Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance

Abstract

Spinal instrumentation has made significant advances in the last two decades, with transpedicular constructs now widely used in spinal fixation. Pedicle screw constructs are routinely used in thoracolumbar-instrumented fusions, and in recent years, the cervical spine as well. Three-column fixations with pedicle screws provide the most rigid form of posterior stabilization. Surgical landmarks and fluoroscopy have been used routinely for pedicle screw insertion, but a number of studies reveal inaccuracies in placement using these conventional techniques (ranging from 10% to 50%). The ability to combine 3D imaging with intraoperative navigation systems has improved the accuracy and safety of pedicle screw placement, especially in more complex spinal deformities. However, in the authors' experience with image guidance in more than 1500 cases, several potential pitfalls have been identified while using intraoperative spinal navigation that could lead to suboptimal results. This article summarizes the authors' experience with these various pitfalls using spinal navigation, and gives practical tips on their avoidance and management.

Initial Experience with O-Arm Navigated Spinal Surgery - Report on Two Cases

“…It allows intraoperative control and immediate correction of misplaced spinal implants that can eventually result in lower incidence of redo surgery. Similar results have been reported by other researchers in the treatment of scoliotic deformities 3 , diseases affecting the cervical [4][5][6][7] and the thoraco-lumbar spine [7][8][9] . The navigational systems increase the accuracy of pedicle screw placement in spinal segments with diffi cult anatomy such as upper thoracic spine where lateral projections provided by conventional C-arm are less informative due to overlap of multiple bone structures.…”

Comparison of intraoperative O-arm- and conventional fluoroscopy (C-arm)-assisted insertion of pedicle screws in the treatment of fracture of thoracic vertebrae

“…3 The most commonly used image-assisted forms in spine surgery include two-dimensional (2-D) images, in which a fluoroscope or plain radiography is used, and threedimensional (3-D) navigation, making use of cone-beam computerized tomography (O-arm) or isocentric-C-arm 3D navigation system. 4,5 Conventional pedicle screw placement focused on the anatomical landmarks, entry point, and insertion angle with or without intraoperative 2D imaging can be performed by experienced surgeons. However, in the treatment of thoracic vertebrae fracture, especially upper and middle thoracic vertebrae, 2D imaging can be influenced by the structures of shoulders, scapulas, and ribs, which decreases the accuracy of thoracic pedicle screw placement.…”

Reliability of the Planned Pedicle Screw Trajectory versus the Actual Pedicle Screw Trajectory using Intra-operative 3D CT and 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. Proper screw placement is imperative in order to avoid complications such as CSF leak, and pedicle fractures.…”