decreasing the number of malpositioned screws, complications, length of stay, oper­ative time, and radiation to the surgical team.

In spinal deformity, pedicle screw accuracy is of the utmost importance to decrease complications such as spinal cord or nerve root injury. Improved screw accuracy and precision also allows for ideal placement of screws within the pedicle, or in an intentional in-out-in position. Ideal placement of screws gives the screw greater pull out strength when correcting deformity [26]. Additionally, accurate screw placement makes surgery faster, as screws do not have to be exchanged or removed for being malpositioned, thus improving overall efciency.

Overall, there are many factors that can contribute to the costs a hospital may face when adopting new technology that make it difcult to evaluate the cost­benets in a straight-forward analysis. However, the literature leans toward naviga­tion technology limiting reoperations, shortening procedures, and improving accuracy, thus creating cost savings to the healthcare system.

shots for a single patient [10]. A study by Su etal., described a pediatric protocol for the O-arm that only utilized 1.17mSv per spin, which is equivalent to 6–7 chest X-rays [55]. However, the superiority of the navigation is reliant on the low-dose protocols, and is only superior to uoroscopy if a surgeon uses a signicant amount of uoroscopy during a freehand pedicle screw placement. Contrasting these other studies, Dabaghi Richerand etal. noted that a standard pediatric scoliosis patient was exposed to 1.48mSv when using the O-arm and 0.34mSv when using uoros­copy [56]. However, this amount of radiation from the O-arm could increase up to 2–6 times in obese patients [56]. A follow-up study by Su etal. using a 0.65mSv low-dose protocol found that the patients undergoing O-arm spin experienced four times the radiation of those undergoing uoroscopy, and noted that 1 low-dose O-arm spin was equivalent to 85s of C-arm time [57]. Again, the conicting infor­mation in these studies underscore that a direct comparison is difcult, since each hospital utilizes different dosing protocols on the O-arm, and each surgeon uses a different amount of uoroscopy imaging intraoperatively when placing freehand screws. Of note, an adult study by Mehdelsohn found that the radiation experienced by the patient when using the O-arm was nearly nine times greater when the surgical team was inside the OR than when they stepped out, and that by stepping out of the OR, the radiation became nearly equivocal to that of freehand uoroscopy [51]. Further, none of these take into account the use of postoperative evaluation of screw position with CT scans. In the end, this makes the calculations difcult and the conclusions limited.