Comparative Prospective Study Reporting Intraoperative Parameters, Pedicle Screw Perforation, and Radiation Exposure in Navigation-Guided versus Non-navigated Fluoroscopy-Assisted Minimal Invasive Transforaminal Lumbar Interbody Fusion

Abstract

Study DesignProspective cohort study.PurposeTo compare intraoperative parameters, radiation exposure, and pedicle screw perforation rate in navigation-guided versus non-navigated fluoroscopy-assisted minimal invasive transforaminal lumbar interbody fusion (MIS TLIF).Overview of LiteratureThe poor reliability of fluoroscopy-guided instrumentation and growing concerns about radiation exposure have led to the development of navigation-guided instrumentation techniques in MIS TLIF. The literature evaluating the efficacy of navigation-guided MIS TLIF is scant.MethodsEighty-seven patients underwent navigation- or fluoroscopy-guided MIS TLIF for symptomatic lumbar/lumbosacral spondylolisthesis. Demographics, intraoperative parameters (surgical time, blood loss), and radiation exposure (sec/mGy/Gy.cm2 noted from C-arm for comparison only) were recorded. Computed tomography was performed in patients in the navigation and non-navigation groups at postoperative 12 months and reviewed by an independent observer to assess the accuracy of screw placement, perforation incidence, location, grade (Mirza), and critical versus non-critical neurological implications.ResultsTwenty-seven patients (male/female, 11/16; L4–L5/L5–S1, 9/18) were operated with navigation-guided MIS TLIF, whereas 60 (male/female, 25/35; L4–L5/L5–S1, 26/34) with conventional fluoroscopy-guided MIS TILF. The use of navigation resulted in reduced fluoroscopy usage (dose area product, 0.47 Gy.cm2 versus 2.93 Gy.cm2), radiation exposure (1.68 mGy versus 10.97 mGy), and fluoroscopy time (46.5 seconds versus 119.08 seconds), with p-values of <0.001. Furthermore, 96.29% (104/108) of pedicle screws in the navigation group were accurately placed (grade 0) (4 breaches, all grade I) compared with 91.67% (220/240) in the non-navigation group (20 breaches, 16 grade I+4 grade II; p=0.114). None of the breaches resulted in a corresponding neurological deficit or required revision.ConclusionsNavigation guidance in MIS TLIF reduced radiation exposure, but the perforation status was not statistically different than that for the fluoroscopy-based technique. Thus, navigation in nondeformity cases is useful for significantly reducing the radiation exposure, but its ability to reduce pedicle screw perforation in nondeformity cases remains to be proven.

Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion with Endoscopic Disc Drilling Preparation Technique for Symptomatic Foraminal Stenosis Secondary to Severe Collapsed Disc Space: A Clinical and Computer Tomographic Study with Technical Note

“…Hence, in order to achieve consistent good results in Endo-TLIF, familiarity of lumbar endoscopic unilateral laminotomy with bilateral decompression would be necessary before attempting to perform Endo-TLIF. Navigation at various stages of the fusion procedure might help in orientation under spinal endoscopy in order to flatten the learning curve [ 40 , 41 , 42 ]. In our series, we performed intermittent checks using intraoperative fluoroscopy at various stages of procedure.…”

Narrative review of intraoperative image guidance for transforaminal lumbar interbody fusion

“…Although most studies have included pedicle screws placed in various types of posterior spinal fusions, a recent 2018 study by Dusad et al analyzed the use of navigation in MIS-TLIF. They reported 96.29% (104/108) of pedicle screws in the navigation group were accurately placed compared with 91.67% (220/240) in the non-navigation group; however, the difference was not statistically significant (41).…”

Minimally invasive transforaminal lumbar interbody fusion — A narrative review on the present status

“…Navigation assisted insertion of pedicel screws helps reduce the radiation exposure significantly. In a prospective comparative study, Dusad et al 29 compared the radiation exposure, operating time, blood loss and accuracy of pedicel screw position in fluoroscopy assisted MIS TLIF with that of Navigation assisted MIS TLIF. There was a significant reduction in radiation exposure in terms of cumulative radiation, dose area product (DAP) and radiation time when navigation assistance was used.…”