Abstract
PurposeAccurate placement of spinal pedicle screws (PS) is mandatory for good primary segmental stabilization allowing consequent osseous fusion, requiring judgmental experience developed during a long training process. Computer navigation offers permanent visual control during screw manipulation and has been shown to significantly lower the risk of pedicle perforation. This study aims to evaluate whether safety, accuracy, and judgmental skills in screw placement, comparable to an experienced surgeon, can be developed during training using computer navigation.MethodsLumbosacral PS were placed in 18 patients in a prospective setting, in one segment side with conventional fluoroscopy by a senior spine-surgeon, and computer navigated on the other side by a trainee without prior experience in the technique. At the beginning and at the end of the study, PS were placed freehand in solid foam models by the trainee. PS placement time, intraoperative placement revisions, PS placement accuracy on postoperative CT scans, and postoperative complications were assessed.ResultsSignificant improvement of trainee’s PS placement accuracy (Sclafani score 8.2–8.83; p = 0.006) and time (13.3–6.8 min per screw; p = 0.005) to a similar level as the experienced surgeon state (5.2–4.1 min per screw; p = 0.39) was explored; similar improvement was explored in the foam models. The number of intraoperative placement revisions kept on a low level for surgeon (3.3–0.0%) and trainee (5.1–2.6%) during the whole study, no postoperative complications occurred.ConclusionNavigated PS insertion allows safe teaching from the early beginning of surgical training, due to steady intraoperative control on PS placement. Adequacy of PS placement is similar to screws placed by an experienced surgeon. Progress in judgmental skills in screw placement can be gained rapidly by the trainee, which can also be transferred to non-computer navigated PS placement.
Highlights
Pedicle screw (PS) placement, which is considered complex and technically demanding, is a widely used technique for surgical correction of deformities, degeneration, infection, malignancy, and trauma of the spine
Freehand PS placement in solid foam lumbar model at the end of the study significantly improved concerning cortical pedicle violation rate (1, 0.3; p = 0.001) screw placement accuracy score (7.0, 8.2; p = 0.003) with similar placement time compared to the performance at the beginning of the study (Table 2; Fig. 3)
Permanent real-time control on the trainee during the screw positioning process provided by O-arm technology revealed in a low revision rate for failed screw placement, decreasing from an initially low level of 5.1% of PS to a revision rate of 3.3% at the end of the study. These results suggest that navigated PS insertion already provides a high safety for the patient from the early beginning of spine surgery training
Summary
Pedicle screw (PS) placement, which is considered complex and technically demanding, is a widely used technique for surgical correction of deformities, degeneration, infection, malignancy, and trauma of the spine. Published learning curve analysis revealed, that computer-navigated PS placement offers high accuracy of lumbar PS placement from the beginning [12] and radiation exposure to the surgeon is reduced [13]. Based on these findings computer navigation may be favourable for novice operators to obtain initial experience in spine surgery, offering realtime control and allowing broad adjustment of arrangement during PS placement without increasing radiation exposure. The exact feasibility of computer navigation in training concerning safety, accuracy, and development of judgmental skills is still elusive. The hypothesis was that the observed parameters would significantly improve for the trainee using navigation for PS placement
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