PERCUTANEOUS

PEDICLE SCREW
INSTRUMENTATION
AGUS WAHYUDI
 INTRODUCTION

• Spinal instrumentation has a long history :

- 1911, Hibbs, who performed a posterior spine fusion for deformity
- 1962 , when Harrington began using distraction rods  internal spinal instrumentation gained more
widespread use
- 1982, Luque further refined this technique by introducing segmental instrumentation
- Modern era, of lumbosacral spinal fixation  Roy-Camille et al use of universal instrumentation based on
pedicle screw implants
• With the aim of minimal disruption to normal anatomy while effectively treating spinal
pathology, minimally invasive spine surgery (MIS) has been gaining popularity, especially in
the past 2 decades
• Insertion of pedicle screws through a midline approach requires massive retraction of the
multifidus muscle, subjecting the muscle to high retraction pressures and disruption of its
osseo-tendinous attachments and neurovascular supply
• The goal of minimally invasive spine (MIS) surgery is to accomplish the intended goals of
treatment: decompression, fusion, and/or realignment
• The key concepts that guide MIS approaches are:
(1) decrease muscle crush injuries during retraction
(2) Avoid detachment of tendons to the posterior bony elements, especially the multifidus attachments
to the spinous process and superior articular processes
(3) Maintain the integrity of the dorsolumbar fascia
(4) Limit bony resection
(5) Decrease the size of the surgical corridor to coincide with the area of the surgical target site
ANATOMY OF THE POSTERIOR
PARASPINAL MUSCLES
The posterior lumbar paraspinal muscles are part of a larger biomechanical system that
includes the abdominal muscles and their fibrous attachment to the spine through the
dorsolumbar fascia

Movements of the spine while maintaining its stability

• In addition to maintaining spinal posture in its neutral position, the paraspinal muscles guard the
spine from excessive bending that would otherwise endanger the integrity of the intervertebral
discs and ligaments
 MULTIFIDUS MUSCLES

• The posterior paraspinal muscles are composed of two muscle groups:

(1) The deep paramedian transversospinalis muscle group, which includes the multifidus,
interspinales, intertransversarii, and short rotators
(2) The more superficial and lateral erector spinae muscles that include the longissimus
and iliocostalis

• These muscles run along the thoracolumbar spine and attach caudally to the sacrum, sacroiliac joint, and iliac wing
ERECTOR SPINAE MUSCLES

composed of the longissimus, iliocostalis, and spinalis (in the thoracic area).
• In the lumbar spine, the longissimus is positioned medially. The laterally positioned
iliocostalis
• Unilateral contraction of the lumbar erector spinae laterally flexes the vertebral column;
bilateral contraction produces extension and posterior rotation of the vertebrae in the
sagittal plane
INTERSPINALES, INTERTRANSVERSARII, AND
SHORT ROTATOR MUSCLES
• are short flat muscles that lie dorsal to the intertransverse ligament
• The intertransversarii and interspinales run along the intertransverse and interspinous
ligaments of each segment. The short rotators originate from the posteriorsuperior edge
of the lower vertebra and attach to the lateral side of the upper vertebral lamina
PARASPINAL MUSCLE INJURY

Spine surgery inherently

damage to atrophy of the subsequent

surrounding loss of
muscles muscles and function
 PRESERVATION OF MUSCLE FUNCTION
AND INTEGRITY

• Minimally invasive spine surgery techniques  minimize muscle injury

during surgery. By decreasing/minimizing the use of self-retaining
retractors, intramuscular retraction pressure is reduced  leads to less
crush injury.

• Patients undergoing percutaneous instrumentation displayed more than 50% improvement in

extension strength, while patients undergoing traditional midline open surgery had no significant
improvement in lumbar extension strength
PRESERVATION OF THE BONE-LIGAMENT
COMPLEX
• Excessive facet resection leads to altered motion and spinal instability
• Furthermore, a laminectomy leads to loss of the midline supraspinous/interspinous
ligament complex, which can contribute to flexion instability
• Pedicle screw insertion can be performed :
- percutaneously
- via a paramedian mini-open technique
• With the percutaneous technique, the pedicle is entered using a Jamshidi-type trocar
needle under fluoroscopic control
 Technique
• After the appropriate trajectory is localized with fluoroscopy, sequential
dilators are passed through the fascia and docked onto the facet joint.
• A tubular retractor (typically 20 or 22 mm) is then docked and secured
over the dilators. The use of an expandable retractor allows the blades
to expand cephalad or caudad, creating a corridor for pedicle screw
placement.
• Soft tissue is cleared to expose the standard pedicle screw entry points.
• Screws can be placed using a variety of methods including free hand,
under C-arm guidance, or using navigation depending on surgeon
preference.
• Starting point is at the 10 o’clock and 2 o’clock positions on the left and right pedicles, respectively. The
Jamshidi is slowly advanced a few millimeters.
• A lateral fluoroscopic image is obtained and should confirm that the Jamshidi is placed within the center
of the pedicle.
• Under AP fluoroscopic imaging the Jamshidi is advanced about 20 mm. The tip should stay lateral to the
medial border of the pedicle.
• A lateral image is obtained and should show the tip of the Jamshidi at or past the neurocentral junction.
• If so, the Jamshidi can be safely advanced to its desired depth. If the tip of the Jamshidi is at or medial to
the medial border of the pedicle on the AP view and has not yet passed the neurocentral junction on the
lateral, the pedicel screw tract has breached the medial border of the pedicle
• After the Jamshidi is placed appropriately, a guidewire is passed. This is repeated at each
pedicle.
• The k-wires are secured out of the field, and the decompressive and interbody work is
performed.
• The pedicle screw is then placed over each k-wire and the appropriately sized rod is
passed.
• It is critical to continue lateral C-arm visualization to avoid advancing the k-wire
anteriorly.
JAMSHIDI NEEDLE
MUSCLE DILATOR
 PEDICLE ACCESS USING A LATERAL-TO-MEDIAL
TRAJECTORY

• Patient in prone position

• A Jamshidi needle is used to dock on the junction between the facet complex
and transverse process
• The Jamshidi needle is then advanced through the pedicle, making sure not to
cross the medial border of the pedicle until the junction between the pedicle
base and vertebral body has been reached
• The Jamshidi needle is typically passed to one quarter or one half the depth of the vertebral body and then a K-
wire passed down the Jamshidi needle
• The K-wire is then passed a little farther to seat it into bone, and the Jamshidi needle is then carefully removed.
An assistant holds the K-wire with a Kocher clamp to assure that it is not pulled out of the vertebral body while
removing the Jamshidi needle.
• A series of cannulated muscle dilators is then passed over the K-wire
• While passing cannulated instruments over the K-wire, an assistant should hold the K-wire with a Kocher clamp
to prevent inadvertent advancement of the K-wire. The pedicle is tapped and the appropriate-size screw placed
 BULL’S-EYE TARGETING OF THE PEDICLE SCREWS

• Another effective method of targeting the pedicles percutaneously is a technique we call the ‘‘bull’s-
eye’’ approach
• The AP view of the pedicle is performed as previously described
• A specially made P-C (Perez-Cruet) pedicle access device
• The trajectory of the device is then manipulated so that the center of the pedicle is targeted
• Once in position, a few gentle taps with a mallet secures the device to the superior articular process
• The center trocar of the P-C device is removed, and a K-wire on a driver is used to drive the K-wire
into the pedicle partway
• The P-C device is removed and AP fluoroscopy performed to ensure
that the K-wire is properly positioned
• Care is taken during passage of any cannulated instrument over the K-
wire to hold the K-wire firmly with an instrument to ensure that it does
not pass beyond the border of the vertebral body, where it could injure
abdominal viscera
• Percutaneous pedicle screw instrumentation can be performed safely and effectively. The benefits to our patients
are reduced tissue dissection, reduced blood loss, preservation of normal anatomical supporting structures of the
spine, and quicker recoveries.
• The pedicle offers the strongest site of fixation for spinal instrumentation.
• Mastering radiographic targeting of the pedicle can be done with a thorough appreciation of the bony anatomy of
the spine and those landmarks critical in performing safe and accurate percutaneous pedicle screw placement. In
addition, intraoperative percutaneous pedicle screw stimulation seems to reduce approach-related morbidity and,
in our studies, was an excellent technique to confirm the adequacy of the screw placement
Thank You