We would like to thank Mr. Yudai Watanabe, a representative of Medtronic, for the implant information, Editage for editing and reviewing this manuscript in the English language, and radiology technicians and all surgical staff for helping obtain surgical images.

This protocol was approved by the Institutional Review Board of Showa University Hospital (No.2023-017-A) and conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The protocol follows the guidelines of our institution&#39;s human research ethics committee. As this representative case series is retrospective in nature, informed consent from each patient was waived in accordance with the institutional review board policy. Informed consent was obtained from patients presented in the figures and video of this protocol.
1. Indication of this protocol and preoperative planning
<ol>
	<li>Before the surgery, ensure the indication for the use of the SAS system and trauma reduction device. As mentioned earlier, there are controversies regarding surgical indications of TL burst fractures. Discuss the potential risks and benefits of surgery with the patient before surgery based on the best available evidence, even if it is limited. 
	NOTE: In case of limited evidence, we believe it is acceptable to rely on the clinician&#39;s personal experience, expert opinion, and method of treatment that is taught and practiced among practitioners in one&#39;s specific region, linguistic group, and local professional community11.
	<ol>
		<li>Select the following indication criteria for the posterior percutaneous short fixation procedure: skeletal maturity, absence of severe osteopenia, no evidence of PLL injury, and meeting at least one of the following criteria: thoracolumbar injury classification and severity (TLICS)12 score &#8805; 4, any Arbeitsgemeinschaft Osteosynthesefragen (AO) classification13 type B1 and B2 fractures with intact PLL, local kyphotic deformity &#62; 15&#176;, coronal deformity &#62; 10&#176;, or inability to tolerate conservative treatment due to other medical/psychological/socioeconomic issues (Table 1).</li>
		<li>Select the following exclusion criteria: severe anterior segmental collapse and multiple consecutive fractures.</li>
	</ol>
	</li>
	<li>Evaluate the patient&#39;s bone status to determine the use of the trauma reduction device. 
	NOTE: Avoid using the device in patients with moderate-to-severe osteoporosis for preventing iatrogenic fracture. Additionally, do not use the reduction device for patients with a ruptured posterior longitudinal ligament (PLL) because a reduction of the retropulsion fragment with ligamentotaxis is not possible.
	<ol>
		<li>If time allows, obtain an MRI for the diagnosis of PLL14 and other posterior ligamentous complex injury, even if the patient is neurologically intact. Use CT to evaluate the presence of &#34;reverse cortical sign&#34;-the posterior wall fragment rotating 180&#176; with the cortical surface facing anteriorly and the cancellous surface facing posteriorly in the canal-indicating PLL rupture and contraindication of ligamentotaxis.15&#8203;</li>
	</ol>
	</li>
	<li>Ensure that the length and diameter of the SAS are measured in advance using an appropriate imaging platform, and use these images to simulate the trajectory of each screw. Draw lines anteriorly, extending from the medial borders of the bilateral pedicles. Check the location of the intersection bilaterally between the abovementioned line and the ideal pedicle screw trajectory.</li>
	<li>Perform surgery as early as reasonably possible. 
	NOTE: A study reported that the quality of TL fracture reduction with ligamentotaxis is better when performed earlier16.</li>
</ol>
2. Equipment and patient positioning
NOTE: The procedure requires intraoperative fluoroscopy (or a navigation system).
<ol>
	<li>Use an open Jackson table for the procedure. Place the patient in the prone position and extend the patient&#39;s legs slightly.</li>
	<li>Make efforts to achieve normal spinal alignment when placing bolsters under the patient&#39;s chest and bilateral anterior superior iliac spine before surgery to make reduction and screw insertion easier. Check the lateral fluoroscopic view, and make sure the abdomen is free of compression.</li>
	<li>When monitoring is used, ensure that all electrodes are securely placed. For average-risk surgeries, such as this procedure, place the recording electrodes with a belly-tendon montage in the vastus medialis, anterior tibialis, and adductor hallucis to monitor major lower extremity myotomes. 
	NOTE: The use of intraoperative neuromonitoring is based on each institutional protocol. In our institution, transcranial stimulation motor evoked potential is used for average-risk surgeries, including this procedure.</li>
	<li>Use fluoroscopy to position the fractured vertebra and pedicles of the planned instrumented levels, one level above and below, as well as the fractured level at a minimum, and two levels above and/or below; if necessary, mark them on the skin. The identification of the fractured level is usually easy; however, if it is unclear or there are multiple previously fractured vertebrae, count the number of vertebrae from the sacrum or first thoracic vertebra. Record the position of the image intensifier to ensure good anteroposterior (AP) and lateral views of the spine during surgery. 
	NOTE: The endplates should be parallel to the image trajectory in the AP view. Keep in mind that the best angles may differ for each vertebra owing to local lordosis/kyphosis in the area.</li>
	<li>Make sure there is enough clearance, at least 30-40 cm, between the patient&#39;s body and the image intensifier. 
	NOTE: Each procedural step of the SAS system, such as needle insertion using a mallet, tapping, and screw placement, requires a certain clearance.</li>
</ol>
3. Skin incisions and needle insertion
<ol>
	<li>After patient positioning, prepare the surgical site using an alcohol or iodine-based skin disinfectant. Subsequently, drape with a disposable surgical sheet set, and apply an iodophor-impregnated adhesive incision drape17.</li>
	<li>Similar to the standard PPS insertion7, make an incision lateral to the skin marks of the pedicles. Place the incisions 1-1.5 cm laterally to the lateral margin of the pedicles in the lumbar spine as per standard technical notes for PPS.</li>
	<li>Dissect the fascia longitudinally after the skin incision. Make the skin incision longer than that of a normal PPS (at least 2 cm) to prevent skin problems when using a trauma incision device. Make skin incisions relatively medial to the standard incisions in patients with a low body mass index and lateral to the standard incisions in obese patients. 
	NOTE: The positions should be modified based on operated levels: 0-0.5 cm lateral to the pedicles in the middle thoracic spine. Rod insertion is easier with a longitudinal incision used as the insertion site than with transverse incisions. The long midline incision, which is not &#34;percutaneous&#34; but still has muscles attached to the lamina, is sometimes used for upper-middle thoracic spine fractures because the pedicles are too close to make separate incisions or in cases requiring direct decompression.</li>
	<li>Position the needle at the intersection of the facet and transverse process after skin incisions and fascia dissection. Obtain an AP image and ensure that the vertebra is not rotated.</li>
	<li>Gentle tapping with a mallet, insert the needle tip into the bone with fluoroscopic control. As the needle advances, ensure the tip of the needle approaches the medial margin of the pedicle on the AP image.</li>
	<li>Obtain a lateral image when the needle is located close to the medial margin of the pedicle. Confirm that the needle tip is located anterior to the posterior wall of the vertebra and close to the intersection point described.</li>
	<li>Repeat all steps bilaterally from steps 3.2 to 3.5 for as many instrumented levels as necessary. Ensure that the bilateral needles are placed in parallel, resembling a rectangle and not a trapezoid. Consider making the incision larger in case of facet degeneration and flattening caused by using a rongeur or surgical bar when placing needles; achieving a good position is difficult because of such a prominent bone.</li>
</ol>
4. Sagittal adjusting screw insertion
<ol>
	<li>Insert the guidewire through the cannulated hole of the needle after insertion. Ensure that the wire does not breach the anterior cortex. 
	NOTE: The anterior cortex of the vertebral body does not always overlap with the anterior margin of the vertebra on the lateral fluoroscopic view due to bone morphology. Recheck the vertebra shape on axial CT images before needle insertion.</li>
	<li>Use a 1 mm undersized cannulated tap for tapping. Assemble the tab extenders and cap to the SAS screws, and insert the screws into the vertebrae (Figure 1). Repeat all steps from steps 4.1 to 4.2 for as many instrumented levels as necessary. 
	NOTE: Place all SAS screws parallel to the endplates in the sagittal plane to maximize the distraction force of the reduction device. Keep in mind that the risk of rod impingement on the facet joint, lamina, or spinous process will increase if the screw heads are located obliquely on the coronal plane.</li>
	<li>If necessary, make modifications to the fixation at this step, such as intermediate screws (screws in the fractured vertebra) and additional screws on the two levels above/below in cases of severe deformity or impaired bone strength. Insert additional screws after fracture reduction as needed. 
	NOTE: When inserting screws into the fractured vertebra, ensure that the instruments do not exceed the anterior wall of the vertebra. The fractured bone offers significantly less resistance, and sharp instruments may easily deviate anteriorly due to the fracture void. 
	Normal multiaxial screws are usually used for intermediate screws or additional screws because rod connections may become difficult when the SAS is used for these levels. When using intermediate screws, ensure that there is no fracture in the pedicles.</li>
</ol>
5. Fracture reduction using a trauma reduction device
NOTE: This process has been described previously10.
<ol>
	<li>Set the distractor pinion of the reduction device in a neutral position. Slide the distractor rack into the distractor pinion.</li>
	<li>Place the inner guides on the extenders until they are fully seated. Ensure that the distractor module is placed in the posts of the extenders, and the distractor module is fully seated.</li>
	<li>Place the lordosis modules in a neutral position. Ensure that the distraction key is turned to distract to obtain ligamentotaxis.</li>
	<li>Stretch the posterior longitudinal ligament and bring the vertebral body segments back into the vertebral body from the spinal canal to restore the vertebral body height. 
	NOTE: Increase the incision size to seat the device if the device pinches the surrounding skin. Ensure that adequate deep application of the device is impossible in morbidly obese patients. Normal distraction/compression devices for the PPS system can still be used in these patients.</li>
	<li>Set the lordosis indicator to zero on the lordosis module so that the lordosis indicator slides along the rack and allows an estimation of the extent of lordosis that has been applied. Each marking on the lordosis module is 2.5&#176;. Check the real-time alignment with fluoroscopy during this maneuver.</li>
	<li>Squeeze the handles to restore lordosis and monitor the correction of lordosis under fluoroscopy. Verify the final correction. (Figure 2 and Figure 3).
	<ol>
		<li>If deemed necessary, perform vertebroplasty using hydroxyapatite bone substitute or bone cement at this point. Place a guide needle, followed by a wire, dilator, and inserter, into the fractured vertebra via a transpedicular approach. 
		NOTE: It is crucial to ensure that all instruments remain within the bone during the procedure, as breaching the vertebral cortex is more likely given the compromised integrity of the fractured bone. Intermediate screw placement is also possible after vertebroplasty. If bone cement is used, prepare the screws in advance to ensure their insertion before the bone cement has fully consolidated.</li>
	</ol>
	</li>
</ol>
6. Rod connection
<ol>
	<li>Measure the rod lengths using a rod ruler placed on the screw heads or a measure placed on the skin. Cut the rods at least 5 mm longer than the measurements to avoid the shortage of rod length; re-confirm the length with a measure before insertion. For fractures in or below the mid-thoracic level, insert the rods through the uppermost incision. For upper thoracic fractures, insert the rods from the lowermost incisions since inserting rods in the cranial to caudal direction is often difficult due to the kyphotic shape of the thoracic spine. 
	NOTE: Rod bending is usually unnecessary at the thoracic or thoracolumbar junctional level. For the lumbar level, rods need to be bent, or use prebent rods to match the lumbar lordosis.</li>
	<li>Ensure again that all the implants, rods, and screw heads are located under the fascial layer before closure to prevent compartment syndrome of back muscles.</li>
	<li>Apply set screws to fix the rod in an appropriate position. If the set screw application is difficult, check the depth of the screws and adjust them adequately. 
	NOTE: Ensure that the bilateral rods are placed parallel on the coronal plane to slide both rods appropriately during reduction.</li>
</ol>
7. Wound closure and after-treatment
<ol>
	<li>Irrigate the wounds with 500-1,000 mL of 0.5% diluted povidone-iodine solution18,19. Subsequently, apply a layered suture with size 0 antibacterial absorbable poly-filament suture for fascial layer closure and 2-0 or 3-0 antibacterial absorbable poly-filament suture for the subcutaneous layer. Close the epidermal layer using a topical skin adhesive glue or thin adhesive bandage. Ensure again that all the implants, rods, and screw heads are located under the fascial layer before closure to prevent compartment syndrome of back muscles20.</li>
	<li>Use a soft brace for comfort and start ambulation as soon as possible. 
	NOTE: Although there is no clear evidence to support the use of a brace after spine fracture surgery21, a Jewett type frame brace may be applied for patients who have certain risk factors of reduction loss, such as preexisting spinal malalignment or osteoporosis, based on the treating physician&#39;s discretion.</li>
	<li>Use intravenous and oral acetaminophen as the first-line medication for pain management or nonsteroidal anti-inflammatory drugs (NSAIDs) to control severe pain and reduce opioid use. Discharge the patient after confirming they can ambulate safely outside the hospital. 
	NOTE: Try to minimize the dosage of NSAIDs as they likely inhibit bone fusion after spinal fusion surgery22, although the effect of NSAIDs on bone healing after spinal fracture is still inconclusive23. Moreover, minimize opioid use since opioids may inhibit bone healing24 and are associated with various complications and higher readmission rates25.</li>
	<li>Perform radiological follow-up per institutional protocol. To follow this protocol, obtain AP and lateral radiographs immediately and at 1, 3, 6, and 9 months after the surgery. Additionally, obtain postoperative CT scans before implant removal, approximately 1 year after the surgery, to confirm bone union.
	<ol>
		<li>For radiological assessment, use the regional kyphotic angle (RKA) and percent loss of anterior vertebral body height (%AVB) on lateral radiographs (Figure 1).
		<ol>
			<li>Measure the RKA of the fractured segment as the angle between the superior endplate of the upper adjacent vertebra and the inferior endplate of the lower adjacent vertebrae26.</li>
			<li>Calculate the %AVB as the anterior height of the fractured vertebra divided by the mean of the anterior height of the adjacent two vertebrae using the following formula: 
			AVB = 100 {1- (a1 + a2)/2 &#215;a0} 
			Where the anterior vertebral body height of the fractured vertebra is marked as a0, and the anterior vertebral body heights of the upper and lower adjacent vertebrae are marked as a1 and a2, respectively27. 
			NOTE: We utilized %AVB because the RKA could be improved even if the fractured vertebra is not reduced, owing to the flexibility of the intervertebral disk.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Remove the implant approximately 1 year after the initial surgery to restore segmental motion and prevent long-term consequences associated with the fixed region. 
	NOTE: Patients who had undergone implant removal had a better quality of life and less symptoms than those not undergoing implant removal28.</li>
</ol>

Technique of Sagittal Adjusting Screw System for Thoracolumbar Burst Fractures

I.O. receives lecture fees from Medtronic. The other authors declare that they have no conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper.

In this video manuscript, we describe our posterior minimally invasive fixation procedure for TL burst fractures using the SAS system and a trauma reduction device. Our representative case series showed good correction of the local kyphotic deformity and vertebral morphology. In previous studies, the potential reduction of kyphosis is 5-9% using an open approach30. Our data demonstrated results comparable to those of the open approach, even with a percutaneous approach. This is consistent with one...

Thoracolumbar (TL) burst fractures are relatively common, occurring in approximately 20% of all vertebral fractures1, and are characterized by retropulsion of the fractured middle column fragments into the spinal canal. Although the management of TL burst fractures has been extensively studied, the indication for surgical treatment remains under debate. Previous studies have reported that long-term functional outcomes may not differ substantially between operative and nonoperative treatment for neurologically intact TL burst fractures1. Nevertheless, these comparative studies were launched decades ago, making their results not applicable in this era when surgical techniques have substantially improved since then. 
Recent advances in surgical techniques may have changed the surgical indications. Recently, minimally invasive approaches for TL injuries have become popular, and good results have been reported. Although their sample sizes are small, studies about the emerging novel techniques and implants support surgical treatment for neurologically intact TL fractures1.
Generally, surgical treatment of neurologically intact TL fractures aims to ensure good alignment correction, reduction of fracture fragments with ligamentotaxis, and secure fixation2,3. In patients with neurological symptoms, direct or indirect decompression of the neural structure is added to these aims. There are variations in the surgical techniques used for posterior fixation of TL burst fractures, such as surgery with and without fusion, the use of vertebroplasty, different numbers of fixation levels, and the use of additional screws on the fractured vertebrae. 
Non-fusion fixation using percutaneous pedicle screws (PPSs) is commonly performed because it is less invasive and allows segmental motion after implant removal. The advantages of PPS over conventional open techniques are not limited to smaller skin incisions; PPS is associated with less paraspinal muscle damage compared to an open approach4. Moreover, a human cadaver study reported that PPS reduces the risk of medial branch nerve injury, which leads to multifidus muscle denervation5. Currently, a TL fracture is among the most common indications for minimally invasive surgery using PPSs, and a minimally invasive PPS system without fusion is reportedly associated with improved surgical outcomes in patients with TL burst fractures2,3.
Reduction techniques are also a topic of interest. Since the 1980s, the Schanz screw system has been used for TL burst fracture treatment; this system allows good angular correction, vertebral height reduction, and reduction of retropulsion fragments by ligamentotaxis. Good results have been reported with the Schanz screw system6. However, the original Schanz system appears unsuitable for percutaneous use because the connectors are too bulky and use a side-loading system. 
In contrast, the designated PPS system, which was developed in the 2000s, has been widely used for various conditions7. Although it is associated with less invasiveness to back muscles, one drawback of conventional multiaxial screws (MAS), compared with the Schanz system, is that screws have less angular stability due to a mobile screw head. Monoaxial screws, which have better angular stability than MAS, are also available as PPS options. However, it is often technically demanding to align all screw heads in the same plane as rods percutaneously without any angulation of the screws to avoid excessive mechanical stress on the screws or bones. Additionally, creating lordosis after screw insertion is almost impossible when monoaxial screws are used. 
To overcome these issues, the sagittal adjusting screw (SAS) system was introduced in 2013 and was first aimed to correct spinal deformity secondary to fractures. The SAS is a monoaxial screw system with a fixed head that resembles a common head-loading pedicle screw; it has a concave sliding saddle that allows lordotic sliding of the rod in the sagittal plane after screw insertion. Since then, the use of SAS has expanded among acute TL burst fractures8,9 as well as elective procedures including correction of spondylolisthesis10. The SAS only allows motion on the sagittal plane, allowing both secure fixation and angular reduction, which is usually impossible after screw insertion using conventional monoaxial screws. 
One biomechanical study demonstrated that the SAS system has better force-displacement properties and fatigue test results than other head-loading PPSs, equivalent to the Schanz screw system. Trauma reduction devices can be attached to the extension towers of the SAS system and, therefore, both distraction and angulation forces can be applied at the instrumented levels using such a device9. Good results have also been reported for such trauma reduction devices used for TL fractures8. 
The aim of this protocol is to describe the technique for alignment correction and fracture reduction methods using the SAS system in TL burst fractures and discuss the advantages of the SAS system. In the following protocol, PPS placement and fracture reduction using the SAS system and trauma reduction device are outlined. We also show representative cases demonstrating the results of this procedure.

<table><tbody><tr><td>3M Ioban 2 antimicrobial incise drape</td><td>3M</td><td>MSDS_0832279_US_EN_RDS</td><td>Iodophor-impregnated adhesive incision drape&amp;nbsp;</td></tr><tr><td>CDH Solera Longitude II &amp;nbsp;SAS</td><td>Medtronic</td><td></td><td>SAS system</td></tr><tr><td>CDH Solera Voyager FNS SAS</td><td>Medtronic</td><td></td><td>SAS system</td></tr><tr><td>DERMABOND ADVANCED Topical Skin Adhesive</td><td>Ethicon Inc.</td><td></td><td>Topical skin adhesive glue or thin adhesive bandage</td></tr><tr><td>INFINITT PACS</td><td>INFINITT Healthcare Co., Ltd.</td><td></td><td>Picture archiving and communication system</td></tr><tr><td>Jewett brace</td><td>(Various manufacturers)</td><td></td><td>Jewett type brace</td></tr><tr><td>Nforce Trauma&amp;nbsp;</td><td>Medtronic</td><td></td><td>Trauma reduction device</td></tr><tr><td>OEC Elite</td><td>GE healthcare</td><td></td><td>Fluoroscopy/image intensifier/c-arm</td></tr><tr><td>Sacro-wide Dx</td><td>Alcare</td><td>368-0208-0223/5</td><td>Soft brace</td></tr><tr><td>Steri Strips Standard Skin Closure</td><td>3M</td><td>MSDS_1084623_US_EN_AIS</td><td>Thin adhesive bandage.</td></tr><tr><td>Trauma Instrument Set</td><td>Medtronic</td><td></td><td>Trauma reduction device</td></tr><tr><td>Vicryl Plus Antibacterial 0</td><td>Ethicon Inc.</td><td>VCP587H</td><td>Antibacterial absorbable poly-filament suture</td></tr><tr><td>Vicryl Plus Antibacterial 2-0</td><td>Ethicon Inc.</td><td>VCP453H</td><td>Antibacterial absorbable poly-filament suture</td></tr><tr><td>Vicryl Plus Antibacterial 3-0</td><td>Ethicon Inc.</td><td>VCP398H</td><td>Antibacterial absorbable poly-filament suture</td></tr></tbody></table>

minimally invasive treatment for thoracolumbar burst fracture using sagittal alignment screws and a trauma reduction device

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the indication for surgical treatment of neurologically intact TL fractures remains under debate, studies have demonstrated that posttraumatic malalignment may lead to a deterioration in the patient&#39;s quality of life. For burst fractures with malalignment or fragments in the spinal canal, a reduction technique using ligamentotaxis is commonly used to improve long-term outcomes.
The sagittal adjusting screw (SAS) system is a monoaxial screw system with a fixed head and concave sliding saddle that allows lordotic sliding of the rod in the sagittal plane after screw insertion. SAS also has a percutaneous option and has been used for TL spine fractures. Notably, the SAS only allows motion on the sagittal plane, allowing both secure fixation and angular reduction. The SAS has certain advantages over the conventional Schanz screw system or normal mono-/multiaxial pedicle screws for TL spine fracture treatment. In addition, specialized trauma reduction devices are available for the SAS system. In this video protocol, we discuss the indication for the SAS system in TL burst fracture and describe a technique of TL burst fracture reduction and fixation using the SAS system. Additionally, we describe our recent case series with radiological evaluation, including regional kyphotic angle and percent loss of anterior vertebral body height, to evaluate the newly introduced trauma reduction device.

Patient selection 
The records of patients with traumatic burst fractures who underwent spine surgery between January 1, 2022, and October 31, 2023, at our university hospital were retrospectively reviewed. Patients who underwent posterior fixation with SAS devices using a trauma reduction device and met the following criteria were included in the final analysis.
Data collection and classifications 
Information on age, biological sex, and fractured l...

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the ...

minimally-invasive-treatment-for-thoracolumbar-burst-fracture-using

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

319 Views.  Tokyo Metropolitan Hiroo Hospital. The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device. 

Video: Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. Transiliac-transsacral screws provide a longer lever arm to withstand the perpendicular vertical shear forces. However, the screw channel is so long that a minor discrepancy can lead to iatrogenic neurovascular injuries. The development of medical robots has improved the precision of surgery. The present protocol describes how to use a new teleoperated robotic system to execute transiliac-transacral screw fixation. The Robot was operated remotely to position the entry point and adjust the orientation of the sleeve. The screw positions were evaluated using postoperative computed tomography (CT). All the screws were safely implanted, as confirmed using intraoperative fluoroscopy. Postoperative CT confirmed that all the screws were in the cancellous bone. This system combines the doctor's initiative with the Robot's stability. The remote control of this procedure is possible. Robot-assisted surgery has a higher position-retention capacity compared with conventional methods. In contrast to active robotic systems, surgeons have full control over the operation. The robot system is fully compatible with operating room systems and does not require additional equipment.

Teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation is a feasible technique. Screw channels can be implemented with high accuracy owing to the excellent freedom of movement and stability of the robotic arms.

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. ...

Engineering

Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. Minimally invasive surgery (MIS) approaches have been applied to this technique with an associated decrease in estimated blood loss (EBL), length of hospital stay, and infection rates, while preserving outcomes with traditional open surgery. Previous MIS TLIF techniques involve significant fluoroscopy that subjects the patient, surgeon, and operating room staff to non-trivial levels of radiation exposure, particularly for complex multi-level procedures. We present a technique that utilizes an intraoperative computed tomography (CT) scan to aid in placement of pedicle screws, followed by traditional fluoroscopy for confirmation of cage placement. Patients are positioned in the standard fashion and a reference arc is placed in the posterior superior iliac spine (PSIS) followed by intraoperative CT scan. This allows for image-guidance-based placement of pedicle screws through a one-inch skin incision on each side. Unlike traditional MIS-TLIF that requires significant fluoroscopic imaging during this stage, the operation can now be performed without any additional radiation exposure to the patient or operating room staff. After completion of the facetectomy and discectomy, final TLIF cage placement is confirmed with fluoroscopy. This technique has the potential to decrease operative time and minimize total radiation exposure.

The purpose of this article is to provide image-guidance for minimally invasive transforaminal interbody fusion.

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. ...

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large implant size and optimal implant position. However, current methods for lateral interbody cage placement require either a two-staged procedure or a single lateral decubitus position that precludes surgeons from having either full access to the posterior spine for direct decompression or comfortable pedicle screw placement.
Herein is one institution's experience with 10 cases of a prone single-position approach for simultaneous access to the anterior and posterior lumbar spine. This allows both lateral lumbar interbody cage placement, direct posterior decompression, and pedicle screw placement, all in one position. Three-dimensional (3D) navigation is utilized for increased precision in both approaching the lateral spine and interbody cage placement. The traditional blind psoas muscle tubular dilation was also modified. Tubular retractors and lateral vertebral body retractor pins were used to minimize the risks to the lumbar plexus.

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large ...

Neuroscience

Diagnosis and Surgical Treatment of Human Brucellar Spondylodiscitis

Brucellar spondylodiscitis (BS) is the most prevalent and significant osteoarticular presentation of human Brucellosis, which is commonly manifested in pastoral communities. It is difficult to differentially diagnose and usually leads to irreversible neurologic deficits and spinal deformities. The initial diagnosis of BS is based on clinical findings and radiographic assessments, and the confirmed diagnosis should be established by the isolation of Brucella species from the blood and/or the standard tube agglutination test. Differential diagnosis of multifocal BS from either degenerative disc diseases or tuberculosis is especially highlighted. The surgical approach, either endoscopic or open, is demonstrated in detail, accompanied by radiographic evidence of structural compression or severe instability. Further, the crucial surgical steps, including single-stage transforaminal decompression, debridement, interbody fusion, and internal fixation, are explained. Moreover, perioperative care and postoperative rehabilitation are also addressed. Taken together, this clinical algorithm presents a practical guide that has yielded substantially satisfactory outcomes in the past decades, which can also be introduced for large-scale application to manage human BS, especially in endemic regions.

We describe a clinical algorithm, based on decades of front-line experience of diagnosis and surgical treatment of human Brucellar spondylodiscitis in the largest medical center of the China's Xinjiang Pastoral Area.

Brucellar spondylodiscitis (BS) is the most prevalent and significant osteoarticular presentation of human Brucellosis, which is commonly manifested in ...

C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 level (OLIF51) is technically difficult because of the anatomical structures. We present a novel simultaneous technique of OLIF51 with percutaneous pedicle screw fixation without fluoroscopy. The patient is placed in a right lateral decubitus position. A percutaneous reference pin is inserted into the right sacroiliac joint. An O-arm scan is performed, and 3D reconstructed images are transmitted to the spinal navigation system. A 4 cm oblique skin incision is made under navigation guidance along the pelvis. The internal/external and transverse abdominal muscles are divided along the muscle fibers, protecting the iliohypogastric and ilioinguinal nerves. Using a retroperitoneal approach, the left common iliac vessels are identified. Special muscle retractors with illumination are used to expose the L5-S1 intervertebral disc. After disc preparation with navigated instruments, the disc space is distracted with navigated trials. Autogenous bone and demineralized bone material are then inserted into the cage hole. The OLIF51 cage is inserted into the disc space with the help of a mallet. Simultaneously, percutaneous pedicle screws are inserted by another surgeon without changing the lateral decubitus position of the patient.
In conclusion, C-arm-free OLIF51 and simultaneous percutaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This novel technique reduces surgical time and radiation hazards.

C-arm-free oblique lumbar interbody fusion at the L5-S1 level (OLIF51) and simultaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This technique does not expose the surgeon or operating staff to radiation hazards.

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

Treating Osteoporotic Spinal Fractures in Elderly Patients via a Modified Clinical Bone Cement Injection Technique

The minimally invasive injection of bone cement (MIIBC) is an effective way to treat senile osteoporotic spinal fractures (OSF) in clinical practice. However, the intraspinal dura and nerves may be damaged when the puncture needle passes through the pedicle. Therefore, in this protocol, the puncture site was optimized during the surgery, selecting the same 1-2 cm away from the surface projection of the diseased vertebra. The needle was punctured along the lateral cortex of the pedicle from the junction of the pedicle and the vertebral body into the vertebral body. Meanwhile, bone cement was used as a filling material, and the MIIBC was performed by a percutaneous puncture at the external edge of the pedicle under C-arm fluoroscopy. This modified puncture site is far away from the spinal canal as possible, thereby reducing the risk of the puncture needles penetrating the spinal canal and damaging the nerves and dura mater. In conclusion, a modified MIIBC by percutaneous lateral pedicle puncture can effectively relieve pain in elderly patients with OSF.

Treating Osteoporotic Spinal Fractures in Elderly Patients via a Modified Clinical Bone Cement Injection Technique

Presented here is a modified procedure for minimally invasive injections of bone cement to treat osteoporotic spinal fractures in elderly patients.

The minimally invasive injection of bone cement (MIIBC) is an effective way to treat senile osteoporotic spinal fractures (OSF) in clinical practice. ...

Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for minimally invasive anterior lumbar interbody fusion (Mini-ALIF). This article is a technical description of anterior lumbar spine surgery under a microscope. We retrospectively collected information on patients who underwent microscope-assisted Mini-ALIF surgery at our hospital between July 2020 and August 2022. A repeated-measures ANOVA was used to compare imaging indicators between periods. Forty-two patients were included in the study. The mean volume of intraoperative bleeding was 180 mL, and the mean operative time was 143 min. The mean follow-up time was 18 months. Apart from one case of peritoneal rupture, no other serious complications occurred. The postoperative foramen and disc height were both higher on average than before surgery. The spreader-assisted micro-Mini-ALIF is simple and easy to use. It can provide good intraoperative disc exposure, good discrimination of important structures, adequate spreading of the intervertebral space, and the restoration of the necessary intervertebral height, which is very helpful for less experienced surgeons.

The technique described in this article is well-suited to the Mini-ALIF procedure, allows for excellent exposure and decompression, and facilitates microscope-assisted manipulation.

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for ...

Anterior Cervical Hybrid Decompression and Fusion Surgery to Treat Multilevel Cervical Spondylotic Myelopathy

Cervical spondylotic myelopathy (CSM) is a common disease resulting from intervertebral disc herniation, ossification of the posterior longitudinal ligament, and other pathological changes that cause spinal cord compression. CSM progresses insidiously with mild upper-limb numbness, which patients tend to ignore. As the condition worsens, the patients may experience a limp, limited fine motor activity, and eventually, a loss of daily activity. Conservative treatments, such as physical therapy and medication, are frequently ineffective for CSM. Once surgery is deemed to be required, decompression surgery is the best option. So far, both anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) have been commonly used to treat CSM. In addition, a type of hybrid procedure that combines ACDF with ACCF has been used to treat some CSM cases and achieved satisfying results. Thus, this study aims to introduce this hybrid surgical technique and advocate for it based on its patient success.

This paper describes a hybrid surgical technique that combines anterior cervical discectomy and fusion with anterior cervical corpectomy and fusion to treat patients with multilevel cervical spondylotic myelopathy.

Cervical spondylotic myelopathy (CSM) is a common disease resulting from intervertebral disc herniation, ossification of the posterior longitudinal ...

A Modified Eggshell Technique for Sclerosing Thoracic Disc Herniation

Sclerosing thoracic disc herniation refers to a condition in which the intervertebral disc in the thoracic region protrudes and becomes calcified, causing compression on the spinal cord and/or nerve roots. Sclerosing herniation of the thoracic disc poses a significant danger as it can lead to serious complications like paraplegia during or after surgery. Iatrogenic spinal cord injury is a common risk for individuals diagnosed with sclerosing thoracic disc herniation due to the inflexible protrusion of the sclerosing disc into the spinal canal and its adhesion to the ventral side of the dural sac. The challenging and crucial aspect of the surgery is how to safely and efficiently eliminate the hardened tissue. The eggshell method is a surgical procedure that addresses the kyphosis abnormality of the spinal column by excavating the vertebral body via the pedicles and subsequently inserting the kyphotic fracture block into the excavated vertebral body. In this article, a revised surgical method using the eggshell technique will be presented for the treatment of sclerosing thoracic disc herniation. The surgical procedure briefly involves hollowing out the anterior intervertebral space of the hardened disc tissue to create an eggshell-like structure, with the sclerotic tissue forming the posterior wall. Subsequently, the sclerotic disc tissue is pushed into the hollow intervertebral space to achieve complete decompression of the ventral spinal cord. The safety and effectiveness of this approach for treating sclerosing thoracic disc herniation have been confirmed.

This protocol introduces a modified eggshell surgical technique used for treating sclerosing thoracic disc herniation.

Sclerosing thoracic disc herniation refers to a condition in which the intervertebral disc in the thoracic region protrudes and becomes calcified, causing ...

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

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Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Diagnosis and Surgical Treatment of Human Brucellar Spondylodiscitis

C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Treating Osteoporotic Spinal Fractures in Elderly Patients via a Modified Clinical Bone Cement Injection Technique

Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion

Anterior Cervical Hybrid Decompression and Fusion Surgery to Treat Multilevel Cervical Spondylotic Myelopathy

A Modified Eggshell Technique for Sclerosing Thoracic Disc Herniation