Clinical and radiographic outcomes of minimally invasive percutaneous pedicle screw placement with intraoperative CT (O-arm) image guidance navigation

Abstract

Object Intraoperative CT image–guided navigation (IGN) has been increasingly incorporated into minimally invasive spine surgery (MIS). The vast improvement in image resolution and virtual real-time images with CT-IGN has proven superiority over traditional fluoroscopic techniques. The authors describe their perioperative MIS technique using the O-arm with navigation, and they report their postoperative experience, accuracy results, and technical aspects. Methods A retrospective review of 48 consecutive adult patients undergoing minimally invasive percutaneous posterior spinal fusion with intraoperative CT-IGN between July 2010 and August 2013 at Cedars-Sinai Medical Center was performed. Two surgeons assessed 290 screws in a blinded fashion on intraoperative O-arm images and postoperative CT scans for bony pedicle wall breach. Grade 1 breach was defined to be < 2 mm, Grade 2 breach to be between 2 and 4 mm, and a Grade 3 breach to be > 4 mm. Additionally, anterior vertebral body breach was recorded. Results Of 290 pedicle screws placed, 280 (96.6%) were in an acceptable position without cortical wall or anterior breach. Of the 10 breaches (3.4%) 5 were lateral (50%), 4 were medial, and 1 was anterior; 90% of breaches were Grade 1–2 and all medial breaches were Grade 1. The one Grade 3 breach was lateral. No vascular or neurological complications were observed intraoperatively, and no significant postoperative complications were noted. The mean clinical follow-up period was 18 months (range 3–39 months). The overall clinical outcomes, measured using the visual analog scale (back pain scores), were improved significantly postoperatively at 3 months compared with preoperatively (visual analog score 6.35 vs 3.57; p < 0.0001). No revision surgery was performed for screw misplacement or neurological deterioration. Conclusions New CT-IGN with the mobile O-arm scanner has increased the accuracy of pedicle screw/instrumentation placement using MIS techniques. The authors' high (96.6%) accuracy rate in MIS compares favorably with historical published accuracy rates for fluoroscopy-based techniques. Additional advantages of CT-IGN over fluoroscopic imaging methods are lower occupational radiation exposure for the surgical team, reduced need for postoperative imaging, and decreased rates of revision surgery. For now, the authors simply conclude that use of intraoperative CT-IGN is safe and accurate.

Initial Experience with O-Arm Navigated Spinal Surgery - Report on Two Cases

“…12 The radiation exposure of the surgical team and the patient substantially decreases in O-arm navigated surgery compared to conventional 2D fl uoroscopic-assisted spinal surgery. 7,11,13 We encountered longer operative time with the use of O-arm spinal navigation in these fi rst two cases. Kotani et al reported that surgeons could shorten operative time as experience increases.…”

“…10 The O-arm navigated surgery can also offer higher precision of pedicle screw placement via minimally-invasive percutaneous procedures. 11 Mason et al reported that the percentages of properly placed pedicle screws aided by 3D navigated spinal surgery reached as high as 95.5%, whereas the same percentages achieved by conventional fl uoroscopicbased surgery with C-arm was just about 68.1%. 12 The radiation exposure of the surgical team and the patient substantially decreases in O-arm navigated surgery compared to conventional 2D fl uoroscopic-assisted spinal surgery.…”

Stereoradiography as a Promising Method of Intraoperative Navigation in Spine Surgery

“…Various intraoperative computer navigation methods have been proposed and are in use today to improve the outcomes of spinal surgery [1; 2; 6-8]. However, despite implantation being quite accurate even in the context of altered and complex anatomy, both methods have disadvantages pertaining to the duration and difficulty of preoperative planning, to the errors of adapting the method to the patientspecific anatomy; besides, the methods require advanced and rather expensive equipment [9][10][11][12].…”

Stereoradiography Is a Promising Way of Intraoperative Navigation in Spine Surgery

“…Для улучшения результатов хирургического лечения заболеваний позвоночника в настоящее время предложены и широко используются методы интраоперационной компьютерной навигации [1; 2; 6-8]. Однако, несмотря на высокую точность имплантации в условиях измененной и сложной анатомии, этим способам присущи недостатки, обусловленные длительностью и трудоемкостью предоперационного планирования, возможными ошибками совмещения с индивидуальной анатомией пациента, зависимость от сложной и дорогостоящей аппаратуры [9][10][11][12].…”