Biomechanical comparison of different techniques in primary spinal surgery in osteoporotic cadaveric lumbar vertebrae: expansive pedicle screw versus polymethylmethacrylate-augmented pedicle screw

Abstract Importance of Navigation Navigation and intraoperative imaging have undergone an enormous development in recent years. By using intraoperative navigation, the precision of pedicle screw implantation can be increased in the sense of patient safety. Especially in the case of complex defects or tumor diseases, navigation is a decisive aid. As a result of the constantly improved technology, the requirements for reduced radiation exposure and intraoperative control can also be met. The high costs of the devices can be amortized, for example by a reduced number of revisions. This overview presents the principles of navigation in spinal surgery and the advantages and disadvantages of the different navigation procedures.

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Image-Guided Spinal Surgery and Robotics in MIS: Where Are We Now?

Neurologico Spinale Medico Chirurgico ◽

10.15562/nsmc.v1i2.80 ◽

2018 ◽

Vol 1 (2) ◽

pp. 2

Author(s):

Chiung Chyi Shen

Keyword(s):

Pedicle Screw ◽

Spinal Surgery ◽

Surgical Navigation ◽

Improve Patient Safety ◽

Intraoperative Imaging ◽

Spinal Instrumentation ◽

Pedicle Screws ◽

Computer Assisted ◽

Navigation Systems ◽

Image Guided

Use of pedicle screws is widespread in spinal surgery for degenerative, traumatic, and oncological diseases. The conventional technique is based on the recognition of anatomic landmarks, preparation and palpation of cortices of the pedicle under control of an intraoperative C-arm (iC-arm) fluoroscopy. With these conventional methods, the median pedicle screw accuracy ranges from 86.7% to 93.8%, even if perforation rates range from 21.1% to 39.8%.The development of novel intraoperative navigational techniques, commonly referred to as image-guided surgery (IGS), provide simultaneous and multiplanar views of spinal anatomy. IGS technology can increase the accuracy of spinal instrumentation procedures and improve patient safety. These systems, such as fluoroscopy-based image guidance ("virtual fluoroscopy") and computed tomography (CT)-based computer-guidance systems, have sensibly minimized risk of pedicle screw misplacement, with overall perforation rates ranging from between 14.3% and 9.3%, respectively."Virtual fluoroscopy" allows simultaneous two-dimensional (2D) guidance in multiple planes, but does not provide any axial images; quality of images is directly dependent on the resolution of the acquired fluoroscopic projections. Furthermore, computer-assisted surgical navigation systems decrease the reliance on intraoperative imaging, thus reducing the use of intraprocedure ionizing radiation. The major limitation of this technique is related to the variation of the position of the patient from the preoperative CT scan, usually obtained before surgery in a supine position, and the operative position (prone). The next technological evolution is the use of an intraoperative CT (iCT) scan, which would allow us to solve the position-dependent changes, granting a higher accuracy in the navigation system.

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Pedicle screw insertion in spine: a randomized controlled study for robot-assisted spinal surgery

10.29007/nbg2 ◽

2018 ◽

Cited By ~ 1

Author(s):

Wei Tian ◽

Mingxing Fan ◽

Yajun Liu

Keyword(s):

Pedicle Screw ◽

Spinal Surgery ◽

Entry Point ◽

Randomized Controlled Study ◽

Controlled Study ◽

Mean Deviation ◽

Robot Assisted ◽

Group Assessment ◽

Randomized Controlled ◽

End Point

To introduce a new robot-assisted surgical system for spinal posterior fixation which called TiRobot, based on intraoperative three-dimensional images. TiRobot has three components: the planning and navigation system, optical tracking system and robotic arm system. By combining navigation and robot techniques, TiRobot can guide the screw trajectories for orthopedic surgeries.In this randomized controlled study approved by the Ethics Committee, 40 patients were involved and all has been fully informed and sign the informed consent. 17 patients were treated by free-hand fluoroscopy-guided surgery, and 23 patients were treated by robot-assisted spinal surgery.A total of 190 pedicle screws was implanted. The overall operation time were not different for both groups. None of the screws necessitated re-surgery for revised placement. In the robot-assisted group, assessment of pedicle screw accuracy showed that 102 of 102 screws (100%) were safely placed (<2 mm, category A+B). And mean deviation in entry point was 1.70 +/- 0.83mm, mean deviation in end point was 1.84 +/- 1.04mm. In the conventional freehand group, assessment of pedicle screw accuracy showed that 87 of 88 (98.9%) were safely placed (<2 mm, category A+B), 1 screw fall in category C, mean deviation in entry point was 3.73 +/- 2.28mm, mean deviation in end point was 4.11 +/- 2.31mm.This randomized controlled study verified that robot-assisted pedicle screw placement with real-time navigation is a more accuracy and safer method, also revealed great clinical potential of robot-assisted surgery in the future.

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A biomechanical comparison of polymethylmethacrylate-reinforced and expansive pedicle and screws in pedicle-screw revisions

Acta Orthopaedica et Traumatologica Turcica ◽

10.3944/aott.2009.272 ◽

2009 ◽

Vol 43 (3) ◽

pp. 272-276 ◽

Cited By ~ 10

Author(s):

Bostan

Keyword(s):

Pedicle Screw ◽

Biomechanical Comparison

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Handmade Cement Spacer Technique for Pedicle Screw Placement in Revision Spinal Surgery

Tzu Chi Medical Journal ◽

10.1016/s1016-3190(10)60034-1 ◽

2010 ◽

Vol 22 (1) ◽

pp. 39-42

Author(s):

Wen-Chun Lu ◽

Wen-Tien Wu ◽

Tzai-Chiu Yu ◽

Ing-Ho Chen

Keyword(s):

Pedicle Screw ◽

Spinal Surgery ◽

Screw Placement ◽

Cement Spacer ◽

Pedicle Screw Placement

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Four Year Experience of Robot-Assisted Pedicle Screw Placement: An Australian Prospective Analysis

Neurosurgery ◽

10.1093/neuros/nyz310_442 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Jordan Cory ◽

Mohammed A Awad ◽

Richard G Bittar

Keyword(s):

Pedicle Screw ◽

Spinal Surgery ◽

Operative Time ◽

Length Of Hospital Stay ◽

Screw Placement ◽

Pedicle Screw Placement ◽

Robot Assisted ◽

Intraoperative Radiation ◽

Fusion Surgery ◽

Spinal Fusion Surgery

Abstract INTRODUCTION Robot-assisted surgery has emerged as an innovative and minimally-invasive technique, touted as superior to the traditional free-hand technique of pedicle screw fixation in spinal fusion surgery. Complications of misplaced pedicle screws include inadequate fixation and surgical failure requiring revision, neural injury, cerebrospinal fluid (CSF) leak, vascular injury, and facet joint trauma with sequela of adjacent segment disease. Literature reports an incidence of pedicle screw misplacement in up to 10% with free-hand technique. Robot-assisted surgery has reported superiority with increased accuracy of pedicle screw placement and reduced complication rates. This prospective multi-institutional single cohort analysis reports the outcomes in robot-assisted spinal fusion surgery in Melbourne, Australia over 4 yr. METHODS Data was prospectively collected from 2015 to 2019 from robot-assisted spinal surgeries performed by 2 surgeons across 2 institutions. Postoperative spinal computed tomography (CT) scan was compared to preoperative CT based planning to determine the accuracy of pedicle screw placement to 0.1 mm. Accurate pedicle screw placement was defined as within 2.0 mm from the target. Intraoperative radiation exposure time, operative time and length of hospital stay were also collected. RESULTS The total number of cases was 164 and the total number of screws placed was 744. Accurate pedicle screw placement was 98.65%. Average intraoperative radiation exposure time was 9.9 s. Average operative time for single-level surgery was 74 min. The average length of hospital stay was 2.4 d. CONCLUSION The authors conclude that robot-assisted pedicle screw placement is a safe and highly accurate adjunct to spinal surgery. While robot-assisted spinal surgery significantly improves patient outcomes with reduced patient morbidity and revision rates, it has limitations in primary capital expenditure, consumable costs and, in training and accreditation. It is the authors’ opinion that the robot-assisted spinal surgery technique requires nuanced patient selection and expertise in the traditional free-hand method is still essential in the event of technological failure.

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Safety and accuracy of robot-assisted versus fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery: a prospective randomized controlled trial

Journal of Neurosurgery Spine ◽

10.3171/2018.10.spine18487 ◽

2019 ◽

Vol 30 (5) ◽

pp. 615-622 ◽

Cited By ~ 24

Author(s):

Xiaoguang Han ◽

Wei Tian ◽

Yajun Liu ◽

Bo Liu ◽

Da He ◽

...

Keyword(s):

Blood Loss ◽

Hospital Stay ◽

Radiation Exposure ◽

Pedicle Screw ◽

Spinal Surgery ◽

Facet Joint ◽

Postoperative Hospital Stay ◽

Screw Placement ◽

Pedicle Screw Placement ◽

The Mean

OBJECTIVEThe object of this study was to compare the safety and accuracy of pedicle screw placement using the TiRobot system versus conventional fluoroscopy in thoracolumbar spinal surgery.METHODSPatients with degenerative or traumatic thoracolumbar spinal disorders requiring spinal instrumentation were randomly assigned to either the TiRobot-assisted group (RG) or the freehand fluoroscopy-assisted group (FG) at a 1:1 ratio. The primary outcome measure was the accuracy of screw placement according to the Gertzbein-Robbins scale; grades A and B (pedicle breach < 2 mm) were considered clinically acceptable. In the RG, discrepancies between the planned and actual screw placements were measured by merging postoperative CT images with the trajectory planning images. Secondary outcome parameters included proximal facet joint violation, duration of surgery, intraoperative blood loss, conversion to freehand approach in the RG, postoperative hospital stay, and radiation exposure.RESULTSA total of 1116 pedicle screws were implanted in 234 patients (119 in the FG, and 115 in the RG). In the RG, 95.3% of the screws were perfectly positioned (grade A); the remaining screws were graded B (3.4%), C (0.9%), and D (0.4%). In the FG, 86.1% screws were perfectly positioned (grade A); the remaining screws were graded B (7.4%), C (4.6%), D (1.4%), and E (0.5%). The proportion of clinically acceptable screws was significantly greater in the RG than in the FG (p < 0.01). In the RG, the mean deviation was 1.5 ± 0.8 mm for each screw. The most common direction of screw deviation was lateral in the RG and medial in the FG. Two misplaced screws in the FG required revision surgery, whereas no revision was required in the RG. None of the screws in the RG violated the proximal facet joint, whereas 12 screws (2.1%) in the FG violated the proximal facet joint (p < 0.01). The RG had significantly less blood loss (186.0 ± 255.3 ml) than the FG (217.0 ± 174.3 ml; p < 0.05). There were no significant differences between the two groups in terms of surgical time and postoperative hospital stay. The mean cumulative radiation time was 81.5 ± 38.6 seconds in the RG and 71.5 ± 44.2 seconds in the FG (p = 0.07). Surgeon radiation exposure was significantly less in the RG (21.7 ± 11.5 μSv) than in the FG (70.5 ± 42.0 μSv; p < 0.01).CONCLUSIONSTiRobot-guided pedicle screw placement is safe and useful in thoracolumbar spinal surgery.Clinical trial registration no.: NCT02890043 (clinicaltrials.gov)

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