title: Improved Accuracy of Minimally Invasive Transpedicular Screw Placement in the Lumbar Spine With 3-Dimensional Stereotactic Image Guidance: A Comparative Meta-Analysis.
abstract: METHODS
  This study compares the accuracy rates of lumbar percutaneous pedicle screw placement (PPSP) using either 2-dimensional (2-D) fluoroscopic guidance or 3-dimensional (3-D) stereotactic navigation in the setting of minimally invasive spine surgery (MISS). This represents the largest single-operator study of its kind and first comprehensive review of 3-D stereotactic navigation in the setting of MISS.
  
  
  OBJECTIVE
  To examine differences in accuracy of lumbar pedicle screw placement using 2-D fluoroscopic navigation and 3-D stereotaxis in the setting of MISS.
  
  
  BACKGROUND
  Surgeons increasingly rely upon advanced image guidance systems to guide minimally invasive PPSP. Three-dimensional stereotactic navigation with intraoperative computed tomography offers well-documented benefit in open surgical approaches. However, the utility of 3-D stereotaxis in the setting of MISS remains incompletely explored by few studies with limited patient numbers.
  
  
  METHODS
  A total of 599 consecutive patients underwent minimally invasive lumbar PPSP aided by 3-D stereotactic navigation. Postoperative imaging and medical records were analyzed for patient demographics, incidence and degree of pedicle breach, and other surgical complications. A total of 2132 screw were reviewed and compared with a meta-analysis created from published data regarding the placement of 4248 fluoroscopically navigated pedicle screws in the setting of MISS.
  
  
  RESULTS
  In the 3-D navigation group, a total of 7 pedicle breaches occurred in 6 patients, corresponding to a per-person breach rate of 1.15% (6/518) and a per-screw breach rate of 0.33% (7/2132). Meta-analysis comprised of data from 10 independent studies showed overall breach risk of 13.1% when 2-D fluoroscopic navigation was utilized in MISS. This translates to a 99% decrease in odds of breach in the 3-D navigation technique versus the traditional 2-D-guided technique, with an odds ratio of 0.01, (95% confidence interval, 0.01-0.03), P<0.001.
  
  
  CONCLUSIONS
  Three-dimensional stereotactic navigation based upon intraoperative computed tomography imaging offers markedly improved accuracy of percutaneous lumbar pedicle screw placement when used in the setting of MISS.
authors.affiliation: *Department of Radiology, University of Tennessee Graduate School of Medicine †Department of Radiology, University of Tennessee Medical Center, Knoxville, TN ‡Fluoroscopic Safety, LLC, Houston, TX §Department of Neurosurgery, Fort Sanders Regional Medical Center, Knoxville, TN.
authors.forename: Austin C
authors.initials: AC
authors.lastname: Bourgeois
authors.forename: Austin R
authors.initials: AR
authors.lastname: Faulkner
authors.forename: Yong C
authors.initials: YC
authors.lastname: Bradley
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Pasciak
authors.forename: Patrick B
authors.initials: PB
authors.lastname: Barlow
authors.forename: Judson R
authors.initials: JR
authors.lastname: Gash
authors.forename: William S
authors.initials: WS
authors.lastname: Reid
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D065289:Pedicle Screws; D013123:Spinal Fusion / Q000379:methods; D013238:Stereotaxic Techniques