Abstract
Various navigation systems are available to aid pedicle screw placement. The O-arm replaces the need for fluoroscopy and generates a 3-dimensional volumetric dataset that can be viewed as transverse, coronal, and sagittal images of the spine, similar to computed tomography (CT) scanning. The dataset can be downloaded to the Stealth system (Medtronic Navigation, Louisville, Colorado) for real-time intraoperative navigation.
The main objectives of the current study were to assess (1) accuracy of pedicle screw placement using the O-arm/Stealth system, and (2) time for draping, positioning of the O-arm, and screw placement. Of 188 screws (25 patients), 116 had adequate images for analysis. The average time for O-arm draping was 3.5 minutes. Initial O-arm positioning was 6.1 minutes, and final positioning was 4.9 minutes. Mean time for screw placement, including O-arm draping and positioning and array attachment, was 8.1 minutes per screw. Mean time for screw placement alone was 5.9 minutes per screw. Screw placements on final O-arm images were on average 3.14 mm deeper than on the snapshot navigation images. Three screws (2.6%) breached the medial cortex, and 3 screws (2.6%) were misaligned and did not follow the pilot hole trajectory.
The use of the O-arm/Stealth system was associated with a low rate of pedicle screw misalignment. The time to place screws was less than previously reported with CT navigation, but longer than conventional techniques. It is important to be aware of the potential discrepancy between snapshot navigation images and actual screw placement on final O-arm images. Our findings suggest that final screw positions may be deeper than awl positions appear on navigation images.
- 1.Esses SI, Sachs BL, Dreyzin V. Complications associated with the technique of pedicle screw fixation. A selected survey of ABS members. Spine (Phila Pa 1976). 1993; 18(15):2231–2238.
10.1097/00007632-199311000-00015 Crossref Medline, Google Scholar - 2.Lonstein JE, Denis F, Perra JH, Pinto MR, Smith MD, Winter RB. Complications associated with pedicle screws. J Bone Joint Surg Am. 1999; 81(11):1519–1528. Crossref Medline, Google Scholar
- 3.Vaccaro AR, Rizzolo SJ, Balderston RA, Placement of pedicle screws in the thoracic spine. Part II: An anatomical and radiographic assessment. J Bone Joint Surg Am. 1995; 77(8):1200–1206. Crossref Medline, Google Scholar
- 4.Weinstein JN, Spratt KF, Spengler D, Brick C, Reid S. Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine (Phila Pa 1976). 1988; 13(9):1012–1018.
10.1097/00007632-198809000-00008 Crossref Medline, Google Scholar - 5.Laine T, Lund T, Ylikoski M, Lohikoski J, Schlenzka D. Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients. Eur Spine J. 2000; 9(3):235–240.
10.1007/s005860000146 Crossref Medline, Google Scholar - 6.Merloz P, Tonetti J, Pittet L, Coulomb M, Lavalleé S, Sautot P. Pedicle screw placement using image guided techniques. Clin Orthop Relat Res. 1998; (354):39–48.
10.1097/00003086-199809000-00006 Crossref Medline, Google Scholar - 7.Grützner PA, Beutler T, Wendl K, von Recum J, Wentzensen A, Nolte LP. Intraoperative three-dimensional navigation for pedicle screw placement [in German]. Chirurg. 2004; 75(10):967–975.
10.1007/s00104-004-0944-3 Crossref Medline, Google Scholar - 8.Holly LT, Foley KT. Three-dimensional fluoroscopy-guided percutaneous thoracolumbar pedicle screw placement. Technical note. J Neurosurg. 2003; 99(3 suppl):324–329. Medline, Google Scholar
- 9.Villavicencio AT, Burneikiene S, Bulsara KR, Thramann JJ. Utility of computerized isocentric fluoroscopy for minimally invasive spinal surgical techniques. J Spinal Disord Tech. 2005; 18(4):369–375.
10.1097/01.bsd.0000168511.67189.64 Crossref Medline, Google Scholar - 10.Park P, Foley KT, Cowan JA, Marca FL. Minimally invasive pedicle screw fixation utilizing O-arm fluoroscopy with computer-assisted navigation: feasibility, technique, and preliminary results. Surg Neurol Int. 2010; 1:44.
10.4103/2152-7806.68705 Crossref Medline, Google Scholar - 11.Fraser J, Gebhard H, Irie D, Parikh K, Härtl R. Iso-C/3-dimensional neuronavigation versus conventional fluoroscopy for minimally invasive pedicle screw placement in lumbar fusion [published online ahead of print December 7, 2010]. Minim Invasive Neurosurg. 2010; 53(4):184–190.
10.1055/s-0030-1267926 Crossref Medline, Google Scholar - 12.Tormenti MJ, Kostov DB, Gardner PA, Kanter AS, Spiro RM, Okonkwo DO. Intraoperative computed tomography image-guided navigation for posterior thoracolumbar spinal instrumentation in spinal deformity surgery. Neurosurg Focus. 2010; 28(3):E11.
10.3171/2010.1.FOCUS09275 Crossref Medline, Google Scholar - 13.Nakashima H, Sato K, Ando T, Inoh H, Nakamura H. Comparison of the percutaneous screw placement precision of isocentric C-arm 3-dimensional fluoroscopy-navigated pedicle screw implantation and conventional fluoroscopy method with minimally invasive surgery. J Spinal Disord Tech. 2009; 22(7):468–472.
10.1097/BSD.0b013e31819877c8 Crossref Medline, Google Scholar - 14.Chatrath V, Agrawal V, Nagariya S, Vyas P. Pedicle screw placement using computer assisted navigation. J Orthopaedics. 2008; 5(3):e12. Google Scholar
- 15.Carl AL, Khanuja HS, Gatto CA, In vivo pedicle screw placement: image-guided virtual vision. J Spinal Disord. 2000; 13(3):225–229.
10.1097/00002517-200006000-00005 Crossref Medline, Google Scholar - 16.Kothe R, Matthias Strauss J, Deuretzbacher G, Hemmi T, Lorenzen M, Wiesner L. Computer navigation of parapedicular screw fixation in the thoracic spine: a cadaver study. Spine (Phila Pa 1976). 2001; 26(21):E496–E501.
10.1097/00007632-200111010-00019 Crossref Medline, Google Scholar - 17.Nowitzke A, Wood M, Cooney K. Improving accuracy and reducing errors in spinal surgery—a new technique for thoracolumbarlevel localization using computer-assisted image guidance [published online ahead of print December 21, 2007]. Spine J. 2008; 8(4):597–604.
10.1016/j.spinee.2007.06.005 Crossref Medline, Google Scholar - 18.Raynor BL, Lenke LG, Bridwell KH, Taylor BA, Padberg AM. Correlation between low triggered electromyographic thresholds and lumbar pedicle screw malposition: analysis of 4857 screws. Spine (Phila Pa 1976). 2007; 32(24):2673–2678.
10.1097/BRS.0b013e31815a524f Crossref Medline, Google Scholar - 19.Raynor BL, Lenke LG, Kim Y, Can triggered electromyograph thresholds predict safe thoracic pedicle screw placement?Spine (Phila Pa 1976). 2002; 27(18):2030–2035.
10.1097/00007632-200209150-00012 Crossref Medline, Google Scholar - 20.Wood MJ, Mannion RJ. Improving accuracy and reducing radiation exposure in minimally invasive lumbar interbody fusion. J Neurosurg Spine. 2010; 12(5):533–539.
10.3171/2009.11.SPINE09270 Crossref Medline, Google Scholar - 21.Alemo S, Sayadipour A. Role of intraoperative neurophysiologic monitoring in lumbosacral spine fusion and instrumentation: a retrospective study [published online ahead of print August 7, 2009]. World Neurosurg. 2010; 73(1):72–76.
10.1016/j.surneu.2009.04.024 Crossref Medline, Google Scholar - 22.Schwartz DM, Auerbach JD, Dormans JP, Neurophysiological detection of impending spinal cord injury during scoliosis surgery. J Bone Joint Surg Am. 2007; 89(11):2440–2449.
10.2106/JBJS.F.01476 Crossref Medline, Google Scholar
