Biplane Fluoroscopic-Guided Percutaneous Thoracic Instrumentation: A Technical Note

Abstract

Biplane fluoroscopy in a hybrid operating room (OR) is commonly used for neuroendovascular and hybrid open/endovascular cases. The image quality is far superior to most C-arm fluoroscopy machines in the regular OR. This advantage can be particularly useful for upper and mid-thoracic percutaneous screw placement because the C-arm visualization in the regular OR is suboptimal due to shoulders absorbing the majority of the photons on lateral fluoroscopy. A 31-year-old man was ejected following a motor vehicle accident and sustained a T7 burst fracture with anterior translation on T8 and spinal cord transection. Following stabilization in the intensive care unit, the patient was taken to the biplane hybrid OR for percutaneous pedicle screw fixation. The patient had percutaneous instrumentation and fixation of T5-T10, and sequential reducers were also used to re-align T7 and T8. The use of biplane fluoroscopy enhanced safety and visualization. The patient tolerated the procedure well without complication. We believe this is an unrealized and underutilized function of a biplane hybrid OR that bears further investigation and study.

Keywords: biplane fluoroscopy; hybrid operating room; neurosurgery; percutaneous instrumentation; percutaneous pedicle fixation; spine; trauma.

Figure 1. Initial computed tomography (CT) images of the patient's thoracic spine

Figure 1A represents the approximate midline sagittal CT slice with the arrow highlighting the burst fracture with marked retropulsion at T7, and the yellow line corresponds to the axial cut of Figure 1B. Additionally of note in Figure 1A is the anterior translation of T7 on T8.

Figure 2. Anterior-posterior and lateral views of the T5-T10 vertebrae following instrumentation

Figure 2A is the anterior-posterior view of the T5-T10 vertebrae following instrumentation with pedicle screws in T5, T6, T9, and T10. Figure 2B demonstrates the lateral view, with the arrows demarcating T7 and T8, the areas of dislocation.

Figure 3. Figure 3A features a standard operating room with C-arm in place, and Figure 3B demonstrates a hybrid operating room with biplane fluoroscopy in place. Not pictured are frames that can be affixed to the operating room bed, the entire sterile set-up, and the process of moving the C-arm in and out of the surgical field while maintaining sterility.