Clinical application of accurate placement of lumbar pedicle screws using three-dimensional printing navigational templates under Quadrant system_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

CHENXuanhuang , YUZhengxi , WUChangfu , LIXing , CHENXu , ZHANGGuodong , ZHENGZugao ,  LINHaibin

Department of Orthopedics, Affiliated Hospital of Putian University, Teaching Hospital of Fujian Medical University & Affiliated Putian Hospital of Southern Medical University & Affiliated Hospital of Putian University, Putian Fujian, 351100, P.R.China;

Corresponding?author：

LINHaibin, Email: ptyygk@163.com

Keywords：

Quadrant system; lumbar pedicle screws; three-dimensional printing technology; minimal invasion; accurate placement

DOI：

10.7507/1002-1892.201610050

Video：

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Objective To explore the feasibility and the effectiveness of the accurate placement of lumbar pedicle screws using three-dimensional (3D) printing navigational templates in Quadrant minimally invasive system. Methods The L_1-5 spines of 12 adult cadavers were scanned using CT. The 3D models of the lumbar spines were established. The screw trajectory was designed to pass through the central axis of the pedicle by using Mimics software. The navigational template was designed and 3D-printed according to the bony surface where the soft tissues could be removed. The placed screws were scanned using CT to create the 3D model again after operation. The 3D models of the designed trajectory and the placed screws were registered to evaluate the placed screws coincidence rate. Between November 2014 and November 2015, 31 patients with lumbar instability accepted surgery assisted with 3D-printing navigation module under Quadrant minimally invasive system. There were 14 males and 17 females, aged from 42 to 60 years, with an average of 45.2 years. The disease duration was 6-13 months (mean, 8.8 months). Single segment was involved in 15 cases, two segments in 13 cases, and three segments in 3 cases. Preoperative visual analogue scale (VAS) was 7.59±1.04; Oswestry disability index (ODI) was 76.21±5.82; and the Japanese Orthopaedic Association (JOA) score was 9.21±1.64. Results A total of 120 screws were placed in 12 cadavers specimens. The coincidence rate of placed screw was 100%. A total of 162 screws were implanted in 31 patients. The operation time was 65-147 minutes (mean, 102.23 minutes); the intraoperative blood loss was 50-116 mL (mean, 78.20 mL); and the intraoperative radiation exposure time was 8-54 seconds (mean, 42 seconds). At 3-7 days after operation, CT showed that the coincidence rate of the placed screws was 98.15% (159/162). At 4 weeks after operation, VAS, ODI, and JOA score were 2.24±0.80, 29.17±2.50, and 23.43±1.14 respectively, showing significant differences when compared with preoperative ones (t=14.842,P=0.006;t=36.927,P=0.002;t=–36.031,P=0.001). Thirty-one patients were followed up 8-24 months (mean, 18.7 months). All incision healed by first intention, and no complication occurred. During the follow-up, X-ray film and CT showed that pedicle screw was accurately placed without loosening or breakage, and with good fusion of intervertebral bone graft. Conclusion 3D-printing navigational templates in Quadrant minimally invasive system can help lumbar surgery gain minimal invasion, less radiation, and accurate placement.

Citation： CHENXuanhuang, YUZhengxi, WUChangfu, LIXing, CHENXu, ZHANGGuodong, ZHENGZugao, LINHaibin. Clinical application of accurate placement of lumbar pedicle screws using three-dimensional printing navigational templates under Quadrant system. Chinese Journal of Reparative and Reconstructive Surgery, 2017, 31(2): 203-209. doi: 10.7507/1002-1892.201610050 Copy

1.	?池永龍. 脊柱外科的微創意識、微創觀念與微創技術. 中國脊柱脊髓雜志, 2005, 15(3): 133-134.
2.	林海濱, 吳獻偉, 李榮議, 等. Metrx Quadrant 可擴張通道管微創系統在腰椎滑脫手術中的初步應用. 中華醫學雜志, 2010, 90(25): 1756-1759.
3.	Kim KT, Lee SH, Suk KS,et al. The quantitative analysis of tissue injury markers after mini-open lumbar fusion. Spine, 2006, 31(6): 712-716．.
4.	Gelalis ID, Paschos NK, Pakos EE,et al. Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J, 2012, 21(2): 247-255.
5.	Starosolski ZA, Kan JH, Rosenfeld SD,et al. Application of 3-D printing (rapid prototyping) for creating physical models of pediatric orthopedic disorders. Pediatr Radiol, 2014, 44(2): 216-221.
6.	Kaneyama S, Sugawara T, Sumi M. Safe and accurate midcervical pedicle screw insertion procedure with the patient-specific screw guide template system. Spine (Phlia Pa 1976), 2015, 40(6): E341-348.
7.	李鑫, 張強, 趙昌松, 等. 椎弓根置釘導板治療嚴重脊柱側凸八例臨床觀察. 中華醫學雜志, 2014, 94(11): 840-843.
8.	Fu M, Lin L, Kong X,et al. Construction and accuracy assessment of patient-specific biocompatible drill template for cervical anterior transpedicular screw (ATPS) insertion: an invitro study. PLoS One, 2013, 8(1): e53580.
9.	Putzier M, Strube P, Cecchinato R,et al. A new navigational tool for pedicle screw placement in patients with severe scoliosis: A pilot study to prove feasibility, accuracy, and identify operative challenges. Clin Spine Surg, 2016. [Epub ahead of print].
10.	陳宣煌, 林海濱, 吳獻偉, 等. 經皮椎弓根固定結合 Quadrant 系統下經椎間孔腰椎椎體間融合技術微創治療腰椎退行性疾病的初步研究. 中華臨床醫師雜志(電子版), 2012, 6(15): 4345-4348.
11.	Brodano GB, Martikos K, Lolli F,et al. Transforaminal lumbar interbody fusion in degenerative disc disease and spondylolisthesis grade I: minimally invasive versus open surgery. J Spinal Disord Tech, 2015, 28(10): E559-564.
12.	Majani G, Tiengo M, Giardini A,et al. Relationship between MPQ and VAS in 962 patients. A rationale for their use. Minerva Anestesiol, 2003, 69(1-2): 67-73.
13.	Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
14.	劉志雄. 常用骨科分類法和功能評定. 北京: 北京科學技術出版社, 2010: 178-336．.
15.	Hu Y, Yuan ZS, Kepler CK,et al. Deviation analysis of C1-C2 transartieular screw placement assisted by a novel rapid prototyping drill template: a cadaveric study. J Spinal Disord Tech, 2014, 27(5): E181-186.
16.	Wu ZX, Huang LY, Sang HX,et al. Accuracy and safety assessment of pedicle screw placement using the rapid prototyping technique in severe congenital scoliosis. J Spinal Disord Tech, 2011, 24(7): 444-450.
17.	Sembrano JN, Santos ER, Polly DW Jr. New generation intraoperative three-dimensional imaging (O-arm) in 100 spine surgeries: does it change the surgical procedure. J Clin Neurosci, 2014, 21(2): 225-231.
18.	Merc M, Drstvensek I, Vogrin M,et al. A multi-level rapid prototyping drill guide template reduces the perforation risk of pedicle screw placement in the lumbar and sacral spine. Arch Orthop Trauma Surg, 2013, 133(7): 893-899.
19.	Lu S, Xu YQ, Chen GP,et al. Efficacy and accuracy of a novel rapid prototyping drill template for cervical pedicle screw placement. Comput Aided Surg, 2011, 16(5): 240-248.
20.	Bagaria V, Deshpande S, Rasalkar DD,et al. Use of rapid prototyping and three-dimensional reconstruction modeling in the management of complex fractures. Eur J Radiol, 2011, 80(3): 814-820.
21.	Rosen DS, O’Toole JE, Eichholz KM,et al. Minimally invasive lumbar spinal decompression in the elderly: outcomes of 50 patients aged 75 years and older. Neurosurgery, 2007, 60(3): 503-509.
22.	Yang M, Li C, Li Y,et al. Application of 3D rapid prototyping technology in posterior corrective surgery for Lenke 1 adolescent idiopathic scoliosis patients. Medicine (Baltimore), 2015, 94(8): e582.

1. ?池永龍. 脊柱外科的微創意識、微創觀念與微創技術. 中國脊柱脊髓雜志, 2005, 15(3): 133-134.
2. 林海濱, 吳獻偉, 李榮議, 等. Metrx Quadrant 可擴張通道管微創系統在腰椎滑脫手術中的初步應用. 中華醫學雜志, 2010, 90(25): 1756-1759.
3. Kim KT, Lee SH, Suk KS,et al. The quantitative analysis of tissue injury markers after mini-open lumbar fusion. Spine, 2006, 31(6): 712-716．.
4. Gelalis ID, Paschos NK, Pakos EE,et al. Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J, 2012, 21(2): 247-255.
5. Starosolski ZA, Kan JH, Rosenfeld SD,et al. Application of 3-D printing (rapid prototyping) for creating physical models of pediatric orthopedic disorders. Pediatr Radiol, 2014, 44(2): 216-221.
6. Kaneyama S, Sugawara T, Sumi M. Safe and accurate midcervical pedicle screw insertion procedure with the patient-specific screw guide template system. Spine (Phlia Pa 1976), 2015, 40(6): E341-348.
7. 李鑫, 張強, 趙昌松, 等. 椎弓根置釘導板治療嚴重脊柱側凸八例臨床觀察. 中華醫學雜志, 2014, 94(11): 840-843.
8. Fu M, Lin L, Kong X,et al. Construction and accuracy assessment of patient-specific biocompatible drill template for cervical anterior transpedicular screw (ATPS) insertion: an invitro study. PLoS One, 2013, 8(1): e53580.
9. Putzier M, Strube P, Cecchinato R,et al. A new navigational tool for pedicle screw placement in patients with severe scoliosis: A pilot study to prove feasibility, accuracy, and identify operative challenges. Clin Spine Surg, 2016. [Epub ahead of print].
10. 陳宣煌, 林海濱, 吳獻偉, 等. 經皮椎弓根固定結合 Quadrant 系統下經椎間孔腰椎椎體間融合技術微創治療腰椎退行性疾病的初步研究. 中華臨床醫師雜志(電子版), 2012, 6(15): 4345-4348.
11. Brodano GB, Martikos K, Lolli F,et al. Transforaminal lumbar interbody fusion in degenerative disc disease and spondylolisthesis grade I: minimally invasive versus open surgery. J Spinal Disord Tech, 2015, 28(10): E559-564.
12. Majani G, Tiengo M, Giardini A,et al. Relationship between MPQ and VAS in 962 patients. A rationale for their use. Minerva Anestesiol, 2003, 69(1-2): 67-73.
13. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
14. 劉志雄. 常用骨科分類法和功能評定. 北京: 北京科學技術出版社, 2010: 178-336．.
15. Hu Y, Yuan ZS, Kepler CK,et al. Deviation analysis of C1-C2 transartieular screw placement assisted by a novel rapid prototyping drill template: a cadaveric study. J Spinal Disord Tech, 2014, 27(5): E181-186.
16. Wu ZX, Huang LY, Sang HX,et al. Accuracy and safety assessment of pedicle screw placement using the rapid prototyping technique in severe congenital scoliosis. J Spinal Disord Tech, 2011, 24(7): 444-450.
17. Sembrano JN, Santos ER, Polly DW Jr. New generation intraoperative three-dimensional imaging (O-arm) in 100 spine surgeries: does it change the surgical procedure. J Clin Neurosci, 2014, 21(2): 225-231.
18. Merc M, Drstvensek I, Vogrin M,et al. A multi-level rapid prototyping drill guide template reduces the perforation risk of pedicle screw placement in the lumbar and sacral spine. Arch Orthop Trauma Surg, 2013, 133(7): 893-899.
19. Lu S, Xu YQ, Chen GP,et al. Efficacy and accuracy of a novel rapid prototyping drill template for cervical pedicle screw placement. Comput Aided Surg, 2011, 16(5): 240-248.
20. Bagaria V, Deshpande S, Rasalkar DD,et al. Use of rapid prototyping and three-dimensional reconstruction modeling in the management of complex fractures. Eur J Radiol, 2011, 80(3): 814-820.
21. Rosen DS, O’Toole JE, Eichholz KM,et al. Minimally invasive lumbar spinal decompression in the elderly: outcomes of 50 patients aged 75 years and older. Neurosurgery, 2007, 60(3): 503-509.
22. Yang M, Li C, Li Y,et al. Application of 3D rapid prototyping technology in posterior corrective surgery for Lenke 1 adolescent idiopathic scoliosis patients. Medicine (Baltimore), 2015, 94(8): e582.

Chinese Journal of Reparative and Reconstructive Surgery

Clinical application of accurate placement of lumbar pedicle screws using three-dimensional printing navigational templates under Quadrant system

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