Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion

A review

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In this paper the authors' goal was to compare the accuracy of computer-navigated pedicle screw insertion with nonnavigated techniques in the published literature.


The authors performed a systematic literature review using the National Center for Biotechnology Information Database (PubMed/MEDLINE) using the Medical Subject Headings (MeSH) terms “Neuronavigation,” “Therapy, computer assisted,” and “Stereotaxic techniques,” and the text word “pedicle.” Included in the meta-analysis were randomized control trials or patient cohort series, all of which compared computer-navigated spine surgery (CNSS) and nonassisted pedicle screw insertions. The primary end point was pedicle perforation, while the secondary end points were operative time, blood loss, and complications.


Twenty studies were included for analysis; of which there were 18 cohort studies and 2 randomized controlled trials published between 2000 and 2011. Foreign-language papers were translated. The total number of screws included was 8539 (4814 navigated and 3725 nonnavigated). The most common indications for surgery were degenerative disease, spinal deformity, myelopathy, tumor, and trauma. Navigational methods were primarily based on CT imaging. All regions of the spine were represented. The relative risk for pedicle screw perforation was determined to be 0.39 (p < 0.001), favoring navigation. The overall pedicle screw perforation risk for navigation was 6%, while the overall pedicle screw perforation risk was 15% for conventional insertion. No related neurological complications were reported with navigated insertion (4814 screws total); there were 3 neurological complications in the nonnavigated group (3725 screws total). Furthermore, the meta-analysis did not reveal a significant difference in total operative time and estimated blood loss when comparing the 2 modalities.


There is a significantly lower risk of pedicle perforation for navigated screw insertion compared with nonnavigated insertion for all spinal regions.

Abbreviations used in this paper:CAS = computer-assisted surgery; CNSS = computer-navigated spine surgery; EBL = estimated blood loss; MeSH = Medical Subject Headings; MIS = minimally invasive surgery; RCT = randomized controlled trial.

Article Information

Address correspondence to: Roger Härtl, M.D., Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Medical College of Cornell University, New York Presbyterian Hospital, 525 East 68th Street, Box 99, New York, New York 10065. email:

Please include this information when citing this paper: published online June 22, 2012; DOI: 10.3171/2012.5.SPINE11399.

© AANS, except where prohibited by US copyright law.



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    Diagram of the search strategy for our systematic review.

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    Forest plot of the overall pedicle screw perforation risk. Events are perforations from the total number of screws. The dagger indicates the 2D navigation studies. All other navigation studies are 3D. M-H = Mantel-Haenszel.

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    Forest plot of the pedicle screw perforation risk for each region of the spine. Events are perforations from the total number of screws per spinal region.

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    Forest plots of the total operative time (in minutes) and EBL (in ml). IV = interval.

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    Funnel plot for the Egger test (−0.48) demonstrated no publication bias (p = 0.47). RR = relative risk; SE = standard error.



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