title: [The Effect of Intraoperative Screw Monitoring (Root Monitoring) with the INS-1 System (NUVASIVE) on the Radiological Outcome of Dorsal Instrumentation of the Lumbar Spine].
abstract: BACKGROUND
  Transpedicular screw fixation of spinal segments has been described for a variety of surgical indications and is a key element in spinal surgery. The aim of transpedicular screw fixation is to achieve maximal stability. Screw malposition should be obviated to avoid neurological complications. There are published methods of applying evoked EMG to control screw position in relation to neural structures. These studies demonstrated that an intact bony pedicle wall acts as an electrical isolator between the screw and spinal nerve root. The aim of our study was to evaluate the impact of intraoperative pedicle screw monitoring on screw positioning.
  
  
  METHODS
  We enrolled 22 patients in this prospective randomised study, who underwent spinal instrumentation after being split into two equal groups. In the first group, dorsal instrumentation was supplemented with intraoperative nerve root monitoring using the INS-1-System (NuVasive, San Diego USA). In the second group, screws were inserted without additional pedicle monitoring. All patients underwent monosegmental instrumentation with "free hand implanted" pedicle screws. 44 screws were inserted in each group. The screw position was evaluated postoperatively using CT scans. The position of the screws in relation to the pedicle was measured in three different planes: sagittal, axial and coronal. The accuracy of the screw position was described using the Berlemann classification system. Screw position is classified in three groups: type 1 correct screw position, type 2 encroachment on the inner cortical wall, type 3 pedicle cortical perforation. Screw angulation and secondary operative criteria were also evaluated.
  
  
  RESULTS
  The use of neuromonitoring did not influence the distance between the centre of the screws and the pedicle wall. Distances only depended on the implantation side (right and left) and the height of implantation (caudal or cranial screw). Because of the low number of cases, no conclusion could be reached about the influence of root monitoring on the correct positioning of the screws. There was at least a non-significant trend towards more frequent perforation of the pedicle in the monitor group. In the present study, we showed that root monitoring had a significant effect on the scattering of transversal angles. These were increased compared to the control group. Otherwise, the implantation angle was not shown to depend on the use of neuromonitoring. Neuromonitoring did not influence blood loss or operative time.
  
  
  CONCLUSIONS
  The data did not permit any conclusion as to whether this technique can minimise the frequency of pedicle screw malposition. The four coronal plane distances did not depend on the use of neuromonitoring. The inclination angle was also unaffected by neuromonitoring. The only parameter for which we found any effect was the transverse angle. The mean values were similar in both groups, but the variances were not equal. The effect of monitoring on the only parameter which could not be evaluated by fluoroscopy is thus rather unfavourable.
authors.affiliation: Zentrum für integrative Traumatologie und Orthopädie, Helios-Klinikum Aue.
authors.forename: G
authors.initials: G
authors.lastname: Bernhardt
authors.affiliation: Klinik für Orthopädie, Otto-von-Guericke-Universität Magdeburg.
authors.forename: F
authors.initials: F
authors.lastname: Awiszus
authors.affiliation: Wirbelsäulenchirurgie und Kinderorthopädie, Helios Seehospital Sahlenburg, Cuxhaven.
authors.forename: U
authors.initials: U
authors.lastname: Meister
authors.affiliation: Orthopädische Klinik und Poliklinik, Universität Leipzig AöR.
authors.forename: C E
authors.initials: CE
authors.lastname: Heyde
authors.affiliation: Klinik für Wirbelsäulenchirurgie und Querschnittgelähmte, Zentralklinik Bad Berka GmbH.
authors.forename: H
authors.initials: H
authors.lastname: Böhm
mesh_terms: D005260:Female; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring / Q000295:instrumentation* / Q000379:methods; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D065289:Pedicle Screws; D019919:Prosthesis Implantation / Q000295:instrumentation / Q000379:methods; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013123:Spinal Fusion / Q000295:instrumentation* / Q000379:methods*; D016896:Treatment Outcome