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Navigation aids accuracy of implant placement, mitigates bone damage
Navigation may reduce surgical time and radiation exposure in spine surgery, according to a presenter.
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Navigation used during spine surgery can help surgeons accurately place pedicle screws and insert the screws in the most optimal position to avoid damage to the bone and adjacent structures. According to a presenter, not only does this allow surgeons to accurately and precisely place pedicle screws, but it allows them to use O-arm navigation to place iliac bolts, perform precise three planar osteotomies and even perform precision tumor resections and simplify revision spinal surgery.
“[Navigation] has been shown that it reduces the number of pedicle screws breaching, it reduces the screw pull-out [and] it reduces our complication rate,” Andrew O’Brien, MD, MBBS, FRCS, said at the British Orthopaedic Association Annual Congress. “I think that navigation should be as essential a part of our armamentarium as the pedicle finder.”
He added, “Navigation has enhanced our ability to visualize the anatomy. It allows us to find pedicles that we cannot see with other techniques; it allows us to define both normal and abnormal anatomy; it allows us to compensate for missing pedicles or for bone loss; it allows us to work around existing metal work; and it allows us to take a bone scalpel and make precise cuts within the bone and take out bone in exactly the location and size we need it for precise facetectomies, decompressions or multiplanar osteotomies. Navigation is extending our range of abilities as surgeons.”
Images: Molloy S
Navigation provides clearer image
O’Brien said patients may have difficult or abnormal anatomy, especially in deformity, with the possibility of distorted or absent traditional landmarks. In these cases, even intensified images are limited in what they can show.
“Navigation allows us to have a clearer image of the abnormal anatomy, that plain radiographs or image-intensifier [scans] allow, but it also enables us to explore the anatomy on a screen in real-time and on the operating table with the patient in front of us and to use a computer simulation to plan and deliver our surgery,” O’Brien said.
Navigation not only helps with the identification of bony structures, but it can also help surgeons preserve or protect the soft tissue, he said.
Navigation allows spine surgeons to “recover and retrieve” situations in which using conventional techniques would be extremely difficult or product a suboptimal result, O’Brien said.
“Navigation gives us another extension to our reality. Instead of losing the pedicle anchorage at that level and finding some alternative fix with a wire, hook or bypassing the level, we can utilize that difficult pedicle optimally by being able to put a pedicle screw with the optimum hold into the area,” he said.
Less radiation exposure for team
“[Looking] at the literature and looking at our experience, navigation reduces the surgical time in many cases. In some studies, that says equivalent,” O’Brien said. “It reduces the radiation exposure to the surgeon and the team, and it did significantly in our experience.”
He said there is conflicting evidence regarding the dose for the patient; however, the navigation dose is less than that of when fluoroscopy is used in larger procedures. Navigation also can compensate for lost landmarks and can allow surgeons to keep their incisions small and avoid stripping tissues, O’Brien said.
Other advantages of navigation he discussed were that surgeons can extend their range of surgical techniques when they use navigation-specific bone scalpels, drills and other devices. In addition, navigation may reduce stress during the surgery because the surgeon will know where the pedicle screw is ultimately going and that it will successfully hold. Navigation also gives surgeons the ability to work around existing metalwork and implants in a way that would be difficult using image intensifiers alone, he noted.
“It is brilliant for teaching. Trainees can look and see and get real-time feedback on what they are doing,” O’Brien said. – by Monica Jaramillo
- Reference:
- O’Brien A. Are the outcomes of spinal surgery better with spinal navigation? Presented at: British Orthopaedic Association Annual Congress; Sept. 13-16, 2016; Belfast, Northern Ireland.
- For more information:
- Andrew O’Brien, MD, MBBS, FRCS, can be reached at Royal Victoria Hospital and Royal Belfast, Hospital for Sick Children, Grosvenor Rd., Belfast BT12 6BA, Northern Ireland; email: dr_andrew_obrien@mac.com.
Disclosure: O’Brien is a paid consultant to Medtronic.
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Charles H. Crawford, MD
During the last 7 years to 8 years, spinal navigation has grown to be an essential part of my practice. Although there are concerns regarding time, effort and cost, the benefits are tremendous. The ability to visualize bony anatomy allows for safer and more effective placement of spinal instrumentation. The frequency of misplaced screws that require reoperation is almost zero, which is a significant improvement from historical rates.
I frequently use navigation for minimally invasive cases with small skin incisions that make classical free-hand instrumentation techniques impossible. I also frequently use it for complex open cases with distorted anatomy (patients with prior surgery, congenital anomalies, significant deformities, tumor, etc.).
I feel fortunate to work in a major spine center where I have access to navigation equipment. I have no doubt that navigation will be part of the future of spine surgery. I think the challenge will be figuring out how to make these technologies available to spine surgeons who may be working in a more resource-constrained environment.
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Jean Charles Le Huec, MD, PhD
The future of surgery is imaging technology to allow us to treat, specifically, the targeted lesion without damaging the surrounding tissue. Image-guided surgery is the key, and we still need to develop and enhance the augmented reality and the infrared and magnetic navigation technology to be able to attain the best way to treat our patients. Intelligent multi-functional robots strongly connected with navigation will also bring accuracy and safety.
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