Percutaneous Lumbar Pedicle Screw Placement Using the Ideal Skin Entry Point and Novel C-Arm Fluoroscopy Technology: A Technical Note

Percutaneous Lumbar Pedicle Screw Placement Using the Ideal Skin Entry Point and Novel C-Arm Fluoroscopy Technology: A Technical Note | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Percutaneous Lumbar Pedicle Screw Placement Using the Ideal Skin Entry Point and Novel C-Arm Fluoroscopy Technology: A Technical Note Baojia Yang, Jianrong He, Ming Zhang, Zhou Zhou, Zhengliang Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3839228/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: This study aimed to introduce an optimal skin entry point, determined via novel two-dimensional fluoroscopy-guided technology, with an intention to decrease screw placement and fluoroscopy times during the learning curve of percutaneous pedicle screw placement. Methods: The radiologic background and principles of the novel C-arm fluoroscopy technology, as well as the methodology for determining the appropriate skin entry point using a self-designed body surface locator are described, as well as an evaluation study of the technique in patients. In the study, a total of 120 percutaneous lumbar pedicle screws were placed from L-3 to S-1 in adult patients. Postoperative fine-cut CT scans were acquired to evaluate the pedicle screw placement. The K-wire placement time and fluoroscopy count were recorded by the operating room staff. Results: The presented technique has become the standard for percutaneous screw placement in the prone position in our department. Out of 120 guidewires and screws inserted in the evaluation study, there were no instances of new or worsening neurological symptoms or deficits, resulting in an overall clinical accuracy of 100%. The average implantation time for each guide wire was 3.64 minutes, and the average number of fluoroscopies per spinal level was 8.13. Conclusions: The findings of this study suggest that selecting the optimal skin entry point can enhance the performance of this technique. Specifically, it can ensure more accurate and safe percutaneous lumbar pedicle screw placement, reduce the procedure and fluoroscopy times, and is feasible based on our clinical experience. Body surface locator Percutaneous pedicle screw Skin entry point Two-dimensional fluoroscopy Figures Figure 1 Figure 2 Figure 3 Introduction Percutaneous pedicle screw (PPS) placement is currently the most widely utilized approach for the minimally invasive treatment of spinal diseases, thanks to advances in spinal instrumentation and surgical techniques. 1 Although PPS placement minimizes muscle dissection, blood loss, and infection rates, it also presents new challenges and specific complications. 2-6 One of the initial obstacles in the learning curve of this technique is the absence of tactile and visual feedback as provided by conventional open surgical techniques, in addition to the reliance on fluoroscopy, which is necessary for minimally invasive pedicle cannulation. 7 Adapting to the process of inserting a screw by palpation with the tip of a Jamshidi needle while observing a fluoroscope screen can be challenging and frustrating, particularly when issues related to radiation exposure or inherent complications in the surgical technique come into play. Also, the authors postulate that the ideal skin entry point is crucial for accurately and quickly reaching the bone structure with the Jamshidi needle, as inaccurate skin entry points can not only cause incision enlargement, and possible nerve and blood vessel damage during puncture, but also increase radiation exposure and even lead to puncture failure in severe cases. Multiple techniques can be employed to navigate screw placement, such as three-dimensional (3D) CT or robot-assisted navigation. Although these navigation techniques reduce the incidence of percutaneous pedicle screw injuries to the cranial articular process joints, they require high-end technology and costly instruments. Consequently, two-dimensional (2D) C-arm fluoroscopy remains the most widely used technique. 8-12 To aid finding the ideal skin entry point, we designed a body surface locator based on a new preoperative 2D C-arm fluoroscopic positioning method combined with preoperative CT measurements. In this paper, we describe this novel 2D fluoroscopy-based percutaneous pedicle screw placement technique and evaluate its effectiveness, as well as share our early experiences with this technology. To the best of our knowledge, this is the inaugural investigation of lumbar puncture screw insertion utilizing a novel 2D fluorescence technique, which has not been previously reported. Material and methods Following approval from the institutional review board/ethics committee, we retrospectively reviewed data from 30 adult patients who had undergone percutaneous pedicle screw placement in the lumbar spine using an optimized skin entry point and novel C-arm fluoroscopy technology between November 2019 and February 2023. Radiologic background and principles of the novel 2D fluoroscopy technique In C-arm fluoroscopy, the X-ray emitted by the C-arm forms an invisible cone, with a triangle at its central section. Lateral fluoroscopy is conducted using the C-arm, aligning the central section of the triangular X-ray projection so that it bisects the pedicle. This alignment identifies the optimal skin entry point for percutaneous pedicle screw placement. According to this principle, we designed a positioner with radiopaque steel plates, comprising two main parts (see part 1 and part 2 in Figure 1A). The fine needle part and the hollow part of part 1 are aligned in the same straight line. Part 1 is installed on the X-ray receiver of the C-arm machine with the fine needle part bisecting the plane of the receiver (Figure 1B). The fine needle part of the locator overlaps the triangular section in the middle of the X-ray. The perspective visibility locator bisects the perspective screen (Figure 1C). Part 2 is inserted into the hollow part of part 1 in such a way that the thin needle part at the far end of part 2 and part 1 is in the same plane (Figures 1D-E). This plane is the middle section formed by the C-arm’s perspective X-ray. Determining the appropriate skin entry point Determining the appropriate skin entry point involves a five-step approach, as follows: Step 1: Mount the locator component 1 on the center of the C-arm fluoroscopy monitor. The fine needle component should bisect the plane of the receiver (Figure 1B). Step 2: Tilt the C-arm in the cranial/caudal direction to align with the sagittal plane (Figure 2A). The pedicle should be bisected by the projection of the fine needle component, thereby determining the optimal lateral screw trajectory (Figure 2B). In this way, a true lateral view can be obtained with the targeted vertebra visualized in the middle of the fluoroscopic image, avoiding a double pedicular or posterior wall image in the lateral projection. Step 3: Slide component 2 along the hollow section of component 1 until it comes into contact with the patient's skin (Figure 2A). Draw a horizontal line along part 2 on the patient’s back (Figures 2C,E) showing where the optimal skin entry point must lie. Step 4: Conduct preoperative measurements using CT transpedicle central axial radiographs. Measure the intersection point between the optimal trajectory of the pedicle nail and the skin (left point E and right point F), and the intersection point between the mid-branch line of the vertebral body and spinous process and the skin (G-point), and measure the distances of GE and GF (Figure 2D). Step 5: Reposition the C-arm to obtain appropriate anteroposterior (AP) images, ensuring the spinous process is centered between the two clearly visualized pedicles at the index level (Figures 2F-H). According to the body surface positioning plate, the longitudinal line passing the central line of the spinous process is marked on the body surface, and the intersection points with the horizontal line are marked as points A and C. Draw the left side AB and the right side AB' on the horizontal line so that AB = GE and AB' = GF, where B and B' are the best skin entry points (Figure 2I). Surgical procedure In the surgical procedure, an incision 3 mm in length is made transversely at the best skin entry points described above for each Jamshidi needle. At this time, the incision should not be too large. The skin and soft tissue have the function of stabilizing the puncture needle. The Jamshidi needle is maintained along the desired trajectory. The tip is positioned lateral to the oval image of the pedicle until the dorsal bony cortex overlying the center of the pedicle and confirmed with fluoroscopy. In the traditional prone percutaneous screw placement technique, 1 true AP and lateral views are used to navigate the converging pedicles while guessing their convergence. The needle is manually advanced through the targeted skin site and dorsal spinal musculature along the imaginary pedicle trajectory. By following this trajectory through the skin and soft tissue, the needle encounters the bone very near the appropriate pedicular entry point in a straight line. The Jamshidi needle, adjusted in a cephalocaudal and medial direction, is then gently tapped into the pedicle and vertebral body using standard fluoroscopic landmarks as a guide. Small translational adjustments of the needle tip are made to ensure docking on the dorsal bony cortex overlying the center of the pedicle, as confirmed with fluoroscopy. When the needle tip contacts the bone, it is carefully tapped further to ensure the tip is firmly embedded in the bone. Regarding the best bone entry point for the percutaneous insertion of the pedicle screws, the authors refer to the original description by Wiesner et al., 1 who suggested lateral from the oval image of the pedicle in a perfect anteroposterior view. When the tip of the Jamshidi needle lies at the center of the pedicle shadow on AP imaging, it approaches the junction of the pedicle and vertebral body on a lateral fluoroscopic view. A K-wire is placed through the Jamshidi cannula into the vertebral body to maintain the position for percutaneous screw placement. The Jamshidi assembly is removed over the K-wire, and the process is repeated for each pedicle to be instrumented. The incision is lengthened and subcutaneous tissue is incised with monopolar electrocautery to allow for the easier passage of the surgical instruments, including the dilators. The vertebrae should be “squared up” one by one as their pedicles are being cannulated, thereby avoiding a double image on the superior vertebral end plate in the AP projection and a double pedicular or a posterior wall image in the lateral projection. Lastly, appropriate pedicle screw placement is assessed with AP and lateral imaging. The exact same steps are repeated at other levels and a percutaneous rod is inserted and secured to the polyaxial screw heads with locking caps according to the screw system used (Figures 3A-F). Two trained surgeons follow the steps described by Wiesner et al. in placing the left and right pedicles in the same vertebra. 1 In performing each procedure during our evaluation study, the duration from the initial incision to the final satisfactory placement of the guidewire was meticulously recorded by the operating room staff. These measurements excluded the placement of the screw and the rod and the compression, distraction, or reduction maneuvers, as well as the final tightening. All the pedicle screws were placed by two senior spine surgeons (xxx and xxx) with extensive experience in minimally invasive spinal techniques at the xxx University. Postoperative CT assessment Fine-cut postoperative CT scans were conducted on the 30 patients immediately after the operation to evaluate the pedicle screw placement, as assessed by the two authors (xxx and xxx). CT assessment of the pedicle screw placement using axial, coronal, and sagittal reconstructions was independently reviewed by 2 senior neuroradiologists. Results This technique has become our department's standard for percutaneous screw placement in the prone position. In our study, 120 guidewires and screws were successfully inserted in the lumbosacral spine in 30 patients with spondylolisthesis or degenerative disc disease. The average patient age was 54.6 years old (range 46–63 years old) and 17 patients were men. Screws were placed in a single-level Endo-TLIF operation. No instances of new or worsening neurological symptoms or deficits were observed, thus providing an overall clinical accuracy of 100%. Each guidewire had an average implantation time of 3.64 minutes, and the average number of fluoroscopies performed for each spinal level was 8.13 times (Table 1). Discussion The practice of percutaneous pedicle screw placement was first proposed by Magerl in 1984 as a method for spinal external fixation. 13 Since this introduction, numerous clinical applications have been published. Currently, this technique has found broad application in minimally invasive spinal procedures aimed at restoring spinal stability. This technique offers rigid internal fixation and presents clear advantages over traditional open surgical techniques. These benefits include smaller incisions, less muscle dissection, decreased blood loss and postoperative pain, and consequentially, reduced muscle necrosis and atrophy, shorter hospital stays, and a quicker return to work. 14-17 However, the limitations from the reduced visualization of the local anatomy and tactile feedback can present obstacles to accurate screw placement. 18 Guidance for PPS placement relies on imaging from 2D fluoroscopy, computer-assisted navigation systems, and robotic assistance. Several studies have affirmed that these navigation systems can diminish screw malpositioning and lower radiation exposure. However, these technologies can be prohibitively expensive and challenging to implement globally. 19-26 The majority of hospitals continue to use 2D fluoroscopy guidance due to its cost-effectiveness, practicality, and safety. Percutaneous pedicle cannulation under 2D fluoroscopy guidance has a learning curve that may be more challenging, lengthy, and difficult compared to the conventional open technique, given the absence of direct vision or palpation. 16, 27, 28 This study illustrates that the appropriate skin entry point for percutaneous screw placement can be accurately located with 2D C-arm fluoroscopy. We anticipate that this novel skin entry point technology will minimize errors, making the learning curve safer, less demanding, and shorter. By adopting this technique, surgical efficiency can be enhanced through a reduction in the operating time. Our study introduces this technique and technology for the first time, and validation by other researchers is yet to be accomplished. This novel 2D fluoroscopy technique can be utilized with the patient in the prone position and is suitable for lumbar vertebral levels. However, validation for thoracic vertebrae was not carried out in this study. Our study on percutaneous lumbar pedicle screw placement using a novel marking method demonstrates that both screw placement and fluoroscopy times can be reduced. Accurate identification of the desired skin entry point may enhance the performance of this technique. The technique is highly repeatable, safe, and simple. Altogether, this technique and technology present a viable alternative, and potentially superior option, to existing methods. Abbreviations 3D Three-dimensional 2D Two-dimensional AP Appropriate anteroposterior PPS Percutaneous pedicle screw Declarations Ethics approval and consent to participate : This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by ethics committee of the First Affiliated Hospital of Dali University (0FY20190226001). Consent for publication: Not applicable. Availability of data and materials: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests:The authors declare that they have no competing interests. Funding: This work was supported by Yunnan Provincial University Joint funds (No. 202101BA070001-128). Authors' contributions Study design: BJY and JRH. Study conduct: BJY and MZ. Data collection: BJY,JRH,MZ,ZZ and ZLL. Data analysis: BJY and ZLL. Data interpretation: BJY and ZLL. Drafting manuscript: BJY. Revising manuscript content: BJY and JRH. Approving final version of manuscript: BJY,JRH and ZLL. BJY and JRH take responsibility for the integrity of the data analysis. BJY and JRH contributed equally to this work and should be considered co-first authors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. Acknowledgements Not applicable. 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Spine (Phila Pa 1976) . 2002;27:1444-1450. https://doi.org/10.1097/00007632-200207010-00014 Geerling J, Gösling T, Gösling A, Ortega G, Kendoff D, Citak M, Krettek C, Hüfner T. Navigated pedicle screw placement: experimental comparison between CT- and 3D fluoroscopy-based techniques. Comput Aided Surg . 2008;13:157-166. https://doi.org/10.3109/10929080802102110 Holly LT, Foley KT. Intraoperative spinal navigation. Spine (Phila Pa 1976) . 2003;28:S54-61. https://doi.org/10.1097/01.Brs.0000076899.78522.D9 Laine T, Lund T, Ylikoski M, Lohikoski J, Schlenzka D. Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients. Eur Spine J . 2000;9:235-240. https://doi.org/10.1007/s005860000146 Quiñones-Hinojosa A, Robert Kolen E, Jun P, Rosenberg WS, Weinstein PR. Accuracy over space and time of computer-assisted fluoroscopic navigation in the lumbar spine in vivo. J Spinal Disord Tech . 2006;19:109-113. https://doi.org/10.1097/01.bsd.0000168513.68975.8a Ringstrom MJ, Sullivan HG, Fundell LJ, Nigogosyan MA. A new paradigm for staging pedicle screw-based spinal procedures: rationale, feasibility, safety, and efficacy. J Neurosurg Spine . 2007;7:521-532. https://doi.org/10.3171/spi-07/11/521 Smith HE, Welsch MD, Sasso RC, Vaccaro AR. Comparison of radiation exposure in lumbar pedicle screw placement with fluoroscopy vs computer-assisted image guidance with intraoperative three-dimensional imaging. J Spinal Cord Med . 2008;31:532-537. https://doi.org/10.1080/10790268.2008.11753648 Villavicencio AT, Burneikiene S, Bulsara KR, Thramann JJ. Utility of computerized isocentric fluoroscopy for minimally invasive spinal surgical techniques. J Spinal Disord Tech . 2005;18:369-375. https://doi.org/10.1097/01.bsd.0000168511.67189.64 Patel RD, Graziano GP, Vanderhave KL, Patel AA, Gerling MC. Facet violation with the placement of percutaneous pedicle screws. Spine (Phila Pa 1976) . 2011;36:E1749-1752. https://doi.org/10.1097/BRS.0b013e318221a800 Houten JK, Nasser R, Baxi N. Clinical assessment of percutaneous lumbar pedicle screw placement using theO-arm multidimensional surgical imaging system. Neurosurgery . 2012;70:990-995. https://doi.org/10.1227/NEU.0b013e318237a829 Table 1 Table 1. Guidewire insertion times and fluoroscopy times in all patients Case no. Spinal level No. of guidewires Total insertion time of the guidewire (min) Insertion time per guidewire (min) Total number of fluoroscopies 1 L4-L5 4 13.23 3.06 12 2 L5-S1 4 16.12 4.03 12 3 L4-L5 4 14.34 3.59 8 4 L4-L5 4 18.19 4.55 10 5 L4-L5 4 16.00 4.00 6 6 L3-L4 4 11.22 2.81 10 7 L5-S1 4 17.35 4.34 10 8 L4-L5 4 12.30 3.08 6 9 L4-L5 4 15.58 3.90 8 10 L3-L4 4 16.05 4.01 8 11 L4-L5 4 12.00 3.00 6 12 L4-L5 4 13.23 3.31 10 13 L4-L5 4 14.28 3.57 8 14 L5-S1 4 16.45 4.11 10 15 L4-L5 4 15.35 3.84 10 16 L3-L4 4 14.15 3.54 8 17 L4-L5 4 15.40 3.85 10 18 L4-L5 4 16.33 4.08 8 19 L3-L4 4 11.35 2.84 6 20 L4-L5 4 16.46 4.12 8 21 L4-L5 4 12.29 3.07 8 22 L4-L5 4 14.00 3.50 8 23 L4-L5 4 13.30 3.33 6 24 L4-L5 4 14.54 3.64 6 25 L5-S1 4 17.07 4.27 8 26 L5-S1 4 14.56 3.64 8 27 L3-L4 4 12.12 3.03 6 28 L4-L5 4 14.43 3.61 8 29 L4-L5 4 13.18 3.30 6 30 L5-S1 4 15.57 3.89 6 Average - 4 14.55 3.64 8.13 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3839228","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":265886650,"identity":"54d0e664-edb9-4a41-98ca-8e303f6eee30","order_by":0,"name":"Baojia Yang","email":"","orcid":"","institution":"The First Affiliated Hospital of Dali University","correspondingAuthor":false,"prefix":"","firstName":"Baojia","middleName":"","lastName":"Yang","suffix":""},{"id":265886651,"identity":"a88fcd87-a758-486d-a950-7621b12c3d92","order_by":1,"name":"Jianrong He","email":"","orcid":"","institution":"The First Affiliated Hospital of Dali 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Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYBACxmb+j4//8NTI2bc3EKmFub3B2IBH5hiQOECkFvaeA2YSPDbMiQYSCURq4Z2RkGwgkcOWYC75eOMNhhqbaIJaJGckHHxgcEYmz3J2WrEFw7G03AZCWgxnJDYbJPawFTPczjGTYGw4TFiL/Y1kNomD/5gTG26eIVILY88xNskGHubEDTd4iNXS3sNszMBzzFiyB+iXBGL8wtjMw/iYARiV/OyHN974UGNDWAsyID5qkLSQqmMUjIJRMApGBgAAZr8+sv3zs6EAAAAASUVORK5CYII=","orcid":"","institution":"The First Affiliated Hospital of Dali University","correspondingAuthor":true,"prefix":"","firstName":"Zhengliang","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-01-06 08:14:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3839228/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3839228/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49439142,"identity":"7e96c349-78e5-4fdc-875a-d56522a44e37","added_by":"auto","created_at":"2024-01-10 21:44:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":394783,"visible":true,"origin":"","legend":"\u003cp\u003eAppearance and installation process of body surface locator\u003c/p\u003e","description":"","filename":"FIG.1.png","url":"https://assets-eu.researchsquare.com/files/rs-3839228/v1/489392e1fd8196fb918195d8.png"},{"id":49439140,"identity":"188347a8-4250-4087-b034-59714b22d43f","added_by":"auto","created_at":"2024-01-10 21:44:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":597735,"visible":true,"origin":"","legend":"\u003cp\u003eDetermining and marking the appropriate skin entry point\u003c/p\u003e","description":"","filename":"FIG.2.png","url":"https://assets-eu.researchsquare.com/files/rs-3839228/v1/e2cc2347f905836a8dd8db7c.png"},{"id":49440071,"identity":"d0b4d95b-a313-4b28-a3fe-b13ab2acf61f","added_by":"auto","created_at":"2024-01-10 21:52:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":369890,"visible":true,"origin":"","legend":"\u003cp\u003ePercutaneous pedicle screws (PPS) are inserted through the designated skin entry points.\u003c/p\u003e","description":"","filename":"FIG.3.png","url":"https://assets-eu.researchsquare.com/files/rs-3839228/v1/617c5dcac9348b9ff28aa2da.png"},{"id":55731394,"identity":"98502eca-90e6-4a82-a3d4-422cd9f8fb49","added_by":"auto","created_at":"2024-05-02 11:17:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1784101,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3839228/v1/a277f275-c774-4dce-a034-736590f9c6a8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Percutaneous Lumbar Pedicle Screw Placement Using the Ideal Skin Entry Point and Novel C-Arm Fluoroscopy Technology: A Technical Note","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePercutaneous pedicle screw (PPS)\u0026nbsp;placement is currently the most widely utilized approach for the minimally invasive treatment of spinal diseases, thanks to advances in spinal instrumentation and surgical techniques.\u003csup\u003e1\u003c/sup\u003e Although PPS placement minimizes muscle dissection, blood loss, and infection rates, it also presents new challenges and specific complications.\u003csup\u003e2-6\u003c/sup\u003e One of the initial obstacles in the learning curve of this technique is the absence of tactile and visual feedback as provided by conventional open surgical techniques, in addition to the reliance on fluoroscopy, which is necessary for minimally invasive pedicle cannulation.\u003csup\u003e7\u003c/sup\u003e Adapting to the process of inserting a screw by palpation with the tip of a Jamshidi needle while observing a fluoroscope screen can be challenging and frustrating, particularly when issues related to radiation exposure or inherent complications in the surgical technique come into play.\u003c/p\u003e\n\u003cp\u003eAlso, the authors postulate that the ideal skin entry point is crucial for accurately and quickly reaching the bone structure with the Jamshidi needle, as inaccurate skin entry points\u0026nbsp;can not only cause\u0026nbsp;incision enlargement, and possible nerve and blood vessel damage during puncture, but also increase radiation exposure and even lead to\u0026nbsp;puncture failure in severe cases. Multiple techniques can be employed to navigate screw placement, such as three-dimensional (3D) CT or robot-assisted navigation. Although these navigation techniques reduce the incidence of percutaneous pedicle screw injuries to the cranial articular process joints, they require high-end technology and costly instruments. Consequently, two-dimensional (2D) C-arm fluoroscopy remains the most widely used technique.\u003csup\u003e8-12\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eTo aid finding the ideal skin entry point, we designed a body surface locator based on a new preoperative 2D C-arm fluoroscopic positioning method combined with preoperative CT measurements. In this paper, we describe this novel 2D fluoroscopy-based percutaneous pedicle screw placement technique and evaluate its effectiveness, as well as share our early experiences with this technology. To the best of our knowledge, this is the inaugural investigation of lumbar puncture screw insertion utilizing a novel 2D fluorescence technique, which has not been previously reported.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eFollowing approval from the\u0026nbsp;institutional review board/ethics committee, we retrospectively reviewed data from 30 adult patients who had undergone\u0026nbsp;percutaneous pedicle screw placement\u0026nbsp;in the lumbar spine using an optimized skin entry point and novel C-arm fluoroscopy technology between November 2019 and February 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadiologic background and principles of the novel 2D fluoroscopy technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn C-arm fluoroscopy, the X-ray emitted by the C-arm forms an invisible cone, with a triangle at its central section. Lateral fluoroscopy is conducted using the C-arm, aligning the central section of the triangular X-ray projection so that it bisects the pedicle. This alignment identifies the optimal skin entry point for percutaneous pedicle screw placement. According to this principle, we designed a positioner with radiopaque steel plates, comprising two main parts (see part 1 and part 2 in Figure 1A). The fine needle part and the hollow part of part 1 are aligned in the same straight line. Part 1 is installed on the X-ray receiver of the C-arm machine with the fine needle part bisecting the plane of the receiver (Figure 1B). The fine needle part of the locator overlaps the triangular section in the middle of the X-ray. The perspective visibility locator bisects the perspective screen (Figure 1C). Part 2 is inserted into the hollow part of part 1 in such a way that the thin needle part at the far end of part 2 and part 1 is in the same plane (Figures 1D-E). This plane is the middle section formed by the C-arm\u0026rsquo;s perspective X-ray.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDetermining the appropriate skin entry point\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDetermining the appropriate skin entry point\u0026nbsp;involves a five-step approach, as follows:\u003c/p\u003e\n\u003cp\u003eStep 1: Mount the locator component 1 on the center of the C-arm fluoroscopy monitor. The fine needle component should bisect the plane of the receiver (Figure\u0026nbsp;1B).\u003c/p\u003e\n\u003cp\u003eStep 2: Tilt the C-arm in the cranial/caudal direction to align with the sagittal plane (Figure\u0026nbsp;2A). The pedicle should be bisected by the projection of the fine needle component, thereby determining the optimal lateral screw trajectory (Figure\u0026nbsp;2B). In this way, a true lateral view can be obtained with the targeted vertebra visualized in the middle of the fluoroscopic image, avoiding a double pedicular or posterior wall image in the lateral projection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStep 3: Slide component 2 along the\u0026nbsp;hollow section\u0026nbsp;of component 1 until it comes into contact with the patient\u0026apos;s skin (Figure\u0026nbsp;2A). Draw a horizontal line along part 2 on the patient\u0026rsquo;s back (Figures\u0026nbsp;2C,E) showing where the optimal skin entry point must lie.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStep 4: Conduct preoperative measurements using CT transpedicle central axial radiographs. Measure the intersection point between the optimal trajectory of the pedicle nail and the skin (left point E and right point F), and the intersection point between the mid-branch line of the vertebral body and spinous process and the skin (G-point), and measure the distances of GE and GF (Figure\u0026nbsp;2D).\u003c/p\u003e\n\u003cp\u003eStep 5: Reposition the C-arm to obtain appropriate anteroposterior (AP) images, ensuring the spinous process is centered between the two clearly visualized pedicles at the index level (Figures 2F-H). According to the body surface positioning plate, the longitudinal line passing the central line of the spinous process is marked on the body surface, and the intersection points with the horizontal line are marked as points A and C. Draw the left side AB and the right side AB\u0026apos; on the horizontal line so that AB = GE and AB\u0026apos; = GF, where B and B\u0026apos; are the best skin entry points (Figure 2I).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the surgical procedure, an incision 3 mm in length is made transversely at the best skin entry points described above for each\u0026nbsp;Jamshidi needle. At this time, the incision should not be too large. The skin and soft tissue have the function of stabilizing the puncture needle. The Jamshidi needle is maintained along the desired trajectory. The tip is positioned lateral to the oval image of the pedicle until the dorsal bony cortex overlying the center of the pedicle and confirmed with fluoroscopy. In the traditional prone percutaneous screw placement technique,\u003csup\u003e1\u003c/sup\u003e true AP and lateral views are used to navigate the converging pedicles while guessing their convergence. The needle is manually advanced through the targeted skin site and dorsal spinal musculature along the imaginary pedicle trajectory. By following this trajectory through the skin and soft tissue, the needle encounters the bone very near the appropriate pedicular entry point in a straight line. The Jamshidi needle, adjusted in a cephalocaudal and medial direction, is then gently tapped into the pedicle and vertebral body using standard fluoroscopic landmarks as a guide. Small translational adjustments of the needle tip are made to ensure docking on the dorsal bony cortex overlying the center of the pedicle, as confirmed with fluoroscopy. When the needle tip contacts the bone, it is carefully tapped further to ensure the tip is firmly embedded in the bone. Regarding the best bone entry point for the percutaneous insertion of the pedicle screws, the authors refer to the original description by Wiesner et al.,\u003csup\u003e1\u003c/sup\u003e who suggested lateral from the oval image of the pedicle in a perfect anteroposterior view. When the tip of the Jamshidi needle lies at the center of the pedicle shadow on AP imaging, it approaches the junction of the pedicle and vertebral body on a lateral fluoroscopic view. A K-wire is placed through the Jamshidi cannula into the vertebral body to maintain the position for percutaneous screw placement. The Jamshidi assembly is removed over the K-wire, and the process is repeated for each pedicle to be instrumented. The incision is lengthened and subcutaneous tissue is incised with monopolar electrocautery to allow for the easier passage of the surgical instruments, including the dilators. The vertebrae should be \u0026ldquo;squared up\u0026rdquo; one by one as their pedicles are being cannulated, thereby avoiding a double image on the superior vertebral end plate in the AP projection and a double pedicular or a posterior wall image in the lateral projection. Lastly, appropriate pedicle screw placement is assessed with AP and lateral imaging. The exact same steps are repeated at other levels and a percutaneous rod is inserted and secured to the polyaxial screw heads with locking caps according to the screw system used (Figures 3A-F). Two trained surgeons follow the steps described by Wiesner et al.\u003ca href=\"#bookmark\"\u003e\u0026nbsp;\u003c/a\u003ein placing the left and right pedicles in\u0026nbsp;the same vertebra.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn performing each procedure during our evaluation study, the duration from the initial incision to the final satisfactory placement of the guidewire was meticulously recorded by the operating room staff. These measurements excluded the placement of the screw and the rod and the compression, distraction, or reduction maneuvers, as well as the final tightening. All the pedicle screws were placed by two senior spine surgeons (xxx and xxx) with extensive experience in minimally invasive spinal techniques at the xxx University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative CT assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFine-cut postoperative CT scans were conducted on the 30 patients immediately after the operation to evaluate the pedicle screw placement, as assessed by the two authors (xxx and xxx). CT assessment of the pedicle screw placement using axial, coronal, and sagittal reconstructions was independently reviewed by 2 senior neuroradiologists.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis technique has become our department\u0026apos;s standard for percutaneous screw placement in the prone position. In our study, 120 guidewires and screws were successfully inserted in the lumbosacral spine in 30 patients with spondylolisthesis or degenerative disc disease. The average patient age was 54.6 years old (range 46\u0026ndash;63 years old) and 17 patients were men. Screws were placed in a single-level Endo-TLIF operation. No instances of new or worsening neurological symptoms or deficits were observed, thus providing an overall clinical accuracy of 100%. Each guidewire had an average implantation time of 3.64 minutes, and the average number of fluoroscopies performed for each spinal level was 8.13 times (Table 1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe practice of percutaneous pedicle screw placement was first proposed by Magerl in 1984 as a method for spinal external fixation.\u003csup\u003e13\u003c/sup\u003e Since this introduction, numerous clinical applications have been published. Currently, this technique has found broad application in minimally invasive spinal procedures aimed at restoring spinal stability. This technique offers rigid internal fixation and presents clear advantages over traditional open surgical techniques. These benefits include smaller incisions, less muscle dissection, decreased blood loss and postoperative pain, and consequentially, reduced muscle necrosis and atrophy, shorter hospital stays, and a quicker return to work.\u003csup\u003e14-17\u003c/sup\u003e However, the limitations from the reduced visualization of the local anatomy and tactile feedback can present obstacles to accurate screw placement.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eGuidance for PPS placement relies on imaging from\u0026nbsp;2D fluoroscopy, computer-assisted navigation systems, and robotic assistance. Several studies have affirmed that these\u0026nbsp;navigation systems\u0026nbsp;can diminish screw malpositioning and lower radiation exposure. However, these technologies can be prohibitively expensive and challenging to implement globally.\u003csup\u003e19-26\u003c/sup\u003e The majority of hospitals continue to use\u0026nbsp;2D fluoroscopy guidance\u0026nbsp;due to its cost-effectiveness, practicality, and safety. Percutaneous pedicle cannulation under 2D fluoroscopy guidance has a\u0026nbsp;learning curve\u0026nbsp;that may be more challenging, lengthy, and difficult compared to the conventional open technique, given the absence of\u0026nbsp;direct vision\u0026nbsp;or palpation.\u003csup\u003e16, 27, 28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThis study illustrates that the appropriate skin entry point for percutaneous screw placement can be accurately located with 2D C-arm fluoroscopy. We anticipate that this novel skin entry point technology will minimize errors, making the learning curve safer, less demanding, and shorter. By adopting this technique,\u0026nbsp;surgical efficiency\u0026nbsp;can be enhanced through a reduction in the operating time. Our study introduces this technique and technology for the first time, and validation by other researchers is yet to be accomplished.\u0026nbsp;This novel 2D fluoroscopy technique can be utilized with the patient in the prone position and is suitable for lumbar vertebral levels. However, validation for\u0026nbsp;thoracic vertebrae\u0026nbsp;was not carried out in this study.\u003cbr\u003e\u0026nbsp;Our study on percutaneous lumbar pedicle screw placement using a novel marking method demonstrates that both screw placement and fluoroscopy times can be reduced. Accurate identification of the desired skin entry point may enhance the performance of this technique. The technique is highly repeatable, safe, and simple. Altogether, this technique and technology present a viable alternative, and potentially superior option, to existing methods.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations ","content":"\u003cp\u003e\u003cstrong\u003e3D \u0026nbsp; \u0026nbsp;\u003c/strong\u003eThree-dimensional\u003c/p\u003e\n\u003cp\u003e2D\u0026nbsp; \u0026nbsp; Two-dimensional\u003c/p\u003e\n\u003cp\u003eAP\u0026nbsp; \u0026nbsp; Appropriate anteroposterior\u003c/p\u003e\n\u003cp\u003ePPS \u0026nbsp;Percutaneous pedicle screw\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by ethics committee of the First Affiliated Hospital of Dali University\u0026nbsp;(0FY20190226001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch4\u003eCompeting interests:The authors declare that they have no competing interests.\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis work was supported by Yunnan Provincial University Joint funds (No. 202101BA070001-128).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy design: BJY and JRH. Study conduct: BJY and MZ. Data collection: BJY,JRH,MZ,ZZ and ZLL. Data analysis: BJY and ZLL. Data interpretation: BJY and ZLL. Drafting manuscript: BJY. Revising manuscript content: BJY and JRH. Approving final version of manuscript: BJY,JRH and ZLL. BJY and JRH take responsibility for the integrity of the data analysis. BJY and JRH contributed equally to this work and should be considered co-first authors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e We have obtained written informed consent from all study participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWiesner L, Kothe R, R\u0026uuml;ther W. 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Clinical and radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up. \u003cem\u003eJ Neurosurg Spine\u003c/em\u003e. 2008;9:560-565. https://doi.org/10.3171/spi.2008.9.08142\u003c/li\u003e\n\u003cli\u003ePark Y, Ha JW. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e. 2007;32:537-543. https://doi.org/10.1097/01.brs.0000256473.49791.f4\u003c/li\u003e\n\u003cli\u003eScheufler KM, Dohmen H, Vougioukas VI. Percutaneous transforaminal lumbar interbody fusion for the treatment of degenerative lumbar instability. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2007;60:203-212; discussion 212-203. https://doi.org/10.1227/01.Neu.0000255388.03088.B7\u003c/li\u003e\n\u003cli\u003eLehmann W, Ushmaev A, Ruecker A, Nuechtern J, Grossterlinden L, Begemann PG, Baeumer T, Rueger JM, Briem D. Comparison of open versus percutaneous pedicle screw insertion in a sheep model. \u003cem\u003eEur Spine J\u003c/em\u003e. 2008;17:857-863. https://doi.org/10.1007/s00586-008-0652-7\u003c/li\u003e\n\u003cli\u003eBose B, Wierzbowski LR, Sestokas AK. Neurophysiologic monitoring of spinal nerve root function during instrumented posterior lumbar spine surgery. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e. 2002;27:1444-1450. https://doi.org/10.1097/00007632-200207010-00014\u003c/li\u003e\n\u003cli\u003eGeerling J, G\u0026ouml;sling T, G\u0026ouml;sling A, Ortega G, Kendoff D, Citak M, Krettek C, H\u0026uuml;fner T. Navigated pedicle screw placement: experimental comparison between CT- and 3D fluoroscopy-based techniques. \u003cem\u003eComput Aided Surg\u003c/em\u003e. 2008;13:157-166. https://doi.org/10.3109/10929080802102110\u003c/li\u003e\n\u003cli\u003eHolly LT, Foley KT. Intraoperative spinal navigation. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e. 2003;28:S54-61. https://doi.org/10.1097/01.Brs.0000076899.78522.D9\u003c/li\u003e\n\u003cli\u003eLaine T, Lund T, Ylikoski M, Lohikoski J, Schlenzka D. Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients. \u003cem\u003eEur Spine J\u003c/em\u003e. 2000;9:235-240. https://doi.org/10.1007/s005860000146\u003c/li\u003e\n\u003cli\u003eQui\u0026ntilde;ones-Hinojosa A, Robert Kolen E, Jun P, Rosenberg WS, Weinstein PR. Accuracy over space and time of computer-assisted fluoroscopic navigation in the lumbar spine in vivo. \u003cem\u003eJ Spinal Disord Tech\u003c/em\u003e. 2006;19:109-113. https://doi.org/10.1097/01.bsd.0000168513.68975.8a\u003c/li\u003e\n\u003cli\u003eRingstrom MJ, Sullivan HG, Fundell LJ, Nigogosyan MA. A new paradigm for staging pedicle screw-based spinal procedures: rationale, feasibility, safety, and efficacy. \u003cem\u003eJ Neurosurg Spine\u003c/em\u003e. 2007;7:521-532. https://doi.org/10.3171/spi-07/11/521\u003c/li\u003e\n\u003cli\u003eSmith HE, Welsch MD, Sasso RC, Vaccaro AR. Comparison of radiation exposure in lumbar pedicle screw placement with fluoroscopy vs computer-assisted image guidance with intraoperative three-dimensional imaging. \u003cem\u003eJ Spinal Cord Med\u003c/em\u003e. 2008;31:532-537. https://doi.org/10.1080/10790268.2008.11753648\u003c/li\u003e\n\u003cli\u003eVillavicencio AT, Burneikiene S, Bulsara KR, Thramann JJ. Utility of computerized isocentric fluoroscopy for minimally invasive spinal surgical techniques. \u003cem\u003eJ Spinal Disord Tech\u003c/em\u003e. 2005;18:369-375. https://doi.org/10.1097/01.bsd.0000168511.67189.64\u003c/li\u003e\n\u003cli\u003ePatel RD, Graziano GP, Vanderhave KL, Patel AA, Gerling MC. Facet violation with the placement of percutaneous pedicle screws. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e. 2011;36:E1749-1752. https://doi.org/10.1097/BRS.0b013e318221a800\u003c/li\u003e\n\u003cli\u003eHouten JK, Nasser R, Baxi N. Clinical assessment of percutaneous lumbar pedicle screw placement using theO-arm multidimensional surgical imaging system. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2012;70:990-995. https://doi.org/10.1227/NEU.0b013e318237a829\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Guidewire insertion times and fluoroscopy times in all patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"553\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003eCase no.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eSpinal level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003eNo. of guidewires\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003eTotal insertion time of the guidewire (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003eInsertion time per guidewire (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003eTotal number of fluoroscopies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e13.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL5-S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e16.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e4.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e14.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e3.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e18.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e4.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e16.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL3-L4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e11.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL5-S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e17.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e4.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e12.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e3.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e15.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e3.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL3-L4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e16.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e4.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e12.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e13.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e3.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL4-L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e14.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e3.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.083182640144667%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.211573236889693%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.200723327305607%\"\u003e\n \u003cp\u003eL5-S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.828209764918626%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.965641952983724%\"\u003e\n \u003cp\u003e16.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\"\u003e\n \u003cp\u003e4.11\u003c/p\u003e\n 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\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Body surface locator, Percutaneous pedicle screw, Skin entry point, Two-dimensional fluoroscopy","lastPublishedDoi":"10.21203/rs.3.rs-3839228/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3839228/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eThis study aimed to introduce an optimal skin entry point, determined via novel two-dimensional fluoroscopy-guided technology, with an intention to decrease screw placement and fluoroscopy times during the learning curve of percutaneous pedicle screw placement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eThe radiologic background and principles of the novel C-arm fluoroscopy technology, as well as the methodology for determining the appropriate skin entry point using a self-designed body surface locator are described, as well as an evaluation study of the technique in patients. In the study, a total of 120 percutaneous lumbar pedicle screws were placed from L-3 to S-1 in adult patients. Postoperative fine-cut CT scans were acquired to evaluate the pedicle screw placement. The K-wire placement time and fluoroscopy count were recorded by the operating room staff.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe presented technique has become the standard for percutaneous screw placement in the prone position in our department. Out of 120 guidewires and screws inserted in the evaluation study, there were no instances of new or worsening neurological symptoms or deficits, resulting in an overall clinical accuracy of 100%. The average implantation time for each guide wire was 3.64 minutes, and the average number of fluoroscopies per spinal level was 8.13.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003eThe findings of this study suggest that selecting the optimal skin entry point can enhance the performance of this technique. Specifically, it can ensure more accurate and safe percutaneous lumbar pedicle screw placement, reduce the procedure and fluoroscopy times, and is feasible based on our clinical experience.\u003c/p\u003e","manuscriptTitle":"Percutaneous Lumbar Pedicle Screw Placement Using the Ideal Skin Entry Point and Novel C-Arm Fluoroscopy Technology: A Technical Note","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-10 21:44:20","doi":"10.21203/rs.3.rs-3839228/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3c1d776f-6927-4798-8d57-23ccf307e0d7","owner":[],"postedDate":"January 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-02T11:08:09+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-10 21:44:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3839228","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3839228","identity":"rs-3839228","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}