Original ArticleRobotic Assistance for Minimally Invasive Cervical Pedicle Instrumentation: Report on Feasibility and Safety
Introduction
Posterior cervical spine fixation is a valuable surgical technique commonly performed to treat various degenerative, neoplastic, infectious, and traumatic conditions affecting the cervical spine. Most common screw fixation techniques include lateral mass, pedicle, intralaminar, and transfacet screws.1,2
Cervical transpedicular screw fixation (CTSF) offers more biomechanical stability than do other types of internal fixation, including lateral mass screw.3 However, CTSF placement is technically demanding, and the rate of screw malpositioning was reported as 6.7%–29.1% in conventional fluoroscopy procedures.4, 5, 6, 7 This procedure can be performed through an open or minimally invasive approach.
The fundamental aim of minimally invasive techniques is the reduction of approach-related morbidity secondary to muscle trauma, blood loss, and postoperative neck pain.8,9
Navigation techniques can also be used for CTSF. However, no previous reports have described the accuracy of CTSF using Cirq robotic assistance (Brainlab AG, Munich, Germany). in conjunction with intraoperative computed tomography (iCT) scan navigation via a minimally invasive approach.
We present our first experience using this technique for cervical and upper thoracic transpedicular screw fixation.
Section snippets
Patient Selection
We report a retrospective study carried out in our institution. Eligible patients were 18 years old or older, undergoing a complementary second-stage miniopen transpedicular screw instrumentation of the lower cervical and/or upper thoracic spine, for trauma, tumor, spondylodiscitis, or degenerative spinal diseases using intraoperative Airo computed tomography (CT) scan in conjunction with BrainLab curve navigation, Cirq robotic assistance (Brainlab AG, Munich, Germany).
All patients had
Patient Population
Between February 2020 and December 2020, 7 patients (4 men and 3 women) underwent miniopen transpedicular cervical spine screw instrumentation (Table 1).
The mean age was 58.8 years (range, 29–75 years). The mean body mass index was 24.8 kg/m2 (range, 17.1–38.05 kg/m2).
Five operations were performed for traumatic spine injury (71.4%), 1 for bone metastasis (14.3%), and 1 for infection (14.3%).
The mean surgical time was 115.7 minutes (range, 90–180 minutes). Mean blood loss was 292 mL.
Accuracy of Pedicle Screw Placement
Revision of
Discussion
The accuracy and technical advances in CTSF using the Cirq robotic assistance in conjunction with iCT scan navigation were investigated.
CTSF has more advantages than fixation through the spinous process, lamina, and anterior intervertebral plate, but because of anatomic complexity and possible severe complications, the application of CTSF has been limited.13
CTSF is an established technique for spinal stabilization and deformity correction. Its biomechanical advantages include increased bony
Conclusions
Posterior miniopen fixation using Cirq robotic assistance coupled with iCT navigation system is a major innovation that can improve the accuracy of pedicle screw positioning in the lower cervical and upper thoracic spine. The procedure is associated with acceptable patient radiation and reduced surgical team exposure. Future studies are needed to assess reproducibility, pedicle screw positioning, radiation exposure, and cost-effectiveness.
CRediT authorship contribution statement
Kaissar Farah: Conceptualization, Methodology, Writing - original draft, Writing - review & editing. Mikael Meyer: Conceptualization, Writing - original draft, Writing - review & editing. Solene Prost: Writing - original draft, Writing - review & editing. Faisal Albader: Writing - original draft, Writing - review & editing. Henry Dufour: Writing - review & editing. Benjamin Blondel: Writing - review & editing, Supervision. Stephane Fuentes: Conceptualization, Methodology, Writing - review &
References (35)
- et al.
Cervical pedicle screws vs. lateral mass screws: uniplanar fatigue analysis and residual pullout strengths
Spine J
(2007) - et al.
Does pedicle screw fixation of the subaxial cervical spine provide adequate stabilization in a multilevel vertebral body fracture model? An in vitro biomechanical study
Clin Biomech (Bristol, Avon)
(2018) - et al.
Prospective comparative study in spine surgery between O-arm and Airo systems: efficacy and radiation exposure
World Neurosurg
(2018) - et al.
Minimally invasive percutaneous C1-C2 fixation using an intraoperative three-dimensional imaging-based navigation system for management of odontoid fractures
World Neurosurg
(2020) - et al.
Posterior subaxial cervical spine screw fixation: a review of techniques
Global Spine J
(2018) - et al.
Minimally invasive cervical pedicle screw fixation via the posterolateral approach for metastatic cervical spinal tumors
Spine Surg Relat Res
(2017) - et al.
Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison
Spine (Phila Pa 1976)
(1997) - et al.
Complications of pedicle screw fixation in reconstructive surgery of the cervical spine
Spine (Phila Pa 1976)
(2000) - et al.
A multicenter study on accuracy and complications of freehand placement of cervical pedicle screws under lateral fluoroscopy in different pathological conditions: CT-based evaluation of more than 1,000 screws
Eur Spine J
(2014) - et al.
Clinical accuracy of three-dimensional fluoroscopy-based computer-assisted cervical pedicle screw placement: a retrospective comparative study of conventional versus computer-assisted cervical pedicle screw placement
J Neurosurg Spine
(2010)
The clinical risk of vertebral artery injury from cervical pedicle screws inserted in degenerative vertebrae
Spine (Phila Pa 1976)
Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience
Neurosurgery
Cervical laminoplasty: a critical review
J Neurosurg
Thoracic pedicle screws: postoperative computerized tomography scanning assessment
J Neurosurg
The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103
Ann ICRP
European Guidelines for Multislice Computed Tomography. 2004
Posterior stabilization of subaxial cervical spine trauma: indications and techniques
Injury
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.