Freehand Juxtapedicular Screws Placed in the Apical Concavity of Adult Idiopathic Scoliosis Patients: Technique, Computed Tomography Confirmation, and Radiographic Results

Objective: The purpose of this study is to highlight our technique for freehand placement of juxtapedicular screws along with intraoperative computed tomography (CT) and radiographic results. Methods: Consecutive patients with adult idiopathic scoliosis undergoing primary surgery by the senior author were identified. All type D (absent/slit like channel) pedicles were identified on preoperative CT. Three-dimensional visualization software was used to mea-sure screw angulation and purchase. Radiographs were measured by a fellowship trained spine surgeon. The freehand technique was used to place all screws in a juxtapedicular fash-ion without any fluoroscopic, radiographic, navigational or robotic assistance. Results: Seventy-three juxtapedicular screws were analyzed. The most common level was T7 (9 screws) on the left and T5 (12 screws) on the right. The average medial angulation was 20.7° (range, 7.1°–36.3°), lateral vertebral body purchase was 13.4 mm (range, 0–28.9 mm), and medial vertebral body purchase was 21.1 mm (range, 8.9–31.8 mm). More than half (53.4%) of the screws had bicortical purchase. Two screws were lateral on CT scan, defined by the screw axis lateral to the lateral vertebral body cortex. No screws were medial. There was a difference in medial angulation between screws with (n = 58) and without (n = 15) lateral body purchase (22.0 ± 4.9 vs. 15.5 ± 4.5, p < 0.001). Three of 73 screws were repo-sitioned after intraoperative CT. There were no neurovascular complications. The mean coronal cobb corrections for main thoracic and lumbar curves were 83.0% and 80.5%, re-spectively, at an average of 17.5 months postoperative. Conclusion: Freehand juxtapedicular screw placement is a safe technique for type D pedi-cles in adult idiopathic scoliosis patients.