4. Likewise, research shows that breaches still occur when these tools are used,33,40 and some studies did not find a difference in pedicle breach rates compared to those with traditional fluoroscopic and freehand techniques.33 Ultimately, misplaced instrumentation is a risk of any spinal fusion surgery, and a thorough discussion of these risks, as well as the alternative management options, is essential to maintain high-quality patient care and to avoid litigation. J Neurosurg Spine. 2012;89(10):7071. Call Us Now For a Free Consultation | Toll Free: 800.583.8002 | Local: 312.346.0045, Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants , Illinois Jury Finds in Favor of Doctor in Gallbladder Surgery that Led to Fatal Bowel Perforation , Debate Over Extent of Eye Damage Following Implant Lens Surgery Leads to $1 Million Verdict in, $75 Million Jury Verdict in Failure to Timely Diagnose Stroke, $18 Million Jury Verdict in Late Diagnosis of Breast Cancer, $300,000 Settlement for Excessive Use of Radiation, Chicago Medical Malpractice Lawyer Kreisman Law Offices Home, Contact Illinois Personal Injury Attorney Kreisman Law Offices. Rev Chir Orthop Reparatrice Appar Mot 62:151160, 1976. Svider PF, Kovalerchik O, Mauro AC, et al. It has a great developing technique that is used for fixation and fusion in spine surgery. 2016;102(2):358362. 32. 1. Level of evidence: From the *Department of Orthopaedic Surgery, University of Crete Medical School, Heraklion, Greece; and the **First Department of Orthopaedics, University of Athens Medical School, Athens, Greece. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. Hardware problems were those related to the physical change of metal and screw position. Plaintiff's expert was prepared to testify at trial that these complaints are characteristic of a malpositioned screw impinging upon a neural structure. Figure 1: Lower thoracic pedicles provide the firm purchase of the pedicle screw from a lateral starting point and 10-15 degrees convergent angle Surgical technique "Free Hand" pedicle screw placement [50] Our "Free Hand" technique is equivalent for lumbar and None of these complications resulted in additional surgery or in a significant increase of morbidity. Drs. Sub-analysis of adolescent idiopathic scoliotic patients showed no curve or patient characteristic that correlated with IMP or SAR. Arthrodesis was questionable in eight asymptomatic patients (7.1%). 2012;7(6):e39237. Operative information including fusion level, number of levels fused, level of misplaced screw(s), single versus multiple misplaced screw(s), presence of known CSF leakage, and primary injury due to screw misplacement was also collected. Jury Verdict for Doctor for Screw Allegedly Misplaced During Lumbar 2018;18(2):209215. 5 Those authors recommend that particular care should be taken in inserting the washers without cross threading and ensuring that they are locked down tightly, with an adequate length of rod protruding beyond the screw. Taylor CL. 10. $ = US$; MW = Midwest; NE = Northeast; SE = Southeast; SW = Southwest; W = West. J Spine Surg. 2013;34(6):699705. Pedicle Screw Insertion in Spondylitis Tuberculosis | ORR Linking and Reprinting Policy. Over 40% of patients had screws with either some/major concern. Although the rate of the reported complications was high, the final outcome of the patients was not affected significantly. States were then grouped by US region and case year by 5-year intervals. Despite commonly used, questions remain about their safety especially for the thoracic spine and in deformity where difficulty in positioning can lead to pedicle breach and adjacent structures injury. 2013;123(9):20992103. They both had motor deficits from which 1 patient recovered completely. The site is secure. After the removal of duplicates, a total of 68 unique cases met our inclusion criteria and were included for analysis. Rajasekaran S, Bhushan M, Aiyer S, et al. The defendants explanation provided an explanation for why Nyquists foot drop did not resolve after the misplaced screw was removed and shed doubt on the plaintiffs theory of liability. A misplacement rate of more than 20 % (129 misplaced screws out of 608) seems to be unacceptable compared to only 4.5 % misplacements when using CT-navigation leading to the conclusion that pedicle screw instrumentation in the middle and upper thoracic area should be carried out with the help of navigation only. Steffee AD, Biscup RS, Sitkowski DJ: Segmental spine plates with pedicle screw fixation: A new internal fixation device for disorders of the lumbar and thoracolumbar spine. Cotrel Y, Dubousset J, Guillaumat M: New universal instrumentation in spinal surgery. Using Low-Dose, Biplanar Imaging to Reduce Screw Misplacement. The last two patients had a T12L1 fracture-dislocation and a L4L5 spondylolytic spondylolisthesis at the site of plug dislodgments. The median time to case closure was longer for defendant-awarded cases, but this finding was not statistically significant (61.5 vs 56.3 months, p > 0.05). Epub 2014 Apr 4. pedicle screw misplacement malpractice The radiology results showed that the surgical screw placed at the right L4-5 area had breached the medial wall and was actually extending into the spinal canal. Koktekir E, Ceylan D, Tatarli N, Karabagli H, Recber F, Akdemir G. Spine J. Patient Suffers Permanent Nerve Damage From Spinal Surgery Spine (Phila Pa 1976). National Library of Medicine Pedicle screw placement accuracy impact and comparison between grading 8,24,25,32. One hundred twelve consecutive patients were entered into a retrospective study of instrumented thoracolumbar, lumbar, and lumbosacral spinal arthrodesis at our institution, between September 1994 and January 1999. 2 One of the first obstacles regarding . Would you like email updates of new search results? In addition, the median time to judgment is substantial, particularly for defendant verdicts, spanning over 4.5 years from the time of surgery. Pedicle instrumentation in the thoracolumbar and lumbar spine is a technically challenging procedure. Surg Neurol. Agarwal N, Gupta R, Agarwal P, et al. All of these patients were asymptomatic and had satisfactory final clinical outcomes (Fig 2). and transmitted securely. Forty-seven general complications were seen in 41 patients (36.5%). In addition, seven (6.3%) dural tears occurred during the decompression and none occurred during instrumentation. Please enable scripts and reload this page. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults, Spinal fusion in the United States: analysis of trends from 1998 to 2008, Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws, The accuracy of pedicle screw placement using intraoperative image guidance systems, Accuracy of pedicle screw insertion by AIRO, intraoperative CT in complex spinal deformity assessed by a new classification based on technical complexity of screw insertion, Pedicle screw placement accuracy using ultra-low radiation imaging with image enhancement versus conventional fluoroscopy in minimally invasive transforaminal lumbar interbody fusion: an internally randomized controlled trial, Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine: a retrospective cohort study of 263 patients, Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO, Accuracy of pedicle screw placement and clinical outcomes of robot-assisted technique versus conventional freehand technique in spine surgery from nine randomized controlled trials: a meta-analysis, Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison, Verdict/Settlement Search and Inclusion/Exclusion Criteria, Plaintiff Claim and Index Surgery Information, Impact of Medical Malpractice on Neurosurgeon and Orthopedic Surgeon Careers, Financial Burden of Medical Malpractice Claims Related to Misplaced Pedicle and/or Lateral Mass Screws, Frequency of Misplaced Pedicle and Lateral Mass Screws in Spine Surgery, Strategies to Improve the Accuracy of Screw Placement in Spine Surgery, Top 25 Cited Gamma Knife Surgery Articles - Trigeminal Neuralgia, Top 25 Cited Gamma Knife Surgery Articles - Volume 111, https://doi.org/10.3171/2020.8.FOCUS20600, https://www.bls.gov/data/inflation_calculator.htm, Volume 49 (2020): Issue 5 (Nov 2020): Medicolegal issues in neurosurgery, Single vs multiple misplaced screw(s), no. 2012;21(suppl 2):S196S199. In the Kane County medical malpractice lawsuit of Melissa Nyquist v. Dr. Taras Masnyk and DuPage Neurosurgery, S.C., 06 L 421, the plaintiffs attorney was unable to convince the jury that the plaintiffs medical complications were caused by the defendants negligence. The literature gave a range of screw misplacement rates detected on postoperative imaging of between 1% and 18%, with the rate generally considered to be around 10%. Under the high-low agreement, Drs. Spine 19(20 Suppl):2279S2296, 1994. Pedicle screw construct have become one of the most practiced procedure in spinal surgery. Eur Spine J. Clinical Orthopaedics and Related Research, Get new journal Tables of Contents sent right to your email inbox, The Association of Bone and Joint Surgeons, Complications and Problems Related to Pedicle Screw Fixation of the Spine, Articles in Google Scholar by Pavlos Katonis, MD, Other articles in this journal by Pavlos Katonis, MD, Privacy Policy (Updated December 15, 2022). A rod is used to hold the vertebra together to allow fusion to occur. Studdert DM, Mello MM, Sage WM, et al. government site. The incidence of screw failure, which can occur despite solid arthrodesis, 7 in the current series was 8% and mainly involved patients with thoracolumbar injury. Epub 2014 Jun 13. This site needs JavaScript to work properly. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. A total of 247 screws (9.07%) were BMP, 52 (1.91%) were IMP, and 29 (1.06%) were considered SAR. 1). Therefore, when instrumentation is to be used, the benefits must outweigh the risks. Thirty-five (27.56%) had IMP and 18 (14.17%) had SAR. The physician ordered an MRI of the lumbar spine which showed that the screws had been misplaced and were puncturing the patient's lumbar nerves. Five patients had uneventful early postoperative course. Jury awards $4.5M over misplaced pedicle screw during spine surgery: 5 things to know Spine Monday, May 7th, 2018 Post Listen Text Size On April 6, a Union County, N.J., jury awarded a plaintiff $4.5 million over a botched spine surgery. 8. With pedicle shapes and sizes varying wildly in the scoliotic spine, misplacement of a screwas well as and under- or oversizingare real possibilities in spine surgery. Makhni MC, Park PJ, Jimenez J, et al. 29. Pullout strength of misplaced pedicle screws in the thoracic and lumbar 26. Descriptive analysis of state and federal spine surgery malpractice litigation in the United States. pedicle screw misplacement malpractice. Continued clinical experience with various pedicle screw implant systems has led to ongoing improvements in system design to minimize implant failure rates and to improve ease of system application. Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis. 23. The purpose of current study was to analyze the complications and problems during and after pedicle screw fixation for various spinal disorders and trauma. may email you for journal alerts and information, but is committed Twenty-one patients (18.8%) had thoracolumbar injuries, and loss of immediate postoperative deformity correction ranged from 1.4 to 4.5. The plaintiff will recover $2.25 million because of a high-low agreement the lawyers entered after closing arguments, the New Jersey Law Journal reports. Crawford MJ, Esses SI: Indications for pedicle fixation: Results of NASS/SRS faculty questionnaire: North American Spine Society and Scoliosis Research Society. Both issues represent the most frequent and highest payouts in spine malpractice claims.10,14,22 While several studies have explored many of the factors related to malpractice claims in spine surgery, the medicolegal impact of misplaced pedicle and/or lateral mass screws has not been directly reported in the literature. This study revealed an overall accuracy rate of 95.2% of mainly percutaneously inserted pedicle screws according to the classification of Zdichavsky et al. However, following the spinal fusion, Nyquist began to experience foot drop in her right foot. In six of these patients with injuries at the thoracolumbar area (four patients with bent screws and two patients with broken screws), the loss of correction ranged from 3 to 4.5 without change of anatomic reduction (Fig 1). Before 5-7 Materials and Methods This is a retrospective study of kyphotic spondylitis tuberculosis (Stb) patients conducted at Fatmawati General Hospital, Jakarta, Indonesia, through the year 2020-2021. single homes for sale in lehigh valley, pa single homes for sale in lehigh valley, pa Home Realizacje i porady Bez kategorii single homes for sale in lehigh valley, pa Better strategies need to be devised for evaluation of screw placement, including establishment of a national database of deformity surgery, use of intra-operative image guidance, and reevaluation of postoperative low-dose CT imaging. Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study. This patient recovered completely in 6 weeks. Balch CM, Oreskovich MR, Dyrbye LN, et al. Re: malpositioned pedicle screw resulting in additional surgery and disability. Neurosurgery. Thus, we are unable to comment on whether all misplaced screws, particularly when asymptomatic, should be revised in an effort to prevent litigation. Eur Spine J. Larson AN, Santos ER, Polly DW Jr, Ledonio CG, Sembrano JN, Mielke CH, Guidera KJ. The plaintiff received $2.4 million for pain and suffering and loss of enjoyment of life, $2 million for lost income and approximately $123,000 for medical expenses. It is an effective procedure in that it provides an almost immediate stabilization of the spine [ 2-5 ]. 0 attorneys agreed. Wolters Kluwer Health 2021 Jul 1;41(Suppl 1):S80-S86. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Neurological Outcome and Management of Pedicle Screws Misplaced Totally Except for two patients with spinal metastatic disease, all other patients received an iliac crest autologous bone grafts. I won't be at the office but I will check my voice mail. Rovit RL, Simon AS, Drew J, et al. Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and, Malpractice liability and defensive medicine: a national survey of neurosurgeons, Defensive medicine among high-risk specialist physicians in a volatile malpractice environment, Defensive medicine: a culprit in spiking healthcare costs, Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study, Defensive medicine in U.S. spine neurosurgery, Personal consequences of malpractice lawsuits on American surgeons. (%), Pseudarthrosis requiring revision surgery. Ultimately, no significant differences in case demographics were found between plaintiff and defendant judgments (Table 1). 2017 Mar;5(2):109-116. doi: 10.1016/j.jspd.2016.10.007. Spine 13:10121018, 1988. Epub 2022 Oct 29. What can spine surgeons do to improve patient care and avoid medical negligence suits? doi: 10.1097/BRS.0b013e31822a2e0a. Problems in the instrumented segments were considered those occurring from narrowing of the disc space greater than 3 mm, pseudarthrosis, and loss of reduction. Pedicle screw insertion - AO Foundation Moreover, several cases stated that the surgeon used only the anteroposterior or the lateral view, but not both, and the plaintiffs counsel used this information in support of their claim. Screw Malposition: Are There Long-term Repercussions to Malposition of Pedicle Screws? Pediatric pedicle screw placement using intraoperative computed tomography and 3-dimensional image-guided navigation. concluded that the robot-assisted technique was significantly more accurate than the traditional freehand technique.39 Despite the learning curve and initial cost of obtaining technologies such as 3D fluoroscopic devices, intraoperative CT, or robotic navigational systems, the routine use of these technologies for intraoperative imaging confirmation and potential revision of misplaced screws may help spine surgeons avoid inadvertent iatrogenic morbidity for their patients and potential litigation. 2011;213(5):657667. Deyo RA, Mirza SK, Martin BI. The rate of reoperation for screw misplacement per screw was 0.17%. True accuracy of percutaneous pedicle screw placement in thoracic and Clin Orthop 203:717, 1986. However, only a few complications were related to a poor clinical outcome. MeSH shooting in valdosta leaves one dead Study supervision: Goodwin, Karikari, Shaffrey, Abd-El-Barr, KD Than. Neurological outcome and management of pedicle screws - PubMed Of the 112 patients, 57 patients had a lumbar degenerative disorder, (lumbar degenerative spinal canal stenosis in 23 patients, degenerative or spondylolytic spondylolisthesis in 12 patients, postlaminectomy instability or stenosis in 20 patients, and recurrent disc prolapse in two patients), 42 patients had spinal cord injury, eight patients had infection, and five patients had a spinal tumor (Table 1). In the other patient, L4L5 float arthrodesis was done. Each case was then carefully screened for relevance and sufficient data. ObjectThe goal of this study was to determine the incidence of screw misplacement and complications in a group of 102 patients who underwent transpedicle screw fixation in the lumbosacral spine with conventional open technique and intraoperative. In this example, the surgeon replaced the misplaced screw prior to leaving the operating room, which arguably played a significant role in the jury ruling in favor of the defendant (surgeon). Seven hundred sixty-three screws were inserted in 138 patients. The accuracy of pedicle screw placement using intraoperative image guidance systems. Brodsky AE: Post-laminectomy and post-fusion stenosis of the lumbar spine. 1. Please try again soon. Clipboard, Search History, and several other advanced features are temporarily unavailable. Dr. Shaffrey has received grants from the NIH and Department of Defense. 6 Pedicle screw placement: Robotic assistance for greater precision leg pain. A TLIF is a surgical procedure that attempts to fuse vertebrae in order to stabilize the patient's spine. On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim. Three slender patients complained of soft tissue irritation and a bothersome prominence because of the screws bulky profile. 16,24,28 Simultaneously, the evolution of the surgical techniques has led to increased procedural safety. Clin Orthop 203:4553, 1986. Hardware-related failures were observed in 12 patients (10.7%). Cookie Policy. Despite this problem, the clinical result was excellent. In the current study, the arthrodesis rate of 89.4% compares favorably with other previously reported series in the spinal literature, most of which use radiographic means to access the status of the spinal arthrodesis. This retrospective study analyzes the complications and the problems developed during and after pedicle screw fixation in patients with spinal disorders and trauma. Pullout performance comparison of pedicle screws based on cement application and design parameters Tolga Tolunay, Cemile Bagl, Teyfik Demir, Mesut E Yaman, and Arslan K Arslan Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 2015 229: 11 , 786-793 Download Citation Elsamadicy AA, Sergesketter AR, Frakes MD, Lad SP. The states with the most cases included California (n = 10, 14.7%), New York (n = 6, 8.8%), Pennsylvania (n = 6, 8.8%), and Illinois (n = 5, 7.3%; Table 2). Review of neurosurgery medical professional liability claims in the United States. However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. Comparison of pedicle screw placement accuracy between two types of Both of these patients complained of thigh pain but refused any additional surgery. 13. Pedicle screw | definition of pedicle screw by Medical dictionary 2021 Nov 26;22(1):986. doi: 10.1186/s12891-021-04860-y. This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). 4. In several of the studies in the spinal literature, the contention that instrumentation improves arthrodesis rates, considering that nonunion contributes to a poor outcome in spinal arthrodesis is favored. J Neurosurg. Unilateral nonunion was seen in three patients (2.7%), associated with implant failure in one of the patients. The authors of the current study aimed to describe this impact in the United States, as well as to suggest a potential method for mitigating the problem. Partner, Paul M. da Costa, Obtains $4.5 Million Verdict - Snyder Sarno Junctional problems were recorded as pathologic changes of the adjacent motion segments, just above and below the instrumented and fused segments. Reviewed submitted version of manuscript: all authors. First, this is a retrospective analysis of cases obtained from the web-based Westlaw Edge legal research database. The majority of screws were misplaced in the lumbar spine for both plaintiff- and defendant-awarded cases (66.7% vs 57.4%, respectively, p = 0.564; Table 1). Katonis, Pavlos MD*; Christoforakis, Joseph MD*; Aligizakis, Agisilaos C. MD*; Papadopoulos, Charalampos MD*; Sapkas, George MD, DSc**; Hadjipavlou, Alexander MD*. Plaintiff award amounts were adjusted for inflation as of April 2020 using an online inflation calculator provided by the US Bureau of Labor Statistics (https://www.bls.gov/data/inflation_calculator.htm). Spine 8:970981, 1996. Thoracic Pedicle Screws - ScienceDirect In the remaining patients, the standard construct was three-segment fixation spanning four vertebrae and three discs, two above and one below the fractured vertebra, using six screws. 2014;20(6):636643. In the current series, there were no cases of screw misplacement or vascular or neurologic complications caused by implant application. In addition, studies have shown that over 85% of malpractice claims are either dismissed or settled out of court,14 which likely results in a high degree of underreporting. These complications may have resulted from powerful bending movement acting on the screw at its entry point to the bone. West et al 33 also reported a 29% complication rate for the first 50 patients and a 26% complication rate for the last 74 patients. St Louis, CV Mosby 322327, 1987. Results: A total of 2724 screws were placed in 127 patients. Spine 16:576579, 1991. FOIA 17,18,31,39 Edwards 6 showed that solid arthrodesis developed in 96% of patients without previous surgery, whereas 84% of patients having secondary operations experienced a similar result. Epstein NE. Importantly, these advanced technologies are not always readily available or the standard of care and cannot supplant a thorough understanding of operative anatomy, a high-quality surgical technique, and general complication-avoidance measures. Median screw misplacement rate was 10% in group A and 13% in group B. Spine 14:472476, 1989. Through the use of expert witness testimony, Mr. da Costa was able to prove to the jury that by misplacing the pedicle screw during the surgery, and failing to timely diagnose and correct the malpositioned screw, Defendants deviated from accepted standards of care. A large number of studies have reported that in conventional thoracolumbar surgery, compared with traditional freehand screw placement, the accuracy of intraoperative pedicle screw placement has been improved with O-arm intraoperative navigation technology. A CT scan was taken to try and identify the underlying neurological problem that might be causing the new symptom. Weinstein JN, Spratt KF, Spengler D, Brick C, Reid S: Spinal pedicle fixation: Reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. 11. 6. Friedlander and Bradley will pay half of the $2.25 million. The median time to case closure was 56.3 (35.267.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.477.2) months for defendant (surgeon) verdicts (p = 0.117). Schlegel JD, Smith JA, Schleusener RN: Lumbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. [] The accuracy for free-hand screw placement technique varies from 69% to 94%. 12. Orthop Trans 11:99, 1987. Instrumentation removal is an option for patients with successful arthrodesis, but remains controversial. 2016;124(5):15241530. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. In five patients with thoracolumbar injuries, who were the first treated in the current series, and in four patients with fractures in the lower lumbar spine, two-segment fixation was used. 19. These numbers are in line with the current literature. There were two complete degenerations of the upper disc, one central canal stenosis, and two asymptomatic disc space narrowings and retrolistheses. The patient had to undergo a subsequent surgery to remove the pedicles. Jena AB, Seabury S, Lakdawalla D, Chandra A. Nevertheless, research has shown that screws are misplaced in approximately 14%55% of cases using the standard techniques (freehand and 2D fluoroscopic guidance) employed by most spine surgeons,21,33 resulting in injury in approximately 1%8% of cases.21 In addition to the avoidable procedural risk to the patient, each misplaced screw carries the threat of future litigation, as reported above. Of note, while only 38.2% (n = 26) of cases in our study mentioned the use of intraoperative radiographic confirmation, only one of these cases reported that the misplaced screw had been caught prior to leaving the operating room, which had resulted in an inadvertent dural tear and L5 nerve root injury. The patient had subsequent coronal imbalance and degeneration of the upper disc. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. Patient-specific 3D-printed surgical guides for pedicle screw insertion Cases involving wrong-level or -side surgery, implant malfunction, or other misplaced spinal instrumentation (e.g., interbody cases, rods, surgical instruments, etc.) Pedicle screw instrumentation is widely used for the stabilization of the subaxial cervical, thoracic, and lumbar spine. To investigate intraoperative reinsertion of percutaneous pedicle screw (PPS) with intraoperative CT-based navigation and to evaluate the rate of deviation of PPS at postoperative radiographic examination. There were no observed cases of screw misplacement outside the pedicle on routine AP and lateral radiographs. 2020;162(6):13791387. Two patients had early postoperative postural headache that disappeared after removal of the misplaced screw.
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