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Effectiveness of EMG use in pedicle screw placement for thoracic spinal deformities.

ABSTRACT: STUDY DESIGN: Systematic review. OBJECTIVE: To determine the effectiveness of using electromyography (EMG) during intraoperative pedicle screw placement in patients with thoracic deformity. METHODS: A systematic review of the English-language literature was undertaken for articles published between 1970 and July 2011. For our first question, we identified all articles that were designed to evaluate the diagnostic test characteristics (ie, measures of validity such as sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV]) of EMG for thoracic deformities in adolescent and adult patients. For our second question, we attempted to identify all articles that reported complication rates (pedicle wall breach or new neurological event) after pedicle screw placement in the same population comparing patients who did and did not undergo intraoperative EMG. Articles were excluded if they did not report or give raw data to calculate at least one of the four primary diagnostic test characteristics: sensitivity, specificity, PPV, or NPV for study question one. Articles were excluded if they did not have a "no EMG" control group for study question two. Other exclusions were reviews, editorials, case reports, non-English written studies, and animal studies. We rated the overall body of evidence with respect to each key question using a modified Grades of Recommendation Assessment, Development and Evaluation (GRADE) system for diagnostic and therapeutic studies. RESULTS: The overall strength of evidence evaluating the diagnostic characteristics was low due to inconsistent findings between studies and uncertainty of the impact of false-negatives. The fairly low sensitivity may lead to a high-false negative rate. It is unclear what the impact of false-negatives would be since no neurological injuries were identified in the studies summarized. A higher specificity would suggest a fairly low false-positive rate; however, the rates could be as high as 30%. If sudden changes in treatment are required in the absence of any adverse event, this could be considered a limitation of such testing. The overall strength of evidence for evaluating the efficacy of EMG compared with no EMG was insufficient because of literature shortage on this topic. CONCLUSION: The overall strength of evidence evaluating the diagnostic characteristics was low due to inconsistent findings between studies and uncertainty of the impact of false-negatives. Given the low sensitivity and potential high rate of false-negatives, pedicle wall breaches may occur, without EMG notification. These undetected breaches may lead to loose or weak screw position which may lead to neurovascular complications during or after a translation-rotation maneuver, especially in rigid deformities. The higher sensitivity would suggest a lower rate of false-positives. We recommend considering the use of intraoperative EMG-monitoring method to help identify potential complications based upon available technology, personal experiences and preferences; however, surgeons should keep in mind that false-positive results may lead to increased surgery time and increased blood loss. The surgeon should not depend solely on EMG since it can also render false-negatives.

SUBMITTER: Oner A

PROVIDER: S-EPMC3503513 | biostudies-other | 2012 Feb

REPOSITORIES: biostudies-other

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Project description:ObjectiveTo determine the rates and risk factors of pedicle screw placement accuracy and the proximal facet joint violation (FJV) using TINAVI robot-assisted technique.MethodsPatients with thoracolumbar fractures or degenerative diseases were retrospectively recruited from June 2018 and June 2020. The pedicle penetration and proximal FJV were compared in different instrumental levels to identify the safe and risk segments during insertion. Moreover, the factors were also assessed using univariate and multivariate analyses.ResultsA total of 72 patients with 332 pedicle screws were included in the current study. The optimal and clinically acceptable screw positions were 85.8% and 93.4%. Of the 332 screws concerning the intra-pedicular accuracy, 285 screws (85.8%) were evaluated as Grade A according to the Gertzbein and Robbins scale, with the remaining 25 (7.6%), 10 (3.0%), 6 (1.8%), and 6 screws (1.8%) as Grades B, C, D, and E. Moreover, in terms of the proximal FJV, 255 screws (76.8%) screws were assessed as Grade 0 according to the Babu scale, with the remaining 34 (10.3%), 22 (6.6%), and 21 screws (6.3%) as Grades 1, 2, and 3. Furthermore, the univariate analysis showed significantly higher rate of penetration for patients with age < 61 years old, sex of female, thoracolumbar insertion, shorter distance from skin to insertion point, and smaller facet angle. Meanwhile, the patients with the sex of female, BMI < 25.9, grade I spondylolisthesis, lumbosacral insertion, longer distance from skin to insertion point, and larger facet angle had a significantly higher rate of proximal FJV. The outcomes of multivariate analyses showed that sex of male (adjusted OR 0.320, 95% CI 0.140-0.732; p = 0.007), facet angle ≥ 45° (adjusted OR 0.266, 95% CI 0.090-0.786; p = 0.017), distance from skin to insertion point ≥ 4.5 cm (adjusted OR 0.342, 95% CI 0.134-0.868; p = 0.024), and lumbosacral instrumentation (adjusted OR 0.227, 95% CI 0.091-0.566; p = 0.001) were independently associated with intra-pedicular accuracy; the L5 insertion (adjusted OR 2.020, 95% CI 1.084-3.766; p = 0.027) and facet angle ≥ 45° (adjusted OR 1.839, 95% CI 1.026-3.298; p = 0.041) were independently associated with the proximal FJV.ConclusionTINAVI robot-assisted technique was associated with a high rate of pedicle screw placement and a low rate of proximal FJV. This new technique showed a safe and precise performance for pedicle screw placement in spinal surgery. Facet angle ≥ 45° is independently associated with both the intra-pedicular accuracy and proximal FJV.

Project description:Ascertaining the accuracy of the pedicle screw (PS) trajectories is important as PS malpositioning can cause critical complications. We aimed to determine the angle range over which estimation is unreliable; build a low-cost PS placement support system that uses an inertial measurement unit (IMU) to enable the monitoring of surgical tools and PS trajectories, and determine the situations where IMU support would be most beneficial. In PS insertion experiments, we used cadaver samples that included lumbar porcine spines. Computed tomography images obtained before and after PS insertion were viewed. Offsets between the planned and implanted PS trajectories in the freehand and IMU-assisted groups were analyzed. The PS cortical bone breaches were classified according to the Gertzbein and Robbins criteria (GRC). Added head-down tilted sample experiments were repeated wherein we expected a decreased rostro-caudal rotational accuracy of the PS according to the angle estimation ability results. Evaluation of the PS trajectory accuracy revealed no significant advantage of IMU-assisted rostro-caudal rotational accuracy versus freehand accuracy. According to the GRC, IMU assistance significantly increased the rate of clinically acceptable PS positions (RoCA) than the freehand technique. In the head-down tilted sample experiments, IMU assist provided increased accuracies with both rostro-caudal and medial rotational techniques when compared with the freehand technique. In the freehand group, RoCA was significantly decreased in samples with rostral tilting relative to that in the samples without. However, In the IMU-assisted group, no significant difference in RoCA between the samples with and without head-down tilting was observed. Even when the planned PS medial and/or rostro-caudal rotational angle was relatively large and difficult to reproduce manually, IMU-support helped maintain the PS trajectory accuracy and positioning safety. IMU assist in PS placement was more beneficial, especially for larger rostro-caudal and/or medial rotational pedicle angles.

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Effectiveness of EMG use in pedicle screw placement for thoracic spinal deformities.

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