Review Article

Percutaneous Pedicle Screw

Stabilization: Surgical Technique,
Fracture Reduction, and Review of
Current Spine Trauma Applications

Dirk H. Alander, MD
Shari Cui, MD
From the Department of Orthopaedic
Surgery, Geisinger Medical Center,
Danville, PA (Dr. Alander), and the
Abstract
Percutaneous pedicle screw fixation has evolved as a useful tool in the
management of spinal trauma. As a minimally invasive approach, it
provides the stability of open instrumentation while limiting blood loss,
avoiding excessive muscle/soft-tissue insult, and improving
postoperative pain and mobilization. Muscle-dilating techniques also
preserve greater paraspinal muscle volume and strength compared
with open midline approaches. In patients with spinal trauma, the use
of percutaneous instrumentation and indirect reduction can
theoretically preserve the fracture hematoma and its osteogenic
inflammatory factors. The evolution of spinal instrumentation and the
refinement of indirect reduction techniques has improved the capacity
for correction of traumatic deformity. Although perioperative and short-
term results have been well described, few long-term outcomes data
exist.

Department of Orthopaedic Surgery,
West Virginia University Health
Sciences Center, Morgantown, WV
(Dr. Cui).
Dr. Alander or an immediate family
member serves as a paid consultant
to Corelink Surgical, Saint Louis
University Practical Anatomy and
Surgical Education, and Ulrich
Medical; has stock or stock options
held in Pfizer; and serves as a board
member, owner, officer, or committee
member of the American Spinal Injury
Association, the Board of Specialty
Societies, and the Cervical Spine
Research Society. Neither Dr. Cui nor
any immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2018;0:1-10
DOI: 10.5435/JAAOS-D-15-00638
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
P
edicle screws stabilize the spine by
obtaining purchase in all three col-
umns.1,2 Initially described by Magerl3
as a spinal external fixator, percuta-
neous pedicle screw instrumentation
(PPSI) has evolved as a minimally
invasive method of posterior stabili-
zation. Advances in instrumentation
have improved the surgeon’s ability
to apply percutaneous stabilization
techniques in patients with increas-
ingly complex scenarios of high-energy
spine fractures, multilevel spine in-
juries, and pathologic fractures.
The goals of PPSI are similar to
those of conventional open posterior
instrumentation, with the exception
of fusion. The advantages of percu-
taneous screw and subfascial rod
placement are reductions in tissue
disruption, blood loss, and surgical
time.4-8 In addition, PPSI preserves
soft-tissue connections, vascularity,
and fracture hematoma, which limits
interruption of the osteogenic in-
flammatory factors and the healing
cascade. Extrapolating from the
benefits of biologic (minimal access)
fixation in patients with orthopaedic
trauma, we can theorize that PPSI
may similarly maximize the physio-
logic capacity of the body to heal
while imparting temporary mechan-
ical stability.9 The use of biologic
indirect reduction as an initial step to
promote remodeling in the manage-
ment of spine fracture has also been
described.10
Technique
Room Setup
The proper room setup for PPSI
is essential to allow for precise repro-
ducible fluoroscopic imaging and a

Month 2018, Vol 0, No 0 1

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Percutaneous Pedicle Screw Stabilization

Figure 1 the depth of the soft tissues increases,

the starting point of the incision
should be moved laterally to tri-
angulate the long axis of the pedicle.

A, Preoperative fluoroscopic image with a rotated projection of the vertebral
segment demonstrating obscured end plates, which can result in misplacement
of guidewires and instrumentation, putting neural elements at risk. B, A centered
AP fluoroscopic projection with the spinous process bisecting the pedicles and a
leveled superior end plate, which is ideal for fluoroscopic guidance of
percutaneous instrumentation.
fluid workflow. Placing the long axis
of the surgical table parallel to the
operating room walls and slightly
offset to the center of the room pro-
vides visual cues for quick reference
and allows extra space for the fluo-
roscopic machine and monitor.
Open table frames, such as a Jackson
frame, are preferred to allow easy
access of the fluoroscopy equipment.
Tubes, wires, and monitoring cables
are secured to the edges of the frame,
keeping the underside of the table void
of obstructions to C-arm movement.
The C-arm is situated contralateral to
the surgeon and perpendicular to the
prone patient, with the monitor easily
visible at the head or foot of the bed.
“Parking” the C-arm cephalad or cau-
dad to the surgical field, rather
than having the technician pull the
machine completely away from the
table, improves efficiency by mini-
mizing the amount of manipulation
required to realign the C-arm and
replicate a desired image. Fluoros-
copy units with smaller image in-
tensifiers are less obstructive to
surgical instruments.
Patient Positioning and
Preoperative Imaging
Prior to sterile skin preparation,
fluoroscopic images are obtained to
aid in patient positioning and frac-
ture reduction. Bolsters are adjusted
in a way that reduces fracture dis-
placement and alignment. To obtain
a perfect AP view (with the spinous
processes perfectly bisecting the ped-
icles), some operating tables have the
ability to roll along the long axis of
the body to facilitate a true AP view of
the vertebral body. Alternatively, the
patient can be rotated or bumped into
the desired position to obtain the
desired view (Figure 1). Positioning
should be done with the C-arm
perpendicular to the longitudinal
axis of the table and perpendicular
to the floor, in a neutral position.
This neutral position, at the outset,
helps establish a reference point
from which the only intraoperative
movements required of the radiol-
ogy technician should be cephalad-
caudad translation and C-arm tilt
(not arc motion) to obtain the perfect
superior end plate projection at each
level.
Fluoroscopy is used to identify and
confirm the injured segment and the
segments to be instrumented, assess
indirect reduction, and identify the
angular tilt for optimal vertebral
body projection. Bilateral skin inci-
sions measuring 1.5 to 2 cm are
marked at each level to correlate with
the lateral margins of each pedicle. As
Incision
Individual vertical skin incisions are
made and extended down to the fas-
cia. The fascial incision should be
slightly larger than the screw head
(enough to allow the index finger to
easily pass skin and fascia). Inade-
quate fascial releases can catch the
screw heads during insertion, result-
ing in a bouncing sensation because
the muscle dilators are unable to seat
onto bone. Tethering the fascial layer
under the screw head can result in
pedicle stripping.
Guidewire and Screw
Placement
A bone biopsy trocar (with stylet) is
inserted through the skin and fascial
incisions onto bone. We prefer to use
an 11-gauge bone biopsy trocar with
a 25° single-face bevel. The single
bevel of the trocar can be used to
capture the cortex and helps direct
the trajectory into and through the
pedicle. The tip of the trocar is
placed so that it is centered on the
lateral margin of the pedicle on PA
fluoroscopy. Orienting the tip more
perpendicular to the cortical surface
aids in initial penetration of the
cortex. The trocar is advanced under
AP fluoroscopic guidance through
the pedicle. Care must be taken to
avoid passing more than two thirds
of the distance across the pedicle on
the AP view to minimize the risk of
encroaching on the medial pedicle
wall. Ideally, the trocar tip should be
at, or just past, the posterior verte-
bral wall on the lateral fluoroscopic
view while staying in the lateral two
thirds of the pedicle on the AP view.
The stylet is removed, and a guide-
wire is passed through the trocar and
advanced into the anterior third of
the vertebral body under lateral

2 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

fluoroscopy. The trocar is removed
with care to keep the guidewire in
place.
These steps are repeated until
guidewires are placed for each level to
be instrumented. The fascia can be
reincised along the guidewires to
improve instrument access. The can-
nulated tools should be kept collinear
with the guidewire during insertion
to prevent binding of the guidewire
and thereby prevent unwanted wire
advancement, removal, or breakage.
After the pedicle and soft tissues have
been adequately prepared, the pedicle
screw is inserted over the guidewire.
The guidewire should be carefully
monitored to ensure that it is not
advanced beyond the anterior margin
of the vertebral body.
Failure of screw advancement can
result from entrapment of tissue
beneath the screw head or from inad-
equate preparation of the screw tun-
nel. Tissue entrapment can be avoided
by widening the fascial/muscle inci-
sions along the guidewires to allow
passage of the screw heads. Cannu-
lated pedicle screws have shallower
threads than standard screws have,
which decreases the screw pull-out
force. If pedicle stripping occurs, the
surgeon can re-tap with larger bone
taps and use salvage screws with a
larger thread diameter. In the thoracic
spine, transverse processes can block
screw advancement on the lateral side
of the pedicle. Entering the pedicle
slightly more medially and using a
more vertical screw trajectory can
help avoid this impingement. Hard,
dense bone or arthritic facet joints can
also impede screw placement. In these
situations, the use of excessive force to
start the pedicle screw should be
avoided. Serial tapping and the use of
a small mallet to tap the inserter while
rotating the screw will more safely
capture the bone and maintain control
during insertion.
Another pitfall is noncollinear
placement of screws and instruments
in relation to the guidewire. Failure to
Month 2018, Vol 0, No 0
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
follow and not distort the guidewire
during insertion can result in binding,
inadvertent advancement, or pre-
mature removal of the wire. Toggling
the long lever arm created by the
screw extenders and pedicle screws
can loosen or redirect the screw out of
the vertebral body, regardless of ini-
tial guidewire placement.
Subfascial Rod Insertion
Rods are inserted either through a
slightly enlarged incision or via a
separate incision cephalad to the
proximal, or caudad to the distal,
end screw extender. The rod is first
passed in a more vertical manner to
the top of the screw head to pass
under the fascia and then threaded
subfascially into the remaining
screw heads. Rod seating within
every screw head should be con-
firmed with fluoroscopy before set
screws are placed.
Several factors can hinder rod
placement: muscle and fascia inter-
posed between the rod and the screw
head, bone obstruction in the path of
the rod, uneven screw head height or
alignment, and poor rod contouring.
Care must be taken to pass the rod
under the muscle fascia and keep the
height of the screw heads consistent
between adjacent segments. Deep-
seated screws may be stripped from
the pedicle when the rod is reduced
into the screw head. Another obstacle
can be the adjacent facet joint. In these
situations, backing out the screw one
to two turns will usually allow the rod
to seat. Either the screw height or the
rod contouring, or both, can be
adjusted to facilitate rod placement.
The use of excessive rod contouring as
the sole method of fracture reduction
can result in screw stripping because
the force of reduction overwhelms the
shallow purchase power of the can-
nulated screws. The surgeon can con-
sider dissipating the reduction forces
encountered by each screw by simul-
taneously and incrementally securing
Dirk H. Alander, MD, and Shari Cui, MD
several segments onto the rod using
multiple rod reducers. At the tho-
racolumbar junction, the combination
of regional kyphosis and lordosis can
result in difficulty passing a longer rod
through each screw head. The rod can
be gently rotated up to 180° to direct
its trajectory to the next screw
extender. Tactile feedback from
holding the target screw extender also
helps facilitate rod passage. In longer
constructs, the surgeon can consider
undercontouring the rod and bending
it in situ after the set screws are
placed.
Set screws and nuts are placed in a
sequential fashion starting with the
nut farthest from the rod holder, just
deep enough to engage the threads
while still allowing the rod to rotate
and slide to facilitate placement of the
remaining set screws and nuts. Final
torque locking of the nuts should be
done sequentially either from end to
end or from inside out, depending on
the need for compression or distrac-
tion between any levels. Toggling
should be avoided during torque
tightening to prevent pedicle strip-
ping or blowout of the lateral verte-
bral body wall.
Prior to removal of the screw
extenders, AP and lateral views of the
entire construct should be obtained to
assess the final construct. After the
extenders and rod holders are
removed, additional adjustments will
require additional steps to remove the
rod, cannulate the screw with a guide-
wire, and remove the pedicle screw if
needed. Screws can be revised by re-
directing the guidewire, retapping the
pedicle, and placing a new screw on a
screw extender. After final fluoroscopy
is done, closure is completed with small
radius needles for fascial repair, fol-
lowed by routine skin sutures.
Fracture Reduction
In polytrauma spine patients requir-
ing multidisciplinary procedures and
3
Percutaneous Pedicle Screw Stabilization

Figure 2 management of spine fractures, manipulation of the fractured level.

Computer model depicting
placement of monoaxial pedicle
screws (blue) bilaterally at the level
of the injury for the management of
compression and burst fractures.
Monoaxial screws with contralateral
polyaxial screws (green) are placed
at the superjacent and subjacent
levels in a mirror configuration as
shown.
care, early stabilization with PPSI can
stabilize and prevent secondary injury
to the spinal column and cord during
transport and positioning for other
surgeries. PPSI has been applied in the
including flexion-distraction (Chance)
injuries, burst fractures, and extension
fractures in the ankylosed spine. The
types of screws and screw/head inter-
faces (polyaxial, uniplanar, or fixed-
angle screw heads) can be tailored to
reduce and stabilize each fracture type
(Figure 2). When the injury morphol-
ogy allows, placing screws at the
fractured level maximizes fracture
reduction; this method requires intact
pedicles. Reduction occurs in three
phases: indirect reduction through
patient positioning, direct manipula-
tion of the fractured end plate by
forces applied through the screw and
screw extenders, and indirect reduc-
tion through ligamentotaxis via dis-
traction between levels.
Polyaxial screw heads are easier to
use for longer segment instrumenta-
tions because the screw heads have
varying degrees of range of motion in
multiple planes that can facilitate rod
passage. However, they lack the
angular rigidity to be used for direct
Therefore, they are best used when end
plate reduction is not required, or at
uninjured adjacent levels. When pos-
terior compression is desired for the
management of flexion-distraction
Chance fractures, polyaxial screws
allow the heads to accommodate rod
alignment while compressing along the
rod, thereby promoting posterior
compression while limiting anterior
compression (Figure 3). In patients
with vertebral body compression, in
whom the goal is to reduce anterior
wedging and maintain anterior verte-
bral body height, fixed-angle pedicle
screws placed at the fractured verte-
brae can provide a rigid joystick for
direct leverage of the vertebral body/
end plate (Figure 4). They also serve as
posts for distractive and compressive
reduction maneuvers with the adja-
cent level pedicle screws.
End plate reduction/elevation can
be performed at the level of injury
with bilateral fixed-angle screws if two
intact pedicles are present (Figure 5).

Figure 3

A, Computer model depicting instrumentation of a posterior distraction injury with polyaxial screws and a short posterior rod.
Inset, Lateral fluoroscopic image showing the lumbar spine prior to reduction. B, Computer model depicting reduction
achieved by means of posterior compression, and the placement of set screws. Inset, Lateral fluoroscopic image of the
lumbar spine after reduction. C, Postoperative upright lateral radiograph demonstrating reduction and instrumentation.

4 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Dirk H. Alander, MD, and Shari Cui, MD

Immediately after screw placement Figure 4

and before rod placement, leverage is
applied by the surgeon simulta-
neously through both screw ex-
tenders at the level of the fracture to
manually lift the depressed superior
end plate (Figure 6, A through C).
However, this maneuver should be
avoided if the patient has extensive
comminution of the superior end
plate because the screws will cut out
and do little to reduce or support the
fractured segment. As long as the
patient is positioned appropriately,
the reduction should be maintained
after the levering force is removed
(Figure 6, D). Rods are cut to length
and contoured to approximate a
normal curvature. Rods are passed
subfascially through each screw
extender, and set screws are loosely
placed to just engage the threads.
After the rod is set and pro-
visionally secured with loosely placed
set screws, further indirect reduction
of the fracture height can be accom-
plished. Large point-to-point reduc-
tion forceps placed on the rod
extenders of the affected segment can
be used to distract between vertebral
segments (fulcrum placed below the
A, Computer model depicting vertebral body burst fracture. Lateral radiograph
forceps) or compress them (fulcrum (B) and a sagittal T2-weighted MRI (C) demonstrating a burst fracture with intact
placed above the forceps; Figure 7). posterior ligamentous complex and retropulsion into the conus medullaris.
Distraction and/or compression of
the vertebral bodies can improve
both the coronal and sagittal align- fixed-angle screws across multiple immediately above and below the
ment of the spine. After the desired consecutive segments substantially fracture, with the aforementioned
position is obtained, the set screws increases the difficulty of rod passage, alternating fixed-angle configuration,
are torque-tightened, first at the particularly if the screw heads are not is generally sufficient. In patients with
fracture site and then sequentially at collinear and the trajectories are var- type B or C fractures, two levels above
each successive level cephalad and ied. This situation can be alleviated by and below the level of injury should be
caudad to the injury. After final placing a combination of polyaxial included, with polyaxial screws
positioning and reduction are con- and fixed-angle screws at the level placed bilaterally at the terminal seg-
firmed, the screw extenders are above the injured level and an oppo- ments on each end (for a total of five
removed and the fascia and incisions site configuration at the level below instrumented levels).
are closed. the injury. This modification reduces
For direct fracture reduction by the number of fixed-angle screws that Removal of Instrumentation
levering/manipulation with fixed- need to be threaded on each side,
angle screws, systems with rigid while imparting angular stability for Minimally invasive PPSI preserves
screw-extender interfaces are pre- compression/distraction both proxi- the surrounding tissues while stabi-
ferred over systems with snap-off mal and distal to the level of the injury. lizing vertebral fractures until healing
extenders to better withstand the For the management of AO/Magerl occurs. Another benefit of this tech-
necessary levering forces. The use of type A fractures, fixation one level nique is the return of motion

Month 2018, Vol 0, No 0 5

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Percutaneous Pedicle Screw Stabilization

Figure 5 screws on one side are removed, soft

tissues (capping the rod) are released
at the end of the construct, and the
rod is removed via a rod holder or
heavy needle driver. To remove the
cannulated pedicle screws, a guide-
wire can be placed under fluoroscopy
or direct visualization to facilitate
access of the cannulated screwdriver.
In very slender patients, this step can
be skipped if the screw head is easily
visualized. Closure is otherwise rou-
tine. Upright radiographs are ob-
tained postoperatively. The patient is
discharged home the same day. Sed-
entary activity is recommended for
the first week, with progressive
activity encouraged as tolerated
thereafter.

Limitations
The purpose of fusionless percutane-
ous instrumentation is to reduce and
internally brace a fracture until heal-
ing takes place. Removal of implants
theoretically allows for the return of
increased physiologic motion at the
previously instrumented segment.
Computer model (A) and lateral intraoperative fluoroscopic images However, the capabilities of this
demonstrating the sequential placement of guidewires (B) and cannulated technology have several limitations.
percutaneous pedicle screws (C) with two monoaxial screws placed at the level Severely comminuted vertebral end
of injury. Note the alternating placement of one polyaxial and one monoaxial
screw at the levels above and below the injury. Figure 1 shows this alternating plates do not have the structural
screw configuration from the posterior view. integrity that allows direct leveraging
and reduction of the fracture. In this
situation, indirect distraction of
segments after implant removal. The injured end plate often settles to its adjacent segments via ligamentotaxis
optimal timing of removal is not yet preinstrumented position and dem- can be used to improve fracture
clear; the appropriate balance onstrates less arc motion on flexion/ position. Greater comminution at the
between protecting fracture healing extension radiographs compared level of injury and the presence of
and mobilizing vertebral segments (to with the remaining instrumented rotational or translational instability
avoid permanent stiffness) can be levels. This outcome is more common dictates extension of the fixation to at
challenging to determine. A wide in elderly patients and has not re- least two levels above and below the
range of timing for hardware removal sulted in segmental instability on injury in addition to the instrumented
has been reported. In our experience, follow-up. fractured level itself. Other potential
removing the instrumentation 3 to 4 Spinal implants can be removed on contraindications to PPSI include
months after the fracture fixation an outpatient basis. The previous pedicle discontinuity, extensively
allows adequate time for healing incisions are reused during removal. injured facets, and the inability to
while minimizing stiffness. Using this After incision, electrocautery is used obtain the correct starting point for
time frame has not resulted in frac- with a nasal speculum to split and/or placement of the guidewires.
ture collapse in our experience. The retract tissues. The set screws are Typically, ligamentous injuries are
disk level immediately superior to the exposed and removed. After all set treated with open fusion techniques.

6 Journal of the American Academy of Orthopaedic Surgeons

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 Dirk H. Alander, MD, and Shari Cui, MD

Many surgeons argue that fusion is Figure 6

necessary for adequate healing and
function. However, the authors of a
recent study published their experi-
ence of PPSI in pediatric patients with
spine fractures and reported good
outcomes of fusionless instrumenta-
tion with implant removal for the
management of injuries such as three-
column fractures and pure ligamen-
tous injuries.10 The authors of the
study credited this success to the
abundant healing potential in youn-
ger patients, citing other studies that
note the greater remodeling potential
in children compared with adults. In
our experience with adult patients
(all with implant removal at 4 to 6
months), we have observed a similar
ability of PPSI to restore stable arc
motion in younger patients (age, 20
to 40 years) with ligamentous
involvement. In older patients, we
have noted greater settling at the disk
segments involved. Autofusion at the A, Computer model depicting application of a manual force by the surgeon
through the screw extenders after screw placement at the level of the injury.
injured level can occur, but we have Inset, Illustration depicting compression across the fracture site. Intraoperative
not encountered progressive liga- lateral fluoroscopic images demonstrating the progression before the reduction
mentous instability requiring sec- force is applied (B), during leverage (C), and after the force is removed (D).
ondary surgery.
As with any technology or tech-
nique, patient selection is paramount onstrated the benefit of PPSI over months). Intraoperative correction
to success. Nonetheless, mounting open methods with regard to muscle was similar. Both intraoperative and
evidence suggests that stability does injury, blood loss, surgical time, and postoperative blood loss was con-
not necessitate fusion, even in postoperative visual analog scale siderably less in the minimally inva-
patients with three-column injuries (VAS) pain scores.4-8 Other studies sive group, and no difference was
with ligamentous involvement.10,11 have demonstrated the lack of found between the groups in terms of
necessity of fusion in patients with surgical times, radiograph utiliza-
certain fracture patterns.11,19,20 tion, postoperative functional scores,
Clinical Applications Surgical techniques for the man- or 5-year postoperative loss of
agement of spinal injury can now be reduction.
Conventional open surgical tech- classified into nonfusion and fusion In 2009, Palmisani et al21 reported
niques in the trauma population have techniques, percutaneous versus on 51 patients in whom PPSI was
been associated with increased infec- open approaches, and temporary applied using a variety of systems.
tion rates and blood loss.11-13 The versus permanent stabilization. Most fractures were AO type A;
wide surgical approach results in Wild et al8 retrospectively exam- however, four were type B1 or B2
tissue ischemia resulting from pro- ined 21 neurologically intact patients and three were type C. Instrumen-
longed retraction, substantial tissue with thoracolumbar spine fractures tation was removed in 10 patients.
stripping, paraspinal atrophy, post- (AO type A1-3) treated surgically The authors noted the ability of the
operative pain, and trunk weak- with posterior instrumentation (11 instrumentation to improve both
ness.4,13-19 Since the proliferation with a conventional open approach, segmental kyphosis and vertebral
of minimally invasive surgical tech- 10 with a minimally invasive body kyphosis, with some deterio-
niques for the management of spinal approach with instrumentation ration found on final follow-up
trauma, recent literature has dem- removed at an average of 10 (mean, 14.2 months; range, 6 to 28

Month 2018, Vol 0, No 0 7

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Percutaneous Pedicle Screw Stabilization

Figure 7 described an open hybrid “rod long,

A, Computer model depicting the balancing of the spine with variable
compression and distraction of the pedicle screws. After rods are placed and
confirmed on AP (B) and lateral (C) fluoroscopic views, further reduction can be
done by compressing the screws at and above the injured level to provide
additional “lift” to the end plate before the construct is locked in place with set
screws.
months). However, the patients
treated with multiaxial screws dem-
onstrated worse segmental and ver-
tebral kyphosis at final follow-up,
compared with other patients.
In a prospective study of 35 con-
secutive patients with AO/Magerl
type A3 fractures, Vanek et al6 com-
pared percutaneous short-segment
fixation without fusion (18 pa-
tients) and open conventional short-
segment fixation with fusion (17
patients). They noted a significant
decrease in estimated blood loss in
the percutaneous group (56 6
17 mL) compared with that of the
open control group (331 6 149 mL)
and shorter surgical times in the
percutaneous group than in the open
group (P , 0.05 for both compari-
sons). In addition, VAS scores in the
first 7 postoperative days were sig-
nificantly lower in the percutaneous
group than in the open group (P ,
0.05). The two groups had no dif-
ference in VAS scores after 2 years.
Both the open and percutaneous
methods obtained similar surgical
deformity correction with regard to
vertebral body height index, Cobb
angle, and vertebral body angle. No
notable loss of reduction was
observed in either group at 2-year
follow-up.
Early hybrid techniques of spinal
stabilization and fusion techniques
include “rod long, fuse short”
techniques, mini-open decompres-
sion with fusionless stabilization,
and bridging stabilization of multiple
fractures. Hybrid techniques can
provide early spinal stability without
jeopardizing the ability to decom-
press, or to fuse focal injuries, when
needed. In their original study pub-
lished in 1994, Akbarnia et al22
fuse short” technique that combined
fused and unfused spinal segments.
They showed good outcomes at both
the short-segment fusion sites and
the purposefully unfused segments,
where physiologic motion was rein-
stated after implant removal.
Our experience with hybrid fixa-
tion includes limited open exposure
for posterior lateral fusion and PPSI
stabilization proximally and distally.
Similar to the process used in stan-
dard PPSI, we performed scheduled
implant removal at the percutane-
ously instrumented segments at 4 to 6
months by cutting the rods between
the fused and unfused segments and
removing the implants from the
unfused segments. Although the
number of patients treated with this
technique was small, we found this
technique to be useful in the man-
agement of comminuted fractures in
polytrauma patients. In damage
control situations with compressive
neurologic deficit, limited decom-
pression can be completed through a
small open procedure followed by
percutaneous stabilization of at least
two segments above and below the
fracture level. After the patient is
medically stable, a secondary surgical
procedure can be performed to fuse
the selected levels, if indicated. Lastly,
hybrid techniques that bridge multi-
ple fractures of the thoracolumbar
spine can provide stability, allowing
early patient mobilization without
bracing. This method can help to
avoid the pitfalls and constraints of
the use of an orthosis in a polytrauma
patient when access to the chest,
abdomen, and skin is requisite for
complete critical care. Additional
larger studies are needed to make
definitive recommendations regard-
ing the best use of these hybrid
configurations.
Although the use of percutaneous
transpedicular instrumentation is
gaining support, few level I and II
studies have been published. With an

8 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

increasing body of higher-level
research questioning the necessity of
fusion in patients with select tho-
racolumbar spine fractures, the new
data can be extrapolated to create
better-quality randomized studies in-
volving percutaneous methods.11,19,20
Ongoing research in this area will
continue to clarify the indications for
these procedures and fine-tune the
techniques.
Complications
Minimally invasive techniques are
associated with a steep learning
curve.22-24 Extrapolating known
open anatomy and approaches to
that of indirect, image-guided tech-
niques requires a solid knowledge
base and technical foundation.
Complications, such as facet viola-
tion and screw malposition, can
occur with PPSI, but these compli-
cations also occur with open tech-
niques.24-27 Although studies have
been performed to compare the
accuracy of navigational tools,
including fluoroscopy and CT image
guidance, a clinically significant ben-
efit of these imaging tools has yet to
be defined.27,28
Summary
The use of PPSI continues to gain
momentum and support in recent
literature. In this technique, fusion is
neither the goal nor a desired result.
For the management of select frac-
tures, in short-term and midterm
studies, PPSI has demonstrated non-
inferiority in deformity correction
and clinical outcomes while impart-
ing clear perioperative benefits by
limiting blood loss, postoperative
pain, and surgical time. Longer-term
studies are required to demonstrate
the ramifications of the motion-
sparing nature PPSI, and higher-
level randomized studies with larger
sample sizes are required to defini-
Month 2018, Vol 0, No 0
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
tively prove its benefit or non-
inferiority compared with existing
techniques.
Acknowledgment
The authors acknowledge and are
grateful to Jon Berndt for the creation
of the technique renderings and
computer images used in this article.
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