Clinical and methodological precision of spinal navigation assisted by 3D intraoperative O-arm radiographic imaging

Technical note

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In recent years, the importance of intraoperative navigation in neurosurgery has been increasing. Multiple studies have proven the advantages and safety of computer-assisted spinal neurosurgery. The use of intraoperative 3D radiographic imaging to acquire image information for navigational purposes has several advantages and should increase the accuracy and safety of screw guidance with navigation. The aim of this study was to evaluate the clinical and methodological precision of navigated spine surgery in combination with the O-arm multidimensional imaging system.


Thoracic, lumbar, and sacral pedicle screws that were placed with the help of the combination of the O-arm and StealthStation TREON plus navigation systems were analyzed. To evaluate clinical precision, 278 polyaxial pedicle screws in 139 vertebrae were reviewed for medial or caudal perforations on coronal projection. For the evaluation of the methodological accuracy, virtual and intraoperative images were compared, and the angulation of the pedicle screw to the midsagittal line was measured.


Pedicle perforations were recorded in 3.2% of pedicle screws. None of the perforated pedicle screws damaged a nerve root. The difference in angulation between the actual and virtual pedicle screws was 2.8° ± 1.9°.


The use of the StealthStation TREON plus navigation system in combination with the O-arm system showed the highest accuracy for spinal navigation compared with other studies that used traditional image acquisition and registration for navigation.

Article Information

Address correspondence to: Matthias F. Oertel, M.D., Associate Professor of Neurosurgery, Klinikstrasse 29, Giessen 35385, Germany. email:

Please include this information when citing this paper: published online January 28, 2011; DOI: 10.3171/2010.10.SPINE091032.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    The setup for O-arm–assisted navigated spinal surgery is shown. The patient is positioned prone on a carbon operating table. The reference frame is attached to one of the spinous processes. The O-arm is in the parked position. The operating surgeon is watching the StealthStation's monitor while inserting a polyaxial pedicle screw with a navigable screwdriver.

  • View in gallery

    This coronal image from a 3D data set, acquired using the O-arm after insertion of 4 pedicle screws, shows 3 pedicle screws within the pedicle. The screw at the lower left (arrows) shows a breach of the medial edge of the pedicle.

  • View in gallery

    These images show the angulations of the pedicle screws relative to the midsagittal line. A total of 94 pedicle screws were analyzed. On average, the difference between the actual (left) and virtual (right) angle was 2.8° ± 1.9°.

  • View in gallery

    The distribution of pedicle screws across the spine is shown. Most screws were inserted at the lower lumbar spine for degenerative spondylolisthesis. The screws that were analyzed for methodological precision were randomly photographed by one of the authors (J.H.) who had no knowledge of the ideal screw position.



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