CT Navigation Research Articles

How I do it: MRI-guided stereotactic navigation for Laser Interstitial Thermal Therapy.

MR-guided stereotaxy has emerged as a viable alternative to CT-guided frame-based or frameless approaches. By offering direct MR-guided navigation, this technique addresses most limitations inherent to CT navigation, enabling submillimeter precision. We detail the workflow of using the ClearPoint® MR navigation system for laser catheter placement in the treatment of a hypothalamic hamartoma. MR-guided navigation is a precise and effective stereotactic method for laser ablation of targets with high demands for accuracy. However, compared to standard stereotactic techniques, MR-guided navigation is more time-consuming and costly.

Use of a newly developed minimally invasive bilateral fixed angle locking system in the treatment of pathological pelvic fractures: a case series

BackgroundMetastatic bone disease (MBD) and its complications have a significant impact on patients’ quality of life. Pathological fractures are a particular problem as they affect patient mobility and pose a high risk of non-union. The pelvis is frequently affected by MBD and its fixation is challenging. We present a case series of three pathological sacral fractures treated with a new minimally invasive bilateral fixed angle locking system.Case presentationCase 1 and 2 suffered a pathological transforaminal sacral fracture without adequate trauma in stage 4 carcinomas (gastric cancer and breast cancer). Both were initially treated with non-surgical treatment, which had only a limited effect and led to imminent immobility. Both were operated on with fluoroscopic navigation and underwent transsacral SACRONAIL® stabilisation according to CT morphology (S1 + S2 and S1 respectively). Immediately after the operation, pain decreased and mobilisation improved. Case 3 had a pathological transalar sacral fracture during the 2nd cycle of chemotherapy due to non-Hodgkin’s lymphoma. He soon became immobile and could only move in a wheelchair. The operation was performed with CT navigation due to the very small corridors and an implant was inserted in S1 and S2. The patient reported immediate pain relief and his ability to walk improved over the following months. Despite continued chemotherapy, no wound complications occurred.ConclusionsThe cases show the advantages of the minimally invasive bilateral fixed angle locking system SACRONAIL® in the treatment of patients with pathological sacral fractures. It allows immediate full weight bearing and the risk of secondary surgical complications is low. All cases showed an improvement in pain scores and mobility.

Comparison of Efficacy and Safety of Different Guided Technologies Combined With Ultrathin Bronchoscopic Biopsy for Peripheral Pulmonary Lesions.

Various bronchoscopic guidance techniques have emerged to improve the diagnostic yield of peripheral pulmonary lesions (PPLs), especially when combined with ultra-thin bronchoscopy. However, uncertainties exists in the convenience, accuracy rate, and complications of these techniques. We compared the feasibility, accuracy rate, and complication rates of transbronchial biopsy of PPLs sampled by the standard thin-layer CT navigation combined with ultrathin bronchoscopy (CTNUTB), the Lungpro virtual navigation combined with ultrathin bronchoscopy (VNUTB), and electromagnetic navigation combined with ultrathin bronchoscopy (ENUTB). Retrospectively identified were 256 patients sampled with transbronchial biopsy of PPLs. Eligible patients referred for CTNUTB, VNUTB, and ENUTB from January 2017 to December 2021 were included. We comprehensively compared the accuracy rate, feasibility, and complication rates for each method. There was no significant difference in the accuracy rate of CTNUTB, VNUTB, and ENUTB (p = 0.293). The operation time via Lungpro navigation was the shortest (14.4 min, p < 0.001). The planning time via CT planning was the shortest (7.36 min, p < 0.001). There was no difference in the incidence of complications such as hemorrhage, pneumonia, and pneumothorax (p = 0.123). Besides, ENUTB costs more than $2000, while CTNUTB and VNUTB cost only about $130-230. CTNUTB is still the main bronchoscopy method we recommended, which has low cost, simple operation, and safety no less than the others. In contrast, ENUTB provides a higher accuracy rate for small diameter nodules (less than 2 cm), which has a high use value and is worth promoting in the future.

Perfecting the pour: A novel co-axial technique with sequential injections for optimising cement delivery during sacroplasty.

Percutaneous sacroplasty is an effective treatment for painful sacral fractures and tumours, however there is no accepted optimal technique for performing this procedure. This study investigated a novel approach to sacroplasty combining co-axial sacral access, sequential cement injections and hypothermic cement manipulation to improve cement delivery. This retrospective study analysed 11 patients who underwent co-axial sacroplasty between April 2023 and March 2024 for treatment of painful insufficiency fractures (n = 5) or malignant sacral tumours (n = 6). All cases were performed using biplane fluoroscopy with conebeam CT navigation for planning and monitoring percutaneous access. Procedural details, technical outcomes, and clinical outcomes including Numerical Rating Scale (NRS) pain and analgesic utilisation on a six-point scale were analysed pre-procedure and at follow-up. Technical success of was achieved in all cases using this technique. The mean injected cement volume was 20.5 ± 6.4 ml. Median pre-procedural NRS pain scores of 8 (IQR 7.25-8) significantly decreased to 0 (IQR, 0-0.25) at follow-up (p <.01). The median preprocedural analgesic utilisation score reduced from 3 (IQR, 2-3) to 0 (IQR, 0-2.5) at follow-up (p <.01). Cement leakage occurred during two cases without associated adverse clinical sequelae. There were no major adverse events. Co-axial sequential injection sacroplasty is a safe and effective technique which allows facilitates controlled delivery of cement. Improved control of cement delivery, including around high-risk structures for cement leakage, offers a potential safety advantage over conventional sacroplasty techniques. Further research comparing technical and clinical outcomes to conventional techniques is warranted.

Computed tomography navigation radiofrequency ablation for Meige's syndrome: A game-changer in treatment

BackgroundMeige's syndrome severely impacts quality of life. Current treatments struggle to balance cost, risk, and effectiveness. MethodsPatients with blepharospasm were treated with facial nerves partial radiofrequency ablation guided by CT. Treatment efficacy, complications, and recurrences were evaluated during follow-up. Results116 facial nerves in 58 patients with Meige's syndrome were treated using CT guidance. The average temperature at the end of radiofrequency treatment was 77.93 ± 9.8 °C, and the procedure lasted an average of 30.79 ± 7.69 min. Spasms stopped after treatment, but mild facial paralysis remained. Follow-ups ranging from 12 to 57 months showed that facial paralysis improved in an average of 3.12 ± 0.94 months. Nine patients had unilateral recurrence within 6–13 months, and three had bilateral recurrence at 14, 18, and 22 months. ConclusionsPartial radiofrequency ablation of the facial nerve through percutaneous access to the bilateral stylomastoid foramen using CT navigation is an effective, safe, promising treatment for blepharospasm in Meige's syndrome patients.

A serial case study of the combined use of intraoperative CT and surgical navigation system for the removal of small foreign bodies in the maxillofacial region

PurposeThe removal of small foreign bodies embedded within the deep soft tissues of the maxillofacial region is a complex and challenging task for maxillofacial surgeons. The purpose of this study was to explore the efficacy of the combination of intraoperative CT and surgical navigation for the removal of small foreign objects in the maxillofacial region. MethodsA serial case study was conducted involving all consecutive patients who underwent surgical removal of small foreign bodies in the maxillofacial region. The combination of intraoperative CT and a surgical navigation system was used at a single medical institution from January 2018 to December 2022. Comprehensive data, including patient demographics, characteristics of the foreign bodies, previous surgical interventions, duration of the surgical procedure, and removal success rate were collected for this study. Relevant data were recorded into Microsoft Excel sheet and analyzed using SPSS version 22.0. ResultsNine patients (6 males and 3 females) were included in this study, with an average age of 37 years. Each patient had previously undergone an unsuccessful removal attempt utilizing conventional surgical methods based on preoperative CT imaging or C-arm guidance at a local healthcare facility. Four patients also experienced unsuccessful attempts with preoperative CT image-based navigation systems. However, by employing the combined approach of intraoperative CT and surgical navigation, the foreign bodies were successfully removed in all 9 patients. The mean duration of the surgical procedure was 59 min, and the average size of the foreign bodies was approximately 26 mm³. Postoperative follow-up exceeding 6 months revealed no complications. ConclusionThe combined use of a surgical navigation system and intraoperative CT represents a potent and effective strategy for the precise localization and subsequent removal of small foreign bodies from the soft tissue structures of the maxillofacial region. This integrative approach appears to increase the success rate of surgical interventions in such cases.

CT Navigation is the Key to Successful Bronchоbiopsy for Peripheral Pulmonary Nodules

CT Navigation is the Key to Successful Bronchоbiopsy for Peripheral Pulmonary Nodules

Accuracy in Navigated Percutaneous Sacroiliac Screw Fixation: A Systematic Review and Meta-Analysis

Abstract Background Percutaneous sacroiliac screw placement is a challenging procedure in patients with pelvic fractures. To overcome these challenges, navigated techniques have emerged as an alternative to conventional 2D fluoroscopy for guiding screw placement. However, it remains to be seen whether navigated techniques truly have a beneficial effect on accuracy, radiation exposure and occurrence of complications. Aims We performed a meta-analysis to investigate whether navigated techniques are superior to conventional 2D fluoroscopy in percutaneous sacroiliac screw fixation. Methods The electronic databases were searched for both randomized clinical trials and observational studies comparing percutaneous sacroiliac screw fixation with 2D fluoroscopy to new navigated techniques (2D or 3D fluoroscopic navigation with a c-arm, computer assisted ultrasound navigation, O-Arm navigation, mobile CT navigation, robotic navigation). Effects were pooled and presented as odds ratio, mean difference, and standardized mean difference with corresponding 95% confidence interval. Results In total 18 studies were included. New navigated techniques had a higher accuracy (81% versus 91% with MD 10%, 95% CI 5-14%). The greatest benefit in accuracy was found in studies with more advanced navigated techniques (O-Arm, mobile CT or robotic navigation). Also, fluoroscopy time (MD 72.13 seconds, 95% CI 7.73;92.91) and fluoroscopy frequency (MD 17.22 images in total, 95% CI 7.73;26.70) were lower for new navigated techniques. Radiation dose was higher for new navigated techniques (SMD 0.50, 95% CI 0.01;0.99). Surgery duration showed no significant difference. Similar results were found among in vitro studies. Complications were rare in both groups. Conclusion This meta-analysis demonstrated a higher accuracy of screw positioning, lower fluoroscopic frequency and time for navigated percutaneous sacroiliac screw fixation compared to conventional 2D fluoroscopy. Complications are acceptably low for both groups. Future studies should focus on which of the navigated techniques is the best and whether the implementation costs of a new technique outweigh its benefits.

Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States.

Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9]. We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States. We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows. This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

Rapid brain MRI for image-guided ventricular catheter placement in pediatric patients: protocol and preliminary clinical outcomes.

Neuronavigation is a useful adjunct for catheter placement during neurosurgical procedures for hydrocephalus or ventricular access. MRI protocols for navigation are lengthy and require sedation for young children. CT involves ionizing radiation. In this study, the authors introduce the clinical application of a 1-minute rapid MRI sequence that does not require sedation in young children and report their preliminary clinical experience using this technique in their pediatric population. All patients who underwent ventricular catheter placement at a children's hospital using a rapid noncontrast MRI protocol, standard MRI, or head CT from July 2021 to August 2023 were included. Type of procedure, etiology of hydrocephalus, ventricle configuration and size, morphology of ventricles, need for adjunctive intraoperative ultrasound, duration of procedure, accuracy of catheter placement, and need for proximal revision within 90 days were retrospectively recorded and compared across imaging modalities. Sixty-eight patients underwent 83 procedures: 21 underwent CT navigation, 29 standard MRI, and 33 rapid MRI. Patients who received standard MRI more often had tumor etiology, while those who underwent CT and rapid MRI had posthemorrhagic etiology (χ2 = 13.04, p = 0.042). Intraoperative ultrasound was required for 1 patient in the standard MRI group and 1 patient in the CT group. There was no difference in procedure time across groups (p = 0.831). On multivariable analysis, procedure time differed by procedure type, where external ventricular drain placement and proximal revision were faster (p < 0.001 and p < 0.028, respectively). Proximal revision due to obstruction within 90 days occurred in 3 cases (in the same patient with complex loculated hydrocephalus) in the rapid MRI group and 2 cases in the CT group. Although this study was not powered for statistical inference, the authors report on the clinical use of a 1-minute rapid MRI sequence for neuronavigation in hydrocephalus or ventricular access surgery. There were no instances in which intraoperative ultrasound was required as an adjunct for procedures navigated with rapid MRI, and intraoperative time did not differ from that of standard navigation protocols.

Radiation doses to patients during pedicle screw fixation of the spine

Objective. To analyze the radiation doses to patients during spinal decompression and stabilization surgery under optical CT navigation and fluoroscopy.Material and Methods. Study design: retrospective cohort study. The sample consisted of 164 patients who underwent transpedicular fixation of the spine performed by percutaneous or open techniques. In the O-arm group (n = 109), cone-beam CT combined with optical navigation was used; in the C-arm group, fluoroscopy (n = 55) was used. The effective dose equivalent (EDE) and the maximum absorbed dose (MAD) in the skin were evaluated.Results. EDE in the O-arm group was Me 9.1 mSv, [IQR: 7.1–11.6], and in the C-arm group –Me 1.8 mSv [IQR: 1.8–5.6], p &lt; 0.0001. Maximum absorbed dose in the skin in the O-arm group was Me 49.3 mGy [IQR: 27.0–96.9], and in the C-arm group – Me 36.1 mGy [IQR: 16.6–111.5], p = 0.424.Conclusion. The use of CT navigation and fluoroscopy during pedicle screw fixation of the spine is not associated with the risk of developing deterministic effects. The use of intraoperative CT navigation during pedicle screw fixation is associated with a greater patient EDE compared with that of fluoroscopy (p &lt; 0.05). Differences in EDE received by patients undergoing open and percutaneous techniques of pedicle screw fixation are statistically insignificant, regardless of the type of beam guidance and the number of fixation levels. The number of intraoperative CT scans is proportional to the patient EDE (p = 0.018).

Diagnostic yield of endobronchial ultrasound and virtual CT navigational bronchoscopy for biopsy of pulmonary nodules, mediastinal lymph nodes, and thoracic tumors in children.

Endobronchial ultrasound-guided transbronchial biopsy and needle aspiration (EBUS-TBB/EBUS-TBNA) are first line investigative modalities for lung and mediastinal pathology in adults. We aimed to characterize and assess the diagnostic yield of EBUS and virtual CT navigation guided biopsies in children. This single center, retrospective cohort study included patients who underwent radial or linear EBUS procedures (+/- CT navigation) for biopsy of mediastinal lymph nodes, tumors, and pulmonary nodules. Demographic, procedural, and outcome were collected. Sixty procedures were performed in 56 patients aged 2-22 years of age between January 2015 and May 2023. The most common indications for biopsy were pulmonary nodules (45%) and hilar/mediastinal lymphadenopathy (33%). For cases in which a final diagnosis was ascertained by any means, the diagnostic yield for linear EBUS (mediastinal pathology) was 76% and the diagnostic yield from radial EBUS (pulmonary nodules and lung masses) was 85%. The most common diagnoses were infection (45%), malignancy (17%), and sarcoidosis (11%). Among patients in whom infection was the final diagnosis, a total of 31 pathogens were identified. Eighteen were identified on bronchoalveolar lavage and an additional 14 pathogens identified on EBUS-TBB, representing an increase of 77% (p < .005). The sensitivity, specificity, negative and positive predictive values for malignancy detection were 73%, 100%, 94%, and 100%, respectively. EBUS-TBB/TBNA is a safe and effective way to diagnose lung and mediastinal pathology in children. Pediatric interventional pulmonology is a growing field offering minimally-invasive diagnostic opportunities for children in whom more invasive procedures were previously the only option.

Is Intraoperative CT Navigation feasible for excision of osteoid osteoma in the appendicular skeleton? – Retrospective analysis of 58 cases

BackgroundThe use of intraoperative CT navigation to manage osteoid osteoma is not common. We report our experience managing osteoid osteoma in the appendicular skeleton using an intraoperative AIRO CT navigation system. Materials & methodsBetween May 2013 and December 2022, 59 patients underwent Navigation-assisted excision of osteoid osteoma in the appendicular skeleton. Our primary study outcome was to assess for recurrence of the tumour with recurrence of symptoms. For our secondary outcomes, we evaluated the complications associated with the procedure and evaluated the histological slides of all patients to see for the presence of nidus. ResultsOf the 58 patients available for review, no patient had a lesion recurrence, and all were symptom-free at an average follow-up of 45.6 months (6–100). Two patients (3.5%) had a superficial infection managed conservatively, and 43 patients (74.1%) had the presence of nidus in curetted samples. No patient developed a pathological fracture after the procedure. ConclusionUsing intraoperative CT navigation to manage osteoid osteoma in the appendicular skeleton is safe, minimally invasive, and effective in completely removing the nidus with a negligible complication rate. The absence of nidus on histology should not be a concern to clinicians once thorough burring and verification of excision of nidus has been confirmed intra-operatively. Study designRetrospective Case Series. Level of evidenceLevel IV.

Subtalar Distraction Bone Block Arthrodesis for Calcaneus Fracture Malunion

Intra-articular calcaneus fractures are associated with a high rate of malunion resulting in hindfoot and ankle impingement, peroneal tendinitis, sural neuritis, arthritis, hindfoot varus or valgus deformity, loss of hindfoot height, and resulting gastrocnemius-soleus complex weakness and gait dysfunction. These issues can arise whether the patient’s injury is treated conservatively with non–weight-bearing precautions, neglected/missed, or treated surgically with open reduction and internal fixation. The sequelae of calcaneal malunions can arise early or late in this process. For patients undergoing subtalar arthrodesis following calcaneus fracture malunion, the use of a bone block wedge can assist with achieving a stable ,well-aligned, pain-free hindfoot. Patient selection, preoperative planning, careful surgical technique, and compliance with postoperative care pathways are critical to optimize patient outcomes and healing of this complex reconstruction. Recent evidence supports the utility of weight-bearing CT to assist with preoperative planning for subtalar arthrodesis. Wedges used in subtalar distraction arthrodesis include bulk autograft (tricortical iliac crest), allograft (pre-fashioned or intraoperatively fashioned wedges from femoral head allograft or other source), and metallic wedges. These wedges are typically secured with screws spanning and compressing the arthrodesis site, which is filled with a mixture of concentrated bone marrow aspirate, bone growth factors, and allograft bone. Concomitant procedures may be indicated to ensure the overall success of the procedure, such as extra-articular, calcaneal osteotomy for additional realignment purposes and/or arthrolysis. A review of the literature shows high rates of union following subtalar bone block arthrodesis with improved functional outcomes. Our preferred technique for a bone block distraction subtalar arthrodesis, described herein, includes the use of an allograft wedge. Ongoing advances, such as the development of novel materials and structures for use in subtalar bone block arthrodesis, but most importantly, the incorporation of weight-bearing CT technology and potential for preoperative CT navigation to make this procedure more predictable, are all important areas for further exploration and future research. Level of Evidence: Level—4.

CT Navigation for Percutaneous Needle Placement: How I Do It

CT Navigation for Percutaneous Needle Placement: How I Do It

Percutaneous Superimposed O-Arm-MRI-Navigated Biopsy for Spinal Column Pathologies.

Classifying spinal tumors can be challenging due to nonspecific clinical and radiological qualities, and a precise biopsy is crucial for an accurate diagnosis and treatment planning. This study aimed to enhance the accuracy and efficiency of spinal biopsies integrating Cone Beam Computed Tomography (CBCT) and magnetic resonance imaging (MRI) modalities using an O-arm CT navigation system. Eighteen patients with different spinal lesions underwent 18 biopsies following the Stealth Station navigation system Spine 8 protocol. Preoperative MRI scans were merged with intraoperative CT navigation systems for continuous monitoring during the biopsy process. The combined imaging technique accurately identified the diseased lesion type in all biopsies, demonstrating 100% sensitivity and specificity. In conclusion, combining MRI and CT imaging modalities significantly improved spinal biopsy accuracy and efficiency, differentiating between pathological entities. However, large-scale studies are desired to validate these findings and investigate potential benefits in different clinical scenarios. Although this method requires general anesthesia, its potential profits in avoiding misdiagnosed lesions and decreasing the need for further invasive procedures make it a promising approach for improving spinal biopsy accuracy and efficiency.

Progress in minimally invasive surgery for adjacent segment disease after lumbar fusion

Adjacent segment disease (ASDis) is a common complication of posterior lumbar spine fusion and often requires surgical treatment. In the treatment of ASDis, percutaneous spinal endoscopy can be used for simple decompression without removal of the original internal fixation, or for posterior fixation and fusion under the scope or in combination with other access fixation and fusion techniques, with the advantages of less surgical trauma, less bleeding, and faster postoperative recovery. Traditional trajectory screw technique is one of the risk factors for adjacent segment degeneration because of its tendency to cause damage to the adjacent synovial joint during surgery. In contrast, the cortical tone trajectory (CBT) screw placement technique not only reduces the damage to the articular joint during the screw placement process, but also preserves the original internal fixation in the treatment of ASDis, which significantly reduces the surgical trauma. Secondly, the implantation of CBT screws with the aid of digital technologies such as three-dimentinal printed guides, CT navigation, and robotics allows for more precise "double nailing" of ASDis patients to complete the fusion of adjacent segments, and is a minimally invasive procedure to be considered for patients who meet the clinical indications for fusion. This article reviews the literature on the use of percutaneous spinal endoscopy and CBT in the surgical management of ASDis.

Comparative study on the accuracy, safety and clinical effect of CT navigation and traditional open screw placement in the Treatment of Thoracic Fracture.

To explore the accuracy, safety and clinical effect of descending thoracic pedicle screw fixation assisted by computer CT three-dimensional navigation in the treatment of single segmental compression thoracic fracture. This study was a retrospective analysis. From June 2020 to June 2022, eighty patients with thoracic vertebral fractures admitted to Affiliated Hospital of Beihua University were were divided into observation group and control group according to different methods of screw placement, with 40 cases in each group. The navigation system was used to insert pedicle screws, and the control group used traditional open X-ray to insert pedicle screws by hand. Further comparison was carried out in terms of the operation time, intraoperative blood loss, perioperative complications, accuracy and safety rate of screw placement, and vertebral compression ratio between both the groups. The average intraoperative blood loss in the observation group was significantly less than the control group, the average screw insertion time was significantly shorter than the control group, the postoperative average vertebral body compression ratios was significantly better than the control group, the excellent rate of screw insertion was better than the control group, while the incidence of complications was lower than the control group, and the difference was statistically significant (all P<0.05). Intraoperative CT navigation for pedicle screw placement can reduce the time of screw placement and intraoperative blood loss, improve the excellent rate of screw placement and the compression ratio of the anterior edge of the injured vertebra, the complication rate was low.

Robot-assisted percutaneous pedicle screw placement accuracy compared with alternative guidance in lateral single-position surgery: a systematic review and meta-analysis.

While single-position surgery (SPS) eliminates the need for patient repositioning, the placement of screws in the unconventional lateral position poses unique challenges related to asymmetry relative to the surgical table. Use of robotic guidance or intraoperative navigation can help to overcome this. The aim of this study was to compare the relative accuracies offered by these various navigation modalities for pedicle screws placed in lateral SPS. According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the PubMed/Medline, Embase, and Cochrane Library databases were queried for studies reporting pedicle screw placement accuracy using fluoroscopic, CT-navigated, O-arm, or robotic guidance in lateral SPS, and a systematic review and meta-analysis was performed. Included studies all compared evaluated screw placement accuracy in lateral SPS using a single navigation method. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system; risk of bias was assessed using the Newcastle-Ottawa Scale and the Joanna Briggs Institute checklist. The primary outcome, rate of pedicle screw breach, was analyzed using random-effects meta-analysis. Eleven studies were included comprising 548 patients who underwent the placement of instrumentation with 2488 screws. For the fluoroscopic, CT-navigated, O-arm, and robotic guidance cohorts, there were 3, 2, 3, and 3 studies, respectively. Breach rates by modality were as follows: fluoroscopic guidance (6.6%), CT navigation (4.7%), O-arm (3.9%), and robotic guidance (3.9%). Random-effects meta-analysis showed a significant difference between studies, with an overall breach rate of 4.9% (95% CI 3.1%-7.5%; p < 0.001); however, testing for subgroup differences failed to show a significant difference between guidance modalities (QM = 0.69, df = 3; p = 0.88). Heterogeneity between studies was significant (I2 = 79.0%, τ2 = 0.41, χ2 = 47.65, df = 10; p < 0.001). Robotic guidance of screws is noninferior to alternative guidance modalities in lateral SPS; however, additional prospective studies directly comparing different guidance types are merited.

Minimally Invasive 360° Fusion Using a Combination of INFIX and Minimally Invasive Spinopelvic Fixation by Intraoperative Computed Tomography Navigation for Unstable Pelvic Ring Fracture: A Technical Note

Fluoroscopy is often used in the surgery of unstable pelvic ring fractures, and improved safety in implant placement is an issue. An anterior subcutaneous pelvic fixator (INFIX) combined with a percutaneous screw has been reported to be a minimally invasive and effective surgical technique for unstable pelvic ring injuries. However, although percutaneous screw fixation is minimally invasive, its indications for fracture fixation and fractures with large fragment displacements in the vertical plane remain controversial. Therefore, this technical note aims to describe a new technique for unstable pelvic ring fractures. We describe a 360° fusion of the pelvic ring to treat unstable pelvic ring fractures, including vertical shear pelvic ring fractures, using an intraoperative CT navigation system. Seven patients were treated with 360° fusion for type C pelvic ring fractures. In surgery, after reducing the fracture with external fixation, intraoperative CT navigation is used to perform a 360° fusion with INFIX and minimally invasive surgical spinopelvic fixation (MIS-SPF). We will introduce a typical case and explain the procedure. A 360° fixation was performed, and no perioperative complications were noted. The mean blood loss was 253.2 ± 141.0 mL, and the mean operative time was 224.3 ± 67.4min. In a typical case, bone union was obtained 1 year after surgery, and we removed all implants. MIS-SPF has a strong fixation force and helps reduce fractures' horizontal and vertical planes. In addition, 360° fusion with intraoperative CT navigation may help treat unstable pelvic ring fractures.