Pedicle violation and Navigational errors in pedicle screw insertion using the intraoperative O-arm: A preliminary report

Abstract

BackgroundUse of computer-assisted insertion of pedicle screws has some advantages owing to the reportedly decreased incidence of pedicle breach and clinical events. Registration-based methods based on preoperative computed tomography imaging, 2D fluoroscopy, and 3D fluoroscopy are the most popular, however each has its limitations. O-arm–based navigation, which uses intraoperative acquisition and registration of navigated images, may overcome many of these disadvantages. We set out to study the clinical accuracy and navigational accuracy for pedicle screw insertion using our recently acquired O-arm and present our preliminary findings.MethodsThe first 26 patients operated consecutively for L4-5 fusion were included in the study. O-arm–based navigation was used to insert the pedicle screws. Postoperative computed tomography images were acquired and assessed for pedicle breach and anterior cortical perforation. Planned trajectories of each screw were compared with the actual trajectories in the postoperative images to assess navigational accuracy in both axial and sagittal planes.ResultsA total of 104 screws were inserted. One screw (1%) breached the pedicle laterally. Nonsignificant anterolateral cortical perforations were noted in 7 screws (6.7%), all of which occurred at L5 level. The mean axial and sagittal navigational error was 2.3° (±1.7) and 3.1° (±2.3), respectively. There were no significant differences in the errors between L4 or L5 level. The occurrence of anterior perforation correlated with the degree of axial (P = .02) but not sagittal (P = .12) navigational error. There were no clinical events related to the screw insertion.ConclusionUse of O-arm–guided pedicle screw insertion was associated with low incidence of pedicle breach (1%) and a low range of navigational error in both sagittal and axial planes. Anterolateral vertebral body perforation was higher at L5 without any negative clinical events. Despite the high need for technical support, we found that O-arm was a very efficient tool for accurate pedicle screw insertion.

Augmented reality navigation for spinal pedicle screw instrumentation using intraoperative 3D imaging

“…Mean axial and sagittal translational errors in 2D were ranging from 1.3 -1.8 mm and 1.2 -1.5 mm in literature [7,14], whereas other studies did not report on TE [17,[20][21][22]. The 2D accuracy reported ranged from 2.2 -4.0° and 2.6 -4.0° for axial and sagittal AE, respectively [7,14,17,[20][21][22].…”

“…Various different clinical grading systems have been applied to evaluate the outcome of pedicle screw placement, making reproducibility and comparisons between studies difficult [15,16]. Only few studies assessing the performance of navigation systems in spinal surgery reported on the surgical accuracy of pedicle screw placement at all [6,14,[17][18][19][20][21][22][23]. Results reported in literature were mostly conducted in 2D [14,[17][18][19][20][21][22].…”

Feasibility and accuracy of a robotic guidance system for navigated spine surgery in a hybrid operating room: a cadaver study

“…2b, or as the compound 2D distance 16,24,25 . Likewise, the angular deviation was measured in the axial and sagittal planes 15,[25][26][27] .…”

Inserting pedicle screws in lumbar spondylolisthesis – The easy bone conserving way

“…[22][23][24] O-arm-based navigation, which uses intraoperative acquisition and registration of navigated images, may overcome many of the disadvantages of registration-based method as seen in preoperative computed tomography imaging, 2D fluoroscopy, and 3D fluoroscopy. 25 However, these image-guided system and O-arm based system are expensive and may not be affordable for many facilities 19 and also not fool proof because Oarm navigation is tracker dependent and as distance increases from tracker more pedicle screw violation occurs. Lateral perforations are more common due to instability at time of pedicle screw insertion due to translation and rotation of vertebral body.…”

“…3Dimensional (3D), computed tomography (CT) scan preoperatively and intraoperatively whereas others used O-arm fluoroscopy and CT scan post-operatively. [19][20][21][22][23][24][25] O-arm and 3D fluoroscopy IGN gave excellent results but they are expensive and may not be affordable for many facilities. 19 There is no article to the best of our knowledge that describes accurate pedicle screw insertion peroperatively in an anatomical deranged spine like lumbar spondylolisthesis using conventional 2D fluoroscopic images by readily available C-arm and without exposing anteriorly displaced posterior elements (Table 1).…”