Improving accuracy and reducing radiation exposure in minimally invasive lumbar interbody fusion.
OBJECTIVE
The authors assessed the accuracy of placement of lumbar transpedicular screws by using a computer-assisted, imaged-guided, minimally invasive technique with continuous electromyography (EMG) monitoring.


METHODS
This was a consecutive case series with prospective assessment of procedural accuracy. Forty-seven consecutive patients underwent minimally invasive lumbar interbody fusion and placement of pedicle screws (PSs). A computer-assisted image guidance system involving CT-based images was used to guide screw placement, while EMG continuously monitored the lumbar nerve roots at the operated levels with a 5-mA stimulus applied through the pedicle access needle. All patients underwent CT scanning to determine accuracy of PS placement. All episodes of adjusted screw trajectory based on positive EMG responses were recorded. Pedicle screw misplacement was defined as breach of the pedicle cortex by the screw of more than 2 mm.


RESULTS
Two hundred twelve PSs were inserted in 47 patients. The screw misplacement rate was 4.7%. One patient experienced new postoperative radiculopathy resulting from a sacral screw that was too long, with lumbosacral trunk impingement. The trajectory of the pedicle access needle was altered intraoperatively on 20 occasions (9.4% of the PSs) based on positive EMG responses, suggesting that nerve root impingement may have resulted from these screws had the EMG monitoring not been used.


CONCLUSIONS
The combination of computer-assisted navigation combined with continuous EMG monitoring during pedicle cannulation results in a low rate of PS misplacement, with avoidance of screw positions that might cause neural injury. Furthermore, this technique allows reduction of the radiation exposure for the surgical team without compromising the accuracy of screw placement.
Wood
Martin James
MJ
Department of Neurosurgery, The Princess Alexandra Hospital, Brisbane, Australia. mwood@mc.mater.org.au
Mannion
Richard John
RJ
D000328:Adult; D000368:Aged; D001863:Bone Screws; D004576:Electromyography; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D016343:Monitoring, Intraoperative; D013123:Spinal Fusion / Q000379:methods*; D013126:Spinal Nerve Roots / Q000502:physiology; D025321:Surgery, Computer-Assisted; D014057:Tomography, X-Ray Computed