Minimally invasive cervical spine stabilization: A multicenter study of completely percutaneous pedicle screw-rod instrumentation

Brain and Spine, vol. 6, pp. 105996

Abstract

Introduction: Minimally invasive posterior cervical fixation remains technically challenging due to narrow pedicle dimensions and proximity to neurovascular structures. This multicenter study evaluates the accuracy and safety of a dedicated minimally invasive cervical pedicle screw-rod system with 3D navigation guidance. Research question: Can minimally invasive cervical pedicle screw placement achieve accuracy rates comparable to open techniques while maintaining patient safety? Material and methods: Retrospective multicenter analysis of 46 patients (60.7 ± 17.4 years) undergoing percutaneous cervical pedicle screw-rod instrumentation at three German university centers (01/2022-04/2024). Indications included degenerative disease (n = 21), tumors (n = 13), trauma (n = 8), and inflammation (n = 4). Primary outcome was neurological status (Frankel classification); secondary outcomes included screw accuracy (Bredow classification), surgical characteristics, and complications. All procedures utilized 3D navigation based on cone-beam CT or intraoperative CT. Results: In total, 232 pedicle screws were implanted from C2 to T2. Favorable screw position (Bredow grades 1-2) was achieved in 89.7% overall, with significantly lower accuracy at C3-C6 versus other levels (86.0% vs. 95.4%, p = 0.0297). No permanent neurological deficits occurred. Two screws required intraoperative repositioning; zero revision surgeries were needed. Mean surgical duration was 148 ± 66min with blood loss of 236 ± 183 ml. Discussion and conclusion: Minimally invasive cervical pedicle screw-rod instrumentation with 3D navigation achieves high accuracy and safety comparable to open techniques. In the majority of cases, the technique supplemented anterior fusion for additional stability, but it may also serve as posterior-only instrumentation for in tumor-related osteolysis or traumatic injuries. Mid-cervical levels remain particularly challenging and require heightened vigilance.

Authors 17

1. Jan‐Helge Klingler corresponding

   University of Freiburg · University Medical Center Freiburg

   Affiliation as printed

   Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany

   Spine Science Commission of the German Spine Society (DWG), Hamburg, Germany

2. Lars Wessels

   Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany

   Spine Science Commission of the German Spine Society (DWG), Hamburg, Germany

3. Christoph Scholz

   University of Freiburg · University Medical Center Freiburg

   Affiliation as printed

   Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany

4. Tobias Philip Schmidt Aachen Department of Neurosurgery

   RWTH Aachen University

   Affiliation as printed

   Department of Neurosurgery, RWTH Aachen University, Aachen, Germany

5. Ulf Bertram Aachen Department of Neurosurgery

   RWTH Aachen University

   Affiliation as printed

   Department of Neurosurgery, RWTH Aachen University, Aachen, Germany

6. Marc Hohenhaus

   University of Freiburg · University Medical Center Freiburg

   Affiliation as printed

   Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany

   Spine Science Commission of the German Spine Society (DWG), Hamburg, Germany

7. Ulrich Hubbe

   University of Freiburg · University Medical Center Freiburg

   Affiliation as printed

   Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany

8. Claudius Jelgersma

   Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany

9. Nils Hecht

   Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany

10. Ralf Watzlawick

    University of Freiburg · University Medical Center Freiburg

    Affiliation as printed

    Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany

11. Florian Volz

    University of Freiburg · University Medical Center Freiburg

    Affiliation as printed

    Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany

12. Jürgen Beck

    University of Freiburg · University Medical Center Freiburg

    Affiliation as printed

    Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany

13. Julia Onken

    Charité - Universitätsmedizin Berlin

    Affiliation as printed

    Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany

    Spine Science Commission of the German Spine Society (DWG), Hamburg, Germany

14. Ralph Kothe

    Schön Klinik Hamburg Eilbek

    Affiliation as printed

    Spine Department Schön Klinik Hamburg-Eilbek, Hamburg, Germany

15. Peter Vajkoczy

    Charité - Universitätsmedizin Berlin

    Affiliation as printed

    Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany

    Spine Science Commission of the German Spine Society (DWG), Hamburg, Germany

16. Hans Clusmann Aachen Department of Neurosurgery

    RWTH Aachen University

    Affiliation as printed

    Department of Neurosurgery, RWTH Aachen University, Aachen, Germany

17. Christian Blume Aachen Department of Neurosurgery

    RWTH Aachen University

    Affiliation as printed

    Department of Neurosurgery, RWTH Aachen University, Aachen, Germany

    Spine Science Commission of the German Spine Society (DWG), Hamburg, Germany