Image-Guided Navigation and Robotics in Spine Surgery

Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.

Effects of robot-assisted percutaneous kyphoplasty on osteoporotic vertebral compression fractures: a systematic review and meta-analysis

This study systemically reviewed the effects of robot-assisted percutaneous kyphoplasty (R-PKP) on the clinical outcomes and complications of patients with osteoporotic vertebral compression fracture (OVCF). The articles published from the establishment of the database to 19 April 2024 were searched in PubMed, The Cochrane Library, Web of Science, Embase, Scopus, China National Knowledge Infrastructure (CNKI), and Chinese biomedical literature service system (SinoMed). Meta-analysis was employed to evaluate the status of pain relief and complications between the control and R-PKP groups. Standardized mean difference (SMD) or mean difference (MD), risk ratios (RR), and 95% confidence interval (CI) were selected for analysis, and a common or random effect model was adopted to merge the data. Eight studies involving 773 patients with OCVFs were included. R-PKP could effectively Cobb's angles (MD = -1.00, 95% CI -1.68 to -0.33, P = 0.0034), and decrease the occurrence of cement leakage (RR = 0.36, 95% CI 0.21 to 0.60, P < 0.0001). However, there was no significant effect on the results of visual analog scale (MD = -0.09, 95% CI -0.20 to 0.02, P = 0.1145), fluoroscopic frequency (SMD = 5.31, 95% CI -7.24 to 17.86, P = 0.4072), and operation time (MD = -0.72, 95% CI -7.47 to 6.03, P = 0.8342). R-PKP could significantly correct vertebral angle and reduce cement leakage. Thus, R-PKP maybe an effective choice for correction vertebral Angle and reducing postoperative complications, while its impact on relieving pain, decreasing fluoroscopic frequency, and shortening operation time need further exploration.

What is the Marginal Cost of Using Robot Assistance or Navigation for Transforaminal Lumbar Interbody Fusion? A Time-Driven Activity-Based Cost Analysis

BACKGROUND AND OBJECTIVE

Our primary objective was to compare the marginal intraoperative cost of 3 different methods for pedicle screw placement as part of transforaminal lumbar interbody fusions (TLIFs). Specifically, we used time-driven activity-based costing to compare costs between robot-assisted TLIF (RA-TLIF), TLIF with intraoperative navigation (ION-TLIF), and freehand (non-navigated, nonrobotic) TLIF.

METHODS

Total cost was divided into direct and indirect costs. We identified all instances of RA-TLIF (n = 20), ION-TLIF (n = 59), and freehand TLIF (n = 233) from 2020 to 2022 at our institution. Software was developed to automate the extraction of all intraoperatively used personnel and material resources from the electronic medical record. Total costs were determined through a combination of direct observation, electronic medical record extraction, and interdepartmental collaboration (business operations, sterile processing, pharmacy, and plant operation departments). Multivariable linear regression analysis was performed to compare costs between TLIF modalities, accounting for patient-specific factors as well as number of levels fused, surgeon, and hospital site.

RESULTS

The average total intraoperative cost per case for the RA-TLIF, ION-TLIF, and freehand TLIF cohorts was $24 838 ± $10 748, $15 991 ± $6254, and $14 498 ± $6580, respectively. Regression analysis revealed that RA-TLIF had significantly higher intraoperative cost compared with both ION-TLIF (β-coefficient: $7383 ± $1575, P < .001) and freehand TLIF (β-coefficient: $8182 ± $1523, P < .001). These cost differences were primarily driven by supply cost. However, there were no significant differences in intraoperative cost between ION-TLIF and freehand TLIF (P = .32).

CONCLUSION

We demonstrate a novel use of time-driven activity-based costing methodology to compare different modalities for executing the same type of lumbar fusion procedure. RA-TLIF entails significantly higher supply cost when compared with other modalities, which explains its association with higher total intraoperative cost. The use of ION, however, does not add extra expense compared with freehand TLIF when accounting for confounders. This might have implications as surgeons and hospitals move toward bundled payments.

Navigation-Guided/Robot-Assisted Spinal Surgery: A Review Article

The development of minimally invasive spinal surgery utilizing navigation and robotics has significantly improved the feasibility, accuracy, and efficiency of this surgery. In particular, these methods provide improved accuracy of pedicle screw placement, reduced radiation exposure, and shortened learning curves for surgeons. However, research on the clinical outcomes and cost-effectiveness of navigation and robot-assisted spinal surgery is still in its infancy. Therefore, there is limited available evidence and this makes it difficult to draw definitive conclusions regarding the long-term benefits of these technologies. In this review article, we provide a summary of the current navigation and robotic spinal surgery systems. We concluded that despite the progress that has been made in recent years, and the clear advantages these methods can provide in terms of clinical outcomes and shortened learning curves, cost-effectiveness remains an issue. Therefore, future studies are required to consider training costs, variable initial expenses, maintenance and service fees, and operating costs of these advanced platforms so that they are feasible for implementation in standard clinical practice.

Bibliometric Analysis of the Development, Current Status, and Trends in Adult Degenerative Scoliosis Research: A Systematic Review from 1998 to 2023

Purpose

Adult degenerative scoliosis (ADS) research lacks bibliometric analysis, despite numerous studies. This study aimed to systematically analyze the development, current status, hot topics, frontier areas, and trends in ADS research.

Patients and Methods

A systematic literature review was conducted in the Web of Science Core Collection database from January 1998 to June 2023. Information regarding the country, institution, author, journal, and keywords was collected for each article. Bibliometric analysis was performed using VOSviewer and Citespace software.

Results

The final analysis covered 1695 publications, demonstrating a steady increase in ADS research. The United States was the most prolific and influential country with 684 publications, followed by China and Japan. The University of California System was the most productive institution with 113 publications. Shaffrey, CI (47 publications) and Lenke, LG (41 publications) were top authors. The analysis revealed seven main research clusters: "intervertebral disc", "adult spinal deformity", "lumbar fusion", "minimally invasive surgery", "navigation", "postoperative complications", and "mental retardation". Keywords with strong bursts of activity included degeneration, prevalence, imbalance, classification, lumbar spinal stenosis, and kyphosis.

Conclusion

In conclusion, in recent years, ADS research has undergone rapid development. This study analyzed its hot topics, advancements, and research directions, making it the latest bibliometric analysis in this field. The findings aim to provide a new perspective and guidance for clinical practitioners and researchers.

Modern Image-Guided Surgery: A Narrative Review of Medical Image Processing and Visualization

Medical image analysis forms the basis of image-guided surgery (IGS) and many of its fundamental tasks. Driven by the growing number of medical imaging modalities, the research community of medical imaging has developed methods and achieved functionality breakthroughs. However, with the overwhelming pool of information in the literature, it has become increasingly challenging for researchers to extract context-relevant information for specific applications, especially when many widely used methods exist in a variety of versions optimized for their respective application domains. By being further equipped with sophisticated three-dimensional (3D) medical image visualization and digital reality technology, medical experts could enhance their performance capabilities in IGS by multiple folds. The goal of this narrative review is to organize the key components of IGS in the aspects of medical image processing and visualization with a new perspective and insights. The literature search was conducted using mainstream academic search engines with a combination of keywords relevant to the field up until mid-2022. This survey systemically summarizes the basic, mainstream, and state-of-the-art medical image processing methods as well as how visualization technology like augmented/mixed/virtual reality (AR/MR/VR) are enhancing performance in IGS. Further, we hope that this survey will shed some light on the future of IGS in the face of challenges and opportunities for the research directions of medical image processing and visualization.

[Innovative 3D imaging]

Intraoperative 2D fluoroscopy is often performed for repositioning and implant control. However, this does not always provide the details needed to reliably detect joint steps or incorrect repositioning. Over the last few years, intraoperative 3D imaging has been established and further developed. Multiple studies demonstrate an advantage and better intraoperative control through 3D imaging. Examples are the upper ankle, the proximal tibia and the distal radius; the rates of intraoperative revisions with digital volume tomography (DVT) are between 20-30%. Technical advancements, such as metal artifact reductions, automated plane setting, automated screw detection, and robotic DVT devices, facilitate intraoperative operation, shorten surgical time, and provide improved image quality. By processing the data sets in the form of an immersive, computer-simulated image in terms of "augmented reality" (AR), increased precision can be achieved intraoperatively while reducing radiation exposure. The implementation of these systems is associated with costs, which are offset by cost savings from avoided revisions. Adequate counter-financing is still lacking at the present time. Intraoperative 3D imaging represents an important tool for intraoperative control. The current data situation makes it necessary to address the routine use of 3D procedures, especially in the joint area. The indications are becoming increasingly broader. Technical innovations such as robotics and AR have significantly improved 3D devices in recent years and offer high potential for integration into the OR.

PDS-MAR: a fine-grained projection-domain segmentation-based metal artifact reduction method for intraoperative CBCT images with guidewires

Objective.Since the invention of modern Computed Tomography (CT) systems, metal artifacts have been a persistent problem. Due to increased scattering, amplified noise, and limited-angle projection data collection, it is more difficult to suppress metal artifacts in cone-beam CT, limiting its use in human- and robot-assisted spine surgeries where metallic guidewires and screws are commonly used.Approach.To solve this problem, we present a fine-grained projection-domain segmentation-based metal artifact reduction (MAR) method termed PDS-MAR, in which metal traces are augmented and segmented in the projection domain before being inpainted using triangular interpolation. In addition, a metal reconstruction phase is proposed to restore metal areas in the image domain.Main results.The proposed method is tested on both digital phantom data and real scanned cone-beam computed tomography (CBCT) data. It achieves much-improved quantitative results in both metal segmentation and artifact reduction in our phantom study. The results on real scanned data also show the superiority of this method.Significance.The concept of projection-domain metal segmentation would advance MAR techniques in CBCT and has the potential to push forward the use of intraoperative CBCT in human-handed and robotic-assisted minimal invasive spine surgeries.

Microsurgery Robots: Applications, Design, and Development

Microsurgical techniques have been widely utilized in various surgical specialties, such as ophthalmology, neurosurgery, and otolaryngology, which require intricate and precise surgical tool manipulation on a small scale. In microsurgery, operations on delicate vessels or tissues require high standards in surgeons' skills. This exceptionally high requirement in skills leads to a steep learning curve and lengthy training before the surgeons can perform microsurgical procedures with quality outcomes. The microsurgery robot (MSR), which can improve surgeons' operation skills through various functions, has received extensive research attention in the past three decades. There have been many review papers summarizing the research on MSR for specific surgical specialties. However, an in-depth review of the relevant technologies used in MSR systems is limited in the literature. This review details the technical challenges in microsurgery, and systematically summarizes the key technologies in MSR with a developmental perspective from the basic structural mechanism design, to the perception and human-machine interaction methods, and further to the ability in achieving a certain level of autonomy. By presenting and comparing the methods and technologies in this cutting-edge research, this paper aims to provide readers with a comprehensive understanding of the current state of MSR research and identify potential directions for future development in MSR.

Indirect Puncture Using a Novel Arc Puncture-Guided Device in Percutaneous Transforaminal Puncture on Goat Lumbar Spine Specimens

OBJECTIVE

We investigated the indirect puncture method using a novel arc puncture-guided device in percutaneous transforaminal puncture to improve puncture accuracy and reduce the fluoroscopy, puncture, and operation times.

METHODS

We have designed a novel arc puncture-guided device consisting of a 90° arc block and a 30° arc block. Punctures were performed on 8 fresh goat lumbar spine specimens. A senior doctor performed indirect punctures on the left side of the L2-L3, L3-L4, and L4-L5 levels using the novel device (group A) and on the right side of the L2-L3, L3-L4, and L4-L5 levels using the conventional method (group B). We recorded the fluoroscopy, puncture, and operation times.

RESULTS

In group A, the first puncture could successfully reach the target after 1-3 punctures, and the one-time success rate of the second needle puncture was 91.67%. The total fluoroscopy time was 14.88 ± 0.99 minutes in group A and 16.08 ± 2.22 minutes in group B (P = 0.027). The puncture times were 3.00 ± 0.66 minutes in group A and 6.04 ± 2.13 minutes in group B (P < 0.01). The operation time was 273.75 ± 30.19 minutes in group A and 361.25 ± 69.57 minutes in group B (P < 0.01). The differences in fluoroscopy times, puncture times, and operation times between the 2 groups were statistically significantly (P < 0.05).

CONCLUSIONS

Indirect puncture using the novel arc puncture-guided device for percutaneous transforaminal puncture can significantly improve puncture accuracy and reduce the fluoroscopy, puncture, and operation times. Indirect puncture using the novel device in percutaneous transforaminal endoscopic discectomy is a potential and practical puncture method.

Current trends and advancements in spine surgery

In recent years, spine surgery has undergone remarkable advancements, revolutionized the field, and transformed patient care. This special issue of the Journal of Orthopedics provides the best possible knowledge for its readers about the current trends and recent innovations in the field of spine surgery and supports clinicians and surgeons in their daily practice and decision-making process. It covers various topics like artificial intelligence in spine surgery, 3D printing, minimally invasive spine surgery. It also provides needed information on modic changes, management of eary onset scoliosis and recent trends in spinal cord injury management.

The Use of Intraoperative CT Hounsfield Unit Values for the Assessment of Bone Quality in Patients Undergoing Lumbar Interbody Fusion

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

To evaluate the accuracy of intraoperatively measured computed tomography (CT) Hounsfield unit (HU) values by comparison with preoperative CT HU values and to compare the radiation exposure between preoperative and intraoperative CT scans.

METHODS

HU values of lumbar vertebrae were measured and compared between preoperative and intraoperative CT scans in patients undergoing lumbar interbody fusion. In patient group one, Canon CT scanners were used preoperatively and the AIRO CT scanner was used intraoperatively. In patient group two, Canon CT scanners were used preoperatively and the O-arm Cone Beam CT (CBCT) scanner was used intraoperatively. In a subgroup analysis of patient group one, radiation by means of CT Dose Index (CTDI) was compared between Canon and AIRO CT scanners.

RESULTS

In the first patient group, a total of 250 vertebrae were analysed in 74 patients showing a strong Pearson correlation of >.94 between pre- and intraoperative HU values. Bland-Altman analysis indicated consistency and equivalence with a bias of 3.9 and 95% limits of agreement from -27.17 to 34.97 when comparing all pre- and intraoperative HU values of L1-5. In the second patient group, a total of 27 vertebrae were analysed in 10 patients showing weak Pearson correlation and Bland-Altman analysis indicated no equivalence. CTDI did not differ between Canon and AIRO CT scanners.

CONCLUSION

Correct and reliable CT HU measurement as mandatory key factor for the intraoperative assessment of bone quality and robotic-assisted surgery is feasible with intraoperative AIRO CT imaging without increase of radiation exposure.

Technical evolution of pediatric neurosurgery: the evolution of intraoperative imaging

Imaging has always been fundamental to neurosurgery, and its evolution over the last century has made a dramatic transformation in the ability of neurosurgeons to define pathology and preserve normal tissue during their operations. In the mid-70 s, the development of computerized cross-sectional imaging with CT scan and subsequently MRI have revolutionized the practice of neurosurgery. Later, further advances in computer technology and medical engineering have allowed the combination of many modalities to bring them into the operating theater. This evolution has allowed real-time intraoperative imaging, in the hope of helping neurosurgeons achieve accuracy, maximal safe resection, and the implementation of minimally invasive techniques in brain and spine pathologies. Augmented reality and robotic technologies are also being applied as useful intra-operative techniques that will improve surgical planning and outcomes in the future. In this article, we will review imaging modalities and provide our institutional perspective on how we have integrated them into our practice.

Improving pedicle screw path planning by vertebral posture estimation

Objective.Robot-assisted pedicle screw placement in spinal surgery can reduce the complications associated with the screw placement and reduce the hospital return counts due to malfunctions. However, it requires accurate planning for a high-quality procedure. The state-of-the-art technologies reported in the literature either ignore the anatomical variations across vertebrae or require substantial human interactions. We present an improved approach that achieves pedicle screw path planning through multiple projections of a numerically re-oriented vertebra with the estimated posture.Approach.We proposed an improved YOLO-type neural network model (YOLOPOSE3D) to estimate the posture of a vertebra before pedicle path planning. In YOLOPOSE3D, the vertebral posture is given as a rotation quaternion and 3D location coordinates by optimizing the intersection over union of the vertebra with the predicted posture and the actual posture. Then, a new local coordinate system is established for the vertebra based on the estimated posture. Finally, the optimal pedicle screw path trajectory is determined from the multiple projections of the vertebra in the local coordinates.Main results.The experimental results in difficult cases of scoliosis showed that the new YOLOPOSE3D network could accurately detect the location and posture of the vertebra with average translation and orientation errors as small as 1.55 mm and 2.55°. The screw path planning achieved 83.1% success rate without breaking the pedicle cortex for the lumbar vertebral L1-L5, which is better than that of a doctor's manual planning, 82.4%. With the clinical class A requirement to allow less than 2 mm out of the pedicle cortex, the success rate achieved nearly 100%.Significance.The proposed YOLOPOSED3D method can accurately determine the vertebral postures. With the improved posture prior, better clinical outcomes can be achieved for pedicle screw placement in spine internal fixation procedures.

Management of Spinal Metastasis by Minimally Invasive Surgical Techniques: Surgical Principles and Indications-A Literature Review

BACKGROUND

Spinal metastasis is becoming more frequent. This raises the topics of pain and neurological complications, which worsen the functional and survival prognosis of oncological population patients. Surgical treatment must be as complete as possible in order to decompress and stabilize without delaying the management of the oncological disease. Minimally invasive spine surgical techniques inflict less damage on the musculocutaneous plan than opened ones.

METHODS

Different minimally invasive techniques are proposed in this paper for the management of spinal metastasis. We used our experience, developed degenerative and traumatic pathologies, and referred to many authors, establishing a narrative review of our local practice.

RESULTS

Forty-eight articles were selected, and these allowed us to describe the different techniques: percutaneous methods such as vertebro/kyphoplasty, osteosynthesis, mini-open surgery, or that through a posterior or anterior approach. Also, some studies detail the contribution of new technologies, such as intraoperative CT scan and robotic assistance.

CONCLUSIONS

It seems essential to offer a lasting solution to a spinal problem, such as in the form of pain relief, stabilization, and decompression. Our department has embraced a multidisciplinary and multidimensional approach to MISS, incorporating cutting-edge technologies and evidence-based practices.

Projected Lifetime Cancer Risk Associated With Intraoperative Computed Tomography for Lumbar Spine Surgery

STUDY DESIGN

Retrospective cross-sectional study.

OBJECTIVE

(1) To determine the incremental increase in intraoperative ionizing radiation conferred by computed tomography (CT) as compared with conventional radiography; and (2) to model different lifetime cancer risks contextualized by the intersection between age, sex, and intraoperative imaging modality.

SUMMARY OF BACKGROUND DATA

Emerging technologies in spine surgery, like navigation, automation, and augmented reality, commonly utilize intraoperative CT. Although much has been written about the benefits of such imaging modalities, the inherent risk profile of increasing intraoperative CT has not been well evaluated.

MATERIALS AND METHODS

Effective doses of intraoperative ionizing radiation were extracted from 610 adult patients who underwent single-level instrumented fusion for lumbar degenerative or isthmic spondylolisthesis from January 2015 through January 2022. Patients were divided into those who received intraoperative CT (n=138) and those who underwent conventional intraoperative radiography (n=472). Generalized linear modeling was utilized with intraoperative CT use as a primary predictor and patient demographics, disease characteristics, and preference-sensitive intraoperative considerations ( e.g. surgical approach and surgical invasiveness) as covariates. The adjusted risk difference in radiation dose calculated from our regression analysis was used to prognosticate the associated cancer risk across age and sex strata.

RESULTS

(1) After adjusting for covariates, intraoperative CT was associated with 7.6 mSv (interquartile range: 6.8-8.4 mSv; P <0.001) more radiation than conventional radiography. (2) For the median patient in our population (a 62-year-old female), intraoperative CT use increased lifetime cancer risk by 2.3 incidents (interquartile range: 2.1-2.6) per 10,000. Similar projections for other age and sex strata were also appreciated.

CONCLUSIONS

Intraoperative CT use significantly increases cancer risk compared with conventional intraoperative radiography for patients undergoing lumbar spinal fusions. As emerging technologies in spine surgery continue to proliferate and leverage intraoperative CT for cross-sectional imaging data, strategies must be developed by surgeons, institutions, and medical technology companies to mitigate long-term cancer risks.

Visualization in 2D/3D registration matters for assuring technology-assisted image-guided surgery

PURPOSE

Image-guided navigation and surgical robotics are the next frontiers of minimally invasive surgery. Assuring safety in high-stakes clinical environments is critical for their deployment. 2D/3D registration is an essential, enabling algorithm for most of these systems, as it provides spatial alignment of preoperative data with intraoperative images. While these algorithms have been studied widely, there is a need for verification methods to enable human stakeholders to assess and either approve or reject registration results to ensure safe operation.

METHODS

To address the verification problem from the perspective of human perception, we develop novel visualization paradigms and use a sampling method based on approximate posterior distribution to simulate registration offsets. We then conduct a user study with 22 participants to investigate how different visualization paradigms (Neutral, Attention-Guiding, Correspondence-Suggesting) affect human performance in evaluating the simulated 2D/3D registration results using 12 pelvic fluoroscopy images.

RESULTS

All three visualization paradigms allow users to perform better than random guessing to differentiate between offsets of varying magnitude. The novel paradigms show better performance than the neutral paradigm when using an absolute threshold to differentiate acceptable and unacceptable registrations (highest accuracy: Correspondence-Suggesting (65.1%), highest F1 score: Attention-Guiding (65.7%)), as well as when using a paradigm-specific threshold for the same discrimination (highest accuracy: Attention-Guiding (70.4%), highest F1 score: Corresponding-Suggesting (65.0%)).

CONCLUSION

This study demonstrates that visualization paradigms do affect the human-based assessment of 2D/3D registration errors. However, further exploration is needed to understand this effect better and develop more effective methods to assure accuracy. This research serves as a crucial step toward enhanced surgical autonomy and safety assurance in technology-assisted image-guided surgery.

Is There a Difference in Screw Accuracy, Robot Time Per Screw, Robot Abandonment, and Radiation Exposure Between the Mazor X and the Renaissance? A Propensity-Matched Analysis of 1179 Robot-Assisted Screws

STUDY DESIGN

Prospective single-cohort analysis.

OBJECTIVES

To compare the outcomes/complications of 2 robotic systems for spine surgery.

METHODS

Adult patients (≥18-years-old) who underwent robot-assisted spine surgery from 2016-2019 were assessed. A propensity score matching (PSM) algorithm was used to match Mazor X to Renaissance cases. Preoperative CT scan for planning and an intraoperative O-arm for screw evaluation were preformed. Outcomes included screw accuracy, robot time/screw, robot abandonment, and radiation. Screw accuracy was measured using Vitrea Core software by 2 orthopedic surgeons. Screw breach was measured according to the Gertzbein/Robbins classification.

RESULTS

After PSA, a total of 65 patients (Renaissance: 22 vs. X: 43) were included. Patient/operative factors were similar between robot systems (P > .05). The pedicle screw accuracy was similar between robots (Renaissance: 1.1%% vs. X: 1.3%, P = .786); however, the S2AI screw breach rate was significantly lower for the X (Renaissance: 9.5% vs. X: 1.2%, P = .025). Robot time per screw was not statistically different (Renaissance: 4.6 minutes vs. X: 3.9 minutes, P = .246). The X was more reliable with an abandonment rate of 2.3% vs. Renaissance:22.7%, P = .007. Radiation exposure were not different between robot systems. Non-robot related complications including dural tear, loss of motor/sensory function, and blood transfusion were similar between robot systems.

CONCLUSION

This is the first comparative analyses of screw accuracy, robot time/screw, robot abandonment, and radiation exposure between the Mazor X and Renaissance systems. There are substantial improvements in the X robot, particularly in the perioperative planning processes, which likely contribute to the X's superiority in S2AI screw accuracy by nearly 8-fold and robot reliability by nearly 10-fold.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Effects of robot-assisted minimally invasive surgery on osteoporotic vertebral compression fracture: a systematic review, meta-analysis, and meta-regression of retrospective study

OBJECTIVE

To conduct a systematic review on the effect of robot-assisted minimally invasive surgery (R-MIS) on the clinical outcomes and complications of patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

The researchers searched the papers published on PubMed, The Cochrane Library, Web of Science, Embase, Scopus, Ovid MEDLINE, Wiley Online Library, China National Knowledge Infrastructure (CNKI), Chinese biomedical literature service system (SinoMed), and China Medical Association Data. The standardized mean difference (SMD) or mean difference (MD), relative risk (RR), and 95% confidence interval (CI) were calculated. Besides, the data was merged through the random-effect model or common-effect model. A meta-regression mixed-effects single-factor model was utilized to analyze the sources of heterogeneity.

RESULTS

Twelve studies were included, involving 1042 OVCFs cases. The prognosis of patients treated with R-MIS was significantly improved, such as Oswestry disability index (ODI) score (MD = -0.65, P = 0.0171), Cobb's angles (MD = -1.03, P = 0.0027), X-ray fluoroscopy frequency (SMD = -2.41, P < 0.0001), Length of hospital stay (MD = -0.33, P = 0.0002), and Cement leakage (RR = 0.37, P < 0.0001). However, no obvious improvement was found in the results of Visual analog scale (VAS) score (MD = -0.16, P = 0.1555), Volume of bone cement (MD = 0.22, P = 0.8339), and Operation time (MD = -3.20, P = 0.3411) after being treated by R-MIS. The meta-regression analysis demonstrated that R-MIS presented no significant impact on the covariates of VAS and Operation time.

CONCLUSION

R-MIS can significantly reduce the patients' ODI, Cobb's angles, X-ray fluoroscopy frequency, and Cement leakage ratio, and shorten the Length of hospital stay. Therefore, R-MIS may be an effective method to promote the patients' functional recovery, correct spinal deformity, reduce the X-ray fluoroscopy frequency, shorten the Length of hospital stay, and reduce the complications of OVCFs bone Cement leakage.

Intraoperative Navigation and Robotics in Pediatric Spinal Deformity

Current technologies for image guidance navigation and robotic assistance with spinal surgery are improving rapidly with several systems commercially available. Newer machine vision technology has several potential advantages. Limited studies have shown similar outcomes to traditional navigation platforms with decreased intraoperative radiation and time required for registration. However, there are no active robotic arms that can be coupled with machine vision navigation. Further research is necessary to justify the cost, potential increased operative time, and workflow issues but the use of navigation and robotics will only continue to expand given the growing body of evidence supporting their use.

Improved Accuracy and Lowered Learning Curve of Ventricular Targeting Using Augmented Reality-Phantom and Cadaveric Model Testing

BACKGROUND

Augmented reality (AR) has demonstrated significant potential in neurosurgical cranial, spine, and teaching applications. External ventricular drain (EVD) placement remains a common procedure, but with error rates in targeting between 10% and 40%.

OBJECTIVE

To evaluate Novarad VisAR guidance system for the placement of EVDs in phantom and cadaveric models.

METHODS

Two synthetic ventricular phantom models and a third cadaver model underwent computerized tomography imaging and registration with the VisAR system (Novarad). Root mean square (RMS), angular error (γ), and Euclidian distance were measured by multiple methods for various standard EVD placements.

RESULTS

Computerized tomography measurements on a phantom model (0.5-mm targets showed a mean Euclidean distance error of 1.20 ± 0.98 mm and γ of 1.25° ± 1.02°. Eight participants placed EVDs in lateral and occipital burr holes using VisAR in a second phantom anatomic ventricular model (mean RMS: 3.9 ± 1.8 mm, γ: 3.95° ± 1.78°). There were no statistically significant differences in accuracy for postgraduate year level, prior AR experience, prior EVD experience, or experience with video games ( P > .05). In comparing EVDs placed with anatomic landmarks vs VisAR navigation in a cadaver, VisAR demonstrated significantly better RMS and γ, 7.47 ± 0.94 mm and 7.12° ± 0.97°, respectively ( P ≤ .05).

CONCLUSION

The novel VisAR AR system resulted in accurate placement of EVDs with a rapid learning curve, which may improve clinical treatment and patient safety. Future applications of VisAR can be expanded to other cranial procedures.

Technique for Validation of Intraoperative Navigation in Minimally Invasive Spine Surgery

BACKGROUND

Intraoperative 3-dimensional navigation is an enabling technology that has quickly become a commonplace in minimally invasive spine surgery (MISS). It provides a useful adjunct for percutaneous pedicle screw fixation. Although navigation is associated with many benefits, including improvement in overall screw accuracy, navigation errors can lead to misplaced instrumentation and potential complications or revision surgery. It is difficult to confirm navigation accuracy without a distant reference point.

OBJECTIVE

To describe a simple technique for validating navigation accuracy in the operating room during MISS.

METHODS

The operating room is set up in a standard fashion for MISS with intraoperative cross-sectional imaging available. A 16-gauge needle is placed within the bone of the spinous process before intraoperative cross-sectional imaging. The entry level is chosen such that the space between the reference array and the needle encompasses the surgical construct. Before placing each pedicle screw, accuracy is verified by placing the navigation probe over the needle.

RESULTS

This technique has identified navigation inaccuracy and led to repeat cross-sectional imaging. No screws have been misplaced in the senior author's cases since adopting this technique, and there have been no complications attributable to the technique.

CONCLUSION

Navigation inaccuracy is an inherent risk in MISS, but the described technique may mitigate this risk by providing a stable reference point.

Emerging trends and research foci of deep learning in spine: bibliometric and visualization study

As the cognition of spine develops, deep learning (DL) emerges as a powerful tool with tremendous potential for advancing research in this field. To provide a comprehensive overview of DL-spine research, our study utilized bibliometric and visual methods to retrieve relevant articles from the Web of Science database. VOSviewer and CiteSpace were primarily used for literature measurement and knowledge graph analysis. A total of 273 studies focusing on deep learning in the spine, with a combined total of 2302 citations, were retrieved. Additionally, the overall number of articles published on this topic demonstrated a continuous upward trend. China was the country with the highest number of publications, whereas the USA had the most citations. The two most prominent journals were "European Spine Journal" and "Medical Image Analysis," and the most involved research area was Radiology Nuclear Medicine Medical Imaging. VOSviewer identified three visually distinct clusters: "segmentation," "area," and "neural network." Meanwhile, CiteSpace highlighted "magnetic resonance image" and "lumbar" as the keywords with the longest usage, and "agreement" and "automated detection" as the most commonly used keywords. Although the application of DL in spine is still in its infancy, its future is promising. Intercontinental cooperation, extensive application, and more interpretable algorithms will invigorate DL in the field of spine.

Intraoperative CT for Lumbar Fusion Is Not Associated with Improved Short- or Long-Term Complication Profiles

BACKGROUND CONTEXT

The use of intraoperative CT has continued to grow in recent years, as various techniques leverage the promise of improved instrumentation accuracy and the hope for decreased complications. Nonetheless, the literature regarding the short- and long-term complications associated with such techniques remains scant and/or confounded by indication and selection bias.

PURPOSE

To use causal inference techniques to determine whether intraoperative CT use is associated with an improved complication profile as compared to conventional radiography for single-level lumbar fusions, an increasingly commonplace application for this technology.

STUDY DESIGN/SETTING

Inverse probability weighted retrospective cohort study carried out within a large integrated healthcare network PATIENT SAMPLE: Adult patients who underwent surgical treatment of spondylolisthesis via lumbar fusion from January 2016 through December 2021 OUTCOME MEASURES: Our primary outcome was the incidence rate of revision surgery. Our secondary outcome was the incidence of composite 90-day complications (deep and superficial surgical site infection, venous thromboembolic events, and unplanned readmissions).

METHODS

Demographics, intraoperative information, and postoperative complications were abstracted from electronic health records. A propensity score was developed utilizing a parsimonious model to account for covariate interaction with our primary predictor, intraoperative imaging technique. This propensity score was utilized in the creation of inverse probability weights to adjust for indication and selection bias. The rate of revisions within 3 years as well as the rate of revisions at any time-point were compared between cohorts using Cox regression analysis. The incidence of composite 90-day complications were compared using negative binomial regression.

RESULTS

Our patient population consisted of 583 patients, with 132 who underwent intraoperative CT and 451 who underwent conventional radiographic techniques. There were no significant differences between cohorts following inverse probability weighting. No significant differences were detected in 3-year revision rates (HR 0.74 [95% CI 0.29, 1.92]; p=0.5), overall revision rates (HR 0.54 [95% CI 0.20, 1.46]; p=0.2), or 90-day complications (RC -0.24 [95% CI -1.35, 0.87]; p=0.7).

CONCLUSIONS

Intraoperative CT use was not associated with an improved complication profile in either the short- or long-term for patients undergoing single-level instrumented fusion. This observed clinical equipoise should be weighed against resource and radiation-related costs when considering intraoperative CT for low complexity fusions.

Alternative Uses of O-Arm and Stealth Navigation Technology Over 10 Years: The University of Colorado Experience

Intraoperative computed tomography scanning with O-arm and use of Stealth navigation can improve surgical outcomes in a variety of orthopedic subspecialties. In spine surgery, the accuracy, precision, and safety of pedicle screw and interbody implant placement has improved. This technology is now routinely used in percutaneous pedicle screw placement and minimally invasive sacroiliac joint fusion. Other applications include, but are not limited to, isthmic pars defect repair, lumbosacral pseudoarticulation resection in Bertolotti's syndrome, radiofrequency ablation, and en bloc tumor resection. Intraoperative navigation has numerous applications, and use of this technology should continue to evolve as the technology advances. [Orthopedics. 2023;46(2):e89-e97.].

Robotic and navigated pedicle screws are safer and more accurate than fluoroscopic freehand screws: a systematic review and meta-analysis

BACKGROUND CONTEXT

Navigated and robotic pedicle screw placement systems have been developed to improve the accuracy of screw placement. However, the literature comparing the safety and accuracy of robotic and navigated screw placement with fluoroscopic freehand screw placement in thoracolumbar spine surgery has been limited.

PURPOSE

To perform a systematic review and meta-analysis of randomized control trials that compared the accuracy and safety profiles of robotic and navigated pedicle screws with fluoroscopic freehand pedicle screws.

STUDY DESIGN/SETTING

Systematic review and meta-analysis PATIENT SAMPLE: Only randomized controlled trials comparing robotic-assisted or navigated pedicle screws placement with freehand pedicle screw placement in the thoracolumbar spine were included.

OUTCOME MEASURES

Odds ratio (OR) estimates for screw accuracy according to the Gertzbein-Robbins scale and relative risk (RR) for various surgical complications.

METHODS

We systematically searched PubMed and EMBASE for English-language studies from inception through April 7, 2022, including references of eligible articles. The search was conducted according to PRISMA guidelines. Two reviewers conducted a full abstraction of all data, and one reviewer verified accuracy. Information was extracted on study design, quality, bias, participants, and risk estimates. Data and estimates were pooled using the Mantel-Haenszel method for random-effects meta-analysis.

RESULTS

A total of 14 papers encompassing 12 randomized controlled trials were identified (n=892 patients, 4,046 screws). The pooled analysis demonstrated that robotic and navigated pedicle screw placement techniques were associated with higher odds of screw accuracy (OR 2.66, 95% CI 1.24-5.72, p=.01). Robotic and navigated screw placement was associated with a lower risk of facet joint violations (RR 0.09, 95% CI 0.02-0.38, p<.01) and major complications (RR 0.31, 95% CI 0.11-0.84, p=.02). There were no observed differences between groups in nerve root injury (RR 0.50, 95% CI 0.11-2.30, p=.37), or return to operating room for screw revision (RR 0.28, 95% CI 0.07-1.13, p=.07).

CONCLUSIONS

These estimates suggest that robotic and navigated screw placement techniques are associated with higher odds of screw accuracy and superior safety profile compared with fluoroscopic freehand techniques. Additional randomized controlled trials will be needed to further validate these findings.

Application of artificial intelligence in medical technologies: A systematic review of main trends

Objective

Artificial intelligence (AI) has been increasingly applied in various fields of science and technology. In line with the current research, medicine involves an increasing number of artificial intelligence technologies. The introduction of rapid AI can lead to positive and negative effects. This is a multilateral analytical literature review aimed at identifying the main branches and trends in the use of using artificial intelligence in medical technologies.

Methods

The total number of literature sources reviewed is n = 89, and they are analyzed based on the literature reporting evidence-based guideline PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for a systematic review.

Results

As a result, from the initially selected 198 references, 155 references were obtained from the databases and the remaining 43 sources were found on open internet as direct links to publications. Finally, 89 literature sources were evaluated after exclusion of unsuitable references based on the duplicated and generalized information without focusing on the users.

Conclusions

This article is identifying the current state of artificial intelligence in medicine and prospects for future use. The findings of this review will be useful for healthcare and AI professionals for improving the circulation and use of medical AI from design to implementation stage.

Lumbar Spondylodiscitis Mimicking Cholecystitis: A Case Report and Review of Literature

BACKGROUND

 Lower back pain is a frequent cause of emergency department visits and one of the leading causes of the disease burden worldwide. The purpose of this case report and literature review was to discuss atypical abdominal entities mimicking spinal diseases typically presenting with lower back pain.

METHODS

 A 79-year-old man presented with lower back pain and urinary incontinence after receiving a non-image-guided lumbar infiltration treatment 4 weeks prior to admission. The magnetic resonance imaging (MRI) highlighted multisegmental hyperintensities in the intervertebral disk spaces of the lumbar spine indicative for spondylodiscitis. Antibiotic treatment over a week did not lead to significant clinical improvement. Blood cultures, cardiologic, otorhinolaryngologic, and dental examinations turned out negative for a focus of infection. A computed tomography (CT) guided biopsy was indicated after discontinuation of antibiotic treatment for less than 24 hours. Rapid clinical deterioration with concomitant onset of abdominal pain resulted in the diagnosis of cholecystitis, which required cholecystectomy. We performed a systematic literature review using the Pubmed database for the keywords "spondylodiscitis," "spine," "abdominal," and "cholecystitis," to identify abdominal diseases that mimic spine pathologies and spinal diseases that mimic abdominal pathologies.

RESULTS

 No other report in English literature of cholecystitis associated with initial onset of lower back pain was identified. Eighteen reports referred to abdominal conditions that mimic spinal diseases, among them a patient with cyclic lumbar back pain who received a lumbar spinal fusion who, after persisting symptoms led to further diagnostic procedures, was ultimately diagnosed with endometriosis. Spinal symptoms included paraplegia and urinary incontinence as results of acute aortic pathologies. Eleven reports presented spinal pain mimicking abdominal conditions including abdominal pain and diarrhea as well as have had surgical procedures such as an appendectomy before the spinal condition was discovered.

CONCLUSION

 Clinical symptoms of the spine such as lower back pain can be unspecific and lead to false conclusions in the presence of concomitant pathologies in MRI. Only clinical deterioration in our case patient prompted correction of the diagnosis on day 7. Initial workup for alternative common infectious foci such as lung and urinary tract was performed, but further abdominal workup despite the absence of abdominal symptoms may have led to an earlier diagnosis. Our literature review found several cases of misdiagnosed spinal and abdominal conditions. Some had undergone unnecessary surgical procedures before the right diagnosis was made. Because of the high incidence of symptoms such as lumbar back pain and abdominal pain, considering optimal patient care as well as economic aspects, it would be essential to conduct an interdisciplinary clinical management to avoid errors in the early stage of diagnostics.

Minimally invasive trans-superior articular process percutaneous endoscopic lumbar discectomy with robot assistance

BACKGROUND

To compare the clinical outcomes of patients with lumbar disc herniation treated with robot-assisted percutaneous endoscopic lumbar discectomy (r-PELD) or conventional PELD under fluoroscopy guidance (f-PELD).

METHODS

Our study group included 55 patients, 22 in the r-PELD group and 33 in the f-PELD group. The following clinical and surgical outcomes were compared between the two groups: the visual analog scale for radiculopathy pain; Oswestry Disability Index; intraoperative volume of blood loss; frequency of fluoroscopy used during the procedure; and MacNab classification. The follow-up period was 6-8 months.

RESULTS

Compared with f-PELD, r-PELD was associated with a lower volume of intraoperative blood loss and frequency of fluoroscopy (p < 0.01). There were no differences in complications, MacNab classification, postoperative disability and leg pain, and duration of hospitalization between the two groups.

CONCLUSION

Based on our findings, r-PELD provides a safe and effective alternative to conventional PELD for the treatment of lumbar disc herniations, with the accuracy for placement of punctures lowering radiation exposure.

Minimally Invasive Resection of Benign Osseous Tumors of the Spinal Column: 10 Years' Experience and Long-Term Outcomes of a Specialized Center

Background and Objectives: Benign osseous tumors of the spinal column comprise about 10% of all spinal tumors and are rare cause for surgery. However, these tumors pose various management challenges and conventional surgery may be associated with significant morbidity. Previous reports on minimally invasive resection of these lesions are rare. We report a series of patients managed by total resection of benign osseous spine tumors using MIS techniques. Surgical decisions and technical considerations are discussed. Materials and Methods: A retrospective evaluation of prospectively collected data of patients who underwent minimally invasive surgery for removal of benign osseous vertebral tumors. Demographic, clinical and radiographic features, operative details and final pathological reports were summarized. Primary outcomes were completeness of tumor resection and pain relief assessed by VAS for back and leg pain. Secondary outcome measures were recurrence of tumor on repeat post-operative MRI and postoperative unstable deformity on standing scoliosis X-rays. Results: This series included 32 cases of primary osseous spine tumors resected by minimally invasive techniques. There were 17 males and 15 females aged 5-68 years (mean 23.3). The follow-up period was 8-90 months (mean 32 months) and the preoperative symptoms duration was 9-96 months. Axial spinal pain was the presenting symptom in all the patients. Five patients also complained about radicular pain and four patients had antalgic scoliosis. The tumor involved the thoracic spine in 12 cases, the lumbar segment in 11, the cervical in 5 and the sacral area in 4 cases. Complete tumor removal was performed in all patients. No procedure-related complications were encountered. Histopathology showed osteoid osteoma in 24 patients, osteoblastoma in 5 patients, and fibrous dysplasia, fibroadenoma and eosinophilic granuloma in one case each. All patients experienced significant pain relief after surgery, and had stopped pain medications by 12 months postoperatively. No patient suffered from tumor recurrence or spinal deformity. Conclusions: Minimally invasive surgery is feasible for total removal of selected benign vertebral tumors and may have some advantages over conventional surgical techniques.

R2 advances in robotic-assisted spine surgery: comparative analysis of options, future directions, and bibliometric analysis of the literature

Spine surgery has undergone rapid advancements over the past several decades with the emergence of robotic and minimally invasive surgery (MIS). While conventional MIS spine surgery has had relative success, its complication profile has warranted continued efforts to improve clinical outcomes. We discuss the functional, clinical, and financial aspects of four robotic options for spinal pathologies, namely ROSA, Mazor X, Da Vinci, and ExcelsiusGPS, and conduct a bibliometric analysis to better understand current trends and applications of these robots as the field of robotic spine surgery continues to grow. An extensive search of English-language published literature on robotic-assisted spinal surgery was performed in Elsevier's Scopus database. A bibliometric analysis was then performed on the top 100 most cited papers. The search yielded articles regarding robotic-assisted spine surgery application, limitations, and functional outcomes secondary to spine pathology. Accuracy analyses of 1733 screw placements were reviewed. The top 100 papers were published between 1992 and 2020, with a significant increase from 2015 onwards. The top publishing institution was John Hopkins University (n = 8). The top contributing author was Dr. Isador H. Lieberman (n = 6). The USA (n = 34) had the most articles on robotic spinal surgery, followed by Germany (n = 12). This review examines robotic applications in spine surgery, including four available options: ROSA, Mazor X, Da Vinci, and ExcelsiusGPS. Publication output over time, surgical outcomes, screw accuracy, and cost-effectiveness of these technologies have been investigated here. Certain robots have functional, clinical, and financial differences worth noting. Given the dearth of existing literature reporting postoperative complications and long-term comparative outcomes, there is a clear need for further studies on this matter.

Development of a Robotic Spine Surgery Program: Rationale, Strategy, Challenges, and Monitoring of Outcomes After Implementation

Surgical robots were invented in the 1980s, and since then, robotic-assisted surgery has become commonplace. In the field of spine surgery, robotic assistance is utilized mainly to place pedicle screws, and multiple studies have demonstrated that robots can increase the accuracy of screw placement and reduce radiation exposure to the patient and the surgeon. However, this may be at the cost of longer operative times, complications, and the risk of errors in mapping the patient's anatomy.

Comparison of the Accuracy and Safety of TiRobot-Assisted and Fluoroscopy-Assisted Percutaneous Pedicle Screw Placement for the Treatment of Thoracolumbar Fractures

OBJECTIVE

Studies have compared the safety and accuracy of robot-assisted techniques for inserting conventional open pedicle screws for spinal surgery. However, no relevant studies have confirmed that robot-assisted percutaneous screw placement is better than fluoroscopic percutaneous screw placement for the treatment of thoracolumbar fractures. This study compared the accuracy and safety of TiRobot-assisted percutaneous pedicle screw placement with those of the fluoroscopy-assisted percutaneous technique for the treatment of thoracolumbar fractures.

METHODS

This retrospective study included 126 patients with thoracolumbar fractures who underwent percutaneous pedicle screw placement. Sixty-five patients were treated with the TiRobot-assisted technique and 61 patients were treated with the fluoroscopy-assisted technique. Patient demographics, accuracy of screw placement (according to the Gertzbein and Robbins scale of grades A to E), screw insertion angle, radiation exposure, surgical time, intraoperative blood loss, length of hospital stay, incision length, hospital expenses, surgical site infection, and neurological injury of the TiRobot-assisted and fluoroscopy-assisted groups were compared using Student's t-test, Pearson χ² test, or Fisher's exact test.

RESULTS

A total of 729 screws were placed (TiRobot-assisted group: 374 screws; fluoroscopy-assisted group: 355 screws). In the TiRobot-assisted group, 82.8% of screws were optimally positioned (grade A); however, the placement grades of the remaining screws were categorized as grade B (13.3%), grade C (3.2%), and grade D (0.5%). In the fluoroscopy-assisted group, 66.7% of the screws were optimally positioned (grade A); however, the placement grades of the remaining screws were categorized as grade B (21.4%), grade C (7.6%), grade D (3.6%), and grade E (0.5%). The proportion of clinically acceptable screws (grade A or B) was greater in the TiRobot-assisted group than in the fluoroscopy-assisted group. Additionally, the TiRobot-assisted group had a significantly larger mean screw insertion angle (22.27° ± 5.48° vs 20.55° ± 5.15°), larger incision length (13.86 ± 1.24 cm vs 12.77 ± 1.43 cm), and higher hospital expenses (69061.55 ± 7166.60 yuan vs 59383.85 ± 5019.64 yuan) than the fluoroscopy-assisted group. There were no significant differences in the intraoperative blood loss, length of hospital stay, and rates of surgical site infection and neurological injury in both groups (p > 0.05). However, the TiRobot-assisted group had significantly better surgical times, radiation times, and radiation exposure than the fluoroscopy-assisted group (p < 0.05).

CONCLUSIONS

Percutaneous TiRobot-assisted pedicle screw placement is a safe, useful, and potentially more accurate alternative to the percutaneous fluoroscopy-assisted technique for treating thoracolumbar fractures.

Update on imaging of the cervical spine in rheumatoid arthritis

Rheumatoid arthritis is a multisystem, autoimmune, inflammatory disorder with numerous musculoskeletal manifestations. Involvement of the cervical spine is common and may result in severe complications due to synovitis, erosions, pannus formation, spinal instability and ankylosis. The purpose of this article is to review the current role of imaging in the rheumatoid spine, with emphasis on radiographs and MRI.

The impact of misplaced percutaneous iliac dynamic reference frame pins used during navigated spine surgery: incidence and outcomes

OBJECTIVE

Image guidance requires placement of a dynamic reference frame (DRF), often either onto local spinous process or by freehand intraosseous DRF placement into the ilium via the posterior superior iliac spine (PSIS). There is a paucity of studies in the literature that describe the complications of intraosseous DRF placement. The aim of this study was to describe the radiographic location, prevalence and nature of complications, and long-term clinical outcomes of attempted DRF placement into the PSIS.

METHODS

All lumbosacral spine surgical procedures performed between August 2019 and February 2021 at a single institution were queried, and operations in which a DRF was targeted to the PSIS were included. Patient demographic characteristics, indications for surgery, surgical outcomes, and complications were extracted. Intraoperative CT scans were reviewed by 2 independent researchers to determine the accuracy of DRF placement into the PSIS and to assess for DRF malposition.

RESULTS

Of 497 lumbar spine operations performed between August 2019 and February 2021 by 4 surgeons, 85 utilized intraoperative navigation with a PSIS pin. Thirteen operations were excluded due to an inability to visualize the entirety of the pin on intraoperative CT. Of 72 DRFs evaluated, 77.8% had been correctly placed in the PSIS. Of the 22.2% of DRFs not placed into the PSIS, 11 entered the sacrum, 6 crossed the sacroiliac joint, and 2 were deep enough to enter the pelvis. Pain at the pin site was present in 4 patients, of whom 3 had resolution of pain at the last follow-up evaluation. There were no significant complications due to DRF placement: no sacral fractures, significant navigation errors, retroperitoneal hematomas, or neurological deficits. Over a mean ± SD follow-up period of 9 ± 5.2 months, there were no incidences of pin site infection. Interrater reliability between the reviewers was 95.8%.

CONCLUSIONS

This was the first study to examine radiological and clinical outcomes after DRF placement in the PSIS. In this study, a majority of pins were correctly placed within the PSIS, although 22.2% of pins were malpositioned. There were no serious complications, and a majority of those patients with persistent pin site pain had resolution at last follow-up.

Automated Registration-Based Temporal Bone Computed Tomography Segmentation for Applications in Neurotologic Surgery

OBJECTIVE

This study investigates the accuracy of an automated method to rapidly segment relevant temporal bone anatomy from cone beam computed tomography (CT) images. Implementation of this segmentation pipeline has potential to improve surgical safety and decrease operative time by augmenting preoperative planning and interfacing with image-guided robotic surgical systems.

STUDY DESIGN

Descriptive study of predicted segmentations.

SETTING

Academic institution.

METHODS

We have developed a computational pipeline based on the symmetric normalization registration method that predicts segmentations of anatomic structures in temporal bone CT scans using a labeled atlas. To evaluate accuracy, we created a data set by manually labeling relevant anatomic structures (eg, ossicles, labyrinth, facial nerve, external auditory canal, dura) for 16 deidentified high-resolution cone beam temporal bone CT images. Automated segmentations from this pipeline were compared against ground-truth manual segmentations by using modified Hausdorff distances and Dice scores. Runtimes were documented to determine the computational requirements of this method.

RESULTS

Modified Hausdorff distances and Dice scores between predicted and ground-truth labels were as follows: malleus (0.100 ± 0.054 mm; Dice, 0.827 ± 0.068), incus (0.100 ± 0.033 mm; Dice, 0.837 ± 0.068), stapes (0.157 ± 0.048 mm; Dice, 0.358 ± 0.100), labyrinth (0.169 ± 0.100 mm; Dice, 0.838 ± 0.060), and facial nerve (0.522 ± 0.278 mm; Dice, 0.567 ± 0.130). A quad-core 16GB RAM workstation completed this segmentation pipeline in 10 minutes.

CONCLUSIONS

We demonstrated submillimeter accuracy for automated segmentation of temporal bone anatomy when compared against hand-segmented ground truth using our template registration pipeline. This method is not dependent on the training data volume that plagues many complex deep learning models. Favorable runtime and low computational requirements underscore this method's translational potential.

Minimally-Invasive Assisted Robotic Spine Surgery (MARSS)

Minimally-Invasive robotic spine surgery (MARSS) has expanded the surgeons armamentarium to treat a variety of spinal disorders. In the last decade, robotic developments in spine surgery have improved the safety, accuracy and efficacy of instrumentation placement. Additionally, robotic instruments have been applied to remove tumors in difficult locations while maintaining minimally invasive access. Gross movements by the surgeon are translated into fine, precise movements by the robot. This is exemplified in this chapter with the use of the da Vinci robot to remove apical thoracic tumors. In this chapter, we will review the development, technological advancements, and cases that have been conducted using MARSS to treat spine pathology in a minimally invasive fashion.

Comparison of electromagnetic and optical navigation assisted Endo-TLIF in the treatment of lumbar spondylolisthesis

Uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion (Endo-TLIF) with percutaneous pedicle screw fixation is a promising, minimally invasive method for the treatment of lumbar spondylolisthesis. However, repeated radiation exposure from X-rays and the steep learning curve remain to be improved.

Ninety-day complication, revision, and readmission rates for current-generation robot-assisted thoracolumbar spinal fusion surgery: results of a multicenter case series

OBJECTIVE

Robotics is a major area for research and development in spine surgery. The high accuracy of robot-assisted placement of thoracolumbar pedicle screws is documented in the literature. The authors present the largest case series to date evaluating 90-day complication, revision, and readmission rates for robot-assisted spine surgery using the current generation of robotic guidance systems.

METHODS

An analysis of a retrospective, multicenter database of open and minimally invasive thoracolumbar instrumented fusion surgeries using the Mazor X or Mazor X Stealth Edition robotic guidance systems was performed. Patients 18 years of age or older and undergoing primary or revision surgery for degenerative spinal conditions were included. Descriptive statistics were used to calculate rates of malpositioned screws requiring revision, as well as overall complication, revision, and readmission rates within 90 days.

RESULTS

In total, 799 surgical cases (Mazor X: 48.81%; Mazor X Stealth Edition: 51.19%) were evaluated, involving robot-assisted placement of 4838 pedicle screws. The overall intraoperative complication rate was 3.13%. No intraoperative implant-related complications were encountered. Postoperatively, 129 patients suffered a total of 146 complications by 90 days, representing an incidence of 16.1%. The rate of an unrecognized malpositioned screw resulting in a new postoperative radiculopathy requiring revision surgery was 0.63% (5 cases). Medical and pain-related complications unrelated to hardware placement accounted for the bulk of postoperative complications within 90 days. The overall surgical revision rate at 90 days was 6.63% with 7 implant-related revisions, representing an implant-related revision rate of 0.88%. The 90-day readmission rate was 7.13% with 2 implant-related readmissions, representing an implant-related readmission rate of 0.25% of cases.

CONCLUSIONS

The results of this multicenter case series and literature review suggest current-generation robotic guidance systems are associated with low rates of intraoperative and postoperative implant-related complications, revisions, and readmissions at 90 days. Future outcomes-based studies are necessary to evaluate complication, revision, and readmission rates compared to conventional surgery.

Modern surgical therapy for gastric cancer-Robotics and beyond

The surgical paradigm for gastric cancer has been changed from extended surgery to minimally invasive surgery. Laparoscopic surgery is a practical method for minimally invasive surgery for early gastric cancer, and the indication is expanding to advanced gastric cancer. In recent years, robotic gastrectomy has been highlighted as a breakthrough to overcome the drawbacks of laparoscopic gastrectomy. Here, we discuss the recent updates of modern surgical therapy for gastric cancer-robotics and beyond.

Comparative Analysis of Optoelectronic Accuracy in the Laboratory Setting Versus Clinical Operative Environment: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The optoelectronic camera source and data interpolation process serve as the foundation for navigational integrity in robotic-assisted surgical platforms. The current systematic review serves to provide a basis for the numerical disparity observed when comparing the intrinsic accuracy of optoelectronic cameras versus accuracy in the laboratory setting and clinical operative environments.

METHODS

Review of the PubMed and Cochrane Library research databases was performed. The exhaustive literature compilation obtained was then vetted to reduce redundancies and categorized into topics of intrinsic accuracy, registration accuracy, musculoskeletal kinematic platforms, and clinical operative platforms.

RESULTS

A total of 465 references were vetted and 137 comprise the basis for the current analysis. Regardless of application, the common denominators affecting overall optoelectronic accuracy are intrinsic accuracy, registration accuracy, and application accuracy. Intrinsic accuracy equaled or was less than 0.1 mm translation and 0.1 degrees rotation per fiducial. Controlled laboratory platforms reported 0.1 to 0.5 mm translation and 0.1 to 1.0 degrees rotation per array. Accuracy in robotic-assisted spinal surgery reported 1.5 to 6.0 mm translation and 1.5 to 5.0 degrees rotation when comparing planned to final implant position.

CONCLUSIONS

Navigational integrity and maintenance of fidelity of optoelectronic data is the cornerstone of robotic-assisted spinal surgery. Transitioning from controlled laboratory to clinical operative environments requires an increased number of steps in the optoelectronic kinematic chain and error potential. Diligence in planning, fiducial positioning, system registration and intra-operative workflow have the potential to improve accuracy and decrease disparity between planned and final implant position.

A Retrospective Comparative Analysis of Perioperative Complications in Navigated versus Conventional Thoracolumbar Fusion in the Setting of Adult Spinal Deformity

OBJECTIVE

Stereotactic intraoperative computer-assisted navigation has been shown to improve pedicle screw accuracy in spinal fusion surgery, but evidence of impact of navigation on clinical outcomes is lacking. The aim of this study is to compare rates of perioperative complications between navigated and nonnavigated procedures for deformity correction.

METHODS

An administrative database was queried for adult patients undergoing thoracolumbar fusion procedures for deformity. Nonelective cases and those involving malignancy, infection, or trauma were excluded. Individuals were divided into 2 cohorts based on the use of stereotactic intraoperative navigation and paired 1:1 for comparison based on a propensity score matching algorithm. Rates of unplanned reoperation and other perioperative complications were compared between matched groups. A multivariable Cox regression model was constructed to identify the impact of navigation on specific subgroups.

RESULTS

A total of 6150 patients met eligibility criteria for the study; after propensity score matching, 456 patients who underwent conventional fusion were matched to 456 patients receiving intraoperative navigation. Navigated cases took an average of 30 minutes longer than nonnavigated cases. There were no significant differences in rates of complications between cohorts. A subgroup analysis revealed that use of navigation was associated with decreased hazard for reoperation in individuals undergoing interbody fusion.

CONCLUSIONS

Despite increased surgical duration, the use of navigation does not seem to significantly impact rates of perioperative complications outside of procedures involving interbody fusion. Surgeons should elect to use navigation in cases expected to be of high operative complexity at their own discretion.

Systematic Review: Applications of Intraoperative Ultrasound in Spinal Surgery

BACKGROUND

Due to increased practicality and decreased costs and radiation, interest has risen for intraoperative ultrasound (iUS) in spinal surgery applications; however, few studies have provided a robust overview of its use in spinal surgery. We synthesize findings of existing literature on usage of iUS in navigation, pedicle screw placement, and identification of anatomy during spinal interventions.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized in this systematic review. Studies were identified through PubMed, Scopus, and Google Scholar databases using the search string. Abstracts mentioning iUS in spine applications were included. Upon full-text review, exclusion criteria were implemented, including outdated studies or those with weak topic relevance or statistical power. Upon elimination of duplicates, multi-reviewer screening for eligibility, and citation search, 44 manuscripts were analyzed.

RESULTS

Navigation using iUS is safe, effective, and economical. iUS registration accuracy and success is within clinically acceptable limits for image-guided navigation (Table 2). Pedicle screw instrumentation with iUS is precise with a favorable safety profile (Table 2). Anatomical landmarks are reliably identified with iUS, and surgeons are overwhelmingly successful in neural or vascular tissue identification with iUS modalities including standard B mode, doppler, and contrast-enhanced ultrasound (CE-US) (Table 3). iUS use in traumatic reduction of fractures properly identifies anatomical structures, intervertebral disc space, and vasculature (Table 3).

CONCLUSION

iUS eliminates radiation, decreases costs, and provides sufficient accuracy and reliability in identification of anatomical and neurovascular structures in various spinal surgery settings.

Novel use of robotics and navigation for anterior lumbar total disc replacement surgery

The ability to navigate the anterior lumbar disc space may improve clinical outcomes and implant longevity. However, no robotic navigation systems are presently authorized by the U.S. Food and Drug Administration to assist with anterior retroperitoneal lumbar interbody surgery. Furthermore, no studies to date have investigated such an application of this technology. This study examines the application of robotic navigation to anterior lumbar total disc replacement surgery to improve retroperitoneal exposure and orientation of the anterior lumbar spine, enhance coronal plane centralization of the implant, optimize surgical trajectory, and mitigate radiologic exposure. Postoperative outcomes of a small cohort of patients undergoing anterior lumbar total disc replacement surgery using robotic navigation were analyzed. The results of the study revealed that a modified use of the aforementioned robot-assisted surgical technology enhances coronal plane centralization and trajectory, all while mitigating radiologic exposure, resulting in more accurate placement of the implant within the intervertebral space at each level.

Ultrasound image guided and mixed reality-based surgical system with real-time soft tissue deformation computing for robotic cervical pedicle screw placement

Cervical pedicle screw (CPS) placement surgery remains technically demanding due to the complicated anatomy with neurovascular structures. State-of-the-art surgical navigation or robotic systems still suffer from the problem of hand-eye coordination and soft tissue deformation. In this study, we aim at tracking the intraoperative soft tissue deformation and constructing a virtual physical fusion surgical scene, and integrating them into the robotic system for CPS placement surgery. Firstly, we propose a real-time deformation computation method based on the prior shape model and intraoperative partial information acquired from ultrasound images. According to the generated posterior shape, the structure representation of deformed target tissue gets updated continuously. Secondly, a hand tremble compensation method is proposed to improve the accuracy and robustness of the virtual-physical calibration procedure, and a mixed reality based surgical scene is further constructed for CPS placement surgery. Thirdly, we integrate the soft tissue deformation method and virtual-physical fusion method into our previously proposed surgical robotic system, and the surgical workflow for CPS placement surgery is introduced. We conducted phantom and animal experiments to evaluate the feasibility and accuracy of the proposed system. Our system yielded a mean surface distance error of 1.52 ± 0.43 mm for soft tissue deformation computing, and an average distance deviation of 1.04 ± 0.27 mm for CPS placement. Results demonstrated that our system involves tremendous clinical application potential. Our proposed system promotes the efficiency and safety of the CPS placement surgery.

Accuracy of Subaxial Cervical Pedicle Screw Placement Using Direct Visualization Versus Computed Tomography-Based Navigation

STUDY DESIGN

Retrospective analysis of operative data from cadaveric cervical spines.

OBJECTIVE

To evaluate the accuracy of neuronavigation compared with laminotomy with direct visualization (DV) of the pedicle for placement of subaxial pedicle screws.

SUMMARY OF BACKGROUND DATA

Subaxial pedicle screws provide superior fixation compared with other posterior cervical fixation strategies. However, high accuracy is required for safe placement, given the proximity of critical neurovascular structures. Computed tomography (CT)-based neuronavigation has increased in popularity for placement of spinal implants, including subaxial pedicle screws. However, the accuracy of the technique for this application has not been extensively evaluated.

METHODS

Six fresh-frozen cadaveric spines (occiput to T2) were prepared. Pedicle screws were placed from C3 to C7 on either side using either the DV or neuronavigation technique (alternating sides between specimens). Pedicles with diameters <4 mm were excluded. For the DV technique, a hemilaminotomy was performed for DV of pedicle borders and to determine appropriate screw medialization and trajectory. Neuronavigation screws were placed using CT-based navigation with a reference frame mounted on the C2 spinous process. Screw position was evaluated using postoperative CT, and breaches were classified using the Neo classification.

RESULTS

Fifty pedicle screws were placed at 25 levels in 6 cadaveric spines; 25 screws each were placed using neuronavigation or DV. No significant difference in accuracy was found between the 2 techniques. Three (12%) breaches occurred in the DV group, and 9 (36%) breaches occurred in the neuronavigation group (P=0.10). The breaches were evenly distributed across all levels. There were no high-grade breaches with DV and only 1 (4.0%) with neuronavigation (P>0.99). Average pedicle cortical and medullary bone widths were higher for levels with no breach (P=0.009 and P=0.02, respectively).

CONCLUSIONS

High accuracy can be achieved with both neuronavigation and DV for placement of subaxial cervical pedicle screws in cadavers.

Intraoperative Navigation in Spine Surgery: Effects On Complications and Reoperations

INTRODUCTION

Intraoperative navigation during spine surgery improves pedicle screw placement accuracy. However, limited studies have correlated navigation with clinical factors including operative time and safety. This study compares complications and reoperations between surgeries with and without navigation.

METHODS

Posterior cervical and lumbar fusions and deformity surgeries from 2011-2018 were queried from the NSQIP database and divided by navigation use. Patients aged >89, deformity patients aged <25, and patients undergoing surgery for tumors, fractures, infections, or non-elective indications were excluded. Demographics and perioperative factors were compared with univariate analysis. Outcomes were compared with multivariable logistic regression adjusting for age, sex, BMI, ASA class, surgical region, and multiple levels. Outcomes were also compared stratifying by revision status.

RESULTS

Navigated surgery patients had higher ASA status (p<0.0001), more multiple-level surgeries (p<0.0001), and longer operations (p<0.0001). Adjusted analysis revealed navigated lumbar surgeries had lower odds of complications (OR=0.82, 95%CI=0.77-0.90, p<0.0001), blood transfusion (OR=0.79, 95%CI=0.72-0.87, p<0.0001), and wound debridement/drainage (OR=0.66, 95%CI=0.44-0.97, p=0.04) compared to non-navigated procedures. Navigated cervical fusions had increased odds of transfusion (OR=1.53, 95%CI=1.06-2.23, p=0.02). Navigated primary fusions had decreased odds of complications (OR=0.91, 95%CI=0.85-0.98, p=0.01); no difference was found in revisions (OR=0.89, 95%CI=0.69-1.14, p=0.34).

CONCLUSIONS

Navigated surgery patients experienced longer operations due to a combination of time using navigation, more multi-level procedures and larger comorbidity burden, without differences in infections. There were fewer complications and wound washouts in navigated lumbar surgeries due to a higher percentage of minimally invasive cases. Co-utilization of navigation and minimally invasive surgery may benefit properly indicated patients.

What Is the Comparison in Robot Time per Screw, Radiation Exposure, Robot Abandonment, Screw Accuracy, and Clinical Outcomes Between Percutaneous and Open Robot-Assisted Short Lumbar Fusion?: A Multicenter, Propensity-Matched Analysis of 310 Patients

STUDY DESIGN

Multicenter cohort.

OBJECTIVE

To compare the robot time/screw, radiation exposure, robot abandonment, screw accuracy, and 90-day outcomes between robot-assisted percutaneous and robot-assisted open approach for short lumbar fusion (1- and 2-level).

SUMMARY OF BACKGROUND DATA

There is conflicting literature on the superiority of robot-assisted minimally invasive spine surgery to open techniques. A large, multicenter study is needed to further elucidate the outcomes and complications between these two approaches.

METHODS

We included adult patients (≥18 yrs old) who underwent robot-assisted short lumbar fusion surgery from 2015 to 2019 at four independent institutions. A propensity score matching algorithm was employed to control for the potential selection bias between percutaneous and open surgery. The minimum follow-up was 90 days after the index surgery.

RESULTS

After propensity score matching, 310 patients remained. The mean (standard deviation) Charlson comorbidity index was 1.6 (1.5) and 53% of patients were female. The most common diagnoses included high-grade spondylolisthesis (grade >2) (48%), degenerative disc disease (22%), and spinal stenosis (25%), and the mean number of instrumented levels was 1.5(0.5). The operative time was longer in the open (198 min) versus the percutaneous group (167 min, P value = 0.007). However, the robot time/screw was similar between cohorts (P value > 0.05). The fluoroscopy time/ screw for percutaneous (14.4 s) was longer than the open group (10.1 s, P value = 0.021). The rates for screw exchange and robot abandonment were similar between groups (P value > 0.05). The estimated blood loss (open: 146 mL vs. percutaneous: 61.3 mL, P value < 0.001) and transfusion rate (open: 3.9% vs. percutaneous: 0%, P value = 0.013) were greater for the open group. The 90-day complication rate and mean length of stay were not different between cohorts (P value > 0.05).

CONCLUSION

Percutaneous robot-assisted spine surgery may increase radiation exposure, but can achieve a shorter operative time and lower risk for intraoperative blood loss for short-lumbar fusion. Percutaneous approaches do not appear to have an advantage for other short-term postoperative outcomes. Future multicenter studies on longer fusion surgeries and the inclusion of patient-reported outcomes are needed.Level of Evidence: 3.

Patient-Matched 3-D-Printed Guides for the Insertion of Cervical Pedicle Screws in Tumor Surgery

Background

Pedicle screw fixation in the cervical spine provides biomechanical advantages compared to other stabilization techniques. However, pedicle screw insertion in this area is challenging due to the anatomical conditions with a high risk of breaching the small pedicles and violating the vertebral artery or neural structures. Today, several techniques to facilitate screw insertion and to make the procedure safer are used. 3-D-printed patient-matched guides based on a CT reconstruction are a helpful technique which allows to reduce operation time and to improve the safety of pedicle screw insertion at the cervical spine.

Cases

3-D-printed patient-matched drill guides based on a CT scan with a 3-D reconstruction of the spine were used in two challenging cervical spine surgical tumor cases to facilitate the implantation of the pedicle screws. The screw position was controlled postoperatively by means of the routinely performed CT scan.

Results

Postoperative imaging (conventional radiographs and CT scan) revealed the correct position of the pedicle screws. The time needed for screw insertion was short, and the need for intraoperative fluoroscopy could be reduced. There was no intra- or postoperative complication related to the pedicle screw implantation. Both tumors could be removed completely.

Conclusion

These preliminary results show that 3-D-printed patient-specific guides are a promising tool to support and facilitate the implantation of cervical pedicle screws. The time needed for insertion is short, and intraoperative fluoroscopy time can be reduced. This technique allows for both a meticulous preoperative planning and a correct and therefore safe intraoperative positioning of cervical spine pedicle screws.