Elsevier

World Neurosurgery

Volume 100, April 2017, Pages 325-335
World Neurosurgery

Technical Note
Total Navigation in Spine Surgery; A Concise Guide to Eliminate Fluoroscopy Using a Portable Intraoperative Computed Tomography 3-Dimensional Navigation System

https://doi.org/10.1016/j.wneu.2017.01.025Get rights and content

Background

Portable intraoperative computed tomography (iCT) with integrated 3-dimensional navigation (NAV) offers new opportunities for more precise navigation in spinal surgery, eliminates radiation exposure for the surgical team, and accelerates surgical workflows. We present the concept of “total navigation” using iCT NAV in spinal surgery. Therefore, we propose a step-by-step guideline demonstrating how total navigation can eliminate fluoroscopy with time-efficient workflows integrating iCT NAV into daily practice.

Methods

A prospective study was conducted on collected data from patients undergoing iCT NAV–guided spine surgery. Number of scans, radiation exposure, and workflow of iCT NAV (e.g., instrumentation, cage placement, localization) were documented. Finally, the accuracy of pedicle screws and time for instrumentation were determined.

Results

iCT NAV was successfully performed in 117 cases for various indications and in all regions of the spine. More than half (61%) of cases were performed in a minimally invasive manner. Navigation was used for skin incision, localization of index level, and verification of implant position. iCT NAV was used to evaluate neural decompression achieved in spinal fusion surgeries. Total navigation eliminates fluoroscopy in 75%, thus reducing staff radiation exposure entirely. The average times for iCT NAV setup and pedicle screw insertion were 12.1 and 3.1 minutes, respectively, achieving a pedicle screw accuracy of 99%.

Conclusions

Total navigation makes spine surgery safer and more accurate, and it enhances efficient and reproducible workflows. Fluoroscopy and radiation exposure for the surgical staff can be eliminated in the majority of cases.

Introduction

As minimally invasive spine surgery (MISS) constantly progresses, spine surgeons increasingly rely on advanced image-guided navigation (NAV). However, NAV systems still seem to decelerate surgical workflow, which limits its versatility and applicability in the broad field.1 Recent studies suggest intraoperative computed tomography (iCT)-guided NAV provides benefits that outweigh these drawbacks, including reducing radiation exposure, saving operating room (OR) time, and improving the accuracy of instrumentation.2, 3, 4 The portable iCT AIRO NAV (Brainlab AG, Feldkirchen, Germany) is a state-of-the-art iCT that offers new opportunities for more precise navigation in spinal surgery, while at the same time accelerating surgical workflow, particularly in MISS when the anatomy is altered and orientation may be difficult.5, 6, 7

Recently, we have introduced the concept of total navigation in MIS-TLIF.8 Total navigation employs intraoperative 3-dimensional navigation combined with the latest-generation portable iCT in all steps of spine surgery. Application of total navigation results in complete elimination of radiation exposure for the surgical staff, elimination of K-wires for instrumentation, and elimination of the pedicle probe.

Here we propose a “step-by-step” guide for the application of total navigation in spine surgery, which can be used to successfully implement this technique into daily spine surgery practice. Additionally, this manuscript can be considered as a complementary part of our recently published MISS guide, if “total navigation through tubular retractors” is intended.9

The aim of the present study was to prospectively review our first 117 cases using iCT NAV for total navigation and to summarize our experiences regarding surgical workflow, pedicle screw accuracy, and complications into a sufficient guideline. Case examples demonstrating the versatility of this technology are provided in the supplemental digital content. Additionally, an instructional step-by-step illustrative material on how to perform a totally navigated MIS-TLIF is provided.

Section snippets

Indications for Total Navigation

A prospective single-center study of patients undergoing iCT NAV–guided spine surgery with single- or multilevel spinal disorders (occipital-cervical to lumbar-sacral), between November 2014 and January 2016, was conducted. It included diverse pathologies (e.g., degenerative, trauma, neoplasm, deformity) as demonstrated in Table 1. Demographic data including patient history, age, sex, and comorbidities were documented.

Operating Room Setup

The iCT-guided NAV included the Airo CT scanner, an image-guidance system, an

Baseline Characteristics

iCT NAV has been successfully employed in 117 cases (115 patients), without complications (mean age: 62.5 ± 15.4 years; 57% female and 43% male) as illustrated in Table 1. Major indications included degenerative disease (65%), trauma (3.4%), neoplasm (8.5%), deformity (6%), and adjacent segment disease (10.2%). Sixty-nine percent of spine surgeries addressed the lumbar spine, whereas 21% addressed the cervical spine and 10% addressed the thoracic spine (see Table 1).

Utilization of iCT

iCT-guided NAV was used for

Discussion

Over the past years, we have expanded the utilization of iCT NAV in order to make MISS safer, eliminate radiation exposure to the surgical staff, and create more efficient workflows (Table 2). Here we summarize our initial experiences with total navigation in spine surgery.6

Conclusions

In conclusion, the latest generation of mobile iCT expands the role of navigation from a tool that was only used for placement of screws to a technology that is now used throughout the entire procedure. Using iCT NAV in conjunction with navigated guide tubes eliminates the need for fluoroscopy in 75% of cases and optimizes outcomes in spinal surgery.40 We predict that going forward, navigation will increasingly replace fluoroscopy in spinal surgery.

Acknowledgments

We would like to thank AOSpine and NuVasive for fellowship support. In addition, we would like to thank Gulce Askin, MPH for the statistical support.

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    • Cited by (0)

    Conflict of Interest Statement: Roger Härtl has received consulting fees from AO Spine, Brainlab, DePuy-Synthes, and Lanx. Supported/contracted research: Baxter. Gernot Lang has received an educational grant from DePuy-Synthes and a travel grant from the GSK Foundation. Gulce Askin was partially supported by the following grant: Clinical and Translational Science Center at Weill Cornell Medical College (UL1-TR000457-06). Thanks also to the Carol and Grace Hansen Spinal Research Fund.

    The study was approved by our local institutional review board, and informed consent was obtained from all patients before surgery. All human studies have been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

    Supplementary digital content available online.

    ∗

    Rodrigo Navarro-Ramirez, Gernot Lang and Xiaofeng Lian contributed equally to this work.

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