ADVANCED CONCEPTS
`
`IN
`
`SPINAL DEFORMITY SURGERY
`
`MAY I8-I9, 2003
`
`CHEYENNE MOUNTAIN RESORT
`
`COLORADO SPRINGS, COLORADO
`
`PROGRAM CHAIRMEN
`
`Lawrence G. Lenke, M.D.
`
`George D. Picetti, M.D.
`
`Sponsored by:
`
`% Mecltronic
`
`1
`
`
`
`IN
`
`SPINAL DEFORMITY SURGERY
`
`MAY I8-I9, 2003
`
`CHEYENNE MOUNTAIN RESORT
`
`COLORADO SPRINGS, COLORADO
`
`PROGRAM CHAIRMEN
`
`Lawrence G. Lenke, M.D.
`
`George D. Picetti, M.D.
`
`Sponsored by:
`
`% Mecltronic
`
`1
`
`
`
`FREE HAND THORACIC SCREW
`
`PLACEMENT AND CLINCIAL
`
`USE IN SCOLIOSIS AND
`
`KYPHOSIS SURGERY
`
`Lawrence G. Lenka, MD.
`The jcrmnu J. Giidcn Professor 0fOrlhop.1L'dlc Surgery
`Spinal Dcfonnky Scrviu:
`Wnshmgmn Um\'L‘l’SIl_V School of Medicine
`Chief. Spinal S1.-rvia:
`Shrinr.-rs Hospital for Children
`5: Lnuis. Missoun
`
`Half Moon Bay. Califnmu
`February 2N3
`
`INTRODUCTION
`
`“PROS” of Pcdicle Screws
`- Better correction power in three plane
`- Construct stability to allow early
`motion/activity
`- Lack of complications
`“CONS” of Pcdiclc Screws
`l’m'.s‘ibIe (‘alnpliculiolmz
`- Neurologic and Vascular
`~ Learning curve
`- Operative time
`- Cost
`
`INTRODUCTION
`
`Various Insertion Techniques
`1. FREE HAND
`2. Scan image guided/
`Fluorc na\ii_.-anon
`3. Fluoro assist
`4. Pre-insertion K-wire guided
`Confirmation of Optimal
`Placement
`l. Triggered EMGS
`'7. Pedicle seeker/Palpzuion
`. Post-insertion radiogmphs
`or fluoroscopy
`. Laminotomy
`. Postop CT scan
`
`2
`
`
`
`MATERIALS AND METHODS
`
`TECHNIQUE -
`Free Hand Placement of Thoracic
`Pedicle Screws
`
`-Exposure
`-Starting point (burr)
`-Blunt probe
`-Palpation
`-Tapping and Re-palpation
`-Placement
`-Confirmation
`
`Step 1: Complete exposure of the bony anatomy
`
`Step 2: Starting point (5 mm acom-tipped burr)
`
`Proximal Thorn i Tl-T4
`
`junction of proximal transverse process
`and lamina medial to lateral pars
`
`l\4lid-'I‘horaci§1T<-,T8 1
`junction of down slope of proximal
`transverse process and lamina at base of
`superior face; medial to lateral pars
`
`Lower Thoracic (T9-T121
`down slope of bisected t.p. at junction of
`transverse process and lamina at same
`level as lateral pars
`
`3
`
`
`
`Outward Gear
`Shifi until
`the Base
`I of the Pedtcle
`
`-
`
`.] lnmard Gear
`[ Shift Into the
`ivertcbral bod_\-
`After Base of
`The Pcdicle
`
`Step -4: Inner pcdicle palpation and length measurement
`
`1 Palpate all 5 bony walls of the pedicle
`(cephalad. caudad. medial. lateral. and floor)
`2. Mark the length of the tract and measure it.
`
`Step 5: Tapping and Re—palpation
`l. Tap the pedicle wtth a tap that is 0.5 mm smaller
`than the proposed scre\\.
`. Use the palpattng device a second ttmc to assess
`the bony pcdicle walls .
`
`Step 6: Screw placement
`
`( Place the screw slowly)
`
`4
`
`
`
`mEmmACNO4WEB
`
`5
`
`
`
`Step 7: Confirmation of Screw Placement
`
`Intraoperntivc X-rays ; l-{annonious screw position
`.
`. Triggered EMG; Helpful. but no definite minimum EMG.‘
`1
`W
`l
`..
`r
`'
`' ‘
`'
`-
`’»
`
`«
`
`-.
`
`PEDICLE SCREW EMG
`
`STIMULATION
`
`Screw Level
`
`Recording Muscle
`
`T6 - T12
`
`L1 & L2
`
`L3 & L4
`
`Rectus Abdominus
`
`Adductor
`
`Quad.
`Ant. Tib.
`
`Gastroc.
`
`Can Triggered EMG Thresholds
`Accurately Predict Thoracic
`Pedicle Screw Placement?
`
`Barry L. Raynor. B. A.
`Lawrence G. Lcnke, M. D.
`Yongiung Kim. M. D.
`Darrell S. Hanson, M. D.
`Tracy J. Wilson-Holden. .\1. A.
`Keith H. Bridwell. M. D.
`Anne M. Padberg, M. S.
`Saint, SR5‘ Ina: I7(lK):2!l3lI-55, JIIIIZ
`
`6
`
`
`
`CONCLUSION
`
`THORACIC PEDICLE SCREWS
`
`“MEDIAL WALL DEFECT ALERT”
`
`- Triggered EMG threshold < 6.0 mA
`
`- Threshold intensity 65 % decreased
`from mean of all other TrgEMG
`responses
`
`PREREQUISITES FOR SUCCESSFUL
`THORACIC PEDICLE SCREW
`PLACEMENT
`
`- Starting point
`
`- Thoracic pedicle probe
`- Proper 3D orientation
`~ Appropriate intraosseous "feei“ of probe
`down pedicle ——> body
`- Confirmation of “intraosseous“ screw
`pathway
`
`WHAT X-RAY / FLUORO / IMAGE
`
`GUIDANCE PROVIDE:
`
`- Help with "starting point”
`pedicie shadow
`
`- Sagittal/axial orientation/screw
`position
`
`7
`
`
`
`WHAT X-RAY / FLUORO / IMAGE
`
`GUIDANCE CANNOT PROVIDE:
`
`- "Feel" of pedicle probe/curette/
`drill bit down pedicle —> body
`
`- Absolute confirmation of
`
`intraosseous placement
`
`MATERIALS AND METHODS
`
`- Retrospective study
`-
`Independent. non-biased
`- Senior Spinal Surgeon Reviewer
`- 394 consecutive patients! 3204 TPS
`~ Single institution. 2 surgeons (LGL. KHB)
`- July 1992 - June 2002
`
`- Patient mean age: 27-*1 0 (Range; 5+3-87+0)
`
`MATERIALS AND METHODS
`Diagnoses (n=394)
`
`xvmosxs (n-53)
`-Congenital kyphosis (3)
`-At-kylosiug spoudylitis 4
`sagimal imbalanc
`
`Scheuermnnws kyphoais (13)
`Ncuromuscular kyphosis (I)
`'
`
`OTHERS("_6s)
`Fmmn (45) Tumornz)
`.
`lnfectzon (4)
`FBSS (7)
`
`1
`‘
`{
`1
`'
`
`- Adoluuenlidiopathicunliosix(I50)
`' - Adnkidionathicuolioiu (SI)
`- Nzurolmucolar scoliosis (33)
`3
`- Syndrome relntcll (10)
`
`8
`
`
`
`RESULTS
`
`Insertion related Neurologic Complications
`
`POSTOP CLINICAL ASSESSMENT
`
`- No postoperative neurologic deficit
`
`- No thoracic nerve root imitation
`
`- No radicular chest wall complaints
`
`=3204 TPS
`
`RESULTS
`
`Insertion related EARLY complications
`
`‘_\J_c_> pedicle screw ever removed for
`any reason (thoracic/lumbar/sacral)
`
`- No vascular. visceral complications
`
`in 10 years (1992 — present)
`
`Placement of Thoracic Pedicle
`
`Screws by the Free Hand Technique
`Defining the Learning Curve by CT
`Scanning Over a 4 Year Experience
`
`- “EARLY" 1998 - 10 A15 & 1
`Scheuermanrfs case
`- “RECENT” 2001 - 10 AIS & I
`Scheuermann’s case
`
`Subnllllcd SIIS .7002
`
`9
`
`
`
`10
`
`CT SCAN GRADING
`CONTAINED (CT):
`.\'0.‘\‘CONTAl='\'ED
`in-‘MC H"-' huliele
`GRADE A (CA): <2mm uolalmn
`GRADE B (GB): 2-lmm \inl;uiun
`CRADEC(GC): >-lm
`'
`inn
`
`CT SCAN ANALYSIS
`400 TPS - Earlv Results - 1998
`
`Completely lntraosseous
`
`< 2mm Breakthrough
`
`30%
`
`24mm Breakthrough
`
`> 4mm Breakthrough
`
`CT SCAN ANALYSIS
`400 TPS - Recent Results- 2001
`
`|Completely lntraosseous
`
`< 2mm Breakthrough
`2-4mm Breakthrough
`> 4mm Breakthrough
`
`1
`
`7%
`2%(1nt)
`0%
`
`10
`
`
`
`11
`
`TPS USAGE
`
`Non—rotationa1
`
`vs
`
`Rotational (Scoiiotic) deformity
`
`SCHEUERMANN’S KYPHOSIS
`
`VAT / PSF (ALLOGRAFT ALONE)
`
`PREOP
`
`IMPLANT PULL-OFF
`
`
`
`11
`
`
`
`12
`
`REVISION PSF / SPOS X9
`
`
`
`POSTOP
`
`12
`
`
`
`13
`
`SCOLIOSIS DEFORMITIES:
`
`BETTER “3D” CORRECTION???
`
`« Coronal
`
`~ Sagittal
`
`« Axial
`
`CORONAL RESULTS - AIS
`
`-
`
`improved Coronal Correction (screws vs.
`hooks)
`
`- Suk Spine 1995 — thoracic
`
`- Hamill, Lenke Spine 1996 - lumbar
`
`- Barr, Emans Spine 1997 - lumbar
`
`- Liljenqvist, I-Ialm Spine 1997 - thoracic
`
`- Lenke and Polly (unpublished, averaging
`70-75% correction) - thoracic
`
`Suk et al, Spine 1995
`
`CONSTRUCT
`
`‘Z-CORRECTION
`
`TPS (non-segmental)
`
`TPS (segmental)
`
`71%
`
`13
`
`
`
`14
`
`POSTERIOR— AIS EXPERIENCE
`
`D-“T55
`
`Thoracic
`Construct
`
`Main Thoracic
`% Cobb Correction
`
`1992-94
`
`All Hooks
`
`1995-98
`
`1998-2002
`
`Hybrid
`(Hooks/Screws)
`All Screws
`(n ___ 126 cases)
`
`‘ )’./ KIM. 4\«II) RcI'Icu-
`
`52% I
`
`57%
`
`72%*
`
`PSF T3 - L1
`
`37% CRECTION
`
`14
`
`
`
`15
`
`PREOP
`
`POSTO
`
`SEVERE AIS-MOSCOW PT
`
`IMPENDING COR PULMOJVALE
`
`.
`.
`_-_
`.-
`3%
`.3’...
`BILAT. RIB OSTEOTOMIES 8: MERSILENE TAPE REPAIR
`
`15
`
`
`
`16
`
`SAGITTAL PLANE
`
`Increased Thoracic Kyphosis with Stiff Rod
`
`Suk:
`
`(JSD. 1999)
`
`Improved TL&L Lordosis
`
`Hamill, Lenke et al:
`/Spine. 1996)
`
`CURVE CLASSIFICATION 4C+
`
`THORACOLUMBAR KYPHOSIS!
`
`16
`
`
`
`17
`
`AXIAL PLANE
`
`~ Difficult to assess
`
`- Radiographic evaluation
`
`« Apical rotation correction 59%
`/S21/r at al Spine. 1995)
`
`- Clinical assessment
`
`- Greatest potential advantage of
`SCREWS!!!
`
`CURVE CLASSIFICATION IAN
`
`17
`
`
`
`18
`
`CURVE CLASSIFICATION IAN
`
`STCR 81 =1=85=85
`.. _¢...-s..¢—._:
`
`CURVE CLASSIFICATION 1AN
`
`INTRAOP APICAL DEROTATION!
`
`18
`
`
`
`19
`
`INITIAL SCREW DEROTATION
`1
`._,.x
`
`T-
`
`‘i -3.3..-I
`3=24=S=
`.‘
`
`CONCAVE ROD PLACEMENT
`-.3:
`I
`
`19
`
`
`
`20
`
`PRE-DEROTATION
`
`POST-DEROTATION
`u .-.
`
`20
`
`
`
`21
`
`5 DAYS
`POSTOP
`
`8 MOS
`POSTOP
`
`Scoliomctcr 22"
`
`Scoliomctcr 3°
`
`E
`
`Scoliomctcr 4°
`
`AVOIDING ASF - TPS
`
`- Large/Stiff curves
`- Risk of Crankshaft
`
`- Hyperkyphotic T5-T12 alignment
`
`- Scheuermanrfs Kyphosis
`
`- Revision Surgery
`
`CURVE CLASSIFICATION ZAN
`
`21
`
`
`
`22
`
`CURVE CLASSIFICATION 2AN
`
`Scoliometer 23°
`
`Scoliometer 2°
`
`22
`
`
`
`23
`
`POSTOP
`
`7 “I
`
`AVOID CHEST CAGE
`
`DISRUPTION!
`
`IN LAST 18 MONTHS:
`
`- No open ASF or VAT release
`
`- No posterior T-Plasty
`
`For AIS Curves < 95°
`11 = 62
`
`COMPLICATIONS
`
`LONG TERM
`
`- One revision 3yrs postop - implants
`removed due to P. Acnes deep infection
`
`- NO revisions for implant
`disiodgement/failure/pseudarthrosis!
`
`COMPLICATION RATE IS
`LOWER THAN HOOKS
`
`23
`
`
`
`24
`
`CONCLUSIONS
`
`The Free Hand Technique of thoracic
`pedicle screw placement performed in
`a step-wise. consistent and compulsive
`manner is an accurate, reliable, and
`safe method of insertion to treat a
`
`variety of spinal disorders, including
`spinal deformity
`
`CONCLUSIONS
`
`Screws provide:
`-
`Better 3D correction
`
`Lower complication rate
`'
`- Avoid ASF
`
`-
`
`Early Motion
`No activity restrictions
`Avoid Thoracoplasty
`Better outcomes’?'???
`
`24
`
`
`
`25
`
`Thoracic Pedicle Screw Starting Points
`
`
`
`Level
`
`Cephaiad-Caudad Starting
`Point
`
`Medial-Lateral Starting
`Point
`
`
`
`
`Midpoint TP
`
`Midpoint TP
`
`T3
`Midpoint TP
`Juncfion: TP-Lamina
`
`
`.1.4
`
`.
`_p
`.
`.
`._
`Junction. . roximal third
`Midpoint TP
`
`Junction: TP_Lamma
`
`.
`..
`JUI7CZ'IOn.' Proximal edge-
`Proximal third TP
`
`I
`g
`
`Proximal TP
`
`
`T10
`
`Junction.’ Proximal edge-
`Proximai mm. T?
`
`Junction: TP-Lamina-Face’.
`
`| l lI i II
`
`At the level of laterai pars
`
`l
`
`Just medial to lateral pars
`Proximal third TP
`l
`T11
`l
`i
`
`J
`
`Midpoint TP
`
`:
`
`25
`
`
`
`26
`
`1 Ll FREE HAND THORACIC SCREW PLACEMENT AND
`
`CLINCIAL USE IN SCOLIOSIS AND KYPHOSIS SURGERY
`Lawrence G. Lenke, MD.
`The Jerome J. Gilden Profssor of Orthopaedic Surgery
`Spinal Deformity Service
`Washington University School of Medicine
`
`Chief, Spinal Service
`Shriners Hospital for Children
`St. Louis, Missouri
`
`Half Moon Bay, California
`February Z303
`
`2 3 INTRODUCTION
`“PROS” of Pedicle Screws
`
`- Better correction power in three plane
`
`- Construct stability to allow early
`motion/activity
`
`- Lack of complications
`
`“CONS” of Pedicle Screws
`
`Possible Complications.’
`
`- Neurologic and Vascular
`
`- Learning curve
`
`- Operative time
`- Cost
`
`3 _‘_I INTRODUCTION
`
`Various Insertion Techniques
`1. FREE HAND
`
`2. Scan image guidedl
`Fluoro navigation
`3. Fluoro assist
`
`4. Pre-insertion K-wire guided
`
`Confirmation of Optimal Placement
`l. Triggered EMGS
`2. Pedicle seeker/Palpation
`3. Post-insertion radiographs
`or fluoroscopy
`4. Laminotomy
`S Postop CT scan
`
`4 3 MATERIALS AND METHODS
`
`TECHNIQUE -
`Free Hand Placement of Thoracic
`Pedicle Screws
`
`26
`
`
`
`27
`
`7 LJ
`
`8 Ll
`
`9 3
`
`10 ;J
`
`11 ';j
`
`12 j
`
`13 3
`
`14 3 PEDICLE SCREW EMG STIMULATION
`
`Screw Level
`
`Recording Muscle
`
`T6 - T12
`
`L1 & L2
`
`L3 & L4
`
`L5
`
`S1
`
`Rectus Abdominus
`
`Adductor
`
`Quad.
`
`Ant. Tib.
`
`Gastroc.
`
`15 _'J Barry L. Raynor, B. A.
`Lawrence G. Lenke, M. D.
`Yongjung Kim, M. D.
`Darrell S. Hanson, M. D.
`Tracy J. Wilson-Holden. M. A.
`Keith H. Bridwell. M. D.
`Anne M. Padberg, M. S.
`
`16 .1! CONCLUSION
`
`Triggered EMG threshold < 6.0 mA
`
`Threshold intensity 65 % decreased
`other TrgEMG
`responses
`
`from mean of all
`
`17 :1 PREREQUISITES FOR SUCCESSFUL THORACIC PEDICLE
`SCREW PLACEMENT
`
`- Starting point
`
`- Thoracic pedicle probe
`
`- Proper 3D orientation
`
`- Appropriate intraosseous “feel” of probe down pedicle —> body
`
`27
`
`
`
`28
`
`- Confirmation of “intraosseous” screw pathway
`
`18 ;]
`
`- Help with “starting point” pedicle shadow
`
`- Sagittal/axial orientation/screw position
`
`19 _‘J WHAT X-RAY / FLUORO / INIAGE GUIDANCE CANNOT
`
`PROVIDE:
`
`- “Feel” of pedicle probe/curette/ drill bit down pedicle —-> body
`
`- Absolute confirmation of intraosseous placement
`
`20 _'J MATERIALS AND METHODS
`
`Retrospective study
`
`- Independent, non-biased
`
`- Senior Spinal Surgeon Reviewer
`
`- 394 consecutive patients/ 3204 TPS
`
`- Single Institution, 2 surgeons (LGL, KHB)
`
`- July 1992 - June 2002
`
`- Patient mean age; 27+l0 (Range; 5+3-87+0)
`
`21 3
`
`22 .1! RESULTS
`
`No postoperative neurologic deficit
`No thoracic nerve root irritation
`
`No radicular chest wall complaints
`n=3204 TPS
`
`23 iJ RESULTS
`
`- IE pedicle screw ever removed for any reason
`(thoracic/lumbar/sacral)
`
`- No vascular, visceral complications
`
`in 10 years (1992 - present)
`
`24 _‘J Placement of Thoracic Pedicle Screws by the Free Hand
`
`Technique Defining the Learning Curve by CT Scanning Over
`a 4 Year Experience
`- “EARLY” I998 - 10 AIS & 1 Scheuermann’s case
`
`28
`
`
`
`29
`
`- “RECENT” 2001 — 10 AIS & 1 Scheuennann’s case
`
`25 ;j
`
`26 ';'J
`
`27 :1
`
`28 J TPS USAGE
`
`Non-rotational
`
`vs
`
`Rotational (Scoliotic) deformity
`
`29 J
`
`30 ;]
`
`31 _"_|
`
`32 ;1
`
`33 ;I WILLIAMS SYNDROME
`
`34 J SCOLIOSIS DEFORMITIES:
`
`BETTER “3D” CORRECTION???
`
`- Coronal
`
`- Sagittal
`
`- Axial
`
`35 :1 CORONAL RESULTS - AIS
`
`- Improved Coronal Correction (screws vs. hooks)
`
`- Suk Spine 1995 - thoracic
`
`- Hamill, Lenke Spine 1996 - lumbar
`
`- Barr, Emans Spine 1997 - lumbar
`
`- Liljenqvist, Halm Spine 1997 - thoracic
`
`- Lenke and Polly (unpublished, averaging 70-75% correction) - thoracic
`
`36 iJ Suk et al, Spine 1995
`37 i] Thoracic Construct
`
`38 _"_'j
`
`39 _‘_j
`
`29
`
`
`
`30
`
`- Difficult to assess
`
`- Radiographic evaluation
`
`- Apical rotation correction 59% (Suk et al Spine, 1995)
`
`- Clinical assessment
`
`- Greatest potential advantage of SCREWS!!!
`
`40;]
`
`413
`
`42:]
`
`43;]
`
`44;]
`
`45;")
`
`46;]
`
`47:]
`
`48;]
`
`49;]
`
`50_‘_]
`
`51;]
`
`52;]
`
`53;]
`
`54;]
`
`55;]
`
`56;]
`
`57_'__]
`
`53;;
`
`59 _‘J AVOIDING ASF - TPS
`
`- Large/Stiff curves
`
`- Risk of Crankshaft
`
`- Hyperkyphotic T5-T12 alignment
`
`- Scheuermarm’s Kyphosis
`
`30
`
`
`
`- Revision Surgery
`
`so :1
`
`61 j_]
`
`62 ;_J
`
`63 _'_j
`
`54 ;J
`
`65 J AVOID CHEST CAGE DISRUPTION!
`
`IN LAST 18 MONTHS:
`
`- No open ASF or VAT release
`
`- No posterior T-Plasty
`
`66 J COMPLICATIONS
`
`- One revision 3yrs postop - implants removed due to P. Acnes deep
`infection
`
`- NO revisions for implant dislodgement/failure/pseudarthrosis!
`
`67 .3 CONCLUSIONS
`
`68 _‘J CONCLUSIONS
`
`Screws provide:
`- Better 3D correction
`
`- Lower complication rate
`- Avoid ASF
`
`- Early Motion
`
`- No activity restrictions
`
`- Avoid Thoracoplasty
`- Better outcomes????
`
`31
`
`
`
`32
`
`NOTES
`
`
`
`32
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