Iso-C/3-Dimensional Neuronavigation versus Conventional Fluoroscopy for Minimally Invasive Pedicle Screw Placement in Lumbar Fusion

Abstract BACKGROUND: Increasing popularity of minimally invasive surgery for lumbar fusion has led to dependence upon intraoperative fluoroscopy for pedicle screw placement, because limited muscle dissection does not expose the bony anatomy necessary for traditional, freehand techniques nor for registration steps in image-guidance techniques. This has raised concerns about cumulative radiation exposure for both surgeon and operating room staff. The recent introduction of the O-arm Multidimensional Surgical Imaging System allows for percutaneous placement of pedicle screws, but there is limited clinical experience with the technique and data examining its accuracy. OBJECTIVE: We present the first large clinical series of percutaneous screw placement using navigation of O-arm imaging and compare the results with the fluoroscopy-guided method. METHODS: A retrospective review of a 24-month period identified patients undergoing minimally invasive lumbar interbody fusion. The O-arm was introduced in the middle of this period and was used for all subsequent patients. Accuracy of screw placement was assessed by examination of axial computed tomography or O-arm scans. RESULTS: The fluoroscopy group included 141 screws in 42 patients, and the O-arm group included 205 screws in 52 patients. The perforation rate was 12.8% in the fluoroscopy group and 3% in the O-arm group (P < .001). Single-level O-arm procedures took a mean 200 (153–241) minutes, whereas fluoroscopy took 221 (178–302) minutes (P < .03). CONCLUSION: Percutaneous pedicle screw placement with the O-arm Multidimensional Intraoperative Imaging System is a safe and effective technique and provided improved overall accuracy and reduced operative time compared with conventional fluoroscopic techniques.

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Does robot-assisted navigation influence pedicle screw selection and accuracy in minimally invasive spine surgery?

Neurosurgical FOCUS ◽

10.3171/2021.10.focus21526 ◽

2022 ◽

Vol 52 (1) ◽

pp. E4

Keyword(s):

Minimally Invasive ◽

Pedicle Screw ◽

Surgical Navigation ◽

Lumbar Fusion ◽

Pedicle Screws ◽

Screw Placement ◽

Robotic Assistance ◽

Pedicle Screw Placement ◽

Screw Length ◽

The Mean

OBJECTIVE The accuracy of percutaneous pedicle screw placement has increased with the advent of robotic and surgical navigation technologies. However, the effect of robotic intraoperative screw size and trajectory templating remains unclear. The purpose of this study was to compare pedicle screw sizes and accuracy of placement using robotic navigation (RN) versus skin-based intraoperative navigation (ION) alone in minimally invasive lumbar fusion procedures. METHODS A retrospective cohort study was conducted using a single-institution registry of spine procedures performed over a 4-year period. Patients who underwent 1- or 2-level primary or revision minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF) with pedicle screw placement, via either robotic assistance or surgical navigation alone, were included. Demographic, surgical, and radiographic data were collected. Pedicle screw type, quantity, length, diameter, and the presence of endplate breach or facet joint violation were assessed. Statistical analysis using the Student t-test and chi-square test was performed to evaluate the differences in pedicle screw sizes and the accuracy of placement between both groups. RESULTS Overall, 222 patients were included, of whom 92 underwent RN and 130 underwent ION MIS-TLIF. A total of 403 and 534 pedicle screws were placed with RN and ION, respectively. The mean screw diameters were 7.25 ± 0.81 mm and 6.72 ± 0.49 mm (p < 0.001) for the RN and ION groups, respectively. The mean screw length was 48.4 ± 4.48 mm in the RN group and 45.6 ± 3.46 mm in the ION group (p < 0.001). The rates of “ideal” pedicle screws in the RN and ION groups were comparable at 88.5% and 88.4% (p = 0.969), respectively. The overall screw placement was also similar. The RN cohort had 63.7% screws rated as good and 31.4% as acceptable, while 66.1% of ION-placed screws had good placement and 28.7% had acceptable placement (p = 0.661 and p = 0.595, respectively). There was a significant reduction in high-grade breaches in the RN group (0%, n = 0) compared with the ION group (1.2%, n = 17, p = 0.05). CONCLUSIONS The results of this study suggest that robotic assistance allows for placement of screws with greater screw diameter and length compared with surgical navigation alone, although with similarly high accuracy. These findings have implied that robotic platforms may allow for safe placement of the “optimal screw,” maximizing construct stability and, thus, the ability to obtain a successful fusion.

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Spine Navigation Based on 3-Dimensional Robotic Fluoroscopy for Accurate Percutaneous Pedicle Screw Placement: A Prospective Study of 66 Consecutive Cases

World Neurosurgery ◽

10.1016/j.wneu.2017.08.149 ◽

2017 ◽

Vol 108 ◽

pp. 76-83 ◽

Cited By ~ 16

Author(s):

Edward Fomekong ◽

Salah Edine Safi ◽

Christian Raftopoulos

Keyword(s):

Prospective Study ◽

Pedicle Screw ◽

Screw Placement ◽

Pedicle Screw Placement ◽

3 Dimensional ◽

Percutaneous Pedicle Screw ◽

A Prospective Study ◽

Spine Navigation

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Radiographic Accuracy of Percutaneous Pedicle Screw Placement in Fluoroscopic- Versus CT Navigation-Guided Lumbar Spine Instrumentation

Neurosurgery ◽

10.1093/neuros/nyz310_617 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Guang-Ting Cong ◽

Avani Vaishnav ◽

Joseph Barbera ◽

Hiroshi Kumagai ◽

James Dowdell ◽

...

Keyword(s):

Lumbar Spine ◽

Minimally Invasive ◽

Pedicle Screw ◽

Spinal Instrumentation ◽

Screw Placement ◽

Pedicle Screw Placement ◽

Intraoperative Computed Tomography ◽

Percutaneous Pedicle Screw ◽

Spine Instrumentation ◽

Surgical Methods

Abstract INTRODUCTION Posterior spinal instrumentation for fusion using intraoperative computed tomography (CT) navigation is gaining traction as an alternative to the conventional two-dimensional fluoroscopic-guided approach to percutaneous pedicle screw placement. However, few studies to date have directly compared outcomes of these 2 minimally invasive instrumentation methods. METHODS A consecutive cohort of patients undergoing primary percutaneous posterior lumbar spine instrumentation for spine fusion was retrospectively reviewed. Revision surgeries or cases converted to open were excluded. Accuracy of screw placement was assessed using a postoperative CT scan with blinding to the surgical methods used. The Gertzbein-Robbins classification was used to grade cortical breach: Grade 0 (<0 mm cortical breach), Grade I (<2 mm), Grade II (2-4 mm), Grade III (4-6 mm), and Grade IV (>6 mm). RESULTS CT navigation was found to significantly improve accuracy of screw placement (P < .022). There was significantly more facet violation of the unfused level in the fluoroscopy group vs the CT group (9% vs 0.5%; P < .0001). There was also a higher proportion of poor screw placement in the fluoroscopy group (10.1% vs 3.6%). No statistical difference was found in the rate of tip breach, inferomedial breach, or lateral breach. Regression analysis showed that fluoroscopy had twice the odds of incurring poor screw placement as compared to CT navigation. CONCLUSION This radiographic study comparing screw placement in minimally invasive fluoroscopy- vs CT navigation-guided lumbar spine instrumentation provides evidence that CT navigation significantly improves accuracy of screw placement, especially in optimizing the screw trajectory so as to avoid facet violation. Long-term follow-up studies should be performed to ascertain whether this difference can contribute to an improvement in clinical outcomes.

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