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Which Malpositioned Pedicle Screws Should Be Revised?

Lorena V Floccari1, A Noelle Larson1, Charles H Crawford2

  • 1Department of Orthopedic Surgery, Mayo Clinic, Rochester.

Journal of Pediatric Orthopedics
|April 15, 2016
PubMed
Summary

Surgeons show varied opinions on revising malpositioned pedicle screws in asymptomatic patients. More data are needed to establish guidelines for screw revision to reduce unnecessary surgeries.

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Area of Science:

  • Spine Surgery
  • Orthopedic Surgery
  • Neurosurgery

Background:

  • Malpositioned pedicle screws occur in up to 10% of cases, with 1 in 300 requiring revision surgery.
  • Indications for revising asymptomatic malpositioned screws lack clear definition in existing literature.
  • This study aimed to define the threshold for revision among spinal deformity surgeons.

Purpose of the Study:

  • To evaluate the threshold among spinal deformity surgeons for recommending revision of malpositioned pedicle screws.
  • To assess surgeon variability in deciding screw revision based on screw breach location and timing.
  • To inform the development of practice guidelines for pedicle screw revision.

Main Methods:

  • Twelve experienced spine surgeons reviewed 32 cases of malpositioned pedicle screws with varying degrees of breach.
  • Surgeons indicated whether revision was warranted intraoperatively (before/after rod placement) or postoperatively in clinic for asymptomatic patients.
  • Agreement and multirater kappa (κ) statistics were calculated to assess consensus.

Main Results:

  • High agreement (80%, κ=0.703) existed for identifying malpositioned screws.
  • Fewer revisions were recommended after rod placement or postoperatively, with increased surgeon variability.
  • Majority recommended revision for screws breaching the dura (10/12) or aorta (7/12); half for screws fully within the canal.

Conclusions:

  • Significant variability exists among surgeons regarding observation versus revision of asymptomatic malpositioned screws.
  • The frequency of malpositioned screws and morbidity of revision surgery necessitate further research.
  • Long-term data are crucial for developing evidence-based practice guidelines for pedicle screw revision.