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Using the Freehand Pedicle Screw Placement Technique in Adolescent Idiopathic Scoliosis Surgery: What Is the Incidence of Neurological Symptoms Secondary to Misplaced Screws?

Dede, Ozgur MD; Ward, William Timothy MD; Bosch, Patrick MD; Bowles, Austin J. MS; Roach, James W. MD

doi: 10.1097/BRS.0000000000000127

Study Design. Retrospective case series.

Objective. This study evaluated the incidence of postoperative neurological symptoms after a freehand pedicle screw insertion technique in idiopathic posterior scoliosis surgery.

Summary of Background Data. It is generally accepted that pedicle screws can be inserted by a freehand technique in the thoracic and lumbar spine in patients with adolescent idiopathic scoliosis (AIS) with a very low frequency of major complications. The prevalence of clinically significant screw misplacement, with or without the need for revision surgery is less well defined.

Methods. Between January 1, 2000, and October 2, 2012, five hundred fifty-nine patients with AIS had thoracolumbar posterior instrumented spine surgery at the Children's Hospital of Pittsburgh. Each patient's chart and radiographs were reviewed and only those with AIS were included. Patients with neuromuscular and syndromic diagnoses were excluded as well as those with congenital or traumatic etiologies, incomplete charts, less than 3 months of follow-up and those without pedicle screws. The records were studied for complaints of radicular pain, neurological deficit, or severe headache that could be indicative of potential screw misplacement.

Results. Four hundred eighty-one patients with 5923 pedicle screws met the inclusion criteria. Nine patients (1.9%) developed symptoms and underwent computed tomographic scanning. Six patients were found to have pedicle screw malposition (8 screws) and 3 of these patients underwent revision surgery. Of the 3 revision patients, 2 presented with radicular symptoms (leg pain) and 1 with an orthostatic headache due to cerebrospinal fluid leakage. At the final follow-up, all revision patients had complete symptom resolution. In total, there were 8 symptomatic, misplaced pedicle screws (0.14%) in 6 patients (1.25%).

Conclusion. During a 12-year period in a dedicated pediatric orthopedic hospital using the freehand placement technique, the incidence of symptomatic misplaced pedicle screws was exceedingly low.

Level of Evidence: 4

This study evaluated the safety of thoracic and lumbar pedicle screws, placed with a freehand technique in adolescent idiopathic scoliosis at a major pediatric hospital during a period of 12 years. There were no permanent neural deficits, and the revision rate for misplaced pedicle screws was exceedingly low.

From the Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA.

Address correspondence and reprint requests to James W. Roach, MD, UPMC Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224; E-mail:

Acknowledgment date: May 28, 2013. Revision date: September 29, 2013. Acceptance date: November 4, 2013.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

© 2014 by Lippincott Williams & Wilkins