Intraoperative computed tomography image–guided navigation for posterior thoracolumbar spinal instrumentation in 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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The Use of Skin Staples as Fiducial Markers to Confirm Intraoperative Spinal Navigation Registration and Accuracy

Operative Neurosurgery ◽

10.1093/ons/opab132 ◽

2021 ◽

Author(s):

Christopher Alvarez-Breckenridge ◽

Matthew Muir ◽

Laurence D Rhines ◽

Claudio E Tatsui

Keyword(s):

Minimally Invasive ◽

Ct Scan ◽

Image Guidance ◽

Low Cost ◽

Spinal Instrumentation ◽

Fiducial Marker ◽

Intraoperative Ct ◽

Intraoperative Computed Tomography ◽

Skin Staples ◽

Spinal Navigation

Abstract BACKGROUND With the advent of intraoperative computed tomography (CT) for image guidance, numerous examples of accurate navigation being applied to cranial and spinal pathology have come to light. For spinal disorders, the utilization of image guidance for the placement of percutaneous spinal instrumentation, complex osteotomies, and minimally invasive approaches are frequently utilized in trauma, degenerative, and oncological pathologies. The use of intraoperative CT for navigation, however, requires a low target registration error that must be verified throughout the procedure to confirm the accuracy of image guidance. OBJECTIVE To present the use of skin staples as a sterile, economical fiducial marker for minimally invasive spinal procedures requiring intraoperative CT navigation. METHODS Staples are applied to the skin prior to obtaining the registration CT scan and maintained throughout the remainder of the surgery to facilitate confirmation of image guidance accuracy. RESULTS This low-cost, simple, sterile approach provides surface landmarks that allow reliable verification of navigation accuracy during percutaneous spinal procedures using intraoperative CT scan image guidance. CONCLUSION The utilization of staples as a fiducial marker represents an economical and easily adaptable technique for ensuring accuracy of image guidance with intraoperative CT navigation.

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Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws

Journal of Neurosurgery Spine ◽

10.3171/2014.5.spine13567 ◽

2014 ◽

Vol 21 (3) ◽

pp. 320-328 ◽

Cited By ~ 24

Author(s):

Mohamad Bydon ◽

Risheng Xu ◽

Anubhav G. Amin ◽

Mohamed Macki ◽

Paul Kaloostian ◽

...

Keyword(s):

Lumbar Spine ◽

Pedicle Screw ◽

Spinal Instrumentation ◽

Pedicle Screws ◽

Ct Scanning ◽

Screw Placement ◽

Cervical Region ◽

Consecutive Series ◽

Pedicle Screw Placement ◽

Intraoperative Ct

Object A number of imaging techniques have been introduced to minimize the risk of pedicle screw placement. Intraoperative CT has been recently introduced to assist in spinal instrumentation. The aim of this study was to study the effectiveness of intraoperative CT in enhancing the safety and accuracy of pedicle screw placement. Methods The authors included all cases from December 2009 through July 2012 in which intraoperative CT scanning was used to confirm pedicle screw placement. Results A total of 203 patients met the inclusion criteria. Of 1148 screws, 103 screws (8.97%) were revised intraoperatively in 72 patients (35.5%): 14 (18.42%) were revised in the cervical spine (C-2 or C-7), 25 (7.25%) in the thoracic spine, and 64 (8.80%) in the lumbar spine. Compared with screws in the thoracic and lumbar regions, pedicle screws placed in the cervical region were statistically more likely to be revised (p = 0.0061). Two patients (0.99%) required reoperations due to undetected misplacement of pedicle screws. Conclusions The authors describe one of the first North American experiences using intraoperative CT scanning to confirm the placement of pedicle screws. Compared with a similar cohort of patients from their institution who had pedicle screws inserted via the free-hand technique with postoperative CT, the authors found that the intraoperative CT lowers the threshold for pedicle screw revision, resulting in a statistically higher rate of screw revision in the thoracic and lumbar spine (p < 0.0001). During their 2.5-year experience with the intraoperative CT, the authors did not find a reduction in rates of reoperation for misplaced pedicle screws.

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Free hand insertion of pedicle screws in Dorsal / Lumbar / Sacral spine – Our experience

Nepal Orthopaedic Association Journal ◽

10.3126/noaj.v2i1.8138 ◽

2013 ◽

Vol 2 (1) ◽

pp. 35-42

Author(s):

B Bijukachhe ◽

BK Shrestha ◽

JR Pandey ◽

AK Banskota

Keyword(s):

Ct Scan ◽

Wound Closure ◽

Pedicle Screws ◽

Image Intensifier ◽

Fluoroscopic Guidance ◽

Dorsal Region ◽

Surgical Time ◽

Time Saving ◽

Scheuermann’S Kyphosis

Background: Fluoroscopic guidance to put pedicle screws helps to confirm the accuracy of the screw in place; however, it is always not mandatory Methods: In 79 patients, 531 pedicle screws were inserted during a period between July 2006 and November 2009. There were 218 pedicle screws in trauma, 138 in TB spine, 107 in Scoliosis, 26 in Scheuermann’s kyphosis, 18 in Spondylolysis / spondylolisthesis and 24 in tumors. In lumbar / sacral region total of 140 screws and in Dorsal region 391 screws were introduced. All screws were inserted free hand without fluoroscopic guidance. Accuracy of the placement was checked per operatively with pedicle probe by sounding technique. Before wound closure and whenever in doubt position of screws was checked under fluoroscope. Post operatively patients were subjected for CT scan to confirm the position of the screws. Seventeen patients with 107 screws were excluded from the study since they were not subjected for post-operative CT scan. The study consisted of 424 pedicle screws in 62 patients. Results: Out of 424 pedicle screws four screws (0.9%) were misplaced. Three patients complained of dysesthesia. Eleven screws (2.5%) were broken at last follow up of 12.6 months. The average surgical time for insertion of the screw without image intensifier is four minutes whereas with image intensifier was 7.5 minutes. Conclusion: Free hand insertion of pedicle screws is safe and time saving. DOI: http://dx.doi.org/10.3126/noaj.v2i1.8138 Nepal Orthopaedic Association Journal Vol.2(1) 2011: 35-42

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Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort

Journal of Neurosurgery Spine ◽

10.3171/2008.10.spi08383 ◽

2009 ◽

Vol 10 (1) ◽

pp. 33-39 ◽

Cited By ~ 108

Author(s):

Eric W. Nottmeier ◽

Will Seemer ◽

Phillip M. Young

Keyword(s):

Revision Surgery ◽

Nerve Root ◽

Image Guidance ◽

Three Dimensional ◽

Pedicle Screws ◽

Ct Scanning ◽

3D Image ◽

Nerve Root Injury ◽

Large Patient ◽

Root Injury

Object The goal of this study was to analyze the placement accuracy and complications of thoracolumbar pedicle screws (PSs) inserted using 3D image guidance in a large patient cohort. Methods The authors reviewed the charts of 220 consecutive patients undergoing posterior spinal fusion using 3D image guidance for instrumentation placement. A total of 1084 thoracolumbar PSs were placed using either the BrainLAB Vector Vision (BrainLAB, Inc.) or Medtronic StealthStation Treon (Medtronic, Inc.) image guidance systems. Postoperative CT scanning was performed in 184 patients, allowing for 951 screws to be graded by an independent radiologist for bone breach. All complications resulting from instrumentation placement were noted. Using the intraoperative planning function of the image-guided system, the largest diameter screw possible in each particular case was placed. The screw diameter of instrumentation placed into the L3–S1 levels was noted. Results No vascular or visceral complications occurred as a result of screw placement. Two nerve root injuries occurred in 1084 screws placed, resulting in a 0.2% per screw incidence and a 0.9% patient incidence of nerve root injury. Neither nerve root injury was associated with a motor deficit. The breach rate was 7.5%. Grade 1 and minor anterolateral “tip out” breaches accounted for 90% of the total breaches. Patients undergoing revision surgery accounted for 46% of the patients in this study. Accordingly, 154 screws placed through previous fusion mass could be evaluated using postoperative CT scanning. The breach rate in this specific cohort was 7.8%. A total of 765 PSs were placed into the L3–S1 levels in this study; 546 (71%) of these screws were ≥ 7.5 mm in diameter. No statistical difference in breach rate was noted in PSs placed through revision spinal levels versus nonrevision spinal levels (p = 0.499). Additionally, no increase in breach rate was noted with placement of 7.5-mm-diameter screws. Conclusions Three-dimensional image guidance is a useful adjunct to placement of spinal instrumentation. The complication rate in this study was low, and accurate placement of instrumentation was achieved despite the high percentage of revision surgery cases in our patient population. Additionally, because active fluoroscopy was not used for instrumentation placement, there was minimal to no radiation exposure to the surgeon or operating room staff.

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Percutaneous Iliac Screws for Minimally Invasive Spinal Deformity Surgery

Minimally Invasive Surgery ◽

10.1155/2012/173685 ◽

2012 ◽

Vol 2012 ◽

pp. 1-6 ◽

Cited By ~ 2

Author(s):

Michael Y. Wang

Keyword(s):

Blood Loss ◽

Minimally Invasive ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Intraoperative Complications ◽

Ct Scanning ◽

Iliac Screws ◽

Fusion Site ◽

Spinal Deformity Surgery ◽

The Mean

Introduction. Adult spinal deformity (ASD) surgeries carry significant morbidity, and this has led many surgeons to apply minimally invasive surgery (MIS) techniques to reduce the blood loss, infections, and other peri-operative complications. A spectrum of techniques for MIS correction of ASD has thus evolved, most recently the application of percutaneous iliac screws.Methods. Over an 18 months 10 patients with thoracolumbar scoliosis underwent MIS surgery. The mean age was 73 years (70% females). Patients were treated with multi-level facet osteotomies and interbody fusion using expandable cages followed by percutaneous screw fixation. Percutaneous iliac screws were placed bilaterally using the obturator outlet view to target the ischial body.Results. All patients were successfully instrumented without conversion to an open technique. Mean operative time was 302 minutes and the mean blood loss was 480 cc, with no intraoperative complications. A total of 20 screws were placed successfully as judged by CT scanning to confirm no bony violations. Complications included: two asymptomatic medial breaches at T10 and L5, and one patient requiring delayed epidural hematoma evacuation.Conclusions. Percutaneous iliac screws can be placed safely in patients with ASD. This MIS technique allows for successful caudal anchoring to stress-shield the sacrum and L5-S1 fusion site in long-segment constructs.

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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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Combined Image Guidance and Intraoperative Computed Tomography in Facilitating Endoscopic Orientation within and around the Paranasal Sinuses

American Journal of Rhinology ◽

10.2500/ajr.2008.22.3242 ◽

2008 ◽

Vol 22 (6) ◽

pp. 635-641 ◽

Cited By ~ 21

Author(s):

Sarah K. Wise ◽

Richard J. Harvey ◽

John C. Goddard ◽

Patrick O. Sheahan ◽

Rodney J. Schlosser

Keyword(s):

Computed Tomography ◽

Ct Scan ◽

Paranasal Sinus ◽

Image Guidance ◽

Sinus Surgery ◽

Intraoperative Ct ◽

Intraoperative Computed Tomography ◽

Significant Difference ◽

Preoperative Ct ◽

Anatomic Region

Background The utility of image guidance (image-guided surgery [IGS]) and intraoperative computed tomography (CT) scanning as a tool for less experienced endoscopic surgeons to aid in localization of paranasal sinus and skull base anatomic structures was evaluated. Methods Partial endoscopic dissection was performed on cadaver specimens by three fellowship trained rhinologists. Anatomic sites within and around the sinuses were tagged with radio-opaque markers. Otolaryngology residents identified tagged anatomic sites using four successive levels of technology: endoscopy alone (simulating outpatient clinic), endoscopy plus preoperative CT (simulating endoscopic sinus surgery [ESS] without IGS), endoscopy plus IGS registered to preoperative CT (simulating current ESS with IGS), and endoscopy plus IGS registered to real-time intraoperative CT. Responses were graded as follows: consensus rhinologist answer (4 points), close answer without clinically significant difference (3 points), within anatomic region but definite clinical difference (2 points), outside of anatomic region (1 point), no answer (0 points). Results Eleven residents participated. Of 20 specific anatomic sites, IGS-intraoperative CT provided the most accurate anatomic identification at 16 sites. For 8 sites, IGS-intraoperative CT had a significantly higher score than endoscopy alone (p < 0.05; eta2 = 0.29-0.67). For 6 sites, IGS-preoperative CT scan had a significantly higher score than endoscopy alone (p < 0.05; eta2 = 0.30-0.67). All participants found that IGS-intraoperative CT scan made them most comfortable in identifying anatomy. Conclusion Combined IGS and intraoperative CT scan technology may be an instructional adjunct for less experienced paranasal sinus surgeons for dissection and evaluation of unfamiliar or distorted anatomy.

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Does intraoperative CT navigation increase the accuracy of pedicle screw placement in pediatric spinal deformity surgery? A systematic review and meta-analysis

Spine Deformity ◽

10.1007/s43390-021-00385-5 ◽

2021 ◽

Author(s):

Keith D. Baldwin ◽

Manasa Kadiyala ◽

Divya Talwar ◽

Wudbhav N. Sankar ◽

John M. Flynn ◽

...

Keyword(s):

Systematic Review ◽

Pedicle Screw ◽

Spinal Deformity ◽

Meta Analysis ◽

Screw Placement ◽

Pedicle Screw Placement ◽

Intraoperative Ct ◽

Spinal Deformity Surgery

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Idiopathic intracranial hypertension following spinal deformity surgery in children

Neurosurgical FOCUS ◽

10.3171/2011.7.focus11160 ◽

2011 ◽

Vol 31 (4) ◽

pp. E20 ◽

Cited By ~ 3

Author(s):

Justin Kunes ◽

George H. Thompson ◽

Sunil Manjila ◽

Connie Poe-Kochert ◽

Alan R. Cohen

Keyword(s):

Intracranial Hypertension ◽

Spinal Deformity ◽

Idiopathic Intracranial Hypertension ◽

Spinal Instrumentation ◽

Deformity Correction ◽

Aminocaproic Acid ◽

Orthopedic Surgeons ◽

Estimated Blood Loss ◽

Spinal Deformity Surgery ◽

Venous Outflow Obstruction

Idiopathic intracranial hypertension (IIH) after pediatric spinal deformity surgery has not been previously reported. The authors conducted a retrospective analysis of more than 1500 pediatric spinal surgeries performed between 1992 and 2011. From their analysis, they report on 3 adolescent patients who underwent uncomplicated segmental spinal instrumentation for pediatric spinal deformity correction and subsequently developed features of IIH. The common variables in these 3 patients were adolescent age, spinal deformity, being overweight, symptom onset within 2 weeks postoperatively, significant estimated blood loss, and intraoperative use of ε–aminocaproic acid (antifibrinolytic) injection. The authors postulate that the development of IIH could be the result of venous outflow obstruction due to derangement of the epidural venous plexus during surgery. The use of ε–aminocaproic acid could potentially have the risk of causing IIH, probably mediated through hyperfibrinogenemia, although there have not been published cases in the neurosurgical, orthopedic, cardiac, or general surgical literature. Idiopathic intracranial hypertension after spinal deformity correction is a condition that should be recognized by neurosurgeons and orthopedic surgeons, because appropriate intervention with early medical therapy can lead to a satisfactory clinical outcome.

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