The Accuracy of Intraoperative O-arm Images for the Assessment of Pedicle Screw Postion

Santos, Edward Rainier G; Ledonio, Charles Gerald T.; Castro, C. A. Nieto de; Truong, Walter H.; Sembrano, Jonathan N.

doi:10.1097/brs.0b013e3182257cae

Cited by 74 publications

(43 citation statements)

References 11 publications

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“…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.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2016

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Section: Introductionmentioning

confidence: 99%

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

et al. 2016

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“…11 Neuronavigation reduces the risk that tactile feedback cues from previously violated or weakened bone or dense scarring will mislead the surgeon, and also provides the option of acquiring an intraoperative postinstrumentation CT image to confirm Category C7-T3 T4-9 T10-L2 L3-5 S-1 Pelvis Total Rt Lt total screws 29 64 151 131 36 18 429 214 215 good screws w/in bone 13 46 107 107 12 13 298 153 145 bicortical 10 6 10 21 17 0 64 26 38 EP 2 5 15 0 0 0 22 8 correct placement of screws. 10 This option is exceedingly useful in an existing revision, because further revision would place the patient in added jeopardy.…”

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

Hsieh¹,

Drazin²,

Firempong

et al. 2014

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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.

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“…21,36,63,65,68 These approaches show promise but add time and considerable radiation exposure (in the case of CT) to the patient, 44 without necessarily improving placement accuracy. 27,35,50,61 The second approach to detect malpositioned thoracic pedicle screws involves intraoperative neuromonitoring, using a technique first developed for monitoring placement of lumbosacral screws. In that original approach, 9,10 a ball-tipped probe routinely used to palpate the pedicle's margins (medial, superior, lateral, and inferior) was modified to act as a stimulating electrode.…”

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Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 1. Methods and alarm criteria

Calancie¹,

Donohue

Harris

et al. 2014

SPI

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Object Reports of the accuracy of existing neuromonitoring methods for detecting or preventing medial malpositioning of thoracic pedicle screws have varied widely in their claimed effectiveness. The object of this study was to develop, test, and validate a novel neuromonitoring method for preventing medial malpositioning of pedicle screws in the thoracic spine during surgery. Methods This is a prospective, blinded and randomized study using a novel combination of input (4-pulse stimulus trains delivered within the pedicle track) and output (evoked electromyography from leg muscles) to detect pedicle track trajectories that—once implanted with a screw—would cause that screw to breach the pedicle's medial wall and encroach upon the spinal canal. For comparison, the authors also used screw stimulation as an input and evoked electromyogram from intercostal and abdominal muscles as output measures. Intraoperative electrophysiological findings were compared with postoperative CT scans by multiple reviewers blinded to patient identity or intraoperative findings. Results Data were collected from 71 patients, in whom 802 screws were implanted between the T-1 and L-1 vertebral levels. A total of 32 screws ended up with screw threads encroaching on the spinal canal by at least 2 mm. Pulse-train stimulation within the pedicle track using a ball-tipped probe and electromyography from lower limb muscles correctly predicted all 32 (100%) of these medially malpositioned screws. The combination of pedicle track stimulation and electromyogram response from leg muscles proved to be far more effective in predicting these medially malpositioned screws than was direct screw stimulation and any of the target muscles (intercostal, abdominal, or lower limb muscles) we monitored. Based on receiver operating characteristic analysis, the combination of 10-mA (lower alarm) and 15-mA stimulation intensities proved most effective for detection of pedicle tracks that ultimately gave rise to medially malpositioned screws. Additional results pertaining to the impact of feedback of these test results on surgical decision making are provided in the companion report. Conclusions This novel neuromonitoring approach accurately predicts medially malpositioned thoracic screws. The approach could be readily implemented within any surgical program that is already using contemporary neuromonitoring methods that include transcranial stimulation for monitoring motor evoked potentials.

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The Accuracy of Intraoperative O-arm Images for the Assessment of Pedicle Screw Postion

Abstract: Intraoperative O-arm images accurately detect significant pedicle screw violations in the thoracic and lumbosacral spine but are less accurate for the cervical spine.

Cited by 74 publications

References 11 publications

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

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

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

Neuromonitoring with pulse-train stimulation for implantation of thoracic pedicle screws: a blinded and randomized clinical study. Part 1. Methods and alarm criteria

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