Accuracy of Image-Guided Pedicle Screw Placement Using Intraoperative Computed Tomography-Based Navigation With Automated Referencing. Part II: Thoracolumbar Spine

BACKGROUND Image-guided spinal instrumentation may reduce complications in spinal instrumentation. OBJECTIVE To assess accuracy, time efficiency, and staff radiation exposure during thoracolumbar screw instrumentation guided by intraoperative computed tomography (iCT)-based neuronavigation (iCT-N). METHODS In 55 patients treated for idiopathic and degenerative deformities, 826 screws were inserted in the thoracic (T2–T12; n = 243) and lumbosacral (L1–S1; n = 545) spine, as well as ilium (n = 38) guided by iCT-N. Up to 17 segments were instrumented following a single automated registration sequence with the dynamic reference arc (DRA) uniformly attached to L5. Accuracy of iCT-N was assessed by calculating angular deviations between individual navigated tool trajectories and final implant positions. Final screw positions were also graded according to established classification systems. Clinical and radiological outcome was assessed at 12 to 14 months. RESULTS Additional intraoperative fluoroscopy was unnecessary, eliminating staff radiation exposure. Unisegmental K-wire insertion required 4.6 ± 2.9 minutes. Of the thoracic pedicle screws 98.4% were assigned grades I to III according to the Heary classification, with 1.6% grade IV placement. In the lumbar spine, 94.4% of screws were completely contained (Gertzbein classification grade 0), 4.6% displayed minor pedicle breaches <2 mm (grade 1), and 1% of lumbar screws deviated by >2 to <4 mm (grade 2). The accuracy of iCT-N progressively deteriorates with increasing distance from the DRA, but allows safe instrumentation of up to 12 segments. CONCLUSION iCT-N using automated referencing allows for safe, highly accurate multilevel instrumentation of the entire thoracolumbosacral spine and ilium, rendering additional intraoperative imaging dispensable. In addition, automated registration is time-efficient and significantly reduces the need for re-registration in multilevel surgery.

[1]  Thomas Mittlmeier,et al.  Benefit and accuracy of intraoperative 3D-imaging after pedicle screw placement: a prospective study in stabilizing thoracolumbar fractures , 2009, European Spine Journal.

[2]  B. Green,et al.  Computer-assisted Fluoroscopic Targeting System for Pedicle Screw Insertion , 2000, Neurosurgery.

[3]  H. Nakashima,et al.  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 , 2009, Journal of spinal disorders & techniques.

[4]  Phillip M Young,et al.  Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort. , 2009, Journal of neurosurgery. Spine.

[5]  C. Bono,et al.  Thoracic pedicle screws: postoperative computerized tomography scanning assessment. , 2004, Journal of neurosurgery.

[6]  Dominik Morhard,et al.  Intraoperative Computed Tomography With Integrated Navigation System in Spinal Stabilizations , 2009, Spine.

[7]  Choll W. Kim,et al.  Use of navigation-assisted fluoroscopy to decrease radiation exposure during minimally invasive spine surgery. , 2008, The spine journal : official journal of the North American Spine Society.

[8]  A. Samdani,et al.  Learning Curve for Placement of Thoracic Pedicle Screws in the Deformed Spine , 2010, Neurosurgery.

[9]  R. Verma,et al.  Functional outcome of computer-assisted spinal pedicle screw placement: a systematic review and meta-analysis of 23 studies including 5,992 pedicle screws , 2010, European Spine Journal.

[10]  Samuel K. Cho,et al.  Comparative Analysis of Pedicle Screw Versus Hybrid Instrumentation in Posterior Spinal Fusion of Adolescent Idiopathic Scoliosis , 2004, Spine.

[11]  A. Dhawan,et al.  In Vivo Accuracy of Thoracic Pedicle Screws , 2001, Spine.

[12]  Eric W Nottmeier,et al.  Accuracy of upper thoracic pedicle screw placement using three-dimensional image guidance. , 2009, The spine journal : official journal of the North American Spine Society.

[13]  S. Gumina,et al.  Pedicle instrumentation in the thoracic spine. A morphometric and cadaveric study for placement of screws. , 1999, Spine.

[14]  Richard M Schwend,et al.  Pedicle Screw Instrumentation for Adult Idiopathic Scoliosis: An Improvement Over Hook/Hybrid Fixation , 2009, Spine.

[15]  L. Lenke,et al.  Pedicle Morphology In Thoracic Adolescent Idiopathic Scoliosis: Is Pedicle Fixation an Anatomically Viable Technique? , 2000, Spine.

[16]  J. Weber,et al.  Clinical and radiological results after parapedicular screw fixation of the thoracic spine. , 2005, Journal of neurosurgery. Spine.

[17]  John Damilakis,et al.  Estimation of Patient Dose and Associated Radiogenic Risks From Fluoroscopically Guided Pedicle Screw Insertion , 2004, Spine.

[18]  L. Lenke,et al.  Free Hand Pedicle Screw Placement in the Thoracic Spine: Is it Safe? , 2004, Spine.

[19]  C. Rau,et al.  Single Versus Separate Registration for Computer-Assisted Lumbar Pedicle Screw Placement , 2004, Spine.

[20]  S. Glaze,et al.  Surgeon and patient radiation exposure in minimally invasive transforaminal lumbar interbody fusion. , 2008, Journal of neurosurgery. Spine.

[21]  Hideki Yoshikawa,et al.  Surface-based registration accuracy of CT-based image-guided spine surgery , 2005, European Spine Journal.

[22]  Hildegard Dohmen,et al.  Less Invasive Surgical Correction of Adult Degenerative Scoliosis, Part I: Technique and Radiographic Results , 2010, Neurosurgery.

[23]  E. Emel,et al.  Accuracy of Pedicle Screw Placement for Upper and Middle Thoracic Pathologies Without Coronal Plane Spinal Deformity Using Conventional Methods , 2006, Journal of spinal disorders & techniques.

[24]  D. Simon,et al.  Virtual Fluoroscopy: Computer-Assisted Fluoroscopic Navigation , 2001, Spine.

[25]  R. Yeasting,et al.  Anatomic Considerations of Pedicle Screw Placement in the Thoracic Spine: Roy‐Camille Technique Versus Open‐Lamina Technique , 1998, Spine.

[26]  M. O’Brien,et al.  Radiation Exposure During Pedicle Screw Placement in Adolescent Idiopathic Scoliosis: Is Fluoroscopy Safe? , 2006, Spine.

[27]  S. Gertzbein,et al.  Accuracy of Pedicular Screw Placement In Vivo , 1990, Spine.

[28]  H Labelle,et al.  Comparative results between conventional and computer-assisted pedicle screw installation in the thoracic, lumbar, and sacral spine. , 2000, Spine.

[29]  Robert A Hart,et al.  Pedicle Screw Placement in the Thoracic Spine: A Comparison of Image-Guided and Manual Techniques in Cadavers , 2005, Spine.

[30]  Lothar Kinzl,et al.  Does Computer-Assisted Spine Surgery Reduce Intraoperative Radiation Doses? , 2006, Spine.

[31]  J. Massie,et al.  Assessment of Pedicle Screw Placement Utilizing Conventional Radiography and Computed Tomography: A Proposed Systematic Approach to Improve Accuracy of Interpretation , 2004, Spine.

[32]  Jens R. Chapman,et al.  The safety of fluoroscopically-assisted thoracic pedicle screw instrumentation for spine trauma. , 2006, The Journal of trauma.

[33]  K Cleary,et al.  Intraoperative computed tomography for complex craniocervical operations and spinal tumor resections. , 2000, Neurosurgery.

[34]  K. Bulsara,et al.  Utility of Computerized Isocentric Fluoroscopy for Minimally Invasive Spinal Surgical Techniques , 2005, Journal of spinal disorders & techniques.

[35]  T. Laine,et al.  Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients , 2000, European Spine Journal.

[36]  Y. Rampersaud,et al.  Clinical Accuracy of Fluoroscopic Computer-Assisted Pedicle Screw Fixation: A CT Analysis , 2005, Spine.

[37]  Mikael Gunnarsson,et al.  Low-dose helical computed tomography (CT) in the perioperative workup of adolescent idiopathic scoliosis , 2009, European Radiology.

[38]  Kevin T Foley,et al.  Intraoperative Spinal Navigation , 2003, Spine.

[39]  K Ebmeier,et al.  Intraoperative computerized tomography for improved accuracy of spinal navigation in pedicle screw placement of the thoracic spine. , 2003, Acta neurochirurgica. Supplement.

[40]  Wei-Che Lin,et al.  Computer-assisted pedicle screw placement for thoracolumbar spine fracture with separate spinal reference clamp placement and registration. , 2008, Surgical neurology.

[41]  Raja Rampersaud,et al.  Clinical Accuracy of Computer-Assisted Two-Dimensional Fluoroscopy for the Percutaneous Placement of Lumbosacral Pedicle Screws , 2011, Spine.

[42]  M. Austin,et al.  Image-Guided Spine Surgery: A Cadaver Study Comparing Conventional Open Laminoforaminotomy and Two Image-Guided Techniques for Pedicle Screw Placement in Posterolateral Fusion and Nonfusion Models , 2002, Spine.

[43]  Michael Y. Wang,et al.  Percutaneous iliac screw placement: description of a new minimally invasive technique. , 2008, Neurosurgical Focus.

[44]  D J Quint,et al.  Stereotactic Navigation for Placement of Pedicle Screws in the Thoracic Spine , 2001, Neurosurgery.

[45]  Jörg-Christian Tonn,et al.  INTRAOPERATIVE COMPUTED TOMOGRAPHY WITH INTEGRATED NAVIGATION SYSTEM IN A MULTIDISCIPLINARY OPERATING SUITE , 2009, Neurosurgery.

[46]  H. Hashidate,et al.  Accuracy of Multilevel Registration in Image-Guided Pedicle Screw Insertion for Adolescent Idiopathic Scoliosis , 2010, Spine.

[47]  Imaging Assessment of Lumbar Pedicle Screw Placement: Sensitivity and Specificity of Plain Radiographs and Computer Axial Tomography , 2007, Spine.

[48]  Y. Rampersaud,et al.  Radiation Exposure to the Spine Surgeon During Fluoroscopically Assisted Pedicle Screw Insertion , 2000, Spine.

[49]  S Vidyadhara,et al.  Randomized Clinical Study to Compare the Accuracy of Navigated and Non-Navigated Thoracic Pedicle Screws in Deformity Correction Surgeries , 2007, Spine.

[50]  A. Haims,et al.  Morphometric Comparison of the Pedicle Rib Unit to Pedicles in the Thoracic Spine , 2004, Spine.

[51]  Kevin T Foley,et al.  Three-dimensional fluoroscopy-guided percutaneous thoracolumbar pedicle screw placement. Technical note. , 2003, Journal of neurosurgery.

[52]  K Anthony Kim,et al.  Reliability of Three-dimensional Fluoroscopy For Detecting Pedicle Screw Violations in the Thoracic and Lumbar Spine , 2004, Neurosurgery.

[53]  D P McGowan,et al.  Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. , 1990, Spine.

[54]  E. Massicotte,et al.  Clinical Accuracy of Cervicothoracic Pedicle Screw Placement: A Comparison of the “Open” Lamino-foraminotomy and Computer-assisted Techniques , 2007, Journal of spinal disorders & techniques.

[55]  V. P. Kumar,et al.  A CADAVER STUDY , 2008 .

[56]  John J Carbone,et al.  Fluoroscopically Assisted Pedicle Screw Fixation for Thoracic and Thoracolumbar Injuries: Technique and Short-Term Complications , 2003, Spine.

[57]  Rick Sasso,et al.  An Evaluation of Image-Guided Technologies in the Placement of Percutaneous Iliosacral Screws , 2006, Spine.

[58]  Elias C Papadopoulos,et al.  Accuracy of single-time, multilevel registration in image-guided spinal surgery. , 2005, The spine journal : official journal of the North American Spine Society.

[59]  L. Lenke,et al.  Computed Tomography Evaluation of Pedicle Screws Placed in the Pediatric Deformed Spine Over an 8-Year Period , 2007, Spine.

[60]  Moe R. Lim,et al.  Accuracy of Computerized Frameless Stereotactic Image-Guided Pedicle Screw Placement into Previously Fused Lumbar Spines , 2005, Spine.

[61]  G. Deuretzbacher,et al.  Computer Navigation of Parapedicular Screw Fixation in the Thoracic Spine: A Cadaver Study , 2001, Spine.

[62]  Charles Kuntz,et al.  Accuracy of Thoracic Vertebral Body Screw Placement Using Standard Fluoroscopy, Fluoroscopic Image Guidance, and Computed Tomographic Image Guidance: A Cadaver Study , 2003, Spine.

[63]  Rick Sasso,et al.  Comparison of Radiation Exposure in Lumbar Pedicle Screw Placement With Fluoroscopy Vs Computer-Assisted Image Guidance With Intraoperative Three-Dimensional Imaging , 2008, The journal of spinal cord medicine.

[64]  Haruo Misawa,et al.  Usefulness of a navigation system in surgery for scoliosis: segmental pedicle screw fixation in the treatment , 2009, Archives of Orthopaedic and Trauma Surgery.

[65]  Paul A Gardner,et al.  Intraoperative computed tomography image-guided navigation for posterior thoracolumbar spinal instrumentation in spinal deformity surgery. , 2010, Neurosurgical focus.

[66]  Lisa Ferrara,et al.  Pedicle Morphometry in the Upper Thoracic Spine: Limits to Safe Screw Placement in Older Patients , 2002, Spine.

[67]  J. A. Carrino,et al.  Electromagnetic navigation for percutaneous guide-wire insertion: Accuracy and efficiency compared to conventional fluoroscopic guidance , 2009, NeuroImage.

[68]  F. Lolli,et al.  Posterior fusion only for thoracic adolescent idiopathic scoliosis of more than 80°: pedicle screws versus hybrid instrumentation , 2008, European Spine Journal.

[69]  M. O’Brien,et al.  Use of All‐pedicle‐screw Constructs in the Treatment of Adolescent Idiopathic Scoliosis , 2009, The Journal of the American Academy of Orthopaedic Surgeons.

[70]  Gordon Singer,et al.  Occupational Radiation Exposure to the Surgeon , 2005, The Journal of the American Academy of Orthopaedic Surgeons.

[71]  Naoki Ishiguro,et al.  Segmental Pedicle Screwing for Idiopathic Scoliosis Using Computer-assisted Surgery , 2008, Journal of spinal disorders & techniques.

[72]  Dong-Ho Lee,et al.  Thoracic pedicle screw insertion in scoliosis using posteroanterior C-arm rotation method. , 2005, Journal of spinal disorders & techniques.

[73]  H. Halm,et al.  Pedicle Screw Instrumentation of the Thoracic Spine in Idiopathic Scoliosis , 1997, Spine.

[74]  L. Lenke,et al.  Evaluation of Pedicle Screw Placement in the Deformed Spine Using Intraoperative Plain Radiographs: A Comparison With Computerized Tomography , 2005, Spine.

[75]  Richard Assaker,et al.  Transpedicular Screw Placement: Image-Guided Versus Lateral-View Fluoroscopy:In Vitro Simulation , 2001, Spine.