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Accuracy of pedicle screw insertion in posterior scoliosis surgery: a comparison between intraoperative navigation and preoperative navigation techniques

Abstract

Purpose

This study was conducted to compare the efficacy and accuracy of intraoperative navigation (O-arm or Arcadis navigation) and preoperative CT-based navigation in adolescent idiopathic scoliosis (AIS) surgery.

Methods

Sixty-seven patients with scoliosis were grouped according to the method of navigation used in their fixation surgeries. A total of 492 pedicle screws were implanted in 27 patients using intraoperative navigation, and 626 screws were implanted in 40 patients using preoperative navigation. We analyzed the postoperative CT images for pedicle violations using the Gertzbein classification.

Results

There was no statistical difference in the accuracy of pedicle screw placement between two groups. However, in the apical region (the apex ± 2 vertebrae), the accuracy of safe pedicle screw placement (grades 0, 1) was significantly higher in the intraoperative navigation group than in the preoperative navigation group (94.8 vs 89.2%, respectively; P = 0.035). Intraoperative navigation significantly diminished medial perforation compared to preoperative navigation (P = 0.027), and the number of screws per vertebra that could be placed in the apical region was significantly higher in intraoperative navigation group (P < 0.001). In addition, the time required for the registration procedure and insertion of one pedicle screw was 11.3 ± 2.1 min in the preoperative group, but significantly decreased to 5.1 ± 1.1 min in the intraoperative group (P < 0.001).

Conclusions

Both preoperative CT-based and intraoperative navigation systems provide sufficient accuracy and safety in pedicle screw insertion for AIS surgery. Intraoperative navigation systems facilitate pedicle screw insertion in the apical region and reduce registration time during AIS surgery which improves the efficacy and accuracy of pedicle screw insertion.

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References

  1. Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB (1995) Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine (Phila Pa 1976) 20:1399–1405

    CAS  Article  Google Scholar 

  2. Halm H, Niemeyer T, Link T, Liljenqvist U (2000) Segmental pedicle screw instrumentation in idiopathic thoracolumbar and lumbar scoliosis. Eur Spine J 9:191–197

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. Liljenquist U, Lepsien U, Hackenberg L, Niemeyer T, Halm H (2002) Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis. Eur Spine J 11:336–343. doi:10.1007/s00586-002-0415-9

    Article  Google Scholar 

  4. Liljenquist UR, Link TM, Halm HF (2000) Morphometric analysis of thoracic and lumbar vertebrae in idiopathic scoliosis. Spine (Phila Pa 1976) 25:1247–1253

    Article  Google Scholar 

  5. Watanabe K, Lenke LG, Matsumoto M, Harimaya K, Kim YJ, Hensley M, Stobbs G, Toyama Y, Chiba K (2010) A novel pedicle channel classification describing osseous anatomy: how many thoracic scoliotic pedicles have cancellous channels? Spine (Phila Pa 1976) 35:1836–1842. doi:10.1097/BRS.0b013e3181d3cfde

    Article  Google Scholar 

  6. Suk SI, Lee SM, Chung ER, Kim JH, Kim SS (2005) Selective thoracic fusion with segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis: more than 5-year follow-up. Spine (Phila Pa 1976) 30:1602–1609

    Article  Google Scholar 

  7. Kotani Y, Abumi K, Ito M, Takahata M, Sudo H, Ohshima S, Minami A (2007) Accuracy analysis of pedicle screw placement in posterior scoliosis surgery: comparison between conventional fluoroscopic and computer-assisted technique. Spine (Phila Pa 1976) 32:1543–1550. doi:10.1097/BRS.0b013e318068661e

    Article  Google Scholar 

  8. O’Brien MF, Lenke LG, Mardjetko S, Lowe TG, Kong Y, Eck K, Smith D (2000) Pedicle morphology in thoracic adolescent idiopathic scoliosis: is pedicle fixation an anatomically viable technique? Spine (Phila Pa 1976) 25:2285–2293

    Article  Google Scholar 

  9. Liljenqvist UR, Allkemper T, Hackenberg L, Link TM, Steinbeck J, Halm HF (2002) Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction. J Bone Jt Surg Am 84-A:359–368

    Article  Google Scholar 

  10. Vaccaro AR, Rizzolo SJ, Balderston RA, Allardyce TJ, Garfin SR, Dolinskas C, An HS (1995) Placement of pedicle screws in the thoracic spine. Part II: an anatomical and radiographic assessment. J Bone Jt Surg Am 77:1200–1206

    CAS  Article  Google Scholar 

  11. Karatoprak O, Unay K, Tezer M, Ozturk C, Aydogan M, Mirzanli C (2008) Comparative analysis of pedicle screw versus hybrid instrumentation in adolescent idiopathic scoliosis surgery. Int Orthop 32:523–528. doi:10.1007/s00264-007-0359-0 (discussion 529)

    Article  PubMed  Google Scholar 

  12. Cheung KM, Natarajan D, Samartzis D, Wong YW, Cheung WY, Luk KD (2010) Predictability of the fulcrum bending radiograph in scoliosis correction with alternate-level pedicle screw fixation. J Bone Jt Surg Am 92:169–176. doi:10.2106/JBJS.H.01831

    Article  Google Scholar 

  13. Mirza SK, Wiggins GC, Ct Kuntz, 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 (Phila Pa 1976) 28:402–413. doi:10.1097/01.BRS.0000048461.51308.CD

    Google Scholar 

  14. 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. doi:10.1007/s00586-010-1577-5

    Article  PubMed  Google Scholar 

  15. Takahashi J, Hirabayashi H, Hashidate H, Ogihara N, Kato H (2010) Accuracy of multilevel registration in image-guided pedicle screw insertion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 35:347–352. doi:10.1097/BRS.0b013e3181b77f0a

    Article  Google Scholar 

  16. Laine T, Schlenzka D, Makitalo K, Tallroth K, Nolte LP, Visarius H (1997) Improved accuracy of pedicle screw insertion with computer-assisted surgery. A prospective clinical trial of 30 patients. Spine (Phila Pa 1976) 22:1254–1258

    CAS  Article  Google Scholar 

  17. Grutzner PA, Beutler T, Wendl K, von Recum J, Wentzensen A, Nolte LP (2004) Intraoperative three-dimensional navigation for pedicle screw placement. Chirurg 75:967–975. doi:10.1007/s00104-004-0944-3

    CAS  Article  PubMed  Google Scholar 

  18. Van de Kelft E, Costa F, Van der Planken D, Schils F (2012) A prospective multicenter registry on the accuracy of pedicle screw placement in the thoracic, lumbar, and sacral levels with the use of the O-arm imaging system and StealthStation Navigation. Spine (Phila Pa 1976) 37:E1580–E1587. doi:10.1097/BRS.0b013e318271b1fa

    Article  Google Scholar 

  19. Kotani T, Akazawa T, Sakuma T, Koyama K, Nemoto T, Nawata K, Yamazaki A, Minami S (2014) Accuracy of Pedicle screw placement in scoliosis surgery: a comparison between conventional computed tomography-based and O-arm-based navigation techniques. Asian Spine J 8:331–338. doi:10.4184/asj.2014.8.3.331

    Article  PubMed  PubMed Central  Google Scholar 

  20. Sun L, Song Y, Gong Q, Liu L, Zhou C, Zhou Z (2013) Short-term effectiveness of spinal navigation with intra-operative three-dimensional-imaging modality in pedicle screw fixation for congenital scoliosis. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 27:129–134

    PubMed  Google Scholar 

  21. 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. doi:10.1007/s00586-015-4012-0

    Article  PubMed  Google Scholar 

  22. Akazawa T, Kotani T, Sakuma T, Minami S, Tsukamoto S, Ishige M (2015) Evaluation of pedicle screw placement by pedicle channel grade in adolescent idiopathic scoliosis: should we challenge narrow pedicles? J Orthop Sci 20:818–822. doi:10.1007/s00776-015-0746-0

    Article  PubMed  Google Scholar 

  23. 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 (Baltimore) 95:e3581. doi:10.1097/MD.0000000000003581

    CAS  Article  Google Scholar 

  24. Akcali O, Alici E, Kosay C (2003) Apical instrumentation alters the rotational correction in adolescent idiopathic scoliosis. Eur Spine J 12:124–129. doi:10.1007/s00586-002-0477-8

    PubMed  Google Scholar 

  25. Cheng I, Kim Y, Gupta MC, Bridwell KH, Hurford RK, Lee SS, Theerajunyaporn T, Lenke LG (2005) Apical sublaminar wires versus pedicle screws—which provides better results for surgical correction of adolescent idiopathic scoliosis? Spine (Phila Pa 1976) 30:2104–2112

    Article  Google Scholar 

  26. Parent S, Labelle H, Skalli W, de Guise J (2004) Thoracic pedicle morphometry in vertebrae from scoliotic spines. Spine (Phila Pa 1976) 29:239–248

    Article  Google Scholar 

  27. Sakai Y, Matsuyama Y, Nakamura H, Katayama Y, Imagama S, Ito Z, Ishiguro N (2008) Segmental pedicle screwing for idiopathic scoliosis using computer-assisted surgery. J Spinal Disord Tech 21:181–186. doi:10.1097/BSD.0b013e318074d388

    Article  PubMed  Google Scholar 

  28. Gertzbein SD, Robbins SE (1990) Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976) 15:11–14

    CAS  Article  Google Scholar 

  29. Gebhard FT, Kraus MD, Schneider E, Liener UC, Kinzl L, Arand M (2006) Does computer-assisted spine surgery reduce intraoperative radiation doses? Spine (Phila Pa 1976) 31:2024–2027. doi:10.1097/01.brs.0000229250.69369.ac (discussion 2028)

    Article  Google Scholar 

  30. Zhang J, Weir V, Fajardo L, Lin J, Hsiung H, Ritenour ER (2009) Dosimetric characterization of a cone-beam O-arm imaging system. J X-ray Sci Technol 17:305–317. doi:10.3233/XST-2009-0231

    Google Scholar 

  31. Farshad M, Betz M, Farshad-Amacker NA, Moser M (2016) Accuracy of patient-specific template-guided vs. free-hand fluoroscopically controlled pedicle screw placement in the thoracic and lumbar spine: a randomized cadaveric study. Eur. Spine. doi:10.1007/s00586-016-4728-5

    PubMed  Google Scholar 

  32. Kim HJ, Jung WI, Chang BS, Lee CK, Kang KT, Yeom JS (2016) A prospective, randomized, controlled trial of robot-assisted vs freehand pedicle screw fixation in spine surgery. Int J Med Robot. doi:10.1002/rcs.1779

    Google Scholar 

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Correspondence to Masato Tanaka.

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Ethical approval was admitted by our hospital Ethics committee.

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Zhang, W., Takigawa, T., Wu, Y. et al. Accuracy of pedicle screw insertion in posterior scoliosis surgery: a comparison between intraoperative navigation and preoperative navigation techniques. Eur Spine J 26, 1756–1764 (2017). https://doi.org/10.1007/s00586-016-4930-5

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  • DOI: https://doi.org/10.1007/s00586-016-4930-5

Keywords

  • Scoliosis
  • Computer-assisted surgery
  • Pedicle screw
  • Accuracy