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Heydar AM, Tanaka M, Prabhu SP, Komatsubara T, Arataki S, Yashiro S, Kanamaru A, Nanba K, Xiang H, Hieu HK. The Impact of Navigation in Lumbar Spine Surgery: A Study of Historical Aspects, Current Techniques and Future Directions. J Clin Med 2024; 13:4663. [PMID: 39200805 PMCID: PMC11354833 DOI: 10.3390/jcm13164663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/02/2024] [Accepted: 08/06/2024] [Indexed: 09/02/2024] Open
Abstract
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.
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Affiliation(s)
- Ahmed Majid Heydar
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
- Orthopedic and Traumatology Clinic, Memorial Bahçelievler Hospital, Bahçelievler Merkez, Adnan Kahveci Blv. No: 227, 34180 İstanbul, Turkey
| | - Masato Tanaka
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
| | - Shrinivas P. Prabhu
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
| | - Tadashi Komatsubara
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
| | - Shinya Arataki
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
| | - Shogo Yashiro
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
| | - Akihiro Kanamaru
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
| | - Kazumasa Nanba
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
| | - Hongfei Xiang
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
| | - Huynh Kim Hieu
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama 702-8055, Japan; (A.M.H.); (S.P.P.); (T.K.); (S.A.); (S.Y.); (A.K.); (K.N.); (H.X.); (H.K.H.)
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Supanich M, Siewerdsen J, Fahrig R, Farahani K, Gang GJ, Helm P, Jans J, Jones K, Koenig T, Kuhls-Gilcrist A, Lin M, Riddell C, Ritschl L, Schafer S, Schueler B, Silver M, Timmer J, Trousset Y, Zhang J. AAPM Task Group Report 238: 3D C-arms with volumetric imaging capability. Med Phys 2023; 50:e904-e945. [PMID: 36710257 DOI: 10.1002/mp.16245] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 12/21/2022] [Accepted: 01/09/2023] [Indexed: 01/31/2023] Open
Abstract
This report reviews the image acquisition and reconstruction characteristics of C-arm Cone Beam Computed Tomography (C-arm CBCT) systems and provides guidance on quality control of C-arm systems with this volumetric imaging capability. The concepts of 3D image reconstruction, geometric calibration, image quality, and dosimetry covered in this report are also pertinent to CBCT for Image-Guided Radiation Therapy (IGRT). However, IGRT systems introduce a number of additional considerations, such as geometric alignment of the imaging at treatment isocenter, which are beyond the scope of the charge to the task group and the report. Section 1 provides an introduction to C-arm CBCT systems and reviews a variety of clinical applications. Section 2 briefly presents nomenclature specific or unique to these systems. A short review of C-arm fluoroscopy quality control (QC) in relation to 3D C-arm imaging is given in Section 3. Section 4 discusses system calibration, including geometric calibration and uniformity calibration. A review of the unique approaches and challenges to 3D reconstruction of data sets acquired by C-arm CBCT systems is give in Section 5. Sections 6 and 7 go in greater depth to address the performance assessment of C-arm CBCT units. First, Section 6 describes testing approaches and phantoms that may be used to evaluate image quality (spatial resolution and image noise and artifacts) and identifies several factors that affect image quality. Section 7 describes both free-in-air and in-phantom approaches to evaluating radiation dose indices. The methodologies described for assessing image quality and radiation dose may be used for annual constancy assessment and comparisons among different systems to help medical physicists determine when a system is not operating as expected. Baseline measurements taken either at installation or after a full preventative maintenance service call can also provide valuable data to help determine whether the performance of the system is acceptable. Collecting image quality and radiation dose data on existing phantoms used for CT image quality and radiation dose assessment, or on newly developed phantoms, will inform the development of performance criteria and standards. Phantom images are also useful for identifying and evaluating artifacts. In particular, comparing baseline data with those from current phantom images can reveal the need for system calibration before image artifacts are detected in clinical practice. Examples of artifacts are provided in Sections 4, 5, and 6.
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Affiliation(s)
- Mark Supanich
- Rush University Medical Center, Chicago, Illinois, USA
| | | | | | | | | | - Pat Helm
- Medtronic Inc., Minneapolis, Minnesota, USA
| | | | - Kyle Jones
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - MingDe Lin
- Yale University, New Haven, Connecticut, USA
| | | | | | | | | | - Mike Silver
- Canon Medical Systems USA, Long Beach, California, USA
| | | | | | - Jie Zhang
- University of Kentucky, Lexington, Kentucky
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Yamout T, Orosz LD, Good CR, Jazini E, Allen B, Gum JL. Technological Advances in Spine Surgery: Navigation, Robotics, and Augmented Reality. Orthop Clin North Am 2023; 54:237-246. [PMID: 36894295 DOI: 10.1016/j.ocl.2022.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Accurate screw placement is critical to avoid vascular or neurologic complications during spine surgery and to maximize fixation for fusion and deformity correction. Computer-assisted navigation, robotic-guided spine surgery, and augmented reality surgical navigation are currently available technologies that have been developed to improve screw placement accuracy. The advent of multiple generations of new technologies within the past 3 decades has presented surgeons with a diverse array of choices when it comes to pedicle screw placement. Considerations for patient safety and optimal outcomes must be paramount when selecting a technology.
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Affiliation(s)
- Tarek Yamout
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Lindsay D Orosz
- National Spine Health Foundation, 11800 Sunrise Valley Drive, Suite 330, Reston, VA 20191, USA
| | - Christopher R Good
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Ehsan Jazini
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Brandon Allen
- National Spine Health Foundation, 11800 Sunrise Valley Drive, Suite 330, Reston, VA 20191, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street Suite 900, Louisville, KY 40202, USA.
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Cammarata G, Scalia G, Costanzo R, Umana GE, Furnari M, Ponzo G, Giuffrida M, Maugeri R, Iacopino DG, Nicoletti GF, Graziano F. Fluoroscopy-Assisted Freehand Versus 3D-Navigated Imaging-Assisted Pedicle Screw Insertion: A Multicenter Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:425-430. [PMID: 38153504 DOI: 10.1007/978-3-031-36084-8_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Pedicle screw placement is a widely accepted surgical procedure for spinal fixation. Despite increases in knowledge about and expertise in pedicle screw insertion techniques, overall reported screw misplacement rates are still high. Spinal neuronavigation and intraoperative computed tomography (CT) imaging improves the accuracy and safety of pedicle screw placement through the continuous monitoring of screw trajectory. The purpose of this study is to compare pedicle screw placement under an O-arm intraoperative imaging system assisted by the StealthStation navigation system with screw placement under conventional fluoroscopy (C-arm). METHODS For 222 patients, 1288 implanted pedicle screws in total were evaluated between 2018 and 2020. All patients underwent pedicle screw placement in the thoracic and lumbosacral regions through a posterior approach. Moreover, 107 patients (48.2%), 48 men and 59 women, underwent freehand screw placement under conventional fluoroscopy (C-arm group), whereas 115 patients (51.8%), 53 men and 62 women, underwent pedicle screw insertion under O-arm guidance with the help of the StealthStation neuronavigation system (Medtronic Navigation, Louisville, CO, USA) (O-arm group). Data were recorded and retrospectively analyzed. The accuracy of pedicle screw placement was postoperatively examined by using CT imaging and analyzed according to the Gertzbein-Robbins classification. RESULTS Of the 1288 pedicle screws, 665 (51.6%) were placed with C-arm image-guided assistance with a mean of 6.21 ± 2.1 screws per patient and 643 (48.4%) with O-arm image-guided assistance with a mean of 5.59 ± 1.6 screws. The average time for the screw placement procedure was 3:57 ± 1:07 h in the C-arm group and 4:21 ± 1:41 h in the O-arm group. A correct screw placement was detected in 92.78% of patients in the C-arm group and in 98.13% of patients in the O-arm group. Medial cortical breach was shown in 13 Grade B screws (1.95%), 19 Grade C (2.86%), 14 Grade D (2.11%), and two Grade E (0.3%) in the C-arm group, whereas this was shown in 11 Grade B screws (1.71%) and one Grade C (0.16%) in the O-arm group. Lateral breach occurred in eight screws in both groups. Anterior vertebral body breach was shown in eight screws in the C-arm group, whereas it was shown in four screws in the O-arm group. Reoperation for screw misplacement was mandatory in five patients in the C-arm group and two patients in the O-arm group. CONCLUSION Pedicle screw placement under an O-arm intraoperative imaging system assisted by spinal navigation showed greater accuracy compared with placement under conventional fluoroscopic control, thus avoiding the onset of major postoperative complications. Notably, a reduction in medial and anterior breaches has been demonstrated.
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Affiliation(s)
| | - Gianluca Scalia
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Roberta Costanzo
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone", Palermo, Italy
| | - Giuseppe Emmanuele Umana
- Division of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy
| | - Massimo Furnari
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Giancarlo Ponzo
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Massimiliano Giuffrida
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone", Palermo, Italy
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone", Palermo, Italy
| | | | - Francesca Graziano
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone", Palermo, Italy
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Goldberg JL, Härtl R, Elowitz E. Minimally Invasive Spine Surgery: An Overview. World Neurosurg 2022; 163:214-227. [PMID: 35729823 DOI: 10.1016/j.wneu.2022.03.114] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/29/2022]
Abstract
Spinal surgery is undergoing a major transformation toward a minimally invasive paradigm. This shift is being driven by multiple factors, including the need to address spinal problems in an older and sicker population, as well as changes in patient preferences and reimbursement patterns. Increasingly, minimally invasive surgical techniques are being used in place of traditional open approaches due to significant advancements and implementation of intraoperative imaging and navigation technologies. However, in some patients, due to specific anatomic or pathologic factors, minimally invasive techniques are not always possible. Numerous algorithms have been described, and additional efforts are underway to better optimize patient selection for minimally invasive spinal surgery (MISS) procedures in order to achieve optimal outcomes. Numerous unique MISS approaches and techniques have been described, and several have become fundamental. Investigators are evaluating combinations of MISS techniques to further enhance the surgical workflow, patient safety, and efficiency.
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Affiliation(s)
- Jacob L Goldberg
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Roger Härtl
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Eric Elowitz
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.
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Kim CW. MIS TLIF, EndoTLIF, and the Ability of Navigation/Robotics to Enable Spinal Surgery in an Ambulatory Care Setting. Global Spine J 2022; 12:34S-39S. [PMID: 35393877 PMCID: PMC8998480 DOI: 10.1177/21925682221074667] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Technical Report. OBJECTIVE Performing surgeries in the ambulatory surgery center affords improved efficiencies in terms of cost and speed. However, ambulatory surgery is only successful if complications, re-admissions, and re-operations are avoided. This report describes the San Diego Outpatient Lumbar Fusion Program, a culmination of cumulative incremental improvements in patient selection and patient education, meticulous peri-operative management, minimally invasive techniques together with navigation/robotics. METHODS Retrospective review of prospectively collected data on 1-2 level minimally invasive transforaminal lumbar interbody fusions (MIS TLIF). RESULTS Healthy patients (age 72 years old or less, BMI less than 50, ASA 1 or 2) with good social support and reasonable pre-operative function (ODI 50 or less) treated with the MIS TLIF technique can be discharged home in less than 1 midnight with good clinical results. CONCLUSIONS Relatively young, healthy patients can safely and effectively undergo 1-2 level lumbar fusion surgery in the ASC setting when using contemporary minimally invasive techniques and computer-assisted navigation/robotics.
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A real-time 3D electromagnetic navigation system for percutaneous pedicle screw fixation in traumatic thoraco-lumbar fractures: implications for efficiency, fluoroscopic time, and accuracy compared with those of conventional fluoroscopic guidance. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:46-55. [PMID: 34333714 DOI: 10.1007/s00586-021-06948-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/14/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Navigation is becoming more useful in percutaneous pedicle screw fixation (PPSF). The aim of this study was to compare the efficiency, fluoroscopic time, accuracy, and clinical outcomes of PPSF with a novel electromagnetic navigation (EMN) system for thoraco-lumbar (TL) fractures with those of PPSF with conventional C-arm fluoroscopic (CF) guidance. METHODS A retrospective study was conducted. A total of 162 screws were implanted in 29 patients with the assistance of the EMN system (EMN group), and 220 screws were inserted in 40 patients by using CF guidance (CF group). The duration of surgery, placement time per screw, fluoroscopic time per screw, accuracy of pedicle screw placement, and clinical outcomes were compared between the two groups. RESULTS The duration of surgery and placement time per screw in the EMN group were significantly lower than those in the CF group (P < 0.05). The fluoroscopic time per screw in the CF group was significantly longer than that in the EMN group (P < 0.05). The learning curve of PPSF in the EMN group was steeper than that in the CF group. The accuracy of pedicle screw placement in the EMN group was more precise than that in the CF group (P < 0.05). The VAS scores in the EMN group were significantly lower than those in the CF group at one-week postoperatively (P < 0.05). CONCLUSION Compared with PPSF by using conventional fluoroscopic guidance, PPSF with the aid of the EMN system can increase the efficiency and accuracy of pedicle screw placement and reduce the fluoroscopic time.
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Wang ZW, Wang Z, Fan XW, Du PY, Sun JY, Ding WY, Yang DL. Precise Surgical Treatment of Thoracic Ossification of Ligamentum Flavum Assisted by O-Arm Computer Navigation: A Retrospective Study. World Neurosurg 2020; 143:e409-e418. [PMID: 32750521 DOI: 10.1016/j.wneu.2020.07.196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE O-arm computer navigation-assisted technology (OACNAT) has been widely used in the treatment of thoracic ossification of ligamentum flavum (TOLF) in recent years, but there are few in-depth studies on the safety and effectiveness of this approach. The purpose of this study was to investigate the clinical effect of accurate surgical treatment for TOLF with OACNAT. METHODS From January 2010 to January 2018, the clinical data of 64 patients with TOLF who underwent laminectomy and internal fixation in the Third Hospital of Hebei Medical University were retrospectively reviewed. The patients were divided into group A (with OACNAT, n = 33) and group B (without OACNAT, n = 31) according to the application of OACNAT during the operation. The possible operation-related variables, imaging results, and clinical effects were compared between the 2 groups. RESULTS In terms of demographics, there were no significant differences between group A and group B in age, sex, body mass index, smoking, drinking, heart disease, hypertension and diabetes (P > 0.05). In terms of operation-related variables, imaging results, and clinical efficacy, there were significant differences in operation time, wound length, postoperative modified Japanese Orthopaedic Association (JOA) score, JOA score improvement rate, accuracy of screw placement, number of intraoperative fluoroscopy procedures, and cerebrospinal fluid leakage between group A and group B (P < 0.05). There were no significant differences in other variables between the 2 groups (P > 0.05). In contrast to group A, in group B, 2 patients had incorrect segmental localization, 3 patients had residual ossified ligamentum flavum after the operation, and 1 patient had postoperative neurologic impairment. On further analysis, compared with group B, group A had a shorter operation time, more accurate screw placement, fewer fluoroscopy procedures, higher JOA score improvement rate, and lower incidence of complications. CONCLUSIONS The use of OACNAT accurately located the position, size, shape, and boundary of ossification of the ligamentum flavum during the operation, which could guide accurate decompression and improve the accuracy of pedicle screw placement. This approach not only reduced the incidence of incorrect segmental localization and incomplete or excessive decompression but also reduced the risk of related complications and improved the accuracy, safety, and effectiveness of the operation.
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Affiliation(s)
- Zhi-Wei Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Zheng Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Xi-Wen Fan
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Pei-Yu Du
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Jia-Yuan Sun
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Wen-Yuan Ding
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, P.R. China; Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Shijiazhuang, P.R. China
| | - Da-Long Yang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, P.R. China.
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Feng W, Wang W, Chen S, Wu K, Wang H. O-arm navigation versus C-arm guidance for pedicle screw placement in spine surgery: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2020; 44:919-926. [PMID: 31912228 DOI: 10.1007/s00264-019-04470-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 12/11/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND O-arm and C-arm are commonly used in spine surgery to guide pedicle screw placement. However, concerning the accuracy and efficiency of them, no systematical review and meta-analyses are available to help surgeons make comparisons. PURPOSES This study aims to investigate the accuracy and efficiency of O-arm-navigated versus C-arm-guided pedicle screw placement in thoracic and lumbar spine surgery. It would help surgeons choose the optimal technique for pedicle screw placement. PATIENTS AND METHODS A systematic review and meta-analyses were performed after searching the PubMed, Embase, and Cochrane databases to identify all studies that assessed the accuracy and efficiency of navigation coupled with O-arm and conventional C-arm fluoroscopy. RESULTS Eight studies were finally recruited in this systematic review, all of which reported pedicle screw placement outcomes related to accuracy or efficiency in both C-arm and O-arm groups. Five studies showed higher screw insertion accuracy in the O-arm group, while one study showed no significant difference. And the pooled results also indicated that the incidence of screw misplacement in the C-arm groups is higher. Moreover, the pooled results from five studies indicated no significant difference in insertion time between C-arm and O-arm. CONCLUSIONS Navigation coupled with O-arm imaging displayed a lower efficiency outcome in pedicle screw placement compared to conventional C-arm fluoroscopy. However, in terms of accuracy, O-arm navigation had significant advantages in accuracy over conventional C-arm fluoroscopy.
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Affiliation(s)
- Weili Feng
- Orthopaedics Department, Affiliated Xiaolan Hospital, Southern Medical University, No. 65, Jucheng Rd., 528415, Zhongshan, People's Republic of China
| | - Weihao Wang
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, No.57 Changping Road, Shantou, 515041, People's Republic of China
| | - Shubiao Chen
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, No.57 Changping Road, Shantou, 515041, People's Republic of China
| | - Kezhou Wu
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, No.57 Changping Road, Shantou, 515041, People's Republic of China
| | - Hu Wang
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, No.57 Changping Road, Shantou, 515041, People's Republic of China.
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Leitner L, Bratschitsch G, Sadoghi P, Adelsmayr G, Puchwein P, Leithner A, Radl R. Navigation versus experience: providing training in accurate lumbar pedicle screw positioning. Arch Orthop Trauma Surg 2019; 139:1699-1704. [PMID: 31127409 PMCID: PMC6825638 DOI: 10.1007/s00402-019-03206-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Accurate placement of spinal pedicle screws (PS) is mandatory for good primary segmental stabilization allowing consequent osseous fusion, requiring judgmental experience developed during a long training process. Computer navigation offers permanent visual control during screw manipulation and has been shown to significantly lower the risk of pedicle perforation. This study aims to evaluate whether safety, accuracy, and judgmental skills in screw placement, comparable to an experienced surgeon, can be developed during training using computer navigation. METHODS Lumbosacral PS were placed in 18 patients in a prospective setting, in one segment side with conventional fluoroscopy by a senior spine-surgeon, and computer navigated on the other side by a trainee without prior experience in the technique. At the beginning and at the end of the study, PS were placed freehand in solid foam models by the trainee. PS placement time, intraoperative placement revisions, PS placement accuracy on postoperative CT scans, and postoperative complications were assessed. RESULTS Significant improvement of trainee's PS placement accuracy (Sclafani score 8.2-8.83; p = 0.006) and time (13.3-6.8 min per screw; p = 0.005) to a similar level as the experienced surgeon state (5.2-4.1 min per screw; p = 0.39) was explored; similar improvement was explored in the foam models. The number of intraoperative placement revisions kept on a low level for surgeon (3.3-0.0%) and trainee (5.1-2.6%) during the whole study, no postoperative complications occurred. CONCLUSION Navigated PS insertion allows safe teaching from the early beginning of surgical training, due to steady intraoperative control on PS placement. Adequacy of PS placement is similar to screws placed by an experienced surgeon. Progress in judgmental skills in screw placement can be gained rapidly by the trainee, which can also be transferred to non-computer navigated PS placement.
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Affiliation(s)
- L. Leitner
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - G. Bratschitsch
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - G. Adelsmayr
- Department of Radiology, Medical University of Graz, Graz, Austria
| | - P. Puchwein
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - A. Leithner
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - R. Radl
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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Learning curve analysis of 3D-fluoroscopy image-guided pedicle screw insertions in lumbar single-level fusion procedures. Arch Orthop Trauma Surg 2018; 138:1501-1509. [PMID: 29982886 DOI: 10.1007/s00402-018-2994-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The implementation of 3D-navigation in the operating theater is reported to be complex, time consuming, and radiation intense. This prospective single-center cohort study was performed to objectify these assumptions by determining navigation-related learning curves in lumbar single-level posterior fusion procedures using 3D-fluoroscopy for real-time image-guided pedicle screw (PS) insertions. MATERIALS AND METHODS From August 2011 through July 2016, a total of 320 navigated PSs were inserted during 80 lumbar single-level posterior fusion procedures by a single surgeon without any prior experience in image-guided surgery. PS misplacements, navigation-related pre- and intraoperative time demand, and procedural 3D-radiation dose (dose-length-product, DLP) were prospectively recorded and congregated in 16 subgroups of five consecutive procedures to evaluate improving PS insertion accuracy, decreasing navigation-related time demand, and reduction of 3D-radiation dose. RESULTS After PS insertion and intraoperative O-arm control scanning, 11 PS modifications were performed sporadically without showing "learning curve dependencies" (PS insertion accuracies in subgroups 96.6 ± 6.3%). Average navigation-related pre-surgical time from patient positioning on the operating table to skin incision decreased from 61 ± 6 min (subgroup 1) to 28 ± 2 min (subgroup 16, p < 0.00001). Average 3D-radiation dose per surgery declined from 919 ± 225 mGycm (subgroup 1) to 66 ± 4 mGycm (subgroup 16, p < 0.0001). CONCLUSIONS In newly inaugurated O-arm based image-guidance, lumbar PS insertions can be performed at constantly high accuracy, even without prior experience in navigated techniques. Navigation-related time demand decreases considerably due to accelerating workflow preceding skin incision. Procedural 3D-radiation dose is reducible to a fraction (13.2%) of a lumbar diagnostic non-contrast-enhanced computed tomography scan's radiation dose.
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Zhang P, Wang G, Sun Z, Lv X, Guo Y, Wang J, Wu Y, Shi W, Zhang H, Liu H, Lu Y. Application of Multimodal Image Fusion to Precisely Localize Small Intramedullary Spinal Cord Tumors. World Neurosurg 2018; 118:246-249. [PMID: 30031956 DOI: 10.1016/j.wneu.2018.07.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We sought to study the application of precise intraoperative localization of small intramedullary spinal cord tumors. METHODS From November 2015 to August 2017, 5 patients with small intramedullary spinal cord tumors were arranged in this group. By using the O-arm image system, we acquired the intraoperative computed tomography images of all patients and sent them to the Stealth navigation system. Medtronic Synergy Cranial software was used to complete the image fusion with preoperative magnetic resonance images, and the fused images were used to localize the intramedullary spinal cord tumors by the navigation system. The navigation errors were evaluated by measuring the maximum distance between the end of the tumor in sagittal magnetic resonance imaging and its real position. RESULTS Five patients accomplished the multimodal image fusion, and we successfully completed the image-guided surgeries. The mean diameter of tumors was 12.2 ± 3.1 mm in sagittal magnetic resonance imaging, and the mean incision length was 12.7 ± 3.3 mm. The time of image processing was between 13 minutes and 17 minutes, and the mean value was 15 ± 1.6 minutes. The navigation error was between 0.9 mm and 1.5 mm, and the mean value was 1.2 ± 0.2 mm. CONCLUSIONS The application of the multimodal image fusion combined with intraoperative O-arm image navigation system can be used to localize small intramedullary tumors.
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Affiliation(s)
- Peihai Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Guihuai Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China.
| | - Zhenxing Sun
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Yi Guo
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - James Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Youtu Wu
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Wei Shi
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Huifang Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Huiting Liu
- Peking Union Medical University Hospital, Beijing, China
| | - Yang Lu
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
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Sun ZF, Yang KX, Chen HT, Sui T, Yang L, Ge DW, Tang J, Cao XJ. A novel entry point for pedicle screw placement in the thoracic spine. J Biomed Res 2018; 32:123-129. [PMID: 28866657 PMCID: PMC5895566 DOI: 10.7555/jbr.31.20160037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study was aimed to introduce a novel entry point for pedicle screw fixation in the thoracic spine and compare it with the traditional entry point. A novel entry point was found with the aim of improving accuracy, safety and stability of pedicle screw technique based on anatomical structures of the spine. A total of 76 pieces of normal thoracic CT images at the transverse plane and the thoracic pedicle anatomy of 6 cadaveric specimens were recruited. Transverse pedicle angle (TPA), screw length, screw placement accuracy rate and axial pullout strength of the two different entry point groups were compared. There were significant differences in the TPA, screw length, and the screw placement accuracy rate between the two groups (P<0.05). The maximum axial pullout strength of the novel entry point group was slightly larger than that of the traditional group. However, the difference was not significant (P>0.05). The novel entry point significantly improved the accuracy, stability and safety of pedicle screw placement. With reference to the advantages above, the new entry point can be used for spinal internal fixations in the thoracic spine.
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Affiliation(s)
- Zhi-Feng Sun
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Kai-Xiang Yang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Hong-Tao Chen
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Tao Sui
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Lei Yang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Da-Wei Ge
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Jian Tang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xiao-Jian Cao
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Pedicle screw insertion accuracy in terms of breach and reposition using a new intraoperative cone beam computed tomography imaging technique and evaluation of the factors associated with these parameters of accuracy: a series of 695 screws. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017. [DOI: 10.1007/s00586-017-5195-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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15
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Chang CJ, Yu CH, Lin GL, Tse A, Chu HY, Tseng CS. Clinical Pedicle Screw Insertion Trials and System Improvement of C-arm Image Navigation System. J Med Biol Eng 2016. [DOI: 10.1007/s40846-016-0107-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Li W, Liu Y, Sun H, Pan Y, Qian Z. Monitoring reduced scattering coefficient in pedicle screw insertion trajectory using near-infrared spectroscopy. Med Biol Eng Comput 2015; 54:1533-9. [PMID: 26695814 DOI: 10.1007/s11517-015-1428-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 12/07/2015] [Indexed: 11/30/2022]
Abstract
Pedicle screw (PS) implantation is an ideal treatment for severe multilevel vertebra instabilities. The accuracy of fixating PS is a key factor of spinal surgery. We developed a near-infrared spectroscopy device with a needlelike optical fiber probe to monitor optical parameters (reduced scattering coefficient) of vertebra models in real time. The fresh-frozen cadaver, cats and porcine vertebras were first studied in the experiments. Moreover, the reduced scattering coefficient (μ' s) along the different trajectories of PS insertion was obtained. In the fresh-frozen cadavera experiment, μ' s values could be used to distinguish the different compositions of the thoracic vertebra. In cat vertebra experiment, μ' s values of vertebrae bones, including cortical bone (15.30 ± 0.18 cm(-1)), cancellous bone (7.84 ± 1.11 cm(-1)) and spinal cord (19.46 ± 0.21 cm(-1)), were different in vivo. In the pig vertebrae experiment, there were obvious differences between the normal and abnormal PS puncture curves based on μ' s values. Thus, μ' s values measured by using the proposed device could be used as the pattern factor in spinal fusion surgery. Our studies demonstrate that near-infrared spectroscopy method may be potentially used for assisting the PS insertion.
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Affiliation(s)
- Weitao Li
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China.
| | - Yangyang Liu
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China
| | - Haixiang Sun
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China
| | - Yue Pan
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China
| | - Zhiyu Qian
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street 29, Nanjing, 210016, China
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Helm PA, Teichman R, Hartmann SL, Simon D. Spinal Navigation and Imaging: History, Trends, and Future. IEEE TRANSACTIONS ON MEDICAL IMAGING 2015; 34:1738-46. [PMID: 25594965 DOI: 10.1109/tmi.2015.2391200] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The clinical practice of spine navigation has rapidly grown with the development of image-based guidance. In this paper, a brief history of spinal navigation is presented and a review of clinical outcomes for 12,622 pedicle screws placed using the latest technology in the sacral, lumbar and thoracic regions. The clinical evidence demonstrate that intraoperative 3D image guided surgery has a 96.8% success rate. A concluding section detailing existing barriers that limit more widespread adoption and future development efforts is presented.
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Fennell VS, Palejwala S, Skoch J, Stidd DA, Baaj AA. Freehand thoracic pedicle screw technique using a uniform entry point and sagittal trajectory for all levels: preliminary clinical experience. J Neurosurg Spine 2014; 21:778-84. [DOI: 10.3171/2014.7.spine1489] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Experience with freehand thoracic pedicle screw placement is well described in the literature. Published techniques rely on various starting points and trajectories for each level or segment of the thoracic spine. Furthermore, few studies provide specific guidance on sagittal and axial trajectories. The goal of this study was to propose a uniform entry point and sagittal trajectory for all thoracic levels during freehand pedicle screw placement and determine the accuracy of this technique.
Methods
The authors retrospectively reviewed postoperative CT scans of 33 consecutive patients who underwent open, freehand thoracic pedicle-screw fixation using a uniform entry point and sagittal trajectory for all levels. The same entry point for each level was defined as a point 3 mm caudal to the junction of the transverse process and the lateral margin of the superior articulating process, and the sagittal trajectory was always orthogonal to the dorsal curvature of the spine at that level. The medial angulation (axial trajectory) was approximately 30° at T-1 and T-2, and 20° from T-3 to T-12. Breach was defined as greater than 25% of the screw diameter residing outside of the pedicle or vertebral body.
Results
A total of 219 thoracic pedicle screws were placed with a 96% accuracy rate. There were no medial breaches and 9 minor lateral breaches (4.1%). None of the screws had to be repositioned postoperatively, and there were no neurovascular complications associated with the breaches.
Conclusions
It is feasible to place freehand thoracic pedicle screws using a uniform entry point and sagittal trajectory for all levels. The entry point does not have to be adjusted for each level as reported in existing studies, although this technique was not tested in severe scoliotic spines. While other techniques are effective and widely used, this particular method provides more specific parameters and may be easier to learn, teach, and adopt.
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Li W, Liu Y, Qian Z. Determination of detection depth of optical probe in pedicle screw measurement device. Biomed Eng Online 2014; 13:148. [PMID: 25361700 PMCID: PMC4234868 DOI: 10.1186/1475-925x-13-148] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a high probability of accidental perforation of the vertebral pedicle wall in pedicle screw insertion surgery. A pedicle screw (PS) measurement device with an optical probe has been reported to send out a warning signal before the PS tip breaking the vertebral pedicle wall. METHODS In this study, we explored the detection depth of optical probe in this measurement device, which was closely related to the effective alarm distance. In the boundary, the vertebrae tissues could be treated as 2-layer models including spongy bones and compact bones. The Monte Carlo simulation and phantom models were performed to analyse and define the detection depth. Then the porcine vertebrae models were performed to obtain optical spectrum and reduced scattering coefficient, based on which the detection depths were deduced. Moreover, a comparison was made to explore the most significant pattern factor from the experiment results. RESULTS According to the pattern factor, an alarm threshold was successfully deduced to define the alarm distance during pedicle screw monitoring. CONCLUSIONS Thus, the proposed alarm standard based on detection depth provides a potential for guiding pedicle screw in surgery.
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Affiliation(s)
- Weitao Li
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street, Nanjing, China
| | - Yangyang Liu
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street, Nanjing, China
| | - Zhiyu Qian
- Department of Biomedical Engineering, Nanjing University of Aeronautics and Astronautics, Yudao Street, Nanjing, China
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Complications associated with the initial learning curve of minimally invasive spine surgery: a systematic review. Clin Orthop Relat Res 2014; 472:1711-7. [PMID: 24510358 PMCID: PMC4016470 DOI: 10.1007/s11999-014-3495-z] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is an inherently difficult learning curve associated with minimally invasive surgical (MIS) approaches to spinal decompression and fusion. The association between complication rate and the learning curve remains unclear. QUESTIONS/PURPOSES We performed a systematic review for articles that evaluated the learning curves of MIS procedures for the spine, defined as the change in frequency of complications and length of surgical time as case number increased, for five types of MIS for the spine. METHODS We conducted a systematic review in the PubMed database using the terms "minimally invasive spine surgery AND complications AND learning curve" followed by a manual citation review of included manuscripts. Clinical outcome and learning curve metrics were categorized for analysis by surgical procedure (MIS lumbar decompression procedures, MIS transforaminal lumbar interbody fusion, percutaneous pedicle screw insertion, laparoscopic anterior lumbar interbody fusion, and MIS cervical procedures). As the most consistent parameters used to evaluate the learning curve were procedure time and complication rate as a function of chronologic case number, our analysis focused on these. The search strategy identified 15 original studies that included 966 minimally invasive procedures. Learning curve parameters were correlated to chronologic procedure number in 14 of these studies. RESULTS The most common learning curve complication for decompressive procedures was durotomy. For fusion procedures, the most common complications were implant malposition, neural injury, and nonunion. The overall postoperative complication rate was 11% (109 of 966 cases). The learning curve was overcome for operative time and complications as a function of case numbers in 20 to 30 consecutive cases for most techniques discussed within this review. CONCLUSIONS The quantitative assessment of the procedural learning curve for MIS techniques for the spine remains challenging because the MIS techniques have different learning curves and because they have not been assessed in a consistent manner across studies. Complication rates may be underestimated by the studies we identified because surgeons tend to select patients carefully during the early learning curve period. The field of MIS would benefit from a standardization of study design and collected parameters in future learning curve investigations.
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