导航模板辅助脊柱椎弓根内固定术与传统椎弓根内固定术手术效果比较的Meta分析

目的:系统评价快速成型导航模板辅助脊柱椎弓根内固定术与传统通过解剖标志定位的内固定术的优良率与疗效。方法:计算机检索2017年6月前PubMed、The Cochrane Library(2017年5期)、Clinical Trial、Google Scholar、Web of Science、中国知网(CNKI)、万方(Wanfang Data)和维普(VIP)等中英文数据库,查找有关于导航模板辅助脊柱椎弓根螺钉置入与传统置入术临床疗效对比的临床随机对照试验(RCT)和前瞻性病例对照研究或回顾性病例对照研究。由2位研究者分别根据纳入与排除标准进行文献筛选、数据提取,通过Cochrane Handbook对纳入的随机对照试验进行方法学质量评价,通过NOS量表对纳入的前瞻性病例对照研究和回顾性病例对照研究进行方法学质量评价,采用Cochrane协作网RevMan 5.3软件对两种椎弓根螺钉置入方式所得疗效指标进行Meta分析。结果:最终共纳入7篇文献,包括2篇RCT、1篇前瞻性病例对照研究和4篇回顾性病例对照研究,共计237例患者,置入椎弓根螺钉1 688枚,其中导航模板组898枚螺钉,传统手术组790枚螺钉。Meta分析结果显示:导航模板组与传统手术组在螺钉置入优良率的差异有统计学意义[OR=5.05,95%CI(3.13,8.16),P0.000 01];两组胸腰段手术时间存在差异,且差异具有统计学意义[WMD=-27.19,95%CI(-38.21,-16.17),P0.000 01];两组术中出血量存在差异,且差异有统计学差异[WMD=-100.82,95%CI(-182.26,-19.37),P=0.02]。结论:导航模板脊柱椎弓根螺钉内固定术与传统椎弓根螺钉内固定术相比具有更好的临床疗效,可以提高螺钉置入的优良率,减少手术时间及术中出血量。     

脊柱手术机器人在胸腰段窄小椎弓根后路螺钉置入中的应用

目的 探讨Renaissance脊柱手术机器人在胸腰段窄小椎弓根后路螺钉置入中的应用。方法 对156例胸腰段窄小椎弓根的脊柱疾病患者行后路螺钉置入,窄小椎弓根双侧中一侧采用脊柱手术机器人辅助置入椎弓根螺钉,另一侧采用传统方法置入椎弓根螺钉。术后采用Abul-Kasimhierarchy分级系统评价椎弓根螺钉置入的优良性。结果 在T10～L3窄小椎弓根共置入椎弓根螺钉456枚,其中胸椎置钉60枚,置钉优良率机器人辅助侧为93. 3%(28/30),传统手术侧为80. 0%(24/30),两侧比较差异有统计学意义(P 0. 05);腰椎置钉396枚,置钉优良率机器人辅助侧为96. 0%(190/198),传统手术侧为81. 8%(162/198),两侧比较差异有统计学意义(P 0. 05)。结论 Renaissance脊柱手术机器人辅助胸腰段窄小椎弓根螺钉置入能提高置钉优良率。     

O-arm计算机导航辅助脊柱椎弓根螺钉置入的准确性

[目的]分析O-arm计算机辅助导航技术在脊柱椎弓根螺钉置入的准确性。[方法]回顾性分析2017年1月~2018年9月本院椎弓根螺钉置入患者575例,根据椎弓根螺钉置入方式不同,分为两组。导航组采用O-arm计算机辅助导航技术系统置入椎弓根螺钉233例,传统组采用传统徒手法置入椎弓根螺钉342例。行CT检查,依据Neo分型评估置钉准确性。[结果]导航组共置入1459枚椎弓根螺钉,其中C1~7置入222枚,T1~12置入535枚,L1~5置入652枚,S1置入50枚。每名患者置钉数量1~24枚,平均(6.26±3.77)枚。传统组共置入1724枚椎弓根螺钉,其中C1~7置入269枚,T1~12置入601枚,L1~5置入785枚,S1置入87枚。每名患者置钉数量1~20枚,平均(5.67±4.11)枚。导航组全部病例顺利完成手术,术中无血管、神经损伤等并发症,置钉安全率为100%,传统组有4例发生血管、神经损伤等并发症。所有患者术后进行12~24个月随访,随访过程均未发生不良事件。依据CT影像Neo分级标准,导航0型及1型椎弓根螺钉的成功置入率达98.01%,而传统组0型及1型椎弓根螺钉的成功置入率91.85%;两组间置入螺钉准确性的差异具有统计学意义(P<0.05)。[结论]与传统C臂X线机等徒手置钉方式相比,O-arm计算机辅助导航技术可提高脊柱椎弓根螺钉置入准确性,同时降低神经、血管等并发症的发生。     

CT导航寰枢椎后路椎弓根钉置入安全性的初步评估

目的评价CT导航在寰枢椎骨折脱位后路椎弓根钉内固定术中应用的精确性和安全性。方法纳入16例经X线片、CT、MRI检查确诊的寰枢椎骨折脱位,均行后路切开复位椎弓根钉内固定术,其中8例术中应用CT导航置入椎弓根钉(观察组),8例在C型臂X线机透视下置入椎弓根钉(对照组)。结果观察组置入32枚椎弓根钉,其中Ⅰ类置钉27枚,Ⅱ类置钉4例,Ⅲ类置钉1例;对照组置入32枚椎弓根钉,其中Ⅰ类置钉14枚,Ⅱ类置钉9例,Ⅲ类置钉9例。观察组椎弓根钉置入准确率高于对照组,差异有统计学意义(P 0.05)。所有患者均未出现有临床症状的神经、血管损伤,没有因为置钉位置不佳而再次手术者。结论 CT导航下手术可对解剖结构呈现多平面图像,有利于术者更好地判断置钉方向与角度,并可在椎弓根钉置入后立即进行CT扫描评价,及时发现并矫正对脊髓、神经、血管有影响的螺钉,提高椎弓根钉置入准确率。     

个体化导航模板在胸椎椎弓根螺钉置入中的初步临床应用

目的:通过临床应用评价个体化导航模板辅助胸椎椎弓根螺钉置入的准确性和安全性。方法:2008年7月～2009年9月,对11例需要行胸椎椎弓根螺钉置入手术的患者(青少年特发性脊柱侧凸7例,先天性脊柱侧凸2例,胸椎结核后凸畸形1例,多发性胸椎骨折1例)术前根据CT三维重建图像利用计算机辅助设计及快速成型技术设计制作46个胸椎个体化导航模板,术中应用个体化导航模板辅助在T2～T12置入椎弓根螺钉92枚,术后CT扫描评价螺钉位置,记录有无与螺钉置入相关的并发症。结果:通过个体化导航模板辅助置入的92枚胸椎椎弓根螺钉中,83枚完全在椎弓根内,9枚穿破椎弓根壁(其中椎弓根内侧壁穿破2枚、椎弓根外侧壁穿破7枚),其中5枚螺钉因椎弓根宽度小于4mm(3.0～3.8mm)而采用椎弓根旁固定方法(椎弓根螺钉轻度穿破椎弓根外侧壁经胸肋关节内侧进入椎体),椎弓根壁非故意穿破率为4.3%,置钉准确率为95.7%,所有穿破椎弓根壁的螺钉的穿出距离均小于2mm,螺钉位置可接受率为100%。无与螺钉置入有关的神经、血管、内脏损伤等并发症的发生。结论:个体化导航模板辅助胸椎椎弓根螺钉置入的置钉准确率高,安全、可行。     

多层螺旋CT三维重建技术在胸腰椎骨折经椎弓根螺钉内固定术中的应用价值

目的:探讨多层螺旋CT(MSCT)三维重建技术在胸腰椎骨折患者经椎弓根螺钉内固定术中的应用价值。方法:2007年1月~2008年12月,78例胸腰椎骨折患者在我院行椎弓根螺钉内固定术,其中38例使用传统置钉法(Weinstein法或AO法)进行椎弓根螺钉置入(A组),40例采用MSCT三维重建设计钉道的置钉方法进行螺钉置入(B组),术后两组均复查胸腰椎正、侧位X线片和CT了解置入螺钉位置情况,应用Lonstein等的方法评判置钉准确率。结果:78例患者共置入椎弓根螺钉436枚,A组38例共置入212枚,12例32枚螺钉穿破椎弓根皮质,其中穿破椎弓根内外皮质21枚,穿破椎弓根上下皮质11枚,置钉准确率84.91%;B组40例共置入224枚,5例6枚螺钉穿破椎弓根皮质,其中穿破椎弓根内外皮质4枚,穿破椎弓根上下皮质2枚,置钉准确率97.33%。两组置钉准确率有统计学差异(P<0.05)。结论:胸腰椎骨折患者行椎弓根螺钉内固定时应用MSCT三维重建设计钉道的置钉方法较传统置钉方法成功率高。     

数字化导航模板在颈椎椎弓根螺钉置入中的应用

目的 :评价个体化导航模板辅助颈椎椎弓根螺钉置入的准确性和安全性。方法 :2010年8月~2013年8月,对25例需要行颈椎椎弓根螺钉内固定的患者术前行64排螺旋CT连续扫描,计算机重建颈椎三维模型、设计颈椎椎弓根的最佳进钉通道,获取每个颈椎椎板的解剖形态,设计与颈椎椎板吻合的反向模板,并模拟螺钉的最佳进钉通道,形成单侧定位导向孔的导航模板。利用3D打印技术打印颈椎模型和导航模块,通过术前模拟置钉测量出每个椎弓根的螺钉通道长度及椎弓根宽度,术中采用导航模板辅助置入椎弓根螺钉,术后行CT扫描评价螺钉位置,记录有无与螺钉置入相关的并发症。结果:利用导航模板辅助置入颈椎椎弓根螺钉共164枚,其中152枚完全在椎弓根内,4枚螺钉穿破椎弓根内侧皮质,8枚螺钉穿破椎弓根外侧皮质,无椎弓根上方、下方穿破的螺钉,未发现与置钉相关的椎动脉、神经根和颈髓等损伤的症状。结论:个体化导航模板辅助颈椎椎弓根螺钉置入可以提高置钉的准确率,增加颈椎手术的安全性。     

椎弓根角度测量器在下颈椎内固定术中的应用

目的 探讨颈后路椎弓根钉内固定术中应用椎弓根角度测量器辅助置钉的准确性及安全性。方法 纳入2015年1月～2019年1月行后路手术的40例下颈椎骨折脱位患者,随机分为观察组和对照组各20例。观察组术中透视下应用椎弓根角度测量器辅助置钉,对照组透视下徒手置钉。术后均行CT检查并分析两组患者置钉优良率、并发症情况等指标。结果 观察组置入93枚螺钉,优良率96.8%;对照组置入105枚螺钉,优良率为87.6%,观察组显著高于对照组(P<0.05)。观察组术后发生螺钉松动1例,发生率为5%;对照组发生螺钉松动1例,螺钉穿破椎弓根2例,总发生率为15%。观察组并发症发生率显著低于对照组(P<0.05)。结论 椎弓根角度测量器显著提高了置钉准确性,减少了手术时间、术中出血量及术后引流量,降低了术后并发症的发生率。     

个性化导航模板辅助儿童颈椎椎弓根螺钉置入与徒手置入准确性的对比研究

目的 :探讨个性化导航模板辅助儿童颈椎椎弓根螺钉置入的可行性及准确性,并与徒手置钉进行对比。方法:选取儿童尸体4具,男女各2具,年龄6~9岁。随机分为2组,均行颈椎椎弓根螺钉置入术。徒手置钉组(A组)行徒手置钉;个性化导航模板辅助下置钉组(B组)依据颈椎CT扫描资料,利用计算机辅助及快速成型技术设计并制作出相应颈椎椎弓根螺钉置入个性化导航模板,行该模板辅助下置钉。置钉后行颈椎CT扫描评价两种置钉方法的置钉成功率及优级率并行统计分析。结果:A组共置入28枚螺钉,寰椎置入4枚螺钉,其中良级3枚、差级1枚;枢椎置入4枚螺钉,其中优级2枚、良级2枚;下颈椎(C3~C7)置入20枚螺钉,其中优级9枚、良级5枚、差级6枚。B组共置入28枚螺钉,寰椎置入4枚螺钉,其中良级2枚、差级2枚;枢椎置入4枚螺钉,其中优级3枚、良级1枚;下颈椎置入20枚螺钉,其中优级16枚、良级3枚、差级1枚。两组上颈椎的置钉成功率及优级率因样本数太少未进行统计学比较;两组下颈椎置钉的成功率及优级率均有统计学差异(P<0.05)。结论 :个性化导航模板辅助儿童下颈椎椎弓根螺钉置入术具有较好的置钉成功率,该方法操作简单、易于掌握,充分体现了儿童置钉个性化原则。     

术中三维导航引导下脊柱侧凸的椎弓根螺钉置入研究

[目的]探讨术中实施三维导航在脊柱侧凸病人椎弓根螺钉置入的应用价值.[方法] 38例脊柱侧凸病人行三维导航引导下椎弓根螺钉固定术,其中青少年特发性脊柱侧凸18例,老年退行性脊柱侧凸20例.手术中脊柱CT三维扫描后向导航系统输入患者信息资料,用导航棒按导航指引下在最佳位置、直径和长度立体、动态地置入椎弓根螺钉.[结果]三维导航引导下成功对38例脊柱侧凸病人共置入236枚椎弓根螺钉,复查X线片和CT,无螺钉松动和断裂,按分类法:A级227枚,B级7枚,C级2枚,D级0枚.术后侧凸平均26°(21°～118°),矫正率(61％);术后后凸平均14°(5°～29°),矫正率39％.38例平均随访18个月(12 ～25个月),术后无脊髓或神经根损伤.[结论]三维导航引导下的脊柱侧凸椎弓根钉置入方法精确可靠.     

Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies

Studies revealed that navigation systems that provided intraoperative assistance might improve pedicle screw insertion accuracy, and also implied that different systems provided different pedicle screw insertion accuracy. A systematic review and meta-analysis was conducted to focus on the pedicle screw insertion accuracy with or without the assistance of image-guided system, and the variance among the different navigation systems. Comparative studies were searched on pedicle screw insertion accuracy between conventional and navigated method, and among different navigation systems. A total of 43 papers, including 28 clinical, 14 cadaveric and 1 model studies, were included in the current study. For clinical articles, there were 3 randomized clinical trials, 4 prospective comparative studies and 21 retrospective comparative studies. The incidence of pedicle violation among computer tomography-based navigation method group was statistically significantly less than that observed among the conventional group (OR 95% CI, in vivo: 0.32–0.60; in vitro: 0.24–0.75 P < 0.01). Two-dimensional fluoroscopy-based navigation system (OR 95% CI, in vivo: 0.27–0.48; in vitro: 0.43–0.88 P < 0.01) and three-dimension fluoroscopy-based navigation system (OR 95% CI, in vivo: 0.09–0.38; in vitro: 0.09–0.36 P < 0.01) also obtained significant reduced screw deviation rate over traditional methods. Between navigated approaches, statistically insignificant individual and pooled RR values were observed for all in vivo subgroups. Pooled estimate of in vitro studies show that computer tomography-based and three-dimension fluoroscopy-based navigation system provided more accurate pedicle screw insertion over two-dimension fluoroscopy-based navigation system. Our review showed that navigation provided a higher accuracy in the placement of pedicle screws compared with conventional methods. The superiority of navigation systems was obvious when they were applied to abnormal spinal structure. Although no strong in vivo evidence has detected significantly different pedicle screw placement accuracy among the three major navigation systems, meta-analysis revealed the variance in pedicle screw insertion accuracy with different navigation methods.     

Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients

We performed a randomised controlled study to assess the accuracy of computer-assisted pedicle screw insertion versus conventional screw placement under clinical conditions. One hundred patients scheduled for posterior thoracolumbar or lumbosacral pedicle screw instrumentation were randomised into two groups, either for conventional pedicle screw placement or computer-assisted screw application using an optoelectronic navigation system. From the computer-assisted group, nine patients were excluded: one because of an inadequate preoperative computed tomography study, seven because of problems with the specific instruments or the computer system, and one because of an intraoperative anesthesiological complication. Thus, there were 50 patients in the conventional group and 41 in the computer-assisted group, and the number of screws inserted was 277 and 219, respectively. There was no statistical difference between the groups concerning age, gender, diagnosis, type of operation performed, mean operating time, blood loss, or number of screws inserted. The time taken for screw insertion was significantly longer in the computer-assisted group. Postoperatively, screw positions were assessed by an independent radiologist using a sophisticated CT imaging protocol. The pedicle perforation rate was 13.4% in the conventional group and 4.6% in the computer-assisted group (P = 0.006). Pedicle perforations of more than 4 mm were found in 1.4% (4/277) of the screw insertions in the conventional group, and none in the computer-assisted group. Complications not related to pedicle screws were two L5 nerve root lesions, one end plate fracture, one major intraoperative bleeding and one postoperative death in the conventional group, and one deep infection in the computer-assisted group. In conclusion, pedicular screws were inserted more accurately with image-guided computer navigation than with conventional methods. Received: 11 October 1999 Revised: 2 February 2000 Accepted: 15 February 2000     

Pedicle screw placement in the thoracic spine: a randomized comparison study of computer-assisted navigation and conventional techniques

Objective： To evaluate the accuracy of computer-assisted pedicle screw installation and its clinical benefit as compared with conventional pedicle screw installation techniques.
Methods： Total 176 thoracic pedicle screws placed in 42 thoracic fracture patients were involved in the study randomly, 20 patients under conventional fluoroscopic control （84 screws） and 22 patients had screw insertion under three dimensional （3D） computer-assisted navigation （92 screws）. The 2 groups were compared for accuracy of screw placement, time for screw insertion by postoperative thincut CT scans and statistical analysis by χ^2 test. The cortical perforations were then graded by 2-mm increments： Grade Ⅰ （good, no cortical perforation）, Grade Ⅱ （screw outside the pedicle 〈2 mm）, Grade Ⅲ （screw outside the pedicle 〉2 mm）.
Results： In computer assisted group, 88 （95.65%） were Grade Ⅰ （good）, 4 （4.35%） were Grade Ⅱ （〈2mm）, no Grade Ⅲ （〉2 mm） violations. In conventional group, there were 14 cortical violations （16.67%）, 70 （83.33%） were Grade Ⅰ （good）, Ⅱ （13.1%） were Grade Ⅱ （〈2 mm）, and 3 （3,57%） were Grade Ⅲ （〉2 mm） violations （P〈0.001）. The number （19.57%） of upper thoracic pedicle screws （ T1-T4 ） inserted under 3D computer-assisted navigation was significantly higher than that （3.57%） by conventional fluoroscopic control （P〈0.001）. Average screw insertion time in conventional group was （4.56 ±1.03） min and （2.54 ± 0.63） min in computer assisted group （P〈0.001）. In the conventional group, one patient had pleura injury and one had a minor dura violation.
Conclusions： This study provides further evidence that 3D computer-assisted navigation placement ofpedicle screws can increase accuracy, reduce surgical time, and be performed safely and effectively at all levels of the thoracic spine, particularly upper thoracic spine.     

Functional outcome of computer-assisted spinal pedicle screw placement: a systematic review and meta-analysis of 23 studies including 5,992 pedicle screws

A number of studies have shown increased accuracy of pedicle screw placement in spine with the help of computer-assisted navigation. The literature is lacking in regard to functional benefit derived from this technique. The aim of this systematic review was to look at the functional outcomes following computer-assisted pedicle screw placement in spine. A ‘Dialog Datastar’ search was used using optimized search strategy covering the period from 1950 to July 2009; 23 papers were finally included which met our inclusion criteria. We report on a total of 1,288 patients with 5,992 pedicle screws. The comparison of neurological complications in two groups demonstrated an odds ratio of 0.25 (95% CI 0.06, 1.14) in favour of using navigation for pedicle screw insertion (p = 0.07). Comparative trials demonstrated a significant advantage in terms of accuracy of navigation over conventional pedicle screw insertion with a relative risk of 1.12 (95% CI 1.09, 1.15) (p < 0.00001). Navigation does not show statistically significant benefit in reducing neurological complications and there was insufficient data in the literature to infer a conclusion in terms of fusion rate, pain relief and health outcome scores.     

Accuracy of fluoroscopic navigation of pedicle screws. CT-based evaluation of bone screw placement

While the advantages of C-arm navigation in computer-assisted spine surgery are obvious, the accuracy of pedicle screw placement with virtual fluoroscopy still needs to be verified. The C-arm-based ION system (Medtronic Sofamor Danek) was used to navigate pedicle screw insertion in patients undergoing spinal surgery for various conditions. In a prospective study, a total of 160 screws were inserted in the first 30 consecutive patients since introduction of the system at our institution: 54 at the thoracic spine (highest level: TH4) and 106 at the lumbar spine. Computed tomography (CT) scans were performed postoperatively by two independent radiologists to control the accuracy of screw placement at the level of the pedicles after reconstruction of axial images according to Laine et al. The comparison of the calculated accuracy rate of pedicle screw placement using virtual fluoroscopy with reported results achieved with CT-based navigation shows similar results for virtual fluoroscopy and a remarkable increase of accuracy in comparison to reports on conventional pedicle screw placement.     

Computer navigation versus fluoroscopy-guided navigation for thoracic pedicle screw placement: a meta-analysis

Although application of intraoperative computer navigation technique had been integrated into placement of pedicle screws (PSs) in thoracic fusion for years, its security and practicability remain controversial. The aim of this study is to evaluate the accuracy, the operative time consumption, the amount of intraoperative blood loss, time of pedicle insertion and the incidence of complications of thoracic pedicle screw placement in patients with thoracic diseases such as scoliosis and kyphosis. Pubmed, Web of Knowledge, and Google scholar were searched to identify comparative studies of thoracic pedicle screw placement between intraoperative computer navigation and fluoroscopy-guided navigation. Outcomes of malposition rate, operative time consumption, insertion time, intraoperative blood loss, and the incidence of complications are evaluated. Fourteen articles including 1723 patients and 9019 PSs were identified matching inclusion criteria. The malposition rate was lower (RR: 0.33, 95 % CI: 0.28–0.38, P?<?0.01) in computer navigation group than that in fluoroscopy-guided navigation group; the operative time was significantly longer [weighted mean difference (WMD)?=?23.66, 95 % CI: 14.74–32.57, P?<?0.01] in computer navigation group than that in fluoroscopy-guided navigation group. The time of insertion was shorter (WMD?=??1.88, 95 % CI: ?2.25– ?1.52, P?<?0.01) in computer navigation group than that in fluoroscopy-guided navigation group. The incidence of complications was lower (RR?=?0. 23, 95 % CI: 0.12–0.46, P?<?0.01) in computer navigation group than that in the other group. The intraoperative blood loss was fewer (WMD?=??167.49, 95 % CI: ?266.39– ?68.58, P?<?0.01) in computer navigation group than that in the other. In conclusion, the meta-analysis of thoracic pedicle screw placement studies clearly demonstrated lower malposition rate, less intraoperative blood loss, and fewer complications when using computer navigation. This result provides strong evidence that computer technology could be safer and more reliable than fluoroscopy-guided navigation.     

Robotic and navigated pedicle screws are safer and more accurate than fluoroscopic freehand screws: a systematic review and meta-analysis

BACKGROUND CONTEXTNavigated and robotic pedicle screw placement systems have been developed to improve the accuracy of screw placement. However, the literature comparing the safety and accuracy of robotic and navigated screw placement with fluoroscopic freehand screw placement in thoracolumbar spine surgery has been limited.PURPOSETo perform a systematic review and meta-analysis of randomized control trials that compared the accuracy and safety profiles of robotic and navigated pedicle screws with fluoroscopic freehand pedicle screws.STUDY DESIGN/SETTINGSystematic review and meta-analysisPATIENT SAMPLEOnly randomized controlled trials comparing robotic-assisted or navigated pedicle screws placement with freehand pedicle screw placement in the thoracolumbar spine were included.OUTCOME MEASURESOdds ratio (OR) estimates for screw accuracy according to the Gertzbein-Robbins scale and relative risk (RR) for various surgical complications.METHODSWe systematically searched PubMed and EMBASE for English-language studies from inception through April 7, 2022, including references of eligible articles. The search was conducted according to PRISMA guidelines. Two reviewers conducted a full abstraction of all data, and one reviewer verified accuracy. Information was extracted on study design, quality, bias, participants, and risk estimates. Data and estimates were pooled using the Mantel-Haenszel method for random-effects meta-analysis.RESULTSA total of 14 papers encompassing 12 randomized controlled trials were identified (n=892 patients, 4,046 screws). The pooled analysis demonstrated that robotic and navigated pedicle screw placement techniques were associated with higher odds of screw accuracy (OR 2.66, 95% CI 1.24–5.72, p=.01). Robotic and navigated screw placement was associated with a lower risk of facet joint violations (RR 0.09, 95% CI 0.02–0.38, p<.01) and major complications (RR 0.31, 95% CI 0.11–0.84, p=.02). There were no observed differences between groups in nerve root injury (RR 0.50, 95% CI 0.11–2.30, p=.37), or return to operating room for screw revision (RR 0.28, 95% CI 0.07–1.13, p=.07).CONCLUSIONSThese estimates suggest that robotic and navigated screw placement techniques are associated with higher odds of screw accuracy and superior safety profile compared with fluoroscopic freehand techniques. Additional randomized controlled trials will be needed to further validate these findings.     

新型C1侧块-C2椎弓根螺钉置钉导向器的临床应用

目的 评价新型C1侧块-C2椎弓根螺钉置钉导向器辅助置钉的有效性和安全性.方法 2017年7月—2019年9月,64例患者在海军军医大学长征医院接受C1,2重建.其中16例由经验较丰富医师在导向器辅助下完成置钉(A组);16例由经验较丰富医师徒手置钉(B组);16例由经验较少医师在导向器辅助下完成置钉(C组);16例由经验较少医师徒手置钉(D组).记录并比较各组置钉时间和螺钉等级.结果 A组置钉准确率高于B组,差异有统计学意义(P<0.05);2组置钉时间差异无统计学意义(P>0.05).C组置钉时间低于D组,准确率高于D组,差异均有统计学意义(P<0.05).经验较少医师采用导向器辅助置钉的学习曲线趋于稳定的手术次数分别为12次(C1)和13次(C2),经验较丰富医师分别为12次(C1)和10次(C2).结论 新型C1侧块-C2椎弓根螺钉置钉导向器辅助置钉安全有效,适用于野战和急救等医疗条件有限的极端情况.     

Segmental pedicle screwing for idiopathic scoliosis using computer-assisted surgery

STUDY DESIGN: Retrospective clinical study. OBJECTIVES: To evaluate the accuracy of computer-assisted surgery for idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Segmental pedicle screw fixation has been proven to enable enhanced correction of scoliotic deformities. However, both neurovascular and visceral structures are at potential risk from screw misplacement due to pedicle drift. No reports exist on the accuracy and benefits of computer-assisted surgery for pedicle screwing in scoliosis surgery. METHODS: A total of 40 consecutive patients with idiopathic scoliosis were evaluated. Postoperative computed tomography was assessed for the accuracy of pedicle screw placement in 20 cases treated without a navigation system and 20 cases with a computed tomography-based navigation system. Correlations between registered levels and pedicle perforation were investigated. RESULTS: Pedicle violation was observed in 28.0% of the control group and 11.4% of the navigation group, with significant differences. No screw misplacements at the registered levels were seen, and the longer the distance between the registered level and level of screw insertion, the higher the rate of pedicle violation. No intraoperative complications caused by pedicle perforation occurred. CONCLUSIONS: In the navigation group, a tendency to lateral perforation at the concave side and medial perforation at the convex side was noted, like in the control group. Use of the navigation system significantly reduced the screw misplacement rate for rotated vertebrae as compared with the control group. Separate registration is recommended for rotated vertebrae when possible.     

Safety and accuracy of robot-assisted placement of pedicle screws compared to conventional free-hand technique: a systematic review and meta-analysis

BACKGROUND CONTEXTThe introduction and integration of robot technology into modern spine surgery provides surgeons with millimeter accuracy for pedicle screw placement. Coupled with computer-based navigation platforms, robot-assisted spine surgery utilizes augmented reality to potentially improve the safety profile of instrumentation.PURPOSEIn this study, the authors seek to determine the safety and efficacy of robotic-assisted pedicle screw placement compared to conventional free-hand (FH) technique.STUDY DESIGN/SETTINGWe conducted a systematic review of the electronic databases using different MeSH terms from 1980 to 2020.OUTCOME MEASURESThe present study measures pedicle screw accuracy, complication rates, proximal-facet joint violation, intraoperative radiation time, radiation dosage, and length of surgery.RESULTSA total of 1,525 patients (7,379 pedicle screws) from 19 studies with 777 patients (51.0% with 3,684 pedicle screws) in the robotic-assisted group were included. Perfect pedicle screw accuracy, as categorized by Gerztbein-Robbin Grade A, was significantly superior with robotic-assisted surgery compared to FH-technique (Odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.20–2.35; p=.003). Similarly, clinically acceptable pedicle screw accuracy (Grade A+B) was significantly higher with robotic-assisted surgery versus FH-technique (OR: 1.54, 95% CI: 1.01–2.37; p=.05). Furthermore, the complication rates and proximal-facet joint violation were 69% (OR: 0.31, 95% CI: 0.20–0.48; p<.00001) and 92% less likely (OR: 0.08, 95% CI: 0.03–0.20; p<.00001) with robotic-assisted surgery versus FH-group. Robotic-assisted pedicle screw implantation significantly reduced intraoperative radiation time (MD: ?5.30, 95% CI: ?6.83–3.76; p<.00001) and radiation dosage (MD: ?3.70, 95% CI: ?4.80–2.60; p<.00001) compared to the conventional FH-group. However, the length of surgery was significantly higher with robotic-assisted surgery (MD: 22.70, 95% CI: 6.57–38.83; p=.006) compared to the FH-group.CONCLUSIONThis meta-analysis corroborates the accuracy of robot-assisted pedicle screw placement.