The use of guide templates in the surgical treatment of preschool children with congenital scoliosis of thoracic and lumbar localization

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Abstract

Background. The use of transpedicular screws as support elements from the standpoint of biomechanics is preferable as compared to that of laminar fixation, albeit the former carries the risk of various complications (such as malposition screws, damage to the Dura mater, spinal cord, and major blood vessels) caused by structural changes in the vertebrae under the background of their defects, with small size of roots arcs vertebrae in young children. Thus, the issue of ensuring safe and correct installation of transpedicular screws in the surgical treatment of children with congenital scoliosis remains relevant.

Aim. We aimed to evaluate the correctness of the position of the transpedicular screws installed in the vertebral bodies in preschool children with congenital scoliosis of thoracic and lumbar localization using guide templates (SHN).

Materials and methods. We conducted a prospective analysis of the outcomes of surgical treatment of 30 patients with congenital scoliosis against the background of impaired formation of the vertebrae of the thoracic and lumbar spine. The patients included 12 boys and 18 girls of age: 1 year 8 months to 6 years 5 months (average: 3 years 4 months). Based on the computed tomography of the spine, performed postoperatively, the correctness of the position of the installed elements of the corrective multi-support metal structure was evaluated. The correctness of the position of the installed transpedicular support elements was evaluated based on the scale described by S.D. Gertzbein and co-authors (1990).

Results. The total number of implanted transpedicular screws sets was 96 (100% of the planned transpedicular screws set), and 48 SHN were used for transpedicular screws installation. The correct position of installed screws by degree of displacement revealed Grade 0 — 93.7% (90 screws), Grade I — 4.2% (4 screws), Grade II — 2.1% (2 screws), Grade III — 0%. The number of screws with a Grade 0 + Grade I offset was 94 (97.9%).

Conclusion. The results obtained with the use of SHN among preschool children with congenital scoliosis of thoracic and lumbar localization revealed high accuracy and correctness of transpedicular screws installation (93.7%) with the use of this type of navigation in clinical practice. The use of SHN for installing transpedicular screws in the surgical treatment of congenital spinal deformities in young patients allows for the selection of the optimal size and correct position of the transpedicular support elements in the vertebrae to be instrumented.

Full Text

Some children with congenital scoliosis also present with a disorder of the vertebrae formation. Surgical intervention in these cases aims to provide effective correction of deformity and fixation of a few spine segments. Presently, the approach to surgical treatment is based on the principles of radical correction of the spinal column curvature, which can be achieved through the removal of the semi-vertebra and fixation with local metal structures at an early age [12]. Surgical intervention for congenital scoliosis, when performed in older children, does not achieve radical correction of deformity, rather it can lead to an increase in the length of instrumental spondylosyndesis [3]. From the perspective of biomechanics, the use of transpedicular screws (TS) as supporting elements is preferable than laminar fixation, considering that the former type of fixation has a corrective effect on all three spinal columns [4]. However, the use of TS is associated with the risk of various complications (such as screw malposition and damage to the dura mater, spinal cord, and large vessels), which can be attributed to the resultant structural changes in the vertebrae in the presence of the scoliotic process, malformations of the spinal column, as well as the small size of the roots of vertebral arches in young children [5–7]. Therefore, the issue of ensuring safe and precise installation of the TS is relevant to the consideration of an appropriate surgical approach for patients with congenital scoliosis. Prevention of these complications can significantly improve the quality of medical care provided to pediatric patients [8].

However, the best approach for controlling precise TS installation remains unclear. To resolve this issue, various navigation techniques have been employed, such as fluoroscopy, computed tomography-assisted navigation, and robot-assisted surgery [9, 10]. One of the navigational methods that has demonstrated sufficiently high accuracy and correctness in the positioning of installed TS in the bone structures of the vertebrae in its various anatomical sections is the use of guide templates (GT) for installing the TSs toward correcting various diseases and deformities of the spinal column (such as spinal injury, degenerative-dystrophic, inflammatory diseases, craniovertebral pathology, and idiopathic scoliosis) [11–14]. This technology has become quite widespread, primarily for transpedicular fixation of the cervical spine in adult patients [15–19]. However, the available publications on the analysis of the use of GT in children mainly discusses the issues of surgical treatment of school-age patients who have closer to adult anatomical and anthropometric characteristics of the spine bone structures. Past studies on the use of GT in pediatric patients with congenital spinal deformities are sporadic and, as a rule, also include school-age children [20, 21]. The studies that have analyzed the effectiveness of GT in congenital scoliosis in young and preschool children belong to the in vitro category [22].

Thus, when analyzing Russian and international literature, we did not investigate those on the use of GTs for installing TSs in congenital thoracic and lumbar scoliosis in case of impaired formation of the vertebrae in preschool children.

The present study aimed to assess the preciseness of the positioning of TSs installed in the vertebral bodies among preschool children presenting with congenital thoracic and lumbar scoliosis with reference to GT.

Materials and methods

The present study is based on the prospective analysis of the results of examination and surgical treatment of 30 patients (including 12 men and 18 women) of age 1 year and 8 months to 6 years 5 months (average age: 3 years 4 months) presenting with congenital scoliosis in case of impaired formation of the vertebrae (posterolateral semi-vertebrae of the thoracic and lumbar spine). All children underwent examination and surgical treatment during 2018–2019.

The present work consisted of two stages: stage 1 — the GT optimal design for installing the TS was selected based on the preliminary assessment of the reliability of its “adhesion” on the plastic model of the spine and then directly during the surgical intervention (n = 10), and stage 2 — the implanted TSs were assessed for correct positioning using the GTs (n = 20).

The standard examination during the preoperative and postoperative period involved multispiral computed tomography (MSCT) of the thoracic and lumbar spine. All children underwent extirpation of the semi-vertebra with adjacent intervertebral discs, correction of congenital deformity of the spine with a multi-support transpedicular system, anterior fusion, and posterior spondylosyndesis with auto-bone to create a bone block between intact vertebrae adjacent to the area of the removed semi-vertebra.

Before the surgical intervention, virtual screws, and GTs were planned based on the data of the preoperative MSCT examination of the spine, which were imported into the PME Planner software (Polygon Medical Engineering, polygonmed.ru). A 3D model of the spine was used to determine the size and optimal positioning of the TSs implanted in the vertebrae. The TS interposition was then corrected considering the age-related anatomical and morphological aspects of the vertebrae. Then, using the “brush” tool, the necessary boundaries of the GT were established on the dorsal surface of the vertebral bone structures (Fig. 1). The created 3D models of the GT were finally printed on the Formlabs Form 2 3D printer (SLA technology).

 

Fig. 1. Planning of virtual screws and guide templates in the PME Planner software environment: a — selection of the size of the transpedicular screw; b — creating the boundaries of the guide template

 

Stage of intraoperative examination with GT. The dorsal bone structures of the spine were skeletonized in the area of the proposed implantation of the metal structure. The GT was then installed on the dorsal surface of the vertebra, and the drill was used to form canals in a specified direction, passing through the root of the arch into the vertebral body. The probe was used to verify the integrity of the walls of the bone canal in the vertebra. After the formation of all the necessary channels, X-ray tracers were installed in the vertebral bodies and X-ray control was implemented. The transpedicular support elements were then inserted into the canals (Fig. 2).

 

Fig. 2. Stages of intraoperative examination: a — installation of a guide template on the dorsal bone structures of the vertebra and drilling of a channel for the transpedicular screw; b — probe verification of the integrity of the walls of the formed bone canal in the vertebra; c — installation of X-ray tracers in the vertebral bodies to manage X-ray control

 

Based on the MSCT examination of the spine, which was performed during the postoperative period, the correct positioning of the installed TS of the correcting multi-support metal structure was assessed.

The preciseness of the TS position was assessed with reference to the scale proposed by Gertzbein et al., where Grade 0 (full correct) implied that TS is completely at the root of the arch, Grade I indicated displacement of TS relative to the cortical layer of the root of the arch up to 2 mm, Grade II implied displacement within 2–4 mm, and Grade III implied displacement of >4 mm [23]. To determine the spatial type of TS malpositioning, the SLIM + V scheme was used, with S (superior) indicating the upper (cranial) wall of the arch root, L (lateral) indicating the lateral (outer) wall of the arch root, I (inferior) indicating the lower (caudal) wall of the arch root, M (medial) indicating the medial (internal) wall of the root of the arch, and V (vertebral body) indicating the anterolateral surface of the vertebral body [24].

Statistical analysis was performed using the Statistica 10 software (StartSoftInk, USA). The statistical significance of differences when using GT, which depended on the design option, was determined using Fisher’s exact test (F-test).

Results

At the stage of refinement of the GT optimal design for installing TS among preschool children with congenital scoliosis, 3 main options were tested: option 1: monosegmental GT with a limited contact area; option 2: monosegmental GT with a contact area including the edges of the spinous process, the arch, and the transverse processes of the vertebra; and option 3: polysegmental GT involving ≥2 vertebrae in the contact area (Fig. 3).

 

Fig. 3. Design options for the guide template: a — monosegmental with a limited contact area (option 1); b — monosegmental with a contact area including the edges of the spinous process, the arch, and the transverse processes of the vertebra (option 2); c — polysegmental, including ≥2 vertebrae in the contact area (option 3)

 

Before surgery, all the GT options were tested on plastic 3D prototypes of the spine of patients with congenital scoliosis to assess the quality of the GT “adhesion” to the dorsal surface of the plastic model. However, even under the condition of good “adhesion” to the plastic model of the spine, during the surgery, the patient experienced GT displacements, which deviated from the planned TS trajectory. In such cases, the standard “free-hand” method or laminar support elements were used for TS implantation.

Thus, when using a polysegmental GT, owing to its massiveness, a sufficiently wide skeletonization of the spine in the area of screw implantation becomes necessary. This template overlapped completely the bony structures of the spine, which led to the loss of visual control of the screw insertion point during drilling of the bone canal. Monosegmental GT with a limited contact area enabled visualization and control of the localization of the screw insertion point in relation to the anatomical structures of the vertebra dorsal surface, but did not provide a sufficiently close contact and rigidity of “adhesion” with the vertebra, which together resulted in GT displacement during drilling of the bone canal and, consequently, in the deviation of the TS trajectory. The option 2 of monosegmental GT was fond to be most reliable in the course of surgical intervention (Table 1).

 

Table 1

Assessment of the reliability of “adhesion” of the guide template depending on the design

GT design

GT number

GT “adhesion” on the plastic model of the spine

GT “adhesion” during surgical intervention in the patient

Fisher’s ratio test

 

Н

У

Н

Option 1

10

10

0

5

5

F = 0.021 (for GT options 1 and 2)

Option 2

10

10

0

10*

0

Option 3

5

5

0

2

3

F = 0.033 (for GT options 2 and 3)

Note. GT — guide template; S — satisfactory; P — poor; * — statistically significant difference.

 

The application of a guide template and the assessment of the correctness of the TS positioning and the types of their malposition relative to the bone structures of the instrumented vertebrae are presented in Tables 2 and 3.

 

Table 2

The use of a guide template and precise positioning of the transpedicular screws

Indicators

Planned

Performed

Guide template (option 2)

48

48 (100%)

Total number of transpedicular support elements

96

96 (100%)

Precise screw position (Grade 0)

93.7% (90 screws)

Total incorrect screw position

6.3% (6 screws)

Grade I

4.2% (4 screws)

Grade II

2.1% (2 screws)

Grade III

Grade 0 + Grade I

97.9% (94 screws)

Table 3

Types of transpedicular screw malpositioning

UO

Vert.

Th

L

5

6

7

8

9

10

11

12

13

1

2

3

4

1

R

L1

HV

0

L

0

0

2

R

0

HV

0

L

M1

0

3

R

0

L2

HV

0

L

0

0

0

4

R

0

0

N

HV

L2

L

0

0

N

M1

5

R

0

N

0

HV

0

L

0

N

0

V1

Note. UO — clinical case; Vert. — vertebra; Th — thoracic region; L — lumbar region; R — screws installed on the right; L — screws installed on the left; HV — semi-vertebra; N — the vertebra under the indicated serial number is absent; “–” — vertebrae not included in the area of instrumental spondylosyndesis; SLIM + V: S — superior, L — lateral, I — inferior and M — medial walls of the arch root, V — vertebral body (0, 1, 2, 3 — screw malposition according to the degree of displacement), Th13 — supernumerary semi-vertebra.

 

All templates out of the 48 printed GTs (monosegmental, option 2) were successfully applied during the surgical intervention. In total, 96 virtual screws were provided in the program during preoperative planning. All 96 TSs were installed using the GT. Thus, the correspondence between the proposed arrangement of the transpedicular metal structure and the performed one was 100%. The correct positioning of the TSs relative to the bone structures of the instrumented vertebrae was generally noted in 93.7% of cases (90 screws), while incorrect positioning of the screws during the analysis of MSCT scans of the spine was recorded in 6.3% of cases (6 screws). Based on the degree of displacement, out of 6 screws installed, 4 (4.2%) were rated as Grade I and 2 (2.1%) as Grade II. No Grade III displacements were noted. Based on the type of displacement, type L was noted in three cases, type M was registered in two cases, and type V was noted in one case. The number of screws with the degree of displacement Grade 0 + Grade I was 97.9% (94 screws). No neurological disorders or destabilization of the metal structure in the postoperative period and in the follow-up period were noted (Fig. 4).

 

Fig. 4. Multispiral computed tomogram of the spine of a patient with congenital scoliosis after extirpation of the posterolateral semi-vertebra L2 with installed transpedicular screws using a guide template, with the completely correct positioning of the screws: a — section in the axial plane; b — section in the coronal plane; c — section in the sagittal plane

 

Discussion

Notably, the literature includes reports on the use of GT based on two main aspects: the assessment of the correctness of the TS installation and the GT optimal design. Thus, in a systematic review that included data from 13 studies (n = 466, 1700 TSs were installed using the GT and 1675 TSs using the “free-hand” method), the positive effect of GT on the improvement of accuracy and correctness of the TS installation was revealed [25].

The use of GT of diverse designs has also been extensively discussed in the literature, with the denotation of various options for the arrangement and design characteristics of GT toward proving the effectiveness of the GT proposed, namely, the reliability of “adhesion” to the vertebral surface and the accuracy of the TS installation. Thus, in a study conducted on 3 cadaver preparations, 60 TSs were inserted into the С2–Th4 vertebrae using various design GT (such as unilateral, bilateral matrices, and bilateral ones with a support to the spinous process). Based on the data obtained, the authors recommended using a bilateral GT with a support on the spinous process to install the TS in the cervical and thoracic spines [26]. Meanwhile, in another work, researchers preferred to install TS in the thoracic spine using a monolateral “hook” type of GT without the support on the spinous process of the vertebra [27]. In a study on the use of GT in older children (aged 10–17 years) with congenital spinal deformities in the presence of thoracic semi-vertebrae, the authors used 3-level GTs to achieve a completely correct TS positioning in 11 (91.7%) of the 12 cases [21].

During the course of our study, we noted special aspect of using the GT in the installation of TS into the vertebrae of the thoracic and lumbar spine in young children with congenital scoliosis who required sufficiently close contact with the spinous process of the vertebra (both with its cranial and caudal surfaces) and the boundaries of the GT contact area with the surface of the arch as well as required that the transverse processes of the instrumented vertebra must correlate accurately with the anatomical structures surrounding this area.

When analyzing the literature on the use of GT in pediatric patients, the following data were obtained, as shown in Table 4.

In total, 107 patients, aged 5–25 years (average: 16.5 years), were operated using a GT. The distribution by nosology revealed that 91 patients had idiopathic scoliosis, 13 had congenital scoliosis, 2 had Marfan syndrome, and 1 had neuromuscular scoliosis. A total of 1120 TSs were installed in the patients using the GT [14, 21, 28–31].

 

Table 4

Literature data on the use of a guide template in vivo in children

Spine region

Year

Author

Study type

Number of cases, pathology

Age, years

Number of screws

CorScrew, Grade, %/(n)

0

1

2

3

0 + 1

T

2012

Lu S. et al. [28]

PlM + in vivo

16: idiopathic scoliosis (14), congenital scoliosis (2)

5–18

168

93.5% (157)

6.5% (11)

100% (168)

2016

Takemoto M. et al. [29]

PM + in vivo

36: idiopathic scoliosis (34), Marfan syndrome (2)

15.0

(11–19)

420

98.4% (408)

1.4% (6)

0.2% (1)

99.8% (414)

2018

Pan Y. et al. [30]

In vivo

GT versus FH

37: idiopathic scoliosis (deformity >90°)

16.4

(10–18)

GT — 396

89.4% (354)

7.3% (29)

3.3% (13)

96.7% (383)

FH — 312

75% (234)

11.9% (37)

11.5% (36)

1.6% (5)

86.9% (271)

2020

A.V. Kosulin et al. [21]

PlM + in vivo

4: congenital scoliosis

10–17

12

91.7% (11)

8.3% (1)

100% (12)

T + L

2017

Liu K. et al. [31]

In vivo

GT versus FH

10 (deformity >70°): idiopathic scoliosis (3), congenital scoliosis (7)

17.7

(13–23)

GT — 48

93.8% (45)

6.2% (3)

100% (48)

FH — 104

78.8% (82)

18.3% (19)

2.9% (3)

97.1% (101)

2017

Putzier M. et al. [14]

PlM + in vivo

4: idiopathic scoliosis (3), neuromuscular scoliosis (1)

17

(13–25)

76

84.2% (64)

11.8% (9)

4% (3)

96.1% (73)

Note. T — thoracic spine; T + L — thoracic and lumbar spine; GT — guide template; FH — free-hand method; PM — plaster model of the vertebrae; PlM — plastic model of the vertebrae; in vivo — installation of transpedicular screws in patients using a guide template; GT versus FH — comparative analysis of the correct positioning of transpedicular screws installed using a guide template and the “free-hand” method; CorScrew — the correct positioning of the screws.

 

In 2 studies, a comparative analysis of the correctness of the TS installation with the use of GT (444 screws) and the “free-hand” method (416 screws) was performed. The correctness of the TS installation was found to be 98.4%–93.8% when using the GT and 75%–78.8% with the “free-hand” method [30, 31]. In three studies, the authors practiced surgery on plastic models of the spine before using the GT during a surgical intervention [14, 21, 28]; in another study, for this purpose, a plaster model of the spine was employed [29]; and, in two studies, the GT was used immediately during the surgery [30, 31]. In general, according to the authors, the correctness of the TS positioning (Grade 0) in the vertebrae ranged from 84.2 to 98.4% (mean value: 91.8%) [14, 21, 28–31].

Our results with the use of GT in preschool children with congenital thoracic and lumbar scoliosis revealed high accuracy and correctness of TS installation (93.7%), which was consistent with the literature data on the use of GT in vivo.

Notably, the number of installed TSs using GT corresponded completely to the number of virtual TSs planned in the program. This is quite important, since, in several cases, it was difficult to predict the final arrangement (the length of instrumental spondylosyndesis and the number of supporting elements) of the spinal metal structure by the standard technique of installing the TS by the “free-hand” method.

Our study data was found to be consistent with that of the work that analyzed the correctness of the TS placement in plastic models of the vertebrae of young and preschool children with congenital kyphoscoliosis in presence of an impaired formation of the vertebrae of the thoracolumbar transition and the lumbar spine. The correctness of the TSs established in vivo in our study was Grade 0 in 93.7% of cases and that in plastic models of the vertebrae (in vitro) was Grade 0 in 96.3%. Meanwhile, using the “free-hand” method, a statistically significantly lower degree of correctness of the TS positioning was achieved with Grade 0 of 80.8% (p = 0.011), which is quite consistent with the literature data [22].

There remains an open issue with the use of GT in pediatric patients presenting with spinal deformities in the presence of multiple vertebral malformations, such as with pronounced changes in the dorsal bone structures of the vertebrae and, particularly, defects in the form of hypoplasia and fusion of vertebral processes or spina bifida posterior.

Obviously, to resolve these issues, preliminary prototyping of the spine with approbation and selection of the GT optimal design are required.

Conclusion

Our results with the use of GT in preschool pediatric patients presenting with congenital scoliosis of the thoracic and lumbar localization indicated high accuracy and correctness of TS installation (93.7%). The installation of TSs using the GT for surgical treatment of spinal congenital deformities in young patients facilitates ensuring of the selection of the optimal standard size and the correct positioning of the transpedicular supporting elements in the instrumented vertebrae. When planning GT, the age-related anatomical and morphological aspects of the dorsal bone structures of the vertebrae as well as the mutual arrangement of the planned virtual TSs should be considered.

Additional information

Source of funding. The present study was conducted within the framework of the Union State program “Development of new spinal systems with the use of prototyping technologies in surgical treatment of pediatric patients with severe congenital deformities and spinal injuries.”

Conflict of interests. The authors declare no conflict of interests.

Ethical statement. The study was conducted in accordance with the ethical standards of the Declaration of Helsinki of the World Medical Association, as amended by the Ministry of Health of Russia, and approved by the ethical committee of the H. Turner National Medical Research Center for Сhildren’s Orthopedics and Trauma Surgery (protocol No. 20-2 of 07/03/2020). The legal representatives of the patients provided their voluntary consent to the publication of clinical cases.

Author contributions

D.N. Kokushin developed the study concept and design; collected and processed the material, analyzed the literary sources, performed surgical treatment of patients, and wrote all sections of the article.

S.V. Vissarionov and A.G. Baindurashvili developed the study concept and design as well as performed staged editing of the text of the article.

A.V. Ovechkina and A.V. Zaletina executed final editing of the article text designed the manuscript.

N.O. Khusainov, M.S. Poznovich collected and processed the study material, analyzed the literary sources, and conducted the surgical treatment of the patients.

All authors made significant contributions to the research and to the preparation of the article, and all of them have read and approved the final version of the manuscript before its publication.

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About the authors

Dmitry N. Kokushin

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Author for correspondence.
Email: partgerm@yandex.ru
ORCID iD: 0000-0002-6112-3309

MD, PhD, Senior Research Associate of the Department of Pathology of the Spine and Neurosurgery

Russian Federation, Saint Petersburg

Sergei V. Vissarionov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: vissarionovs@gmail.ru
ORCID iD: 0000-0003-4235-5048

MD, PhD, D.Sc., Professor, Corresponding Member of RAS, Deputy Director for Research and Academic Affairs, Head of the Department of Spinal Pathology and Neurosurgery

Russian Federation, Saint Petersburg

Alexey G. Baindurashvili

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: turner01@mail.ru
ORCID iD: 0000-0001-8123-6944

MD, PhD, D.Sc., Professor, Member Of RAS, Honored Doctor of the Russian Federation, Director

Russian Federation, Saint Petersburg

Alla V. Ovechkina

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: turner01@mail.ru
ORCID iD: 0000-0002-3172-0065

MD, PhD, Associate Professor, Academic Secretary

Russian Federation, Saint Petersburg

Nikita O. Khusainov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: nikita_husainov@mail.ru
ORCID iD: 0000-0003-3036-3796

MD, PhD, Research Associate of the Department of Pathology of the Spine and Neurosurgery

Russian Federation, Saint Petersburg

Mahmud S. Poznovich

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: poznovich@bk.ru
ORCID iD: 0000-0003-2534-9252

MD, Research Associate of the Genetic Laboratory of the Center for Rare and Hereditary Diseases in Children

Russian Federation, Saint Petersburg

Anna V. Zaletina

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: turner01@mail.ru
ORCID iD: 0000-0002-9838-2777

канд. мед. наук, руководитель научно-организационного отдела, врач — травматолог-ортопед отделения № 11

Russian Federation, Saint Petersburg

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Supplementary files

Supplementary Files
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1. Fig. 1. Planning of virtual screws and guide templates in the PME Planner software environment: a — selection of the size of the transpedicular screw; b — creating the boundaries of the guide template

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2. Fig. 2. Stages of intraoperative examination: a — installation of a guide template on the dorsal bone structures of the vertebra and drilling of a channel for the transpedicular screw; b — probe verification of the integrity of the walls of the formed bone canal in the vertebra; c — installation of X-ray tracers in the vertebral bodies to manage X-ray control

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3. Fig. 3. Design options for the guide template: a — monosegmental with a limited contact area (option 1); b — monosegmental with a contact area including the edges of the spinous process, the arch, and the transverse processes of the vertebra (option 2); c — polysegmental, including ≥2 vertebrae in the contact area (option 3)

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4. Fig. 4. Multispiral computed tomogram of the spine of a patient with congenital scoliosis after extirpation of the posterolateral semi-vertebra L2 with installed transpedicular screws using a guide template, with the completely correct positioning of the screws: a — section in the axial plane; b — section in the coronal plane; c — section in the sagittal plane

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  1. Kosulin AV, Elyakin DV, Korchagina DO, Lukina NA, Shibutova YI, Kolesnikova ES. Transpedicular fixation of the spine with two-level navigation templates for narrow pedicles. Hirurgiâ pozvonočnika (Spine Surgery). 2021;18(2):26. doi: 10.14531/ss2021.2.26-33

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Copyright (c) 2020 Kokushin D.N., Vissarionov S.V., Baindurashvili A.G., Ovechkina A.V., Khusainov N.O., Poznovich M.S., Zaletina A.V.

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