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Bindels BJJ, Hovenier R, Groot OQ, Vincken KL, Rongen JJ, Smits MLJ, Verlaan JJ. Impact of intraoperative imaging on decision-making during spine surgery: a survey among spine surgeons using simulated intraoperative images. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2031-2042. [PMID: 38548932 DOI: 10.1007/s00586-024-08222-9] [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: 11/09/2023] [Revised: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE To assess whether the intention to intraoperatively reposition pedicle screws differs when spine surgeons evaluate the same screws with 2D imaging or 3D imaging. METHODS In this online survey study, 21 spine surgeons evaluated eight pedicle screws from patients who had undergone posterior spinal fixation. In a simulated intraoperative setting, surgeons had to decide if they would reposition a marked pedicle screw based on its position in the provided radiologic imaging. The eight assessed pedicle screws varied in radiologic position, including two screws positioned within the pedicle, two breaching the pedicle cortex < 2 mm, two breaching the pedicle cortex 2-4 mm, and two positioned completely outside the pedicle. Surgeons assessed each pedicle screw twice without knowing and in random order: once with a scrollable three-dimensional (3D) image and once with two oblique fluoroscopic two-dimensional (2D) images. RESULTS Almost all surgeons (19/21) intended to reposition more pedicle screws based on 3D imaging than on 2D imaging, with a mean number of pedicle screws to be repositioned of, respectively, 4.1 (± 1.3) and 2.0 (± 1.3; p < 0.001). Surgeons intended to reposition two screws placed completely outside the pedicle, one breaching 2-4mm, and one breaching < 2 mm more often based on 3D imaging. CONCLUSION When provided with 3D imaging, spine surgeons not only intend to intraoperatively reposition pedicle screws at risk of causing postoperative complications more often but also screws with acceptable positions. This study highlights the potential of intraoperative 3D imaging as well as the need for consensus on how to act on intraoperative 3D information.
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Affiliation(s)
- Bas J J Bindels
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Renée Hovenier
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Koen L Vincken
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jan J Rongen
- Philips Medical Systems International B.V., Veenpluis 6, 5684 PC, Best, The Netherlands
| | - Maarten L J Smits
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jorrit-Jan Verlaan
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Solitro GF, Welborn MC, Mehta AI, Amirouche F. How to Optimize Pedicle Screw Parameters for the Thoracic Spine? A Biomechanical and Finite Element Method Study. Global Spine J 2024; 14:187-194. [PMID: 35499547 PMCID: PMC10676166 DOI: 10.1177/21925682221099470] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Pedicle screw study. OBJECTIVE The selection of pedicle screw parameters usually involves the surgeon's analysis of preoperative CT imaging along with anatomical landmarks and tactile examination. However, there is minimal consensus on a standardized guideline for selection methods on pedicle screws. We aimed to determine the effects of thoracic screw diameter to pedicle width on pullout strength determined by cortical bone purchase. METHODS Biomechanical study performed with human cadaveric thoracic vertebrae and experimentally validated three-dimensional finite element model instrumented with pedicle screws of various diameters. We used a variable (SD/PW) ratio to express the screw selection. We hypothesized a positive correlation between the pullout load determined by the bone purchase and the SD/PW. This relationship was first investigated in a validated finite element model considering bone purchase related to the strength of an upper thoracic vertebra. Then, the correlation to the entire spine is evaluated. RESULTS The failure load ranged from 371.3 to 1601.0 N, respectively, for 3 and 6 mm screws. The determinant coefficient was increased to R2=.421 when a linear relationship between pullout load and the SD/PW ratio was used. The peak loads of 1216 and 1288N were found for an SD/PW ratio of .83. CONCLUSION We have found that the screw pullout load is more correlated to SD/PW than other pedicle measures for a maximized SD/PW ratio of .83. This particular value should be considered the upper limit of the indicated SD/PW ratio and a means to determine the optimal screw diameter to enhance pullout strength.
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Affiliation(s)
| | - Michelle C. Welborn
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Il, USA
| | - Ankit I. Mehta
- Department of Orthopaedic Surgery, NorthShore University HealthSystem, Evanston, Il, USA
| | - Farid Amirouche
- Department of Orthopaedics, Louisiana State University, Chicago, Il, USA
- College of Medicine, University of Illinois at Chicago, Chicago, Il, USA
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Yamada T, Hasegawa T, Yamato Y, Yoshida G, Banno T, Arima H, Oe S, Mihara Y, Ushirozako H, Ide K, Watanabe Y, Nakai K, Kurosu K, Matsuyama Y. Characteristics of pedicle screw misplacement using freehand technique in degenerative scoliosis surgery. Arch Orthop Trauma Surg 2023; 143:1861-1867. [PMID: 35194658 DOI: 10.1007/s00402-022-04380-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 02/05/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to estimate the accuracy of pedicle screw (PS) placement in degenerative scoliosis surgery, characterize a patient population with PS misplacement, and analyze the association between misplaced PS vector and lumbar coronal curve. METHODS In this study, 122 patients (average age 68.6 years), who underwent corrective and decompression surgery, were selected retrospectively. PS accuracy was evaluated in the thoracic to lumbar spine. We identified characteristics of misplacement in each patient. Screw positions were categorized into grade A, entirely in the pedicle; grade B, < 2 mm breach; grade C, 2-4 mm breach; and grade D, > 4 mm breach using postoperative computed tomography. RESULTS The mean preoperative lumbar coronal curve was 32.3 ± 18.4°, and the number of fused vertebrae was 8.9 ± 2.8. A total of 2032 PS were categorized as follows: grade A, 1897 PS (93.3%); grade B, 67 (3.3%); grade C, 26 (1.3%); and grade D, 43 (2.1%). One PS (grade D), inserted at T5, needed surgery for removal due to neurological deficit. The misplacement group (grades C and D) had a significantly stronger lumbar coronal curve and apical vertebral rotation than the accuracy group (grades A and B). Misplaced PS vector (direction and degree) was significantly correlated with inserted vertebral rotation. Grade D misplacement was distributed mainly around the transitional vertebra of the lumbar curve. CONCLUSIONS The accuracy of PS insertion in the thoracic to lumbar spine was high in DS surgery, but the need for care was highlighted in the transitional vertebra.
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Affiliation(s)
- Tomohiro Yamada
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan.
| | - Tomohiko Hasegawa
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yu Yamato
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan
| | - Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Tomohiro Banno
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Hideyuki Arima
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Shin Oe
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan
| | - Yuki Mihara
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Koichiro Ide
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yuh Watanabe
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Keiichi Nakai
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Kenta Kurosu
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
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Croci DM, Nguyen S, Streitmatter SW, Sherrod BA, Hardy J, Cole KL, Gamblin AS, Bisson EF, Mazur MD, Dailey AT. O-Arm Accuracy and Radiation Exposure in Adult Deformity Surgery. World Neurosurg 2023; 171:e440-e446. [PMID: 36528322 DOI: 10.1016/j.wneu.2022.12.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE In long thoracolumbar deformity surgery, accurate screw positioning is critical for spinal stability. We assessed pedicle and pelvic screw accuracy and radiation exposure in patients undergoing long thoracolumbar deformity fusion surgery (≥4 levels) involving 3-dimensional fluoroscopy (O-Arm/Stealth) navigation. METHODS In this retrospective single-center cohort study, all patients aged >18 years who underwent fusion in 2016-2018 were reviewed. O-Arm images were assessed for screw accuracy. Effective radiation doses were calculated. The primary outcome was pedicle screw accuracy (Heary grade). Secondary outcomes were pelvic fixation screw accuracy, radiation exposure, and screw-related perioperative and postoperative complications or revision surgery within 3 years. RESULTS Of 1477 pedicle screws placed in 91 patients (mean 16.41 ± 5.6 screws/patient), 1208 pedicle screws (81.8%) could be evaluated by 3-dimensional imaging after placement. Heary Grade I placement was achieved in 1150 screws (95.2%), Grade II in 47 (3.9%), Grade III in 10 (0.82%), Grade IV in 1 (0.08%), and Grade V in 0; Grade III-V were replaced intraoperatively. One of 60 (1.6%) sacroiliac screws placed showed medial cortical breach and was replaced. The average O-Arm-related effective dose was 29.54 ± 14.29 mSv and effective dose/spin was 8.25 ± 2.65 mSv. No postoperative neurological worsening, vascular injuries, or revision surgeries for screw misplacement were recorded. CONCLUSIONS With effective radiation doses similar to those in interventional neuroendovascular procedures, the use of O-Arm in multilevel complex deformity surgery resulted in high screw accuracy, no need for surgical revision because of screw malposition, less additional imaging, and no radiation exposure for the surgical team.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Sarah Nguyen
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Seth W Streitmatter
- Medical Imaging Physics and Radiation Safety, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Brandon A Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Jeremy Hardy
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Austin S Gamblin
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Richter M. [Spinal navigation with preoperative computed tomography]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:3-16. [PMID: 36446936 DOI: 10.1007/s00064-022-00791-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/13/2022] [Accepted: 06/26/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Safe placement of posterior cervical-sacral pedicle screws, S2-Ala-iliac screws, iliac screws, transarticular screws C1/2, translaminar screws C2 or cervical lateral mass screws under the guidance of spinal navigation. INDICATIONS All posterior spinal instrumentations with screws: instabilities and deformities of rheumatic, traumatic, neoplastic, infectious, iatrogenic or congenital origin; multilevel cervical spinal stenosis with degenerative instability or kyphosis of the affected spinal segment. CONTRAINDICATIONS There are no absolute contraindications for spinal navigation. SURGICAL TECHNIQUE Cervical spine: Prone position on a gel mattress, rigid head fixation, e.g., with Mayfield tongs; if appropriate, closed reduction under lateral image intensification; thoracic + lumbar spine: prone position on a cushioned frame; midline posterior surgical approach at the level of the segments to be instrumented; if necessary, open reduction; insertion of the cervical/upper thoracic screws under the guidance of spinal navigation; if necessary, posterior decompression; instrumentation longitudinal rods; if fusion is to be obtained, decortication of the posterior bone elements with a high-speed burr and onlay of cancellous bone or bone substitutes. POSTOPERATIVE MANAGEMENT In stable instrumentations, no postoperative immobilization with orthosis is necessary, removal of drains (if used) 2-3 days postoperatively (postop), removal of the sutures 14 days postop, clinical and x‑ray controls 3 and 12 months postop or in case of clinical or neurological deterioration. RESULTS Numerous studies showed that the use of spinal navigation significantly reduces implant malplacement rates, complications, and revision surgery. Furthermore, intraoperative radiation exposure to the operation team can be reduced by up to 90%.
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Affiliation(s)
- Marcus Richter
- Wirbelsäulenzentrum, St. Josefs-Hospital GmbH, Beethovenstr. 20, 65189, Wiesbaden, Deutschland.
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6
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Navigation Techniques in Endoscopic Spine Surgery. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8419739. [PMID: 36072476 PMCID: PMC9444441 DOI: 10.1155/2022/8419739] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 07/31/2022] [Accepted: 08/08/2022] [Indexed: 12/04/2022]
Abstract
Endoscopic spine surgery (ESS) advances the principles of minimally invasive surgery, including minor collateral tissue damage, reduced blood loss, and faster recovery times. ESS allows for direct access to the spine through small incisions and direct visualization of spinal pathology via an endoscope. While this technique has many applications, there is a steep learning curve when adopting ESS into a surgeon's practice. Two types of navigation, optical and electromagnetic, may allow for widespread utilization of ESS by engendering improved orientation to surgical anatomy and reduced complication rates. The present review discusses these two available navigation technologies and their application in endoscopic procedures by providing case examples. Furthermore, we report on the future directions of navigation within the discipline of ESS.
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Matsuoka A, Toyone T, Okano I, Kudo Y, Ishikawa K, Maruyama H, Ozawa T, Shirahata T, Inagaki K. Comparison of pedicle screw placement accuracy between two types of imaging support (Artis Zeego versus two-dimensional fluoroscopy): a cross-sectional observational study. BMC Musculoskelet Disord 2022; 23:644. [PMID: 35790951 PMCID: PMC9254419 DOI: 10.1186/s12891-022-05602-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/28/2022] [Indexed: 02/07/2023] Open
Abstract
Background The pedicle screw system is widely used in spine surgery, and it provides rigid fixation and leads to successful subsequent deformity correction and bony fusion. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. Artis Zeego is an emerging intraoperative imaging technique that can provide conventional two-dimensional fluoroscopic images and rapid three-dimensional fluoroscopic computed tomography reconstruction imaging. The aim of this study is to compare the insertion accuracies of PS placement using Artis Zeego and conventional 2D X-ray fluoroscopy. Methods In this study, we retrospectively reviewed the postoperative images of thoracolumbar fusion patients who underwent surgery using pedicle screws between 2013 and 2018. Pedicle screw malplacement was assessed using a four-grade classification by Rao et al. Misplacement rates were compared between pedicle screws assisted with Artis Zeego and two-dimensional fluoroscopy. Results A total of 1107 pedicle screws in 153 patients were inserted using Artis Zeego, and 427 pedicle screws in 80 patients were inserted using fluoroscopy. The overall perforation rate was 4.2% (46 perforations of 1106 pedicle screws) in the Artis Zeego group and 7.7% (33 perforations of 427 pedicle screws) in the fluoroscopy group. In the Artis Zeego group, 43 (3.9%) screws were classified as grade 1, and three (0.3%) screws were classified as grade 2. In the fluoroscopy group, 21 (4.9%) screws were classified as grade 1, 10 (2.3%) screws were classified as grade 2, and 2 (0.5%) screws were classified as grade 3. The use of Artis Zeego was associated with a significantly lower screw malplacement rate than was the use of fluoroscopy (p < 0.001). Conclusions Our results demonstrated that pedicle screw placement with Artis Zeego was associated with a lower malplacement rate than was conventional two-dimensional fluoroscopy. No severe malplacement was observed in the Artis Zeego group. Thus, Artis Zeego could be a good option for improving pedicle screw accuracy.
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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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Computed Tomography-Based Navigation System in Current Spine Surgery: A Narrative Review. Medicina (B Aires) 2022; 58:medicina58020241. [PMID: 35208565 PMCID: PMC8880580 DOI: 10.3390/medicina58020241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 02/03/2022] [Indexed: 11/26/2022] Open
Abstract
The number of spine surgeries using instrumentation has been increasing with recent advances in surgical techniques and spinal implants. Navigation systems have been attracting attention since the 1990s in order to perform spine surgeries safely and effectively, and they enable us to perform complex spine surgeries that have been difficult to perform in the past. Navigation systems are also contributing to the improvement of minimally invasive spine stabilization (MISt) surgery, which is becoming popular due to aging populations. Conventional navigation systems were based on reconstructions obtained by preoperative computed tomography (CT) images and did not always accurately reproduce the intraoperative patient positioning, which could lead to problems involving inaccurate positional information and time loss associated with registration. Since 2006, an intraoperative CT-based navigation system has been introduced as a solution to these problems, and it is now becoming the mainstay of navigated spine surgery. Here, we highlighted the use of intraoperative CT-based navigation systems in current spine surgery, as well as future issues and prospects.
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Vertebrae segmentation in reduced radiation CT imaging for augmented reality applications. Int J Comput Assist Radiol Surg 2022; 17:775-783. [PMID: 35025073 DOI: 10.1007/s11548-022-02561-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/04/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE There is growing evidence for the use of augmented reality (AR) navigation in spinal surgery to increase surgical accuracy and improve clinical outcomes. Recent research has employed AR techniques to create accurate auto-segmentations, the basis of patient registration, using reduced radiation dose intraoperative computed tomography images. In this study, we aimed to determine if spinal surgery AR applications can employ reduced radiation dose preoperative computed tomography (pCT) images. METHODS We methodically decreased the imaging dose, with the addition of Gaussian noise, that was introduced into pCT images to determine the image quality threshold that was required for auto-segmentation. The Gaussian distribution's standard deviation determined noise level, such that a scalar multiplier (L: [0.00, 0.45], with steps of 0.03) simulated lower doses as L increased. We then enhanced the images with denoising algorithms to evaluate the effect on the segmentation. RESULTS The pCT radiation dose was decreased to below the current lowest clinical threshold and the resulting images produced segmentations that were appropriate for input into AR applications. This held true at simulated dose L = 0.06 (estimated 144 mAs) but not at L = 0.09 (estimated 136 mAs). The application of denoising algorithms to the images resulted in increased artifacts and decreased bone density. CONCLUSIONS The pCT image quality that is required for AR auto-segmentation is lower than that which is currently employed in spinal surgery. We recommend a reduced radiation dose protocol of approximately 140 mAs. This has the potential to reduce the radiation experienced by patients in comparison to procedures without AR support. Future research is required to identify the specific, clinically relevant radiation dose thresholds required for surgical navigation.
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The use of ionising radiation in orthopaedic surgery: principles, regulations and managing risk to surgeons and patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:947-955. [PMID: 33825954 DOI: 10.1007/s00590-021-02955-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/21/2021] [Indexed: 12/28/2022]
Abstract
The use of ionising radiation for plain film radiography and computerised tomography is fundamental in both diagnostics and treatment for orthopaedics. However, radiation is not without risk as high exposure can increase the risk of cancer. Little time is spent educating doctors about the relative risks of radiation, both to patients and themselves. In addition, there are common misunderstandings about the best ways to mitigate such risk. We aim to provide an overview of the fundamental principles of the use of ionising radiation and its risks within the context of orthopaedic surgery. While providing a narrative review of the current literature, we discuss the basic physics, standards of good practice and relevant UK and European regulations. We discuss the risks to patients and surgeons and suggest ways that these can be mitigated in the operating theatre. A thorough understanding of the risks, and appropriate procedural rules, with respect to the use of ionising radiation is essential for those in orthopaedic practice.
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Mao JZ, Khan A, Soliman MAR, Levy BR, McGuire MJ, Starling RV, Hess RM, Agyei JO, Meyers JE, Mullin JP, Pollina J. Use of the Scan-and-Plan Workflow in Next-Generation Robot-Assisted Pedicle Screw Insertion: Retrospective Cohort Study and Literature Review. World Neurosurg 2021; 151:e10-e18. [PMID: 33684584 DOI: 10.1016/j.wneu.2021.02.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report our experience using the scan-and-plan workflow and review current literature on surgical efficiency, safety, and accuracy of next-generation robot-assisted (RA) spine surgery. METHODS The records of patients who underwent RA pedicle screw fixation were reviewed. The accuracy of pedicle screw placement was determined based on the Ravi classification system. To evaluate workflow efficiency, 3 demographically matched cohorts were created to analyze differences in time per screw placement (defined as operating room [OR] time divided by number of screws placed). Group A had <4 screws placed, Group B had 4 screws placed, and Group C had >4 screws placed. Intraoperative errors and postoperative complications were collected to elucidate safety. RESULTS Eighty-four RA cases (306 pedicle screws) were included for analysis. The mean number of screws placed was 2.1 ± 0.3 in Group A and 6.4 ± 1.2 in Group C; 4 screws were placed in Group B patients. The accuracy rate (Ravi grade I) was 98.4%. Screw placement time was significantly longer in Group A (101 ± 37.7 minutes) than Group B (50.5 ± 25.4 minutes) or C (43.6 ± 14.7 minutes). There were no intraoperative complications, robot failures, or in-hospital complications requiring a return to the OR. CONCLUSIONS The scan-and-plan workflow allowed for a high degree of accuracy. It was a safe method that provided a smooth and efficient OR workflow without registration errors or robotic failures. After the placement of 4 pedicle screws, the per-screw time remained constant. Further studies regarding efficiency and utility in multilevel procedures are necessary.
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Affiliation(s)
- Jennifer Z Mao
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA; Department of Biomedical Sciences, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA; Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt; Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - Bennett R Levy
- George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Matthew J McGuire
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA
| | - Robert V Starling
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Justice O Agyei
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Joshua E Meyers
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA.
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Hussain I, Fu KM, Uribe JS, Chou D, Mummaneni PV. State of the art advances in minimally invasive surgery for adult spinal deformity. Spine Deform 2020; 8:1143-1158. [PMID: 32761477 DOI: 10.1007/s43390-020-00180-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/27/2020] [Indexed: 12/21/2022]
Abstract
Adult spinal deformity (ASD) can be associated with substantial suffering due to pain and disability. Surgical intervention for achieving neural decompression and restoring physiological spinal alignment has shown to result in significant improvement in pain and disability through patient-reported outcomes. Traditional open approaches involving posterior osteotomy techniques and instrumentation are effective based on clinical outcomes but associated with high complication rates, even in the hands of the most experienced surgeons. Minimally invasive techniques may offer benefit while decreasing associated morbidity. Minimally invasive surgery (MIS) for ASD has evolved over the past 20 years, driven by improved understanding of open procedures along with novel technique development and technologic advancements. Early efforts were hindered due to suboptimal outcomes resulting from high pseudarthrosis, inadequate correction, and fixation failure rates. To address this, multi-center collaborative groups have been established to study large numbers of ASD patients which have been vital to understanding optimal patient selection and individualized management strategies. Different MIS decision-making algorithms have been described to better define appropriate candidates and interbody selection approaches in ASD. The purpose of this state of the review is to describe the evolution of MIS surgery for adult deformity with emphasis on landmark papers, and to discuss specific MIS technology for ASD, including percutaneous pedicle screw instrumentation, hyperlordotic grafts, three-dimensional navigation, and robotics.
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Affiliation(s)
- Ibrahim Hussain
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, Box 99, New York, NY, USA.
| | - Juan S Uribe
- Department of Neurological Surgery, Barrow Neurologic Institute, Phoenix, AZ, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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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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Rezaii PG, Pendharkar AV, Ho AL, Sussman ES, Veeravagu A, Ratliff JK, Desai AM. Conventional versus stereotactic image guided pedicle screw placement during spinal deformity correction: a retrospective propensity score-matched study of a national longitudinal database. Int J Neurosci 2020; 131:953-961. [PMID: 32364414 DOI: 10.1080/00207454.2020.1763343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE/AIM To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity. METHODS The Thomson Reuters MarketScan national longitudinal database was used to identify patients undergoing osteotomy, posterior instrumentation, and fusion for treatment of spinal deformity with or without image-guided navigation between 2007-2016. Conventional and navigated groups were propensity-matched (1:1) to normalize differences between demographics, comorbidities, and surgical characteristics. Clinical outcomes and charges were compared between matched groups using bivariate analyses. RESULTS A total of 4,604 patients were identified as having undergone deformity correction, of which 286 (6.2%) were navigated. Propensity-matching resulted in a total of 572 well-matched patients for subsequent analyses, of which half were navigated. Rate of mechanical instrumentation-related complications was found to be significantly lower for navigated procedures (p = 0.0371). Navigation was also associated with lower rates of 90-day unplanned readmissions (p = 0.0295), as well as 30- and 90-day postoperative revisions (30-day: p = 0.0304, 90-day: p = 0.0059). Hospital, physician, and total payments favored the conventional group for initial admission (p = 0.0481, 0.0001, 0.0019, respectively); however, when taking into account costs of readmissions, hospital payments became insignificantly different between the two groups. CONCLUSIONS Procedures involving image-guided navigation resulted in decreased instrumentation-related complications, unplanned readmissions, and postoperative revisions, highlighting its potential utility for the treatment of spine deformity. Future advances in navigation technologies and methodologies can continue to improve clinical outcomes, decrease costs, and facilitate widespread adoption of navigation for deformity correction.
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Affiliation(s)
- Paymon G Rezaii
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | | | - Allen L Ho
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Atman M Desai
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
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Abstract
INTRODUCTION Traditionally, fluoroscopy and postoperative computed tomographic (CT) scans are used to evaluate screw position after pediatric cervical spine fusion. However, noncontained screws detected postoperatively can require revision surgery. Intraoperative O-arm is a 3-dimensional CT imaging technique, which allows intraoperative evaluation of screw position and potentially avoids reoperations because of implant malposition. This study's objective was to evaluate the use of intraoperative O-arm in determining the accuracy of cervical implants placed by a free-hand technique using anatomic landmarks or fluoroscopic guidance in pediatric cervical spine instrumentation. METHODS A single-center retrospective study of consecutive examinations of children treated with cervical spine instrumentation and intraoperative O-arm from 2014 to 2018 was performed. In total, 44 cases (41 children, 44% men) with a mean age of 11.9 years (range, 2.1 to 23.5 y) were identified. Instability (n=16, 36%) and deformity (n=10, 23%) were the most frequent indications. Primary outcomes were screw revision rate, neurovascular complications caused by noncontained screws, and radiation exposure. RESULTS A total of 272 screws were inserted (60 occipital and 212 cervical screws). All screws were evaluated on fluoroscopy as appropriately placed. Four screws (1.5%) in 4 cases (9%) were noncontained on O-arm imaging and required intraoperative revision. A mean of 7.7 levels (range, 5 to 13) were scanned. The mean CT dose index and dose-length product were 15.2±6.87 mGy and 212.3±120.48 mGy×cm. Mean effective dose was 1.57±0.818 mSv. There was no association between screw location and noncontainment (P=0.129). No vertebral artery injuries, dural injuries, or neurologic deficits were related to the 4 revised screws. CONCLUSIONS Intraoperative non-navigated O-arm is a safe and efficient method to evaluate screw position in pediatric patients undergoing cervical spine instrumentation. Noncontained screws were detected in 9% of cases (n=4). O-arm delivers low radiation doses, allows for intraoperative screw revision, and negates the need for postoperative CT scans after confirmation of optimal implant position. LEVEL OF EVIDENCE Level IV.
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Hussain I, Cosar M, Kirnaz S, Schmidt FA, Wipplinger C, Wong T, Härtl R. Evolving Navigation, Robotics, and Augmented Reality in Minimally Invasive Spine Surgery. Global Spine J 2020; 10:22S-33S. [PMID: 32528803 PMCID: PMC7263339 DOI: 10.1177/2192568220907896] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Innovative technology and techniques have revolutionized minimally invasive spine surgery (MIS) within the past decade. The introduction of navigation and image-guided surgery has greatly affected spinal surgery and will continue to make surgery safer and more efficient. Eventually, it is conceivable that fluoroscopy will be completely replaced with image guidance. These advancements, among others such as robotics and virtual and augmented reality technology, will continue to drive the value of 3-dimensional navigation in MIS. In this review, we cover pertinent features of navigation in MIS and explore their evolution over time. Moreover, we aim to discuss the key features germane to surgical advancement, including technique and technology development, accuracy, overall health care costs, operating room time efficiency, and radiation exposure.
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Affiliation(s)
- Ibrahim Hussain
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
- Ibrahim Hussain and Murat Cosar are equal contributors to this study
| | - Murat Cosar
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
- Ibrahim Hussain and Murat Cosar are equal contributors to this study
| | - Sertac Kirnaz
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Franziska A. Schmidt
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Christoph Wipplinger
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Taylor Wong
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Roger Härtl
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
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Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE To assess staff and patient radiation exposure during augmented reality surgical navigation in spine surgery. SUMMARY OF BACKGROUND DATA Surgical navigation in combination with intraoperative three-dimensional imaging has been shown to significantly increase the clinical accuracy of pedicle screw placement. Although this technique may increase the total radiation exposure compared with fluoroscopy, the occupational exposure can be minimized, as navigation is radiation free and staff can be positioned behind protective shielding during three-dimensional imaging. The patient radiation exposure during treatment and verification of pedicle screw positions can also be reduced. METHODS Twenty patients undergoing spine surgery with pedicle screw placement were included in the study. The staff radiation exposure was measured using real-time active personnel dosimeters and was further compared with measurements using a reference dosimeter attached to the C-arm (i.e., a worst-case staff exposure situation). The patient radiation exposures were recorded, and effective doses (ED) were determined. RESULTS The average staff exposure per procedure was 0.21 ± 0.06 μSv. The average staff-to-reference dose ratio per procedure was 0.05% and decreased to less than 0.01% after a few procedures had been performed. The average patient ED was 15.8 ± 1.8 mSv which mainly correlated with the number of vertebrae treated and the number of cone-beam computed tomography acquisitions performed. A low-dose protocol used for the final 10 procedures yielded a 32% ED reduction per spinal level treated. CONCLUSION This study demonstrated significantly lower occupational doses compared with values reported in the literature. Real-time active personnel dosimeters contributed to a fast optimization and adoption of protective measures throughout the study. Even though our data include both cone-beam computed tomography for navigation planning and intraoperative screw placement verification, we find low patient radiation exposure levels compared with published data. LEVEL OF EVIDENCE 3.
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19
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[Relevance of spinal navigation in reconstructive surgery of the cervical spine]. DER ORTHOPADE 2019; 47:518-525. [PMID: 29663038 DOI: 10.1007/s00132-018-3568-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Spinal navigation has made significant advances in the last two decades. After initial experiences with pedicle screws in the thoracic and lumbar spine, technological improvements have resulted in their increased application in the cervical spine. Instrumentation techniques like cervical pedicle screws, lateral mass screws in C1 and transarticular screws C1/C2 have become standard due to the application of image guidance. TECHNIQUE Different navigation techniques can be distinguished based on the type of imaging. In the cervical spine, the preoperative computer tomography (CT) scan that requires intraoperative matching is still the standard of care due to the high image quality. 3D fluoroscopy navigation techniques are currently widely used in the lumbar spine, but the reduced image quality obviates the application in the more sophisticated cervical anatomy or the cervicothoracic region. The future availability of intraoperative CT scans (iCT) combines the advantages of high image quality with those of intraoperative image acquisition. This will lead to a wider use of image guidance in the cervical spine and will enable the surgeon to apply minimally invasive techniques with higher accuracy. APPLICATION The successful application of spinal navigation is based on the technical knowledge of navigation systems and its exercise in daily routine. Only the sufficient experience of the clinical staff makes it possible to standardize operational procedures to increase patient safety, reduce radiation dose and shorten operation time.
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Richter M, Ploux D. [Spinal navigation for posterior cervical and cervicothoracic instrumentation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:263-274. [PMID: 31197402 DOI: 10.1007/s00064-019-0610-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/02/2019] [Accepted: 03/06/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Safe placement of posterior cervical or high-thoracic pedicle screws, transarticular screws C1/2, translaminar screws C2 or cervical lateral mass screws under the guidance of spinal navigation. INDICATIONS All posterior cervical and cervicothoracic instrumentation with screws: instabilities and deformities of rheumatoid, traumatic, neoplastic, infectious, iatrogenic or congenital origin; multilevel cervical spinal stenosis with degenerative instability or kyphosis of the affected spinal segment. CONTRAINDICATIONS There are no absolute contraindications. SURGICAL TECHNIQUE Prone position on a gel mattress, rigid head fixation, e.g., with Mayfield tongs; if appropriate, closed reduction under lateral image intensification; midline posterior surgical approach at the level of the segments to be instrumented; if necessary, open reduction; insertion of the cervical/upper thoracic screws under the guidance of spinal navigation; if necessary, posterior decompression; instrumentation longitudinal rods; if a fusion is to be obtained, decortication of the posterior bone elements with a high-speed burr and onlay of cancellous bone or bone substitutes. POSTOPERATIVE MANAGEMENT In stable instrumentation, no postoperative immobilization with cervical collar is necessary. Drain removal on postoperative day 2-3, suture removal on postoperative day 14, clinical and x‑ray control 3 and 12 months after surgery or in case of clinical or neurological deterioration. RESULTS Numerous studies showed that the use of spinal navigation reduces implant malplacement rates significantly. Furthermore, it allows a reduction of the radiation dose for the operation team up to 90%.
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Affiliation(s)
- M Richter
- Wirbelsäulenzentrum, St.-Josefs Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Deutschland.
| | - D Ploux
- Wirbelsäulenzentrum, St.-Josefs Hospital GmbH, Beethovenstraße 20, 65189, Wiesbaden, Deutschland
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21
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Pedicle Screw Placement Using Augmented Reality Surgical Navigation With Intraoperative 3D Imaging: A First In-Human Prospective Cohort Study. Spine (Phila Pa 1976) 2019; 44:517-525. [PMID: 30234816 PMCID: PMC6426349 DOI: 10.1097/brs.0000000000002876] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE The aim of this study was to evaluate the accuracy of pedicle screw placement using augmented reality surgical navigation (ARSN) in a clinical trial. SUMMARY OF BACKGROUND DATA Recent cadaveric studies have shown improved accuracy for pedicle screw placement in the thoracic spine using ARSN with intraoperative 3D imaging, without the need for periprocedural x-ray. In this clinical study, we used the same system to place pedicle screws in the thoracic and lumbosacral spine of 20 patients. METHODS The study was performed in a hybrid operating room with an integrated ARSN system encompassing a surgical table, a motorized flat detector C-arm with intraoperative 2D/3D capabilities, integrated optical cameras for augmented reality navigation, and noninvasive patient motion tracking. Three independent reviewers assessed screw placement accuracy using the Gertzbein grading on 3D scans obtained before wound closure. In addition, the navigation time per screw placement was measured. RESULTS One orthopedic spinal surgeon placed 253 lumbosacral and thoracic pedicle screws on 20 consenting patients scheduled for spinal fixation surgery. An overall accuracy of 94.1% of primarily thoracic pedicle screws was achieved. No screws were deemed severely misplaced (Gertzbein grade 3). Fifteen (5.9%) screws had 2 to 4 mm breach (Gertzbein grade 2), occurring in scoliosis patients only. Thirteen of those 15 screws were larger than the pedicle in which they were placed. Two medial breaches were observed and 13 were lateral. Thirteen of the grade 2 breaches were in the thoracic spine. The average screw placement time was 5.2 ± 4.1 minutes. During the study, no device-related adverse event occurred. CONCLUSION ARSN can be clinically used to place thoracic and lumbosacral pedicle screws with high accuracy and with acceptable navigation time. Consequently, the risk for revision surgery and complications could be minimized. LEVEL OF EVIDENCE 3.
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Perdomo-Pantoja A, Ishida W, Zygourakis C, Holmes C, Iyer RR, Cottrill E, Theodore N, Witham TF, Lo SFL. Accuracy of Current Techniques for Placement of Pedicle Screws in the Spine: A Comprehensive Systematic Review and Meta-Analysis of 51,161 Screws. World Neurosurg 2019; 126:664-678.e3. [PMID: 30880208 DOI: 10.1016/j.wneu.2019.02.217] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pedicle screws (PSs) are routinely used for stabilization to enhance fusion in a variety of spinal diseases. Although the accuracy of different PS placement methods has been previously reported, most of these studies have been limited to 1 or 2 techniques. The purpose was to determine the current accuracy of PS placement among 4 modalities of PS insertion (freehand [FH], fluoroscopy-assisted [FA], computed tomography navigation-guided [CTNav], and robot-assisted [RA]) and analyze variables associated with screw misplacement. METHODS A systematic review was performed of peer-reviewed articles reporting PS accuracy of 1 technique from January 1990 to June 2018. Accuracy of PS placement, PS insertion technique, and pedicle breach (PB) data were collected. A meta-analysis was performed to estimate the overall pooled (OP) rates of PS accuracy as a primary outcome, stratified by screw insertion techniques. Potential determinants were analyzed via meta-regression analyses. RESULTS Seventy-eight studies with 7858 patients, 51,161 PSs, and 3614 cortical PBs were included. CTNav showed the highest PS placement accuracy compared with other techniques: OP accuracy rates were 95.5%, 93.1%, 91.5%, and 90.5%, via CTNav, FH, FA, and RA techniques, respectively. RA and CTNav were associated with the highest PS accuracy in the thoracic spine, compared with FH. CONCLUSIONS The OP data show that CTNav has the highest PS accuracy rates. Thoracic PSs were associated with lower accuracy rates; however, RA showed fewer breaches in the thoracic spine compared with FH and FA. Given the heterogeneity among studies, further standardized and comparative investigations are required to confirm our findings.
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Affiliation(s)
| | - Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Corinna Zygourakis
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christina Holmes
- Florida A&M University-Florida State University College of Engineering, Tallahassee, Florida, USA
| | - Rajiv R Iyer
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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23
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Maejima R, Takeuchi M, Wakao N, Kamiya M, Aoyama M, Joko M, Osuka K, Takayasu M. Reliability of an Intraoperative Radiographic Anteroposterior View of the Spinal Midline for Detection of Pedicle Screws Breaching the Medial Pedicle Wall in the Thoracic, Lumbar, and Sacral Spine. World Neurosurg 2019; 125:e257-e261. [PMID: 30684715 DOI: 10.1016/j.wneu.2019.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/02/2019] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the sensitivity and specificity of using the spinal midline (M line) on a radiographic anteroposterior (AP) view for detecting pedicle screws (PSs) breaching the medial pedicle wall. METHODS We retrospectively reviewed 145 patients who underwent fusion surgery using PSs between January 2006 and May 2017. We defined the M line as a line that connected the upper and lower spinous processes through the fixed vertebrae. The M line was positive if the tip of the PS crossed the M line. The reference standard was a computed tomography scan. The reliability of the M line was examined. RESULTS The subjects included 145 patients (70 men and 75 women; mean age, 63.4 years). A total of 599 PSs were examined. Most cases were because of spondylolisthesis (66.9%). Most screws were inserted at a lower lumber level (77.6%). Analysis of the diagnostic accuracy of the M line yielded a sensitivity of 74.1% and a specificity of 95.3%. In addition, the positive predictive value of the M line was 42.6%, and the negative predictive value of the M line was 98.7%. CONCLUSIONS Assessment of the M line via an intraoperative radiographic AP view is a simple, readily available, complementary method for detecting PSs that have breached the medial pedicle wall in the thoracic, lumbar, and sacral spine. In particular, the M line has a strong negative predictive value, which is much more meaningful.
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Affiliation(s)
- Ryuya Maejima
- Department of Neurological Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Mikinobu Takeuchi
- Department of Neurological Surgery, Aichi Medical University, Nagakute, Aichi, Japan; Department of Spine Surgery Aichi Spine Institute, Goromaru, Inuyama, Japan.
| | - Norimitsu Wakao
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Mitsuhiro Kamiya
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Masahiro Aoyama
- Department of Neurological Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Masahiro Joko
- Department of Neurological Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Koji Osuka
- Department of Neurological Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Masakazu Takayasu
- Department of Neurological Surgery, Aichi Medical University, Nagakute, Aichi, Japan
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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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Allaoui M, Zairi F, Tétard MC, Gaughan J, Chopin D, Assaker R. Contribution of Dynamic Surgical Guidance to the Accurate Placement of Pedicle Screws in Deformity Surgery: A Retrospective Case Series. World Neurosurg 2018; 120:e466-e471. [PMID: 30149178 DOI: 10.1016/j.wneu.2018.08.105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 08/12/2018] [Accepted: 08/13/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We assessed the contribution of a dynamic surgical guidance (DSG) probe in the accurate placement of thoracic and lumbar pedicle screws (PSs) in patients with spinal deformity. METHODS A retrospective review was performed of 98 patients (104 procedures) with various spinal deformities, who had received posterior instrumentation with PSs inserted using either DSG or the conventional free-hand (FH) technique. A total of 882 PSs were inserted using DSG (DSG group) and 603 using the FH technique (FH group). The DSG probe was preferably chosen for large osteosyntheses and severe deformities. Two neurosurgeons, unaware of the surgical groups, reviewed all the intraoperative computed tomography scans and assessed all the PS placements. RESULTS Of the PSs used, 95.4% in the DSG group and 92.2% in the FH group were correctly placed (P = 0.0136). The difference in screw placement accuracy was greater at the thoracic level (DSG group, 92.5%; vs. FH group, 87.0%; P = 0.0310) than at the lumbar level (DSG group, 98.0%; vs. FH group, 95.4%; P = 0.0385). Severe (>4 mm) lateral breaches occurred in 24 cases (4.0%) in the FH group but in only 5 (0.6%) in the DSG group (P < 0.0001). No severe medial breach was observed in either group. CONCLUSIONS Despite having more patients with severe deformities in the DSG group, PS insertion was significantly more accurate with DSG. This technique also reduced the severe unacceptable lateral misplacement rate (>4 mm) and, consequently, the incidence of intraoperative screw revisions even in patients with severe deformities.
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Affiliation(s)
- Mohamed Allaoui
- Department of Neurosurgery, Polyclinique de Navarre, Pau, France; Department of Neurosurgery, Lille University Hospital, Lille, France
| | - Fahed Zairi
- Department of Neurosurgery, Lille University Hospital, Lille, France; Department of Neurosurgery, Ramsay Général de Santé, Hôpital Privé Le Bois, Lille, France.
| | | | - John Gaughan
- Biostatistics Consulting Center, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Daniel Chopin
- Department of Neurosurgery, Lille University Hospital, Lille, France
| | - Richard Assaker
- Department of Neurosurgery, Lille University Hospital, Lille, France
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Accuracy and Safety of Percutaneous Lumbosacral Pedicle Screw Placement Using Dual-Planar Intraoperative Fluoroscopy. Asian Spine J 2018; 12:238-245. [PMID: 29713404 PMCID: PMC5913014 DOI: 10.4184/asj.2018.12.2.238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/14/2017] [Accepted: 07/08/2017] [Indexed: 01/14/2023] Open
Abstract
Study Design Retrospective case series with prospective arm. Purpose To assess the safety and accuracy of percutaneous lumbosacral pedicle screw placement (PLPSP) in the lumbosacral spine using intraoperative dual-planar fluoroscopy (DPF). Overview of Literature There are several techniques available for achieving consistent, safe, and accurate results with PLPSP. There is a paucity of literature describing the beneficial operative, economic, and clinical outcomes of DPF, the most readily accessible image guidance system. Methods From 2004 to 2014, 451 consecutive patients underwent PLPSP using DPF, for a total of 2,345 screw placement. The results of prospectively obtained postoperative computed tomography (CT) examinations of an additional 41 consecutive patients were compared with the results of 104 CT examinations obtained postoperatively due to clinical symptomatology; these results were interpreted by three reviewers. The rates of revision indicated by misplaced screws with consistent clinical symptomatology were compared between groups. Pedicle screw placement was graded according to 2-mm increments in medial pedicle wall breach and measurement of screw axis placement. Results Seven of the 2,345 pedicle screws placed percutaneously with the use of the dual-planar fluoroscopic technique required revision because of a symptomatic misplaced screw, for a screw revision rate of 0.3%. There were no statistically significant demographic differences between patients who had screws revised and those who did not. All screws registered greater than 10 mA on electromyographic stimulation. In the 41 prospectively obtained CT examinations, one out of 141 screws (0.7%) was revised due to pedicle wall breach; whereas among the 104 patients with 352 screws, three screws were revised (0.9%). Conclusions DPF is an extremely accurate, safe, and reproducible technique for placement of percutaneous pedicle screws and is a readily available and cost-effective alternative to CT-guided pedicle screw placement techniques. Postoperative CT evaluation is not necessary with PLPSP unless the patient is symptomatic. Acceptable electromyographic thresholds may need to be reevaluated.
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Schröder ML, Staartjes VE. Revisions for screw malposition and clinical outcomes after robot-guided lumbar fusion for spondylolisthesis. Neurosurg Focus 2017; 42:E12. [DOI: 10.3171/2017.3.focus16534] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVEThe accuracy of robot-guided pedicle screw placement has been proven to be high, but little is known about the impact of such guidance on clinical outcomes such as the rate of revision surgeries for screw malposition. In addition, there are very few data about the impact of robot-guided fusion on patient-reported outcomes (PROs). Thus, the clinical benefit for the patient is unclear. In this study, the authors analyzed revision rates for screw malposition and changes in PROs following minimally invasive robot-guided pedicle screw fixation.METHODSA retrospective cohort study of patients who had undergone minimally invasive posterior lumbar interbody fusion (MI-PLIF) or minimally invasive transforaminal lumbar interbody fusion was performed. Patients were followed up clinically at 6 weeks, 12 months, and 24 months after treatment and by mailed questionnaire in March 2016 as a final follow-up. Visual analog scale (VAS) scores for back and leg pain severity, Oswestry Disability Index (ODI), screw revisions, and socio-demographic factors were analyzed. A literature review was performed, comparing the incidence of intraoperative screw revisions and revision surgery for screw malposition in robot-guided, navigated, and freehand fusion procedures.RESULTSSeventy-two patients fit the study inclusion criteria and had a mean follow up of 32 ± 17 months. No screws had to be revised intraoperatively, and no revision surgery for screw malposition was needed. In the literature review, the authors found a higher rate of intraoperative screw revisions in the navigated pool than in the robot-guided pool (p < 0.001, OR 9.7). Additionally, a higher incidence of revision surgery for screw malposition was observed for freehand procedures than for the robot-guided procedures (p < 0.001, OR 8.1). The VAS score for back pain improved significantly from 66.9 ± 25.0 preoperatively to 30.1 ± 26.8 at the final follow-up, as did the VAS score for leg pain (from 70.6 ± 22.8 to 24.3 ± 28.3) and ODI (from 43.4 ± 18.3 to 16.2 ± 16.7; all p < 0.001). Undergoing PLIF, a high body mass index, smoking status, and a preoperative ability to work were identified as predictors of a reduction in back pain. Length of hospital stay was 2.4 ± 1.1 days and operating time was 161 ± 50 minutes. Ability to work increased from 38.9% to 78.2% of patients (p < 0.001) at the final follow-up, and 89.1% of patients indicated they would choose to undergo the same treatment again.CONCLUSIONSIn adults with low-grade spondylolisthesis, the data demonstrated a benefit in using robotic guidance to reduce the rate of revision surgery for screw malposition as compared with other techniques of pedicle screw insertion described in peer-reviewed publications. Larger comparative studies are required to assess differences in PROs following a minimally invasive approach in spinal fusion surgeries compared with other techniques.
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Affiliation(s)
- Marc L. Schröder
- 1Department of Neurosurgery, Bergman Clinics, Naarden, The Netherlands; and
| | - Victor E. Staartjes
- 1Department of Neurosurgery, Bergman Clinics, Naarden, The Netherlands; and
- 2Faculty of Medicine, University of Zurich, Switzerland
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Innocenzi G, Bistazzoni S, D’Ercole M, Cardarelli G, Ricciardi F. Does Navigation Improve Pedicle Screw Placement Accuracy? Comparison Between Navigated and Non-navigated Percutaneous and Open Fixations. ACTA NEUROCHIRURGICA SUPPLEMENT 2017; 124:289-295. [DOI: 10.1007/978-3-319-39546-3_42] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Intrinsic Vertebral Markers for Spinal Level Localization in Anterior Cervical Spine Surgery: A Preliminary Report. Asian Spine J 2016; 10:1033-1041. [PMID: 27994778 PMCID: PMC5164992 DOI: 10.4184/asj.2016.10.6.1033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/08/2016] [Accepted: 05/06/2016] [Indexed: 11/21/2022] Open
Abstract
Study Design Prospective clinical study. Purpose To observe the usefulness of anterior cervical osteophytes as intrinsic markers for spinal level localization (SLL) during sub-axial cervical spinal surgery via the anterior approach. Overview of Literature Various landmarks, such as the mandibular angle, hyoid bone, thyroid cartilage, first cricoid ring, and C6 carotid tubercle, are used for gross cervical SLL; however, none are used during cervical spinal surgery via the anterior approach. We present our preliminary assessment of SLL over anterior vertebral surfaces (i.e., intrinsic markers) in 48 consecutive cases of anterior cervical spinal surgeries for the disc-osteophyte complex (DOC) in degenerative diseases and granulation or tumor tissue associated with infectious or neoplastic diseases, respectively, at an ill-equipped center. Methods This prospective study on patients undergoing anterior cervical surgery for various sub-axial cervical spinal pathologies aimed to evaluate the feasibility and accuracy of SLL via intraoperative palpation of disease-related morphological changes on anterior vertebral surfaces visible on preoperative midline sagittal T1/2-weighted magnetic resonance images. Results During a 3-year period, 48 patients (38 males,10 females; average age, 43.58 years) who underwent surgery via the anterior approach for various sub-axial cervical spinal pathologies, including degenerative disease (n= 42), tubercular infection (Pott's disease; n=3), traumatic prolapsed disc (n=2), and a metastatic lesion from thyroid carcinoma (n=1), comprised the study group. Intrinsic marker palpation yielded accurate SLL in 79% of patients (n=38). Among those with degenerative diseases (n=42), intrinsic marker palpation yielded accurate SLL in 76% of patients (n=32). Conclusions Intrinsic marker palpation is an attractive potential adjunct for SLL during cervical spinal surgeries via the anterior approach in well-selected patients at ill-equipped centers (e.g., those found in developing countries). This technique may prove helpful when radiographic visualization is occasionally inadequate.
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Al-Habib AF, Al-Akkad S. Segmental Surface Referencing during Intraoperative Three-dimensional Image-Guided Spine Navigation: An Early Validation with Comparison to Automated Referencing. Global Spine J 2016; 6:765-770. [PMID: 27853660 PMCID: PMC5110353 DOI: 10.1055/s-0036-1582393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 02/16/2016] [Indexed: 11/09/2022] Open
Abstract
Study Design Interventional human cadaver study. Objective Intraoperative three-dimensional (3-D)-guided navigation improves spine instrumentation accuracy. However, image acquisition may need to be repeated with segment hypermobility or distant target from reference frame (RF). The current study evaluates the usefulness of internal metal fiducials (IMFs) as surface references in enhancing registration accuracy and avoiding repeating imaging. Methods Six fresh-frozen cadaveric human torsos were utilized. Posterior C1-T2 exposure was done, and three IMFs were inserted per level; intraoperative 3-D images were then acquired. Two registration methods were utilized: autoregistration (AR, group 1) and point registration using IMF (IMFR, group 2). Registration accuracy was checked by identifying IMFs in both groups. Pedicle screws inserted into C2, C4, C5, and C7 based on the two registration methods (three cadavers each) with RF on C7 and then on C2. Results The mean registration error was lower with IMFR compared with AR (0.35 ± 0.5 mm versus 2.02 ± 0.85 mm, p = 0.0001). Overall, 34 pedicle screws were inserted (AR, 18; IMFR, 16). Final screw placement was comparable using both techniques (p = 0.58). Lateral screws violations were observed in four IMFR screws (1 to 2 mm) as compared with five in AR group (2 to 3 mm). Reregistration after moving RF to C2 was possible using surface screws in IMFR group, thus avoiding new 3-D image acquisition. Conclusion During intraoperative 3-D navigation in spine procedures, surface fiducial registration using IMF provided superior accuracy over automated registration. It allowed repeat registration without repeating radiation during long spine segment instrumentations. More studies are needed to clarify both practical and clinical application of this method.
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Affiliation(s)
- Amro F. Al-Habib
- Division of Neurosurgery, Department of Surgery, King Saud University, Riyadh, Saudi Arabia,Address for correspondence Amro F. Al-Habib, MD, FRCSC, MPH Division of Neurosurgery, Department of Surgery, College of MedicineKing Saud University, PO Box 59220, Riyadh 11525Saudi Arabia
| | - Salah Al-Akkad
- Neurospinal Unit, Department of Surgery, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
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Pakzaban P. Modified Mini-open Transforaminal Lumbar Interbody Fusion: Description of Surgical Technique and Assessment of Free-hand Pedicle Screw Insertion. Spine (Phila Pa 1976) 2016; 41:E1124-E1130. [PMID: 26909829 PMCID: PMC5001135 DOI: 10.1097/brs.0000000000001510] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE To describe a modified technique for mini-open transforaminal lumbar interbody fusion (TLIF) that improves visualization for decompression, fusion, and freehand pedicle screw insertion. Accuracy of freehand pedicle screw placement with this technique was assessed. SUMMARY OF BACKGROUND DATA Mini-open TLIF is a minimally invasive technique that allows limited visualization of the bone and neural anatomy via an expandable tubular retractor inserted through the Wiltse plane. No significant modification that of this technique has been described in detail. METHODS In this study, 92 consecutive patients underwent one-level modified mini-open TLIF (MOTLIF). MOTLIF modifications consisted of (i) transmuscular dissection through the multifidus muscle rather than intermuscular dissection in the Wiltse plane; (ii) microsurgical detachment of multifidus from the facet rather than muscle dilation; (iii) en bloc total facetectomy (unilateral or bilateral, as needed for decompression); (iv) facet autograft used for interbody fusion; and (v) solid pedicle screws placed bilaterally by a freehand technique under direct vision. RESULTS The mean age was 53 years. Mean follow-up was 35 months (minimum 2 yrs). By 6 months, mean Visual Analog Scale for back and leg pain had improved from 51 to 19 and from 58 to 17, respectively, and mean Oswestry Disability Index (ODI) improved from 53 to 16. These improvements persisted at 2 years. Solid fusion, defined by computed tomography at 1 year, was achieved in 88.1%, whereas satisfactory fusion was achieved in 95.2% of patients. Pedicle screws were accurately placed in 335 of 336 imaged pedicles (pedicle breach grades: 91.1% grade 1; 8.6% grade 2; and 0.3% grade 3). Mean fluoroscopy time was 29.3 seconds. CONCLUSION MOTLIF is a safe and effective minimally invasive technique with a high fusion rate. It allows accurate pedicle screw placement by a freehand technique. By eliminating bi-planar fluoroscopy, it helps reduce radiation exposure. This is the largest published report of mini-open TLIF to date. LEVEL OF EVIDENCE 4.
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Hu Y, Yuan ZS, Spiker WR, Dong WX, Sun XY, Yuan JB, Zhang J, Zhu B. A comparative study on the accuracy of pedicle screw placement assisted by personalized rapid prototyping template between pre- and post-operation in patients with relatively normal mid-upper thoracic spine. 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 2016; 25:1706-15. [DOI: 10.1007/s00586-016-4540-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 03/18/2016] [Accepted: 03/19/2016] [Indexed: 11/28/2022]
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Cervical pedicle screw placement using intraoperative computed tomography imaging with a mobile scanner gantry. 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 2016; 25:1690-7. [DOI: 10.1007/s00586-016-4508-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 02/29/2016] [Accepted: 03/01/2016] [Indexed: 11/26/2022]
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Kosztowski T, Gokaslan ZL, Goodwin RC. Perspective on Ionizing Radiation Exposure to Neurosurgery Residents in the Modern Era. World Neurosurg 2015; 99:790-791. [PMID: 26529295 DOI: 10.1016/j.wneu.2015.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 10/24/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Thomas Kosztowski
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Rory C Goodwin
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
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Accuracy of thoracolumbar transpedicular and vertebral body percutaneous screw placement: coupling the Rosa® Spine robot with intraoperative flat-panel CT guidance—a cadaver study. J Robot Surg 2015; 9:331-8. [DOI: 10.1007/s11701-015-0536-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 09/27/2015] [Indexed: 10/22/2022]
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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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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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