title: Accuracy of Percutaneous Lumbosacral Pedicle Screw Placement Using the Oblique Fluoroscopic View Based on Computed Tomography Evaluations.
abstract: METHODS
  Retrospective.
  
  
  OBJECTIVE
  This study aims to investigate the accuracy of the oblique fluoroscopic view, based on preoperative computed tomography (CT) images for accurate placement of lumbosacral percutaneous pedicle screws (PPS).
  
  
  BACKGROUND
  Although PPS misplacement has been reported as one of the main complications in minimally invasive spine surgery, there is no comparative data on the misplacement rate among different fluoroscopic techniques, or comparing such techniques with open procedures.
  
  
  METHODS
  We retrospectively selected 230 consecutive patients who underwent posterior spinal fusion with a pedicle screw construct for degenerative lumbar disease, and divided them into 3 groups, those who had undergone: minimally invasive percutaneous procedure using biplane (lateral and anterior-posterior views using a single C-arm) fluoroscope views (group M-1), minimally invasive percutaneous procedure using the oblique fluoroscopic view based on preoperative CT (group M-2), and conventional open procedure using a lateral fluoroscopic view (group O: controls). The relative position of the screw to the pedicle was graded for the pedicle breach as no breach, <2 mm, 2-4 mm, or >4 mm. Inaccuracy was calculated and assessed according to the spinal level, direction and neurological deficit. Inter-group radiation exposure was estimated using fluoroscopy time.
  
  
  RESULTS
  Inaccuracy involved an incline toward L5, causing medial or lateral perforation of pedicles in group M-1, but it was distributed relatively equally throughout multiple levels in groups M-2 and controls. The mean fluoroscopy time/case ranged from 1.6 to 3.9 minutes.
  
  
  CONCLUSIONS
  Minimally invasive lumbosacral PPS placement using the conventional fluoroscopic technique carries an increased risk of inaccurate screw placement and resultant neurological deficits, compared with that of the open procedure. Inaccuracy tended to be distributed between medial and lateral perforations of the L5 pedicle, as a result of pedicle morphology and the PPS pathway. Oblique fluoroscopic views, based on CT measurement, may allow accurate PPS insertion with a shorter fluoroscopy time.
authors: Department of Orthopedic Surgery, Hamamatsu Medical Center, Hamamatsu, Japan.
authors: Go
authors: G
authors: Yoshida
authors: Department of Orthopedic Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
authors: Koji
authors: K
authors: Sato
authors: Department of Orthopedic Surgery, Konan Kosei Hospital, Aichi, Japan.
authors: Tokumi
authors: T
authors: Kanemura
authors: Department of Orthopedic Surgery, Hamamatsu Medical Center, Hamamatsu, Japan.
authors: Toshiki
authors: T
authors: Iwase
authors: Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan.
authors: Daisuke
authors: D
authors: Togawa
authors: Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan.
authors: Yukihiro
authors: Y
authors: Matsuyama
keywords: Accuracy; Minimally invasive; Oblique view; Pedicle screw fixation; Percutaneous