Accuracy of pedicle screw placement based on preoperative computed tomography versus intraoperative data set acquisition for spinal navigation system

Líu, Hao; Chen, Weikai; Liu, Tao; Meng, Bin; Yang, Huilin

doi:10.1177/2309499017718901

Cited by 29 publications

(16 citation statements)

References 30 publications

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“…However, in this study, the AR and FH techniques showed no significant difference in terms of primary or secondary screw perforation, average MAPW, average doMLCA, or cranio-caudal inclination angle in the hands of the expert surgeons. Several studies demonstrated significantly higher accuracy of pedicle screw placement using other navigation systems providing three-dimensional information to the surgeon compared to the free-hand technique [20,23,24]. Three-dimensional navigation proved to be of use not only in patients with but particularly when treating spinal deformity [25,26].…”

Section: Discussionmentioning

confidence: 99%

Augmented reality-based navigation increases precision of pedicle screw insertion

Dennler¹,

Jaberg²,

Spirig³

et al. 2020

J Orthop Surg Res

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Background: Precise insertion of pedicle screws is important to avoid injury to closely adjacent neurovascular structures. The standard method for the insertion of pedicle screws is based on anatomical landmarks (free-hand technique). Head-mounted augmented reality (AR) devices can be used to guide instrumentation and implant placement in spinal surgery. This study evaluates the feasibility and precision of AR technology to improve precision of pedicle screw insertion compared to the current standard technique. Methods: Two board-certified orthopedic surgeons specialized in spine surgery and two novice surgeons were each instructed to drill pilot holes for 40 pedicle screws in eighty lumbar vertebra sawbones models in an agarbased gel. One hundred and sixty pedicles were randomized into two groups: the standard free-hand technique (FH) and augmented reality technique (AR). A 3D model of the vertebral body was superimposed over the AR headset. Half of the pedicles were drilled using the FH method, and the other half using the AR method. Results: The average minimal distance of the drill axis to the pedicle wall (MAPW) was similar in both groups for expert surgeons (FH 4.8 ± 1.0 mm vs. AR 5.0 ± 1.4 mm, p = 0.389) but for novice surgeons (FH 3.4 mm ± 1.8 mm, AR 4.2 ± 1.8 mm, p = 0.044). Expert surgeons showed 0 primary drill pedicle perforations (PDPP) in both the FH and AR groups. Novices showed 3 (7.5%) PDPP in the FH group and one perforation (2.5%) in the AR group, respectively (p > 0.005). Experts showed no statistically significant difference in average secondary screw pedicle perforations (SSPP) between the AR and the FH set 6-, 7-, and 8-mm screws (p > 0.05). Novices showed significant differences of SSPP between most groups: 6-mm screws, 18 (45%) vs. 7 (17.5%), p = 0.006; 7-mm screws, 20 (50%) vs. 10 (25%), p = 0.013; and 8-mm screws, 22 (55%) vs. 15 (37.5%), p = 0.053, in the FH and AR group, respectively. In novices, the average optimal medio-lateral convergent angle (oMLCA) was 3.23°(STD 4.90) and 0.62°(STD 4.56) for the FH and AR set screws (p = 0.017), respectively. Novices drilled with a higher precision with respect to the cranio-caudal inclination angle (CCIA) category (p = 0.04) with AR. Conclusion: In this study, the additional anatomical information provided by the AR headset superimposed to realworld anatomy improved the precision of drilling pilot holes for pedicle screws in a laboratory setting and decreases the effect of surgeon's experience. Further technical development and validations studies are currently being performed to investigate potential clinical benefits of the herein described AR-based navigation approach.

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Section: Discussionmentioning

confidence: 99%

Augmented reality-based navigation increases precision of pedicle screw insertion

Dennler¹,

Jaberg²,

Spirig³

et al. 2020

J Orthop Surg Res

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show abstract

“…This is in line with recent meta-analyses comparing other types of navigation systems to conventional surgical methods, showing increased accuracy when using navigation 1,5 . Navigation has been demonstrated to have the largest impact on accuracy in complex deformity surgeries, especially in the neuromuscular type of scoliosis 14 , and in the thoracic spine where the pedicles can be very small 15 . Narrow thoracic pedicles, altered by scoliosis, can provide a formidable challenge in spinal instrumentation 8,9,16 .…”

Section: Discussionmentioning

confidence: 99%

“…Unfortunately, the retrospectively collected data of the control group only included the total procedure time and the fluoroscopy time could not be calculated for comparison. Studies on procedural time using navigation have shown conflicting results, demonstrating both longer 14,15,28 and shorter times 6,29 .…”

Section: Figurementioning

confidence: 99%

Augmented reality navigation with intraoperative 3D imaging vs fluoroscopy-assisted free-hand surgery for spine fixation surgery: a matched-control study comparing accuracy

Elmi-Terander

Burström

Nachabé

et al. 2020

Sci Rep

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This study aimed to compare screw placement accuracy and clinical aspects between Augmented Reality Surgical Navigation (ARSN) and free-hand (FH) technique. Twenty patients underwent spine surgery with screw placement using ARSN and were matched retrospectively to a cohort of 20 FH technique cases for comparison. All ARSN and FH cases were performed by the same surgeon. Matching was based on clinical diagnosis and similar proportions of screws placed in the thoracic and lumbosacral vertebrae in both groups. Accuracy of screw placement was assessed on postoperative scans according to the Gertzbein scale and grades 0 and 1 were considered accurate. Procedure time, blood loss and length of hospital stay, were collected as secondary endpoints. A total of 262 and 288 screws were assessed in the ARSN and FH groups, respectively. The share of clinically accurate screws was significantly higher in the ARSN vs FH group (93.9% vs 89.6%, p < 0.05). The proportion of screws placed without a cortical breach was twice as high in the ARSN group compared to the FH group (63.4% vs 30.6%, p < 0.0001). No statistical difference was observed for the secondary endpoints between both groups. This matched-control study demonstrated that ARSN provided higher screw placement accuracy compared to free-hand.Compared to conventional free-hand (FH) surgical technique, computer-assisted navigation using intraoperative 3D imaging has been shown to improve screw placement accuracy and reduce complications due to screw misplacements 1 . Moreover, improved accuracy has also been shown in more challenging conditions, such as scoliosis surgery, where it may be of even greater importance 2 . Consequently, navigation also reduces the frequency of postoperative revision surgery compared to FH surgery 3 .Although several studies have compared intraoperative image guidance to free-hand (FH) technique, the evidence in favor of navigation is still limited. In a recent systematic review, Chan et al., found only four studies comparing computed tomography (CT) guidance with free-hand methods head-to-head, including one small (10 patients in each group, 169 screws in total) randomized study 4 . Overall, the reviewers found only moderate level evidence showing that CT guidance has lower breach rates than FH, while screw-related complication rates were conflicting at 0% in CT navigation compared with 0%-1.7% in FH groups 5 . In a more recent retrospective study comparing O-arm navigation to FH, Wang et al. demonstrated higher pedicle screw accuracy and lower total

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“…Implants of the wrong size can ultimately lead to unstable fixation 10 or may lead to pedicle fracture or damage to the nerves and vessels. 7,11,15 For osteoporotic fractures, which are commonly stabilized using cement augmentation, pedicle fractures may lead to cement leaks into the spinal canal. Furthermore, the surgeon should be aware preoperatively of whether sufficient implant material of the correct length and diameter for a stable osteosynthesis is in stock.…”

Section: Discussionmentioning

confidence: 99%

“…Posterior spinal fusion is an important tool in the treatment of patients with spinal trauma or with degenerative disorders like spinal stenosis or spondylolisthesis. [1][2][3][4][5][6][7][8][9] Numerous studies have been aimed at quantifying the ideal biomechanical properties of the implants required to maximize pullout resistance, [10][11][12][13][14] but the optimal trajectory angle for placing pedicle screws remains unclear. While some authors aim for a trajectory that results in the longest possible screw, others favor a position parallel position to the pedicle wall, accepting a decreased insertion depth.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Preoperative Pedicle Screw Measurement Between Computed Tomography and Magnet Resonance Imaging

et al. 2020

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Background: Pedicle screw fixation is commonly used in the treatment of spinal pathologies. While the biomechanical factors that affect bone fixation have been frequently described, questions remain as to which imaging modality is the ideal medium for preoperative planning. Due to its perceived superiority in assessing bony changes, computed tomography (CT) scan is assumed to be the gold standard for preparative planning, and we hypothesize that magnetic resonance imaging (MRI) is sufficiently accurate to predict screw length and diameter compared to CT. Methods: We retrospectively measured the length and diameter of vertebral bodies in the lumbar region in both MRI and CT and tested for differences between the modalities as well as for confounding effects of age, sex, and the presence of spondyloarthrosis. Results: We found a significant difference in pedicle screw length between CT and MRI measurements for both sides. For the left pedicle, the mean difference was 1.89 mm (95% confidence interval [CI] À3.03 to À0.75; P , .002), while for the right pedicle, the mean difference was 2.05 mm (95% CI À3.27 to À0.84; P ¼ .001). We also found a significant difference in diameter measurements between CT and MRI for the left pedicle (0.53 mm; 95% CI 0.13 to 0.93; P ¼ .011) but not for the right pedicle (0.36 mm; 95% CI À0.06 to 0.78; P ¼ .094). We identified no significant effect of sex, age or spondyloarthrosis on the results (P. .05). Conclusions: Pedicle screw planning measurements were more accurate using CT images compared to MRI images. CT scan remains the gold standard for pedicle screw planning in trauma surgery. When using MRI images, the surgeon should be aware of the differences in screw length and diameter compared to CT in order to avoid intra-and postoperative risks.

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Accuracy of pedicle screw placement based on preoperative computed tomography versus intraoperative data set acquisition for spinal navigation system

Cited by 29 publications

References 30 publications

Augmented reality-based navigation increases precision of pedicle screw insertion

Augmented reality-based navigation increases precision of pedicle screw insertion

Augmented reality navigation with intraoperative 3D imaging vs fluoroscopy-assisted free-hand surgery for spine fixation surgery: a matched-control study comparing accuracy

Comparison of Preoperative Pedicle Screw Measurement Between Computed Tomography and Magnet Resonance Imaging

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