J Neurol Surg A Cent Eur Neurosurg 2021; 82(03): 262-269
DOI: 10.1055/s-0040-1715485
Technical Note

Simulation with 3D Neuronavigation for Learning Cortical Bone Trajectory Screw Placement

1   Division of Neurosurgery University Hospital 12 de Octubre, Madrid, Spain
Natalia Frade-Porto
2   Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
Guillermo Blasco
2   Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
Patricia Gonzalez-Tarno
2   Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
Ricardo Gil-Simoes
2   Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
Paloma Pulido
2   Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
R.G. Sola
3   Department of Innovation in Neurosurgery, Universidad Autónoma de Madrid, Madrid, Spain
4   Neurosurgical Department Hospital Nuestra Señora del Rosario, Madrid, Spain
› Author Affiliations


Background and Objective Learning a new technique in neurosurgery is a big challenge especially for trainees. In recent years, simulations and simulators got into the focus as a teaching tool. Our objective is to propose a simulator for placement of cortical bone trajectory (CBT) screws to improve results and reduce complications.

Methods We have created a platform consisting of a sawbone navigated with a 3D fluoroscope to familiarize our trainees and consultants with CBT technique and later implement it in our department. Objective Structured Assessment of Technical Skills (OSATS) and Physician Performance Diagnostic Inventory Scale (PPDI) were obtained before and after the use of the simulator by the five participants in the study. Patients who were operated on after the implementation of the technique were retrospectively reviewed.

Results During the simulation, there were 4 cases of pedicle breach out of 24 screws inserted (16.6%). After having completed simulation, participants demonstrated an improvement in OSATS and PPDI (p = 0.039 and 0.042, respectively). Analyzing the answers to the different items of the tests, participants mainly improved in the knowledge (p = 0.038), the performance (p = 0.041), and understanding of the procedure (p = 0.034). In our retrospective series, eight patients with L4–L5 instability were operated on using CBT, improving their Oswestry Disability Index (ODI) score (preoperative ODI 58.5 [SD 16.7] vs. postoperative ODI 31 [SD 13.4]; p = 0.028). One intraoperative complication due to a dural tear was observed. In the follow-up, we found a case of pseudoarthrosis and a facet joint violation, but no other complications related to misplacement, pedicle fracture, or hardware failure.

Conclusion The simulation we have created is useful for the implementation of CBT. In our study, consultants and trainees have valued very positively the learning obtained using the system. Moreover, simulation facilitated the learning of the technique and the understanding of surgical anatomy. We hope that simulation helps reducing complications in the future.

Publication History

Received: 22 November 2019

Accepted: 23 March 2020

Article published online:
01 December 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Volbers B, Wagner I, Willfarth W, Doerfler A, Schwab S, Staykov D. Intraventricular fibrinolysis does not increase perihemorrhagic edema after intracerebral hemorrhage. Stroke 2013; 44 (02) 362-366
  • 2 Macdonald RL. Editorial: see one, simulate fifty, then do one?. J Neurosurg 2014; 121 (02) 225-227 , discussion 226–227
  • 3 Weinstock P, Rehder R, Prabhu SP, Forbes PW, Roussin CJ, Cohen AR. Creation of a novel simulator for minimally invasive neurosurgery: fusion of 3D printing and special effects. J Neurosurg Pediatr 2017; 20 (01) 1-9
  • 4 Bergeson RK, Schwend RM, DeLucia T, Silva SR, Smith JE, Avilucea FR. How accurately do novice surgeons place thoracic pedicle screws with the free hand technique?. Spine 2008; 33 (15) E501-E507
  • 5 Ray WZ, Ganju A, Harrop JS, Hoh DJ. Developing an anterior cervical diskectomy and fusion simulator for neurosurgical resident training. Neurosurgery 2013; 73 (Suppl. 01) 100-106
  • 6 Krishnaney AA. Incorporating simulators into neurosurgical education. World Neurosurg 2015; 84 (06) 1527-1529
  • 7 Spicer MA, Apuzzo MLJ. Virtual reality surgery: neurosurgery and the contemporary landscape. Neurosurgery 2003; 52 (03) 489-497 , discussion 496–497
  • 8 Chan S, Conti F, Salisbury K, Blevins NH. Virtual reality simulation in neurosurgery: technologies and evolution. Neurosurgery 2013; 72 (Suppl. 01) 154-164
  • 9 Craven CL, Cooke M, Rangeley C, Alberti SJMM, Murphy M. Developing a pediatric neurosurgical training model. J Neurosurg Pediatr 2018; 21 (03) 329-335
  • 10 Milburn JA, Khera G, Hornby ST, Malone PSC, Fitzgerald JEF. Introduction, availability and role of simulation in surgical education and training: review of current evidence and recommendations from the Association of Surgeons in Training. Int J Surg 2012; 10 (08) 393-398
  • 11 Marcus H, Vakharia V, Kirkman MA, Murphy M, Nandi D. Practice makes perfect? The role of simulation-based deliberate practice and script-based mental rehearsal in the acquisition and maintenance of operative neurosurgical skills. Neurosurgery 2013; 72 (Suppl. 01) 124-130
  • 12 Luciano CJ, Banerjee PP, Bellotte B. et al. Learning retention of thoracic pedicle screw placement using a high-resolution augmented reality simulator with haptic feedback. Neurosurgery 2011; 69 (1, Suppl Operative): ons14-ons19, discussion ons19
  • 13 Gragnaniello C, Abou-Hamden A, Mortini P. et al. Complex spine pathology simulator: an innovative tool for advanced spine surgery training. J Neurol Surg A Cent Eur Neurosurg 2016; 77 (06) 515-522
  • 14 Gasco J, Patel A, Ortega-Barnett J. et al. Virtual reality spine surgery simulation: an empirical study of its usefulness. Neurol Res 2014; 36 (11) 968-973
  • 15 Boody BS, Rosenthal BD, Jenkins TJ, Patel AA, Savage JW, Hsu WK. The effectiveness of bioskills training for simulated open lumbar laminectomy. Global Spine J 2017; 7 (08) 794-800
  • 16 Gonzalvo A, Fitt G, Liew S. et al. The learning curve of pedicle screw placement: how many screws are enough?. Spine 2009; 34 (21) E761-E765
  • 17 Delgado-Fernández J, Pulido P, García-Pallero MÁ, Blasco G, Frade-Porto N, Sola RG. Image guidance in transdiscal fixation for high-grade spondylolisthesis in adults with correct spinal balance. Neurosurg Focus 2018; 44 (01) E9
  • 18 Santoni BG, Hynes RA, McGilvray KC. et al. Cortical bone trajectory for lumbar pedicle screws. Spine J 2009; 9 (05) 366-373
  • 19 Dabbous B, Brown D, Tsitlakidis A, Arzoglou V. Clinical outcomes during the learning curve of MIDline Lumbar Fusion (MIDLF®) using the cortical bone trajectory. Acta Neurochir (Wien) 2016; 158 (07) 1413-1420
  • 20 Delgado-Fernandez J, García-Pallero MÁ, Blasco G, Pulido-Rivas P, Sola RG. Review of cortical bone trajectory: evidence of a new technique. Asian Spine J 2017; 11 (05) 817-831
  • 21 Asamoto S, Kojima K, Winking M, Jödicke A, Ishikawa M, Ishihara S, Deinsberger W, Muto J, Nishiyama M, Asamoto S. et al. Optimized Screw Trajectory for Lumbar Cortical Bone Trajectory Pedicle Screws Based on Clinical Outcome: Evidence Favoring the Buttress Effect Theory. J Neurol Surg A Cent Eur Neurosurg 2018; Nov; 79 (06) 464-470
  • 22 Snyder LA, Martinez-Del-Campo E, Neal MT. et al. Lumbar spinal fixation with cortical bone trajectory pedicle screws in 79 patients with degenerative disease: perioperative outcomes and complications. World Neurosurg 2016; 88: 205-213
  • 23 Brasiliense LBC, Lazaro BCR, Reyes PM. et al. Characteristics of immediate and fatigue strength of a dual-threaded pedicle screw in cadaveric spines. Spine J 2013; 13 (08) 947-956
  • 24 Iwatsuki K, Yoshimine T, Ohnishi Y, Ninomiya K, Ohkawa T. Isthmus-guided cortical bone trajectory for pedicle screw insertion. Orthop Surg 2014; 6 (03) 244-248
  • 25 Delgado-Fernández J, Pulido Rivas P, Gil-Simoes R, de Sola RG. How I do it? Lumbar cortical bone trajectory fixation with image-guided neuronavigation. Acta Neurochir (Wien) 2019; 161 (12) 2423-2428
  • 26 Martin JA, Regehr G, Reznick R. et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 1997; 84 (02) 273-278
  • 27 Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000; 25 (22) 2940-2952 , discussion 2952
  • 28 Ericsson A, Krampe R, Tesch-Romer C. The role of deliberate practice in the aquisition of expert performance. Psychol Rev 1993; 100 (03) 363-406
  • 29 Silva F, Silva PS, Vaz R, Pereira P. Midline lumbar interbody fusion (MIDLIF) with cortical screws: initial experience and learning curve. Acta Neurochir (Wien) 2019; 161 (12) 2415-2420
  • 30 Dayani F, Chen YR, Johnson E. et al. Minimally invasive lumbar pedicle screw fixation using cortical bone trajectory: screw accuracy, complications, and learning curve in 100 screw placements. J Clin Neurosci 2019; 61: 106-111
  • 31 Khanna N, Deol G, Poulter G, Ahuja A. Medialized, muscle-splitting approach for posterior lumbar interbody fusion: technique and multicenter perioperative results. Spine 2016; 41 (08) (Suppl. 08) S90-S96
  • 32 Khanna N, Deol G, Poulter G, Ahuja A. Medialized, muscle-splitting approach for posterior lumbar interbody fusion: technique and multicenter perioperative results. Spine (Phila Pa 1976) 2016; 41 (Suppl 8): S90-S96
  • 33 Marengo N, Berjano P, Cofano F. et al. Cortical bone trajectory screws for circumferential arthrodesis in lumbar degenerative spine: clinical and radiological outcomes of 101 cases. Eur Spine J 2018; 27 (0123456789, Suppl 2): 213-221
  • 34 Lee GW, Son JH, Ahn MW, Kim HJ, Yeom JS. The comparison of pedicle screw and cortical screw in posterior lumbar interbody fusion: a prospective randomized noninferiority trial. Spine J 2015; 15 (07) 1519-1526
  • 35 Sakaura H, Miwa T, Yamashita T, Kuroda Y, Ohwada T. Posterior lumbar interbody fusion with cortical bone trajectory screw fixation versus posterior lumbar interbody fusion using traditional pedicle screw fixation for degenerative lumbar spondylolisthesis: a comparative study. J Neurosurg Spine 2016; 25 (05) 591-595
  • 36 Hussain I, Virk MS, Link TW, Tsiouris AJ, Elowitz E. Posterior lumbar interbody fusion with 3D-navigation guided cortical bone trajectory screws for L4/5 degenerative spondylolisthesis: 1-year clinical and radiographic outcomes. World Neurosurg 2018; 110: e504-e513
  • 37 Lee GW, Shin JH. Comparative study of two surgical techniques for proximal adjacent segment pathology after posterior lumbar interbody fusion with pedicle screws: fusion extension using conventional pedicle screw vs cortical bone trajectory-pedicle screw (cortical screw). World Neurosurg 2018; 117: e154-e161
  • 38 Penner F, Marengo N, Ajello M. et al. Preoperative 3D CT planning for cortical bone trajectory screws: a retrospective radiological cohort study. World Neurosurg 2019; 126: e1468-e1474
  • 39 Kirkman MA, Ahmed M, Albert AF, Wilson MH, Nandi D, Sevdalis N. The use of simulation in neurosurgical education and training. A systematic review. J Neurosurg 2014; 121 (02) 228-246
  • 40 Marengo N, Matsukawa K, Monticelli M. et al. Cortical bone trajectory screw placement accuracy with a patient-matched 3-dimensional printed guide in lumbar spinal surgery: a clinical study. World Neurosurg 2019; 130: e98-e104
  • 41 Matsukawa K, Kaito T, Abe Y. Accuracy of cortical bone trajectory screw placement using patient-specific template guide system. Neurosurg Rev 2019; (e-pub ahead of print) DOI: 10.1007/s10143-019-01140-1.