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. 2021 Mar;11(2):196-202.
doi: 10.1177/2192568220902093. Epub 2020 Jan 27.

Spinal Navigation for Cervical Pedicle Screws: Surgical Pearls and Pitfalls

Gerrard Gan  1 , Arun-Kumar Kaliya-Perumal  1   2 , Chun Sing Yu  1 , Colum Patrick Nolan  3 , Jacob Yoong-Leong Oh  1
Affiliations

Spinal Navigation for Cervical Pedicle Screws: Surgical Pearls and Pitfalls

Gerrard Gan et al. Global Spine J. 2021 Mar.

Abstract

Study design: Retrospective cohort study.

Objective: We intend to evaluate the accuracy and safety of cervical pedicle screw (CPS) insertion under O-arm-based 3-dimensional (3D) navigation guidance.

Methods: This is a retrospective study of patients who underwent CPS insertion under intraoperative O-arm-based 3D navigation during the years 2009 to 2018. The radiological accuracy of CPS placement was evaluated using their intraoperative scans.

Results: A total of 297 CPSs were inserted under navigation. According to Gertzbein classification, 229 screws (77.1%) were placed without any pedicle breach (grade 0). Of the screws that did breach the pedicle, 51 screws (17.2%) had a minor breach of less than 2 mm (grade 1), 13 screws (4.4%) had a breach of between 2 and 4 mm (grade 2), and 4 screws (1.3%) had a complete breach of 4 mm or more (grade 3). Six screws were revised intraoperatively. There was no incidence of neurovascular injury in this series of patients. 59 of the 68 breaches (86.8%) were found to perforate laterally, and the remaining 9 (13.2%) medially. It was noted that the C5 cervical level had the highest breach rate of 33.3%.

Conclusions: O-arm-based 3D navigation can improve the accuracy and safety of CPS insertion. The overall breach rate in this study was 22.9%. Despite these breaches, there was no incidence of neurovascular injury or need for revision surgery for screw malposition.

Keywords: computer-assisted surgery; equipment safety; intraoperative complications; neuronavigation; pedicle screws.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Verification process for the registration of navigated instruments.
Figure 2.
Figure 2.
Sequence of cervical pedicle screw (CPS) insertion under O-arm-based 3-dimensional navigation.
Figure 3.
Figure 3.
Radiological accuracy of cervical pedicle screw (CPS) insertion under O-arm-based 3-dimensional navigation according to Gertzbein and Robbins classification.
Figure 4.
Figure 4.
The surgical exposure required for screw insertion represented by curved lines.(Red line) Medial-most entry point and corresponding trajectory to clear the pedicle without breach. (Blue line) Desired entry point and trajectory. Notice the relative lateral entry point and the high medial angulation trajectory. (Green line) Relative medializing forces of the paraspinal muscles.
Figure 5.
Figure 5.
The modified funnel technique; the difference in pedicle axis length and window of safety is illustrated (A) with the technique employed and (B) without the technique employed. There is a relatively shorter pedicle axis length the screw will have to traverse, with an increase in the angle of safety from breaching.
See this image and copyright information in PMC

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