Fluoroscopy for transpedicular screw placement in scoliosis: what is the best method of measuring radiation exposure?

Abstract Background The transiliac-transsacral screw placement is a clinical challenge for surgeons. This study explored a point-to-point coaxial guide apparatus assisting the transiliac-transsacral screw insertion and aimed to investigate the feasibility and accuracy of the guide apparatus in the treatment of posterior ring unstable pelvic fracture compared with a free-hand technique. Methods A retrospective study was performed to evaluate patients treated with transiliac-transsacral screws assisted by the point-to-point coaxial guide apparatus or free-hand technique. The intraoperative data of operative time and radiation exposure times were recorded. Postoperative radiographs and CT scans were performed to scrutinize the accuracy of screws position. The quality of the postoperative fracture reduction was assessed according to Matta radiology criteria. The pelvic function was assessed according to the Majeed scoring criteria at 6 months postoperatively. Results From July 2017 to December 2019, a total of 38 patients were included in this study, 20 from the point-to-point guide apparatus group and 18 from the free-hand group. There were no significant differences between the two groups in gender, age, injury causes, pelvic fracture type, screws level, and follow-up time (P > 0.05). The average operative time of the guide apparatus group for each screw was significantly less than that in the free-hand group (25.8 ± 4.7 min vs 40.5 ± 5.1, P < 0.001). The radiation exposure times were significantly lower in the guide apparatus group than that in the free-hand group (24.4 ± 6.0 vs 51.6 ± 8.4, P < 0.001). The intraosseous and juxtacortical rate of screw placement (100%) higher than in the free-hand group (94.4%). Conclusion The point-to-point coaxial guide apparatus is feasible for assisting the transiliac-transsacral screw in the treatment of posterior unstable pelvic fractures. It has the advantages of simple operation, reasonable design and no need for expensive equipment, and provides an additional surgical strategy for the insertion of the transiliac-transsacral screw.

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Navigated iliac screw placement may reduce radiation and OR time in lumbopelvic fixation of unstable complex sacral fractures

European Journal of Orthopaedic Surgery & Traumatology ◽

10.1007/s00590-021-02892-7 ◽

2021 ◽

Author(s):

M. F. Hoffmann ◽

E. Yilmaz ◽

D. C. Norvel ◽

T. A. Schildhauer

Keyword(s):

Radiation Exposure ◽

Operative Time ◽

Pelvic Ring ◽

Screw Placement ◽

Fluoroscopy Time ◽

Complication Rates ◽

Lumbopelvic Fixation ◽

Navigation Group ◽

Iliac Screws ◽

Iliac Screw

Abstract Purpose Instability of the posterior pelvic ring may be stabilized by lumbopelvic fixation. The optimal osseous corridor for iliac screw placement from the posterior superior iliac spine to the anterior inferior iliac spine requires multiple ap- and lateral-views with additional obturator-outlet and -inlet views. The purpose of this study was to determine if navigated iliac screw placement for lumbopelvic fixation influences surgical time, fluoroscopy time, radiation exposure, and complication rates. Methods Bilateral lumbopelvic fixation was performed in 63 patients. Implants were inserted as previously described by Schildhauer. A passive optoelectronic navigation system with surface matching on L4 was utilized for navigated iliac screw placement. To compare groups, demographics were assessed. Operative time, fluoroscopic time, and radiation were delineated. Results Conventional fluoroscopic imaging for lumbopelvic fixation was performed in 32 patients and 31 patients underwent the procedure with navigated iliac screw placement. No differences were found between the groups regarding demographics, comorbidities, or additional surgical procedures. Utilization of navigation led to fluoroscopy time reduction of more than 50% (3.2 vs. 8.6 min.; p < 0.001) resulting in reduced radiation (2004.5 vs. 5130.8 Gy*cm2; p < 0.001). Operative time was reduced in the navigation group (176.7 vs. 227.4 min; p = 0.002) despite the necessity of additional surface referencing. Conclusion For iliac screws, identifying the correct entry point and angle of implantation requires detailed anatomic knowledge and multiple radiographic views. In our study, additional navigation reduced operative time and fluoroscopy time resulting in a significant reduction of radiation exposure for patients and OR personnel.

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A five-step remedial screw placement method to treat severe spinal deformity with free-hand transpedicular screw placement

European Spine Journal ◽

10.1007/s00586-012-2546-y ◽

2012 ◽

Vol 22 (2) ◽

pp. 417-424 ◽

Cited By ~ 1

Author(s):

Jing-Ming Xie ◽

Zhi Zhao ◽

Hua Yang ◽

Ying-Song Wang ◽

Ying Zhang ◽

...

Keyword(s):

Spinal Deformity ◽

Screw Placement ◽

Placement Method ◽

Transpedicular Screw ◽

Severe Spinal Deformity

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Morphometry of the Thoracic and Lumbar Spine Related to Transpedicular Screw Placement for Surgical Spinal Fixation

Spine ◽

10.1097/00007632-198801000-00007 ◽

1988 ◽

Vol 13 (1) ◽

pp. 27-32 ◽

Cited By ~ 205

Author(s):

MARTIN H. KRAG ◽

DONALD L. WEAVER ◽

BRUCE D. BEYNNON ◽

LARRY D. HAUGH

Keyword(s):

Lumbar Spine ◽

Screw Placement ◽

Spinal Fixation ◽

Transpedicular Screw ◽

Thoracic And Lumbar Spine

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A Novel Augmented-Reality-Based Surgical Navigation System for Spine Surgery in a Hybrid Operating Room: Design, Workflow, and Clinical Applications

Operative Neurosurgery ◽

10.1093/ons/opz236 ◽

2019 ◽

Vol 18 (5) ◽

pp. 496-502 ◽

Cited By ~ 18

Author(s):

Erik Edström ◽

Gustav Burström ◽

Rami Nachabe ◽

Paul Gerdhem ◽

Adrian Elmi Terander

Keyword(s):

Augmented Reality ◽

Radiation Exposure ◽

Pedicle Screw ◽

Operating Room ◽

Wound Closure ◽

Surgical Navigation ◽

Pedicle Screws ◽

Screw Placement ◽

Hybrid Operating Room ◽

Pedicle Screw Placement

Abstract BACKGROUND Treatment of several spine disorders requires placement of pedicle screws. Detailed 3-dimensional (3D) anatomic information facilitates this process and improves accuracy. OBJECTIVE To present a workflow for a novel augmented-reality-based surgical navigation (ARSN) system installed in a hybrid operating room for anatomy visualization and instrument guidance during pedicle screw placement. METHODS The workflow includes surgical exposure, imaging, automatic creation of a 3D model, and pedicle screw path planning for instrument guidance during surgery as well as the actual screw placement, spinal fixation, and wound closure and intraoperative verification of the treatment results. Special focus was given to process integration and minimization of overhead time. Efforts were made to manage staff radiation exposure avoiding the need for lead aprons. Time was kept throughout the procedure and subdivided to reflect key steps. The navigation workflow was validated in a trial with 20 cases requiring pedicle screw placement (13/20 scoliosis). RESULTS Navigated interventions were performed with a median total time of 379 min per procedure (range 232-548 min for 4-24 implanted pedicle screws). The total procedure time was subdivided into surgical exposure (28%), cone beam computed tomography imaging and 3D segmentation (2%), software planning (6%), navigated surgery for screw placement (17%) and non-navigated instrumentation, wound closure, etc (47%). CONCLUSION Intraoperative imaging and preparation for surgical navigation totaled 8% of the surgical time. Consequently, ARSN can routinely be used to perform highly accurate surgery potentially decreasing the risk for complications and revision surgery while minimizing radiation exposure to the staff.

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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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Improving accuracy and reducing radiation exposure in minimally invasive lumbar interbody fusion

Journal of Neurosurgery Spine ◽

10.3171/2009.11.spine09270 ◽

2010 ◽

Vol 12 (5) ◽

pp. 533-539 ◽

Cited By ~ 33

Author(s):

Martin James Wood ◽

Richard John Mannion

Keyword(s):

Minimally Invasive ◽

Radiation Exposure ◽

Interbody Fusion ◽

Case Series ◽

Guidance System ◽

Screw Placement ◽

Invasive Technique ◽

Computer Assisted ◽

Lumbar Interbody Fusion ◽

Screw Misplacement

Object The authors assessed the accuracy of placement of lumbar transpedicular screws by using a computer-assisted, imaged-guided, minimally invasive technique with continuous electromyography (EMG) monitoring. Methods This was a consecutive case series with prospective assessment of procedural accuracy. Forty-seven consecutive patients underwent minimally invasive lumbar interbody fusion and placement of pedicle screws (PSs). A computer-assisted image guidance system involving CT-based images was used to guide screw placement, while EMG continuously monitored the lumbar nerve roots at the operated levels with a 5-mA stimulus applied through the pedicle access needle. All patients underwent CT scanning to determine accuracy of PS placement. All episodes of adjusted screw trajectory based on positive EMG responses were recorded. Pedicle screw misplacement was defined as breach of the pedicle cortex by the screw of more than 2 mm. Results Two hundred twelve PSs were inserted in 47 patients. The screw misplacement rate was 4.7%. One patient experienced new postoperative radiculopathy resulting from a sacral screw that was too long, with lumbosacral trunk impingement. The trajectory of the pedicle access needle was altered intraoperatively on 20 occasions (9.4% of the PSs) based on positive EMG responses, suggesting that nerve root impingement may have resulted from these screws had the EMG monitoring not been used. Conclusions The combination of computer-assisted navigation combined with continuous EMG monitoring during pedicle cannulation results in a low rate of PS misplacement, with avoidance of screw positions that might cause neural injury. Furthermore, this technique allows reduction of the radiation exposure for the surgical team without compromising the accuracy of screw placement.

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