Accuracy of intraoperative computed tomography image-guided surgery in placing pedicle and pelvic screws for primary versus revision spine surgery

Abstract

Object Revision spine surgery, which is challenging due to disrupted anatomy, poor fluoroscopic imaging, and altered tactile feedback, may benefit from CT image-guided surgery (CT-IGS). This study evaluates accuracy of CT-IGS–navigated screws in primary versus revision spine surgery. Methods Pedicle and pelvic screws placed with the O-arm in 28 primary (313 screws) and 33 revision (429 screws) cases in which institutional postoperative CT scans were available were retrospectively reviewed for placement accuracy. Screw accuracy was categorized as 1) good (< 1-mm pedicle breach in any direction or “in-out-in” thoracic screws through the lateral thoracic pedicle wall and in the costovertebral joint); 2) fair (1- to 3-mm breach); or 3) poor (> 3-mm breach). Results Use of CT-IGS resulted in high rates of good or fair screws for both primary (98.7%) and revision (98.6%) cases. Rates of good or fair screws were comparable for the following regions: C7–T3 at 100% (good or fair) in primary versus 100% (good or fair) in revision; T4–9 at 96.8% versus 100%; T10–L2 at 98.2% versus 99.3%; L3–5 at 100% versus 99.2%; and pelvis at 98.7% versus 98.6%, respectively. On the other hand, revision sacral screws had statistically significantly lower rates of good placement compared with primary (100% primary vs 80.6% revision, p = 0.027). Of these revision sacral screws, 11.1% had poor placement, with bicortical screws extending > 3 mm beyond the anterior cortex. Revision pelvic screws demonstrated the highest rate of fair placement (28%), with the mode of medial breach in all cases directed into the sacral-iliac joint. Conclusions In the cervical, thoracic, and lumbar spine, CT-IGS demonstrated comparable accuracy rates for both primary and revision spine surgery. Use of 3D imaging of the bony pedicle anatomy appears to be sufficient for the spine surgeon to overcome the difficulties associated with instrumentation in revision cases. Although the bony structures of sacral pedicles and pelvis are relatively larger, the complexity of local anatomy was not overcome with CT-IGS, and an increased trend toward inaccurate screw placement was demonstrated.

Percutaneous screw placement in the lumbar spine with a modified guidance technique based on 3D CT navigation system

“…Neuronavigation technologies have evolved significantly in spine surgery during the last decades and have provided significant advantages as an adjunct to minimally invasive surgical techniques (56). The reported accuracy in PS placement when fluoroscopic guidance is used ranges between 79.8% and 96.9% (26,28,30,(34)(35)(36)46,54,(57)(58)(59) while the intraoperative CT-based navigation technique is between 95.3% and 100% (60)(61)(62)(63), and the robotic guidance technique between 83.6% and 100% (46,49,(64)(65)(66).…”

Reliability of the Planned Pedicle Screw Trajectory versus the Actual Pedicle Screw Trajectory using Intra-operative 3D CT and Image Guidance

“…5,6 Examples of these techniques include the use of anatomic landmarks, 7 laminotomy for palpation of the pedicle, plain radiography, fluoroscopic imaging (standard or image guidance), 8,9 and CT image guidance. [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Extensive literature has been published describing the technique, benefits, and drawbacks of each method, as well as comparisons between different approaches. [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45] With its increasing use has come a multitude of studies regarding the safety of this technique.…”

Accuracy Analysis of Iliac Screw Using Freehand Technique in Spinal Surgery : Relation between Screw Breach and Revision Surgery

“…The present study showed that 12.4% (24/193) iliac screw breaches could develop even with a 10-year experienced spinal surgeon, and especially occurred in the younger patients and post AIS surgery. We believe that this might be associated with revision surgery after AIS surgery in the relatively younger patients and could affect the high misplaced rates 6) .…”