Pedicle Screw Insertion

ENN
Introduction
• A standard method for achieving internal fixation and providing
spinal alignment, especially for the treatment of an unstable spine
• Although the complication rate is low, there have been reports of
inaccurate screw placement, dural tear, and screw failure
• A screw-related neural injury to the nerve root or spinal cord can
result in neurologic or radicular pain after surgery, sometimes
requiring revision surgery.
• Intraoperative imaging and newer navi- gation technologies are
designed to help surgeons improve the accuracy of pedicle screw
placement
Patient selection
• Patients with osteopenia or osteoporosis may not be candidates for
pedicle screws
• Patients with deformity or abnormal spinal anatomy must also be care-
fully evaluated, as their anatomic landmarks may not enable the proper
placement of pedicle screws.
• Finally, the pedicle size should also be assessed.
Anatomy Pedicle Screw
Indications Contraindications
> Significant osteoporosis (relative
contraindication)
• Stabilization of the thoracic spine after neural decompression
for tumor or infection
> Medical illness precluding major
• Thoracic spinal column fractures surgery
• Kyphotic deformities without signicant osteoporosis
> Life expectancy less than 3 to 6
• Patients with deficit posterior spinal elements due to failed
past surgeries
months

• Potential instability: spinal stenosis & degenerative scoliosis > Patients with thoracic pedicles too
small for screw placement with screw
diameter of at least 6 mm

> Compromised thoracic pedicles (e.g.,

fractured pedicles)
Advantages
• Does not require the dorsal elements
to be intact
• Avoids placing instrumentation within
the spinal canal
• Higher fusion rates
• High stability with three-column
involvement and three-dimensional
correction forces
• The strongest point of attachment of
the spine
• Less requirements for postoperative
bracing
Disadvantages
> Smaller pedicles may result in higher
incidence of durotomy or nerve injury
> Requires increased exposure to obtain
necessary trajectory
> Medial screw misplacement can lead to
iatrogenic neurologic injury
>. Steep learning curve.
> Lengthy operative time with potential for
significant blood loss and increased risk of
infection.
> Postoperative imaging studies (especially
MRI) are, in part, obscured by the implants.
> Costly procedures.
Preoperative imaging
• X-rays may include dynamic to assess instability and sagittal/coronal
balance.
• CT may enable the accurate assessment of complex bony spinal
anatomy and the most accurate planning for screw placement.
• MRI provides excellent visualization of soft tissue contrast for simulta-
neous evaluation of the thecal sac and spinal canal contents
Durante OP
1. Posisi meja dan C arm, Apron
2. Positioning
3. Desinfeksi (1 arah melingkar
keluar)
4. Drapping
5. Leveling C Arm
6. Insisi kulit

The skin incision is made over the

spinous processes of the levels
involved.

The construct should include three

normal levels above the pathology
and two normal levels below the
pathology, and the incision should
provide adequate exposure

Assited by Gelpi
7. Diseksi otot, ekspose lamina, rawat perdarahan
The incision is carried down subperiosteally along the spinous
processes and laminae, and should expose the transverse
processes.
8. Menentukan titik pedicel
Thoracal Pedicle

• The thoracic pedicle is oriented in a

posterolateral to antero- medial
direction by ~ 10 degrees along
most of the thoracic spine (Fig.
80.1).
• There is a slight anterior and lateral
angulation of the pedicle at T12.
• It is also important to note that the
thoracic pedicle height is greater
than the width and therefore
smaller-diameter pedicle screws
should be utilized in the thoracic
region as compared with the lumbar
spine (Fig. 80.2).
Entry Point,
Thoracal
Entry Point, Lumbal

A hole is made using an awl or high-speed drill at the junction

of the pars interarticularis, the mamillary ridge, and transverse
process
Lumbal pedicle insertion
Entry Point, Sacrum
Next
9. Cunnabeling / drilling titik masuk Awl
10. Buat jalur dengan Awl
- Disini dapat konfirmasi untuk arah ke
pedicle dengan C Arm (dipegang dengan
kocher Panjang)
• 11. Pasang Pin (15-20 mm) sesuai track
sebelumnya, dapat dibantu dengan
menggunakan Hammer, untuk menentukan arah
pedicle.
• Evaluasi C Arm
12. Masukkan Probe pada jalur pin (kedalaman lebih
pendek 5mm dari Panjang screw yang rencana kita
pasang) > dapat c arm evaluasi
13. Evaluasi Filler/Ball Tip
14. Masukkan Tapper, pilih diameter yg lebih kecil dari diameter screw
15. Evaluasi Filler/Ball Tip
16. Insersi screw

• At T1-3, 4.5 mm diameter screws that are 25-30 mm in length are

usually recommended.
• At T4-T10, screws are usually 4.5 mm in diameter and 30-35 mm
in length
• Typical lumbar pedicle screws range from 6 to 7.5 mm in diameter
and are 50 to 55 mm in length
• Typically, the sacrum accepts 7.5- to 8.5-mm diameter screws
measuring 40 to 55 mm in length.

.
> Konfirmasi ulang sebelum ke
operator

> Pastikan posisi screw lurus

C arm evaluasi post screwing

Intraoperative Verification of the Screw

Trajectory and Placement:

* direct AP views demonstrate the lateral to

medial orientation of the screws.
- excessive medial orientation of the screws
seen on AP films raises the concern of
medial penetration of the pedicle by the
screw.

* lateral imaging is useful to view the depth

of penetration into the vertebral body and
sagittal
angulation of the trajectory

- ventral screw penetration is usually

between 50 and 80% of the AP diameter of
the vertebral
body; penetration >80% of the vertebral
body on lateral plain x-ray raises the
concern of ventral penetration of the
vertebral body cortex.
17. Pasang rod
• Ukur dahulu Panjang antar screw
dengan penggaris

• Pastikan kurvatura rod sesuai

curvature normal spine
Pemasangan Nut (Break Off Set
Screw)
Pemasangan Crosslink
Follow up, post operative care
• Patients may receive physical therapy for early mobilization during
their hospitalization.
• Activity should be limited within the rst 1. 3 months to enable the fusion to
solidify.7
• Given the rigidity of current instrumentation systems, bracing is not routinely
used for degenerative spinal fusions. For deformity and trauma, we are more
inclined to brace.
• Daily dressing changes are performed until postoperative day 3 or 4.
• Follow-up routine radiographs are taken at 10 days, 1 month, 3 to 6 months,
and 1 year. They may include 36-inch standing lms in cases of deformity
correction. We typically obtain a CT scan at 1 year to assess the fusion.