title: Total Navigation in Spine Surgery; A Concise Guide to Eliminate Fluoroscopy Using a Portable Intraoperative Computed Tomography 3-Dimensional Navigation System.
abstract: BACKGROUND
  Portable intraoperative computed tomography (iCT) with integrated 3-dimensional navigation (NAV) offers new opportunities for more precise navigation in spinal surgery, eliminates radiation exposure for the surgical team, and accelerates surgical workflows. We present the concept of "total navigation" using iCT NAV in spinal surgery. Therefore, we propose a step-by-step guideline demonstrating how total navigation can eliminate fluoroscopy with time-efficient workflows integrating iCT NAV into daily practice.
  
  
  METHODS
  A prospective study was conducted on collected data from patients undergoing iCT NAV-guided spine surgery. Number of scans, radiation exposure, and workflow of iCT NAV (e.g., instrumentation, cage placement, localization) were documented. Finally, the accuracy of pedicle screws and time for instrumentation were determined.
  
  
  RESULTS
  iCT NAV was successfully performed in 117 cases for various indications and in all regions of the spine. More than half (61%) of cases were performed in a minimally invasive manner. Navigation was used for skin incision, localization of index level, and verification of implant position. iCT NAV was used to evaluate neural decompression achieved in spinal fusion surgeries. Total navigation eliminates fluoroscopy in 75%, thus reducing staff radiation exposure entirely. The average times for iCT NAV setup and pedicle screw insertion were 12.1 and 3.1 minutes, respectively, achieving a pedicle screw accuracy of 99%.
  
  
  CONCLUSIONS
  Total navigation makes spine surgery safer and more accurate, and it enhances efficient and reproducible workflows. Fluoroscopy and radiation exposure for the surgical staff can be eliminated in the majority of cases.
authors.affiliation: Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Navarro-Ramirez
authors.affiliation: Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA; Department of Orthopedic and Trauma Surgery, Freiburg University Medical Center, Freiburg, Germany.
authors.forename: Gernot
authors.initials: G
authors.lastname: Lang
authors.affiliation: Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Xiaofeng
authors.initials: X
authors.lastname: Lian
authors.affiliation: Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Connor
authors.initials: C
authors.lastname: Berlin
authors.affiliation: Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
authors.forename: Insa
authors.initials: I
authors.lastname: Janssen
authors.affiliation: Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Ajit
authors.initials: A
authors.lastname: Jada
authors.affiliation: Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA.
authors.forename: Marjan
authors.initials: M
authors.lastname: Alimi
authors.affiliation: Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA. Electronic address: roger@hartlmd.net.
authors.forename: Roger
authors.initials: R
authors.lastname: Härtl
mesh_terms: D000368:Aged; D005260:Female; D005471:Fluoroscopy / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000295:instrumentation / Q000379:methods*; D064795:Intraoperative Neurophysiological Monitoring / Q000295:instrumentation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D038361:Neuronavigation / Q000295:instrumentation / Q000379:methods*; D019635:Neurosurgical Procedures / Q000295:instrumentation / Q000379:methods; D056888:Patient Positioning / Q000379:methods; D065289:Pedicle Screws; D011446:Prospective Studies; D013122:Spinal Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D025321:Surgery, Computer-Assisted / Q000295:instrumentation / Q000379:methods; D014057:Tomography, X-Ray Computed / Q000295:instrumentation / Q000379:methods*
keywords: Computed tomography; Fusion; Minimally invasive spine surgery; Navigation; Neural decompression; Spine