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Prost M, Taday R, Beyersdorf CCP, Latz D, Windolf J, Scheyerer MJ, Konieczny MR. Navigation versus fluoroscopy in minimalinvasive iliosacral screw placement. J Orthop Surg Res 2024; 19:185. [PMID: 38491520 PMCID: PMC10943796 DOI: 10.1186/s13018-024-04669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
INTRODUCTION When needed operative treatment of sacral fractures is mostly performed with percutaneous iliosacral screw fixation. The advantage of navigation in insertion of pedicle screws already could be shown by former investigations. The aim of this investigation was now to analyze which influence iliosacral screw placement guided by navigation has on duration of surgery, radiation exposure and accuracy of screw placement compared to the technique guided by fluoroscopy. METHODS 68 Consecutive patients with sacral fractures who have been treated by iliosacral screws were inclouded. Overall, 85 screws have been implanted in these patients. Beside of demographic data the duration of surgery, duration of radiation, dose of radiation and accuracy of screw placement were analyzed. RESULTS When iliosacral screw placement was guided by navigation instead of fluoroscopy the dose of radiation per inserted screw (155.0 cGy*cm2 vs. 469.4 cGy*cm2 p < 0.0001) as well as the duration of radiation use (84.8 s vs. 147.5 s p < 0.0001) were significantly lower. The use of navigation lead to a significant reduction of duration of surgery (39.0 min vs. 60.1 min p < 0.01). The placement of the screws showed a significantly higher accuracy when performed by navigation (0 misplaced screws vs 6 misplaced screws-p < 0.0001). CONCLUSION Based on these results minimal invasive iliosacral screw placement guided by navigation seems to be a safe procedure, which leads to a reduced exposure to radiation for the patient and the surgeon, a reduced duration of surgery as well as a higher accuracy of screw placement.
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Affiliation(s)
- Max Prost
- Department of Orthopedic and Trauma Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Roman Taday
- Department of Orthopedic and Trauma Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Carl Christoph Paul Beyersdorf
- Department of Orthopedic and Trauma Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - David Latz
- Department of Orthopedic and Trauma Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Joachim Windolf
- Department of Orthopedic and Trauma Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Max Joseph Scheyerer
- Department of Orthopedic and Trauma Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Markus Rafael Konieczny
- Department of Orthopedic and Trauma Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
- Department of Spine Surgery, Volmarstein Orthopedic Clinic, Volmarstein, Germany
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Beisemann N, Gierse J, Mandelka E, Hassel F, Grützner PA, Franke J, Vetter SY. Radiation exposure for pedicle screw placement with three different navigation system and imaging combinations in a sawbone model. BMC Musculoskelet Disord 2023; 24:752. [PMID: 37742007 PMCID: PMC10517448 DOI: 10.1186/s12891-023-06880-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Studies have shown that pedicle screw placement using navigation can potentially reduce radiation exposure of surgical personnel compared to conventional methods. Spinal navigation is based on an interaction of a navigation software and 3D imaging. The 3D image data can be acquired using different imaging modalities such as iCT and CBCT. These imaging modalities vary regarding acquisition technique and field of view. The current literature varies greatly in study design, in form of dose registration, as well as navigation systems and imaging modalities analyzed. Therefore, the aim of this study was a standardized comparison of three navigation and imaging system combinations in an experimental setting in an artificial spine model. METHODS In this experimental study dorsal instrumentation of the thoracolumbar spine was performed using three imaging/navigation system combinations. The system combinations applied were the iCT/Curve, cCBCT/Pulse and oCBCT/StealthStation. Referencing scans were obtained with each imaging modality and served as basis for the respective navigation system. In each group 10 artificial spine models received bilateral dorsal instrumentation from T11-S1. 2 referencing and control scans were acquired with the CBCTs, since their field of view could only depict up to five vertebrae in one scan. The field of view of the iCT enabled the depiction of T11-S1 in one scan. After instrumentation the region of interest was scanned again for evaluation of the screw position, therefore only one referencing and one control scan were obtained. Two dose meters were installed in a spine bed ventral of L1 and S1. The dose measurements in each location and in total were analyzed for each system combination. Time demand regarding screw placement was also assessed for all system combinations. RESULTS The mean radiation dose in the iCT group measured 1,6 ± 1,1 mGy. In the cCBCT group the mean was 3,6 ± 0,3 mGy and in the oCBCT group 10,3 ± 5,7 mGy were measured. The analysis of variance (ANOVA) showed a significant (p < 0.0001) difference between the three groups. The multiple comparisions by the Kruskall-Wallis test showed no significant difference for the comparison of iCT and cCBCT (p1 = 0,13). Significant differences were found for the direct comparison of iCT and oCBCT (p2 < 0,0001), as well as cCBCT and oCBCT (p3 = 0,02). Statistical analysis showed that significantly (iCT vs. oCBCT p = 0,0434; cCBCT vs. oCBCT p = 0,0083) less time was needed for oCBCT based navigated pedicle screw placement compared to the other system combinations (iCT vs. cCBCT p = 0,871). CONCLUSION Under standardized conditions oCBCT navigation demanded twice as much radiation as the cCBCT for the same number of scans, while the radiation exposure measured for the iCT and cCBCT for one scan was comparable. Yet, time effort was significantly less for oCBCT based navigation. However, for transferability into clinical practice additional studies should follow evaluating parameters regarding feasibility and clinical outcome under standardized conditions.
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Affiliation(s)
- Nils Beisemann
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Jula Gierse
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Eric Mandelka
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Frank Hassel
- Department of Spine Surgery, Loretto Hospital, Mercystrasse 6, 79100, Freiburg Im Breisgau, Germany
| | - Paul A Grützner
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Jochen Franke
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Sven Y Vetter
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany.
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Metaxas V, Efthymiou F, Dimitroukas C, Delis H, Gatzounis G, Zampakis P, Tzortzidis F, Papadakos D, Constantoyannis C, Panayiotakis G. Lumbar discectomy and fusion: Organs’ dose and effective dose estimation using Monte Carlo simulation. Appl Radiat Isot 2023; 196:110781. [PMID: 36996533 DOI: 10.1016/j.apradiso.2023.110781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/19/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
In this study, the effect of patient- and procedure-related parameters on organs' dose (OD), peak skin dose (PSD) and effective dose (ED) during lumbar discectomy and fusion (LDF) was assessed. Intra-operative parameters obtained from 102 LDFs were inserted into VirtualDose-IR software implementing sex-specific and BMI-adjustable anthropomorphic phantoms for dosimetric calculations. Fluoroscopy time (FT), kerma-area product (KAP), cumulative and incident air-kerma (Kair) were also recorded from the dosimetric report of the mobile C-arm. An increase in KAP, Kair, PSD and ED was found for male or higher BMI patients, multi-level or fusion or L5/S1 procedures. However, a significant difference was found only for PSD and incident Kair between normal and obese patients and for FT between discectomy and discectomy and fusion procedures. The spleen, kidneys and colon received the highest doses. The BMI have a significant impact only for kidneys, pancreas, and spleen doses when comparing obese to overweight and for urinary bladder when comparing overweight to normal patients. Multi-level and fusion procedures resulted in significantly higher doses for lungs, heart, stomach, adrenals, gallbladder and kidneys, while pancreas and spleen doses significantly increased only for multi-level procedures. Additionally, a significant increase was found only for urinary bladder, adrenals, kidneys, and spleen ODs when comparing L5/S1 and L3/L4 levels. The mean ODs were lower compared to the literature. These data may aid neurosurgeons in optimising exposure techniques during LDF to keep patients' dose as low as is practicably possible.
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Affiliation(s)
- Vasileios Metaxas
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece
| | - Fotios Efthymiou
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece
| | - Christos Dimitroukas
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece; Department of Medical Physics, University Hospital of Patras, 26504, Patras, Greece
| | - Harry Delis
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece
| | - George Gatzounis
- Department of Neurosurgery, University Hospital of Patras, 26504, Patras, Greece; Department of Neurosurgery, School of Medicine, University of Patras, 26504, Patras, Greece
| | - Petros Zampakis
- Department of Radiology, University Hospital of Patras, 26504, Patras, Greece; Department of Radiology, School of Medicine, University of Patras, 26504, Patras, Greece
| | - Fotios Tzortzidis
- Department of Neurosurgery, University Hospital of Patras, 26504, Patras, Greece
| | - Dimitrios Papadakos
- Department of Neurosurgery, University Hospital of Patras, 26504, Patras, Greece
| | - Constantine Constantoyannis
- Department of Neurosurgery, University Hospital of Patras, 26504, Patras, Greece; Department of Neurosurgery, School of Medicine, University of Patras, 26504, Patras, Greece
| | - George Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, 26504, Patras, Greece; Department of Medical Physics, University Hospital of Patras, 26504, Patras, Greece.
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Matinfar S, Salehi M, Suter D, Seibold M, Dehghani S, Navab N, Wanivenhaus F, Fürnstahl P, Farshad M, Navab N. Sonification as a reliable alternative to conventional visual surgical navigation. Sci Rep 2023; 13:5930. [PMID: 37045878 PMCID: PMC10097653 DOI: 10.1038/s41598-023-32778-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/02/2023] [Indexed: 04/14/2023] Open
Abstract
Despite the undeniable advantages of image-guided surgical assistance systems in terms of accuracy, such systems have not yet fully met surgeons' needs or expectations regarding usability, time efficiency, and their integration into the surgical workflow. On the other hand, perceptual studies have shown that presenting independent but causally correlated information via multimodal feedback involving different sensory modalities can improve task performance. This article investigates an alternative method for computer-assisted surgical navigation, introduces a novel four-DOF sonification methodology for navigated pedicle screw placement, and discusses advanced solutions based on multisensory feedback. The proposed method comprises a novel four-DOF sonification solution for alignment tasks in four degrees of freedom based on frequency modulation synthesis. We compared the resulting accuracy and execution time of the proposed sonification method with visual navigation, which is currently considered the state of the art. We conducted a phantom study in which 17 surgeons executed the pedicle screw placement task in the lumbar spine, guided by either the proposed sonification-based or the traditional visual navigation method. The results demonstrated that the proposed method is as accurate as the state of the art while decreasing the surgeon's need to focus on visual navigation displays instead of the natural focus on surgical tools and targeted anatomy during task execution.
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Affiliation(s)
- Sasan Matinfar
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany.
- Nuklearmedizin rechts der Isar, Technical University of Munich, 81675, Munich, Germany.
| | - Mehrdad Salehi
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany
| | - Daniel Suter
- Department of Orthopaedics, Balgrist University Hospital, 8008, Zurich, Switzerland
| | - Matthias Seibold
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist Campus, 8008, Zurich, Switzerland
| | - Shervin Dehghani
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany
- Nuklearmedizin rechts der Isar, Technical University of Munich, 81675, Munich, Germany
| | - Navid Navab
- Topological Media Lab, Concordia University, Montreal, H3G 2W1, Canada
| | - Florian Wanivenhaus
- Department of Orthopaedics, Balgrist University Hospital, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist Campus, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, 8008, Zurich, Switzerland
| | - Nassir Navab
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany
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Yamout T, Orosz LD, Good CR, Jazini E, Allen B, Gum JL. Technological Advances in Spine Surgery: Navigation, Robotics, and Augmented Reality. Orthop Clin North Am 2023; 54:237-246. [PMID: 36894295 DOI: 10.1016/j.ocl.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Accurate screw placement is critical to avoid vascular or neurologic complications during spine surgery and to maximize fixation for fusion and deformity correction. Computer-assisted navigation, robotic-guided spine surgery, and augmented reality surgical navigation are currently available technologies that have been developed to improve screw placement accuracy. The advent of multiple generations of new technologies within the past 3 decades has presented surgeons with a diverse array of choices when it comes to pedicle screw placement. Considerations for patient safety and optimal outcomes must be paramount when selecting a technology.
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Affiliation(s)
- Tarek Yamout
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Lindsay D Orosz
- National Spine Health Foundation, 11800 Sunrise Valley Drive, Suite 330, Reston, VA 20191, USA
| | - Christopher R Good
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Ehsan Jazini
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA 20191, USA
| | - Brandon Allen
- National Spine Health Foundation, 11800 Sunrise Valley Drive, Suite 330, Reston, VA 20191, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street Suite 900, Louisville, KY 40202, USA.
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Kuttner H, Benninger E, Fretz V, Meier C. Fluoroscopy-guided vs. navigated iliosacral screw placement with intraoperative 3D scan or postoperative CT control: Impact of the clinical workflow on patients' radiation exposure: Radiation exposure of different workflows for iliosacral screw placement. Injury 2022; 53:3764-3768. [PMID: 36150911 DOI: 10.1016/j.injury.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/30/2022] [Accepted: 09/03/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION To guide iliosacral screws (ISS) and verify safe placement different techniques, e.g. Fluoroscopy-guided (FSG) or 3D navigation are known. However, higher radiation exposure for the conventional technique is a concern. It was the aim of this experimental study to evaluate radiation exposure for three clinical workflows. METHODS An anthropomorphic, cross sectional dosimetry phantom was equipped with metal oxide semiconductor field effect transistors to measure organ specific radiation exposure. The effective dose was calculated. Radiation exposure was measured for FSG placement of 2 transverse ISS based on clinical experience regarding fluoroscopy time (240s). Additional measurements were conducted to calculate the effective dose for an intraoperative 3D scan as used for navigated ISS (high-quality 3D), for intraoperative verification of proper guide wire placement (standard-quality 3D) and for postoperative CT, using three different protocols. The following workflows were compared: FSG including postoperative CT (FSG-CT, including 3 different protocols) vs. FSG with intraoperative 3D scan in standard quality (FSG-3D) vs. navigation including two intraoperative 3D scan for navigated ISS (NAV-3D). RESULTS The effective dose for FSG-CT ranged from 4.41 mSv to 5.27 mSv. FSG-3D resulted in a total of 4.93 mSv. For NAV-3D, the effective dose was the lowest (3.00 mSv). The effective dose of a high-quality 3D scan required for navigation was 1.94 mSv, compared to 1.06 mSv for a standard-quality 3D scan as used for control. CONCLUSIONS Intraoperative 3D scanning may be recommended, either combined with prior FSG ISS placement or following 3D navigation without increasing radiation exposure compared with alternative workflows with postoperative CT control.
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Affiliation(s)
- Hannes Kuttner
- Cantonal Hospital Winterthur, Switzerland, Division for Orthopaedics and Traumatology, Brauerstrasse 15, CH-8401 Winterthur.
| | - Emanuel Benninger
- Cantonal Hospital Winterthur, Switzerland, Division for Orthopaedics and Traumatology, Brauerstrasse 15, CH-8401 Winterthur
| | - Valentin Fretz
- Cantonal Hospital Winterthur, Switzerland, Division for Radiology and Nuclear Medicine, Brauerstarsse 15, CH-8401 Winterthur
| | - Christoph Meier
- Cantonal Hospital Winterthur, Switzerland, Division for Orthopaedics and Traumatology, Brauerstrasse 15, CH-8401 Winterthur
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Liu ZQ, Hsieh CT, Hsu WE, Tseng CS, Chang CJ. Two-dimensional C-arm robotic navigation system (i-Navi) in spine surgery: a pilot study. Int J Comput Assist Radiol Surg 2022; 17:2281-2290. [PMID: 36100733 DOI: 10.1007/s11548-022-02751-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 09/06/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Pedicle screws placement is very common procedure in spinal surgery. Robotic assisted surgery has been widely used in this operation. We assessed the accuracy of thoracolumbar spine trans-pedicle screws (TPS) implantation utilizing a noval robotic navigation system (i-Navi robotic navigation system) by planning with two-dimensional (2-D) C-arm. METHODS This study was approved by the Institutional Review Board of the Cathay General Hospital on June 21, 2018 (IRB number: CGH-P 106,092), and written informed consents were obtained from all the patients. There are 18 patients were enrolled in the study. All the patients received the posterior fusion with TPS insertion under the assistant of our robotic navigation system. RESULTS There are 18 patients were included into our study, there are 2 patients were quitted from the study due to the equipment setup was not complete. Other 16 patients completed the entire procedure successfully. There is total 88 pedicle screws were inserted through i-Navi robotic navigation system. There are 79 of 88 screws were graded A, and 9 screws were graded B; no screws were graded C or D. No vascular or nerve injuries were noted after the operations. CONCLUSION We present our i-Navi robotic navigation system, by planning with 2-D C-arm imaging and pre-operative CT scans. According to the results of study, we think it can provide a reliable and easy tool to perform the TPS in thoracic lumbar spine surgery.
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Affiliation(s)
- Zhao-Quan Liu
- Division of Neurosurgery, Department of Surgery, Cathay General Hospital, Taipei City, 106, Taiwan.,Division of Neurosurgery, Department of Surgery, Sijhih Cathay General Hospital, New Taipei City, 221, Taiwan
| | - Cheng-Ta Hsieh
- Division of Neurosurgery, Department of Surgery, Cathay General Hospital, Taipei City, 106, Taiwan.,Division of Neurosurgery, Department of Surgery, Sijhih Cathay General Hospital, New Taipei City, 221, Taiwan.,School of Medicine, National Tsing Hua University, Hsinchu, 300044, Taiwan.,Department of Medicine, School of Medicine, Fu Jen Catholic University, New Taipei City, 242, Taiwan
| | - Wei-En Hsu
- Department of Mechanical Engineering, National Central University, Taoyuan County, Taiwan
| | - Ching-Shiow Tseng
- Department of Mechanical Engineering, National Central University, Taoyuan County, Taiwan
| | - Chih-Ju Chang
- Division of Neurosurgery, Department of Surgery, Cathay General Hospital, Taipei City, 106, Taiwan. .,Division of Neurosurgery, Department of Surgery, Sijhih Cathay General Hospital, New Taipei City, 221, Taiwan. .,School of Medicine, National Tsing Hua University, Hsinchu, 300044, Taiwan. .,Department of Medicine, School of Medicine, Fu Jen Catholic University, New Taipei City, 242, Taiwan.
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Anderson D, Szarvas D, Koontz C, Hebert J, Li N, Hasoon J, Viswanath O, Kaye AD, Urits I. A Comprehensive Review of Cluneal Neuralgia as a Cause of Lower Back Pain. Orthop Rev (Pavia) 2022; 14:35505. [PMID: 35769655 PMCID: PMC9235435 DOI: 10.52965/001c.35505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 03/29/2022] [Indexed: 08/31/2023] Open
Abstract
Lower back pain (LBP) is one of the most common presenting complaints in clinical adult medical patients. While most often diagnosed as "nonspecific mechanical" in etiology, several lesser known, rarer causes of LBP exist, some of which can even cause neuropathic pain. One of these infrequent causes, cluneal neuralgia (CN), is associated most often with damage or entrapment of the cluneal nerves, particularly the superior cluneal nerve (SCN) and/or the middle cluneal nerve (MCN). These nerves supply sensation to the posterior lumbar and buttock area. However, the LBP caused by CN is often difficult to recognize because it can mimic radiculopathy or sacroiliac joint (SIJ) pain or lead to symptoms in the legs. This makes CN significantly important for clinicians and surgeons to include in their differential. A thorough history proves beneficial in the diagnostic workup, as many risk factors for CN have been reported in the literature. If a CN diagnosis is made, several effective conservative measures can alleviate patients' pain, such as nerve blocks, peripheral nerve stimulation, or high frequency thermal coagulation. Additionally, surgical treatments, such as CN release or endoscopic decompression, have resulted in fantastic patient outcomes. The purpose of the present investigation is to investigate the existing literature about CN as a cause for LBP, consider its epidemiology, discuss its pathophysiology and risk factors, elucidate its clinical presentation and diagnosis, and examine the various treatment modalities that have been reported across the world.
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Affiliation(s)
| | - David Szarvas
- School of Medicine, Louisiana State University Health Sciences Center
| | - Colby Koontz
- School of Medicine, Louisiana State University Health Sciences Center
| | - Julia Hebert
- School of Medicine, Louisiana State University Health Sciences Center
| | - Nathan Li
- Medical School, Medical College of Wisconsin
| | - Jamal Hasoon
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School
| | - Omar Viswanath
- School of Medicine, Louisiana State University Health Sciences Center
| | - Alan D Kaye
- School of Medicine, Louisiana State University Health Sciences Center
| | - Ivan Urits
- School of Medicine, Louisiana State University Health Sciences Center
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Vaishnav AS, Gang CH, Qureshi SA. Time-demand, Radiation Exposure and Outcomes of Minimally Invasive Spine Surgery With the Use of Skin-Anchored Intraoperative Navigation: The Effect of the Learning Curve. Clin Spine Surg 2022; 35:E111-E120. [PMID: 33769982 DOI: 10.1097/bsd.0000000000001167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE The aim was to evaluate the learning curve of skin-anchored intraoperative navigation (ION) for minimally invasive lumbar surgery. SUMMARY OF BACKGROUND DATA ION is increasingly being utilized to provide better visualization, improve accuracy, and enable less invasive procedures. The use of noninvasive skin-anchored trackers for navigation is a novel technique, with the few reports on this technique demonstrating safety, feasibility, and significant reductions in radiation exposure compared with conventional fluoroscopy. However, a commonly cited deterrent to wider adoption is the learning curve. METHODS Retrospective review of patients undergoing 1-level minimally invasive lumbar surgery was performed. Outcomes were: (1) time for ION set-up and image-acquisition; (2) operative time; (3) fluoroscopy time; (4) radiation dose; (5) operative complications; (6) need for repeat spin; (7) incorrect localization.Chronologic case number was plotted against each outcome. Derivative of the nonlinear curve fit to the dataset for each outcome was solved to find plateau in learning. RESULTS A total of 270 patients [114 microdiscectomy; 79 laminectomy; 77 minimally invasive transforaminal lumbar interbody fusion (MI-TLIF)] were included. (1) ION set-up and image-acquisition: no learning curve for microdiscectomy. Proficiency at 23 and 31 cases for laminectomy and MI-TLIF, respectively. (2) Operative time: no learning curve for microdiscectomy. Proficiency at 36 and 31 cases for laminectomy and MI-TLIF, respectively. (3) Fluoroscopy time: no learning curve. (4) Radiation dose: proficiency at 42 and 33 cases for microdiscectomy and laminectomy, respectively. No learning curve for MI-TLIF. (5) Operative complications: unable to evaluate for microdiscectomy and MI-TLIF. Proficiency at 29 cases for laminectomy. (6) Repeat spin: unable to evaluate for microdiscectomy and laminectomy. For MI-TLIF, chronology was not associated with repeat spins. (7) Incorrect localization: none. CONCLUSIONS Skin-anchored ION did not result in any wrong level surgeries. Learning curve for other parameters varied by surgery type, but was achieved at 25-35 cases for a majority of outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
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Richter PH, Blidon A, Eickhoff A, Gebhard F, Schuetze K. Accuracy of screw stabilization of the dorsal pelvic ring using a hybrid operating room: 5 Year experience in a level 1 trauma center. Injury 2021; 52:2968-2972. [PMID: 34275645 DOI: 10.1016/j.injury.2021.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Accuracy for screw placement in the dorsal pelvic ring can be enhanced using intraoperative 3D navigation. Advances in intraoperative imaging lead to benefits for pelvic surgery. New c-arms are equipped with flat panel detectors, which have a larger detector and assure higher image quality with accompanying dose reduction. A hybrid OR is defined by a fixed imaging system in an operating room providing the benefit of the surgical environment in combination with advanced intraoperative imaging. Aim of our investigation was to analyze the accuracy of navigated sacroiliac (SI) and transsacral transiliac (TSTI) screws in the dorsal pelvic ring, which were implanted with a hybrid OR in the first five years of use. MATERIAL AND METHODS All percutaneous SI or TSTI screws implanted in the hybrid OR using intraoperative navigation in the first 5 years of utilization (between June 2012 to June 2017) were included. Intraoperative 3D-scans and postoperative computed tomography were examined for screw perforation. RESULTS 210 SI and TSTI screws were implanted in 187 patients using intraoperative navigation in the hybrid-OR. 90.6 % of SI screws showed no cortical perforation. 6,3 % had a grade 1, 2.4 % a grade 2 and 0.8 % a grade 3 perforation. In 80.7 % of TSTI screws no perforation and in 13.3 % a grade 1 perforation was detected. 3.6 % showed a grade 2 and 2.4 % a grade 3 perforation. No significant difference between both screw types regarding the grade of cortical perforation could be seen. No significant relation between perforation rate and year of operation could be detected. CONCLUSION Intraoperative navigation in a hybrid OR ensures a high accuracy for SI screws. Due to the large field of view and high image quality TSTI screws can be safely implanted in S1 and S2. Utilization of a hybrid-OR is accompanied with a steep learning curve.
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Affiliation(s)
- P H Richter
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany.
| | - A Blidon
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - A Eickhoff
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - F Gebhard
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - K Schuetze
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
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11
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Lee NJ, Zuckerman SL, Buchanan IA, Boddapati V, Mathew J, Leung E, Park PJ, Pham MH, Buchholz AL, Khan A, Pollina J, Mullin JP, Jazini E, Haines C, Schuler TC, Good CR, Lombardi JM, Lehman RA. Is there a difference between navigated and non-navigated robot cohorts in robot-assisted spine surgery? A multicenter, propensity-matched analysis of 2,800 screws and 372 patients. Spine J 2021; 21:1504-1512. [PMID: 34022461 DOI: 10.1016/j.spinee.2021.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/23/2021] [Accepted: 05/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Robot-assisted spine surgery continues to rapidly develop as evidenced by the growing literature in recent years. In addition to demonstrating excellent pedicle screw accuracy, early studies have explored the impact of robot-assisted spine surgery on reducing radiation time, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. Recently, the Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic's Stealth navigation technology into the Mazor X platform, which was introduced in 2016. It is unclear what the impact of these advancements have made on clinical outcomes. PURPOSE To compare the outcomes and complications between the most recent iterations of the Mazor Robot systems: Mazor X and Mazor X Stealth Edition. STUDY DESIGN Multicenter cohort PATIENT SAMPLE: Among four different institutions, we included adult (≥18 years old) patients who underwent robot-assisted spine surgery with either the Mazor X (non-navigated robot) or Stealth (navigated robot) platforms. OUTCOME MEASURES Primary outcomes included robot time per screw, fluoroscopic radiation time, screw accuracy, robot abandonment, and clinical outcomes with a minimum 90 day follow up. METHODS A one-to-one propensity-score matching algorithm based on perioperative factors (e.g. demographics, comorbidities, primary diagnosis, open vs. percutaneous instrumentation, prior spine surgery, instrumented levels, pelvic fixation, interbody fusion, number of planned robot screws) was employed to control for the potential selection bias between the two robotic systems. Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively. RESULTS From a total of 646 patients, a total of 372 adult patients were included in this study (X: 186, Stealth: 186) after propensity score matching. The mean number of instrumented levels was 4.3. The mean number of planned robot screws was 7.8. Similar total operative time and robot time per screw occurred between cohorts (p>0.05). However, Stealth achieved significantly shorter fluoroscopic radiation time per screw (Stealth: 7.2 seconds vs. X: 10.4 seconds, p<.001) than X. The screw accuracy for both robots was excellent (Stealth: 99.6% vs. X: 99.1%, p=0.120). In addition, Stealth achieved a significantly lower robot abandonment rate (Stealth: 0% vs. X: 2.2%, p=0.044). Furthermore, a lower blood transfusion rate was observed for Stealth than X (Stealth: 4.3% vs. X: 10.8%, p=0.018). Non-robot related complications such as dura tear, motor/sensory deficits, return to the operating room during same admission, and length of stay was similar between robots (p>0.05). The 90-day complication rates were low and similar between robot cohorts (Stealth: 5.4% vs. X: 3.8%, p=0.456). CONCLUSION In this multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, using Stealth led to significantly less fluoroscopic radiation time, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including length of stay, and 90-day complications were similar.
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Affiliation(s)
- Nathan J Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA.
| | - Scott L Zuckerman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ian A Buchanan
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Justin Mathew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Eric Leung
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Paul J Park
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Martin H Pham
- Department of Neurosurgery, University of San Diego Health, Sand Diego, CA, USA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Asham Khan
- Department of Neurosurgery, State University of New York, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, State University of New York, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, State University of New York, Buffalo, NY, USA
| | - Ehsan Jazini
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | - Colin Haines
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | - Thomas C Schuler
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | | | - Joseph M Lombardi
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
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Usability of Graphical Visualizations on a Tool-Mounted Interface for Spine Surgery. J Imaging 2021; 7:jimaging7080159. [PMID: 34460795 PMCID: PMC8404910 DOI: 10.3390/jimaging7080159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/29/2021] [Accepted: 08/17/2021] [Indexed: 12/01/2022] Open
Abstract
Screw placement in the correct angular trajectory is one of the most intricate tasks during spinal fusion surgery. Due to the crucial role of pedicle screw placement for the outcome of the operation, spinal navigation has been introduced into the clinical routine. Despite its positive effects on the precision and safety of the surgical procedure, local separation of the navigation information and the surgical site, combined with intricate visualizations, limit the benefits of the navigation systems. Instead of a tech-driven design, a focus on usability is required in new research approaches to enable advanced and effective visualizations. This work presents a new tool-mounted interface (TMI) for pedicle screw placement. By fixing a TMI onto the surgical instrument, physical de-coupling of the anatomical target and navigation information is resolved. A total of 18 surgeons participated in a usability study comparing the TMI to the state-of-the-art visualization on an external screen. With the usage of the TMI, significant improvements in system usability (Kruskal–Wallis test p < 0.05) were achieved. A significant reduction in mental demand and overall cognitive load, measured using a NASA-TLX (p < 0.05), were observed. Moreover, a general improvement in performance was shown by means of the surgical task time (one-way ANOVA p < 0.001).
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13
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Kelley BV, Hsiue PP, Upfill-Brown AM, Chen CJ, Villalpando C, Lord EL, Shamie AN, Stavrakis AI, Park DY. Utilization trends and outcomes of computer-assisted navigation in spine fusion in the United States. Spine J 2021; 21:1246-1255. [PMID: 33794362 DOI: 10.1016/j.spinee.2021.03.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Computer-assisted navigation (CAN) has emerged in spine surgery as an approach to improve patient outcomes. While there is substantial evidence demonstrating improved pedicle screw accuracy in CAN as compared to conventional spinal fusion (CONV), there is limited data regarding clinical outcomes and utilization trends in the United States. PURPOSE The purpose of this study was to determine the utilization rates of CAN in the United States, identify patient and hospital trends associated with both techniques, and to compare their results. STUDY DESIGN Retrospective review of national database. PATIENT SAMPLE Nationwide Inpatient Sample (NIS), United States national database. OUTCOME MEASURES CAN utilization, mortality, medical complications, neurologic complications, discharge destination, length of hospital stay, cost of hospital stay. METHODS The NIS database was queried to identify patients undergoing spinal fusion with CAN or CONV. CAN and CONV utilization were tracked by year and anatomic location (cervical, thoracic, lumbar/lumbosacral). Patient demographics, hospital characteristics, index length of stay (LOS), and cost of stay (COS) were compared between the cohorts. After multivariate adjustment, index hospitalization clinical outcomes were compared. RESULTS A total of 4,275,413 patients underwent spinal fusion surgery during the study period (2004 to 2014). CONV was performed in 98.4% (4,208,068) of cases and CAN was performed in 1.6% (67,345) of cases. The utilization rate of CAN increased from 0.04% in 2004 to 3.3% in 2014. Overall, CAN was performed most commonly in the lumbar/lumbosacral region (70.4%) compared to the cervical (20.4%) or thoracic (9.2%) regions. When normalized to region-specific rates of fusion with any technique, the proportional utilization of CAN was highest in the thoracic spine (2.7%), followed by the lumbar/lumbosacral (2.2%) and cervical (0.9%) regions. CAN utilization was positively correlated with patient factors including increasing age and number of medical comorbidities. Multivariate adjusted clinical outcomes demonstrated that compared to CONV, CAN was associated with a statistically significant decreased risk of mortality (0.28% vs 0.31%, OR=0.67, 95% CI: 0.46-0.97, p=.035) and increased risk of blood transfusions (9.1% vs 6.7%, OR=1.19, 95% CI: 1.02-1.39, p=.032). However, there was no difference in risk of neurologic complications. CAN patients had an increased average LOS (4.44 days vs. 3.97 days, p<.0001) and average COS ($34,669.49 vs $26,784.62, p<.0001) compared to CONV patients. CONCLUSIONS CAN utilization increased in the United States from 2004-2014. Use of CAN was proportionately higher in the thoracic and lumbar/lumbosacral regions and in older patients with more comorbidities. Given the continued trend towards increased CAN utilization, large-scale studies are needed to determine the impact of this technology on long-term clinical outcomes.
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Affiliation(s)
- Benjamin V Kelley
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Peter P Hsiue
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Alexander M Upfill-Brown
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Clark J Chen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Cristina Villalpando
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Elizabeth L Lord
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Arya N Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Alexandra I Stavrakis
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA.
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14
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Rawicki N, Dowdell JE, Sandhu HS. Current state of navigation in spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:85. [PMID: 33553378 PMCID: PMC7859779 DOI: 10.21037/atm-20-1335] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of navigation has become more prevalent in spine surgery. The multitude of available platforms, as well as increased availability of navigation systems, have led to increased use worldwide. Specific subsets of spine surgeons have incorporated this new technology in their practices, including minimally invasive spine (MIS) spine surgeons, neurosurgeons, and high-volume surgeons. Improved accuracy with the use of navigation has been demonstrated and its use has proven to be a safe alternative to fluoroscopic guided procedures. Navigation use allows the limitation of radiation exposure to the surgeon during common spine procedures, which over the course of a surgeon's lifetime may offer significant health benefits. Navigation has also been beneficial in tumor resection and MIS surgery, where traditional anatomic landmarks are missing or in the case of MIS not visible. As cost effectiveness improves, the use of navigation is likely to continue to expand. Navigation will also continue to expand with further innovation such as coupling the use of navigation with robotics and improving tools to enhance the end user experience.
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Affiliation(s)
- Nathaniel Rawicki
- Department of Orthopedics, Westchester Medical Center, Valhalla, NY, USA
| | - James E Dowdell
- Department of Spine, Hospital for Special Surgery, New York, NY, USA
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15
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Ho SY, Chuen SY, Man MC. Early Clinical Result of Computerized Navigated Screw Fixation in Treatment of Fragility Pelvic Fracture. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720980008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: Minimal invasive fixation of fragility pelvic fracture is feasible with advancement of computerized navigation. However, the clinical outcomes compared with conservative care were seldom mentioned. Method: This is a retrospective study comparing the outcomes of elderly with stable pelvic fracture treated conservatively or operatively using computerized navigation. Outcome parameters included pain score, analgesics requirement, length of hospital stay and complication(s), if any. Result: Operations were performed in 15 patients from July 2017 to November 2018. A retrospective cohort of 37 patients who were treated conservatively was recruited. In the operative group, it showed a statistically significant reduction in analgesics consumption at 4-week time only. There was significant improvement in pain score at 1-week, 4-week and 3-month time. Patients showed earlier return to premorbid walking status. No major surgical complication was noted. Conclusion: Treating fragility pelvic fracture with computerized navigated screw fixation achieve better pain control, reduction in analgesics requirement and earlier mobilization.
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Affiliation(s)
- Sin Yiu Ho
- Department of Orthopedics and Traumatology, North District Hospital, Hong Kong
| | - Siu Yuk Chuen
- Department of Orthopedics and Traumatology, North District Hospital, Hong Kong
| | - Ma Chun Man
- Department of Orthopedics and Traumatology, North District Hospital, Hong Kong
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16
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Guidelines for navigation-assisted spine surgery. Front Med 2020; 14:518-527. [PMID: 32681209 DOI: 10.1007/s11684-020-0775-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 03/14/2020] [Indexed: 10/23/2022]
Abstract
Spinal surgery is a technically demanding and challenging procedure because of the complicated anatomical structures of the spine and its proximity to several important tissues. Surgical landmarks and fluoroscopy have been used for pedicle screw insertion but are found to produce inaccuracies in placement. Improving the safety and accuracy of spinal surgery has increasingly become a clinical concern. Computerassisted navigation is an extension and application of precision medicine in orthopaedic surgery and has significantly improved the accuracy of spinal surgery. However, no clinical guidelines have been published for this relatively new and fast-growing technique, thus potentially limiting its adoption. In accordance with the consensus of consultant specialists, literature reviews, and our local experience, these guidelines include the basic concepts of the navigation system, workflow of navigation-assisted spinal surgery, some common pitfalls, and recommended solutions. This work helps to standardize navigation-assisted spinal surgery, improve its clinical efficiency and precision, and shorten the clinical learning curve.
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17
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Wang M, Li D, Shang X, Wang J. A review of computer-assisted orthopaedic surgery systems. Int J Med Robot 2020; 16:1-28. [PMID: 32362063 DOI: 10.1002/rcs.2118] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/07/2020] [Accepted: 04/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Computer-assisted orthopaedic surgery systems have great potential, but no review has focused on computer-assisted surgery systems for the spine, hip, and knee. METHODS A systematic search was performed in Web of Science and PubMed. We searched the literature on computer-assisted orthopaedic surgery systems from 2008 to the present and focused on three aspects of systems: training, planning, and intraoperative navigation. RESULTS AND DISCUSSION In this review study, we reviewed 34 surgical training systems, 31 surgical planning systems, and 41 surgical navigation systems. The functions and characteristics of the surgical systems were compared and analysed, and the current concerns about and the impact of the surgical systems on doctors and surgery were clarified. CONCLUSION Computer-assisted orthopaedic surgery systems are still in the development stage. Future surgical training systems should include synthetic models with patient anatomy. Surgical planning systems with automatic planning should be developed, and surgical navigation systems with multimodal fusion, robotic assistance and imaging should be developed.
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Affiliation(s)
- Monan Wang
- Mechanical & Power Engineering College , Harbin University of Science and Technology, Harbin, China
| | - Donghui Li
- Mechanical & Power Engineering College , Harbin University of Science and Technology, Harbin, China
| | - Xiping Shang
- Mechanical & Power Engineering College , Harbin University of Science and Technology, Harbin, China
| | - Jian Wang
- Mechanical & Power Engineering College , Harbin University of Science and Technology, Harbin, China
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18
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Tonetti J, Boudissa M, Kerschbaumer G, Seurat O. Role of 3D intraoperative imaging in orthopedic and trauma surgery. Orthop Traumatol Surg Res 2020; 106:S19-S25. [PMID: 31734181 DOI: 10.1016/j.otsr.2019.05.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/03/2019] [Accepted: 05/09/2019] [Indexed: 02/02/2023]
Abstract
Intraoperative three-dimensional (3D) imaging is now feasible because of recent technological advances such as 3D cone-beam CT (CBCT) and flat-panel X-ray detectors (FPDs). These technologies reduce the radiation dose to the patient and surgical team. The aim of this study is to review the advantages of 3D intraoperative imaging in orthopedic and trauma surgery by answering the following 5 questions: What are its technical principles? CBCT with a FPD produces non-distorted digital images and frees up the surgical field. The high quality of these 3D intraoperative images allows them to be integrated into surgical navigation systems. Human-robot comanipulation will likely follow soon after. Conventional multislice CT technology has also improved to the point where it can be used in the operating room. What can we expect from 3D intraoperative imaging and which applications have been validated clinically? We reviewed the literature on this topic for the past 10 years. The expected benefits were determined during the implantation of pedicular screws: more accurate implantation, fewer surgical revisions and time savings. There are few studies in trauma or arthroplasty cases, as robotic comanipulation is a more recent development. What is the tolerance for irradiation to the patient and surgical team? The health drawbacks are the harmful radiation-induced effects. The deterministic effects that we will develop are correlated to the absorbed dose in Gray units (Gy). The stochastic and carcinogenic effects are related to the effective dose in milliSievert (mSv) of linear evolution without threshold. The International Commission on Radiological Protection (ICRP) states that irradiation for medical purposes with risk of detriment is acceptable if it is justified by an optimization attempt. The radioprotection limits must be known but do not constitute opposable restrictions. The superiority of intraoperative 3D imaging over fluoroscopy has been demonstrated for spine surgery and sacroiliac screw fixation. How does the environment need to be adapted? The volume, access, wall protection and floor strength of the operating room must take into account the features of each machine. The instrumentation implants and need for specialized staff result in additional costs. Not every system can track movements during the CBCT acquisition thus transient suspension of assisted ventilation may be required. Is it financially viable? This needs to be calculated based on the expected clinical benefits, which mainly correspond to the elimination of expenses tied to surgical revisions. Our society's search for safety has driven the investments in this technology. LEVEL OF EVIDENCE: V, Expert opinion.
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Affiliation(s)
- Jérôme Tonetti
- Clinique universitaire de chirurgie orthopédique et traumatologie, hôpital Michallon, CS 10217, 38043 Grenoble cedex 09, France.
| | - Mehdi Boudissa
- Clinique universitaire de chirurgie orthopédique et traumatologie, hôpital Michallon, CS 10217, 38043 Grenoble cedex 09, France
| | - Gael Kerschbaumer
- Clinique universitaire de chirurgie orthopédique et traumatologie, hôpital Michallon, CS 10217, 38043 Grenoble cedex 09, France
| | - Olivier Seurat
- Clinique universitaire de chirurgie orthopédique et traumatologie, hôpital Michallon, CS 10217, 38043 Grenoble cedex 09, France
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Fukunaga M, Matsubara K, Takei Y, Mitsui H, Kameiyama H, Tanaka T, Ichikawa S. [Scatter Radiation Intensities during Transforaminal Lumbar Interbody Fusion Using a Mobile C-arm System]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2020; 76:572-578. [PMID: 32565514 DOI: 10.6009/jjrt.2020_jsrt_76.6.572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The purpose of this study was to measure the scatter radiation intensity during transforaminal lumbar interbody fusion using a mobile C-arm system (Arcadis Orbic 3D; Siemens) and minimize radiation exposure. Dosimetry was performed with anterior-posterior and lateral continuous fluoroscopy, and cone beam computed tomography (CT). A scaffold tower (L: 300 cm×W: 200 cm×H: 150 cm) was built with radiation-resistant paper cylinders at intervals of 50 cm and plastic joints over the bed, and 100 optically stimulated luminescence dosimeters (nanoDot; Nagase Landauer) were placed on each joint. A human torso phantom from head to pelvis (Kyoto Kagaku) was positioned on the bed in a prone position. The scatter radiation dose in a lateral view was highest on the X-ray tube side at the height of 100 cm (170.5 μGy/min). The scatter radiation dose increased significantly on the X-ray tube side during lateral continuous fluoroscopy. Continuous change of surgeons' standing positions is important to minimize radiation exposure received by a specific surgeon.
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Affiliation(s)
- Masaaki Fukunaga
- Department of Radiological Technology, Kurashiki Central Hospital
- Department of Quantum Medical Technology, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University
| | - Kosuke Matsubara
- Department of Quantum Medical Technology, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University
| | - Yasutaka Takei
- Department of Radiological Technology, Faculty of Medical Science and Technology, Kawasaki University of Medical Welfare
| | - Hideki Mitsui
- Department of Radiological Technology, Kurashiki Central Hospital
| | | | - Takanao Tanaka
- Department of Radiological Technology, Kurashiki Central Hospital
| | - Shota Ichikawa
- Department of Radiological Technology, Kurashiki Central Hospital
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Chang CJ, Fong YW, Su IC, Hsieh CT, Huang CT. Accuracy and safety of pedicle screws implantation using Zeego and Brainlab navigation system in hybrid operation room. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_65_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Revisiting the Middle Cluneal Nerves: An Anatomic Study with Application to Pain Syndromes and Invasive Procedures Around the Sacrum. World Neurosurg 2019; 127:e1228-e1231. [DOI: 10.1016/j.wneu.2019.04.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 11/18/2022]
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22
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Vaishnav AS, Othman YA, Virk SS, Gang CH, Qureshi SA. Current state of minimally invasive spine surgery. JOURNAL OF SPINE SURGERY 2019; 5:S2-S10. [PMID: 31380487 DOI: 10.21037/jss.2019.05.02] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Over the past two decades, minimally invasive surgical approaches have become increasingly feasible, efficient and popular for the management of a wide range of spinal disorders, with a growing body of research demonstrating numerous advantages of these techniques over the traditional open approach. In this article, we review the technologies and innovations that are expanding the horizon of minimally invasive spine surgery (MISS), and highlight high-quality peer-reviewed literature in the past year that expands our knowledge and understanding of indications, advantages and limitations of MISS.
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Affiliation(s)
| | - Yahya A Othman
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | | | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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Popkin CA, Chan CM, Nowell JA, Crowley SG, Wright M, Ahmad CS. Computer Navigation for Pediatric Femoral ACL Tunnel Placement. THE IOWA ORTHOPAEDIC JOURNAL 2019; 39:121-129. [PMID: 31413685 PMCID: PMC6604552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND To compare accuracy, time and radiation exposure of pediatric femoral tunnel placement using computer navigation with a traditional freehand technique. METHODS A single all-epiphyseal femoral tunnel was placed in the distal femur of 20 Sawbones™ adolescent knee models. Ten tunnels were drilled using standard fluoroscopic guidance (FG). An additional 10 tunnels were drilled using 3D fluoroscopic computer navigation (CN). Both techniques aimed to match an exact point described by the quadrant system of Bernard. Time to perform the procedure was recorded as were number of single shot fluoroscopic images and approximate effective radiation doses. RESULTS The deviation from ideal femoral tunnel position was on average 6.4 ± 4.2 mm for FG tunnels and 2.7 ± 3.1 mm for CN tunnels (p<0.05) . There was no violation of the femoral growth plate using either technique. The surgeon was exposed to 17 ± 5.3 and 3 ± 0.66 single fluoroscopy exposures for FG and CN guidance, respectively (p<0.05). However, the effective dose for the CN because of the acquisition of 3D images was 0.52±.003 mSv and for FG was only 0.09mSv ± .027 (p <0.001). CN however required on average 12.5 ± 3.4 min compared to 4.6 ± 1.7 for FG (p<0.05) to complete drilling of the tunnel. CONCLUSON CN achieves a more accurate epiphyseal femoral ACL tunnel position but requires more time to complete and has a higher effective radiation dose than FG. Whether the CN ACL tunnels can translate to improved clinical outcomes is still unknown.Level of Evidence: V.
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Affiliation(s)
- Charles A Popkin
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY USA
| | - Charles M Chan
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY USA
| | - Jared A Nowell
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY USA
| | | | - Margaret Wright
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY USA
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY USA
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Buser Z, Chung AS, Abedi A, Wang JC. The future of disc surgery and regeneration. INTERNATIONAL ORTHOPAEDICS 2018; 43:995-1002. [PMID: 30506089 DOI: 10.1007/s00264-018-4254-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/25/2018] [Indexed: 12/21/2022]
Abstract
Low back and neck pain are among the top contributors for years lived with disability, causing patients to seek substantial non-operative and operative care. Intervertebral disc herniation is one of the most common spinal pathologies leading to low back pain. Patient comorbidities and other risk factors contribute to the onset and magnitude of disc herniation. Spine fusions have been the treatment of choice for disc herniation, due to the conflicting evidence on conservative treatments. However, re-operation and costs have been among the main challenges. Novel technologies including cage surface modifications, biologics, and 3D printing hold a great promise. Artificial disc replacement has demonstrated reduced rates of adjacent segment degeneration, need for additional surgery, and better outcomes. Non-invasive biological approaches are focused on cell-based therapies, with data primarily from preclinical settings. High-quality comparative studies are needed to evaluate the efficacy and safety of novel technologies and biological therapies.
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Affiliation(s)
- Zorica Buser
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA.
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo St, HC4 - #5400A, Los Angeles, CA, 90033, USA.
| | | | - Aidin Abedi
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
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Comparison of the Clinical Accuracy Between Point-to-Point Registration and Auto-Registration Using an Active Infrared Navigation System. Spine (Phila Pa 1976) 2018; 43:E1329-E1333. [PMID: 29689003 DOI: 10.1097/brs.0000000000002704] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A model experiment. OBJECTIVE To measure and compare the clinical accuracy of point-to-point registration (PR) and auto-registration (AR) in an operative set using an active infrared navigation system. SUMMARY OF BACKGROUND DATA PR and AR are two major registration methods of navigation assisted spinal surgery. No previous study compared the difference between the two methods with respect to clinical accuracy. METHODS A novel method was used to measure the clinical accuracy of the navigation system under an operative set using a Sawbone model with titanium beads on the surface, which was essential to measure the accuracy numerically, instead of a real patient. Both the operative set and the procedure mimicked a regular surgery. The clinical accuracy was defined as the average distance between the "navigation coordinate" and the "image coordinate." The clinical accuracy of the PR using preoperative computed tomography (CT) images and the AR using intraoperative CT images was measured and compared. RESULTS The average clinical accuracy of PR was different among different segments. The accuracy of the most accurate segment, which provided the reference points during the PR, was 1.10 mm. In the two segments adjacent to the reference segment, the clinical accuracy deteriorated to 1.37 and 1.50 mm. The accuracy of the farther segments was worse. In comparison, the clinical accuracy of different segments of AR was of no significant difference. The average accuracy of AR was 0.74 mm, which was significantly better than the best accuracy of PR. CONCLUSION AR is better than PR with respect to clinical accuracy in navigation assisted spinal surgery. LEVEL OF EVIDENCE N/A.
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Kouyoumdjïan P, Gras-Combe G, Grelat M, Fuentes S, Blondel B, Tropiano P, Zairi F, Beaurain J, Charles YP, Dhenin A, Elfertit H, Le Roy J, Greffier J, Lonjon N. Surgeon's and patient's radiation exposure during percutaneous thoraco-lumbar pedicle screw fixation: A prospective multicenter study of 100 cases. Orthop Traumatol Surg Res 2018; 104:597-602. [PMID: 29969721 DOI: 10.1016/j.otsr.2018.05.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 04/26/2018] [Accepted: 05/16/2018] [Indexed: 02/02/2023]
Abstract
HYPOTHESIS Percutaneous pedicle screw fixations (PPSF) are increasingly used in spine surgery, minimizing morbidity through less muscle breakdown but at the cost of intraoperative fluoroscopic guidance that generates high radiation exposure. Few studies have been conducted to measure them accurately. MATERIAL AND METHODS The objective of our study is to quantify, during a PPSF carried out in different experimented centers respecting current radiation protection recommendations, this irradiation at the level of the surgeon and the patient. We have prospectively included 100 FPVP procedures for which we have collected radiation doses from the main operator. For each procedure, the doses of whole-body radiation, lens and extremities were measured. RESULTS Our results show a mean whole body, extremity and lens exposure dose per procedure reaching 1.7±2.8μSv, 204.7±260.9μSv and 30.5±25.9μSv, respectively. According to these values, the exposure of the surgeon's extremities and lens will exceed the annual limit allowed by the International Commission on Radiological Protection (ICRP) after 2440 and 4840 procedures respectively. CONCLUSION Recent European guidelines will reduce the maximum annual exposure dose from 150 to 20mSv. The number of surgical procedures to not reach the eye threshold, according to our results, should not exceed 645 procedures per year. Pending the democratization of neuronavigation systems, the use of conventional fluoroscopy exposes the eyes in the first place. Therefore they must be protected by leaded glasses. LEVEL OF PROOF IV, case series.
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Affiliation(s)
- Pascal Kouyoumdjïan
- Orthopedic Surgery, Spine Unit, Hôpital Carémeau, University Montpellier 1, CHU de Nîmes, 30029 Nîmes, France
| | - Guillaume Gras-Combe
- Neurosurgery Unit, Hôpital Gui-de-Chauliac, CHU de Montpellier, 34000 Montpellier, France
| | - Mickael Grelat
- Neurosurgery Unit, CHU Dijon-Bourgogne, 21000 Dijon, France
| | - Stéphane Fuentes
- Neurosurgery Unit, Hôpital la Timone, AP-HM, 13385 Marseille, France
| | - Benjamin Blondel
- Orthopedic Surgery, Spine Unit, Hôpital la Timone, AP-HM, 13385 Marseille, France
| | - Patrick Tropiano
- Orthopedic Surgery, Spine Unit, Hôpital la Timone, AP-HM, 13385 Marseille, France
| | - Fahed Zairi
- Neurosurgery Units, Hôpital Roger-Salengro, CHR, 59037 Lille, France
| | | | - Yann-Philippe Charles
- Orthopedic Surgery, Spine Unit, CHRU de Strasbourg, BP 426, 67091 Strasbourg, France
| | - Alexandre Dhenin
- Orthopedic Surgery, Spine Unit, Hôpital Carémeau, University Montpellier 1, CHU de Nîmes, 30029 Nîmes, France
| | - Hassan Elfertit
- Neurosurgery Unit, Hôpital Carémeau, CHU de Nîmes, 30029 Nîmes, France
| | - Julien Le Roy
- Department of radiation Physics, CHRU de Montpellier, 34295 Montpellier, France
| | - Joel Greffier
- Department of Medical Imaging, Hôpital Caremeau, CHU de Nîmes, 30029 Nîmes, France
| | - Nicolas Lonjon
- Neurosurgery Unit, Hôpital Gui-de-Chauliac, CHU de Montpellier, 34000 Montpellier, France.
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Thadani VN, Riaz MJ, Singh G. The evolution of three-dimensional technology in musculoskeletal oncology. J Clin Orthop Trauma 2018; 9:269-274. [PMID: 30202160 PMCID: PMC6128801 DOI: 10.1016/j.jcot.2018.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/21/2018] [Indexed: 12/25/2022] Open
Abstract
Musculoskeletal tumours pose considerable challenges for the orthopaedic surgeon during pre-operative planning, resection and reconstruction. Improvements in imaging technology have improved the diagnostic process of these tumours. Despite this, studies have highlighted the difficulties in achieving consistent resection free margins especially in tumours of the pelvis and spine when using conventional methods. Three-dimensional technology - three-dimensional printing and navigation technology - while relatively new, may have the potential to prove useful in the musculoskeletal tumour surgeon's arsenal. Three-dimensional printing (3DP) allows the production of objects by adding material layer by layer rather than subtraction from raw materials as performed conventionally. High resolution imaging, computer tomography (CT) and magnetic resonance imaging (MRI), are used to print highly complex and accurate items. Powder-based printing, vat polymerization-based printing and droplet-based printing are the common 3DP technologies applied. 3DP has been utilized pre-operatively in surgical planning and intra-operatively for patient specific instruments and custom made prosthesis. Pre-operative 3DP models transfer information to the surgeon in a concise yet exhaustive manner. Patient specific instruments are customized 3DP instruments utilized with the intention to easily replicate surgical plans. Complex musculoskeletal tumours pose reconstructive challenges and standard implants are often unable to reconstruct defects satisfactorily. The ability to use custom materials and tailor the pore size, elastic modulus and porosity of the 3DP prosthesis to be comparable to the patient's bone allows for a potential patient-specific prosthesis with unique incorporation and longevity properties. Similarly, navigation technology utilizes CT or MRI images to provides surgeons with real time intraoperative three-dimensional calibration of instruments. It has been shown to potentially allow surgeons to perform more accurate resections. These technological advancements have the potential to greatly impact the management of musculoskeletal tumours. 3D planning models, patient-specific instruments and customized 3DP implants and navigation should not be thought of as separate, but rather, patient-specific adaptation of relevant modes of application should be selected on a case-by-case basis when taking all unique factors of each case into consideration.
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Affiliation(s)
| | | | - Gurpal Singh
- University Orthopaedics, Hand and Reconstructive Microsurgery (UOHC), National University Health System, Singapore
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Radiation exposure for the surgical team in a hybrid-operating room. J Robot Surg 2018; 13:91-98. [PMID: 29748746 DOI: 10.1007/s11701-018-0821-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/30/2018] [Indexed: 01/29/2023]
Abstract
Hybrid-operating rooms enable the surgeon to acquire intraoperative high-resolution 2- and 3D images and use them for navigation. The radiation dose of the operating personal and the patient remains the major concern. In 9 months, 109 pelvic and spine cases were performed using a hybrid operating room. Radiation dose of the surgeon and the assisting nurse was recorded using real-time dosimeters. Lower radiation doses for the main surgeon in navigated dorsal instrumentations of the thoracic spine were recorded. Standing between the C-arm during screw placement increased the radiation dose sixfold. Lumbar dorsal instrumentation showed a similar radiation dose compared to the previous studies in traditional operating room settings. The use of a hybrid-operating room for dorsal spine instrumentation showed no increase in radiation dose compared to traditional settings. Intraoperative navigation can help to reduce the radiation dosage for the operating personnel.
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Abstract
Navigation in surgery has increasingly become more commonplace. The use of this technological advancement has enabled ever more complex and detailed surgery to be performed to the benefit of surgeons and patients alike. This is particularly so when applying the use of navigation within the field of orthopedic oncology. The developments in computer processing power coupled with the improvements in scanning technologies have permitted the incorporation of navigational procedures into day-to-day practice. A comprehensive search of PubMed using the search terms "navigation", "orthopaedic" and "oncology" yielded 97 results. After filtering for English language papers, excluding spinal surgery and review articles, this resulted in 38 clinical studies and case reports. These were analyzed in detail by the authors (GM and JS) and the most relevant papers reviewed. We have sought to provide an overview of the main types of navigation systems currently available within orthopedic oncology and to assess some of the evidence behind its use.
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Affiliation(s)
- Guy Vernon Morris
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom,Address for correspondence: Dr. Guy Vernon Morris, The Oncology Unit, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham B31 2AP, West Midlands, United Kingdom. E-mail:
| | - Jonathan D Stevenson
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom
| | - Scott Evans
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom
| | - Michael C Parry
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom
| | - Lee Jeys
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom,School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
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Déjardin LM, Fauron AH, Guiot LP, Guillou RP. Minimally invasive lag screw fixation of sacroiliac luxation/fracture using a dedicated novel instrument system: Apparatus and technique description. Vet Surg 2017; 47:93-103. [DOI: 10.1111/vsu.12746] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/19/2017] [Accepted: 09/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Loïc M. Déjardin
- College of Veterinary Medicine; Michigan State University; East Lansing Michigan
| | - Albane H. Fauron
- College of Veterinary Medicine; Michigan State University; East Lansing Michigan
| | - Laurent P. Guiot
- Bone & Joint Center, ACCESS Specialty Animal Hospitals; Los Angeles California
| | - Reunan P. Guillou
- Bone & Joint Center, ACCESS Specialty Animal Hospitals; Los Angeles California
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Janssen I, Lang G, Navarro-Ramirez R, Jada A, Berlin C, Hilis A, Zubkov M, Gandevia L, Härtl R. Can Fan-Beam Interactive Computed Tomography Accurately Predict Indirect Decompression in Minimally Invasive Spine Surgery Fusion Procedures? World Neurosurg 2017; 107:322-333. [DOI: 10.1016/j.wneu.2017.07.167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/25/2017] [Accepted: 07/27/2017] [Indexed: 12/29/2022]
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Abstract
Spinal instrumentation often involves placing implants without direct visualization of their trajectory or proximity to adjacent neurovascular structures. Two-dimensional fluoroscopy is commonly used to navigate implant placement, but with the advent of computed tomography, followed by the invention of a mobile scanner with an open gantry, three-dimensional (3D) navigation is now widely used. This article critically appraises the available literature to assess the influence of 3D navigation on radiation exposure, accuracy of instrumentation, operative time, and patient outcomes. Also explored is the latest technological advance in 3D neuronavigation: the manufacturing of, via 3D printers, patient-specific templates that direct implant placement.
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Ecker TM, Jost J, Cullmann JL, Zech WD, Djonov V, Keel MJB, Benneker LM, Bastian JD. Percutaneous screw fixation of the iliosacral joint: A case-based preoperative planning approach reduces operating time and radiation exposure. Injury 2017; 48:1825-1830. [PMID: 28687363 DOI: 10.1016/j.injury.2017.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 05/25/2017] [Accepted: 06/19/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A preoperative planning approach for percutaneous screw fixation of the iliosacral joint provides specific entry points (EPs) and aiming points (APs) of intraosseous screw pathways (as defined by CT scans) for lateral fluoroscopic projections used intraoperatively. The potential to achieve the recommended EPs and APs, to obtain an ideal screw position (perpendicular to the iliosacral joint), to avoid occurrence of extraosseous screw misplacement, to reduce the operating time and the radiation exposure by utilizing this planning approach have not been described yet. METHODS On preoperative CT scans of eight human cadaveric specimen individual EPs and APs were identified and transferred to the lateral fluoroscopic projection using a coordinate system with the zero-point in the center of the posterior cortex of the S1 vertebral body (x-axis parallel to upper S1 endplate). Distances were expressed in relation to the anteroposterior distance of the S1 upper endplate (in%). In each specimen on one side a screw was placed with provided EP and AP (New Technique) whereas at the contralateral side a screw was placed without given EP and AP (Conventional Technique). Both techniques were compared using postoperative CT scans to assess distances between predefined EPs and APs and the actually obtained EPs and APs, screw angulations in relation to the iliosacral joint in coronal and axial planes and the occurrence of any extraosseous screw misplacement. The "operating time (OT)" and the "time under fluoroscopy (TUF)" were recorded. Statistical analysis was performed by the Wilcoxon signed-rank test. RESULTS EPs were realized significantly more accurate using the new technique in vertical direction. The screw positions in relation to the iliosacral joint showed no significant difference between both techniques. Both techniques had one aberrantly placed screw outside the safe corridor. The (mean±SD) "OT" and the (mean±SD) "TUF" were significantly decreased using the new technique compared to the conventional technique (OT: 7.6±2min versus 13.1±5.8min, p=0.012; TUF: 1.5±0.8min versus 2.2±1.1min). CONCLUSION The presented preoperative planning approach increases the accuracy in percutaneous screw fixation of the iliosacral joint, reduces operating time and minimizes radiation exposure to patient and staff.
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Affiliation(s)
- T M Ecker
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - J Jost
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - J L Cullmann
- Institute for Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - W D Zech
- Institute of Forensic Medicine, Department of Forensic Medicine and Imaging, University of Bern, Bühlstrasse 20, 3010 Bern, Switzerland
| | - V Djonov
- Institute of Anatomy, University of Bern, Switzerland
| | - M J B Keel
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - L M Benneker
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Freiburgstrasse 3, 3010 Bern, Switzerland
| | - J D Bastian
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Freiburgstrasse 3, 3010 Bern, Switzerland.
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Radiation dose reduction in thoracic and lumbar spine instrumentation using navigation based on an intraoperative cone beam CT imaging system: a prospective randomized clinical trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2818-2827. [DOI: 10.1007/s00586-017-5229-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 07/09/2017] [Accepted: 07/18/2017] [Indexed: 02/06/2023]
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Nasser R, Drazin D, Nakhla J, Al-Khouja L, Brien E, Baron EM, Kim TT, Patrick Johnson J, Yassari R. Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis. Neurosurg Focus 2017; 41:E15. [PMID: 27476839 DOI: 10.3171/2016.5.focus16136] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions. METHODS This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance. RESULTS The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14-87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62-865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5-7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1-36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden. CONCLUSIONS O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.
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Affiliation(s)
- Rani Nasser
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York;
| | | | - Jonathan Nakhla
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York;
| | | | - Earl Brien
- Orthopedics, Cedars-Sinai Medical Center, Los Angeles; and
| | | | - Terrence T Kim
- Departments of 2 Neurosurgery and.,Orthopedics, Cedars-Sinai Medical Center, Los Angeles; and
| | - J Patrick Johnson
- Departments of 2 Neurosurgery and.,Department of Neurosurgery, University of California, Davis, California
| | - Reza Yassari
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York;
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Overley SC, Cho SK, Mehta AI, Arnold PM. Navigation and Robotics in Spinal Surgery: Where Are We Now? Neurosurgery 2017; 80:S86-S99. [DOI: 10.1093/neuros/nyw077] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/22/2016] [Indexed: 11/12/2022] Open
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Wang TY, Farber SH, Perkins SS, Back AG, Byrd SA, Chi D, Vincent D, Karikari IO. Internally Randomized Control Trial of Radiation Exposure Using Ultra-low Radiation Imaging Versus Traditional C-arm Fluoroscopy for Patients Undergoing Single-level Minimally Invasive Transforaminal Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2017; 42:217-223. [PMID: 28207655 DOI: 10.1097/brs.0000000000001720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Randomized controlled trial. OBJECTIVE To compare radiation exposure between ultra-low radiation imaging (ULRI) with image enhancement and standard-dose fluoroscopy for patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA Although the benefits of MIS are lauded by many, there is a significant amount of radiation exposure to surgeon and operating room personnel. Our goal with this work was to see if by using ultra-low dose radiation settings coupled with image enhancement, this exposure could be minimized. METHODS An institutional review board approved, prospective, internally randomized controlled trial was performed comparing ultra-low dose settings coupled with image enhancement software to conventional fluoroscopic imaging. In this study, each patient served as their own control, randomly assigning one side of MIS-TLIF for cannulation and K-wire placement using each imaging modality. Further, the case was also randomly divided into screw placement and cage placement/final images to allow further comparisons amongst patients. Radiation production from the C-arm fluoroscope and radiation exposure to all operating room personnel were recorded. RESULTS Twenty-four patients were randomly assigned to undergo a single level MIS-TLIF. In no case was low radiation imaging abandoned, and no patient had a neurologic decline or required hardware repositioning. Everyone in the operating room-the physician, scrub nurse, circulator, and anesthesiologist-all benefited with 61.6% to 83.5% reduction in radiation exposure during cannulation and K-wire placement to screw insertion aided by ULRI. In every case but the anesthesiologist dose, this was statistically significant (P < 0.05). This benefit required no additional time (P = 0.78 for K-wire placement). CONCLUSION ULRI, when aided by image enhancement software, affords the ability for all parties in the operating room to substantially decrease their radiation exposure compared with standard-dose C-arm fluoroscopy without adding additional time or an increased complication rate. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Timothy Y Wang
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | - S Harrison Farber
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | - Scott S Perkins
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | - Adam G Back
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | - Sarah A Byrd
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | - Debbie Chi
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | | | - Isaac O Karikari
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
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Theologis AA, Burch S, Pekmezci M. Placement of iliosacral screws using 3D image-guided (O-Arm) technology and Stealth Navigation: comparison with traditional fluoroscopy. Bone Joint J 2017; 98-B:696-702. [PMID: 27143744 DOI: 10.1302/0301-620x.98b5.36287] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 11/12/2015] [Indexed: 11/05/2022]
Abstract
AIMS We compared the accuracy, operating time and radiation exposure of the introduction of iliosacral screws using O-arm/Stealth Navigation and standard fluoroscopy. MATERIALS AND METHODS Iliosacral screws were introduced percutaneously into the first sacral body (S1) of ten human cadavers, four men and six women. The mean age was 77 years (58 to 85). Screws were introduced using a standard technique into the left side of S1 using C-Arm fluoroscopy and then into the right side using O-Arm/Stealth Navigation. The radiation was measured on the surgeon by dosimeters placed under a lead thyroid shield and apron, on a finger, a hat and on the cadavers. RESULTS There were no neuroforaminal breaches in either group. The set-up time for the O-Arm was significantly longer than for the C-Arm, while total time for placement of the screws was significantly shorter for the O-Arm than for the C-Arm (p = 0.001). The mean absorbed radiation dose during fluoroscopy was 1063 mRad (432.5 mRad to 4150 mRad). No radiation was detected on the surgeon during fluoroscopy, or when he left the room during the use of the O-Arm. The mean radiation detected on the cadavers was significantly higher in the O-Arm group (2710 mRem standard deviation (sd) 1922) than during fluoroscopy (11.9 mRem sd 14.8) (p < 0.01). CONCLUSION O-Arm/Stealth Navigation allows for faster percutaneous placement of iliosacral screws in a radiation-free environment for surgeons, albeit with the same accuracy and significantly more radiation exposure to cadavers, when compared with standard fluoroscopy. TAKE HOME MESSAGE Placement of iliosacral screws with O-Arm/Stealth Navigation can be performed safely and effectively. Cite this article: Bone Joint J 2016;98-B:696-702.
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Affiliation(s)
- A A Theologis
- University of California, San Francisco, 500 Parnassus MU West 3rd Floor, San Francisco, CA, 94143, USA
| | - S Burch
- University of California, San Francisco, 500 Parnassus MU West 3rd Floor, San Francisco, CA, 94143, USA
| | - M Pekmezci
- University of California, San Francisco, 500 Parnassus MU West 3rd Floor, San Francisco, CA, 94143, USA
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Kleck CJ, Perry JM, Burger EL, Cain CMJ, Milligan K, Patel VV. Sacroiliac Joint Treatment Personalized to Individual Patient Anatomy Using 3-Dimensional Navigation. Orthopedics 2016; 39:89-94. [PMID: 27023416 DOI: 10.3928/01477447-20160304-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
During the past 10 years, the sacroiliac (SI) joint has evolved from being barely recognized as a source of pain, to being a joint treated only nonsurgically or with great surgical morbidity, to currently being a joint treated with minimally invasive techniques that are personalized to the individual patient. The complex 3-dimensional anatomy of the SI joint and lack of parallel to traditional imaging planes requires a thorough understanding of the structures within and around the SI joint that may be at risk of injury. Thus, the SI joint is ideally suited for intraoperative 3-dimensional imaging and surgical navigation when being treated minimally invasively.
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Hazards of Ionizing Radiation and its Impact on Spine Surgery. World Neurosurg 2016; 92:353-359. [DOI: 10.1016/j.wneu.2016.05.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 12/28/2022]
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Mendelsohn D, Strelzow J, Dea N, Ford NL, Batke J, Pennington A, Yang K, Ailon T, Boyd M, Dvorak M, Kwon B, Paquette S, Fisher C, Street J. Patient and surgeon radiation exposure during spinal instrumentation using intraoperative computed tomography-based navigation. Spine J 2016; 16:343-54. [PMID: 26686604 DOI: 10.1016/j.spinee.2015.11.020] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 08/12/2015] [Accepted: 11/10/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Imaging modalities used to visualize spinal anatomy intraoperatively include X-ray studies, fluoroscopy, and computed tomography (CT). All of these emit ionizing radiation. PURPOSE Radiation emitted to the patient and the surgical team when performing surgeries using intraoperative CT-based spine navigation was compared. STUDY DESIGN/SETTING This is a retrospective cohort case-control study. PATIENT SAMPLE Seventy-three patients underwent CT-navigated spinal instrumentation and 73 matched controls underwent spinal instrumentation with conventional fluoroscopy. OUTCOME MEASURES Effective doses of radiation to the patient when the surgical team was inside and outside of the room were analyzed. The number of postoperative imaging investigations between navigated and non-navigated cases was compared. METHODS Intraoperative X-ray imaging, fluoroscopy, and CT dosages were recorded and standardized to effective doses. The number of postoperative imaging investigations was compared with the matched cohort of surgical cases. A literature review identified historical radiation exposure values for fluoroscopic-guided spinal instrumentation. RESULTS The 73 navigated operations involved an average of 5.44 levels of instrumentation. Thoracic and lumbar instrumentations had higher radiation emission from all modalities (CT, X-ray imaging, and fluoroscopy) compared with cervical cases (6.93 millisievert [mSv] vs. 2.34 mSv). Major deformity and degenerative cases involved more radiation emission than trauma or oncology cases (7.05 mSv vs. 4.20 mSv). On average, the total radiation dose to the patient was 8.7 times more than the radiation emitted when the surgical team was inside the operating room. Total radiation exposure to the patient was 2.77 times the values reported in the literature for thoracolumbar instrumentations performed without navigation. In comparison, the radiation emitted to the patient when the surgical team was inside the operating room was 2.50 lower than non-navigated thoracolumbar instrumentations. The average total radiation exposure to the patient was 5.69 mSv, a value less than a single routine lumbar CT scan (7.5 mSv). The average radiation exposure to the patient in the present study was approximately one quarter the recommended annual occupational radiation exposure. Navigation did not reduce the number of postoperative X-rays or CT scans obtained. CONCLUSIONS Intraoperative CT navigation increases the radiation exposure to the patient and reduces the radiation exposure to the surgeon when compared with values reported in the literature. Intraoperative CT navigation improves the accuracy of spine instrumentation with acceptable patient radiation exposure and reduced surgical team exposure. Surgeons should be aware of the implications of radiation exposure to both the patient and the surgical team when using intraoperative CT navigation.
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Affiliation(s)
- Daniel Mendelsohn
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Jason Strelzow
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Nicolas Dea
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Nancy L Ford
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Juliet Batke
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Andrew Pennington
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Kaiyun Yang
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Tamir Ailon
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Michael Boyd
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Marcel Dvorak
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - Brian Kwon
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Scott Paquette
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Charles Fisher
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada
| | - John Street
- Combined Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, Departments of Orthopedics and Neurosurgery, University of British Columbia, Vancouver, Canada; Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, Canada.
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Richter PH, Gebhard F, Dehner C, Scola A. Accuracy of computer-assisted iliosacral screw placement using a hybrid operating room. Injury 2016; 47:402-7. [PMID: 26708797 DOI: 10.1016/j.injury.2015.11.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/03/2015] [Accepted: 11/13/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In recent years hybrid operating rooms were established all over the world. In our setting we combined a 3D flat-panel c-arm (Artis zeego, Siemens) with a navigation system (BrainLab curve, BrainLab). This worldwide unique combination enables the surgeon to visualise an entire pelvis in CT-like image quality with a single 3D-scan. The aim of our study was to investigate, if utilisation of a hybrid operating room increases the accuracy of SI-screws in comparison to standard 3D-navigation. MATERIAL AND METHODS Retrospective, not randomised single centre case series at a level I trauma centre. Inclusion criterion was insertion of a percutaneous iliosacral screw using image-guidance in the hybrid operating room. 61 patients (35 female, 26 male) were included from June 2012 till October 2014. 65 iliosacral screws were inserted. Intraoperative 3D-scans and postoperative scans were examined to investigate screw placement. The results were compared to a preceding study performed in 2012 using conventional 3D-navigation. Statistical calculations were performed with Microsoft Excel 2011 and SPSS. RESULTS 65 iliosacral screws were implanted. Two different types of screws were implanted: 1. "Standard" iliosacral screws stabilizing one joint/a unilateral fracture. 2. Single SI-screws stabilizing both SI-joints and if present a bilateral fracture. Forty one patients were included in group 1 (screws n=45). There was no perforation in 43 screws, grade 1 perforation in 2 screws. There was no grade 2 or 3 perforation in this group. Compared to the conventional 3D-navigated screws there was a highly significant difference (p<0.001). Twenty patients could be included in group 2. Eleven screws showed a complete intraosseous position. There was grade 1 perforation in 2 screws, grade 2 perforation in 5 screws and grade 3 perforation in 2 screws. CONCLUSION Improvements in image quality and enlargement of the display window lead to better intraoperative visualisation of the entire dorsal pelvis. Thereby the accuracy of computer-assisted iliosacral screws could be increased using a hybrid operating room. Furthermore difficult tasks like a single screw for both joints can be accomplished.
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Affiliation(s)
- P H Richter
- Ulm University, Department for Orthopaedic Trauma, Hand and Reconstructive Surgery, Albert-Einstein Allee 23, 89081 Ulm, Germany.
| | - F Gebhard
- Ulm University, Department for Orthopaedic Trauma, Hand and Reconstructive Surgery, Albert-Einstein Allee 23, 89081 Ulm, Germany
| | - C Dehner
- Ulm University, Department for Orthopaedic Trauma, Hand and Reconstructive Surgery, Albert-Einstein Allee 23, 89081 Ulm, Germany
| | - A Scola
- Ulm University, Department for Orthopaedic Trauma, Hand and Reconstructive Surgery, Albert-Einstein Allee 23, 89081 Ulm, Germany
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Richter PH, Yarboro S, Kraus M, Gebhard F. One year orthopaedic trauma experience using an advanced interdisciplinary hybrid operating room. Injury 2015; 46 Suppl 4:S129-34. [PMID: 26542859 DOI: 10.1016/s0020-1383(15)30032-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hybrid operating rooms have been used successfully in several surgical specialties, but no data have been published for orthopaedic trauma. We present our one-year orthopaedic trauma experience using a hybrid operating room, which incorporates 3D fluoroscopic imaging as well as navigation capabilities. Data were compiled for a series of 92 cases performed in an advanced hybrid operating room at the level one trauma center in Ulm, Germany. All patients who had surgery performed using this operating room during the first year were included. Setup time and surgical complications using hybrid operating room were recorded and analysed. The hybrid operating room resulted in no higher rate of complication than expected from the same cases in a conventional operating room. The hybrid room did however allow the surgeon to confidently place implants for orthopaedic trauma cases, and was most advantageous for spine and pelvis cases, both minimally invasive and conventional. Further, appropriate reduction and implant position was confirmed with 3D imaging prior to leaving the operating room and obviated the need for postoperative CT scan. Based on our one-year experience, the hybrid operating room is a useful and safe tool for orthopaedic trauma surgery.
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Affiliation(s)
| | - Seth Yarboro
- University of Virginia; Charlottesville, Virginia, United States
| | - Michael Kraus
- Donau-Ries Hospital Donauwörth; Donauwoerth, Germany
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Standalone percutaneous transiliac plating of vertically unstable sacral fractures: outcomes, complications, and recommendations. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1153-62. [PMID: 25900300 DOI: 10.1007/s00586-015-3976-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 04/16/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study is to evaluate results of a standalone percutaneous posterior plating of the vertically unstable sacral fractures, to analyze the influencing factors, to discuss encountered complications, and to express the related recommendations. METHODS Forty two cases were included; all of them had type C vertical sacral fractures; and 16 cases had associated nerve roots injury. Subcutaneous 3.5-mm reconstruction plate was used in all cases, through vertical incisions in 28 cases and transverse incisions in 14 cases. Hannover pelvic outcome scoring system was implemented for results evaluation. RESULTS The mean follow-up period was 22.1 ± 7.5 months; the mean operative time was 43.3 ± 7 min; the mean surgical incision length was 4.6 ± 1.1 cm. 14 cases had excellent scores, 16 cases had good scores, 6 cases had fair scores, and 6 cases had poor scores. Younger age groups had significantly better outcome (P = 0.015), whereas the comminuted sacrum had significantly worse score (P = 0.041). Final residual posterior displacements significantly improved (P = 0.001) in comparison to the initial displacement. The nerve roots injury had final significant recovery (P = 0.012). Transverse skin incisions had subjectively significant satisfaction (P = 0.017). CONCLUSIONS Percutaneous 3.5-mm reconstruction plate is a good alternative to percutaneous iliosacral screws in vertically unstable sacral fractures; especially in the presence of contraindication to the latter. It is simple procedure with minimal incisions; short operative time; less radiological exposure; good mechanical stability; and less iatrogenic injuries.
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Kraus M, Weiskopf J, Dreyhaupt J, Krischak G, Gebhard F. Computer-aided surgery does not increase the accuracy of dorsal pedicle screw placement in the thoracic and lumbar spine: a retrospective analysis of 2,003 pedicle screws in a level I trauma center. Global Spine J 2015; 5:93-101. [PMID: 25844281 PMCID: PMC4369205 DOI: 10.1055/s-0034-1396430] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 10/21/2014] [Indexed: 10/29/2022] Open
Abstract
Study Design A retrospective analysis of a prospective database. Objective Meta-analyses suggest that computer-assisted systems can increase the accuracy of pedicle screw placement for dorsal spinal fusion procedures. The results of further meta-analyses report that in the thoracic spine, both the methods have comparable placement accuracy. These studies are limited due to an abundance of screw classification systems. The aim of this study was to assess the placement accuracy and potentially influencing factors of three-dimensionally navigated versus conventionally inserted pedicle screws. Methods This was a retrospective analysis of a prospective database at a level I trauma center of pedicle screw placement (computer-navigated versus traditionally placed) for dorsal spinal stabilizations. The cases spanned a 5.5-year study period (January 1, 2005, to June 30, 2010). The perforations of the pedicle were differentiated in three grades based on the postoperative computed tomography. Results The overall placement accuracy was 86% in the conventional group versus 79% in the computer-navigated group (grade 0). The computer-navigated procedures were superior in the lumbar spine and the conventional procedures were superior in the thoracic spine, but both failed to be of statistical significance. The level of experience of the performing surgeon and the patient's body mass index did not influence the placement accuracy. The only significant influence was the spinal segment: the higher the spinal level where the fusion was performed, the more likely the screw was displaced. Conclusions The computer-navigated and conventional methods are both safe procedures to place transpedicular screws at the traumatized thoracic and lumbar spine. At the moment, three-dimensionally based navigation does not significantly increase the placement accuracy.
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Affiliation(s)
- Michael Kraus
- Centre for Orthopaedic Trauma and Spine Surgery, Donau-Ries Hospital Donauwörth, Donauwörth, Germany,Address for correspondence PD Dr. med. Michael Kraus Centre for Orthopaedic Trauma and Spine SurgeryDonau-Ries Hospital Donauwörth, Neudegger Allee 6, 86609 DonauwörthGermany
| | - Julia Weiskopf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
| | - Jens Dreyhaupt
- Ulm University, Institute of Epidemiology and Medical Biometry, Ulm, Germany
| | - Gert Krischak
- Ulm University, Institute of Research in Rehabilitation Medicine, Bad Buchau, Germany
| | - Florian Gebhard
- Department of Trauma, Hand, and Reconstructive Surgery, Ulm University, Ulm, Germany
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Alemdaroğlu KB, Yücens M, Kara T, Gül D, Aydoğan NH. Pedicle axis view combined by sacral mapping can decrease fluoroscopic shot count in percutaneous iliosacral screw placement. Injury 2014; 45:1921-7. [PMID: 25457343 DOI: 10.1016/j.injury.2014.10.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 07/23/2014] [Accepted: 10/14/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Percutaneous iliosacral screw fixation of the posterior pelvic ring is a demanding procedure with high exposure to radiation. The conventional technique includes the use of three classical projections with the C-arm: inlet, outlet, and true lateral views. A projection in the axis of the upper sacral alar pedicles with a 30° cephalad and 30° ventral oblique view would help in obtaining a more accurate visualization of the safe corridor. Two subcutaneously placed K-wires, one placed horizontally and one vertically, may facilitate the starting point and aim changes by offering the surgeon an option for exactly matching the position of the sacrum with the image. The purpose of this study was to detect if the radiation application could be decreased by our new methodology. METHODS Seventeen patients with pelvic posterior ring disruptions, in which percutaneous iliosacral screw placement was indicated, were included in the study. Group 1 comprised 7 patients in whom conventional projections and technique were used. Group 2 comprised 10 patients in whom 30°–30° projection and sacral mapping technique via two subcutaneous K-wires were applied. Radiation exposure time, total fluoroscopic shot count, fluoroscopic shot count needed for only guide wire and screw placement, radiation dose, and complications were compared between the two groups. RESULTS The median number of fluoroscopic images for guide and screw placement was 132 (56–220) and 29.5 (19–83) in Groups 1 and 2, respectively, and the difference was statistically significant (p < 0.001). The median total fluoroscopic radiation time was 138 (68–234) and 52 (28–77) s in Groups 1 and 2, respectively, and the difference was significant (p < 0.001). Group 1 had a significantly higher median radiation dose than Group 2 [3020 (1502–6032) vs. 1192 (426–2359); (p = 0.001)]. CONCLUSIONS Iliosacral screw placement with the help of sacral mapping and a fourth view, “30°–30°”, helps the surgeon to markedly reduce the fluoroscopic shots, radiation time and dose during guide wire and screw placement. LEVEL OF EVIDENCE Therapeutic, Level II.
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Alvis-Miranda HR, Farid-Escorcia H, Alcalá-Cerra G, Castellar-Leones SM, Moscote-Salazar LR. Sacroiliac screw fixation: A mini review of surgical technique. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2014; 5:110-3. [PMID: 25336831 PMCID: PMC4201009 DOI: 10.4103/0974-8237.142303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The sacral percutaneous fixation has many advantages but can be associated with a significant exposure to X-ray radiation. Currently, sacroiliac screw fixation represents the only minimally invasive technique to stabilize the posterior pelvic ring. It is a technique that should be used by experienced surgeons. We present a practical review of important aspects of this technique.
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Yu E, Khan SN. Does less invasive spine surgery result in increased radiation exposure? A systematic review. Clin Orthop Relat Res 2014; 472:1738-48. [PMID: 24549771 PMCID: PMC4016453 DOI: 10.1007/s11999-014-3503-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radiation exposure to patients and spine surgeons during spine surgery is expected. The risks of radiation exposure include thyroid cancer, cataracts, and lymphoma. Although imaging techniques facilitate less invasive approaches and improve intraoperative accuracy, they may increase radiation exposure. QUESTIONS/PURPOSES We performed a systematic review to determine whether (1) radiation exposure differs in open spine procedures compared with less invasive spine procedures; (2) radiation exposure differs in where the surgeon is positioned in relation to the C-arm; and (3) if radiation exposure differs using standard C-arm fluoroscopy or fluoroscopy with computer-assisted navigation. METHODS A PubMed search was performed from January 1980 to July 2013 for English language articles relating to radiation exposure in spine surgery. Twenty-two relevant articles met inclusion criteria. Level of evidence was assigned on clinical studies. Traditional study quality evaluation of nonclinical studies was not applicable. RESULTS There are important risks of radiation exposure in spine surgery to both the surgeon and patient. There is increased radiation exposure in less invasive spine procedures, but the use of protective barriers decreases radiation exposure. Where the surgeon stands in relation to the image source is important. Increasing the distance between the location of the C-arm radiation source and the surgeon, and standing contralateral from the C-arm radiation source, decreases radiation exposure. The use of advanced imaging modalities such as CT or three-dimensional computer-assisted navigation can potentially decrease radiation exposure. CONCLUSIONS There is increased radiation exposure during less invasive spine surgery, which affects the surgeon, patient, and operating room personnel. Being cognizant of radiation exposure risks, the spine surgeon can potentially minimize radiation risks by optimizing variables such as the use of barriers, knowledge of position, distance from the radiation source, and use of advanced image guidance navigation-assisted technology to minimize radiation exposure. Continued research is important to study the long-term risk of radiation exposure and its relationship to cancer, which remains a major concern and needs further study as the popularity of less invasive spine surgery increases.
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Affiliation(s)
- Elizabeth Yu
- Division of Spine Surgery, Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 West 10th Avenue, Columbus, OH 43210 USA
| | - Safdar N. Khan
- Division of Spine Surgery, Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 West 10th Avenue, Columbus, OH 43210 USA
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Kraus M, von dem Berge S, Schöll H, Krischak G, Gebhard F. Integration of fluoroscopy-based guidance in orthopaedic trauma surgery - a prospective cohort study. Injury 2013; 44:1486-92. [PMID: 23507528 DOI: 10.1016/j.injury.2013.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 01/29/2013] [Accepted: 02/04/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Computer-assisted guidance systems are not used frequently for musculoskeletal injuries unless there are potential advantages. We investigated a novel fluoroscopy-based image guidance system in orthopaedic trauma surgery. MATERIALS AND METHODS The study was a prospective, not randomised, single-centre case series at a level I trauma centre. A total of 45 patients with 46 injuries (foot 12, shoulder 10, long bones seven, hand and wrist seven, ankle seven and spine and pelvis four) were included. Different surgical procedures were examined following the basic principles of the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF). Main outcome measurements were the number of trials for implant placement, total surgery time, usability via user questionnaire and system failure rate. RESULTS In all cases, the trajectory function was used, inserting a total of 56 guided implants. The system failed when used in pelvic and spinal injuries, resulting in a total failure rate of 6.5% (n=3) of all included cases. The overall usability was rated as good, scoring 84.3%. CONCLUSION The novel image-guidance system could be integrated into the surgical workflow and was used successfully in orthopaedic trauma surgery. Expected advantages should be explored in randomised studies.
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Affiliation(s)
- Michael Kraus
- Ulm University, Institute of Research in Rehabilitation Medicine, Wuhrstrasse 2/1, 88422 Bad Buchau, Germany; Federseeklinik Bad Buchau, Freihofgasse 14, 88422 Bad Buchau, Germany.
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