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Assessing intraoperative pedicle screw placement accuracy using biplanar radiographs compared to three-dimensional imaging

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Abstract

To date, biplanar imaging (2D) has been the method of choice for pedicle screw (PS) positioning and verified for the anteroposterior view and (spinal midline) M-line method. In recent years, the use of intraoperative three-dimensional (3D) imaging has become available with the Gertzbein–Robbins system (GRS) to assess PS breach and positioning confirmation. The aim is to determine if 2D imaging is sufficient to assess PS position in comparison to advanced 3D imaging.

Retrospective review of prospectively collected data from 204 consecutive adult patients who underwent posterior thoracic and lumbar instrumented fusion for degenerative spinal surgery by a single surgeon (2019–2022).

Of the 204 patients, 187 (91.6%) had intraoperative images available for analysis. A total of 1044 PS implants were used; 922 (88.3%) were robotically placed. Postoperative CT scans were verified with M-line/GRS findings. Among 103 patients (50.5%) with a total of 362 screws, (34.7%) had postoperative CT, intraoperative 3D scan, and intraoperative 2D scan for analysis. Postoperative CT findings were consistent with all GRS findings, validating that 3D imaging was accurate. Screws (1%) were falsely verified by the M-line as 3D imaging confirmed false negative or positive findings.

In our series, intraoperative 3D scan was as accurate as postoperative CT scan in assessing PS breach. A significant number of PS may be falsely read as accurate on 2D imaging, that is in fact inaccurate when assessed on 3D imaging. An intraoperative post-instrumentation 3D scan may be preferable to prevent postoperative recognition of a falsely verified screw on biplanar imaging.

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Data availability

The data that support the findings of this study are available from the corresponding author, DRL, upon reasonable request.

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Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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Authors and Affiliations

  1. Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    George Gorgy, Fedan Avrumova, Philip K. Paschal, Gregory K. Paschal & Darren R. Lebl

  2. Department of Radiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    John A. Carrino

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  1. George Gorgy
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  2. Fedan Avrumova
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  4. Gregory K. Paschal
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Contributions

GG, FA, and DRL contributed to the study conception and design. Material preparation, data collection, and analysis were performed by GG and FA. The first draft of the manuscript was written by GG and FA and all authors commented on previous versions of the manuscript. GG and FA prepared all figures and tables. All authors read and approved the final manuscript. Conceptualization: FA, JAC, DRL. Data Curation: GG, FA, PKP, GKP. Formal Analysis: GG, FA, JAC. Investigation: All authors. Methodology: DRL, FA, JAC. Project Administration: FA. Resources: DRL, FA. Validation: All authors. Writing—original draft: GG, FA, DRL. Writing—review and editing: All authors.

Corresponding author

Correspondence to Darren R. Lebl.

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Conflict of interest

GG, FA, PKP, and GKP do not have any conflicts of interest to disclose. JAC reports being a Governing Board Member for the American College of Rheumatology (ACR), the International Society of Osteoarthritis Imaging, and the Radiology Society of North America. JAC reports to be a consultant for AstraZeneca, Covera Health, Eli Lilly & Company, Globus Medical, Inc., Pfizer, and Regeneron Pharmaceuticals, Inc. DRL reports royalties from Stryker, royalties from NuVasive, ownership interest from Woven Orthopedic Technologies, ownership interest from Viseon, Inc, ownership interest from Vestia Ventures MiRus Investment LLC, ownership interest from ISPH II, LLC, ownership interest from HS2, LLC, ownership interest from Remedy Logic, on the advisory board for Remedy Logic, on the advisory board for Choice Spine, a consultant for Choice Spine, a consultant for Depuy Synthes and a consultant for Viseon, Inc outside the submitted work.

Ethical approval

Ethical approval was obtained from the Institutional Review Board at the Hospital for Special Surgery (IRB#2019-1402). The study was conducted in accordance with the Declaration of Helsinki. Approval was granted by the Ethics Committee at the Hospital for Special Surgery (2019-1402).

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The participants did not need to give informed consent in addition to routine informed consent procedures.

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Gorgy, G., Avrumova, F., Paschal, P.K. et al. Assessing intraoperative pedicle screw placement accuracy using biplanar radiographs compared to three-dimensional imaging. J Robotic Surg 18, 68 (2024). https://doi.org/10.1007/s11701-023-01760-2

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