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Obid P, Zahnreich S, Frodl A, Rahim T, Niemeyer T, Mayr M. Freehand Technique for Pedicle Screw Placement during Surgery for Adolescent Idiopathic Scoliosis Is Associated with Less Ionizing Radiation Compared to Intraoperative Navigation. J Pers Med 2024; 14:142. [PMID: 38392576 PMCID: PMC10890154 DOI: 10.3390/jpm14020142] [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: 11/23/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
PURPOSE We aim to compare radiation exposure and implant-related complications of the freehand (FH) technique versus intraoperative image-guided navigation (IN) for pedicle screw placement in adolescent idiopathic scoliosis (AIS) and estimate associated lifetime attributable cancer risks. METHODS A retrospective analysis of prospectively collected data from 40 consecutive AIS patients treated with pedicle screw instrumentation using the FH technique was performed. The dose area product (DAP) and effective dose (ED) were calculated. Screw-related complications were analysed, and the age- and gender-specific lifetime attributable cancer risks were estimated. The results were compared to previously published data on IN used during surgery for AIS. RESULTS There were no implant-related complications in our cohort. Implant density was 86.6%. The mean Cobb angle of the main curve was 75.2° (SD ± 17.7) preoperatively and 27.7° (SD ± 10.8) postoperatively. The mean ED of our cohort and published data for the FH technique was significantly lower compared to published data on the IN technique (p < 0.001). The risk for radiogenic cancer for our FH technique AIS cohort was 0.0014% for male patients and 0.0029% for female patients. Corresponding risks for IN were significantly higher (p < 0.001), ranging from 0.0071 to 0.124% and from 0.0144 to 0.253% for male and female patients, respectively. CONCLUSION The routine use of intraoperative navigation in AIS surgery does not necessarily reduce implant-related complications but may increase radiation exposure to the patient.
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Affiliation(s)
- Peter Obid
- Department of Orthopaedics and Traumatology, University Medical Center Freiburg, 79106 Freiburg, Germany
| | - Sebastian Zahnreich
- Department of Radiation Oncology and Radiation Therapy, Mainz University Hospital, 55131 Mainz, Germany
| | - Andreas Frodl
- Department of Orthopaedics and Traumatology, University Medical Center Freiburg, 79106 Freiburg, Germany
| | - Tamim Rahim
- Spine and Scoliosis Center, Asklepios Klinik Wiesbaden, 65197 Wiesbaden, Germany
| | - Thomas Niemeyer
- Spine and Scoliosis Center, Asklepios Klinik Wiesbaden, 65197 Wiesbaden, Germany
| | - Moritz Mayr
- Department of Orthopaedics and Traumatology, University Medical Center Freiburg, 79106 Freiburg, Germany
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2
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Fares N, Levey ST, Ashy C, McFadden R, Barfield W, Murphy RF, Dow MA, Van Nortwick SS. Intraoperative Radiation Exposure in Adolescent Idiopathic and Neuromuscular Scoliosis. J Pediatr Orthop 2024; 44:e40-e45. [PMID: 37822208 DOI: 10.1097/bpo.0000000000002547] [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: 10/13/2023]
Abstract
BACKGROUND Intraoperative imaging is often used to aid pedicle screw placement during scoliosis operations. Higher rates of cancer and death have been observed in orthopaedic surgeons and radiation technologists, including a fourfold higher rate of breast cancer in female orthopaedic surgeons. The purpose of this study was to evaluate variability in intraoperative radiation during spinal fusions for both adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS). METHODS A retrospective review of posterior spinal fusion and segmental spinal instrumentation for scoliosis performed by pediatric orthopaedic surgeons from 2017 to 2019 at a single institution was performed. Inclusion criteria included: a diagnosis of AIS or NMS and patients between 8 and 18 years of age. Exclusion criteria included: revision surgery, use of intraoperative navigation, and patients younger than 10 at the time of scoliosis onset within the AIS cohort. Data collected included: preoperative curve, body mass index (BMI), number of levels fused, number of Ponte osteotomies, and fluoroscopy time. One-way analysis of variance tests, Bonferroni post hoc tests, independent t tests, and Pearson correlations were utilized with significance determined at the 95% confidence level ( a = 0.05). RESULTS A total of 148 patients were included in the study. The average fluoroscopy time was 143 ± 67 seconds. Patients with NMS had higher average fluoroscopy times (193 ± 75 s) compared with patients with AIS (129 ± 58 s, P < 0.001). In patients with AIS, fluoroscopy time correlated to the patient's preoperative curve ( r = 0.182, P = 0.050). Patients with AIS with fewer than 12 levels fused had significantly less radiation exposure than those with 12 or more levels fused ( P = 0.01). When controlling for the number of levels fused, patients with AIS with higher BMIs had significantly greater fluoroscopy times ( P = 0.001). In patients with NMS, fluoroscopy time negatively correlated with BMI ( r = -0.459, P = 0.009) and positively correlated with a preoperative curve ( r = 0.475, P = 0.007). CONCLUSION Fluoroscopy times vary greatly during adolescent spinal fusions for scoliosis. Longer fluoroscopy times are correlated with: NMS diagnosis, larger preoperative curve, BMI, and number of levels fused. Surgeons' knowledge of factors affecting fluoroscopy time will increase awareness and may be the first step in decreasing intraoperative radiation risks. LEVEL OF EVIDENCE Level III; Therapeutic-a retrospective study.
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Affiliation(s)
- Nicole Fares
- Department of Anesthesia, University of Miami Miami, FL
| | - Sarah Toner Levey
- Department of Orthoapedic Surgery, Indiana University Indianapolis, IN
| | - Cody Ashy
- Department of Orthopaedic Surgery and Physical Medicine, Medical University of South Carolina
| | - Ryan McFadden
- Medical University of South Carolina, Charleston, SC
| | - William Barfield
- Department of Orthopaedic Surgery and Physical Medicine, Medical University of South Carolina
- Medical University of South Carolina, Charleston, SC
| | - Robert F Murphy
- Department of Orthopaedic Surgery and Physical Medicine, Medical University of South Carolina
| | - Matthew A Dow
- Department of Orthopaedic Surgery and Physical Medicine, Medical University of South Carolina
| | - Sara S Van Nortwick
- Department of Orthopaedic Surgery and Physical Medicine, Medical University of South Carolina
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Ansorge A, Sarwahi V, Bazin L, Vazquez O, De Marco G, Dayer R. Accuracy and Safety of Pedicle Screw Placement for Treating Adolescent Idiopathic Scoliosis: A Narrative Review Comparing Available Techniques. Diagnostics (Basel) 2023; 13:2402. [PMID: 37510146 PMCID: PMC10378125 DOI: 10.3390/diagnostics13142402] [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: 06/08/2023] [Revised: 07/15/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
Posterior spinal fusion and segmental spinal instrumentation using pedicle screws (PS) is the most used procedure to correct adolescent idiopathic scoliosis. Computed navigation, robotic navigation, and patient-specific drill templates are available, besides the first described free-hand technique. None of these techniques are recognized as the gold standard. This review compares the PS placement accuracy and misplacement-related complication rates achieved with the techniques mentioned above. It further reports PS accuracy classifications and anatomic PS misplacement risk factors. The literature suggests a higher PS placement accuracy for robotic relative to computed navigation and for the latter relative to the free-hand technique (misplacement rates: 0.4-7.2% versus 1.9-11% versus 1.5-50.7%) using variable accuracy classifications. The reported PS-misplacement-related complication rates are, however, uniformly low (0-1.4%) for every technique, while robotic and computed navigation induce a roughly fourfold increase in the patient's intraoperative radiation exposure relative to the free-hand technique with fluoroscopic implant positioning control. The authors, therefore, recommend dedicating robotic and computed navigation for complex deformities or revisions with altered landmarks, underline the need for a generally accepted PS accuracy classification, and advise against PS placement in grade 4 pedicles yielding higher misplacement rates (22.2-31.5%).
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Affiliation(s)
- Alexandre Ansorge
- Department of Spine Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
| | - Vishal Sarwahi
- Department of Pediatric Orthopedics, Cohen Children's Medical Center, Northwell Health System, New Hyde Park, NY 11040, USA
| | - Ludmilla Bazin
- Pediatric Orthopedic Unit, Geneva University Hospital, 1211 Geneva, Switzerland
| | - Oscar Vazquez
- Pediatric Orthopedic Unit, Geneva University Hospital, 1211 Geneva, Switzerland
| | - Giacomo De Marco
- Pediatric Orthopedic Unit, Geneva University Hospital, 1211 Geneva, Switzerland
| | - Romain Dayer
- Pediatric Orthopedic Unit, Geneva University Hospital, 1211 Geneva, Switzerland
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4
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Paediatric Spinal Deformity Surgery: Complications and Their Management. Healthcare (Basel) 2022; 10:healthcare10122519. [PMID: 36554043 PMCID: PMC9778654 DOI: 10.3390/healthcare10122519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022] Open
Abstract
Surgical correction of paediatric spinal deformity is associated with risks, adverse events, and complications that must be preoperatively discussed with patients and their families to inform treatment decisions, expectations, and long-term outcomes. The incidence of complications varies in relation to the underlying aetiology of spinal deformity and surgical procedure. Intraoperative complications include bleeding, neurological injury, and those related to positioning. Postoperative complications include persistent pain, surgical site infection, venous thromboembolism, pulmonary complications, superior mesenteric artery syndrome, and also pseudarthrosis and implant failure, proximal junctional kyphosis, crankshaft phenomenon, and adding-on deformity, which may necessitate revision surgery. Interventions included in enhanced recovery after surgery protocols may reduce the incidence of complications. Complications must be diagnosed, investigated and managed expeditiously to prevent further deterioration and to ensure optimal outcomes. This review summarises the complications associated with paediatric spinal deformity surgery and their management.
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Zimmermann F, Kohl K, Mandelka E, Grützner PA, Franke J, Vetter SY. Is the postoperative pedicle screw position after dorsal instrumentation with or without intraoperative cone beam CT imaging worse in patients with obesity than in normal-weight patients? J Orthop Surg Res 2022; 17:474. [PMID: 36329438 PMCID: PMC9632097 DOI: 10.1186/s13018-022-03369-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Intraoperative cone beam CT (CBCT) imaging in dorsal instrumentation facilitates pedicle screw positioning. However, in patients with obesity, the benefit may be reduced due to artifacts that affect image quality. The purpose of this study was to evaluate whether intraoperative CBCT leads to an improved postoperative screw position compared to conventional fluoroscopy independent of body weight. Methods A total of 71 patients (18 patients with a BMI > 30 kg/m2, 53 patients with a BMI < 30 kg/m2) who underwent dorsal instrumentation with intraoperative CBCT imaging were included in study groups one (SG1) and two (SG2). Two control groups (CG1 and CG2) were randomly sampled to include 22 patients with a BMI > 30 kg/m2 and 60 patients with a BMI < 30 kg/m2 who underwent dorsal instrumentation without intraoperative CBCT imaging. The pedicle screw position in postoperative computed tomography was assessed using the Gertzbein–Robbins classification. Results In SG1 (BMI > 30 kg/m2), a total of 107 (83.6%) pedicle screws showed no relevant perforation (type A + B), and 21 (16.4%) pedicle screws showed relevant perforation (type C − E). In SG2 (BMI < 30 kg/m2), 328 (90.9%) screws were classified as type A + B, and 33 (9.1%) screws were classified as type C − E. In CG1 (BMI > 30 kg/m2), 102 (76.1%) pedicle screws showed no relevant perforation (type A + B), and 32 (23.9%) pedicle screws showed relevant perforation (type C − E). In CG2 (BMI < 30 kg/m2), 279 (76.9%) screws were classified as type A + B, and 84 (23.1%) screws were classified as type C − E. There were significant differences between the values of SG1 and SG2 (p = 0.03) and between the values of SG2 and CG2 (p < 0.0001). Conclusion CBCT imaging in dorsal instrumentation can lead to an improved pedicle screw position among both patients with obesity and normal-weight patients. However, patients with obesity showed significantly worse pedicle screw positions postoperatively after dorsal instrumentation with intraoperative CBCT imaging than normal-weight patients.
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Affiliation(s)
- Felix Zimmermann
- grid.418303.d0000 0000 9528 7251BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen am Rhein, Germany
| | - Katharina Kohl
- grid.418303.d0000 0000 9528 7251BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen am Rhein, Germany
| | - Eric Mandelka
- grid.418303.d0000 0000 9528 7251BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen am Rhein, Germany
| | - Paul A. Grützner
- grid.418303.d0000 0000 9528 7251BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen am Rhein, Germany
| | - Jochen Franke
- grid.418303.d0000 0000 9528 7251BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen am Rhein, Germany
| | - Sven Y. Vetter
- grid.418303.d0000 0000 9528 7251BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen am Rhein, Germany
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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: 9] [Impact Index Per Article: 4.5] [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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7
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Zimmermann F, Kohl K, Privalov M, Franke J, Vetter SY. Intraoperative 3D imaging with cone-beam computed tomography leads to revision of pedicle screws in dorsal instrumentation: a retrospective analysis. J Orthop Surg Res 2021; 16:706. [PMID: 34863238 PMCID: PMC8642936 DOI: 10.1186/s13018-021-02849-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/15/2021] [Indexed: 12/11/2022] Open
Abstract
Background Correct positioning of pedicle screws can be challenging. Intraoperative imaging may be helpful. The purpose of this study was to evaluate the use of intraoperative 3D imaging with a cone-beam CT. The hypotheses were that intraoperative 3D imaging (1) will lead to an intraoperative revision of pedicle screws and (2) may diminish the rate of perforated screws on postoperative imaging. Methods Totally, 351 patients (age 60.9 ± 20.3 a (15–96); m/f 203/148) underwent dorsal instrumentation with intraoperative 3D imaging with 2215 pedicle screws at a trauma center level one. This study first evaluates intraoperative imaging. After this, 501 screws in 73 patients (age 62.5 ± 19.7 a; m/f 47/26) of this collective were included in the study group (SG) and their postoperative computed tomography was evaluated with regard to screw position. Then, 500 screws in 82 patients (age 64.8 ± 14.4 a; m/f 51/31) as control group (CG), who received the screws with conventional 2D fluoroscopy but without 3D imaging, were evaluated with regard to screw position. Results During the placement of the 2215 pedicle screws, 158 (7.0%) intraoperative revisions occurred as a result of 3D imaging. Postoperative computed tomography of the SG showed 445 (88.8%) screws without relevant perforation (type A + B), of which 410 (81.8%) could be classified as type A and 35 (7.0%) could be classified as type B. Fifty-six (11.2%) screws in SG showed relevant perforation (type C–E). In contrast, 384 (76.8%) screws in the CG were without relevant perforation (type A + B), of which 282 (56.4%) could be classified as type A and 102 (20.4%) as type B. One hundred and sixteen (23.2%) screws in the CG showed relevant perforation (type C–E). Conclusion This study shows that correct placement of pedicle screws in spine surgery with conventional 2D fluoroscopy is challenging. Misplacement of screws cannot always be prevented. Intraoperative 3D imaging with a CBCT can be helpful to detect and revise misplaced pedicle screws intraoperatively. The use of intraoperative 3D imaging will probably minimize the number of revision procedures due to perforating pedicle screws.
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Affiliation(s)
- Felix Zimmermann
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Katharina Kohl
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Maxim Privalov
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Jochen Franke
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Sven Y Vetter
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany.
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8
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Campbell DH, McDonald D, Araghi K, Araghi T, Chutkan N, Araghi A. The Clinical Impact of Image Guidance and Robotics in Spinal Surgery: A Review of Safety, Accuracy, Efficiency, and Complication Reduction. Int J Spine Surg 2021; 15:S10-S20. [PMID: 34607916 DOI: 10.14444/8136] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Image guidance (IG) and robotic-assisted (RA) surgery are modern technological advancements that have provided novel ways to perform precise and accurate spinal surgery. These innovations supply real-time, three-dimensional imaging information to aid in instrumentation, decompression, and implant placement. Although nothing can replace the knowledge and expertise of an experienced spine surgeon, these platforms do have the potential to supplement the individual surgeon's capabilities. Specific advantages include more precise pedicle screw placement, minimally invasive surgery with less reliance on intraoperative fluoroscopy, and lower radiation exposure to the surgeon and staff. As these technologies have become more widely adopted over the years, novel uses such as tumor resection have been explored. Disadvantages include the cost of implementing IG and robotics platforms, the initial learning curve for both the surgeon and the staff, and increased patient radiation exposure in scoliosis surgery. Also, given the relatively recent transition of many procedures from inpatient settings to ambulatory surgery centers, access to current devices may be cost prohibitive and not as readily available at some centers. Regarding patient-related outcomes, much further research is warranted. The short-term benefits of minimally invasive surgery often bolster the perioperative and early postoperative outcomes in many retrospective studies on IG and RA surgery. Randomized controlled trials limiting such confounding factors are warranted to definitively show potential independent improvements in patient-related outcomes specifically attributable to IG and RA alone. Nonetheless, irrespective of these current unknowns, it is clear that these technologies have changed the field and the practice of spine surgery. Surgeons should be familiar with the potential benefits and tradeoffs of these platforms when considering adopting IG and robotics in their practices.
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Affiliation(s)
- David H Campbell
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona
| | - Donnell McDonald
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona
| | | | | | - Norman Chutkan
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona.,The CORE Institute, Phoenix, Arizona
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Rezaii PG, Pendharkar AV, Ho AL, Sussman ES, Veeravagu A, Ratliff JK, Desai AM. Conventional versus stereotactic image guided pedicle screw placement during spinal deformity correction: a retrospective propensity score-matched study of a national longitudinal database. Int J Neurosci 2020; 131:953-961. [PMID: 32364414 DOI: 10.1080/00207454.2020.1763343] [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] [Indexed: 10/24/2022]
Abstract
PURPOSE/AIM To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity. METHODS The Thomson Reuters MarketScan national longitudinal database was used to identify patients undergoing osteotomy, posterior instrumentation, and fusion for treatment of spinal deformity with or without image-guided navigation between 2007-2016. Conventional and navigated groups were propensity-matched (1:1) to normalize differences between demographics, comorbidities, and surgical characteristics. Clinical outcomes and charges were compared between matched groups using bivariate analyses. RESULTS A total of 4,604 patients were identified as having undergone deformity correction, of which 286 (6.2%) were navigated. Propensity-matching resulted in a total of 572 well-matched patients for subsequent analyses, of which half were navigated. Rate of mechanical instrumentation-related complications was found to be significantly lower for navigated procedures (p = 0.0371). Navigation was also associated with lower rates of 90-day unplanned readmissions (p = 0.0295), as well as 30- and 90-day postoperative revisions (30-day: p = 0.0304, 90-day: p = 0.0059). Hospital, physician, and total payments favored the conventional group for initial admission (p = 0.0481, 0.0001, 0.0019, respectively); however, when taking into account costs of readmissions, hospital payments became insignificantly different between the two groups. CONCLUSIONS Procedures involving image-guided navigation resulted in decreased instrumentation-related complications, unplanned readmissions, and postoperative revisions, highlighting its potential utility for the treatment of spine deformity. Future advances in navigation technologies and methodologies can continue to improve clinical outcomes, decrease costs, and facilitate widespread adoption of navigation for deformity correction.
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Affiliation(s)
- Paymon G Rezaii
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | | | - Allen L Ho
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Atman M Desai
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
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10
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Marco RAW, Curry MC, Mujezinovic F, Linton J. Decreased radiation exposure using pulsed fluoroscopy and a detachable pedicle marker and probe to place pedicle screws: a comparison to current fluoroscopy techniques and CT navigation. Spine Deform 2020; 8:405-411. [PMID: 32096141 PMCID: PMC7220984 DOI: 10.1007/s43390-020-00086-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Quality improvement evaluation with retrospective analysis. OBJECTIVES To compare a technique to place pedicle screws (PS) using a novel detachable pedicle marker and probe (DPMP) and pulsed fluoroscopy (PF) vs. conventional technique utilizing PF with standard instruments (SI) and O-arm. Spinal fusion with pedicle screw instrumentation (PSI) is the mainstay in treatment of spinal deformities. Reports suggest that CT navigated (O-arm) PS placement is more accurate than fluoroscopy. However, these studies have not considered the increased radiation exposure associated with CT. METHODS Thirty-six patients with spinal deformity had PSI using PF and DPMPs. Accuracy of PS placement and radiation data from 14 dosimeters placed on the patient and around the operating room was analyzed. Results were compared to published data. RESULTS Mean fluoroscopic time was 13.4 s (range 6.0-32.4), and the mean cumulative dose was 3.1 mGy (range 0.2-16.4). Median estimated effective dose to the patient was 0.22 mSv (range 0.0-0.7). The effective dose of radiation was reduced by 80% (0.22 mSv vs. 1.11 mSv) compared to low-dose O-arm. The surgical team did not receive any detectable radiation. The seconds of PF used to assist and confirm placement of PSs was reduced to 1.2 s/level compared to previous reports of 4.49 s/level using SIs. DPMPs reduced fluoroscopy to 0.84 s/PS compared to 7.36 s/PS using SIs to assist and confirm PS placement. PSs were accurately placed in 561 of 576 (97.4%), which is comparable to O-arm and fluoroscopy with SIs. CONCLUSIONS PS placement using PF and DPMPs to assist and confirm PS placement lowers radiation exposure to the patient and surgical team without compromising accuracy compared to O-arm and fluoroscopy with SIs. LEVEL OF EVIDENCE Therapeutic, Level IV (Retrospective case series, historical control).
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Affiliation(s)
- Rex A. W. Marco
- Shriners Hospitals for Children-Houston, 6977 Main St., Houston, TX 77030 USA ,Houston Methodist Orthopedics and Sports Medicine, 6445 Main St, Outpatient Center, Suite 2500, Houston, TX 77030 USA
| | - Michael C. Curry
- Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, 7200 Cambridge, Suite 10A, Houston, TX 77030 USA
| | - Faruk Mujezinovic
- Shriners Hospitals for Children-Houston, 6977 Main St., Houston, TX 77030 USA ,Houston Methodist Orthopedics and Sports Medicine, 6445 Main St, Outpatient Center, Suite 2500, Houston, TX 77030 USA ,Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine, 7200 Cambridge, Suite 10A, Houston, TX 77030 USA
| | - Judith Linton
- Shriners Hospitals for Children-Houston, 6977 Main St., Houston, TX 77030 USA
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11
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Pennington Z, Cottrill E, Westbroek EM, Goodwin ML, Lubelski D, Ahmed AK, Sciubba DM. Evaluation of surgeon and patient radiation exposure by imaging technology in patients undergoing thoracolumbar fusion: systematic review of the literature. Spine J 2019; 19:1397-1411. [PMID: 30974238 DOI: 10.1016/j.spinee.2019.04.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive spine techniques are becoming increasingly popular owing to their ability to reduce operative morbidity and recovery times. The downside to these new procedures is their need for intraoperative radiation guidance. PURPOSE To establish which technologies provide the lowest radiation exposure to both patient and surgeon. STUDY DESIGN/SETTING Systematic review OUTCOME MEASURES: Average intraoperative radiation exposure (in mSv per screw placed) to surgeon and patient. Average fluoroscopy time per screw placed. METHODS We reviewed the available English medical literature to identify all articles reporting patient and/or surgeon radiation exposure in patients undergoing image-guided thoracolumbar instrumentation. Quantitative meta-analysis was performed for studies providing radiation exposure or fluoroscopy use per screw placed to determine which navigation modality was associated with the lowest intraoperative radiation exposure. Values on meta-analysis were reported as mean ± standard deviation. RESULTS We identified 4956 unique articles, of which 85 met inclusion/exclusion criteria. Forty-one articles were included in the meta-analysis. Patient radiation exposure per screw placed for each modality was: conventional fluoroscopy without navigation (0.26±0.38 mSv), conventional fluoroscopy with pre-operative CT-based navigation (0.027±0.010 mSv), intraoperative CT-based navigation (1.20±0.91 mSv), and robot-assisted instrumentation (0.04±0.30 mSv). Values for fluoroscopy used per screw were: conventional fluoroscopy without navigation (11.1±9.0 seconds), conventional fluoroscopy with navigation (7.20±3.93 s), 3D fluoroscopy (16.2±9.6 s), intraoperative CT-based navigation (19.96±17.09 s), and robot-assistance (20.07±17.22 s). Surgeon dose per screw: conventional fluoroscopy without navigation (6.0±7.9 × 10-3 mSv), conventional fluoroscopy with navigation (1.8±2.5 × 10-3 mSv), 3D Fluoroscopy (0.3±1.9 × 10-3 mSv), intraoperative CT-based navigation (0±0 mSv), and robot-assisted instrumentation (2.0±4.0 × 10-3 mSv). CONCLUSION All image guidance modalities are associated with surgeon radiation exposures well below current safety limits. Intraoperative CT-based (iCT) navigation produces the lowest radiation exposure to surgeon albeit at the cost of increased radiation exposure to the patient relative to conventional fluoroscopy-based methods.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA.
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12
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Nachabe R, Strauss K, Schueler B, Bydon M. Radiation dose and image quality comparison during spine surgery with two different, intraoperative 3D imaging navigation systems. J Appl Clin Med Phys 2019; 20:136-145. [PMID: 30677233 PMCID: PMC6370984 DOI: 10.1002/acm2.12534] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/07/2018] [Accepted: 12/22/2018] [Indexed: 12/20/2022] Open
Abstract
Careful protocol selection is required during intraoperative three-dimensional (3D) imaging for spine surgery to manage patient radiation dose and achieve clinical image quality. Radiation dose and image quality of a Medtronic O-arm commonly used during spine surgery, and a Philips hybrid operating room equipped with XperCT C-arm 3D cone-beam CT (hCBCT) are compared. The mobile O-arm (mCBCT) offers three different radiation dose settings (low, standard, and high), for four different patient sizes (small, medium, large, and extra large). The patient's radiation dose rate is constant during the entire 3D scan. In contrast, C-CBCT spine imaging uses three different field of views (27, 37, and 48 cm) using automatic exposure control (AEC) that modulates the patient's radiation dose rate during the 3D scan based on changing patient thickness. hCBCT uses additional x-ray beam filtration. Small, medium, and large trunk phantoms designed to mimic spine and soft tissue were imaged to assess radiation dose and image quality of the two systems. The estimated measured "patient" dose for the small, medium, and large phantoms imaged by the mCBCT considering all the dose settings ranged from 9.4-27.6 mGy, 8.9-33.3 mGy, and 13.8-40.6 mGy, respectively. The "patient" dose values for the same phantoms imaged with hCBCT were 2.8-4.6 mGy, 5.7-10.0 mGy, and 11.0-15.2 mGy. The CNR for the small, medium, and large phantoms was 2.9 to 3.7, 2.0 to 3.0, and 2.5 to 2.6 times higher with the hCBCT system, respectively. Hounsfield unit accuracy, noise, and uniformity of hCBCT exceeded the performance of the mCBCT; spatial resolution was comparable. Added x-ray beam filtration and AEC capability achieved clinical image quality for intraoperative spine surgery at reduced radiation dose to the patient in comparison to a reference O-arm system without these capabilities.
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Affiliation(s)
- Rami Nachabe
- Image Guided Therapy SystemsPhilips HealthcareBestThe Netherlands
| | - Keith Strauss
- Department of RadiologyCincinnati Children's HospitalCincinnatiOHUSA
| | - Beth Schueler
- Department of Neurologic RadiologyMayo ClinicRochesterMNUSA
| | - Mohamad Bydon
- Department of Neurologic SurgeryMayo ClinicRochesterMNUSA
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Prod’homme M, Sans-Merce M, Pitteloud N, Damet J, Lascombes P. Intraoperative 2D C-arm and 3D O-arm in children: a comparative phantom study. J Child Orthop 2018; 12:550-557. [PMID: 30294382 PMCID: PMC6169555 DOI: 10.1302/1863-2548.12.180016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Exposure to ionizing radiation is a concern for children during intraoperative imaging. We aimed to assess the radiation exposure to the paediatric patient with 2D and 3D imaging. METHODS To evaluate the radiation exposure, patient absorbed doses to the organs were measured in an anthropomorphic phantom representing a five-year-old child, using thermoluminescent dosimeters. For comparative purposes, organ doses were measured using a C-arm for one minute of fluoroscopy and one acquisition with an O-arm. The cone-beam was centred on the pelvis. Direct and scattered irradiations were measured and compared (Student's t-test). Skin entrance dose rates were also evaluated. RESULTS All radiation doses were expressed in µGy. Direct radiation doses of pelvic organs were between 631.22 and 1691.87 for the O-arm and between 214.08 and 737.51 for the C-arm, and were not significant (p = 0.07). Close scattered radiation on abdominal organs were between 25.11 and 114.85 for the O-arm and between 8.03 and 55.34 for the C-arm, and were not significant (p = 0.07). Far scattered radiation doses on thorax, neck and head varied from 0.86 to 6.42 for the O-arm and from 0.04 to 3.08 for the C-arm, and were significant (p = 0.02). The dose rate at the skin entrance was 328.58 µGy.s-1 for the O-arm and 1.90 with the C-arm. CONCLUSION During imaging of the pelvis, absorbed doses for a 3D O-arm acquisition were higher than with one minute fluoroscopy with the C-arm. Further clinical studies comparing effective doses are needed to assess ionizing risks of the intraoperative imaging systems in children.
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Affiliation(s)
- M. Prod’homme
- Medical University of Geneva, Geneva, Switzerland,Paediatric Orthopaedic Division, Geneva University Hospital (HUG), Geneva, Switzerland, Correspondence should be sent to M. Prod’homme, Paediatric Orthopaedic Division, Geneva University Hospital (HUG), Rue Willy-Donzé 6, CH-1211 Geneva, Switzerland. E-mail:
| | - M. Sans-Merce
- Radiology Division, Geneva University Hospital (HUG), Geneva, Switzerland,Institute of Radiation Physics, Lausanne University Hospital, Lausanne, Switzerland
| | - N. Pitteloud
- Institute of Radiation Physics, Lausanne University Hospital, Lausanne, Switzerland,Physics Section, University of Geneva, Geneva, Switzerland
| | - J. Damet
- Institute of Radiation Physics, Lausanne University Hospital, Lausanne, Switzerland,Department of Radiology, University of Otago, Christchurch, New Zealand
| | - P. Lascombes
- Medical University of Geneva, Geneva, Switzerland,Paediatric Orthopaedic Division, Geneva University Hospital (HUG), Geneva, Switzerland
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Bohoun CA, Naito K, Yamagata T, Tamrakar S, Ohata K, Takami T. Safety and accuracy of spinal instrumentation surgery in a hybrid operating room with an intraoperative cone-beam computed tomography. Neurosurg Rev 2018; 42:417-426. [PMID: 29663092 DOI: 10.1007/s10143-018-0977-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/20/2018] [Accepted: 03/28/2018] [Indexed: 11/25/2022]
Abstract
Although spinal instrumentation technique has undergone revolutionary progress over the past few decades, it may still carry significant surgery-related risks. The purpose of the present study was to assess the radiological accuracy of spinal screw instrumentation using a hybrid operating room (OR) and quantify the related radiation exposure. This retrospective study included 33 cases of complex spine fusion surgeries that were conducted using a hybrid OR with a flat panel detector (FPD) angiography system. Twelve cases (36.4%) were cervical, and 21 (63.6%) were thoracolumbar. The average number of spine fusion levels was 3 and 4.8, respectively, at the cervical and thoracolumbar spine levels. A FPD angiography system was used for intraoperative cone-beam computed tomography (CBCT) to obtain multi-slice spine images. All operations were conducted under optimized radiation shielding. Entrance surface doses (ESDs) and exposure times were recorded in all cases. A total of 313 screws were placed. Satisfactory screw insertion could be achieved in all cases with safe screw placement in 97.4% and acceptable placement in 2.6%. None of the cases showed any significant anatomical violation by the screws. The radiation exposure to the patients was absolutely consistent with the desired ESD value, and that to the surgeons, under the annual dose limit. These results suggest that the hybrid OR with a FPD angiography system is helpful to achieve safe and precise spinal fusion surgery, especially in complex cases.
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Affiliation(s)
- Christian A Bohoun
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kentaro Naito
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Toru Yamagata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
- Department of Neurosurgery, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 531-0021, Japan
| | - Samantha Tamrakar
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
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Riis J, Lehman RR, Perera RA, Quinn JR, Rinehart P, Tuten HR, Kuester V. A retrospective comparison of intraoperative CT and fluoroscopy evaluating radiation exposure in posterior spinal fusions for scoliosis. Patient Saf Surg 2017; 11:32. [PMID: 29299062 PMCID: PMC5740881 DOI: 10.1186/s13037-017-0142-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background Radiation exposure is a concern in the field of medicine. Deformity spine surgeons depend on modalities that have high exposure through scoliosis x-rays or computed tomography. The use of fluoroscopy has increased with the increased use of pedicle screws. Recently other 3-D imaging devices with navigation have also been brought onto the market to improve accuracy of screw placement. There is concern that because of the use of CT, the radiation dose to the patient is increased, however there is little literature that directly compares the amount of radiation using the 3-D devices to traditional fluoroscopy. Although we know intraoperative CT decreases the amount of radiation to the surgeon and operating room staff, there is limited comparison data for exposure to patients. Our study focused on a comparison of radiation exposure data for pediatric scoliosis patients receiving posterior spinal fusions using traditional fluoroscopy and the Medtronic O-arm in an effort to determine the method most likely to decrease radiation exposure in the pediatric population. Methods Retrospective review of data in patient charts from two pediatric surgeons practicing in both a University and private hospital setting. Data collected included age, weight, height, diagnosis, Cobb angle, fusion levels, number of screws, and number of hooks, O-arm spins, fluoro doses and O-arm doses. Effective dose was calculated using output measures and radiation doses were compared along a continuum that took into account the amount of correction as indicated by Cobb angle. Results A total of 57 patients, 25 using the O-arm and 32 using traditional fluoroscopy, were analyzed. Effective dose was calculated and then compared as a factor correlated to curve severity. At lower angles of correction we found no statistically significant difference between methods in terms of effective radiation dose. There was no statistically significant divergence until a Cobb angle correction of greater than 74 degrees, where the Oarm dose was shown to be lower by comparison. Conclusion We found that regardless of the methods used there is still a significant radiation dose that is utilized in scoliosis procedures. The two methods analyzed did not display statistically significant differences in effective dose for the average case. Safely managing radiation exposure for pediatric patients is of the utmost priority. Healthcare professionals, however, face repeated exposure to radiation over the course of a long career. In our data set the O-Arm system does not increase overall exposure for patients and decreases radiation doses for providers and thereby provides a safe alternative to traditional fluoroscopy without compromising accuracy of implant placement or patient care. Level of Evidence: III.
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Affiliation(s)
- Jacob Riis
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1201 East Main Street, Richmond, VA USA
| | - Rebecca R Lehman
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA USA
| | - Robert A Perera
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA USA
| | - John Ryan Quinn
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1201 East Main Street, Richmond, VA USA
| | - Patricia Rinehart
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1201 East Main Street, Richmond, VA USA
| | | | - Victoria Kuester
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1201 East Main Street, Richmond, VA USA
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16
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Zhang YH, White I, Potts E, Mobasser JP, Chou D. Comparison Perioperative Factors During Minimally Invasive Pre-Psoas Lateral Interbody Fusion of the Lumbar Spine Using Either Navigation or Conventional Fluoroscopy. Global Spine J 2017; 7:657-663. [PMID: 28989845 PMCID: PMC5624381 DOI: 10.1177/2192568217716149] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
STUDY DESIGN Retrospective clinical study. OBJECTIVES The aim of this study was to compare intraoperative conditions and clinical results of patients undergoing pre-psoas oblique lateral interbody fusion (OLIF) using navigation or conventional fluoroscopy (C-ARM) techniques. METHODS Forty-two patients (22 patients by navigation and 20 by fluoroscopy) underwent the OLIF procedure at 2 medical centers, and records were reviewed. Clinical data was collected and compared between the 2 groups. Patients were followed-up with a range of 6 to 24 months. RESULTS There were no significant differences on demographic data between groups. The navigation group had zero radiation exposure (RE) to the surgeon and radiation time compared to the C-ARM group, with total RE of 44.59 ± 26.65 mGy and radiation time of 88.30 ± 58.28 seconds (P < .05). The RE to the patient was significantly lower in the O-ARM group (9.38 mGy) compared to the C-ARM group (44.59 ± 26.65 mGy). Operating room time was slightly longer in the navigation group (2.49 ± 1.35 hours) compared to the C-ARM group (2.30 ± 1.17 hours; P > .05), although not statistically significant. No differences were found in estimated blood loss, length of hospitalization, surgery-related complications, and outcome scores with an average of 8-month follow-up. CONCLUSIONS Compared with C-ARM techniques, using navigation can eliminate RE to surgeon and decrease RE to the patient, and it had no significant effect on operating time, estimated blood loss, length of hospitalization, or perioperative complications in the patients with OLIF procedure. This study shows that navigation is a safe alternative to fluoroscopy during the OLIF procedure in the treatment of degenerative lumbar conditions.
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Affiliation(s)
- Yue-Hui Zhang
- University of California San Francisco, CA, USA,Xin Hua Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ian White
- Goodman Campbell Brain and Spine, Indianapolis, IN, USA
| | - Eric Potts
- Goodman Campbell Brain and Spine, Indianapolis, IN, USA
| | | | - Dean Chou
- University of California San Francisco, CA, USA,Dean Chou, 505 Parnassus Ave, Box 0112, San Francisco, CA 94143, USA.
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17
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Mendelsohn D, Strelzow J, Dea N, Ford NL, Batke J, Pennington A, Yang K, Ailon T, Boyd M, Dvorak M, Kwon B, Paquette S, Fisher C, Street J. Patient and surgeon radiation exposure during spinal instrumentation using intraoperative computed tomography-based navigation. Spine J 2016; 16:343-54. [PMID: 26686604 DOI: 10.1016/j.spinee.2015.11.020] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 08/12/2015] [Accepted: 11/10/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Imaging modalities used to visualize spinal anatomy intraoperatively include X-ray studies, fluoroscopy, and computed tomography (CT). All of these emit ionizing radiation. PURPOSE Radiation emitted to the patient and the surgical team when performing surgeries using intraoperative CT-based spine navigation was compared. STUDY DESIGN/SETTING This is a retrospective cohort case-control study. PATIENT SAMPLE Seventy-three patients underwent CT-navigated spinal instrumentation and 73 matched controls underwent spinal instrumentation with conventional fluoroscopy. OUTCOME MEASURES Effective doses of radiation to the patient when the surgical team was inside and outside of the room were analyzed. The number of postoperative imaging investigations between navigated and non-navigated cases was compared. METHODS Intraoperative X-ray imaging, fluoroscopy, and CT dosages were recorded and standardized to effective doses. The number of postoperative imaging investigations was compared with the matched cohort of surgical cases. A literature review identified historical radiation exposure values for fluoroscopic-guided spinal instrumentation. RESULTS The 73 navigated operations involved an average of 5.44 levels of instrumentation. Thoracic and lumbar instrumentations had higher radiation emission from all modalities (CT, X-ray imaging, and fluoroscopy) compared with cervical cases (6.93 millisievert [mSv] vs. 2.34 mSv). Major deformity and degenerative cases involved more radiation emission than trauma or oncology cases (7.05 mSv vs. 4.20 mSv). On average, the total radiation dose to the patient was 8.7 times more than the radiation emitted when the surgical team was inside the operating room. Total radiation exposure to the patient was 2.77 times the values reported in the literature for thoracolumbar instrumentations performed without navigation. In comparison, the radiation emitted to the patient when the surgical team was inside the operating room was 2.50 lower than non-navigated thoracolumbar instrumentations. The average total radiation exposure to the patient was 5.69 mSv, a value less than a single routine lumbar CT scan (7.5 mSv). The average radiation exposure to the patient in the present study was approximately one quarter the recommended annual occupational radiation exposure. Navigation did not reduce the number of postoperative X-rays or CT scans obtained. CONCLUSIONS Intraoperative CT navigation increases the radiation exposure to the patient and reduces the radiation exposure to the surgeon when compared with values reported in the literature. Intraoperative CT navigation improves the accuracy of spine instrumentation with acceptable patient radiation exposure and reduced surgical team exposure. Surgeons should be aware of the implications of radiation exposure to both the patient and the surgical team when using intraoperative CT navigation.
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Affiliation(s)
- Daniel Mendelsohn
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Jason Strelzow
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Nicolas Dea
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Nancy L Ford
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Juliet Batke
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Andrew Pennington
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Kaiyun Yang
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Tamir Ailon
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Michael Boyd
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Marcel Dvorak
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Brian Kwon
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Scott Paquette
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Charles Fisher
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - John Street
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
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Lee CY, Wu MH, Li YY, Cheng CC, Hsu CH, Huang TJ, Hsu RWW. Intraoperative computed tomography navigation for transpedicular screw fixation to treat unstable thoracic and lumbar spine fractures: clinical analysis of a case series (CARE-compliant). Medicine (Baltimore) 2015; 94:e757. [PMID: 25997042 PMCID: PMC4602888 DOI: 10.1097/md.0000000000000757] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Transpedicular screw (TPS) fixation in unstable thoracic and lumbar (TL) spine fractures remains technically difficult because of destroyed anatomical landmarks, unstable gross segments, and discrepancies in anatomic orientation using conventional anatomic landmarks, fluoroscopic guidance, or computed tomography (CT)-based navigation. In this study, we evaluated the safety and accuracy of TPS placement under intraoperative computed tomography (iCT) navigation in managing unstable TL spine fractures.From 2010 to 2013, we retrospectively reviewed the Spine Operation Registry records of patients who underwent posterior instrumented fusion to treat unstable TL spine fractures via the iCT navigation system. An unstable spine fracture was identified as AO/Magerl classification type B or type C.In all, 316 screws in 37 patients with unstable TL spine fractures were evaluated and involved 7 thoracic, 23 thoracolumbar junctional, and 7 lumbar fractures. The accuracy of TPS positioning in the pedicle without breach was 98% (310/316). The average number of iCT scans per patient was 2.1 (range 2-3). The average total radiation dose to patients was 15.8 mSv; the dose per single level exposure was 2.7 mSv. The TPS intraoperative revision rate was 0.6% (2/316) and no neurovascular sequela was observed. TPS fixation using the iCT navigation system obtained a 98% accuracy in stabilizing unstable TL spine fractures. A malplaced TPS could be revised during real-time confirmation of the TPS position, and no secondary operation was required to revise malplaced screws.The iCT navigation system provides accurate and safe management of unstable TL spine fractures. In addition, operating room personnel, including surgeons and nurses, did not need to wear heavy lead aprons as they were not exposed to radiation.
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Affiliation(s)
- Ching-Yu Lee
- From the Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi (C-YL, M-HW, Y-YL, C-CC, T-JH, RW-WH); Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung (T-JH); College of Medicine, Chang Gung University, Taoyuan (Y-YL, C-CC, T-JH, RW-WH); Department of Radiology, Chang Gung Memorial Hospital, Chiayi (C-HH); and Department of Orthopedic Surgery, Taipei Medical University Hospital, Taipei, Taiwan (T-JH)
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Walker CT, Turner JD. Radiation Exposure in Scoliosis Surgery: Freehand Technique versus Image Guidance. World Neurosurg 2015; 83:282-4. [DOI: 10.1016/j.wneu.2015.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Adolescent idiopathic scoliosis surgery with patient-specific screw placement-guides. 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 2014; 23:2765-6. [DOI: 10.1007/s00586-014-3645-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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