimal areas we proposed may help guide the mini-screw implantation positions. 10.1007/s00586-016-4785-9
    Three Dimensional Measurement of Ideal Trajectory of Pedicle Screws of Subaxial Cervical Spine Using the Algorithm Could Be Applied for Robotic Screw Insertion. Huh Jisoon,Hyun Jae Hwan,Park Hyeong Geon,Kwak Ho-Young Journal of Korean Neurosurgical Society OBJECTIVE:To define optimal method that calculate the safe direction of cervical pedicle screw placement using computed tomography (CT) image based three dimensional (3D) cortical shell model of human cervical spine. METHODS:Cortical shell model of cervical spine from C3 to C6 was made after segmentation of in vivo CT image data of 44 volunteers. Three dimensional Cartesian coordinate of all points constituting surface of whole vertebra, bilateral pedicle and posterior wall were acquired. The ideal trajectory of pedicle screw insertion was defined as viewing direction at which the inner area of pedicle become largest when we see through the biconcave tubular pedicle. The ideal trajectory of 352 pedicles (eight pedicles for each of 44 subjects) were calculated using custom made program and were changed from global coordinate to local coordinate according to the three dimensional position of posterior wall of each vertebral body. The transverse and sagittal angle of trajectory were defined as the angle between ideal trajectory line and perpendicular line of posterior wall in the horizontal and sagittal plane. The averages and standard deviations of all measurements were calculated. RESULTS:The average transverse angles were 50.60º±6.22º at C3, 51.42º ±7.44º at C4, 47.79º ±7.61º at C5, and 41.24º ±7.76º at C6. The transverse angle becomes more steep from C3 to C6. The mean sagittal angles were 9.72º ±6.73º downward at C3, 5.09º±6.39º downward at C4, 0.08º ±6.06º downward at C5, and 1.67º ±6.06º upward at C6. The sagittal angle changes from caudad to cephalad from C3 to C6. CONCLUSION:The absolute values of transverse and sagittal angle in our study were not same but the trend of changes were similar to previous studies. Because we know 3D address of all points constituting cortical shell of cervical vertebrae. we can easily reconstruct 3D model and manage it freely using computer program. More creative measurement of morphological characteristics could be carried out than direct inspection of raw bone. Furthermore this concept of measurement could be used for the computing program of automated robotic screw insertion. 10.3340/jkns.2018.0176
    Posterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations. Bajamal Abdul Hafid,Kim Se-Hoon,Arifianto Mohammad Reza,Faris Muhammad,Subagio Eko Agus,Roitberg Ben,Udo-Inyang Inyang,Belding Jonathan,Zileli Mehmet,Parthiban Jutty K B C, Neurospine OBJECTIVE:This study was conducted to determine and recommend the most up-to-date information on the indications, complications, and outcomes of posterior surgical treatments for cervical spondylotic myelopathy (CSM) on the basis of a literature review. METHODS:A comprehensive literature search was performed, using the MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and Web of Science databases, for peer-reviewed articles published in English during the last 10 years. RESULTS:Posterior techniques, which include laminectomy alone, laminectomy with fusion, and laminoplasty, are often used in patients with involvement of 3 or more levels. Posterior decompression for CSM is effective for improving patients' neurological function. Complications resulting from posterior cervical spine surgery include injury to the spinal cord and nerve roots, complications related to posterior screw fixation or instrumentation, C5 palsy, spring-back closure of lamina, and postlaminectomy kyphosis. CONCLUSION:It is necessary to consider multiple factors when deciding on the appropriate operation for a particular patient. Surgeons need to tailor preoperative discussions to ensure that patients are aware of these facts. Further research is needed on the cost-to-benefit analysis of various surgical approaches, the comparative efficacy of surgical approaches using various techniques, and long-term outcomes, as current knowledge is deficient in this regard. 10.14245/ns.1938274.137
    Cervical spine surgical approaches and techniques. Schnake Klaus J,Tropiano Patrick,Berjano Pedro,Lamartina Claudio European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 10.1007/s00586-016-4863-z
    Long-Term Influence of C1-C2 Pedicle Screw Fixation on Occipitoatlantal Angle and Subaxial Cervical Spine in the Pediatric Population. Tang Xiangsheng,Dong Liang,Tan Mingsheng,Yi Ping,Yang Feng,Hao Qingying Pediatric neurosurgery OBJECTIVE:The goal of this study was to evaluate the impact of C1-C2 pedicle screw fixation on the occipitoatlantal angle and subaxial cervical spine for a pediatric population, and the clinical efficacy and adjacent-segment degeneration after C1-C2 pedicle screw fixation with a minimum of 2 years of follow-up. METHODS:Twenty-two pediatric patients with atlantoaxial dislocation who were enrolled in this study underwent atlantoaxial pedicle screw fixation. The correlation between C0-C1, C2-C7, and C1-C2 pre- and postoperative sagittal angles was assessed using plain radiographs, and adjacent-segment degeneration (ASD) and JOA scores (Japanese Orthopaedic Association scores) were evaluated after atlantoaxial pedicle screw fixation. RESULTS:The C1-C2 angle increased from 16.1 ± 13.37 to 28.1 ± 5.1° (p < 0.01). The pre- and postoperative C1-C2 angles were negatively correlated with the pre- and postoperative C0-C1 and C2-C7 angles, respectively. In accordance with the optimal atlantoaxial fusion angle (25-30°) obtained from the literature, postoperative JOA scores were greater in the groups with angles of more than 30° and less than 25°, although the difference in ASD was not statistically significant. Postoperative JOA scores were not relevant to the postoperative C1-C2 angle; however, there was a positive correlation between JOA improvement rate and the change of the C1-C2 angle postoperatively. CONCLUSION:Atlantoaxial pedicle screw fixation can be used easily to reduce atlantoaxial dislocation in the pediatric population; however, outside the range of the optimal atlantoaxial fusion angle it can change the occipitoatlantal angle and subaxial alignment, which induces ASD and influences the clinical efficacy. It is necessary to achieve an optimal atlantoaxial angle when using atlantoaxial pedicle screw fixation. 10.1159/000481784
    Minimally invasive cervical pedicle screw fixation via the posterolateral approach for metastatic cervical spinal tumors. Sugimoto Yoshihisa,Hayashi Takahiro,Tokioka Takamitsu Spine surgery and related research Background:To avoid lateral misplacement of midcervical pedicle screws, we developed a method for Minimally Invasive Cervical Pedicle Screw (MICEPS) fixation via a posterolateral approach. This intramuscular approach allows for horizontal pedicle screw insertion and reduced intraoperative bleeding. We reviewed our initial experience with MICEPS fixation for patients with cervical metastases. Methods:This study included 18 consecutive patients who received cervical spinal surgery for metastatic tumor. We treated 12 patients with conventional cervical pedicle screw fixation, and 6 patients with the MICEPS fixation technique. Average follow-up was 14 months (range 3 to 34). We inserted 117 pedicle screws using the navigation system. Average fusion area was 4.9 vertebrae (range 3 to 8). Alpha-angles between a line perpendicular to the posterior cortex of the vertebral body and the screw trajectory in the transverse plane were also measured. Results:The average surgical time was 250 min (range 151 to 420 min) with the conventional pedicle screw fixation and 234 min (range 154 to 300 min) with the MICEPS fixation. The average total blood loss was 780 mL (range, 180-1430 mL) in the conventional pedicle screw fixation group and 180 mL (range, 70-400 mL) in the MICEPS fixation group. At the level of midcervical (C3-5), average alpha-angles was 52 degrees (range 43 to 62) in MICEPS fixation group, and 39 degrees (range 19 to 55) in conventional cervical pedicle screw group. Conclusions:The MICEPS fixation technique uses an intramuscular approach, which is minimally invasive and reduces intraoperative bleeding. Intramuscular approach allows for horizontal pedicle screw insertion, and reduced critical screw deviation. 10.22603/ssrr.1.2016-0025
    Biomechanical comparison of transfacet screws to lateral mass screw-rod constructs in the lower cervical spine. Tong Jie,Ji Wei,Zhou Ruozhou,Huang Zhiping,Liu Sheting,Zhu Qingan European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society PURPOSE:Transfacet screws have been used as an alternative posterior fixation in the cervical spine. There is lack of spinal stability of the transfacet screws either as stand-along constructs or combined with anterior plate. This study was designed to evaluate spinal stability of transfacet screws following posterior ligamentous injury and combined with anterior plate, respectively, and compare transfacet screws to lateral mass screw-rod constructs. METHODS:Flexibility tests were conducted on eight cadaveric specimens in an intact and injury, and instrumented with the transfacet screw fixation and lateral mass screw-rod construct at C5-C7 levels either after section of the posterior ligamentous complex or combined with an anterior plate and a mesh cage for C6 corpectomy reconstruction. A pure moment of ±2.0 Nm was applied to the specimen in flexion-extension, lateral bending, and axial rotation. Ranges of motion (ROM) were calculated for the C5-C7 segment. RESULTS:ROM with the transfacet screws was 22 % of intact in flexion-extension, 9 % in lateral bending and 11 % in axial rotation, while ROM with the lateral mass screw-rod construct was 9 % in flexion-extension, 8 % in lateral bending and 22 % in axial rotation. The only significant difference between two constructs was seen in flexion-extension (5.8 ± 4.2° vs. 2.4 ± 1.2°, P = 0.002). When combined with an anterior plate and mesh cage, the transfacet screw fixation reduced ROM to 3.0° in flexion-extension, 1.2° in lateral bending, and 1.1° in axial rotation, which was similar to the lateral mass screw-rod construct. CONCLUSIONS:This study identified the transfacet screw fixation, as stand-alone posterior fixation, was equivalent to the lateral mass screw-rod constructs in axial rotation and lateral bending except in flexion-extension. When combined with an anterior plate, the transfacet screw fixation was similar to the lateral mass screw-rod construct in motion constraint. The results suggested the transfacet screw fixation a biomechanically effective way as supplementation of anterior fixation. 10.1007/s00586-015-4305-3
    Anatomic Study of Anterior Transdiscal Axial Screw Fixation for Subaxial Cervical Spine Injuries. Ji Wei,Zheng Minghui,Qu Dongbin,Zou Lin,Chen Yongquan,Chen Jianting,Zhu Qingan Medicine Anterior transdiscal axial screw (ATAS) fixation is an alternative or supplement to the plate and screw constructs for the upper cervical spine injury. However, no existing literatures clarified the anatomic feasibility of this technique for subaxial cervical spine. Therefore, the objective of this study was to evaluate the anatomical feasibility and to establish guidelines for the use of the ATAS fixation for the subaxial cervical spine injury.Fifty normal cervical spines had radiographs to determine the proposed screw trajectory (the screw length and insertion angle) and the interbody graft-related parameters (the disc height and depth, and the distance between anterior vertebral margin and the screw) for all levels of the subaxial cervical spine. Following screw insertion in 8 preserved human cadaver specimens, surgical simulation and dissection verified the feasibility and safety of the ATAS fixation.Radiographic measurements showed the mean axial screw length and cephalic incline angle of all levels were 41.2 mm and 25.2°, respectively. The suitable depth of the interbody graft was >11.7 mm (the distance between anterior vertebral margin and the screw), but <17.1 mm (disc depth). Except the axial screw length, increase in all the measurements was seen with level up to C5-C6 segment. Simulated procedure in the preserved specimens demonstrated that ATAS fixation could be successfully performed at C2-C3, C3-C4, C4-C5, and C5-C6 levels, but impossible at C6-C7 due to the obstacle of the sternum. All screws were placed accurately. None of the screws penetrated into the spinal canal and caused fractures determined by dissecting the specimens.The anterior transdiscal axial screw fixation, as an alternative or supplementary instrumentation for subaxial cervical spine injuries, is feasible and safe with meticulous surgical planning. 10.1097/MD.0000000000003723
    Long-term outcomes and prognostic analysis of modified open-door laminoplasty with lateral mass screw fusion in treatment of cervical spondylotic myelopathy. Su Nan,Fei Qi,Wang Bingqiang,Li Dong,Li Jinjun,Meng Hai,Yang Yong,Guo Ai Therapeutics and clinical risk management OBJECTIVES:The purpose of the present study was to explore and analyze the long-term outcomes and factors that affect the prognosis of expansive open-door laminoplasty with lateral mass screw fusion in treatment of cervical spondylotic myelopathy (CSM). METHODS:We retrospectively reviewed 49 patients with multilevel CSM who had undergone expansive open-door laminoplasty with lateral mass screws fixation and fusion in our hospital between February 2008 and February 2012. The average follow-up period was 4.6 years. The clinical data of patients, including age, sex, operation records, pre- and postoperation Japanese Orthopedic Association (JOA) scores, cervical spine canal stenosis, and cervical curvature, were collected. Increased signal intensity (ISI) on T2-weighted magnetic resonance imaging and ossification of the posterior longitudinal ligament were also observed. Paired t-test was used to analyze the treatment effectiveness and recovery of neuronal function. The prognostic factors were analyzed with multivariable linear regression model. RESULTS:Forty-nine patients with CSM with a mean age of 59.44 years were enrolled in this study. The average of preoperative JOA score was 9.14±2.25, and postoperative JOA score was 15.31±1.73. There was significant difference between the pre- and postoperative JOA scores. The clinical improvement rate was 80.27%. On follow-up, five patients had complaints of neck and shoulder pain, but no evidence of C5 nerve palsy was found. Developmental cervical spine canal stenosis was present in all patients before surgery. Before surgery, ISI was observed in eight patients, while ossification of the posterior longitudinal ligament was found in 12 patients. The average of preoperative cervical curvature was 21.27°±8.37° and postoperative cervical curvature was 20.09°±1.29°, and there was no significant difference between the pre- and postoperative cervical curvatures. Multivariable linear regression analysis results showed that the postoperation JOA scores were significantly affected by age, preoperative JOA scores, and preoperative ISI. Except one case of epidural hematoma, there were no complications associated with the surgery. CONCLUSION:Treatment of CSM with posterior open-door laminoplasty with lateral mass screw fusion is effective with few complications. In addition, the normal cervical lordosis was well maintained. Age, preoperative JOA scores, and preoperative ISI were the independent factors that significantly affect disease prognosis and surgical outcomes. 10.2147/TCRM.S110340
    Precision and safety of Multilevel Cervical Transpedicular Screw Fixation with 3D Patient-Specific Guides; A Cadaveric Study. Sallent Andrea,Ramírez Manuel,Catalá Jordi,Rodríguez-Baeza Alfonso,Bagó Joan,de Albert Matías,Vélez Roberto Scientific reports The aim is to design a patient-specific instrument (PSI) for multilevel cervical pedicle screw placement from C2 to C7, as well as verifying reliability and reproducibility. Computed tomography (CT) scans were obtained from 7 cadaveric cervical spines. Using Mimics software, semiautomatic segmentation was performed for each cervical spine, designing a 3D cervical spine bone model in order to plan transpedicular screw fixation. A PSI was designed according to the previously cited with two cannulated chimneys to guide the drill. The guides were 3D printed and surgeries performed at the laboratory. Postoperative scans were obtained to study screw placement. Sixty-eight transpedicular screws were available for study. 61.8% of all screws were within the pedicle or partially breached <4 mm. No differences were observed between cervical levels. None of these screws had neurovascular injury. Of the 27 screws with a grade 3 (screw outside the pedicle; 39.7%), only 2 had perforation of the transverse foramen and none of them would have caused a neural injury. In conclusion, multilevel PSI for cervical pedicle screw is a promising technology that despite showing improvements regarding free-hand technique requires further studies to improve the positioning of the PSI and their accuracy. 10.1038/s41598-019-51936-w
    Novel unilateral C1 double screw and ipsilateral C2 pedicle screw placement combined with contralateral laminar screw-rod fixation for atlantoaxial instability. Shi Lei,Shen Kai,Deng Rui,Yan Zheng-Jian,Liang Kai-Lu,Chen Liang,Ke Zhen-Yong,Deng Zhong-Liang European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society PURPOSE:To investigate the anatomical and biomechanical feasibility of the unilateral C1 double screw [pedicle screw (PS) + lateral mass screw (LMS)] and ipsilateral C2 PS combined with contralateral C2 laminar screw (LS)-rod fixation for atlantoaxial instability by comparison with traditional posterior fixation methods. METHODS:Fifteen sets of complete dry bony specimens of atlas were used for morphometric analysis. The working length, width and thickness of the C1 PSs and LMSs were manually measured. Ten fresh-frozen cervical spines (C0-C7) were used to complete the range of motion (ROM) testing in their intact condition, under destabilization and after stabilization by the following procedures: unilateral C1-C2 PS rod fixation (Group A), bilateral C1-C2 PS rod fixation (Group B), and unilateral C1 double screw and ipsilateral C2 PS combined with contralateral C2 LS rod fixation (Group C). RESULTS:The working thickness of the C1 PS was ≤ 3.5 mm in only one (1/15 = 6.7%) specimen. The other parameters were > 3.5 mm in all specimens. In the ROM test, all fixation groups showed significantly reduced flexibility in all directions compared with both the intact and destabilization groups. Further, Groups B and C showed better stability in all directions than Group A. However, no significant differences were observed between Groups B and C. CONCLUSION:The C1 unilateral lateral mass could mostly contain two screws(PS + LMS) with diameters ≤ 3.5 mm. The novel technique of unilateral C1 double screw and ipsilateral C2 PS combined with contralateral C2 LS rod fixation provided better stability than unilateral PS rod fixation and similar as bilateral PS rod fixation. Therefore, it is a feasible salvage method that provides a new insight into atlantoaxial instability. These slides can be retrieved under Electronic Supplementary Material. 10.1007/s00586-018-5853-0
    Is Initial Posterior Atlantoaxial Fixation and Fusion Applying Bilateral C1-2 Transarticular Screws and C1 Laminar Hooks Reliable for Acute Pediatric Atlantoaxial Instability?: A Minimal 10-Year Analysis of Outcome and Radiological Evaluation. Guo Xiang,Han Zhao,Chen Qunxiang,Yang Jun,Chen Fei,Guo Qunfeng,Lin Peida,Ni Bin Spine STUDY DESIGN:A retrospective case series study with at least 10 years of follow-up data. OBJECTIVE:To validate the reliability of bilateral C1-2 transarticular screws and C1 laminar hooks and a bone autograft for acute pediatric atlantoaxial instability. SUMMARY OF BACKGROUND DATA:The reliability of initial posterior atlantoaxial fusion in pediatric patients is still controversial. To date, however, only a few published articles with short-term follow-up data are available to help spinal surgeons understand the effects of posterior atlantoaxial fusion in the skeletally immature spine. METHODS:Five pediatric patients with acute atlantoaxial instability underwent atlantoaxial fusion using the above technique over a 3-year period. During a minimum 10-year follow-up period, not only outcomes and complications were investigated, but the vertical growth of the constructed spine in relation to the growth of the entire cervical spine, overall cervical spinal alignment, and adjacent-segment instability were evaluated. RESULTS:The clinical follow-up indicated solid fusion and complete clinical relief from symptoms. No neural or vascular impairment was observed. The radiological evaluation showed that all patients had growth within the fusion construct reaching a mean 35.4% of the entire cervical spine. There were no radiological indicators of subaxial instability, even when cervical sagittal alignments became straight with a mean C2-7 angle of 6.4°. CONCLUSION:The results showed that initial posterior atlantoaxial fusion accomplished with bilateral C1-2 transarticular screws, C1 laminar hooks fixation, and bony autograft is a reliable surgical technique for treating acute pediatric atlantoaxial instability without negative effects on vertical growth at the fused level or the stability of the subaxial spine. LEVEL OF EVIDENCE:3. 10.1097/BRS.0000000000003259
    The accuracy of the lateral vertebral notch-referred pedicle screw insertion technique in subaxial cervical spine: a human cadaver study. Luo Jiaquan,Wu Chunyang,Huang Zhongren,Pan Zhimin,Li Zhiyun,Zhong Junlong,Chen Yiwei,Han Zhimin,Cao Kai Archives of orthopaedic and trauma surgery STUDY DESIGN:This is a cadaver specimen study to confirm new pedicle screw (PS) entry point and trajectory for subaxial cervical PS insertion. OBJECTIVE:To assess the accuracy of the lateral vertebral notch-referred PS insertion technique in subaxial cervical spine in cadaver cervical spine. BACKGROUNDS:Reported morphometric landmarks used to guide the surgeon in PS insertion show significant variability. In the previous study, we proposed a new technique (as called "notch-referred" technique) primarily based on coronal multiplane reconstruction images (CMRI) and cortical integrity after PS insertion in cadavers. However, the PS position in cadaveric cervical segment was not confirmed radiologically. Therefore, the difference between the pedicle trajectory and the PS trajectory using the notch-referred technique needs to be illuminated. METHODS:Twelve cadaveric cervical spines were conducted with PS insertion using the lateral vertebral notch-referred technique. The guideline for entry point and trajectory for each vertebra was established based on the morphometric data from our previous study. After 3.5-mm diameter screw insertion, each vertebra was dissected and inspected for pedicle trajectory by CT scan. The pedicle trajectory and PS trajectory were measured and compared in axial plane. The perforation rate was assessed radiologically and was graded from ideal to unacceptable: Grade 0 = screw in pedicle; Grade I = perforation of pedicle wall less than one-fourth of the screw diameter; Grade II = perforation more than one-fourth of the screw diameter but less than one-second; Grade III = perforation more than one-second outside of the screw diameter. In addition, pedicle width between the acceptable and unacceptable screws was compared. RESULTS:A total of 120 pedicle screws were inserted. The perforation rate of pedicle screws was 78.3% in grade 0 (excellent PS position), 10.0% in grade I (good PS position), 8.3% in grade II (fair PS position), and 3.3% in grade III (poor PS position). The overall accepted accuracy of pedicle screws was 96.7% (Grade 0 + Grade I + Grade II), and only 3.3% had critical breach. There was no statistical difference between the pedicle trajectory and PS trajectory (p > 0.05). Compared to the pedicle width (4.4 ± 0.7 mm) in acceptably inserted screw, the unacceptably screw is 3.2 ± 0.3 mm which was statistically different (p < 0.05). CONCLUSION:The accuracy of the notch-referred PS insertion in cadaveric subaxial cervical spine is satisfactory. 10.1007/s00402-017-2647-5
    The Learning Curve of Subaxial Cervical Pedicle Screw Placement: How Can We Avoid Neurovascular Complications in the Initial Period? Heo Yeon,Lee Su Bum,Lee Byung Ju,Jeong Sung Kyun,Rhim Seung Chul,Roh Sung Woo,Park Jin Hoon Operative neurosurgery (Hagerstown, Md.) BACKGROUND:Despite the biomechanical benefits of subaxial cervical pedicle screw (CPS) placement, possible neurovascular complications, including vertebral artery and nerve root injury, are of great concern. We have demonstrated many times the safety and efficacy of CPS deployments, even when using freehand technology. OBJECTIVE:To analyze the learning curve of CPS placement to determine the number of cases necessary for assuring safe CPS placement and to identify a reasonable accuracy rate. METHODS:From March 2012 to August 2018, a single surgeon performed posterior cervical fusion surgery using CPS placement on 162 consecutive patients. We classified whole surgical periods, 6 years, into 4 periods. We analyzed the screw breach rate, lateral mass screw conversion (LMSC) rate, and reposition rate. We also compared the CPS placement accuracy in the initial 15, 20, and 30 patients with the other 147, 142, and 132 patients, respectively, to assess the number of procedures necessary to reach the learning curve plateau and to identify a reasonable accuracy rate. RESULT:The total number of planned CPS placements was 979. Our learning curve showed that the breach rate plateaus at 3% to 4%. The necessary numbers for safe and accurate CPS placement during learning curve were 30 patients and 170 screws. None of the patients undergoing CPS developed a neurologic or vascular complication. CONCLUSION:By following our 5 safety steps, the steady state for safety and accuracy can be reached without neurovascular complications even in the initial period of the learning curve. 10.1093/ons/opz070
    "Beyond the thin ideal: Development and validation of the Fit Ideal Internalization Test (FIIT) for women": Correction to Uhlmann et al. (2019). Psychological assessment Reports an error in "Beyond the thin ideal: Development and validation of the Fit Ideal Internalization Test (FIIT) for women" by Laura R. Uhlmann, Caroline L. Donovan and Melanie J. Zimmer-Gembeck (, Advanced Online Publication, Sep 19, 2019, np). In the article, there are two errors in the Method section for Study 2. First, in the "Body dissatisfaction" subsection, the range of total scores for the Body-Image Ideals Questionnaire was incorrectly listed as being "between 0 and 99." The correct range is from - 3 to 9. Second, in the "Dieting and bulimia" subsection, the reference for the Eating Attitudes Test (EAT-26) was incorrectly cited as "Garner et al., 1983." Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. , 12, 871-878. http://dx.doi .org/10.1017/s0033291700049163. (The following abstract of the original article appeared in record 2019-55793-001.) Females are at risk for body image and eating disturbance when they internalize societally prescribed standards of Western beauty. With respect to messages to be thin or muscular, numerous scales are available that measure internalization. However, many women are now receiving messages about the desirability of being both thin and toned, yet no self-report measure of internalization of a fit female body ideal exists. Our aim was to develop a multidimensional tool (i.e., the Fit Ideal Internalization Test; FIIT) useful for assessing women's internalization of the fit ideal (i.e., a lean and toned body ideal). Three studies were conducted, recruiting independent groups of women attending university to complete surveys. In Study 1 ( = 300, age 16-51), women completed the FIIT items, and a 3-factor structure of fit idealization (8 items), fit overvaluation (8 items), and fit behavioral drive (4 items) was established through exploratory factor analysis. Also, items loading highly on each of the factors had good interitem correlations. In Study 2 ( = 354, age 16-63), women completed the 20-item FIIT and validation measures. The 3-factor structure of the FIIT was confirmed, and findings supported convergent, discriminant, and incremental validity of the FIIT subscale scores (and a total score). In Study 3 ( = 67, age 17-50), the 2-week test-retest reliability of the FIIT scores was high. Overall, the 3 FIIT subscales are related but also distinct domains of fit ideal internalization that conform to theory and may be used as individual subscales or potentially as a composite score. (PsycINFO Database Record (c) 2020 APA, all rights reserved). 10.1037/pas0000794
    Erratum to: Rectocutaneous fistula with transmigration of the suture: a rare delayed complication of vault fixation with the sacrospinous ligament. Kadam Pratima Datta,Chuan Han How International urogynecology journal There was an oversight in the Authorship of a recent Images in Urogynecology article titled: Rectocutaneous fistula with transmigration of the suture: a rare delayed complication of vault fixation with the sacrospinous ligament (DOI 10.1007/ s00192-015-2823-5). We would like to include Adj A/P Han How Chuan’s name in the list of authors. Adj A/P Han is a Senior Consultant and Department Head of Urogynaecology at the KK Hospital for Women and Children, Singapore. 10.1007/s00192-016-2952-5
    Answer to the Letter to the Editor of G.C. Willhuber concerning "Proposal for a new trajectory for subaxial cervical lateral mass screws" by S. Amhaz-Escanlar et al. (Eur Spine J; 2018: doi: 10.1007/s00586-018-5670-5). Díez-Ulloa Máximo-Alberto European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 10.1007/s00586-018-5714-x
    Correction to Lancet Diabetes Endocrinol 2019; published online March 1. DOI:10.1016/ S2213-8587(19)30066-X. The lancet. Diabetes & endocrinology 10.1016/S2213-8587(19)30109-3
    Posterior Transpedicular Screw Fixation of Subaxial Vertebrae: Accuracy Rates and Safety of Mini-laminotomy Technique. Celikoglu Erhan,Borekci Ali,Ramazanoglu Ali Fatih,Cecen Dilber Aycicek,Karakoc Abdullah,Bektasoglu Pinar Kuru Asian journal of neurosurgery Background and Aim:Posterior cervical transpedicular screw fixation has the strongest resistance to pullout forces compared with other posterior fixation systems. Here, we present a case on the use of this technique combined with a mini-laminotomy technique, which serves as a guide for accurate insertion of posterior cervical transpedicular screws. Materials and Methods:We retrospectively analyzed data from 40 patients who underwent this procedure in our clinic between January 2014 and March 2017. Results:The study population comprised 27 males (67.5%) and 13 females (32.5%) aged 15-80 years (median, 51.5 years). Surgical indications included trauma ( = 18, 45%), degenerative disease ( = 19, 47.5%), spinal infection ( = 2, 5%), and basilar invagination due to systemic rheumatoid disease ( = 1, 2.5%). In the 18 trauma patients, 14 short-segment (1-2 levels) and 4 long-segment (≥3 levels) posterior cervical instrumentation and fusion procedures were performed. The mini-laminotomy technique was used in all patients to insert, direct, and achieve exact screw fixation in the pedicles. Pedicle perforations were classified as medial or lateral and were also graded. Among the 227 cervical pedicle fixations performed, 48 were at the C3 level, 49 at C4, 60 at C5, 50 at C6, and 20 at C7. Axial computed tomography scan measurements showed that 205 of 227 (90.3%, Grade 0 and 1) screws were accurately placed, whereas 22 (9.69%, Grade 2 and 3) were misplaced. However, no additional neurological injury due to misplacement was observed. Conclusion:As negligible complications were observed when performed by experienced surgeons, the mini-laminotomy technique can be safely used for posterior transpedicular screw fixation in the subaxial vertebrae for single-staged fusion. 10.4103/ajns.AJNS_178_17