Screw perforation rates in 359 consecutive patients receiving computer-guided pedicle screw insertion along the cervical to lumbar spine

The Impact of Navigation in Lumbar Spine Surgery: A Study of Historical Aspects, Current Techniques and Future Directions

Background/Objectives: We sought to improve accuracy while minimizing radiation hazards, improving surgical outcomes, and preventing potential complications. Despite the increasing popularity of these systems, a limited number of papers have been published addressing the historical evolution, detailing the areas of use, and discussing the advantages and disadvantages, of this increasingly popular system in lumbar spine surgery. Our objective was to offer readers a concise overview of navigation system history in lumbar spine surgeries, the techniques involved, the advantages and disadvantages, and suggestions for future enhancements to the system. Methods: A comprehensive review of the literature was conducted, focusing on the development and implementation of navigation systems in lumbar spine surgeries. Our sources include PubMed-indexed peer-reviewed journals, clinical trial data, and case studies involving technologies such as computer-assisted surgery (CAS), image-guided surgery (IGS), and robotic-assisted systems. Results: To develop more practical, effective, and accurate navigation techniques for spine surgery, consistent advancements have been made over the past four decades. This technological progress began in the late 20th century and has since encompassed image-guided surgery, intraoperative imaging, advanced navigation combined with robotic assistance, and artificial intelligence. These technological advancements have significantly improved the accuracy of implant placement, reducing the risk of misplacement and related complications. Navigation has also been found to be particularly useful in tumor resection and minimally invasive surgery (MIS), where conventional anatomic landmarks are lacking or, in the case of MIS, not visible. Additionally, these innovations have led to shorter operative times, decreased radiation exposure for patients and surgical teams, and lower rates of reoperation. As navigation technology continues to evolve, future innovations are anticipated to further enhance the capabilities and accessibility of these systems, ultimately leading to improved patient outcomes in lumbar spine surgery. Conclusions: The initial limited utilization of navigation system in spine surgery has further expanded to encompass almost all fields of lumbar spine surgeries. As the cost-effectiveness and number of trained surgeons improve, a wider use of the system will be ensured so that the navigation system will be an indispensable tool in lumbar spine surgery. However, continued research and development, along with training programs for surgeons, are essential to fully realize the potential of these technologies in clinical practice.

Comparison of iCT-based navigation and fluoroscopic-guidance for atlantoaxial screw placement in 78 patients with traumatic cervical spine injuries

BACKGROUND CONTEXT

Studies have shown biomechanical superiority of cervical pedicle screw placement over other techniques. However, accurate placement is challenging due to the inherent risk of neurovascular complications. Navigation technology based on intraoperative 3D imaging allows highly accurate screw placement, yet studies specifically investigating screw placement in patients with traumatic atlantoaxial injuries are scarce. The aim of this study was to compare atlantoaxial screw placement as treatment of traumatic instabilities using iCT-based navigation or fluoroscopic-guidance with intraoperative 3D control scans.

METHODS

This was a retrospective review of patients with traumatic atlantoaxial injuries treated operatively with dorsal stabilization of C1 and C2. Patients were either assigned to the intraoperative navigation or fluoroscopic-guidance group. Screw accuracy, procedure time, and revisions were compared.

RESULTS

Seventy-eight patients were included in this study with 51 patients in the navigation group and 27 patients in the fluoroscopic-guidance group. In total, 312 screws were placed in C1 and C2. Screw accuracy was high in both groups; however, pedicle perforations > 1 mm occurred significantly more often in the fluoroscopic-guidance group (P = 0.02). Procedure time was on average 23 min shorter in the navigation group (P = 0.02).

CONCLUSIONS

This study contributes to the available data showing that navigated atlantoaxial screw placement proves to be feasible as well as highly accurate compared to the fluoroscopic-guidance technique without prolonging the time needed for surgery. When comparing these data with other studies, the application of different classification systems for assessment of screw accuracy should be considered.

Cervical Spondylopathy and Lumbar Intervertebral Disc Herniation Coexist in Free Radical Metabolism and Focus Separation in the Body

Lumbar disc herniation is a common lumbar disease in clinics, which is related to improper use of lumbar vertebrae and osteoporosis. Surgical removal of nucleus pulposus and maintenance of lumbar structural stability are important for the treatment of lumbar disc herniation. At present, in clinical percutaneous intervertebral foramen endoscopic surgery for lumbar disc herniation, interlaminar and intervertebral foramen approaches can be selected. Different approaches have different degrees of difficulty in the treatment of lumbar disc herniation, and the clinical effects that may be obtained are different. In this study, we observed the influencing factors of plasma nitric oxide (NO) and free radical metabolism in patients with lumbar disc herniation and the correlation between the effects of focus separation. The organic combination of local and total illness differentiation and dialectics, conventional acupuncture, and electrical stimulation was highlighted in this study, which linked local acupoints squeezed by nerve roots with distant acupoints along meridians. The use of authoritative quantitative standards and a multifactor assessment of the disease can accurately represent the disease's severity. The patient's condition changes in each period may be expressed more accurately, thoroughly, and objectively through the rise or reduction of the score, making self-evaluation easier for the patient. Electroacupuncture at point may be one of the most important strategies to minimize free radical damage, based on changes in plasma levels.

The Clinical Impact of Image Guidance and Robotics in Spinal Surgery: A Review of Safety, Accuracy, Efficiency, and Complication Reduction

Image guidance (IG) and robotic-assisted (RA) surgery are modern technological advancements that have provided novel ways to perform precise and accurate spinal surgery. These innovations supply real-time, three-dimensional imaging information to aid in instrumentation, decompression, and implant placement. Although nothing can replace the knowledge and expertise of an experienced spine surgeon, these platforms do have the potential to supplement the individual surgeon's capabilities. Specific advantages include more precise pedicle screw placement, minimally invasive surgery with less reliance on intraoperative fluoroscopy, and lower radiation exposure to the surgeon and staff. As these technologies have become more widely adopted over the years, novel uses such as tumor resection have been explored. Disadvantages include the cost of implementing IG and robotics platforms, the initial learning curve for both the surgeon and the staff, and increased patient radiation exposure in scoliosis surgery. Also, given the relatively recent transition of many procedures from inpatient settings to ambulatory surgery centers, access to current devices may be cost prohibitive and not as readily available at some centers. Regarding patient-related outcomes, much further research is warranted. The short-term benefits of minimally invasive surgery often bolster the perioperative and early postoperative outcomes in many retrospective studies on IG and RA surgery. Randomized controlled trials limiting such confounding factors are warranted to definitively show potential independent improvements in patient-related outcomes specifically attributable to IG and RA alone. Nonetheless, irrespective of these current unknowns, it is clear that these technologies have changed the field and the practice of spine surgery. Surgeons should be familiar with the potential benefits and tradeoffs of these platforms when considering adopting IG and robotics in their practices.

Accuracy and safety of C2 pedicle or pars screw placement: a systematic review and meta-analysis

Study design

Systematic review and meta-analysis.

Aim

The purpose of this study was to compare the safety and accuracy of the C2 pedicle versus C2 pars screws placement and free-hand technique versus navigation for upper cervical fusion patients.

Methods

Databases searched included PubMed, Scopus, Web of Science, and Cochrane Library to identify all papers published up to April 2020 that have evaluated C2 pedicle/pars screws placement accuracy. Two authors individually screened the literature according to the inclusion and exclusion criteria. The accuracy rates associated with C2 pedicle/pars were extracted. The pooled accuracy rate estimated was performed by the CMA software. A funnel plot based on accuracy rate estimate was used to evaluate publication bias.

Results

From 1123 potentially relevant studies, 142 full-text publications were screened. We analyzed data from 79 studies involving 4431 patients with 6026 C2 pedicle or pars screw placement. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Overall, funnel plot and Begg’s test did not indicate obvious publication bias. The pooled analysis reveals that the accuracy rates were 93.8% for C2 pedicle screw free-hand, 93.7% for pars screw free-hand, 92.2% for navigated C2 pedicle screw, and 86.2% for navigated C2 pars screw (all, P value < 0.001). No statistically significant differences were observed between the accuracy of placement C2 pedicle versus C2 pars screws with the free-hand technique and the free-hand C2 pedicle group versus the navigated C2 pedicle group (all, P value > 0.05).

Conclusion

Overall, there was no difference in the safety and accuracy between the free-hand and navigated techniques. Further well-conducted studies with detailed stratification are needed to complement our findings.

[Assessment of the safety and accuracy of implantation of screws into the C2 vertebra using individual 3D-navigation matrices]

Introduction

Individual 3D-navigation matrices are valuable to increase the safety of screw implantation into the axis.

Objective

To analyze safety and accuracy of screw deployment into the axis using individual 3D-navigation matrices compared to free hand technique.

Material and methods

A retrospective analysis included 23 patients (group 1) who underwent implantation of 44 screws into the axis using the «free hand» technique. The screws were installed along the transpedicular or pars trajectory. A prospective analysis enrolled 17 patients (group 2) who underwent installation of 34 screws using individual navigation matrices. 3D-printing technology was applied for manufacturing these matrices. Implantation results were evaluated considering postoperative CT data and SGT (Screw Guide Template) system.

Results

In the 1st group («free hand»), grade 0 and 1 (no malposition or less than 50% of screw diameter) were recorded for 29 (65.91%) screws, grade 2 - for 13 (29.55%) screws, grade 3 - for 2 (4.45%) screws. Intraoperative injury of the vertebral artery without postoperative neurological deficit occurred in 4 (8.89%) patients. In the 2nd group, 97% of screws were implanted in accordance with grades 1 and 2. Deviation grade 2 was registered in 11 cases (32.35%). Mean deviation was 1.8 ± 1.0 mm. In the 2nd group, 28 (82.35%) out of 34 screws were completely within the bone structures (grade 0), 4 (11.76%) screws perforated pedicles for less than 50% of their diameter (grade 1). There were 2 cases of malposition grade 2 and 3 without vertebral artery injury.

Conclusion

Individual 3D navigation matrix is an effective method for screw installation into the axis. This approach exceeds fluoroscopy-assisted "free hand" technique in terms of safety of implantation.

A minimally invasive, 3D-fluoroscopy-navigation-guided, 3D-controlled pedicle approach in spine surgery: first reliable results and impact on patient safety

PURPOSE

Safe pedicle screw placement is a daily challenge to every spine surgeon. Introduction of minimally invasive approaches in spinal surgery led to an impaired facility of inspection of the surgical field increasing the importance of intraoperative imaging and navigation. During the past years, we established a minimally invasive, navigated approach in our clinical setting.

METHODS

We retrospectively reviewed the accuracy of pedicle approaches in patients treated due to traumatic or osteoporotic fractures, spondylitis/discitis, and tumoral lesions. Guide wires for pedicle screws or kyphoplasty cannulas were inserted in a 3D-navigation-guided, minimally invasive technique. Positioning of the guide wires was verified via 3D-scan, and pedicle screws/kyphoplasty cannulas were then visualized via a.p./lateral radiographs. Accuracy data were compared to a standard navigated open approach control group with indications similar to the MIS-group.

RESULTS

23 MIS patients were included in this study (25-84 years, mean 70 years) with a total of 154 placed guide wires. Handling of the navigated Jamshidi needle was easy and secure. The guide wires showed correct placement in 151/154 cases. Three wires (1.9%) needed correction of placement after control scan. There were no vascular or neurologic complications due to wire misplacement. In the open-surgery control group, 7/181 screws (3.9%) needed intraoperative correction presenting no significant difference compared to the correction rate of the MIS-group (p = 0.35).

CONCLUSION

Our study shows the feasibility and reliability of a navigation-guided, minimally invasive pedicle approach in the clinical setting. Therefore, reduced morbidity due to minimized approaches can be combined with higher accuracy of navigated pedicle screw/kyphoplasty cannula placement improving patient safety.

Role of 3D intraoperative imaging in orthopedic and trauma surgery

Intraoperative three-dimensional (3D) imaging is now feasible because of recent technological advances such as 3D cone-beam CT (CBCT) and flat-panel X-ray detectors (FPDs). These technologies reduce the radiation dose to the patient and surgical team. The aim of this study is to review the advantages of 3D intraoperative imaging in orthopedic and trauma surgery by answering the following 5 questions: What are its technical principles? CBCT with a FPD produces non-distorted digital images and frees up the surgical field. The high quality of these 3D intraoperative images allows them to be integrated into surgical navigation systems. Human-robot comanipulation will likely follow soon after. Conventional multislice CT technology has also improved to the point where it can be used in the operating room. What can we expect from 3D intraoperative imaging and which applications have been validated clinically? We reviewed the literature on this topic for the past 10 years. The expected benefits were determined during the implantation of pedicular screws: more accurate implantation, fewer surgical revisions and time savings. There are few studies in trauma or arthroplasty cases, as robotic comanipulation is a more recent development. What is the tolerance for irradiation to the patient and surgical team? The health drawbacks are the harmful radiation-induced effects. The deterministic effects that we will develop are correlated to the absorbed dose in Gray units (Gy). The stochastic and carcinogenic effects are related to the effective dose in milliSievert (mSv) of linear evolution without threshold. The International Commission on Radiological Protection (ICRP) states that irradiation for medical purposes with risk of detriment is acceptable if it is justified by an optimization attempt. The radioprotection limits must be known but do not constitute opposable restrictions. The superiority of intraoperative 3D imaging over fluoroscopy has been demonstrated for spine surgery and sacroiliac screw fixation. How does the environment need to be adapted? The volume, access, wall protection and floor strength of the operating room must take into account the features of each machine. The instrumentation implants and need for specialized staff result in additional costs. Not every system can track movements during the CBCT acquisition thus transient suspension of assisted ventilation may be required. Is it financially viable? This needs to be calculated based on the expected clinical benefits, which mainly correspond to the elimination of expenses tied to surgical revisions. Our society's search for safety has driven the investments in this technology. LEVEL OF EVIDENCE: V, Expert opinion.

Design and application of subaxial cervical pedicle screw placement guide device

In the present study, a novel subaxial cervical pedicle screw placement guide device was designed and developed. In cervical specimens (C3-C7), a pedicle screw was inserted into the left pedicle using the guide device with a keyhole partial laminectomy and tapping technique, and the right pedicle by drilling using the Abumi technique. After removing the pedicle screws, the channel wall of each pedicle screw was probed with a pedicle probe. The vertebral body was then dissociated for direct observation of the screw channel. Among the 10 specimens, 2 of the 50 pedicles (4%) in the guide device group were perforated. Screw placement failed in 8 of 50 pedicles (16%) in the Abumi technique group. Significant differences were observed in the outcomes for the guide device and Abumi technique groups. The subaxial cervical pedicle screw placement guide device developed in the present study decreased the failure rate of pedicle screw placement.

Three-Dimensional Printed Model-Assisted Screw Installation in Treating Posterior Atlantoaxial Internal Fixation

The aim of this study was to evaluate the efficacy and feasibility of a life-size 3-dimensional printing assisted posterior internal fixation. We performed a retrospective review of 138 patients who received posterior atlantoaxial internal fixation from October 2009 to March 2015 with a minimum follow-up period of 12 months. Group A included 76 patients who received the conventional free-hand technique. Group B included 62 patients who were treated with internal fixation assisted by 3D printing. The placement accuracy of the screw was evaluated in the computed tomography images according to the methods of Hojo and clinical outcomes were evaluated using the visual analogue scale, the Japanese Orthopedic Association Score, and the Neck Disability Index score. There were no significant differences in the clinical results at any of the follow-up time points regarding the JOA, VAS, or NDI scores between two group. However, compared to Group A, Group B had better results for screw installation (P = 0.003), shorter surgery time (P = 0.001), and less blood loss (P = 0.037). Compared to the conventional free-hand technique, 3D printed model–assisted is helpful to screw placement in atlantoaxial internal fixation, which can be used as a common tool to provides important guidance for upper cervical surgery.