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González-Vargas PM, Calero Félix L, Martín-Gallego Á, Thenier-Villa JL, de la Lama Zaragoza AR, Conde Alonso C. Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:71-81. [PMID: 35248301 DOI: 10.1016/j.neucie.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/10/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control. METHODS The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification. RESULTS 92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05). CONCLUSION The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.
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Affiliation(s)
- Pedro Miguel González-Vargas
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain.
| | - Lourdes Calero Félix
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Álvaro Martín-Gallego
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - José Luis Thenier-Villa
- Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain; Department of Neurosurgery, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Adolfo Ramón de la Lama Zaragoza
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
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Treating Lumbar Fracture Using the Mixed Reality Technique. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6620746. [PMID: 33860042 PMCID: PMC8024068 DOI: 10.1155/2021/6620746] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/16/2021] [Accepted: 03/20/2021] [Indexed: 11/30/2022]
Abstract
The mixed reality (MR) technique has recently been widely used in the orthopedic surgery with satisfactory results reported. However, few studies have focused on the application of MR in the Lumbar fracture (LF). In this retrospective study, our aim is to analyze some findings by investigating the feasibility of MR applied to lumbar fracture treatment. Posterior vertebrectomy has been operated on 7 patients. The MR–based intraoperative three-dimensional image-guided navigation system (MITINS) was used to assist implantation of pedicle screws. The feasibility and safety of pedicle screw implantation were assessed by postsurgery radiography. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to assess the pain level and recovery situation before and after surgery. 57 pedicle screws were safely and precisely placed into three-dimensional lumbar models by using MITINS. No screw was found outside the pedicle of the models, and it was not necessary for the X-ray to provide extra locative information during the operation with the use of MITINS. In summary, the application of MITINS is feasible, safe, and accurate while the lumbar fracture surgery is processing, providing satisfactory assistance for spine surgeons.
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González-Vargas PM, Calero Félix L, Martín-Gallego Á, Thenier-Villa JL, de la Lama Zaragoza AR, Conde Alonso C. Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00010-5. [PMID: 33663907 DOI: 10.1016/j.neucir.2021.01.001] [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: 08/17/2020] [Revised: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control. METHODS The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification. RESULTS 92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05). CONCLUSION The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.
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Affiliation(s)
- Pedro Miguel González-Vargas
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain.
| | - Lourdes Calero Félix
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Álvaro Martín-Gallego
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - José Luis Thenier-Villa
- Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain; Department of Neurosurgery, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Adolfo Ramón de la Lama Zaragoza
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
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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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Lee YC, Lee R. Image-guided pedicle screws using intraoperative cone-beam CT and navigation. A cost-effectiveness study. J Clin Neurosci 2020; 72:68-71. [PMID: 31964560 DOI: 10.1016/j.jocn.2020.01.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Abstract
Image-guided surgery using intraoperative cone-beam CT and navigation improves screw placement accuracy rates. However, this technology is associated with high acquisition costs. The aim of this study is to evaluate the costs of revision surgery from symptomatic pedicle screw malposition to justify whether the costs of acquiring intraoperative navigation justify the expected benefits. This is a retrospective cost-effectiveness analysis of consecutive patients who had pedicle screw instrumentation using intraoperative cone-beam CT and navigation compared with patients who underwent freehand pedicle screw instrumentation at our institution over 4 years. The costs associated with revision surgery for symptomatic pedicle screw malposition (excess length of stay, intensive care, theatre time, implants and additional outpatient appointments) were calculated. A total of 19 patients had symptomatic screw malpositioning requiring revision surgery. None of these patients had screws inserted under navigation. Revision surgery accounted for an extra 304 bed days and an additional 97 h theatre time. The total extra spent over 4 years was £464,038. When compared to the costs of revision surgery for screw malpositioning, it was cost neutral to acquire and maintain this technology. Intraoperative image-guided surgery reduces reoperation rates for symptomatic screw malposition and is cost-effective in high volume centers with improved patients outcomes. High acquisition and maintenance cost of such technologies is economically justifiable.
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Affiliation(s)
- Yu Chao Lee
- Spinal Surgery Unit, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore HA7 4LP, United Kingdom
| | - Robert Lee
- Spinal Surgery Unit, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore HA7 4LP, United Kingdom.
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Mukhametzhanov K, Mukhametzhanov DZ, Karibaev BM, Bulekbaev SA, Bekarisov OS, Кusainova KK, Dyusenbaev NN. Using an intraoperative computed tomography scanner with a navigation station for spinal surgery. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2019. [DOI: 10.29333/ejgm/115859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Wu X, Liu R, Xu S, Yang C, Yang S, Shao Z, Li S, Ye Z. Feasibility of mixed reality-based intraoperative three-dimensional image-guided navigation for atlanto-axial pedicle screw placement. Proc Inst Mech Eng H 2019; 233:1310-1317. [PMID: 31617820 DOI: 10.1177/0954411919881255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study aimed to evaluate the safety and accuracy of mixed reality-based intraoperative three-dimensional navigated pedicle screws in three-dimensional printed model of fractured upper cervical spine. A total of 27 cervical model from patients of upper cervical spine fractures formed the study group. All the C1 and C2 pedicle screws were inserted under mixed reality-based intraoperative three-dimensional image-guided navigation system. The accuracy and safety of the pedicle screw placement were evaluated on the basis of postoperative computerized tomography scans. A total of 108 pedicle screws were properly inserted into the cervical three-dimensional models under mixed reality-based navigation, including 54 C1 pedicle screws and 54 C2 pedicle screws. Analysis of the dimensional parameters of each pedicle at C1/C2 level showed no statistically significant differences in the ideal and the actual entry points, inclined angles, and tailed angles. No screw was misplaced outside the pedicle of the three-dimensional printed model, and no ionizing X-ray radiation was used during screw placement under navigation. It is easy and safe to place C1/C2 pedicle screws under MR surgical navigation. Mixed reality-based navigation is feasible within upper cervical spinal fractures with improved safety and accuracy of C1/C2 pedicle screw insertion.
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Affiliation(s)
- Xinghuo Wu
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Liu
- Department of Orthopaedic Surgery, Puren Hospital of Wuhan, Wuhan University of Science and Technology, Wuhan, China
| | - Song Xu
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cao Yang
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuhua Yang
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zengwu Shao
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suyun Li
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhewei Ye
- Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Restelli U, Anania CD, Porazzi E, Banfi G, Croce D, Fornari M, Costa F. Economic study: an observational analysis of costs and effectiveness of an intraoperative compared with a preoperative image-guided system in spine surgery fixation: analysis of 10 years of experience. J Neurosurg Sci 2019; 66:350-355. [PMID: 30916525 DOI: 10.23736/s0390-5616.19.04638-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Image-guided navigation systems are well establish technologies; their use in clinical practice is growing. To date many publications have demonstrated their accuracy and safety. However, the acquisition and maintenance costs are high. In an era in which health expenditures are rising exponentially, analyses of the economic impact of new technologies are mandatory to assess their sustainability. METHODS A retrospective analysis to assess the overall costs of a series of patients admitted to our Neurosurgical Department for spinal instrumentation. We compared two different types of spinal navigation systems: based on preoperative CT scan (January 2003-April 2009) and on intraoperative CT-like scan (April 2009-March 2013). We used a micro-costing approach by a hospital perspective considering all the phases of the treatment process, from pre admission testing to discharge. RESULTS The study includes 875 patients. Baseline data, hospitalization and complications were similar for both. Mean cost was 7,305.9 € for intraoperative CT scan procedure and 7,666.2 € for preoperative image-guided system. The effectiveness, in terms of screw accuracy was similar. Higher costs were related to implanted materials, human resources, and disposable. CONCLUSIONS There was a statistically significant difference between the two groups in terms of costs. A break-even point for the acquisition of an intraoperative image system is calculated in almost 130 procedures. Moreover, nowadays this system is used for more than only screw insertion reducing the financial impact of this technology on a Hospital.
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Affiliation(s)
- Umberto Restelli
- Center for Health Economics, Social and Health Care Management, LIUC, Università Cattaneo, Castellanza, Varese, Italy.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carla D Anania
- Neurosurgery Department, Humanitas Clinical and Research Center, Neuro Center, Rozzano, Milan, Italy
| | - Emanuele Porazzi
- Center for Health Economics, Social and Health Care Management, LIUC, Università Cattaneo, Castellanza, Varese, Italy
| | - Giuseppe Banfi
- Scientific Direction, Istituto Ortopedico Galeazzi, IRCCS, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Davide Croce
- Center for Health Economics, Social and Health Care Management, LIUC, Università Cattaneo, Castellanza, Varese, Italy.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maurizio Fornari
- Neurosurgery Department, Humanitas Clinical and Research Center, Neuro Center, Rozzano, Milan, Italy
| | - Francesco Costa
- Neurosurgery Department, Humanitas Clinical and Research Center, Neuro Center, Rozzano, Milan, Italy -
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Wu X, Liu R, Yu J, Xu S, Yang C, Yang S, Shao Z, Ye Z. Mixed Reality Technology Launches in Orthopedic Surgery for Comprehensive Preoperative Management of Complicated Cervical Fractures. Surg Innov 2019; 25:421-422. [PMID: 30012077 DOI: 10.1177/1553350618761758] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Xinghuo Wu
- 1 Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , China
| | - Rong Liu
- 2 Department of Orthopaedic Surgery, Puren Hospital of Wuhan, Wuhan University of Science and Technology, Wuhan, China
| | - Jie Yu
- 1 Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , China
| | - Song Xu
- 1 Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , China
| | - Cao Yang
- 1 Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , China
| | - Shuhua Yang
- 1 Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , China
| | - Zengwu Shao
- 1 Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , China
| | - Zhewei Ye
- 1 Department of Orthopaedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , China
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Accuracy and revision rate of intraoperative computed tomography point-to-point navigation for lateral mass and pedicle screw placement: 11-year single-center experience in 1054 patients. Neurosurg Rev 2018; 42:895-905. [PMID: 30569212 DOI: 10.1007/s10143-018-01067-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/07/2018] [Accepted: 12/06/2018] [Indexed: 10/27/2022]
Abstract
High accuracy in intraoperative computed tomography (iCT) navigation utilizing an intraoperatively acquired dataset for screw placement in the spine has been reported in the literature. To further improve the accuracy and counteract any intraoperative movement of predefined registration points, we introduce an iCT point-to-point navigation, where marker screws are inserted intraoperatively to increase patient safety. In all, 1054 patients who underwent iCT point-to-point navigation for lateral mass and pedicle screw placement were retrospectively analyzed between 09/2005 and 09/2016. Implant-related complications such as screw misplacement, screw loosening, and revision rate were determined. Furthermore, we investigated the rate of complications and the clinical outcome. In total, 6059 screws were inserted in 1054 patients. There were 553 (52.5%) female and 501 (47.5%) male patients. Average age was 63.5 years, mean BMI 27.5 (SD 13.9). Here, 1427 (23.5%) screws were inserted in the cervical, 995 (16.4%) in the thoracic, 3167 (52.3%) in the lumbar, and 470 (7.8%) in the sacral spine. Eight patients required a revision procedure for screw misplacement (0.8%). Total screw misplacement rate was 0.3% (16/6059). With the use of reference markers in iCT-based, spinal, point-to-point navigation, we achieved a high accuracy of screw placement with a low revision rate (0.8%) and a total screw misplacement rate of 0.3%.
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11
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Shaw KA, Murphy JS, Devito DP. Accuracy of robot-assisted pedicle screw insertion in adolescent idiopathic scoliosis: is triggered electromyographic pedicle screw stimulation necessary? JOURNAL OF SPINE SURGERY 2018; 4:187-194. [PMID: 30069506 DOI: 10.21037/jss.2018.04.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Screw malpositioning is an identifiable cause of intraoperative neurophysiologic changes. Although triggered screw electromyography (t-EMG) has been found to exhibit high sensitivity for identifying malpositioned screws, no previous study has assessed the utility of combining t-EMG with robotic-assisted pedicle screw placement for identifying malpositioned screws. We sought to evaluate the utility of t-EMG used in combination with robotic-assisted pedicle screw placement for identifying malpositioned screws in patients with adolescent idiopathic scoliosis (AIS). Methods Patients undergoing robotic-assisted posterior spinal fusion with pedicle screw fixation for AIS underwent retrospective review from a single surgeons prospectively collected database. Preoperative demographic data and curve characteristics were recorded. Computed tomography (CT) scans were reviewed, measuring pedicle width and classifying pedicle morphology using the channel classification system. Pedicle data was compared against intra-operative t-EMG data, with a minimal threshold of 8 mA used for screw removal and screw path examination and the rate of screw re-direction recorded. All pedicle screws were verified using image intensification. Results Forty-nine patients (11 males, 38 females, average age 14.49 years) with an average curve magnitude of 51 degrees and placement of 844 pedicle screws to attain an average curve correction of 67.7%. The incidence of an absent pedicle (type C or D morphology) was 2%. Overall, 24 screws (2.8%) were identified with an abnormal t-EMG threshold. All screws were found to have an intact medial wall upon probing and were reinserted without re-direction. No patient or curve characteristic was predictive of abnormal t-EMG amplitude but smaller pedicles correlated with smaller amplitudes. Conclusions With precise pre-operative planning, robotic-assisted pedicle screw placement has shown to be a safe and effective method in treating AIS patients as shown by the lack of medial pedicle breach and malpositioned screws. We found no evidence to support combined use of t-EMG for identifying medially malpositioned screws.
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Affiliation(s)
- K Aaron Shaw
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Joshua S Murphy
- Department of Pediatric Orthopaedics, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
| | - Dennis P Devito
- Department of Pediatric Orthopaedics, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
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12
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Szczodry M, Solitro GF, Amirouche F, Patel P. Pedicle Screw With Increased Cortical Purchase Can Be Inserted With Same Accuracy as the Screw in Straightforward Trajectory Using 3D Modeling Landmarks. Spine Deform 2018; 6:20-27. [PMID: 29287813 DOI: 10.1016/j.jspd.2017.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/05/2017] [Accepted: 06/18/2017] [Indexed: 11/29/2022]
Abstract
STUDY DESIGN Comparison, in terms of insertion accuracy and biomechanical performance, between an increased cortical purchase and straightforward pedicle screw trajectory. OBJECTIVE This study aims to compare a trajectory with increased cortical purchase to the more common straightforward trajectory in terms of strength and insertion accuracy using real-time navigation. SUMMARY OF BACKGROUND DATA In previous studies, it was suggested that pedicle screw pullout strength is strongly correlated with bone mineral density, and using a more cortical tract allows a greater portion of the denser bone, the cortex, to be in contact with the screw. In light of this advantage, an insertion technique has been proposed more recently, to increase the cortical purchase to maximize screw thread contact with cortical bone. It is performed inserting the screw with reduced transverse inclination and results in cortical bone purchase in the lateral portion of the pedicle. METHODS Eight T1 and eight T3 vertebra models were reconstructed in Mimics Suite (Materialise, Leuven, Belgium) using CT data obtained with a Medtronic O-arm. Using a previously developed computer algorithm, we calculated all achievable safe trajectories for pedicle screw placement ensuring a minimal distance of 0.5 mm between screw and pedicle edges. For both vertebrae, among these, the straightest and the most convergent trajectories with the calculated insertion region greater than 15% of the total were selected to safely instrument the vertebrae, respectively, as ICP and straightforward techniques. The straightforward technique was planned with a transverse angle of 22.50° in both vertebrae whereas the ICP was planned with a transverse angle of 12.50° for T1 and 2.5° for T3. The screws were implanted by a surgeon experienced in straightforward insertion, and other independent investigators measured placement accuracy and mechanical performance. RESULTS The transverse screw angles for T1 and T3 with straightforward technique had average values of 24.93° ± 2.96° and 23.53° ± 2.70°, respectively. For the ICP technique, the average values were 15.60° ± 2.95° for T1 and 2.29° ± 1.55° for T3. The resultant errors associated with screw placement for T1 and T3 were not significantly different (p > .05). The pullout failure loads with straightforward techniques ranged from 756 ± 164 N in T1 to 703 ± 74 N in T3 and were not significantly different (p > .05) from the values of 699 ± 84 N for T1 and of 732 ± 113 N measured for the ICP. CONCLUSIONS For the upper thoracic vertebrae tested, despite the use of shorter screws, the insertion technique with increased cortical purchase, in biomechanical terms, is comparable with the straightforward trajectory. Using guidance, the proposed ICP technique was performed with the same accuracy as the popular straightforward technique. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Michal Szczodry
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave., Chicago, IL 21287, USA.
| | - Giovanni F Solitro
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave., Chicago, IL 21287, USA
| | - Farid Amirouche
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave., Chicago, IL 21287, USA
| | - Priyesh Patel
- Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd, North Chicago, IL 60064, USA
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Dea N, Fisher CG, Batke J, Strelzow J, Mendelsohn D, Paquette SJ, Kwon BK, Boyd MD, Dvorak MFS, Street JT. Economic evaluation comparing intraoperative cone beam CT-based navigation and conventional fluoroscopy for the placement of spinal pedicle screws: a patient-level data cost-effectiveness analysis. Spine J 2016; 16:23-31. [PMID: 26456854 DOI: 10.1016/j.spinee.2015.09.062] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 08/28/2015] [Accepted: 09/29/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Pedicle screws are routinely used in contemporary spinal surgery. Screw misplacement may be asymptomatic but is also correlated with potential adverse events. Computer-assisted surgery (CAS) has been associated with improved screw placement accuracy rates. However, this technology has substantial acquisition and maintenance costs. Despite its increasing usage, no rigorous full economic evaluation comparing this technology to current standard of care has been reported. PURPOSE Medical costs are exploding in an unsustainable way. Health economic theory requires that medical equipment costs be compared with expected benefits. To answer this question for computer-assisted spinal surgery, we present an economic evaluation looking specifically at symptomatic misplaced screws leading to reoperation secondary to neurologic deficits or biomechanical concerns. STUDY DESIGN/SETTING The study design was an observational case-control study from prospectively collected data of consecutive patients treated with the aid of CAS (treatment group) compared with a matched historical cohort of patients treated with conventional fluoroscopy (control group). PATIENT SAMPLE The patient sample consisted of consecutive patients treated surgically at a quaternary academic center. OUTCOME MEASURES The primary effectiveness measure studied was the number of reoperations for misplaced screws within 1 year of the index surgery. Secondary outcome measures included were total adverse event rate and postoperative computed tomography usage for pedicle screw examination. METHODS A patient-level data cost-effectiveness analysis from the hospital perspective was conducted to determine the value of a navigation system coupled with intraoperative 3-D imaging (O-arm Imaging and the StealthStation S7 Navigation Systems, Medtronic, Louisville, CO, USA) in adult spinal surgery. The capital costs for both alternatives were reported as equivalent annual costs based on the annuitization of capital expenditures method using a 3% discount rate and a 7-year amortization period. Annual maintenance costs were also added. Finally, reoperation costs using a micro-costing approach were calculated for both groups. An incremental cost-effectiveness ratio was calculated and reported as cost per reoperation avoided. Based on reoperation costs in Canada and in the United States, a minimal caseload was calculated for the more expensive alternative to be cost saving. Sensitivity analyses were also conducted. RESULTS A total of 5,132 pedicle screws were inserted in 502 patients during the study period: 2,682 screws in 253 patients in the treatment group and 2,450 screws in 249 patients in the control group. Overall accuracy rates were 95.2% for the treatment group and 86.9% for the control group. Within 1 year post treatment, two patients (0.8%) required a revision surgery in the treatment group compared with 15 patients (6%) in the control group. An incremental cost-effectiveness ratio of $15,961 per reoperation avoided was calculated for the CAS group. Based on a reoperation cost of $12,618, this new technology becomes cost saving for centers performing more than 254 instrumented spinal procedures per year. CONCLUSIONS Computer-assisted spinal surgery has the potential to reduce reoperation rates and thus to have serious cost-effectiveness and policy implications. High acquisition and maintenance costs of this technology can be offset by equally high reoperation costs. Our cost-effectiveness analysis showed that for high-volume centers with a similar case complexity to the studied population, this technology is economically justified.
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Affiliation(s)
- Nicolas Dea
- Department of Surgery, Division of Neurosurgery, Université de Sherbrooke, 3001, 12th Ave Nord, Sherbrooke, Quebec, Canada J1H 5N4.
| | - Charles G Fisher
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
| | - Juliet Batke
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
| | - Jason Strelzow
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
| | - Daniel Mendelsohn
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
| | - Scott J Paquette
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
| | - Brian K Kwon
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
| | - Michael D Boyd
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
| | - Marcel F S Dvorak
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
| | - John T Street
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Ave, Vancouver, British-Columbia, Canada V5Z 1M9
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Kovanda TJ, Ansari SF, Qaiser R, Fulkerson DH. Feasibility of CT-based intraoperative 3D stereotactic image-guided navigation in the upper cervical spine of children 10 years of age or younger: initial experience. J Neurosurg Pediatr 2015. [PMID: 26207668 DOI: 10.3171/2015.2.peds14556] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Rigid screw fixation may be technically difficult in the upper cervical spine of young children. Intraoperative stereotactic navigation may potentially assist a surgeon in precise placement of screws in anatomically challenging locations. Navigation may also assist in defining abnormal anatomy. The object of this study was to evaluate the authors' initial experience with the feasibility and accuracy of this technique, both for resection and for screw placement in the upper cervical spine in younger children. METHODS Eight consecutive pediatric patients 10 years of age or younger underwent upper cervical spine surgery aided by image-guided navigation. The demographic, surgical, and clinical data were recorded. Screw position was evaluated with either an intraoperative or immediately postoperative CT scan. RESULTS One patient underwent navigation purely for guidance of bony resection. A total of 14 navigated screws were placed in the other 7 patients, including 5 C-2 pedicle screws. All 14 screws were properly positioned, defined as the screw completely contained within the cortical bone in the expected trajectory. There were no immediate complications associated with navigation. CONCLUSIONS Image-guided navigation is feasible within the pediatric cervical spine and may be a useful surgical tool for placing screws in a patient with small, often difficult bony anatomy. The authors describe their experience with their first 8 pediatric patients who underwent navigation in cervical spine surgery. The authors highlight differences in technique compared with similar navigation in adults.
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Affiliation(s)
| | | | | | - Daniel H Fulkerson
- Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, Indiana
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15
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Kleck CJ, Cullilmore I, LaFleur M, Lindley E, Rentschler ME, Burger EL, Cain CMJ, Patel VV. A new 3-dimensional method for measuring precision in surgical navigation and methods to optimize navigation accuracy. 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; 25:1764-74. [DOI: 10.1007/s00586-015-4235-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/07/2015] [Accepted: 09/07/2015] [Indexed: 10/23/2022]
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16
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Jacob C, Annoni E, Haas JS, Braun S, Winking M, Franke J. Burden of disease of reoperations in instrumental spinal surgeries in Germany. 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; 25:807-13. [PMID: 26118335 DOI: 10.1007/s00586-015-4073-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 06/13/2015] [Accepted: 06/14/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To estimate the incidence of instrumental spinal surgeries (ISS) and consecutive reoperations and to calculate the related resource utilization and costs. METHODS ISS and subsequent reoperations were identified retrospectively using surgery codes in claims data. The study period included January 01, 2009 to December 31, 2011. The reoperation rate was calculated for 1 year after the primary ISS. Resource utilization and costs were analyzed by group comparison. RESULTS A total of 3316 incident ISS patients were identified in 2010 with an annual reoperation rate of 9.98% (95% CI 8.98-11.02%). Mean costs per patient were €11,331 per ISS and €11,370 per reoperation, with €8432 directly attributed to the reoperation and €2938 to additional resources. CONCLUSIONS Costs of ISS and subsequent reoperations have a significant impact on health insurances budgets. The annual cost of reoperations exceeds the direct cost of the primary surgery driven by the need for further inpatient and outpatient care.
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Affiliation(s)
| | - Elena Annoni
- Medtronic International Trading Sàrl, Route de Molliau 31, 1131, Tolochenaz, Switzerland
| | | | | | - Michael Winking
- Klinikum Osnabrück GmbH, Am Finkenhügel 3, 49076, Osnabrück, Germany
| | - Jörg Franke
- Klinikum Dortmund, Beurhausstraße 40, 44137, Dortmund, Germany
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17
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Al-Khouja L, Shweikeh F, Pashman R, Johnson JP, Kim TT, Drazin D. Economics of image guidance and navigation in spine surgery. Surg Neurol Int 2015; 6:S323-6. [PMID: 26167370 PMCID: PMC4496834 DOI: 10.4103/2152-7806.159381] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 03/06/2015] [Indexed: 12/31/2022] Open
Abstract
Background: Image-guidance and navigation in spinal surgery is becoming more widely utilized. Several studies have shown the use of this technology to increase accuracy of pedicle screw placement, decrease the rates of revision surgery, and minimize radiation exposure. In this paper, the authors analyze the economics of image-guided surgery (IGS) and navigation in spine surgery. Methods: A literature review was performed using PubMed, the CEA Registry, and the National Health Service Economic Evaluation Database. Each article was screened for inclusion and exclusion criteria, including costs, reoperation, readmission rates, operating room time, and length of stay. Results: Thirteen studies were included in the analysis. Six studies were identified to meet the inclusion criteria for reporting costs and seven met the criteria for analysis of efficacy. Average costs ranged from $17,650 to $39,643. Pedicle screw misplacement rates using IGS ranged from 1.20% to 15.07% while reoperation rates ranged from 0% to 7.42%. Conclusion: There is currently an insufficient amount of studies reporting on the economics of spinal navigation to accurately conclude on its cost-effectiveness in clinical practice. Although a few of these studies showed less costs associated with intraoperative imaging, none were able to establish a statistically significant difference. Preliminary findings drawn from this study indicate a possible cost-effectiveness advantage with IGS, but more comprehensive data on costs need to be reported in order to validate its utilization.
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Affiliation(s)
- Lutfi Al-Khouja
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Faris Shweikeh
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Robert Pashman
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA ; Department of Neurosurgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Terrence T Kim
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Doniel Drazin
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
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18
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Mason A, Paulsen R, Babuska JM, Rajpal S, Burneikiene S, Nelson EL, Villavicencio AT. The accuracy of pedicle screw placement using intraoperative image guidance systems. J Neurosurg Spine 2013; 20:196-203. [PMID: 24358998 DOI: 10.3171/2013.11.spine13413] [Citation(s) in RCA: 244] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECT Several retrospective studies have demonstrated higher accuracy rates and increased safety for navigated pedicle screw placement than for free-hand techniques; however, the accuracy differences between navigation systems has not been extensively studied. In some instances, 3D fluoroscopic navigation methods have been reported to not be more accurate than 2D navigation methods for pedicle screw placement. The authors of this study endeavored to identify if 3D fluoroscopic navigation methods resulted in a higher placement accuracy of pedicle screws. METHODS A systematic analysis was conducted to examine pedicle screw insertion accuracy based on the use of 2D, 3D, and conventional fluoroscopic image guidance systems. A PubMed and MEDLINE database search was conducted to review the published literature that focused on the accuracy of pedicle screw placement using intraoperative, real-time fluoroscopic image guidance in spine fusion surgeries. The pedicle screw accuracy rates were segregated according to spinal level because each spinal region has individual anatomical and morphological variations. Descriptive statistics were used to compare the pedicle screw insertion accuracy rate differences among the navigation methods. RESULTS A total of 30 studies were included in the analysis. The data were abstracted and analyzed for the following groups: 12 data sets that used conventional fluoroscopy, 8 data sets that used 2D fluoroscopic navigation, and 20 data sets that used 3D fluoroscopic navigation. These studies included 1973 patients in whom 9310 pedicle screws were inserted. With conventional fluoroscopy, 2532 of 3719 screws were inserted accurately (68.1% accuracy); with 2D fluoroscopic navigation, 1031 of 1223 screws were inserted accurately (84.3% accuracy); and with 3D fluoroscopic navigation, 4170 of 4368 screws were inserted accurately (95.5% accuracy). The accuracy rates when 3D was compared with 2D fluoroscopic navigation were also consistently higher throughout all individual spinal levels. CONCLUSIONS Three-dimensional fluoroscopic image guidance systems demonstrated a significantly higher pedicle screw placement accuracy than conventional fluoroscopy or 2D fluoroscopic image guidance methods.
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Charles YP, Buy X, Gangi A, Steib JP. Fracture in ankylosing spondylitis after minor trauma: radiological pitfalls and treatment by percutaneous instrumentation. A case report. Orthop Traumatol Surg Res 2013; 99:115-9. [PMID: 23270725 DOI: 10.1016/j.otsr.2012.09.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 08/10/2012] [Accepted: 09/07/2012] [Indexed: 02/02/2023]
Abstract
Patients with ankylosing spondylitis may experience spinal fractures even after minor injuries. The diagnosis of non-dislocated spinal fracture is based on clinical symptoms and radiological findings. Difficulties in interpreting the imaging studies can result in considerable diagnostic delays. We describe the steps of the radiological diagnosis in a patient with a fracture of L2 that was not visible on standard lumbar spine radiographs. Magnetic resonance imaging (MRI) T2 STIR sequences allowed determining the location and showed signs of a recent fracture. Then, MRI T1 images and computed tomography provided a detailed evaluation of the fracture line. In patients with ankylosing spondylitis, fracture instability is common, making surgical treatment mandatory. Open surgery is associated with substantial rates of infection and implant loosening. Percutaneous instrumentation has not yet been evaluated for the treatment of spinal fractures in patients with ankylosing spondylitis. This minimally invasive surgical technique enables multilevel internal fixation and may constitute an interesting alternative to open surgery.
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Affiliation(s)
- Y P Charles
- Spine Surgery Department, Strasbourg Academic Hospitals, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
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