Assessment of the accuracy of pedicle screw fixation in thoracolumbar vertebrae using freehand technique in resource-limited settings: insights from a prospective analysis

Abstract

Background. Thoracolumbar fractures and diseases represent a significant healthcare problem. Pedicle fixation is a cornerstone in the surgical stabilization of spinal disorders, where spinal stability is crucial for maintaining proper biomechanical function and preventing neurological compromise. The aims: 1) to reassess the accuracy of freehand pedicle screw fixation in thoracolumbar vertebrae, particularly within the context of resource-limited settings where image-guidance technologies are not feasible; 2) to explore how surgical ergonomics, particularly surgeon handedness, affects screw placement accuracy. Methods. A prospective study was conducted, recruiting 90 patients with thoracolumbar lesions who underwent pedicle screw fixation by freehand technique in 2024. We excluded patients with congenital spine deformities and revision surgery. The accuracy and incidence of cortical breach of screws were determined by postoperative CT. Results. Six hundred eighty-one screws were inserted in the lumbar and thoracic spine of 90 patients using a freehand approach. Out of them, 579 (85%) screws were installed within the pedicle without cortical breach, 78 (11.4%) screws — with a cortical breach less than 2 mm, and 24 (3.5%) screws — a with a cortical breach more than 2 mm. Six hundred fifty-seven (96.4%) screws were considered a safe breach, and 24 (3.6%) screws were considered a dangerous breach. Conclusions. The use of freehand technique in pedicle screw fixation appears to be reliable and safe. It remains a valuable method, particularly in a resource-limited environment, providing a cost-effective and radiation-free alternative to navigation-assisted systems. This study reveals that surgical ergonomics, specifically surgeon handedness, do not significantly impact a breach when proper technique is maintained.