title: Computer-assisted spinal navigation versus serial radiography and operative time for posterior spinal fusion at L5-S1.
abstract: OBJECTIVE
  To review the operative time differences between computer-assisted spinal navigation versus serial radiography.
  
  
  BACKGROUND
  There have been multiple studies describing the use of computer-assisted image guided surgery (IGS) in the application of spinal instrumentation. Techniques have evolved to allow attainment of multilevel visualization intraoperatively both successfully and safely. These have proven to result in low screw misplacement rates, low incidence of radiation exposure and excellent operative field viewing. As a result, image guidance has become an increasingly accepted and practiced form of intraoperative spinal navigation. However, potential limitations to IGS have been described including longer operating times. Many studies have looked at the success of beneficial outcomes; however, none to our knowledge have reviewed such described operative time increments with IGS.
  
  
  METHODS
  The authors performed a retrospective database analysis of 105 patients undergoing posterior L5-S1 spine fusion with pedicle screw instrumentation for isthmic spondylolisthesis with and without the use of fluoroscopy-based image guidance. This was followed by a chart review of anesthesia operative time documentation. Subsequent time calculations and statistical analysis were performed for comparison.
  
  
  RESULTS
  Computer-assisted image-guided spine surgery has overall demonstrated shorter mean operative times when compared with intraoperative serial radiography technique; an average of 40 minutes less per case (P<0.001). There is also less variation in operative times using image guidance, with 13 of 43 (30%) cases using serial x-ray lasting more than 3.75 hours compared with none of the 57 done via image guidance (P<0.001). The operative duration for both procedures trended downward over time. For both procedural cohorts operating room time continued to decrease as of the most recent year being performed. Lastly, in an attempt to minimize such a confounding factor as a learning curve, the last 20 cases in each group were compared. There was an average difference of about 22 minutes less for the image guidance group but missed being statistically significant (P=0.0503).
  
  
  CONCLUSIONS
  Image-guided spinal surgery did not cause an increase in operative time. In the best scenario, image navigation saved a statistically significant (P<0.001) amount of time in the operating room. At its worst, fluoroscopy-based image-guided navigation is not significantly different from standard serial radiography.
authors.affiliation: Clinical Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46260, USA. rsasso@indianaspinegroup.com
authors.forename: Rick C
authors.initials: RC
authors.lastname: Sasso
authors.forename: Ben J
authors.initials: BJ
authors.lastname: Garrido
mesh_terms: D001863:Bone Screws; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging* / Q000601:surgery*; D008297:Male; D019919:Prosthesis Implantation / Q000379:methods; D011857:Radiographic Image Interpretation, Computer-Assisted / Q000379:methods; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods*; D013168:Spondylolisthesis / Q000000981:diagnostic imaging* / Q000601:surgery*; D025321:Surgery, Computer-Assisted / Q000379:methods*; D013647:Task Performance and Analysis; D013996:Time and Motion Studies; D016896:Treatment Outcome