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Arts MP, Lycklama À Nijeholt G, Van Eeckhoven E, Wolfs JFC. Accurate placement of thoracolumbar pedicle screws using a handheld iOS-based navigation device: a prospective intra-patient agreement study. Spine J 2024; 24:1671-1677. [PMID: 38704097 DOI: 10.1016/j.spinee.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/26/2024] [Accepted: 04/28/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Accurate pedicle screw placement is a challenge with reported misplacement rates of 10% and higher. A handheld navigation device (HND) may provide accuracy equal to CT-based navigation (CT-Nav) but without the cost and complexity. OBJECTIVE To study the accuracy of a handheld navigation device for pedicle screw placement. STUDY DESIGN This prospective cross-sectional study with consistently applied reference standard enrolled 20 patients undergoing 92 pedicle screw placements. PATIENTS Patients who underwent pedicle screw placement between May 2022 and September 2022. OUTCOME MEASURES Pedicle screw placement accuracy per Gertzbein-Robbins. METHODS Once the screw pilot hole was established, the proposed trajectory of the HND was compared with that proposed by CT-Nav. Postoperatively, screw accuracy was graded according to Gertzbein-Robbins by a blinded radiologist based on CT scans. Accuracy was compared between the two systems and published control for fluoroscopy assisted and CT-Nav placement using Bayesian posterior distribution. RESULTS The trajectory proposed by the HND and CT-Nav were in agreement in 98.9% (95% Exact CI; 94.09%-99.97%). The HND accuracy was 98.9% with 91 screws rated "A" and 1 rated "C". Noninferiority to fluoroscopic placement was achieved because the one-sided normal-approximation 95% CI Lower Bound (LB) of 95.3% is greater than the Performance Goal (PG) of 83.4%. Posthoc analysis demonstrated that the probability of superiority of the HND relative to the historical accuracy rate of 91.5% for fluoroscopy assisted procedures is >0.999 and that the HND's accuracy rate is within 4.5% of CT-Nav of 95.5% is >0.999. No adverse events or intra-operative complications associated with HND were observed. There was 1 (1.1%) intra-operative repositioning and no reoperations for any reason. CONCLUSIONS The accuracy rate of the HND was 98.9%, and the proposed trajectory matched with CT-Nav in 98.9% of the time. This is superior to the historical published accuracy rate for fluoroscopy-assisted procedures and equivalent to the historical published accuracy rate for CT-Nav. CLINICAL TRIAL REGISTRATION NUMBER Dutch trial register NL74268.058.20.
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Affiliation(s)
- Mark P Arts
- Department of Neurosurgery, Haaglanden Medical Center, PO Box 432, 2501 CK, The Hague, The Netherlands.
| | | | | | - Jasper F C Wolfs
- Department of Neurosurgery, Haaglanden Medical Center, PO Box 432, 2501 CK, The Hague, The Netherlands
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Wilson JP, Fontenot L, Stewart C, Kumbhare D, Guthikonda B, Hoang S. Image-Guided Navigation in Spine Surgery: From Historical Developments to Future Perspectives. J Clin Med 2024; 13:2036. [PMID: 38610801 PMCID: PMC11012660 DOI: 10.3390/jcm13072036] [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: 12/18/2023] [Revised: 03/08/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Intraoperative navigation is critical during spine surgery to ensure accurate instrumentation placement. From the early era of fluoroscopy to the current advancement in robotics, spinal navigation has continued to evolve. By understanding the variations in system protocols and their respective usage in the operating room, the surgeon can use and maximize the potential of various image guidance options more effectively. At the same time, maintaining navigation accuracy throughout the procedure is of the utmost importance, which can be confirmed intraoperatively by using an internal fiducial marker, as demonstrated herein. This technology can reduce the need for revision surgeries, minimize postoperative complications, and enhance the overall efficiency of operating rooms.
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Affiliation(s)
| | | | | | | | | | - Stanley Hoang
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA; (J.P.W.J.); (L.F.); (C.S.); (D.K.); (B.G.)
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Sharma M, Uddin SA, Hanna G, Ugiliweneza B, Kim TT, Johnson JP, Boakye M, Drazin D. Trends and Long-term Health Care Utilization of Computer-assisted Neuronavigation in Spine Fusions: An Exact Matched Analysis of National Administrative Database. World Neurosurg 2022; 166:e850-e858. [PMID: 35944855 DOI: 10.1016/j.wneu.2022.07.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Computer-assisted neuronavigation (CAN) during spine fusions has increasingly been utilized in the United States. The aim of this study was to analyze the trends, health care utilization, and clinical outcomes associated with CAN use. METHODS The MarketScan database was queried using the ICD-9/10 and CPT 4th edition, from 2003 to 2019. We included patients aged ≥18 years with at least 2 years of follow-up. Outcomes were repeat/new fusions, length of stay (LOS), discharge disposition, hospital re-admissions, outpatient services, and medication refills for up to 24 months. RESULTS Of 183,620 patients who underwent spine fusions, 5046 (2.75%) were identified to have CAN utilized. CAN is increasingly being utilized for spine fusions since 2010, reaching 10.76% of all fusions in 2017, compared to 0.38% in 2010. CAN had no impact on LOS, home discharge, or complications at index hospitalization and 30-days post discharge. CAN was associated with lower rates of repeat fusions at 6 months (1% vs. 2%) and 24 months (5% vs. 6%), P < 0.05. Patients who underwent CAN had lower payments at 6 months ($5186 vs. $5527, P = 0.0159), 12 months ($10,267 v.s $11,262, P = 0.0207), and 24 months ($21,453 vs. $24,355, P = 0.0021). CONCLUSIONS CAN is increasing being used for spine fusions primarily for thoracolumbar procedures. No difference in complications, discharge disposition, and LOS were noted across the cohorts at index hospitalization, with higher index payments with CAN use. CAN was associated with lower rates of repeat fusions and corresponding health care utilization for up to 24 months.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.
| | - Syed Abdullah Uddin
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - George Hanna
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA; Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky, USA; Department of Health Management and Systems Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Terrence T Kim
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA; Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky, USA
| | - Doniel Drazin
- Department of Neurosurgery, Providence Regional Medical Center, Everett, Washington, USA
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Striano BM, Xiong GX, Lightsey HM, Crawford AM, Pisano AJ, Schoenfeld AJ, Simpson AK. Comparison of Radiation Exposure Between Anterior, Lateral, and Posterior Interbody Fusion Techniques and the Influence of Patient and Procedural Factors. Spine (Phila Pa 1976) 2021; 46:1669-1675. [PMID: 34610614 DOI: 10.1097/brs.0000000000004247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The aim of this study was to elucidate the relative influence of multiple factors on radiation usage for anterior, lateral, and posterior based lumbar interbody fusion techniques. SUMMARY OF BACKGROUND DATA There has been substantial global growth in the performance of lumbar interbody fusions, due to evolution of techniques and approaches and increased attention to sagittal alignment. Utilization of intraoperative imaging guidance has similarly expanded, with a predominance of fluoroscopy and consequent increased radiation exposure. There have been no larger-scale studies examining the role of patient and procedural factors in driving radiation exposure across different interbody techniques. METHODS We used a clinical registry to review all single-level lumbar interbody fusions performed between January 2016 and October 2020. Operative records were reviewed for the amount of radiation exposure during the procedure. Patient age, biologic sex, body mass index (BMI), operative surgeon, surgical level, surgical time, and fusion technique were recorded. Multivariable adjusted analyses using negative binomial regression were used to account for confounding. RESULTS We included 134 interbody fusions; 80 performed with a posterior approach (TLIF/PLIF), 43 via an anterior approach (ALIF) with posterior pedicle fixation, and 9 performed with a lateral approach (LLIF/XLIF). Average radiation per case was 136.4 mGy (SE 17.3) for ALIF, 108.6 mGy (16.9) for LLIF/XLIF, and 60.5 mGy (7.4) for TLIF/PLIF. We identified lateral approaches, increased BMI, minimally invasive techniques, and more caudal operative levels as significantly associated with increased radiation exposure. CONCLUSION We identified several novel drivers of radiation exposure during interbody fusion procedures, including the relative importance of technique and the level at which the fusion is performed. More caudal levels of intervention and lateral based techniques had significantly greater radiation exposure.Level of Evidence: 4.
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Affiliation(s)
- Brendan M Striano
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, M
| | - Grace X Xiong
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, M
| | - Harry M Lightsey
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, M
| | - Alexander M Crawford
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, M
| | - Alfred J Pisano
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew K Simpson
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Banat M, Wach J, Salemdawod A, Domurath L, Scorzin J, Vatter H. Can Postoperative CT Imaging in Spine Surgery Be Replaced by Intraoperative 3D Rotation With the C-Arm?: Results of a Prospective Single Center Cohort Study. Front Surg 2021; 8:692189. [PMID: 34336918 PMCID: PMC8321091 DOI: 10.3389/fsurg.2021.692189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Dorsal instrumentation of the spine is an established treatment option for a range of spinal pathologies. Intraoperative fluoroscopy connected with navigation minimize the risk of incorrect screws placement. In several cases, post-operative CT scans are needed to verify possible mismatches. In this study, we evaluated the efficacy of 3D intraoperative fluoroscopy as compared to post-operative CT and the need of post-operative CT. Methods: We conducted a prospective single-center cohort study, 94 patients were included. The screws were implanted using 3D rotation with C-arm and navigation system. The definitive position of the screws was verified by a post-operative CT scan. Finally, we compared the discrepance between intraoperative imaging and post-operative CT scan using Rampersaud-grade (A-D). Results: 607 screws in 94 patients were included. Some 3% of the screws had to be replaced immediately intraoperative due to inadequate position with lateral or medial trajectory. An A-score was achieved for 85.5% of the 3D controlled screws and 87% of the post-operative CT. A B-score was found in 11.5% of either groups. In the 3D group a C-score was achieved for 2.5% and in the CT group for 0.8%. A D-score was found in 0.5% of the screws in both groups, p = 0.45. Only a mismatch of 3% could be detected for the intraoperative and post-operative imaging results. Conclusion: Our study data shows that the placement of screws using the 3D rotation and navigation tool is safe and accurate. There were no relevant mismatches between intraoperative images and the post-operative CT.
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Affiliation(s)
- Mohammed Banat
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | - Johannes Wach
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | | | - Lisa Domurath
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | - Jasmin Scorzin
- Department of Neurosurgery, University of Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University of Bonn, Bonn, Germany
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Banat M, Wach J, Salemdawod A, Bahna M, Scorzin J, Vatter H. The Role of Intraoperative Image Guidance Systems (Three-Dimensional C-arm versus O-arm) in Spinal Surgery: Results of a Single-Center Study. World Neurosurg 2020; 146:e817-e821. [PMID: 33181376 DOI: 10.1016/j.wneu.2020.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/09/2022]
Abstract
OBJECTIVE Spinal dorsal instrumentation is an established treatment option for a range of spinal disorders. In combination with navigation, intraoperative fluoroscopy reduces the risk of incorrectly placing screws. This study aimed to evaluate the efficacy and validity of fluoroscopy (intraoperative navigation with three-dimensional rotation of C-arm vs. O-arm). METHODS In this retrospective single-center study, 240 patients were included between July 2017 and April 2020. Intraoperative images were acquired using a Siemens-Arcadis Orbic 3D C-arm with a navigation system (Brainlab, AG, Munich, Germany) or using O-arm (Medtronic, Minneapolis, Minnesota, USA) with a navigation system (S7 StealthStation). Finally, we compared mismatches between intraoperative and postoperative computed tomography imaging results using Rampersaud-grade (A-D). RESULTS A total of 1614 screws were included: 94 patients in the C-arm group (cAG) and 146 in the O-arm group (oAG). In cAG, 3% (n = 20) of the screws had to be replaced directly due to inadequate positioning with median or lateral breaches, and 3.5 % of screws in oAG (n = 35). An A-score was achieved for 85.7% in the cAG and 87.4% in the oAG. A B-score was found in 11.5% in the cAG and 11.9% in the oAG. In the cAG, a C-score was achieved for 2.5% and in oAG for 0.7%. For 0.3% of the screws, a D-score was found in cAG and for none in oAG. CONCLUSIONS Our study shows that placement of screws using intraoperative imaging in combination with a navigation tool is accurate. Furthermore, navigation coupled with the O-arm had significant advantages in accuracy over navigation with 3D C-arm fluoroscopy. However, both systems offer a high level of accuracy.
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Affiliation(s)
- Mohammed Banat
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Bonn, Germany.
| | - Johannes Wach
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Bonn, Germany
| | - Abduallah Salemdawod
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Bonn, Germany
| | - Majd Bahna
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Bonn, Germany
| | - Jasmin Scorzin
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Bonn, Germany
| | - Hartmut Vatter
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Bonn, Bonn, Germany
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Shin Y, Sunada H, Shiraishi Y, Hosokawa M, Koh Y, Tei R, Aketa S, Motoyama Y, Yonezawa T, Nakase H. Navigation-assisted full-endoscopic spine surgery: a technical note. JOURNAL OF SPINE SURGERY 2020; 6:513-520. [PMID: 32656389 DOI: 10.21037/jss-2019-fess-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Full-endoscopic spine surgery (FESS) necessitates the use of X-ray fluoroscopy for intraoperative guidance and orientation. However, the two-dimensional X-ray fluoroscopic images do not provide real-time guidance. The authors developed a new real-time three-dimensional (3D) navigation technique for FESS that entails the use of intraoperative cone beam computed tomography (CBCT) in a hybrid operating room (OR). Methods A total of 23 patients undergoing FESS using real-time 3D navigation system were enrolled. Preoperative and intraoperative CBCT data were registered in the navigation system. The 3D navigation was used to intraoperatively determine the trajectory and obtain position information. The feasibility and usefulness of the navigation system were retrospectively analyzed. Results Twenty patients had lumbar spine disease, whereas three patients had cervical spine disease. The 3D navigation was successfully used for intraoperative guidance and provided accurate information in all patients. X-ray fluoroscopy was not required in any of the patients. No complications associated with the use of 3D navigation system were encountered. Conclusions The use of real-time 3D navigation system in the hybrid OR was found to be safe and effective in providing intraoperative guidance for FESS.
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Affiliation(s)
- Yasushi Shin
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Hiromu Sunada
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Yuki Shiraishi
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Makoto Hosokawa
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Yumi Koh
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Rinsei Tei
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Shuta Aketa
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Taiji Yonezawa
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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Chen L, Zhang F, Zhan W, Gan M, Sun L. Research on the accuracy of three‐dimensional localization and navigation in robot‐assisted spine surgery. Int J Med Robot 2020; 16:e2071. [PMID: 31875428 DOI: 10.1002/rcs.2071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Long Chen
- School of Mechanical and Electrical EngineeringSoochow University Suzhou China
| | - Fengfeng Zhang
- School of Mechanical and Electrical EngineeringSoochow University Suzhou China
- Collaborative Innovation Center of Suzhou Nano Science and TechnologySoochow University Suzhou
| | - Wei Zhan
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Minfeng Gan
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Lining Sun
- School of Mechanical and Electrical EngineeringSoochow University Suzhou China
- Collaborative Innovation Center of Suzhou Nano Science and TechnologySoochow University Suzhou
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