J Korean Neurosurg Soc.  2020 Mar;63(2):237-247. 10.3340/jkns.2019.0172.

Comparative Analysis of Surgical Outcomes of C1–2 Fusion Spine Surgery between Intraoperative Computed Tomography Image Based Navigation-Guided Operation and Fluoroscopy-Guided Operation

• Lee JS
• Son DW
• Lee SH
• Ki SS
• Lee SW
• Song GS

• KMID: 2501710
• DOI: http://doi.org/10.3340/jkns.2019.0172

Abstract

Objective
: Fixation of the C1–2 segment is challenging because of the complex anatomy in the region and the need for a high degree of accuracy to avoid complications. Preoperative 3D-computed tomography (CT) scans can help reduce the risk of complications in the vertebral artery, spinal cord, and nerve roots. However, the patient may be susceptible to injury if the patient’s anatomy does not match the preoperative CT scans. The intraoperative 3D image-based navigation systems have reduced complications in instrument-assisted techniques due to greater accuracy. This study aimed to compare the radiologic outcomes of C1–2 fusion surgery between intraoperative CT image-guided operation and fluoroscopy-guided operation.
Methods
: We retrospectively reviewed the radiologic images of 34 patients who underwent C1–2 fusion spine surgery from January 2009 to November 2018 at our hospital. We assessed 17 cases each of degenerative cervical disease and trauma in a study population of 18 males and 16 females. The mean age was 54.8 years. A total of 139 screws were used and the surgical procedures included 68 screws in the C1 lateral mass, 58 screws in C2 pedicle, nine screws in C2 lamina and C2 pars screws, four lateral mass screws in sub-axial level. Of the 34 patients, 19 patients underwent screw insertion using intraoperative mobile CT. Other patients underwent atlantoaxial fusion with a standard fluoroscopy-guided device.
Results
: A total of 139 screws were correctly positioned. We analyzed the positions of 135 screws except for the four screws that performed the lateral mass screws in C3 vertebra. Minor screw penetration was observed in seven cases (5.2%), and major pedicle screw penetration was observed in three cases (2.2%). In one case, the malposition of a C2 pedicle screw was confirmed, which was subsequently corrected. There were no complications regarding vertebral artery injury or onset of new neurologic deficits. The screw malposition rate was lower (5.3%) in patients who underwent intraoperative CT-based navigation than that for fluoroscopy-guided cases (10.2%). And we confirmed that the operation time can be significantly reduced by surgery using intraoperative O-arm device.
Conclusion
: Spinal navigation using intraoperative cone-beam CT scans is reliable for posterior fixation in unstable C1-2 pathologies and can be reduced the operative time.

Keyword

Cervical vertebrae; Arthrodesis; Dimensional measurement accuracy; Atlanto-axial joint

Figure

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  Fig. 1. Schematic flow chart for the choice of the C2 vertebral screws. Va : vertebral artery.

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  Fig. 2. Change in surgery results according to the accumulation of experience. a : In the C-arm group, the estimated blood loss varied widely from case to case and the trend line of the operative time did not change much with time. B : In the O-arm group, the trend line of the operative time shows a decrease and estimated blood loss is stabilized to a certain level with the increase in the number of surgical cases. EBL : estimated blood loss, OP : operative time.

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  Fig. 3. Cases presentation. a : Preoperative CT images of the C2 vertebra showing C1/2 right facet arthropathy with severe sclerotic change (red arrow). B : Preoperative MRI image showing diffuse soft tissue lesion (pannus) around the odontoid process with enhancement. C : With intraoperative CT, we confirmed that the right C2 pedicle screw had invaded into the spinal canal; the right C2 pedicle screw was removed and alternative C2 laminar screw was inserted . CT : computed tomography, MRI : magnetic resonance imaging.

Reference

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