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Aortic Abutment After Direct Vertebral Rotation: Plowing of Pedicle Screws

Wagner, Matthew R, MD, MA*; Flores, Jesus Burgos, MD; Sanpera, Ignacio, MD; Herrera-Soto, Jos, MD

doi: 10.1097/BRS.0b013e31820107d0

Study Design. Retrospective case series.

Objective. To report the occurrence of pedicle screw plow after individual-level direct vertebral rotation (DVR) that resulted in critical screw proximity to the aorta, from three institutions over a four-year period (2004–2008).

Summary of Background Data. Thoracic pedicle screws are generally accepted as safe implants that possess sufficient strength to correct the coronal, sagittal, and now transverse plane deformities associated with scoliosis. Structural failure of the bone resulting in translation of the screw in the transverse plane, defined as plow, can occur with individual-level DVR.

Methods. We performed a retrospective review of all pediatric patients who underwent posterior spinal fusion with pedicle screws for neuromuscular and idiopathic scoliosis and underwent postoperative computed tomographic scan. We identified all patients who required a secondary procedure for implant removal because of malposition of the screw.

Results. Six patients with lateral screw direction after a DVR maneuver required screw removal because of proximity to the aorta. All patients had intraoperative confirmation of adequate screw placement before introducing the rod and performing derotation.

Conclusions. The biologic limitations of vertebrae are approached as we strive to achieve further correction of the spine. Surgeons' experience and methods to assess proper screw placement may give a false sense of adequate final implant position after DVR. Vigilance to ensure proper pedicle screw position can avoid potential iatrogenic catastrophes.

Pedicle screw derotation used to correct axial spinal deformity may exceed the biologic capacity of individual vertebra. We report six adolescent scoliosis patients who had intraoperative confirmation of successful screw placement that required subsequent screw removal after lateral cortical breach, or plow, because of a direct vertebral rotation maneuver.

*Pediatric Orthopaedic Surgery, Orlando Regional Healthcare, Orlando, FL

Departamento de Cirugí Ortopédica y Traumatología Acute, Hospital Ramón y Cajal, Madrid, Spain

Pediatric Orthopaedic Unit, Hospital Universitari de Son Dureta, Palma de Mallorca, Spain

§Pediatric Orthopaedic Surgery Academic Office, Orlando Health, Orlando, FL

Pediatric Orthopedic Surgery, Arnold Palmer Hospital for Children, Orlando, FL.

Address correspondence and reprint requests to Jose Herrera-Soto, MD, Pediatric Orthopaedic Surgery Academic Office, Orlando Health, 83 West Columbia Street, Orlando, FL 32806; E-mail:

Acknowledgement date: March 18, 2009. Revision Date: May 20, 2009. Acceptance date: May 22, 2009.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

© 2011 Lippincott Williams & Wilkins, Inc.