Citation: joseph s.Domino, md, mph, kyle a.Smith, md, and paul m.Arnold, md, facs, clinical and radiologic outcomes of thoracolumbar fusions using intraoperative ct guidance and stereotactic navigation in a spinal trauma population, clin spine surg, 2020.Summary: study design: retrospective review of prospectively collected single-institution database.Objective: to analyze the clinical and radiographic outcomes of posterior thoracolumbar fusions using intraoperative computed tomography (ct)-guidance and stereotactic navigation in thoracolumbar spinal trauma.Summary of background data: pedicle screw instrumentation is utilized for stabilization in thoracolumbar fusions.Suboptimal placement may lead to neurovascular complications, pseudarthrosis, postoperative pain, and the need for revision surgery.Image- guided spinal surgery is commonly used to improve accuracy, particularly for complex anatomy such as encountered with traumatic fractures.Methods: we retrospectively identified 58 patients undergoing posterior thoracolumbar fusions using intraoperative ct and stereotactic navigation for traumatic fractures from 2010 to 2017 at a single institution.Pedicle screw accuracy, realignment, clinical outcomes, and ease of use were retrospectively reviewed.Accuracy was assessed on post-placement or postoperative ct.Breach grades included: grade 1 (< 2 mm), grade 2 (2¿4 mm), and grade 3 (> 4 mm).Results: a total of 58 patients were identified having undergone 58 operations, which involved placement of 519 pedicle screws.Traumatic fracture patterns and levels of injury were varied.Accurate pedicle screw placement was found in 95.8% and was stable over time.Breach included: grade 1 in 19 screws, grade 2 in 2 screws, and grade 3 in 1 screw.No neurovascular complications were noted.No revision surgery was performed for misplacement.A subgroup of 6 ankylosing spondylitis patients were identified having undergone 6 operations with 63 pedicle screws.Accurate pedicle screw placement was found in 93.7%.Conclusion: intraoperative ct-guidance and stereotactic navigation can overcome the difficulty associated with thoracolumbar trauma resulting in complex anatomy with malalignment and unpredictable trajectories.Intraoperative ct can be used with stereotactic guidance or for intraoperative verification of free-hand screw placement with repositioning as needed.Ct-guidance maintains the benefit of reduced fluoroscopic exposure while improving accuracy of instrumentation and reducing reoperation for screw malposition.Reported event: 1.Two screws were grade ii and one screw was grade iii.Due to the availability to obtain immediate post-placement ct, all three of the screws with grade ii or iii breaches were identified intraoperatively, and the screws were repositioned, thereby avoiding potential revision surgery.2.No neurovascular complications occurred in the 59 operations.Alignment was restored in all patients based on assessment of post operative ct imaging.No immediate revision surgery was performed for misplacement of screws.Complication rates were low, with infection occurring in two patients (3.4%) and pseudarthrosis in four patients (6.9% of cases).The cases of pseudarthrosis were identified during routine follow-up as the facility's standard practice was to obtain plain radiographs at follow-up appointments until evidence of advanced fusion was observed.Imaging evidence of pseudarthrosis was seen on plain radiograph in three patients and on ct in a fourth patient who was having recurrent back pain.The median length of follow-up was 12 months.
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