1
|
Sarikonda A, Tecce E, Leibold A, Mansoor Ali D, Thalheimer S, Heller J, Prasad S, Sharan A, Jallo J, Harrop J, Vaccaro AR, Sivaganesan A. What is the Marginal Cost of Using Robot Assistance or Navigation for Transforaminal Lumbar Interbody Fusion? A Time-Driven Activity-Based Cost Analysis. Neurosurgery 2024; 95:556-565. [PMID: 38465927 DOI: 10.1227/neu.0000000000002899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/08/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Our primary objective was to compare the marginal intraoperative cost of 3 different methods for pedicle screw placement as part of transforaminal lumbar interbody fusions (TLIFs). Specifically, we used time-driven activity-based costing to compare costs between robot-assisted TLIF (RA-TLIF), TLIF with intraoperative navigation (ION-TLIF), and freehand (non-navigated, nonrobotic) TLIF. METHODS Total cost was divided into direct and indirect costs. We identified all instances of RA-TLIF (n = 20), ION-TLIF (n = 59), and freehand TLIF (n = 233) from 2020 to 2022 at our institution. Software was developed to automate the extraction of all intraoperatively used personnel and material resources from the electronic medical record. Total costs were determined through a combination of direct observation, electronic medical record extraction, and interdepartmental collaboration (business operations, sterile processing, pharmacy, and plant operation departments). Multivariable linear regression analysis was performed to compare costs between TLIF modalities, accounting for patient-specific factors as well as number of levels fused, surgeon, and hospital site. RESULTS The average total intraoperative cost per case for the RA-TLIF, ION-TLIF, and freehand TLIF cohorts was $24 838 ± $10 748, $15 991 ± $6254, and $14 498 ± $6580, respectively. Regression analysis revealed that RA-TLIF had significantly higher intraoperative cost compared with both ION-TLIF (β-coefficient: $7383 ± $1575, P < .001) and freehand TLIF (β-coefficient: $8182 ± $1523, P < .001). These cost differences were primarily driven by supply cost. However, there were no significant differences in intraoperative cost between ION-TLIF and freehand TLIF ( P = .32). CONCLUSION We demonstrate a novel use of time-driven activity-based costing methodology to compare different modalities for executing the same type of lumbar fusion procedure. RA-TLIF entails significantly higher supply cost when compared with other modalities, which explains its association with higher total intraoperative cost. The use of ION, however, does not add extra expense compared with freehand TLIF when accounting for confounders. This might have implications as surgeons and hospitals move toward bundled payments.
Collapse
Affiliation(s)
- Advith Sarikonda
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Eric Tecce
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Adam Leibold
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Daniyal Mansoor Ali
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Sara Thalheimer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Joshua Heller
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Srinivas Prasad
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Jack Jallo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| | - Alexander R Vaccaro
- Rothman Orthopedic Institute, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Ahilan Sivaganesan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia , Pennsylvania , USA
| |
Collapse
|
2
|
Safahieh AH, Nazemi H, Arjmand N, Azimi P, Khalaf K. Design, fabrication, and evaluation of single- and multi-level 3D-printed non-covering cervical spinal fusion surgery templates. Front Bioeng Biotechnol 2024; 12:1416872. [PMID: 39070162 PMCID: PMC11272535 DOI: 10.3389/fbioe.2024.1416872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 06/17/2024] [Indexed: 07/30/2024] Open
Abstract
Background Cervical spinal fusion surgeries require accurate placement of the pedicle screws. Any misplacement/misalignment of these screws may lead to injuries to the spinal cord, arteries and other organs. Template guides have emerged as accurate and cost-effective tools for the safe and rapid insertions of pedicle screws. Questions/Purposes Novel patient-specific single- and multi-level non-covering templates for cervical pedicle screw insertions were designed, 3D-printed, and evaluated. Methods CT scans of two patients were acquired to reconstruct their 3D spine model. Two sets of single-level (C3-C7) and multi-level (C4-C6) templates were designed and 3D-printed. Pedicle screws were inserted into the 3D-printed vertebrae by free-hand and guided techniques. For single-level templates, a total of 40 screws (2 patients × 5 vertebrae × 2 methods × 2 screws) and for multi-level templates 24 screws (2 patients × 3 vertebrae × 2 methods × 2 screws) were inserted by an experienced surgeon. Postoperative CT images were acquired to measure the errors of the entry point, 3D angle, as well as axial and sagittal plane angles of the inserted screws as compared to the initial pre-surgery designs. Accuracy of free-hand and guided screw insertions, as well as those of the single- and multi-level guides, were also compared using paired t-tests. Results Despite the minimal removal of soft tissues, the 3D-printed templates had acceptable stability on the vertebrae during drillings and their utilization led to statistically significant reductions in all error variables. The mean error of entry point decreased from 3.02 mm (free-hand) to 0.29 mm (guided) using the single-level templates and from 5.7 mm to 0.76 mm using the multi-level templates. The percentage reduction in mean of other error variables for, respectively, single- and multi-level templates were as follows: axial plane angle: 72% and 87%, sagittal plane angle: 56% and 78%, and 3D angle: 67% and 83%. The error variables for the multi-level templates generally exceeded those of the single-level templates. The use of single- and multi-level templates also considerably reduced the duration of pedicle screw placements. Conclusion The novel single- and multi-level non-covering templates are valuable tools for the accurate placement of cervical pedicle screws.
Collapse
Affiliation(s)
- A. H. Safahieh
- Mechanical Engineering Department, Sharif University of Technology, Tehran, Iran
| | - H. Nazemi
- Mechanical Engineering Department, Sharif University of Technology, Tehran, Iran
| | - N. Arjmand
- Mechanical Engineering Department, Sharif University of Technology, Tehran, Iran
| | - P. Azimi
- Neuroscience Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - K. Khalaf
- Department of Biomedical Engineering and Health Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| |
Collapse
|
3
|
Dietz N, Spiessberger A. Consistent anatomical relationships of pedicle, lamina, and superior articulating process in severe idiopathic scoliosis allow for safe freehand pedicle screw placement: A proof-of-concept technical study. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:224-229. [PMID: 38957756 PMCID: PMC11216649 DOI: 10.4103/jcvjs.jcvjs_16_24] [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: 01/29/2024] [Accepted: 03/18/2024] [Indexed: 07/04/2024] Open
Abstract
Introduction Transpedicular screw placement has superior pullout strength compared to alternative forms of spinal fusion and is often performed in deformity correction surgery with navigation for optimal accuracy and reliability. Freehand technique for pedicle screws minimizes operation time and radiation exposure without fluoroscopy but is not widely adopted given the challenge of difficult anatomical corridors and accurate placement, especially in idiopathic scoliosis and advanced deformity. We used a computer-generated model to assess a proof-of-concept and anatomical feasibility of a freehand screw technique in severe scoliosis. Methods Three-dimensional (3D) reconstructions of vertebra from a sample of two male patients with severe idiopathic scoliosis deformity (1 thoracic and 1 lumbar) with Cobb angles of 100° were used for planned placement of 17 levels of thoracolumbar (6.5 mm × 45 mm) pedicle screws. 3D reconstruction of each vertebra was created and measurements of screw entries and trajectories were reproduced with a 3D slicer software image computing platform. Results Accurate transpedicular screw placement is possible with anatomical landmarks based on the 3D reconstructed vertebral levels. A series of 5 figures were assembled to demonstrate sagittal, coronal, and axial planes and key anatomical landmarks and trajectories of thoracic and lumbar freehand pedicle screws in severe idiopathic scoliosis. Conclusions Anatomical landmarks for freehand transpedicular screw placement (between pedicle, lamina, and superior articulating process) are constant and reliable in severe idiopathic scoliosis as evidenced by 3D computer modeling. Preoperative computed tomography modeling may assist appropriate screw entry and trajectory based on anatomical landmarks for spine surgeons, and guide freehand technique for screw placement in adolescent idiopathic scoliosis.
Collapse
Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | | |
Collapse
|
4
|
Tannoury T, Seo HH, Saade A, Chahine MN, Atallah B, Tannoury C. Evaluating the safe zone for lumbar pedicle screws: are midline crossing screws indicative of pedicle breach? Spine J 2024; 24:617-624. [PMID: 37939920 DOI: 10.1016/j.spinee.2023.10.019] [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: 05/11/2023] [Revised: 10/02/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND CONTEXT Pedicle screw breach (PSB) is not uncommon following lumbar instrumentation, and in some instances, it may lead to vascular and/or neurologic complications. Previous literature suggested that screws crossing the vertebral midline on an anterior-posterior (AP) radiograph (or midsagittal on CT) are concerning for medial pedicle breach. OBJECTIVE Our primary aim was to map out the safe zones (SZ) of bilateral pedicle instrumentation and their relationship at each lumbar vertebral level. Our secondary aim was to evaluate the presence of SZs' intersection at each lumbar level, denoting safe midline pedicle screw crossing not otherwise associated with medial pedicle breach. STUDY DESIGN/SETTING Retrospective Anatomical Study. PATIENT SAMPLE Adult patients in the from "The Cancer Imaging Archive" (TCIA) database who have not had thoraco-lumbo-sacral fusion. OUTCOME MEASURES Physiologic measures obtained through 3D analysis of CT images and virtual pedicle screws. METHOD CT scans of 51 patients were randomly selected from "The Cancer Imaging Archive" (TCIA) online database for analysis. The Sectra 3D Spine software was used to create 3D renderings, place virtual screws, and make measurements. At each lumbar vertebra, the right and left pedicle corridors were mapped. At each pedicle, two screw positions were templated, the "medial limit screw" (MLS) and the "lateral limit screw" (LLS). Each limit screw was the most extreme position that the screw could exist in without causing a medial or lateral breach. The safe zone was defined as the zone between MLS and LLS. Measurements were taken for each level (between L1 and L5) and side (Left, Right). RESULTS A total of 253 lumbar vertebrae from 51 patients (mean age 53.1, 56.9% male) were included. Two vertebrae from two patients were removed for poor image quality. Out of the 506 screw positions analyzed in our study, 97.4% had overlapping SZ and crossed the midplane without medial pedicle breach. The significant factors (p<.01) for safe midplane-crossing screws included: the screw length (L1-L5); the laterality of the screw entry point (L1-L4); and the pedicle diameter (L2 and L5). CONCLUSIONS A midline crossing pedicle screw on a lumbar AP radiograph is not necessarily indicative of a medial pedicle screw breach. Anatomical (ie, larger pedicle diameter) and technical (ie, longer screws, and lateral entry points) factors allow for safety zone intersections and indicate safe midline crossing by pedicle screws.
Collapse
Affiliation(s)
- Tony Tannoury
- Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | | | | | - Mirna N Chahine
- The Lebanese University Faculty of Medicine, Beirut, Lebanon
| | - Bachir Atallah
- The Lebanese University Faculty of Medicine, Beirut, Lebanon
| | - Chadi Tannoury
- Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
| |
Collapse
|
5
|
Lee YS, Cho DC, Kim KT. Navigation-Guided/Robot-Assisted Spinal Surgery: A Review Article. Neurospine 2024; 21:8-17. [PMID: 38569627 PMCID: PMC10992634 DOI: 10.14245/ns.2347184.592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 04/05/2024] Open
Abstract
The development of minimally invasive spinal surgery utilizing navigation and robotics has significantly improved the feasibility, accuracy, and efficiency of this surgery. In particular, these methods provide improved accuracy of pedicle screw placement, reduced radiation exposure, and shortened learning curves for surgeons. However, research on the clinical outcomes and cost-effectiveness of navigation and robot-assisted spinal surgery is still in its infancy. Therefore, there is limited available evidence and this makes it difficult to draw definitive conclusions regarding the long-term benefits of these technologies. In this review article, we provide a summary of the current navigation and robotic spinal surgery systems. We concluded that despite the progress that has been made in recent years, and the clear advantages these methods can provide in terms of clinical outcomes and shortened learning curves, cost-effectiveness remains an issue. Therefore, future studies are required to consider training costs, variable initial expenses, maintenance and service fees, and operating costs of these advanced platforms so that they are feasible for implementation in standard clinical practice.
Collapse
Affiliation(s)
- Young-Seok Lee
- Department of Neurosurgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Dae-Chul Cho
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kyoung-Tae Kim
- Department of Neurosurgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
6
|
Larson AN, Polly DW, Sponseller PD, Kelly MP, Richards BS, Garg S, Parent S, Shah SA, Weinstein SL, Crawford CH, Sanders JO, Blakemore LC, Oetgen ME, Fletcher ND, Kremers WK, Marks MC, Brearley AM, Aubin CE, Sucato DJ, Labelle H, Erickson MA. The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial. J Bone Joint Surg Am 2024; 106:180-189. [PMID: 37973031 DOI: 10.2106/jbjs.23.00178] [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: 11/19/2023]
Abstract
BACKGROUND Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | - Sumeet Garg
- Children's Hospital of Colorado, Aurora, Colorado
| | | | | | | | | | | | | | | | | | | | - Michelle C Marks
- Harms Study Group/Setting Scoliosis Straight Foundation, El Cajon, California
| | | | - Carl-Eric Aubin
- Ecole Polytechnique, St. Justine Hospital, Montreal, Quebec, Canada
| | | | | | | |
Collapse
|
7
|
Ghenbot Y, Ahmad HS, Chauhan D, Wathen C, Arena J, Turlip R, Parr R, Gibby W, Yoon JW. Effects of Augmented Reality on Thoracolumbar Pedicle Screw Instrumentation Across Different Levels of Surgical Experience. World Neurosurg 2024; 182:e284-e291. [PMID: 38008167 DOI: 10.1016/j.wneu.2023.11.100] [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: 10/30/2023] [Revised: 11/18/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE Augmented reality (AR) is an emerging technology that may accelerate skill acquisition and improve accuracy of thoracolumbar pedicle screw placements. We aimed to quantify the relative assistance of AR compared with freehand (FH) pedicle screw accuracy across different surgical experience levels. METHODS A spine fellowship-trained and board-certified attending neurosurgeon, postgraduate year 4 neurosurgery resident, and second-year medical student placed 32 FH and 32 AR-assisted thoracolumbar pedicle screws in 3 cadavers. A cableless, voice-activated AR system was paired with a headset. Accuracy was assessed using χ2 analysis and the Gertzbein-Robbins scale. Angular error, distance error, and time per pedicle screw were collected and compared. RESULTS The attending neurosurgeon had 91.6% (11/12) clinically acceptable (Gertzbein-Robbins scale A or B) insertion in both FH and AR groups; the resident neurosurgeon had 100% (9/9) FH and AR in both cases; the medical student had 72.3% (8/11) FH accuracy and 81.8% (9/11) AR accuracy. The medical student displayed significantly lower ideal (Gertzbein-Robbins scale A) FH accuracy compared with the resident neurosurgeon (P = 0.017) and attending neurosurgeon (P = 0.005), but no difference when using AR. FH screw placement was faster by both the attending neurosurgeon (median 46 seconds vs. 94.5 seconds, P = 0.0047) and the neurosurgery resident neurosurgeon (median 144 seconds vs. 140 seconds, P = 0.05). Total clinically acceptable AR and FH accuracy was 90.6% (29/32) and 87.5% (28/32), respectively (P = 0.69). CONCLUSIONS AR screw placement allowed an inexperienced medical student to double their accuracy in 1 training session. With subsequent iterations, this promising technology could serve as an important tool for surgical training.
Collapse
Affiliation(s)
- Yohannes Ghenbot
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hasan S Ahmad
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daksh Chauhan
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Arena
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Turlip
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Parr
- Novarad Corporation, Provo, Utah, USA
| | - Wendell Gibby
- Novarad Corporation, Provo, Utah, USA; Department of Radiology, University of California San Diego School of Medicine, San Diego, California, USA
| | - Jang W Yoon
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
8
|
Chen Z, Lv G, Zhang O, Li Y, Wang X, He H, Yuan H, Pan C, Kuang L. Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF). BMC Musculoskelet Disord 2024; 25:1. [PMID: 38166792 PMCID: PMC10759594 DOI: 10.1186/s12891-023-07116-z] [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: 04/29/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND For patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for symptom relief. However, hardware failure is not rare and results in neck pain or even permanent neurological lesions. There are no in-depth studies of hardware-related complications following laminectomy and PCF with instrumentation. METHODS The present study was a retrospective, single centre, observational study. Patients who underwent laminectomy and PCF with instrumentation in a single institution between January 2019 and January 2021 were included. Patients were divided into hardware failure and no hardware failure group according to whether there was a hardware failure. Data, including sex, age, screw density, end vertebra (C7 or T1), cervical sagittal alignment parameters (C2-C7 cervical lordosis, C2-C7 sagittal vertical axis, T1 slope, Cervical lordosis correction), regional Hounsfield units (HU) of the screw trajectory and osteoporosis status, were collected and compared between the two groups. RESULTS We analysed the clinical data of 56 patients in total. The mean overall follow-up duration was 20.6 months (range, 12-30 months). Patients were divided into the hardware failure group (n = 14) and no hardware failure group (n = 42). There were no significant differences in the general information (age, sex, follow-up period) of patients between the two groups. The differences in fusion rate, fixation levels, and screw density between the two groups were not statistically significant (p > 0.05). The failure rate of fixation ending at T1 was lower than that at C7 (9% vs. 36.3%) (p = 0.019). The regional HU values of the pedicle screw (PS) and lateral mass screw (LMS) in the failure group were lower than those in the no failure group (PS: 267 ± 45 vs. 368 ± 43, p = 0.001; LMS: 308 ± 53 vs. 412 ± 41, p = 0.001). The sagittal alignment parameters did not show significant differences between the two groups before surgery or at the final follow-up (p > 0.05). The hardware failure rate in patients without osteoporosis was lower than that in patients with osteoporosis (14.3% vs. 57.1%) (p = 0.001). CONCLUSIONS Osteoporosis, fixation ending at C7, and low regional HU value of the screw trajectory were the independent risk factors of hardware failure after laminectomy and PCF. Future studies should illuminate if preventive measures targeting these factors can help reduce hardware failure and identified more risk factors, and perform long-term follow-up.
Collapse
Affiliation(s)
- Zejun Chen
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Guohua Lv
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Ou Zhang
- California University of Science and Medicine, Colton, CA, USA
| | - Yunchao Li
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Xiaoxiao Wang
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Haoyu He
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Hui Yuan
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Changyu Pan
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Lei Kuang
- Department of Spinal Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China.
| |
Collapse
|
9
|
Solitro GF, Welborn MC, Mehta AI, Amirouche F. How to Optimize Pedicle Screw Parameters for the Thoracic Spine? A Biomechanical and Finite Element Method Study. Global Spine J 2024; 14:187-194. [PMID: 35499547 PMCID: PMC10676166 DOI: 10.1177/21925682221099470] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Pedicle screw study. OBJECTIVE The selection of pedicle screw parameters usually involves the surgeon's analysis of preoperative CT imaging along with anatomical landmarks and tactile examination. However, there is minimal consensus on a standardized guideline for selection methods on pedicle screws. We aimed to determine the effects of thoracic screw diameter to pedicle width on pullout strength determined by cortical bone purchase. METHODS Biomechanical study performed with human cadaveric thoracic vertebrae and experimentally validated three-dimensional finite element model instrumented with pedicle screws of various diameters. We used a variable (SD/PW) ratio to express the screw selection. We hypothesized a positive correlation between the pullout load determined by the bone purchase and the SD/PW. This relationship was first investigated in a validated finite element model considering bone purchase related to the strength of an upper thoracic vertebra. Then, the correlation to the entire spine is evaluated. RESULTS The failure load ranged from 371.3 to 1601.0 N, respectively, for 3 and 6 mm screws. The determinant coefficient was increased to R2=.421 when a linear relationship between pullout load and the SD/PW ratio was used. The peak loads of 1216 and 1288N were found for an SD/PW ratio of .83. CONCLUSION We have found that the screw pullout load is more correlated to SD/PW than other pedicle measures for a maximized SD/PW ratio of .83. This particular value should be considered the upper limit of the indicated SD/PW ratio and a means to determine the optimal screw diameter to enhance pullout strength.
Collapse
Affiliation(s)
| | - Michelle C. Welborn
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Il, USA
| | - Ankit I. Mehta
- Department of Orthopaedic Surgery, NorthShore University HealthSystem, Evanston, Il, USA
| | - Farid Amirouche
- Department of Orthopaedics, Louisiana State University, Chicago, Il, USA
- College of Medicine, University of Illinois at Chicago, Chicago, Il, USA
| |
Collapse
|
10
|
Xu HF, Li C, Tang G, Li TQ, Fan ZZ, Huang LY. 3D-printed guides versus computer navigation for pedicle screw placement in the surgical treatment of congenital scoliosis deformities. J Orthop Surg (Hong Kong) 2024; 32:10225536241233785. [PMID: 38378476 DOI: 10.1177/10225536241233785] [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] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND To compare the safety and clinical outcomes of 3D-printed guides versus computer navigation for pedicle screw placement in the correction of congenital scoliosis deformities. METHODS The study was a single-centre retrospective controlled study and was approved by the hospital ethics committee for the analysis all patients under the age of 18 years with at least 2 years of follow-up. Sixty-three patients who underwent surgical correction for congenital scoliosis deformities in our hospital from January 2015 to December 2020 were divided into two groups based on the decision following preoperative doctor‒patient communication. Among them, 43 patients had pedicle screws placed with 3D-printed guider plates, while the remaining 20 patients had screws inserted with the assistance of computer navigation. The perioperative period, follow-up results and imaging data were compared between the groups. RESULTS The operation was completed successfully for patients in both groups. The 3D-printed guide-assisted screw placement technique proved to be significantly superior to the computer navigation technique in terms of operation time, screw placement time, and intraoperative blood loss (p < .05), although the former had more frequent intraoperative fluoroscopies than the latter (p < .05). The mean follow-up time was 41.4 months, and the SRS-22 scores significantly improved in both groups over time postoperatively (p < .05). The 3D-printing group had better SRS-22 scores than the navigation group 6 months after surgery and at the last follow-up (p < .05). Compared with preoperative values, the coronal Cobb angle, local kyphotic Cobb angle, C7-S1 coronal deviation (C7PL-CSVL), and sagittal deviation (SVA) were significantly improved in both groups after surgery (p < .05). CONCLUSION Both techniques achieve the purpose of precise screw placement and proper correction of the deformities. In contrast, the 3D-printed guide-assisted screw placement technique showed advantages in terms of operation time, screw placement time, intraoperative blood loss and patient satisfaction with outcomes.
Collapse
Affiliation(s)
- Hui-Fa Xu
- Department of Orthopaedics, First Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Chao Li
- Department of Orthopaedics, First Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Guoliang Tang
- Department of Orthopaedics, First Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Tian-Qing Li
- Department of Orthopaedics, First Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Zong-Zhi Fan
- Department of Orthopaedics, First Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| | - Lu-Yu Huang
- Department of Orthopaedics, First Affiliated Hospital, Air Force Military Medical University, Xi'an, China
| |
Collapse
|
11
|
Vardiman AB, Wallace DJ, Booher GA, Toossi N, Bucklen BS. Decreasing the Pedicle Screw Misplacement Rate in the Thoracic Spine With Robot-guided Navigation. Clin Spine Surg 2023; 36:431-437. [PMID: 37348067 PMCID: PMC10681281 DOI: 10.1097/bsd.0000000000001474] [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: 12/08/2022] [Accepted: 05/17/2023] [Indexed: 06/24/2023]
Abstract
STUDY DESIGN A retrospective chart review. OBJECTIVE The aim of this study was to evaluate the screw accuracy of thoracic pedicle screws placed with a robot-guided navigation system. SUMMARY OF BACKGROUND DATA Thoracic pedicles are smaller in diameter than lumbar pedicles, making pedicle screw placement difficult. Misplaced pedicle screws may present complications including decreased construct stability, and increased risks of neurological deficits and blood vessel perforation. There is a dearth of knowledge on thoracic pedicle screw accuracy placed with a robot. MATERIALS AND METHODS A retrospective analysis of the robot-assisted placement of thoracic pedicle screws was performed. Preoperative and postoperative computed tomography (CT) scans of the implanted thoracic screws were collected to assess screw placement accuracy, pedicle breadth, and placement deviations. A CT-based Gertzbein and Robbins System was used to classify pedicle screw accuracy in 2 mm increments. A custom image overlay software was used to determine the deviations between the preoperatively planned trajectory of pedicle screws and final placement at screw entry (tail), and tip in addition to the angular deviation. RESULTS Seventy-five thoracic pedicle screws were implanted by navigated robotic guidance in 17 patients, only 1.3% (1/75) were repositioned intraoperatively. Average patient age and body mass index were 57.5 years and 25.9 kg/m 2 , respectively, with 52.9% female patients. Surgery diagnoses were degenerative disk disease (47.1%) and adjacent segment disease (17.6%). There were zero complications, with no returns to the operating room. According to the CT-based Gertzbein and Robbins pedicle screw breach classification system, 93.3% (70/75) screws were grade A or B, 6.6% (5/75) were grade C, and 0% were grade D or E. The average deviation from the preoperative plan to actual final placement was 1.8±1.3 mm for the screw tip, 1.6±0.9 mm for the tail, and 2.1±1.5 degrees of angulation. CONCLUSIONS The current investigation found a 93.3% accuracy of pedicle screw placement in the thoracic spine. Navigated robot assistance is a useful system for placing screws in the smaller pedicles of the thoracic spine. LEVEL OF EVIDENCE Level III-retrospective nonexperimental study.
Collapse
Affiliation(s)
- Arnold B. Vardiman
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - David J. Wallace
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Grant A. Booher
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Nader Toossi
- Musculoskeletal Education and Research Center (MERC), Audubon, PA
| | | |
Collapse
|
12
|
Jeong S, Yang A, Dhodapkar MM, Jabbouri SS, Jonnalagadda A, Tuason D. 3D printed pedicle screw guides reduce the rate of intraoperative screw revision in adolescent idiopathic scoliosis surgery. Spine J 2023; 23:1894-1899. [PMID: 37553024 DOI: 10.1016/j.spinee.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/14/2023] [Accepted: 08/02/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND CONTEXT Pedicle screw fixation has become common in the treatment of adolescent idiopathic scoliosis (AIS). Malpositioned pedicle screws have significant complications and identifying surgical techniques to optimize screw placement accuracy is imperative. PURPOSE To compare the rate of intraoperative revision, replacement, or removal of pedicle screws placed utilizing 3D printed guides compared with pedicle screws placed utilizing a freehand technique. STUDY DESIGN/SETTING Retrospective cohort study/single academic center. PATIENT SAMPLE Thirty-two patients aged 10 to 18 with AIS. OUTCOME MEASURES Revision rate of pedicle screws and operative time between groups. METHODS A retrospective study was performed on patients 10 to 18 years of age who underwent posterior spinal instrumented fusion for AIS from February 2021 to July 2022. The study received an IRB exemption. Patient demographics, intraoperative measures, and outcome variables were recorded. Intraoperatively, all patients underwent a 3-dimensional fluoroscopic "check scan," which included axial, sagittal, and coronal images, to assess for screw accuracy. A secondary outcome of operative time was compared between groups. The p-values <.05 were considered significant. RESULTS A total of 32 patients were included in this study. There were 17 cases in the 3D guided and 15 cases in fluoroscopy-guided freehand cohort. There was a total of 254 pedicle screws using 3D guides and 402 screws using freehand technique. Between cohorts, there were no significant differences in a number of levels fused (p=.54) or length of surgery (p=.36). The total revision rate of 3D guided screw placement was 5.5% and that of the freehand technique was 8.5%. The freehand screw placement group had significantly higher revision rates per vertebral level compared with 3D guided (p=.0096). Notably, 3D printed guides had fewer screws that were removed/revised for being too anterior (7.1%) compared with freehand (23.5%). Surgical time was not significantly different between the 3D guided and freehand cohort (p=.35). CONCLUSIONS 3D printed guides reduce intraoperative revision rate compared with freehand techniques. Total operative time is comparable to freehand technique.
Collapse
Affiliation(s)
- Seongho Jeong
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Ally Yang
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Meera M Dhodapkar
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Sahir S Jabbouri
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Anshu Jonnalagadda
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA
| | - Dominick Tuason
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, 47 College St, New Haven, CT 06510, USA.
| |
Collapse
|
13
|
Boucas P, Mamdouhi T, Rizzo SE, Megas A. Cement Augmentation of Pedicle Screw Instrumentation: A Literature Review. Asian Spine J 2023; 17:939-948. [PMID: 37788974 PMCID: PMC10622820 DOI: 10.31616/asj.2022.0216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 10/05/2023] Open
Abstract
This literature review aimed to review the current understanding, indications, and limitations of pedicle screw instrumentation cement augmentation. Since they were first reported in the 1980s, pedicle screw cement augmentation rates have been increasing. Several studies have been published to date that describe various surgical techniques and the biomechanical changes that occur when cement is introduced through the screw-bone interface. This article provides a concise review of the uses, biomechanical properties, cost analysis, complications, and surgical techniques used for pedicle screw cement augmentation to help guide physician practices. A comprehensive review of the current literature was conducted, with key studies, and contributions from throughout history being highlighted. Patients with low bone mineral density are the most well-studied indication for pedicle screw cement augmentation. Many studies show that cement augmentation can improve pullout strength in patients with low bone mineral density; however, the benefit varies inversely with pathology severity and directly with technique. The various screw types are discussed, with each having its own mechanical advantages. Cement distribution is largely dependent on the filling method and volume of cement used. Cement composition and timing of cement use after mixing are critical considerations in practice because they can significantly alter the bone-cement and screw-cement interfaces. Overall, studies have shown that pedicle screw cement augmentation has a low complication rate and increased pullout strength, justifying its universal use in patients with a suboptimal bone-implant interface.
Collapse
Affiliation(s)
- Peter Boucas
- Department of Orthopaedic Surgery, Huntington Hospital Northwell Health, Huntington, NY,
USA
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY,
USA
| | - Tania Mamdouhi
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY,
USA
| | - Sarah E. Rizzo
- Department of Orthopaedic Surgery, Huntington Hospital Northwell Health, Huntington, NY,
USA
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY,
USA
| | - Andrew Megas
- Department of Orthopaedic Surgery, Grewal Orthopaedic and Spine Care, East Meadow, NY,
USA
| |
Collapse
|
14
|
Jia S, Weng Y, Wang K, Qi H, Yang Y, Ma C, Lu WW, Wu H. Performance evaluation of an AI-based preoperative planning software application for automatic selection of pedicle screws based on computed tomography images. Front Surg 2023; 10:1247527. [PMID: 37753530 PMCID: PMC10518392 DOI: 10.3389/fsurg.2023.1247527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
Introduction Recent neurosurgical applications based on artificial intelligence (AI) have demonstrated its potential in surgical planning and anatomical measurement. We aimed to evaluate the performance of an AI planning software application on screw length/diameter selection and insertion accuracy in comparison with freehand surgery. Methods A total of 45 patients with 208 pedicle screw placements on thoracolumbar segments were included in this analysis. The novel AI planning software was developed based on a deep learning model. AI-based pedicle screw placements were selected on the basis of preoperative computed tomography (CT) data, and freehand surgery screw placements were observed based on postoperative CT data. The performance of AI pedicle screw placements was evaluated on the components of screw length, diameter, and Gertzbein grade in comparison with the results achieved by freehand surgery. Results Among 208 pedicle screw placements, the average screw length/diameters selected by the AI model and used in freehand surgery were 48.65 ± 5.99 mm/7.39 ± 0.42 mm and 44.78 ± 2.99 mm/6.1 ± 0.27 mm, respectively. Among AI screw placements, 85.1% were classified as Gertzbein Grade A (no cortical pedicle breach); among free-hand surgery placements, 64.9% were classified as Gertzbein Grade A. Conclusion The novel AI planning software application could provide an accessible and safe pedicle screw placement strategy in comparison with traditional freehand pedicle screw placement strategies. The choices of pedicle screw dimensional parameters made by the model, including length and diameter, may provide potential inspiration for real clinical discretion.
Collapse
Affiliation(s)
- Shanhang Jia
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Yuanzhi Weng
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Pharmaceutical Materials Science and Translational Medicine, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen, China
| | - Kai Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Huan Qi
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yuhua Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chi Ma
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Weijia William Lu
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Pharmaceutical Materials Science and Translational Medicine, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
| |
Collapse
|
15
|
Peng F, Gao M, Li Q, Jiang Z, Chen F, Sun M, Lai Y, Wang H, Wang X, Li T, Zhang W. Supraspinous ligament arc tangent guided freehand thoracic pedicle screw insertion technique: high parallelism between screws and upper endplate. Front Surg 2023; 10:1219816. [PMID: 37609000 PMCID: PMC10441773 DOI: 10.3389/fsurg.2023.1219816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/24/2023] [Indexed: 08/24/2023] Open
Abstract
Research objective To propose a technique for placing pedicle screws in the thoracic spine using the Supraspinous ligament Arc Tangent (SLAT) as a guide to increase the safety and stability of screw placement. Content and methods A retrospective analysis of postoperative anteroposterior and lateral x-ray images was performed for 118 patients with thoracic spine diseases who received conventional freehand technique from January 2016 to May 2020 and SLAT-guided technique since June 2020 to present. The diagnoses included thoracic spinal stenosis, deformity, fractures, infections, and tumors. The angle between the screw and the upper endplate was categorized as grade 1 (0°-5°), grade 2 (5°-10°), and grade 3 (>10°). Three surgeons with more than 10 years of experience in spinal surgery measured the angle between the screw and the upper endplate in the lateral view. Chi-square test was used for statistical analysis, and p < 0.05 was considered statistically significant. Results A total of 1315 pedicle screws were placed from T1 to T12 in all patients. In the conventional freehand technique group, 549 screws were grade 1, 35 screws were grade 2, and 23 screws were grade 3. In the SLAT-guided freehand technique group, 685 screws were grade 1, 15 screws were grade 2, and 8 screws were grade 3. The data of each group was p < 0.05 by Chi-squared test, which was statistically significant, indicating that the SLAT-guided freehand technique resulted in a higher rate of parallelism between the screws and the upper endplate. All patients underwent intraoperative neurophysiological monitoring, immediate postoperative neurological examination, postoperative x-ray examination, and assess the eventual recovery. The screws were safe and stable, and no complications related to pedicle screw placement were found. Conclusion The SLAT-guided freehand technique for placing pedicle screws in the thoracic spine can achieve a higher rate of screw-upper endplate parallelism, making screw placement safer and more accurate. Our method provides a convenient and reliable technique for most spinal surgeons, allowing for increased accuracy and safety with less fluoroscopic guidance.
Collapse
Affiliation(s)
- Fushuai Peng
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Meng Gao
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Qiang Li
- Department of Radiology, The Second Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Zhensong Jiang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Fei Chen
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Mingtong Sun
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yudong Lai
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Haoyu Wang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xingpeng Wang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Tao Li
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wen Zhang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
LeRoy TE, Smith IC, Kim DH, Golenbock SW, Baker KC, Arnold PM, Sasso RC, Park DK, Fischgrund JS, Zaidi QH, Hwang RW. Clinical Significance of Lateral Pedicle Screw Malposition in Lumbar Spine Fusion. Clin Spine Surg 2023; 36:E258-E262. [PMID: 36823702 DOI: 10.1097/bsd.0000000000001440] [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] [Received: 02/13/2022] [Accepted: 12/13/2022] [Indexed: 02/25/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Our objective was to determine whether lateral pedicle screw breach affects fusion rates and patient-reported outcomes in lumbar fusion surgery. SUMMARY OF BACKGROUND DATA Although lateral pedicle screw malposition is considered relatively benign, few studies have focused specifically on clinical outcomes or fusion rates associated with lateral screw malposition. METHODS Twelve-month postoperative computed tomography scans were reviewed for lateral breach, severity of breach, and fusion status. Patients with lateral breach were compared with patients with no breach. Outcome measures included Numerical Pain Rating Scale for back and leg pain, Oswestry Disability Index, and SF-36 physical function (SF-36 PF). Multivariable linear and logistic regression and were adjusted for age, procedure, level, and/or baseline pain score. RESULTS Forty-five patients (31%) demonstrated 1 or more lateral breaches as compared with 99 patients without breach. After adjusting for baseline scores and fusion level, patients with 2 or more screw breaches experienced SF-36 PF score improvements that were 3.43 points less ( P =0.016) than patients with no lateral breach. After adjusting for baseline Numerical Pain Rating Scale, there was also a significant decrease in the odds of achieving minimally clinical important difference in back pain relief in these patients. There was no observed effect of lateral breach on the odds of successful fusion. CONCLUSIONS The current study did not observe an association between laterally malpositioned pedicle screws and nonunion. However, results are consistent with a negative effect on SF-36 PF scores and self-reported back pain at 12 months.
Collapse
Affiliation(s)
- Taryn E LeRoy
- Department of Orthopaedic Surgery, Tufts Medical Center
| | - Isabel C Smith
- Department of Orthopaedic Surgery, New England Baptist Hospital
- Department of Research, New England Baptist Hospital
| | - David H Kim
- Department of Orthopaedic Surgery, New England Baptist Hospital
- Tufts University School of Medicine, Boston, MA
| | | | - Kevin C Baker
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI
| | | | | | - Daniel K Park
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI
| | | | - Qasim H Zaidi
- Department of Orthopaedic Surgery, New England Baptist Hospital
| | - Raymond W Hwang
- Department of Orthopaedic Surgery, New England Baptist Hospital
- Tufts University School of Medicine, Boston, MA
- Boston Orthopaedic and Spine, Chestnut Hill, MA
| |
Collapse
|
18
|
Wang S, Zhang W, Sun J, Wang Y, Fan J, Yu Y, Zhao F, Gao J, Shi J, Guo Y. Detection of Common Anatomical Landmarks and Vertical Trajectories for Freehand Pedicle Screw Placement. Orthop Surg 2023. [PMID: 37183354 DOI: 10.1111/os.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVE It is clinically important for pedicle screws to be placed quickly and accurately. Misplacement of pedicle screws results in various complications. However, the incidence of complications varies greatly due to the different professional titles of physicians and surgical experience. Therefore, physicians must minimize pedicle screw dislocation. This study aims to compare the three nail placement methods in this study, and explore which method is the best for determining the anatomical landmarks and vertical trajectories. METHODS This study involved 70 patients with moderate idiopathic scoliosis who had undergone deformity correction surgery between 2018 and 2021. Two spine surgeons used three techniques (preoperative computed tomography scan [CTS], visual inspection-X-freehand [XFH], and intraoperative detection [ID] of anatomical landmarks) to locate pedicle screws. The techniques used include visual inspection for 287 screws in 21 patients, preoperative planning for 346 screws in 26 patients, and intraoperative probing for 309 screws in 23 patients. Observers assessed screw conditions based on intraoperative CT scans (Grade A, B, C, D). RESULTS There were no significant differences between the three groups in terms of age, sex, and degree of deformity. We found that 68.64% of screws in the XFH group, 67.63% in the CTS group, and 77.99% in the ID group were placed within the pedicle margins (grade A). On the other hand, 6.27% of screws in the XFH group, 4.33% in the CTS group, and 6.15% in the ID group were considered misplaced (grades C and D). The results show that the total amount of upper thoracic pedicle screws was fewer, meanwhile their placement accuracy was lower. The three methods used in this study had similar accuracy in intermediate physicians (P > 0.05). Compared with intermediate physicians, the placement accuracy of three techniques in senior physicians was higher. The intraoperative detection group was better than the other two groups in the good rate and accuracy of nail placement (P < 0.05). CONCLUSION Intraoperative common anatomical landmarks and vertical trajectories were beneficial to patients with moderate idiopathic scoliosis undergoing surgery. It is an optimal method for clinical application.
Collapse
Affiliation(s)
- Shunmin Wang
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
- 910 Hospital of China Joint Logistics Support Force, Quanzhou, China
| | - Weihang Zhang
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jingchuan Sun
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yuan Wang
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jianping Fan
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yaping Yu
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Feng Zhao
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
- 910 Hospital of China Joint Logistics Support Force, Quanzhou, China
| | - Jie Gao
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
- 910 Hospital of China Joint Logistics Support Force, Quanzhou, China
| | - Jiangang Shi
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yongfei Guo
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| |
Collapse
|
19
|
Diltz ZR, Sheffer BJ. Intraoperative Navigation and Robotics in Pediatric Spinal Deformity. Orthop Clin North Am 2023; 54:201-207. [PMID: 36894292 DOI: 10.1016/j.ocl.2022.11.005] [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: 03/11/2023]
Abstract
Current technologies for image guidance navigation and robotic assistance with spinal surgery are improving rapidly with several systems commercially available. Newer machine vision technology has several potential advantages. Limited studies have shown similar outcomes to traditional navigation platforms with decreased intraoperative radiation and time required for registration. However, there are no active robotic arms that can be coupled with machine vision navigation. Further research is necessary to justify the cost, potential increased operative time, and workflow issues but the use of navigation and robotics will only continue to expand given the growing body of evidence supporting their use.
Collapse
Affiliation(s)
- Zachary R Diltz
- Department of Orthopedic Surgery, LeBonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA; Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Benjamin J Sheffer
- Department of Orthopedic Surgery, LeBonheur Children's Hospital, 848 Adams Avenue, Memphis, TN 38103, USA; Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA.
| |
Collapse
|
20
|
Yamada T, Hasegawa T, Yamato Y, Yoshida G, Banno T, Arima H, Oe S, Mihara Y, Ushirozako H, Ide K, Watanabe Y, Nakai K, Kurosu K, Matsuyama Y. Characteristics of pedicle screw misplacement using freehand technique in degenerative scoliosis surgery. Arch Orthop Trauma Surg 2023; 143:1861-1867. [PMID: 35194658 DOI: 10.1007/s00402-022-04380-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 02/05/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to estimate the accuracy of pedicle screw (PS) placement in degenerative scoliosis surgery, characterize a patient population with PS misplacement, and analyze the association between misplaced PS vector and lumbar coronal curve. METHODS In this study, 122 patients (average age 68.6 years), who underwent corrective and decompression surgery, were selected retrospectively. PS accuracy was evaluated in the thoracic to lumbar spine. We identified characteristics of misplacement in each patient. Screw positions were categorized into grade A, entirely in the pedicle; grade B, < 2 mm breach; grade C, 2-4 mm breach; and grade D, > 4 mm breach using postoperative computed tomography. RESULTS The mean preoperative lumbar coronal curve was 32.3 ± 18.4°, and the number of fused vertebrae was 8.9 ± 2.8. A total of 2032 PS were categorized as follows: grade A, 1897 PS (93.3%); grade B, 67 (3.3%); grade C, 26 (1.3%); and grade D, 43 (2.1%). One PS (grade D), inserted at T5, needed surgery for removal due to neurological deficit. The misplacement group (grades C and D) had a significantly stronger lumbar coronal curve and apical vertebral rotation than the accuracy group (grades A and B). Misplaced PS vector (direction and degree) was significantly correlated with inserted vertebral rotation. Grade D misplacement was distributed mainly around the transitional vertebra of the lumbar curve. CONCLUSIONS The accuracy of PS insertion in the thoracic to lumbar spine was high in DS surgery, but the need for care was highlighted in the transitional vertebra.
Collapse
Affiliation(s)
- Tomohiro Yamada
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan.
| | - Tomohiko Hasegawa
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yu Yamato
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan
| | - Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Tomohiro Banno
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Hideyuki Arima
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Shin Oe
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan
| | - Yuki Mihara
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Koichiro Ide
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yuh Watanabe
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Keiichi Nakai
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Kenta Kurosu
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| |
Collapse
|
21
|
Sahri IE, Tlemcani ZC, Akroud SE, Cherif EAA, Gazzaz M. Accuracy and Safety of Fluoroscopy-Assisted Transpedicular Screw Insertion in Thoracolumbar Spine Surgery: Evaluation of 122 Screws. Asian J Neurosurg 2023; 18:12-16. [PMID: 37056880 PMCID: PMC10089733 DOI: 10.1055/s-0043-1763523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
AbstractThe objective of this study is to determine the accuracy and safety of trans-pedicular screws' insertion in the thoracolumbar spine using a fluoroscopy-assisted surgical technique. We retrospectively evaluated all patients who underwent a postoperative computed tomography scan to assess the location of the pedicular screws following thoracolumbar spinal surgery, at the Mohammed Vth Military Training Hospital-Rabat, from January 2020 to April 2022. We used Gertzbein's classification to grade pedicular cortex breaches. A screw penetration greater than 4 mm (grades D–E) was considered critical and one less than 4 mm was classified as noncritical (grades A–C). A total of 122 screws inserted in the T1 to L5 vertebrae were included from 25 patients. The average age was 46 years old. Pathologies included degenerative disorders (5 patients), tumors (8 patients), and trauma (12 patients). All screws were inserted using lateral and anteroposterior fluoroscopic guidance. A total of 11 transpedicular screws breaches were identified. The breaches incidence was significantly higher in thoracic pedicles (8 screws) than in lumbar pedicles (3 screws). Of these, three critical cases occurred in two patients and one of them required reintervention. The remaining eight exceedances were not critical and were closely monitored and followed up. Transpedicular screws fluoroscopy-assisted surgical fixation can be performed for the stabilization of the thoracolumbar spine with satisfactory safety and precision.
Collapse
|
22
|
Marker Screw Utilization for Minimally Invasive Transforaminal Lumbar Interbody Fusion (MS-MIS TLIF): Promises and Advantages. Medicina (B Aires) 2023; 59:medicina59030585. [PMID: 36984586 PMCID: PMC10056701 DOI: 10.3390/medicina59030585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
Background and Objective: Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) has been investigated and shown excellent short- and long-term outcomes. In this paper, we describe a new MIS-TLIF technique and pedicle screw insertion using a marker screw as a guidance method. Moreover, we report perioperative, postoperative, and patient-related outcomes. In addition, this paper outlines major differences in radiation exposure, cost effectiveness and accuracy of Marker Screw Minimally Invasive Transforaminal Interbody Fusion (MS-MIS TLIF) compared to other techniques. We report our technique to share our knowledge and experience with the aim of achieving a better MIS-TLIF that would help both surgeons and patients. Materials and Methods: A prospective case series was conducted between October 2018 and February 2021. Patients undergoing MS-MIS TLIF with marker screws were consecutively included. The surgery did not exceed two levels. The patients’ medical records were reviewed, and the included patients were asked to complete two outcome-questionnaires before surgery and at the six-month visit. The surgical technique is described in this paper. Results: A total of 37 patients were recruited. The mean age was 57.35 ± 12.8 years, and more than half of the patients were females. The most common indications for surgery were degenerative disc disease and spondylolisthesis, with the typical level at L4–5. The operative time was 3.02 ± 0.83 h, while the estimated blood loss was 127.7 ± 71.1 mL. The average time for ambulation and hospitalization was 1 ± 1.1 and 2.84 ± 1.4 days, respectively. The patients described significant improvement in both questionnaires. No screw-related complications or screw revisions were needed up to two years of follow-up. Conclusions: The use of marker screws for pedicle screw placement through a minimally invasive fashion is shown to be a promising technique that can overcome many drawbacks, including cost, operative time, and radiation exposure. Performing MS-MIS TLIF can achieve a 360- degree fusion compared to percutaneous MIS-TLIF.
Collapse
|
23
|
Alomari S, Lubelski D, Lehner K, Tang A, Wolinsky JP, Theodore N, Sciubba DM, Larry Lo SF, Belzberg A, Weingart J, Witham T, Gokaslan ZL, Bydon A. Safety and Accuracy of Freehand Pedicle Screw Placement and the Role of Intraoperative O-Arm: A Single-Institution Experience. Spine (Phila Pa 1976) 2023; 48:180-188. [PMID: 36190990 DOI: 10.1097/brs.0000000000004497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 08/02/2022] [Indexed: 11/05/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim was to investigate the accuracy of pedicle screw placement by freehand technique and to compare revision surgery rates among three different imaging verification pathways. SUMMARY OF BACKGROUND DATA Studies comparing different imaging modalities in freehand screw placement surgery are limited. MATERIALS AND METHODS A single-institution retrospective chart review identified adult patients who underwent freehand pedicle screw placement in the thoracic, lumbar or sacral levels. Patients were stratified into three cohorts based on the intraoperative imaging modality used to assess the accuracy of screw position: intraoperative X-rays (cohort 1); intraoperative O-arm (cohort 2); or intraoperative computed tomography (CT)-scan (cohort 3). Postoperative CT scans were performed on all patients in cohorts 1 and 2. Postoperative CT scan was not required in cohort 3. Screw accuracy was assessed using the Gertzbein-Robbins grading system. RESULTS A total of 9179 pedicle screws were placed in the thoracic or lumbosacral spine in 1311 patients. 210 (2.3%) screws were identified as Gertzbein-Robbins grades C-E on intraoperative/postoperative CT scan, 137 thoracic screws, and 73 lumbar screws ( P <0.001). Four hundred and nine patients underwent placement of 2754 screws followed by intraoperative X-ray (cohort 1); 793 patients underwent placement of 5587 screws followed by intraoperative O-arm (cohort 2); and 109 patients underwent placement of 838 screws followed by intraoperative CT scan (cohort 3). Postoperative CT scans identified 65 (2.4%) and 127 (2.3%) malpositioned screws in cohorts 1 and 2, respectively. Eleven screws (0.12%) were significantly malpositioned and required a second operation for screw revision. Nine patients (0.69%) required revision operations: eight of these patients were from cohort 1 and one patient was from cohort 2. CONCLUSION When compared to intraoperative X-ray, intraoperative O-arm verification decreased the revision surgery rate for malpositioned screws from 0.37% to 0.02%. In addition, our analysis suggests that the use of intraoperative O-arm can obviate the need for postoperative CT scans.
Collapse
Affiliation(s)
- Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kurt Lehner
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anthony Tang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jean-Paul Wolinsky
- Department of Neurological Surgery, Northwestern University, Chicago, IL
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Allan Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
24
|
Schupper AJ, Lin JD, Osorio JA, Lee NJ, Steinberger JM, Lombardi JM, Lehman RA, Lenke LG. Freehand Juxtapedicular Screws Placed in the Apical Concavity of Adult Idiopathic Scoliosis Patients: Technique, Computed Tomography Confirmation, and Radiographic Results. Neurospine 2022; 19:1116-1121. [PMID: 36597645 PMCID: PMC9816604 DOI: 10.14245/ns.2244798.399] [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: 08/31/2022] [Accepted: 11/12/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The purpose of this study is to highlight our technique for freehand placement of juxtapedicular screws along with intraoperative computed tomography (CT) and radiographic results. METHODS Consecutive patients with adult idiopathic scoliosis undergoing primary surgery by the senior author were identified. All type D (absent/slit like channel) pedicles were identified on preoperative CT. Three-dimensional visualization software was used to measure screw angulation and purchase. Radiographs were measured by a fellowship trained spine surgeon. The freehand technique was used to place all screws in a juxtapedicular fashion without any fluoroscopic, radiographic, navigational or robotic assistance. RESULTS Seventy-three juxtapedicular screws were analyzed. The most common level was T7 (9 screws) on the left and T5 (12 screws) on the right. The average medial angulation was 20.7° (range, 7.1°-36.3°), lateral vertebral body purchase was 13.4 mm (range, 0-28.9 mm), and medial vertebral body purchase was 21.1 mm (range, 8.9-31.8 mm). More than half (53.4%) of the screws had bicortical purchase. Two screws were lateral on CT scan, defined by the screw axis lateral to the lateral vertebral body cortex. No screws were medial. There was a difference in medial angulation between screws with (n = 58) and without (n = 15) lateral body purchase (22.0 ± 4.9 vs. 15.5 ± 4.5, p < 0.001). Three of 73 screws were repositioned after intraoperative CT. There were no neurovascular complications. The mean coronal cobb corrections for main thoracic and lumbar curves were 83.0% and 80.5%, respectively, at an average of 17.5 months postoperative. CONCLUSION Freehand juxtapedicular screw placement is a safe technique for type D pedicles in adult idiopathic scoliosis patients.
Collapse
Affiliation(s)
| | - James D. Lin
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, NY, USA,Corresponding Author James D. Lin Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, USA
| | - Joseph A. Osorio
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Nathan J. Lee
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | | | - Joseph M. Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Ronald A. Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Lawrence G. Lenke
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
25
|
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.
Collapse
|
26
|
Jiang J, Chen X, Qiu Y, Wang B, Zhu ZZ, Yu Y. Accuracy of thoracic pedicle screw placement in adolescent idiopathic scoliosis patients using the entry point identified by new landmarks: a computed tomography study. BMC Surg 2022; 22:379. [PMID: 36333715 PMCID: PMC9636753 DOI: 10.1186/s12893-022-01827-1] [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: 06/08/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Although thoracic pedicle (TP) screw has gained increasingly popularity in the surgical treatment of adolescent idiopathic scoliosis (AIS) patients, questions remain about the accurate selection of entry point for TP screw placement in these patient. The main objective of the present study was to evaluate the accuracy of TP screw placement in AIS patients using the entry point identified by new landmarks. Methods Thirty-four thoracic AIS patients treated with posterior TP screw instrumentation were included. All these TP screws were inserted through the entry point identified by new landmarks with free-hand technique. Postoperative CT scans were obtained to evaluate the screw position. The perforations of the pedicle were classified as grade 0 (no perforation), grade 1 (≤ 2 mm), grade 2 (2.1–4 mm), grade 3 (4.1–6 mm) and grade 4 (6.1–8.0 mm). Screws in grade 0, displaced either medially or anteriorly in grade 1 and displaced laterally in grades 1 to 2 were considered acceptable. Results Of the 495 TP screws inserted, 34 (6.9%) screws were displaced with 7 screws (1.4%) displaced medially, 20 screws (4.1%) displaced laterally and 7 screws (1.4%) displaced anteriorly (P < 0.05). Among the 34 displaced screws, 11 screws (32.4%) were considered as grade 1, 14 screws (38.2%) as grade 2 and 9 screws (29.4%) as grade 3 (P < 0.05). The overall rate of acceptable screws was 97.8%. No screw-related complication was noted. Conclusion Our new method for selecting the entry point of TP screw in AIS patients is convenient and can achieve high accuracy of screw placement, which is worthy of being widely popularized.
Collapse
Affiliation(s)
- Jun Jiang
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| | - Xu Chen
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China ,grid.41156.370000 0001 2314 964XMedical School of Nanjing University, Nanjing, China
| | - Yong Qiu
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| | - Bin Wang
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| | - Ze-zhang Zhu
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| | - Yang Yu
- grid.412676.00000 0004 1799 0784Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008 China
| |
Collapse
|
27
|
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.
Collapse
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
| |
Collapse
|
28
|
Peterson SL, Mounsef JB, Sebastian AS, Morrissey PB. Intraoperative Triggered Electromyography: Indispensable in Routine Lumbar Fusions? Clin Spine Surg 2022; 35:329-332. [PMID: 33872222 DOI: 10.1097/bsd.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Shian Liu Peterson
- Department of Orthopedic Surgery, Naval Medical Center San Diego, San Diego, CA
| | - Jad Bou Mounsef
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | - Patrick B Morrissey
- Department of Orthopedic Surgery, Naval Medical Center San Diego, San Diego, CA
| |
Collapse
|
29
|
CT-Navigated Spinal Instrumentations-Three-Dimensional Evaluation of Screw Placement Accuracy in Relation to a Screw Trajectory Plan. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091200. [PMID: 36143877 PMCID: PMC9506171 DOI: 10.3390/medicina58091200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/25/2022] [Accepted: 08/27/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: In the literature, spinal navigation and robot-assisted surgery improved screw placement accuracy, but the majority of studies only qualitatively report on screw positioning within the vertebra. We sought to evaluate screw placement accuracy in relation to a preoperative trajectory plan by three-dimensional quantification to elucidate technical benefits of navigation for lumbar pedicle screws. Materials and Methods: In 27 CT-navigated instrumentations for degenerative disease, a dedicated intraoperative 3D-trajectory plan was created for all screws. Final screw positions were defined on postoperative CT. Trajectory plans and final screw positions were co-registered and quantitatively compared computing minimal absolute differences (MAD) of screw head and tip points (mm) and screw axis (degree) in 3D-space, respectively. Differences were evaluated with consideration of the navigation target registration error. Clinical acceptability of screws was evaluated using the Gertzbein−Robbins (GR) classification. Results: Data included 140 screws covering levels L1-S1. While screw placement was clinically acceptable in all cases (GR grade A and B in 112 (80%) and 28 (20%) cases, respectively), implanted screws showed considerable deviation compared to the trajectory plan: Mean axis deviation was 6.3° ± 3.6°, screw head and tip points showed mean MAD of 5.2 ± 2.4 mm and 5.5 ± 2.7 mm, respectively. Deviations significantly exceeded the mean navigation registration error of 0.87 ± 0.22 mm (p < 0.001). Conclusions: Screw placement was clinically acceptable in all screws after navigated placement but nevertheless, considerable deviation in implanted screws was noted compared to the initial trajectory plan. Our data provides a 3D-quantitative benchmark for screw accuracy achievable by CT-navigation in routine spine surgery and suggests a framework for objective comparison of screw outcome after navigated or robot-assisted procedures. Factors contributing to screw deviations should be considered to assure optimal surgical results when applying navigation for spinal instrumentation.
Collapse
|
30
|
Zhang JK, Del Valle AJ, Alexopoulos G, Patel N, Van Nispen J, Patel M, Xu E, Mercier P, Kohn NA, Mattei TA. Malpractice litigation in elective lumbar spinal fusion: a comprehensive review of reported legal claims in the U.S. in the past 50 years. Spine J 2022; 22:1254-1264. [PMID: 35381361 DOI: 10.1016/j.spinee.2022.03.015] [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: 01/11/2022] [Revised: 03/08/2022] [Accepted: 03/28/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In the U.S., medical malpractice litigation is associated with significant financial costs and often leads to the practice of defensive medicine. Among medical subspecialities, spine surgery is disproportionately impacted by malpractice claims. PURPOSE To provide a comprehensive assessment of reported malpractice litigation claims involving elective lumbar spinal fusion (LSF) surgery during the modern era of spine surgery instrumentation in the U.S., to identify factors associated with verdict outcomes, and to compare malpractice claims characteristics between different approaches for LSF. STUDY DESIGN/SETTING A retrospective review. PATIENT SAMPLE Patients undergoing elective lumbar spinal fusion surgery. OUTCOME MEASURES The primary outcome measure was verdict outcome (defendant vs. plaintiff verdict). Secondary outcome measures included alleged malpractice, injury/damage claimed, and award payouts. METHODS The Westlaw legal database (Thomson Reuters, New York, NY, USA) was queried for verdict and settlement reports pertaining to elective LSF cases from 1970 to 2021. Data were collected regarding patient demographics, surgeon specialty, fellowship training, state/region, procedure, institutional setting (academic vs. community hospital), alleged malpractice, injury sustained, case outcomes, and monetary award. RESULTS A total of 310 cases were identified, yielding 67% (n=181) defendant and 24% (n=65) plaintiff verdicts, with 9% (n=26) settlements. Neurosurgeons and orthopedic spine surgeons were equally named as the defendant (45% vs. 51% respectively, p=0.59). When adjusted for inflation, the median final award for plaintiff verdicts was $1,241,286 (95% CI: $884,850-$2,311,706) while the median settlement award was $925,000 (95% CI: $574,800-$1,787,130), with no stastistically significant differences between verdict and reported settlement payouts (p=0.49). The Northeast region displayed significantly higher award payouts compared to other U.S. regions (p=0.02). There were no associations in awards outcomes when comparing alleged malpractice, alleged injuries/damages, institutional setting, surgical procedures, and surgeon specialty or fellowship training. The most common claims were intraoperative error (28%, n=107) followed by failure to obtain informed consent (24%, n=94). In the analyzed cohort, the most common injuries leading to litigation were refractory pain and suffering (37%, n=149) followed by permanent neurological deficits (26%, n=106). There were no differences in alleged malpractice or injury sustained between cases in which the outcome was favorable to defendant versus plaintiff. Anterior lumbar interbody fusion (ALIF) cases were 2.75 times more likely to be cited for excessive or inappropriate surgery (OR: 2.75 [95% CI: 1.14, 6.86], p=0.02) when compared to posterior surgical approaches. CONCLUSION The results of our analysis of reported claims suggest that medical malpractice litigation involving elective LSF is associated with jury verdicts over $1 million per case, with the most common alleged malpractice being intraoperative error and failure to obtain informed consent. Surgeon specialty, fellowship training, procedure type, and institution type were not associated with greater litigation risks; however, ALIF surgery had a significantly higher risk of involving claims of excessive or inappropriate surgery compared to posterior approaches for lumbar fusion. In addition, claims were significantly higher in the Northeast compared to other U.S. regions. Efforts to improve patient education through shared-decision making and proactive strategies to avoid, detect, and mitigate intra-operative procedural errors may decrease the risk of litigation in elective LSF.
Collapse
Affiliation(s)
- Justin K Zhang
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Armando J Del Valle
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Georgios Alexopoulos
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Niel Patel
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Johan Van Nispen
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Mayur Patel
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Evan Xu
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Philippe Mercier
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Nina A Kohn
- David M. Levy Professor of Law, Syracuse University College of Law, Syracuse, NY, USA
| | - Tobias A Mattei
- Division of Neurological Surgery, Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA.
| |
Collapse
|
31
|
Tovar MA, Dowlati E, Zhao DY, Khan Z, Pasko KBD, Sandhu FA, Voyadzis JM. Robot-assisted and augmented reality-assisted spinal instrumentation: a systematic review and meta-analysis of screw accuracy and outcomes over the last decade. J Neurosurg Spine 2022; 37:299-314. [PMID: 35213837 DOI: 10.3171/2022.1.spine211345] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of technology-enhanced methods in spine surgery has increased immensely over the past decade. Here, the authors present the largest systematic review and meta-analysis to date that specifically addresses patient-centered outcomes, including the risk of inaccurate screw placement and perioperative outcomes in spinal surgeries using robotic instrumentation and/or augmented reality surgical navigation (ARSN). METHODS A systematic review of the literature in the PubMed, EMBASE, Web of Science, and Cochrane Library databases spanning the last decade (January 2011-November 2021) was performed to present all clinical studies comparing robot-assisted instrumentation and ARSN with conventional instrumentation techniques in lumbar spine surgery. The authors compared these two technologies as they relate to screw accuracy, estimated blood loss (EBL), intraoperative time, length of stay (LOS), perioperative complications, radiation dose and time, and the rate of reoperation. RESULTS A total of 64 studies were analyzed that included 11,113 patients receiving 20,547 screws. Robot-assisted instrumentation was associated with less risk of inaccurate screw placement (p < 0.0001) regardless of control arm approach (freehand, fluoroscopy guided, or navigation guided), fewer reoperations (p < 0.0001), fewer perioperative complications (p < 0.0001), lower EBL (p = 0.0005), decreased LOS (p < 0.0001), and increased intraoperative time (p = 0.0003). ARSN was associated with decreased radiation exposure compared with robotic instrumentation (p = 0.0091) and fluoroscopy-guided (p < 0.0001) techniques. CONCLUSIONS Altogether, the pooled data suggest that technology-enhanced thoracolumbar instrumentation is advantageous for both patients and surgeons. As the technology progresses and indications expand, it remains essential to continue investigations of both robotic instrumentation and ARSN to validate meaningful benefit over conventional instrumentation techniques in spine surgery.
Collapse
Affiliation(s)
- Matthew A Tovar
- 1School of Medicine and Health Sciences, George Washington University, Washington, DC
| | - Ehsan Dowlati
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - David Y Zhao
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Ziam Khan
- 3Center for Bioinformatics and Computational Biology, University of Maryland, Baltimore County, Baltimore, Maryland; and
| | - Kory B D Pasko
- 4Georgetown University School of Medicine, Washington, DC
| | - Faheem A Sandhu
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jean-Marc Voyadzis
- 2Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| |
Collapse
|
32
|
Goldberg JL, Härtl R, Elowitz E. Challenges Hindering Widespread Adoption of Minimally Invasive Spinal Surgery. World Neurosurg 2022; 163:228-232. [PMID: 35729824 DOI: 10.1016/j.wneu.2022.03.129] [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: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Minimally invasive spinal surgery (MISS) techniques offer several beneficial prospects and are being increasingly requested by patients. However, these techniques have not been uniformly adopted by spinal surgeons, and they remain controversial among some. Several barriers have prevented widespread adoption of MISS. These include concerns regarding high start-up costs, limited evidence base, and lack of surgeon training. In addition, the unique approaches involved in MISS expose spinal surgeons to unfamiliar anatomy. Further, while MISS can address a growing spectrum of spinal pathology, some conditions, as well as complications encountered during MISS procedures, require open surgery. This requires surgeons to not only acquire the new and specialized MISS skillset but also maintain their ability to perform open surgery. These factors present challenges common to developing and innovative surgical techniques. Here, we review the barriers preventing wider adoption of MISS and present a framework to promote the safe and effective growth of MISS.
Collapse
Affiliation(s)
- Jacob L Goldberg
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Roger Härtl
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Eric Elowitz
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.
| |
Collapse
|
33
|
Harel R, Anekstein Y, Raichel M, Molina CA, Ruiz-Cardozo MA, Orrú E, Khan M, Mirovsky Y, Smorgick Y. The XVS System During Open Spinal Fixation Procedures in Patients Requiring Pedicle Screw Placement in the Lumbosacral Spine. World Neurosurg 2022; 164:e1226-e1232. [PMID: 35671991 DOI: 10.1016/j.wneu.2022.05.134] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This pilot study was undertaken to evaluate the safety, performance, and usability of the Xvision-Spine (XVS) System (Augmedics, Arlington Heights, IL) during open spinal fixation procedures in patients requiring pedicle screw placement in the lumbosacral spine. METHODS The XVS System is an augmented reality head-mounted display (HMD) based on a computer navigation system designed to assist surgeons in accurately placing pedicle screws. It uses an HMD-mounted tracking camera to provide optical tracking technology, and provides the surgeon a translucent direct near-eye display of the navigated surgical instrument's location relative to the computed tomographic image. We report the preliminary results of a prospective series of all consecutive patients who underwent augmented reality-assisted pedicle screw placement in the lumbosacral vertebrae at 3 institutions. Clinical accuracy for each pedicle screw was graded with Gertzbein-Robbins scores by 2 independent and blinded neuroradiologists. RESULTS The 19 study participants included 8 men and 11 women with a mean age of 59.13 ± 12.09 and 59.91 ± 12.89 years, respectively. Seventeen procedures were successfully completed via the XVS System. Two procedures were not completed due to technical issues with the system's intraoperative scanner. A total of 86 screws were inserted. The accuracy of the XVS System was 97.7%. CONCLUSIONS The XVS System's performance in accurate placement of pedicle screws in the lumbosacral vertebrae had an overall accuracy of 97.7%. These preliminary results were comparable to the accuracy of other manual computer-assisted navigation systems reported in the literature.
Collapse
Affiliation(s)
- Ran Harel
- Department of Neurosurgery and the Spine Unit, Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yoram Anekstein
- Department of Orthopedic Surgery and the Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michael Raichel
- Department of Orthopedic Surgery and the Spine Unit, Haemek Medical Center, Affula, Israel
| | - Camilo A Molina
- Department of Neurosurgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Miguel A Ruiz-Cardozo
- Department of Neurosurgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Emanuele Orrú
- Department of Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Majid Khan
- Department of Neurosurgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Yigal Mirovsky
- Department of Orthopedic Surgery and the Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yossi Smorgick
- Department of Orthopedic Surgery and the Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| |
Collapse
|
34
|
Yue Q, Hale T, Gotoff JM, Mercuri MA. Intraoperative Transcranial Electrical Motor Evoked Potential (TceMEP) as a Therapeutic Tool in Spine Surgery: A Case Series Report. Neurodiagn J 2022; 62:99-107. [PMID: 35709522 DOI: 10.1080/21646821.2022.2062190] [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: 08/20/2021] [Accepted: 03/31/2022] [Indexed: 06/15/2023]
Abstract
We report two cases of unilateral loss of TceMEP secondary to spinal instrumentation errors and the subsequent recovery of TceMEP responses following prompt intervention. During the period of TceMEP loss, there were no concomitant SSEP changes beyond the threshold criteria. Postoperative physical examination revealed normal strength and motion in the affected extremities in both patients. These cases illustrate that in addition to being a reliable intraoperative diagnostic tool, TceMEP monitoring displays therapeutic usefulness in appraising corrective actions to the existential risk of neurological injuries.
Collapse
Affiliation(s)
- Qing Yue
- Department of Communication Science and Disorders, Bloomsburg University of Pennsylvania, Bloomsburg, Pennsylvania
| | - Tyson Hale
- Department of Neurophysiology, Geisinger Medical Center, Danville, Pennsylvania
| | - Jill M Gotoff
- Department of Neurophysiology, Geisinger Medical Center, Danville, Pennsylvania
| | - Matthew A Mercuri
- Department of Neurophysiology, Geisinger Medical Center, Danville, Pennsylvania
| |
Collapse
|
35
|
Carelli LE, Almeida LE, Cabrera JP, Khan AA, Mendonça ML, Vital RT, Fonseca GV, Jardim MM. Correlation between Single-pulse and Pulse-train stimulation during Neuromonitoring of Thoracic Pedicle Screws in Scoliosis Surgery. World Neurosurg 2022; 164:e611-e618. [PMID: 35577202 DOI: 10.1016/j.wneu.2022.05.023] [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: 02/08/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The use of thoracic pedicle screws (TPS) during scoliosis surgery entails an inherent risk of neurological deficit. Triggered electromyography (t-EMG) is an accurate neuromonitoring test for the detection of malpositioned TPS. However, single-pulse t-EMG (SP t-EMG) stimulation has shown variable capability for detecting medial pedicle breaches while pulse-train t-EMG (PT t-EMG) could be more accurate. The aim is to analyze the correlation between SP t-EMG and PT t-EMG. METHODS Retrospective study including 20 patients of scoliosis correction with 294 TPS placed. A total of 588 tests with both SP t-EMG and PT t-EMG were performed, analyzed, and compared. The results of both t-EMG techniques were stratified into three different groups according to threshold obtained: Group 1 (≤6 mA), Group 2 (6.1 - 11.9 mA) and Group 3 (=12 mA). Generalized Linear Model was performed to analyze the correlation between the methods. RESULTS SP t-EMG elicited response in 5 screws (1.7%) at ≤ 6 mA; 28 screws (9.5%) at 6.1 - 11.9 mA; and 261 screws (88.8%) at =12 mA. PT t-EMG elicited response in 16 screws (5.4%) at ≤6 mA; 30 screws (10.2%) at 6.1 - 11.9mA; and 248 screws (84.4%) at =12 mA. There is a strong positive and significant association between SP t-EMG and PT t-EMG with a decrease ratio of 2% (95% CI: 1% to 3%). CONCLUSIONS SP t-EMG and PT t-EMG stimulation techniques had similar results when the stimuli were applied the TPS, but PT t-EMG may have better efficacy in low-threshold group.
Collapse
Affiliation(s)
- Luis E Carelli
- National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil; Spine Institute of Rio de Janeiro, Rio de Janeiro, Brazil; Department of Neurology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Luiz E Almeida
- Spine Institute of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Juan P Cabrera
- National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil; Spine Institute of Rio de Janeiro, Rio de Janeiro, Brazil; Faculty of Medicine, University of Concepción, Concepción, Chile
| | - Ahsan Ali Khan
- National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil; Spine Institute of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria L Mendonça
- National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Robson Teixeira Vital
- National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil; Department of Neurology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Marcia M Jardim
- Department of Neurology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
36
|
Simulation Training in Spine Surgery. J Am Acad Orthop Surg 2022; 30:400-408. [PMID: 35446299 DOI: 10.5435/jaaos-d-21-00756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 01/19/2022] [Indexed: 02/01/2023] Open
Abstract
Simulated surgery is part of a growing paradigm shift in surgical education as a whole. Various modalities from cadaver models to virtual reality have been developed and studied within the context of surgical education. Simulation training in spine surgery has an immense potential to improve education and ultimately improve patient safety. This is due to the inherent risk of operating the spine and the technical difficulty of modern techniques. Common procedures in the modern orthopaedic armamentarium, such as pedicle screw placement, can be simulated, and proficiency is rapidly achieved before application in patients. Furthermore, complications such as dural tears can be simulated and effectively managed in a safe environment with simulation. New techniques with steeper learning curves, such as minimally invasive techniques, can now be safely simulated. Hence, augmenting surgical education through simulation has great potential to benefit trainees and practicing orthopaedic surgeons in modern spine surgery techniques. Additional work will aim to improve access to such technologies and integrate them into the current orthopaedic training curriculum.
Collapse
|
37
|
Hagan MJ, Syed S, Leary OP, Persad-Paisley EM, Lin Y, Zheng B, Shao B, Abdulrazeq H, Yu JYH, Telfeian AE, Gokaslan ZL, Fridley JS, Oyelese AA. Pedicle Screw Placement Using Intraoperative Computed Tomography and Computer-Aided Spinal Navigation Improves Screw Accuracy and Avoids Postoperative Revisions: Single-Center Analysis of 1400 Pedicle Screws. World Neurosurg 2022; 160:e169-e179. [PMID: 34990843 DOI: 10.1016/j.wneu.2021.12.112] [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: 11/08/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Intraoperative computed tomography and navigation (iCT-Nav) is increasingly used to aid spinal instrumentation. We aimed to document the accuracy and revision rate of pedicle screw placement across many screws placed using iCT-Nav. We also assess patient-level factors predictive of high-grade pedicle breach. METHODS Medical records of patients who underwent iCT-Nav pedicle screw placement between 2015 and 2017 at a single center were retrospectively reviewed. Screw placement accuracy was individually assessed for each screw using the 2-mm incremental grading system for pedicle breach. Predictors of high-grade (>2 mm) breach were identified using multiple logistic regression. RESULTS In total, 1400 pedicle screws were placed in 208 patients undergoing cervicothoracic (29; 13.9%), thoracic (30; 14.4), thoracolumbar (19; 9.1%) and lumbar (130; 62.5%) surgeries. iCT-Nav afforded high-accuracy screw placement, with 1356 of 1400 screws (96.9%) being placed accurately. In total, 37 pedicle screws (2.64%) were revised intraoperatively during the index surgery across 31 patients, with no subsequent returns to the operating room because of screw malpositioning. After correcting for potential confounders, males were less likely to have a high-grade breach (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.10-0.59, P = 0.003) whereas lateral (OR 6.21; 95% CI 2.47-15.52, P < 0.001) or anterior (OR 5.79; 95% CI2.11-15.88, P = 0.001) breach location were predictive of a high-grade breach. CONCLUSIONS iCT-Nav with postinstrumentation intraoperative imaging is associated with a reduced need for costly postoperative return to the operating room for screw revision. In comparison with studies of navigation without iCT where 1.5%-1.7% of patients returned for a second surgery, we report 0 revision surgeries due to screw malpositioning.
Collapse
Affiliation(s)
- Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Sohail Syed
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Owen P Leary
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Yang Lin
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Belinda Shao
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Hael Abdulrazeq
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - James Y H Yu
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Albert E Telfeian
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA.
| |
Collapse
|
38
|
Driver J, Groff MW. Editorial. Navigation in spine surgery: an innovation here to stay. J Neurosurg Spine 2022; 36:347-349. [PMID: 34624836 DOI: 10.3171/2021.4.spine21207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Joseph Driver
- 1Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael W Groff
- 1Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
39
|
Swany L, Larson AN, Garg S, Hedequist D, Newton P, Sponseller P. 0.4% incidence of return to OR due to screw malposition in a large prospective adolescent idiopathic scoliosis database. Spine Deform 2022; 10:361-367. [PMID: 34746979 DOI: 10.1007/s43390-021-00434-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/17/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE In contrast to infection and curve progression, return to OR for implant malposition is potentially within the surgeon's control. With increasing surgeon familiarity with freehand/fluoroscopic pedicle screw placement, rates of return to OR due to malposition may have decreased over time. We sought to document the incidence and risk factors for return to OR due to screw malposition in a large cohort of patients with idiopathic scoliosis. METHODS AIS patients enrolled in a multicenter prospective registry with minimum 2-year follow-up undergoing PSF between 2003 and 2017 were included. Surgeries with the use of intraoperative CT-guided navigation were excluded. Return to OR due to screw malposition over time was tabulated. Lenke class, age at surgery, year of surgery, height, weight, surgeon and site were evaluated. RESULTS 2435 patients underwent PSF with non-navigated open pedicle screw instrumentation. Mean age was 14.6 years, mean thoracic curve magnitude was 53°, and mean lumbar was 40°. Patients did not routinely undergo intraoperative or postoperative CT evaluation. There were 10 returns to OR for screw malposition at a mean of 0.83 years postoperatively (range 0.1-3.4 years), for an overall incidence of 0.4%. Of the 14 screws, 10 were thoracic, 7 were left-sided. No association was found between screw malposition and curve size, enrolling site, surgeon, BMI, Lenke class, or age. Five patients had radiculopathy which improved after screw revision. Return to OR for screw malposition changed from 2003 to 2017 (1-0.2%) but this did not reach statistical significance. CONCLUSION Although the incidence of asymptomatic malpositioned screws is unknown, the rate of return to the OR for implant malposition overall in this registry was 1 in 250 patients. Recent data suggest the rate has decreased to 1 in 500 patients. Further work may determine whether enabling technologies can reduce the rate, ideally to a "never event".
Collapse
Affiliation(s)
- Lauren Swany
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, USA.
| | - Sumeet Garg
- Pediatric Orthopaedics and Spine Surgery Center, Children's Hospital Colorado, Aurora, CO, USA
| | - Daniel Hedequist
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Peter Newton
- Department of Orthopedics and Scoliosis, Rady Children's Hospital, San Diego, CA, USA
| | - Paul Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | | |
Collapse
|
40
|
Driver J, Dorman JK, Chi JH. A Novel Mobile Device-Based Navigation System for Placement of Posterior Spinal Fixation. Oper Neurosurg (Hagerstown) 2022; 22:249-254. [DOI: 10.1227/ons.0000000000000116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
|
41
|
Shao X, Peng P, Yang P, Xu T, Liu Z, Hua X, Zhu X, Qian Z, Yang H, Mao H, Chen K. A retrospective comparative study of clinical efficacy of percutaneous short segment pedicle screw fixation with or without screwing of the fractured vertebra with O-arm navigation. BMC Musculoskelet Disord 2022; 23:108. [PMID: 35105365 PMCID: PMC8808771 DOI: 10.1186/s12891-022-05069-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 01/27/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To retrospectively analyze the short and long-term efficacies of O-arm-navigated percutaneous short segment pedicle screw fixation, with or without screwing of the fractured vertebra. Methods A total of 42 patients who underwent O-arm-navigated percutaneous short segment pedicle screw fixation for the treatment of thoracolumbar fractures from February 2015 to December 2018 were selected for analysis. The patients were divided into two groups according to the surgical intervention they received: Group A received percutaneous short segment pedicle screw fixation with screwing of the fractured vertebra and Group B received percutaneous short segment pedicle screw fixation without screwing of the fractured vertebra. Radiographic analysis included Cobb angles and percentage of anterior vertebral height (AVH%). Clinical functional outcomes were assessed using the visual analog scale (VAS) for back pain and the oswestry disability index (ODI) scores. Results No significant differences were observed in the operation time and intraoperative blood loss between the two groups (P > 0.05). The length of incision was statistically significantly different between the two groups (P < 0.05). There was no significant difference in Cobb angle and AVH% between the two groups before and after the surgery (P > 0.05). However, the Cobb angle and AVH% were both significantly larger in Group A than Group B at the final follow-up (P < 0.05). In terms of clinical outcomes, there were no statistically significant differences in VAS and ODI scores between the two groups (P > 0.05). Conclusion In the short term, both minimally invasive treatments were safe and effective in treating thoracolumbar fracture. Although there was significant difference between the two groups in Cobb angle and vertebral body height at the last follow-up, the difference was small. Therefore, these specific parameters will be an important outcome measure in further investigations. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05069-3.
Collapse
Affiliation(s)
- Xiaofeng Shao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Peng Peng
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Peng Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Tian Xu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Zixiang Liu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Xi Hua
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Xiaoyu Zhu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Zhonglai Qian
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China
| | - Huilin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China.
| | - Haiqing Mao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China.
| | - Kangwu Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou, 215006, Jiangsu, China.
| |
Collapse
|
42
|
Improved Accuracy and Safety of Pedicle Screw Placement by Using a Probe with an Electrical Conductivity-Measuring Device during Severe Syndromic and Neuromuscular Scoliosis Spine Surgery. J Clin Med 2022; 11:jcm11020419. [PMID: 35054113 PMCID: PMC8778992 DOI: 10.3390/jcm11020419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 02/01/2023] Open
Abstract
An electrical conductivity-measuring device (ECD) has recently been developed to support pedicle screw placement. However, no evidence exists regarding its efficacy for syndromic/neuromuscular scoliosis with extremely difficult screwing. We retrospectively reviewed 2010-2016 medical records of 21 consecutive syndromic/neuromuscular scoliosis patients undergoing free-hand segmental fixation surgery at our institution and compared the pedicle screw insertion accuracy and safety between 10 with a conventional non-ECD probe (2010-2013) and 11 with an ECD probe (2014-2016). We analyzed preoperative pedicle shape and postoperative screw placement in computed tomography. There were no significant differences between ECD and non-ECD groups in demographic, clinical, and treatment characteristics including scoliosis severity and pedicle diameter. The abandonment rate due to liquorrhea or perforation was lower in ECD (12.3%) than in non-ECD (26.7%) (p < 0.01). Acceptable insertion without perforation or <2-mm lateral/cranial position was more frequent in ECD (67.1%) than in non-ECD (56.9%) (p = 0.02). Critical ≥5-mm medial/caudal malposition was not seen in ECD (0.0%) but in non-ECD (2.4%) (p = 0.02). The perforation distance was shorter in ECD (2.2 ± 1.1 mm) than in non-ECD (2.6 ± 1.7 mm) (p = 0.01). Results involve small sample size, selection, performance, and learning curve biases; nevertheless, ECD could be useful for more accurate and safer pedicle screw placement in severe syndromic/neuromuscular scoliosis.
Collapse
|
43
|
State of the art review of new technologies in spine deformity surgery-robotics and navigation. Spine Deform 2022; 10:5-17. [PMID: 34487345 PMCID: PMC8741671 DOI: 10.1007/s43390-021-00403-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/14/2021] [Indexed: 12/24/2022]
Abstract
STUDY DESIGN/METHODS Review article. OBJECTIVES The goal of this article is to review the available evidence for computerized navigation and robotics as an accuracy improvement tool for spinal deformity surgery, as well as to consider potential complications, impact on clinical outcomes, radiation exposure, and costs. Pedicle screw and rod construct are widely utilized for posterior spinal fixation in spinal deformity correction. Freehand placement of pedicle screws has long been utilized, although there is variable potential for inaccuracy depending on surgeon skill and experience. Malpositioned pedicle screws may have significant clinical implications ranging from nerve root irritation, inadequate fixation, CSF leak, perforation of the great vessels, or spinal cord damage. Computer-based navigation and robotics systems were developed to improve pedicle screw insertion accuracy and consistency, and decrease the risk of malpositioned pedicle fixation. The available evidence suggests that computer-based navigation and robotic-assisted guidance systems for pedicle cannulation are at least equivalent, and in several reports superior, to freehand techniques in terms of accuracy. CT and robotic navigation systems do appear to decrease radiation exposure to the operative team in some reports. Published reports do indicate longer operative times with use of robotic navigation compared with traditional freehand techniques for pedicle screw placement. To date, there is no conclusive evidence that use of CT or robotic navigation has any measurable impact on patient outcomes or overall complication reduction. There are theoretical advantages with robotic and CT navigation in terms of both speed and accuracy for severe spinal deformity or complex revision cases, however, there is a need for studies to investigate this technology in these specific cases. There is no evidence to date demonstrating the cost effectiveness of CT or robotic navigation as compared with traditional pedicle cannulation techniques. CONCLUSIONS The review of available evidence suggests that computer-based navigation and robotic-assisted guidance systems for pedicle cannulation are at least equivalent, and in several reports superior, to freehand techniques in terms of radiographic accuracy. There is no current clinical evidence that the use of navigation or robotic techniques leads to improved patient outcomes or decreased overall complications or reoperation rates, and the use of these systems may substantially increase surgical costs. LEVEL OF EVIDENCE V.
Collapse
|
44
|
Librianto D, Saleh I, Ipang F, Aprilya D. Freehand Pedicle Screw Insertion in Spondylitis Tuberculosis Kyphosis Correction Using Cantilever Method: A Breach Rate Analysis of 168 Consecutive Screws. Orthop Res Rev 2022; 14:17-24. [PMID: 35115848 PMCID: PMC8807407 DOI: 10.2147/orr.s349729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/14/2022] [Indexed: 11/24/2022] Open
Abstract
Background The cantilever method is a standard for two-dimensional deformity correction, as in spondylitis tuberculosis kyphotic deformity. An accurate and secured pedicle screw placement as part of the correction tools is essential to accommodate reduction while preventing screw-related complications. Many literatures have described the pedicle screw misplacement in cases with “normal” bone quality (ie, scoliosis, Scheuermann’s kyphosis, ankylosing spondylitis, trauma) or in the obviously abnormal bone such as osteoporosis. However, to our knowledge, the pedicle screw accuracy in cases of deformity correction of tuberculous kyphosis was not previously reported. Methods This is a retrospective study of 168 pedicle screws in 14 consecutive cases of spondylitis tuberculosis with kyphotic deformity. The cantilever reduction method with freehand screw insertion technique was done in all cases to correct the deformity. Postoperative computed tomography (CT) evaluation was done to evaluate screw position and breach rates. Results Among the 168 screws, accurate pedicle screw placement was accomplished in 39.3% screws (Gertzbein–Robbins Grade A). The overall breach rate was 61.9%, which was most commonly occurred on the segment proximal to the apex of the deformity (p=0.001). The lateral breach was more common than the medial breach (52.3% vs 7.7%). The pedicle screw on the thoracal region has a greater breach incidence than those on the lumbar region especially those on T9, T10, and T11. There was no injury to the surrounding neurovascular and pleural structures. No revision surgeries were required. Conclusion Freehand pedicle screw insertion in spondylitis tuberculosis kyphotic reduction has proved to be safe. However, the accuracy should be improved to prevent long-term screw-related complications.
Collapse
Affiliation(s)
- Didik Librianto
- Orthopedic Spine Surgery, Fatmawati General Hospital, Jakarta, Indonesia
| | - Ifran Saleh
- Department of Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Fachrisal Ipang
- Orthopedic Spine Surgery, Fatmawati General Hospital, Jakarta, Indonesia
| | - Dina Aprilya
- Department of Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Correspondence: Dina Aprilya, Department of Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Prof. Soelarto building, 1st floor, RS Fatmawati Street, Jakarta, 12430, Indonesia, Tel +62 89655106136, Fax +62 21-7660616, Email
| |
Collapse
|
45
|
Kulkarni R, Mesare V, Gursale A, Tiwari A, Kaware R. Accuracy of pedicle screw fixation in lumbar spine by freehand technique studied postoperatively by computed tomography. JOURNAL OF ORTHOPAEDICS AND SPINE 2022. [DOI: 10.4103/joasp.joasp_3_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
46
|
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.
Collapse
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.
| |
Collapse
|
47
|
Simulation on synthetic bone: A tool for teaching thoracolumbar pedicle screw placement. Orthop Traumatol Surg Res 2021; 107:103056. [PMID: 34536595 DOI: 10.1016/j.otsr.2021.103056] [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: 07/08/2020] [Revised: 11/11/2020] [Accepted: 01/11/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Simulation workshops for surgical training of residents are becoming popular. The gold standard for teaching thoracolumbar pedicle screw placement are cadaver labs; however, the availability of human bodies is limited. The primary objective of this study was to determine if training on a synthetic bone model improves the apprenticeship of accurate pedicle screw placement. The secondary objective was to check the influence of residents' previous experience in spine surgery. HYPOTHESIS The main hypothesis was that theoretical learning with practical application on synthetic bone was superior to theoretical learning alone. METHODS Twenty-three orthopedic residents were taught about free-hand pedicle screw placement using a theoretical presentation. Six residents had previous experience with screwing techniques. After randomization in two groups, 11 residents (group 1) participated in a workshop on synthetic bone, whereas 12 residents received only theoretical instruction (group 2). Each resident was asked to place two thoracic screws (T7-T11) and two lumbar screws (L1-L5) on a cadaver. Screw placement accuracy was analyzed using the Gertzbein classification on computed tomography (grades 0 and 1=accurate positioning; grades 2 and 3=malposition>2mm). RESULTS Rates of accurate screw positioning were 64.0% and 62.5% for thoracic levels, and 72.7% and 66.6% for lumbar levels in group 1 and 2, respectively. There was no significant difference in malposition rates on cadavers between the groups (p=0.1809). A resident who was first trained by simulation had a chance of decreasing the Gertzbein score with an odds-ratio of 1.7714 [0.7710-4.1515]. The odds ratio was 4.5188 [0.0456-0.8451] when comparing residents with previous experience in spinal surgery to novice residents. DISCUSSION Theoretical teaching associated with a simulation model is relevant for learning a surgical technique. A single simulation workshop on synthetic bone seems insufficient to improve pedicle screw placement accuracy compared to theoretical teaching alone. Progressive experience and the repetition of technical gestures during hands-on supervised learning in spine surgery with a senior surgeon had an influence on the accuracy of pedicle screw placement. LEVEL OF EVIDENCE II.
Collapse
|
48
|
Liu A, Jin Y, Cottrill E, Khan M, Westbroek E, Ehresman J, Pennington Z, Lo SFL, Sciubba DM, Molina CA, Witham TF. Clinical accuracy and initial experience with augmented reality-assisted pedicle screw placement: the first 205 screws. J Neurosurg Spine 2021:1-7. [PMID: 34624854 DOI: 10.3171/2021.2.spine202097] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Augmented reality (AR) is a novel technology which, when applied to spine surgery, offers the potential for efficient, safe, and accurate placement of spinal instrumentation. The authors report the accuracy of the first 205 pedicle screws consecutively placed at their institution by using AR assistance with a unique head-mounted display (HMD) navigation system. METHODS A retrospective review was performed of the first 28 consecutive patients who underwent AR-assisted pedicle screw placement in the thoracic, lumbar, and/or sacral spine at the authors' institution. Clinical accuracy for each pedicle screw was graded using the Gertzbein-Robbins scale by an independent neuroradiologist working in a blinded fashion. RESULTS Twenty-eight consecutive patients underwent thoracic, lumbar, or sacral pedicle screw placement with AR assistance. The median age at the time of surgery was 62.5 (IQR 13.8) years and the median body mass index was 31 (IQR 8.6) kg/m2. Indications for surgery included degenerative disease (n = 12, 43%); deformity correction (n = 12, 43%); tumor (n = 3, 11%); and trauma (n = 1, 4%). The majority of patients (n = 26, 93%) presented with low-back pain, 19 (68%) patients presented with radicular leg pain, and 10 (36%) patients had documented lower extremity weakness. A total of 205 screws were consecutively placed, with 112 (55%) placed in the lumbar spine, 67 (33%) in the thoracic spine, and 26 (13%) at S1. Screw placement accuracy was 98.5% for thoracic screws, 97.8% for lumbar/S1 screws, and 98.0% overall. CONCLUSIONS AR depicted through a unique HMD is a novel and clinically accurate technology for the navigated insertion of pedicle screws. The authors describe the first 205 AR-assisted thoracic, lumbar, and sacral pedicle screws consecutively placed at their institution with an accuracy of 98.0% as determined by a Gertzbein-Robbins grade of A or B.
Collapse
Affiliation(s)
- Ann Liu
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yike Jin
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ethan Cottrill
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Majid Khan
- 2Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Erick Westbroek
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheng-Fu L Lo
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Camilo A Molina
- 3Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Timothy F Witham
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
49
|
Patel AV, White CA, Schwartz JT, Pitaro NL, Shah KC, Singh S, Arvind V, Kim JS, Cho SK. Emerging Technologies in the Treatment of Adult Spinal Deformity. Neurospine 2021; 18:417-427. [PMID: 34610669 PMCID: PMC8497255 DOI: 10.14245/ns.2142412.206] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/12/2021] [Indexed: 12/29/2022] Open
Abstract
Outcomes for adult spinal deformity continue to improve as new technologies become integrated into clinical practice. Machine learning, robot-guided spinal surgery, and patient-specific rods are tools that are being used to improve preoperative planning and patient satisfaction. Machine learning can be used to predict complications, readmissions, and generate postoperative radiographs which can be shown to patients to guide discussions about surgery. Robot-guided spinal surgery is a rapidly growing field showing signs of greater accuracy in screw placement during surgery. Patient-specific rods offer improved outcomes through higher correction rates and decreased rates of rod breakage while decreasing operative time. The objective of this review is to evaluate trends in the literature about machine learning, robot-guided spinal surgery, and patient-specific rods in the treatment of adult spinal deformity.
Collapse
Affiliation(s)
- Akshar V Patel
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher A White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John T Schwartz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicholas L Pitaro
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kush C Shah
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sirjanhar Singh
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varun Arvind
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
50
|
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.
Collapse
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
| | | |
Collapse
|