Accuracy of Current Techniques for Placement of Pedicle Screws in the Spine: A Comprehensive Systematic Review and Meta-Analysis of 51,161 Screws

Perdomo‐Pantoja, Alexander; Ishida, Wataru; Zygourakis, Corinna C.; Holmes, Christina; Iyer, Rajiv R.; Cottrill, Ethan; Theodore, Nicholas; Witham, Timothy F.; Lo, Sheng Fu L.

doi:10.1016/j.wneu.2019.02.217

Cited by 112 publications

(113 citation statements)

References 93 publications

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“…However, the unique anatomy of the lumbar spine poses a significant challenge for inserting pedicle screws accurately. The rate of inaccuracy of the freehand technique for thoracolumbar pedicle screw placement is nearly 10% according to a systematic review. Even with fluoroscopic assistance, there is still high risk of screw malposition, which may compromise the stiffness of the screw–rod construct.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Superior‐Level Facet Joint Violations Between Robot‐Assisted Percutaneous Pedicle Screw Placement and Conventional Open Fluoroscopic‐Guided Pedicle Screw Placement

Zhang

Tian

et al. 2019

Orthopaedic Surgery

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Objective To compare the superior‐level facet joint violations (FJV) between robot‐assisted (RA) percutaneous pedicle screw placement and conventional open fluoroscopic‐guided (FG) pedicle screw placement in a prospective cohort study. Methods This was a prospective cohort study without randomization. One‐hundred patients scheduled to undergo RA (n = 50) or FG (n = 50) transforaminal lumbar interbody fusion were included from February 2016 to May 2018. The grade of FJV, the distance between pedicle screws and the corresponding proximal facet joint, and intra‐pedicle accuracy of the top screw were evaluated based on postoperative CT scan. Patient demographics, perioperative outcomes, and radiation exposure were recorded and compared. Perioperative outcomes include surgical time, intraoperative blood loss, postoperative length of stay, conversion, and revision surgeries. Results Of the 100 screws in the RA group, 4 violated the proximal facet joint, while 26 of 100 in the FG group had FJV (P = 0.000). In the RA group, 3 and 1 screws were classified as grade 1 and 2, respectively. Of the 26 FJV screws in the FG group, 17 screws were scored as grade 1, 6 screws were grade 2, and 3 screws were grade 3. Significantly more severe FJV were noted in the FG group than in the RA group (P = 0.000). There was a statistically significant difference between RA and FG for overall violation grade (0.05 vs 0.38, P = 0.000). The average distance of pedicle screws from facet joints in the RA group (4.16 ± 2.60 mm) was larger than that in the FG group (1.92 ± 1.55 mm; P = 0.000). For intra‐pedicle accuracy, the rate of perfect screw position was greater in the RA group than in the FG group (85% vs 71%; P = 0.017). No statistically significant difference was found between the clinically acceptable screws between groups (P = 0.279). The radiation dose was higher in the FG group (30.3 ± 11.3 vs 65.3 ± 28.3 μSv; P = 0.000). The operative time in the RA group was significantly longer (184.7 ± 54.3 vs 117.8 ± 36.9 min; P = 0.000). Conclusions Compared to the open FG technique, minimally invasive RA spine surgery was associated with fewer proximal facet joint violations, larger facet to screw distance, and higher intra‐pedicle accuracy.

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Section: Introductionmentioning

confidence: 99%

Comparison of Superior‐Level Facet Joint Violations Between Robot‐Assisted Percutaneous Pedicle Screw Placement and Conventional Open Fluoroscopic‐Guided Pedicle Screw Placement

Zhang

Tian

et al. 2019

Orthopaedic Surgery

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“…Originally, screws were inserted via the freehand technique, which presents the risk of misplacement. Misplaced screws are not only biomechanically disadvantageous but also carry an increased risk for neurological deficit, vascular damage, and morbidity [1][2][3]. Advances in imaging and navigation such as fluoroscopic guidance have improved the accuracy of screw placement in the spine, yet significantly increased the amount of radiation exposure to the patient, surgeon, and operating room (OR) staff [4,5].…”

Section: Introductionmentioning

confidence: 99%

Navigated robotic assistance results in improved screw accuracy and positive clinical outcomes: an evaluation of the first 54 cases

Benech¹,

Perez²,

Benech³

et al. 2019

J Robotic Surg

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Computer-aided navigation and robotic guidance systems have become widespread in their utilization for spine surgery. A recent innovation combines these two advances, which theoretically provides accuracy in spinal screw placement. This study describes the cortical and pedicle screw accuracy for the first 54 cases where navigated robotic assistance was used in a surgical setting. This is a retrospective chart review of the initial 54 patients undergoing spine surgery with pedicle and cortical screws using robotic guidance with navigation. A computed tomography (CT)-based Gertzbein and Robbins System (GRS) was used to classify pedicle screw accuracy. Screw tip, tail, and angulation offsets were measured using image overlay analysis. Screw malposition, reposition, and return to operating room rates were collected. 1 of the first 54 cases was a revision surgery and was excluded from the study. Ten screws were placed without the robot due to surgeon discretion and were excluded for the data analysis of 292 screws. Only 0.68% (2/292) of the robot-assisted screws was repositioned based on surgeon discretion. Based on the GRS CT-based grading, 98.3% (287/292) were graded A or B, 1.0% (3/292) screws were graded C, and only 0.7% (2/292) screws was graded D. The average offset from preoperative plan to actual final placement was 1.9 mm from the tip, 2.3 mm from the tail, and 2.8° of angulation. In the first 53 cases, 292 screws placed with navigated robotic assistance resulted in a high level of accuracy (98.3%), adequate screw offsets from planned trajectory, and zero complications.

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“…Surgical techniques have evolved from open surgery to minimally invasive surgery (MIS), in an effort to decrease surgical site exposure, reduce blood loss and complications, and shorten recovery time and hospital stay. 1 , 2 Advancements in computer-aided navigation (CAN) and robotic technologies have the potential to improve accuracy of screw placement in comparison to freehand methods 3 and to reduce excessive radiation exposure resulting from repetitive intraoperative fluoroscopy. 4 - 7 Robot-assisted navigation (RAN) platforms (SpineAssist/Renaissance/Mazor X, Mazor Robotics Ltd, Caesarea, Israel; ROSA, Medtech SA, Montpellier, France; and ExcelsiusGPS, Globus Medical, Inc, Audubon, PA) use 3-dimensional (3D), real-time patient data mapped via computed tomography (CT) registration, which is displayed on a monitor, allowing for the intraoperative navigation of surgical instruments using a camera system.…”

Section: Introductionmentioning

confidence: 99%

Assessment of Surgical Procedural Time, Pedicle Screw Accuracy, and Clinician Radiation Exposure of a Novel Robotic Navigation System Compared With Conventional Open and Percutaneous Freehand Techniques: A Cadaveric Investigation

Vaccaro

Harris

Hussain

et al. 2019

Global Spine Journal

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Study Design: Cadaveric study. Objective: To evaluate accuracy, radiation exposure, and surgical time of a new robotic-assisted navigation (RAN) platform compared with freehand techniques in conventional open and percutaneous procedures. Methods: Ten board-certified surgeons inserted 16 pedicle screws at T10–L5 (n = 40 per technique) in 10 human cadaveric torsos. Pedicle screws were inserted with (1) conventional MIS technique (L2–L5, patient left pedicles), (2) MIS RAN (L2–L5, patient right pedicles), (3) conventional open technique (T10–L1, patient left pedicles), and (4) open RAN (T10–L1, patient right pedicles). Output included (1) operative time, (2) number of fluoroscopic images, and (3) screw accuracy. Results: In the MIS group, compared with the freehand technique, RAN allowed for use of larger screws (diameter: 6.6 ± 0.6 mm vs 6.3 ± 0.5 mm; length: 50.3 ± 4.1 mm vs 46.9 ± 3.5 mm), decreased the number of breaches >2 mm (0 vs 7), fewer fluoroscopic images (0 ± 0 vs 108.3 ± 30.9), and surgical procedure time per screw (3.6 ± 0.4 minutes vs 7.6 ± 2.0 minutes) (all P < .05). Similarly, in the open group, RAN allowed for use of longer screws (46.1 ± 4.1 mm vs 44.0 ± 3.8 mm), decreased the number of breaches >2 mm (0 vs 13), fewer fluoroscopic images (0 ± 0 vs 24.1 ± 25.8) (all P < .05), but increased total surgical procedure time (41.4 ± 8.8 minutes vs 24.7 ± 7.0 minutes, P = .000) while maintaining screw insertion time (3.31.4 minutes vs 3.1 ± 1.0 minutes, P = .650). Conclusion: RAN significantly improved accuracy and decreased radiation exposure in comparison to freehand techniques in both conventional open and percutaneous surgical procedures in cadavers. RAN significantly increased setup time compared with both conventional procedures.

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Accuracy of Current Techniques for Placement of Pedicle Screws in the Spine: A Comprehensive Systematic Review and Meta-Analysis of 51,161 Screws

Cited by 112 publications

References 93 publications

Comparison of Superior‐Level Facet Joint Violations Between Robot‐Assisted Percutaneous Pedicle Screw Placement and Conventional Open Fluoroscopic‐Guided Pedicle Screw Placement

Comparison of Superior‐Level Facet Joint Violations Between Robot‐Assisted Percutaneous Pedicle Screw Placement and Conventional Open Fluoroscopic‐Guided Pedicle Screw Placement

Navigated robotic assistance results in improved screw accuracy and positive clinical outcomes: an evaluation of the first 54 cases

Assessment of Surgical Procedural Time, Pedicle Screw Accuracy, and Clinician Radiation Exposure of a Novel Robotic Navigation System Compared With Conventional Open and Percutaneous Freehand Techniques: A Cadaveric Investigation

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