Accuracy and revision rate of intraoperative computed tomography point-to-point navigation for lateral mass and pedicle screw placement: 11-year single-center experience in 1054 patients

  • Basem Ishak
  • Alexander Younsi
  • Carola Wieckhusen
  • Paula Slonczewski
  • Andreas W. Unterberg
  • Karl L. Kiening
Original Article


High accuracy in intraoperative computed tomography (iCT) navigation utilizing an intraoperatively acquired dataset for screw placement in the spine has been reported in the literature. To further improve the accuracy and counteract any intraoperative movement of predefined registration points, we introduce an iCT point-to-point navigation, where marker screws are inserted intraoperatively to increase patient safety. In all, 1054 patients who underwent iCT point-to-point navigation for lateral mass and pedicle screw placement were retrospectively analyzed between 09/2005 and 09/2016. Implant-related complications such as screw misplacement, screw loosening, and revision rate were determined. Furthermore, we investigated the rate of complications and the clinical outcome. In total, 6059 screws were inserted in 1054 patients. There were 553 (52.5%) female and 501 (47.5%) male patients. Average age was 63.5 years, mean BMI 27.5 (SD 13.9). Here, 1427 (23.5%) screws were inserted in the cervical, 995 (16.4%) in the thoracic, 3167 (52.3%) in the lumbar, and 470 (7.8%) in the sacral spine. Eight patients required a revision procedure for screw misplacement (0.8%). Total screw misplacement rate was 0.3% (16/6059). With the use of reference markers in iCT-based, spinal, point-to-point navigation, we achieved a high accuracy of screw placement with a low revision rate (0.8%) and a total screw misplacement rate of 0.3%.


Intraoperative CT Computer-assisted spinal surgery Point-to-point navigation Spinal instrumentation 



The authors of this study would like to thank Sherryl Sundell for language editing and proofreading the manuscript. Special thanks also go to Klaus Zweckberger, Jan Oliver Neumann, Daniel Hertle, Patrick Schiebel, Berk Orakcioglu, Oliver Sakowitz, Daniel Haux, and Martin Volz.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the local ethical committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This retrospective study was approved by the Ethics Committee of the Heidelberg University Medical School (No. S-723/2017).

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Acikbas SC, Arslan FY, Tuncer MR (2003) The effect of transpedicular screw misplacement on late spinal stability. Acta Neurochir 145:949–954; discussion 954-945. CrossRefGoogle Scholar
  2. 2.
    Amiot LP, Lang K, Putzier M, Zippel H, Labelle H (2000) Comparative results between conventional and computer-assisted pedicle screw installation in the thoracic, lumbar, and sacral spine. Spine 25:606–614CrossRefGoogle Scholar
  3. 3.
    Aota Y, Kumano K, Hirabayashi S (1995) Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord 8:464–473CrossRefGoogle Scholar
  4. 4.
    Belmont PJ Jr, Klemme WR, Dhawan A, Polly DW Jr (2001) In vivo accuracy of thoracic pedicle screws. Spine 26:2340–2346CrossRefGoogle Scholar
  5. 5.
    Bergeson RK, Schwend RM, DeLucia T, Silva SR, Smith JE, Avilucea FR (2008) How accurately do novice surgeons place thoracic pedicle screws with the free hand technique? Spine 33:E501–E507. CrossRefGoogle Scholar
  6. 6.
    Castro WH, Halm H, Jerosch J, Malms J, Steinbeck J, Blasius S (1996) Accuracy of pedicle screw placement in lumbar vertebrae. Spine 21:1320–1324CrossRefGoogle Scholar
  7. 7.
    Costa F, Cardia A, Ortolina A, Fabio G, Zerbi A, Fornari M (2011) Spinal navigation: standard preoperative versus intraoperative computed tomography data set acquisition for computer-guidance system: radiological and clinical study in 100 consecutive patients. Spine 36:2094–2098. CrossRefGoogle Scholar
  8. 8.
    Czabanka M, Haemmerli J, Hecht N, Foehre B, Arden K, Liebig T, Woitzik J, Vajkoczy P (2017) Spinal navigation for posterior instrumentation of C1-2 instability using a mobile intraoperative CT scanner. J Neurosurg Spine 27:268–275. CrossRefGoogle Scholar
  9. 9.
    Dea N, Fisher CG, Batke J, Strelzow J, Mendelsohn D, Paquette SJ, Kwon BK, Boyd MD, Dvorak MF, Street JT (2016) Economic evaluation comparing intraoperative cone beam CT-based navigation and conventional fluoroscopy for the placement of spinal pedicle screws: a patient-level data cost-effectiveness analysis. Spine J 16:23–31. CrossRefGoogle Scholar
  10. 10.
    Eftekhar B, Ghodsi M, Ketabchi E, Rasaee S (2002) Surgical simulation software for insertion of pedicle screws. Neurosurgery 50:222–223 discussion 223-224Google Scholar
  11. 11.
    Fichtner J, Hofmann N, Rienmuller A, Buchmann N, Gempt J, Kirschke JS, Ringel F, Meyer B, Ryang YM (2018) Revision rate of misplaced pedicle screws of the thoracolumbar spine-comparison of three-dimensional fluoroscopy navigation with freehand placement: a systematic analysis and review of the literature. World Neurosurg 109:e24–e32. CrossRefGoogle Scholar
  12. 12.
    Fu TS, Wong CB, Tsai TT, Liang YC, Chen LH, Chen WJ (2008) Pedicle screw insertion: computed tomography versus fluoroscopic image guidance. Int Orthop 32:517–521. CrossRefGoogle Scholar
  13. 13.
    Gaines RW Jr (2000) The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Joint Surg Am 82-A:1458–1476CrossRefGoogle Scholar
  14. 14.
    Gautschi OP, Schatlo B, Schaller K, Tessitore E (2011) Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: a literature review of 35,630 pedicle screws. Neurosurg Focus 31:E8. CrossRefGoogle Scholar
  15. 15.
    Gelalis ID, Paschos NK, Pakos EE, Politis AN, Arnaoutoglou CM, Karageorgos AC, Ploumis A, Xenakis TA (2012) Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J 21:247–255. CrossRefGoogle Scholar
  16. 16.
    Gertzbein SD, Robbins SE (1990) Accuracy of pedicular screw placement in vivo. Spine 15:11–14CrossRefGoogle Scholar
  17. 17.
    Hecht N, Yassin H, Czabanka M, Fohre B, Arden K, Liebig T, Vajkoczy P (2018) Intraoperative computed tomography versus 3D C-arm imaging for navigated spinal instrumentation. Spine 43:370–377. CrossRefGoogle Scholar
  18. 18.
    Helm PA, Teichman R, Hartmann SL, Simon D (2015) Spinal navigation and imaging: history, trends, and future. IEEE Trans Med Imaging 34:1738–1746. CrossRefGoogle Scholar
  19. 19.
    Hicks JM, Singla A, Shen FH, Arlet V (2010) Complications of pedicle screw fixation in scoliosis surgery: a systematic review. Spine 35:E465–E470. CrossRefGoogle Scholar
  20. 20.
    Hodges SD, Eck JC, Newton D (2012) Analysis of CT-based navigation system for pedicle screw placement. Orthopedics 35:e1221–e1224. CrossRefGoogle Scholar
  21. 21.
    Ishak B, Schneider T, Gimmy V, Unterberg AW, Kiening KL (2017) Early complications, morbidity, and mortality in octogenarians and nonagenarians undergoing posterior intra-operative spinal navigation-based C1/2 fusion for type II odontoid process fractures. J Neurotrauma 34:3326–3335. CrossRefGoogle Scholar
  22. 22.
    Jin M, Liu Z, Liu X, Yan H, Han X, Qiu Y, Zhu Z (2016) Does intraoperative navigation improve the accuracy of pedicle screw placement in the apical region of dystrophic scoliosis secondary to neurofibromatosis type I: comparison between O-arm navigation and free-hand technique. Eur Spine J 25:1729–1737. CrossRefGoogle Scholar
  23. 23.
    Jones EL, Heller JG, Silcox DH, Hutton WC (1997) Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine 22:977–982CrossRefGoogle Scholar
  24. 24.
    Klein S, Whyne CM, Rush R, Ginsberg HJ (2009) CT-based patient-specific simulation software for pedicle screw insertion. J Spinal Disord Tech 22:502–506. CrossRefGoogle Scholar
  25. 25.
    Kosmopoulos V, Schizas C (2007) Pedicle screw placement accuracy: a meta-analysis. Spine 32:E111–E120. CrossRefGoogle Scholar
  26. 26.
    Krag MH (1991) Biomechanics of thoracolumbar spinal fixation. A review. Spine 16:S84–S99CrossRefGoogle Scholar
  27. 27.
    Lee MH, Lin MH, Weng HH, Cheng WC, Tsai YH, Wang TC, Yang JT (2013) Feasibility of intra-operative computed tomography navigation system for pedicle screw insertion of the thoraco-lumbar spine. J Spinal Disord Tech 26:E183–E187. CrossRefGoogle Scholar
  28. 28.
    Liu Z, Jin M, Qiu Y, Yan H, Han X, Zhu Z (2016) The superiority of intraoperative O-arm navigation-assisted surgery in instrumenting extremely small thoracic pedicles of adolescent idiopathic scoliosis: a case-control study. Medicine 95:e3581. CrossRefGoogle Scholar
  29. 29.
    Luciano CJ, Banerjee PP, Bellotte B, Oh GM, Lemole M Jr, Charbel FT, Roitberg B (2011) Learning retention of thoracic pedicle screw placement using a high-resolution augmented reality simulator with haptic feedback. Neurosurgery 69:ons14–ons19; discussion ons19. Google Scholar
  30. 30.
    Ludwig SC, Kramer DL, Balderston RA, Vaccaro AR, Foley KF, Albert TJ (2000) Placement of pedicle screws in the human cadaveric cervical spine: comparative accuracy of three techniques. Spine 25:1655–1667CrossRefGoogle Scholar
  31. 31.
    Mirza SK, Wiggins GC, Ct K, York JE, Bellabarba C, Knonodi MA, Chapman JR, Shaffrey CI (2003) Accuracy of thoracic vertebral body screw placement using standard fluoroscopy, fluoroscopic image guidance, and computed tomographic image guidance: a cadaver study. Spine 28:402–413. Google Scholar
  32. 32.
    Neo M, Sakamoto T, Fujibayashi S, Nakamura T (2005) The clinical risk of vertebral artery injury from cervical pedicle screws inserted in degenerative vertebrae. Spine 30:2800–2805CrossRefGoogle Scholar
  33. 33.
    Nooh A, Lubov J, Aoude A, Aldebeyan S, Jarzem P, Ouellet J, Weber MH (2017) Differences between manufacturers of computed tomography-based computer-assisted surgery systems do exist: a systematic literature review. Global Spine J 7:83–94. CrossRefGoogle Scholar
  34. 34.
    Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE (2004) Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine 29:1938–1944CrossRefGoogle Scholar
  35. 35.
    Podolsky DJ, Martin AR, Whyne CM, Massicotte EM, Hardisty MR, Ginsberg HJ (2010) Exploring the role of 3-dimensional simulation in surgical training: feedback from a pilot study. J Spinal Disord Tech 23:e70–e74. CrossRefGoogle Scholar
  36. 36.
    Rajasekaran S, Vidyadhara S, Ramesh P, Shetty AP (2007) Randomized clinical study to compare the accuracy of navigated and non-navigated thoracic pedicle screws in deformity correction surgeries. Spine 32:E56–E64. CrossRefGoogle Scholar
  37. 37.
    Roy-Camille R, Saillant G, Mazel C (1986) Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop 203:7–17Google Scholar
  38. 38.
    Ryang YM, Villard J, Obermuller T, Friedrich B, Wolf P, Gempt J, Ringel F, Meyer B (2015) Learning curve of 3D fluoroscopy image-guided pedicle screw placement in the thoracolumbar spine. Spine J 15:467–476. CrossRefGoogle Scholar
  39. 39.
    Samdani AF, Ranade A, Sciubba DM, Cahill PJ, Antonacci MD, Clements DH, Betz RR (2010) Accuracy of free-hand placement of thoracic pedicle screws in adolescent idiopathic scoliosis: how much of a difference does surgeon experience make? Eur Spine J 19:91–95. CrossRefGoogle Scholar
  40. 40.
    Scheufler KM, Franke J, Eckardt A, Dohmen H (2011) Accuracy of image-guided pedicle screw placement using intraoperative computed tomography-based navigation with automated referencing, part I: cervicothoracic spine. Neurosurgery 69:782–795; discussion 795. CrossRefGoogle Scholar
  41. 41.
    Schwarzenbach O, Berlemann U, Jost B, Visarius H, Arm E, Langlotz F, Nolte LP, Ozdoba C (1997) Accuracy of computer-assisted pedicle screw placement. An in vivo computed tomography analysis. Spine 22:452–458CrossRefGoogle Scholar
  42. 42.
    Shin BJ, James AR, Njoku IU, Hartl R (2012) Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. J Neurosurg Spine 17:113–122. CrossRefGoogle Scholar
  43. 43.
    Tian NF, Huang QS, Zhou P, Zhou Y, Wu RK, Lou Y, Xu HZ (2011) Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies. Eur Spine J 20:846–859. CrossRefGoogle Scholar
  44. 44.
    Tjardes T, Shafizadeh S, Rixen D, Paffrath T, Bouillon B, Steinhausen ES, Baethis H (2010) Image-guided spine surgery: state of the art and future directions. Eur Spine J 19:25–45. CrossRefGoogle Scholar
  45. 45.
    Tormenti MJ, Kostov DB, Gardner PA, Kanter AS, Spiro RM, Okonkwo DO (2010) Intraoperative computed tomography image-guided navigation for posterior thoracolumbar spinal instrumentation in spinal deformity surgery. Neurosurg Focus 28:E11. CrossRefGoogle Scholar
  46. 46.
    Uhl E, Zausinger S, Morhard D, Heigl T, Scheder B, Rachinger W, Schichor C, Tonn JC (2009) Intraoperative computed tomography with integrated navigation system in a multidisciplinary operating suite. Neurosurgery 64:231–239; discussion 239-240. CrossRefGoogle Scholar
  47. 47.
    Villard J, Ryang YM, Demetriades AK, Reinke A, Behr M, Preuss A, Meyer B, Ringel F (2014) Radiation exposure to the surgeon and the patient during posterior lumbar spinal instrumentation: a prospective randomized comparison of navigated versus non-navigated freehand techniques. Spine 39:1004–1009. CrossRefGoogle Scholar
  48. 48.
    Wang VY, Chin CT, Lu DC, Smith JS, Chou D (2010) Free-hand thoracic pedicle screws placed by neurosurgery residents: a CT analysis. Eur Spine J 19:821–827. CrossRefGoogle Scholar
  49. 49.
    Waschke A, Walter J, Duenisch P, Reichart R, Kalff R, Ewald C (2013) CT-navigation versus fluoroscopy-guided placement of pedicle screws at the thoracolumbar spine: single center experience of 4,500 screws. Eur Spine J 22:654–660. 660. CrossRefGoogle Scholar
  50. 50.
    Watkins RG, Gupta A, Watkins RG (2010) Cost-effectiveness of image-guided spine surgery. Open Orthopt J 4:228–233. CrossRefGoogle Scholar
  51. 51.
    Zausinger S, Scheder B, Uhl E, Heigl T, Morhard D, Tonn JC (2009) Intraoperative computed tomography with integrated navigation system in spinal stabilizations. Spine 34:2919–2926. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryHeidelberg University HospitalHeidelbergGermany

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