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Doniel Drazin, Terrence T. Kim, David W. Polly Jr and J. Patrick Johnson

Image-guided surgery (IGS) has been evolving since the early 1990s and is now used on a daily basis in the operating theater for spine surgery at many institutions. In the last 5 years, spinal IGS has greatly benefitted from important enhancements including portable intraoperative CT (iCT) coupled with high-speed computerized stereotactic navigation systems and optical-based camera tracking technology.

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J. Patrick Johnson, Doniel Drazin, Wesley A. King and Terrence T. Kim

Object

Video-assisted thoracoscopic surgery (VATS) has evolved for treatment of a variety of spinal disorders. Early incorporation with image-guided surgery (IGS) was challenged due to reproducibility and adaptability, limiting the procedure's acceptance. In the present study, the authors report their experience with second-generation IGS and VATS technologies for anterior thoracic minimally invasive spinal (MIS) procedures.

Methods

The surgical procedure is described in detail including operating room set-up, patient positioning (a lateral decubitus position), placement of the spinal reference frame and portal, radiographic localization, registration, surgical instruments, and the image-guided thoracoscopic discectomy.

Results

Combined IGS and VATS procedures were successfully performed and assisted in anatomical localization in 14 patients. The mean patient age was 59 years (range 32–73 years). Disc herniation pathology represented the most common indication for surgery (n = 8 patients); intrathoracic spinal tumors were present in 4 patients and the remaining patients had infection and ossification of the posterior longitudinal ligament. All patients required chest tube drainage postoperatively, and all but 1 patient had drainage discontinued the following day. The only complication was a seroma that was presumed to be due to steroid therapy for postoperative weakness. At the final follow-up, 11 of the patients were improved neurologically, 2 patients had baseline neurological status, and the 1 patient with postoperative weakness was able to ambulate, albeit with an assistive device.

The evolution of thoracoscopic surgical procedures occurring over 20 years is presented, including their limitations. The combination of VATS and IGS technologies is discussed including their safety and the importance of 3D imaging. In cases of large open thoracotomy procedures, surgeries require difficult, extensive, and invasive access through the chest cavity; using a MIS procedure can potentially eliminate many of the complications and morbidities associated with large open procedures. The authors report their experience with thoracic spinal surgeries that involved MIS procedures and the new technologies.

Conclusions

The most significant advance in IGS procedures has resulted from intraoperative CT scanning and automatic registration with the IGS workstation. Image guidance can be used in conjunction with VATS techniques for thoracic discectomy, spinal tumors, infection, and ossification of the posterior longitudinal ligament. The authors' initial experience has revealed this technique to be useful and potentially applicable to other MIS procedures.

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Terrence T. Kim, Doniel Drazin, Faris Shweikeh, Robert Pashman and J. Patrick Johnson

Object

Intraoperative CT image–guided navigation (IGN) has been increasingly incorporated into minimally invasive spine surgery (MIS). The vast improvement in image resolution and virtual real-time images with CT-IGN has proven superiority over traditional fluoroscopic techniques. The authors describe their perioperative MIS technique using the O-arm with navigation, and they report their postoperative experience, accuracy results, and technical aspects.

Methods

A retrospective review of 48 consecutive adult patients undergoing minimally invasive percutaneous posterior spinal fusion with intraoperative CT-IGN between July 2010 and August 2013 at Cedars-Sinai Medical Center was performed. Two surgeons assessed 290 screws in a blinded fashion on intraoperative O-arm images and postoperative CT scans for bony pedicle wall breach. Grade 1 breach was defined to be < 2 mm, Grade 2 breach to be between 2 and 4 mm, and a Grade 3 breach to be > 4 mm. Additionally, anterior vertebral body breach was recorded.

Results

Of 290 pedicle screws placed, 280 (96.6%) were in an acceptable position without cortical wall or anterior breach. Of the 10 breaches (3.4%) 5 were lateral (50%), 4 were medial, and 1 was anterior; 90% of breaches were Grade 1–2 and all medial breaches were Grade 1. The one Grade 3 breach was lateral. No vascular or neurological complications were observed intraoperatively, and no significant postoperative complications were noted. The mean clinical follow-up period was 18 months (range 3–39 months). The overall clinical outcomes, measured using the visual analog scale (back pain scores), were improved significantly postoperatively at 3 months compared with preoperatively (visual analog score 6.35 vs 3.57; p < 0.0001). No revision surgery was performed for screw misplacement or neurological deterioration.

Conclusions

New CT-IGN with the mobile O-arm scanner has increased the accuracy of pedicle screw/instrumentation placement using MIS techniques. The authors' high (96.6%) accuracy rate in MIS compares favorably with historical published accuracy rates for fluoroscopy-based techniques. Additional advantages of CT-IGN over fluoroscopic imaging methods are lower occupational radiation exposure for the surgical team, reduced need for postoperative imaging, and decreased rates of revision surgery. For now, the authors simply conclude that use of intraoperative CT-IGN is safe and accurate.

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Lutfi T. Al-Khouja, Eli M. Baron, J. Patrick Johnson, Terrence T. Kim and Doniel Drazin

Object

Medical care has been evolving with the increased influence of a value-based health care system. As a result, more emphasis is being placed on ensuring cost-effectiveness and utility in the services provided to patients. This study looks at this development in respect to minimally invasive spine surgery (MISS) costs.

Methods

A literature review using PubMed, the Cost-Effectiveness Analysis (CEA) Registry, and the National Health Service Economic Evaluation Database (NHS EED) was performed. Papers were included in the study if they reported costs associated with minimally invasive spine surgery (MISS). If there was no mention of cost, CEA, cost-utility analysis (CUA), quality-adjusted life year (QALY), quality, or outcomes mentioned, then the article was excluded.

Results

Fourteen studies reporting costs associated with MISS in 12,425 patients (3675 undergoing minimally invasive procedures and 8750 undergoing open procedures) were identified through PubMed, the CEA Registry, and NHS EED. The percent cost difference between minimally invasive and open approaches ranged from 2.54% to 33.68%—all indicating cost saving with a minimally invasive surgical approach. Average length of stay (LOS) for minimally invasive surgery ranged from 0.93 days to 5.1 days compared with 1.53 days to 12 days for an open approach. All studies reporting EBL reported lower volume loss in an MISS approach (range 10–392.5 ml) than in an open approach (range 55–535.5 ml).

Conclusions

There are currently an insufficient number of studies published reporting the costs of MISS. Of the studies published, none have followed a standardized method of reporting and analyzing cost data. Preliminary findings analyzing the 14 studies showed both cost saving and better outcomes in MISS compared with an open approach. However, more Level I CEA/CUA studies including cost/QALY evaluations with specifics of the techniques utilized need to be reported in a standardized manner to make more accurate conclusions on the cost effectiveness of minimally invasive spine surgery.

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Doniel Drazin, Neil Bhamb, Lutfi T. Al-Khouja, Ari D. Kappel, Terrence T. Kim, J. Patrick Johnson and Earl Brien

OBJECTIVE

The aim of this study was to identify and discuss operative nuances utilizing image guidance in the surgical management of aggressive sacral tumors.

METHODS

The authors report on their single-institution, multi-surgeon, retrospective case series involving patients with pathology-proven aggressive sacral tumors treated between 2009 and 2016. They also reviewed the literature to identify articles related to aggressive sacral tumors, their diagnosis, and their surgical treatment and discuss the results together with their own experience. Information, including background, imaging, treatment, and surgical pearls, is organized by tumor type.

RESULTS

Review of the institutional records identified 6 patients with sacral tumors who underwent surgery between 2009 and 2016. All 6 patients were treated with image-guided surgery using cone-beam CT technology (O-arm). The surgical technique used is described in detail, and 2 illustrative cases are presented. From the literature, the authors compiled information about chordomas, chondrosarcomas, giant cell tumors, and osteosarcomas and organized it by tumor type, providing a detailed discussion of background, imaging, and treatment as well as surgical pearls for each tumor type.

CONCLUSIONS

Aggressive sacral tumors can be an extremely difficult challenge for both the patient and the treating physician. The selected surgical intervention varies depending on the type of tumor, size, and location. Surgery can have profound risks including neural compression, lumbopelvic instability, and suboptimal oncological resection. Focusing on the operative nuances for each type can help prevent many of these complications. Anecdotal evidence is provided that utilization of image-guided surgery to aid in tumor resection at our institution has helped reduce blood loss and the local recurrence rate while preserving function in both malignant and aggressive benign tumors affecting the sacrum.

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Doniel Drazin, Mir Hussain, Jonathan Harris, John Hao, Matt Phillips, Terrence T. Kim, J. Patrick Johnson and Brandon Bucklen

OBJECT

Abnormal sacral slope (SS) has shown to increase progression of spondylolisthesis, yet there exists a paucity in biomechanical studies investigating its role in the correction of adult spinal deformity, its influence on lumbosacral shear, and its impact on the instrumentation selection process. This in vitro study investigates the effect of SS on 3 anterior lumbar interbody fusion constructs in a biomechanics laboratory.

METHODS

Nine healthy, fresh-frozen, intact human lumbosacral vertebral segments were tested by applying a 550-N axial load to specimens with an initial SS of 20° on an MTS Bionix test system. Testing was repeated as SS was increased to 50°, in 10° increments, through an angulated testing fixture. Specimens were instrumented using a standalone integrated spacer with self-contained screws (SA), an interbody spacer with posterior pedicle screws (PPS), and an interbody spacer with anterior tension band plate (ATB) in a randomized order. Stiffness was calculated from the linear portion of the load-deformation curve. Ultimate strength was also recorded on the final construct of all specimens (n = 3 per construct) with SS of 40°.

RESULTS

Axial stiffness (N/mm) of the L5–S1 motion segment was measured at various angles of SS: for SA 292.9 ± 142.8 (20°), 277.2 ± 113.7 (30°), 237.0 ± 108.7 (40°), 170.3 ± 74.1 (50°); for PPS 371.2 ± 237.5 (20°), 319.8 ± 167.2 (30°), 280.4 ± 151.7 (40°), 233.0 ± 117.6 (50°); and for ATB 323.9 ± 210.4 (20°), 307.8 ± 125.4 (30°), 249.4 ± 126.7 (40°), 217.7 ± 99.4 (50°). Axial compression across the disc space decreased with increasing SS, indicating that SS beyond 40° threshold shifted L5–S1 motion into pure shear, instead of compression-shear, defining a threshold. Trends in ultimate load and displacement differed from linear stiffness with SA > PPS > ATB.

CONCLUSIONS

At larger SSs, bilateral pedicle screw constructs with spacers were the most stable; however, none of the constructs were significantly stiffer than intact segments. For load to failure, the integrated spacer performed the best; this may be due to angulations of integrated plate screws. Increasing SS significantly reduced stiffness, which indicates that surgeons need to consider using more aggressive fixation techniques.

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Joseph C. Hsieh, Doniel Drazin, Alexander O. Firempong, Robert Pashman, J. Patrick Johnson and Terrence T. Kim

Object

Revision spine surgery, which is challenging due to disrupted anatomy, poor fluoroscopic imaging, and altered tactile feedback, may benefit from CT image-guided surgery (CT-IGS). This study evaluates accuracy of CT-IGS–navigated screws in primary versus revision spine surgery.

Methods

Pedicle and pelvic screws placed with the O-arm in 28 primary (313 screws) and 33 revision (429 screws) cases in which institutional postoperative CT scans were available were retrospectively reviewed for placement accuracy. Screw accuracy was categorized as 1) good (< 1-mm pedicle breach in any direction or “in-out-in” thoracic screws through the lateral thoracic pedicle wall and in the costovertebral joint); 2) fair (1- to 3-mm breach); or 3) poor (> 3-mm breach).

Results

Use of CT-IGS resulted in high rates of good or fair screws for both primary (98.7%) and revision (98.6%) cases. Rates of good or fair screws were comparable for the following regions: C7–T3 at 100% (good or fair) in primary versus 100% (good or fair) in revision; T4–9 at 96.8% versus 100%; T10–L2 at 98.2% versus 99.3%; L3–5 at 100% versus 99.2%; and pelvis at 98.7% versus 98.6%, respectively. On the other hand, revision sacral screws had statistically significantly lower rates of good placement compared with primary (100% primary vs 80.6% revision, p = 0.027). Of these revision sacral screws, 11.1% had poor placement, with bicortical screws extending > 3 mm beyond the anterior cortex. Revision pelvic screws demonstrated the highest rate of fair placement (28%), with the mode of medial breach in all cases directed into the sacral-iliac joint.

Conclusions

In the cervical, thoracic, and lumbar spine, CT-IGS demonstrated comparable accuracy rates for both primary and revision spine surgery. Use of 3D imaging of the bony pedicle anatomy appears to be sufficient for the spine surgeon to overcome the difficulties associated with instrumentation in revision cases. Although the bony structures of sacral pedicles and pelvis are relatively larger, the complexity of local anatomy was not overcome with CT-IGS, and an increased trend toward inaccurate screw placement was demonstrated.

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Faris Shweikeh, Jordan P. Amadio, Monica Arnell, Zachary R. Barnard, Terrence T. Kim, J. Patrick Johnson and Doniel Drazin

Object

Robotics in the operating room has shown great use and versatility in multiple surgical fields. Robot-assisted spine surgery has gained significant favor over its relatively short existence, due to its intuitive promise of higher surgical accuracy and better outcomes with fewer complications. Here, the authors analyze the existing literature on this growing technology in the era of minimally invasive spine surgery.

Methods

In an attempt to provide the most recent, up-to-date review of the current literature on robotic spine surgery, a search of the existing literature was conducted to obtain all relevant studies on robotics as it relates to its application in spine surgery and other interventions.

Results

In all, 45 articles were included in the analysis. The authors discuss the current status of this technology and its potential in multiple arenas of spinal interventions, mainly spine surgery and spine biomechanics testing.

Conclusions

There are numerous potential advantages and limitations to robotic spine surgery, as suggested in published case reports and in retrospective and prospective studies. Randomized controlled trials are few in number and show conflicting results regarding accuracy. The present limitations may be surmountable with future technological improvements, greater surgeon experience, reduced cost, improved operating room dynamics, and more training of surgical team members. Given the promise of robotics for improvements in spine surgery and spine biomechanics testing, more studies are needed to further explore the applicability of this technology in the spinal operating room. Due to the significant cost of the robotic equipment, studies are needed to substantiate that the increased equipment costs will result in significant benefits that will justify the expense.

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Rani Nasser, Doniel Drazin, Jonathan Nakhla, Lutfi Al-Khouja, Earl Brien, Eli M. Baron, Terrence T. Kim, J. Patrick Johnson and Reza Yassari

OBJECTIVE

The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions.

METHODS

This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance.

RESULTS

The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14–87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62–865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5–7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1–36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden.

CONCLUSIONS

O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

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Sunil Jeswani, Doniel Drazin, Joseph C. Hsieh, Faris Shweikeh, Eric Friedman, Robert Pashman, J. Patrick Johnson and Terrence T. Kim

Object

Traditionally, instrumentation of thoracic pedicles has been more difficult because of their relatively smaller size. Thoracic pedicles are at risk for violation during surgical instrumentation, as is commonly seen in patients with scoliosis and in women. The laterally based “in-out-in” approach, which technically results in a lateral breach, is sometimes used in small pedicles to decrease the comparative risk of a medial breach with neurological involvement. In this study the authors evaluated the role of CT image–guided surgery in navigating screws in small thoracic pedicles.

Methods

Thoracic (T1–12) pedicle screw placements using the O-arm imaging system (Medtronic Inc.) were evaluated for accuracy with preoperative and postoperative CT. “Small” pedicles were defined as those ≤ 3 mm in the narrowest diameter orthogonal to the long axis of the pedicle on a trajectory entering the vertebral body on preinstrumentation CT. A subset of “very small” pedicles (≤ 2 mm in the narrowest diameter, 13 pedicles) was also analyzed. Screw accuracy was categorized as good (< 1 mm of pedicle breach in any direction or in-out-in screws), fair (1–3 mm of breach), or poor (> 3 mm of breach).

Results

Twenty-one consecutive patients (age range 32–71 years) had large (45 screws) and small (52 screws) thoracic pedicles. The median pedicle diameter was 2.5 mm (range 0.9–3 mm) for small and 3.9 mm (3.1–6.7 mm) for large pedicles. Computed tomography–guided surgical navigation led to accurate screw placement in both small (good 100%, fair 0%, poor 0%) and large (good 96.6%, fair 0%, poor 3.4%) pedicles. Good screw placement in very small or small pedicles occurred with an in-out-in trajectory more often than in large pedicles (large 6.8% vs small 36.5%, p < 0.0005; vs very small 69.2%, p < 0.0001). There were no medial breaches even though 75 of the 97 screws were placed in postmenopausal women, traditionally at higher risk for osteoporosis.

Conclusions

Computed tomography–guided surgical navigation allows for safe, effective, and accurate instrumentation of small (≤ 3 mm) to very small (≤ 2 mm) thoracic pedicles.