Translaminar screw fixation of the lumbar spine

Summary Lower lumbar spinal fusion was carried out in 72 patients by a technique which involved screw fixation of the facet joints. Stability was achieved and mobilisation was allowed immediately. Radiographs after operation showed bony fusion in 94.5%. Pain was diminished and 76% of the patients would undergo the same treatment again. There were no neurological complications. The technique is useful and safe for the fusion of short segments of the lumbar spine.

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Résumé Une arthodèse du rachis lombaire a été réalisée chez 72 patients selon la technique décrite par Magerl, dont le principe est une fixation des articulations interapophysaires par deux vis. Les indications de cette intervention sont les lésions dégénératives, les anomalies congénitales, l'hypermobilité segmentaire ou les déformations post-traumatiques. Chez 37 patients l'arthrodèse a porté sur un niveau, chez 34 sur deux niveaux et chez 3 sur trois niveaux. Une décompression du canal vertébral a été effectuée dans 56 cas. Une fusion radiologique sans déplacement des vis a été obtenue dans 94.5% des cas. Les douleurs pré-opératoires, évaluées en moyenne à 7.7 sur une échelle de 0 à 10, sont tombées à 2.9 aprés l'intervention. 76% des patients accepteraient le même traitement si cela était nécessaire. Le vissage translaminaire offre une stabilité post-opératoire satisfaisante et permet une mobilisation immédiate. Aucune complication neurologique n'a été observée. Au vu de ces résultats nous pouvons conclure que cette technique est efficace et peu dangereuse pour stabiliser de petits segments de la colonne lombaire ou lombo sacrée.

     

Translaminar screw fixation of the lumbar facet joints

Surgical Principle Posterior fusion of one or two levels of the lumbar spine with arthrodesis of the facet joints using screws. The technique has been developed by one of us (Magerl [10–13]). It constitutes an improvement of a technique of transarticular screw fixation first described by King in 1944 [7, 8] and modified by Boucher [3] (Figures 1a to 1c).     

Translaminar screw fixation in lumbar spine pathology

Summary Two technical variations of the method of translaminar screw fixation for unstable lumbar and lumbosacral segments are presented. Distraction-arthrodesis with intraarticular bone grafts allows definitive enlargement of narrowed foramina with consecutive root decompression as well as repositioning and intracanalicular decompression in cases of instability after lumbar disc surgery and in degenerative spondylolisthesis. Reconstruction of a hemilamina after hemilaminectomy and facet reduction allows reconstitution of the spinal canal and its posterior parts as well as direct treatment of intraforaminal pathology.     

Posterior atlantoaxial transpedicular screw and plate fixation. Technical note

The authors describe a modified posterior atlantoaxial fixation technique for the treatment of reducible atlantoaxial instability, which can be performed simply and easily, and can decrease the risk of vessel and/or neural damage. During an 18-month period, this technique was undertaken in 11 patients with atlantoaxial instability. There was no procedure-related morbidity. The follow-up period ranged from 8 to 18 months (mean 13.2 months). Fusion was documented in all 11 patients, and there was no progression of spinal deformity. This technique can be considered an effective alternative in the treatment of atlantoaxial subluxation.     

Palliative dual iliac screw fixation for lumbosacral metastasis. Technical note

Spinal fixation for destructive metastatic lesions at the lumbosacral junction is challenging because of the large and unique load-bearing characteristics present. In particular, caudal fixation is difficult in cases of sacral destruction because of insufficient S-1 pedicle screw anchorage. The authors describe their surgical technique for secure iliac screw placement and the clinical results obtained in five patients with metastatic spinal disease. All patients in this study underwent palliative operations with dual iliac screw fixation between April 1999 and October 2002, and the clinical and radiological findings were assessed. In all five patients, spinal metastases extended into the sacrum. The metastases were from renal cell carcinomas in two patients, lung cancer in two, and a paraganglioma in one patient. Postoperative follow-up periods ranged from 3 months to 6 years (mean 28.4 months). Preoperatively, four patients could not walk due to severe pain or neurological compromise. Postoperatively, all patients reported a reduction in pain and regained the ability to walk. Complications included one case of early wound infection. In the patients with long survival after the operation, there was one case of iliac screw loosening and one case of rod breakage. The dual iliac screw fixation technique provided sufficient immediate stability for destructive lumbosacral metastasis.     

Computed tomography-guided percutaneous facet screw fixation in the lumbar spine. Technical note

The authors describe a new minimally invasive technique for posterior supplementation using percutaneous translaminar facet screw (TFS) fixation with computed tomography (CT) guidance. Oblique axial images were used to determine facet screw fixation sites. After the induction of local anesthesia and conscious sedation, a guide pin was inserted and guided with a laser mounted on the CT gantry. Cannulated TFSs were placed via a percutaneous approach. From December 2002 to August 2003, 18 patients underwent CT-guided TFS. In 17 of these patients this procedure was supplementary to anterior lumbar interbody fusion, which had been performed several days earlier; in the remaining patient, CT-guided TFS fixation was undertaken as the primary therapy. Twelve patients had painful degenerative disc disease or unstable degenerative spondylolisthesis, three had infections, and three had deformities. All screws were inserted accurately and there were no complications. This new minimally invasive surgical technique may offer an alternative to pedicle screw fixation as a method of posterior supplementation.     

Atlantooccipital transarticular screw fixation for the treatment of traumatic occipitoatlantal dislocation. Technical note

The authors describe a new technique of internal atlantooccipital screw fixation involving posterior wiring and fusion for the treatment of traumatic atlantooccipital dislocation, which was performed in a 17-year-old male patient involved in a motor vehicle accident and who suffered from atlantooccipital dislocation without neurological injury. At the 6-month follow-up examination, the patient was neurologically intact with a solid occipitocervical fusion and full range of motion of the neck.     

Application of a novel headrest system for odontoid screw fixation. Technical note

The authors describe a unique headholder device adapted to facilitate the placement of anterior odontoid screws. The patient's head is affixed in the headholder equipped with an articulating arm that can be placed in a paramedian fashion. This configuration rigidly fixates the head and provides an unencumbered open-mouth view of the odontoid using radiographic images, thus making screw placement easier.     

Intra-operative screw trimming in direct screw fixation of the odontoid process fracture — Technical note

Summary For a satisfactory direct screw fixation of fractures of the odontoid process it is necessary to use a screw of the proper total length and thread length, but such an optimal ready-made screw is not always available. The authors describe a technique of intra-operative screw trimming using a high-speed diamond drill. This adjustment is easily and quickly performed. It enables the screw to act as a compression screw, which facilitates fusion of the fractured surfaces.     

Laminar screw fixation of the axis

OBJECT: Laminar fixation of the axis with crossing bilateral screws has been shown to provide rigid fixation with a theoretically decreased risk of vertebral artery damage compared with C1-2 transarticular screw fixation and C-2 pedicle screw fixation. Some studies, however, have shown restricted rigidity of such screws compared with C-2 pedicle screws, and others note that anatomical variability exists within the posterior elements of the axis that may have an impact on successful placement. To elucidate the clinical impact of such screws, the authors report their experience in placing C-2 laminar screws in adult patients over a 2-year period, with emphasis on clinical outcome and technical placement. METHODS: Sixteen adult patients with cervical instability underwent posterior cervical and cervicothoracic fusion procedures at our institution with constructs involving C-2 laminar screws. Eleven patients were men and 5 were women, and they ranged in age from 28 to 84 years (mean 57 years). The reasons for fusion were degenerative disease (9 patients) and treatment of trauma (7 patients). In 14 patients (87.5%) standard translaminar screws were placed, and in 2 (12.5%) an ipsilateral trajectory was used. All patients underwent preoperative radiological evaluation of the cervical spine, including computed tomography scanning with multiplanar reconstruction to assess the posterior anatomy of C-2. Anatomical restrictions for placement of standard translaminar screws included a deeply furrowed spinous process and/or an underdeveloped midline posterior ring of the axis. In these cases, screws were placed into the corresponding lamina from the ipsilateral side, allowing bilateral screws to be oriented in a more parallel, as opposed to perpendicular, plane. All patients were followed for >2 years to record rates of fusion, instrumentation failure, and other complications. RESULTS: Thirty-two screws were placed without neurological or vascular complications. The mean follow-up duration was 27.3 months. Complications included 2 revisions, one for pseudarthrosis and the other for screw pullout, and 3 postoperative infections. CONCLUSIONS: Placement of laminar screws into the axis from the standard crossing approach or via an ipsilateral trajectory may allow a safe, effective, and durable means of including the axis in posterior cervical and cervicothoracic fusion procedures.     

Translaminar screw fixation in the lumbar spine: technique, indications, results

Translaminar screw fixation of the lumbar spine represents a simple and effective technique for short segment fusion in the degenerative spine. Clinical experience with 173 patients who underwent translaminar screw fixation revealed a fusion rate of 94%. The indications for translaminar screw fixation as a primary fixation procedure are: segmental dysfunction, lumbar spinal stenosis with painful degenerative changes, segmental revision surgery after discectomies, and painful disc-related syndromes such as internal disc disruption and lumbar disc herniation with concomitant degenerative changes. As an additional stabilization procedure, translaminar screws can be used to augment anterior fusion or reinforce pedicle systems. Translaminar screw fixation achieves as high fusion rate provided the biomechanical principles of the lumbar spine with an intact anterior column are respected and a meticulous operative technique is employed to enhance bony ingrowth of the graft. Received: 12 January 1998 Revised: 18 March 1998 Accepted: 6 April 1998     

Atlantoaxial stabilization with the use of C1-3 lateral mass screw fixation. Technical note

Atlantoaxial stabilization has evolved from simple posterior wiring to transarticular screw fixation. In some patients, however, the course of the vertebral artery (VA) through the axis varies, and therefore transarticular screw placement is not always feasible. For these patients, the authors have developed a novel method of atlantoaxial stabilization that does not require axial screws. In this paper, they describe the use of this technique in the first 10 cases. Ten consecutive patients underwent the combined C1-3 lateral mass-sublaminar axis cable fixation technique. The mean age of the patients was 62.6 years (range 23-84 years). There were six men and four women. Eight patients were treated after traumatic atlantoaxial instability developed (four had remote trauma and previous nonunion), whereas in the other two atlantoaxial instability was caused by arthritic degeneration. All had VA anatomy unsuitable to traditional transarticular screw fixation. There were no intraoperative complications in any of the patients. Postoperative computed tomography studies demonstrated excellent screw positioning in each patient. Nine patients were treated postoperatively with the aid of a rigid cervical orthosis. The remaining patient was treated using a halo fixation device. One patient died of respiratory failure 2 months after surgery. Follow-up data (mean follow-up duration 13.1 months) were available for seven of the remaining nine patients and demonstrated a stable construct with fusion in each patient. The authors present an effective alternative method in which C1-3 lateral mass screw fixation is used to treat patients with unfavorable anatomy for atlantoaxial transarticular screw fixation. In this series of 10 patients, the method was a safe and effective way to provide stabilization in these anatomically difficult patients.     

枢椎椎板螺钉固定与枢椎椎弓根螺钉固定对枕颈融合术临床疗效的影响

目的探讨经枢椎椎弓根螺钉与经枢椎椎板螺钉固定对枕颈融合术临床疗效的影响。方法选取2007年4月—2012年2月在本院行枕颈融合术的患者66例,回顾分析其临床资料、影像学资料以及随访资料。按照术式分为经枢椎椎弓根螺钉枕颈融合组(A组,37例)和经单侧枢椎椎板螺钉枕颈融合组(B组,29例)。对2组患者的颈髓角、日本骨科学会(JOA)评分、Odom功能分级以及寰枢关节复位情况进行分析比较。结果 2组患者术后随访26~56个月,平均37.6个月。术后1周及末次随访JOA评分与术前相比差异有统计学意义(P0.05),各时间点组间差异无统计学意义(P0.05)。2组患者术后1周颈髓角均有较大改善,与术前相比差异有统计学意义(P0.05);末次随访时2组患者颈髓角均有丢失,但与术后1周相比差异无统计学意义(P0.05);各时间点组间差异无统计学意义(P0.05)。术后3 d时A组解剖复位36例(97.3%),B组解剖复位27例(93.2%),差异无统计学意义(P0.05);末次随访时A组解剖复位丢失1例(2.7%),B组解剖复位丢失6例(20.7%),组间差异有统计学意义(P0.05)。末次随访时所有患者均骨性融合,随访过程中未发生严重并发症及后遗症。结论 2种融合方式均可取得满意的临床疗效,且对颈髓的减压充分。经椎弓根螺钉枕颈融合术可获得长期复位效果,是枕颈融合的首选术式。对必须采用经椎板螺钉枕颈融合的患者,术中应充分植骨,以增加复位的强度和稳定性。     

组合枢椎椎板螺钉及经枢椎椎板关节突螺钉固定技术的临床应用

目的探讨组合枢椎椎板螺钉及经枢椎椎板关节突螺钉(TLFS)固定技术治疗颈椎损伤的可行性和应用价值。方法自2005年10月～2008年10月,采用枢椎椎板螺钉及经枢椎TLFS固定技术治疗颈椎损伤36例。结果本组获随访13~32个月,平均18个月。30例行自体髂骨植骨,6例行异体骨植骨,获得了良好的骨性愈合。术后CT示枢椎椎板螺钉及经枢椎TLFS位置良好,未侵犯椎管和脊髓。结论枢椎椎板螺钉及经枢椎TLFS固定技术不受C2横突孔中椎动脉的位置和C2椎弓根大小限制,避免了螺钉置入过程中损伤椎动脉的风险,所以该方法可作为传统枢椎后路螺钉固定技术的补充。     

枢椎椎板螺钉固定的解剖可行性研究

目的:评价对国人进行枢椎椎板螺钉固定的可行性,探讨进钉技术。方法:用电子游标卡尺和量角器在30例干燥枢椎标本上测量与进钉技术相关的解剖学数据,包括枢椎椎板的厚度,棘突根部、椎板和下关节突的高度。设定枢椎椎板螺钉的进钉点位于枢椎棘突中线两侧5mm,上位螺钉距椎板上缘5mm,对侧的下位螺钉距椎板上缘9mm,螺钉在棘突根部上下交叉进入对侧椎板,并于下关节突中心点出钉,测量上位和下位椎板螺钉的钉道长度和进钉角度。结果:枢椎椎板上缘、中部、下缘的厚度分别是3.02mm、5.91mm和5.59mm;枢椎棘突根部、椎板和下关节突中部的高度分别是12.40mm、12.95mm、14.03mm;上位和下位椎板螺钉的平均长度分别是25.41mm和27.39mm;上位螺钉前斜26.4°,下斜7.6°;下位螺钉前斜30.1°,上斜1.4°。结论:对国人进行枢椎椎板螺钉固定在解剖学上是可行的,该方法可作为传统枢椎后路螺钉固定技术的补充。     

Technical factors related to Herbert screw fixation

We reviewed 24 patients treated for an acute fracture or a nonunion of the scaphoid bone using the Herbert screw. Mean follow-up in 22 patients who returned for examination was 17 months. The overall union rate was 67% for both acute fractures and nonunions. Fracture healing correlated strongly with technical factors of the procedure. The fracture failed to heal in seven of nine cases with poor scaphoid realignment, inaccurate jig placement, or improper screw length for a nonunion rate of 78%. Conversely, without these technical problems, 14 (93%) of 16 fractures achieved union. Applying Herbert's criteria, a satisfactory rating for clinical function was achieved in 59% of all patients and for patient satisfaction in 68% of all patients. Although the postoperative immobilization period was reduced using the screw, the final functional result in our nonunions was similar to that reported for the Russe bone grafting procedure. Appropriate modifications of the standard technique and recognition of equipment limitations may improve union rates.