Comprehensive Error Analysis for Robotic-assisted Placement of Pedicle Screws in Pediatric Spinal Deformity

Introduction: Pediatric spinal deformity involves a complex 3-dimensional (3D) deformity that increases the risk of pedicle screw placement due to the close proximity of neurovascular structures. To increase screw accuracy, improve patient safety, and minimize surgical complications, the placement of pedicle screws is evolving from freehand techniques to computer-assisted navigation and to the introduction of robotic-assisted placement. Purpose: The aim of this review was to review the current literature on the use of robotic navigation in pediatric spinal deformity surgery to provide both an error analysis of these techniques and to provide recommendations to ensure its safe application. Methods: A narrative review was conducted in April 2021 using the MEDLINE (PubMed) database. Studies were included if they were peer-reviewed retrospective or prospective studies, included pediatric patients, included a primary diagnosis of pediatric spine deformity, utilized robotic-assisted spinal surgery techniques, and reported thoracic or lumbar pedicle screw breach rates or pedicle screw malpositioning. Results: In the few studies published on the use of robotic techniques in pediatric spinal deformity surgery, several found associations between the technology and increased rates of screw placement accuracy, reduced rates of breach, and minimal complications. All were retrospective studies. Conclusions: Current literature is of a low level of evidence; nonetheless, the findings suggest the accuracy and safety of robotic-assisted spinal surgery in pediatric pedicle screw placement. The introduction of robotics may drive further advances in less invasive pediatric spinal deformity surgery. Further study is warranted.

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State of the art review of new technologies in spine deformity surgery–robotics and navigation

Spine Deformity ◽

10.1007/s43390-021-00403-6 ◽

2021 ◽

Author(s):

J. Alex Sielatycki ◽

Kristen Mitchell ◽

Eric Leung ◽

Ronald A. Lehman

Keyword(s):

Radiation Exposure ◽

Pedicle Screw ◽

Patient Outcomes ◽

Spinal Deformity ◽

Pedicle Screws ◽

Robotic Navigation ◽

Robotic Assisted ◽

Computer Based ◽

Guidance Systems ◽

And Robotics

Abstract Study design/methods Review article. Objectives The goal of this article is to review the available evidence for computerized navigation and robotics as an accuracy improvement tool for spinal deformity surgery, as well as to consider potential complications, impact on clinical outcomes, radiation exposure, and costs. Summary of background data/results Pedicle screw and rod construct are widely utilized for posterior spinal fixation in spinal deformity correction. Freehand placement of pedicle screws has long been utilized, although there is variable potential for inaccuracy depending on surgeon skill and experience. Malpositioned pedicle screws may have significant clinical implications ranging from nerve root irritation, inadequate fixation, CSF leak, perforation of the great vessels, or spinal cord damage. Computer-based navigation and robotics systems were developed to improve pedicle screw insertion accuracy and consistency, and decrease the risk of malpositioned pedicle fixation. The available evidence suggests that computer-based navigation and robotic-assisted guidance systems for pedicle cannulation are at least equivalent, and in several reports superior, to freehand techniques in terms of accuracy. CT and robotic navigation systems do appear to decrease radiation exposure to the operative team in some reports. Published reports do indicate longer operative times with use of robotic navigation compared with traditional freehand techniques for pedicle screw placement. To date, there is no conclusive evidence that use of CT or robotic navigation has any measurable impact on patient outcomes or overall complication reduction. There are theoretical advantages with robotic and CT navigation in terms of both speed and accuracy for severe spinal deformity or complex revision cases, however, there is a need for studies to investigate this technology in these specific cases. There is no evidence to date demonstrating the cost effectiveness of CT or robotic navigation as compared with traditional pedicle cannulation techniques. Conclusions The review of available evidence suggests that computer-based navigation and robotic-assisted guidance systems for pedicle cannulation are at least equivalent, and in several reports superior, to freehand techniques in terms of radiographic accuracy. There is no current clinical evidence that the use of navigation or robotic techniques leads to improved patient outcomes or decreased overall complications or reoperation rates, and the use of these systems may substantially increase surgical costs. Level of evidence V.

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Intraoperative computed tomography image–guided navigation for posterior thoracolumbar spinal instrumentation in spinal deformity surgery

Neurosurgical FOCUS ◽

10.3171/2010.1.focus09275 ◽

2010 ◽

Vol 28 (3) ◽

pp. E11 ◽

Cited By ~ 64

Author(s):

Matthew J. Tormenti ◽

Dean B. Kostov ◽

Paul A. Gardner ◽

Adam S. Kanter ◽

Richard M. Spiro ◽

...

Keyword(s):

Ct Scan ◽

Spinal Deformity ◽

Image Guidance ◽

Wound Closure ◽

Comparison Group ◽

Spinal Instrumentation ◽

Pedicle Screws ◽

Ct Scanning ◽

Intraoperative Ct ◽

Spinal Deformity Surgery

Object Placement of thoracolumbar pedicle screws in spinal deformity surgery has a reported inaccuracy rate as high as 30%. At present, image-guided navigation systems designed to improve instrumentation accuracy typically use intraoperative fluoroscopy or preoperative CT scans. The authors report the prospective evaluation of the accuracy of posterior thoracolumbar spinal instrumentation using a new intraoperative CT operative suite with an integrated image guidance system. They compare the accuracy of thoracolumbar pedicle screw placement using intraoperative CT image guidance with instrumentation placement utilizing fluoroscopy. Methods Between December 2007 and July 2008, 12 patients underwent posterior spinal instrumentation for spinal deformity correction using intraoperative CT-based image guidance. An intraoperative CT scan of the sterile surgical field was obtained after decompression and before instrumentation. Instrumentation was placed, and a postinstrumentation CT scan was obtained before wound closure to assess the accuracy of instrumentation placement and the potential need for revision. The accuracy of pedicle screw placement was later reviewed and recorded by independent observers. A comparison group of 14 patients who underwent thoracolumbar instrumentation utilizing fluoroscopy and postoperative CT scanning during the same time period was evaluated and included in this analysis. Results In the intraoperative CT-based image guidance group, a total of 164 thoracolumbar pedicle screws were placed. Two screws were found to have breached the pedicle wall (1.2%). Neither screw was deemed to need revision due to misplacement. In the comparison group, 211 pedicle screws were placed. Postoperative CT scanning revealed that 11 screws (5.2%) had breached the pedicle. One patient in the fluoroscopy group awoke with a radiculopathy attributed to a misplaced screw, which required revision. The difference in accuracy was statistically significant (p = 0.031). Conclusions Intraoperative CT-based image guidance for placement of thoracolumbar instrumentation has an accuracy that exceeds reported rates with other image guidance systems, such as virtual fluoroscopy and 3D isocentric C-arm-based stereotactic systems. Furthermore, with the use of intraoperative CT scanning, a postinstrumentation CT scan allows the surgeon to evaluate the accuracy of instrumentation before wound closure and revise as appropriate.

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Complications associated with thoracic pedicle screws in spinal deformity

European Spine Journal ◽

10.1007/s00586-010-1316-y ◽

2010 ◽

Vol 19 (9) ◽

pp. 1576-1584 ◽

Cited By ~ 51

Author(s):

Gang Li ◽

Guohua Lv ◽

Peter Passias ◽

Michal Kozanek ◽

Umesh S. Metkar ◽

...

Keyword(s):

Spinal Deformity ◽

Pedicle Screws ◽

Thoracic Pedicle Screws

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THE HISTORY OF SPINAL DEFORMITY

Neurosurgery ◽

10.1227/01.neu.0000324520.95150.4c ◽

2008 ◽

Vol 63 (suppl_3) ◽

pp. A5-A15 ◽

Cited By ~ 17

Author(s):

Robert F. Heary ◽

Karthik Madhavan

Keyword(s):

Spinal Deformity ◽

Thoracolumbar Spine ◽

Surgical Techniques ◽

Pedicle Screws ◽

First Record ◽

Surgical Approaches ◽

Spinal Deformities ◽

X Rays ◽

Rod System ◽

History Of

ABSTRACT SPINAL DEFORMITY IS the oldest disease known to humankind. The first record of correction of spinal deformity was documented in an Indian religious mythological book written between 3500 BC and 1800 BC. Initially, all spinal deformities were treated with the use of braces, traction, or casts. Hippocrates was the first physician to treat spinal deformities by using axial traction combined with direct pressure. Galen specifically described the anatomy of the spine and spinal nerves. The treatment of spinal deformity was greatly improved by the development of radiographic imaging by Roentgen. After x-rays became available, spinal fusions began to be used to treat scoliotic curves. Hibbs described the first spinal fusion to stabilize a deformed tuberculous spine. Soon enough, other investigators began to report on a variety of surgical techniques used to treat spinal deformity. Surgical approaches from both the posterior and anterior directions were developed and modified in an attempt to achieve durable curve corrections. Harrington's distraction rod system was a major innovation in providing a method to improve coronal plane deformity. Luque introduced segmental instrumentation, which opened up the era of modern surgical techniques for spinal deformity. This concept allowed surgeons to begin to achieve three-dimensional corrections by respecting both the sagittal and coronal curves simultaneously. The introduction of pedicle screws, throughout the thoracolumbar spine, has increased the ability of surgeons to achieve greater degrees of curve correction than had previously been possible. The history of spinal deformity is still maturing as newer procedures continue to be performed on a daily basis.

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Thoracic pedicle screw fixation for spinal deformity

Neurosurgical FOCUS ◽

10.3171/foc.2003.14.1.8 ◽

2003 ◽

Vol 14 (1) ◽

pp. 1-6 ◽

Cited By ~ 13

Author(s):

Michael K. Rosner ◽

David W. Polly ◽

Timothy R. Kuklo ◽

Stephen L. Ondra

Keyword(s):

Spinal Deformity ◽

Screw Fixation ◽

Pedicle Screws ◽

Pedicle Screw Fixation ◽

Thoracic Pedicle Screw ◽

Transpedicular Screw ◽

Thoracic Pedicle Screws ◽

Spinal Deformity Surgery ◽

Minimum Number ◽

Transpedicular Screw Fixation

Techniques to improve segmental fixation have advanced the ability to correct complex spinal deformity. The purpose of instrumentation is to correct spinal deformity or to stabilize the spine to enhance the long-term biological fusion. The ultimate goal of spinal deformity surgery is the creation of a stable, balanced, pain-free spine centered over the pelvis in the coronal and sagittal planes. The minimum number of segments should be fused. These concepts remain challenging in the setting of deformity and instability. Successful results can be obtained if the surgeon understands the technology available, its capabilities, biological limitations, and the desired solution. The authors prefer to use thoracic pedicle screws when treating patients with spinal deformity because they provide greater corrective forces for realignment. This allows shorter-segment constructs and the possibility of true derotation in correction. In this article the authors focus on the use of thoracic transpedicular screw fixation in the management of complex spinal disorders and deformity.

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The lexicon of multirod constructs in adult spinal deformity: a concise description of when, why, and how

Journal of Neurosurgery Spine ◽

10.3171/2021.10.spine21745 ◽

2021 ◽

pp. 1-7

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Pedicle Screws ◽

Lumbosacral Junction ◽

Coronal Balance ◽

Clinical Scenarios ◽

Iliac Screw ◽

Correction Surgery ◽

Rod Fracture ◽

Concise Description

The use of multirod constructs in the setting of adult spinal deformity (ASD) began to prevent rod fracture and pseudarthrosis near the site of pedicle subtraction osteotomies (PSOs) and 3-column osteotomies (3COs). However, there has been unclear and inconsistent nomenclature, both clinically and in the literature, for the various techniques of supplemental rod implantation. In this review the authors aim to provide the first succinct lexicon of multirod constructs available for the treatment of ASD, providing a universal nomenclature and definition for each type of supplementary rod. The primary rod of ASD constructs is the longest rod that typically spans from the bottom of the construct to the upper instrumented vertebrae. The secondary rod is shorter than the primary rod, but is connected directly to pedicle screws, albeit fewer of them, and connects to the primary rod via lateral connectors or cross-linkers. Satellite rods are a 4-rod technique in which 2 rods span only the site of a 3CO via pedicle screws at the levels above and below, and are not connected to the primary rod (hence the term “satellite”). Accessory rods are connected to the primary rods via side connectors and buttress the primary rod in areas of high rod strain, such as at a 3CO or the lumbosacral junction. Delta rods span the site of a 3CO, typically a PSO, and are not contoured to the newly restored lordosis of the spine, thus buttressing the primary rod above and below a 3CO. The kickstand rod itself functions as an additional means of restoring coronal balance and is secured to a newly placed iliac screw on the side of truncal shift and connected to the primary rod; distracting against the kickstand then helps to correct the concavity of a coronal curve. The use of multirod constructs has dramatically increased over the last several years in parallel with the increasing prevalence of ASD correction surgery. However, ambiguity persists both clinically and in the literature regarding the nomenclature of each supplemental rod. This nomenclature of supplemental rods should help unify the lexicon of multirod constructs and generalize their usage in a variety of scientific and clinical scenarios.

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Sublaminar banding as an adjunct to pedicle screw-rod constructs: a review and technical note on novel hybrid constructs in spinal deformity surgery

Journal of Neurosurgery Spine ◽

10.3171/2018.11.spine181154 ◽

2019 ◽

Vol 30 (6) ◽

pp. 807-813

Author(s):

Vibhu K. Viswanathan ◽

Amy J. Minnema ◽

Stephanus Viljoen ◽

H. Francis Farhadi

Keyword(s):

Pedicle Screw ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Relevant Literature ◽

Case Series ◽

Deformity Correction ◽

Pedicle Screws ◽

Technical Note ◽

Mineral Density ◽

Bone Contact

Sublaminar implants that encircle cortical bone are well-established adjuncts to pedicle screw-rod constructs in pediatric deformity surgery. Sublaminar bands (SLBs) in particular carry the advantage of relatively greater bone contact surface area as compared to wires and pullout loads that are independent of bone mineral density, in contrast to pedicle screws. Whereas the relevant technical considerations have been reported for pediatric deformity correction, an understanding of the relative procedural specifics of these techniques is missing for adult spinal deformity (ASD), despite several case series that have used distinct posterior tethering techniques for proximal junctional kyphosis prevention. In this paper, the authors summarize the relevant literature and describe a novel technique wherein bilateral tensioned SLBs are introduced at the nonfused proximal junctional level of long-segment ASD constructs.

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The Accuracy of 3D Printing Assistance in the Spinal Deformity Surgery

BioMed Research International ◽

10.1155/2019/7196528 ◽

2019 ◽

Vol 2019 ◽

pp. 1-9

Author(s):

Po-Chen Chen ◽

Chien-Chun Chang ◽

Hsien-Te Chen ◽

Chia-Yu Lin ◽

Tsung-Yu Ho ◽

...

Keyword(s):

3D Printing ◽

Pedicle Screw ◽

Spinal Deformity ◽

Deformity Correction ◽

Pedicle Screws ◽

Evoke Potential ◽

Printing Technology ◽

3D Printing Technology ◽

Spinal Deformity Surgery ◽

Correction Surgery

Background. The pedicle screw is one of the main tools used in spinal deformity correction surgery. Robotic and navigated surgeries are usually used, and they provide superior accuracy in pedicle screw placement than free-hand and fluoroscopy-guided techniques. However, their high cost and space limitation are problematic. We provide a new solution using 3D printing technology to facilitate spinal deformity surgery. Methods. A workflow was developed to assist spinal deformity surgery using 3D printing technology. The trajectory and profile of pedicle screws were determined on the image system by the surgical team. The engineering team designed drill templates based on the bony surface anatomy and the trajectory of pedicle screws. Their effectiveness and safety were evaluated during a preoperative simulation surgery. The surgery consisted in making a pilot hole through the drill template on a computed tomography- (CT-) based, full-scale 3D spine model for every planned segment. Somatosensory evoke potential (SSEP) and motor evoke potential (MEP) were used for intraoperative neurophysiological monitoring. Postoperative CT was obtained 6 months after the correction surgery to confirm the screw accuracy. Results. From July 2015 to November 2016, we performed 10 spinal deformity surgeries with 3D printing technology assistance. In total, 173 pedicle screws were implanted using drill templates. No notable change in SSEP and MEP or neurologic deficit was noted. Based on postoperative CT scans, the acceptable rate was 97.1% (168/173). We recorded twelve pedicle screws with medial breach, six with lateral breach, and five with inferior breach. Medial breach (12/23) was the main type of penetration. Lateral breach occurred mostly in the concave side (5/6). Most penetrations occurred above the T8 level (69.6%, 16/23). Conclusion. 3D printing technology provides an effective alternative for spinal deformity surgery when expensive medical equipment, such as intraoperative navigation and robotic systems, is unavailable.

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