|
1
|
Cui K, Chen W, Wang M, Hou P, Tian Z, Guo J, Hao Y, Xu Z. Accuracy of Percutaneous Pedicle Screw Placement Using Modified Single Anterior-Posterior Fluoroscopy with the C-Arm for the Treatment of Traumatic Thoracic and Lumbar Fractures. World Neurosurg 2025; 194:123494. [PMID: 39603454 DOI: 10.1016/j.wneu.2024.11.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 11/15/2024] [Accepted: 11/16/2024] [Indexed: 11/29/2024]
Abstract
OBJECTIVE We aimed to assess percutaneous pedicle screw (PPS) placement accuracy, fluoroscopy shot number, and operation time using a modified single anterior-posterior (AP) fluoroscopy with a C-arm in treating traumatic thoracic and lumbar vertebral fractures. METHODS In total, 164 patients with single-level traumatic thoracic or lumbar fracture who underwent 6 PPS placements between April 2018 and September 2020 were divided into 2 groups. Conventional AP combined lateral fluoroscopy was used in Group A, whereas modified single AP fluoroscopy was used in Group B. The accuracy of the PPS placement, number of fluoroscopy shots, and operation time were compared. All patients underwent computed tomography 2-4 days after surgery to evaluate screw position. Pedicle breach was divided into 4 grades based on postoperative computed tomography. RESULTS Our study included 984 implanted pedicle screws, of which 36 (3.7%) were malpositioned. The breach rate was 3.5% (grade 1, 3.1%; grade 2, 0.4%) in Group A and 3.7% (grade 1, 3.0%; grade 2, 0.8%) in Group B. The median number of fluoroscopy shots during PPS placement was 21.9 in Group A and 8.4 in Group B. The median operation time was 76.07 ± 6.86 minutes in Group A and 55.78 ± 7.21 minutes in Group B. CONCLUSIONS The PPS placement method using modified single AP fluoroscopy for treating traumatic thoracic and lumbar spine fractures was fairly accurate and reduced the number of fluoroscopy shots and operation time. This technique requires only a C-arm for assistance and can be easily mastered by spinal surgeons across hospitals of various levels.
Collapse
Affiliation(s)
- Kaiying Cui
- Department of Spine Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China; College of First Clinical Medical, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Wenming Chen
- Department of Spine Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Mingliang Wang
- Department of Orthopedics, Rizhao Hospital of Traditional Chinese Medicine, Rizhao, Shandong Province, China
| | - Pengfei Hou
- Department of Spine Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Zenghui Tian
- College of First Clinical Medical, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Jinxing Guo
- College of First Clinical Medical, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Yanke Hao
- Department of Spine Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Zhanwang Xu
- Department of Spine Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China; College of First Clinical Medical, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China.
| |
Collapse
|
|
2
|
Feng C, Wang L, Yang S, Wu X, Fan Y, Yan H, Chen F, Chen J, Wang X, Guo Q, Yao L, Zhao Y, He S, Ni H. A New Pilot Hole Preparation System for Percutaneous Pedicle Screw Placement: A Randomized Controlled Study. Spine (Phila Pa 1976) 2025; 50:115-121. [PMID: 39394652 DOI: 10.1097/brs.0000000000005184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 09/17/2024] [Indexed: 10/13/2024]
Abstract
STUDY DESIGN A randomized controlled study. OBJECTIVE To introduce a new pilot hole preparation system for percutaneous pedicle screw placement and investigate its efficiency and safety in comparison with the conventional method. SUMMARY OF BACKGROUND DATA Placing screws accurately, rapidly, and safely with less radiation exposure is critical for minimally invasive lumbar interbody fusion (LIF). Optimizing pilot hole preparation instruments has important clinical implications. MATERIALS AND METHODS A total of 60 patients (180 screws) were included in this study. All patients were randomized into two groups (new system vs. conventional method) and performed single-level minimally invasive percutaneous fixation, interbody fusion, and unilateral decompression. Basic information, time of pilot hole preparation, time of screw placement, and fluoroscopy time were recorded. Screw placement accuracy was graded based on the Gertzbein-Robbins scale, and the angle between the screw axis and the pedicle axis was collected in postoperative CT. RESULTS There was no statistical difference in basic information between the 2 groups. The mean time of single pilot hole preparation was 4.08±1.01 minutes in the new system group and 5.34±1.30 minutes in the conventional method group ( P <0.001). The time of single screw placement was significantly shorter in the new system group (0.82±0.20 vs. 1.72±0.33 min), and the fluoroscopy time was also less in the new system group (13.70±3.42 vs. 19.95±5.50 s) ( P <0.001). Screw placement accuracy assessment showed that there were 85 (94.45%) A-grade screws in the new system group while 76 (84.44%) A-grade screws in the conventional method group ( P =0.027). CONCLUSIONS The new pilot hole preparation system has shown significant reductions in the time of pilot hole preparation, time of screw placement, and radiation exposure, and has good clinical application value.
Collapse
Affiliation(s)
- Chaobo Feng
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound lmaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen, P. R. China
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, P. R. China
| | - Longfei Wang
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Sheng Yang
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Xinbo Wu
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Yunshan Fan
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Huang Yan
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Fangjing Chen
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Jia Chen
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Xiang Wang
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Qishuai Guo
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Longxiang Yao
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Yingchuan Zhao
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Shisheng He
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| | - Haijian Ni
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, P.R. China
| |
Collapse
|
|
3
|
Papalia GF, Vadalà G, Russo F, Marcello G, Nardi N, Papalia R, Denaro V. Higher Accuracy and Better Clinical Outcomes in Navigated Thoraco-Lumbar Pedicle Screw Fixation Versus Conventional Techniques : A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2024; 49:1370-1380. [PMID: 39049509 PMCID: PMC11386964 DOI: 10.1097/brs.0000000000005105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/03/2024] [Indexed: 07/27/2024]
Abstract
STUDY DESIGN A systematic review and meta-analysis. OBJECTIVE This study aims to compare pedicle screw accuracy, clinical outcomes, and complications between navigated and conventional techniques. SUMMARY OF BACKGROUND DATA In the last decades, intraoperative navigation has been introduced in spinal surgery to prevent risks and complications. MATERIALS AND METHODS The search was executed on Cochrane Central Library, PubMed, and Scopus on April 30, 2023. Randomized controlled trials, prospective and retrospective studies that compared pedicle screw accuracy in the thoracic-lumbar-sacral segments, blood loss, operative time, hospital stay, intraoperative and postoperative revision of screws, neurological and systemic complications, Visual Analogue Scale (VAS), and Oswestry Disability Index (ODI) between navigated and freehand or fluoroscopy-assisted techniques were included in this study. The meta-analysis was performed using Review Manager software. Clinical outcomes were assessed as continuous outcomes with mean difference, while pedicle screw accuracy and complications were assessed as dichotomous outcomes with odds ratio, all with 95% CIs. The statistical significance of the results was fixed at P <0.05. RESULTS This meta-analysis included 30 studies for a total of 17,911 patients and 24,600 pedicle screws. Statistically significant results in favor of the navigated technique were observed for the accuracy of pedicle screws ( P =0.0001), hospital stay ( P =0.0002), blood loss ( P <0.0001), postoperative revision of pedicle screws ( P <0.00001), and systemic complications ( P =0.0008). In particular, the positioning of the screws was clinically acceptable in 96.2% of the navigated group and 94.2% with traditional techniques. No significant differences were found in VAS, ODI, and operative time between the two groups. CONCLUSION Navigated pedicle screw fixation has been demonstrated to be a safe and effective technique with high improvement in clinical outcomes and accuracy in patients undergoing spinal fusion compared with conventional techniques. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Giuseppe F. Papalia
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Departmental Faculty of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, Roma, Italy
| | - Gianluca Vadalà
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Departmental Faculty of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, Roma, Italy
| | - Fabrizio Russo
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Departmental Faculty of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, Roma, Italy
| | - Gianmarco Marcello
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Departmental Faculty of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, Roma, Italy
| | - Niccolò Nardi
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Departmental Faculty of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, Roma, Italy
| | - Rocco Papalia
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Departmental Faculty of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, Roma, Italy
| | - Vincenzo Denaro
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Departmental Faculty of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, Roma, Italy
| |
Collapse
|
|
4
|
Li H, Zhang P, Wang G, Liu H, Yang X, Wang G, Sun Z. Real-Time Navigation with Guide Template for Pedicle Screw Placement Using an Augmented Reality Head-Mounted Device: A Proof-of-Concept Study. Indian J Orthop 2023; 57:776-781. [PMID: 37128571 PMCID: PMC10147887 DOI: 10.1007/s43465-023-00859-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/26/2023] [Indexed: 05/03/2023]
Abstract
Objective This study aims to explore the real-time navigation with guide template using an augmented reality head-mounted device (ARHMD) for pedicle screw placement. Methods The spatial coordinate relationships between augmented reality images and real objects were established through the custom-made guide template, and the registration and tracking were completed using an ARHMD. The feasibility and accuracy of this method were verified by pedicle screw placement in 2 lumbar models. According to the Gertzbein-Robbins grading scale, the accuracy of pedicle screw placement was assessed. The navigation errors were estimated by measuring the deviation values of entry point and trajectory angle. Results A total of 20 pedicle K-wires were placed into L1-L5 in 2 lumbar models, which were successfully completed, with an average time of 11.5 min per model and 69 s per screw. The overall K-wires placement accuracy was 100% (20 screws). The navigation error was 2.77 ± 0.82 mm for the deviation value of entry point, and 3.03° ± 0.94° for the deviation value of trajectory angle. Conclusions The application of an ARHMD combined with guide template for pedicle screw placement is a promising navigation approach.
Collapse
Affiliation(s)
- Haowei Li
- Tsinghua University School of Medicine, Beijing, 100091 China
| | - Peihai Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, 102218 China
| | - Guangzhi Wang
- Tsinghua University School of Medicine, Beijing, 100091 China
| | - Huiting Liu
- Peking Union Medical College Hospital, Beijing, 100730 China
| | - Xuejun Yang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, 102218 China
| | - Guihuai Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, 102218 China
| | - Zhenxing Sun
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, 102218 China
| |
Collapse
|
|
5
|
Scarone P, Chatterjea A, Jenniskens I, Klüter T, Weuster M, Lippross S, Presilla S, Distefano D, Chianca V, Sedaghat S, Nelson M, Lampe F, Seekamp A. Percutaneous thoraco-lumbar-sacral pedicle screw placement accuracy results from a multi-center, prospective clinical study using a skin marker-based optical navigation system. 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 2022; 31:3098-3108. [PMID: 36149493 DOI: 10.1007/s00586-022-07387-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/05/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
STUDY DESIGN Prospective multi-center study. OBJECTIVE The study aimed to evaluate the accuracy of pedicle screw placement using a skin marker-based optical surgical navigation system for minimal invasive thoraco-lumbar-sacral pedicle screw placement. METHODS The study was performed in a hybrid Operating Room with a video camera-based navigation system integrated in the imaging hardware. The patient was tracked with non-invasive skin markers while the instrument tracking was via an on-shaft optical marker pattern. The screw placement accuracy assessment was performed by three independent reviewers, using the Gertzbein grading. The screw placement time as well as the staff and patient radiation doses was also measured. RESULTS In total, 211 screws in 39 patients were analyzed for screw placement accuracy. Of these 32.7% were in the thoracic region, 59.7% were in the lumbar region, and 7.6% were in the sacral region. An overall accuracy of 98.1% was achieved. No screws were deemed severely misplaced (Gertzbein grading 3). The average time for screw placement was 6 min and 25 secs (± 3 min 33 secs). The average operator radiation dose per subject was 40.3 µSv. The mean patient effective dose (ED) was 11.94 mSv. CONCLUSION Skin marker-based ON can be used to achieve very accurate thoracolumbarsacral pedicle screw placements.
Collapse
Affiliation(s)
- Pietro Scarone
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Ospedale Regionale Di Lugano Civico E Italiano, Lugano, Switzerland
| | - Anindita Chatterjea
- Image Guided Therapy Systems, Philips Healthcare, Veenpluis 6, 5684 PC, Best, The Netherlands.
| | - Inge Jenniskens
- Image Guided Therapy Systems, Philips Healthcare, Veenpluis 6, 5684 PC, Best, The Netherlands
| | - Tim Klüter
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| | - Matthias Weuster
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| | - Sebastian Lippross
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| | - Stefano Presilla
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Ospedale Regionale Di Lugano Civico E Italiano, Lugano, Switzerland
| | - Daniela Distefano
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Ospedale Regionale Di Lugano Civico E Italiano, Lugano, Switzerland
| | - Vito Chianca
- Clinica di Radiologia EOC IIMSI, Lugano, Switzerland
- Ospedale Evangelico Betania, Naples, Italy
| | - Sam Sedaghat
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Ospedale Regionale Di Lugano Civico E Italiano, Lugano, Switzerland
| | - Melissa Nelson
- Image Guided Therapy Systems, Philips Healthcare, Veenpluis 6, 5684 PC, Best, The Netherlands
| | - Finn Lampe
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| | - Andreas Seekamp
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| |
Collapse
|
|
6
|
CT-Navigated Spinal Instrumentations-Three-Dimensional Evaluation of Screw Placement Accuracy in Relation to a Screw Trajectory Plan. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091200. [PMID: 36143877 PMCID: PMC9506171 DOI: 10.3390/medicina58091200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/25/2022] [Accepted: 08/27/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: In the literature, spinal navigation and robot-assisted surgery improved screw placement accuracy, but the majority of studies only qualitatively report on screw positioning within the vertebra. We sought to evaluate screw placement accuracy in relation to a preoperative trajectory plan by three-dimensional quantification to elucidate technical benefits of navigation for lumbar pedicle screws. Materials and Methods: In 27 CT-navigated instrumentations for degenerative disease, a dedicated intraoperative 3D-trajectory plan was created for all screws. Final screw positions were defined on postoperative CT. Trajectory plans and final screw positions were co-registered and quantitatively compared computing minimal absolute differences (MAD) of screw head and tip points (mm) and screw axis (degree) in 3D-space, respectively. Differences were evaluated with consideration of the navigation target registration error. Clinical acceptability of screws was evaluated using the Gertzbein−Robbins (GR) classification. Results: Data included 140 screws covering levels L1-S1. While screw placement was clinically acceptable in all cases (GR grade A and B in 112 (80%) and 28 (20%) cases, respectively), implanted screws showed considerable deviation compared to the trajectory plan: Mean axis deviation was 6.3° ± 3.6°, screw head and tip points showed mean MAD of 5.2 ± 2.4 mm and 5.5 ± 2.7 mm, respectively. Deviations significantly exceeded the mean navigation registration error of 0.87 ± 0.22 mm (p < 0.001). Conclusions: Screw placement was clinically acceptable in all screws after navigated placement but nevertheless, considerable deviation in implanted screws was noted compared to the initial trajectory plan. Our data provides a 3D-quantitative benchmark for screw accuracy achievable by CT-navigation in routine spine surgery and suggests a framework for objective comparison of screw outcome after navigated or robot-assisted procedures. Factors contributing to screw deviations should be considered to assure optimal surgical results when applying navigation for spinal instrumentation.
Collapse
|
|
7
|
Futakawa H, Nogami S, Seki S, Kawaguchi Y, Nakano M. Evaluation of Triggered Electromyogram Monitoring during Insertion of Percutaneous Pedicle Screws. J Clin Med 2022; 11:1197. [PMID: 35268288 PMCID: PMC8910926 DOI: 10.3390/jcm11051197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/02/2022] [Accepted: 02/18/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE percutaneous pedicle screw (PPS) fixation has been widely used in minimally invasive spine stabilization. Triggered electromyogram (TrEMG) monitoring is performed to prevent PPS misplacement, but is not widely accepted. We have newly developed an insulating tap device to minimize the misplacement of PPS. METHODS TrEMG was measurable in insulation tap devices in 31 cases, and in non-insulating tap devices in 27 cases. Fluoroscopy was used to insert 194 PPS and 154 PPS, respectively. Based on the Rampersaud classification of postoperative computed tomography, we classified PPS insertion into four categories (Grade A as no violation, Grade D as more than 4 mm perforation). RESULTS Grade A was noted in 168 PPSs (86.6%) and Grade B to D in 26 PPSs in the insulation tap device group, and Grade A was noted in 129 PPSs (83.8%) and Grade B to D in 25 PPSs in the non-insulating tap device group, respectively. At a cutoff value of 11 mA, the sensitivity was 41.4% and the specificity was 98.2%. The sensitivity and specificity of the non-insulating tap device were 4.0% and 99.2%, respectively. CONCLUSIONS The insulation treatment of the tap device has improved the sensitivity of TrEMG. TrEMG using the insulating tap device is one of the methods for safe PPS insertion.
Collapse
Affiliation(s)
- Hayato Futakawa
- Department of Orthopedic Surgery, Takaoka City Hospital, Toyama 933-8550, Japan; (S.N.); (M.N.)
- Department of Orthopedic Surgery, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan; (S.S.); (Y.K.)
| | - Shigeharu Nogami
- Department of Orthopedic Surgery, Takaoka City Hospital, Toyama 933-8550, Japan; (S.N.); (M.N.)
| | - Shoji Seki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan; (S.S.); (Y.K.)
| | - Yoshiharu Kawaguchi
- Department of Orthopedic Surgery, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan; (S.S.); (Y.K.)
| | - Masato Nakano
- Department of Orthopedic Surgery, Takaoka City Hospital, Toyama 933-8550, Japan; (S.N.); (M.N.)
| |
Collapse
|
|
8
|
Flynn SC, Eli IM, Ghogawala Z, Yew AY. Minimally Invasive Surgery for Spinal Metastasis: A Review. World Neurosurg 2021; 159:e32-e39. [PMID: 34861449 DOI: 10.1016/j.wneu.2021.11.097] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) techniques have advanced the treatment of metastatic diseases to the spine. The objective of this review is to describe clinical outcomes, benefits, and complications of these techniques. METHODS All relevant clinical studies describing the role of MIS, computer-assisted navigation (CAN), robot-assisted (RA) procedures, and laser interstitial thermal therapy (LITT) in the treatment of metastatic spine diseases were identified from PubMed, MEDLINE, and relevant article bibliographies. RESULTS For MIS articles, we filtered 1480 results and identified 26 studies. For CAN, we searched 464 articles to identify 18 articles for review. For RA, we searched 321 results to identify 7 studies for review. For LITT, we identified 21 articles for review. CONCLUSIONS MIS for the treatment of spine metastasis has significant potential benefits in reducing surgical site infections, hospital stay, and blood loss without compromising instrument accuracy or overall outcomes. Overall, MIS and its adjuncts have the potential to reduce the risks involved in the treatment of patients with metastatic disease to the spinal column without compromising the benefits of decompression and stabilization of the spine.
Collapse
Affiliation(s)
- Scott C Flynn
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ilyas M Eli
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, Massachusetts, USA; Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, Massachusetts, USA
| | - Andrew Y Yew
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, Massachusetts, USA.
| |
Collapse
|
|
9
|
Cervical Spine Pedicle Screw Accuracy in Fluoroscopic, Navigated and Template Guided Systems-A Systematic Review. Tomography 2021; 7:614-622. [PMID: 34698301 PMCID: PMC8544736 DOI: 10.3390/tomography7040052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/07/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Pedicle screws provide excellent fixation for a wide range of indications. However, their adoption in the cervical spine has been slower than in the thoracic and lumbar spine, which is largely due to the smaller pedicle sizes and the proximity to the neurovascular structures in the neck. In recent years, technology has been developed to improve the accuracy and thereby the safety of cervical pedicle screw placement over traditional fluoroscopic techniques, including intraoperative 3D navigation, computer-assisted Systems and 3D template moulds. We have performed a systematic review into the accuracy rates of the various systems. Methods: The PubMed and Cochrane Library databases were searched for eligible papers; 9 valid papers involving 1427 screws were found. Results: fluoroscopic methods achieved an 80.6% accuracy and navigation methods produced 91.4% and 96.7% accuracy for templates. Conclusion: Navigation methods are significantly more accurate than fluoroscopy, they reduce radiation exposure to the surgical team, and improvements in technology are speeding up operating times. Significantly superior results for templates over fluoroscopy and navigation are complemented by reduced radiation exposure to patient and surgeon; however, the technology requires a more invasive approach, prolonged pre-operative planning and the development of an infrastructure to allow for their rapid production and delivery. We affirm the superiority of navigation over other methods for providing the most accurate and the safest cervical pedicle screw instrumentation, as it is more accurate than fluoroscopy and lacks the limitations of templates.
Collapse
|
|
10
|
Molina CA, Sciubba DM, Greenberg JK, Khan M, Witham T. Clinical Accuracy, Technical Precision, and Workflow of the First in Human Use of an Augmented-Reality Head-Mounted Display Stereotactic Navigation System for Spine Surgery. Oper Neurosurg (Hagerstown) 2021; 20:300-309. [PMID: 33377137 DOI: 10.1093/ons/opaa398] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Augmented reality mediated spine surgery is a novel technology for spine navigation. Benchmark cadaveric data have demonstrated high accuracy and precision leading to recent regulatory approval. Absence of respiratory motion in cadaveric studies may positively bias precision and accuracy results and analogous investigations are prudent in live clinical scenarios. OBJECTIVE To report a technical note, accuracy, precision analysis of the first in-human deployment of this technology. METHODS A 78-yr-old female underwent an L4-S1 decompression, pedicle screw, and rod fixation for degenerative spine disease. Six pedicle screws were inserted via AR-HMD (xvision; Augmedics, Chicago, Illinois) navigation. Intraoperative computed tomography was used for navigation registration as well as implant accuracy and precision assessment. Clinical accuracy was graded per the Gertzbein-Robbins (GS) scale by an independent neuroradiologist. Technical precision was analyzed by comparing 3-dimensional (3D) (x, y, z) virtual implant vs real implant position coordinates and reported as linear (mm) and angular (°) deviation. Present data were compared to benchmark cadaveric data. RESULTS Clinical accuracy (per the GS grading scale) was 100%. Technical precision analysis yielded a mean linear deviation of 2.07 mm (95% CI: 1.62-2.52 mm) and angular deviation of 2.41° (95% CI: 1.57-3.25°). In comparison to prior cadaveric data (99.1%, 2.03 ± 0.99 mm, 1.41 ± 0.61°; GS accuracy 3D linear and angular deviation, respectively), the present results were not significantly different (P > .05). CONCLUSION The first in human deployment of the single Food and Drug Administration approved AR-HMD stereotactic spine navigation platform demonstrated clinical accuracy and technical precision of inserted hardware comparable to previously acquired cadaveric studies.
Collapse
Affiliation(s)
- Camilo A Molina
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jacob K Greenberg
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Majid Khan
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
|
11
|
Molina CA, Dibble CF, Lo SFL, Witham T, Sciubba DM. Augmented reality-mediated stereotactic navigation for execution of en bloc lumbar spondylectomy osteotomies. J Neurosurg Spine 2021; 34:700-705. [PMID: 33668026 DOI: 10.3171/2020.9.spine201219] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/03/2020] [Indexed: 11/06/2022]
Abstract
En bloc spinal tumor resections are technically demanding procedures with high morbidity because of the conventionally large exposure area and aggressive resection goals. Stereotactic surgical navigation presents an opportunity to perform the smallest possible resection plan while still achieving an en bloc resection. Augmented reality (AR)-mediated spine surgery (ARMSS) via a mounted display with an integrated tracking camera is a novel FDA-approved technology for intraoperative "heads up" neuronavigation, with the proposed advantages of increased precision, workflow efficiency, and cost-effectiveness. As surgical experience and capability with this technology grow, the potential for more technically demanding surgical applications arises. Here, the authors describe the use of ARMSS for guidance in a unique osteotomy execution to achieve an en bloc wide marginal resection of an L1 chordoma through a posterior-only approach while avoiding a tumor capsule breach. A technique is described to simultaneously visualize the navigational guidance provided by the contralateral surgeon's tracked pointer and the progress of the BoneScalpel aligned in parallel with the tracked instrument, providing maximum precision and safety. The procedure was completed by reconstruction performed with a quad-rod and cabled fibular strut allograft construct, and the patient did well postoperatively. Finally, the authors review the technical aspects of the approach, as well as the applications and limitations of this new technology.
Collapse
Affiliation(s)
- Camilo A Molina
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri; and
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher F Dibble
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Sheng-Fu Larry Lo
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy Witham
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel M Sciubba
- 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
|
12
|
Molina CA, Phillips FM, Colman MW, Ray WZ, Khan M, Orru' E, Poelstra K, Khoo L. A cadaveric precision and accuracy analysis of augmented reality-mediated percutaneous pedicle implant insertion. J Neurosurg Spine 2021; 34:316-324. [PMID: 33126206 DOI: 10.3171/2020.6.spine20370] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Augmented reality-mediated spine surgery (ARMSS) is a minimally invasive novel technology that has the potential to increase the efficiency, accuracy, and safety of conventional percutaneous pedicle screw insertion methods. Visual 3D spinal anatomical and 2D navigation images are directly projected onto the operator's retina and superimposed over the surgical field, eliminating field of vision and attention shift to a remote display. The objective of this cadaveric study was to assess the accuracy and precision of percutaneous ARMSS pedicle implant insertion. METHODS Instrumentation was placed in 5 cadaveric torsos via ARMSS with the xvision augmented reality head-mounted display (AR-HMD) platform at levels ranging from T5 to S1 for a total of 113 total implants (93 pedicle screws and 20 Jamshidi needles). Postprocedural CT scans were graded by two independent neuroradiologists using the Gertzbein-Robbins scale (grades A-E) for clinical accuracy. Technical precision was calculated using superimposition analysis employing the Medical Image Interaction Toolkit to yield angular trajectory (°) and linear screw tip (mm) deviation from the virtual pedicle screw position compared with the actual pedicle screw position on postprocedural CT imaging. RESULTS The overall implant insertion clinical accuracy achieved was 99.1%. Lumbosacral and thoracic clinical accuracies were 100% and 98.2%, respectively. Specifically, among all implants inserted, 112 were noted to be Gertzbein-Robbins grade A or B (99.12%), with only 1 medial Gertzbein-Robbins grade C breach (> 2-mm pedicle breach) in a thoracic pedicle at T9. Precision analysis of the inserted pedicle screws yielded a mean screw tip linear deviation of 1.98 mm (99% CI 1.74-2.22 mm) and a mean angular error of 1.29° (99% CI 1.11°-1.46°) from the projected trajectory. These data compare favorably with data from existing navigation platforms and regulatory precision requirements mandating that linear and angular deviation be less than 3 mm (p < 0.01) and 3° (p < 0.01), respectively. CONCLUSIONS Percutaneous ARMSS pedicle implant insertion is a technically feasible, accurate, and highly precise method.
Collapse
Affiliation(s)
- Camilo A Molina
- 1Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Frank M Phillips
- 3Department of Orthopedic Surgery, Rush University School of Medicine, Chicago, Illinois
| | - Matthew W Colman
- 3Department of Orthopedic Surgery, Rush University School of Medicine, Chicago, Illinois
| | - Wilson Z Ray
- 1Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Majid Khan
- 2Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emanuele Orru'
- 4Department of Neurointerventional Radiology, Lahey Clinic Tufts University School of Medicine, Boston, Massachusetts
| | - Kornelis Poelstra
- 5The Robotic Spine Institute of Silicon Valley at OrthoNorCal, Los Gatos, California; and
| | - Larry Khoo
- 6The Spine Clinic of Los Angeles, California
| |
Collapse
|
|
13
|
Dibble CF, Molina CA. Device profile of the XVision-spine (XVS) augmented-reality surgical navigation system: overview of its safety and efficacy. Expert Rev Med Devices 2020; 18:1-8. [PMID: 33322948 DOI: 10.1080/17434440.2021.1865795] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: The field of augmented reality mediated spine surgery is growing rapidly and holds great promise for improving surgical capabilities and patient outcomes. Augmented reality can assist with complex or atypical cases involving challenging anatomy. As neuronavigation evolves, fundamental technical limitations remain in line-of-sight interruption and operator attention shift, which this novel augmented reality technology helps to address.Areas covered: XVision is a recently FDA-approved head mounted display for intraoperative neuronavigation, compatible with all current conventional pedicle screw technology. The device is a wireless, customizable headset with an integrated surgical tracking system and transparent retinal display. This review discusses the available literature on the safety and efficacy of XVision, as well as the current state of augmented reality technology in spine surgery.Expert opinion: Augmented-reality spine surgery is an emerging technology that may increase precision, efficiency, and safety as well as decrease radiation exposure of manual and robotic computer-navigated pedicle screw insertion techniques. The initial clinical experience with XVision has shown good outcomes and it has received positive operator feedback. Now that initial clinical safety and efficacy has been demonstrated, ongoing experience must be studied to empirically validate this technology and generate further innovation in this rapidly evolving field.
Collapse
Affiliation(s)
- Christopher F Dibble
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, USA
| | - Camilo A Molina
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, USA
| |
Collapse
|
|
14
|
Stübig T, Windhagen H, Krettek C, Ettinger M. Computer-Assisted Orthopedic and Trauma Surgery. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:793-800. [PMID: 33549155 PMCID: PMC7947640 DOI: 10.3238/arztebl.2020.0793] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/06/2020] [Accepted: 08/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are many ways in which computer-assisted orthopedic and trauma surgery (CAOS) procedures can help surgeons to plan and execute an intervention. METHODS This study is based on data derived from a selective search of the literature in the PubMed database, supported by a Google Scholar search. RESULTS For most applications the evidence is weak. In no sector did the use of computer-assisted surgery yield any relevant clinical or functional improvement. In trauma surgery, 3D-navigated sacroiliac screw fixation has become clinically established for the treatment of pelvic fractures. One randomized controlled trial showed a reduction in the rate of screw misplacement: 0% with 3D navigation versus 20.4% with the conventional procedure und 16.6% with 2D navigation. Moreover, navigation-assisted pedicle screw stabilization lowers the misplacement rate. In joint replacements, the long-term results showed no difference in respect of clinical/functional scores, the time for which the implant remained in place, or aseptic loosening. CONCLUSION Computer-assisted procedures can improve the precision of certain surgical interventions. Particularly in joint replacement and spinal surgery, the research is moving away from navigation in the direction of robotic procedures. Future studies should place greater emphasis on clinical and functional results.
Collapse
Affiliation(s)
- Timo Stübig
- Department of Traumatology, Hannover Medical School
| | - Henning Windhagen
- Department of Orthopedic Surgery, Hannover Medical School, Annastift
| | | | - Max Ettinger
- Department of Orthopedic Surgery, Hannover Medical School, Annastift
| |
Collapse
|
|
15
|
Xu WX, Ding WG, Xu B, Hu TH, Sheng HF, Zhu JF, Zhu XL. Appropriate insertion point for percutaneous pedicle screw placement in the lumbar spine using c-arm fluoroscopy: a cadaveric study. BMC Musculoskelet Disord 2020; 21:750. [PMID: 33189133 PMCID: PMC7666764 DOI: 10.1186/s12891-020-03751-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/28/2020] [Indexed: 11/25/2022] Open
Abstract
Background We studied the characteristics and regularity of appropriate insertion points for percutaneous pedicle screw placement in the lumbar spine using C-arm X-ray fluoroscopy. The purpose of this study was to improve the accuracy of percutaneous pedicle screw placement and reduce the incidence of superior-level facet joint violation. Methods Six normal spinal specimens were included. Three different methods for placing percutaneous pedicle screws in the lumbar spine were applied, including the Roy-Camille method, Magerl method and Weinstein method. The relationships among the insertion point, pedicle projection and proximal facet joint on C-arm X-ray films were studied. The projection morphology of the vertebral pedicle in different segments of the lumbar spine was observed. The relationship between the outer edge of the pedicle projection and the outer edge of the cranial articular process was also studied. The distance between the insertion point and the facet joint (M1), the distance between the insertion point and outer edge of the cranial articular process (M2), and the distance between the insertion point and the projection center of the pedicle (M) were measured. Results In this study, we found that the projection shape of the vertebral pedicle differed across segments of the lumbar spine: the shape for L1-L3 was oval, and that for L4-L5 was round. The radiographic study showed that the outer edge of the cranial articular process was located on the lateral side of the outer edge of the pedicle projection and did not overlap with the pedicle projection. M for the Weinstein group was larger than that for the Roy-Camille group (P < 0.05). M1 for the Weinstein group was larger than that for the Roy-Camille and Magerl groups (P < 0.05). M2 for the Roy-Camille group was negative, M2 for the Magerl group was 0, and M2 for the Weinstein group was positive. Conclusion Under C-arm X-ray fluoroscopy, we were able to accurately identify the characteristics and regularity of the appropriate insertion point for percutaneous pedicle screw placement in the lumbar spine, which was important for improving the accuracy of percutaneous pedicle screw placement and reducing the incidence of superior-level facet joint violation.
Collapse
Affiliation(s)
- Wei-Xing Xu
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234# Gu-cui Road, Hangzhou, 310012, People's Republic of China
| | - Wei-Guo Ding
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234# Gu-cui Road, Hangzhou, 310012, People's Republic of China.
| | - Bin Xu
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234# Gu-cui Road, Hangzhou, 310012, People's Republic of China
| | - Tian-Hong Hu
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234# Gu-cui Road, Hangzhou, 310012, People's Republic of China
| | - Hong-Feng Sheng
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234# Gu-cui Road, Hangzhou, 310012, People's Republic of China
| | - Jia-Fu Zhu
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234# Gu-cui Road, Hangzhou, 310012, People's Republic of China
| | - Xiao-Long Zhu
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234# Gu-cui Road, Hangzhou, 310012, People's Republic of China
| |
Collapse
|
|
16
|
Li Q, Chen B, Chen R, Yu Y, Jiang L, Fan X. Comparison of the perioperative parameters between computer navigation and fluoroscopy guidance for pedicle screw placement: A protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21064. [PMID: 32664123 PMCID: PMC7360262 DOI: 10.1097/md.0000000000021064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Computer navigation technology is gradually applied to the placement of pedicle screws, but its security and effectiveness still lack of high-quality evidence-based medical evidence. In this study, we will perform a systematic review of previously published randomized controlled trials to investigate the accuracy and effectiveness of computer navigation vsersus fluoroscopy guidance for pedicle screw placement. METHODS All study protocols adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed (MEDLINE), The excerpta medica database, Web of Science (science and social science citation index), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), China National Knowledge Infrastructure, Chinese Science and Technology Periodical Database, WanFang, Chinese Biomedical Literature Database will be searched for relevant articles up to 18 April, 2020. We will include randomized controlled trials of computer navigation and fluoroscopy guidance for pedicle screw placement. The Cochrane Handbook (v6) will be used for assessment of study bias and reliability, and a meta-analysis will be performed using STATA 16.0. The main outcome will be the proportion of accurate implanted screws. Additional outcomes including: overall complication rate, radiation dosage, length of surgery, length of stay, estimated blood loss. RESULTS The quality of the assessments will be assessed through Grading of Recommendations Assessment, Development, and Evaluation. Data will be disseminated through publications in peer-reviewed journals. CONCLUSION We will evaluate the accuracy and other perioperative parameters between computer navigation and fluoroscopy guidance for pedicle screw placement. TRIAL REGISTRATION NUMBER PROSPERO 2020 CRD42020172087.
Collapse
|
|
17
|
Wang M, Li D, Shang X, Wang J. A review of computer-assisted orthopaedic surgery systems. Int J Med Robot 2020; 16:1-28. [PMID: 32362063 DOI: 10.1002/rcs.2118] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/07/2020] [Accepted: 04/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Computer-assisted orthopaedic surgery systems have great potential, but no review has focused on computer-assisted surgery systems for the spine, hip, and knee. METHODS A systematic search was performed in Web of Science and PubMed. We searched the literature on computer-assisted orthopaedic surgery systems from 2008 to the present and focused on three aspects of systems: training, planning, and intraoperative navigation. RESULTS AND DISCUSSION In this review study, we reviewed 34 surgical training systems, 31 surgical planning systems, and 41 surgical navigation systems. The functions and characteristics of the surgical systems were compared and analysed, and the current concerns about and the impact of the surgical systems on doctors and surgery were clarified. CONCLUSION Computer-assisted orthopaedic surgery systems are still in the development stage. Future surgical training systems should include synthetic models with patient anatomy. Surgical planning systems with automatic planning should be developed, and surgical navigation systems with multimodal fusion, robotic assistance and imaging should be developed.
Collapse
Affiliation(s)
- Monan Wang
- Mechanical & Power Engineering College , Harbin University of Science and Technology, Harbin, China
| | - Donghui Li
- Mechanical & Power Engineering College , Harbin University of Science and Technology, Harbin, China
| | - Xiping Shang
- Mechanical & Power Engineering College , Harbin University of Science and Technology, Harbin, China
| | - Jian Wang
- Mechanical & Power Engineering College , Harbin University of Science and Technology, Harbin, China
| |
Collapse
|
|
18
|
Cranial facet joint injuries in percutaneous lumbar pedicle screw placement: a matched-pair analysis comparing intraoperative 3D navigation and conventional fluoroscopy. 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 2020; 30:88-96. [PMID: 32462309 DOI: 10.1007/s00586-020-06467-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 04/01/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The violation of the cranial adjacent facet is a frequent complication in lumbar instrumentations and can induce local pain and adjacent segment disease. Minimally invasive screw implantation is often stated as risk factor in comparison with open approaches. Percutaneous pedicle screw placement (PPSP) can be performed using single X-ray images (fluoroscopy) or intraoperative 3D navigation. The study compares top-level screws in percutaneous lumbar instrumentations regarding facet violations and screw pedicle position using navigation or fluoroscopy. METHODS Patients after lumbar PPSP were retrospectively separated according to the intraoperative technique: navigation (NAV) or fluoroscopy (FLUORO). Two blinded investigators graded the top-level screws regarding facet violations and pedicle breach in postoperative CT scans. Subsequent matched cohort analysis was performed for comparable groups. RESULTS Evaluating 768 screws, we assessed 70 (9.1%) facet violations. Overall, 186 (24.2%) screws were implanted using navigation. There was no significant difference in the rate of facet violations between both imaging groups (NAV 19/186, 10.2%, FLUORO 51/582, 8.8%, p = 0.55). Totally, 728 (94.8%) of all screws showed a correct pedicle position. Most of the 40 unfavorable pedicle positions were placed by fluoroscopy (NAV 4/186, 2.2%, FLUORO 36/582, 6.6%, p = 0.03). The matched cohorts verified these results (facet violations: NAV 19/186, 10.2%, FLUORO 18/186, 9.7%, p = 0.55; pedicle penetrations: NAV 4/186, 2.2%, FLUORO 12/186, 6.9%, p = 0.04). CONCLUSIONS Both intraoperative imaging techniques allow lumbar PPSP with low rates of cranial facet violations if the surgeon intends to preserve facet integrity. Navigation was superior concerning accurate pedicle screw position, but could not significantly prevent facet violations.
Collapse
|
|
19
|
Lumbar Percutaneous Pedicle Screw Breach Rates: A Comparison of Robotic Navigation Platform Versus Conventional Techniques. Clin Spine Surg 2020; 33:E162-E167. [PMID: 32149744 DOI: 10.1097/bsd.0000000000000963] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Cadaveric study. SUMMARY OF BACKGROUND DATA Pedicle screw fixation is an established means of stabilizing the thoracic and lumbar spine. However, there are associated complications including pedicle breach which can result in neurological injury, durotomy, vascular injury, and suboptimal fixation. OBJECTIVE The aim of this study is to determine whether use of a navigated robotic platform results in fewer pedicle breaches and the underlying reasons for any difference in pedicle breach rates. MATERIALS AND METHODS Ten board-certified neuro- and orthopedic spine surgeons inserted 80 percutaneous lumbar screws in 10 unembalmed human cadavers. Forty screws were inserted using conventional fluoroscopic guidance and 40 were inserted using a navigated robotic platform. None of the participating surgeons had any prior experience with navigated robotic spine surgery. At the end of the study each screw was assessed with a computed tomography scan, plain radiographs and visual inspection to determine the presence or absence of pedicle breaches. RESULTS Forty percent (40%) of screws inserted using conventional fluoroscopic guidance breached compared with 2.5% of screws inserted with robot assistance (P=0.00005). Lateral breaches accounted for 88.2% (15/17) of all breaches. Detailed analysis revealed that the starting point of screws that breached laterally were significantly more lateral than that of the contralateral accurate screw (P=0.016). Pedicle screw diameter, length, and angulation in the transverse plane did not differ significantly between accurate screws and those that breached (P>0.05). CONCLUSIONS The use of a navigated robotic platform in the present study resulted in significantly fewer pedicle breaches. This was achieved through correct starting point selection with subsequent safe pedicle screw insertion.
Collapse
|
|
20
|
Wu C, Deng J, Li T, Tan L, Yuan D. Percutaneous Pedicle Screw Placement Aided by a New Drill Guide Template Combined with Fluoroscopy: An Accuracy Study. Orthop Surg 2020; 12:471-479. [PMID: 32133781 PMCID: PMC7189065 DOI: 10.1111/os.12642] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/22/2020] [Accepted: 02/04/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To evaluate the accuracy of percutaneous pedicle screw (PPS) placement aided by a new drill guide template. Methods The patients were divided into guide template group and conventional perspective group. In the conventional perspective group, the screws were placed by hand under fluoroscopy. In the guide template group, the screw placement was aided by a new drill guide template, and the drill guide template is designed according to the patient's ideal pedicle screw, but not based on skin morphology. The accuracy was evaluated by comparing the following parameters between the two groups: pedicle breach level, inclination angle deviation between the left and right screws, sagittal angle deviation between the left and right screws, and position deviation of the left and right screw entry points. The consistency of the postoperative screw angle and the corresponding guide template inclination angle was compared in the guide template group. The operative time, blood loss, and radiation times were compared between the groups. Results A total of 146 patients (876 screws) were enrolled in our study including 79 (474 screws) in the guide template group and 67 (402 screws) in the conventional perspective group. The pedicle breach level in the guide template group (22/474) was significantly lower than that in the conventional perspective group (47/402) (P < 0.05). The position and direction deviations of the left and right screws in the guide template group (2.06 ± 1.02 mm, 1.23 ± 1.25 mm, 1.83° ± 1.49°) were significantly less than those in the conventional perspective group (5.33 ± 2.99 mm, 4.32 ± 3.25 mm, 2.87° ± 1.56°). The operation time, blood loss, and radiation times were significantly lower in the guide template group (80.49 ± 9.14 min, 50.42 ± 8.9 mL, 11.02 ± 2.44) than those in the conventional perspective group (108.1 ± 21.18 min, 71.7 ± 17.09 mL, 23.53 ± 4.54). There were no significant differences between the postoperative screw angle and the corresponding guide template angle in the guide template group. Conclusion PPS placement aided by a new drill guide template yielded higher screw accuracy and less operative time, blood loss, and radiation exposure than traditional screw placement.
Collapse
Affiliation(s)
- Chao Wu
- Represent Orthopedics Center of Zigong Fourth People's Hospital, Zigong, Sichuan as province, China.,Represent Digital Medical Center of Zigong Fourth People's Hospital, Zigong, Sichuan as province, China
| | - Jiayan Deng
- Represent Digital Medical Center of Zigong Fourth People's Hospital, Zigong, Sichuan as province, China
| | - Tao Li
- Represent Orthopedics Center of Zigong Fourth People's Hospital, Zigong, Sichuan as province, China
| | - Lun Tan
- Represent Orthopedics Center of Zigong Fourth People's Hospital, Zigong, Sichuan as province, China
| | - Dechao Yuan
- Represent Orthopedics Center of Zigong Fourth People's Hospital, Zigong, Sichuan as province, China
| |
Collapse
|
|
21
|
Accuracy of K-Wireless Insertion of Percutaneous Pedicle Screws Using Computer-Assisted Spinal Navigation: A Systematic Review and Single-Center Experience. World Neurosurg 2020; 138:e267-e274. [PMID: 32105880 DOI: 10.1016/j.wneu.2020.02.079] [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: 12/17/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study sought to 1) describe the use K-wireless pedicle screw insertion among adults (age ≥18 years) undergoing a minimally invasive fusion and 2) perform a systematic review (SR) of all studies that describe a navigated, K-wireless technique with 3-dimensional fluoroscopy. METHODS Patients undergoing a minimally invasive fusion requiring pedicle screw fixation for any indication were prospectively enrolled in the observational component of this study. An assessment of pedicle breach was performed independently and in duplicate based on a modification of the Belmont grading scale. Articles for the SR were identified from a structured search of Medline from inception to May 8, 2019, without restriction of language. RESULTS A total of 82 pedicle screws were placed in 20 patients who underwent surgery between January and June 2014. There was no significant difference in mean operative time between the cases included in this study and a matched cohort of 20 patients undergoing surgery with 2-dimensional fluoroscopy and K-wire-assisted pedicle screw placement (95 ± 13 vs. 87 ± 20 minutes, respectively; P > 0.05). There were 2 major pedicle breaches (Belmont grade 3) in a single patient, yielding a major breach rate of 2.44%. A total of 6 papers that described the placement of 700 pedicle screws in 160 patients between May 2011 and March 2017 were included in the SR. The overall breach rate was 7.00% (n = 37). CONCLUSIONS Percutaneous pedicle screws can be placed accurately and safely using 3-dimensional navigation without the use of K-wires and may confer benefits to patients and clinicians by reducing K-wire-associated complications and radiation exposure.
Collapse
|
|
22
|
Abstract
PURPOSE OF REVIEW The goal of the review is to discuss the common general applications of navigation in the context of minimally invasive spine surgery and assess its value in the published literature comparing against non-navigated or navigated techniques. RECENT FINDINGS There is increasing utilization of computer navigation in minimally invasive spine surgery. There is synergy between navigation and minimally invasive technologies, such that one enhances or facilitates the other, thus leading to wider applications for both. Specifically, navigation has been shown to improve performance of percutaneous pedicle screw placement, vertebral augmentation, and minimally invasive fusion procedures. Overall, clinical studies have shown better accuracy and less radiation exposure with the use of navigation in spine surgery. The use of navigation in minimally invasive spine surgery enhances the accuracy of instrumentation and decreases radiation exposure. It is yet to be determined whether patient-reported outcomes will differ. Further research on its effect on clinical outcomes may further define the future impact of navigation in minimally invasive spine surgery.
Collapse
Affiliation(s)
- Jonathan N Sembrano
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave S R200, Minneapolis, MN, 55454, USA.
| | - Sharon C Yson
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave S R200, Minneapolis, MN, 55454, USA
| | - Jeffrey J Theismann
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave S R200, Minneapolis, MN, 55454, USA
| |
Collapse
|
|
23
|
Pennington Z, Cottrill E, Westbroek EM, Goodwin ML, Lubelski D, Ahmed AK, Sciubba DM. Evaluation of surgeon and patient radiation exposure by imaging technology in patients undergoing thoracolumbar fusion: systematic review of the literature. Spine J 2019; 19:1397-1411. [PMID: 30974238 DOI: 10.1016/j.spinee.2019.04.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive spine techniques are becoming increasingly popular owing to their ability to reduce operative morbidity and recovery times. The downside to these new procedures is their need for intraoperative radiation guidance. PURPOSE To establish which technologies provide the lowest radiation exposure to both patient and surgeon. STUDY DESIGN/SETTING Systematic review OUTCOME MEASURES: Average intraoperative radiation exposure (in mSv per screw placed) to surgeon and patient. Average fluoroscopy time per screw placed. METHODS We reviewed the available English medical literature to identify all articles reporting patient and/or surgeon radiation exposure in patients undergoing image-guided thoracolumbar instrumentation. Quantitative meta-analysis was performed for studies providing radiation exposure or fluoroscopy use per screw placed to determine which navigation modality was associated with the lowest intraoperative radiation exposure. Values on meta-analysis were reported as mean ± standard deviation. RESULTS We identified 4956 unique articles, of which 85 met inclusion/exclusion criteria. Forty-one articles were included in the meta-analysis. Patient radiation exposure per screw placed for each modality was: conventional fluoroscopy without navigation (0.26±0.38 mSv), conventional fluoroscopy with pre-operative CT-based navigation (0.027±0.010 mSv), intraoperative CT-based navigation (1.20±0.91 mSv), and robot-assisted instrumentation (0.04±0.30 mSv). Values for fluoroscopy used per screw were: conventional fluoroscopy without navigation (11.1±9.0 seconds), conventional fluoroscopy with navigation (7.20±3.93 s), 3D fluoroscopy (16.2±9.6 s), intraoperative CT-based navigation (19.96±17.09 s), and robot-assistance (20.07±17.22 s). Surgeon dose per screw: conventional fluoroscopy without navigation (6.0±7.9 × 10-3 mSv), conventional fluoroscopy with navigation (1.8±2.5 × 10-3 mSv), 3D Fluoroscopy (0.3±1.9 × 10-3 mSv), intraoperative CT-based navigation (0±0 mSv), and robot-assisted instrumentation (2.0±4.0 × 10-3 mSv). CONCLUSION All image guidance modalities are associated with surgeon radiation exposures well below current safety limits. Intraoperative CT-based (iCT) navigation produces the lowest radiation exposure to surgeon albeit at the cost of increased radiation exposure to the patient relative to conventional fluoroscopy-based methods.
Collapse
Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA.
| |
Collapse
|
|
24
|
Siccoli A, Klukowska AM, Schröder ML, Staartjes VE. A Systematic Review and Meta-Analysis of Perioperative Parameters in Robot-Guided, Navigated, and Freehand Thoracolumbar Pedicle Screw Instrumentation. World Neurosurg 2019; 127:576-587.e5. [DOI: 10.1016/j.wneu.2019.03.196] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/21/2022]
|
|
25
|
Accuracy in Percutaneous Transpedicular Screws Placement Using Biplane Radioscopy: Systematic Review and Meta-Analysis. Clin Spine Surg 2019; 32:198-207. [PMID: 30762838 DOI: 10.1097/bsd.0000000000000801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Systematic review and descriptive data meta-analysis. OBJECTIVE The objective of this study was to appropriately establish the accuracy in the percutaneous transpedicular screws (PTS) placement using biplane radioscopy (Rx-2D). SUMMARY OF BACKGROUND DATA The Rx-2D is a widely-used technique for PTS as it is practical, ubiquitous, and cost-effective. However, the reported "acceptable" accuracy attained by this method is widely variable ranging between 76% and 100%. METHODS A systematic review was conducted to screen publications about PTS placement using Rx-2D guidance. PubMed/MEDLINE database was consulted using the search term "percutaneous pedicle screw" from 1977 to 2017. Previous meta-analysis and reference lists of the selected articles were reviewed. Accuracy values were assessed fulfilling the proposed criteria. Observational data meta-analysis was performed. Cochran's Q test was used to determine heterogeneity among data extracted from the series, which was quantified by I test. P-values≤0.05 were considered statistically significant. The results were depicted by Forest plots. Funnel plots were outlined to visualize a possible bias of publication among the selected articles. RESULTS In total, 27 articles were included in the analysis. Results of the accuracy were as follow, 91.5% (n=7993; 95% CI, 89.3%-93.6%) of the screws were placed purely intrapedicular, and 96.1% (n=8579; 95% CI, 94.0%-98.2%) when deviation from the pedicle was up to 2 mm. CONCLUSIONS This meta-analysis is the largest review of PTS placed with Rx-2D guidance reported up to date. We concluded that the procedure is a safe and reproducible technique. The key values obtained in this work set reliable references for both clinical and training outcome assessing.
Collapse
|
|
26
|
Navigation Versus Fluoroscopy in Multilevel MIS Pedicle Screw Insertion: Separate Analysis of Exposure to Radiation of the Surgeon and of the Patients. Clin Spine Surg 2019; 32:E258-E265. [PMID: 30762840 DOI: 10.1097/bsd.0000000000000807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This study was a retrospective radiographic analysis of consecutive patients. OBJECTIVES To analyze exposure to radiation of the surgeon and-separately-of patients in minimally invasive surgery (MIS) of multilevel posterior stabilization by percutaneous pedicle screw insertion guided by navigation (PIN) versus percutaneous pedicle screw insertion guided by fluoroscopy (PIF). SUMMARY OF BACKGROUND DATA Spine surgeons are exposed to a 12-fold higher dose of radiation than other nonspinal musculoskeletal surgeons and PIF in MIS leads to a 2-fold higher dose of radiation than in open surgery. PIN might reduce the dose of radiation for the surgeon and the patient, especially in multilevel MIS surgery. To the best of our knowledge, there are only rare data of short-segment fusions that do not focus on exposure to radiation of surgeons. METHODS After power analysis, we included 205 consecutive screws (22 patients). We monitored dose of radiation (recorded separately for patient and surgeon), accuracy of screw placement, time of operation, and approach-related complications. RESULTS In PIN, only 58.7% of dose area product (cGy×cm) per screw of PIF was determined for patients (P<0.01). The surgeon was only exposed to 19.9% of radiation per screw in PIN compared with dosage in PIF (P<0.01). Four of 205 screws (2.0%) were classified as being incorrectly positioned: 2 of 87 screws (2.3%) in PIF and 2 of 118 screws (1.7%) in PIN (P>0.05). We did not observe any wound infections. CONCLUSIONS PIN in MIS is a safe procedure and does, compared with PIF, lead to significant reduction of radiation dose for patients and-even more-for spine surgeons.
Collapse
|
|
27
|
Radiation Exposure and Operation Time in Percutaneous Endoscopic Lumbar Discectomy Using Fluoroscopy-Based Navigation System. World Neurosurg 2019; 127:e39-e48. [PMID: 30802551 DOI: 10.1016/j.wneu.2019.01.289] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study evaluated radiation exposure and operation time of percutaneous endoscopic lumbar discectomy (PELD) by using a fluoroscopy-based navigation system for access and localization. METHODS Eighty-six PELDs performed by a single surgeon were retrospectively analyzed. Patients were separated into 2 groups: group A (using a three-dimensional [3D]-printed navigation instrument and fluoroscopy-based navigation system) and group B (with conventional fluoroscopy and standard instrumentation). The operation, fluoroscopy, and total access time were collected, as well as fluoroscopy and access times. RESULTS The operative time for group A was 59 minutes (standard deviation [SD], 6 minutes) and 106 minutes (SD, 15 minutes) in group B (P < 0.001). In group A, fluoroscopy was used an average of 5 times (SD, 0.7) and 29 times (SD, 8) in group B (P < 0.001). The fluoroscopy time was 9 minutes (SD, 2 minutes) in group A and 40 minutes (SD, 8 minutes) in group B (P < 0.001). The number of access attempts was 1.3 (SD, 0.5) in group A and 8 (SD, 2 times) in group B (P < 0.001). The total access time was 11 minutes (SD, 2 minutes) in group A and 28 minutes (SD, 5 minutes) in group B (P < 0.001). CONCLUSIONS PELD using the fluoroscopy-based navigation system showed lower operative, fluoroscopy, and access time compared with conventional techniques. In addition, fewer fluoroscopy images and access attempts were made in the navigation group. These data suggest that this novel technique reduces fluoroscopy and operation time and may reduce risks of repeated surgical access attempts.
Collapse
|
|
28
|
[Navigation in lumbar spinal surgery: When is it useful?]. DER ORTHOPADE 2018; 48:59-68. [PMID: 30560400 DOI: 10.1007/s00132-018-03671-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Spinal navigation has evolved greatly since its implementation in the mid-1990s and is now widely used in lumbar spine surgery. However, navigation is not yet accepted as a standard technique. APPLICATIONS In addition to the classic use in lumbar pedicle screw instrumentation, navigation technology, especially in combination with intraoperative 3D imaging, can be applied in a wide range of indications and in all lumbar approaches. The technology is particularly helpful in minimally invasive operations. The concept of "total navigation" stands for an efficient use of the technique from skin incision on and aims at complete elimination of radiation exposure for the surgical team. ADVANTAGES AND PITFALLS High accuracy and low radiation exposure of the OR team are indisputable advantages of navigated operations, while time savings and economic benefits are yet to be demonstrated. Regular use and standardized workflow are essential for the safe and effective application of lumbar navigation. Currently, lumbar navigation technology is already of great importance, yet the complex technology requires intensive training. With improved user comfort and image quality, spinal navigation will continue to spread in the future.
Collapse
|
|
29
|
Learning curve analysis of 3D-fluoroscopy image-guided pedicle screw insertions in lumbar single-level fusion procedures. Arch Orthop Trauma Surg 2018; 138:1501-1509. [PMID: 29982886 DOI: 10.1007/s00402-018-2994-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The implementation of 3D-navigation in the operating theater is reported to be complex, time consuming, and radiation intense. This prospective single-center cohort study was performed to objectify these assumptions by determining navigation-related learning curves in lumbar single-level posterior fusion procedures using 3D-fluoroscopy for real-time image-guided pedicle screw (PS) insertions. MATERIALS AND METHODS From August 2011 through July 2016, a total of 320 navigated PSs were inserted during 80 lumbar single-level posterior fusion procedures by a single surgeon without any prior experience in image-guided surgery. PS misplacements, navigation-related pre- and intraoperative time demand, and procedural 3D-radiation dose (dose-length-product, DLP) were prospectively recorded and congregated in 16 subgroups of five consecutive procedures to evaluate improving PS insertion accuracy, decreasing navigation-related time demand, and reduction of 3D-radiation dose. RESULTS After PS insertion and intraoperative O-arm control scanning, 11 PS modifications were performed sporadically without showing "learning curve dependencies" (PS insertion accuracies in subgroups 96.6 ± 6.3%). Average navigation-related pre-surgical time from patient positioning on the operating table to skin incision decreased from 61 ± 6 min (subgroup 1) to 28 ± 2 min (subgroup 16, p < 0.00001). Average 3D-radiation dose per surgery declined from 919 ± 225 mGycm (subgroup 1) to 66 ± 4 mGycm (subgroup 16, p < 0.0001). CONCLUSIONS In newly inaugurated O-arm based image-guidance, lumbar PS insertions can be performed at constantly high accuracy, even without prior experience in navigated techniques. Navigation-related time demand decreases considerably due to accelerating workflow preceding skin incision. Procedural 3D-radiation dose is reducible to a fraction (13.2%) of a lumbar diagnostic non-contrast-enhanced computed tomography scan's radiation dose.
Collapse
|
|
30
|
Kouyoumdjïan P, Gras-Combe G, Grelat M, Fuentes S, Blondel B, Tropiano P, Zairi F, Beaurain J, Charles YP, Dhenin A, Elfertit H, Le Roy J, Greffier J, Lonjon N. Surgeon's and patient's radiation exposure during percutaneous thoraco-lumbar pedicle screw fixation: A prospective multicenter study of 100 cases. Orthop Traumatol Surg Res 2018; 104:597-602. [PMID: 29969721 DOI: 10.1016/j.otsr.2018.05.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 04/26/2018] [Accepted: 05/16/2018] [Indexed: 02/02/2023]
Abstract
HYPOTHESIS Percutaneous pedicle screw fixations (PPSF) are increasingly used in spine surgery, minimizing morbidity through less muscle breakdown but at the cost of intraoperative fluoroscopic guidance that generates high radiation exposure. Few studies have been conducted to measure them accurately. MATERIAL AND METHODS The objective of our study is to quantify, during a PPSF carried out in different experimented centers respecting current radiation protection recommendations, this irradiation at the level of the surgeon and the patient. We have prospectively included 100 FPVP procedures for which we have collected radiation doses from the main operator. For each procedure, the doses of whole-body radiation, lens and extremities were measured. RESULTS Our results show a mean whole body, extremity and lens exposure dose per procedure reaching 1.7±2.8μSv, 204.7±260.9μSv and 30.5±25.9μSv, respectively. According to these values, the exposure of the surgeon's extremities and lens will exceed the annual limit allowed by the International Commission on Radiological Protection (ICRP) after 2440 and 4840 procedures respectively. CONCLUSION Recent European guidelines will reduce the maximum annual exposure dose from 150 to 20mSv. The number of surgical procedures to not reach the eye threshold, according to our results, should not exceed 645 procedures per year. Pending the democratization of neuronavigation systems, the use of conventional fluoroscopy exposes the eyes in the first place. Therefore they must be protected by leaded glasses. LEVEL OF PROOF IV, case series.
Collapse
Affiliation(s)
- Pascal Kouyoumdjïan
- Orthopedic Surgery, Spine Unit, Hôpital Carémeau, University Montpellier 1, CHU de Nîmes, 30029 Nîmes, France
| | - Guillaume Gras-Combe
- Neurosurgery Unit, Hôpital Gui-de-Chauliac, CHU de Montpellier, 34000 Montpellier, France
| | - Mickael Grelat
- Neurosurgery Unit, CHU Dijon-Bourgogne, 21000 Dijon, France
| | - Stéphane Fuentes
- Neurosurgery Unit, Hôpital la Timone, AP-HM, 13385 Marseille, France
| | - Benjamin Blondel
- Orthopedic Surgery, Spine Unit, Hôpital la Timone, AP-HM, 13385 Marseille, France
| | - Patrick Tropiano
- Orthopedic Surgery, Spine Unit, Hôpital la Timone, AP-HM, 13385 Marseille, France
| | - Fahed Zairi
- Neurosurgery Units, Hôpital Roger-Salengro, CHR, 59037 Lille, France
| | | | - Yann-Philippe Charles
- Orthopedic Surgery, Spine Unit, CHRU de Strasbourg, BP 426, 67091 Strasbourg, France
| | - Alexandre Dhenin
- Orthopedic Surgery, Spine Unit, Hôpital Carémeau, University Montpellier 1, CHU de Nîmes, 30029 Nîmes, France
| | - Hassan Elfertit
- Neurosurgery Unit, Hôpital Carémeau, CHU de Nîmes, 30029 Nîmes, France
| | - Julien Le Roy
- Department of radiation Physics, CHRU de Montpellier, 34295 Montpellier, France
| | - Joel Greffier
- Department of Medical Imaging, Hôpital Caremeau, CHU de Nîmes, 30029 Nîmes, France
| | - Nicolas Lonjon
- Neurosurgery Unit, Hôpital Gui-de-Chauliac, CHU de Montpellier, 34000 Montpellier, France.
| |
Collapse
|
|
31
|
Staartjes VE, Klukowska AM, Schröder ML. Pedicle Screw Revision in Robot-Guided, Navigated, and Freehand Thoracolumbar Instrumentation: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 116:433-443.e8. [DOI: 10.1016/j.wneu.2018.05.159] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/19/2018] [Accepted: 05/22/2018] [Indexed: 11/16/2022]
|
|
32
|
Comparing Lumbar Disc Space Preparation With Fluoroscopy Versus Cone Beam-Computed Tomography and Navigation: A Cadaveric Study. Spine (Phila Pa 1976) 2018; 43:959-964. [PMID: 29280932 DOI: 10.1097/brs.0000000000002526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaveric study. OBJECTIVE This cadaveric study sought to evaluate the efficacy of disc space preparation with cone beam-computed tomography with navigation (CBCT+N) for instrument placement compared with instrument placement with conventional fluoroscopy. SUMMARY OF BACKGROUND DATA Disc space preparation from a transforaminal lumbar approach is challenging with respect to visualization, and surgeons currently rely on tactile feel and two-dimensional imaging in the operating room to assess instrument positioning. METHODS Two orthopedic spine surgeons performed 40 disc space preparations after eight cadavers were randomly assigned to fluoroscopy versus CBCT+N. Digital images of each vertebral endplate were captured and the percent disc removed by area for the total disc and by quadrants was determined using digital imaging software. RESULTS There were 20 lumbar disc levels prepared in the fluoroscopy group. There were 3 thoracolumbar, and 17 lumbar disc levels prepared in the experimental group. Percent disc removed relative to the total area of the disc, as determined by the digital imaging software, was higher in the CBCT+N group (P ≤ 0.0001). More disc was removed in both the anterior contralateral and posterior contralateral quadrants in the CBCT+N group (P = 0.0006 and P ≤ 0.0001 respectively). The intraclass correlation coefficient among blinded reviewers for percent disc removed was 0.759 (95% confidence interval, 0.587-0.866)]. There was no difference in time to complete disc space preparation, number of instrument passes, or number of endplate violations between the two groups (P = 0.28, P = 0.92, and P = 0.34 respectively). CONCLUSION The results of this cadaveric investigation reveal that CBCT+N guidance may be used to assess instrument placement for interbody disc space preparation in a similar length of time, with no difference in instrument passes or endplate violations, in comparison with fluoroscopy. LEVEL OF EVIDENCE 5.
Collapse
|
|
33
|
Feasibility and Accuracy of Thoracolumbar Minimally Invasive Pedicle Screw Placement With Augmented Reality Navigation Technology. Spine (Phila Pa 1976) 2018; 43:1018-1023. [PMID: 29215500 PMCID: PMC6039394 DOI: 10.1097/brs.0000000000002502] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [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 Cadaveric laboratory study. OBJECTIVE To assess the feasibility and accuracy of minimally invasive thoracolumbar pedicle screw placement using augmented reality (AR) surgical navigation. SUMMARY OF BACKGROUND DATA Minimally invasive spine (MIS) surgery has increasingly become the method of choice for a wide variety of spine pathologies. Navigation technology based on AR has been shown to be feasible, accurate, and safe in open procedures. AR technology may also be used for MIS surgery. METHODS The AR surgical navigation was installed in a hybrid operating room (OR). The hybrid OR includes a surgical table, a motorized flat detector C-arm with intraoperative 2D/3D imaging capabilities, integrated optical cameras for AR navigation, and patient motion tracking using optical markers on the skin. Navigation and screw placement was without any x-ray guidance. Two neurosurgeons placed 66 Jamshidi needles (two cadavers) and 18 cannulated pedicle screws (one cadaver) in the thoracolumbar spine. Technical accuracy was evaluated by measuring the distance between the tip of the actual needle position and the corresponding planned path as well as the angles between the needle and the desired path. Time needed for navigation along the virtual planned path was measured. An independent reviewer assessed the postoperative scans for the pedicle screws' clinical accuracy. RESULTS Navigation time per insertion was 90 ± 53 seconds with an accuracy of 2.2 ± 1.3 mm. Accuracy was not dependent on operator. There was no correlation between navigation time and accuracy. The mean error angle between the Jamshidi needles and planned paths was 0.9° ± 0.8°. No screw was misplaced outside the pedicle. Two screws breached 2 to 4 mm yielding an overall accuracy of 89% (16/18). CONCLUSION MIS screw placement directed by AR with intraoperative 3D imaging in a hybrid OR is accurate and efficient, without any fluoroscopy or x-ray imaging during the procedure. LEVEL OF EVIDENCE N/A.
Collapse
|
|
34
|
Woo EJ, DiCuccio MN. Clinically significant pedicle screw malposition is an underestimated cause of radiculopathy. Spine J 2018; 18:1166-1171. [PMID: 29221759 DOI: 10.1016/j.spinee.2017.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 10/13/2017] [Accepted: 11/02/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Emily Jane Woo
- Center for Biologics Evaluation and Research, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD 20993, USA.
| | | |
Collapse
|
|
35
|
Landriel F, Hem S, Rasmussen J, Vecchi E, Yampolsky C. [Learning curve of minimally invasive pedicle screw placement]. Surg Neurol Int 2018; 9:S43-S49. [PMID: 29900033 PMCID: PMC5981185 DOI: 10.4103/sni.sni_428_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 12/11/2017] [Indexed: 02/02/2023] Open
Abstract
Objetivo: El objetivo de este estudio fue estimar la curva de aprendizaje necesaria para la correcta colocación de tornillos transpediculares percutáneos (TTP). Introducción: Los TTP son la forma de instrumentación más utilizada en el tratamiento quirúrgico de lesiones espinales que requieren estabilización. Métodos: Evaluamos retrospectivamente la inserción de 422 TTP (T5 a S1) en 75 pacientes operados entre 2013–2016, bajo guía fluoroscópica bidimensional. El cirujano 1 colocó siempre los tornillos del lado derecho y el cirujano 2, la totalidad del lado izquierdo. El posicionamiento y ruptura pedicular fue determinando con la clasificación tomográfica de Gertzbein. Se comparó la precisión en la colocación de TTP de nuestra serie con una tasa de ruptura de 8,08% (rango de 0,67-20,83%), valor de referencia obtenido de un meta-análisis propio. Resultados: De los 422 TTP, 395 fueron insertados en el pedículo sin violación de su cortical (Grado 1 = 93,6%), 27 (6,4%) rompieron la pared pedicular, de los cuales el 3,8% fue Grado 2, el 1,65% Grado 3 y sólo el 0,9% Grado 4. El Cirujano 1, presentó una tasa se ruptura global de 6,6%, alcanzando valores estándares de precisión al colocar 74 TTP; el Cirujano 2 presentó una tasa de ruptura de 6,1%, alcanzando valores de referencia a los 64 TTP; la diferencia entre ambos no fue estadísticamente significativa (P = 0,9009). Conclusión: En la serie evaluada se evidenció que se necesitan colocar aproximadamente 70 TTP para lograr resultados en términos de exactitud intrapedicular comparables con lo reportado por cirujanos experimentados en esta técnica mínimamente invasiva.
Collapse
Affiliation(s)
- Federico Landriel
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Argentina
| | - Santiago Hem
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Argentina
| | - Jorge Rasmussen
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Argentina
| | - Eduardo Vecchi
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Argentina
| | - Claudio Yampolsky
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Argentina
| |
Collapse
|
|
36
|
Time Demand and Radiation Dose in 3D-Fluoroscopy-based Navigation-assisted 3D-Fluoroscopy-controlled Pedicle Screw Instrumentations. Spine (Phila Pa 1976) 2018; 43:E512-E519. [PMID: 28922280 DOI: 10.1097/brs.0000000000002422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective single-center cohort study to record additional time requirements and radiation dose in navigation-assisted O-arm-controlled pedicle screw (PS) instrumentations. OBJECTIVE The aim of this study was to evaluate amount of extra-time and radiation dose for navigation-assisted PS instrumentations of the thoracolumbosacral spine using O-arm 3D-real-time-navigation (O3DN) compared to non-navigated spinal procedures (NNSPs) with a single C-arm and postoperative computed tomography (CT) scan for controlling PS positions. SUMMARY OF BACKGROUND DATA 3D-navigation is reported to enhance PS insertion accuracy. But time-consuming navigational steps and considerable additional radiation doses seem to limit this modern technique's attraction. A detailed analysis of additional time demand and extra-radiation dose in 3D-navigated spine surgery is not provided in literature, yet. METHODS From February 2011 through July 2015, 306 consecutive posterior instrumentations were performed in vertebral levels T10-S1 using O3DN for PS insertion. The duration of procedure-specific navigational steps of the overall collective (I) and the last cohort of 50 consecutive O3DN-surgeries (II) was compared to the average duration of analogous surgical steps in 100 consecutive NNSP using a single C-arm. 3D-radiation dose (dose-length-product, DLP) of navigational and postinstrumentation O-arm scans in group I and II was compared to the average DLP of 100 diagnostic lumbar CT scans. RESULTS The average presurgical time from patient positioning on the operating table to skin incision was 46.2 ± 10.1 minutes (O3DN, I) and 40.6 ± 9.8 minutes (O3DN, II) versus 30.6 ± 8.3 minutes (NNSP) (P < 0.001, each). Intraoperative interruptions for scanning and data processing took 3.0 ± 0.6 minutes. DLPs averaged 865.1 ± 360.8 mGycm (O3DN, I) and 562.1 ± 352.6 mGycm (O3DN, II) compared to 575.5 ± 316.5 mGycm in diagnostic lumbar CT scans (P < 0.001 (I), P ≈ 0.81 [II]). CONCLUSION After procedural experience, navigated surgeries can be performed with an additional time demand of 13.0 minutes compared to NNSP, and with a total DLP below that of a diagnostic lumbar CT scan (P ≈ 0.81). LEVEL OF EVIDENCE 4.
Collapse
|
|
37
|
Tajsic T, Patel K, Farmer R, Mannion RJ, Trivedi RA. Spinal navigation for minimally invasive thoracic and lumbosacral spine fixation: implications for radiation exposure, operative time, and accuracy of pedicle screw placement. 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 2018; 27:1918-1924. [DOI: 10.1007/s00586-018-5587-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 01/16/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
|
|
38
|
Xie CL, Huang QS, Wu L, Xu L, Dou HC, Wang XY, Lin ZK. Transmuscular Ultrasonography of the Placement of Thoracolumbar Pedicle Screws: A Cadaveric Study. World Neurosurg 2018; 115:e360-e365. [PMID: 29678714 DOI: 10.1016/j.wneu.2018.04.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/09/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Transpedicular screw fixation has a biomechanical advantage of improving fusion rates. In posterior thoracolumbar immobilization, a large number of screws cause perforation to the pedicle or vertebral body. Radiography and computed tomography (CT) have been used to minimize this complication. The ability of ultrasound (US) to detect the pedicle breach during placement of the screw is unknown. The aim of this study was to evaluate the sensitivity of US for detecting breaches. METHODS A B-type transducer was used to scan 216 titanium pins inserted into cadaveric pedicles. Of the pins, 180 were intentionally misplaced: 90 pins breached the lateral wall of the pedicle, and 90 pins pierced the anterior wall of the vertebral body. US images were reviewed by 3 examiners blinded to both the procedure and the corresponding CT findings. The perforation length of pins was measured by 3 radiologists on CT images. RESULTS CT data were divided into 2 groups. In group 1 (perforation length 0-2 mm), sensitivity of US for detecting lateral wall and anterior wall perforation was 80.95% and 76.42%, respectively; in group 2 (perforation length 2-4 mm), sensitivity was 94.79% and 91.93%. Overall sensitivity of US to detect lateral wall and anterior wall perforation was 89.63% and 86.30%, respectively. The sensitivity of US for detecting perforation was greater in the lateral wall than in the anterior wall. Sensitivity of US was greater in group 2 than group 1 for both lateral and anterior perforation. CONCLUSIONS US can be applied to detect perforation of ≤4 mm. Use of US may improve patient safety.
Collapse
Affiliation(s)
- Cheng-Long Xie
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qi-Shan Huang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Long Wu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lei Xu
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hai-Cheng Dou
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiang-Yang Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhong-Ke Lin
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.
| |
Collapse
|
|
39
|
Comparative Prospective Study Reporting Intraoperative Parameters, Pedicle Screw Perforation, and Radiation Exposure in Navigation-Guided versus Non-navigated Fluoroscopy-Assisted Minimal Invasive Transforaminal Lumbar Interbody Fusion. Asian Spine J 2018; 12:309-316. [PMID: 29713413 PMCID: PMC5913023 DOI: 10.4184/asj.2018.12.2.309] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/28/2017] [Accepted: 08/24/2017] [Indexed: 12/23/2022] Open
Abstract
Study Design Prospective cohort study. Purpose To compare intraoperative parameters, radiation exposure, and pedicle screw perforation rate in navigation-guided versus non-navigated fluoroscopy-assisted minimal invasive transforaminal lumbar interbody fusion (MIS TLIF). Overview of Literature The poor reliability of fluoroscopy-guided instrumentation and growing concerns about radiation exposure have led to the development of navigation-guided instrumentation techniques in MIS TLIF. The literature evaluating the efficacy of navigation-guided MIS TLIF is scant. Methods Eighty-seven patients underwent navigation- or fluoroscopy-guided MIS TLIF for symptomatic lumbar/lumbosacral spondylolisthesis. Demographics, intraoperative parameters (surgical time, blood loss), and radiation exposure (sec/mGy/Gy.cm2 noted from C-arm for comparison only) were recorded. Computed tomography was performed in patients in the navigation and non-navigation groups at postoperative 12 months and reviewed by an independent observer to assess the accuracy of screw placement, perforation incidence, location, grade (Mirza), and critical versus non-critical neurological implications. Results Twenty-seven patients (male/female, 11/16; L4–L5/L5–S1, 9/18) were operated with navigation-guided MIS TLIF, whereas 60 (male/female, 25/35; L4–L5/L5–S1, 26/34) with conventional fluoroscopy-guided MIS TILF. The use of navigation resulted in reduced fluoroscopy usage (dose area product, 0.47 Gy.cm2 versus 2.93 Gy.cm2), radiation exposure (1.68 mGy versus 10.97 mGy), and fluoroscopy time (46.5 seconds versus 119.08 seconds), with p-values of <0.001. Furthermore, 96.29% (104/108) of pedicle screws in the navigation group were accurately placed (grade 0) (4 breaches, all grade I) compared with 91.67% (220/240) in the non-navigation group (20 breaches, 16 grade I+4 grade II; p=0.114). None of the breaches resulted in a corresponding neurological deficit or required revision. Conclusions Navigation guidance in MIS TLIF reduced radiation exposure, but the perforation status was not statistically different than that for the fluoroscopy-based technique. Thus, navigation in nondeformity cases is useful for significantly reducing the radiation exposure, but its ability to reduce pedicle screw perforation in nondeformity cases remains to be proven.
Collapse
|
|
40
|
Kwan MK, Chiu CK, Chan CYW, Zamani R, Hansen-Algenstaedt N. The use of fluoroscopic guided percutaneous pedicle screws in the upper thoracic spine (T1-T6): Is it safe? J Orthop Surg (Hong Kong) 2018; 25:2309499017722438. [PMID: 28748740 DOI: 10.1177/2309499017722438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE This study analysed the accuracy and safety of the fluoroscopic guided percutaneous screws in the upper thoracic vertebrae (T1-T6). METHODS Computed tomography scans from 74 patients were retrospectively evaluated between January 2008 and December 2012. Pedicle perforations were classified by two types of grading systems. For medial, lateral, superior and inferior perforations: grade 0 - no violation; grade 1 - <2 mm; grade 2 - 2-4 mm and grade 3 - >4 mm. For anterior perforations: grade 0 - no violation; grade 1 - <4 mm; grade 2 - 4-6 mm and grade 3 - >6 mm. RESULTS There were 35 (47.3%) male and 39 (52.7%) female patients with a total 260 thoracic pedicle screws (T1-T6) analysed. There were 32 screw perforations which account to a perforation rate of 12.3% (11.2% grade 1, 0.7% grade 2 and 0.4% grade 3). None led to pedicle screw-related complications. The perforation rate was highest at T1 (33.3%, all grade 1 perforations), followed by T6 (14.5%) and T4 (14.0%). CONCLUSION Fluoroscopic guided percutaneous pedicle screws of the upper thoracic spine (T1-T6) are technically more demanding and carry potential risks of serious complications. Extra precautions need to be taken when fluoroscopic guided percutaneous pedicle screws are placed at T1 and T2 levels, due to high medial pedicular angulation and obstruction of lateral fluoroscopic images by the shoulder girdle and at T4-T6 levels, due to smaller pedicular width.
Collapse
Affiliation(s)
- Mun Keong Kwan
- 1 Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia
| | - Chee Kidd Chiu
- 1 Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia
| | - Chris Yin Wei Chan
- 1 Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia
| | - Reza Zamani
- 2 Department of Spine Surgery, Orthocentrum Hamburg, Parkklinik Manhagen, Hansastrasse, Hamburg, Germany
| | - Nils Hansen-Algenstaedt
- 2 Department of Spine Surgery, Orthocentrum Hamburg, Parkklinik Manhagen, Hansastrasse, Hamburg, Germany.,3 Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
|
41
|
Comparison of 30-Day Complications Between Navigated and Conventional Single-level Instrumented Posterior Lumbar Fusion: A Propensity Score Matched Analysis. Spine (Phila Pa 1976) 2018; 43:447-453. [PMID: 28700450 DOI: 10.1097/brs.0000000000002327] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort comparison study. OBJECTIVE To compare perioperative outcomes between navigated and conventional single-level instrumented posterior lumbar fusions in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. SUMMARY OF BACKGROUND DATA Although multiple studies have investigated the accuracy of pedicle screw placement and radiation exposure with navigation, no study has compared perioperative complications between navigated and conventional posterior lumbar fusion. The potential benefits of navigation include improved accuracy of screw placement and reduced surgeon radiation exposure, but this is balanced by potential operative time and surgical site contamination/infection related to this bulky technology. METHODS Patients who underwent navigated or conventional single-level posterior instrumented lumbar fusions were identified in the 2010-2015 NSQIP database. The usage of navigation was characterized. Patient characteristics and comorbidities were compared between the two treatment groups. Propensity score matching was done and comparisons were made for operative time, hospital length of stay, postoperative complications, and 30-day readmissions between the two cohorts. RESULTS The percentage of navigated cases tended to increase over years studied to approximately 10%. After propensity matching to control potential confounding factors, statistical analysis revealed no significant difference in operative time and for most adverse events including wound infection, return to the operating room, and readmission. There were significantly lower blood transfusions in the navigated cohort (2.84% vs. 7.15%, P < 0.001). Patients who underwent navigated surgery also had a shorter mean hospital length of stay (0.2 day difference, P = 0.016). CONCLUSION The reduced blood loss and mildly reduced hospital length of stay identified for the navigated cases are probably markers of more minimally invasive surgery in the navigated cohort. The current study could not identify other differences in operative time, wound infection, or return to the operating room/readmission between navigated and conventional single level posterior instrumented lumbar cases. LEVEL OF EVIDENCE 3.
Collapse
|
|
42
|
Chiu CK, Chan CYW, Kwan MK. The accuracy and safety of fluoroscopic-guided percutaneous pedicle screws in the thoracic and lumbosacral spine in the Asian population: A CT scan analysis of 1002 screws. J Orthop Surg (Hong Kong) 2018; 25:2309499017713938. [PMID: 28705124 DOI: 10.1177/2309499017713938] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE This study investigates the safety and accuracy of percutaneous pedicle screws placed using fluoroscopic guidance in the thoracolumbosacral spine among Asian patients. METHODS Computerized tomography scans of 128 patients who had surgery using fluoroscopic-guided percutaneous pedicle screws were selected. Medial, lateral, superior, and inferior screw perforations were classified into grade 0 (no violation), grade 1 (<2 mm perforation), grade 2 (2-4 mm perforation), and grade 3(>4 mm perforation). Anterior perforations were classified into grade 0 (no violation), grade 1 (<4 mm perforation), grade 2 (4-6 mm perforation), and grade 3(>6 mm perforation). Grade 2 and grade 3 perforation were considered as "critical" perforation. RESULTS In total, 1002 percutaneous pedicle screws from 128 patients were analyzed. The mean age was 52.7 ± 16.6. There were 70 male patients and 58 female patients. The total perforation rate was 11.3% (113) with 8.4% (84) grade 1, 2.6% (26) grade 2, and 0.3% (3) grade 3 perforations. The overall "critical" perforation rate was 2.9% (29 screws) and no complications were noted. The highest perforation rates were at T4 (21.6%), T2 (19.4%), and T6 (19.2%). CONCLUSION The total perforation rate of 11.3% with the total "critical" perforation rate of 2.9% (2.6% grade 2 and 0.3% grade 3 perforations). The highest perforation rates were found over the upper to mid-thoracic region. Fluoroscopic-guided percutaneous pedicle screws insertion among Asians has the safety and accuracy comparable to the current reported percutaneous pedicle screws and open pedicle screws techniques.
Collapse
Affiliation(s)
- Chee Kidd Chiu
- Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chris Yin Wei Chan
- Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
|
43
|
Siasios ID, Pollina J, Khan A, Dimopoulos VG. Percutaneous screw placement in the lumbar spine with a modified guidance technique based on 3D CT navigation system. JOURNAL OF SPINE SURGERY 2017; 3:657-665. [PMID: 29354745 DOI: 10.21037/jss.2017.12.05] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Several guidance techniques have been employed to increase accuracy and reduce surgical time during percutaneous placement of pedicle screws (PS). The purpose of our study was to present a modified technique for percutaneous placement of lumbar PS that reduces surgical time. We reviewed 23 cases of percutaneous PS placement using our technique for minimally invasive lumbar surgeries and 24 control cases where lumbar PS placement was done via common technique using Jamshidi needles (Becton, Dickinson and Company, Franklin Lakes, NJ, USA). An integrated computer-guided navigation system was used in all cases. In the technique modification, a handheld drill with a navigated guide was used to create the path for inserting guidewires through the pedicles and into the vertebral bodies. After drill removal, placement of the guidewires through the pedicles took place. The PS were implanted over the guidewires, through the pedicles and into the vertebral bodies. Intraoperative computed tomography was performed after screw placement to ensure optimal positioning in all cases. There were no intraoperative complications with either technique. PS placement was correct in all cases. The average time for each PS placement was 6.9 minutes for the modified technique and 9.2 minutes for the common technique. There was no significant difference in blood loss. In conclusion, this modified technique is efficient and contributes to reduced operative time.
Collapse
Affiliation(s)
- Ioannis D Siasios
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center at Kaleida Health, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center at Kaleida Health, Buffalo, NY, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center at Kaleida Health, Buffalo, NY, USA
| | - Vassilios George Dimopoulos
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Department of Neurosurgery, Buffalo General Medical Center at Kaleida Health, Buffalo, NY, USA
| |
Collapse
|
|
44
|
Sembrano JN. Trials that fail to show advantages of 3D navigation in spine surgery-is it the technology or the trial? JOURNAL OF SPINE SURGERY 2017; 2:348-350. [PMID: 28097256 DOI: 10.21037/jss.2016.12.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
|
45
|
Minimally Invasive Posterior Decompression Combined With Percutaneous Pedicle Screw Fixation for the Treatment of Thoracolumbar Fractures With Neurological Deficits: A Prospective Randomized Study Versus Traditional Open Posterior Surgery. Spine (Phila Pa 1976) 2016; 41 Suppl 19:B23-B29. [PMID: 27656782 DOI: 10.1097/brs.0000000000001814] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective randomized cohort study. OBJECTIVE To compare the surgical results of minimally invasive posterior decompression combined with percutaneous pedicle screws fixation (minimally invasive surgery [MIS]) and posterior open surgery (OS) for the treatment of thoracolumbar fracture with neurological deficits. SUMMARY OF BACKGROUND DATA Thoracolumbar fracture with neurological deficits usually undergoes surgical intervention. OS can achieve satisfied results, but the main disadvantage is approach-related complications. No study, however, focused on the treatment of this disease by MIS through posterior approach. METHODS Sixty consecutive cases of thoracolumbar fractures with neurological deficits were randomized into MIS group and OS group. Incision length, blood loss, postoperative drainage volume, hospitalization days, blood transfusion rate, analgesic use rate, and x-ray exposure time were used to evaluate the perioperative information and Visual Analog Scale (VAS), Japanese Orthopedics Association (JOA) score, and American Spinal Injury Association grade for patients' symptom. For radiological assessment, sagittal Cobb angle, percentage of vertebral height, and vertebral wedging angle were measured. RESULTS Fifty-nine of sixty patients were followed-up for at least 12 months. MIS group was superior in perioperative information (P < 0.05), except in the operative time (P = 0.165) and x-ray time (P = 0.000). The operative time seemed longer in MIS group, but no significant difference was found. The x-ray time was significantly higher in MIS group. The mean Visual Analog Scale and Japanese Orthopedics Association scores of the final follow-up in MIS group were better than that in OS group (P < 0.05). Patients in both group achieved a similar neurological recovery according to American Spinal Injury Association grade (P = 0.760). A broken screw was found in one patient in MIS group and a broken rod in one patient in OS group. CONCLUSION MIS group has achieved the similar effect of OS group and it can minimize the approach-related complication. It also faced with some shortages, such as larger radiation dose and longer learning curve. LEVEL OF EVIDENCE 2.
Collapse
|
|
46
|
Total 3D Airo® Navigation for Minimally Invasive Transforaminal Lumbar Interbody Fusion. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5027340. [PMID: 27529069 PMCID: PMC4978816 DOI: 10.1155/2016/5027340] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/08/2016] [Indexed: 12/04/2022]
Abstract
Introduction. A new generation of iCT scanner, Airo®, has been introduced. The purpose of this study is to describe how Airo facilitates minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Method. We used the latest generation of portable iCT in all cases without the assistance of K-wires. We recorded the operation time, number of scans, and pedicle screw accuracy. Results. From January 2015 to December 2015, 33 consecutive patients consisting of 17 men and 16 women underwent single-level or two-level MIS-TLIF operations in our institution. The ages ranged from 23 years to 86 years (mean, 66.6 years). We treated all the cases in MIS fashion. In four cases, a tubular laminectomy at L1/2 was performed at the same time. The average operation time was 192.8 minutes and average time of placement per screw was 2.6 minutes. No additional fluoroscopy was used. Our screw accuracy rate was 98.6%. No complications were encountered. Conclusions. Airo iCT MIS-TLIF can be used for initial planning of the skin incision, precise screw, and cage placement, without the need for fluoroscopy. “Total navigation” (complete intraoperative 3D navigation without fluoroscopy) can be achieved by combining Airo navigation with navigated guide tubes for screw placement.
Collapse
|
|
47
|
Nakahara M, Yasuhara T, Inoue T, Takahashi Y, Kumamoto S, Hijikata Y, Kusumegi A, Sakamoto Y, Ogawa K, Nishida K. Accuracy of Percutaneous Pedicle Screw Insertion Technique with Conventional Dual Fluoroscopy Units and a Retrospective Comparative Study Based on Surgeon Experience. Global Spine J 2016; 6:322-8. [PMID: 27190733 PMCID: PMC4868583 DOI: 10.1055/s-0035-1563405] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/08/2015] [Indexed: 11/04/2022] Open
Abstract
Study Design Retrospective comparative study. Objective To evaluate the accuracy of percutaneous pedicle screw (PPS) placement and intraoperative imaging time using dual fluoroscopy units and their differences between surgeons with more versus less experience. Methods One hundred sixty-one patients who underwent lumbar fusion surgery were divided into two groups, A (n = 74) and B (n = 87), based on the performing surgeon's experience. The accuracy of PPS placement and radiation time for PPS insertion were compared. PPSs were inserted with classic technique under the assistance of dual fluoroscopy units placed in two planes. The breach definition of PPS misplacement was based on postoperative computed tomography (grade I: no breach; grade II: <2 mm; grade III: ≤2 to <4 mm). Results Of 658 PPSs, only 21 screws were misplaced. The breach rates of groups A and B were 3.3% (grade II: 3.4%, grade III: 0%) and 3.1% (grade II: 2.6%, grade III: 0.6%; p = 0.91). One patient in grade III misplacement had a transient symptom of leg numbness. Median radiation exposure time during PPS insertion was 25 seconds and 51 seconds, respectively (p < 0.01). Conclusions Without using an expensive imaging support system, the classic technique of PPS insertion using dual fluoroscopy units in the lumbar and sacral spine is fairly accurate and provides good clinical outcomes, even among surgeons lacking experience.
Collapse
Affiliation(s)
- Masayuki Nakahara
- Department of Spinal Surgery, Fukuoka Wajiro Hospital, Fukuoka, Japan
| | - Takao Yasuhara
- Department of Spinal Surgery, Shinkomonji Hospital, Fukuoka, Japan
| | - Takafumi Inoue
- Department of Spinal Surgery, Fukuoka Wajiro Hospital, Fukuoka, Japan
| | - Yuichi Takahashi
- Department of Spinal Surgery, Shinkomonji Hospital, Fukuoka, Japan
| | - Shinji Kumamoto
- Department of Spinal Surgery, Shinkomonji Hospital, Fukuoka, Japan
| | | | - Akira Kusumegi
- Department of Spinal Surgery, Shinkomonji Hospital, Fukuoka, Japan
| | - Yushi Sakamoto
- Department of Spinal Surgery, Shinkomonji Hospital, Fukuoka, Japan
| | - Koichi Ogawa
- Department of Spinal Surgery, Shinkomonji Hospital, Fukuoka, Japan
| | - Kenki Nishida
- Department of Spinal Surgery, Shinkomonji Hospital, Fukuoka, Japan
| |
Collapse
|
|
48
|
Mendelsohn D, Strelzow J, Dea N, Ford NL, Batke J, Pennington A, Yang K, Ailon T, Boyd M, Dvorak M, Kwon B, Paquette S, Fisher C, Street J. Patient and surgeon radiation exposure during spinal instrumentation using intraoperative computed tomography-based navigation. Spine J 2016; 16:343-54. [PMID: 26686604 DOI: 10.1016/j.spinee.2015.11.020] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 08/12/2015] [Accepted: 11/10/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Imaging modalities used to visualize spinal anatomy intraoperatively include X-ray studies, fluoroscopy, and computed tomography (CT). All of these emit ionizing radiation. PURPOSE Radiation emitted to the patient and the surgical team when performing surgeries using intraoperative CT-based spine navigation was compared. STUDY DESIGN/SETTING This is a retrospective cohort case-control study. PATIENT SAMPLE Seventy-three patients underwent CT-navigated spinal instrumentation and 73 matched controls underwent spinal instrumentation with conventional fluoroscopy. OUTCOME MEASURES Effective doses of radiation to the patient when the surgical team was inside and outside of the room were analyzed. The number of postoperative imaging investigations between navigated and non-navigated cases was compared. METHODS Intraoperative X-ray imaging, fluoroscopy, and CT dosages were recorded and standardized to effective doses. The number of postoperative imaging investigations was compared with the matched cohort of surgical cases. A literature review identified historical radiation exposure values for fluoroscopic-guided spinal instrumentation. RESULTS The 73 navigated operations involved an average of 5.44 levels of instrumentation. Thoracic and lumbar instrumentations had higher radiation emission from all modalities (CT, X-ray imaging, and fluoroscopy) compared with cervical cases (6.93 millisievert [mSv] vs. 2.34 mSv). Major deformity and degenerative cases involved more radiation emission than trauma or oncology cases (7.05 mSv vs. 4.20 mSv). On average, the total radiation dose to the patient was 8.7 times more than the radiation emitted when the surgical team was inside the operating room. Total radiation exposure to the patient was 2.77 times the values reported in the literature for thoracolumbar instrumentations performed without navigation. In comparison, the radiation emitted to the patient when the surgical team was inside the operating room was 2.50 lower than non-navigated thoracolumbar instrumentations. The average total radiation exposure to the patient was 5.69 mSv, a value less than a single routine lumbar CT scan (7.5 mSv). The average radiation exposure to the patient in the present study was approximately one quarter the recommended annual occupational radiation exposure. Navigation did not reduce the number of postoperative X-rays or CT scans obtained. CONCLUSIONS Intraoperative CT navigation increases the radiation exposure to the patient and reduces the radiation exposure to the surgeon when compared with values reported in the literature. Intraoperative CT navigation improves the accuracy of spine instrumentation with acceptable patient radiation exposure and reduced surgical team exposure. Surgeons should be aware of the implications of radiation exposure to both the patient and the surgical team when using intraoperative CT navigation.
Collapse
Affiliation(s)
- Daniel Mendelsohn
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Jason Strelzow
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Nicolas Dea
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Nancy L Ford
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Juliet Batke
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Andrew Pennington
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Kaiyun Yang
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Tamir Ailon
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Michael Boyd
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Marcel Dvorak
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Brian Kwon
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Scott Paquette
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Charles Fisher
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - John Street
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
| |
Collapse
|
|
49
|
Chang CJ, Yu CH, Lin GL, Tse A, Chu HY, Tseng CS. Clinical Pedicle Screw Insertion Trials and System Improvement of C-arm Image Navigation System. J Med Biol Eng 2016. [DOI: 10.1007/s40846-016-0107-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
|
50
|
Accuracy and safety of fluoroscopic guided percutaneous pedicle screws in thoracic and lumbosacral spine: a review of 2000 screws. Spine (Phila Pa 1976) 2015; 40:E954-63. [PMID: 25929207 DOI: 10.1097/brs.0000000000000958] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To investigate the accuracy and safety of percutaneous pedicle screws placed using fluoroscopic guidance in the thoracic and lumbosacral spine. SUMMARY OF BACKGROUND DATA Several studies had examined the accuracy and safety of percutaneous pedicle screws but provided large variations in their results with small number of patients or few number of pedicle screws evaluated. METHODS Computerized tomography of patients who had surgery with fluoroscopic guided percutaneous pedicle screws were chosen from 2 centers: (1) European patients from University Medical Center Hamburg-Eppendorf, Germany and (2) Asian patients from University Malaya Medical Centre, Malaysia. Screw perforations were classified into Grade 0, Grade 1 (<2 mm), Grade 2 (2-4 mm), and Grade 3 (>4 mm). RESULTS In total, 2000 percutaneous pedicle screws from 273 patients were analyzed: 1290 screws from 183 European patients and 710 screws from 90 Asian patients. The mean age was 59.1 ± 15.6. There were 140 male patients and 133 female patients. The total perforation rate was 9.4% with 151 (7.5%) Grade 1, 31 (1.6%) Grade 2, and 5 (0.3%) Grade 3 perforations. The total perforation rates among Europeans were 9.4% and among Asians were 9.3%. There was no difference between the 2 groups (P > 0.05). There were 3 distinct peaks in perforation rates (trimodal distribution) at T1, midthoracic region (T4-T7), and lumbosacral junction (L5 and S1). The highest perforation rates were at T1 (33.3%), S1 (19.4%), and T4 (18.6%). CONCLUSION Implantation of percutaneous pedicle screws insertion using fluoroscopic guidance is safe and has the accuracy comparable to open techniques of pedicle screws insertion. LEVEL OF EVIDENCE 4.
Collapse
|