Advertisement

Cortical bone trajectory technique’s outcomes and procedures for posterior lumbar fusion: A retrospective study

Published:April 21, 2020DOI:https://doi.org/10.1016/j.jocn.2020.04.070

      Highlights

      • CBT screws need a limited soft tissue dissection with mechanical properties comparable to traditional pedicle screws.
      • The Cortical Bone Trajectory represents a more demanding procedure associated with an acceptable rate of complication.
      • Preoperative CT scan: planning the maximum length and size of the screw. Identify unfavorable anatomical conditions.
      • The highest screw positioning accuracy is reached with a 3D patient-tailored template guide.

      Abstract

      Cortical Bone Trajectory screws allow a limited soft tissue dissection with mechanical properties comparable to traditional pedicle screws. However, clinical results are still reported on limited samples.
      The study aimed to evaluate perioperative and mid-term follow up outcomes, clinical results and complications in 238 consecutive patients underwent CBT fusion for degenerative lumbosacral disease.
      Pre- and intraoperative data, clinical outcomes and complications were collected. The patients were stratified in three groups. The original technique was performed in the first 43 cases without a preoperative CT scan planning. The second group includes the patients who underwent preoperative CT scan for entry point and screw trajectory planning (158 patients). Surgical procedures in the last group were performed with patient-matched 3D printed guide (37 patients). The accuracy in screws positioning was evaluated on postoperative CT scan.
      The mean follow-up was 32.3 months. Mean ODI and VAS index improved with statistical significance. Mean procedural time was 187, 142 and 124 min in the three subgroups. The total amount of recorded complications was 4.2% (16.3%, 3.8% and 0.0% respectively). Screws entirely within the cortex of the pedicle were 78.9%, 90.5% and 93.9% in the three groups. Fusion was obtained in 92.4% of cases.
      The CBT technique is a safe procedure, especially with an accurate preoperative CT scan-based planning. This seems more evident with the 3D template patient-matched guide. More studies are needed to directly compare traditional pedicle screws and CBT screws on long-term outcomes.

      Keywords

      To read this article in full you will need to make a payment

      References

        • Snyder L.A.
        • Martinez-Del-Campo E.
        • Neal M.T.
        • et al.
        Lumbar spinal fixation with cortical bone trajectory pedicle screws in 79 patients with degenerative disease: perioperative outcomes and complications.
        World Neurosurg. 2016; 2016: 205-213https://doi.org/10.1016/j.wneu.2015.12.065
        • Kojima K.
        • Asamoto S.
        • Kobayashi Y.
        • et al.
        Cortical bone trajectory and traditional trajectory—a radiological evaluation of screw-bone contact.
        Acta Neurochir (Wien). 2015; 157: 1173-1178https://doi.org/10.1007/s00701-015-2432-6
        • Marengo N.
        • Ajello M.
        • Pecoraro M.F.
        • et al.
        Cortical bone trajectory screws in posterior lumbar interbody fusion: minimally invasive surgery for maximal muscle sparing — a prospective comparative study with the traditional open technique.
        BioMed Res Int. 2018; 2018: 7424568https://doi.org/10.1155/2018/7424568
        • Lee G.W.
        • Son J.H.
        • Ahn M.W.
        • et al.
        The comparison of pedicle screw and cortical screw in Posterior Lumbar interbody fusion: A prospective randomized noninferiority trial.
        Spine J. 2015; 15: 1519-1526https://doi.org/10.1016/j.spinee.2015.02.038
      1. Darryl A. Raley Ralph J. Mobbs Retrospective Computed Tomography Scan Analysis of Percutaneously Inserted Pedicle Screws for Posterior Transpedicular Stabilization of the Thoracic and Lumbar Spine: Accuracy and Complication Rates Spine 37 12 2012 1092 1100 10.1097/BRS.0b013e31823c80d8 http://journals.lww.com/00007632-201205200-00014

        • Kasukawa Yuji
        • Miyakoshi Naohisa
        • Hongo Michio
        • Ishikawa Yoshinori
        • Kudo Daisuke
        • Shimada Yoichi
        Short-term results of transforaminal lumbar interbody fusion using pedicle screw with cortical bone trajectory compared with conventional trajectory.
        Asian Spine J. 2015; 9
        • Lee G.W.
        • Son J.H.
        • Ahn M.W.
        • et al.
        The comparison of pedicle screw and cortical screw in posterior lumbar interbody fusion: a prospective randomized noninferiority trial.
        Spine J. 2015; 15: 1519-1526
      2. Khanna N, Deol G, Poulter G, et al. Medialized, Muscle-Splitting Approach for Posterior Lumbar Interbody Fusion: Technique and Multicenter Perioperative Results. Spine (Phila Pa 1976). 2016 Apr;41 Suppl 8:S90-6.

        • Dabbous B.
        • Brown D.
        • Tsitlakidis A.
        • et al.
        Clinical outcomes during the learning curve of MIDline Lumbar Fusion (MIDLF®) using the cortical bone trajectory.
        Acta Neurochir (Wien). 2016; 158: 1413-1420
        • Hung C.W.
        • Wu M.F.
        • Hong R.T.
        • et al.
        Comparison of multifidus muscle atrophy after posterior lumbar interbody fusion with conventional and cortical bone trajectory.
        Clin Neurol Neurosurg. 2016; 145: 41-45
        • Marengo N.
        • Ajello M.
        • Pecoraro M.F.
        • et al.
        Cortical bone trajectory screws in posterior lumbar interbody fusion: minimally invasive surgery for maximal muscle sparing-a prospective comparative study with the traditional open technique.
        Biomed Res Int. 2018; 18: 7424568
        • Dayani F.
        • Chen Y.R.
        • Johnson E.
        • et al.
        Minimally invasive lumbar pedicle screw fixation using cortical bone trajectory – Screw accuracy, complications, and learning curve in 100 screw placements.
        J Clin Neurosci. 2018; 61: 106-111https://doi.org/10.1016/j.jocn.2018.10.131
        • Gautschi O.P.
        • Garbossa D.
        • Tessitore E.
        • et al.
        Maximal access surgery for posterior lumbar interbody fusion with divergent, cortical bone trajectory pedicle screws: a good option to minimize spine access and maximize the field for nerve decompression.
        J Neurosurg Sci. 2017; 61: 335-341https://doi.org/10.23736/S0390-5616.16.03230-6
        • Berjano P.
        • Damilano M.
        • Ismael M.
        • et al.
        Minimally invasive PLIF with divergent, cortical trajectory pedicle screws.
        Eur Spine J. 2015; 24: 654-655https://doi.org/10.1007/s00586-015-3802-8
        • Matsukawa K.
        • Yato Y.
        • Nemoto O.
        • et al.
        Morphometric measurement of cortical bone trajectory for lumbar pedicle screw insertion using computed tomography.
        J Spinal Disord Tech. 2013; 26: E248-E253https://doi.org/10.1097/BSD.0b013e318288ac39
        • Matsukawa Keitaro
        • Yato Yoshiyuki
        • Kato Takashi
        • Imabayashi Hideaki
        • Asazuma Takashi
        • Nemoto Koichi
        In vivo analysis of insertional torque during pedicle screwing using cortical bone trajectory technique.
        Spine. 2014; 39: E240-E245
        • Matsukawa K.
        • Yato Y.
        • Imabayashi H.
        • et al.
        Biomechanical evaluation of the fixation strength of lumbar pedicle screws using cortical bone trajectory: a finite element study.
        J Neurosurg Spine. 2015; 23: 471-478
      3. Akpolat YT, İnceoğlu S, Kinne N, et al. Fatigue performance of cortical bone trajectory screw compared with standard trajectory pedicle screw. Spine (Phila Pa 1976). 2016; 41: E335-E341

      4. McKinley TO, McLain RF, Yerby SA, et al. Characteristics of pedicle screw loading: effect of surgical technique on intravertebral and intrapedicular bending moments. Spine (Phila Pa 1976) 1999; 24: 18 – 25

      5. Perez-Orribo L, Kalb S, Reyes PM, et al. Biomechanics of lumbar cortical screw-rod fixation versus pedicle screw-rod fixation with and without interbody support. Spine 1 (Phila Pa 1976) 2013; 38: 635-641

        • Matsukawa K.
        • Abe Y.
        • Yanai Y.
        • et al.
        Regional Hounsfield unit measurement of screw trajectory for predicting pedicle screw fixation using cortical bone trajectory: a retrospective cohort study.
        Acta Neurochir (Wien). 2018; 160: 405-411https://doi.org/10.1007/s00701-017-3424-5
        • Matsukawa K.
        • Yato Y.
        • Imabayashi H.
        • et al.
        Biomechanical evaluation of fixation strength among different sizes of pedicle screws using the cortical bone trajectory: what is the ideal screw size for optimal fixation?.
        Acta Neurochir (Wien). 2016; 158: 465-471https://doi.org/10.1007/s00701-016-2705-8
        • Matsukawa K.
        • Yato Y.
        • Imabayashi H.
        • et al.
        Biomechanical evaluation of cross trajectory technique for pedicle screw insertion: combined use of traditional trajectory and cortical bone trajectory.
        Orthop Surg. 2015; 7: 317-323https://doi.org/10.1111/os.12212
        • Senoglu M.
        • Karadag A.
        • Kinali B.
        • et al.
        Cortical bone trajectory screw for lumbar fixation: a quantitative anatomic and morphometric evaluation.
        World Neurosurg. 2017; 103: 694-701https://doi.org/10.1016/j.wneu.2017.03.137
        • Asamoto S.
        • Kojima K.
        • Winking M.
        • et al.
        Optimized screw trajectory for lumbar cortical bone trajectory pedicle screws based on clinical outcome: evidence favoring the buttress effect theory.
        J Neurol Surg A Cent Eur Neurosurg. 2018; 79: 464-470https://doi.org/10.1055/s-0038-1641147
      6. Rexiti P, Abudurexiti T, Abuduwali N, et al. Measurement of lumbar isthmus parameters for novel starting points for cortical bone trajectory screws using computed radiography. Am J Transl Res. 2018;10(8):2413-2423. http://www.ncbi.nlm.nih.gov/pubmed/30210680. Accessed June 2, 2019.

        • Penner F.
        • Marengo N.
        • Ajello M.
        • et al.
        Preoperative 3D CT planning for cortical bone trajectory screws a retrospective radiological cohort study.
        World Neurosurg. 2019; : 1-7https://doi.org/10.1016/j.wneu.2019.03.121
      7. Zachary Tan Stewart McLachlin Cari Whyne Joel Finkelstein Validation of a freehand technique for cortical bone trajectory screws in the lumbar spine 31 2 2019 201 208 10.3171/2019.1.SPINE181402 https://thejns.org/view/journals/j-neurosurg-spine/31/2/article-p201.xml

        • Mason A.
        • Paulsen R.
        • Babuska J.M.
        • et al.
        The accuracy of pedicle screw placement using intraoperative image guidance systems.
        J Neurosurg Spine. 2014; 20: 196-203https://doi.org/10.3171/2013.11.SPINE13413
        • Siasios I.D.
        • Pollina J.
        • Khan A.
        • et al.
        Percutaneous screw placement in the lumbar spine with a modified guidance technique based on 3D CT navigation system.
        J Spine Surg. 2017; 3: 657-665https://doi.org/10.21037/jss.2017.12.05
        • Kim S.B.
        • Rhee J.M.
        • Lee G.S.
        • et al.
        Computer-assisted Patient-specific Prototype Template for Thoracolumbar Cortical Bone Trajectory Screw Placement.
        Tech Orthop. 2018; 33: 246-250https://doi.org/10.1097/BTO.0000000000000285
        • Marengo N.
        • Matsukawa K.
        • Monticelli M.
        • et al.
        Cortical bone trajectory screw placement accuracy with a patient-matched 3D printed guide in lumbar spinal surgery: a clinical study.
        World Neurosurg. 2019; https://doi.org/10.1016/J.WNEU.2019.05.241