Screw perforation rates in 359 consecutive patients receiving computer-guided pedicle screw insertion along the cervical to lumbar spine

Pedicle screw (PS) insertion has been criticized for its risk of serious injury to neurovascular structures. Although computed tomography (CT)-based navigation has been developed to avoid such complications, perforation remains an issue, even with the aid of additional guidance. We clarify screw perforation rate and direction in 359 consecutive patients treated using CT-based PS insertion and present important considerations for more accurate screw placement. The medical records of 359 consecutive patients who underwent PS insertion involving C2-L5 using a CT-based navigation system were reviewed. Postoperative CT images were analyzed to evaluate the accuracy of screw placement. We investigated both rate and direction of screw perforation according to vertebral level. Of the 3413 PS that were inserted, 6.9% were judged as Grade 2 or 3 perforations. The combined rate of these perforations was 5.0% for C2, 11.4% for C3-5, 7.0% for C6-7, 10.4% for T1-4, 8.8% for T5-8, 4.5% for T9-12, and 3.8% for L1-5. We also analyzed the odds ratio (OR) for screw perforation in vertebrae accounting for the effects of age and disease. Multivariate analysis identified that PS insertions at C3-5 (OR 2.9, 95% CI 1.6-5.1; p < 0.001), T1-4 (OR 2.7, 95% CI 1.6-4.7; p < 0.001), and T5-8 (OR 2.3; 95% CI 1.4-3.8; p = 0.001) were significantly associated with Grade 2 or 3 screw perforation as compared with that of L1-5. Even with CT-based navigation, careful insertion of PS is needed in the middle cervical spine because of a significantly higher perforation rate as compared with the lumbar region.