Objective:To introduce a novel method of the virtual construction for pedicle screw trajectory (PST) of subaxial cervical spine based on CT data and to investigate its effects on improving the accuracy rate of subaxial cervical pedicle screw technique.Methods:The CT data of cervical spine (C 3, 4) of 60 subjects, including 30 males and 30 females, were collected for analysis. The data were imported into Mimics 20.0. Further, the virtual safe core (G-zone) of the PST was constructed using the method designed by authors. The following data was collected: 1) the efficiency rate of the method for virtual constructed of PST and G-zone; 2) the spatial position of the virtual safe core, including the distance between G-zone and the tangent line of upper and lower outer edge of Luschka's joint on the coronal plane, and the distance between the G-zone and the posterior edge of the vertebral body on sagittal plane; 3) the length, width and height of G-zone; 4) the abduction angle of pedicle screw on axial plane, and the cranial and caudad inclination angle on the sagittal plan of the pedicle; 5) the mean distance between the cortex of lateral mass and the G-zone; 6) the positive projection area of the trajectory on the coronal plan. Results:The efficiency rate of the method for virtual constructed of PST and safe core were C 3 95% (57/60) and C 4 100% with 97.5% (117/120) the total efficiency rate. The mean height of safe core was C 3 4.99±1.04 mm (left) and 4.95±0.88 mm (right), C 4 5.41±0.93 mm (left) and 5.16±1.39 mm (right). The mean width of safe core was C 3 3.79±0.87 mm (left) and 3.44±0.88 mm (right), C 4 3.99±0.68 mm (left) and 3.60±0.92 mm (right). The mean length of safe core was 3.5 mm. The distance between the G-zone and the tangent line of upper and lower outer edge of Luschka's joint on the coronal plane was C 3 0.66±0.54 mm (left) and 0.69±0.67 mm (right), C 4 0.62±0.59 mm (left) and 0.65±0.64 mm (right). The distance between the G-zone and the posterior edge of the vertebral body on sagittal plane was C 3 2.08±0.41 mm and C 4 2.34±0.60 mm, C 4>C 3 ( P<0.05). The interval of abduction angle on the axial plane of C 3 were 28.16°±7.82° to 67.46°±7.54° (left) and 29.46°±7.5° to 64.08°±9.79° (right), C 4 27.64°±4.56° to 69.95°±6.66° (left) and 29.17°±5.92° to 71.14°±5.07° (right). The range of cranial and caudad inclination angle of pedicle screw on sagittal plane were C 3 24.12°±5.35° (left) and 24.40°±4.86° (right), C 4 24.87°±5.7° (left) and 25.65°±5.62° (right). The mean distance between the entering cortex and the center of G-zone was C 3 11.93±0.76 mm (left) and 12.12±0.83 mm (right), C 4 11.24±0.71 mm (left) and 11.34±1.01 mm (right). The positive projection area of the PST on the coronal plan was C 3 41.38±15.68 mm 2 (left) and 37.66±13.77 mm 2 (right), C 4 44.54±12.96 mm 2 (left) and 40.33±15.54 mm 2 (right), C 4 left>C 4 right ( P<0.05). Conclusion:The efficiency rate of the virtual construction method for PST and safe core of the subaxial cervical spine was 97.5%. The length, width, and height of the virtual safe core were suitable for the implantation of the commonly used cervical pedicle screw with a diameter of 3.5 mm. The virtual G-zone was morphologically stable and easy to recognize on the anteroposterior and lateral cervical fluoroscopy view, which can provide a reliable landmark for the implementation of the pedicle screw of the subaxial cervical spine.

Objectives:To construct the “safe core” of the pedicle screw trajectory using CT imaging data of the subaxial cervical spine in adults, and to assess the accuracy and feasibility of the pedicle screw insertion assisted with the “safe core-referred technique” for subaxial cervical spine with a cadaver specimen study.Methods:This is an experimental study. From January 2015 to March 2020,60 adults′ CT images data of the cervical spine were collected from the database of the First Affiliated Hospital of Gannan Medical University,and were imported into Mimics 20.0 software. Virtual cervical pedicle trajectory and safe core were constructed according to the self-designed “virtual construction method of pedicle in the subaxial cervical spine”. The success rate of the construction and the spatial position data of the virtual safe core of was recorded,including the distance between the safe core and the tangent line of the upper and lower outer edge of Luschka′s joint on coronal plane,and the distance between the safe core and the posterior edge of the vertebral body on sagittal plane.The 3.5 mm column was used to simulate the pedicle screw placement,using the safe core as the only hub in pedicle screw trajectory.The length of the anterior pedicle screw trajectory,the interval of the abductive angle of the pedicle screw in axial plane, and the projection area of the entry area on periapical radiograph was calculated.In addition,8 adult cervical cadaver specimens were collected for the pedicle screw insertion experiment.The left side group used the “safe core-referred technique” for pedicle screw insertion,while the right side group used the Abumi method for pedicle screw insertion.The accuracy of pedicle screw placement was verified by CT scan.The difference between the accuracy of subjective judgment based on X-ray monitoring of operator and the actual accuracy of pedicle screw insertion verified by CT scan was compared between the two groups.The chi-square test was used to compare the intergroup data.Results:The total success rate of the virtual construction method for the safe core of the subaxial cervical spine was 97.0% (291/300); The distance between the safe core and the tangent line of the upper and lower outer edge of Luschka′s joint on coronal plane was ( M(IQR)) 0.91 (0.98) mm (range: 0 to 1.85 mm);The distance between the safe core and the posterior wall on the sagittal plane of the vertebral body was (2.01±0.86) mm (range: 0.67 to 3.53 mm). The distance (anterior pedicle screw trajectory) from the posterior cortex to the central point of the safe core was (11.58±1.00)mm (range: 8.27 to 14.93 mm).The projection area of the entry point on the coronal plane was (36.18±11.67) mm 2 (range: 13.38 to 83.11 mm 2). Pedicle screw insertion experiment in cervical cadaver specimen showed the rate of intraoperative correction of the pedicle screw trajectory was 7.5% (3/40) in the experimental group and 12.5% (5/40) in the control group ( χ2=0.139, P=0.709). The operator ′s correct rate of subjective judgment on CT in the stage of pedicle screw trajectory preparation was 100% (40/40) in the experimental group and 82.5% (33/40) in the control group, the difference was statistically significant ( χ2=5.638, P=0.018). The actual correct rate of CT verification in the stage of pedicle screw insertion was 100% (40/40) in the experimental group and 90.0% (36/40) in the control group, the difference was statistically significant ( χ2=2.368, P=0.124); The operator ′s correct rate of subjective judgment in the stage of pedicle screw insertion completion was 100% (83/83) in the experimental group and 92.9% (79/85) in the control group ( χ2=4.199, P=0.040). Conclusions:The virtual safe-core of subaxial cervical spine can be use as a reliable anatomical fluoroscopy landmark for freehand pedicle screw insertion.“Safe core-referred technique” can improve the accuracy rate of the operator′s subjective judgment on the intraoperative fluoroscopy monitoring,and hence improve the accuracy of freehand pedicle screw insertion technology for subaxial cervical spine. And it still needs to be further verified in clinical practice.

Objectives:To construct the “safe core” of the pedicle screw trajectory using CT imaging data of the subaxial cervical spine in adults, and to assess the accuracy and feasibility of the pedicle screw insertion assisted with the “safe core-referred technique” for subaxial cervical spine with a cadaver specimen study.Methods:This is an experimental study. From January 2015 to March 2020,60 adults′ CT images data of the cervical spine were collected from the database of the First Affiliated Hospital of Gannan Medical University,and were imported into Mimics 20.0 software. Virtual cervical pedicle trajectory and safe core were constructed according to the self-designed “virtual construction method of pedicle in the subaxial cervical spine”. The success rate of the construction and the spatial position data of the virtual safe core of was recorded,including the distance between the safe core and the tangent line of the upper and lower outer edge of Luschka′s joint on coronal plane,and the distance between the safe core and the posterior edge of the vertebral body on sagittal plane.The 3.5 mm column was used to simulate the pedicle screw placement,using the safe core as the only hub in pedicle screw trajectory.The length of the anterior pedicle screw trajectory,the interval of the abductive angle of the pedicle screw in axial plane, and the projection area of the entry area on periapical radiograph was calculated.In addition,8 adult cervical cadaver specimens were collected for the pedicle screw insertion experiment.The left side group used the “safe core-referred technique” for pedicle screw insertion,while the right side group used the Abumi method for pedicle screw insertion.The accuracy of pedicle screw placement was verified by CT scan.The difference between the accuracy of subjective judgment based on X-ray monitoring of operator and the actual accuracy of pedicle screw insertion verified by CT scan was compared between the two groups.The chi-square test was used to compare the intergroup data.Results:The total success rate of the virtual construction method for the safe core of the subaxial cervical spine was 97.0% (291/300); The distance between the safe core and the tangent line of the upper and lower outer edge of Luschka′s joint on coronal plane was ( M(IQR)) 0.91 (0.98) mm (range: 0 to 1.85 mm);The distance between the safe core and the posterior wall on the sagittal plane of the vertebral body was (2.01±0.86) mm (range: 0.67 to 3.53 mm). The distance (anterior pedicle screw trajectory) from the posterior cortex to the central point of the safe core was (11.58±1.00)mm (range: 8.27 to 14.93 mm).The projection area of the entry point on the coronal plane was (36.18±11.67) mm 2 (range: 13.38 to 83.11 mm 2). Pedicle screw insertion experiment in cervical cadaver specimen showed the rate of intraoperative correction of the pedicle screw trajectory was 7.5% (3/40) in the experimental group and 12.5% (5/40) in the control group ( χ2=0.139, P=0.709). The operator ′s correct rate of subjective judgment on CT in the stage of pedicle screw trajectory preparation was 100% (40/40) in the experimental group and 82.5% (33/40) in the control group, the difference was statistically significant ( χ2=5.638, P=0.018). The actual correct rate of CT verification in the stage of pedicle screw insertion was 100% (40/40) in the experimental group and 90.0% (36/40) in the control group, the difference was statistically significant ( χ2=2.368, P=0.124); The operator ′s correct rate of subjective judgment in the stage of pedicle screw insertion completion was 100% (83/83) in the experimental group and 92.9% (79/85) in the control group ( χ2=4.199, P=0.040). Conclusions:The virtual safe-core of subaxial cervical spine can be use as a reliable anatomical fluoroscopy landmark for freehand pedicle screw insertion.“Safe core-referred technique” can improve the accuracy rate of the operator′s subjective judgment on the intraoperative fluoroscopy monitoring,and hence improve the accuracy of freehand pedicle screw insertion technology for subaxial cervical spine. And it still needs to be further verified in clinical practice.