Original ArticleIncidence and Risk Factors for Facet Joint Violation in Open Versus Minimally Invasive Procedures During Pedicle Screw Placement in Patients with Trauma
Introduction
Fractures of the thoracolumbar spine are relatively common injuries. The operative management varies from minimally invasive procedures to open surgery. The general aim is posterior reduction and to restore correct spinal alignment. When handling AOSpine type B lesions or unstable burst fractures, pedicle screw/rod-based devices can be used as a stand-alone technique.1 Traditional open pedicle screw procedure is a widely accepted treatment option but it is being gradually replaced by minimally invasive procedures as indications for the latter are expanded. Less blood loss, lower infection rates, reduced postoperative pain, early mobilization, and fast recovery to work are the advantages of percutaneous pedicle screw placement compared with open surgery.2, 3, 4, 5
Although the standard midline approach provides wide exposure to the facet joint complex, minimally invasive screw insertion (MIS) renders the direct visualization of the relevant anatomic landmarks impossible. Posterior MIS has been described previously1, 6, 7, 8 and in this regard, the owl's eye and the true anteroposterior (AP) and lateral techniques are well known. Generally, percutaneous screw instrumentation is performed with the aid of intraoperative C-arm fluoroscopy in 2 planes (AP and lateral) to ensure that the relevant spinal anatomy is visible.
When performing the open procedure, additional intersegmental fusion is possible, although this is not the case in minimally invasive percutaneous screw placement. In most cases, the implant removal is performed after 6–12 months to release the motion segment. In this regard, it is most important that the facet joints of the segments under consideration are not severely altered as a result of worse screw positioning. Degenerative processes, in particular adjacent segment degeneration, might be the consequence. Because facet joints and intervertebral discs are the primary load-bearing and stabilizing structures in the physiologic spine, degenerative processes of the facets resulting from their violation might lead to increased sagittal-plane instability, especially in flexion,9 which in turn leads to more degeneration, initiating a vicious circle. However, the facet joints are at risk for iatrogenic damage within the instrumented segment during screw instrumentation, irrespective of an additional fusion procedure being performed or not.
Although several studies have focused on facet joint violation (FV) after pedicle screw instrumentation in the lumbar spine for degenerative indications,10, 11, 12, 13 little is known about the effects of FV at the thoracic spine and in trauma cases. Tannous et al.14 analyzed 2 different techniques in screw placement within the thoracic and lumbar spine (T2-L5) in a cadaver study. These investigators found that the lateral-to-medial technique reduced the risk for iatrogenic FV. In their retrospective analysis, Tromme et al.15 found a moderate rate of FV within the thoracolumbar spine (15.4%) and stated that the implant can be safely removed and the facet joint complex preserved. It is against this background that the present study aimed 1) to examine the incidence of FV in the thoracic and the lumbar spine and 2) to analyze implant-related and patient-related factors associated with FV.
The aim of the present study is to 1) examine the incidence of FV in the thoracic and the lumbar spine, 2) to analyze implant-dependent and 3) to analyze patient-dependent factors associated with FV including the assessment of pedicle screw accuracy referring to the classification system according to Zdichavsky et al.16
Section snippets
Methods
This retrospective study was conducted on all patients who underwent posterior pedicle screw instrumentation by MIS or open surgery caused by any type of thoracic or lumbar spine fracture (T1-L5) at our institution (level 1 trauma center) between January 2010 and December 2016. Inclusion criteria surgery at the thoracolumbar spine, age ≥16 years, bilateral pedicle screw instrumentation with/without fusion procedure, and a computed tomography (CT) scan within 12 months after the surgical
Results
In total, 275 patients met the inclusion criteria and 1099 inserted pedicle screws were studied. A total of 485 pedicle screws (44.13%) were implanted in female patients and 614 (55.87%) in male patients. The mean age of the study population at index surgery was 52.10 years (range, 14–87 years). The overall rate of FV, defined as a score between 1 and 4 (3), was 39.4% (n = 433), and the rate of FV was found to be lower in the thoracic spine and higher in the lumbar spine, which was stated to be
Discussion
The most important findings of our study are 1) the overall FV rate during pedicle screw placement was substantial (i.e., 39.9%); 2) open instrumentation led to a lower risk of FV within the lumbar and thoracic spine; 3) the screw position, especially at the thoracic spine, is a determining factor for a higher rate of FV, but 4) BMI has no significant influence on FV; (5) independent risk factors for a higher risk of FV were pedicle screws within the upper thoracic spine (T1-T8) or within the
Conclusions
FV is a common complication after thoracic and lumbar spine surgery. Although both, the SL instrumentation and the MIS procedure increases its occurrence, age, gender, facet angle, and BMI do not affect the rate of FV. In both, the thoracic and the lumbar spine, advanced experience with percutaneous instrumentation reduced the risk of FV over time.
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Cited by (26)
Robotic-Navigated Percutaneous Pedicle Screw Placement Has Less Facet Joint Violation Than Fluoroscopy-Guided Percutaneous Screws
2021, World NeurosurgeryCitation Excerpt :Babu et al.14 demonstrated that PPS placement has a greater overall violation grade and greater incidence of high-grade violations compared with open procedures. Herren et al.60 found that the rate of FJV was lower in the thoracic spine compared with the lumbar spine (34% vs. 44%, respectively, P = 0.028) in patients undergoing open or minimally invasive surgery fixation for traumatic injuries. Our study shows no significant difference FJV rates between the thoracic and lumbar spine screws when combining both robot and control cohorts, however, with 9.7% of the thoracic screws and 7.3% of the lumbar screws violating the facet joint (P = 0.5013).
Comparison of Clinical and Radiologic Outcome Between Mini-Open Wiltse Approach and Fluoroscopic-Guided Percutaneous Pedicle Screw Placement: A Randomized Controlled Trial
2020, World NeurosurgeryCitation Excerpt :However, PPS placement should be monitored under fluoroscopy or guided by a navigation or robotic system; the intraoperative radiation exposure is nonnegligible. Additionally, some studies have shown that invasion of the superior segment facet joint is more common in PPS placement than in open surgery, which can change the stress distribution of the facet joints resulting in the spontaneous fusion of the facet joints and the occurrence of spondylolisthesis in the adjacent disc and residual lower back pain.4-9 In 1968, Wiltse et al.10 first used the muscle-splitting approach to treat lumbar spinal fractures, in which the pedicle screw was inserted through the muscle space between the longissimus and multifidus.
Robot-assisted minimally invasive transforaminal lumbar interbody fusion in treatment of lumbar degenerative diseases
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.