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European Journal of Trauma and Emergency Surgery

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Open Access 01-06-2021 | Spinal Surgery | Original Article

A minimally invasive, 3D-fluoroscopy-navigation-guided, 3D-controlled pedicle approach in spine surgery: first reliable results and impact on patient safety

Authors: André El Saman, Simon Lars Meier, Ingo Marzi

Published in: European Journal of Trauma and Emergency Surgery | Issue 3/2021

Abstract

Purpose

Safe pedicle screw placement is a daily challenge to every spine surgeon. Introduction of minimally invasive approaches in spinal surgery led to an impaired facility of inspection of the surgical field increasing the importance of intraoperative imaging and navigation. During the past years, we established a minimally invasive, navigated approach in our clinical setting.

Methods

We retrospectively reviewed the accuracy of pedicle approaches in patients treated due to traumatic or osteoporotic fractures, spondylitis/discitis, and tumoral lesions. Guide wires for pedicle screws or kyphoplasty cannulas were inserted in a 3D-navigation-guided, minimally invasive technique. Positioning of the guide wires was verified via 3D-scan, and pedicle screws/kyphoplasty cannulas were then visualized via a.p./lateral radiographs. Accuracy data were compared to a standard navigated open approach control group with indications similar to the MIS-group.

Results

23 MIS patients were included in this study (25–84 years, mean 70 years) with a total of 154 placed guide wires. Handling of the navigated Jamshidi needle was easy and secure. The guide wires showed correct placement in 151/154 cases. Three wires (1.9%) needed correction of placement after control scan. There were no vascular or neurologic complications due to wire misplacement. In the open-surgery control group, 7/181 screws (3.9%) needed intraoperative correction presenting no significant difference compared to the correction rate of the MIS-group (p = 0.35).

Conclusion

Our study shows the feasibility and reliability of a navigation-guided, minimally invasive pedicle approach in the clinical setting. Therefore, reduced morbidity due to minimized approaches can be combined with higher accuracy of navigated pedicle screw/kyphoplasty cannula placement improving patient safety.

El Saman A, Meier SL, Sander AL, et al. Reduced loosening rate and loss of correction following posterior stabilization with or without PMMA augmentation of pedicle screws in vertebral fractures in the elderly. Eur J Trauma. 2013;39:455–60. https://doi.org/10.1007/s00068-013-0310-6.CrossRef

Hoshino M, Takahashi S, Yasuda H, et al. Balloon kyphoplasty versus conservative treatment for acute osteoporotic vertebral fractures with poor prognostic factors. Spine. 2019;44:110–7. https://doi.org/10.1097/BRS.0000000000002769.CrossRefPubMed

Schnake KJ, Blattert TR, Hahn P, et al. Classification of osteoporotic thoracolumbar spine fractures: recommendations of the spine section of the german society for orthopaedics and trauma (DGOU). Glob Spine J. 2018;8:46S–9S. https://doi.org/10.1177/2192568217717972.CrossRef

Chang M-C, Liu C-L, Chen T-H. Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. SPINE. 2008;33:E317–E324324. https://doi.org/10.1097/BRS.0b013e31816f6c73.CrossRefPubMed

Chang M-C, Kao H-C, Ying S-H, Liu C-L. Polymethylmethacrylate augmentation of cannulated pedicle screws for fixation in osteoporotic spines and comparison of its clinical results and biomechanical characteristics with the needle injection method. J Spin Disord Tech. 2013;26:305–15. https://doi.org/10.1097/BSD.0b013e318246ae8a.CrossRef

Chen L-H, Tai C-L, Lai P-L, et al. Pullout strength for cannulated pedicle screws with bone cement augmentation in severely osteoporotic bone: influences of radial hole and pilot hole tapping. Clin Biomech (Bristol, Avon). 2009;24:613–8. https://doi.org/10.1016/j.clinbiomech.2009.05.002.CrossRef

Choma TJ, Pfeiffer FM, Swope RW, Hirner JP. Pedicle screw design and cement augmentation in osteoporotic vertebrae effects of fenestrations and cement viscosity on fixation and extraction. SPINE. 2012;37:E1628–E16321632. https://doi.org/10.1097/BRS.0b013e3182740e56.CrossRefPubMed

Tan Q-C, Wu J-W, Peng F, et al. Augmented PMMA distribution: improvement of mechanical property and reduction of leakage rate of a fenestrated pedicle screw with diameter-tapered perforations. J Neurosurg Spine. 2016;24:971–7. https://doi.org/10.3171/2015.10.SPINE141275.CrossRefPubMed

Waschke A, Walter J, Duenisch P, et al. CT-navigation versus fluoroscopy-guided placement of pedicle screws at the thoracolumbar spine: single center experience of 4500 screws. Eur Spine J. 2013;22:654–60. https://doi.org/10.1007/s00586-012-2509-3.CrossRefPubMed

10.

Meng X-T, Guan X-F, Zhang H-L, He S-S. Computer navigation versus fluoroscopy-guided navigation for thoracic pedicle screw placement: a meta-analysis. Neurosurg Rev. 2016;39:385–91.CrossRef

11.

Wu M-H, et al. Comparison of minimally invasive spine surgery using intraoperative computed tomography integrated navigation, fluoroscopy, and conventional open surgery for lumbar spondylolisthesis: a prospective registry-based cohort study. Spine J. 2017;17:1082–90. https://doi.org/10.1016/j.spinee.2017.04.002.CrossRefPubMed

12.

Kim J-S, Härtl R, Mayer HM. Minimally invasive spinal surgery. Biomed Res Int. 2016;2016:1–2. https://doi.org/10.1155/2016/5048659.CrossRef

13.

Court C, Vincent C. Percutaneous fixation of thoracolumbar fractures: current concepts. Orthop Traumatol Surg Res. 2012;98:900–9. https://doi.org/10.1016/j.otsr.2012.09.014.CrossRefPubMed

14.

Ohba T, Ebata S, Fujita K, et al. Percutaneous pedicle screw placements: accuracy and rates of cranial facet joint violation using conventional fluoroscopy compared with intraoperative three-dimensional computed tomography computer navigation. Eur Spine J. 2016;25:1775–800. https://doi.org/10.1007/s00586-016-4489-1.CrossRefPubMed

15.

Aoude AA, Fortin M, Figueiredo R, et al. Methods to determine pedicle screw placement accuracy in spine surgery: a systematic review. Eur Spine J. 2015;24:990–1004. https://doi.org/10.1007/s00586-015-3853-x.CrossRefPubMed

16.

Du JP, Fan Y, Wu QN, et al. Accuracy of pedicle screw insertion among 3 image-guided navigation systems: systematic review and meta-analysis. World Neurosurg. 2018;109:24–30. https://doi.org/10.1016/j.wneu.2017.07.154.CrossRefPubMed

17.

El Saman A, Kelm A, Meier SL, et al. Intraoperative PEEP-ventilation during PMMA-injection for augmented pedicle screws: improvement of leakage rate in spinal surgery. Eur J Trauma. 2013;39:461–8. https://doi.org/10.1007/s00068-013-0319-x.CrossRef

18.

Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. SPINE. 1990;15:11–4.CrossRef

19.

Zdichavsky M, Blauth M, Knop C, et al. Accuracy of pedicle screw placement in thoracic spine fractures. Eur J Trauma. 2004;30:234–40. https://doi.org/10.1007/s00068-004-1422-9.CrossRef

20.

Zdichavsky M, Blauth M, Knop C, et al. Accuracy of pedicle screw placement in thoracic spine fractures. Eur J Trauma. 2004;30:241–7. https://doi.org/10.1007/s00068-004-1423-8.CrossRef

21.

Mirza SK, Wiggins GC, Kuntz C IV, et al. Accuracy of thoracic vertebral body screw placement using standard fluoroscopy, fluoroscopic image guidance, and computed tomographic image guidance. SPINE. 2003;28:402–13. https://doi.org/10.1097/01.BRS.0000048461.51308.CD.CrossRefPubMed

22.

Luther N, Iorgulescu JB, Geannette C, et al. Comparison of navigated versus non-navigated pedicle screw placement in 260 patients and 1434 screws. J Spin Disord Tech. 2015;28:E298–E303. https://doi.org/10.1097/BSD.0b013e31828af33e.CrossRef

23.

Uehara M, Takahashi J, Ikegami S, et al. Screw perforation rates in 359 consecutive patients receiving computer-guided pedicle screw insertion along the cervical to lumbar spine. Eur Spine J. 2016;26:2858–64. https://doi.org/10.1007/s00586-016-4843-3.CrossRefPubMed

24.

Kraus M, Weiskopf J, Dreyhaupt J, et al. Computer-aided surgery does not increase the accuracy of dorsal pedicle screw placement in the thoracic and lumbar spine: a retrospective analysis of 2003 pedicle screws in a level I trauma center. Glob Spine. 2015;5:93–101. https://doi.org/10.1055/s-0034-1396430.CrossRef

25.

Bledsoe JM, et al. Accuracy of upper thoracic pedicle screw placement using three-dimensional image guidance. Spine J. 2009;9:817–21. https://doi.org/10.1016/j.spinee.2009.06.014.CrossRefPubMed

26.

Eck JC, Lange J, Street J, et al. Accuracy of intraoperative computed tomography-based navigation for placement of percutaneous pedicle screws. Glob Spine. 2013;3:103–7. https://doi.org/10.1055/s-0033-1345037.CrossRef

27.

Ryang Y-M, Villard J, Obermüller T, et al. Learning curve of 3D fluoroscopy image-guided pedicle screw placement in the thoracolumbar spine. Spine J. 2015;15:467–76. https://doi.org/10.1016/j.spinee.2014.10.003.CrossRefPubMed

28.

Miekisiak G, Kornas P, Lekan M, et al. Accuracy of the free-hand placement of pedicle screws in the lumbosacral spine using a universal entry point. J Spin Disord Tech. 2015;28:E194–E198198. https://doi.org/10.1097/BSD.0000000000000243.CrossRef

29.

Kleck CJ, Cullilmore I, LaFleur M, et al. A new 3-dimensional method for measuring precision in surgical navigation and methods to optimize navigation accuracy. Eur Spine. 2015;25:1764–74. https://doi.org/10.1007/s00586-015-4235-0.CrossRef

30.

Elmi-Terander A, Nachabe R, Skulason H, et al. Feasibility and accuracy of thoracolumbar minimally invasive pedicle screw placement with augmented reality navigation technology. Spine. 2018;43:1018–23. https://doi.org/10.1097/BRS.0000000000002502.CrossRefPubMedPubMedCentral

31.

Tajsic T, Patel K, Farmer R, et al. Spinal navigation for minimally invasive thoracic and lumbosacral spine fixation: implications for radiation exposure, operative time, and accuracy of pedicle screw placement. Eur Spine. 2018;27:1918–24. https://doi.org/10.1007/s00586-018-5587-z.CrossRef

32.

Lee YC, Selby M, Zotti M, et al. Minimally invasive stabilization for thoracolumbar and lumbar fractures: a comparative study with short segment open Schanz screw constructs. J Spine Surg. 2019;5:13–8. https://doi.org/10.21037/jss.2019.01.06.CrossRefPubMedPubMedCentral

33.

Chenin L, Capel C, Fichten A, et al. Evaluation of screw placement accuracy in circumferential lumbar arthrodesis using robotic assistance and intraoperative flat-panel computed tomography. World Neurosurg. 2017;105:86–94. https://doi.org/10.1016/j.wneu.2017.05.118.CrossRefPubMed

34.

Schröder ML, Staartjes VE. Revisions for screw malposition and clinical outcomes after robot-guided lumbar fusion for spondylolisthesis. Neurosurg Focus. 2017;42:E12–E1919. https://doi.org/10.3171/2017.3.FOCUS16534.CrossRefPubMed

35.

Malham GM, Parker RM. Early experience of placing image-guided minimally invasive pedicle screws without K-wires or bone-anchored trackers. J Neurosurg Spine. 2018;28:357–63. https://doi.org/10.3171/2017.7.SPINE17528.CrossRefPubMed

36.

Wood MJ, Wood J, McMillen J. The surgical learning curve and accuracy of minimally invasive lumbar pedicle screw placement using CT based computer-assisted navigation plus continuous electromyography monitoring—a retrospective review of 627 screws in 150 patients. Int J Spine Surg. 2014;8:27–27. https://doi.org/10.14444/1027.CrossRefPubMedCentral

Title: A minimally invasive, 3D-fluoroscopy-navigation-guided, 3D-controlled pedicle approach in spine surgery: first reliable results and impact on patient safety
Authors: André El Saman
Simon Lars Meier
Ingo Marzi
Publication date: 01-06-2021
Publisher: Springer Berlin Heidelberg
Keyword: Spinal Surgery
Published in: European Journal of Trauma and Emergency Surgery / Issue 3/2021
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-020-01332-1

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

A minimally invasive, 3D-fluoroscopy-navigation-guided, 3D-controlled pedicle approach in spine surgery: first reliable results and impact on patient safety

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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