title: Use of anteroposterior view fluoroscopy for targeting percutaneous pedicle screws in cases of spinal deformity with axial rotation.
abstract: OBJECTIVE
  Over the past decade percutaneous pedicle screws have become popular for the minimally invasive treatment of spinal disorders. However, until the last 5 years the presence of a significant spinal deformity was regarded as a relative contraindication for percutaneous instrumentation. Recent advances in surgical technique and intraoperative technology have made percutaneous fixation in complex spinal pathologies more commonplace. The authors report their experience using a parsimonious method for uniplanar fluoroscopic targeting of pedicles in challenging cases.
  
  
  METHODS
  The authors performed a retrospective analysis of patients with adult spinal deformity who underwent percutaneous pedicle screw instrumentation from 2008 to 2013. Cases were included if a spiral slice postoperative CT scan was obtained. All cases had a minimum of 10° of axial rotation and typically had additional accompanying anatomical abnormalities. Screws were assessed for any pedicle violations as well as any impingement of the surrounding facet joints.
  
  
  RESULTS
  A total of 410 pedicle screws were placed in 36 patients with an average 6.4 levels of instrumentation per patient. The mean age was 67 years (range 44-86 years) and there were 25 females. Of the 410 screws, 29 (7.1%) had some medial or lateral pedicle violation. Of these, 15 (3.7%) were Grade 1, 6 (1.4%) were Grade 2, and 8 (2.0%) were Grade 3 violations. Of the Grade 3 violations, 2 each were at the L-4, L-5, and S-1 levels, and 1 each was at the T-10 and L-1 levels. Two of the patients had symptoms and both underwent screw repositioning, one during the same admission and the other in a delayed fashion. Both were at the L-5 and S-1 levels with anatomically highly medialized pedicles. There were no motor deficits, and both removals were for numbness. Of the 72 screws at the proximal end of the construct, there were 6 facet violations (8.3%). Four (5.6%) of these were Grade 1, 1 (1.4%) was Grade 2, and 1 (1.4%) was Grade 3.
  
  
  CONCLUSIONS
  The anteroposterior fluoroscopic technique can be effectively used by spinal surgeons to cannulate the pedicles in patients with rotational deformities. The complication rate in this challenging population is acceptable and is in accordance with the existing literature. However, caution should be used at L-5 and S-1 when the pedicle is narrow and highly medialized, rendering an indistinct medial wall on anteroposterior imaging.
authors.affiliation: Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Faiz U
authors.initials: FU
authors.lastname: Ahmad
authors.forename: Michael Y
authors.initials: MY
authors.lastname: Wang
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005471:Fluoroscopy / Q000379:methods; D006801:Humans; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000295:instrumentation*; D065289:Pedicle Screws; D011857:Radiographic Image Interpretation, Computer-Assisted; D012189:Retrospective Studies; D012399:Rotation; D013122:Spinal Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: AP = anteroposterior; MIS = minimally invasive surgery; TLIF = transforaminal lumbar interbody fusion; adjacent segment; complication; facet joint; minimally invasive; pedicle screw; percutaneous; scoliosis; spinal deformity; technique