Does image guidance decrease pedicle screw-related complications in surgical treatment of adolescent idiopathic scoliosis: a systematic review update and meta-analysis
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Surgical treatment of severe adolescent idiopathic scoliosis (AIS) with posterior spinal instrumentation and fusion with pedicle screws is common, requiring careful screw insertion to prevent pedicle breaches and neurologic complications. Image guidance has been suggested to improve breach rates, though the radiation risk for AIS precludes its common usage. The purpose of this systematic review and meta-analysis was to compare the breach rates and screw-related complications for AIS patients undergoing spine surgery with pedicle screws between freehand screw insertion and image guidance methods.
A comprehensive search of MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science databases was conducted. Two reviewers independently screened abstracts, full-texts, extracted data and performed risk of bias assessment using the QUIPS quality appraisal tool. Level of evidence summary statements were formulated based on consistency and quality of reporting.
Ninety-four studies were found, with 18 studies of moderate risk of bias or better. Moderate evidence from two head-to-head studies shows CT guidance has lower breach rates than freehand methods (OR 0.28 [0.20–0.40, I2 = 1%]), with no complications in either study. From individual studies, moderate evidence showed lower breach rates for image guidance versus freehand methods (13%, I2 = 98% vs. 20%, I2 = 95%). Complication rates were conflicting (0–1.6% for image guidance, 0–1.7% for freehand). Moderate evidence showed increased surgical time for image guidance versus freehand (257.7 min vs. 226.8 min).
Meta-analyzed breach rates show moderate evidence of decreased breaches with CT navigation compared with freehand methods. Complication rates remain unknown due to the low complication rates from small sample sizes.
KeywordsImage guidance Spine surgery Systematic review Meta-analysis Pedicle breaches
Elizabeth Dennett from the University of Alberta provided guidance on search terms and search strategy. Dr. Marc Moreau and Sarah Southon from Alberta Health Services and the Edmonton Scoliosis Clinic provided search terms and guidance on objectives and key outcomes for this study. Undergraduate student Suzana Trac helped with study de-duplication and study design assessment.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 7.Coe JD, Arlet V, Donaldson W, Berven S, Hanson DS, Mudiyam R et al (2006) Complications in spinal fusion for adolescent idiopathic scoliosis in the new millennium. A report of the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976) 31:345–349. https://doi.org/10.1097/01.brs.0000197188.76369.13 CrossRefGoogle Scholar
- 9.Chan A, Parent E, Narvacan K, San C, Lou E (2017) Intraoperative image guidance compared with free-hand methods in adolescent idiopathic scoliosis posterior spinal surgery: a systematic review on screw-related complications and breach rates. Spine J 17:1215–1229. https://doi.org/10.1016/j.spinee.2017.04.001 CrossRefPubMedGoogle Scholar
- 10.Gao B, Gao W, Chen C, Wang Q, Lin S, Xu C et al (2017) What is the difference in morphologic features of the thoracic pedicle between patients with adolescent idiopathic scoliosis and healthy subjects? A CT-based case-control study. Clin Orthop. https://doi.org/10.1007/s11999-017-5448-9 CrossRefPubMedGoogle Scholar
- 14.Hayden JA, van der Windt DA, Cartwright JL, Côté P, Bombardier C (2013) Assessing bias in studies of prognostic factors. Ann Intern Med 158:280–286. https://doi.org/10.7326/0003-4819-158-4-201302190-00009 CrossRefPubMedGoogle Scholar
- 17.Su AW, McIntosh AL, Schueler BA, Milbrandt TA, Winkler JA, Stans AA et al (2017) How does patient radiation exposure compare with low-dose o-arm versus fluoroscopy for pedicle screw placement in idiopathic scoliosis? J Pediatr Orthop 37:171–177. https://doi.org/10.1097/BPO.0000000000000608 CrossRefPubMedGoogle Scholar
- 18.Ughwanogho E, Patel NM, Baldwin KD, Sampson NR, Flynn JM (2012) Computed tomography-guided navigation of thoracic pedicle screws for adolescent idiopathic scoliosis results in more accurate placement and less screw removal. Spine 37:E473–E478. https://doi.org/10.1097/BRS.0b013e318238bbd9 CrossRefPubMedGoogle Scholar
- 21.Zhu W, Sun W, Xu L, Sun X, Liu Z, Qiu Y et al (2017) Minimally invasive scoliosis surgery assisted by O-arm navigation for Lenke Type 5C adolescent idiopathic scoliosis: a comparison with standard open approach spinal instrumentation. J Neurosurg Pediatr 19:472–478. https://doi.org/10.3171/2016.11.PEDS16412 CrossRefGoogle Scholar
- 22.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. https://doi.org/10.1097/MD.0000000000003581 CrossRefGoogle Scholar
- 25.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. https://doi.org/10.1007/s00776-015-0746-0 CrossRefPubMedGoogle Scholar
- 26.Zhang W, Takigawa T, Wu Y, Sugimoto Y, Tanaka M, Ozaki T (2017) Accuracy of pedicle screw insertion in posterior scoliosis surgery: a comparison between intraoperative navigation and preoperative navigation techniques. Eur Spine J 26:1756–1764. https://doi.org/10.1007/s00586-016-4930-5 CrossRefPubMedGoogle Scholar
- 30.Sudo H, Ito M, Abe Y, Abumi K, Takahata M, Nagahama K et al (2014) Surgical treatment of Lenke 1 thoracic adolescent idiopathic scoliosis with maintenance of kyphosis using the simultaneous double-rod rotation technique. Spine 39:1163–1169. https://doi.org/10.1097/BRS.0000000000000364 CrossRefPubMedGoogle Scholar
- 40.Wang W, Zhu Z, Zhu F, Wang B, Chu WCW, Cheng JCY et al (2008) The changes of relative position of the thoracic aorta after anterior or posterior instrumentation of type I Lenke curve in adolescent idiopathic thoracic scoliosis. Eur Spine J 17:1019–1026. https://doi.org/10.1007/s00586-008-0691-0 CrossRefPubMedPubMedCentralGoogle Scholar
- 44.Burton DC, Carlson BB, Place HM, Fuller JE, Blanke K, Cho R et al (2016) Results of the scoliosis research society morbidity and mortality database 2009–2012: a report from the morbidity and mortality committee. Spine Deform 4:338–343. https://doi.org/10.1016/j.jspd.2016.05.003 CrossRefPubMedGoogle Scholar
- 45.Vasudeva V, Moses Z, Cole T, Gologorsky Y, Lu Y (2015) Chapter 14—image guidance for spine surgery. In: Golby AJ (ed) Image-guided neurosurgery. Academic Press, Boston, pp 325–364. https://doi.org/10.1016/b978-0-12-800870-6.00014-5 CrossRefGoogle Scholar
- 47.Lee CK, Chan CYW, Gani SMA, Kwan MK (2017) Accuracy of cannulated pedicle screw versus conventional pedicle screw for extra-pedicular screw placement in dysplastic pedicles without cancellous channel in adolescent idiopathic scoliosis: a computerized tomography (CT) analysis. Eur Spine J. https://doi.org/10.1007/s00586-017-5266-5 CrossRefPubMedGoogle Scholar