Vertebral artery injury in cervical spine surgery: anatomical considerations, management, and preventive measures.

Study Design. A prospective interventional case-series study plus a retrospective analysis of historical patients for comparison of data. Objective. To evaluate workflow, feasibility, and clinical outcome of navigated stabilization procedures with data acquisition by intraoperative computed tomography. Summary of Background Data. Routine fluoroscopy to assess pedicle screw placement is not consistently relyable. Our hypothesis was that image-guided spinal navygation using an intraoperative CT-scanner can improve the safety and precision of spinal stabilization surgery. Methods. CT data of 94 patients (thoracolumbar [n = 66], C1/2 [n = 12], cervicothoracic instability [n = 16]) were acquired after positioning the patient in the final surgical position. A sliding gantry 40-slice CT was used for image acquisition. Data were imported to a frameless infrared-based neuronavigation workstation. Intraoperative CT was obtained to assess the accuracy of instrumentation and, if necessary, the extent of decompression. All patients were clinically evaluated by Odom-criteria after surgery and after 3 months. Results. Computed accuracy of the navigation system reached <2 mm (0.95 ± 0.3 mm) in all cases. Additional time necessary for the preoperative image acquisition including data transfer was 14 ± 5 minutes. The duration of interrupting the surgical process for iCT until resumption of surgery was 9 ± 2.5 minutes. Control-iCT revealed incorrect screw position ≥2 mm without persistent neurologic or vascular damage in 20/414 screws (4.8%) leading to immediate correction of 10 screws (2.4%). Control-iCT changed the course of surgery in 8 cases (8.5% of all patients). The overall revision rate was 8.5% (4 wound revisions, 2 CSF fistulas, and 2 epidural hematomas). There was no reoperation due to implant malposition. According to Odom-criteria all patients experienced a clinical improvement. A retrospective analysis of 182 patients with navigated thoracolumbar transpedicular stabilizations in the preiCTera revealed an overall revision rate of 10.4% with 4.4% of patients requiring screw revision. Conclusion. Intraoperative CT in combination with neuronavigation provides high accuracy of screw placement and thus safety for patients undergoing spinal stabilization. Reoperations due to implant malpositions could be completely avoided. The system can be installed into a pre-existing operating environment without need for special surgical instruments. The procedure is rapid and easy to perform without restricted access to the patient and— by replacing pre- and postoperative imaging—is not associated with an additional exposure to radiation. Multidisciplinary use increases utilization of the system and thus improves cost-efficiency relation.

Intraoperative computed tomography with integrated navigation system in spinal stabilizations.

Study Design. Fifty-two study participants underwent ceryical spine surgery using intraoperative Iso-C imaging with or without spinal navigation. Objectives. To evaluate prospectively the feasibility, sevantages. limitations, and applications of Iso-C in cervical spine surgery, Summary of Background Data. Existing stereotactic spinal navigational systems images must be acquired before surgery and typically require cumbersome point-to-point registration. intraoperative computed tomography (CT) and magnetic resonance imaging (MRI) provide real-time information but can restrict access to the patient, preclude the use of traditional operating room tables, and are time-consuming. The Iso-C allows quick, CT-quality, real-tiem data acquisition without restricting access to the patient. The data acquired can be automatically transferred to navigational systems with the immediate ability to navigate for anterior or posterior cervical spine procedures. Methods. High-resolution isotropic three-dimensional data sets were acquired using the Iso-C intraoperative fluoroscopy in 52 cervical spine cases. In 30 cases, the data were imported automatically to the StealthStation Treon to support neuronavigation. In 22 cases, a postprocedural intraoperative CT was obtained with the Iso-C primarily to assess the extent of osseous decompression and/or the accuracy of implants or instrumentation. In most cases, a postoperative high-resolution CT image was obtained and compared with the Iso-C data. Results. Successful automated registration suitable for navigation was attained for all anterior and posterior cervical spinal cases. The postprocedural intraoperative Iso-C data were 100% concordant with those of postoperative high-resolution CT as determined by a blinded neuroradiologist. Conclusions. Iso-C intraoperative fluoroscopy is an accurate and rapid way to perform CT-quality image-guided navigation in cervical spinal surgery. In most cases, it obviates the need for postoperative imaging.

Intraoperative Iso-C C-arm navigation in cervical spinal surgery: review of the first 52 cases.

We report on our experiences with the use of intraoperative CT imaging in surgery of the thoracic spine and on our results of pedicle screw insertion using spinal navigation and implantable fiducial markers. For our operations we used the Tomoscan M-EG and the EasyGuideSpine (Philips Medical Systems). During the operation the patient was positioned on the mobile CT table. Following dorsal preparation, small titanium screws were implanted in the vertebrae so as to serve as fiducial markers. Image data were obtained by performing a spiral CT scan. Ventilation was suspended for the duration of the CT scan. Screw insertion as well as vertebral biopsies were performed using spinal navigation. Intraoperative CT scans were obtained to confirm the position of the implants and to assess the amount of bony decompression as well as the realignment. Since 1998, 112 patients with various disorders of the thoracic spine have been operated on using the described technique. 365 screws were inserted in the area of T1 to T12. There were 23 (6.3%) misplacements of pedicle screws. In 42 cases (11.5%) we observed a minimal lateral perforation (<2 mm) of the pedicle wall. No neurological, cardiovascular, or pulmonary injury occurred. Intraoperative CT imaging influenced surgical decisions as well as the final result of surgery. Despite the use of intraoperative imaging and accurate spinal navigation, pedicle screw placement in the thoracic spine remains extremely challenging.

Intraoperative computerized tomography for improved accuracy of spinal navigation in pedicle screw placement of the thoracic spine.

OBJECTIVE: Thoracic and lombar pedicle screws have become popular because of their biomechanical superiority over other methods of spiral fixation. However, the safety and efficacy of transpedicular screws depend on their proper placement. Recent advances in imaging have resulted in the ability to acquire three-dimensional (3-D) axial images of the spine during surgery, and this study was undertaken to assess the reliability of this technology to detect pedicle violations. METHODS: Pedicle screws were placed in six human cadaver spines from T1 to S1 using standard techniques. Intentional pedicle violations were created in 74 of 216 pedicles, and violations were graded on a four-point scale (range, 0-3). Radiographic images were then obtained using a conventional spiral computed tomographic scanner and the Stremobil Iso-C 3D (Siemens Medical Solutions, Erlangen, Germany). 3-D fluoroscopy unit. An independent neuroradiologist then graded pedicle violations as ascertained by the two imaging modalities. RESULTS: Using direct inspection of the pedicles as the gold standard, the overall sensitivity and specificity for detecting pedicle violations were 0,716 and 0,789, respectively, with 3-D fluoroscopy. The overall sensitivity and specificity for detecting pedicle violations were 0,608 and 0,937, respectively, with conventional computed tomography. All Grade 2 pedicle violations were detected in the thoracic spine by both modalities, and all Grade 3 violations were detected by both modalities. CONCLUSION: Axial images obtained with 3-D fluoroscopy demonstrate a higher sensitivity but lower specificity than conventional computed comographic scanning for assessing pedicle violations. By providing real-time intraoperative imaging, 3-D fluoroscopy may enhance the safety of thoracic transpedicular instrumentation.

Reliability of three-dimensional fluoroscopy for detecting pedicle screw violations in the thoracic and lumbar spine.

Object. The purpose of this study was to improve the accuracy of bone removal during anterior spinal surgery. Intraoperative computerized tomography (CT) scanning was used to assess the success of bone resection and permit immediate correction in the event of inadequate bone removal. Methods. The Phillips Tomoscan M was used to obtain preoperative cervical scans before and after cervical bone resection was complete. The completeness of bone removal was assessed by the operating neurosurgeon by reviewing the postresection CT scan. If the bone removal was deemed inadequate, additional bone was removed using a high-speed drill. A CT scan was obtained after each subsequent decompression until adequate bone removal was achieved. In 31 patients undergoing anterior cervical decompression intraoperative CT scanning was performed. Nineteen patients underwent corpectomy and 12 discectomy. Of the 31 patients, assessment of intraoperative CT scans obtained in 17 indicated further bone removal was required. Conclusion...

Intraoperative computerized tomography scanning to assess the adequacy of decompression in anterior cervical spine surgery

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Intraoperative computerized tomography scanning to assess the adequacy of decompression in anterior cervical spine surgery