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Wilson JP, Fontenot L, Stewart C, Kumbhare D, Guthikonda B, Hoang S. Image-Guided Navigation in Spine Surgery: From Historical Developments to Future Perspectives. J Clin Med 2024; 13:2036. [PMID: 38610801 PMCID: PMC11012660 DOI: 10.3390/jcm13072036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/08/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Intraoperative navigation is critical during spine surgery to ensure accurate instrumentation placement. From the early era of fluoroscopy to the current advancement in robotics, spinal navigation has continued to evolve. By understanding the variations in system protocols and their respective usage in the operating room, the surgeon can use and maximize the potential of various image guidance options more effectively. At the same time, maintaining navigation accuracy throughout the procedure is of the utmost importance, which can be confirmed intraoperatively by using an internal fiducial marker, as demonstrated herein. This technology can reduce the need for revision surgeries, minimize postoperative complications, and enhance the overall efficiency of operating rooms.
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Affiliation(s)
| | | | | | | | | | - Stanley Hoang
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA; (J.P.W.J.); (L.F.); (C.S.); (D.K.); (B.G.)
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2
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Guevara F, Foss KD, Harper TAM, Moran CA, Hague DW, Hamel PES, Schaeffer DJ, McCoy AM. Ex vivo comparison of pin placement with patient-specific drill guides or freehand technique in canine cadaveric spines. Vet Surg 2024; 53:254-263. [PMID: 37822110 DOI: 10.1111/vsu.14042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE To compare vertebral implant placement in the canine thoracolumbar spine between 3D-printed patient-specific drill guides (3DPG) and the conventional freehand technique (FH). STUDY DESIGN Ex vivo study. ANIMALS Cadaveric canine spines (n = 24). METHODS Implant trajectories were established for the left and right sides of the T10 through L6 vertebrae based on computed tomography (CT) imaging. Customized drill guides were created for each vertebra of interest. Each cadaver was randomly assigned to one of six veterinarians with varying levels of experience placing vertebral implants. Vertebrae were randomly assigned a surgical order and technique (3DPG or FH) for both sides. Postoperative CT images were acquired. A single, blinded observer assessed pin placement using a modified Zdichavsky classification. RESULTS A total of 480 implants were placed in 240 vertebrae. Three sites were excluded from the analysis; therefore, a total of 238 implants were evaluated using the FH technique and 239 implants using 3DPG. When evaluating implant placement, 152/239 (63.6%) of 3DPG implants were considered to have an acceptable placement in comparison with 115/248 (48.32%) with FH. Overall, pin placement using 3DPG was more likely to provide acceptable pin placement (p < .001) in comparison with the FH technique for surgeons at all levels of experience. CONCLUSION The use of 3DPG was shown to be better than the conventional freehand technique regarding acceptable placement of implants in the thoracolumbar spine of canine cadavers. CLINICAL SIGNIFICANCE Utilizing 3DPG can be considered better than the traditional FH technique when placing implants in the canine thoracolumbar spine.
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Affiliation(s)
- Francisco Guevara
- Department of Veterinary Clinical Medicine, University of Illinois College of Veterinary Medicine, Urbana, Illinois, USA
| | - Kari D Foss
- Department of Veterinary Clinical Medicine, University of Illinois College of Veterinary Medicine, Urbana, Illinois, USA
| | - Tisha A M Harper
- Department of Veterinary Clinical Medicine, University of Illinois College of Veterinary Medicine, Urbana, Illinois, USA
| | - Clara A Moran
- Department of Veterinary Clinical Medicine, University of Illinois College of Veterinary Medicine, Urbana, Illinois, USA
| | - Devon W Hague
- Department of Veterinary Clinical Medicine, University of Illinois College of Veterinary Medicine, Urbana, Illinois, USA
| | - Philip E S Hamel
- Boundary Bay Veterinary Specialty Hospital, Langley, British Columbia, Canada
| | - David J Schaeffer
- Department of Veterinary Clinical Medicine, University of Illinois College of Veterinary Medicine, Urbana, Illinois, USA
| | - Annette M McCoy
- Department of Veterinary Clinical Medicine, University of Illinois College of Veterinary Medicine, Urbana, Illinois, USA
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3
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Scherer M, Kausch L, Bajwa A, Neumann JO, Ishak B, Naser P, Vollmuth P, Kiening K, Maier-Hein K, Unterberg A. Automatic Planning Tools for Lumbar Pedicle Screws: Comparison and Validation of Planning Accuracy for Self-Derived Deep-Learning-Based and Commercial Atlas-Based Approaches. J Clin Med 2023; 12:jcm12072646. [PMID: 37048730 PMCID: PMC10094754 DOI: 10.3390/jcm12072646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Background: This ex vivo experimental study sought to compare screw planning accuracy of a self-derived deep-learning-based (DL) and a commercial atlas-based (ATL) tool and to assess robustness towards pathologic spinal anatomy. Methods: From a consecutive registry, 50 cases (256 screws in L1-L5) were randomly selected for experimental planning. Reference screws were manually planned by two independent raters. Additional planning sets were created using the automatic DL and ATL tools. Using Python, automatic planning was compared to the reference in 3D space by calculating minimal absolute distances (MAD) for screw head and tip points (mm) and angular deviation (degree). Results were evaluated for interrater variability of reference screws. Robustness was evaluated in subgroups stratified for alteration of spinal anatomy. Results: Planning was successful in all 256 screws using DL and in 208/256 (81%) using ATL. MAD to the reference for head and tip points and angular deviation was 3.93 ± 2.08 mm, 3.49 ± 1.80 mm and 4.46 ± 2.86° for DL and 7.77 ± 3.65 mm, 7.81 ± 4.75 mm and 6.70 ± 3.53° for ATL, respectively. Corresponding interrater variance for reference screws was 4.89 ± 2.04 mm, 4.36 ± 2.25 mm and 5.27 ± 3.20°, respectively. Planning accuracy was comparable to the manual reference for DL, while ATL produced significantly inferior results (p < 0.0001). DL was robust to altered spinal anatomy while planning failure was pronounced for ATL in 28/82 screws (34%) in the subgroup with severely altered spinal anatomy and alignment (p < 0.0001). Conclusions: Deep learning appears to be a promising approach to reliable automated screw planning, coping well with anatomic variations of the spine that severely limit the accuracy of ATL systems.
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Affiliation(s)
- Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Lisa Kausch
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, 69120 Heidelberg, Germany
| | - Akbar Bajwa
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Paul Naser
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Klaus Maier-Hein
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, 69120 Heidelberg, Germany
- Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
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Tumbiolo S, Gerardi RM, Brunasso L, Costanzo R, Lombardo MC, Porcaro S, Adorno A, La Fata G, Paolini S, Visocchi M, Iacopino DG, Maugeri R. Pedicle Screw Placement Aided by C-Arm Fluoroscopy: A "Nevermore without" Technology to Pursue Optimal Spine Fixation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:213-217. [PMID: 38153472 DOI: 10.1007/978-3-031-36084-8_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
The surgical technique and the intraoperative technology that support spinal pedicle screw placement have consistently evolved over the past decades to decrease the misplacement rate of pedicle screws. We retrospectively evaluated our case series by analyzing the period 2016-2020. Patients undergoing pedicle screw fixation for cervical, thoracic, or lumbar spine degenerative diseases have been included. Surgery was carried out with the aid of intraoperative 3D C-arm fluoroscopy to assess and optimize screw placement and/or correct possible mispositioning. Each patient underwent a postoperative CT scan. Our aim was to evaluate the safety and accuracy of pedicle screw placement and estimate the variation in mispositioning rates. We carried out 329 surgical procedures, as follows: 70 cervical, 78 thoracic spine, and 181 lumbar spine surgeries. An excellent overall pedicle screw positioning was obtained, with slight differences between the cervical (98.6%), thoracic (100%), and lumbar (98.9%) tracts. Accordingly, only three patients required a revision surgery owing to mispositioning (0.91%). In particular, intraoperative C-arm fluoroscopy significatively improved the accuracy of thoracic screw positioning, as shown by postoperative CT scans. Our experience proves the crucial role of intraoperative C-arm fluoroscopy in pursuing optimal technical results and improving patient outcomes at follow-up.
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Affiliation(s)
- Silvana Tumbiolo
- Division of Neurosurgery, Department of Emergency and Neuroscience, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Rosa Maria Gerardi
- Neurosurgical Clinic, AOUP "Paolo Giaccone," Postgraduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
| | - Lara Brunasso
- Neurosurgical Clinic, AOUP "Paolo Giaccone," Postgraduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
| | - Roberta Costanzo
- Neurosurgical Clinic, AOUP "Paolo Giaccone," Postgraduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
| | - Maria Cristina Lombardo
- Division of Neurosurgery, Department of Emergency and Neuroscience, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Simona Porcaro
- Division of Neurosurgery, Department of Emergency and Neuroscience, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Alessandro Adorno
- Division of Neurosurgery, Department of Emergency and Neuroscience, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Giuseppe La Fata
- Division of Neurosurgery, Department of Emergency and Neuroscience, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Saverio Paolini
- Neurosurgical Clinic, AOUP "Paolo Giaccone," Postgraduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
| | | | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP "Paolo Giaccone," Postgraduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP "Paolo Giaccone," Postgraduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
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Scherer M, Kausch L, Ishak B, Norajitra T, Vollmuth P, Kiening K, Unterberg A, Maier-Hein K, Neumann JO. Development and validation of an automated planning tool for navigated lumbosacral pedicle screws using a convolutional neural network. Spine J 2022; 22:1666-1676. [PMID: 35584757 DOI: 10.1016/j.spinee.2022.05.002] [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: 12/17/2021] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Navigation and robotic systems have been increasingly applied to spinal instrumentation but dedicated screw planning is a time-consuming prerequisite to tap the full potential of these techniques. PURPOSE To develop and validate an automated planning tool for lumbosacral pedicle screw placement using a convolutional neural network (CNN) to facilitate the planning process. STUDY DESIGN/SETTING Retrospective analysis and processing of CT and screw planning data randomly selected from a consecutive registry of CT-navigated instrumentations from a single academic institution. PATIENT SAMPLE Data from 179 cases was processed for CNN training and validation (155 for training, 24 for validation) leveraging a total of 1182 screws (1052 for training, 130 for validation). OUTCOME MEASURES Quantitative and qualitative (Gertzbein-Robbins classification [GR]) validation via comparison of automatically and manually planned reference screws, inter-rater and intra-rater variability. METHODS Annotated data from CT-navigated instrumentation was used to train a CNN operating in a vertebra instance-based approach employing a state-of-the-art U-Net framework. Internal five-fold cross-validation and external validation on an independent cohort not previously involved in training was performed. Quantitative validation of automatically planned screws was performed in comparison to corresponding manually planned screws by calculating the minimal absolute difference (MAD) of screw head and tip points, length and diameter, screw direction and Dice coefficient. Results were evaluated in relation to inter-rater and intra-rater variability of manual screw planning. RESULTS Automated screw planning was successful in all targeted 130 screws. Compared with manually planned screws as a reference, mean MAD of automatically planned screws was 4.61±2.27 mm for screw head, 3.96±2.19 mm for tip points and 5.51±3.64° for screw direction. These differences were either statistically comparable or significantly smaller when compared with interrater variability of manual screw planning (p>.99 for head point and direction, p=.004 for tip point, respectively). Mean Dice coefficient of 0.61±0.16 indicated significantly greater agreement of automatic screws with the manual reference compared with interrater agreement (Dice 0.56±0.18, p<.001). Automatically planned screws were marginally shorter (MAD 3.4±3.2 mm) and thinner (MAD mean 0.3±0.6 mm) compared with the manual reference, but with statistical significance (p<.0001, respectively). Automatically planned screws were GR grade A in 96.2% in qualitative validation. Planning time was significantly shorter with the automatic approach (0:41 min vs. 6:41 min, p<.0001). CONCLUSIONS We derived and validated a fully automated planning tool for lumbosacral pedicle screws using a CNN. Our validation showed noninferiority to manual screw planning and provided sufficient accuracy to facilitate and expedite the screw planning process. These results offer a high potential to improve workflows in spine surgery when integrated into navigation or robotic assistance systems.
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Affiliation(s)
- Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany.
| | - Lisa Kausch
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Tobias Norajitra
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Klaus Maier-Hein
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, Im Neuenheimer Feld 280, Heidelberg 69120, Germany; Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
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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.
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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.
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González-Vargas PM, Calero Félix L, Martín-Gallego Á, Thenier-Villa JL, de la Lama Zaragoza AR, Conde Alonso C. Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:71-81. [PMID: 35248301 DOI: 10.1016/j.neucie.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/10/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control. METHODS The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification. RESULTS 92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05). CONCLUSION The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.
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Affiliation(s)
- Pedro Miguel González-Vargas
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain.
| | - Lourdes Calero Félix
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Álvaro Martín-Gallego
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - José Luis Thenier-Villa
- Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain; Department of Neurosurgery, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Adolfo Ramón de la Lama Zaragoza
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
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Rosinski AA, Mittal A, Odeh K, Ungurean V, Leasure J, Telles C, Kondrashov D. Alternatives to Traditional Pedicle Screws for Posterior Fixation of the Degenerative Lumbar Spine. JBJS Rev 2021; 9:01874474-202107000-00016. [PMID: 34319968 DOI: 10.2106/jbjs.rvw.20.00177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Traditional pedicle screws are currently the gold standard to achieve stable 3-column fixation of the degenerative lumbar spine. However, there are cases in which pedicle screw fixation may not be ideal. Due to their starting point lateral to the pars interarticularis, pedicle screws require a relatively wide dissection along with a medialized trajectory directed toward the centrally located neural elements and prevertebral vasculature. In addition, low bone mineral density remains a major risk factor for pedicle screw loosening, pullout, and pseudarthrosis. The purpose of this article is to review the indications, advantages, disadvantages, and complications associated with posterior fixation techniques of the degenerative lumbar spine beyond the traditional pedicle screws. METHODS Comprehensive literature searches of the PubMed, Scopus, and Web of Science databases were performed for 5 methods of posterior spinal fixation, including (1) cortical bone trajectory (CBT) screws, (2) transfacet screws, (3) translaminar screws, (4) spinous process plates, and (5) fusion mass screws and hooks. Articles that had been published between January 1, 1990, and January 1, 2020, were considered. Non-English-language articles and studies involving fixation of the cervical or thoracic spine were excluded from our review. RESULTS After reviewing over 1,700 articles pertaining to CBT and non-pedicular fixation techniques, a total of 284 articles met our inclusion criteria. CBT and transfacet screws require less-extensive exposure and paraspinal muscle dissection compared with traditional pedicle screws and may therefore reduce blood loss, postoperative pain, and length of hospital stay. In addition, several methods of non-pedicular fixation such as translaminar and fusion mass screws have trajectories that are directed away from or posterior to the spinal canal, potentially decreasing the risk of neurologic injury. CBT, transfacet, and fusion mass screws can also be used as salvage techniques when traditional pedicle screw constructs fail. CONCLUSIONS CBT and non-pedicular fixation may be preferred in certain lumbar degenerative cases, particularly among patients with osteoporosis. Limitations of non-pedicular techniques include their reliance on intact posterior elements and the lack of 3-column fixation of the spine. As a result, transfacet and translaminar screws are infrequently used as the primary method of fixation. CBT, transfacet, and translaminar screws are effective in augmenting interbody fixation and have been shown to significantly improve fusion rates and clinical outcomes compared with stand-alone anterior lumbar interbody fusion. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander A Rosinski
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Ashish Mittal
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Khalid Odeh
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | | | | | | | - Dimitriy Kondrashov
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
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9
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González-Vargas PM, Calero Félix L, Martín-Gallego Á, Thenier-Villa JL, de la Lama Zaragoza AR, Conde Alonso C. Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00010-5. [PMID: 33663907 DOI: 10.1016/j.neucir.2021.01.001] [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: 08/17/2020] [Revised: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control. METHODS The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification. RESULTS 92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05). CONCLUSION The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.
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Affiliation(s)
- Pedro Miguel González-Vargas
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain.
| | - Lourdes Calero Félix
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Álvaro Martín-Gallego
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - José Luis Thenier-Villa
- Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain; Department of Neurosurgery, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Adolfo Ramón de la Lama Zaragoza
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
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10
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Sankey EW, Mehta VA, Wang TY, Than TT, Goodwin CR, Karikari IO, Shaffrey CI, Abd-El-Barr MM, Than KD. The medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the United States. Neurosurg Focus 2020; 49:E20. [PMID: 33130620 DOI: 10.3171/2020.8.focus20600] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. The authors of the current study aimed to describe this impact in the United States, as well as to suggest a potential method for mitigating the problem.This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). Litigation resulted in average payouts of $1,204,422 ± $753,832 between 1995 and 2019, when adjusted for inflation. The median time to case closure was 56.3 (35.2-67.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.4-77.2) months for defendant (surgeon) verdicts (p = 0.117).
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Affiliation(s)
- Eric W Sankey
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Vikram A Mehta
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Timothy Y Wang
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | | | - C Rory Goodwin
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Isaac O Karikari
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Christopher I Shaffrey
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Muhammad M Abd-El-Barr
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Khoi D Than
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
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11
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Harel R, Kimchi G, Knoller N. One-step insertion of navigated pedicle screws in minimally invasive transforaminal lumbar interbody fusion (MITLIF): preliminary results of a novel technique. Br J Neurosurg 2020; 35:753-756. [PMID: 32522043 DOI: 10.1080/02688697.2020.1777257] [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: 10/24/2022]
Abstract
OBJECTIVE To describe a novel technique modification and evaluate initial results of pedicle screw insertion in minimally invasive transforaminal lumbar interbody fusion (MITLIF), using self-drilling self-tapping one-step screws. PATIENTS AND METHODS All patients who were operated for MITLIF using the one-step technique over the last 6 months period at a single institute, were retrospectively identified. The surgical technique is described and depicted. Outcome evaluation was performed, including screw misplacement, screw insertion time, and post-operative complications. RESULTS We describe a novel technique modification in which self-drilling self-tapping navigated screws incorporate an embedded K-wire that enables a one-step insertion which obviates the need for instrument exchange. The first four patients in whom this technique was implemented were included (mean age was 55). All patients had been previously operated at the fused level. The mean surgical duration was 142 minutes and the calculated mean screw insertion time was 8.2 minutes. The mean estimated blood loss was 66 cc. An intraoperative 3D scan demonstrated no screw pedicle breach. There were no neurological complications or wound healing disturbances. The clinical course was uneventful for all patients. CONCLUSION To our knowledge, the use of one-step navigation-assisted self-drilling self-tapping pedicle screws with an embedded K-wire has not been previously described. Our initial experience with this novel technique modification was efficient and safe. Navigated surgery allows for newer and safer techniques to be incorporated into the surgeon's toolbox. Further studies should be performed to thoroughly evaluate this technique.
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Affiliation(s)
- Ran Harel
- Spine Surgery Unit, Department of Neurosurgery, Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Tel-Aviv, Israel
| | - Gil Kimchi
- Spine Surgery Unit, Department of Neurosurgery, Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Tel-Aviv, Israel
| | - Nachshon Knoller
- Spine Surgery Unit, Department of Neurosurgery, Sheba Medical Center, Sackler Medical School, Tel-Aviv University, Tel-Aviv, Israel
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12
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Incidence of pedicle breach following open and minimally invasive spinal instrumentation: A postoperative CT analysis of 513 pedicle screws applied under fluoroscopic guidance. Biomedicine (Taipei) 2020; 10:30-35. [PMID: 33854918 PMCID: PMC7608845 DOI: 10.37796/2211-8039.1016] [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: 10/23/2019] [Accepted: 11/25/2019] [Indexed: 11/12/2022] Open
Abstract
Background Even though pedicle screw application is a common procedure, and in-spite of spine surgeons being proficient with the technique, mal-positioning of pedicle screws can still occur. We intend to determine by postoperative CT analysis, the incidence of pedicle screw breach in the thoracolumbar spine despite satisfactory intraoperative placement confirmed by fluoroscopy. Materials and methods Consecutive patients diagnosed with thoracolumbar fractures who underwent open or minimally invasive posterior stabilization under fluoroscopic guidance were retrospectively reviewed. Postoperative CT scans of patients were analysed to determine the incidence of pedicle breach despite satisfactory intraoperative placement, and also to determine the factors that can predict a breach during intraoperative assessment. Results A total of 61 patients with 513 thoracolumbar pedicle screws were available for analysis. Based on our postoperative CT assessment, 28 screws (5.5%; 18 thoracic screws; 10 lumbar screws) had breached the pedicle. There were 14 minor (<3 mm) and 14 major (≥3 mm) breaches. The minimally invasive technique had a significantly lower breach rate compared to open surgery (1.9% vs. 7.9%). By retrospectively analysing the intra-operative fluoroscopic images, we determined certain parameters that could predict a breach during surgery. Conclusion Pedicle breaches can still be present despite satisfactory placement of screws visualized intra-operatively. A medial breach is most likely when the length of the pedicle screw spans only up to 50% of the vertebral body as seen on the lateral view but the pedicle screw tip has already transgressed the midline as seen on an AP view. A lateral breach is likely when the tip of the pedicle screw is overlapped by the screw head or is only minimally visualized on an AP view.
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13
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Peng T, Kramer DR, Lee MB, Barbaro MF, Ding L, Liu CY, Kellis S, Lee B. Comparison of Intraoperative 3-Dimensional Fluoroscopy With Standard Computed Tomography for Stereotactic Frame Registration. Oper Neurosurg (Hagerstown) 2020; 18:698-709. [PMID: 31584102 PMCID: PMC7225008 DOI: 10.1093/ons/opz296] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 07/19/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Three-dimensional fluoroscopy via the O-arm (Medtronic, Dublin, Ireland) has been validated for intraoperative confirmation of successful lead placement in stereotactic electrode implantation. However, its role in registration and targeting has not yet been studied. After frame placement, many stereotactic neurosurgeons obtain a computed tomography (CT) scan and merge it with a preoperative magnetic resonance imaging (MRI) scan to generate planning coordinates; potential disadvantages of this practice include increased procedure time and limited scanner availability. OBJECTIVE To evaluate whether the second-generation O-arm (O2) can be used in lieu of a traditional CT scan to obtain accurate frame-registration scans. METHODS In 7 patients, a postframe placement CT scan was merged with preoperative MRI and used to generate lead implantation coordinates. After implantation, the fiducial box was again placed on the patient to obtain an O2 confirmation scan. Vector, scalar, and Euclidean differences between analogous X, Y, and Z coordinates from fused O2/MRI and CT/MRI scans were calculated for 33 electrode target coordinates across 7 patients. RESULTS Marginal means of difference for vector (X = -0.079 ± 0.099 mm; Y = -0.076 ± 0.134 mm; Z = -0.267 ± 0.318 mm), scalar (X = -0.146 ± 0.160 mm; Y = -0.306 ± 0.106 mm; Z = 0.339 ± 0.407 mm), and Euclidean differences (0.886 ± 0.190 mm) remained within the predefined equivalence margin differences of -2 mm and 2 mm. CONCLUSION This study demonstrates that O2 may emerge as a viable alternative to the traditional CT scanner for generating planning coordinates. Adopting the O2 as a perioperative tool may offer reduced transport risks, decreased anesthesia time, and greater surgical efficiency.
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Affiliation(s)
- Terrance Peng
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Daniel R Kramer
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Morgan B Lee
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael F Barbaro
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Li Ding
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Charles Y Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Spencer Kellis
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California
- T&C Chen BMI Center, Chen Institute for Neuroscience, California Institute of Technology, Pasadena, California
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, California
| | - Brian Lee
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California
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14
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Optical Topographic Imaging for Spinal Intraoperative 3-Dimensional Navigation in the Cervical Spine: Initial Preclinical and Clinical Feasibility. Clin Spine Surg 2019; 32:303-308. [PMID: 30839418 DOI: 10.1097/bsd.0000000000000795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OF BACKGROUND DATA Computer-assisted 3-dimensional navigation may guide spinal instrumentation. Optical topographic imaging (OTI) is a novel navigation technique offering comparable accuracy and significantly faster registration workflow relative to current navigation systems. It has previously been validated in open posterior thoracolumbar exposures. OBJECTIVE To validate the utility and accuracy of OTI in the cervical spine. STUDY DESIGN This is a prospective preclinical cadaveric and clinical cohort study. METHODS Standard midline open posterior cervical exposures were performed, with segmental OTI registration at each vertebral level. In cadaveric testing, OTI navigation guidance was used to track a drill guide for cannulating screw tracts in the lateral mass at C1, pars at C2, lateral mass at C3-6, and pedicle at C7. In clinical testing, translaminar screws at C2 were also analyzed in addition. Planned navigation trajectories were compared with screw positions on postoperative computed tomographic imaging, and quantitative navigation accuracies, in the form of absolute translational and angular deviations, were computed. RESULTS In cadaveric testing (mean±SD) axial and sagittal translational navigation errors were (1.66±1.18 mm) and (2.08±2.21 mm), whereas axial and sagittal angular errors were (4.11±3.79 degrees) and (6.96±5.40 degrees), respectively.In clinical validation (mean±SD) axial and sagittal translational errors were (1.92±1.37 mm) and (1.27±0.97 mm), whereas axial and sagittal angular errors were (3.68±2.59 degrees) and (3.47±2.93 degrees), respectively. These results are comparable to those achieved with OTI in open thoracolumbar approaches, as well as using current spinal neuronavigation systems in similar applications. There was no radiographic facet, canal or foraminal violations, nor any neurovascular complications. CONCLUSIONS OTI is a novel navigation technique allowing efficient initial and repeat registration. Accuracy even in the more mobile cervical spine is comparable to current spinal neuronavigation systems.
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15
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Guha D, Jakubovic R, Alotaibi NM, Klostranec JM, Saini S, Deorajh R, Gupta S, Fehlings MG, Mainprize TG, Yee A, Yang VX. Optical Topographic Imaging for Spinal Intraoperative Three-Dimensional Navigation in Mini-Open Approaches: A Prospective Cohort Study of Initial Preclinical and Clinical Feasibility. World Neurosurg 2019; 125:e863-e872. [DOI: 10.1016/j.wneu.2019.01.201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
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16
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Solitro GF, Whitlock K, Amirouche F, Mehta AI, McDonnell A. Currently Adopted Criteria for Pedicle Screw Diameter Selection. Int J Spine Surg 2019; 13:132-145. [PMID: 31131212 PMCID: PMC6510178 DOI: 10.14444/6018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Transpedicular screw insertion has become widely accepted for the correction of spinal deformity as well as degenerative and traumatic injury, but adoption of this technique has remained less widespread in the thoracic compared to the lumbar spine. This is thought to be associated with the relative technical difficulty of screw insertion into the narrower widths of the thoracic pedicles and the neurologic and mechanical risks associated with breach of the pedicle wall. The surgical decision making involves determining the appropriate sized screw for maximum fixation strength while simultaneously respecting the structural integrity of the vertebral pedicles to prevent a breach and provide better fixation. This paper presents a systematic review of criteria for thoracic pedicle screw diameter (SD) selection in order to orient inexperienced surgeons on the impact of this selection on pedicle breaching and fixation strength. METHODS We performed a systematic literature review focused on studies reporting SD selection in relation to pedicle dimensions, measures of fixation strength, and breach rate. RESULTS Twenty-nine articles that measured fixation strength, breach rate, and/or provided SD in relation to pedicle width were selected for inclusion. CONCLUSIONS A commonly accepted criteria for pedicle SD selection has not yet been proposed. Screw diameters approximately 80% of the pedicle width have been adopted, but this proportion is rarely reported in the midthoracic vertebrae for which smaller pedicles and inadequate hardware specificity result in higher breach rates. Depending upon the insertion technique adopted, greater specificity in diameter selection by vertebral level should be pursued in order to maximally target cortical bone purchase. CLINICAL RELEVANCE Based on this review of the literature, we believe that proper selection of the SD for individual vertebral level directly affects the insertion technique and the potential breach.
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Affiliation(s)
- Giovanni F Solitro
- Department of Orthopaedics, Louisiana State University Health Science Center, Shreveport, Louisiana
| | - Keith Whitlock
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Farid Amirouche
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Annie McDonnell
- Department of Mechanical Engineering, University of Illinois at Chicago, Chicago, Illinois
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17
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Prospective Multicenter Study of a Multistep Screw Insertion Technique Using Patient-Specific Screw Guide Templates for the Cervical and Thoracic Spine. Spine (Phila Pa 1976) 2018; 43:1685-1694. [PMID: 30045345 DOI: 10.1097/brs.0000000000002810] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective clinical study of a multistep screw insertion method using a patient-specific screw guide template system (SGTS) for the cervical and thoracic spine. OBJECTIVE To evaluate the efficacy of SGTS for inserting screws into the cervical and thoracic spine. SUMMARY OF BACKGROUND DATA Posterior screw fixation is a standard procedure for spinal instrumentation; however, screw insertion carries the risk of injury to neuronal and vascular structures. METHODS Preoperative bone images of the computed tomography (CT) scans were analyzed using 3D/multiplanar imaging software, and the screw trajectories were planned. Plastic templates with screw-guiding structures were created for each lamina using 3D design and printing technology. Three types of templates were made for precise multistep guidance, and all the templates were specially designed to fit and lock onto the lamina during the procedure. In addition, plastic vertebra models were generated, and preoperative screw insertion simulation was performed. This patient-specific SGTS was used to perform the surgery, and CT scanning was used to postoperatively evaluate screw placement. RESULTS Enrolled to verify this procedure were 103 patients with cervical, thoracic, or cervicothoracic pathologies. The SGTS were used to place 813 screws. Preoperatively, each template was found to fit exactly and to lock onto the lamina of the vertebra models. In addition, intraoperatively, the templates fit and locked onto the patient lamina, and the screws were inserted successfully. Postoperative CT scans confirmed that 801 screws (98.5%) were accurately placed without cortical violation. There were no injuries to the vessels or nerves. CONCLUSION The multistep, patient-specific SGTS is useful for intraoperative pedicle screw (PS) navigation in the cervical and thoracic spine. This method improves the accuracy of PS insertion and reduces the operating time and radiation exposure during spinal fixation surgery. LEVEL OF EVIDENCE 3.
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18
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Jakubovic R, Guha D, Gupta S, Lu M, Jivraj J, Standish BA, Leung MK, Mariampillai A, Lee K, Siegler P, Skowron P, Farooq H, Nguyen N, Alarcon J, Deorajh R, Ramjist J, Ford M, Howard P, Phan N, Costa LD, Heyn C, Tan G, George R, Cadotte DW, Mainprize T, Yee A, Yang VXD. High Speed, High Density Intraoperative 3D Optical Topographical Imaging with Efficient Registration to MRI and CT for Craniospinal Surgical Navigation. Sci Rep 2018; 8:14894. [PMID: 30291261 PMCID: PMC6173775 DOI: 10.1038/s41598-018-32424-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 09/05/2018] [Indexed: 11/09/2022] Open
Abstract
Intraoperative image-guided surgical navigation for craniospinal procedures has significantly improved accuracy by providing an avenue for the surgeon to visualize underlying internal structures corresponding to the exposed surface anatomy. Despite the obvious benefits of surgical navigation, surgeon adoption remains relatively low due to long setup and registration times, steep learning curves, and workflow disruptions. We introduce an experimental navigation system utilizing optical topographical imaging (OTI) to acquire the 3D surface anatomy of the surgical cavity, enabling visualization of internal structures relative to exposed surface anatomy from registered preoperative images. Our OTI approach includes near instantaneous and accurate optical measurement of >250,000 surface points, computed at >52,000 points-per-second for considerably faster patient registration than commercially available benchmark systems without compromising spatial accuracy. Our experience of 171 human craniospinal surgical procedures, demonstrated significant workflow improvement (41 s vs. 258 s and 794 s, p < 0.05) relative to benchmark navigation systems without compromising surgical accuracy. Our advancements provide the cornerstone for widespread adoption of image guidance technologies for faster and safer surgeries without intraoperative CT or MRI scans. This work represents a major workflow improvement for navigated craniospinal procedures with possible extension to other image-guided applications.
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Affiliation(s)
- Raphael Jakubovic
- Department of Biomedical Physics, Ryerson University, Toronto, ON, Canada.,Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Daipayan Guha
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, School of Graduate Studies, University of Toronto, Toronto, ON, Canada
| | - Shaurya Gupta
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael Lu
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jamil Jivraj
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON, Canada
| | - Beau A Standish
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Michael K Leung
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Adrian Mariampillai
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kenneth Lee
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Peter Siegler
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Patryk Skowron
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON, Canada
| | - Hamza Farooq
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON, Canada
| | - Nhu Nguyen
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON, Canada
| | - Joseph Alarcon
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON, Canada
| | - Ryan Deorajh
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON, Canada
| | - Joel Ramjist
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON, Canada
| | - Michael Ford
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Peter Howard
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Nicolas Phan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Leo da Costa
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Chris Heyn
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Gamaliel Tan
- Jurong Health, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Rajeesh George
- Jurong Health, Ng Teng Fong General Hospital, Singapore, Singapore
| | - David W Cadotte
- Spine Program and Division of Neurosurgery, Department of Clinical Neurosciences, Department of Radiology, University of Calgary, Calgary, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Todd Mainprize
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Albert Yee
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Victor X D Yang
- Biophotonics and Bioengineering Laboratory, Ryerson University Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Institute of Medical Science, School of Graduate Studies, University of Toronto, Toronto, ON, Canada. .,Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON, Canada.
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19
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Scarone P, Vincenzo G, Distefano D, Del Grande F, Cianfoni A, Presilla S, Reinert M. Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine: a retrospective cohort study of 263 patients. J Neurosurg Spine 2018; 29:397-406. [DOI: 10.3171/2018.1.spine17927] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVENavigation-enabling technology such as 3D-platform (O-arm) or intraoperative mobile CT (iCT-Airo) systems for use in spinal surgery has considerably improved accuracy over that of traditional fluoroscopy-guided techniques during pedicular screw positioning. In this study, the authors compared 2 intraoperative imaging systems with navigation, available in their neurosurgical unit, in terms of the accuracy they provided for transpedicular screw fixation in the thoracic and lumbar spine.METHODSThe authors performed a retrospective analysis of clinical and surgical data of 263 consecutive patients who underwent thoracic and lumbar spine screw placement in the same center. Data on 97 patients who underwent surgery with iCT-Airo navigation (iCT-Airo group) and 166 with O-arm navigation (O-arm group) were analyzed. Most patients underwent surgery for a degenerative or traumatic condition that involved thoracic and lumbar pedicle screw fixation using an open or percutaneous technique. The primary endpoint was the proportion of patients with at least 1 screw not correctly positioned according to the last intraoperative image. Secondary endpoints were the proportion of screws that were repositioned during surgery, the proportion of patients with a postoperative complication related to screw malposition, surgical time, and radiation exposure. A blinded radiologist graded screw positions in the last intraoperative image according to the Heary classification (grade 1–3 screws were considered correctly placed).RESULTSA total of 1361 screws placed in 97 patients in the iCT-Airo group (503 screws) and in 166 in the O-arm group (858 screws) were graded. Of those screws, 3 (0.6%) in the iCT-Airo group and 4 (0.5%) in the O-arm group were misplaced. No statistically significant difference in final accuracy between these 2 groups or in the subpopulation of patients who underwent percutaneous surgery was found. Three patients in the iCT-Airo group (3.1%, 95% CI 0%–6.9%) and 3 in the O-arm group (1.8%, 95% CI 0%–4.0%) had a misplaced screw (Heary grade 4 or 5). Seven (1.4%) screws in the iCT-Airo group and 37 (4.3%) in the O-arm group were repositioned intraoperatively (p = 0.003). One patient in the iCT-Airo group and 2 in the O-arm group experienced postoperative neurological deficits related to hardware malposition. The mean surgical times in both groups were similar (276 [iCT-Airo] and 279 [O-arm] minutes). The mean exposure to radiation in the iCT-Airo group was significantly lower than that in the O-arm group (15.82 vs 19.12 mSv, respectively; p = 0.02).CONCLUSIONSIntroduction of a mobile CT scanner reduced the rate of screw repositioning, which enhanced patient safety and diminished radiation exposure for patients, but it did not improve overall accuracy compared to that of a mobile 3D platform.
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Affiliation(s)
- Pietro Scarone
- 1Neurosurgical Service, Neurocenter of Southern Switzerland, and
| | | | | | | | | | - Stefano Presilla
- 3Medical Physics Service, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Michael Reinert
- 1Neurosurgical Service, Neurocenter of Southern Switzerland, and
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20
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Abstract
STUDY DESIGN A cadaveric biomechanical study designed to test the pullout strength of pedicle screws. OBJECTIVE To evaluate the pullout strength of redirected pedicle screws with a larger diameter following lateral wall breach, redirected pedicle screws of the same diameter following medial wall breach, and redirected pedicle screws with a larger diameter following medial wall breach. SUMMARY OF BACKGROUND DATA Screw malposition is one of the main pitfalls of inserting pedicle screws. Intraoperatively a malpositioned screw is redirected and inserted along the correct axis. METHODS Forty-seven vertebrae (T9-L5) were harvested from eight fresh cadaveric spines. The 18 pedicle screws that breached the lateral wall were then removed and redirected using a pedicle screw of 1 mm larger in diameter. The 16 pedicle screws that had breached the medial wall were then removed and redirected using a pedicle screw of the same diameter. The other 13 pedicle screws that had breached the medial wall were then removed and redirected using a pedicle screw of 1 mm larger in diameter. The pullout strength was measured. RESULTS Following lateral wall breach, mean pullout strength for the larger redirected screws was 46.9% greater than that of the correctly aligned screws. Following medial wall breach, mean pullout strength for the redirected screws of the same diameter was 20.6% less than that of the correctly aligned screws. Mean pullout strength for the larger pedicle screws following medial wall breach was 27.3% more than that of the correctly aligned screws. CONCLUSION Redirected pedicle screws of larger diameter after a lateral or medial pedicle breach show recovery of pullout strength. However, the pullout strength of redirected pedicle screws of the same diameter after a medial pedicle breach is significantly less than that of correctly aligned screws. LEVEL OF EVIDENCE 1.
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Satarasinghe P, Hamilton KD, Tarver MJ, Buchanan RJ, Koltz MT. Thoracic, Lumbar, and Sacral Pedicle Screw Placement Using Stryker-Ziehm Virtual Screw Technology and Navigated Stryker Cordless Driver 3: Technical Note. J Clin Med 2018; 7:jcm7040084. [PMID: 29673199 PMCID: PMC5920458 DOI: 10.3390/jcm7040084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 04/13/2018] [Accepted: 04/13/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECT Utilization of pedicle screws (PS) for spine stabilization is common in spinal surgery. With reliance on visual inspection of anatomical landmarks prior to screw placement, the free-hand technique requires a high level of surgeon skill and precision. Three-dimensional (3D), computer-assisted virtual neuronavigation improves the precision of PS placement and minimization steps. METHODS Twenty-three patients with degenerative, traumatic, or neoplastic pathologies received treatment via a novel three-step PS technique that utilizes a navigated power driver in combination with virtual screw technology. (1) Following visualization of neuroanatomy using intraoperative CT, a navigated 3-mm match stick drill bit was inserted at an anatomical entry point with a screen projection showing a virtual screw. (2) A Navigated Stryker Cordless Driver with an appropriate tap was used to access the vertebral body through a pedicle with a screen projection again showing a virtual screw. (3) A Navigated Stryker Cordless Driver with an actual screw was used with a screen projection showing the same virtual screw. One hundred and forty-four consecutive screws were inserted using this three-step, navigated driver, virtual screw technique. RESULTS Only 1 screw needed intraoperative revision after insertion using the three-step, navigated driver, virtual PS technique. This amounts to a 0.69% revision rate. One hundred percent of patients had intraoperative CT reconstructed images taken to confirm hardware placement. CONCLUSIONS Pedicle screw placement utilizing the Stryker-Ziehm neuronavigation virtual screw technology with a three step, navigated power drill technique is safe and effective.
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Affiliation(s)
- Praveen Satarasinghe
- Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
| | - Kojo D Hamilton
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | - Michael J Tarver
- Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
| | - Robert J Buchanan
- Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
- Department of Neurosurgery, Seton Brain and Spine Institute, Austin, TX 78712, USA.
| | - Michael T Koltz
- Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
- Department of Neurosurgery, Seton Brain and Spine Institute, Austin, TX 78712, USA.
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Liu H, Chen W, Liu T, Meng B, Yang H. Accuracy of pedicle screw placement based on preoperative computed tomography versus intraoperative data set acquisition for spinal navigation system. J Orthop Surg (Hong Kong) 2018; 25:2309499017718901. [PMID: 28673199 DOI: 10.1177/2309499017718901] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM To investigate the accuracy of pedicle screw placement based on preoperative computed tomography in comparison with intraoperative data set acquisition for spinal navigation system. METHODS The PubMed (MEDLINE), EMBASE, and Web of Science were systematically searched for the literature published up to September 2015. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Statistical analysis was performed using the Review Manager 5.3. The dichotomous data for the pedicle violation rate was summarized using relative risk (RR) and 95% confidence intervals (CIs) with the fixed-effects model. The level of significance was set at p < 0.05. RESULTS For this meta-analysis, seven studies used a total of 579 patients and 2981 screws. The results revealed that the accuracy of intraoperative data set acquisition method is significantly higher than preoperative one using 2 mm grading criteria (RR: 1.82, 95% CI: 1.09, 3.04, I2 = 0%, p = 0.02). However, there was no significant difference between two kinds of methods at the 0 mm grading criteria (RR: 1.13, 95% CI: 0.88, 1.46, I2 = 17%, p = 0.34). Using the 2-mm grading criteria, there was a higher accuracy of pedicle screw insertion in O-arm-assisted navigation than CT-based navigation method (RR: 1.96, 95% CI: 1.05, 3.64, I2 = 0%, p = 0.03). The accuracy between CT-based navigation and two-dimensional-based navigation showed no significant difference (RR: 1.02, 95% CI: 0.35-3.03, I2 = 0%, p = 0.97). CONCLUSIONS The intraoperative data set acquisition method may decrease the incidence of perforated screws over 2 mm but not increase the number of screws fully contained within the pedicle compared to preoperative CT-based navigation system. A significantly higher accuracy of intraoperative (O-arm) than preoperative CT-based navigation was revealed using 2 mm grading criteria.
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Affiliation(s)
- Hao Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Weikai Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Tao Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Bin Meng
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Huilin Yang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
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Fomekong E, Pierrard J, Raftopoulos C. Comparative Cohort Study of Percutaneous Pedicle Screw Implantation without Versus with Navigation in Patients Undergoing Surgery for Degenerative Lumbar Disc Disease. World Neurosurg 2018; 111:e410-e417. [DOI: 10.1016/j.wneu.2017.12.080] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 11/16/2022]
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Wagner SC, Morrissey PB, Kaye ID, Sebastian A, Butler JS, Kepler CK. Intraoperative pedicle screw navigation does not significantly affect complication rates after spine surgery. J Clin Neurosci 2017; 47:198-201. [PMID: 29050896 DOI: 10.1016/j.jocn.2017.09.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/30/2017] [Indexed: 11/19/2022]
Abstract
Various forms of intraoperative computer-assisted navigation technologies exist, and have consistently been shown to improve pedicle screw accuracy. However, the overall clinical effects of inaccurate pedicle screw placement have been debated. We examined the clinical effects of improved pedicle screw accuracy with computer navigation technology in reducing complication rates in patients undergoing multi-level spinal fusion. We retrospectively reviewed the ACS-NSQIP registry utilizing Current Procedural Terminology (CPT) codes 22843 + 22844 to identify patients undergoing spinal instrumentation of greater than 7 levels, as well as the CPT code 61783 to denote the use of intraoperative computer-assisted navigation. The data were then subdivided to into cohorts consisting of instrumentation cases with and without navigation. Demographic information, as well as intraoperative and postoperative complications, were compared between groups. A total of 3168 patients met our inclusion criteria. There were no statistically significant differences in preoperative population data. Surgical time was significantly longer in the navigation group (391.41 versus 350.3 min), but there were no significant improvements in complication rates with the use of navigation. We found that the mean operative time was significantly increased for patients undergoing spinal instrumentation with computer navigation. This increase in operative time was not associated with any increase in surgical or medical complications. However, in this large series, we were unable to show any clinical benefit to intraoperative navigation, and no reductions in short term complications or rates of return to surgery were observed.
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Affiliation(s)
- Scott C Wagner
- Department of Orthopaedic Surgery, Rothman Instititute at Thomas Jefferson University, United States.
| | - Patrick B Morrissey
- Department of Orthopaedic Surgery, Rothman Instititute at Thomas Jefferson University, United States
| | - Ian D Kaye
- Department of Orthopaedic Surgery, Rothman Instititute at Thomas Jefferson University, United States
| | - Arjun Sebastian
- Department of Orthopaedic Surgery, Rothman Instititute at Thomas Jefferson University, United States
| | - Joseph S Butler
- Department of Orthopaedic Surgery, Rothman Instititute at Thomas Jefferson University, United States
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Instititute at Thomas Jefferson University, United States
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Revision Rate of Misplaced Pedicle Screws of the Thoracolumbar Spine-Comparison of Three-Dimensional Fluoroscopy Navigation with Freehand Placement: A Systematic Analysis and Review of the Literature. World Neurosurg 2017; 109:e24-e32. [PMID: 28951183 DOI: 10.1016/j.wneu.2017.09.091] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/13/2017] [Accepted: 09/14/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recent studies have shown higher accuracy rates of image-guided pedicle screw placement compared to freehand (FH) placement. However, data focusing on the impact of spinal navigation on the rate of revision surgeries caused by misplaced pedicle screws (PS) are scarce. OBJECTIVE This study is aimed at identifying the rate of revision surgeries for misplaced PS comparing three-dimensional (3D) fluoroscopy navigation (3DFL) with FH PS placement. METHODS A retrospective analysis was conducted of 2232 patients (mean age, 65.3 ± 13.5 years) with 13,703 implanted PS who underwent instrumentation of the thoracolumbar spine between 2007 and 2015. Group 1 received surgery with use of 3DFL (January 2011 to December 2015), group 2 received surgery in the FH technique (April 2007 to December 2015). Because the use of 3DFL was initiated in January 2011, the examined period for 3DFL-navigated surgeries is shorter. Patients routinely received postoperative computed tomography scans and/or intraoperative control 3D scans. RESULTS There was an overall rate of revision surgeries for malpositioned PS of 2.9%. In the 3DFL group, the rate of secondary revision surgeries was significantly lower with 1.35% (15/1112 patients) compared to 4.38% (49/1120 patients) in the FH group, respectively (odds ratio, 3.35; P < 0.01). Of all PS in the 3DFL group (30/7548 PS), 0.40% needed revision surgery (P < 0.01) compared to 1.14% in the FH group (70/6155 PS). CONCLUSIONS We were able to show that the use of 3DFL-navigated PS placement significantly reduces the rate of revision surgeries after posterior spinal instrumentation compared to freehand PS placement.
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Du JP, Fan Y, Wu QN, Wang DH, Zhang J, Hao DJ. Accuracy of Pedicle Screw Insertion Among 3 Image-Guided Navigation Systems: Systematic Review and Meta-Analysis. World Neurosurg 2017; 109:24-30. [PMID: 28917704 DOI: 10.1016/j.wneu.2017.07.154] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Many retrospective studies of pedicle screw placement have revealed that intraoperative navigation systems provide higher accuracy rates and safety than do free-hand techniques. The accuracy of various image-guided navigation systems has been studied; however, differences have not been well defined due to the lack of adequate evidence-based comparative studies. OBJECTIVE A meta-analysis was conducted to focus on the variation in pedicle screw insertion among 3 navigation systems: a 3-dimensional fluoroscopy-based navigation system (3D FluoroNav), a 2-dimensional fluoroscopy-based navigation system (2D FluoroNav), and a conventional computed tomography navigation system (CT Nav). METHODS We screened for comparative studies on different pedicle screw insertion navigation systems published through January 2017 using the Cochrane Library, Ovid, Web of Science, PubMed, and EMBASE databases. RESULTS From 125 papers that were identified, 10 articles were finally chosen. The present comparative study included 8 retrospective clinical studies, 1 prospective clinical trial, and 1 randomized controlled cadaveric study. The prevalence rate of pedicle violation in the 3D FluoroNav group was significantly lower than the rates of the 2D FluoroNav group (relative risk [RR] 95%, confidence interval [CI]: 0.16-0.61, P < 0.01) and the CT Nav group (RR 95%, CI: 0.42-0.90, P = 0.01), and the rate of the CT Nav group was significantly lower than that of the 2D FluoroNav group (RR 95%, CI: 0.29-0.81, P < 0.01). CONCLUSION Significant differences exist among CT Nav, 3D FluoroNav, and 2D FluoroNav. Our review suggests that 3D FluoroNav may be superior to the other 2 methods in reducing pedicle violation and that clinicians should consider 3D FluoroNav as a better choice.
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Affiliation(s)
- Jin Peng Du
- Medical College, Yan'an University, Yan'an City, Shanxi Province, China
| | - Yong Fan
- Department of Spine Surgery, Xi'an Jiaotong University-Affiliated Honghui Hospital, Youyidong Road, Xi'an City, China
| | - Qi Ning Wu
- Department of Spine Surgery, Xi'an Jiaotong University-Affiliated Honghui Hospital, Youyidong Road, Xi'an City, China
| | - Dai Hua Wang
- Medical College, Yan'an University, Yan'an City, Shanxi Province, China
| | - Jing Zhang
- Medical College, Yan'an University, Yan'an City, Shanxi Province, China
| | - Ding Jun Hao
- Department of Spine Surgery, Xi'an Jiaotong University-Affiliated Honghui Hospital, Youyidong Road, Xi'an City, China.
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Narain AS, Hijji FY, Yom KH, Kudaravalli KT, Haws BE, Singh K. Radiation exposure and reduction in the operating room: Perspectives and future directions in spine surgery. World J Orthop 2017; 8:524-530. [PMID: 28808622 PMCID: PMC5534400 DOI: 10.5312/wjo.v8.i7.524] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/21/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
Intraoperative imaging is vital for accurate placement of instrumentation in spine surgery. However, the use of biplanar fluoroscopy and other intraoperative imaging modalities is associated with the risk of significant radiation exposure in the patient, surgeon, and surgical staff. Radiation exposure in the form of ionizing radiation can lead to cellular damage via the induction of DNA lesions and the production of reactive oxygen species. These effects often result in cell death or genomic instability, leading to various radiation-associated pathologies including an increased risk of malignancy. In attempts to reduce radiation-associated health risks, radiation safety has become an important topic in the medical field. All practitioners, regardless of practice setting, can practice radiation safety techniques including shielding and distance to reduce radiation exposure. Additionally, optimization of fluoroscopic settings and techniques can be used as an effective method of radiation dose reduction. New imaging modalities and spinal navigation systems have also been developed in an effort to replace conventional fluoroscopy and reduce radiation doses. These modalities include Isocentric Three-Dimensional C-Arms, O-Arms, and intraoperative magnetic resonance imaging. While this influx of new technology has advanced radiation safety within the field of spine surgery, more work is still required to overcome specific limitations involving increased costs and inadequate training.
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Rate and mode of screw misplacements after 3D-fluoroscopy navigation-assisted insertion and 3D-imaging control of 1547 pedicle screws in spinal levels T10-S1 related to vertebrae and spinal sections. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2898-2905. [DOI: 10.1007/s00586-017-5108-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 03/18/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
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Guha D, Jakubovic R, Gupta S, Alotaibi NM, Cadotte D, da Costa LB, George R, Heyn C, Howard P, Kapadia A, Klostranec JM, Phan N, Tan G, Mainprize TG, Yee A, Yang VXD. Spinal intraoperative three-dimensional navigation: correlation between clinical and absolute engineering accuracy. Spine J 2017; 17:489-498. [PMID: 27777052 DOI: 10.1016/j.spinee.2016.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/19/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal intraoperative computer-assisted navigation (CAN) may guide pedicle screw placement. Computer-assisted navigation techniques have been reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably and reported in less than a quarter of clinical studies of CAN-guided pedicle screw accuracy. PURPOSE This study aimed to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy. DESIGN/SETTING This is a retrospective review of a prospectively collected cohort. PATIENT SAMPLE We recruited 30 patients undergoing first-time posterior cervical-thoracic-lumbar-sacral instrumented fusion±decompression, guided by intraoperative three-dimensional CAN. OUTCOME MEASURES Clinical or radiographic screw accuracy (Heary and 2 mm classifications) and absolute quantitative navigation accuracy (translational and angular error in axial and sagittal planes). METHODS We reviewed a prospectively collected series of 209 pedicle screws placed with CAN guidance. Each screw was graded clinically by multiple independent raters using the Heary and 2 mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes. RESULTS Acceptable screw accuracy was achieved for significantly fewer screws based on 2 mm grade versus Heary grade (92.6% vs. 95.1%, p=.036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2 mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational-angular accuracies were 1.75 mm-3.13° and 1.20 mm-3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy. CONCLUSIONS Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on postoperative imaging may be more reliable if performed in multiple by radiologist raters.
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Affiliation(s)
- Daipayan Guha
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Raphael Jakubovic
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Department of Biomedical Physics, Ryerson University, 350 Victoria St., Toronto, ON, M5B 2K3, Canada
| | - Shaurya Gupta
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - David Cadotte
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Leodante B da Costa
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Rajeesh George
- JurongHealth, Ng Teng Fong General Hospital, 1 Jurong East Street, Singapore, 609606, Singapore
| | - Chris Heyn
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Peter Howard
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Anish Kapadia
- Department of Medical Imaging, University of Toronto, 263 McCaul St., Toronto, ON, M5T 1W7, Canada
| | - Jesse M Klostranec
- Department of Medical Imaging, University of Toronto, 263 McCaul St., Toronto, ON, M5T 1W7, Canada
| | - Nicolas Phan
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Gamaliel Tan
- JurongHealth, Ng Teng Fong General Hospital, 1 Jurong East Street, Singapore, 609606, Singapore
| | - Todd G Mainprize
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Albert Yee
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 149 College St., Toronto, ON, M5T 1P5, Canada
| | - Victor X D Yang
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Department of Electrical and Computer Engineering, Ryerson University, 350 Victoria St., Toronto, ON, M5B 2K3, Canada.
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Minimizing Pedicle Screw Pullout Risks: A Detailed Biomechanical Analysis of Screw Design and Placement. Clin Spine Surg 2017; 30:E226-E232. [PMID: 28323704 DOI: 10.1097/bsd.0000000000000151] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
STUDY DESIGN Detailed biomechanical analysis of the anchorage performance provided by different pedicle screw designs and placement strategies under pullout loading. OBJECTIVE To biomechanically characterize the specific effects of surgeon-specific pedicle screw design parameters on anchorage performance using a finite element model. SUMMARY OF BACKGROUND DATA Pedicle screw fixation is commonly used in the treatment of spinal pathologies. However, there is little consensus on the selection of an optimal screw type, size, and insertion trajectory depending on vertebra dimension and shape. METHODS Different screw diameters and lengths, threads, and insertion trajectories were computationally tested using a design of experiment approach. A detailed finite element model of an L3 vertebra was created including elastoplastic bone properties and contact interactions with the screws. Loads and boundary conditions were applied to the screws to simulate axial pullout tests. Force-displacement responses and internal stresses were analyzed to determine the specific effects of each parameter. RESULTS The design of experiment analysis revealed significant effects (P<0.01) for all tested principal parameters along with the interactions between diameter and trajectory. Screw diameter had the greatest impact on anchorage performance. The best insertion trajectory to resist pullout involved placing the screw threads closer to the pedicle walls using the straightforward insertion technique, which showed the importance of the cortical layer grip. The simulated cylindrical single-lead thread screws presented better biomechanical anchorage than the conical dual-lead thread screws in axial loading conditions. CONCLUSIONS The model made it possible to quantitatively measure the effects of both screw design characteristics and surgical choices, enabling to recommend strategies to improve single pedicle screw performance under axial loading.
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Accurate and Simple Screw Insertion Procedure With Patient-Specific Screw Guide Templates for Posterior C1-C2 Fixation. Spine (Phila Pa 1976) 2017; 42:E340-E346. [PMID: 27454537 DOI: 10.1097/brs.0000000000001807] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective clinical trial of the screw insertion method for posterior C1-C2 fixation utilizing the patient-specific screw guide template technique. OBJECTIVE To evaluate the efficacy of this method for insertion of C1 lateral mass screws (LMS), C2 pedicle screws (PS), and C2 laminar screws (LS). SUMMARY OF BACKGROUND DATA Posterior C1LMS and C2PS fixation, also known as the Goel-Harms method, can achieve immediate rigid fixation and high fusion rate, but the screw insertion carries the risk of injury to neuronal and vascular structures. Dissection of venous plexus and C2 nerve root to confirm the insertion point of the C1LMS may also cause problems. We have developed an intraoperative screw guiding method using patient-specific laminar templates. METHODS Preoperative bone images of computed tomography (CT) were analyzed using three-dimensional (3D)/multiplanar imaging software to plan the trajectories of the screws. Plastic templates with screw guiding structures were created for each lamina using 3D design and printing technology. Three types of templates were made for precise multistep guidance, and all templates were specially designed to fit and lock on the lamina during the procedure. Surgery was performed using this patient-specific screw guide template system, and placement of the screws was postoperatively evaluated using CT. RESULTS Twelve patients with C1-C2 instability were treated with a total of 48 screws (24 C1LMS, 20 C2PS, 4 C2LS). Intraoperatively, each template was found to exactly fit and lock on the lamina and screw insertion was completed successfully without dissection of the venous plexus and C2 nerve root. Postoperative CT showed no cortical violation by the screws, and mean deviation of the screws from the planned trajectories was 0.70 ± 0.42 mm. CONCLUSION The multistep, patient-specific screw guide template system is useful for intraoperative screw navigation in posterior C1-C2 fixation. This simple and economical method can improve the accuracy of screw insertion, and reduce operation time and radiation exposure of posterior C1-C2 fixation surgery. LEVEL OF EVIDENCE 3.
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Miller CA, Ledonio CG, Hunt MA, Siddiq F, Polly DW. Reliability of the Planned Pedicle Screw Trajectory versus the Actual Pedicle Screw Trajectory using Intra-operative 3D CT and Image Guidance. Int J Spine Surg 2016; 10:38. [PMID: 27909659 DOI: 10.14444/3038] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Technological advances, including navigation, have been made to improve safety and accuracy of pedicle screw fixation. We evaluated the accuracy of the virtual screw placement (Stealth projection) compared to actual screw placement (intra-operative O-Arm) and examined for differences based on the distance from the reference frame. METHODS A retrospective evaluation of prospectively collected data was conducted from January 2013 to September 2013. We evaluated thoracic and lumbosacral pedicle screws placed using intraoperative O-arm and Stealth navigation by obtaining virtual screw projections and intraoperative O-arm images after screw placement. The screw trajectory angle to the midsagittal line and superior endplate was compared in the axial and sagittal views, respectively. Percent error and paired t-test statistics were then performed. RESULTS Thirty-one patients with 240 pedicle screws were analyzed. The mean angular difference between the virtual and actual image in all screws was 2.17° ± 2.20° on axial images and 2.16° ± 2.24° on sagittal images. There was excellent agreement between actual and virtual pedicle screw trajectories in the axial and sagittal plane with ICC = 0.99 (95%CI: 0.992-0.995) (p<0.001) and ICC= 0.81 (95%CI: 0.759-0.855) (p<0.001) respectively. When comparing thoracic and lumbar screws, there was a significant difference in the sagittal angulation between the two distributions. No statistical differences were found distance from the reference frame. CONCLUSION The virtual projection view is clinically accurate compared to the actual placement on intra-operative CT in both the axial and sagittal views. There is slight imprecision (~2°) in the axial and sagittal planes and a minor difference in the sagittal thoracic and lumbar angulation, although these did not affect clinical outcomes. In general, we find that pedicle screw placement using intraoperative cone beam CT and navigation to be accurate and reliable, and as such have made it a routine part of our spine practice. This study was approved by the University of Minnesota IRB (#1303E30544).
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Affiliation(s)
| | | | - Matthew A Hunt
- University of Minnesota Department of Neurosurgery, Minneapolis, MN
| | - Farhan Siddiq
- Jefferson University Department of Neurosurgery, St. Mary Medical Center, Langhorne, PA
| | - David W Polly
- University of Minnesota Department of Orthopaedics, Minneapolis, MN
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Abstract
BACKGROUND Intraoperative imaging during spinal interventions has experienced significant developments over the last two decades. By the introduction of flat screen detectors, 3D imaging has been made possible and easier and by developing compact and mobile systems computed tomography can even be used in the operating theater. OBJECTIVE Presentation of modern intraoperative 3D imaging and navigation in spinal surgery. MATERIAL AND METHODS The techniques of intraoperative 3D imaging and navigation during spinal procedures are presented based on the currently available literature and own experiences at a German national spine and trauma center. RESULTS The use of flat panel detectors and the possibility of 3D visualization nowadays substantially facilitate the use of navigation and allow certain control of surgical results even during the intervention. Radiation exposure of the whole team in the operating theater can be significantly reduced by the new techniques. CONCLUSION The advantages of intraoperative 3D imaging with a clear improvement of visualization for spinal surgeons and the certain control of materials at the end of the operation are obvious. Even the use of navigation has been greatly simplified and can therefore lead to an even greater precision and less radiation exposure. There are even more sophisticated developments, such as operation suites and intraoperative computed tomography but these are initially reserved for selected centers.
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The Pullout Strength of Pedicle Screws Following Redirection After Lateral Wall Breach or End-plate Breach. Spine (Phila Pa 1976) 2016; 41:1218-1223. [PMID: 27046637 DOI: 10.1097/brs.0000000000001600] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Using fresh cadavers, the biomechanical testing were used to examine the pullout strength of each pedicle screw. OBJECTIVE The aim of this study was to evaluate pullout strength of (1) a redirected pedicle screw following lateral wall breach; (2) a redirected pedicle screw following end-plate breach; and (3) a pedicle without redirection after end-plate breach without redirection. SUMMARY OF BACKGROUND DATA Screw malposition, such as lateral wall breach or end-plate breach, is one of the main pitfalls of inserting pedicle screws. METHODS From 17 fresh spines, 54 vertebrae were harvested. In each vertebra on one pedicle, the screw was inserted correctly down the axis of the pedicle, while on the other pedicle, the screw was inserted to breach the lateral wall or the end-plate. The 18 pedicle screws that breached the lateral wall were then removed and redirected along the correct axis of the pedicle. The 18 pedicle screws that breached the end-plate were removed and redirected along the correct axis of the pedicle. The 18 other pedicle screws that had breached the end-plate were not removed. The pullout force of pedicle screws was measured. RESULTS First, the mean pullout strength for the redirected screws following lateral wall breach was 24.0% less as compared with the correctly aligned screws. Second, the mean pullout strength for the redirected screws following end-plate breach was 23.3% less as compared with the correctly aligned screws. Third, the mean pullout strength for the pedicle screws end-plate breach was 7.6% less as compared with the correctly aligned screws. CONCLUSION The pullout strength of redirected pedicle screws after either a lateral pedicle breach or end-plate breach is significantly less than the pullout strength of correctly aligned screw. A pedicle screw that is not redirected after end-plate breach is weaker than a pedicle screw correctly aligned; however, the difference is not significant. LEVEL OF EVIDENCE N/A.
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Surgery for ventral intradural thoracic spinal tumors with a posterolateral transpedicular approach. Acta Neurochir (Wien) 2016; 158:1563-9. [PMID: 27290663 DOI: 10.1007/s00701-016-2864-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 06/02/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surgery for ventrally seated thoracic tumors requires an anatomically specific approach that is distinct from cervical or lumbar spinal cord surgery as the narrower spinal canal of the thoracic spinal cord makes it sensitive to surgical procedures. However, reports describing this operative technique are few. To obtain a wide operative field and minimize thoracic spinal cord retraction, we employed a posterolateral transpedicular approach in ventral-located tumors and investigated the efficacy and limitations of this technique. METHOD Eighteen patients with lesions (meningioma or neurinoma) located in the ventral intradural thoracic region were surgically treated between 2009 and 2014. The relationship among the clinical outcome, tumor location, and postoperative spinal alignment was analyzed. RESULTS Postoperative neurological function improved in all patients, namely those with meningioma (p = 0.012) and schwannoma (p = 0.018). One patient who underwent removal of two facet joints suffered a postoperative compression fracture. Removal of two facet joints and pedicles resulted in a worsening of spinal alignment (p = 0.03), while this was not the case for the removal of one facet joint and pedicle (p = 0.72). CONCLUSIONS This case series clarified the benefits of the posterolateral transpedicular approach for resection of ventral intradural extramedullary tumors. Removal of one pedicle and facet joint seems to be more beneficial.
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Verma SK, Singh PK, Agrawal D, Sinha S, Gupta D, Satyarthee GD, Sharma BS. O-arm with navigation versus C-arm: a review of screw placement over 3 years at a major trauma center. Br J Neurosurg 2016; 30:658-661. [DOI: 10.1080/02688697.2016.1206179] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
BACKGROUND There is a relatively high incidence of screw misplacement during spinal instrumentation due to distortion of normal anatomy following spinal trauma. AIMS AND OBJECTIVES To evaluate and share the initial experience with the use of neuro-navigated 3D O-arm(®) (Medtronic, USA) as compared to traditional 2D fluoroscopy in atrauma center in India. MATERIALS AND METHODS In this retrospective study, consecutive patients of spinal injury who underwent screw fixation under O-arm guidance over nine-month period (July 2010 till March 2011) were evaluated for accuracy of screw placement. An equal number of consecutive patients prior to March 2011 who underwent screw fixation in 2D fluoroscopy were included for comparison. Patient demographics and radiology were reviewed and spinal injury was assessed using the ASIA grading in both the groups. Screw placement was assessed by postoperative CT scans of the relevant spine and accuracy of screw placement and breach of the medial or lateral cortex of the pedicle were recorded for each case. RESULTS In the O-arm group, there were 57 patients in whom 210 screws were inserted. None of the patients had screw mal-placement. In 2D fluoroscopy group, 57 patients had 268 screws insertions. 10 (3.73%) screws were found to be malpositioned in the postoperative CT scans (8 in thoracic spine and 2 in odontoid fractures). The malposition rate was highly significant in 2D fluoroscopy thoracolumbar (P = 0.0015) subgroup. One patient had neurological deterioration and three patients required repositioning of the screws. CONCLUSION In a teaching center with multiple surgeons, the O-arm(®) imaging ensures accurate placement of screws as compared to traditional 2D fluoroscopy.
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Affiliation(s)
- Deepak Agrawal
- Department of Neurosurgery, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Accuracy of Pedicle Screw Placement in Children 10 Years or Younger Using Navigation and Intraoperative CT. Clin Spine Surg 2016; 29:E135-8. [PMID: 27007788 DOI: 10.1097/bsd.0000000000000230] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN A consecutive case series. OBJECTIVE To determine the revision rate for pedicle screws placed using intraoperative CT and image-guided navigation in children 10 years or younger. SUMMARY OF BACKGROUND DATA Screws are frequently used for spinal instrumentation in young children, although this is only by physician-directed use. This is a multicenter retrospective study of patients aged 10 years or younger, who underwent spinal screw instrumentation with image-guided navigation. We hypothesized that intraoperative navigation would result in a high rate of accuracy for screw placement. METHODS Between 2007 and 2013, 130 pedicle and 7 lateral mass screws were placed in 16 consecutive patients undergoing a total of 17 surgeries at 2 institutions. Mean age at surgery was 6.9 years (range, 0.8-10.9 y). Screws were placed using an open technique with intraoperative CT (O-arm) and image-guided navigation (Stealth). Procedures included: growing spine device (3), hemivertebrae excision (4), posterior fusion (7), cervical fusion (2), and vertebral column resection (1). Congenital deformity was the most common diagnosis. Primary outcome measures were need for intraoperative screw revision or complication associated with screw placement. RESULTS Mean number of screws used per procedure was 8.1 (range, 2-17). Screws were placed from C1 to L5. Of the 137 screws, 3 required revision to shorter screws for an overall accuracy rate of 97.8%. In 1 case, a right T3 screw was revised due to anterior penetration. In another case, left-sided T1 and T2 pedicle screws were shortened 5 mm because they had penetrated the anterior aspect of their respective vertebral bodies. There were no screw-related complications. CONCLUSIONS In this series, image-guided navigation resulted in accurate placement of screws in patients aged 10 years or younger with no associated intraoperative complications. The navigated accuracy rate (97.8%) is significantly higher (P=0.01) than the reported 90.9% pedicle screw accuracy rate without navigation in the same age group by Baghdadi and colleagues. Intraoperative CT and image guidance were useful in our practice for placement of screws in skeletally immature patients.
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Yoon JW, Nottmeier EW, Rahmathulla G, Fenton DS, Pirris SM. Redirecting pedicle screws: a revision spinal fusion strategy using three-dimensional image guidance. Int J Med Robot 2016; 12:758-764. [PMID: 26756720 DOI: 10.1002/rcs.1721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 09/10/2015] [Accepted: 11/13/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pedicle screws are a preferred method for spinal fixation because of their three-column support and rigid posterior stabilization. The purpose of this study was to evaluate the outcome of patients requiring pedicle screw redirection, and to describe a technique using cone-beam computed tomography (cbCT). METHODS A retrospective review of 30 patients undergoing revision spinal fusion with redirection of pedicle screws was performed. Fifty pedicle screws were redirected in these patients using cbCT-based 3D image guidance. They were graded pre- and post-operatively using an established grading system. RESULTS No complications occurred in this study as a result of redirection. No pedicle breach was noted in all of the redirected pedicle screws. CONCLUSION Redirection of misplaced pedicle screws using cbCT-based 3D image guidance seems to be safe and accurate in our experience. Further studies are needed to establish its safety, accuracy, fusion rate, and clinical outcome compared with other methods. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jang W Yoon
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Eric W Nottmeier
- St. Vincent's Spine and Brain Institute, Jacksonville, Florida, USA
| | - Gazanfar Rahmathulla
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA.,Department of Neurosurgery, Mayo Clinic Health System, Waycross, Georgia
| | - Douglas S Fenton
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Stephen M Pirris
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
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Comparison of navigated versus non-navigated pedicle screw placement in 260 patients and 1434 screws: screw accuracy, screw size, and the complexity of surgery. ACTA ACUST UNITED AC 2016; 28:E298-303. [PMID: 23511642 DOI: 10.1097/bsd.0b013e31828af33e] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Computer 3D navigation (3D NAV) techniques in spinal instrumentation can theoretically improve screw placement accuracy and reduce injury to critical neurovascular structures, especially in complex cases. In this series, we analyze the results of 3D NAV in pedicle screw placement accuracy, screw outer diameter, and case complexity in comparison with screws placed with conventional lateral fluoroscopy. METHODS Pedicle screws placed in the cervical, thoracic, or lumbar spine using either standard lateral fluoroscopy or 3D NAV using isocentric fluoroscopy were retrospectively analyzed. The accuracy of each individual screw was graded on a 4-tiered classification system. Screw and pedicle diameter measurements were also made in both cohorts, and case complexity was compared between the 2 cohorts. Complex cases were defined as deformity surgery, re-do cases, and minimally invasive surgery. RESULTS A total of 708 screws were placed under 3D NAV guidance and 726 screws were placed without stereotaxy. Eighty-eight percent of 3D NAV-guided pedicle screws were graded nonbreach versus 82% of cases with lateral fluoroscopy (P<0.001). The ratio of screw/pedicle diameter was significantly larger in the 3D NAV cohort (0.71 vs. 0.63, P<0.05). Seventy-six percent of 3D NAV cases had a predefined aspect of complexity, whereas 44% of non-3D NAV cases met criteria to be labeled complex (P<0.001). Reoperation occurred less frequently in 3D NAV cases than fluoroscopy alone. CONCLUSIONS The use of 3D NAV was associated with improved screw placement accuracy, improved screw-to-pedicle diameter measurements, and was used in cases with a higher degree of surgical complexity. We conclude that 3D NAV is a valuable tool in current spinal instrumentation, especially for more complex surgeries.
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Soriano-Sánchez JA, Ortega-Porcayo LA, Gutiérrez-Partida CF, Ramírez-Barrios LR, Ortíz-Leyva RU, Rodríguez-García M, Sánchez-Escandón O. Fluoroscopy-guided pedicle screw accuracy with a mini-open approach: a tomographic evaluation of 470 screws in 125 patients. Int J Spine Surg 2015; 9:54. [PMID: 26609509 DOI: 10.14444/2054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Transpedicular screws are currently placed with open free hand and minimally invasive techniques assisted with either fluoroscopy or navigation. Screw placement accuracy had been investigated with several methods reaching accuracy rates from 71.9% to 98.8%. The objective of this study was to assess the accuracy and safety for 2-D fluoroscopy-guided screw placement assisted with electrophysiological monitoring and the inter-observer agreement for the breach classification. METHODS A retrospective review was performed on 125 consecutive patients who underwent minimally invasive transforaminal lumbar interbody fusion and transpedicular screws placement between the levels of T-12 and S-1. Screw accuracy was evaluated using a postoperative computed tomography by three independent observers. Pedicle breach was documented when there was a violation in any direction of the pedicle. Inter-observer agreement was assessed with the Kappa coefficient. RESULTS A total of 470 transpedicular screws were evaluated between the levels of T-12 and S-1. In 57 patients the instrumentation was bilateral and in 68 unilateral. A substantial degree of agreement was found between the observers AB (κ=0.769) and A-C (κ=0.784) and almost perfect agreement between observers B-C (κ=0.928). There were a total of 427.33 (90.92%) screws without breach, 39.33 (8.37%) minor breach pedicles and 3.33 (0.71%) major breach pedicles. The pedicle breach rate was 9.08% Trajectory pedicle breach percentages were as follows: minor medial pedicle breach 4.68%, minor lateral pedicle breach 3.47%, minor inferior pedicle breach 0.22%, and major medial breach 0.70%. No intraoperative instrumentation-related or postoperative clinical complications were encountered and no surgical revision was needed. CONCLUSIONS Our study demonstrated a high accuracy (90.2%) for 2-D fluoroscopy-guided pedicle screw using electromonitoring. Only 0.71% of the 470 screws had a major breach. Knowing the radiological spine pedicle anatomy and the correct interpretation of EMG are the key factors for this technique.
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Affiliation(s)
| | - Luis Alberto Ortega-Porcayo
- Neurological Center, American British Cowdray Medical Center, Mexico City, Mexico ; Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez," Mexico City, Mexico
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Kleck CJ, Cullilmore I, LaFleur M, Lindley E, Rentschler ME, Burger EL, Cain CMJ, Patel VV. A new 3-dimensional method for measuring precision in surgical navigation and methods to optimize navigation accuracy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1764-74. [DOI: 10.1007/s00586-015-4235-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/07/2015] [Accepted: 09/07/2015] [Indexed: 10/23/2022]
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Walsh KM, Machado AG, Krishnaney AA. Spinal cord stimulation: a review of the safety literature and proposal for perioperative evaluation and management. Spine J 2015; 15:1864-9. [PMID: 25957536 DOI: 10.1016/j.spinee.2015.04.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/03/2015] [Accepted: 04/29/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There is currently no consensus on appropriate perioperative management of patients with spinal cord stimulator implants. Magnetic resonance imaging (MRI) is considered safe under strict labeling conditions. Electrocautery is generally not recommended in these patients but sometimes used despite known risks. PURPOSE The aim was to discuss the perioperative evaluation and management of patients with spinal cord stimulator implants. STUDY DESIGN A literature review, summary of device labeling, and editorial were performed, regarding the safety of spinal cord stimulator devices in the perioperative setting. METHODS A literature review was performed, and the labeling of each Food and Drug Administration (FDA)-approved spinal cord stimulation system was reviewed. The literature review was performed using PubMed and the FDA website (www.fda.gov). RESULTS Magnetic resonance imaging safety recommendations vary between the models. Certain systems allow for MRI of the brain to be performed, and only one system allows for MRI of the body to be performed, both under strict labeling conditions. Before an MRI is performed, it is imperative to ascertain that the system is intact, without any lead breaks or low impedances, as these can result in heating of the spinal cord stimulation (SCS) and injury to the patient. Monopolar electrocautery is generally not recommended for patients with SCS; however, in some circumstances, it is used when deemed required by the surgeon. When cautery is necessary, bipolar electrocautery is recommended. Modern electrocautery units are to be used with caution as there remains a risk of thermal injury to the tissue in contact with the SCS. As with MRI, electrocautery usage in patients with SCS systems with suspected breaks or abnormal impedances is unsafe and may cause injury to the patient. CONCLUSIONS Spinal cord stimulation is increasingly used in patients with pain of spinal origin, particularly to manage postlaminectomy syndrome. Knowledge of the safety concerns of SCS and appropriate perioperative evaluation and management of the SCS system can reduce risks and improve surgical planning.
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Affiliation(s)
- Kevin M Walsh
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA.
| | - Andre G Machado
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, 500 Euclid Ave., Cleveland, OH 44195, USA; Center for Spine Health, Neurological Institute, Cleveland Clinic, 500 Euclid Ave., Cleveland, OH 44195, USA
| | - Ajit A Krishnaney
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Center for Spine Health, Neurological Institute, Cleveland Clinic, 500 Euclid Ave., Cleveland, OH 44195, USA
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Shih YT, Kao TH, Pan HC, Chen HT, Tsou HK. The Surgical Treatment Principles of Atlantoaxial Instability Focusing on Rheumatoid Arthritis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:518164. [PMID: 26273625 PMCID: PMC4529935 DOI: 10.1155/2015/518164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 04/29/2015] [Accepted: 05/14/2015] [Indexed: 01/27/2023]
Abstract
OBJECT This retrospective review was conducted to determine the surgical treatment principle for rheumatoid arthritis (RA) patients with atlantoaxial instability (AAI). METHODS Thirteen patients with AAI, including 5 RA patients, received preoperative computed tomography- (CT-) based image-guided navigation system (IGS) in C1 lateral mass-C2 pedicle screw-rod system fixation (LC1-PC2 fixation). These 13 patients were analyzed for 52 screws inserted into C1 and C2. We defined these patients as non-RA group (8 patients, 32 screws) and RA group (5 patients, 20 screws). The neurological status for RA group was evaluated using the Ranawat classification. The causes of AAI, surgical indications, complications, surgical method revolution, and CT-based navigation application are discussed. RESULTS None of the 13 patients expressed neurological function deterioration. The non-RA group screw accuracy was 100%. In the RA group, 1 RA patient developed left C2 screw loosening at 1(+) months after operation due to screw malposition. The screw accuracy for this group was 95%. CONCLUSIONS Higher intraoperative surgical complication rate was described in RA patients. Preoperative CT-based IGS in LC1-PC2 fixation can provide good neurological function and screw accuracy results. However, for higher screw accuracy in RA patients, intraoperative CT-based IGS application may be considered.
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Affiliation(s)
- Yu-Tung Shih
- Department of Neurosurgery, Jen-Ai Hospital, No. 483 Dong Rong Road, Dali, Taichung 41265, Taiwan
| | - Ting-Hsien Kao
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard, Section 4, Taichung 40705, Taiwan
- Graduate Institute of Medical Science, National Defense Medical Center, No. 161, Section 6, Minquan E. Road, Neihu District, Taipei 11490, Taiwan
- Department of Acupressure Technology, Jen-Teh Junior College of Medicine, Nursing and Management, No. 79-9, Sha-Luen-Hu, Xi Zhou Li, Hou-Loung Town, Miaoli County 35664, Taiwan
| | - Hung-Chuan Pan
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard, Section 4, Taichung 40705, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, No. 155, Section 2, Linong Street, Taipei 11266, Taiwan
| | - Hsien-Te Chen
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, No. 91, Hsueh-Shih Road, Taichung 40402, Taiwan
- Department of Orthopaedic Surgery, China Medical University Hospital, No. 91, Hsueh-Shih Road, Taichung 40402, Taiwan
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard, Section 4, Taichung 40705, Taiwan
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, No. 79-9, Sha-Luen-Hu, Xi Zhou Li, Hou-Loung Town, Miaoli County 35664, Taiwan
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Al-Khouja L, Shweikeh F, Pashman R, Johnson JP, Kim TT, Drazin D. Economics of image guidance and navigation in spine surgery. Surg Neurol Int 2015; 6:S323-6. [PMID: 26167370 PMCID: PMC4496834 DOI: 10.4103/2152-7806.159381] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 03/06/2015] [Indexed: 12/31/2022] Open
Abstract
Background: Image-guidance and navigation in spinal surgery is becoming more widely utilized. Several studies have shown the use of this technology to increase accuracy of pedicle screw placement, decrease the rates of revision surgery, and minimize radiation exposure. In this paper, the authors analyze the economics of image-guided surgery (IGS) and navigation in spine surgery. Methods: A literature review was performed using PubMed, the CEA Registry, and the National Health Service Economic Evaluation Database. Each article was screened for inclusion and exclusion criteria, including costs, reoperation, readmission rates, operating room time, and length of stay. Results: Thirteen studies were included in the analysis. Six studies were identified to meet the inclusion criteria for reporting costs and seven met the criteria for analysis of efficacy. Average costs ranged from $17,650 to $39,643. Pedicle screw misplacement rates using IGS ranged from 1.20% to 15.07% while reoperation rates ranged from 0% to 7.42%. Conclusion: There is currently an insufficient amount of studies reporting on the economics of spinal navigation to accurately conclude on its cost-effectiveness in clinical practice. Although a few of these studies showed less costs associated with intraoperative imaging, none were able to establish a statistically significant difference. Preliminary findings drawn from this study indicate a possible cost-effectiveness advantage with IGS, but more comprehensive data on costs need to be reported in order to validate its utilization.
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Affiliation(s)
- Lutfi Al-Khouja
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Faris Shweikeh
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Robert Pashman
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA ; Department of Neurosurgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Terrence T Kim
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Doniel Drazin
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
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Pirris SM, Nottmeier EW, O'Brien M, Rahmathulla G, Pichelmann M. Radiographic comparison of cross-sectional lumbar pedicle fill when placing screws with navigation versus free-hand technique. Int J Med Robot 2015; 12:309-15. [PMID: 25941010 DOI: 10.1002/rcs.1666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 03/16/2015] [Accepted: 04/05/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pedicle screws are often used for spinal fixation. Increasing the percentage of pedicle that is filled with the screw presumably yields greater fixation. It has not been shown whether spinal navigation helps surgeons more completely fill their instrumented pedicles. METHODS Fifty consecutive patients from each arm (navigated and free-hand) were retrospectively reviewed. The cross-sectional area of each instrumented lumbar pedicle and screw were measured using an automatic area calculation tool. The coronal images and measurements were blinded to the surgeons. RESULTS The instrumented pedicles in the navigated patients were significantly more filled by screws than the pedicles in the non-navigated patients (P < 0.001). CONCLUSION Obtaining a higher cross-sectional percentage fill of the pedicle with a screw is expected to provide greater spinal fixation in instrumented fusion surgery. This study shows that utilizing spinal navigation helps to more completely fill the pedicles that are being instrumented. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Eric W Nottmeier
- Department of Neuroscience, Mayo Clinic, Jacksonville, Florida.,St. Vincent's Brain and Spine Institute, Jacksonville, Florida
| | - Michael O'Brien
- Mayo School of Health Sciences Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, Florida.,College of Science, University of Notre Dame, South Bend, Indiana
| | | | - Mark Pichelmann
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida
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Fogelson JL, Krauss WE. Are Pedicle Screws Dangerous? World Neurosurg 2015; 83:744-6. [DOI: 10.1016/j.wneu.2014.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/13/2014] [Indexed: 11/16/2022]
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Ryang YM, Villard J, Obermüller T, Friedrich B, Wolf P, Gempt J, Ringel F, Meyer B. Learning curve of 3D fluoroscopy image-guided pedicle screw placement in the thoracolumbar spine. Spine J 2015; 15:467-76. [PMID: 25315133 DOI: 10.1016/j.spinee.2014.10.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 09/10/2014] [Accepted: 10/07/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT During the past decade, a disproportionate increase of spinal fusion procedures has been observed. Along with this trend, image-guided spine surgery has been experiencing a renaissance in the recent years. A wide range of different navigation systems are available on the market today. However, only few published studies assess the learning curves concerning these new spinal navigation techniques. So far, a study on the learning curve for intraoperative three-dimensional fluoroscopy (3DFL)-navigated pedicle screw (PS) placement is still lacking. PURPOSE The purpose of the study was to analyze the learning curve for 3DFL-navigated thoracolumbar PS placement. STUDY DESIGN/SETTING The study design included a prospective case series. PATIENT SAMPLE A cohort of 145 patients were recruited from January 2011 to June 2012. OUTCOME MEASURES The outcome measures were duration of intraoperative 3D scans, PS placement, PS accuracy on postoperative computed tomography (CT) scans, and PS-related revisions and complications. METHODS From the introduction of spinal navigation to our department in January 2011 until June 2012, the learning curve for the duration of intraoperative 3D scan acquisition (navigation or control scan) and placement time per screw, intraoperative screw revisions, screw-related complications, revision surgeries, and PS accuracy on postoperative CT scans were assessed in 145 patients undergoing dorsal navigated instrumentation for 928 PS (736 lumbosacral and 192 thoracic). The observed time span was divided into four intervals. Results of the second, third, and last periods were compared with the first (reference) period, respectively. RESULTS The mean navigation 3D scan time decreased (first and fourth periods) from 15.4±7.8 (range, 4-40) to 8.4±3.3 (3-15) minutes (p<.001). The mean control 3D scan time (after PS placement) decreased from 11.2±4.8 (5-25) to 6.6±3.0 (3-15) minutes (p<.001). The mean PS insertion time decreased from 5.3±2.5 (1-15) to 3.2±2.3 (1-17) minutes (p<.001). The mean proportion of correctly positioned PS (all 928) according to the Gertzbein and Robbins classification grades A and B increased initially from 83.1% (first period) to 95.1% (second period, p=.001), 96.4% (third period, p=.002), and 92.4% (fourth period, p=.049). No learning effect was found with respect to intraoperative screw revisions. There was one revision surgery. CONCLUSIONS We could demonstrate significant learning effects for 3DFL-navigated PS placement with regard to intraoperative 3D scan acquisition, PS placement time, and PS accuracy.
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Affiliation(s)
- Yu-Mi Ryang
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany.
| | - Jimmy Villard
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany
| | - Thomas Obermüller
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany
| | - Benjamin Friedrich
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany
| | - Petra Wolf
- Institute of Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany
| | - Florian Ringel
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Germany
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Lee DJ, Zwienenberg-Lee M, Seyal M, Shahlaie K. Intraoperative computed tomography for intracranial electrode implantation surgery in medically refractory epilepsy. J Neurosurg 2015; 122:526-31. [DOI: 10.3171/2014.9.jns13919] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Accurate placement of intracranial depth and subdural electrodes is important in evaluating patients with medically refractory epilepsy for possible resection. Confirming electrode locations on postoperative CT scans does not allow for immediate replacement of malpositioned electrodes, and thus revision surgery is required in select cases. Intraoperative CT (iCT) using the Medtronic O-arm device has been performed to detect electrode locations in deep brain stimulation surgery, but its application in epilepsy surgery has not been explored. In the present study, the authors describe their institutional experience in using the O-arm to facilitate accurate placement of intracranial electrodes for epilepsy monitoring.
METHODS
In this retrospective study, the authors evaluated consecutive patients who had undergone subdural and/or depth electrode implantation for epilepsy monitoring between November 2010 and September 2012. The O-arm device is used to obtain iCT images, which are then merged with the preoperative planning MRI studies and reviewed by the surgical team to confirm final positioning. Minor modifications in patient positioning and operative field preparation are necessary to safely incorporate the O-arm device into routine intracranial electrode implantation surgery. The device does not obstruct surgeon access for bur hole or craniotomy surgery. Depth and subdural electrode locations are easily identified on iCT, which merge with MRI studies without difficulty, allowing the epilepsy surgical team to intraoperatively confirm lead locations.
RESULTS
Depth and subdural electrodes were implanted in 10 consecutive patients by using routine surgical techniques together with preoperative stereotactic planning and intraoperative neuronavigation. No wound infections or other surgical complications occurred. In one patient, the hippocampal depth electrode was believed to be in a suboptimal position and was repositioned before final wound closure. Additionally, 4 strip electrodes were replaced due to suboptimal positioning. Postoperative CT scans did not differ from iCT studies in the first 3 patients in the series and thus were not obtained in the final 7 patients. Overall, operative time was extended by approximately 10–15 minutes for O-arm positioning, less than 1 minute for image acquisition, and approximately 10 minutes for image transfer, fusion, and intraoperative analysis (total time 21–26 minutes).
CONCLUSIONS
The O-arm device can be easily incorporated into routine intracranial electrode implantation surgery in standard-sized operating rooms. The technique provides accurate 3D visualization of depth and subdural electrode contacts, and the intraoperative images can be easily merged with preoperative MRI studies to confirm lead positions before final wound closure. Intraoperative CT obviates the need for routine postoperative CT and has the potential to improve the accuracy of intracranial electroencephalography recordings and may reduce the necessity for revision surgery.
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Affiliation(s)
| | | | - Masud Seyal
- 2Neurology, UC Davis School of Medicine, Sacramento, California
| | - Kiarash Shahlaie
- 1Departments of Neurological Surgery and
- 2Neurology, UC Davis School of Medicine, Sacramento, California
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Rahmathulla G, Nottmeier EW, Pirris SM, Deen HG, Pichelmann MA. Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance. Neurosurg Focus 2014; 36:E3. [PMID: 24580004 DOI: 10.3171/2014.1.focus13516] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal instrumentation has made significant advances in the last two decades, with transpedicular constructs now widely used in spinal fixation. Pedicle screw constructs are routinely used in thoracolumbar-instrumented fusions, and in recent years, the cervical spine as well. Three-column fixations with pedicle screws provide the most rigid form of posterior stabilization. Surgical landmarks and fluoroscopy have been used routinely for pedicle screw insertion, but a number of studies reveal inaccuracies in placement using these conventional techniques (ranging from 10% to 50%). The ability to combine 3D imaging with intraoperative navigation systems has improved the accuracy and safety of pedicle screw placement, especially in more complex spinal deformities. However, in the authors' experience with image guidance in more than 1500 cases, several potential pitfalls have been identified while using intraoperative spinal navigation that could lead to suboptimal results. This article summarizes the authors' experience with these various pitfalls using spinal navigation, and gives practical tips on their avoidance and management.
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