Introduction: Several retrospective studies have demonstrated higher accuracy rates and increased safety for navigated pedicle screw placement compared to free-hand techniques; however, the accuracy differences between navigation systems has not been extensively studied. In some instances, three-dimensional (3D) fluoroscopic navigation methods have been reported to not be more accurate than two-dimensional (2D) navigation for pedicle screw placement. A systematic review was conducted to examine pedicle screw insertion accuracy using conventional fluoroscopy, 2D or 3D fluoroscopic image guidance systems.
Methods: A PubMed and Medline database search was conducted to review published literature that focused on the accuracy of pedicle screw placement using intraoperative, real-time fluoroscopic image guidance in spine fusion surgeries. Descriptive statistics were employed to compare the pedicle screw insertion accuracy rate differences between the navigation methods.
Results: A total of 39 studies were included in our analysis: 10 studies that utilized 2D fluoroscopic navigation, 24 studies that utilized 3D fluoroscopic navigation and 11 studies that utilized conventional fluoroscopy. These studies included 2,221 patients in which 10,876 pedicle screws were inserted in total. With conventional fluoroscopy 2,566 screws out of 3,699 screws were inserted accurately (69.4% accuracy). With 2D fluoroscopic navigation, 1,188 out of 1,386 screws were inserted accurately (85.7% accurate), and with 3D fluoroscopic navigation, 5,489 screws out of 5,791 screws were inserted accurately (94.8% accuracy). The accuracy rates with 3D compared to 2D fluoroscopic navigation were also consistently higher throughout all individual spinal levels.
Conclusions: Three-dimensional fluoroscopic image guidance systems demonstrated a significantly higher pedicle screw placement accuracy than conventional fluoroscopy or 2D fluoroscopic image guidance methods.
Patient Care: Improved accuracy in pedicle screw placement during spine surgeries will potentially reduce postoperative complication rates and improve the stability of the biomechanical construct.
Learning Objectives: 1. Demonstrate improved pedicle screw placement accuracy using 3D navigation
2. Demonstrate pedicle screw placement accuracy at different levels of the spine.