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67 Cement Augmentation ofPedicle Screw Fixation
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screw augmentation techniques and screw designs in osteoporotic
spines. Euro Spine J. 2008;17:1462–9.
4. Chang MC, Liu CL, Chen T.Polymethylmethacrylate augmentation of pedicle screws for osteoporotic spinal surgery: a novel technique. Spine. 2008;33(1):317–24.
5. Hoppe S, Keel MJB. Pedicle screw augmentation in osteoporotic
spine: indications, limitations and technical aspects. Eur J Trauma
Emerg Surg. 2017;43:3–7.
6. Sun H, Liu C, Chen S, et al. Effect of surgical factors on the augmentation of cementinjectable cannulated pedicle screw xation
by a novel calcium phosphate-based nanocomposite. Front Med.
2019;13(5):590–601.
7. Bai B, Kummer F, etal. Augmentation of anterior vertebral body
screw xation by an injectable, biodegradable calcium phosphate
bone substitute. Spine. 2001;15(26):2679–83.
8. Kobayashi H, Fujishiro T, Belkoff SM, et al. Long-term evaluation of a calcium phosphate bone cement with carboxymethyl
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architecture—assessed by a new method. Bone. 1988;9(4):247–50.
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of cement-augmented pedicle screws with CT-volumetric measurement of cement. Biomed Tech. 2012;57(6):473–80.
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Less Invasive Pedicle Screw
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Instrumentation ofLumbar Spine
Fractures
UlrichHahn
68
68.1 Introduction and Core Messages
The distinctive feature of the minimally invasive posterior dorsal instrumentation is not so much the less
invasive placement of mono- or polyaxial pedicle
screws, but rather the fact that it allows a genuine distraction and lordosis reduction, the real benet of the
procedure described here. However, this minimally
invasive reduction requires a special instrumentation
and the mandatory use of monoaxial pedicle screws,
since only such screws can sustain the preload resulting from the reduction. The goals of the minimally
invasive posterior instrumentation with S4 fracture
reduction instruments are almost no soft tissue damage, because muscle attachments are not detached,
same reduction results as in open procedures, same
implants as for open procedures, reduced postoperative pain, shorter operation time, and negligible blood
loss.
68.2 Indications
• Anterior compression fractures with kyphosis angle and
unstable fractures of the lumbar spine [1]
• Only restricted indication in AO C-type fractures (see
contraindications [2])
• Only relative indications in multilevel injuries [3]
68.3 Contraindications
• Severe osteoporosis, osteopenia, or osteomyelitis
• Transverse connector required in cases of rotational
instability
• Same contraindications as for open procedures [4, 5]
68.4 Technical Prerequisites
Fluoroscopy, radiolucent operating table, cannulated pedicle
screws (S4 Spinal System, Aesculap AG), special fracture
reduction instruments (e.g., S4 spinal system with fracture
reduction instrument—FRI, Aesculap, see Fig. 68.1). If
kyphosis correction is intended, the use of monoaxial fracture screws is required, because only these screws can sustain the preload of the reduction maneuver. There are other
devices available for percutaneous dorsal instrumentation
(e.g., Sextant, Medtronic), but at the moment, only the FRI
device allows genuine fracture reduction.
U. Hahn (*)
Rems-Murr Schorndorf Hospital, Department of Orthopedics and
Traumatology, Schorndorf, Germany
e-mail: u.hahn@ots-praxisklinik.de
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_68
507
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Fig. 68.1 S4 fracture reduction instrument (Aesculap AG). (With per-
mission from Aesculap AG, Tuttlingen, Germany)
U. Hahn
Fig. 68.2 Preoperative uoroscopy-based planning of the skin
incision
68.5 Planning, Preparation,
andPositioning
During the operation, the patient is in a prone position on a
radiolucent operating table. Different positioning systems
can be used (Wilson frame, chest rolls, Relton-Hall frame,
etc.).
Exact C-arm-controlled planning of the approach is man-
datory (see Fig.68.2).
68.6 Surgical Technique
68.6.1 Approach
• Access is obtained by an incision of the thoracolumbar
fascia between the multidus and the longissimus muscles. The muscles are dissected bluntly only in the ber
direction. As a rule, this procedure can be carried out
without bleeding or with minimal blood loss. With the
help of an appropriate cannulated guiding device (see
Fig.68.3), the entry point is selected at the junction of the
facet and the transverse process.
• Remove the trocar; the K-wire aiming device remains in
the pedicle (see Fig.68.4).
To guide the cannulated pedicle screw, insert the K-wire
into the aiming device. As alternative, you can use a K-wire
protection sleeve (see Fig.68.5).
Fig. 68.3 Selection of entry point at the junction of the facet and the
transverse process and decortication with cannulated guiding device.
(With permission from Aesculap AG, Tuttlingen, Germany)
Note: The Kirschner wire should be inserted so far that its
tip represents the end position of the pedicle screw tip.
• You must be absolutely certain that the Kirschner wire is
not inserted too far to avoid damaging soft tissue and vessels. Use intraoperative uoroscopy!
68 Less Invasive Pedicle Screw Instrumentation ofLumbar Spine Fractures
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• Insert dilatation sleeves via the K-wire aiming device to
• Slide the blue tissue protection sleeve over the dilatation
68.6.2 Instrumentation [1–7]
• If necessary, use a pedicle reamer to further prepare the
• To determine the length of the screw, insert the screw
• Insert the screws with the cannulated screwdriver under
• Note: If necessary, after 3–4 turns of the screw, the K-wire
Fig. 68.4 Removal of trocar, the K-wire aiming device remains in the
pedicle. (With permission from Aesculap AG, Tuttlingen, Germany)
509
create sufcient space for the pedicle screw (see Fig.68.6).
sleeve (see Fig.68.7).
pedicle (see Fig.68.8) or, in the case of sclerotic bone,
a thread cutter with the appropriate diameter (see
Fig.68.9).
length-measuring instrument, with the calibration markings turned upward, via the K-wire and place it on the
vertebral body with the distal end (see Fig.68.10). The
length of the screw can be read from the markings on the
K-wire (see Fig.68.10).
uoroscopy guidance in lateral and anteroposterior
projections.
should be removed to avoid its rotation and ventral
perforation.
Fig. 68.5 Insertion of K-wire, if necessary, a K-wire protection sleeve
is used. (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 68.6 Insertion of dilatation sleeves via the K-wire aiming device.
(With permission from Aesculap AG, Tuttlingen, Germany)
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U. Hahn
Fig. 68.7 Sliding of the blue tissue protection sleeve over the dilata-
tion sleeve. (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 68.9 Preparation of pedicle using a thread cutter in the case of scle-
rotic bone. (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 68.8 Preparation of pedicle using a pedicle awl. (With permission
from Aesculap AG, Tuttlingen, Germany)
Fig. 68.10 Length determination using the cannulated measuring
instrument. (With permission from Aesculap AG, Tuttlingen, Germany)
68 Less Invasive Pedicle Screw Instrumentation ofLumbar Spine Fractures
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Fig. 68.11 Correct alignment of the screw slot, using the wings of the
alignment device. (With permission from Aesculap AG, Tuttlingen,
Germany)
• Align the screw to the cranio-caudal axis. Both sides of
the screwdriver must show in the cranio-caudal direction
(see Fig.68.11). If necessary, a special top piece can be
used (Fig.68.12).
• Measure the length of the rod with the rod length–measuring instrument (see Fig.68.13). If a distraction is necessary, a longer rod should be used accordingly. If you use
prebent rods, add ca. 10mm.
• Then, insert the FRI outer sleeves through the tissue protection sleeves. Align the longitudinal slit of the outer
sleeve caudally. Then, remove the protection sleeves and
insert the transverse rod with the rod inserter (see
Fig.68.14).
• Note: Before placing the FRI outer sleeves, the surgical
eld can be kept free using a Langenbeck hook; the rod
can then be inserted through this aperture (see
Fig.68.15).
• Put the reduction lever in place, the setscrew is received;
then insert the construct through the FRI sleeve in the
pedicle screw (see Fig.68.16). Screw the construct as far
as it will go into the anks of the pedicle screw (see
Fig.68.17).
Note: Make sure the setscrew does not block the rod to
avoid blocking the distraction (s. b.). If necessary, loosen
the setscrews a quarter of a turn.
Fig. 68.12 Alternatively, a special alignment device can be used.
(With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 68.13 Measurement of rod length with the rod length–measuring
instrument. (With permission from Aesculap AG, Tuttlingen, Germany)
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U. Hahn
Fig. 68.14 Representation of screw with two Langenbeck hooks.
(With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 68.16 Assembly of reduction lever. (With permission from
Aesculap AG, Tuttlingen, Germany)
Fig. 68.15 Insertion of rod with rod inserter. (With permission from
Aesculap AG, Tuttlingen, Germany)
Fig. 68.17 Turning of setscrew down to contact. If necessary, loosen a
quarter of a turn. (With permission from Aesculap AG, Tuttlingen, Germany)
ab
68 Less Invasive Pedicle Screw Instrumentation ofLumbar Spine Fractures
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Fig. 68.18 (a)
Installation of distractor
and (b) reduction of
vertebral height. (With
permission from Aesculap
AG, Tuttlingen, Germany)
513
68.6.3 Reduction
• Now, the installation of the distraction tool follows. The
distractor is inserted via the bolt in the guiding groove of
the cranial and caudal outer sleeve. The distraction blades
must be aligned parallel to the outer sleeves (see
Fig. 68.18a, b). The distraction is carried out consecutively (1 surgeon) or simultaneously (surgeon and assistant) under C-arm guidance.
• To reconstruct the natural lordosis, insert the spindle distractor into the corresponding nut and, by activating the
control knob, adjust the lordosis under uoroscopy guidance (see Fig.68.19a, b).
68.7 Tips andTricks
• Accurate positioning of patient, carefully aligned anterioposteriorly to the perpendicular line of the room axis, is
enormously helpful for the surgeon’s spatial orientation
and facilitates the initial pedicle screw alignment.
• If the instrumentation “is stuck,” then loosen the setscrew
or regulating screw little bit.
• If the insertion of prebent rods is planned, then it is helpful to position the cranial pedicle screws at an angle of ca.
10° cranially and the caudal pedicle screws at an angle of
ca. 10° caudally.
• Using the regulating screw on the threaded tube, press the
rod rmly. You must loosen the regulating crew a quarter
68.8 Results
of a turn to avoid blocking of the setscrew. Then, tighten
up the setscrew with the screwdriver (see Fig.68.20).
• Remove the screwdriver and unscrew the threaded tube
with the ratchet handle (see Fig.68.21).
• Final tightening of the construct is carried out with a
countering instrument and a 10-Nm (90-in/lb) torque
wrench (see Fig.68.22). Finally, the anks are broken off
using the ank breaking forceps (Fig.68.23).
The example of an LWK 1 AO-A3.1 fracture shows that,
through a minimally invasive procedure, the FRI instrumentation allows to achieve an anatomical reduction in
spite of restricted access. It permits a clearly more expeditious postoperative mobilization of the patients while causing them less pain in comparison to the open procedure
(Figs.68.23).
514
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Fig. 68.19 (a, b)
Installation of spindle
retractor and lordosis
reduction. (With
permission from Aesculap
AG, Tuttlingen, Germany)
U. Hahn
Fig. 68.20 Tightening the regulating screw and loosening a quarter of
a turn. Tightening up the setscrew. (With permission from Aesculap
AG, Tuttlingen, Germany)
Fig. 68.21 Removal of screwdriver and threaded tubes. (With permis-
sion from Aesculap AG, Tuttlingen, Germany)
68 Less Invasive Pedicle Screw Instrumentation ofLumbar Spine Fractures
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References
1. Foley KT, Gupta SK. Percutaneous pedicle screw xation of the
2. Hahn U, Andermahr J, Prokop A, Rehm KE. Minimal-invasive
3. Palmisani M, Gasbarrini A, Brodano GB, etal. Minimally invasive
4. Grass R, Biewener A, Dickopf A, etal. Percutaneous dorsal versus
5. Prokop A, Lohlein F, Chmielnicki M, Volbracht J.Minimally inva-
6. Korovessis P, Hadjipavlou A, Repantis T.Minimal invasive short
7. Merom L, Raz N, Hamud C etal. Minimally invasive burst fracture
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lumbar spine: preliminary clinical results. J Neurosurg. 2002;97(1
suppl):7–12.
Operationstechniken an der Wirbelsäule. Mediathek der Deutschen
Gesellschaft für Chirurgie: Aesculap Akademie; 2006.
percutaneous xation in the treatment of thoracic and lumbar spine
fractures. Eur Spine J. 2009;18(suppl 1):71–4.
open instrumentation for fractures of the thoracolumbar border. a
comparative, prospective study. Unfallchirurg. 2006;109:297–305.
sive percutaneous instrumentation for spine fractures. Unfallchirurg.
2009;112:621–6.
posterior instrumentation plus balloon kyphoplasty with calcium
phosphate for burst and severe compression lumbar fractures. Spine.
2008;33:658–67.
xation in the thoracolumbar region. Orthopedics. 2009;32(4).
Fig. 68.22 Final tightening with prescribed torque. (With permission
from Aesculap AG, Tuttlingen, Germany)
Fig. 68.23 Scars after less invasive transpedicular stabilization
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