Surgeon Perceptions of Minimally Invasive Spine Surgery

Determining the learning curve for percutaneous endoscopic lumbar interbody fusion for lumbar degenerative diseases

PURPOSE

Percutaneous endoscopic lumbar interbody fusion (PELIF) is one of the least invasive procedures for lumbar degenerative disorders (LDD). There is limited knowledge of the learning curve for PELIF.

METHODS

A total of 93 consecutive patients who underwent PELIF performed by a single spine surgeon for LDD failed with conservative treatment were retrospectively reviewed. The case series was split into three groups based on timing: A (earliest third of patients); B (middle third of patients); and C (latest third of patients). The following were also recorded: operating time, X-ray exposure time, complications, radiologic fusion rates, pre- and postoperative patient-reported outcome measures (PROMs) scores (visual analogue scale (VAS) for back pain, VAS for leg pain, Japanese Orthopaedic Association, Oswestry Disability Index and MacNab criteria), length of hospital stay, and need for revision surgeries. A learning curve was then developed by a logarithmic curve-fit regression analysis.

RESULTS

The operative time gradually decreased over time, and an asymptote was reached after about 25 cases. Compared with group B or C, group A had significantly longer operative time, significantly longer length of hospital stay, needed significantly more x-ray exposure time. Though not significantly different, there are fewer complications and revision surgeries over time. There is no significant difference over time in PROMs scores except for the VAS back scores.

CONCLUSIONS

PELIF is an alternative for minimal invasive surgery for LDD, PELIF presents a learning curve to the practicing spine surgeon with regard to operative time, x-ray exposure time, length of hospital stay, clinical PROMs and radiographic outcomes and complications. The presented PELIF learning curve provided valuable insight to surgeons interested in performing this surgery.

Defining Cervical Sagittal Plane Deformity - When Are Sagittal Realignment Procedures Necessary in Patients Presenting Primarily With Radiculopathy or Myelopathy?

OBJECTIVE

It remains unclear whether cervical sagittal deformity (CSD) should be defined by radiographic parameters alone versus both clinical and radiographic factors, and whether radiographic malalignment by itself warrants a CSD corrective surgery in patients who present primarily with neurologic symptoms.

METHODS

We administered a survey to a group of expert surgeons to evaluate whether radiographic parameters alone were sufficient to diagnose CSD, and in which scenarios surgeons recommend a CSD realignment procedure versus addressing the neurologic symptoms alone.

RESULTS

No single radiographic criteria reached a 50% threshold as being sufficient to establish the diagnosis of CSD. When asymptomatic radiographic malalignment was present, a sagittal deformity correction was more likely to be recommended in patients with myelopathy versus those with radiculopathy alone. The majority of surgeons recommended deformity correction when symptoms of cervical deformity were present in addition to radiographic malalignment (85% with deformity symptoms and radiculopathy, 93% with deformity symptoms and myelopathy).

CONCLUSION

There is no consensus on which radiographic and/or clinical criteria are necessary to define the presence of CSD. We recommend that symptoms of cervical deformity, in addition to radiographic parameters, be considered when deciding whether to perform deformity correction in patients who present primarily with myelopathy or radiculopathy.

Clinical Accuracy, Technical Precision, and Workflow of the First in Human Use of an Augmented-Reality Head-Mounted Display Stereotactic Navigation System for Spine Surgery

BACKGROUND

Augmented reality mediated spine surgery is a novel technology for spine navigation. Benchmark cadaveric data have demonstrated high accuracy and precision leading to recent regulatory approval. Absence of respiratory motion in cadaveric studies may positively bias precision and accuracy results and analogous investigations are prudent in live clinical scenarios.

OBJECTIVE

To report a technical note, accuracy, precision analysis of the first in-human deployment of this technology.

METHODS

A 78-yr-old female underwent an L4-S1 decompression, pedicle screw, and rod fixation for degenerative spine disease. Six pedicle screws were inserted via AR-HMD (xvision; Augmedics, Chicago, Illinois) navigation. Intraoperative computed tomography was used for navigation registration as well as implant accuracy and precision assessment. Clinical accuracy was graded per the Gertzbein-Robbins (GS) scale by an independent neuroradiologist. Technical precision was analyzed by comparing 3-dimensional (3D) (x, y, z) virtual implant vs real implant position coordinates and reported as linear (mm) and angular (°) deviation. Present data were compared to benchmark cadaveric data.

RESULTS

Clinical accuracy (per the GS grading scale) was 100%. Technical precision analysis yielded a mean linear deviation of 2.07 mm (95% CI: 1.62-2.52 mm) and angular deviation of 2.41° (95% CI: 1.57-3.25°). In comparison to prior cadaveric data (99.1%, 2.03 ± 0.99 mm, 1.41 ± 0.61°; GS accuracy 3D linear and angular deviation, respectively), the present results were not significantly different (P > .05).

CONCLUSION

The first in human deployment of the single Food and Drug Administration approved AR-HMD stereotactic spine navigation platform demonstrated clinical accuracy and technical precision of inserted hardware comparable to previously acquired cadaveric studies.

Conjoint Nerve Root an Intraoperative Challenge in Minimally Invasive Tubular Discectomy

Conjoint nerve root (CNR) is an embryological nerve root anomaly that mainly involves the lumbosacral region. The presence of CNR during tubular discectomy raises the chances of failure in spinal surgery and the risk of neural injuries. Tubular discectomy can be challenging in the presence of CNR owing to limited visualization. Here, we present a technical note on two cases of L5–S1 disc prolapse in the presence of conjoint S1 nerve root that was operated via a minimally invasive tubular approach. Any intraoperative suspicion of CNR while using the tubular approach should prompt the surgeon to perform a thorough tubular decompression prior to nerve root retraction. In patients with a large disc, disc should be approached via the axilla because the axillary area between the dura and the medial boarder of the root is very easy to approach in the presence of CNR. Safe performance of tubular discectomy is possible even in the presence of CNR in the lumbar spine.

Cauda Equina Syndrome: A Review of 15 Patients Who Underwent Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD) Under Local Anaesthesia

INTRODUCTION

To analyse the results of Cauda Equina Syndrome (CES) operated by Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD).

MATERIAL AND METHODS

The study is a retrospective series of 15 patients operated by PTELD. Bladder dysfunction was classified as incomplete CES (CESI) and complete CES retention (CESR). Bladder / motor recovery rate and its timing, Oswestry Disability Index (ODI), Visual Analogue Score (VAS), patient satisfaction index, and sexual dysfunction were used to measure the outcome objectively. Additionally, in CESR patients, post-void residual (PVR) urine was measured by sonography. Complications and technical problems were noted.

RESULTS

There were ten patients of CESI and five patients of CESR. The average follow-up was 20.33(12.05) months. Bladder symptoms recovery was 100%, and motor recovery was 80%. VAS for back pain recovered to 0.53(0.52) from 8(2.39). VAS for leg pain recovered to 0.13(0.35) from 9.20(1.32). ODI improved to 6.07(2.85) from 77.52(13.20). The time to the recovery of bladder function was 1.47(1.55) days. All CESR patient's abnormal PVR urine was normalised at five weeks post-operative. No complications were reported. However, five technical executional problems occurred.

CONCLUSION

PTELD can be considered for CES treatment due to its substantial and quick recovery advantages. However, more evidence support is needed to make it a practice recommendation.

Measuring the performance of patient-specific solutions for minimally invasive transforaminal lumbar interbody fusion surgery

Pre-surgical planning using 3D-printed BioModels enables the preparation of a "patient-specific" kit to assist instrumented spinal fusion surgery. This approach has the potential to decrease operating time while also offering logistical benefits and cost savings for healthcare. We report our experience with this method in 129 consecutive patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) over 27 months at a single centre and performed by a single surgeon. Patient imaging and surgical planning software were used to manufacture a 3D-printed patient-specific MIS TLIF kit for each patient consisting of a 1:1 scale spine BioModel, stereotactic K-wire guide, osteotomy guide, and retractors. Pre-selected pedicle screws, rods, and cages were sourced and supplied with the patient-specific kit. Additional implants were available on-shelf to address a size discrepancy between the kit implant and intraoperative measurements. Each BioModel was used pre-operatively for surgical planning, patient consent and education. The BioModel was sterilised for intraoperative reference and navigation purposes. Efficiency measures included operating time (153 ± 44 min), sterile tray usage (14 ± 3), fluoroscopy screening time (57.2 ± 23.7 s), operative waste (19 ± 8 L contaminated, 116 ± 30 L uncontaminated), and median hospital stay (4 days). The pre-selected kit implants exactly matched intraoperative measurements for 597/639 pedicle screws, 249/258 rods, and 46/148 cages. Pedicle screw placement accuracy was 97.8% (625/639) on postoperative CT. Complications included one intraoperative dural tear, no blood products administered, and six reoperations. Our experience demonstrates a viable application of patient-specific 3D-printed solutions and provides a benchmark for studies of efficiency in spinal fusion surgery.

The Prevalence of the Use of MIS Techniques in the Treatment of Adult Spinal Deformity (ASD) Amongst Members of the Scoliosis Research Society (SRS) in 2016

STUDY DESIGN

Electronic survey administered to Scoliosis Research Society members.

OBJECTIVE

To determine the prevalence of minimally invasive surgery (MIS) techniques for the treatment of adult spinal deformity.

SUMMARY OF BACKGROUND DATA

There is a paucity of data available on the practice pattern, prevalence of minimally invasive spine surgery, and the preferred minimally invasive techniques in the treatment of adult spine deformity.

METHODS

An electronic nine-question survey regarding individual usage pattern of minimally invasive spine surgery techniques was administered in 2016 to the members of the Scoliosis Research Society. Determinants included complexity in condition of patient population, prevalence of use of minimally invasive techniques in the surgeon's practice, prevalence of use of a particular MIS technique, strategy elected during surgery, adoption of staging of procedures and timing between staging of procedures.

RESULTS

A total of 357 surgeons responded (61.3% response rate), and 154 (43.1%) of the respondents said that they use MIS as a part of their surgical treatment of adult spinal deformity. However, of these 154 respondents, 67 (43.5%) said that their MIS usage in deformity practice was between 1% and 20%. Only 11 (7.2%) said that they used MIS 81% to 100% of the time. The top MIS approaches that surgeons chose were MIS lateral lumbar interbody fusion 109 (70.59%) and MIS percutaneous screws 91 (58.8%).

CONCLUSIONS

The low rate of adoption of these techniques among the SRS members may be due to the false perception that there is not enough data to support that MIS techniques are better. This and the fact that a practitioner needs to be facile at different MIS techniques may be the true impediment to the adoption of MIS techniques in the treatment of ASD.

LEVEL OF EVIDENCE

Level IV.

Minimally invasive techniques for lumbar decompressions and fusions

PURPOSE OF REVIEW

The purpose of this study is to summarize the recent literature investigating the use of minimally invasive (MIS) techniques in the treatment of lumbar degenerative stenosis, spondylolisthesis, and scoliosis.

RECENT FINDINGS

MIS lumbar decompression and fusion techniques for degenerative pathology are associated with reduced operative morbidity, shortened length of hospital stay, and reduced postoperative pain and narcotics utilization. Recent studies with long-term clinical follow-up have demonstrated equivalence in clinical outcomes between open and MIS surgical procedures. Radiographically, MIS procedures provide adequate postoperative correction of coronal alignment. Correction of sagittal alignment, however, is more variable based on current reports. MIS techniques are both safe and effective in the treatment of lumbar degenerative pathologies. While some studies have reported on long-term outcomes and costs associated with MIS procedures, more investigation into these topics is still necessary. Additionally, further work is required to analyze the training requirements and learning curves of MIS procedures to better promote adoption amongst surgeons.

Treatment of cauda equina syndrome caused by lumbar disc herniation with percutaneous endoscopic lumbar discectomy

To evaluate the feasibility and clinical efficacy of percutaneous endoscopic lumbar discectomy (PELD) for cauda equina syndrome (CES) caused by disc herniation. 16 patients with CES caused by LDH at the early and middle stages of Shi's classification were selected as the objects of study, who underwent PELD. Clinical outcomes were assessed using the Macnab criteria and the visual analogue scale (VAS). The VAS for leg pain and back pain significantly decreased from preoperative scores of 7.67 ± 1.23 and 7.52 ± 1.42, respectively, to postoperative scores of 1.71 ± 0.53 and 3.18 ± 0.72. Thirteen patients showed favorable results. Complications included one patient of motor weakness, and one patient developed an ipsilateral recurrent herniation who finally acquired satisfactory result after reoperation. Hence, PELD could be used as an alternative surgical method for the treatment of CES in properly selected cases and appropriate patient selection and a reasonable surgical approach will give rise to better outcomes.

Three-dimensional intraoperative imaging with O-arm to establish a working trajectory in percutaneous endoscopic lumbar discectomy

Introduction

Successful percutaneous endoscopic lumbar discectomy (PELD) requires an appropriate working trajectory. Due to the complexity of spinal anatomy, this is difficult to verify with conventional 2-dimensional fluoroscopy.

Aim

Here we assessed the feasibility and utility of the O-arm for establishing the working trajectory for PELD.

Material and methods

We retrospectively reviewed the records of 89 patients with lumbar disc herniation who underwent PELD using the O-arm. The working trajectory was evaluated with standard fluoroscopic images or 3-dimensional, volumetric computed tomography scan. Based on the detail provided by the multiplanar view, we confirmed the ideal working trajectory and adjusted the surgical approach accordingly.

Results

At the 12-month follow-up, based on MacNab's criteria, 85.9% of patients showed an excellent or good outcome. There were no major complications.

Conclusions

The O-arm provides detailed multiplanar intraoperative high-quality imaging for PELD, and enables the surgeon to ascertain the surgical anatomy, determine the optimal working trajectory, and improve the accuracy of surgery.

Prospective Evaluation of a Low-Dose Radiation Fluoroscopy Protocol for Minimally Invasive Transforaminal Lumbar Interbody Fusion

BACKGROUND

Recent research on radiation exposure in minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF) has led to the development of a low-dose radiation fluoroscopy protocol, with resulting reductions in fluoroscopy times and radiation exposures.

OBJECTIVE

To prospectively evaluate a previously reported low-dose radiation fluoroscopy protocol for MIS TLIF.

METHODS

A prospective evaluation of the low-dose radiation fluoroscopy protocol for MIS TLIF was performed for 65 consecutive patients. Total fluoroscopy time, radiation dose, and operative times were prospectively analyzed for all enrolled patients.

RESULTS

Sixty-five consecutive patients (43 women; 22 men) who underwent an MIS TLIF were prospectively enrolled in this study of the low-dose fluoroscopy protocol. A total of 260 pedicle screws were placed. The mean age of the patients was 63 years (range, 46-82 years). They had a mean operative time of 178.7 minutes (range, 119-247 minutes), a mean fluoroscopic time of 10.43 seconds (range, 5-24 seconds), and a mean radiation dose of 0.295 mGy × m2 (range, 0.092-0.314 mGy × m2).

CONCLUSION

The combination of low-dose pulsed images and digital spot images in a low-dose protocol decreases fluoroscopy times and radiation doses in patients undergoing MIS TLIF without compromising visualization of the bony anatomy or the safety and efficiency of the procedure. The application of this low-dose protocol uncouples the otherwise linear relationship between fluoroscopy times and radiation dose. This is due primarily to the use of the digital spot technique. Equal emphasis should be placed on radiation dose and acquisition time to optimize this protocol.

Minimally invasive transforaminal lumbar interbody fusions and fluoroscopy: a low-dose protocol to minimize ionizing radiation

Object

There is an increasing awareness of radiation exposure to surgeons and the lifelong implications of such exposure. One of the main criticisms of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is the amount of ionizing radiation required to perform the procedure. The goal in this study was to develop a protocol that would minimize the fluoroscopy time and radiation exposure needed to perform an MIS TLIF without compromising visualization of the anatomy or efficiency of the procedure.

Methods

A retrospective review of a prospectively collected database was performed to review the development of a low-dose protocol for MIS TLIFs in which a combination of low-dose pulsed fluoroscopy and digital spot images was used. Total fluoroscopy time and radiation dose were reviewed for 50 patients who underwent single-level MIS TLIFs.

Results

Fifty patients underwent single-level MIS TLIFs, resulting in the placement of 200 pedicle screws and 57 interbody spacers. There were 28 women and 22 men with an average age of 58.3 years (range 32–78 years). The mean body mass index was 26.2 kg/m2 (range 17.1–37.6 kg/m2). Indications for surgery included spondylolisthesis (32 patients), degenerative disc disease with radiculopathy (12 patients), and recurrent disc herniation (6 patients). Operative levels included 7 at L3–4, 40 at L4–5, and 3 at L5–S1. The mean operative time was 177 minutes (range 139–241 minutes). The mean fluoroscopic time was 18.72 seconds (range 7–29 seconds). The mean radiation dose was 0.247 mGy*m2 (range 0.06046–0.84054 mGy*m2). No revision surgery was required for any of the patients in this series.

Conclusions

Altering the fluoroscopic technique to low-dose pulse images or digital spot images can dramatically decrease fluoroscopy times and radiation doses in patients undergoing MIS TLIFs, without compromising image quality, accuracy of pedicle screw placement, or efficiency of the procedure.

Learning curve for percutaneous endoscopic lumbar discectomy depending on the surgeon's training level of minimally invasive spine surgery

PURPOSE

To evaluate the differences of learning curve for PELD depending on the surgeon' s training level of minimally invasive spine surgery.

METHODS

We retrospectively reviewed the medical records of 120 patients (surgeon A with his first 60 patients, surgeon B with his first 60 patients) with sciatica and single-level L4/5 disk herniation who underwent PELD by the two surgeons with different training level of minimally invasive spine surgery (Group A: surgeon with little professional training of PELD; Group B: surgeon with 2 years of demonstration teaching of PELD).

RESULTS

Significant differences were observed in the operation time (p=0.000), postoperative hospital stay (p=0.026) and reoperation rate (p=0.050) between the two groups. In the operation time, significant differences were observed between the 1-20 patients group and 41-60 patients group in Group B (p=0.041), but there were no significant differences among the 1-20 patients group, 21-40 patients group and 41-60 patients group in Group A. In the postoperative hospital stay, the significant differences were observed in the 1-20 patients group between Group A and Group B (p=0.011). Significant differences were observed between preoperative and postoperative VAS back score, VAS leg score and JOA score. Higher improvement in the VAS leg score was observed in Group B than Group A (p=0.031). In the rate of reoperation, the significant difference was observed between the 1-20 patients group and 41-60 patients group in Group A (p=0.028) but there were no significant differences among the 1-20 patients group, 21-40 patients group and 41-60 patients group in Group B.

CONCLUSIONS

The surgeons' training level of minimally invasive spine surgery was an important factor for the success of PELD, especially the demonstration teaching of PELD for the new minimally invasive spine surgeons.

Complications of endoscopic microdiscectomy using the EASYGO! system: is there any difference with conventional discectomy during the learning-curve period?

BACKGROUND

Microendoscopic discectomy (MED) is emerging as a minimally invasive alternative to conventional microsurgical discectomy (MSD). EASYGO! is a new system for spinal endoscopy that claims smooth transition from MSD to MED, with a reduced learning curve period. The aims of this study were to describe the complications that appeared during the learning curve period of MED and to compare their incidence with the rate and type of complications that occurred during a simultaneous non-randomised series of standard MSDs.

METHODS

Between July 2009 and December 2010, 138 patients underwent scheduled first-time discectomy in our institution, 37 using an MED approach and 101 by a conventional MSD. A MED learning curve was obtained by plotting every case with its respective operative time. Complications, length of hospital stay, need of further surgery and outcome were prospectively recorded in both groups.

RESULTS

The mean operative time was 66 min for the MSD group and 100 min for the MED group, although for the last 14 cases of the latter group the time was reduced. Curve-fitting techniques showed that the inverse equation, ƒ(x) = 122.12/x + 73.05, had the best correlation between case number and operative time. The learning curve was overcome after the 30th case. Complications occurred in 9.8 % of the MSD group and 8.1 % of the MED group (P = 0.49). Average length of hospital stay was 2.36 days for the MED group and 3.36 days for the MSD group (P = 0.01). The procedure successfully relieved patient symptoms in 68.63 % of the MSD group and 89.92 % of the MED group. No revision surgery was required in the MED group, but it was necessary in ten patients of the MSD group.

CONCLUSIONS

Between 25 and 30 cases are needed to reach the learning curve's asymptote of MED. Even during this initial learning period MED is a safe procedure, with comparable results to those obtained with conventional MSD and with a similar complication rate. The key points for reducing intraoperative complications are an adequate expertise in MSD, a precise selection of initial cases, a proper surgical planning and a careful technique, which are mandatory to avoid unnecessary neurological injury in an otherwise secure surgical approach.

Use of a quantitative pedicle screw accuracy system to assess new technology: Initial studies on O-arm navigation and its effect on the learning curve of percutaneous pedicle screw insertion

Background

A quantitative screw accuracy system is proposed that allows for high-fidelity discrimination between various methods of pedicle screw insertion. Our purpose was to study the utility of a quantitative screw accuracy scoring system to assess new imaging technologies and their effects on the minimally invasive spine learning curve.

Methods

By use of a hypothetical “perfect screw,” a scoring system is proposed that may be used to compare the position of a small number of screws inserted according to a desired optimal position. This study incorporates a retrospective review of imaging studies for 10 patients who underwent percutaneous pedicle screw placement with either navigation-assisted O-arm imaging or navigation-assisted C-arm imaging. For the learning-curve portion of the study, 2 cadaveric adult torsos were used for instrumentation. Computed tomography imaging studies were used in both studies to assess screw position in the pedicle and vertebral body in relation to an optimal screw by use of a quantitative scoring system to rate accuracy.

Results

The quantitative scoring system allowed a statistically significant accuracy difference to be ascertained between 2 different technologies using fewer data points than previously published methods. When this screw scoring system is applied to minimally invasive percutaneous pedicle screw insertion, an optimal screw position can be achieved with greater accuracy through navigation-assisted technology (O-arm with computer-assisted navigation). When the O-arm with computer-assisted navigation was used by a novice surgeon learning the technique of percutaneous screw insertion, screws were inserted in a shorter period without loss of accuracy. In contrast, use of the traditional C-arm fluoroscopy leads to a loss of accuracy with faster insertion times. Increased accuracy can be seen clinically when compared with fluoroscopic navigation.

Conclusions

The use of a quantitative scoring system allows for rapid assessment of screw accuracy. As additional technologies and new teaching techniques for pedicle screw insertion are developed, this scoring system may be useful as an early assessment tool.

Surgeons' perceptions of spinal navigation: analysis of key factors affecting the lack of adoption of spinal navigation technology

Background

Computer-assisted spinal navigation allows for real time localization of surgical instruments in multiple views. Its use decreases radiation exposure and clears the surgical field of the C-arm fluoroscope. Despite these advantages, spinal navigation has yet to gain general acceptance among spine surgeons. The purpose of this study is to survey spine surgeons about their opinions on the strengths and weaknesses of spinal navigation.

Methods

Spine surgeons from the membership of the Spine Arthroplasty Society (SAS) and the Society for Minimally Invasive Spine Surgery (SMISS) were surveyed regarding their current use of spinal navigation and their perceptions of the strengths and weaknesses of spinal navigation (N = 147). Responses were analyzed using 2-sided chi-square tests.

Results

Most spine surgeons (63.4%) have only superficial experience with spinal navigation, and 76.2% of surgeons rarely use spinal navigation in their cases. Spine surgeons have the most experience with virtual fluoroscopy spinal navigation systems (35.9%). Surgeons considered longer operating times (63.5%), increased cost (48.3%), lack of necessity (40.7%), unreliable navigation accuracy (37.9%), and too many intraoperative glitches (35.2%) to be the major weaknesses of spinal navigation.

Surgeons considered decreased radiation exposure to the surgeon (76.1%), increased screw placement accuracy (65.7%), decreased radiation exposure to the patient (41.8%), and keeping the C-arm away from the operating field (29.1%) to be the greatest advantages of spinal navigation. Among the types of procedures surgeons believe are most likely to benefit from spinal navigation are minimally invasive instrumentation and fusion (72.5%) and complex open deformity (55.6%).

Conclusion

Most spine surgeons have only superficial experience in spinal navigation. The most commonly selected weaknesses of spinal navigation are increased operative time, cost, and lack of necessity. Increased fluoroscopy and MIS use in the future may shift focus from weaknesses to the strengths of spinal navigation, including decreased radiation exposure and elimination of the C-arm from the operative field.

Surgeons' perceptions of spinal navigation: analysis of key factors affecting the lack of adoption of spinal navigation technology

BACKGROUND

Computer-assisted spinal navigation allows for real time localization of surgical instruments in multiple views. Its use decreases radiation exposure and clears the surgical field of the C-arm fluoroscope. Despite these advantages, spinal navigation has yet to gain general acceptance among spine surgeons. The purpose of this study is to survey spine surgeons about their opinions on the strengths and weaknesses of spinal navigation.

METHODS

Spine surgeons from the membership of the Spine Arthroplasty Society (SAS) and the Society for Minimally Invasive Spine Surgery (SMISS) were surveyed regarding their current use of spinal navigation and their perceptions of the strengths and weaknesses of spinal navigation (N = 147). Responses were analyzed using 2-sided chi-square tests.

RESULTS

Most spine surgeons (63.4%) have only superficial experience with spinal navigation, and 76.2% of surgeons rarely use spinal navigation in their cases. Spine surgeons have the most experience with virtual fluoroscopy spinal navigation systems (35.9%). Surgeons considered longer operating times (63.5%), increased cost (48.3%), lack of necessity (40.7%), unreliable navigation accuracy (37.9%), and too many intraoperative glitches (35.2%) to be the major weaknesses of spinal navigation. Surgeons considered decreased radiation exposure to the surgeon (76.1%), increased screw placement accuracy (65.7%), decreased radiation exposure to the patient (41.8%), and keeping the C-arm away from the operating field (29.1%) to be the greatest advantages of spinal navigation. Among the types of procedures surgeons believe are most likely to benefit from spinal navigation are minimally invasive instrumentation and fusion (72.5%) and complex open deformity (55.6%).

CONCLUSION

Most spine surgeons have only superficial experience in spinal navigation. The most commonly selected weaknesses of spinal navigation are increased operative time, cost, and lack of necessity. Increased fluoroscopy and MIS use in the future may shift focus from weaknesses to the strengths of spinal navigation, including decreased radiation exposure and elimination of the C-arm from the operative field.