With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety. Cite this article: Bone Joint J 2020;102-B(3):371–375.

Aim of the study:Neurofibromatosis type 1 (NF-1) is associated with the development of scoliosis or kyphoscoliosis. The deformity is rapidly progressive in the presence of dystrophic changes producing bone erosion. Vertebral subluxation or dislocation can occur in children with highly dystrophic kyphoscoliosis and carries an increased risk of paralysis. There is no standardised treatment for this extreme deformity with very few patients currently reported in the literature.Methods:Retrospective review of a patient with NF-1 who developed a dystrophic upper thoracic kyphoscoliosis with segmental displacement of T2 on T3.Results:We report a patient with NF-1 who presented at 8.9 years with a progressive upper thoracic kyphoscoliosis. At 18.8 years, the deformity had deteriorated to scoliosis 65° and kyphosis 78° with fixed segmental rotatory dislocation at T2-T3. He underwent posterior cervico-thoracic fusion with concave pedicle screw/hook/rod instrumentation and iliac crest bone. Minimum correction was achieved due to curve rigidity and inability to reduce the T2/T3 displacement by halo-femoral traction. At 7 months, an elective posterior re-grafting procedure was performed followed by anterior fusion with rib strut grafts between T2-T6 through a midline sternotomy. The patient is now 3.5 years after anterior surgery and remains neurologically intact with stable residual deformity and computed tomographic evidence of circumferential fusion. He has no back pain and resumed non-contact physical activities.Conclusions:Patients with NF-1 can develop dystrophic kyphoscoliosis with segmental spinal subluxation/dislocation. Circumferential fusion is a technically challenging procedure which often requires a multi-disciplinary surgical team but produces satisfactory clinical outcome preventing paraplegia.

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With the expansion of patient data collection and storage, it is important for doctors to maintain an awareness of how to handle such data. DPT is not currently common practice. Our study suggests positive benefits from DPT, and we suggest it could improve the safety with which patient data is handled.