Intraoperative image guidance compared with free-hand methods in adolescent idiopathic scoliosis posterior spinal surgery: a systematic review on screw-related complications and breach rates

Chan, Andrew; Parent, Éric; Narvacan, Karl; San, Cindy; Lou, Edmond

doi:10.1016/j.spinee.2017.04.001

Cited by 77 publications

(53 citation statements)

References 56 publications

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“…The study demonstrates that ARSN has a higher accuracy than FH for pedicle screw placement (93.9% vs 89.6%). This is in line with recent meta-analyses comparing other types of navigation systems to conventional surgical methods, showing increased accuracy when using navigation 1,5 . Navigation has been demonstrated to have the largest impact on accuracy in complex deformity surgeries, especially in the neuromuscular type of scoliosis 14 , and in the thoracic spine where the pedicles can be very small 15 .…”

Section: Discussionsupporting

confidence: 88%

Augmented reality navigation with intraoperative 3D imaging vs fluoroscopy-assisted free-hand surgery for spine fixation surgery: a matched-control study comparing accuracy

Elmi-Terander

Burström

Nachabé

et al. 2020

Sci Rep

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This study aimed to compare screw placement accuracy and clinical aspects between Augmented Reality Surgical Navigation (ARSN) and free-hand (FH) technique. Twenty patients underwent spine surgery with screw placement using ARSN and were matched retrospectively to a cohort of 20 FH technique cases for comparison. All ARSN and FH cases were performed by the same surgeon. Matching was based on clinical diagnosis and similar proportions of screws placed in the thoracic and lumbosacral vertebrae in both groups. Accuracy of screw placement was assessed on postoperative scans according to the Gertzbein scale and grades 0 and 1 were considered accurate. Procedure time, blood loss and length of hospital stay, were collected as secondary endpoints. A total of 262 and 288 screws were assessed in the ARSN and FH groups, respectively. The share of clinically accurate screws was significantly higher in the ARSN vs FH group (93.9% vs 89.6%, p < 0.05). The proportion of screws placed without a cortical breach was twice as high in the ARSN group compared to the FH group (63.4% vs 30.6%, p < 0.0001). No statistical difference was observed for the secondary endpoints between both groups. This matched-control study demonstrated that ARSN provided higher screw placement accuracy compared to free-hand.Compared to conventional free-hand (FH) surgical technique, computer-assisted navigation using intraoperative 3D imaging has been shown to improve screw placement accuracy and reduce complications due to screw misplacements 1 . Moreover, improved accuracy has also been shown in more challenging conditions, such as scoliosis surgery, where it may be of even greater importance 2 . Consequently, navigation also reduces the frequency of postoperative revision surgery compared to FH surgery 3 .Although several studies have compared intraoperative image guidance to free-hand (FH) technique, the evidence in favor of navigation is still limited. In a recent systematic review, Chan et al., found only four studies comparing computed tomography (CT) guidance with free-hand methods head-to-head, including one small (10 patients in each group, 169 screws in total) randomized study 4 . Overall, the reviewers found only moderate level evidence showing that CT guidance has lower breach rates than FH, while screw-related complication rates were conflicting at 0% in CT navigation compared with 0%-1.7% in FH groups 5 . In a more recent retrospective study comparing O-arm navigation to FH, Wang et al. demonstrated higher pedicle screw accuracy and lower total

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Section: Discussionsupporting

confidence: 88%

Augmented reality navigation with intraoperative 3D imaging vs fluoroscopy-assisted free-hand surgery for spine fixation surgery: a matched-control study comparing accuracy

Elmi-Terander

Burström

Nachabé

et al. 2020

Sci Rep

View full text Add to dashboard Cite

show abstract

“…Several studies demonstrated significantly higher accuracy of pedicle screw placement using other navigation systems providing three-dimensional information to the surgeon compared to the free-hand technique [20,23,24]. Three-dimensional navigation proved to be of use not only in patients with but particularly when treating spinal deformity [25,26]. Although similar clinical results are currently missing, AR-based navigation techniques already demonstrated remarkable precision in an experimental setting [27].…”

Section: Discussionmentioning

confidence: 99%

Augmented reality-based navigation increases precision of pedicle screw insertion

Dennler¹,

Jaberg²,

Spirig³

et al. 2020

J Orthop Surg Res

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Background: Precise insertion of pedicle screws is important to avoid injury to closely adjacent neurovascular structures. The standard method for the insertion of pedicle screws is based on anatomical landmarks (free-hand technique). Head-mounted augmented reality (AR) devices can be used to guide instrumentation and implant placement in spinal surgery. This study evaluates the feasibility and precision of AR technology to improve precision of pedicle screw insertion compared to the current standard technique. Methods: Two board-certified orthopedic surgeons specialized in spine surgery and two novice surgeons were each instructed to drill pilot holes for 40 pedicle screws in eighty lumbar vertebra sawbones models in an agarbased gel. One hundred and sixty pedicles were randomized into two groups: the standard free-hand technique (FH) and augmented reality technique (AR). A 3D model of the vertebral body was superimposed over the AR headset. Half of the pedicles were drilled using the FH method, and the other half using the AR method. Results: The average minimal distance of the drill axis to the pedicle wall (MAPW) was similar in both groups for expert surgeons (FH 4.8 ± 1.0 mm vs. AR 5.0 ± 1.4 mm, p = 0.389) but for novice surgeons (FH 3.4 mm ± 1.8 mm, AR 4.2 ± 1.8 mm, p = 0.044). Expert surgeons showed 0 primary drill pedicle perforations (PDPP) in both the FH and AR groups. Novices showed 3 (7.5%) PDPP in the FH group and one perforation (2.5%) in the AR group, respectively (p > 0.005). Experts showed no statistically significant difference in average secondary screw pedicle perforations (SSPP) between the AR and the FH set 6-, 7-, and 8-mm screws (p > 0.05). Novices showed significant differences of SSPP between most groups: 6-mm screws, 18 (45%) vs. 7 (17.5%), p = 0.006; 7-mm screws, 20 (50%) vs. 10 (25%), p = 0.013; and 8-mm screws, 22 (55%) vs. 15 (37.5%), p = 0.053, in the FH and AR group, respectively. In novices, the average optimal medio-lateral convergent angle (oMLCA) was 3.23°(STD 4.90) and 0.62°(STD 4.56) for the FH and AR set screws (p = 0.017), respectively. Novices drilled with a higher precision with respect to the cranio-caudal inclination angle (CCIA) category (p = 0.04) with AR. Conclusion: In this study, the additional anatomical information provided by the AR headset superimposed to realworld anatomy improved the precision of drilling pilot holes for pedicle screws in a laboratory setting and decreases the effect of surgeon's experience. Further technical development and validations studies are currently being performed to investigate potential clinical benefits of the herein described AR-based navigation approach.

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“…The potential value of robotic surgery might be greater when it comes to situation such as complex anatomical structures (e.g., cervical spine and spinal deformities) [ 12 ]. For spinal deformity, several studies have proved the superior accuracy and perioperative outcomes of robot-assisted pedicle screw placement for adolescent idiopathic scoliosis [ 13 – 17 ]. However, few retrospective studies have focused on the application of robotic surgery to adult degenerative scoliosis [ 18 , 19 ].…”

Section: Introductionmentioning

confidence: 99%

Robot-assisted orthopedic surgery in the treatment of adult degenerative scoliosis: a preliminary clinical report

Chen

Feng

et al. 2020

J Orthop Surg Res

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Study design A single-institution, retrospective cohort study. Objective To compare the accuracy and short-term clinical outcomes of pedicle screw placement between robot-assisted (RA) and freehand (FH) technique in the treatment of adult degenerative scoliosis (ADS). Methods From February 2018 to October 2019, 97 adult patients with degenerative scoliosis admitted to our department were retrospectively reviewed. Thirty-one patients received robot-assisted pedicle screw placement (RA group), and 66 patients underwent freehand pedicle screw placement (FH group). Patient demographics and short-term clinical outcomes were recorded and compared between two groups. Gertzbein-Robbins grading system was adopted to evaluate the accuracy of pedicle screw placement by means of postoperative CT scan. Short-term clinical outcomes consist of operative time, intraoperative blood loss, length of hospital stay (LOS), radiological parameters, Scoliosis Research Society-22 (SRS-22) scores before the operation, 6 months after operation, adverse events, and revisions. Results The accuracy of screw placement was higher than that of the FH group (clinically acceptable 98.7% vs. 92.2%; P < 0.001). Intraoperative blood loss of the RA group was less than those in the FH group (499 vs. 573 ml; P < 0.001). Operative time (283.1 vs. 291.9 min; P = 0.31) and length of stay (12.8 vs. 13.7 days; P = 0.36) were compared between RA and FH groups. In terms of radiological parameters, both of groups were improved postoperatively. The SRS-22 scores at 6 months after operation from both groups were better than those before operation. For surgery-related complication, one case had pressure sores in the RA group while two cases developed dural tears in the FH group. No revision was required in both groups. Conclusion Combined with other surgical correction modalities, robot-assisted pedicle screw fixation is an effective and safe method of treating degenerative scoliosis. Due to its satisfactory surgical outcomes such as higher accuracy and less trauma, it provides a good alternative for clinical practice. Level of evidence 3.

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Intraoperative image guidance compared with free-hand methods in adolescent idiopathic scoliosis posterior spinal surgery: a systematic review on screw-related complications and breach rates

Cited by 77 publications

References 56 publications

Augmented reality navigation with intraoperative 3D imaging vs fluoroscopy-assisted free-hand surgery for spine fixation surgery: a matched-control study comparing accuracy

Augmented reality navigation with intraoperative 3D imaging vs fluoroscopy-assisted free-hand surgery for spine fixation surgery: a matched-control study comparing accuracy

Augmented reality-based navigation increases precision of pedicle screw insertion

Robot-assisted orthopedic surgery in the treatment of adult degenerative scoliosis: a preliminary clinical report

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