Comparative analysis of the effectiveness of the combined method of inserting pedicle screws with the free-hand technique in patients with idiopathic scoliosis

Objective. To analyze intraoperative data and results of treatment of patients with idiopathic scoliosis with two options of the open insertion of pedicle screws using the free-hand technique.
Material and Methods. The data of 457 patients aged 16–35 years who underwent surgical treatment for idiopathic scoliosis by one surgeon were analyzed. In 236 patients (Group I), the screws were placed manually, and in 221 (Group II) – using power tool. The preparation of the canal for pedicle screws in both groups was performed using the free-hand technique. The correct position of the screws was
assessed intraoperatively using an image intensifier and neurophysiological monitoring. The duration of surgery and X-ray monitoring, blood loss, and the presence of intra- and postoperative complications were assessed.

Results. In Group I, 4243 screws were inserted, and in Group II – 3978. The correct position of pedicle screws was recorded in 89.1 % of cases in Group I, and in 89.6 % of cases in Goup II. In Group I, the incorrect position of anchor elements was detected in 10.9 % of cases, and in Group II – in 10.4 % of cases. The number of screws re-positioned intraoperatively corresponded to the number of incorrectly positioned screws. There was a statistically significant difference in the volume of intraoperative blood loss and duration of surgery between
patients of both groups (p < 0.05).

Conclusion. The development and active introduction of high-tech methods of surgical treatment of spinal deformities increase the number of interventions performed annually. The proposed combined method of surgical treatment seems to be optimal because manual formation of the canal reduces the risk of intraoperative complications, and the use of power tool during screw placement shortens duration of surgery and reduces blood loss.

1. Rosenberg JJ. Scoliosis. Pediatr Rev. 2011;32:397–398. DOI: 10.1542/pir.32-9-397.

2. Gacitua MV, Gonzalez MC, Sanz C, Mulli V, Goddard P, Rolon ED, Castello P, Hiebra MDC, Pappolla R, Gentile LF, Ruggiero S, Severini A, Pasqualini D. [Adolescent idiopathic scoliosis]. Arch Argent Pediatr. 2016;114:585–594. DOI: 10.5546/aap.2016.585.

3. Weinstein SL. The natural history of adolescent idiopathic scoliosis. J Pediatr Orthop. 2019;39:S44–S46. DOI: 10.1097/BPO.0000000000001350.

4. Kuznia AL, Hernandez AK, Lee LU. Adolescent idiopathic scoliosis: common questions and answers. Am Fam Physician 2020;101:19–23.

5. Sosnin AG, Aleynik AYa, Mlyavykh SG, Yarikov AV, Smirnov II. Posterior spondylosyndesis in the treatment of idiopathic thoracic scoliosis. University Proceedings. Volga Region. Medical. Sciences. 2020;(3):5–20. DOI: 0.21685/2072-3032-2020-3-1.

6. Дудин М.Г., Михайловский М.В., Садовой М.А., Пинчук Д.Ю., Фомичев Н.Г. Идиопатический сколиоз: кто виноват и что делать? // Хирургия позвоночника. 2014. № 2. С. 8–20. [Dudin MG, Mikhailovsky MV, Sadovoy MA, Pinchuk DYu, Fomichev NG. Idiopathic scoliosis: who is to blame and what to do? Hir. Pozvonoc. 2014;(2):8–20]. DOI: 10.14531/ss2014.2.8-20.

7. Пятакова Г.В., Оконешникова О.В., Кожевникова А.О., Виссарионов С.В. Психологические аспекты лечения и реабилитации пациентов с подростковым идиопатическим сколиозом: анализ исследований. Oртопедия, травматология и восстановительная хирургия детского возраста. 2019. Т. 7. № 2. С. 103–115. [Pyatakova GV, Okoneshnikova OV, Kozhevnikova AO, Vissarionov SV. Psychological aspects of treatment and rehabilitation of patients with adolescent idiopathic scoliosis: research analysis. Pediatr Traumatol Orthop Reconstr Surg. 2019;7(2):103–115]. DOI: 10.17816/PTORS72103-115.

8. Lonstein JE. Scoliosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 2006;443:248–259. DOI: 10.1097/01.blo.0000198725.54891.73.

9. Cotrel Y, Dubousset J, Guillaumat M. New universal instrumentation in spinal surgery. Clin Orthop Relat Res. 1988;227:19–23.

10. Asghar J, Samdani AF, Pahys JM, D'andrea LP, Guille JT, Clements DH, Betz RR. Computed tomography evaluation of rotation correction in adolescent idiopathic scoliosis a comparison of an all pedicle screw construct versus a hook-rod system. Spine. 2009;34:804–807. DOI: 10.1097/BRS.0b013e3181996c1b.

11. Dobbs MB, Lenke LG, Kim YJ, Kamath G, Peelle MW, Bridwell KH. Selective posterior thoracic fusions for adolescent idiopathic scoliosis comparison of hooks versus pedicle screws. Spine. 2006;31:2400–2404. DOI: 10.1097/01.brs.0000240212.31241.8e.

12. Wu X, Yang S, Xu W, Yang C, Ye S, Liu X, Li J, Wang J. Comparative intermediate and long-term results of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis. J Spinal Disord Tech. 2010;23:467–473. DOI: 10.1097/BSD.0b013e3181bf6797.

13. Kim YJ, Lenke LG, Kim J, Bridwell KH, Cho SK, Cheh G, Sides B. Comparative analysis of pedicle screw versus hybrid instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine. 31:291–298. DOI: 10.1097/01.brs.0000197865.20803.d4.

14. Liljenqvist U, Lepsien U, Hackenberg L, Niemeyer T, Halm H. Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis. Eur Spine J. 2002;11:336–343. DOI: 10.1007/s00586-002-0415-9.

15. Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER. Thoracic pedicle screw fixation in spinal deformities are they really safe? Spine. 2001;26:2049–2057. DOI: 10.1097/00007632-200109150-00022.

16. Cote P, Cassidy JD, Carroll L. The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine. 1998;23:1689–1698. DOI: 10.1097/00007632-199808010-00015.

17. Esses SI, Sachs BL, Dreyzin V. Complications associated with the technique of pedicle screw fixation. Spine. 1993;18:2231–2239. DOI: 10.1097/00007632-199311000-00015.

18. Suk SI, Lee SM, Chung ER, Kim JH, Kim SS. Selective thoracic fusion with segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis more than 5-year follow-up. Spine. 2005;30:1602–1609. DOI: 10.1097/01.brs.0000169452.50705.61.

19. Suk SI, Kim JH, Kim SS, Lim DJ. Pedicle screw instrumentation in adolescent idiopathic scoliosis (AIS). Eur Spine J. 2012;21:13–22. DOI: 10.1007/s00586-011-1986-0.

20. Liljenqvist UR, Halm HF, Link TM. Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine. 1997;22:2239–2245. DOI: 10.1097/00007632-199710010-00008.

21. Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine. 2004;29:333–342. DOI: 10.1097/01.brs.0000109983.12113.9b.

22. AlQahtani SM, Alzahrani MM, Harvey EJ. Prevalence of musculoskeletal disorders among orthopedic trauma surgeons: an OTA survey. Can J Surg. 2016;59:42–47. DOI: 10.1503/cjs.014415.

23. Alzahrani MM, Alqahtani SM, Tanzer M, Hamdy RC. Musculoskeletal disorders among orthopedic pediatric surgeons: an overlooked entity. J Child Orthop. 2016;10:461–466. DOI: 10.1007/s11832-016-0767-z.

24. Auerbach JD, Weidner ZD, Milby AH, Diab M, Lonner BS. Musculoskeletal disorders among spine surgeons: Results of a survey of the Scoliosis Research Society membership. Spine. 2011;36:E1715–E1721. DOI: 10.1097/BRS.0b013e31821cd140.

25. Seehausen DA, Skaggs DL, Andras LM, Javidan Y. Safety and efficacy of power-assisted pedicle tract preparation and screw placement. Spine Deform. 2015;3:159–165. DOI: 10.1016/j.jspd.2014.07.001.

26. Yan H, Jiang D, Xu L, Liu Z, Sun X, Sha S, Qiu Y, Zhu Z. Does the full power-assisted technique used in pedical screw placement affect the safety and efficacy of adolescent idiopathic scoliosis surgery? World Neurosurg. 2018;116:e79–e85. DOI: 10.1016/j.wneu.2018.04.047.

27. Faldini C, Viroli G, Fiore M, Barile F, Manzetti M, Di Martino A, Ruffilli A. Power-assisted pedicle screws placement: Is it as safe and as effective as manual technique? Narrative review of the literature and our technique. Musculoskelet Surg. 2021;105:117–123. DOI: 10.1007/s12306-021-00714-x.

28. Skaggs DL, Compton E, Vitale MG, Garg S, Stone J, Fletcher ND, Illingworth KD, Kim HJ, Ball J, Kim EB, Keil L, Harris H, Shah SP, Andras LM. Power versus manual pedicle tract preparation: a multi-center study of early adopters. Spine Deform. 2021;9:1395–1402. DOI: 10.1007/s43390-021-00347-x.

29. Колесов С.В. Хирургия деформаций позвоночника / под ред. акад. РАН и РАМН С.П. Миронова. М., 2014. С. 115–118. [Kolesov SV. Surgery of Spine Deformities, ed. by acad. S.P. Mironov. Moscow, 2014:115–118.]

30. Guisse NF, Stone JD, Keil LG, Bastrom TP, Erickson MA, Yaszay B, Cahill PJ, Parent S, Gabos PG, Newton PO, Glotzbecker MP, Kelly MP, Pahys JM, Fletcher ND. Modified Clavien–Dindo–sink classification system for adolescent idiopathic scoliosis. Spine Deform. 2022;10:87–95. DOI: 10.1007/s43390-021-00394-4.

31. Lotan S, Kalichman L. Manual therapy treatment for adolescent idiopathic scoliosis. J Bodyw Mov Ther. 2019;23:189–193. DOI: 10.1016/j.jbmt.2018.01.005.

32. Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O'Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: Orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018;13:3. DOI: 10.1186/s13013-017-0145-8.

33. Day JM, Fletcher J, Coghlan M, Ravine T. Review of scoliosis-specific exercise methods used to correct adolescent idiopathic scoliosis. Arch Physiother. 2019;9:8. DOI: 10.1186/s40945-019-0060-9.

34. Yu T, Li QJ, Zhang XW, Wang Y, Jiang QY, Zhu XJ, Jiang ZD, Zhao JW. Multimodal intraoperative monitoring during surgical correction of scoliosis to avoid neurologic damage. Medcine (Baltimore). 2019;98:e15067. DOI: 10.1097/MD.0000000000015067.

35. Thirumala PD, Huang J, Thiagarajan K, Cheng H, Balzer J, Crammond DJ. Diagnostic accuracy of combined multimodality somatosensory evoked potential and transcranial motor evoked potential intraoperative monitoring in patients with idiopathic scoliosis. Spine. 2016;41:e1177–e1184. DOI: 10.1097/BRS.0000000000001678.

36. Thirumala PD, Bodily L, Tint D, Ward WT, Deeney VF, Crammond DJ, Habeych ME, Balzer JR. Somatosensory-evoked potential monitoring during instrumented scoliosis corrective procedures: validity revisited. Spine J. 2014;14:1572–1580. DOI: 10.1016/j.spinee.2013.09.035.

37. Nino MC, Cohen D, Mejia JA, Onate R, Gonzalez M, Vallejo CA, Vallejo MG. Regarding intraoperative neurophysiologic monitoring in idiopathic scoliosis surgery: other techniques to improve safety. Can J Anaesth. 2021;68:1290–1291. DOI: 10.1007/s12630-021-02000-7.

38. Cofano F, Zenga F, Mammi M, Altieri R, Marengo N, Ajello M, Pacca P, Melcarne A, Junemann C, Ducati A, Garbossa D. Intraoperative neurophysiological monitoring during spinal surgery: technical review in open and minimally invasive approaches. Neurosurg Rev. 2019;42:297–307. DOI: 10.1007/s10143-017-0939-4.

39. Elliott D. The use of power tools in the insertion of cortical bone screws. Injury. 1992;23:451–452. DOI: 10.1016/0020-1383(92)90061-v.

40. Clavien PA, Sanabria JR, Strasberg SM. Proposed classifcation of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992;111:518–526.

41. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. DOI: 10.1097/01.sla.0000133083.54934.ae.