Safety of supplemental endplate screws in thoracic pedicle hook fixation

Object. The AO Universal Spine System thoracic pedicle hook design includes a fixation screw that passes obliquely through the inferior facet into the pedicle to engage in the posterior portion of the superior vertebral body endplate. This endplate screw provides additional purchase at the hook-bone interface. To determine the safety of this fixation system the authors reviewed the operative notes, radiographs, and outcomes of patients who underwent placement of endplate screws. Methods. Thirty-six patients (16 male and 20 female patients) who required posterior thoracic instrumentation for spinal deformity (11 cases), neoplasm (15 cases), and traumatic injury (10 cases) were included in this study. One hundred sixty-four endplate screws were placed (mean 4.3/patient) to augment pedicle hooks for posterior thoracic instrumentation. The number of instrumented levels ranged from seven to 16. The positions of the screws in relation to the pedicle, neural foramen, spinal canal, and endplate were evaluated by assessing plain radiographs and computerized tomography scans (10 cases). Eighty-two screws (56%) were in ideal position. Lateral pedicle wall perforation occurred with 51 screws (35%). Three screws violated the medial wall and nine screws violated the superior or inferior walls of the pedicle. There were no clinical sequelae associated with any of the malpositioned screws. Adequate follow-up radiographic data were not available in five patients. The mean follow-up duration was 19.8 months (range 3-61 months). Two patients required revision surgery at 3 months and 18 months, respectively, because of hook/endplate screw displacement. There was also one case of an endplate screw fracture without hook displacement that was discovered during subsequent revision surgery. The remainder of the endplate screws and associated pedicles hooks maintained their original positions. There was no case of spinal cord, nerve root, pulmonary, or vascular injury. Conclusions. The placement of supplemental endplate screws in conjunction with thoracic pedicle hooks can be conducted safely.