World Neurosurg 2021 149 15-25

Technical Note
20 Tips to Avoid and Handle Problems in the Placement of Percutaneous Pedicle

Screws
Federico Landriel1, Alfredo Guiroy2, Alejandro Morales Ciancio2, Nestor Taboada3, Cristiano Menezes4, Alberto Gotfryd5,
Sebastián Kornfeld1, Santiago Hem1 AO Spine Latin America Minimally Invasive Study Group
- BACKGROUND: Two-dimensional fluoroscopy-guided adhesive drape control; (16) bend the rod; (17) lower rods;
percutaneous pedicle screw placement is currently the (18) freehand inner; (19) posterior fusion; (20) revision.
most widely applied instrumentation for minimally invasive - CONCLUSIONS: Implementation of these tips might
treatment of spinal injuries requiring stabilization.
improve performance of this technique and reduce the
Although this technique has advantages over open instru-
complications related to percutaneous pedicle screw
mentation, it also presents new challenges and specific
placement.
complications. The objective of this study was to provide
recommendations developed from the experience of
several spinal surgeons at different minimally invasive
spine surgery reference centers to solve specific problems
and prevent complications during the learning curve of this INTRODUCTION
T
technique. wo-dimensional (2D) fluoroscopy-guided percutaneous
pedicle screw (PPS) placement is currently the most
- METHODS: An AO Spine Latin America minimally inva- widely applied instrumentation for minimally invasive
sive spine surgery study group analyzed the most frequent treatment of spinal injuries requiring stabilization.1 Although this
complications and challenges occurring during the place- technique has advantages over open instrumentation, it also
ment of >14,000 two-dimensional fluoroscopyeguided presents new challenges and specific complications.2 One of
percutaneous pedicle screws at different centers over 15 the first obstacles regarding the learning curve of this
years. Twenty tips considered most relevant to performing technique is absence of palpation and direct view of the
osseous structures marking the classic entry points for open
this technique, excluding problems directly related to
instrumentation, in addition to dependence on imaging
specific brands of instruments, were presented. systems, which are necessary for minimally invasive pedicle
- RESULTS: The 20 tips included the following: (1) posi- cannulation. Adapting to placing a screw by palpating with the
tip of a trephine Jamshidi needle while looking at a fluoroscope
tioning; (2) clean and painless; (3) fewer x-rays; (4) check
screen is not easy and can be frustrating when accompanied
the clock; (5) beveled tip; (6) transverse-rib-pedicle; (7) by problems with instrumentation devices or complications
double Jamshidi; (8) hammer the Kirschner wire; (9) bent inherent to the surgical technique. The objective of this study
tip; (10) too loose, too tight; (11) new trajectory; (12) manual was to provide recommendations developed from the
control; (13) start over; (14) Kirschner wire first; (15) experience of several spinal surgeons at different minimally
Key words From the 1Neurosurgical Department, Spine Unit, Hospital Italiano de Buenos Aires, Buenos
- Minimally invasive instrumentation Aires, Argentina; 2Spine Unit, Orthopedic Department, Hospital Español de Mendoza,
- Percutaneous pedicle screws Mendoza, Argentina; 3Department of Neurosurgery, Clínica Portoazul, Barranquila, Colombia;
4
- PPS complications Department of Orthopedic and Traumatology, Hospital Vera CruzeInstituto da Coluna, Belo
- PPS recommendations
Horizonte, Brazil; and 5Department of Orthopedic, Hospital Israelita Albert Einstein, São
Paulo, Brazil
- PPS tips
To whom correspondence should be addressed: Federico Landriel, M.D.
Abbreviations and Acronyms [E-mail: federico.landriel@hospitalitaliano.org.ar]
2D: Two-dimensional Citation: World Neurosurg. (2021) 149:15-25.
AP: Anteroposterior https://doi.org/10.1016/j.wneu.2021.01.149
MISS: Minimally invasive spine surgery Journal homepage: www.journals.elsevier.com/world-neurosurgery
PPS: Percutaneous pedicle screw
Available online: www.sciencedirect.com
VB: Vertebral body
1878-8750/$ - see front matter ª 2021 Elsevier Inc. All rights reserved http://
creativecommons.org/licenses/by-nc-nd/4.0/).
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TECHNICAL NOTE
invasive spine surgery (MISS) reference centers to solve specific fascia opening. A significant amount of postoperative pain may
problems and prevent complications during the learning curve of originate at this stage.
this technique.
For each screw, skin and soft tissue infiltration with 1% lidocaine
is recommended to avoid nociceptive input, and epinephrine is
MATERIALS AND METHODS recommended to reduce bleeding. Local anesthetics interrupt
The AO Spine Latin America MISS study group analyzed the sensitive terminal activity, thus suppressing generation and
most frequent complications and challenges occurring during transmission of the nerve impulse during surgical manipulation.
By blocking the first link on the nociceptive pathway, the
the placement of >14,000 2D fluoroscopyeguided PPS at
ascending sensitizing effect is reduced.3 Skin incision will depend
different centers over 15 years. We describe 20 tips that we
on the diameter of the screw extenders used, usually between 1
consider most relevant to performing this technique,
and 2 cm. If a small skin bridge is left between incisions, they can
excluding problems directly related to specific brands of in-
be joined to prevent necrosis. This should be considered mostly
struments. Institutional review board/ethics committee in L5-S1 fixations, where incisions are usually very close.
approval and patient consent were not required for this
retrospective study. Opening the subcutaneous tissue and fascias can be directly
performed with a monopolar electric scalpel. To achieve
enhanced direct vision, we recommend the use of 2 Cobb ele-
RESULTS vators. The Cobb elevator next to midline allows for medial
approach angulation and wide fascia opening. An insufficient
Recommendations opening might cause the fascias to descend, trapped by the
Tip 1. Positioning. PPS placement technique begins by correctly screw heads or the rod, thus causing pain. The other Cobb
positioning the patient on the operating table, ensuring that we elevator keeps the contralateral soft tissues retracted, improving
maintain the physiological curvatures in the segments to pro- visibility while the incision is deepened with a monopolar electric
ceed. C-arm fluoroscope transition should be confirmed to be scalpel, which considerably reduces bleeding of these small in-
correct and smooth, under the surgical table, from ante- cisions (Figure 1).
roposterior (AP) to lateral projection, as well as confirming
optimal visualization of pedicles or entry points in all the seg-
ments involved. Tip 3. Fewer X-Rays. Correct PPS placement requires radioscopic
guidance and control in AP and lateral projections. We recom-
We recommend “squaring up” the vertebrae one by one as their
mend assessing image quality before starting, and in cases
pedicles are being cannulated, avoiding a double image on the
where images are unsuitable, this technique should be
superior vertebral end plate in AP projection and a double ped-
abandoned.
icular or a posterior wall image in lateral projection. Surgical
drapes should be separated enough from the skin incisions to Simultaneous “mirror” pedicle cannulation reduces radiation
allow the introduction of the rod either cephalad or caudal, dose and shortens surgical time. Two trained surgeons follow the
especially in long-segment fixations. steps described by Wiesner et al.4 in left and right pedicles in the
same vertebra (Figure 2). The fluoroscope screen needs to be
Tip 2. Clean and Painless. In contrast to vertebroplasty or kypho- directly visible to both surgeons. The senior surgeon stands on
plasty, PPS placement requires a wider skin incision and muscle the side of the image intensifier, and the junior surgeon stands
Figure 1. Intraoperative image showing use of Cobb for right percutaneous pedicle screw. (B) Left-side
separators to enhance visualization of soft tissue incision.
opening with a monopolar electric scalpel. (A) Opening
16 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2021.01.149
TECHNICAL NOTE
Figure 2. (A and B) Mirror percutaneous pedicle screw technique.
on the opposite side, which is more comfortable. This maneuver convergent trajectory of PPS and, above all, to avoid inadvertent
could also be simultaneously performed in pedicles of adjacent and iatrogenic proximal facet violation (Figure 3).
vertebrae as long as they do not show a double-layer vertebral
end plate in AP projection or double pedicle in lateral projection.
Tip 5. Beveled Tip. The Jamshidi needles initially carve the
An additional advantage of this tip is that in strict lateral pro-
transpedicular bone trajectory. Multiple redirections can break
jections, it allows the Jamshidi needles to be redirected to
the pedicle or reduce its anti-pullout strength; the beveled-tip
maintain better cannulation symmetry in the sagittal plane.
Jamshidi needles make it possible to delicately modify the path
We recommend, especially at multiple levels without coronal through the pedicle, as they preferably advance contralateral to
deformity, keeping homogeneous axial convergence when the bevel. If the needle is rotated, this particularity of the bevel
introducing the Jamshidi needles. This allows placement of the can be used to redirect the needle in multiple planes (Figure 4).
screws and their corresponding screw extenders on the same Most of these needles have a mark on the handle identifying
line, facilitating rod insertion. the bevel side, which should be checked before insertion. In
case multiple pedicles are simultaneously cannulated, we
Taking care not to exceed 2.5-cm depth from the entry point with suggest using different-sized Jamshidi needles, alternating
the Jamshidi needles, all the Kirschner wires can be inserted
using only AP fluoroscopy, followed by only 1 lateral fluoroscopic
control. This maneuver significantly reduces radiation exposure
and surgical time, although it should be attempted only after
achieving proficiency in the original step-by-step technique
described.
Another way to reduce lateral x-ray controls is to count screw
rotations as they advance through the pedicle and vertebral body
(VB). We measure how many threads of the PPS are equal to 1
cm, and the desired depth is calculated in number of threads,
considering that a complete rotation will be equal to 1.5
Tip 4. Check the Clock. According to the Ferguson angle, L5-S1

segment slope may vary. This is significant, as L5 is frequently
the pedicle with most variations in its anatomy, and it is some-
times associated with lysis of the pars. To avoid multiple can-
nulation attempts, we suggest modifying the entry point. Usually,
pedicles are cannulated following clockwise order: left, from
Figure 3. Left L4 pedicle showing an incorrect entry point, with high
9e10 to 3e4; right, from 2e3 to 8e9. At L5 and S1, more vertical probability of injuring the pedicle proximal facet and medial face. Left L5
trajectories could be applied, following an 11-to-5 trajectory in the pedicle showing correct initial Jamshidi needle placement, millimeters
left pedicle and a 1-to-7 trajectory in the right one. In turn, the outside the lateral pedicle shadow. Right L4 pedicle showing the usual
entry point of the inferior lumbar pedicles is usually located pedicle cannulation trajectory. In right L5 pedicle, we show the
recommended trajectory in cases of listhesis with significant slippage or
several millimeters outside the lateral border of the pedicle high Ferguson angles.
shadow on AP fluoroscopy. This is important so as to keep the
TECHNICAL NOTE
Figure 4. (A) Diamond-tipped Jamshidi needle. (B and C) Beveled-tipped needle and the possibility to modify its
trajectory in multiple planes.
short and long ones, so that they do not hamper the surgeon’s MISS cannulation of small thoracic pedicles might be difficult. For
hand as he or she places them at different levels. this reason, we suggest applying the TRP technique, by which
the screw is intentionally placed more laterally, thus reducing
Tip 6. Transverse-Rib-Pedicle (TRP). When thoracic PPSs are the risk of medial pedicle wall rupture and potentially improving
placed under fluoroscopic guidance, it is essential to clearly grip as the transverse process and rib bone is incorporated.6
identify the pedicles in AP projection. If fluoroscopic images are This is achieved by starting cannulation a few millimeters
not clear, PPSs should not be placed owing to risk of medial further cephalad and more laterally than the usual entry point
pedicle wall rupture. on AP fluoroscopic projection. In this way, the bone trajectory
Figure 5. (A) Incorrect trajectory of a Jamshidi needle in new path in the desired direction is opened (yellow
right L5 pedicle (orange circle). (B) How the incorrect arrow).
trajectory of a Jamshidi needle is occupied, while a
TECHNICAL NOTE
begins at the transverse process/rib head, then the pedicle is the Kirschner wire. Otherwise, they will inevitably bend the
entered through its lateral wall, and the VB is finally reached. guidewire tip, preventing the instrument from advancing further
This technique allows for the use of longer screws, with a inside the VB and, occasionally, docking the Kirschner wire bent
higher convergence angle and therefore with a better grip. tip in the VB (Figure 7).
To remove a bent-tip Kirschner wire, we recommend taking it
Tip 7. Double Jamshidi. In some cases, the Jamshidi needle
with a needle inserter and levering on the tap handle, or screw
repeatedly enters the same wrong hole. When this occurs, it is
holder, avoiding sharp blows on the tap or screw (Figure 8).
difficult to redirect it to create a new entry site.
Reverse hammering, bottom to top, can pull it out together
In this case, we recommend leaving the Jamshidi needle placed with the tap or screw, creating a defect in the transpedicular
in the wrong path and opening a new entry site with a new trajectory, or break it, leaving a fragment of the guidewire in
needle. As the previous path is occupied by the first Jamshidi the VB (Figure 9). Once a bent-tip Kirschner wire is pulled out, a
needle or guidewire, it will be easier to open a new path with the new wire should be placed through the instrument, protruding its
second needle. Moreover, the direction of the wrong Jamshidi tip a few millimeters and advancing the tap or wire to the desired
needle allows for better three-dimensional orientation of the new point.
path. In this way, after partially advancing the second needle, the
first one can be removed, thus clearing the way (Figure 5).
Tip 10. Too Loose, Too Tight. The VB is not a homogeneous
Tip 8. Hammer the Kirschner Wire. It is sometimes difficult to rectangular structure; if the guidewire is progressed far anterior,
manually advance the Kirschner wire through the Jamshidi nee- it can violate the anterior vertebral wall even when, in lateral
dle into the VB; this usually occurs in young patients with better projection, we seem to continue inside the VB. Correct place-
bone quality. In the absence of a drill to advance the guidewire, ment of the guidewire is in the anterior third of the VB.
we recommend threading it in the thinner soft tissue dilator. This
We do not recommend approaching too much, or even less,
prevents the Kirschner wire portion protruding from the Jamshidi
going beyond the Kirschner wire tip with the tap, as the latter
needle from bending, and it allows for delicately hammering the
increases trajectory diameter through the bone, reducing guide-
Kirschner wire, advancing it to the desired depth inside the VB
wire grip strength. Because it is loose, it may inadvertently be
(Figure 6). Another alternative is to hold the guidewire with a
removed during the change from tap to screw (Figure 10).
Kocher clamp near the Jamshidi handle and to hammer on the
clamp in such a way that the introduction is controlled and the Depending on the thickness of the Kirschner wire and surgical
Kirschner wire is not bent. time, these may end up significantly bent, thus blocking the free
passage of cannulated instruments, such as the tap or screw. In
Tip 9. Bent Tip. The most effective way to prevent the Kirschner these cases, we recommend replacing the Jamshidi needle
wire tip from bending is to perform lateral fluoroscopic control through the guidewire until the posterior border of the VB,
before advancing the tap or screw through it. These instruments changing the Kirschner wire and then advancing the tap or the
should be aligned in such a way that they deepen coaxially with screw.
Figure 6. (A and B) Attempt at advancing a Kirschner wire by means of dilator threaded on the guidewire so as to provide it with support and to
manual control and hammering without external support. (C and D) Thin facilitate hammering without bending the Kirschner wire.
TECHNICAL NOTE
Figure 7. (A) Incorrect tap position in sagittal plane advancement of the Kirschner wire to the vertebral
(orange circle). (B) Tap non-coaxial deepening causing body anterior end.
(1) a kink in the guidewire and (2) undesired
We also suggest removing the guidewire once the screw tip Tip 11. New Trajectory. It is possible to slightly correct a Kirschner
has entered the VB. In this way, unintentional advancement wire sagittal trajectory inside the VB with the tap. However, this
of the Kirschner wire toward the prevertebral space is is a strong instrument and can break the pedicle. For this reason,
avoided. we recommend delicate millimetric movements.
Figure 8. (A and B) Lever maneuver on the tap handle to remove a bent-tip Kirschner wire.
TECHNICAL NOTE
Figure 9. (A) Bent tip of Kirschner wire in L5 vertebral body. (B) Bent-tip broken Kirschner wire fragment (yellow arrow) in front of the right S1 screw
Kirschner wire removal together with tap after an inverted hammering tip.
maneuver. (C) Anteroposterior fluoroscopy of another patient showing a
The tap is threaded in the Kirschner wire that we wish to correct; We recommend restarting the procedure step by step by placing
once the tap has passed the pedicle, it is advanced a few milli- the Jamshidi needle under fluoroscopic guidance in AP and
meters deep into the VB; then the Kirschner wire is removed. lateral projections because usually we cannot find the original
Under lateral fluoroscopic guidance, the wireless tap can be trajectory. In some cases, it might be helpful to use a thinner
reoriented, following the aforementioned recommendations. Jamshidi needle, which can allow for a new trajectory inside the
Once reoriented, a new Kirschner wire is placed through it and hole already opened in the pedicle resulting from the failed
advanced to the appropriate depth. attempts.
Tip 14. Kirschner Wire First. In cases where PPS placement is

Tip 12. Manual Control. Especially in osteoporotic patients, it is
associated with some type of intracanal decompression, we
advisable to introduce the Jamshidi needle to the posterior third
recommend placing the guidewires first because the screw and
of the body and to continue with the Kirschner wire only for the
screw extenders might significantly restrict the view if they are
remaining trajectory until reaching the anterior third of the VB.
placed first. In addition, percutaneous placement of Jamshidi
This maneuver provides the guidewire with higher clamping
needles after decompression might be difficult, owing to loss of
force to the bone.
palpatory sensation of the undamaged bone anatomy. This is also
One of the most common mistakes during PPS placement is extremely risky because the Jamshidi needle might incorrectly
unintentional guidewire removal. This often occurs when the enter the canal and damage the dura mater, nerve root, or spinal
Jamshidi needle or the tap is removed after the transpedicular cord.
path has been created. We recommend keeping manual control
In cases related to decompression, we recommend first cannu-
of the wire during these maneuvers. It is essential to have direct
lating the pedicles, placing the Kirschner wires, tying them to the
visualization of the end of the Kirschner wire at all times, which
surgical fields moving their distal end away from the operating
should be long enough to protrude any instrument that may be
site, and then decompressing. In many cases, the relationship
used.
between the articular process and the pedicle is not easy to
Quite frequently when removing the tap, its handle blocks the identify with a tubular separator. If we first place the guidewires,
end of the Kirschner wire, which may result in its simultaneous these will mark where the pedicles are within the surgical field,
removal. It is recommended to unscrew the screw extender a allowing for better planning of the decompressive gesture.
couple of turns, disassemble its handle, and remove the rest of
the screw extender under strict visualization and manual control Tip 15. Adhesive Drape Control. Polyester surgical adhesives are
of the guidewire (Figure 11). often used (Ioban; 3M, St. Paul, Minnesota, USA). These are
good antimicrobial mechanical barriers, from which hematic re-
mains are easily cleaned.
Tip 13. Start Over. Accidental Kirschner wire removal delays the
procedure significantly. There is a high risk of dural or myelor- If skin incisions are very narrow, the screw extenders and
adicular damage when attempting to reintroduce the wire free- screws, as they descend, may push adhesive residue into the
hand through the previous trajectory. incision depth. If they are not removed, they are likely to cause
TECHNICAL NOTE
Figure 10. (A) Correct tap placement. (B) Incorrect approach of the tap to the removal along with the tap. (E) Guidewire repositioning. (F) Percutaneous
Kirschner wire tip. (C and D) Guidewire loosening causes its inadvertent pedicle screw placement.
surgical site infection. We recommend making skin incisions Tip 17. Lower Rods. Not bending or lowering the rod by reducing
wide enough for the screw extender to descend without forcing each independent screw may pull it out or make the screw
the skin or cutting the adhesive around the incision before extender holding it come loose. In cases of long-segment fixa-
inserting the aforementioned instruments. tions, we recommend lowering the rod slowly as symmetrical
and parallel to the spine as possible, allowing for the screw ex-
tenders to freely adopt their angle as the rod is lowered. In
Tip 16. Bend the Rod. As with open systems, the rod should be kyphosis and lordosis, we suggest adjusting the screws halfway
bent according to the segment involved. In the case of kyphotic
during construction, followed by the superior and inferior distal
segments, or transition from kyphosis to lordosis, we recom-
screws to prevent pullout.
mend holding the rod inserter in such a way that the tip points
ventral when grasped with the rod inserter. Then, we start Trying to align a single screw extender by force during this ma-
threading the screw extender sideways, with the curvature par- neuver may cause it to break free from the screw head. It is
allel to the floor. Once the rod passes the last screw extender, advisable to lower all the screw extenders simultaneously and
rod position is changed once more in such a way that the tip progressively so as to reduce force in the screw extender unions.
points ventral again.
It is also important to check, in lateral projection, that there are no
In kyphosis, we suggest passing the rod from caudal to cephalic. differences in height or unevenness between the screw heads,
This maneuver should be delicately performed because the rod apart from the respective sagittal differences. If a screw head is
can be inadvertently placed into the canal. In lordosis, we sug- too high or too low with respect to the other screws, it will be
gest placing the rod from cephalad to caudal, with the exception difficult or impossible for the rod to lower this screw or the
of high-grade spondylolisthesis, particularly L5-S1, in which slip- nearest ones. If this is observed, it is advisable to modify it before
page is readily evident, or in some significantly increased Fer- placing the rod. An example is high-grade L5-S1 spondylolis-
guson angles, in which cases it is advisable to pass the rod from thesis, where it is very complex to pass the rod owing to the
caudal to cephalad, regardless of the percutaneous system presence of the sagittal slippage. In these cases, we recommend
applied. placing the intersomatic cage first, and if the slippage persists,
TECHNICAL NOTE
Figure 11. (AeD) Sequential images of Kirschner wire manual control while handle is dismantled and tap is removed.
we suggest placing longer than usual PPSs in L5, leaving a If an intraoperative pullout is identified, the Kirschner wire should
couple of threads outside the pedicles, to facilitate alignment of be inserted again through the screw core, its end protruding, and
their heads with those of PPSs in S1 (Figure 12). once again a screw of greater length and diameter should be
Figure 12. (A) High-grade L5-S1 spondylolisthesis. (B) with external threads to improve alignment with S1
Placement of longer percutaneous pedicle screw at L5 screws.
TECHNICAL NOTE
placed. The rod may need to be re-bent in the sagittal plane so 91.5% (n ¼ 7993; 95% confidence interval, 89.3%e93.6%) of
that it can lower the screw without forcing it. the screws were placed purely intrapedicular, and 96.1% (n ¼
8579; 95% confidence interval, 94.0%e98.2%) of screws with
Tip 18. Freehand Inner. In some cases, the screw head can detach an extrapedicular deviation <2 mm were included, which is the
from the screw extender while placing the rod. In this situation, cutoff point adopted by many authors to define screw placement
we recommend widening the skin incision slightly, separating the as acceptable, even though the screw is not being perfectly
soft tissue with a Cobb or another soft tissue retractor, and trying inserted in the pedicle.9,13,14,16-18
to place the inner freehand under direct vision or digital palpation
of the screw extender for head before confirming that the rod Because of its safety, this guidance method was used in >14,000
has already passed through it. PPS placements performed by our group. MISS pedicle cannula-
tion guided by 2D fluoroscopy requires a learning curve that might
The rod might slightly exceed the upper part of the screw head be demanding, long, and difficult compared with the conventional
without inner. In this case, we recommend slightly loosening the open technique, as there is no direct vision or palpation.8,10,12,14
inners in the other screws and lowering the rod so that it can
better fit the screw extender for head, pressing it down with the Surgeons are considered to have completed their training when
rod inserter. In cases where the construct cannot be correctly they reach expert surgeon’s standards. In an attempt at
visualized, we resort to a wider Wiltse-type approach. measuring the learning curve, 2 spinal surgeons without experi-
ence in the technique simultaneously placed 422 PPSs under
Tip 19. Posterior Fusion. If it were also necessary to perform a supervision. One surgeon placed all the PPSs on the right side in
posterior fusion, this can be done in 2 ways. First, the incisions all patients of the series, and the other surgeon did the same on
and intermuscular plane should be connected at the levels the the left side. This was done to narrow down diversity in pedicle
fusion is desired. The simplest way is facet fusion, in which the anatomy, allowing for more rigorous comparison. The authors
facet adjacent to the screws is exposed and decorticated; intra- reported that it is necessary to place approximately 70 PPSs to
articular tissue is removed with a monopolar electric scalpel; reach good results in intrapedicular accuracy comparable to
and autologous, heterologous, bank, or some bone substitute is experienced surgeons on this minimally invasive technique.19
inserted by means of compression. The second way is to expose
the corresponding transverse process, decorticate it, and place a The steps guided by 2D fluoroscopy are usually similar and not
graft seeking an intertransverse fusion. dependent on the instrumentation system used. This allowed us
to agree on the most frequent problems and complications we
Tip 20. Revision. In cases in which extension of a percutaneous experienced while performing the technique. We hope these tips
instrumentation is required, we recommend making 2 para- can help reduce mistakes, making the learning curve safer, less
median incisions connecting, on each side, the old incisions for demanding, and shorter.
the PPS. Once instrumentation is exposed, the inners are
removed from each screw; a Kirschner wire is rethreaded in
each, protruding its distal end by a few millimeters; and the CONCLUSIONS
screw is removed and inserted again, connected to a screw The implementation of these tips might improve performance of
extender. This recommendation is based on the fact that it is this technique and reduce the complications related to PPS
usually very difficult and time-consuming to attempt to place the placement.
screw extenders directly on the heads of the screws that have
already been inserted. If there is loosening of a screw, it should
be replaced by other of greater length and diameter. Once all the CRediT AUTHORSHIP CONTRIBUTION STATEMENT
old screws are joined to their respective screw extenders, the Federico Landriel: Methodology, Formal analysis, Writing -
PPSs are placed at the new levels, and they are connected by original draft, Writing - review & editing. Alfredo Guiroy:
threading them with a new, longer rod. Methodology, Formal analysis, Writing - original draft, Writing -
review & editing. Alejandro Morales Ciancio: Formal analysis,
DISCUSSION Writing - original draft, Writing - review & editing. Nestor
Taboada: Writing - original draft, Writing - review & editing, Su-
The PPS placement technique described >2 decades ago4,7-15 is
pervision. Cristiano Menezes: Writing - original draft, Writing -
currently widely used in MISS stabilization because of its versa-
review & editing, Supervision. Alberto Gotfryd: Writing - original
tility. However, as with other techniques, there is a risk of pedicle
draft, Writing - review & editing, Supervision. Sebastián Korn-
wall rupture and neurovascular injury if insertion is incorrect. This
feld: Methodology, Writing - original draft, Writing - review &
is why, except for neurophysiologic monitoring of Jamshidi
editing. Santiago Hem: Methodology, Writing - original draft,
needles or Kirschner wires, guidance for PPS placement is based
Writing - review & editing.
on images used by navigation systems, robotic assistance,
intraoperative computed tomography, or 2D fluoroscopy.
Although development of new technologies to provide higher ACKNOWLEDGMENTS
accuracy of pedicle cannulation and/or lower radiation exposure
This study was organized by the AO Spine Latin America mini-
has been promoted, most of the technologies are costly and
mally invasive spine surgery study group. AO Spine is a clinical
difficult to apply worldwide.
division of the AO Foundation, which is an independent medically
The 2D fluoroscopy guidance technique is used at most centers guided not-for-profit organization. Study support was provided
because it is profitable, practical, and safe. A recent meta- directly through AO Spine Latin America regarding data collec-
analysis by Rasmussen et al.11 on screw-to-screw accuracy of tion, data analysis, and proofreading. The authors thank Idaura
transpedicular cannulation using 2D fluoroscopy reported that Lobo (AO Spine) for administrative assistance.
TECHNICAL NOTE
8. Mohi Eldin MM, Hassan AS. Percutaneous trans- insertion of pedicle screws in the lumbar spine.
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the article content was composed in the absence of any
5. Li X, Zhang F, Zhang W, Shang X, Han J, Liu P. 13. Schizas C, Michel J, Kosmopoulos V, et al. Com- commercial or financial relationships that could be
A new method to precisely control the depth of puter tomography assessment of pedicle screw construed as a potential conflict of interest.
percutaneous screws into the pedicle by counting insertion in percutaneous posterior transpedicular
stabilization. Eur Spine J. 2007;16:613-617. Received 4 January 2021; accepted 30 January 2021
the rotation number of the screw with low radia-
tion exposure: technical note. Eur Spine J. 2017;26: Citation: World Neurosurg. (2021) 149:15-25.
750-753. 14. Spitz SM, Sandhu FA, Voyadzis JM. Percutaneous https://doi.org/10.1016/j.wneu.2021.01.149
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lumbar spine with external skeletal fixation. Clin Clinical evaluation and computed tomography nd/4.0/).
Orthop Relat Res. 1984;189:125-141. scan analysis of screw tracts after percutaneous

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Technical Note

20 Tips to Avoid and Handle Problems in the Placement of Percutaneous Pedicle

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Figure 2. (A and B) Mirror percutaneous pedicle screw technique.

Tip 4. Check the Clock. According to the Ferguson angle, L5-S1

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Tip 14. Kirschner Wire First. In cases where PPS placement is

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