The goal of PPSI is to decrease the trauma associated with the standard open approach, which can lead to significant devascularization and denervatation of the paraspinal musculature. This tissue trauma may be a contributing factor to patients’ chronic pain after surgery

1. “Percutaneous Pedicle Screw Fixation For
Thoracolumbar injuries using a low cost implant”
Mohd Ansarul Haq Lone
MBBS, MS Orthopaedics
Senior Resident Bone
and Joint Hospital
Barzulla Srinagar .

2. Surgical treatment of thoracic and lumbar fractures
has demonstrated better clinical and radiological
results than conservative treatment. It allows for
immediate stabilization of the spine, restoration of
sagittal alignment, and the possibility of spinal canal
decompression.

3. Conventional open spine surgery has several reported
limitations including extensive blood loss,
postoperative muscle pain and infection risk. The
paraspinal muscle dissection involved in open spine
surgery can cause muscular denervation, increased
intramuscular pressure, ischaemia, necrosis and
revascularization injury resulting in muscle atrophy
and scarring, often associated with prolonged
postoperative pain and disability

4. Pedicle procedure for thoracolumbar fractures was first
introduced by Roy-Camille in 1963. Use of pedicle
screws with conventional open surgery had been a
recognized method for treatment of non-stable
vertebral fractures.
Magerl introduced pedicle screw procedure with
percutaneous method in 1977. Percutaneous pedicle
screw has been increasingly used within last two
decades

5. There is a trend towards MIS of the spine due to lower
complication rates and approach-related morbidity,
with minimal soft tissue trauma, reduced intra-
operative blood loss/risk of transfusion, improved
cosmesis, decreased postoperative pain and narcotic
usage, shorter hospital stays with faster return to work
and thus reduced overall health care costs.
Mobbs, Ralph J., Praveenan Sivabalan, and Jane Li. "Technique, challenges and indications for percutaneous
pedicle screw fixation." Journal of Clinical Neuroscience 18.6 (2011): 741-749.

6. The goal of PPSI is to decrease the trauma associated with
the standard open approach, which can lead to significant
devascularization and denervatation of the paraspinal
musculature. This tissue trauma may be a contributing
factor to patients’ chronic pain after surgery
1.. Kawaguchi Y, Matsui H, Tsuji H: Back muscle injury after posterior lumbar spine surgery. Part 1: histologic
and histochemical analyses in rats. Spine (Phila Pa 1976) 19:2590–2597, 1994
2. Kawaguchi Y, Matsui H, Tsuji H: Back muscle injury after posterior lumbar spine surgery. Part 2: histologic
and histochemical analyses in humans. Spine (Phila Pa 1976) 19:2598–2602, 1994.
3. Rantanen J, Hurme M, Falck B, Alaranta H, Nykvist F, Lehto M, et al: The lumbar multifidus muscle five
years after surgery for a lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 18:568–574, 1993

7. In a cadaveric study, PPSI was shown to spare the motor
nerve to the multifidus muscle 80% of the time whereas
standard approaches were shown to require transection of
the nerve 84% of the time.
“Regev GJ, Lee YP, Taylor WR, Garfin SR, Kim CW: Nerve injury to the posterior rami medial branch during
the insertion of pedicle screws: comparison of mini-open versus percutaneous pedicle screw insertion
techniques. Spine (Phila Pa 1976) 34:1239–1242, 2009”

8. In a MRI-based study, Kim et al. highlighted reduced
muscle atrophy associated with the use of PPSI compared
with a standard open approach.
“Kim DY, Lee SH, Chung SK, Lee HY: Comparison of multifidus muscle atrophy and trunk extension muscle
strength: percutaneous versus open pedicle screw fixation. Spine (Phila Pa 1976) 30:123–129, 2005”

9. Studies supporting percutaneous pedicle screw
instrumentation.

10. “Wild MH, Glees M, Plieschnegger C, Wenda K: Five-year follow-up examination after purely minimally invasive
posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and
conventionally open treated patients. Arch Orthop Trauma Surg 127:335–343, 2007”
In a study of 21 patients with thoracolumbar compression
injuries (Type A3 according to /AO classification) without
neurological deficits, Wild et al. compared factors in those
treated PPSI or standard open pedicle instrumentation.
The PPSI-treated patients had significantly less
intraoperative blood loss and less operative time was. There
was no difference in radiographic or clinical outcomes 5
years after implant removal.

11. “Wang H, Li C, Zhou Y, Zhang Z, Wang J, Chu T: Percutaneous pedicle screw fixation through the pedicle of fractured
vertebra in the treatment of type A thoracolumbar fractures using Sextant system: an analysis of 38 cases. Chin J Traumatol
13:137–145, 2010”
Wang et al. reported on 38 patients with similar
injuries for whom the average follow-up was 11.6
months. They found significant decreases in blood
loss, operative time, hospital stay, blood
transfusions, proportion of analgesic supplement,
and postoperative incisional visual analog scale
(VAS) pain score between the 2 groups, in favor of
PPSI.

12. “Vanek P, Bradac O, Konopkova R, de Lacy P, Lacman J, Benes V: Treatment of thoracolumbar trauma by short-segment percutaneous
transpedicular screw instrumentation: prospective comparative study with a minimum 2-year follow-up. Clinical article. J Neurosurg
Spine 20:150–156, 2014
Vanek et al. recently published a prospective study
comparing outcomes after PPSI compared with
standard open surgery in 35 patients with
thoracolumbar burst fractures (Type A3 of
Magerl/AO classification).Those patients treated
with PPSI had significantly shorter operative
times, less blood loss, and less postoperative pain.
Radiographic and clinical outcomes at 2-year
follow-up were not significantly different between
the 2 groups.

13. Operative time was significantly shorter in percutaneous fixation group than
open fixation group.
Merom et al. (2009) reported that with short-segment
fixation, the operative time for percutaneous fixation
(73 to 85 minutes) was slightly less than for open
fixation (78 to 102 minutes).
Elsawaf et al. (2016) reported mean operative time of 115
minutes (range 60–220 minutes) for percutaneous
group vs 189 minutes (range 110–310 minutes) for the
open group.

14. Total amount of perioperative blood loss was significantly lower in percutaneous fixation
group than open fixation group.
Wild et al. (2007) reported statistically lower blood loss
in trauma cases after internal fixation was implanted
percutaneously than when implanted during an open
procedure.
Merom et al. (2009) reported an average blood loss of
50 mL less in the percutaneous group than in the open
group (range 200 to 500 mL).

15. Regarding the post-operative imaging evaluation
Above studies have found insignificant difference
between both groups as regard accuracy of screw
insertion where 85% of percutaneous fixation group
had no pedicle violation versus 90% in open fixation
group.

16. Complications of PPSI
Wiesner et al. (2000) reported that in a series of
408 screws implanted percutaneously, 6.6% (27
screws) had pedicle wall violations, with two cases
needing an open revision procedure because of
neurological problems. They observed that many
of these misplaced screws (11 of 27) occurred in the
sacrum

17. Complications of PPSI
“Pelegri et al. (2008) reported a 3.8% rate of
misplacement out of 50 screws; in one case, an
open revision had to be performed because of
neurological problems”.
“Ni et al. (2010) found that 6.7% of 104 screws
implanted were misplaced, but there were no
neurological complications”.

18. Complications of PPSI
Elsawaf et al. (2016) reported that: In the percutaneous group,
392 screws were inserted in the seventy two patients of that
group; 325 screws (83%) were classified as satisfactory, 67
screw as accepted and no screw was classified as non-
accepted regarding their classification. In the open group,
however, 658 screws were inserted in the ninety-four
patients of that group; 490 screws were satisfactory (75%),
154 screws were acceptable and 14 screws were classified as
non-accepted and showed violation of the pedicle cortex
more than 3 mm, but only 6 of them needed revision
surgery.

19. Complications of PPSI
Facet joint violation is seen in both groups but more
with the percutaneous group.

20. The main issue however is cost

21. The cost for percutaneous pedicle screw
instrumentation using cannulated system
ranges from 40 to 70 thousand Indian
rupees in the market.
Most of our patients are poor. Thy will not
Opt for this.

22. We have done PPSI using conventional non-cannulated
pedicle screw using home made tissue dilator

23. Percutaneous Pedicle screw fixation for
thoracolumbar injuries using low cost
non- cannulated implant in
underdeveloped Kashmir valley

24. Is it possible
?

25. 30 yrs old patient with burst fracture L1

29. 40 yrs old patient with Burst fracture L2