Pedicle Screw Placement Research Articles

Level-specific comparison of 3D navigated and robotic arm-guided screw placement: an accuracy assessment of 1210 pedicle screws in lumbar surgery

BACKGROUND CONTEXTRobotic spine surgery, utilizing 3D imaging and robotic arms, has been shown to improve the accuracy of pedicle screw placement compared to conventional methods, although its superiority remains under debate. There are few studies evaluating the accuracy of 3D navigated versus robotic-guided screw placement across lumbar levels, addressing anatomical challenges to refine surgical strategies and patient safety. PURPOSEThis study aims to investigate the pedicle screw placement accuracy between 3D navigation and robotic arm-guided systems across distinct lumbar levels. STUDY DESIGNA retrospective review of a prospectively collected registry. PATIENT SAMPLEPatients undergoing fusion surgery with pedicle screw placement in the prone position, using either via 3D image navigation only or robotic arm guidance. OUTCOME MEASURERadiographical screw accuracy was assessed by the postoperative computed tomography (CT) according to the Gertzbein-Robbins classification, particularly focused on accuracy at different lumbar levels. METHODSAccuracy of screw placement in the 3D navigation (Nav group) and robotic arm guidance (Robo group) was compared using Chi-squared test/Fisher's exact test with effect size measured by Cramer's V, both overall and at each specific lumbosacral spinal level. RESULTSA total of 321 patients were included (Nav, 157; Robo, 189) and evaluated 1210 screws (Nav, 651; Robo 559). The Robo group demonstrated significantly higher overall accuracy (98.6 vs 93.9%; p<.001, V=0.25). This difference of no breach screw rate was signified the most at the L3 level (No breach screw: Robo 91.3 vs 57.8%, p<.001, V=0.35) followed by L4 (89.6 vs 64.7%, p<.001, V=0.28), and L5 (92.0 vs 74.5%, p<.001, V=0.22). However, screw accuracy at S1 was not significant between the groups (81.1 vs 72.0%, V=0.10). CONCLUSIONThis study highlights the enhanced accuracy of robotic arm-guided systems compared to 3D navigation for pedicle screw placement in lumbar fusion surgeries, especially at the L3, L4, and L5 levels. However, at the S1 level, both systems exhibit similar effectiveness, underscoring the importance of understanding each system's specific advantages for optimization of surgical complications.

Robotic-assisted spine surgery-a narrative review.

Emerging technologies have increasingly been adopted in spine surgery in the attempt to increase precision and improve outcomes. Robotic assistance is an area of significant interest, with proposed benefits including increased accuracy, decreased complication rates, and decreased radiation exposure. The purpose of this review is to provide an overview of the currently available robotic assistance systems and their associated outcomes and limitations. A review of national databases was performed using key terms "robotic", "spine", and "surgery" for literature from 2014 to 2023. Studies that aimed to describe the utilities of endoscopic surgeries, associated outcomes, limitations, and future directions were included. Studies that were not in English were excluded. This review includes a brief overview of the history of robotic spine surgery as well as its clinical outcomes, limitations, and future directions. Robotic-assisted spine surgery has seen increasing use in the attempt to increase precision and improve outcomes and has been associated with increased accuracy in pedicle screw placement and decreased complication rates. Barriers to its adoption include a significant learning curve, possibly longer operative cases, and significant associated costs. As robotic assistance continues to become increasingly popular in spine surgery, it is critical for surgeons to understand the technology available and the associated outcomes to make informed decisions when considering which system to incorporate into their practice.

Pedicle Screw Placement Using an Augmented Reality Head-Mounted Display in a Porcine Model

Pedicle Screw Placement Using an Augmented Reality Head-Mounted Display in a Porcine Model

Incidental dural tears during pediatric posterior spinal fusions

PurposeTo characterize the frequency of incidental dural tears in pediatric spine surgery, their treatment, complications, and results of long-term follow-up.MethodsA retrospective review of all pediatric patients who underwent a posterior spinal fusion (PSF) between 2004–2019 at a tertiary children’s hospital was conducted. Electronic medical records were reviewed for patient demographics, intra-operative data, presence of an incidental dural tear, repair method, and patient outcomes.Results3043 PSFs were reviewed, with 99 dural tears identified in 94 patients (3.3% overall incidence). Mean follow-up was 35.7 months (range 0.1–142.5). When the cause of the dural tear was specified, 69% occurred during exposure, 5% during pedicle screw placement, 4% during osteotomy, 2% during removal of implants, and 2% during intra-thecal injection of morphine. The rate of dural tears during primary PSF was significantly lower than during revision PSF procedures (2.6% vs. 6.2%, p < 0.05). 86.9% of dural tears were repaired and/or sealed intraoperatively, while 13.1% had spontaneous resolution. Postoperative headaches developed in 13.1% of patients and resolved at a mean of 7.6 days. There was no difference in the incidence of headaches in patients that were ordered bedrest vs. no bedrest (p > 0.99). Postoperative infections occurred in 9.5% of patients and 24.1% patients were identified to have undergone a revision surgery.ConclusionsIncidence of intra-operative dural tears in pediatric spine surgery is 3.3%. Although complications associated with the dural tear occur, most resolve over time and there were no long-term sequelae in patients with 2 years of follow up.Level of evidenceLevel IV.

Feasibility of Using Intraoperative Neurophysiological Monitoring for Detecting Bone Layer of Cervical Spine Surgery.

Intraoperative neurophysiological monitoring (IONM) as a guide to bone layer estimation was examined during posterior cervical spine lamina grinding. To explore the feasibility of IONM to estimate bone layer thickness. Cervical laminoplasty is a classic operation for cervical spondylosis. To increase safety and accuracy, surgery-assistant robots are currently being studied. It combines the advantages of various program awareness methods to form a feasible security strategy. In the field of spinal surgery, robots have been successfully used to help place pedicle screws. IONM is used to monitor intraoperative nerve conditions in spinal surgery. This study was designed to explore the feasibility of adding IONM to robot safety strategies. Chinese miniature pig model was used. Electrodes were placed on the lamina, and the minimum stimulation threshold of DNEP for each lamina was measured (Intact lamina, IL). The laminae were ground to measure the DNEP threshold after incomplete grinding (Inner cortical bone preserved, ICP) and complete grinding (Inner cortical bone grinded, ICG). Subsequently, the lateral cervical mass screw canal drilling was performed, and the t-EMG threshold of the intact and perforated screw canals was measured and compared. The threshold was significantly lower than that of the recommended threshold of DENP via percutaneous cervical laminae measurement. The DNEP threshold decreases with the process of laminae grinding. The DNEP threshold of the IL group was significantly higher than ICP and ICG group, while there was no significant difference between the ICP group and the ICG group. There was no significant relationship between the integrity of the cervical spine lateral mass screw path and t-EMG threshold. It is feasible to use DENP threshold to estimate lamina thickness. Cervical lateral mass screw canals by t-EMG showed no help to evaluate the integrity.

Comparative evaluation of postoperative outcomes and expenditure between robotic and conventional single-level lumbar fusion surgery: a comprehensive analysis of nationwide inpatient sample data

IntroductionIn this study, we investigate the evolution of lumbar fusion surgery with robotic assistance, specifically focusing on the impact of robotic technology on pedicle screw placement and fixation. Utilizing data from the Nationwide Inpatient Sample (NIS) covering 2016 to 2019, we conduct a comprehensive analysis of postoperative outcomes and costs for single-level lumbar fusion surgery. Traditionally, freehand techniques for pedicle screw placement posed risks, leading to the development of robotic-assisted techniques with advantages such as reduced misplacement, increased precision, smaller incisions, and decreased surgeon fatigue. However, conflicting study results regarding the efficacy of robotic assistance in comparison to conventional techniques have prompted the need for a thorough evaluation. With a dataset of 461,965 patients, our aim is to provide insights into the impact of robotic assistance on patient care and healthcare resource utilization. Our primary goal is to contribute to the ongoing discourse on the efficacy of robotic technology in lumbar fusion procedures, offering meaningful insights for optimizing patient-centered care and healthcare resource allocation.MethodsThis study employed data from the Nationwide Inpatient Sample (NIS) spanning the years 2016 to 2019 from USA, 461,965 patients underwent one-level lumbar fusion surgery, with 5770 of them having the surgery with the assistance of robotic technology. The study focused primarily on one-level lumbar fusion surgery and excluded non-elective cases and those with prior surgeries. The analysis encompassed the identification of comorbidities, surgical etiologies, and complications using specific ICD-10 codes. Throughout the study, a constant comparison was made between robotic and non-robotic lumbar fusion procedures. Various statistical methods were applied, with a p value threshold of < 0.05, to determine statistical significance.ResultsRobotic-assisted lumbar fusion surgeries demonstrated a significant increase from 2016 to 2019, comprising 1.25% of cases. Both groups exhibited similar patient demographics, with minor differences in payment methods, favoring Medicare in non-robotic surgery and more private payer usage in robotic surgery. A comparison of comorbid conditions revealed differences in the prevalence of hypertension, dyslipidemia, and sleep apnea diagnoses—In terms of hospitalization outcomes and costs, there was a slight shorter hospital stay of 3.06 days, compared to 3.13 days in non-robotic surgery, showcasing a statistically significant difference (p = 0.042). Robotic surgery has higher charges, with a mean charge of $154,673, whereas non-robotic surgery had a mean charge of $125,467 (p < 0.0001). Robotic surgery demonstrated lower rates of heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury compared to non-robotic surgery, with statistically significant differences (p < 0.05). Conversely, robotic surgery demonstrated increased post-surgery anemia and blood transfusion requirements compared to non-robotic patients (p < 0.0001). Renal disease prevalence was similar before surgery, but acute kidney injury was slightly higher in the robotic group post-surgery (p = 0.038).ConclusionThis is the first big data study on this matter, our study showed that Robotic-assisted lumbar fusion surgery has fewer post-operative complications such as heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury in comparison to conventional methods. Conversely, robotic surgery demonstrated increased post-surgery anemia, blood transfusion and acute kidney injury. Robotic surgery has higher charges compared to non-robotic surgery.

Accurate placement of thoracolumbar pedicle screws using a handheld iOS-based navigation device: a prospective intra-patient agreement study

BACKGROUNDAccurate pedicle screw placement is a challenge with reported misplacement rates of 10% and higher. A handheld navigation device (HND) may provide accuracy equal to CT-based navigation (CT-Nav) but without the cost and complexity. OBJECTIVETo study the accuracy of a handheld navigation device for pedicle screw placement. STUDY DESIGNThis prospective cross-sectional study with consistently applied reference standard enrolled 20 patients undergoing 92 pedicle screw placements. PATIENTSPatients who underwent pedicle screw placement between May 2022 and September 2022. OUTCOME MEASURESPedicle screw placement accuracy per Gertzbein–Robbins. METHODSOnce the screw pilot hole was established, the proposed trajectory of the HND was compared with that proposed by CT-Nav. Postoperatively, screw accuracy was graded according to Gertzbein–Robbins by a blinded radiologist based on CT scans. Accuracy was compared between the two systems and published control for fluoroscopy assisted and CT-Nav placement using Bayesian posterior distribution. RESULTSThe trajectory proposed by the HND and CT-Nav were in agreement in 98.9% (95% Exact CI; 94.09%–99.97%). The HND accuracy was 98.9% with 91 screws rated “A” and 1 rated “C”. Noninferiority to fluoroscopic placement was achieved because the one-sided normal-approximation 95% CI Lower Bound (LB) of 95.3% is greater than the Performance Goal (PG) of 83.4%. Posthoc analysis demonstrated that the probability of superiority of the HND relative to the historical accuracy rate of 91.5% for fluoroscopy assisted procedures is >0.999 and that the HND's accuracy rate is within 4.5% of CT-Nav of 95.5% is >0.999. No adverse events or intra-operative complications associated with HND were observed. There was 1 (1.1%) intra-operative repositioning and no reoperations for any reason. CONCLUSIONSThe accuracy rate of the HND was 98.9%, and the proposed trajectory matched with CT-Nav in 98.9% of the time. This is superior to the historical published accuracy rate for fluoroscopy-assisted procedures and equivalent to the historical published accuracy rate for CT-Nav. Clinical Trial Registration NumberDutch trial register NL74268.058.20.

AB089. SOH24AB_163. Accuracy of augmented reality assisted pedicle screw placement: a systematic review

AB089. SOH24AB_163. Accuracy of augmented reality assisted pedicle screw placement: a systematic review

Mixed Reality-Based Navigation for Pedicle Screw Placement: A Preliminary Study Using a 3D-Printed Spine Model.

Background and objectives Mixed reality (MR) is one of the image processing technologies that allows the user to manipulate three-dimensional (3D) virtual images (hologram). The aim of this study was to evaluate the accuracy of MR-based pedicle screw (PS) placement using 3D spine models. Materials and methods Using the preoperative CT data of a patient with adolescent idiopathic scoliosis (AIS) who had undergone posterior spinal fusion in our hospital, a 3D-printed spine model was created. On the other hand, a 3D hologram of the same patient was automatically created using the preoperative CT data uploaded to the Holoeyes MD service website (Holoeyes Inc., Tokyo, Japan). Using a Magic Leap One® headset (Magic LeapInc., Plantation, FL), the 3D hologram with lines of predetermined PS trajectories was superimposed onto the 3D-printed spine model and PS were inserted bilaterally along with the trajectory lines from T5 to L3. As a control, we used a readymade 3D spine model of AIS and inserted PS bilaterally with a freehand technique from T4 to L3. The rate of pedicle violation was compared between the MR-based and freehand techniques. Results A total of 22 and 24 PS were placed into the 3D-printed spine model of our patient and the readymade 3D spine model, respectively. The rate of pedicle violation was 4.5% (1/22 screws) in the MR-based technique and 29.2% (7/24 screws) in the freehand technique (P = 0.049). Conclusions We demonstrated a significantly lower rate of PS misplacement in the MR-based technique than in the freehand technique. Therefore, an MR-assisted system is a promising tool for PS placement in terms of feasibility, safety, and accuracy, warranting further studies including cadaveric and clinical studies.

Evolution of the meta-neurosurgeon: A systematic review of the current technical capabilities, limitations, and applications of augmented reality in neurosurgery.

Augmented reality (AR) applications in neurosurgery have expanded over the past decade with the introduction of headset-based platforms. Many studies have focused on either preoperative planning to tailor the approach to the patient's anatomy and pathology or intraoperative surgical navigation, primarily realized as AR navigation through microscope oculars. Additional efforts have been made to validate AR in trainee and patient education and to investigate novel surgical approaches. Our objective was to provide a systematic overview of AR in neurosurgery, provide current limitations of this technology, as well as highlight several applications of AR in neurosurgery. We performed a literature search in PubMed/Medline to identify papers that addressed the use of AR in neurosurgery. The authors screened three hundred and seventy-five papers, and 57 papers were selected, analyzed, and included in this systematic review. AR has made significant inroads in neurosurgery, particularly in neuronavigation. In spinal neurosurgery, this primarily has been used for pedicle screw placement. AR-based neuronavigation also has significant applications in cranial neurosurgery, including neurovascular, neurosurgical oncology, and skull base neurosurgery. Other potential applications include operating room streamlining, trainee and patient education, and telecommunications. AR has already made a significant impact in neurosurgery in the above domains and has the potential to be a paradigm-altering technology. Future development in AR should focus on both validating these applications and extending the role of AR.

Comparison of iCT-based navigation and fluoroscopic-guidance for atlantoaxial screw placement in 78 patients with traumatic cervical spine injuries

Background contextStudies have shown biomechanical superiority of cervical pedicle screw placement over other techniques. However, accurate placement is challenging due to the inherent risk of neurovascular complications. Navigation technology based on intraoperative 3D imaging allows highly accurate screw placement, yet studies specifically investigating screw placement in patients with traumatic atlantoaxial injuries are scarce. The aim of this study was to compare atlantoaxial screw placement as treatment of traumatic instabilities using iCT-based navigation or fluoroscopic-guidance with intraoperative 3D control scans.MethodsThis was a retrospective review of patients with traumatic atlantoaxial injuries treated operatively with dorsal stabilization of C1 and C2. Patients were either assigned to the intraoperative navigation or fluoroscopic-guidance group. Screw accuracy, procedure time, and revisions were compared.ResultsSeventy-eight patients were included in this study with 51 patients in the navigation group and 27 patients in the fluoroscopic-guidance group. In total, 312 screws were placed in C1 and C2. Screw accuracy was high in both groups; however, pedicle perforations > 1 mm occurred significantly more often in the fluoroscopic-guidance group (P = 0.02). Procedure time was on average 23 min shorter in the navigation group (P = 0.02).ConclusionsThis study contributes to the available data showing that navigated atlantoaxial screw placement proves to be feasible as well as highly accurate compared to the fluoroscopic-guidance technique without prolonging the time needed for surgery. When comparing these data with other studies, the application of different classification systems for assessment of screw accuracy should be considered.

Accuracy and clinical characteristics of robot-assisted cervical spine surgery: a systematic review and meta-analysis.

To evaluate the accuracy and feasibility of robot-assisted cervical screw placement and factors that may affect the accuracy. A comprehensive search was made on PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang Med for the selection of potential eligible literature. The outcomes were evaluated in terms of the relative risk (RR) or standardized mean difference (MD) and corresponding 95% confidence interval (CI). Subgroup analyses of the accuracy of screw placement at different cervical segments and with different screw placement approaches were performed. A comparison was made between robotic navigation and conventional freehand cervical screw placement. Six comparative cohort studies and five case series studies with 337 patients and 1342 cervical screws were included in this study. The perfect accuracy was 86% (95% CI, 82-89%) and the clinically acceptable rate was 98% (95% CI, 95-99%) in robot-assisted cervical screw placement. The perfect accuracy of robot-assisted C1 lateral mass screw placement was the highest (96%), followed by C6-7 pedicle screw placement (93%) and C2 pedicle screw placement (86%), and the lowest was C3-5 pedicle screw placement (75%). The open approach had a higher perfect accuracy than the percutaneous/intermuscular approach (91% vs 83%). Compared with conventional freehand cervical screw placement, robot-assisted cervical screw placement had a higher accuracy, a lower incidence of perioperative complications, and less intraoperative blood loss. With good collaboration between the operator and the robot, robot-assisted cervical screw placement is accurate and feasible. Robot-assisted cervical screw placement has a promising prospect.

Comparison of Cervical Pedicle Screw Placement Accuracy With Robotic Guidance System Versus Image Guidance System Using Propensity Score Matching.

A retrospective study. To compare the accuracy of cervical pedicle screw (CPS) placement using a robotic guidance system (RGS) with that of using an image guidance system (IGS; navigation system) through propensity score matching. The RGS may provide accurate CPS placement, which may outperform IGS. However, no study has directly compared the accuracy of CPS placement with the RGS to that with the IGS. We retrospectively reviewed the data of patients who had undergone cervical fusion surgery using CPS with the RGS or IGS. To adjust for potential confounders (patient demographic characteristics, disease etiology, and registration material), propensity score matching was performed, creating robotic guidance (RG) and matched image guidance (IG) groups. The accuracy of CPS placement from C2 to C6, where the vertebral artery runs, was evaluated on postoperative computed tomography images according to the Neo classification (grade 0 to grade 3). Furthermore, the intraoperative CPS revisions and related complications were examined. Using propensity score matching, 22 patients were included in the RG and matched groups each, and a total of 95 and 105 CPSs, respectively, were included in the analysis. In both the axial and sagittal planes, the clinically acceptable rate (grades 0 + 1) of CPS placement did not differ between the RG and matched IG groups (97.9% vs 94.3% and 95.8% vs 96.2%, respectively). The incidence of CPS revision was similar between the groups (2.1% vs 2.9%), and no CPS-related complications were documented. Meanwhile, the incidence of lateral breach (grades 1 + 2 + 3) was significantly lower in the RG group than in the matched IG group (1.1% vs 7.7%, P= 0.037). The RGS and IGS can equally aid in accurate and safe CPS placement in clinical settings. Nonetheless, RGS can further reduce the lateral breach, compared with IGS.

A Novel Intraoperative CT Navigation System for Spinal Fusion Surgery in Lumbar Degenerative Disease: Accuracy and Safety of Pedicle Screw Placement.

Background: In recent years, intraoperative computed tomography (CT) navigation has become widely used for the insertion of pedicle screws in spinal fusion surgery. However, conventional intraoperative CT navigation may be impaired by infrared interference between the infrared camera and surgical instruments, which can lead to the misplacement of pedicle screws. Recently, a novel intraoperative CT navigation system, NextAR, has been developed. It uses a small infrared camera mounted on surgical instruments within the surgical field. NextAR navigation can minimize the problem of infrared interference and be expected to improve the accuracy of pedicle screw placement. Methods: This study investigated the accuracy of pedicle screw insertion under NextAR navigation in spinal fusion surgery for lumbar degenerative diseases. The accuracy of pedicle screw placement was evaluated in 15 consecutive patients using a CT grading scale. Results: Screw perforation occurred in only 1 of the total 70 screws (1.4%). Specifically, there was one grade 1 perforation within 2 mm, but no perforations larger than 2 mm. There were no reoperations or neurological complications due to screw misplacement. Conclusions: NextAR navigation can provide high accuracy for pedicle screw insertion and help ensure safe spinal fusion surgery for lumbar degenerative diseases.

Efficacy of computer-assisted robotic based clinical training program for spinal oncology education on pedicle screw placement.

Pedicle screw placement (PSP) is the fundamental surgical technique that requires high accuracy for novice orthopedists studying spinal oncology education. Therefore, we set forth to establish a computer-assisted robotic navigation training program for novice spinal oncology education. Novice orthopedists were involved in this study to evaluate the feasibility and safety of the computer-assisted robotic navigation (CARN) training program. In this research, trainees were randomly taught by the CARN training program and the traditional training program. We prospectively collected the clinical data of patients with spinal tumors from 1st May 2021 to 1st March 2022. The ability of PSP was evaluated by cumulative sum (CUSUM) analysis, learning curve, and accuracy of pedicle screws. The patients included in both groups had similar baseline characteristics. In the CUSUM analysis of the learning curve for accurate PSP, the turning point in the CARN group was lower than that in the traditional group (70th vs. 92nd pedicle screw). The LC-CUSUM test indicated competency for PSP at the 121st pedicle screw in the CARN group and the 138th pedicle screw in the traditional group. The accuracy of PSP was also significantly higher in the CARN group than in the traditional group (88.17% and 79.55%, P = 0.03 < 0.05). Furthermore, no major complications occurred in either group. We first described CARN in spinal oncology education and indicated the CARN training program as a novel, efficient and safe training program for surgeons.

284 CT-Based Assessment of Prone Versus Lateral Pedicle Screw Placement Accuracy: A Retrospective Single-surgeon Study

INTRODUCTION: Lateral lumbar interbody fusion (LLIF) including the anterior-to-psoas oblique lumbar interbody fusion (OLIF) has conventionally relied on pedicle screw placement (PSP) for construct stabilization. Single-position surgery with lumbar interbody fusion (LIF) in the lateral decubitus position with concomitant PSP has been associated with increased operative efficiency. What remains unclear is the accuracy of PSP with robotic guidance when compared to the more familiar prone patient positioning. METHODS: We identified all consecutive patients treated with interbody fusion and PSP in the prone or lateral position by a single surgeon between January 2019 and October 2022. All pedicle screws placed were analyzed using CT imaging to determine appropriate positioning according to the Gertzbein-Robbins Classification Grading System. Multivariate logistic regression models were constructed to identify risk factors for the occurrence of a radiographically significant breach. RESULTS: 89 consecutive patients were included (n = 690 screws), of whom 46 were treated in the prone position (n = 477 screws) and 43 in the lateral decubitus position (n = 213 screws). There were fewer breaches in the prone (n = 13; 2.7%) versus lateral decubitus group (n = 15; 7.0%; p = 0.012). Nine (1.9%) radiographically significant breaches occurred in the prone group compared to 10 (4.7%) in the lateral decubitus group (p = 0.019), for a prone vs. lateral decubitus pedicle screw accuracy rate of 98.1% vs. 95.3%. There were no significant differences in BMI between prone vs. lateral decubitus cohorts (30.1 vs. 29.6) or breached patients vs. non-breached patients (31.2 vs. 29.5). In multivariate models, prone position was the only significant protective factor for screw accuracy; we did not identify any other significant risk factors for screw breach. CONCLUSIONS: The present data suggest pedicle screws placed with robotic assistance have higher placement accuracy in the prone position.

Consistent anatomical relationships of pedicle, lamina, and superior articulating process in severe idiopathic scoliosis allow for safe freehand pedicle screw placement: A proof-of-concept technical study.

Transpedicular screw placement has superior pullout strength compared to alternative forms of spinal fusion and is often performed in deformity correction surgery with navigation for optimal accuracy and reliability. Freehand technique for pedicle screws minimizes operation time and radiation exposure without fluoroscopy but is not widely adopted given the challenge of difficult anatomical corridors and accurate placement, especially in idiopathic scoliosis and advanced deformity. We used a computer-generated model to assess a proof-of-concept and anatomical feasibility of a freehand screw technique in severe scoliosis. Three-dimensional (3D) reconstructions of vertebra from a sample of two male patients with severe idiopathic scoliosis deformity (1 thoracic and 1 lumbar) with Cobb angles of 100° were used for planned placement of 17 levels of thoracolumbar (6.5 mm × 45 mm) pedicle screws. 3D reconstruction of each vertebra was created and measurements of screw entries and trajectories were reproduced with a 3D slicer software image computing platform. Accurate transpedicular screw placement is possible with anatomical landmarks based on the 3D reconstructed vertebral levels. A series of 5 figures were assembled to demonstrate sagittal, coronal, and axial planes and key anatomical landmarks and trajectories of thoracic and lumbar freehand pedicle screws in severe idiopathic scoliosis. Anatomical landmarks for freehand transpedicular screw placement (between pedicle, lamina, and superior articulating process) are constant and reliable in severe idiopathic scoliosis as evidenced by 3D computer modeling. Preoperative computed tomography modeling may assist appropriate screw entry and trajectory based on anatomical landmarks for spine surgeons, and guide freehand technique for screw placement in adolescent idiopathic scoliosis.

1071 Initial Experience Using an Augmented Reality Head-Mounted Display System During Surgical Management of Thoracolumbar Spinal Trauma

INTRODUCTION: Advancements in trauma medicine can improve the speed and accuracy of care response with a major impact on downstream operative outcomes. Augmented reality using a head-mounted-display (AR-HMD) is a novel technology that may be applied to spine surgery to provide surgeons with a real-time CT-guided 3-dimensional reconstruction of a patient’s spinal anatomy. METHODS: We retrospectively reviewed trauma patients who underwent pedicle screw placement guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between January 1, 2021 and December 31, 2022. Demographic, clinical, cost, and perioperative outcome information was analyzed and outcome profiles were compared using a U test. RESULTS: The AR cohort (4 females, 5 males) had a mean age of 66.0 years, BMI of 29.4 kg/m2, Charlson Comorbidity Index (CCI) of 4.11, and Surgical Invasiveness Index (SII) of 8.78. Pedicle screws (77) were placed in the thoracic (51%), lumbar (39%), and sacral spine (10%). Intraoperatively, there was a mean blood loss of 377.78 ml, 0.78 units transfused, 398.33 minutes spent in the operating room, and a 20.00 day LOS. The average 3-month, 6-month, and 12-month ODI scores were 14.25 (n = 8), 15.40 (n = 5), and 12.66 (n = 3). The robotic cohort (5 females, 8 males) had a mean age of 55.6 years, BMI of 27.1 kg/m2, CCI of 3.77, and SII of 14.23. Pedicle screws (128) were placed in the thoracic (59%), lumbar (37%), sacral spine (2%), iliac spine (2%), and pelvis (2%). Intra-operatively, there was a mean blood loss of 431.54 ml, 0.46 units transfused, 330.61 minutes spent in the operating room, and a 10.38 day LOS. The average 3-month, 6-month, and 12-month ODI scores were 22.67 (n = 9), 18.60 (n = 5), and 29.50 (n = 2). CONCLUSIONS: This case series demonstrates the utility of AR-HMD in surgical spinal trauma cases by showing operative outcomes comparable to those observed in robotic-assisted surgery.

1067 Accuracy of an Augmented Reality Spine Surgery Guidance System With Stereoscopic Targeting Head Mounted Display Compared to Standard Computer Navigation, Robotic Systems, and Existing AR Systems

INTRODUCTION: Augmented Reality (AR) offers the benefit of improved hand-eye coordination by accurately superimposing 3D stereoscopic displays for surgical instruments onto anatomic landmarks. METHODS: 120 pedicle screws were implanted using an AR system (OnPoint AR, OnPoint Surgical, Bedford, MA) (thoracic 50, lumbosacral 70; pre-op CT 40, O-arm 80). Heary grading was applied by an independent radiologist assessing the degree of pedicle breaches. 3D measurements of positional error (PE) and angular error (AE) were performed by comparing post-operative CT scans of implanted screws with planned trajectories. Statistical analyses compared PE and AE for OnPoint AR with the available values for other systems using an unequal variance t-test method. RESULTS: 113 screws placed demonstrated Heary grade 1 accuracy. 6 screws had a larger diameter than the pedicle and were planned with in-out-in technique with Heary grade 2 accuracy. One screw demonstrated a lateral breach (grade 2) caused by a loose connection to the screwdriver. PE and AE (mean ± 1SD) for OnPoint AR were the following: for intra-operative spin 1.1mm±0.5mm and 1.3°±0.5°; for pre-operative CT 1.9mm±1.2mm and 2.2°±1.3°. Percent increment in PE and AE for Medtronic Stealth Station, Brainlab navigation, Stryker nav3i, Medtronic Mazor X robot, Globus Excelsius robot, Augmedics Xvision, and Novarad VisAR compared to OnPoint AR ranged between 40–80%, with differences being highly significant for all comparisons. CONCLUSIONS: PE and AE for placing pedicle screws are statistically significantly smaller for the novel AR system compared to existing navigation, robotic, and AR systems. A positional error of 1.1mm and angular error of 1.3° makes this technology particularly suited for small pedicles, challenging anatomy, and MIS techniques.

Analysis of 5,070 consecutive pedicle screws placed utilizing robotically assisted surgical navigation in 334 patients by experienced pediatric spine deformity surgeons: surgical safety and early perioperative complications in pediatric posterior spinal fusion.

This study evaluates the intraoperative and short-term complications associated with robotically assisted pedicle screw placement in pediatric posterior spinal fusion (PSF) from three surgeons at two different institutions. We retrospectively reviewed 334 pediatric patients who underwent PSF with robotic-assisted navigation at 2 institutions over 3 years (2020-2022). Five thousand seventy robotically placed screws were evaluated. Data collection focused on intraoperative and early postoperative complications with minimum 30-day follow-up. Patients undergoing revision procedures were excluded. Intraoperative complications included 1 durotomy, 6 patients with neuromonitoring alerts not related to screw placement, and 62 screws (1.2%) with documented pedicle breaches, all of which were revised at time of surgery. By quartile, pedicle breaches statistically declined from first quartile to fourth quartile (1.8% vs. 0.56%, p < 0.05). No breach was associated with neuromonitoring changes or neurological sequelae. No spinal cord or vascular injuries occurred. Seventeen postoperative complications occurred in eleven (3.3%) of patients. There were five (1.5%) patients with unplanned return to the operating room. Robotically assisted pedicle screw placement was safely and reliably performed on pediatric spinal deformity by three surgeons across two centers, demonstrating an acceptable safety profile and low incidence of unplanned return to the operating room.