Accuracy of Patient-Specific Template-Guided Versus Freehand Cervical Pedicle Screw Placement from C2 to C7: A Randomized Cadaveric Study

Background: Dorsal spinal instrumentation with cervical pedicle screws (CPS) and rod constructs is performed for numerous pathologies of the cervical spine, although technically demanding. Screw misplacement is biomechanically disadvantageous and carries the risk of neurovascular sequelae. The aim of this study was to assess the accuracy of patient-specific, template-guided CPS placement from C2 to C7 compared with the freehand technique.

Methods: Patient-specific targeting guides were used for placement of 3.5 mm CPS from C2 to C7 in 4 cadaveric specimens. Template-guided instrumentation was randomized for each cervical level and side and the contralateral side instrumented likewise but with the freehand technique. No fluoroscopy was used at all, and the spinal canal was not opened for the freehand technique. Accuracy was assessed by computed tomography, grading perforations using a 2-mm increment method, and time efficiency was compared between the 2 techniques.

Results: In total, 48 screws were inserted with an equal distribution of 24 screws (50%) in each of the 2 groups. Outer pedicle width averaged 5.1 ± 1.0 mm (range 2.7-7.8); 66.7% (n = 16) of template-guided versus 20.8% (n = 5) of freehand CPS were fully contained within the pedicle (P = 0.001), whereas 91.7% (n = 22) versus 50% (n = 12) were within the <2 mm "safe" zone (P = 0.001). The mean time for instrumentation per level and side was 03:09 ± 01:37 minutes for the template-guided versus 02:32 ± 01:04 minutes for the freehand technique (P = 0.132).

Conclusions: In a cadaver model, template-guided CPS placement has a significantly greater accuracy than the freehand technique. This accuracy is comparable with navigated techniques reported in the literature.