Free Hand Technique Lumbar Spine Pedicle Screw Placement in Indian Population

International Journal of Orthopaedics Sciences 2017; 3(4): 621-625
ISSN: 2395-1958
IJOS 2017; 3(4): 621-625
2017 IJOS Free hand technique lumbar spine pedicle screw
www.orthopaper.com
Received: 22-08-2017 placement in Indian population
Accepted: 25-09-2017
Dr. P Maharajothi Dr. P Maharajothi

MS ortho, Senior assistant
professor, govt chengalpattu
medical college, Chengalpattu, DOI: https://doi.org/10.22271/ortho.2017.v3.i4i.87
Tamil Nadu, India
Abstract
There are different pedicle screws entry point techniques are used for the lumbar pedicle screws
placement. This study reported using confluence of pars, mamillary process, midpoint of transverse
process, on lateral border of face joint as entry point of lumbar pedicle screws with free hand technique
and the accuracy of this technique.
Materials and Methods: A prospective study was done from may 2015 to November 2017 in our
hospital using free hand technique lumbar pedicle screw placement includes 50 patients 270 screws. The
diagnosis includes degenerative spine, trauma, and spondylolithesis. cortical breach by misplaced pedicle
screw was determined by review of computed tomography.
Results: Among the total 270 lumbar free hand placed pedicle screws, 10 screws with lateral breach, 1
screw inferior breach, 2 medial breach without significant neurological involvement with two cases of
radicular pain which subsides over period of time without any revision.
Conclusion: Free hand pedicle screw placement based on external landmark using confluence of pars,
mamillary process, midpoint of transverse process, on lateral border of face joint as entry point of lumbar
pedicle screws with free hand technique and the accuracy of this technique showed acceptable safety and
accuracy and avoidance of radiation exposure.
Keywords: Lumbar spine, pedicle screw placement, free hand technique, cortical breach
Introduction
Pedicle screw fixation has the advantage of utilization in the lumbar spine for superior three-
column fixation without encroaching into the spinal canal which was used for trauma,
instability, degenerative disease and deformity correction [1, 2]. Its usage has the potential for
neurologic deficit, the safety margin for this techniques include the use of anatomical
landmarks, laminoforaminotomy, C-arm fluoroscopy, and navigation computer-assisted
techniques [3] these techniques through the use of image-guided techniques require additional
equipment as well as the use of fluoroscopy which increases the radiation exposure [4].
The use of the free hand technique is to mimic as close as possible the technique of lumbar
screw placement without use of any intraoperative fluoroscopy, radiography, and/or image-
guided techniques.
This study aimed to evaluate the safety and accuracy of the pedicle screw placement with a
free hand technique by analyzing post-operative imaging in the lumbar region.
Materials and Methods

A prospective study was done from may 2015 to November 2017 in our hospital using free
hand technique lumbar pedicle screw placement includes 50 patients 270 screws. The
diagnosis includes degenerative spine, trauma, and spondylolithesis.
Surgical technique
Correspondence Through posterior approach spine exposed till lateral border of transverse process. Entry made
Dr. P Maharajothi at junction of pars, mamillary process, midpoint of transverse process, on lateral border of face
MS ortho, Senior assistant joint. Entry made with bone awl probed with straight gear shift blunt probe with medial
professor, govt chengalpattu angulation 5 degree at l1 and increasing 5 degree additionally l2, l3, l4 25 degree at l5. Sagittal
medical college, Chengalpattu,
angulation in direction of contralateral transverse process.
Tamil Nadu, India
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International Journal of Orthopaedics Sciences
Fig 1: pedicle screw entry point
While entering if there is any resistance direction has to be Preoperatively pedicle diameter, length of pedicle and angle
changed little bit, if there is any free movement it means there measured in CT.
is some breach in cortex remove the probe and reinsert with Post operatively CT scan obtained for checking position and
direction change after probing with ball tipped pedicle feeler detect breach.
inserted and checked all four walls superior, inferior, medial CT scans were performed in all patents with follow-up. The
and lateral wall and anterior wall should not be penetrated CT scans (axial and sagittal) were examined to evaluate the
depth measured and screws inserted usually 5.5mm to 6.5mm position of screw according to the classification of Learch and
diameter screw with length average from 40 to 55mm screws Wiesner [5].
used,and connected with rods.
Fig 2: pedicle screw in position
Computed tomography assessment visualized.

Multislice CT scans (axial, sagittal, coronal, and Grade 1-Minor penetration: the screw trajectory is less than
reconstruction) were examined to evaluate the position of the 3mm outside the pedicular boundaries.
screws according to the classification of Learch et al. and Grade 2-Moderate penetration: the screw trajectory is 36mm
Wiesner et al. In this classification, there are four main outside the pedicular boundaries.
categories for screw misplacement. Grade 3-Severe penetration: the screw trajectory is more than
Grade 0 -Encroachment: the pedicle cortex cannot be 6mm outside the pedicular boundaries.
~ 622 ~
Number of screws l1-30, l2 30, l3 20, l4 80, l5 110
Fig 3: example for pediclescrew without breach
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Fig 4: example for post op ct pics
Discussion hemiplegia after 5 days of surgery but it has no correlation

Pedicle screw fixation provides three column strong construct with surgery. One patient had transverse process fracture. we
in fractures and instability. Various techniques for this have not revised any screws. free hand technique in
includes free hand technique, fluoroscopy guided, stereotactic experienced hand produce safety and accuracy with reduced
navigation assisted and robotic assisted. but they need radiation exposure in experienced hands.
specialized equipments and also hazardous in form of
radiation exposure. Free hand technique needs experience and Results
thorough knowledge of anatomy and experience. the author Among the total 270 lumbar free hand placed pedicle screws,
tried free hand technique after performing more than hundred 10 screws with lateral breach, 1 screw inferior breach, 2
cases with fluoroscopy assistance. But free hand technique medial breach without significant neurological involvement
provides accuracy and safety by reducing radiation exposure with two cases of radicular pain which subsides over period of
both to patients and surgeon. our study limits to fracture, time without any revision.
spondylolisthesis and degenerative disc disease, our limitation
is we have not included scoliosis or kyphosis case in free Conclusion
hand technique. Free hand pedicle screw placement based on external
Cortical breach medially 4mm and laterally 6mm does not landmark using confluence of pars, mamillary process,
have significant neurological deficit because medialy there is midpoint of transverse process, on lateral border of face joint
2mm epidural and 2mm subarachnoid space which provide as entry point of lumbar pedicle screws with free hand
safe zone for medial breach in lumbar spine. but even 2mm of technique and the accuracy of this technique showed
inferior breach will present with root irritation. acceptable safety and accuracy and avoidance of radiation
Postoperatively two cases had radiating pain with nerve root exposure in experienced hand.
irritation but it resolves after 3 weeks. one case had
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References
1. Hyun SJ, Kim YJ, Cheh G, Yoon SH, Rhim SC. Free
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3. Cotrel Y, Dubousset J, Guillaumat M. New universal
instrumentation in spinal surgery. Clin Orthop Relat Res.
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7. Learch TJ, Massie JB, Pathria MN, Ahlgren BA, Garfin
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PMID: 15087800
8. Wiesner L, Kothe R, Ruther W. Anatomic evaluation of
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International Journal of Orthopaedics Sciences 2017; 3(4): 621-625

Dr. P Maharajothi Dr. P Maharajothi

Materials and Methods

Fig 1: pedicle screw entry point

Fig 2: pedicle screw in position

Computed tomography assessment visualized.

Number of screws l1-30, l2 30, l3 20, l4 80, l5 110

Fig 3: example for pediclescrew without breach

Fig 4: example for post op ct pics

Discussion hemiplegia after 5 days of surgery but it has no correlation

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