Neuronavigation in the Minimally Invasive Presacral Approach for Lumbosacral Fusion

Abstract

Introduction: Intraoperative 3D navigation (3D NAV) is gaining importance in spinal surgery, especially with the advancement of minimally invasive techniques in this field. We hypothesized that 3D NAV may be of benefit in the recently described minimally invasive presacral approach for L4-S1 fusion (AxiaLIF).

Methods: Five patients with refractory low back pain and L5-S1 degenerative disease underwent 3D NAV-assisted placement of a presacral L5-S1 screw. Additionally, a patient recently underwent a two-level AxiaLIF procedure (L4-S1) which was also performed with 3D NAV. Navigation was performed by acquiring intraoperative images via isocentric fluoroscopy and utilizing frameless stereotaxy. Accuracy of 3D NAV was confirmed by overlapping intraoperative images, navigation screenshots, and postoperative CT scans. Outcome was determined by pre- and postoperative VAS (back and leg pain) and ODI.

Results: Operative results were reviewed for all six patients and clinical outcomes were retrospectively reviewed for the five L5-S1 procedure patients. Postoperative imaging demonstrated accurate screw placement in comparison to intraoperative C-arm imaging and navigation imaging in all patients. No perioperative complications were encountered. In the five one-level patients, mean VAS (for back and leg pain) and ODI improved significantly at most recent follow-up.

Conclusion: The minimally invasive presacral approach to L4-L5-S1 fusion can be performed safely and accurately with intraoperative 3D NAV. This is especially the case in two-level AxiaLIF procedures, where computer guidance can provide better planning possibilities for optimal screw trajectory.

Key words

lumbar fusion - minimally invasive spine - pedicle screws - axiaLIF - transsacral screw

References

• 1 Marotta N, Cosar M, Pimenta L. et al . A novel minimally invasive presacral approach and instrumentation technique for anterior L5-S1 intervertebral discectomy and fusion: technical description and case presentations.  Neurosurg Focus. 2006;  20 E9
• 2 Yuan PS, Day TF, Albert TJ. et al . Anatomy of the percutaneous presacral space for a novel fusion technique.  J Spinal Dis Techn. 2006;  19 237-241
• 3 Fraser JF, et al. . Iso-C/3D Neuronavigation versus conventional fluoroscopy for minimally invasive pedicle screw placement in lumbar fusion: prospective comparison of screw placement.  Spine. 2009;  , in print
• 4 Laine T, Schlenzka D, Makitalo K. et al . Improved accuracy of pedicle screw insertion with computer-assisted surgery.  A prospective clinical trial of 30 patients. , Spine 1997;  22 1254-1258
• 5 Nolte L, Zamorano L, Arm E. et al . Image-guided computer-assisted spine surgery: a pilot study on pedicle screw fixation.  Stereotact Funct Neurosurg. 1996;  66 108-117
• 6 Richter M, Mattes T, Cakir B. Computer-assisted posterior instrumentation of the cervical and cervico-thoracic spine.  , [see comment]. Eur Spine J. 2004;  13 50-59
• 7 Austin MS, Vaccaro AR, Brislin B. et al . Image-guided spine surgery: a cadaver study comparing conventional open laminoforaminotomy and two image-guided techniques for pedicle screw placement in posterolateral fusion and nonfusion models.  Spine. 2002;  27 2503-2508
• 8 Laine T, Lund T, Ylikoski M. et al . Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients.  , [see comment]. Eur Spine J. 2000;  9 235-240
• 9 Merloz P, Tonetti J, Pittet L. et al . Pedicle screw placement using image guided techniques.  Clin Orthop Rel Res. 1998;  39-48
• 10 Richter M, Cakir B, Schmidt R. Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws.  Spine. 2005;  30 2280-2287
• 11 Villavicencio AT, Burneikiene S, Bulsara KR. et al . Utility of computerized isocentric fluoroscopy for minimally invasive spinal surgical techniques.  J Spinal Dis Techn. 2005;  18 369-375
• 12 Rajasekaran S, Vidyadhara S, Ramesh P. et al . Randomized clinical study to compare the accuracy of navigated and non-navigated thoracic pedicle screws in deformity correction surgeries.  Spine. 2007;  32 E56-E64
• 13 Laufer I, Greenfield JP, Anand VK. et al . Endonasal endoscopic resection of the odontoid process in a nonachondroplastic dwarf with juvenile rheumatoid arthritis: feasibility of the approach and utility of the intraoperative Iso-C three-dimensional navigation.  J Neurosurg Spine. 2008;  8 376-380
• 14 Hott JS, Papadopoulos SM, Theodore N. et al . Intraoperative Iso-C C-arm navigation in cervical spinal surgery: review of the first 52 cases.  Spine. 2004;  29 2856-2860

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