Internal Fixation of the Spine Principles and Practice

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Foreword by Gending Dang

Principles and Practice of Spinal Internal Fixation Systems is a monograph focusing exclu-
sively on spinal internal fixation techniques. Though the content of the book is concise and
focused, its approach is systemic and comprehensive. The book is laudable in its making full
use of pictorial content and illustrative cases, making the reading and learning process intuitive
and visually appealing. The authors have spared no efforts and are innovative in bringing to
fruition a professional reference book that meets the needs of current clinical practice and has
great reference and practical value.
The value of any new technology lies in its applicability. The more widely and universally
applied a technology, the more it can play its role in promoting transformation and progress of
the real world. In this sense, the development, application, and widespread dissemination of
new technologies are equally important. At present, in the application of spinal internal fixa-
tion systems, orthopedic surgeons face the problem of how to optimize and rationally apply an
internal fixation system. Meanwhile, they also tackle the issue of how to fully understand,
master, and apply these new technologies so that these technologies are practiced in wider
areas in order to enhance the treatment of patients. Therefore, the publication of this book is of
practical significance.
A good book is like a handy tool dedicated to readers. I fully believe that readers will benefit
from reading Principles and Practice of Spinal Internal Fixation Systems and thereby improve
their skills in the use of spinal fixation systems.

Beijing, China  Gending Dang

v
Foreword by Yan Wang

I am greatly honored to have the opportunity to write the Foreword for Principles and Practice
of Spinal Internal Fixation Systems!
This monograph is a witness to as well as a natural outcome of the remarkable development
in spinal internal fixation techniques over the past two decades in China. It contains more than
seven hundred pages of useful and practical contents, over 1500 images, more than 30 illustra-
tive cases, and numerous caveats. The monograph is the culmination of the teamwork led by
Professor Wei Lei, which fully reflects the contemporary understanding and treatment concept
of spinal internal fixation techniques by spine surgeons. The authors not only unreservedly
detail the operative techniques of spinal internal fixation but also highlight potential pitfalls
during the operation. The book is full of illustrations, and intraoperative and radiological
images, and, especially through these exquisite images, the authors simplify our understanding
of complicated operative procedures by visualizing abstract concepts and by presenting both
two-dimensional and three-dimensional images to the readers. This is a landmark monograph
in the application of spinal internal fixation techniques.
The successful writing of this book is the result of Professor Wei Lei and his team’s long-­
term commitment to the study on the diagnosis and treatment of spinal diseases as well as their
research and development of new spinal internal fixation devices. For many years, they have
led clinical developments by clinically oriented innovations. They have focused on identifying,
analyzing, and solving problems in their clinical work and have been awarded numerous
national and international PCT invention patents. They have successfully applied expansive
pedicle screws and bone cement augmented pedicle screws in spinal internal fixation.
I am very pleased to see that the many years of clinical experience of Professor Wei Lei and
his clinical team are presented in the form of a book. This is a classic and practical textbook.
It is a must-have companion for the new generation of spine surgeons to improve their opera-
tive techniques.

Beijing, China  Yan Wang

vii
Acknowledgments

It has been my long-cherished wish to write a truly practical and somewhat artistic reference
book on the applications of spinal internal fixation systems. Today, with the launch of Principles
and Practice of Spinal Internal Fixation Systems, I am filled with joy and thankfulness, as the
book marks the culmination of my twenty years of clinical services as an orthopedic surgeon.
I am greatly indebted to several of my great teachers who have provided guidance and teaching
at critical junctures of my life and setting me on the right path.
I would like to express my thanks to my middle school teacher Mrs. Jingfeng LIN whose
patience, care, and emphasis on the importance of knowledge in career life have ever since
motivated me to lead a purpose-driven life. She has instilled in me the values of ideal, life goal,
endeavors, self-respect, kindness, and generosity. She has led me to the shiny path of pursuing
my ideals in life.
I am also forever indebted to my university instructor, Mr. Ruyi TANG, who taught me to
always think from a different perspective and think dialectically. He has shaped my rigorous
and open mindset. I fought under him during the border war and the war experience as an army
surgeon, which has taught me to be thankful for and respect life, has become part of my cher-
ished memory. Until this very day, he is still my mentor in the philosophy of life.
I am also grateful to my medical professor, Dr. Yupu LU, who personally went to see the
chancellor of the medical university to allow me to shadow him as an orthopedic surgeon. His
professionalism and truth-seeking attitude have deeply influenced me. His kind and straight-
forward personality has deeply attracted me. His strict requirements and meticulous care have
laid a solid foundation for me to develop good work and living habits and strive to be a good
doctor. He is the initiator of my medical career.
I would also like to express my thanks to my graduate tutor, Professor Yaotian HUANG,
who recommended me for directly doing doctoral studies. His scientific attitude of being hon-
est and seeking truth from facts has guided me to pursue scientific research and motivated me
to continue to develop and dare to transcend. He made me determined to become a research-­
oriented and innovative surgeon. He is the leader of my exploration of medical mysteries.
Finally, this book is dedicated to my teachers and friends who have encouraged and took
pride in each progress and achievement of mine. I will carry forward the excellent qualities and
profound knowledge of my teachers and pass them on to the students so that our common
cause keeps ever improving and moving forward!

ix
Introduction

The aims of this book are to familiarize young spine surgeons with the surgical anatomy of the
spine, train their three-dimensional thinking, and help them gain mastery of operative tech-
niques of the spine. Meanwhile, we aim at sharing our practical clinical experiences with the
readers and introduce the use of clinically effective spinal internal fixation devices.
The book consists of seventeen chapters, in the order of the cervical vertebrae, thoracic
vertebrae, and lumbar vertebrae. The book describes in detail the application of 16 major spi-
nal internal fixation systems in the treatment of spinal degeneration, trauma, and malforma-
tion. The book covers the clinical indications and contraindications of internal fixation systems,
surgical steps of each operative procedure, clinical vignettes, intraoperative considerations and
clinical pearls, and postoperative management.
The main features of this book are: (1) it is rich in information and contains both textual and
pictorial contents with a total of 1500 high-resolution images; (2) the book clearly delineates
the relationship between the implant and its surrounding important anatomical structures by
using a large number of high-quality sectional images of vertebral specimens along with three-­
dimensional images; 3) the book graphically describes commonly used spinal internal fixation
techniques; and 4) for each internal fixation system, clinical vignettes and intraoperative pit-
falls and clinical pearls are provided. All anatomical images and radiological images in the
book were completed by the authors, and all cases in the book were provided by the authors.
The authors would like to thank Jing CONG, Xin ZHANG, Rui HU, Jianxiong ZHU,
Ruohui ZHAO, Ran SHENG, Xiaoliang HU, Mei GUO, Wei LU, Ye LU, and Shining LI for
their assistance and support in the writing of this book. We are particularly grateful to radiodi-
agnostic experts Professors Jing REN and Yi YI, especially Professor YI. Most of the three-­
dimensional reconstructed CT images in the book have been the hard and gifted work of
Professor YI, which contribute enormously to the appeal of this book.

xi
Contents

1 Technique and Application of Atlas Internal Fixation���������������������������������������������   1

Yi Cui and Wei Lei
2 C2 Internal Fixation Techniques and Their Applications��������������������������������������� 15
Junxiong Ma, Liangbi Xiang, and Wei Lei
3 Lateral Mass Screw Fixation Techniques for the Lower Cervical Spine��������������� 29
Lei Shi, Yabo Yan, and Wei Lei
4 Surgical Techniques for Pedicle Screw Fixation of the Cervical Spine
and Their Applications����������������������������������������������������������������������������������������������� 39
Hailong Yu, Yi Huan, and Wei Lei
5 Anterior Cervical Plate Techniques and Their Applications ��������������������������������� 57
Tianqing Li, Yabo Yan, and Wei Lei
6 Artificial Cervical Disc Techniques and Their Applications����������������������������������� 83
Mingxuan Gao and Wei Lei
7 The CENTERPIECE™ Posterior Cervical Laminoplasty
and Internal Fixation System������������������������������������������������������������������������������������� 105
Yang Zhang and Wei Lei
8 Surgical Techniques for Pedicle Screw Fixation of the Thoracic Spine����������������� 137
Xiong Zhao, Yi Huan, and Wei Lei
9 Lumbar Pedicle Screw Fixation Techniques and Their Applications ������������������� 153
Xinxin Wen, Yabo Yan, and Wei Lei
10 Surgical Techniques for Iliac Screws������������������������������������������������������������������������� 207
Yabo Yan, Yi Huan, and Wei Lei
11 Surgical Techniques for Sacral Pedicle Screws ������������������������������������������������������� 215
Wei Qi, Yabo Yan, and Wei Lei
12 Surgical Techniques for Thoracolumbar Anterior Internal Fixation ������������������� 225
Pengchong Cao, Yabo Yan, and Wei Lei
13 Spine Minimally Invasive Internal Fixation Techniques
and Their Applications����������������������������������������������������������������������������������������������� 241
Zixiang Wu and Wei Lei
14 Thoracolumbar Percutaneous Vertebroplasty (PVP) and Percutaneous
Kyphoplasty (PKP)����������������������������������������������������������������������������������������������������� 303
Jiang-Jun Zhou, Min Zhao, and Wei Lei
15 Internal Fixation Technique and Application in the Osteoporotic Spine��������������� 319
YaFei Feng and Wei Lei

xiii
xiv Contents

16 Anterior Odontoid Screw Techniques and Application������������������������������������������� 337

Junxiong Ma, Liangbi Xiang, and Wei Lei
17 The Interbody Fusion System ����������������������������������������������������������������������������������� 345
Yabo Yan and Wei Lei
 Technique and Application of Atlas
Internal Fixation 1
Yi Cui and Wei Lei

Abstract

The developmental history of the internal fixation screw

and the different methods of atlantoaxial fixation were
briefly introduced in this chapter. Furthermore, the anat-
omy of the atlas and the corresponding measurement
parameters were introduced. The different screw entry
points and surgical techniques of C1 lateral mass screws
were introduced in detail, and the VERTEX internal fixa-
tions were introduced in two cases. Finally, the precau-
tions in the process of C1 lateral mass screw placement
are summarized.

Keywords
Fig. 1.1 Gallie technique for atlantoaxial fusion
Atlas · Atlas internal fixation · C1 lateral mass screw ·
Screw entry points · Atlantoaxial fusion

1.1  tlas Internal Fixation: A Historical

A
Perspective

Atlas fixation technique was developed to meet the needs of

reconstruction of atlantoaxial stability. It has undergone the
development of the wire technique, the laminoplasty tech-
nique, and the lateral mass technique. Milestones in the
development of atlas fixation techniques include Gallie tech-
nique [1] (Fig. 1.1); Brooks-Jenkins technique [2] (Fig. 1.2);
Dickman method [3], also called Sonntag technique
(Fig. 1.3); Halifax technique [4] (Fig. 1.4); Jeanneret and
Magerl technique [5] (Fig. 1.5); Goel technique by Goel and
Laher [6] (Fig. 1.6); Harms and Melcher technique [7] Fig. 1.2 Brooks-Jenkins technique for atlantoaxial fusion
(Fig. 1.7); and Tan’s technique [8] (Fig. 1.8).

Y. Cui
920th Hospital of Joint Logistics Support Force of PLA,
Kunming, China
W. Lei (*)
Department of Orthopedics, Xijing Hospital, Air Force Medical
University, Xi’an, Shaanxi, China
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 1
W. Lei, Y. Yan (eds.), Internal Fixation of the Spine, https://doi.org/10.1007/978-981-16-1562-7_1
2 Y. Cui and W. Lei

Fig. 1.3 Sonntag technique for atlantoaxial fusion

Fig. 1.4 Halifax technique for atlantoaxial fusion

Fig. 1.5 Magerl’s transarticular screw technique for atlantoaxial fusion. (Left) Posterior view. (Right) Lateral view
1 Technique and Application of Atlas Internal Fixation 3

1.2 Atlas Anatomy 1. Measurement of the transverse section (Fig. 1.9)

2. The anterior view of C1 (Fig. 1.10)
The atlas consists of an anterior and posterior arch con- 3. The posterior view of C1 (Fig.1.11)
nected by two lateral articular masses, forming a ring that 4. The lateral view of C1 (Fig. 1.12)
pivots about the odontoid process. It lacks a vertebral 5. The sectional view of screw entry site in the lateral mass
body.
Screw entry site via the posterior arch lateral mass
(Figs. 1.13, 1.14, and 1.15):

Fig. 1.6 Goel technique for atlantoaxial fusion

a b c

Fig. 1.7 Harms and Melcher technique for atlantoaxial fusion. (a) Posterior view of the upper cervical spine showing the location of the entry
points in C1 and C2. (b) Lateral view. (c) Posterior view

a b

Fig. 1.8 Tan’s technique for atlantoaxial fusion. (a) Axial view; (b) Lateral view
4 Y. Cui and W. Lei

Fig. 1.9 The superior view

of the atlas. The axial image Height of the
Idea screw
shows the screw entry site on anterior ring
path
the lateral mass and direction
of screw entry (forming a
5°–10°angle with the sagittal The transverse
plane) diameter of the
vertebral body

The anteroposterior
diameter of the lateral mass
at the entry point superior
to the posterior ring

Height of the
The anteroposterior
posterior ring
diameter of the
vertebral body

The anteroposterior
Anterior Height of the diameter of the lateral mass
height of the lateral mass at the screw site superior to
atlas (lateral) the posterior ring

Idea entry path

Height of the
lateral mass
(medial) The anteroposterior
diameter of the lateral mass
at the screw site inferiror to
Fig. 1.10 The anterior view of the atlas. The height of the lateral mass the posterior ring
in the medial border is 8.81 ± 1.46 mm; the height of the lateral mass in
the lateral border is 18.01 ± 2.33 mm [9]
Fig. 1.12 The lateral view of the atlas. The ideal entry path can be seen
in the lateral view (at a caudocephalad angle of 10–15°). Note that the
entry site is located at the junction of the posterior ring and the lateral
mass

Height of pedicle

Height of the Height of pedicle

lateral mass and the lateral
inferior to the mass inferior to
pedicle the pedicle

Fig. 1.11 The posterior view of the atlas. The vertebral artery courses
through the groove and overlaps with the posterior arch of the atlas in
the posterior view. The pedicle height is 4.80 ± 0.93 mm; the pedicle
width is 9.82 ± 1.48 mm [9]

Fig. 1.13 Dimensions of the lateral mass of the atlas. (a) The distance
between the entry site and the anterior edge of the lateral mass is
28.01 ± 1.35 mm in the right and 27.98 ± 1.24 in the left; (b) The dis-
tance between the entry site and the middle line is 13.82 ± 1.05 mm in
the right and 13.81 ± 1.06 mm in the left; (c) The width of the lateral
mass is 8.27 ± 1.63 mm in the right and 8.24 ± 1.62 mm in the left
1 Technique and Application of Atlas Internal Fixation 5

Section 1

Section 2

Section 1 Section 2

Fig. 1.14 Dimensions of the lateral mass of the atlas. (d) The height of the lateral mass is 10.24 ± 0.80 mm in the right and 10.22 ± 0.80 mm in
the left

Section 3

Section 3

Fig. 1.15 Dimensions of the pedicle of the atlas. (e) The pedicle height is 4.62 ± 1.06 mm in the right and 4.56 ± 1.12 mm in the left; (f) The
pedicle width is 9.63 ± 1.51 mm in the right and 9.69 ± 1.36 mm in the left

1.3  ey Points of Atlas Lateral Mass Screw

K There are two entry methods (methods A and B) for screw
Technique placement in the atlas (Figs. 1.16, 1.17, and 1.18).
Method A is a clinically commonly used fixation tech-
1.3.1  etermining Screw Entry Points
D nique for screw entry into C1 lateral mass via the posterior
in the Lateral Mass of the Atlas arch and the isthmus.
In method B, the screw is directly inserted along the lon-
Anatomically, the atlas is peculiar as it has neither a vertebral gitudinal axis of the lateral mass of the atlas at the transition
body nor a vertebral lamina. Therefore, the vertebral pedicle zone between the inferior border of the posterior arch and the
does not exist anatomically. posterior border of the lateral mass of the atlas. Because the
6 Y. Cui and W. Lei

Fig. 1.16 Two methods of

screw entry
Method A
Method B

Fig. 1.17 Comparison of two

screw entry sites Method A
Method B

Fig. 1.18 An illustrative case

with free dens showing the
pedicle section

OS odontoideum

Section of
the entry point

vertebral vein and C2 nerve roots run across the entry path, 1.3.2 Entry Angle for a C1 Lateral Mass Screw
nerves and blood vessels may be inadvertently injured intra-
operatively, leading to profuse bleeding; however, hemosta- 6. Method A: The entry angle for a lateral mass screw via
sis is difficult to achieve (Table 1.1). the posterior arch of the atlas (Fig. 1.19)
1 Technique and Application of Atlas Internal Fixation 7

Table 1.1 Comparison of methods A and B 1.3.3 Depth of C1 Lateral Mass Screws
A B
Via the posterior Yes No 1. The screw is inserted for an approximate depth of 25 mm
arch of the atlas into the lateral mass of the atlas.
Exposure of the No Yes 2. Diameter of C1 lateral mass screws: The diameter of the
atlantoaxial venous
plexus most commonly used lateral mass screws is 3.5 mm.
Volume of blood Smaller Larger 3. The length of screw inside the bone in method A is longer
loss than that of method B.
Possibility of Higher Lower
vertebral artery
injury
Screw length Longer Shorter
1.4 Surgical Steps (Method A)
Level of difficulty Greater difficulty in Greater difficulty in
preparation of screw exposure of screw 1. A mill is used to disrupt the cortical bone at the screw
entry path entry points entry point (Fig.1.21).
2. A screw hole is drilled using a drill bit (Fig. 1.22).
3. Drill depth is increased using a 3.5-mm drill bit with drill
guide (Fig. 1.23).

About 90º

Fig. 1.19 Screw entry angle

Fig. 1.21 A mill is used to disrupt the cortical bone

Converge
Converge
Conver ge
about
about 15°
15° About 90
About 90°°

Method
Method B Method
Met hod A

Fig. 1.20 Screw entry angle

7. Method B: The entry angle for a screw with direct entry

into the lateral mass (Fig. 1.20)

The screw is situated in the lateral mass of the atlas, at a

distance of 3–4 mm from the superior facet of C1 with a
medial inclination of 15°. Fig. 1.22 A screw hole is drilled using a drill bit
8 Y. Cui and W. Lei

Fig. 1.23 Increasing the drill depth

Fig. 1.25 Tapping the screw path

Fig. 1.24 Probing the screw path

4. The screw path is then probed (Fig. 1.24).

5. The screw path is tapped (Fig. 1.25).
6. The screw is implanted (Figs. 1.26 and 1.27).
7. Section at the screw path of a C1 lateral mass screw
(Figs. 1.28, 1.29, and 1.30). Fig. 1.26 The screw is implanted

Posterior arch of the atlas/section of screw entry site

1.5 I maging Features of Standard Pedicle

Screws of the Atlas (Figs. 1.31, 1.32,
1.33, 1.34, and 1.35)

Case 1
Patient: A 54-year old female complained of traumatic neck
pain with limited mobility for 25 days.
Diagnosis: C2 odontoid fracture (Fig. 1.36).
Surgery: VERTEX internal fixation with bone graft and
fusion (Figs. 1.37 and 1.38).
Fig. 1.27 The contralateral screw is implanted
1 Technique and Application of Atlas Internal Fixation 9

Case 2
Patient: A 40-year-old female complained of cervico-­
occipital pain for 5 years
Diagnosis: Congenital odontoid malformation and C1–
C2 dislocation (Fig. 1.39).
Surgery: C1–C3 open reduction via the posterior,
VERTEX internal fixation, iliac crest bone graft and fusion
(Figs. 1.40 and 1.41).
Caution: Simple instability of C1–C2 only requires stabi-
lization by reduction. When atlantoaxial or foramen mag-
num decompression is not required, C1 and C2 segments
should be chosen for stabilization. In this patient, C3 was
stabilized (Fig. 1.41), which is beyond the aforementioned
segments to be stabilized. In addition, stabilization should
not be extended to the occipital bone.

Fig. 1.28 Lateral view of the screw path

Fig. 1.29 Sectional view of

the screw path

Posterior arch of the atlas

section of screw entry site

Fig. 1.30 Sectional view of

the screw path in the lateral
mass Section at the lateral mass
and mid transverse foramen
10 Y. Cui and W. Lei

Fig. 1.33 The anterior view of atlantoaxial fixation

Fig. 1.31 Lateral view of atlantoaxial fixation

Fig. 1.34 The posterior view of atlantoaxial fixation

Fig. 1.32 The superior view of C1 lateral mass screw

Fig. 1.35 The coronal section view of Atlantoaxial fixation

1.6 Pearls and Pitfalls prepared with caution, and use of a tap is recommended
to prevent rupture of the screw path.
1. Caution should be exercised when a C1 lateral mass screw 3. Lateral to the posterior arch of the atlas runs the vertebral
is inserted. The lateral mass of the atlas is approximately artery, and inferior to the posterior arch travels the venous
27 mm in length, 8 mm in width, and 10 mm in height, plexus and inside is the cervical spinal cord. A surgeon
and anatomical studies have demonstrated that a screw of should be familiar with regional anatomy and avoid injury
3.5 mm in diameter is safe. to the nerve roots and vessels during operation.
2. The posterior arch and lateral mass of the atlas have scant
cancellous bone and are solid. The screw path should be