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Chapter 5
Imaging-Based Navigation: Applications
Beyond Instrumentation
KeemiaSorayaHeidari andChristopherJ.Kleck
Introduction
Navigation using three-dimensional (3D) computed tomography (CT) scanning or
uoroscopy has many uses intraoperatively. While the techniques are most commonly used for placement of pedicle screws, there are many other applications.
These include, but are not limited to, placement of interbody cages, sacroiliac joint
(SIJ) fusions, and targeted resections, such as in infection, pseudarthrosis, and en
bloc tumor resection.
Intraoperative imaging assists surgeons in the placement of instrumentation as
well as localization. In spine surgery, navigation is frequently employed for transpedicular screw xation, increasing accuracy and precision and allowing for projections to assist in implant selection [1–24]. These technologies have also been utilized
to facilitate minimally invasive techniques, such as in the placement of percutaneous pedicle screws, interbody devices, and SIJ fusion, as well as interbody device
placement [5, 8, 9, 21, 25–32].
Numerous studies have shown improved accuracy of pedicle screw placement
using intraoperative navigation techniques, with reduced screw malposition and
penetration [1–6, 9–15, 17–22, 24]. There have also been several studies that suggest increased safety with navigation placed pedicle screw technique. When compared to freehand or uoroscopically placed pedicle screws, these have included
decreased rates of return to the operating room and neurologic complication rates
[3, 6, 11, 14, 15, 17, 20, 21]. One systematic review by Chan etal. reviewing 94
studies found “moderate evidence of decreased breaches with CT navigation compared with freehand methods,” with 13% breaches with navigation and 20% with
freehand techniques, although they were not able to make a determination regarding
K. S. Heidari (*) · C. J. Kleck
University of Colorado School of Medicine, Aurora, CO, USA
e-mail: keemiasoraya.heidari@ucdenver.edu
Switzerland AG 2024
S. Garg, C. J. Kleck (eds.), Navigation, Robotics and 3D Printing in Spine
Surgery, https://doi.org/10.1007/978-3-031-68678-8_5
47© The Author(s), under exclusive license to Springer Nature
48
complication rates [4]. One study by Xiao etal. also noted shorter hospital stays
[22]. In this chapter, we aim to discuss additional uses of navigation outside of
instrumentation.
K. S. Heidari and C. J. Kleck
Mapping
By creating 3D imaging of the surgical eld, navigation allows for a visual aid to
surgeons with reproduction of the patient’s anatomy. In cases of distorted anatomy,
such as deformity, prior surgery, trauma, extensive spondyloarthropathy, infection,
and tumor, navigation can be utilized to render atypical anatomy and allow for safer
instrumentation [13, 16, 18–20, 23, 26, 33]. Using navigated probes, drills, and/or
high-speed burrs, it can also be used to guide joint preparation, such as in SIJ
fusions, or with facet joint decortication in percutaneous fusion procedures. Other
applications include measured resections, such as in heterotopic bone formation,
pseudarthrosis, anatomic variants such as those seen in Bertolotti’s syndrome, and
direct repair of pars defects. The various forms of the technology can also be utilized for repeat imaging in the operating room to conrm surgical goals.
Sacroiliac Joint Fusion
In their radiographic anatomical study of the SIJ, Rana etal. found signicant variation not only between men and women, but also between the right and left sides of
individuals [34]. As navigation allows for mapping of anatomy in real time, it is
ideal for individualized treatment of the complex anatomy of the SIJ [25, 26, 29,
35]. It can be used to identify the synovialized portion of the joint when joint prepa-
ration is performed. It also allows precise implant placement through the synovial
portion of the joint during implant placement. Cleveland etal. describe a mini-open
technique for SIJ fusion with direct bone grafting utilizing navigation in which a
posterior incision over the distal SIJ is made and a navigated drill then used to
decorticate the joint. By staying parallel with the synovial portion, they were able to
create a channel allowing for placement of a navigated cannula, which is then used
to pass graft material directly into the joint [25]. Navigation also allows for identication of optimal locations for placement of fusion implants through minimally
invasive techniques, as well as identication of landmarks to avoid injury, such as
the sciatic notch and neural foramina.
5 Imaging-Based Navigation: Applications Beyond Instrumentation
49
Pseudoarticulation Resection inBertolotti’s Syndrome
Bertolotti’s syndrome is described as low back pain and altered biomechanics
occurring in patients with transitional lumbosacral vertebrae [36]. This congenital
difference can occur in 4–30% of the population and is often identied incidentally
[37]. Symptomatic cases can often involve a pseudoarticulation between an enlarged
fth lumbar transverse process and the sacrum or iliac crest. This pseudoarticulation
can contribute to pain via arthritic changes and osteophyte formation which can also
go on to cause radicular pain through irritation of the nerve root. Altered biomechanics can also result in pain as the relative lack of motion from the stiff transitional segment can lead to increased load across the superior mobile segment [38].
When conservative measures fail and the pseudoarticulation has been identied as
the main pain generator, often through targeted injection, surgical intervention in
the form of resection can be considered [37, 39]. With the use of navigation, the
precise extent of the pseudoarticulation can be identied to aid in resection. A
postresection “spin” can also be obtained intraoperatively to conrm complete
resection [26].
Direct Pars Repair
Isthmic pars defects, fracture, or spondylolysis can lead to low back pain and, eventually, spondylolisthesis. Painful spondylolysis that is refractory to conservative
measures, including bracing, therapy, and medications, is considered for surgical
treatment. Though multiple reports have described repair with pedicle screws and
sublaminar hooks, direct repair in young patients with a lag screw through minimally invasive techniques can be undertaken with the assistance of navigation.
Navigated instruments can be utilized to identify the optimal trajectory for a lag
screw and therefore also the optimal incision to avoid signicant destruction of and
interference from soft tissues [26, 40–45]. Using navigation, a guide wire or drill
can be passed across the pars defect. It is then possible to place a screw orthogonal
to the defect in the appropriate trajectory under navigated guidance [26]. Figure5.1
demonstrates intraoperative CT imaging conrming screw placement orthogonal to
pars defect in a young patient undergoing direct pars repair. Figures 5.2 and 5.3
show immediate postoperative radiographs for the same patient.
50
Fig. 5.1 Direct pars repair
intra-op CT
K. S. Heidari and C. J. Kleck
Fig. 5.2 Direct pars repair
postop XR lateral
5 Imaging-Based Navigation: Applications Beyond Instrumentation
Fig. 5.3 Direct pars repair
postop XR AP
Thoracic Calcied Disc Herniation
51
Thoracic disc herniations are often incidental ndings on imaging without clinical
signicance. However, large herniations can lead to myelopathy and neurological
decline. About 40% of thoracic herniations are calcied and the vast majority occur
between T8 and L1. The herniation is considered “giant” if occupying greater than
40% of the spinal canal [46]. Giant calcied disc herniations present the highest
likelihood of symptomatic herniations and complications. These can be difcult to
treat due to potential for dural erosion with calcication, spinal cord injury during
resection, and overall higher risk of surgical complications. The choice of surgical
approach depends on the location and characteristics of the disc herniation, with
posterior, anterior, lateral posterolateral, and lateral endoscopic approaches
described [46–48].
Here we present a case of a giant calcied disc herniation leading to myelopathy
in an elderly patient. The patient was transferred to our institution with one week of
progressive bilateral lower extremity weakness, as well as urinary retention.
Advanced imaging revealed a calcied disc herniation at T11/T12. There was signicant spinal cord compression and associated cord signal increase on T2 STIR
(short tau inversion r) sequencing. Figures5.4 and 5.5 depict sagittal and axial CT
images demonstrating the calcied disc and Fig.5.6 depicts T2 magnetic resonance
imaging (MRI) through the same level.
The patient was brought to the operating room, and after initial exposure intraoperative CT scan was performed for navigation. Following instrumentation bilateral
52
Fig. 5.4 Thoracic disc
herniation sagittal CT
Fig. 5.5 Thoracic disc
herniation axial CT
K. S. Heidari and C. J. Kleck
5 Imaging-Based Navigation: Applications Beyond Instrumentation
Fig. 5.6 Thoracic disc herniation MR
Fig. 5.7 Thoracic disc
herniation intra-op tract
53
facetectomies were performed at the T11/12 level, and subsequently the bilateral
T12 pedicles were removed. The navigated probe was then utilized to plan and periodically check a measured resection utilizing curettes; Peneld and Woodson elevators were used to create a small void into the vertebral body from either side. This
process is presented in sequence with Fig.5.7 demonstrating the start of planning
and Fig.5.8 demonstrating the probe placed within the created void in the midline
54
Fig. 5.8 Thoracic disc
herniation intra-op void
creation
K. S. Heidari and C. J. Kleck
portion. A Woodson elevator was then carefully used to create a plane between the
dural sac and calcied disc, which was subsequently impacted into the void. Final
ultrasound imaging was used to verify reconstitution of the spinal cord and
thecal sac.
Infection
With the use of navigation, surgeons can also effectively target optimal areas and
trajectories for sampling and debridement of spinal infection. This allows for targeted resection and debridement. For example, during corpectomy work, a navigated probe can be utilized to map and plan the resection. During the resection,
image guidance can be used to check the depth of resection, as well as at the end of
the case to ensure adequate bone removal with minimization of potential damage to
surrounding structures. The technology can also be utilized to map available space
to assist in sizing of a strut graft or expandable cage following corpectomy for anterior column support [26].