European Spine Journal

, Volume 22, Issue 3, pp 654–660 | Cite as

CT-navigation versus fluoroscopy-guided placement of pedicle screws at the thoracolumbar spine: single center experience of 4,500 screws

  • Albrecht WaschkeEmail author
  • Jan Walter
  • Pedro Duenisch
  • Rupert Reichart
  • Rolf Kalff
  • Christian Ewald
Original Article



Single center evaluation of the placement accuracy of thoracolumbar pedicle screws implanted either with fluoroscopy or under CT-navigation using 3D-reconstruction and intraoperative computed tomography control of the screw position. There is in fact a huge variation in the reported placement accuracy of pedicle screws, especially concerning the screw placement under conventional fluoroscopy most notably due to the lack of the definition of screw misplacement, combined with a potpourri of postinstrumentation evaluation methods.


The operation data of 1,006 patients operated on in our clinic between 1995 and 2005 is analyzed retrospectively. There were 2,422 screws placed with the help of CT-navigation compared to 2,002 screws placed under fluoroscopy. The postoperative computed tomography images were reviewed by a radiologist and an independent spine surgeon.


In the lumbar spine, the placement accuracy was 96.4 % for CT-navigated screws and 93.9 % for pedicle screws placed under fluoroscopy, respectively. This difference in accuracy was statistically significant (Fishers Exact Test, p = 0.001). The difference in accuracy became more impressing in the thoracic spine, with a placement accuracy of 95.5 % in the CT-navigation group, compared to 79.0 % accuracy in the fluoroscopy group (p < 0.001).


This study underlines the relevance of CT-navigation-guided pedicle screw placement, especially when instrumentation of the middle and upper thoracic spine is carried out.


Pedicle screws Navigation Placement accuracy Computed tomography Fluoroscopy 


Conflict of interest



  1. 1.
    Boachie-Adjei O, Girardi FP, Bansal M, Rawlins BA (2000) Safety and efficacy of pedicle screw placement for adult spinal deformity with a pedicle-probing conventional anatomic technique. J Spinal Disord 13:496–500PubMedCrossRefGoogle Scholar
  2. 2.
    Kosmopoulos V, Schizas C (2007) Pedicle screw placement accuracy: a meta-analysis. Spine 32:E111–E120PubMedCrossRefGoogle Scholar
  3. 3.
    Laine T, Lund T, Ylikoski M, Lohikoski J, Schlenzka D (2000) Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients. Eur Spine J 9:235–240PubMedCrossRefGoogle Scholar
  4. 4.
    Learch TJ, Massie JB, Pathria MN, Ahlgren BA, Garfin SR (2004) Assessment of pedicle screw placement utilizing conventional radiography and computed tomography: a proposed systematic approach to improve accuracy of interpretation. Spine 29:767–773PubMedCrossRefGoogle Scholar
  5. 5.
    Beck M, Mittlmeier T, Gierer P, Harms C, Gradl G (2009) Benefit and accuracy of intraoperative 3D-imaging after pedicle screw placement: a prospective study in stabilizing thoracolumbar fractures. Eur Spine J 18:1469–1477PubMedCrossRefGoogle Scholar
  6. 6.
    Pechlivanis I, Kiriyanthan G, Engelhardt M, Scholz M, Lucke S, Harders A, Schmieder K (2009) Percutaneous placement of pedicle screws in the lumbar spine using a bone mounted miniature robotic system: first experiences and accuracy of screw placement. Spine 34:392–398PubMedCrossRefGoogle Scholar
  7. 7.
    Idler C, Rolfe KW, Gorek JE (2010) Accuracy of percutaneous lumbar pedicle screw placement using the oblique or “owl’s-eye” view and novel guidance technology. J Neurosurg Spine 13:509–515PubMedCrossRefGoogle Scholar
  8. 8.
    Tian NF, Xu HZ (2009) Image-guided pedicle screw insertion accuracy: a meta-analysis. Int Orthop 33:895–903PubMedCrossRefGoogle Scholar
  9. 9.
    Rampersaud YR, Pik JH, Salonen D, Farooq S (2005) Clinical accuracy of fluoroscopic computer-assisted pedicle screw fixation: a CT analysis. Spine 30:E183–E190PubMedCrossRefGoogle Scholar
  10. 10.
    Bledsoe JM, Fenton D, Fogelson JL, Nottmeier EW (2009) Accuracy of upper thoracic pedicle screw placement using three-dimensional image guidance. Spine J 9:817–821PubMedCrossRefGoogle Scholar
  11. 11.
    Zausinger S, Scheder B, Uhl E, Heigl T, Morhard D, Tonn JC (2009) Intraoperative computed tomography with integrated navigation system in spinal stabilizations. Spine 34:2919–2926PubMedCrossRefGoogle Scholar
  12. 12.
    Amato V, Giannachi L, Irace C, Corona C (2010) Accuracy of pedicle screw placement in the lumbosacral spine using conventional technique: computed tomography postoperative assessment in 102 consecutive patients. J Neurosurg Spine 12:306–313PubMedCrossRefGoogle Scholar
  13. 13.
    Gertzbein SD, Robbins SE (1990) Accuracy of pedicular screw placement in vivo. Spine 15:11–14PubMedCrossRefGoogle Scholar
  14. 14.
    Laine T, Makitalo K, Schlenzka D, Tallroth K, Poussa M, Alho A (1997) Accuracy of pedicle screw insertion: a prospective CT study in 30 low back patients. Eur Spine J 6:402–405PubMedCrossRefGoogle Scholar
  15. 15.
    Liljenqvist UR, Halm HF, Link TM (1997) Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine 22:2239–2245PubMedCrossRefGoogle Scholar
  16. 16.
    Guzey FK, Emel E, Hakan Seyithanoglu M, Serdar Bas N, Ozkan N, Sel B, Aycan A, Alatas I (2006) Accuracy of pedicle screw placement for upper and middle thoracic pathologies without coronal plane spinal deformity using conventional methods. J Spinal Disord Tech 19:436–441PubMedCrossRefGoogle Scholar
  17. 17.
    Belmont PJ Jr, Klemme WR, Dhawan A, Polly DW Jr (2001) In vivo accuracy of thoracic pedicle screws. Spine 26:2340–2346PubMedCrossRefGoogle Scholar
  18. 18.
    Carbone JJ, Tortolani PJ, Quartararo LG (2003) Fluoroscopically assisted pedicle screw fixation for thoracic and thoracolumbar injuries: technique and short-term complications. Spine 28:91–97PubMedCrossRefGoogle Scholar
  19. 19.
    Schnake KJ, Konig B, Berth U, Schroeder RJ, Kandziora F, Stockle U, Raschke M, Haas NP (2004) Accuracy of CT-based navigation of pedicle screws in the thoracic spine compared with conventional technique. Unfallchirurg 107:104–112PubMedCrossRefGoogle Scholar
  20. 20.
    Schizas C, Theumann N, Kosmopoulos V (2007) Inserting pedicle screws in the upper thoracic spine without the use of fluoroscopy or image guidance. Is it safe? Eur Spine J 16:625–629PubMedCrossRefGoogle Scholar
  21. 21.
    Odgers CJ, Vaccaro AR, Pollack ME, Cotler JM (1996) Accuracy of pedicle screw placement with the assistance of lateral plain radiography. J Spinal Disord 9:334–338PubMedCrossRefGoogle Scholar
  22. 22.
    Kuntz C, Maher PC, Levine NB, Kurokawa R (2004) Prospective evaluation of thoracic pedicle screw placement using fluoroscopic imaging. J Spinal Disord Tech 17:206–214PubMedCrossRefGoogle Scholar
  23. 23.
    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–E64PubMedCrossRefGoogle Scholar
  24. 24.
    Abul-Kasim K, Strombeck A, Ohlin A, Maly P, Sundgren PC (2009) Reliability of low-radiation dose CT in the assessment of screw placement after posterior scoliosis surgery, evaluated with a new grading system. Spine 34:941–948PubMedCrossRefGoogle Scholar
  25. 25.
    Rao G, Brodke DS, Rondina M, Bacchus K, Dailey AT (2003) Inter- and intraobserver reliability of computed tomography in assessment of thoracic pedicle screw placement. Spine 28:2527–2530PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Albrecht Waschke
    • 1
    Email author
  • Jan Walter
    • 1
  • Pedro Duenisch
    • 1
  • Rupert Reichart
    • 1
  • Rolf Kalff
    • 1
  • Christian Ewald
    • 1
  1. 1.Department of NeurosurgeryJena University Hospital-Friedrich Schiller University JenaJenaGermany

Personalised recommendations