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5 Imaging-Based Navigation: Applications Beyond Instrumentation
Fig. 5.22 Tumor resection planning 1
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Fig. 5.23 Tumor resection planning 2
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Fig. 5.24 Tumor resection planning 3
K. S. Heidari and C. J. Kleck
Fig. 5.25 Tumor resection planning 4
5 Imaging-Based Navigation: Applications Beyond Instrumentation
Fig. 5.26 Tumor resection planning 5
Fig. 5.27 Postoperative
PA radiograph
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Fig. 5.28 Postoperative
lateral radiograph
K. S. Heidari and C. J. Kleck
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K. S. Heidari and C. J. Kleck
Chapter 6
Imaging-Based Navigation: Summary
ofClinical Results
JohnWhitaker andDavidOu-Yang
Early Development andInitial Navigation Systems
Spinal navigation software originated from stereotactic neurologic surgery. The
Brown-Roberts-Wells frame and software were rst described in 1979 [1]. This
technique was created to allow surgeons to extrapolate information from preoperative computerized tomography (CT), magnetic resonance, or positron-emission
tomography images and use it intraoperatively to increase surgical precision. This
was of particular interest for intracranial lesion resection. In 1986, Roberts etal.
rened this technology by using a stereotaxic frame to overlay these preoperative
images onto the operating eld underneath a microscope [2].
The rst report describing navigation software in spinal surgery was published in
1995 by Nolte etal. [3]. This is represented in Fig.6.1. In that same year, Lavelle
etal. described the implementation of this software for the placement of pedicle
screws on a cadaveric specimen [5]. This paper described their process of transferring preoperative CT scan information into the placement of pedicle screws. The
surgeon would set the ideal trajectory of the pedicle screw based on the patient’s
preoperative imaging, and then calibrated instrumentation allowed for placement in
this trajectory.
One of the largest comparative evaluations of this technology was performed by
Amiot et al. [6]. This study evaluated 544 conventionally placed pedicle screws
inserted from T5 to S1 versus 294 computer-assisted pedicle screws from T2 to S1.
They examined accuracy of placement, neurologic compromise from screw placement, and location of improperly placed screws. They concluded that there was a
signicant increase in the accurate placement of pedicle screws using computerassisted insertion (85% vs. 95%). There were seven patients in this series that
J. Whitaker (*) · D. Ou-Yang
Division of Spine Surgery, Department of Orthopedic Surgery, School of Medicine,
University of Colorado, Boulder, CO, USA
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_6
73© The Author(s), under exclusive license to Springer Nature
74
Fig. 6.1 Fluoroscopic-guided navigation [4]
J. Whitaker and D. Ou-Yang
required re-treatment for neurologic compromise from misplaced screws in the conventional group compared with none in the navigation group. All misplaced screws
placed under navigation assistance were within 2mm of the pedicle cortex, while
there was a signicantly larger variation in the conventional group (>6.0mm of
variation). The ndings of this study supported several other earlier studies. Merloz
etal. reported in 1997 that there was a signicant increase in the accuracy and reliability of pedicle screw placement in the thoracic spine as compared to conventional
techniques for placement [7]. Schwarzenbach etal. examined the success of pedicle
screw placement using the Orthopedic Surgery Planning System. This study also
determined that there was increased accuracy and precision in placing pedicle
screws [8]. Interestingly, this study did not demonstrate an increase in accuracy of
screw placement over time; however, they did note that there was improved efciency in system use over time. Regarding a learning curve, Amoit etal. did not
demonstrate any evidence of a learning curve effect over their 3-year experience [6].
Fluoroscopic-Guided Navigation Systems
Conventional uoroscopy using a C-arm has been a staple for pedicle and lateral
mass screw placement in spinal surgery. Fluoroscopy is also readily available in
most facilities and the use and set-up are familiar to the operating room staff.
Fluoroscopic navigation systems rely on conventionally obtained intraoperative
uoroscopic images. These are stored and compiled through the navigation platform, and then placed in an overlay for the surgeon to visualize the instrumentation’s trajectory and depth. These advantages make uoroscopy a convenient
modality to augment freehand screw placement. Freehand pedicle screw placement
has been associated with screw misplacement rates as high as 40%. With supplementation of standard uoroscopic imaging, this rate can be lowered to 3.4% [9].
This utilization of uoroscopy is not without signicant drawbacks. Radiation
exposure to the neck is 8.3 mrem/min and to the torso is 53 mrem/min. Hand dosing
is 58 mrem/min [10]. These dose rates are 10–12 times the radiation exposure for