Robot-assisted minimally invasive transforaminal lumbar interbody fusion in treatment of lumbar degenerative diseases / 中国组织工程研究

BACKGROUND:Minimally invasive surgery is developing rapidly.Robot-assisted minimally invasive transforaminal lumbar interbody fusion and robot-assisted unilateral biportal endoscopic transforaminal/posterior lumbar interbody fusion are important posterior minimally invasive surgical approaches to treat lumbar degenerative diseases.However,it is worth discussing which operation method is more advantageous. OBJECTIVE:To compare the clinical efficacy and imaging examination between different operation groups,and discuss the clinical application value of robot-assisted minimally invasive lumbar posterior fusion technology to treat lumbar degenerative diseases. METHODS:Clinical data of 83 patients with lumbar degenerative diseases from January 2018 to June 2022 at the Department of Orthopedics,Sichuan Academy of Medical Sciences&Sichuan Provincial People's Hospital were retrospectively analyzed.Of them,27 patients received robot-assisted minimally invasive transforaminal lumbar interbody fusion treatment(group A);30 patients received robot-assisted unilateral biportal endoscopic transforaminal/posterior lumbar interbody fusion treatment(group B),and 26 traditional minimally invasive transforaminal lumbar interbody fusion patients were selected as the control group(group C).There were no significant differences in gender,age,body mass index,surgical segment,preoperative visual analog scale score and Oswestry Disability Index among the three groups(P＞0.05).The operation time,intraoperative blood loss,complications,fluoroscopic dose,fluoroscopic time,and fluoroscopic frequency were compared among the three groups.Gertzbein-Robbins'classification was used to evaluate the accuracy of percutaneous pedicle screw.Visual analog scale and Oswestry Disability Index scores were evaluated after surgery.The excellent and good rate of the three surgical options was evaluated using Macnab's criteria. RESULTS AND CONCLUSION:(1)The operation time of group A was significantly shorter than that of groups B and C(P＜0.05),but there was no significant difference between group B and group C(P＞0.05).The intraoperative blood loss in group B was significantly less than that in group A,and that in group A was significantly less than that in group C(P＜0.05).(2)The fluoroscopic dose,fluoroscopic time,and fluoroscopic frequency of group C were significantly higher than those of groups A and B(P＜0.05).(3)Visual analog scale score and Oswestry Disability Index in the three groups significantly improved after operation when compared with that before operation(P＜0.05),but there was no significant difference among the three groups 1 day and 6 months after surgery(P＞0.05).(4)Postoperative imaging showed that the accuracy of percutaneous pedicle screw placement in groups A and B was better than that in group C(P＜0.05).(5)There was no significant difference in the excellent and good rate of MacNab criteria among the three groups(P＞0.05).(6)There was no significant difference in complications among the three groups(P＞0.05).(7)The results indicated that robot-assisted minimally invasive transforaminal lumbar interbody fusion and robot-assisted unilateral biportal endoscopic transforaminal/posterior lumbar interbody fusion are effective surgery methods for lumbar degenerative diseases.Compared with traditional minimally invasive transforaminal lumbar interbody fusion,robot-assisted minimally invasive transforaminal lumbar interbody fusion surgery has higher efficiency,less intraoperative radiation and higher internal fixation accuracy,which has a good clinical application value.

Stage Ⅲ Kümmell's disease treated with injured-vertebra screw placement combined with transpedicular impaction bone grafting:quick restoration of spinal stability / 中国组织工程研究

BACKGROUND:Stage Ⅲ Kümmell's disease is characterized by a high degree of vertebral compression and posterior wall defects.Most of the patients are elderly people with severe osteoporosis and various medical diseases.Clinically,some surgical methods are often at high risk and are controversial. OBJECTIVE:To investigate the clinical efficacy of screw placement combined with transpedicular impaction bone grafting in the treatment of stage Ⅲ Kümmell's disease. METHODS:The clinical data of injured vertebral screw placement combined with transpedicular impaction bone grafting in treatment of stage Ⅲ Kummell's disease from May 2016 to August 2021 were retrospectively analyzed.Visual analog scale score,Oswestry disability index,anterior vertebral heights,kyphotic Cobb angle and American Spinal Injury Association(ASIA)impairment scale were used to evaluate the effects of surgery.The operation time,intraoperative blood loss and complications were recorded.CT scans were used to evaluate the healing of injured vertebrae at the final follow-up visit. RESULTS AND CONCLUSION:(1)A total of 26 patients were included,with 7 males and 19 females,at the age range of 62-81 years[mean(69.7±4.8)years].The follow-up time was 18-60 months[mean(35.1±8.9)months].The average operative duration was 133.5 minutes(100-165 minutes),and the average intraoperative blood loss was 285.3 mL(210-350 mL).(2)Visual analog scale and Oswestry disability index scores 1 week after surgery were significantly lower than those before surgery.(3)At 1 week after surgery,the anterior vertebral height corrections and the Cobb angle were(9.0±0.7)mm and(16.2±1.0)°,respectively.During the follow-up period,the loss of vertebral height and kyphosis correction were(5.1±0.3)mm and(8.0±0.4)°,respectively.(4)14 patients(54%)had ASIA grade D before operation,which recovered to grade E at the last follow-up.CT scan showed that all patients achieved good osseous union.(5)Complications occurred in seven patients(27%),including hypostatic pneumonia in two cases,postoperative superficial wound tissue liquefaction in two cases,and adjacent vertebral compression fractures in three cases.(6)It is concluded that screw placement of the injured vertebra combined with transpedicular impaction bone grafting can rapidly rebuild spinal stability,effectively relieve pain and improve neurological function in the treatment of stage Ⅲ Kümmell's disease.This technique is an effective and relatively minimally invasive surgical option.

Accuracy of sacroiliac screw placement in robot-assisted navigation / 中国组织工程研究

BACKGROUND:Orthopedic robots have been widely used in clinical practice,and relevant reports have shown that they have many advantages such as minimal trauma and short surgical time.However,there is currently no clear report on how accurate they are. OBJECTIVE:To evaluate the accuracy of robot-assisted sacroiliac screw insertion. METHODS:A total of 131 patients with sacroiliac joint fracture and dislocation and sacral fracture admitted to the Department of Trauma Surgery,Gansu Provincial Hospital from January 2020 to April 2023 were retrospectively collected,including 131 S1 screws and 46 S2 screws,totaling 177 screws.They were divided into two groups based on whether robot-assisted navigation was performed.There were 63 cases of sacroiliac screws inserted under robot-assisted navigation(observation group),with 36 males and 27 females,aged 19-72 years,with a mean age of(45.3±17.6)years.Among them,39 cases were fixed with only S1 screws,while 24 cases were fixed with S1S2 screws,resulting in a total of 87 sacroiliac screws.Under C-arm fluoroscopy,68 cases of sacroiliac screws were inserted with bare hands(control group),including 41 males and 27 females,aged 23-67 years,with a mean age of(42.6±21.3)years.Among them,46 cases were fixed with simple S1 screws,while 22 cases were fixed with S1S2 screws,resulting in a total of 90 sacroiliac screws.A postoperative CT scan was performed to evaluate the number of S1 screws,S2 screws,total screw level,and calculate accuracy based on the method introduced by SMITH et al. RESULTS AND CONCLUSION:(1)In the observation group,62 S1 screws were accurately placed(62/63),with an accuracy rate of 98%.24 S2 screws were accurately placed(24/24),with an accuracy rate of 100%.The total number of screws accurately placed was 86(86/87),with an accuracy rate of 99%.(2)In the control group,58 S1 screws were accurately inserted(58/68),with an accuracy rate of 85%.19 S2 screws were accurately inserted(19/22),with an accuracy rate of 86%.The total number of screws accurately inserted was 77(77/90),with an accuracy rate of 86%.(3)There was a statistically significant difference in the accuracy of the S1 screw,S2 screw,and total screw between the two groups(P<0.05).It is suggested that the placement of sacroiliac screws under robot navigation has higher accuracy compared to manual placement under C-arm fluoroscopy,but still has a lower error rate in placement.

Finite element method predicts the effect of screw placement position in anterior cervical discectomy and fusion on stability of internal fixation / 中国组织工程研究

BACKGROUND:The angle of screw placement in anterior cervical discectomy and fusion plays a crucial role in determining the stability of the internal fixation system. OBJECTIVE:To predict the impact of different screw placement angles on the stress experienced by the internal fixation system in anterior cervical discectomy and fusion utilizing finite element analysis,with the ultimate goal of identifying the optimal screw placement angle. METHODS:A three-dimensional reconstruction method was employed to establish a mechanical model of the cervical spine,enabling the simulation of three distinct working conditions:scoliosis,uprightness,and forward flexion.In SolidWorks 2017,the anterior cervical plate and screw models were built according to different placement angles of the screws,with a as the inward offset,b as the ideal position,c as the outward offset,d as the downward offset,and e as the upward offset.The stress distribution of internal fixation system at different screw placement angles was observed,and the stress and displacement were recorded. RESULTS AND CONCLUSION:(1)By constructing a finite element model of the entire cervical spine and incorporating an anterior titanium plate,it was found that the biomechanical changes in the spine did not significantly differ based on the various angles of screw insertion on the titanium plate under the same working conditions.(2)However,microscopic analysis revealed that the outward offset(c)screw position exhibited the most effective resistance against side bending,while the downward offset(d)screw demonstrated optimal load-bearing capacity in the upright condition.Additionally,the outward deviation(c)screw displayed superior anti-bending effects in the reverse buckling condition.(3)The fixation effect of the internal fixation device remained relatively stable across different motion conditions.Although there was a 10％variation in the internal fixation effect under the three working conditions when the screw was placed inward,outward,downward,or upward,the displacement changes were minimal.These findings suggest that the requirements of load bearing,bending resistance,and flexion resistance could be simultaneously met without a specific optimal screw location in clinical practice.(4)The placement direction of titanium plate screw in anterior cervical disc-resection and fusion has little effect on the mechanical stability of the cervical spine.The screw angles in different directions have little influence on the stability of the internal fixation device in the lateral,upright,and forward flexion movements of the cervical spine.There is no need to pursue the direction of screw placement in clinical operations.

Robot-assisted pedicle screw internal fixation in treatment of atlantoaxial dislocation / 中国组织工程研究

BACKGROUND:Atlantoaxial dislocation,because of its high difficulty and high risk of surgery,has been regarded as the"surgical restricted area"by the international orthopedic community.However,with the rapid development of intelligent digitization in orthopedics,robot-assisted navigation screw placement technology has been widely used in clinical practice,which significantly reduces the difficulty and risk of surgery and improves the safety of surgery.However,there are few reports on the application of this technique in the treatment of atlantoaxial dislocation. OBJECTIVE:To explore the application value of robot-assisted pedicle screw internal fixation in the treatment of atlantoaxial dislocation. METHODS:The medical records of five patients with atlantoaxial dislocation treated with C1-C2 pedicle screw fixation under robot-assisted navigation in Zhuhai Hospital of Guangdong Provincial Hospital of Chinese Medicine from October 2021 to July 2022 were retrospectively analyzed.Operation time,length of neck incision,blood loss,postoperative drainage volume,and length of hospital stay were recorded.Attention should be paid to cerebrospinal fluid leakage,vertebral artery injury,nerve injury,operative area infection and other complications.The visual analog scale score of neck pain,the spinal cord injury grade of the American Spinal Injury Association,the cervical spine score of the Japanese Orthopaedic Association,and the imaging indicators were collected before surgery and at the last follow-up.Screw placement accuracy was assessed. RESULTS AND CONCLUSION:(1)Five patients were successfully completed surgery,without vascular,nerve injury or other complications,and were followed up for 12-20 months.(2)A total of 20 cervical pedicle screws were placed in 5 patients,including 9 type A screws,10 type B screws,and 1 type C screw.The accuracy of screw placement was 95%.(3)At the last follow-up,the visual analog scale score was(0.80±0.71)points,which was significantly lower than that before operation(4.00±2.83)points;the Japanese Orthopaedic Association score was(14.80±0.84)points,which was significantly higher than that before operation(8.00±0.71)points.Anterior atlantodental interval decreased from(7.86±3.25)mm to(2.82±0.93)mm;space available of the spinal cord increased from(6.74±1.99)mm to(12.10±3.51)mm;cervicomedullary angle increased from(133.32±13.55)° to(153.44±9.53)°;clivus-canal angle increased from(128.02±9.92)° to(143.25±12.99)°.The results of the last follow-up indexes were improved compared with those before operation,and the differences were significant(all P<0.05).(4)Postoperative imaging follow-up showed that all patients had bone fusion in the bone graft area,and no internal fixation loosening,fracture or pull-out occurred.(5)This method can avoid relying on the doctor's experience and hand feeling,ensure the accuracy of upper cervical screw placement,reduce the risk of surgery,and obtain satisfactory results in mid-term follow-up.

Study on the accuracy of cervical pedicle screw placement assisted with improved 3D-printed drill guiding template / 中国脊柱脊髓杂志

Objectives:To explore the accuracy of pedicle screw placement assisted with improved 3D-print-ed drill guiding template in cervical spine.Methods:The clinical data of 60 patients undergone posterior cervical pedicle screw placement in our hospital between January 2016 and January 2023 were analyzed retro-spectively,including 30 males and 30 females with an average age of 17-84 years(58.7±13.8 years).The pa-tients were divided into guiding template group and free-hand group based on whether the guiding template was used to assist the placement of screws or not.The improved 3D-printed guiding template was used to assist cervical pedicle screw placement in the guiding template group(n=30),and the self-made angular-ruler was used in the free-hand group(n=30).There was no significant difference in age,gender ratio,and preoper-ative diagnosis between the two groups(P＞0.05).Cervical CT scan was performed at one week after surgery,and the accuracy of pedicle screw placement was evaluated according to the Kaneyama standard:Grade 0,the screw was completely in the pedicle;Grade 1,the size of screw penetrating the cortex＜50%of the screw diameter;Grade 2,the size of screw penetrating the cortex≥50%of the screw diameter but not com pletely out;Grade 3,the screw was completely on the outside of the pedicle.The accuracy of pedicle screw placement(ratio of grades 0 and 1)and complications such as vascular and nerve injury,incision infection,cerebrospinal fluid leakage,screw loosening and breakage caused by screw misplacement were recorded.Re-sults:A total of 152 pedicle screws were placed in the guiding template group,including 74 screws of grade 0,68 of grade 1,10 of grade 2 and 0 of grade 3,with an accuracy of screw placement of 93.4%.A total of 136 pedicle screws were placed in free-hand group,including 53 screws of grade 0,61 of grade 1,18 of grade 2 and 4 of grade 3,with an accuracy of screw placement of 83.8%.The accuracy of screw placement in the guiding template group was significantly higher than that in the free-hand group(P＜0.05).There were no related complications such as vascular and nerve injury,incision infection and cerebrospinal fluid leakage caused by misplacement of pedicle screws.The patients were followed up for 5-29 months(14.2±7.7months),and there were no complications such as screw loosening or breakage.Conclusions:Improved 3D-printed drill guiding template can improve the accuracy of pedicle screw placement in cervical spine.

Meta-analysis of clinical efficacy of robot-assisted pedicle screw placement for the treatment of thoracolumbar vertebral fractures / 中国医学装备

Objective:To analyze and compare the clinical efficacy of robot-assisted and conventional navigation-assisted percutaneous minimally invasive pedicle screw placement in the treatment of thoracolumbar fractures and to provide reference for clinical treatment decisions.Methods:A literature search was performed in China National Knowledge Infrastructure(CNKI),VIP,Wanfang and English databases PubMed and Web of science by using the keywords"vertebral pedicle screws,"and"robot"in Chinese and"robot"and"pedicle screws"in English.The search time in both Chinese and English was from the establishment of the database to December 2022.The relevant clinical studies on robot-assisted and traditional navigation-assisted percutaneous minimally invasive pedicle screw placement for the treatment of thoracolumbar cone fractures were collected.Cochrane Scale and Newcastle-Ottawa Scale(NOS)were used to evaluate the quality of literatures and meta-analysis was carried out.The clinical effects of robot-assisted and traditional navigation-assisted surgery was compared.Results:A total of 15 articles were included in the study.Compared with traditional navigation-assisted percutaneous minimally invasive pedicle screw placement,robotic-assisted surgery resulted in shorter operative time[WMD=-11.45,95% CI(-18.94～-3.95),P＜0.05],less intraoperative bleeding[WMD=-19.11,95% CI(-27.51～-10.70),P<0.001],higher screw placement accuracy[number of grade A nails:RR=1.20,95% CI(1.16～1.25),P<0.001;number of grade A+B nails:RR=1.09,95% CI(1.07～1.11),P<0.001],and fewer complications[RR=0.35,95% CI(0.13～0.93),P＜0.05].The difference in hospitalization time was not statistically significant(P>0.05).Conclusion:In percutaneous minimally invasive pedicle screw placement for the treatment of thoracolumbar fractures,robot-assisted surgery has advantages over navigation-assisted surgery in terms of operative time,intraoperative bleeding,placement accuracy and complications.

Comparison of screw placement guided by O-arm navigation and ultrasound volume navigation in minimally invasive transforaminal lumbar interbody fusion / 中国修复重建外科杂志

OBJECTIVE@#To compare the effectiveness of O-arm navigation and ultrasound volume navigation (UVN) in guiding screw placement during minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery.@*METHODS@#Sixty patients who underwent MIS-TLIF surgery for lumbar disc herniation between June 2022 and June 2023 and met the selection criteria were included in the study. They were randomly assigned to group A (screw placement guided by UVN during MIS-TLIF) or group B (screw placement guided by O-arm navigation during MIS-TLIF), with 30 cases in each group. There was no significant difference in baseline data, including gender, age, body mass index, and surgical segment, between the two groups ( P>0.05). Intraoperative data, including average single screw placement time, total radiation dose, and average single screw effective radiation dose, were recorded and calculated. Postoperatively, X-ray film and CT scans were performed at 10 days to evaluate screw placement accuracy and assess facet joint violation. Pearson correlation and Spearman correlation analyses were used to observe the relationship between the studied parameters (average single screw placement time and screw placement accuracy grading) and BMI.@*RESULTS@#The average single screw placement time in group B was significantly shorter than that in group A, and the total radiation dose of single segment and multi-segment and the average single screw effective radiation dose in group B were significantly higher than those in group A ( P<0.05). There was no significant difference in the total radiation dose between single segment and multiple segments in group B ( P>0.05), while the total radiation dose of multiple segments was significantly higher than that of single segment in group A ( P<0.05). No significant difference was found in the accuracy of screw implantation between the two groups ( P>0.05). In both groups, the grade 1 and grade 2 screws broke through the outer wall of the pedicle, and no screw broke through the inner wall of the pedicle. There was no significant difference in the rate of facet joint violation between the two groups ( P>0.05). In group A, both the average single screw placement time and screw placement accuracy grading were positively correlated with BMI ( r=0.677, P<0.001; r=0.222, P=0.012), while in group B, neither of them was correlated with BMI ( r=0.224, P=0.233; r=0.034, P=0.697).@*CONCLUSION@#UVN-guided screw placement in MIS-TLIF surgery demonstrates comparable efficiency, visualization, and accuracy to O-arm navigation, while significantly reducing radiation exposure. However, it may be influenced by factors such as obesity, which poses certain limitations.

Comparison of clinical efficacies between cortical bone trajectory screw and pedicle screw fixation techniques under robot-assisted technology in posterior lumbar short-segment decompression and fu-sion / 中国脊柱脊髓杂志

Objectives:To compare the clinical efficacy between robot-assisted cortical bone trajectory screw(RCBTS)and robot-assisted pedicle screw(RPS)for patients with lumbar spinal stenosis(LSS)undergoing sin-gle-level decompression and fusion.Methods:In this retrospective cohort study,LSS patients who underwent robot-assisted single-level decompression and fusion in Beijing Shijitan Hospital between June 2020 and June 2022 were reviewed.A total of 99 patients were included and divided into RCBTS group of 41 patients and RPS group of 58 patients.There were 59 males and 40 females,with an average age of 67.07±4.65 years old.The incision length,operative time,intraoperative blood loss,24h postoperative drainage,and postopera-tive hospital stay were compared between groups.The Japanese Orthopaedic Association(JOA)score and visual analogue scale(VAS)of low back pain were compared at 3d,3 months and 6 months after operation,and the fixed effects of JOA score and VAS score changes were tested.The screw positions were graded according to the Gertzbein-Robbins method.The accuracy of screw placement of the two surgical methods was evaluated by reviewing the postoperative imaging data.The perioperative and postoperative 3 months of complications were compared between the two groups.Results:There were no significant differences in baseline data be-tween the two groups(P＜0.05).Comparing with the RPS group,the RCBTS group was shorter in operative time(134.39±22.23min vs 152.93±19.10min,P＜0.001),smaller in incision length(64.93±3.71mm vs 78.84±3.82mm,P＜0.001),less in intraoperative blood loss(155.61±37.15mL vs 172.41±43.22mL,P=0.001)and postoperative drainage within 24h(83.66±21.54mL vs 101.21±29.80mL,P=0.002),and shorter in postoperative hospital stay(4.90±1.26d vs 6.26±1.66d,P＜0.001),with statistical significance.There was no significant difference in JOA score and VAS score changes between the two groups at each time point(P＞0.05).The fixed effect test showed that time was a fixed effect of JOA and VAS score changes(P＜0.001).The RCBTS group was no sig-nificantly different from the RPS group in the accuracy of screw placement(grade A:152/164 vs 211/232,P=0.538;grade B:9/164 vs 15/232,P=0.688;grade C:3/164 vs 6/232,P=0.619),the rate of clinically accept-able screw placement(161/164 vs 226/232,P=0.619),the rate of bad screw placement(3/164 vs 6/232,P=0.619),and the incidence of postoperative complications(only 1 patient in the RCBTS group developed delayed wound healing)(P＞0.05).Conclusions:Compared with RPS,RCBTS has significant advantages in operative time,incision length,intraoperative blood loss,volume of postoperative drainage,and postoperative hospital stay.However,there is no significant difference between the two groups in terms of postoperative functional recovery and alleviation in low back pain.

Clinical effects of robot-assisted minimal invasive transforaminal lumbar interbody fusion in the treatment of single-segment lumbar disc herniation / 西安交通大学学报(医学版)

【Objective】 To compare the clinical effects and screw placement accuracy for treating lumbar disc herniation between robot-assisted minimal invasive transforaminal lumbar interbody fusion (RA-MIS-TLIF) and minimal invasive transforaminal lumbar interbody fusion (MIS-TLIF). 【Methods】 We retrospectively recruited 69 patients with single segment lumbar disc herniation treated between January 2018 and August 2019 at Honghui Hospital of Xi’an Jiaotong University. There were cases of 33 RA-MIS-TLIF (RA group) and 36 MIS-TLIF (MIS-TLIF group). Subsequently, the patients’ baseline characteristics were collected, including age, gender, body mass index, complication with diabetes, duration of symptoms, operated segment, and follow-up time. We also collected perioperative parameters such as operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, screw placement accuracy, wound drainage, hospitalization duration, postoperative complicatins, and fusion rate. Lower back pain, lower extremity pain visual analogue score (VAS), and lumbar Japanese Orthopaedic Association Scores (JOA) were obtained preoperatively, postoperative 3 days/6 months/12 months, and the last follow-up. 【Results】 All the procedures were successfully completed and the follow-up time was 14.82±1.83 (RA group) and 15.11±1.62 (MIS-TLIF group) months, without significant difference (P>0.05). Compared with MIS-TLIF group, RA group had less intraoperative blood loss [(116.67±18.48) min vs. (128.06±22.53) min], fluoroscopy frequency [(12.42±2.28) vs. (15.67±2.46)], screw placement accuracy (93.18% vs. 84.03%), postoperative drainage [(73.03±23.52) mL vs. (88.33±28.54) mL], and shorter hospitalization stay [(6.45±1.52)d vs. (7.69±1.85) d] (all P0.05). The VAS of lower back pain and lower extremity pain, and lumbar JOA were significantly improved after the operation (P0.05). Meanwhile, fusion rate and incidence of complications did not significantly differ between the two groups (P>0.05). 【Conclusion】 Both robot-assisted MIS-TLIF and MIS-TLIF can achieve excellent clinical effects in treating single-segment lumbar disc herniation. However, the former can improve the accuracy of screw placement and reduce intraoperative blood loss, fluoroscopy frequency, postoperative drainage and hospitalization time, which indicates a promising application.

Accuracy of 3D printing navigation template in pedicle screw placement for idiopathic scoliosis / 中国组织工程研究

BACKGROUND: Idiopathic scoliosis surgery is difficult and requires a long operation time. Using 3D printing navigation templates to assist in nail placement can reduce the difficulty of surgery, optimize the operation of nail placement, and improve the effect of nail placement, which has significant advantages. OBJECTIVE: To evaluate the application of 3D printing navigation template assisted screw placement in the pedicle screw internal fixation of idiopathic scoliosis. METHODS: Clinical data of 17 cases of idiopathic scoliosis treated by pedicle screw fixation from January 2018 to August 2019 were retrospectively analyzed. Among them, eight patients were treated with 3D printing navigation template assisted screw placement (3D group), while nine patients were treated with conventional screw placement (conventional group). CT scan was used to evaluate the level and acceptability of screw placement after surgery. The time of nail placement, the times of intraoperative X-ray fluoroscopy, the amount of nailing bleeding, the level of nail placement, the acceptable rate of nail placement, the rate of secondary nail placement, the rate of main bending correction and the complications related to nail placement were compared between the two groups. RESULTS AND CONCLUSION: (1) All the 17 patients successfully completed the operation of nail placement, and there were no complications related to nail placement in blood vessel and nerve injury. One case of back pain and one case of lower extremity pain were found in the conventional group, and the symptoms disappeared after symptomatic treatment. (2) The time of nail placement, the times of intraoperative X-ray fluoroscopy and the amount of nailing bleeding in the 3D group were less than those in the conventional group, and the difference was statistically significant (P 0.05). (5) 3D printing navigation template can reduce the difficulty of screw placement and improve the effect of screw placement during pedicle screw internal fixation of idiopathic scoliosis.

Comparison of three-dimensional printing-assisted pedicle screw placement and traditional surgery for lumbar spondylolisthesis: A meta-analysis / 中国组织工程研究

BACKGROUND: With the development of three-dimensional (3D) printing technology, it has been widely used in spinal surgery. However, whether 3D printing-assisted surgery for lumbar spondylolisthesis has an advantage over traditional surgery is still controversial. OBJECTIVE: To compare the clinical efficacy and safety of 3D printing-assisted versus conventional surgery for the treatment of lumbar spondylolisthesis using system evaluation. METHODS: Randomized controlled trials about 3D printing technology for lumbar spondylolisthesis in CNKI, Wanfang database, CBM, VIP, PubMed, Cochrane Library, Embase, and Web of Science were searched via computer from inception to November 16, 2019. The retrieved literatures were screened according to predefined inclusion and exclusion criteria, and quality evaluation was performed. Then, the available data were extracted and analyzed with the Stata 11. 0 software. RESULTS AND CONCLUSION: (1) Six randomized controlled trials including 394 cases were included. Among them, 201 cases were assigned to the 3D printing-assisted group and 193 cases to the conventional group. (2) Meta-analysis results showed that the 3D printing-assisted group proved significantly superior to the conventional group regrading the operation time [WMD=-38. 17, 95%CI(-43. 93, -32. 41), P=0. 00], intraoperative blood loss [WMD=-61. 61, 95%CI(-69. 19, -54. 03), P=0. 00], the frequency of fluoroscopy [WMD=-4. 89, 95%CI(-6. 38, -3. 41), P=0. 00] and the screw placement accuracy [OR=3. 89, 95%CI(2. 43, 6. 25), P=0. 00]. (3) However, in terms of the postoperative visual analogue scale scores [WMD=-0. 47, 95%CI(-1. 21, 0. 27), P=0. 215], Oswestry disability index [WMD=-1. 41, 95%CI(-2. 87, 0. 05), P=0. 058], Japanese Orthopaedic Association scores [WMD=1. 02, 95%CI(-0. 68, 2. 72), P=0. 240] and the rate of complications [OR=0. 37, 95%CI(0. 12, 1. 11), P=0. 075], no statistically significant differences were found between the two groups. (4) In conclusion, the application of 3D printing technology in the surgical treatment of lumbar spondylolisthesis has the advantage of shortening the operation time, reducing intraoperative blood loss and frequency of fluoroscopy and improving the accuracy of the screw placement.

Robot-assisted and fluoroscopy-guided pedicle screw placement: A meta-analysis / 中国组织工程研究

BACKGROUND: Computer navigation system and orthopedic surgery robot have been developed rapidly in spine surgery in recent years, but the operation effect of computer navigation or navigation robot is still questioned. OBJECTIVE: To compare the difference in robot-assisted and fluoroscopy-guided pedicle screw placement. METHODS: The study included clinical trials published in and outside China from August 2008 to August 2019. The retrieval was performed in the online databases including Embase, PubMed, CNKI, and Wanfang Data. Key words in Chinese were: robot assisted, fluoroscopy guided, pedicle screw, pedicle nail, pedicle screw rod, pedicle internal fixation. Search strategy was: pedicle screw AND robot assisted OR fluoroscopy guided. Key words in English were: Robot assisted, Fluoroscopy guided, Pedicle screw, Pedicle stick, Pedicle screw fixation. Search strategy was: “Pedicle screw” OR “Pedicle stick” OR “Pedicle screw fixation” AND “Fluoroscopy guided” OR “Robot assisted”. After data extraction, statistical software Review Manager 5.3 was used for data analysis. RESULTS AND CONCLUSION: (1) Based on the above search strategy, 357 studies were retrieved. A total of 19 trials were included, containing 17 English studies and 2 Chinese studies. (2) Meta-analysis results displayed that the accuracy of placement of the robot-assisted group was superior to that of the fluoroscopy-guided group [95%CI(1.82, 2.52), P < 0.001]. Number of surgical complications [95%CI(0.25, 0.69), P=0.0006] and revision number [95%CI(0.23, 0.71), P=0.002] were less in the robot-assisted group than in the fluoroscopy-guided group. (3) When evaluating pedicle screw placement, robot-assisted has higher pedicle screw placement accuracy, fewer complications and fewer revisions, and is superior to traditional fluoroscopy-guided technique in accuracy and safety. Considering the expensive price and complex operation steps of navigation robot technology, the selection of specific nail placement method should still follow the principle of individualized treatment.

Early- and mid-term effects of trans-injured and cross-injured vertebra pedicle screw fixation in the treatment of thoracolumbar fractures / 中国组织工程研究

BACKGROUND: The bone trabecula of the vertebral body cannot be fully recovered, and the mechanical stability of the sagittal position of the spinal column Is affected. The antl-bendlng force and the anti-torsion force of the short-segment fixation of fractured vertebra are obviously Increased. The bearing load of various activities such as flexion, extension, and rotation of the vertebral body is increased. The stability of the injured vertebra is better maintained, and favorable conditions are created for fracture healing. OBJECTIVE: To compare the early- and mid-term follow-up results of trans-injured and cross-injured vertebra pedicle screw fixation in the treatment of thoracolumbar fractures. METHODS: Eighty-eight patients with thoracolumbar vertebrae fracture treated in Affiliated Hospital of Qinghai University from April 2017 to April 2018 were divided into trans-injured vertebra group and cross-injured vertebra group according to the treatment plan. All patients signed the informed consent. This study was approved by the Hospital Ethics Committee. Intraoperative blood loss, operation time, postoperative bed rest time, postoperative site infection, and subcutaneous hematoma were analyzed in both groups. Visual analogue scale score, Oswestry Disability Index, anterior edge height ratio and kyphosis Cobb angle were compared before surgery, 6 and 12 months after surgery between the two groups. RESULTS AND CONCLUSION: (1) The operation time was longer and intraoperative blood loss was higher in the trans-injured group than those in the cross-injured group, but the postoperative bed rest time was shorter in the trans-injured group than that in the cross-injured group (P 0.05). (3) At 6 and 12 months after surgery, visual analogue scale score and Oswestry Disability Index were lower in the trans-injured group than in the cross-injured group; anterior edge height ratio was larger in the trans-injured group than in the cross-injured group; kyphosis Cobb angle was smaller in the trans-injured group than in the cross-injured group (all P < 0.05). (4) Incidence of complications was higher in the cross-injured group (30%) than in the trans-injured group (7%) (P=0.001). (5) The treatment of thoracolumbar fracture with trans-injured pedicle screw can not only effectively restore and maintain the injured vertebral height and kyphosis Cobb angle, restore the physiological height and curvature of vertebral body, but also the incidence of postoperative complications is low, which can effectively improve the prognosis of patients and improve the quality of life of patients.

Accuracy of robot-assisted and fluoroscopy-guided pedicle screw placement: A meta-analysis / 中国组织工程研究

BACKGROUND: Traditional fluoroscopy-guided pedicle screw fixation is not highly accurate and can lead to serious surgical complications. To reduce surgical complications and improve the success rate of surgery, robotic assistive technology emerges as the times require. OBJECTIVE: To compare the difference of robot-assisted and fluoroscopy-guided pedicle screw placement using meta-analysis. METHODS: The study included clinical controlled trials on robot-assisted and fluoroscopy-guided pedicle screw placement published in and outside China from December 2008 to December 2018. The retrieval was performed in the online databases include Embase, PubMed, Central, CNKI, CQVIP, Wanfang, and CBM. Keywords used for search were robot assisted, fluoroscopy guided, conventional, freehand, pedicle screw in English and Chinese. After the data were extracted, statistical software Review Manager 5.3 was used for data-analysis. RESULTS AND CONCLUSION: (1) Based on the above search strategy, 1 615 studies were retrieved, and 13 were included. (2) Statistical analysis found that placement accuracy in the robot-assisted group was better than that of the fluoroscopy group [95%CI(1.55, 4.06), P=0.000 2]. Radiation intensity in the fluoroscopy group was lower than that in the robot-assisted group [95%CI(0.42, 0.82), P < 0.001], and the difference was statistically significant. (3) However, the incidence of complications [95%CI(0.23, 4.65), P=0.96] and revised surgery [95%CI(0.03, 3.17), P=0.33] were not statistically significant between the robot-assisted group and the fluoroscopy group. Intraoperative fluoroscopy time was similar between the two groups [95%CI(-38.55, 78.26), P=0.51]. Postoperative back pain [95%CI(-0.58, 0.38), P=0.68], leg pain score [95%CI(-0.20, 0.19), P=0.94] and operation time [95%CI(-6.33, 53.02), P=0.12] were also similar between the two groups, and the differences were not statistically significant. (4) Compared with fluoroscopy, robot-assisted technique has higher pedicle screw placement accuracy, especially under percutaneous conditions. Inevitably, the intraoperative radiation intensity is also more than conventional fluoroscopy.

Curative effect of selective screw placement with different screw densities in treatment of lenke I adolescent idiopathic scoliosis: A comparative study / 第二军医大学学报

Objective To evaluate the curative effect of selective screw placement of posterior three-dimensional correction for Lenkeadolescent idiopathic scoliosis (AIS), and to compare the effects of different screw densities on the orthopedic parameters. Methods We retrospectively analyzed the clinical data of LenkeAIS patients undergoing posterior correction of scoliosis＋selective fusion and internal fixation surgery in Department of Spine Surgery of Changhai Hospital of Naval Medical University (Second Military Medical University) between Jan. 2013 and Jan. 2017. According to the references, the screw density was defined as the number of nails/(fusion segment×2). The patients were divided into high density group (screw density0.7) and low density group (screw density≤0.7). The general characteristics, surgical correction rates 2 weeks and 2 years after operation, loss of correction rate after 2 years and correction ratio were compared between the two groups. Results A total of 36 eligible patients (11 males and 25 females) with LenkeAIS were included in this study, with an average age of (13.97±1.89) years old. There were 23 cases in the high density group and 13 cases in the low density group, with the screw densities being 0.80±0.04 and 0.64±0.06, respectively, and the difference was significant (t＝10.799，P0.01). There were no significant differences in gender, age, brand of pedicle screw, preoperation coronal main curve Cobb angle, preoperation bending Cobb angle or preoperation scoliosis flexibility between the two groups (all P 0.05). Compared with the high density group, the low density group had no significant disadvantages in coronal main curve Cobb angles 2 weeks and 2 years after operation, surgical correction rate 2 weeks after operation, or loss of correction rate 2 years after operation (all P0.05). Pearson correlation analysis showed that there were no significant correlations between screw density and surgical correction rate 2 weeks after operation, correction ratio and the loss of correction rate (r＝0.149, 0.348, 0.217; P＝0.387, 0.874, 0.177). Conclusion For LenkeAIS patients with better flexibility, appropriate reduction of the nail number in selective screw placement surgery may not adversely affect the short-term and mid-term outcomes.

Accuracy analysis of screw-setting through second sacral alar-iliac with interoperative cone beam CT scan / 局解手术学杂志

Objective To evaluate the accuracy and safety of screw placement position through second sacral alar -iliac(S2AI)with in-teroperative cone beam CT(CBCT)scan.Methods Collected 22 patients who underwent second sacral alar-iliac screw implant surgery in our hospital from June 2015 to June 2017.All the patients had intraoperative CBCT scan and conventional CT scan after operation.Regard the postoperative CT scan imageing as gold standard to assess the accuracy and safety of S 2AI screws position.The S2AI tract parameters were measured with intraoperative CBCT images and postoperative CT images respectively.Results There was no significant difference between the S2AI tract parameters which were measured with intraoperative CBCT images and postoperative CT images(P>0.05).Conclusion The intraoperative CBCT scan could accurately evaluate the position of S 2AI screws,as well as clarify the damage of the inner and outer plate of the iliac bone in the process of fixation.Compared with postoperative conventional CT scan,the intraoperative CBCT scan can potentially re-duce the reoperation rate.

Study on sustentaculum tali screw placement for constant fragment of calcaneal fracture / 中国修复重建外科杂志

Objective: To investigate the anatomical characters of the sustentaculum tali (ST), accurate entry point and direction for the placement of ST screw from posterior subtalar joint facet to the constant fragment (CF) in calcaneal fractures. Methods: A total of 100 patients with calcaneal fractures performed ankle CT scans were enrolled between January 2016 and April 2016. According to the inclusion criteria, the clinical data of 33 patients were analyzed, including 18 males and 15 females, with a median age of 41.0 years (range, 18-60 years). There were 16 cases on left side and 17 cases on the right side. Three-dimensional (3D) calcaneal model was reconstructed by Mimics 17.0 software, and the ST anatomical references were measured, including the length of upper and lower edge, the length and height of the midline, the horizontal angle between the midline and foot plantar surface. The parameters of the optimal entry point position (P' point) and placement angle of the ST screw were determined. The length of ST screw was also measured. The differences between males and females or left and right sides were compared. Results: The length of upper edge of the ST was (16.60±2.23) mm, lower edge (20.65±2.90) mm, midline (20.56±2.62) mm, and the height of midline was (9.61±1.36) mm. The horizontal angle between the midline and foot plantar surface was (23.43±3.36)°. The vertical distance from P' point to the lowest point of the tarsal sinus was (3.09±1.65) mm, while the horizontal distance was (14.29±2.75) mm. The distance from P' point to the apex of the lateral talus, subchondral bone of subtalar joint, calcaneocuboid joint was (11.41±3.22), (6.59±2.22), (34.58±3.75) mm, respectively. The horizontal angle between the ST screw and foot plantar surface was (-1.17±2.07)°. The anteversion angle of ST screw was (16.18±2.05)° and the length was (41.64 ± 3.09) mm. There were significant differences in the length of upper and lower edge, the length and height of the midline, the distance from P' point to the apex of the lateral talus, subchondral bone of subtalar joint, and calcaneocuboid joint, and the anteversion angle and length of the ST screw between males and females ( P0.05). Conclusion: After appropriate reduction of the calcaneal fractures, the entry point of ST screw was recommended at about 14 mm posterior and about 3 mm upper related to the foot horizontal line through the lowest tarsal sinus point; and the direction of ST screw placement was about 17° anteversion for males and 15° anteversion for females.

A new technique of pedicle screw placement with the use of sequential multilevel navigation templates based on patient-specific 3D CT reconstruction model: applicability in spine deformity / Una nueva técnica de colocación de tornillos pediculares con el uso de plantillas de navegación multinivel secuenciales basadas en el modelo de reconstrucción de CT 3D específico del paciente: aplicabilidad en la deformidad de la columna vertebral

Abstract: Introduction: The technique of placement of pedicle screws has gradually improved, but even misplacement observed in 1.2 to 20% of cases, have appeared techniques fluoroscopic, tomographic and electromagnetic navigation, which led it to 1.3 to 4.3%, but nevertheless they are expensive and complex technologies. Present technique pedicle screw placement by using templates with a modification in the art, performing tomography and reconstruction in the same surgical position and with the templates of 3 or more levels. Methods: Five cases of idiopathic scoliosis were performed, with correction and instrumentation with pedicular screws, where a three-dimensional model of the spine was performed with a tomography in a surgical position, whose images were exported to a 3D printer to reconstruct the desired trajectory of the screws in a template using cylinders resting on the inverse surface of the vertebrae. The direction of the screw was planned in the center of the pedicle and parallel to the upper platform of the vertebra. Each template was of several levels and transoperative X-rays were not used. Results: Under electrophysiologic monitoring transoperative «red alerts¼ were not reported, the placement of the screws in postoperative CT scan was evaluated, showing a standard deviation in placement of 1.9 and 2.2 mm on the right and left respectively pedicles, with respect to their planning. Discussion: This technique is simple and safe, besides not requiring great technology, its use is suggested in beginner spine surgeons and in severe deformities, it can be performed in any hospital where spinal surgery is performed.

Resumen: Introducción: La técnica de colocación de tornillos transpediculares ha mejorado paulatinamente, a pesar de ello, la mala colocación oscila entre 1.2 al 20% de los casos; han surgido técnicas de navegación asistidas por flouroscopía, tomografía y resonancia magnética mejorando el índice de falla al 1.3-4.3%. La presente técnica de colocación utiliza plantillas con la modificación de que la tomografía y la reconstrucción son realizadas con el paciente en la posición quirúrgica, además que las plantillas abarcan tres o más niveles. Métodos: Se presentan cinco casos de escoliosis idiopática tratados con instrumentación y colocación de tornillos transpediculares donde se generó un modelo tridimensional de la columna en posición quirúrgica; las imágenes fueron exportadas a una impresora 3-D para reconstruir la trayectoria apropiada de los tornillos, la dirección de éstos fue planeada tomando de referencia el centro del pedículo y paralela a la plataforma superior de la vértebra. Cada plantilla consta de diferentes niveles y no se requirió del uso de rayos X trans­operatorios. Resultados: Bajo monitoreo electrofisiológico transquirúrgico no se reportó ninguna «alerta roja¼; la evaluación postoperatoria por tomografía de la colocación de los tornillos mostró una desviación estándar de 1.9 y 2.2 mm tanto a la derecha y a la izquierda, respectivamente, de acuerdo con lo planeado. Discusión: La técnica es simple y segura, no requiere de mucho despliegue tecnológico, se sugiere su uso para los cirujanos de columna con poca experiencia y para deformidades severas; consideramos que puede desarrollarse en cualquier hospital donde se realice cirugía de columna.

Guiding chunnel-assisted percutaneous pedicle screw placement for thoracolumbar vertebral fractures not accompanied by nerve injury / 介入放射学杂志

Objective To analyze the operation time,radiation exposure time and the screw placement accuracy of a newly-developed guiding chunnel-assisted percutaneous pedicle screw placement technique for thoracolumbar vertebral fractures not accompanied by nerve injury.Methods The clinical data of 35 patients with thoracolumbar vertebral fractures not accompanied by nerve injury,who were treated with newly-developed guiding chunnel-assisted percutaneous pedicle screw placement technique during the period from July 2010 to October 2012,were retrospectively analyzed.A total of 178 procedures of pedicle screw placement were performed in the 35 patients by the one and the same surgeon.The operation time and radiation exposure time of each pedicle screw placement procedure were recorded,and based on the findings of postoperative consecutive two CT scans of the operated vertebrae the screw placement accuracy was graded and evaluated.Results The technical success rate of screw placement was 100％.The mean time used for a single pedicle screw placement was (11.35±2.82) minutes,the average radiation exposure time was (8.06± 2.15) seconds.Screw placement accuracy of grade A was obtained in 156 screws (87.64％),grade B in 20 screws (11.24％),grade C in one screw (0.56％),and grade D in one screw (0.56％).Conclusion The newly-developed guiding chunnel-assisted percutaneous pedicle screw placement technique is very helpful in localizing the puncture point,in improving the screw placement accuracy,and in reducing both operation time and radiation exposure time.