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Farshad M, Zindel C, Safa NA, Spirig JM, Winkler E. Instrumentation of hypoplastic pedicles with patient-specific guides. Spine Deform 2024:10.1007/s43390-024-00852-9. [PMID: 38558382 DOI: 10.1007/s43390-024-00852-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 02/20/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE Hypoplastic pedicles of the thoracolumbar spine (<5 mm diameter) are often found in syndromic deformities of the spine and pose a challenge in pedicle screw instrumentation. 3D-printed patient-specific guides might help overcome anatomical difficulties when instrumenting pedicles with screws, thereby reducing the necessity for less effective fixation methods such as hooks or sublaminar wires. In this study, the surgical feasibility and clinical outcome of patients with hypoplastic pedicles following pedicle screw instrumentation with 3D-printed patient-specific guides were assessed. METHODS Hypoplastic pedicles were identified on preoperative computed tomography (CT) scans in six patients undergoing posterior spinal fusion surgery between 2017 and 2020. Based on these preoperative CT scans, patient-specific guides were produced to help with screw instrumentation of these thin pedicles. Postoperatively, pedicle-screw-related complications or revisions were analyzed. RESULTS 93/105 (88.6%) pedicle screws placed with patient-specific guides were instrumented. 62/93 (66.7%) of these instrumented pedicles were defined as hypoplastic with a mean width of 3.07 mm (SD ±0.98 mm, 95% CI [2.82-3.32]). Overall, 6 complications in the 62 hypoplastic pedicles (9.7%) were observed and included intraoperatively managed 4 cerebrospinal fluid leaks, 1 pneumothorax and 1 delayed revision due to 2 lumbar screws (2/62, 3.3%) impinging the L3 nerve root causing a painful radiculopathy. The mean follow-up time was 26.7 (SD ±11.7) months. Complications were only noted when the pedicle-width-to-screw-diameter ratio measured less than 0.62. CONCLUSION Patient-specific 3D-printed guides can aid in challenging instrumentation of hypoplastic pedicles in the thoracolumbar spine, especially if the pedicle-width-to-screw-diameter ratio is greater than 0.62.
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Affiliation(s)
- Mazda Farshad
- Department of Spine Surgery, Balgrist University Hospital Zürich, University of Zürich, Forchstrasse 340, 8008, Zurich, CH, Switzerland
| | - Christoph Zindel
- Department of Spine Surgery, Balgrist University Hospital Zürich, University of Zürich, Forchstrasse 340, 8008, Zurich, CH, Switzerland
| | - Nico Akhavan Safa
- Department of Spine Surgery, Balgrist University Hospital Zürich, University of Zürich, Forchstrasse 340, 8008, Zurich, CH, Switzerland
| | - José Miguel Spirig
- Department of Spine Surgery, Balgrist University Hospital Zürich, University of Zürich, Forchstrasse 340, 8008, Zurich, CH, Switzerland
| | - Elin Winkler
- Department of Spine Surgery, Balgrist University Hospital Zürich, University of Zürich, Forchstrasse 340, 8008, Zurich, CH, Switzerland.
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Youssef S, McDonnell JM, Wilson KV, Turley L, Cunniffe G, Morris S, Darwish S, Butler JS. Accuracy of augmented reality-assisted pedicle screw placement: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:974-984. [PMID: 38177834 DOI: 10.1007/s00586-023-08094-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE Conventional freehand methods of pedicle screw placement are associated with significant complications due to close proximity to neural and vascular structures. Recent advances in augmented reality surgical navigation (ARSN) have led to its adoption into spine surgery. However, little is known regarding its overall accuracy. The purpose of this study is to delineate the overall accuracy of ARSN pedicle screw placement across various models. METHODS A systematic review was conducted of Medline/PubMed, Cochrane and Embase Library databases according to the PRISMA guidelines. Relevant data extracted included reports of pedicle screw placement accuracy and breaches, as defined by the Gertzbein-Robbins classification, in addition to deviation from pre-planned trajectory and entry point. Accuracy was defined as the summation of grade 0 and grade 1 events per the Gertzbein-Robbins classification. RESULTS Twenty studies reported clinically accurate placed screws. The range of clinically accurate placed screws was 26.3-100%, with 2095 screws (93.1%) being deemed clinically accurate. Furthermore, 5.4% (112/2088) of screws were reported as grade two breaches, 1.6% (33/2088) grade 3 breaches, 3.1% (29/926) medial breaches and 2.3% (21/926) lateral breaches. Mean linear deviation ranged from 1.3 to 5.99 mm, while mean angular/trajectory deviation ranged 1.6°-5.88°. CONCLUSION The results of this study highlight the overall accuracy of ARSN pedicle screw placement. However, further robust prospective studies are needed to accurately compare to conventional methods of pedicle screw placement.
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Affiliation(s)
- Salma Youssef
- School of Medicine, University College Dublin, Belfield, Dublin, Ireland
| | - Jake M McDonnell
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
- Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Kielan V Wilson
- School of Medicine, University College Dublin, Belfield, Dublin, Ireland.
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Luke Turley
- Department of Orthopaedics, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Gráinne Cunniffe
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Seamus Morris
- School of Medicine, University College Dublin, Belfield, Dublin, Ireland
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Stacey Darwish
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Orthopaedics, St. Vincent's University Hospital, Dublin, Ireland
| | - Joseph S Butler
- School of Medicine, University College Dublin, Belfield, Dublin, Ireland
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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Rosa Filezio M, Peiro-Garcia A, Parsons DL, Thomas K, Ferri-de-Barros F. Accuracy of imaging grading in comparison to open laminectomy to evaluate pedicle screws positioning. Ann Med Surg (Lond) 2024; 86:199-206. [PMID: 38222761 PMCID: PMC10783280 DOI: 10.1097/ms9.0000000000001515] [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: 08/22/2023] [Accepted: 11/05/2023] [Indexed: 01/16/2024] Open
Abstract
Study design Prospective experimental study. Objective To compare the accuracy of O-Arm-acquired radiographic and computed tomography (CT) evaluation of thoracic pedicle screw placement with open laminectomy in a simulation laboratory. Summary of background data Improving surgical safety and procedural efficiency during thoracic posterior spine instrumentation is essential for decreasing complication rates and possible related risks. The most common way of verifying the position of pedicle screws during the surgical procedure and immediately postoperatively is to acquire intraoperative fluoroscopic images and plain radiographs of the spine, respectively. Laboratory simulated surgery is a valuable tool to evaluate the accuracy of those exams. Methods Twenty simulation models of scoliosis from T3 to T7 were instrumented by five spine fellows (total of 200 pedicle screws), followed by radiographic and CT images acquired with the assistance of the O-Arm which were evaluated by three independent raters. A fellowship-trained spine neurosurgeon performed laminectomies on the instrumented levels and assessed pedicle integrity (gold standard). Results Forty-eight breaches were identified in the axial direct view after laminectomy. Of those, eighteen breaches were classified as unacceptable. Regarding the sagittal direct view, four breaches were observed, three of which were classified as unacceptable. Overall, both O-arm radiographic and CT evaluations had a significantly high negative predicted value but a low positive predicted value to identify unacceptable breaches, especially in the sagittal plane. The frequency of missed breaches by all three examiners was high, particularly in the sagittal plane. Conclusion Postoperative evaluation of pedicle screws using O-arm-acquired radiographic or CT images may underdiagnose the presence of breaches. In our study, sagittal breaches were more difficult to diagnose than axial breaches. Although most breaches do not have clinical repercussions, this study suggests that this modality of postoperative radiographic assessment may be inaccurate. Level of evidence 4.
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4
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McCormick B, Asdourian PL, Johnson DC, Moatz BW, Duvall GT, Soda MT, Beaufort AR, Chotikul LG, McAfee PC. 100 Complex posterior spinal fusion cases performed with robotic instrumentation. J Robot Surg 2023; 17:2749-2756. [PMID: 37707742 DOI: 10.1007/s11701-023-01707-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
Robotic navigation has been shown to increase precision, accuracy, and safety during spinal reconstructive procedures. There is a paucity of literature describing the best techniques for robotic-assisted spine surgery for complex, multilevel cases or in cases of significant deformity correction. We present a case series of 100 consecutive multilevel posterior spinal fusion procedures performed for multilevel spinal disease and/or deformity correction. 100 consecutive posterior spinal fusions were performed for multilevel disease and/or deformity correction utilizing robotic-assisted placement of pedicle screws. The primary outcome was surgery-related failure, which was defined as hardware breakage or reoperation with removal of hardware. A total of 100 consecutive patients met inclusion criteria. Among cases included, 31 were revision surgeries with existing hardware in place. The mean number of levels fused was 5.6, the mean operative time was 303 min, and the mean estimated blood loss was 469 mL. 28 cases included robotic-assisted placement of S2 alar-iliac (S2AI) screws. In total, 1043 pedicle screws and 53 S2AI screws were placed with robotic-assistance. The failure rate using survivorship analysis was 18/1043 (1.7%) and the failure rate of S2AI screws using survivorship analysis was 3/53 (5.7%). Four patients developed postoperative wound infections requiring irrigation and debridement procedures. None of the 1043 pedicle screws nor the 53 S2AI screws required reoperation due to malpositioning or suboptimal placement. This case series of 100 multilevel posterior spinal fusion procedures demonstrates promising results with low failure rates. With 1043 pedicle screws and 53 S2AI screws, we report low failure rates of 1.7% and 5.7%, respectively with zero cases of screw malpositioning. Robotic screw placement allows for accurate screw placement with no increased rate of postoperative infection compared to historical controls. Level of evidence: IV, Retrospective review.
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Stone L, McDonald M, Wojdyla L, Osorio JA. Integrating navigation assistance for redirecting freehanded spinal instrumentation: experience and technique. J Robot Surg 2023; 17:2729-2734. [PMID: 37665478 PMCID: PMC10678822 DOI: 10.1007/s11701-023-01686-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/16/2023] [Indexed: 09/05/2023]
Abstract
Retrospective review of all spinal fusions > 3 levels involving the thoracolumbar and/or sacroiliac at a single institution, by a single surgeon between 3/12/2020 and 8/13/2021 were reviewed. All screws that were secondarily navigated after identified as misdirected on intraoperative CT scan were included. Neuromonitoring reports were culled for mA threshold to triggered EMG response for all redirected screws. Intraoperative, post-de novo screw placement images (fluoroscopy scout and intraoperative CT) and post-redirection intraoperative scoliosis films and post-operative scoliosis films were independently reviewed by a senior neuroradiologist. Fifty redirected screws in the thoracic, lumbar, sacral, and ilium were identified as misdirected and redirected via navigation. The new trajectory of all screws was confirmed satisfactory by independent review between a senior neuroradiologist and neurosurgeon. Four screws could not be verified by post-operative imaging (4/50, 8%). All triggered EMG stimulated > 15 mA. No screws required return to the operating room for revision. No patients experienced a post-operative deficit. Redirection of misdirected thoracolumbar and sacroiliac screws can be performed using intraoperative CT and navigation as a means to detect and directly visualize appropriate placement.
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Affiliation(s)
- Lauren Stone
- Department of Neurological Surgery, UC San Diego, San Diego, CA, USA
| | - Marin McDonald
- Department of Neuroradiology, UC San Diego, San Diego, CA, USA
| | - Luke Wojdyla
- Department of Neuroradiology, UC San Diego, San Diego, CA, USA
| | - Joseph A Osorio
- Department of Neurological Surgery, UC San Diego, San Diego, CA, USA.
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Lin T, Xie Q, Peng T, Zhao X, Chen D. The role of robotic surgery in neurological cases: A systematic review on brain and spine applications. Heliyon 2023; 9:e22523. [PMID: 38046149 PMCID: PMC10686875 DOI: 10.1016/j.heliyon.2023.e22523] [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: 05/31/2023] [Revised: 10/20/2023] [Accepted: 11/14/2023] [Indexed: 12/05/2023] Open
Abstract
The application of robotic surgery technologies in neurological surgeries resulted in some advantages compared to traditional surgeries, including higher accuracy and dexterity enhancement. Its success in various surgical fields, especially in urology, cardiology, and gynecology surgeries was reported in previous studies, and similar advantages in neurological surgeries are expected. Surgeries in the central nervous system with the pathology of millimeters through small working channels around vital tissue need especially high precision. Applying robotic surgery is therefore an interesting dilemma for these situations. This article reviews various studies published on the application of brain and spine robotic surgery and discusses the current application of robotic technology in neurological cases.
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Affiliation(s)
- Tong Lin
- Neurosurgery, Guangxi Hospital Division of The First Affiliated Hospital, Sun Yat-Sen University, 535000, Nanning, China
| | - Qinghai Xie
- Neurosurgery, Qinzhou First People's Hospital, Qinzhou City, 535000, China
| | - Tao Peng
- Neurosurgery, Qinzhou First People's Hospital, Qinzhou City, 535000, China
| | - Xianxiao Zhao
- Neurosurgery, Qinzhou First People's Hospital, Qinzhou City, 535000, China
| | - Dongliang Chen
- Neurosurgery, Qinzhou First People's Hospital, Qinzhou City, 535000, China
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Zawar A, Chhabra HS, Mundra A, Sharma S, Kalidindi KKV. Robotics and navigation in spine surgery: A narrative review. J Orthop 2023; 44:36-46. [PMID: 37664556 PMCID: PMC10470401 DOI: 10.1016/j.jor.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/12/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction In recent decades, there has been a rising trend of spinal surgical interventional techniques, especially Minimally Invasive Spine Surgery (MIS), to improve the quality of life in an effective and safe manner. However, MIS techniques tend to be difficult to adapt and are associated with an increased risk of radiation exposure. This led to the development of 'computer-assisted surgery' in 1983, which integrated CT images into spinal procedures evolving into the present day robotic-assisted spine surgery. The authors aim to review the development of spine surgeries and provide an overview of the benefits offered. It includes all the comparative studies available to date. Methods The manuscript has been prepared as per "SANRA-a scale for the quality assessment of narrative review articles". The authors searched Pubmed, Embase, and Scopus using the terms "(((((Robotics) OR (Navigation)) OR (computer assisted)) OR (3D navigation)) OR (Freehand)) OR (O-Arm)) AND (spine surgery)" and 68 articles were included for analysis excluding review articles, meta-analyses, or systematic literature. Results The authors noted that 49 out of 68 studies showed increased precision of pedicle screw insertion, 10 out of 19 studies show decreased radiation exposure, 13 studies noted decreased operative time, 4 out of 8 studies showed reduced hospital stay and significant reduction in rates of infections, neurological deficits, the need for revision surgeries, and rates of radiological ASD, with computer-assisted techniques. Conclusion Computer-assisted surgeries have better accuracy of pedicle screw insertion, decreased blood loss and operative time, reduced radiation exposure, improved functional outcomes, and lesser complications.
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Affiliation(s)
- Amogh Zawar
- Rajiv Gandhi Medical College and CSMH, Thane, Maharashtra. 400605, India
| | | | - Anuj Mundra
- Sri Balaji Action Medical Institute, A4 Block, Paschim Vihar, New Delhi, 110063, India
| | - Sachin Sharma
- Sri Balaji Action Medical Institute, A4 Block, Paschim Vihar, New Delhi, 110063, India
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Park C, Shabani S, Agarwal N, Tan L, Mummaneni PV. Robotic-Assisted Surgery and Navigation in Deformity Surgery. Neurosurg Clin N Am 2023; 34:659-664. [PMID: 37718112 DOI: 10.1016/j.nec.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Deformity surgery is advancing quickly with the use of three-dimensional navigation and robotics. In spinal fusion, the use of robotics improves screw placement accuracy and reduces radiation, complications, blood loss, and recovery time. Currently, there is limited evidence showing that robotics is better than traditional freehand techniques. Most studies favoring robotics are small and retrospective due to the novelty of the technology in deformity surgery. Using these systems can also be expensive and time-consuming. Surgeons should use these advancements as tools, but not rely on them to replace surgical experience, anatomy knowledge, and good judgment.
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Affiliation(s)
- Christine Park
- Department of Neurological Surgery, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Saman Shabani
- Department of Neurological Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Lee Tan
- Department of Neurological Surgery, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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Wang Y, Sun X, Li W, Shi B, Liu Z, Wang B, Qiu Y, Zhu Z. Hemivertebra resection after age three produces the similar results but with less complications compared to earlier surgery: a minimum of 5-year follow-up. J Orthop Surg Res 2023; 18:651. [PMID: 37660023 PMCID: PMC10474705 DOI: 10.1186/s13018-023-04096-7] [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: 05/03/2023] [Accepted: 08/12/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND The optimal timing for hemivertebra resection remains controversial. Early intervention before 3 years of age seems being able to get better correction with less fusion segments. However, it was also reported that early surgery may be associated with more complications. The purpose of this study is to investigate correction outcomes and complications of delayed hemivertebra resection (between 3 and 5 years of age), in comparison with earlier surgery (before 3 years of age). METHODS Patients who had undergone thoracolumbar hemivertebra resection at a single level before 5 years of age and had more than 5 years of follow-up were reviewed. Twenty-four patients had hemivertebra resection surgery below 3 years of age (early surgery, Group E), and 33 patients received surgery between 3 and 5 years of age (delayed surgery, Group D). Radiographs from preoperative, immediately postoperative, and the latest follow-up visits were reviewed to investigate the correction outcomes. Complications were recorded and compared between these two groups. RESULTS The patients of Group E had shorter operation time and less blood loss than those of Group D (P = 0.003 and P = 0.006). Notably, the fusion segments were 2.3 ± 0.7 and 3.1 ± 1.2 in group E and group D (P = 0.005), respectively, indicating group E averagely saved 0.8 motion segments. At the time of surgery, group E had smaller main curve magnitude either in the coronal or in the sagittal plane than group D and experienced similar correction rates of scoliosis (83.3 ± 21.6% vs. 81.2 ± 20.1%, P = 0.707) and kyphosis (65.1 ± 23.8% vs. 71.7 ± 24.9%, P = 0.319). However, group E had relatively higher complication rates than group D and relatively greater correction loss in either coronal or sagittal plane during follow-up. CONCLUSIONS Hemivertebra resection resulted in similar correction results in both age groups. However, the rate of complications was lower for Group D than Group E. Thus, for non-kyphotic hemivertebra, surgery may be delayed till 3 to 5 years of age.
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Affiliation(s)
- Yu Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Wenhan Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Zhongshan Road 321, Nanjing, 210008, China
| | - Benlong Shi
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Zhongshan Road 321, Nanjing, 210008, China.
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Morris JM, Wentworth A, Houdek MT, Karim SM, Clarke MJ, Daniels DJ, Rose PS. The Role of 3D Printing in Treatment Planning of Spine and Sacral Tumors. Neuroimaging Clin N Am 2023; 33:507-529. [PMID: 37356866 DOI: 10.1016/j.nic.2023.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
Three-dimensional (3D) printing technology has proven to have many advantages in spine and sacrum surgery. 3D printing allows the manufacturing of life-size patient-specific anatomic and pathologic models to improve preoperative understanding of patient anatomy and pathology. Additionally, virtual surgical planning using medical computer-aided design software has enabled surgeons to create patient-specific surgical plans and simulate procedures in a virtual environment. This has resulted in reduced operative times, decreased complications, and improved patient outcomes. Combined with new surgical techniques, 3D-printed custom medical devices and instruments using titanium and biocompatible resins and polyamides have allowed innovative reconstructions.
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Affiliation(s)
- Jonathan M Morris
- Division of Neuroradiology, Department of Radiology, Anatomic Modeling Unit, Biomedical and Scientific Visualization, Mayo Clinic, 200 1st Street, Southwest, Rochester, MN, 55905, USA.
| | - Adam Wentworth
- Department of Radiology, Anatomic Modeling Unit, Mayo Clinic, Rochester, MN, USA
| | - Matthew T Houdek
- Division of Orthopedic Oncology, Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - S Mohammed Karim
- Division of Orthopedic Oncology, Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Peter S Rose
- Division of Orthopedic Oncology, Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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11
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Degulmadi D, Dave BR, Chauhan V, Krishnan A, Mayi SC, Rai R, Dave MB, Bali S, Charde P, Anil A. Comparative Study on Accuracy of Intra-Operative Computed Tomography-Navigation Based Pedicle Screw Placement With Skin vs Bone Fixed Dynamic Reference Frame in Minimally Invasive Transforaminal Lumbar Interbody Fusion. Global Spine J 2023:21925682231181884. [PMID: 37279918 DOI: 10.1177/21925682231181884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To compare the accuracy of intra-operative navigation-assisted percutaneous pedicle screw insertion between bone fixed and skin fixed dynamic reference frame (DRF) in Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS Between October 2018 and September 2022, patients who underwent MIS-TLIF were included in this study with DRF fixed either on bone (group B) or skin (group S). Pedicle screws were inserted under the guidance of intra-operative Cone bean Computed tomography (cbCT) based navigation. Accuracy of pedicle screw placement was immediately checked by a final intra-operative cbCT Spin. RESULTS Among 170 patients, group B included 91 patients and group S included 79 patients. Out of total 680 screws, 364 screws (group B) and 316 screws (group S) were placed. Patient's demographic data and distribution of screws showed no statistically significant difference. The accuracy showed no significant difference between both the groups (94.5% in group B and 94.3% in group S). CONCLUSION Skin fixed DRF can serve as an alternate way for placement and avoids extra incision with similar accuracy in pedicle screw insertions with bone fixed DRF using intra-operative CT guided navigation in MIS TLIF.
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Affiliation(s)
- Devanand Degulmadi
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Bharat R Dave
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Vikrant Chauhan
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Ajay Krishnan
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Shivanand C Mayi
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Ravi Rai
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Mirant Bharat Dave
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Shivkumar Bali
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Pranav Charde
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Abhijith Anil
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
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Yamout T, Orosz LD, Good CR, Jazini E, Allen B, Gum JL. Technological Advances in Spine Surgery: Navigation, Robotics, and Augmented Reality. Orthop Clin North Am 2023; 54:237-246. [PMID: 36894295 DOI: 10.1016/j.ocl.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Accurate screw placement is critical to avoid vascular or neurologic complications during spine surgery and to maximize fixation for fusion and deformity correction. Computer-assisted navigation, robotic-guided spine surgery, and augmented reality surgical navigation are currently available technologies that have been developed to improve screw placement accuracy. The advent of multiple generations of new technologies within the past 3 decades has presented surgeons with a diverse array of choices when it comes to pedicle screw placement. Considerations for patient safety and optimal outcomes must be paramount when selecting a technology.
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Affiliation(s)
- Tarek Yamout
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Lindsay D Orosz
- National Spine Health Foundation, 11800 Sunrise Valley Drive, Suite 330, Reston, VA 20191, USA
| | - Christopher R Good
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Ehsan Jazini
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Brandon Allen
- National Spine Health Foundation, 11800 Sunrise Valley Drive, Suite 330, Reston, VA 20191, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street Suite 900, Louisville, KY 40202, USA.
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13
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Delcont MR, Ou-Yang DC, Burger EL, Patel VV, Wessell NM, Kleck CJ. Alternative Uses of O-Arm and Stealth Navigation Technology Over 10 Years: The University of Colorado Experience. Orthopedics 2023; 46:e89-e97. [PMID: 35876781 DOI: 10.3928/01477447-20220719-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.].
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A superior articular process morphology of 5th lumbar vertebra prone to screws placement failure: an anatomical study of 299 patients. J Orthop Surg Res 2022; 17:505. [PMID: 36434721 PMCID: PMC9694565 DOI: 10.1186/s13018-022-03403-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/13/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSES This study aimed to investigate whether the morphology of the superior articular processes of L5 vertebra affected the accuracy of pedicle screw placement by reviewing 299 patients who had undergone L5 pedicle screw fixation over the past 12 months and measuring relevant parameters. METHODS We retrospectively analyzed patients who underwent L5 vertebra fixation at our spine surgery department from October 20, 2020 to October 20, 2021. Patients with spondylolisthesis, spondylolysis, and scoliosis were excluded. Parameters associated with the superior articular process were analyzed, including Mammillary process-Spinal canal Distance (MCD), Inter-Facet Distance (IFD), Inter-Pedicle Distance (IPD), Zygapophysial Joints Angle (ZJA), Superior Articular Width, and Lateral Recess Transverse Diameter. The L5 vertebral body was reconstructed by Mimics 21.0, and the simulated L5 screws were inserted at multiple entry points to measure the Maximum Safe Transverse Angle (STAmax). RESULTS A total of 299 patients who underwent L5 vertebra fixation with 556 pedicle screws were analyzed. An MCD < 6 mm was associated with a significant increase in screw placement failure rate and decrease in ZJA. The MCD was positively correlated with IFD. No significant change in IPD was observed. Mimics software analysis showed that the STAmax decreased with a decrease of MCD. When WBV < 6 mm, 93% of the trans-mammillary vertical line was located within 50% of the pedicle. CONCLUSIONS The superior articular process tended to narrow the spinal canal and exhibit a steep and a "cloverleaf" morphology when the MCD was < 6 mm. This morphology increased the risk of operator mis-judgement resulting in screw placement failure. Assessment of the relationship between the trans-mammillary vertical line and the pedicle represents a simple method to predict abnormal morphology of the superior articular process before surgery.
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Liu ZQ, Hsieh CT, Hsu WE, Tseng CS, Chang CJ. Two-dimensional C-arm robotic navigation system (i-Navi) in spine surgery: a pilot study. Int J Comput Assist Radiol Surg 2022; 17:2281-2290. [PMID: 36100733 DOI: 10.1007/s11548-022-02751-8] [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: 01/30/2022] [Accepted: 09/06/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Pedicle screws placement is very common procedure in spinal surgery. Robotic assisted surgery has been widely used in this operation. We assessed the accuracy of thoracolumbar spine trans-pedicle screws (TPS) implantation utilizing a noval robotic navigation system (i-Navi robotic navigation system) by planning with two-dimensional (2-D) C-arm. METHODS This study was approved by the Institutional Review Board of the Cathay General Hospital on June 21, 2018 (IRB number: CGH-P 106,092), and written informed consents were obtained from all the patients. There are 18 patients were enrolled in the study. All the patients received the posterior fusion with TPS insertion under the assistant of our robotic navigation system. RESULTS There are 18 patients were included into our study, there are 2 patients were quitted from the study due to the equipment setup was not complete. Other 16 patients completed the entire procedure successfully. There is total 88 pedicle screws were inserted through i-Navi robotic navigation system. There are 79 of 88 screws were graded A, and 9 screws were graded B; no screws were graded C or D. No vascular or nerve injuries were noted after the operations. CONCLUSION We present our i-Navi robotic navigation system, by planning with 2-D C-arm imaging and pre-operative CT scans. According to the results of study, we think it can provide a reliable and easy tool to perform the TPS in thoracic lumbar spine surgery.
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Affiliation(s)
- Zhao-Quan Liu
- Division of Neurosurgery, Department of Surgery, Cathay General Hospital, Taipei City, 106, Taiwan.,Division of Neurosurgery, Department of Surgery, Sijhih Cathay General Hospital, New Taipei City, 221, Taiwan
| | - Cheng-Ta Hsieh
- Division of Neurosurgery, Department of Surgery, Cathay General Hospital, Taipei City, 106, Taiwan.,Division of Neurosurgery, Department of Surgery, Sijhih Cathay General Hospital, New Taipei City, 221, Taiwan.,School of Medicine, National Tsing Hua University, Hsinchu, 300044, Taiwan.,Department of Medicine, School of Medicine, Fu Jen Catholic University, New Taipei City, 242, Taiwan
| | - Wei-En Hsu
- Department of Mechanical Engineering, National Central University, Taoyuan County, Taiwan
| | - Ching-Shiow Tseng
- Department of Mechanical Engineering, National Central University, Taoyuan County, Taiwan
| | - Chih-Ju Chang
- Division of Neurosurgery, Department of Surgery, Cathay General Hospital, Taipei City, 106, Taiwan. .,Division of Neurosurgery, Department of Surgery, Sijhih Cathay General Hospital, New Taipei City, 221, Taiwan. .,School of Medicine, National Tsing Hua University, Hsinchu, 300044, Taiwan. .,Department of Medicine, School of Medicine, Fu Jen Catholic University, New Taipei City, 242, Taiwan.
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16
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La Rocca G, Mazzucchi E, Pignotti F, Nasto LA, Galieri G, Olivi A, De Santis V, Rinaldi P, Pola E, Sabatino G. Intraoperative CT-guided navigation versus fluoroscopy for percutaneous pedicle screw placement in 192 patients: a comparative analysis. J Orthop Traumatol 2022; 23:44. [PMID: 36048284 PMCID: PMC9437178 DOI: 10.1186/s10195-022-00661-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Percutaneous pedicle screw (PPS) placement is a key step in several minimally invasive spinal surgery (MISS) procedures. Traditional technique for PPS makes use of C-arm fluoroscopy assistance (FA). More recently, newer intraoperative imaging techniques have been developed for PPS, including CT-guided navigation (CTNav). The aim of this study was to compare FA and CTNav techniques for PPS with regard to accuracy, complications, and radiation dosage. Materials and methods A total of 192 patients with degenerative lumbar spondylolisthesis and canal stenosis who underwent MISS posterior fusion ± interbody fusion through transforaminal approach (TLIF) were retrospectively reviewed. Pedicle screws were placed percutaneously using either standard C-arm fluoroscopy guidance (FA group) or CT navigation (CTNav group). Intraoperative effective dose (ED, mSv) was measured. Screw placement accuracy was assessed postoperatively on a CT scan using Gertzbein and Robbins classification (grades A–E). Oswestry disability index (ODI) and visual analog scale (VAS) scores were compared in both groups before and after surgery. Results A total of 101 and 91 procedures were performed with FA (FA group) and CTNav approach (CTNav group), respectively. Median age was 61 years in both groups, and the most commonly treated level was L4–L5. Median ED received from patients was 1.504 mSv (0.494–4.406) in FA technique and 21.130 mSv (10.840–30.390) in CTNav approach (p < 0.001). Percentage of grade A and B screws was significantly higher for the CTNav group (96.4% versus 92%, p < 0.001), whereas there were 16 grade E screws in the FA group and 0 grade E screws in the CTNav group (p < 0.001). A total of seven and five complications were reported in the FA and CTNav group, respectively (p = 0.771). Conclusions CTNav technique increases accuracy of pedicle screw placement compared with FA technique without affecting operative time. Nevertheless, no significant difference was noted in terms of reoperation rate due to screw malpositioning between CTNav and FA techniques. Radiation exposure of patients was significantly higher with CTNav technique. Level of Evidence: Level 3.
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Affiliation(s)
- Giuseppe La Rocca
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy.,Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy.,Neurosurgical Training Center and Brain Research, Mater Olbia Hospital, Olbia, Italy
| | - Edoardo Mazzucchi
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy.,Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Fabrizio Pignotti
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy.,Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Luigi Aurelio Nasto
- Unit of Orthopedics and Spine Surgery, Primo Policlinico Di Napoli, Università Della Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 2, 80138, Naples, Italy
| | - Gianluca Galieri
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy.,Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy.,Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Vincenzo De Santis
- Institute of Orthopedics, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University of Rome, Rome, Italy.,Unit of Orthopedics, Mater Olbia Hospital, Olbia, Italy
| | | | - Enrico Pola
- Unit of Orthopedics and Spine Surgery, Primo Policlinico Di Napoli, Università Della Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 2, 80138, Naples, Italy.
| | - Giovanni Sabatino
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy.,Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy.,Neurosurgical Training Center and Brain Research, Mater Olbia Hospital, Olbia, Italy
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Conrads N, Grunz JP, Huflage H, Luetkens KS, Feldle P, Grunz K, Köhler S, Westermaier T. Accuracy of pedicle screw placement using neuronavigation based on intraoperative 3D rotational fluoroscopy in the thoracic and lumbar spine. Arch Orthop Trauma Surg 2022; 143:3007-3013. [PMID: 35794344 DOI: 10.1007/s00402-022-04514-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In spinal surgery, precise instrumentation is essential. This study aims to evaluate the accuracy of navigated, O-arm-controlled screw positioning in thoracic and lumbar spine instabilities. MATERIALS AND METHODS Posterior instrumentation procedures between 2010 and 2015 were retrospectively analyzed. Pedicle screws were placed using 3D rotational fluoroscopy and neuronavigation. Accuracy of screw placement was assessed using a 6-grade scoring system. In addition, screw length was analyzed in relation to the vertebral body diameter. Intra- and postoperative revision rates were recorded. RESULTS Thoracic and lumbar spine surgery was performed in 285 patients. Of 1704 pedicle screws, 1621 (95.1%) showed excellent positioning in 3D rotational fluoroscopy imaging. The lateral rim of either pedicle or vertebral body was protruded in 25 (1.5%) and 28 screws (1.6%), while the midline of the vertebral body was crossed in 8 screws (0.5%). Furthermore, 11 screws each (0.6%) fulfilled the criteria of full lateral and medial displacement. The median relative screw length was 92.6%. Intraoperative revision resulted in excellent positioning in 58 of 71 screws. Follow-up surgery due to missed primary malposition had to be performed for two screws in the same patient. Postsurgical symptom relief was reported in 82.1% of patients, whereas neurological deterioration occurred in 8.9% of cases with neurological follow-up. CONCLUSIONS Combination of neuronavigation and 3D rotational fluoroscopy control ensures excellent accuracy in pedicle screw positioning. As misplaced screws can be detected reliably and revised intraoperatively, repeated surgery for screw malposition is rarely required.
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Affiliation(s)
- Nora Conrads
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
| | - Jan-Peter Grunz
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Henner Huflage
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Karsten Sebastian Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Philipp Feldle
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Katharina Grunz
- Department of Orthopedics and Trauma Surgery, Klinikum Würzburg Mitte - Standort Juliusspital, Juliuspromenade 19, 97070, Würzburg, Germany
| | - Stefan Köhler
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.,Die Neurochirurgie-Praxis, Eichhornstraße 28, 97070, Würzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.,Department of Neurosurgery, Helios-Amper-Klinikum Dachau, Krankenhausstraße 15, 85221, Dachau, Germany
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Hadgaonkar S, Modipalli D, Sancheti P, Kothari A, Aiyer S, Shyam A, Acharya H, Acharya H. Accuracy of ‘O arm’ guided pedicle screw placement in osteoporotic spine with the ‘precious pedicle’. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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19
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Good CR, Orosz L, Schroerlucke SR, Cannestra A, Lim JY, Hsu VW, Zahrawi F, Villalobos HJ, Ramirez PM, Sweeney T, Wang MY. Complications and Revision Rates in Minimally Invasive Robotic-Guided Versus Fluoroscopic-Guided Spinal Fusions: The MIS ReFRESH Prospective Comparative Study. Spine (Phila Pa 1976) 2021; 46:1661-1668. [PMID: 33826591 PMCID: PMC8565511 DOI: 10.1097/brs.0000000000004048] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/26/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, multicenter, partially randomized. OBJECTIVE Assess rates of complications, revision surgery, and radiation between Mazor robotic-guidance (RG) and fluoro-guidance (FG). SUMMARY OF BACKGROUND DATA Minimally invasive surgery MIS ReFRESH is the first study designed to compare RG and FG techniques in adult minimally invasive surgery (MIS) lumbar fusions. METHODS Primary endpoints were analyzed at 1 year follow-up. Analysis of variables through Cox logistic regression and a Kaplan-Meier Survival Curve of surgical complications. RESULTS Nine sites enrolled 485 patients: 374 (RG arm) and 111 (FG arm). 93.2% of patients had more than 1 year f/u. There were no differences for sex, Charlson Comorbidity Index, diabetes, or tumor. Mean age of RG patients was 59.0 versus 62.5 for FG (P = 0.009) and body mass index (BMI) was 31.2 versus 28.1 (P< 0.001). Percentage of smokers was almost double in the RG (15.2% vs. 7.2%, P = 0.029). Surgical time was similar (skin-to-skin time/no. of screws) at 24.9 minutes RG and 22.9 FG (P = 0.550). Fluoroscopy during surgery/no. of screws was 15.5 seconds RG versus 35.4 seconds FG, (15 seconds average reduction). Fluoroscopy time during instrumentation/no. of screws was 3.6 seconds RG versus 17.8 seconds FG showing an 80% average reduction of fluoro time/screw in RG (P < 0.001). Within 1 year follow-up, there were 39 (10.4%) surgical complications RG versus 39 (35.1%) FG, and 8 (2.1%) revisions RG versus 7 (6.3%) FG. Cox regression analysis including age, sex, BMI, CCI, and no. of screws, demonstrated that the hazard ratio (HR) for complication was 5.8 times higher FG versus RG (95% CI: 3.5-9.6, P < 0.001). HR for revision surgery was 11.0 times higher FG versus RG cases (95% CI 2.9-41.2, P < 0.001). CONCLUSION Mazor robotic-guidance was found to have a 5.8 times lower risk of a surgical complication and 11.0 times lower risk for revision surgery. Surgical time was similar between groups and robotic-guidance reduced fluoro time per screw by 80% (approximately 1 min/case).Level of Evidence: 2.
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Affiliation(s)
| | | | | | | | | | | | - Faissal Zahrawi
- Department of Orthopedic Surgery, Florida Hospital, Celebration, FL
| | | | | | - Thomas Sweeney
- Southeastern Spine Center & Research Institute, Sarasota, FL
| | - Michael Y. Wang
- Department of Neurological Surgery, University of Miami Hospital, Miami, FL
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Gonzalez EA, Jain A, Bell MAL. Combined Ultrasound and Photoacoustic Image Guidance of Spinal Pedicle Cannulation Demonstrated With Intact ex vivo Specimens. IEEE Trans Biomed Eng 2021; 68:2479-2489. [PMID: 33347403 PMCID: PMC8345233 DOI: 10.1109/tbme.2020.3046370] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Spinal fusion surgeries require accurate placement of pedicle screws in anatomic corridors without breaching bone boundaries. We are developing a combined ultrasound and photoacoustic image guidance system to avoid pedicle screw misplacement and accidental bone breaches, which can lead to nerve damage. METHODS Pedicle cannulation was performed on a human cadaver, with co-registered photoacoustic and ultrasound images acquired at various time points during the procedure. Bony landmarks obtained from coherence-based ultrasound images of lumbar vertebrae were registered to post-operative CT images. Registration methods were additionally tested on an ex vivo caprine vertebra. RESULTS Locally weighted short-lag spatial coherence (LW-SLSC) ultrasound imaging enhanced the visualization of bony structures with generalized contrast-to-noise ratios (gCNRs) of 0.99 and 0.98-1.00 in the caprine and human vertebrae, respectively. Short-lag spatial coherence (SLSC) and amplitude-based delay-and-sum (DAS) ultrasound imaging generally produced lower gCNRs of 0.98 and 0.84, respectively, in the caprine vertebra and 0.84-0.93 and 0.34-0.99, respectively, in the human vertebrae. The mean ± standard deviation of the area of -6 dB contours created from DAS photoacoustic images acquired with an optical fiber inserted in prepared pedicle holes (i.e., fiber surrounded by cancellous bone) and holes created after intentional breaches (i.e., fiber exposed to cortical bone) was 10.06 ±5.22 mm 2 and 2.47 ±0.96 mm 2, respectively (p 0.01). CONCLUSIONS Coherence-based LW-SLSC and SLSC beamforming improved visualization of bony anatomical landmarks for ultrasound-to-CT registration, while amplitude-based DAS beamforming successfully distinguished photoacoustic signals within the pedicle from less desirable signals characteristic of impending bone breaches. SIGNIFICANCE These results are promising to improve visual registration of ultrasound and photoacoustic images with CT images, as well as to assist surgeons with identifying and avoiding impending bone breaches during pedicle cannulation in spinal fusion surgeries.
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Ashouri-Sanjani M, Mohammadi-Moghadam S, Azimi P, Arjmand N. Design, Fabrication, and Accuracy of a Novel Noncovering Lock-Mechanism Bilateral Patient-Specific Drill Guide Template for Nondeformed and Deformed Thoracic Spines. HSS J 2021; 17:213-222. [PMID: 34421433 PMCID: PMC8361592 DOI: 10.1177/1556331621996331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/11/2020] [Indexed: 01/26/2023]
Abstract
Background: Pedicle screw (PS) placement has been widely used in fusion surgeries on the thoracic spine. Achieving cost-effective yet accurate placements through nonradiation techniques remains challenging. Questions/Purposes: Novel noncovering lock-mechanism bilateral vertebra-specific drill guides for PS placement were designed/fabricated, and their accuracy for both nondeformed and deformed thoracic spines was tested. Methods: One nondeformed and 1 severe scoliosis human thoracic spine underwent computed tomographic (CT) scanning, and 2 identical proportions of each were 3-dimensional (3D) printed. Pedicle-specific optimal (no perforation) drilling trajectories were determined on the CT images based on the entry point/orientation/diameter/length of each PS. Vertebra-specific templates were designed and 3D printed, assuring minimal yet firm contacts with the vertebrae through a noncovering lock mechanism. One model of each patient was drilled using the freehand and one using the template guides (96 pedicle drillings). Postoperative CT scans from the models with the inserted PSs were obtained and superimposed on the preoperative planned models to evaluate deviations of the PSs. Results: All templates fitted their corresponding vertebra during the simulated operations. As compared with the freehand approach, PS placement deviations from their preplanned positions were significantly reduced: for the nonscoliosis model, from 2.4 to 0.9 mm for the entry point, 5.0° to 3.3° for the transverse plane angle, 7.1° to 2.2° for the sagittal plane angle, and 8.5° to 4.1° for the 3D angle, improving the success rate from 71.7% to 93.5%. Conclusions: These guides are valuable, as the accurate PS trajectory could be customized preoperatively to match the patients' unique anatomy. In vivo studies will be required to validate this approach.
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Affiliation(s)
| | | | - Parisa Azimi
- Neuroscience Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Navid Arjmand
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran,Navid Arjmand, PhD, Department of Mechanical Engineering, Sharif University of Technology, Tehran 11155-9567, Iran.
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Wang E, Manning J, Varlotta CG, Woo D, Ayres E, Abotsi E, Vasquez-Montes D, Protopsaltis TS, Goldstein JA, Frempong-Boadu AK, Passias PG, Buckland AJ. Radiation Exposure in Posterior Lumbar Fusion: A Comparison of CT Image-Guided Navigation, Robotic Assistance, and Intraoperative Fluoroscopy. Global Spine J 2021; 11:450-457. [PMID: 32875878 PMCID: PMC8119907 DOI: 10.1177/2192568220908242] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
STUDY DESIGN Retrospective clinical review. OBJECTIVE To assess the use of intraoperative computed tomography (CT) image-guided navigation (IGN) and robotic assistance in posterior lumbar surgery and their relationship with patient radiation exposure and perioperative outcomes. METHODS Patients ≥18 years old undergoing 1- to 2-level transforaminal lateral interbody fusion in 12-month period were included. Chart review was performed for pre- and intraoperative data on radiation dose and perioperative outcomes. All radiation doses are quantified in milliGrays (mGy). Univariate analysis and multivariate logistic regression analysis were utilized for categorical variables. One-way analysis of variance with post hoc Tukey test was used for continuous variables. RESULTS A total of 165 patients were assessed: 12 IGN, 62 robotic, 56 open, 35 fluoroscopically guided minimally invasive surgery (MIS). There was a lower proportion of women in open and MIS groups (P = .010). There were more younger patients in the MIS group (P < .001). MIS group had the lowest mean posterior levels fused (P = .015). Total-procedure radiation, total-procedure radiation/level fused, and intraoperative radiation was the lowest in the open group and highest in the MIS group compared with IGN and robotic groups (all P < .001). Higher proportion of robotic and lower proportion of MIS patients had preoperative CT (P < .001). Estimated blood loss (P = .002) and hospital length of stay (P = .039) were lowest in the MIS group. Highest operative time was observed for IGN patients (P < .001). No differences were observed in body mass index, Charlson Comorbidity Index, and postoperative complications (P = .313, .051, and .644, respectively). CONCLUSION IGN and robotic assistance in posterior lumbar fusion were associated with higher intraoperative and total-procedure radiation exposure than open cases without IGN/robotics, but significantly less than MIS without IGN/robotics, without differences in perioperative outcomes. Fluoro-MIS procedures reported highest radiation exposure to patient, and of equal concern is that the proportion of total radiation dose also applied to the surgeon and operating room staff in fluoro-MIS group is higher than in IGN/robotics and open groups.
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Affiliation(s)
- Erik Wang
- NYU Langone Orthopedic
Hospital, New York, NY, USA
| | | | | | - Dainn Woo
- NYU Langone Orthopedic
Hospital, New York, NY, USA
| | - Ethan Ayres
- NYU Langone Orthopedic
Hospital, New York, NY, USA
| | - Edem Abotsi
- NYU Langone Orthopedic
Hospital, New York, NY, USA
| | | | | | | | | | | | - Aaron J. Buckland
- NYU Langone Orthopedic
Hospital, New York, NY, USA,Aaron J. Buckland, Spine Research Center,
Department of Orthopaedic Surgery, NYU Langone Health, 306 East 15th Street,
Ground Floor, New York, NY 10003, USA.
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23
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Computer Navigation and 3D Printing in the Surgical Management of Bone Sarcoma. Cells 2021; 10:cells10020195. [PMID: 33498287 PMCID: PMC7909290 DOI: 10.3390/cells10020195] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
The long-term outcomes of osteosarcoma have improved; however, patients with metastases, recurrence or axial disease continue to have a poor prognosis. Computer navigation in surgery is becoming ever more commonplace, and the proposed advantages, including precision during surgery, is particularly applicable to the field of orthopaedic oncology and challenging areas such as the axial skeleton. Within this article, we provide an overview of the field of computer navigation and computer-assisted tumour surgery (CATS), in particular its relevance to the surgical management of osteosarcoma.
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Rawicki N, Dowdell JE, Sandhu HS. Current state of navigation in spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:85. [PMID: 33553378 PMCID: PMC7859779 DOI: 10.21037/atm-20-1335] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of navigation has become more prevalent in spine surgery. The multitude of available platforms, as well as increased availability of navigation systems, have led to increased use worldwide. Specific subsets of spine surgeons have incorporated this new technology in their practices, including minimally invasive spine (MIS) spine surgeons, neurosurgeons, and high-volume surgeons. Improved accuracy with the use of navigation has been demonstrated and its use has proven to be a safe alternative to fluoroscopic guided procedures. Navigation use allows the limitation of radiation exposure to the surgeon during common spine procedures, which over the course of a surgeon's lifetime may offer significant health benefits. Navigation has also been beneficial in tumor resection and MIS surgery, where traditional anatomic landmarks are missing or in the case of MIS not visible. As cost effectiveness improves, the use of navigation is likely to continue to expand. Navigation will also continue to expand with further innovation such as coupling the use of navigation with robotics and improving tools to enhance the end user experience.
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Affiliation(s)
- Nathaniel Rawicki
- Department of Orthopedics, Westchester Medical Center, Valhalla, NY, USA
| | - James E Dowdell
- Department of Spine, Hospital for Special Surgery, New York, NY, USA
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Weiner JA, McCarthy MH, Swiatek P, Louie PK, Qureshi SA. Narrative review of intraoperative image guidance for transforaminal lumbar interbody fusion. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:89. [PMID: 33553382 PMCID: PMC7859762 DOI: 10.21037/atm-20-1971] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Recent advancements in imaging technology have changed the landscape of transforaminal lumbar interbody fusion (TLIF) with the objective of improving safety and efficacy for the patient and surgical team. Spine surgery, and specifically TLIFs, involve challenging anatomy and command precise surgical accuracy, creating an essential role for intraoperative imaging, navigation, and robotics. Traditionally, surgeons have relied upon fluoroscopy for pedicle screw and interbody placement. More recently, intraoperative 3-dimensional navigation (ION) has risen in popularity in TLIF surgery. This technology utilizes intra-operative advanced imaging, such as computed tomography (CT) and 3D-fluroscopy, to accurately track instruments and implants in relation to the patient’s anatomy. ION has demonstrated improved accuracy of pedicle screw placement, decreased operating room times, and lower radiation exposure to the surgeon and staff. However, conventional fluoroscopy, 3D fluoroscopy, intraoperative CT, image-guided navigation, and robot-assisted surgery all have a role in TLIF surgery. Numerous studies have been published regarding the benefits and pitfalls of these intraoperative tools in spine surgery, but there is a relative lack of research regarding some of the newer technologies surrounding TLIF. As future studies are published, and technology continues to evolve, surgeons must stay abreast of novel techniques to maximize patient safety and outcomes. Over the coming decade, we can expect intraoperative navigation and robotics to play a more significant role in spine surgery.
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Affiliation(s)
- Joseph A Weiner
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL, USA
| | - Michael H McCarthy
- Hospital for Special Surgery Department of Orthopedic Surgery, New York, NY, USA
| | - Peter Swiatek
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL, USA
| | - Philip K Louie
- Hospital for Special Surgery Department of Orthopedic Surgery, New York, NY, USA
| | - Sheeraz A Qureshi
- Hospital for Special Surgery Department of Orthopedic Surgery, New York, NY, USA
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Alraiyes TM, Alrajhi A, Abou-Al-Shaar H, Zekry A, Alotaibi NM, Aleissa S, Alzayed Z. The Use of Image-Guided Navigation Systems During Spine Surgeries in Saudi Arabia: A Cross-Sectional Study. Int J Spine Surg 2020; 14:1016-1022. [PMID: 33560263 DOI: 10.14444/7152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We used a cross-sectional study design (questionnaire) to investigate the use of image-guided navigation (IGN) in Saudi Arabia and explore possible differences in implementing IGN for daily practice. METHODS An internet-based survey was sent to all spine surgeons who are practicing in Saudi Arabia (orthopedics or neurosurgery). The survey is composed of 12 items that collected demographic and academic data. RESULTS Ninety-nine answered the questionnaire from 197; 80% were from Riyadh, the capital, and 50% were consultants (attending physicians). Orthopedic surgeons were almost 60% of responders compared to 40% neurosurgeons. The use of navigation in Saudi hospitals was high (76.8%). There was a significant difference between specialties in the preference of using navigation (23.2% for orthopedics versus 81.4% for neurosurgery, P < .001) and routine use in surgical spine cases (88.4% for neurosurgery versus 50.0% orthopedics, P < .001). The majority of responders from neurosurgery learned to use navigation during residency compared to orthopedics responders (51.2% versus 28.6%, P = .001). More than 30% of orthopedics responders expressed they never learned navigation compared to only 4% of neurosurgery responders. The comfort level of > 75% with performing surgery using navigation was significantly different between specialties (25% for orthopedics versus 46.5% for neurosurgery, P < .001). CONCLUSION Saudi spine surgeons are among the highest users of IGN systems. The strong healthcare infrastructure and the availability of these devices across the country are among the most important factors for its prevalence. Enhancing surgical exposure and education of postgraduate trainees to use these tools, especially within orthopedics, could increase use and comfort level rates.
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Affiliation(s)
- Thamer M Alraiyes
- Department of Orthopaedics, King Faisal Specialist Hospital & Research Centre Riyadh, Saudi Arabia
| | - Abdulrhman Alrajhi
- Department of Orthopaedics, King Saud University & Hospitals, Riyadh, Saudi Arabia
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
| | - Abdulrahman Zekry
- Department of Orthopaedics, King Saud University & Hospitals, Riyadh, Saudi Arabia
| | - Naif M Alotaibi
- National Neuroscience Institute, King Fahad Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Sami Aleissa
- Department of Surgery, Division of Orthopedics, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Zayed Alzayed
- Department of Orthopaedics, King Faisal Specialist Hospital & Research Centre Riyadh, Saudi Arabia
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Guevar J, Bleedorn J, Cullum T, Hetzel S, Zlotnick J, Mariani CL. Accuracy and safety of three-dimensionally printed animal-specific drill guides for thoracolumbar vertebral column instrumentation in dogs: Bilateral and unilateral designs. Vet Surg 2020; 50:336-344. [PMID: 33340136 DOI: 10.1111/vsu.13558] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/04/2020] [Accepted: 11/26/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the safety and accuracy of a unilateral three-dimensionally printed animal-specific drill guide (3DASDG) design for unilateral stabilization in the thoracolumbar vertebral column of dogs compared to a bilateral design. STUDY DESIGN Cadaveric study. SAMPLE POPULATION Fifty-two corridors in one canine cadaver. METHODS Two 3DASDG designs with 2 drilling tubes each were created from T8 to L7 vertebrae. Fifty-two corridors were drilled on the right and the left sides by using unilateral and bilateral designs, respectively. Planned and postoperative trajectories (entry point, exit point, angle) were compared to establish the accuracy. Statistical analysis was used for accuracy comparison between designs. Safety was evaluated by using Zdichavsky classification. RESULTS Unilateral and bilateral drill guide designs were not different for entry point and angle deviations; however, they were different for the exit point deviations. Two corridors breached outside the vertebra. For all guides, mean entry and exit point deviations were less than 1 and 2 mm, respectively. The maximum entry or exit point deviation in both groups was 4.7 mm. The mean angle deviation was <3.5°, and the maximum angle deviation was 9.3°. CONCLUSION No difference was detected in accuracy of entry points and angle deviations between drill guide designs tested in normal vertebrae. The technique was classified as highly safe. CLINICAL SIGNIFICANCE A unilateral drill guide design may be a safe alternative to bilateral guides for unilateral stabilization of the thoracolumbar vertebral column in dogs.
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Affiliation(s)
- Julien Guevar
- Division of Clinical Neurology, Vetsuisse Faculty, University of Bern, Bern, Switzerland.,Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin- Madison, Madison, Wisconsin
| | - Jason Bleedorn
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin- Madison, Madison, Wisconsin
| | | | - Scott Hetzel
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin
| | - Josh Zlotnick
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Christopher L Mariani
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
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Baba S, Kawaguchi K, Itamoto K, Watanabe T, Hayashida M, Mae T, Nakashima Y, Kato G. Use of an inertial measurement unit sensor in pedicle screw placement improves trajectory accuracy. PLoS One 2020; 15:e0242512. [PMID: 33196657 PMCID: PMC7668595 DOI: 10.1371/journal.pone.0242512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/03/2020] [Indexed: 12/02/2022] Open
Abstract
Ascertaining the accuracy of the pedicle screw (PS) trajectories is important as PS malpositioning can cause critical complications. We aimed to determine the angle range over which estimation is unreliable; build a low-cost PS placement support system that uses an inertial measurement unit (IMU) to enable the monitoring of surgical tools and PS trajectories, and determine the situations where IMU support would be most beneficial. In PS insertion experiments, we used cadaver samples that included lumbar porcine spines. Computed tomography images obtained before and after PS insertion were viewed. Offsets between the planned and implanted PS trajectories in the freehand and IMU-assisted groups were analyzed. The PS cortical bone breaches were classified according to the Gertzbein and Robbins criteria (GRC). Added head-down tilted sample experiments were repeated wherein we expected a decreased rostro-caudal rotational accuracy of the PS according to the angle estimation ability results. Evaluation of the PS trajectory accuracy revealed no significant advantage of IMU-assisted rostro-caudal rotational accuracy versus freehand accuracy. According to the GRC, IMU assistance significantly increased the rate of clinically acceptable PS positions (RoCA) than the freehand technique. In the head-down tilted sample experiments, IMU assist provided increased accuracies with both rostro-caudal and medial rotational techniques when compared with the freehand technique. In the freehand group, RoCA was significantly decreased in samples with rostral tilting relative to that in the samples without. However, In the IMU-assisted group, no significant difference in RoCA between the samples with and without head-down tilting was observed. Even when the planned PS medial and/or rostro-caudal rotational angle was relatively large and difficult to reproduce manually, IMU-support helped maintain the PS trajectory accuracy and positioning safety. IMU assist in PS placement was more beneficial, especially for larger rostro-caudal and/or medial rotational pedicle angles.
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Affiliation(s)
- Satoshi Baba
- Department of Spine Surgery, Saga Medical Center, Koseikan, Saga, Japan
- Trauma Center, Saga Medical Center, Koseikan, Saga, Japan
- Department of Orthopedic Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kenichi Kawaguchi
- Department of Orthopedic Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazuhito Itamoto
- Department of Small Animal Clinical Science, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Takeshi Watanabe
- Department of Orthopedic Surgery, Watanabe Orthopedic Hospital, Itoshima, Fukuoka, Japan
| | - Mitsumasa Hayashida
- Department of Spine Surgery, Saga Medical Center, Koseikan, Saga, Japan
- Trauma Center, Saga Medical Center, Koseikan, Saga, Japan
- Department of Orthopedic Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takao Mae
- Trauma Center, Saga Medical Center, Koseikan, Saga, Japan
- Department of Orthopedic Surgery, Saga Medical Center, Koseikan, Saga, Japan
| | - Yasuharu Nakashima
- Department of Orthopedic Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Go Kato
- Department of Spine Surgery, Saga Medical Center, Koseikan, Saga, Japan
- Trauma Center, Saga Medical Center, Koseikan, Saga, Japan
- Department of Orthopedic Surgery, Fukuoka Red Cross Hospital, Fukuoka, Japan
- * E-mail:
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Three-dimensional Printed Drill Guides Versus Fluoroscopic-guided Freehand Technique for Pedicle Screw Placement: A Systematic Review and Meta-analysis of Radiographic, Operative, and Clinical Outcomes. Clin Spine Surg 2020; 33:314-322. [PMID: 32496309 DOI: 10.1097/bsd.0000000000001023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
STUDY DESIGN A systematic review and meta-analysis. OBJECTIVE The objective of this study was to compare surgical, clinical, and radiographic outcomes of 3-dimensional printed (3DP) drill guides to the fluoroscopic-guided, freehand placement of pedicle screws in the spine. SUMMARY OF BACKGROUND DATA 3DP is a budding technology in spine surgery and has recently been applied to patient-specific drill guides for pedicle screw placement. Several authors have reported the benefits of these drill guides, but no clear consensus exists on their utility. MATERIALS AND METHODS A comprehensive search of the literature was conducted and independent reviewers assessed eligibility for included studies. Outcomes analyzed included: total operation time, estimated blood loss, screw accuracy, pain score, Japanese Orthopedic Association score, and postoperative complications. Weighted mean differences (WMD) and weighted risk differences were calculated using a random-effects model. RESULTS Six studies with a total of 205 patients were included. There were significantly lower operation times [WMD=-32.32 min, 95% confidence interval (CI)=-53.19 to -11.45] and estimated blood loss (WMD=-51.42 mL, 95% CI=-81.12 to -21.72) in procedures performed with 3DP drill guides as compared with freehand technique. The probability of "excellent" screw placement was significantly higher in 3DP guides versus freehand (weighted risk difference=-0.12, 95% CI=-0.17 to 0.07); however, no differences were observed in "poor" or "good" screw placement. There were no significant differences between groups in pain scores or Japanese Orthopedic Association scores. No difference in the rate of surgical complications was noted between the groups. CONCLUSIONS Pedicle screws placed with 3DP drill guides may result in shorter operative time, less blood loss, and a greater probability of excellent screw placement as compared with those placed with freehand techniques. We conclude that 3DP guides may potentially develop into an efficient and accurate option for pedicle screw placement. However, more prospective, randomized controlled trials are needed to strengthen the confidence of these conclusions. LEVEL OF EVIDENCE Level III.
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Tokala DP, Ahuja S. Is it mandatory to routinely use image intensifier during scoliosis surgery? – Results of an email survey. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2020; 3:100024. [PMID: 35141592 PMCID: PMC8820072 DOI: 10.1016/j.xnsj.2020.100024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 11/02/2022]
Abstract
Background Methods Results Conclusions
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31
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Lin HH, Lu YH, Chou PH, Chang MC, Wang ST, Liu CL. Is bony attachment necessary for dynamic reference frame in navigation-assisted minimally invasive lumbar spine fusion surgery? Comput Assist Surg (Abingdon) 2020; 24:7-12. [PMID: 31478764 DOI: 10.1080/24699322.2018.1542028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
This study aimed to compare the accuracy of navigation-assisted percutaneous pedicle screw insertions between traditional posterior superior iliac spine (PSIS) fixed and cutaneously fixed dynamic reference frame (DRF) in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF). This is a prospective randomized clinical study. Between May 2016 and Nov 2017, 100 patients who underwent MIS TLIF were randomly divided into bone fixed group (with PSIS fixed DRF) and skin fixed group (with cutaneously fixed DRF). The pedicel screws were inserted under navigational guidance using computed tomography (CT) data acquired intraoperatively with a Ziehm 3-dimensional fluoroscopy-based navigation system. Screw positions were immediately checked by a final intraoperative scan. The accuracy of screw placement was evaluated by a sophisticated computed tomography protocol. Both groups had similar patient demographics. Totally Five-hundred Twelve pedicle screws were placed in the lumbar spine. There were 2 moderate (2-4 mm) pedicle perforations in each group. The accuracy showed no significant difference between bone fixed and skin fixed DRF. There were no significant procedure-related complications. The skin fixed DRF provides similar accuracy in pedicle screw insertions with bone fixed DRF using intraoperative 3D image guided navigation in MIS TLIF. Skin fixed DRF not only serves as an alternative method but also saves a separate incision wound for bony attachment.
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Affiliation(s)
- Hsi-Hsien Lin
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital , Taipei , Taiwan , ROC.,School of Medicine, National Yang-Ming University , Taiwan , ROC
| | - Yueh-Hsiu Lu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital , Taipei , Taiwan , ROC.,School of Medicine, National Yang-Ming University , Taiwan , ROC
| | - Po-Hsin Chou
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital , Taipei , Taiwan , ROC.,School of Medicine, National Yang-Ming University , Taiwan , ROC
| | - Ming-Chau Chang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital , Taipei , Taiwan , ROC.,School of Medicine, National Yang-Ming University , Taiwan , ROC
| | - Shih-Tien Wang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital , Taipei , Taiwan , ROC.,School of Medicine, National Yang-Ming University , Taiwan , ROC
| | - Chien-Lin Liu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital , Taipei , Taiwan , ROC.,School of Medicine, National Yang-Ming University , Taiwan , ROC
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Caelers IJMH, Rijkers K, van Kuijk SMJ, van Santbrink H, de Bie RA, van Hemert WLW. Neurological events due to pedicle screw malpositioning with lateral fluoroscopy-guided pedicle screw insertion. J Neurosurg Spine 2020; 33:806-811. [PMID: 32823268 DOI: 10.3171/2020.5.spine20550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The risk of novel postoperative neurological events due to pedicle screw malpositioning in lumbar fusion surgery is minimized by using one of the several image-guided techniques for pedicle screw insertion. These techniques for guided screw insertion range from intraoperative fluoroscopy to intraoperative navigation. A practical technique consists of anatomical identification of the screw entry point followed by lateral fluoroscopy used for guidance during insertion of the screw. This technique is available in most clinics and is less expensive than intraoperative navigation. However, the safety of lateral fluoroscopy-guided pedicle screw placement with regard to novel postoperative neurological events due to screw malposition has been addressed only rarely in the literature. In this study the authors aimed to determine the rate of novel postoperative neurological events due to intraoperative and postoperatively established screw malpositioning during lateral fluoroscopy-assisted screw insertion. METHODS Included patients underwent lateral fluoroscopy-assisted lumbosacral screw insertion between January 2012 and August 2017. The occurrence of novel postoperative neurological events was analyzed from patient files. In case of an event, surgical reports were screened for the occurrence of intraoperative screw malposition. Furthermore, postoperative CT scans were analyzed to identify and describe possible screw malposition. RESULTS In total, 246 patients with 1079 screws were included. Novel postoperative neurological events were present in 36 patients (14.6%). In 8 of these 36 patients (3.25% of the total study population), the neurological events could be directly attributed to screw malposition. Screw malpositioning was caused either by problematic screw insertion with immediate screw correction (4 patients) or by malpositioned screws for which the malposition was established postoperatively using CT scans (4 patients). Three patients with screw malposition underwent revision surgery without subsequent symptom relief. CONCLUSIONS Lateral fluoroscopy-assisted lumbosacral screw placement results in low rates of novel postoperative neurological events caused by screw malposition. In the majority of patients suffering from novel postoperative neurological events, these events could not be attributed to screw malpositioning, but rather were due to postoperative neurapraxia of peripheral nerves, neuropathy, or intraoperative traction of nerve roots.
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Affiliation(s)
- Inge J M H Caelers
- 1CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Limburg
- 2Department of Neurosurgery, Zuyderland Medical Center, Sittard-Geleen/Heerlen, Limburg
| | - Kim Rijkers
- 2Department of Neurosurgery, Zuyderland Medical Center, Sittard-Geleen/Heerlen, Limburg
- 3Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Limburg
| | - Sander M J van Kuijk
- 4Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, Limburg
| | - Henk van Santbrink
- 1CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Limburg
- 2Department of Neurosurgery, Zuyderland Medical Center, Sittard-Geleen/Heerlen, Limburg
- 3Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Limburg
| | - Rob A de Bie
- 1CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Limburg
- 5Department of Epidemiology, Maastricht University, Maastricht, Limburg; and
| | - Wouter L W van Hemert
- 6Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen/Heerlen, Limburg, The Netherlands
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Gu Y, Yao Q, Xu Y, Zhang H, Wei P, Wang L. A Clinical Application Study of Mixed Reality Technology Assisted Lumbar Pedicle Screws Implantation. Med Sci Monit 2020; 26:e924982. [PMID: 32647106 PMCID: PMC7370579 DOI: 10.12659/msm.924982] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background This was a prospective comparative study of mixed reality (MR) technology assisted lumbar pedicle screws placement and traditional lumbar pedicle screws placement. Material/Methods Fifty cases of lumbar pedicle screws placement were randomly divided into 2 groups: 25 cases with MR technology in group A, and 25 cases without MR technology in group B. All patients had their scores on the Oswestry disability index (ODI) of low back pain and the visual analog scale (VAS) of the affected lower limb recorded at pre-operation. Blood loss, operative duration, success rate of first penetration by tap, and number of times C-arm fluoroscopy was performed were recorded at intraoperation. The postoperative drainage was recorded. The ODI of low back pain and VAS of the affected lower limb were recorded at 1, 3, and 6 months after operation. Results Group A had less bleeding, shorter operation time, higher success rate of first penetration by tap, and fewer times using C-arm fluoroscopy at intraoperation (P<0.05). There was significant difference in ODI scores and VAS scores at 1 mouth after operation (P<0.05). The postoperative drainage of group A was less than group B (P<0.05). The implantation accuracy of group A was higher than group B (P<0.05). The postoperative recovery rate of low back pain of group A was faster than group B (P<0.05). Conclusions The safety of spinal surgery and implantation accuracy of pedicle screw fixation system could be increased by MR technology.
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Affiliation(s)
- Yue Gu
- The Third Clinical Medical College, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Qingqiang Yao
- Department of Orthopedic, Nanjing First Hospital, Nanjing, Jiangsu, China (mainland)
| | - Yan Xu
- Department of Orthopedic, Nanjing First Hospital, Nanjing, Jiangsu, China (mainland)
| | - Huikang Zhang
- Digital Medicine Institute, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Peiran Wei
- The Third Clinical Medical College, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Liming Wang
- Department of Orthopedic, Nanjing First Hospital, Nanjing, Jiangsu, China (mainland)
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Raasck K, Khoury J, Aoude A, Beland B, Munteanu A, Weber MH, Golan J. The Effect of Thoracolumbar Pedicle Isthmus on Pedicle Screw Accuracy. Global Spine J 2020; 10:393-398. [PMID: 32435557 PMCID: PMC7222685 DOI: 10.1177/2192568219850143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVES Aberrant pedicle screws can cause serious neurovascular complications. We propose that a predominant factor of pedicle screw breach is the vertebral anatomy at a given spinal level. We aim to investigate the inverse correlation between breach incidence and vertebral isthmus width. METHODS The computed tomography scans of patients undergoing thoracolumbar surgery were retrospectively reviewed. Breaches were categorized as minor (<2 mm) or major (>2 mm). Breach incidence was stratified by spinal level. Average isthmus width was then compared to the collected breach incidences. A regression analysis and Pearson's correlation were performed. RESULTS A total of 656 pedicle screws were placed in 91 patients with 233 detected breaches. Incidence of major breach was 6.3%. Four patients developed post-operative radiculopathy due to breach. Breach incidence was higher in the thoracic than lumbar spine (Fisher's exact test, P < .0001). The 2 spinal levels with the thinnest isthmus width (T4 and T5) were breached most often (73.7% and 73.9%, respectively). The 2 spinal levels with the thickest isthmus width (L4 and L5) were breached least often (20.5% and 11.8%). Breach incidence and isthmus width were shown to have a significant inverse correlation (Pearson's correlation, R 2 = 0.7, P < .0001). CONCLUSIONS Thinner vertebral isthmus width increases pedicle screw breach incidence. Image-guided assistance may be most useful where breach incidence is highest and isthmus width is lowest (T2 to T6). Despite high incidence of cortical bone violation, there was little correlation with clinical symptoms. A breach is not automatically a clinical problem, provided the screw is structurally sound and the patient is symptomless.
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Affiliation(s)
- Kyle Raasck
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada,Kyle Raasck, Division of Orthopaedic Surgery, McGill Faculty of Medicine, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.
| | - Jason Khoury
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ahmed Aoude
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Benjamin Beland
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexander Munteanu
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael H. Weber
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jeff Golan
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Wallace N, Schaffer NE, Freedman BA, Nassr A, Currier BL, Patel R, Aleem IS. Computer-assisted navigation in complex cervical spine surgery: tips and tricks. JOURNAL OF SPINE SURGERY 2020; 6:136-144. [PMID: 32309652 DOI: 10.21037/jss.2019.11.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Stereotactic navigation is quickly establishing itself as the gold standard for accurate placement of spinal instrumentation and providing real-time anatomic referencing. There have been substantial improvements in computer-aided navigation over the last decade producing improved accuracy with intraoperative scanning while shortening registration time. The newest iterations of modeling software create robust maps of the anatomy while tracking software localizes instruments in multiple display modes. As a result, stereotactic navigation has become an effective adjunct to spine surgery, particularly improving instrumentation accuracy in the setting of atypical anatomy. This article provides an overview of stereotactic navigation applied to complex cervical spine surgery, details the means for registration and direct referencing, and shares our preferred methods to implement this promising technology.
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Affiliation(s)
- Nicholas Wallace
- Department of Orthopedic Surgery, Division of Spine Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Nathaniel E Schaffer
- Department of Orthopedic Surgery, Division of Spine Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Rakesh Patel
- Department of Orthopedic Surgery, Division of Spine Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ilyas S Aleem
- Department of Orthopedic Surgery, Division of Spine Surgery, University of Michigan, Ann Arbor, MI, USA
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Salama AA, Amin MA, Soliman AY, El-Tantaway A. Postoperative 320 multi-slice computed tomography in assessment of pedicle screw insertion in thoraco-lumbar fixation. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0050-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pedicle screw instrumentation is used widely in lumbar spine for stabilization to enhance arthrodesis and has been accepted in the thoracic spine in recent years. The purpose of this study was to assess the value of postoperative 320 multi-slice computed tomography (MSCT) in assessment of pedicle screw placement in patients with spinal fixation with clinical and surgical correlation.
Results
A total of 340 pedicular screws were inserted to 70 cases. 286 (84.12%) were in, 54 screws (15.88%) were violated, and revision surgeries were required for 5 displaced screws. On axial, coronal reconstruction and three-dimensional (3D) reformatted CT images 36, 47, and 54 displaced screws were detected, respectively. Both sensitivity and specificity for 3D reformatted images were 100%. For axial image, they were 97.6% and 89.4%, respectively, compared with surgical findings in 5 revised screws.
Conclusion
Multi-slice CT scan is a valuable and valid postoperative assessment tool of accuracy of spinal pedicle screw placement.
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Wu X, Liu R, Xu S, Yang C, Yang S, Shao Z, Li S, Ye Z. Feasibility of mixed reality-based intraoperative three-dimensional image-guided navigation for atlanto-axial pedicle screw placement. Proc Inst Mech Eng H 2019; 233:1310-1317. [PMID: 31617820 DOI: 10.1177/0954411919881255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study aimed to evaluate the safety and accuracy of mixed reality-based intraoperative three-dimensional navigated pedicle screws in three-dimensional printed model of fractured upper cervical spine. A total of 27 cervical model from patients of upper cervical spine fractures formed the study group. All the C1 and C2 pedicle screws were inserted under mixed reality-based intraoperative three-dimensional image-guided navigation system. The accuracy and safety of the pedicle screw placement were evaluated on the basis of postoperative computerized tomography scans. A total of 108 pedicle screws were properly inserted into the cervical three-dimensional models under mixed reality-based navigation, including 54 C1 pedicle screws and 54 C2 pedicle screws. Analysis of the dimensional parameters of each pedicle at C1/C2 level showed no statistically significant differences in the ideal and the actual entry points, inclined angles, and tailed angles. No screw was misplaced outside the pedicle of the three-dimensional printed model, and no ionizing X-ray radiation was used during screw placement under navigation. It is easy and safe to place C1/C2 pedicle screws under MR surgical navigation. Mixed reality-based navigation is feasible within upper cervical spinal fractures with improved safety and accuracy of C1/C2 pedicle screw insertion.
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Affiliation(s)
- Xinghuo Wu
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Liu
- Department of Orthopaedic Surgery, Puren Hospital of Wuhan, Wuhan University of Science and Technology, Wuhan, China
| | - Song Xu
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cao Yang
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuhua Yang
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zengwu Shao
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suyun Li
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhewei Ye
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Vijayeswaran N, Venkatesh R, Murugesan G, Balamurugan S, Indunesh K, Pradeep TT. Is Freehand Technique of Pedicle Screw Insertion in Thoracolumbar Spine Safe and Accurate? Assessment of 250 Screws. J Neurosci Rural Pract 2019; 10:256-260. [PMID: 31001014 PMCID: PMC6454967 DOI: 10.4103/jnrp.jnrp_183_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Pedicle screw fixation is one of the widely used procedures for instrumentation and stabilization of the thoracic and lumbar spine. It has the advantage of stabilizing all the three columns in single approach. Various assistive techniques are available to place the pedicle screws more accurately but at the expense of increased exposure to radiation, prolonged surgical duration, and cost. Objective: The objective of this study is to determine the accuracy and safety of pedicle screw fixation in the thoracolumbar spine using freehand surgical technique. Materials and Methods: We evaluated all patients who underwent pedicle screw fixation of the thoracolumbar spine for various ailments at our institute from January 2016 to December 2017 with postoperative computed tomography scan for placement accuracy. We used Gertzbein classification to grade pedicle breaches. Screw penetration more than 4 mm was taken as critical and those less than that were classified as noncritical. Results: A total of 256 screws inserted in T1–L5 vertebrae were included from 40 consecutive patients. Six screws were excluded according to selection criteria. The mean age was 39 years. Trauma (36 patients) was the common reason for which the pedicle screw fixation was done followed by degenerative disease (2 patients) and tumour (2 patients). A total of ten pedicle screw breaches (4%) were identified in eight patients. Among these, three critical breaches (1.2%) were occurred in two patients which required revision. The remaining seven breaches were noncritical and kept under close observation and follow-up. Conclusion: Pedicle screw had become the workhorse of posterior stabilization of the spine. Based on external anatomy and landmarks alone, freehand technique for pedicle screw fixation can be performed with acceptable safety and accuracy avoiding cumulative radiation exposure and prolonged operative time.
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Affiliation(s)
- N Vijayeswaran
- Department of Neurosurgery, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India
| | - Raju Venkatesh
- Department of Neurosurgery, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India
| | - G Murugesan
- Department of Neurosurgery, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India
| | - S Balamurugan
- Department of Neurosurgery, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India
| | - K Indunesh
- Department of Neurosurgery, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India
| | - T T Pradeep
- Department of Neurosurgery, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India
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Optical Topographic Imaging for Spinal Intraoperative 3-Dimensional Navigation in the Cervical Spine: Initial Preclinical and Clinical Feasibility. Clin Spine Surg 2019; 32:303-308. [PMID: 30839418 DOI: 10.1097/bsd.0000000000000795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OF BACKGROUND DATA Computer-assisted 3-dimensional navigation may guide spinal instrumentation. Optical topographic imaging (OTI) is a novel navigation technique offering comparable accuracy and significantly faster registration workflow relative to current navigation systems. It has previously been validated in open posterior thoracolumbar exposures. OBJECTIVE To validate the utility and accuracy of OTI in the cervical spine. STUDY DESIGN This is a prospective preclinical cadaveric and clinical cohort study. METHODS Standard midline open posterior cervical exposures were performed, with segmental OTI registration at each vertebral level. In cadaveric testing, OTI navigation guidance was used to track a drill guide for cannulating screw tracts in the lateral mass at C1, pars at C2, lateral mass at C3-6, and pedicle at C7. In clinical testing, translaminar screws at C2 were also analyzed in addition. Planned navigation trajectories were compared with screw positions on postoperative computed tomographic imaging, and quantitative navigation accuracies, in the form of absolute translational and angular deviations, were computed. RESULTS In cadaveric testing (mean±SD) axial and sagittal translational navigation errors were (1.66±1.18 mm) and (2.08±2.21 mm), whereas axial and sagittal angular errors were (4.11±3.79 degrees) and (6.96±5.40 degrees), respectively.In clinical validation (mean±SD) axial and sagittal translational errors were (1.92±1.37 mm) and (1.27±0.97 mm), whereas axial and sagittal angular errors were (3.68±2.59 degrees) and (3.47±2.93 degrees), respectively. These results are comparable to those achieved with OTI in open thoracolumbar approaches, as well as using current spinal neuronavigation systems in similar applications. There was no radiographic facet, canal or foraminal violations, nor any neurovascular complications. CONCLUSIONS OTI is a novel navigation technique allowing efficient initial and repeat registration. Accuracy even in the more mobile cervical spine is comparable to current spinal neuronavigation systems.
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Development of a Patient-specific Guide for High Cervical Spine Fixation. Rev Bras Ortop 2019; 54:20-25. [PMID: 31363238 PMCID: PMC6424808 DOI: 10.1016/j.rbo.2017.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/05/2017] [Indexed: 11/23/2022] Open
Abstract
Objective High cervical spine fixation represents a challenge for spine surgeons due to the complex anatomy and the risks of vascular and medullar injury. The recent advances in 3-D printing have unfolded a whole new range of options for these surgeons. Methods In the present study, a guide for the placement of the lateral mass screw in the C1 vertebra was developed using 3-D printing. Eight real-size models of the high cervical spine and their respective screw guides were built using computed tomography (CT) scan images. The guidewires were inserted with the help of the printed guides and then the models were analyzed with the help of CT scan images. Results All of the guidewires in the present study obtained a safe placement in the models, avoiding the superior and inferior articular surfaces, the vertebral foramen, and the vertebral artery. Conclusion The present study demonstrated the efficiency of the guide, a reliable tool for aiding the insertion of guidewires for screws in lateral masses of the C1.
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Spyrantis A, Cattani A, Seifert V, Freiman TM, Setzer M. Minimally invasive percutaneous robotic thoracolumbar pedicle screw implantation combined with three-dimensional fluoroscopy can reduce radiation: A cadaver and phantom study. Int J Med Robot 2019; 15:e2022. [PMID: 31216120 DOI: 10.1002/rcs.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/26/2019] [Accepted: 06/04/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Andrea Spyrantis
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Adriano Cattani
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Matthias Setzer
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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Vaishnav AS, Othman YA, Virk SS, Gang CH, Qureshi SA. Current state of minimally invasive spine surgery. JOURNAL OF SPINE SURGERY 2019; 5:S2-S10. [PMID: 31380487 DOI: 10.21037/jss.2019.05.02] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Over the past two decades, minimally invasive surgical approaches have become increasingly feasible, efficient and popular for the management of a wide range of spinal disorders, with a growing body of research demonstrating numerous advantages of these techniques over the traditional open approach. In this article, we review the technologies and innovations that are expanding the horizon of minimally invasive spine surgery (MISS), and highlight high-quality peer-reviewed literature in the past year that expands our knowledge and understanding of indications, advantages and limitations of MISS.
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Affiliation(s)
| | - Yahya A Othman
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | | | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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Junaid M, Afzal A, Kalsoom A, Bukhari SS. Freehand pedicle screw fixation: A safe recipe for dorsal, lumbar and sacral spine. Pak J Med Sci 2019; 35:680-684. [PMID: 31258575 PMCID: PMC6572961 DOI: 10.12669/pjms.35.3.981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To determine outcome of freehand pedicle screw fixation for dorsal, lumbar and sacral fractures at a tertiary care centre in the developing world. Methods: A retrospective review was performed of 150 consecutive patients who underwent pedicle screw fixation from January 1, 2012 to 31st December 2017. A total of 751 pedicle screws were placed. Incidence and extent of cortical breach by misplaced pedicle screw was determined by review of intra-operative and post-operative radiographs and/or computed tomography. Results: Among the total 751 free hand placed pedicle screws, four screws (0.53%) were repositioned due to a misdirected trajectory towards the disc space. six screws (0.79%) were identified to have cause moderate breach while four screws (0.53%) cause severe breach. There was no occurrence of iatrogenic nerve root damage or violation of the spinal canal. Conclusion: Free hand pedicle screw placement based on external landmarks showed remarkable safety and accuracy in our center. The authors conclude that assiduous adherence to technique and preoperative planning is vital to success.
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Affiliation(s)
- Muhammad Junaid
- Dr. Muhammad Junaid, FCPS IFAANS, Department of Neurosurgery, PNS Shifa Hospital, Karachi, Pakistan
| | - Ali Afzal
- Dr. Ali Afzal, FCPS, Department of Neurosurgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Anisa Kalsoom
- Dr. Anisa Kalsoom, FCPS, Department of Radiology, Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Syed Sarmad Bukhari
- Dr. Syed Sarmad Bukhari, MBBS, Department of Neurological Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Guha D, Jakubovic R, Alotaibi NM, Klostranec JM, Saini S, Deorajh R, Gupta S, Fehlings MG, Mainprize TG, Yee A, Yang VX. Optical Topographic Imaging for Spinal Intraoperative Three-Dimensional Navigation in Mini-Open Approaches: A Prospective Cohort Study of Initial Preclinical and Clinical Feasibility. World Neurosurg 2019; 125:e863-e872. [DOI: 10.1016/j.wneu.2019.01.201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
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45
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Cecchinato R, Berjano P, Zerbi A, Damilano M, Redaelli A, Lamartina C. Pedicle screw insertion with patient-specific 3D-printed guides based on low-dose CT scan is more accurate than free-hand technique in spine deformity patients: a prospective, randomized clinical trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1712-1723. [PMID: 31006069 DOI: 10.1007/s00586-019-05978-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/10/2019] [Accepted: 04/14/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Screw misplacement incidence can be as high as 15-30% in spine deformity surgery, with possible devastating consequences. Some technical solutions to prevent misplacement require expensive devices. MySpineTM comprises a low-dose CT scan of the patient's spine to build a virtual model of the spine to plan the screw trajectories and a 3D-printed patient-specific guide system to prepare the screw trajectories and to implant the screws in the vertebrae in order to increase reproducibility and safety of the implants. The aim of this open-label, single-center, prospective randomized clinical trial with independent evaluation of outcomes was to compare the accuracy of free-hand insertion of pedicle screws to MySpineTM 3D-printed patient-specific guides. METHODS Twenty-nine patients undergoing surgical correction for spinal deformity were randomized to Group A (pedicle screws implantation with MySpineTM) or Group B (free-hand implantation). Group A received 297 pedicle screws, and Group B 243 screws. Forty-three screws in Group A crossed over to free-hand implantation. Screw position was graded according to Gertzbein in grades 0, A, B or C, with grades 0 or A considered as "safe area." Total fluoroscopy dose and time were compared in six patients of each group. RESULTS Comparing the two study groups, we observed a statistically significant difference between the two groups (p < 0.05), with 96.1% of screws in the "safe area" in Group A versus a 82.9% in Group B. Group-A patients had a mean effective dose of 0.23 mSv compared to 0.82 mSv in Group B. Patient-specific, 3D-printed pedicle screw guides increase safety in a wide spectrum of deformity conditions. In addition, the total radiation dose is reduced, even considering the need of a low-dose preoperative CT for surgical planning. LEVEL OF EVIDENCE I. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
| | - Pedro Berjano
- GSpine4, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Alberto Zerbi
- GSpine4, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Marco Damilano
- GSpine4, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Comparison of Efficacy between 3D Navigation-Assisted Percutaneous Iliosacral Screw and Minimally Invasive Reconstruction Plate in Treating Sacroiliac Complex Injury. Curr Med Sci 2019; 39:81-87. [PMID: 30868495 DOI: 10.1007/s11596-019-2003-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 01/15/2019] [Indexed: 10/27/2022]
Abstract
The clinical efficacy was compared between 3D navigation-assisted percutaneous iliosacral screw (3DPS) and minimally invasive reconstruction plate (MIRP) in treating sacroiliac complex injury and the surgical procedures of 3DPS were introduced. A retrospective analysis was performed on 49 patients with sacroiliac complex injury from March 2013 to May 2017. Twenty-one cases were treated by 3DPS, and 28 cases by MIRP. Intraoperative indexes as operative time, blood loss, incision length, length of hospital stay and postoperative complications were respectively documented. Quality of reduction was postoperatively evaluated by Matta radiological criteria, and clinical effect was assessed by Majeed scoring criteria at the last follow-up. Operative time and hospital stay were significantly shortened, and blood loss, and incision length were significantly reduced in 3DPS group as compared with those in MIRP group (P<0.05). No statistically significant difference was found between 3DPS group and MIRP group in the assessment of reduction and function (P>0.05). It was concluded that both 3DPS and MIRP can effectively treat the sacroiliac complex injury, and 3DPS can provide an accurate, safe and minimally invasive fixation with shorter operative time and hospital stay.
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Ahmed AK, Zygourakis CC, Kalb S, Zhu AM, Molina CA, Jiang B, Blitz AM, Bydon A, Crawford NR, Theodore N. First spine surgery utilizing real-time image-guided robotic assistance. Comput Assist Surg (Abingdon) 2019; 24:13-17. [PMID: 30821536 DOI: 10.1080/24699322.2018.1542029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Robotics in spinal surgery has significant potential benefits for both surgeons and patients, including reduced surgeon fatigue, improved screw accuracy, decreased radiation exposure, greater options for minimally invasive surgery, and less time required to train residents on techniques that can have steep learning curves. However, previous robotic systems have several drawbacks, which are addressed by the innovative ExcelsiusGPSTM robotic system. The robot is secured to the operating room floor, not the patient. It has a rigid external arm that facilitates direct transpedicular drilling and screw placement, without requiring K-wires. In addition, the ExcelsisuGPSTM has integrated neuronavigation, not present in other systems. It also has surveillance marker that immediately alerts the surgeon in the event of loss of registration, and a lateral force meter to alert the surgeon in the event of skiving. Here, we present the first spinal surgery performed with the assistance of this newly approved robot. The surgery was performed with excellent screw placement, minimal radiation exposure to the patient and surgeon, and the patient had a favorable outcome. We report the first operative case with the ExcelsisuGPSTM, and the first spine surgery utilizing real-time image-guided robotic assistance.
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Affiliation(s)
- A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins School of Medicine , Baltimore , MD , USA
| | - Corinna C Zygourakis
- Department of Neurosurgery, Johns Hopkins School of Medicine , Baltimore , MD , USA
| | - Samuel Kalb
- Department of Neurosurgery, Johns Hopkins School of Medicine , Baltimore , MD , USA.,Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center , Phoenix , AZ , USA
| | - Alex M Zhu
- Department of Neurosurgery, Johns Hopkins School of Medicine , Baltimore , MD , USA
| | - Camilo A Molina
- Department of Neurosurgery, Johns Hopkins School of Medicine , Baltimore , MD , USA
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins School of Medicine , Baltimore , MD , USA
| | - Ari M Blitz
- Department of Neuroradiology, Johns Hopkins School of Medicine , Baltimore , MD , USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins School of Medicine , Baltimore , MD , USA
| | - Neil R Crawford
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center , Phoenix , AZ , USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins School of Medicine , Baltimore , MD , USA
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Grivas TB, Savvidou O, Binos S, Vynichakis G, Lykouris D, Skaliotis M, Velissariou E, Giotopoulos K, Velissarios K. Morphometric characteristics of the thoracοlumbar and lumbar vertebrae in the Greek population: a computed tomography-based study on 900 vertebrae-"Hellenic Spine Society (HSS) 2017 Award Winner". SCOLIOSIS AND SPINAL DISORDERS 2019; 14:2. [PMID: 30820461 PMCID: PMC6381755 DOI: 10.1186/s13013-019-0176-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 01/30/2019] [Indexed: 11/10/2022]
Abstract
Background Vertebrae morphology appears to have genetic and ethnic variations. Knowledge of the vertebra and pedicle morphology is essential for proper selection and safe application of transpedicular screws. The aim of this study is to create a morphometric database for thoracolumbar and lumbar vertebrae (T9-L5) among individuals of both sexes in the Greek population. Material and methods The morphometric dimensions of T9-L5 vertebrae on computed tomography (CT) scan images were measured in 100 adults (79 males and 21 females), without spinal pathology, age from 33 to 87 years old (mean 70 ± 8.73 years). The anterior vertebral body height (AVBH), the posterior vertebral body height (PVBH), the angle formed by the upper end plate of vertebral body and the horizontal line in the sagittal plane, the inner cancellous and outer cortical pedicle height and width, the angle formed by the longitudinal trajectory of the right- and left-sided pedicles and the midline anteroposterior axis of the vertebra (pedicle axis angle (PAA)), and the postero-anterior trajectory's length of the pedicle from the entry point to the anterior cortex of the vertebra (PTLP), for the right- and left-sided pedicles, were calculated. The Mann-Whitney U tests were conducted to compare the differences in various morphometric characteristics between sexes. The collected data were statistically analyzed using the SAS/STAT software 3.1.3 and SPSS version 22. The statistical significance was set at the level of p < 0.05. The intra- and inter-observer reliability of the measured parameters was also calculated. Results The L5 vertebra had the maximum AVBH with a mean of 28.47 mm (SD ± 2.55 mm) in males and 26.48 mm (SD ± 1.61 mm) in females. The maximum PVBH in males was at L1 vertebra with a mean of 27.77 mm (SD ± 1.64 mm) and in females at L2 vertebral with a mean of 27.11 mm (SD ± 1.27 mm). Regarding the left pedicle dimensions, the maximum inner cancellous and outer cortical pedicle height was at T11 with a mean of 12.86 mm (SD ± 1.26 mm) and 18.82 mm (SD ± 1.37 mm) in males and 10.24 mm (SD ± 1.88 mm) and 16.19 mm (SD ± 3.27 mm) in females, respectively. The maximum inner cancellous and outer cortical pedicle width was at L5 with a mean of 11.57 mm (SD ± 1.97 mm) and 17.08 mm (SD ± 1.97 mm) in males and 10.24 mm (SD ± 1.88 mm) and 16.27 mm (SD ± 3.27 mm) in females, respectively. The largest PAA was found at the L5 with a mean angle of 26.23° (SD ± 2.65°) in males and 23.63° (SD ± 4.59°) in females, respectively. The maximum PTLP was found at the level of L4 with a mean of 55.31 mm (SD ± 4.52 mm) in males and 48.7 mm (SD ± 4.17 mm) in females, respectively. Regarding the right pedicle dimensions, the maximum inner cancellous and outer cortical pedicle height was found at T12 with a mean of 13.03 mm (SD ± 2.01 mm) and 18.01 mm (SD ± 1.56 mm) in males and 10.24 mm (SD ± 1.23 mm) and 16.14 mm (SD ± 1.23 mm) in females, respectively. The maximum inner cancellous and outer cortical pedicle width was at L5 with a mean of 11.3 mm (SD ± 2.86 mm) and 16.34 mm (SD ± 2.98 mm) in males and 12 mm (SD ± 3.18 mm) and 15.69 mm (SD ± 2.59 mm) in females, respectively. The greater PAA was at the L5 vertebral with a mean of 25.7° (SD ± 5.19°) in males and 25.56° (SD ± 5.31°) in females, respectively. The maximum PTLP was at the level of L3 with a mean of 54.86 mm (SD ± 3.18 mm) in males and 49.01 mm (SD ± 2.97 mm) in females, respectively. At all vertebrae, the only statistically significant difference (p < 0.0001) between the two sexes was the mean PTLP of the right and the left pedicle. The L5 vertebra was found to have the largest AVBH, PAA, and pedicle width in male and female populations. Conclusions This study provides a database of morphometric characteristics on thoracolumbar and lumbar vertebrae from T9 to L5 in the Greek population. This database may prove to be of great significance for forthcoming comparative studies. It can also serve as a basis in order to detect pathological changes in the spine and furthermore to plan operative interventions. It was found that the dimensions of thoracolumbar and lumbar vertebrae in the Greek population are sex-dependent. In the current study, vertebra and pedicle dimensions seem to have some similarities compared to other Western populations. However, in the thoracolumbar region, the pedicles of T9 and T10 may hardly accommodate a 4.00-mm pedicle screw given the narrow inner cancellous pedicle width. Importantly, the vertebra and pedicle dimensions measured in the current study can be used to guide the selection of transpedicular screws in the Greek population and to guide further research.
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Affiliation(s)
- Theodoros B Grivas
- 1Orthopaedics and Traumatology Department, "Tzaneio" General Hospital of Piraeus, Piraeus, Greece
| | - Olga Savvidou
- 2National and Kapodistrian University of Athens, First Department of Orthopaedics, "Attikon" University Hospital, Rimini 1, Chaidari, Athens Greece
| | - Stefanos Binos
- 1Orthopaedics and Traumatology Department, "Tzaneio" General Hospital of Piraeus, Piraeus, Greece
| | - Georgios Vynichakis
- 1Orthopaedics and Traumatology Department, "Tzaneio" General Hospital of Piraeus, Piraeus, Greece
| | - Dimitrios Lykouris
- 1Orthopaedics and Traumatology Department, "Tzaneio" General Hospital of Piraeus, Piraeus, Greece
| | - Michail Skaliotis
- 1Orthopaedics and Traumatology Department, "Tzaneio" General Hospital of Piraeus, Piraeus, Greece
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Mendenhall S, Mobasser D, Relyea K, Jea A. Spinal instrumentation in infants, children, and adolescents: a review. J Neurosurg Pediatr 2019; 23:1-15. [PMID: 30611158 DOI: 10.3171/2018.10.peds18327] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/04/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVEThe evolution of pediatric spinal instrumentation has progressed in the last 70 years since the popularization of the Harrington rod showing the feasibility of placing spinal instrumentation into the pediatric spine. Although lacking in pediatric-specific spinal instrumentation, when possible, adult instrumentation techniques and tools have been adapted for the pediatric spine. A new generation of pediatric neurosurgeons with interest in complex spine disorder has pushed the field forward, while keeping the special nuances of the growing immature spine in mind. The authors sought to review their own experience with various types of spinal instrumentation in the pediatric spine and document the state of the art for pediatric spine surgery.METHODSThe authors retrospectively reviewed patients in their practice who underwent complex spine surgery. Patient demographics, operative data, and perioperative complications were recorded. At the same time, the authors surveyed the literature for spinal instrumentation techniques that have been utilized in the pediatric spine. The authors chronicle the past and present of pediatric spinal instrumentation, and speculate about its future.RESULTSThe medical records of the first 361 patients who underwent 384 procedures involving spinal instrumentation from July 1, 2007, to May 31, 2018, were analyzed. The mean age at surgery was 12 years and 6 months (range 3 months to 21 years and 4 months). The types of spinal instrumentation utilized included occipital screws (94 cases); C1 lateral mass screws (115 cases); C2 pars/translaminar screws (143 cases); subaxial cervical lateral mass screws (95 cases); thoracic and lumbar spine traditional-trajectory and cortical-trajectory pedicle screws (234 cases); thoracic and lumbar sublaminar, subtransverse, and subcostal polyester bands (65 cases); S1 pedicle screws (103 cases); and S2 alar-iliac/iliac screws (56 cases). Complications related to spinal instrumentation included hardware-related skin breakdown (1.8%), infection (1.8%), proximal junctional kyphosis (1.0%), pseudarthroses (1.0%), screw malpositioning (0.5%), CSF leak (0.5%), hardware failure (0.5%), graft migration (0.3%), nerve root injury (0.3%), and vertebral artery injury (0.3%).CONCLUSIONSPediatric neurosurgeons with an interest in complex spine disorders in children should develop a comprehensive armamentarium of safe techniques for placing rigid and nonrigid spinal instrumentation even in the smallest of children, with low complication rates. The authors' review provides some benchmarks and outcomes for comparison, and furnishes a historical perspective of the past and future of pediatric spine surgery.
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Affiliation(s)
- Stephen Mendenhall
- 1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
| | - Dillon Mobasser
- 1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
| | | | - Andrew Jea
- 1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
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Accuracy and revision rate of intraoperative computed tomography point-to-point navigation for lateral mass and pedicle screw placement: 11-year single-center experience in 1054 patients. Neurosurg Rev 2018; 42:895-905. [PMID: 30569212 DOI: 10.1007/s10143-018-01067-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/07/2018] [Accepted: 12/06/2018] [Indexed: 10/27/2022]
Abstract
High accuracy in intraoperative computed tomography (iCT) navigation utilizing an intraoperatively acquired dataset for screw placement in the spine has been reported in the literature. To further improve the accuracy and counteract any intraoperative movement of predefined registration points, we introduce an iCT point-to-point navigation, where marker screws are inserted intraoperatively to increase patient safety. In all, 1054 patients who underwent iCT point-to-point navigation for lateral mass and pedicle screw placement were retrospectively analyzed between 09/2005 and 09/2016. Implant-related complications such as screw misplacement, screw loosening, and revision rate were determined. Furthermore, we investigated the rate of complications and the clinical outcome. In total, 6059 screws were inserted in 1054 patients. There were 553 (52.5%) female and 501 (47.5%) male patients. Average age was 63.5 years, mean BMI 27.5 (SD 13.9). Here, 1427 (23.5%) screws were inserted in the cervical, 995 (16.4%) in the thoracic, 3167 (52.3%) in the lumbar, and 470 (7.8%) in the sacral spine. Eight patients required a revision procedure for screw misplacement (0.8%). Total screw misplacement rate was 0.3% (16/6059). With the use of reference markers in iCT-based, spinal, point-to-point navigation, we achieved a high accuracy of screw placement with a low revision rate (0.8%) and a total screw misplacement rate of 0.3%.
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