Acta Chir Orthop Traumatol Cech. 2024; 91(6):355-363 | DOI: 10.55095/achot2024/057

O-arm Versus C-arm: Comparison of the Learning Curves and Accuracy in Transpedicular Screw Fixation of Lumbar Spondylolisthesis

J. JABLONSKÝ1, ©. TRNKA1, 2, P. STEJSKAL1, 2, L. HRABÁLEK1, 2, T. WANEK1, 2, M. VAVERKA1, 2
1 Neurochirurgická klinika Fakultní nemocnice Olomouc
2 Lékařská fakulta Univerzity Palackého Olomouc

Purpose of the study: The annual number of spinal fusion procedures has been increasing and is well documented worldwide. The O-arm is slowly becoming the standard for transpedicular screw insertion. The accuracy and safety of this method have been confirmed by many studies. Therefore, the learning curve of this method and its use by younger surgeons is the focus of our investigation. Longer operative time and radiation exposure to the patient are its only disadvantages. Our aim was to evaluate the learning curve of neurosurgical residents receiving specialist training and to demonstrate the safety and accuracy compared to the conventional C-arm-guided screw insertion used in the surgical management of spondylolisthesis.

Material and Methods: Two groups of patients were evaluated - a retrospective cohort composed of patients with degenerative lumbar spinal instability indicated for C-arm-guided posterior transpedicular screw fixation and a prospective group of patients with the same diagnosis and surgical indication for O-arm-navigated screw insertion. In the retrospective group, the surgeons were largely experienced certified spine surgeons and neurosurgeons, whereas in the prospective group there were mainly neurosurgical residents receiving specialist training under the supervision of a certified physician. Both groups underwent a postoperative CT scan to evaluate the pedicle screw malposition using the Grade system and the anatomical plane of malposition. The operative times for both groups were recorded and for the O-arm navigated group a learning curve from the introduction of the method was generated. The values obtained were statistically analysed.

Results: A relatively favourable learning curve of the O-arm-navigation was obtained, with operative times approximating the C-arm-guided group at two years after the introduction of the method. Safety of the O-arm navigation applied by less experienced surgeons was confirmed through statistically significantly higher accuracy achieved in the O-arm group at the expense of longer operative times. Also, a significantly lower number of significant Grade 2 and 3 malposition was reported in the O-arm group.

Discussion: The higher accuracy of transpedicular screw insertion in the navigation method has been confirmed multiple times. In our study, even in the group of less experienced surgeons. The favourable learning curve of neurological residents receiving specialist training is less documented. Time efficiency of the method and its safety when applied by younger surgeons could help make O-arm navigation the new gold standard in spine surgery. The longer operative time, the purchase price of the device, and a relatively higher radiation exposure to the patient continue to be its disadvantages.

Conclusions: Based on the data obtained, a conclusion can be drawn that the O-arm navigation in spine surgery represents a safer and more accurate method for transpedicular fixation compared to the conventional C-arm technique, even when used by less experienced surgeons. In future, we should focus on increasing its time-efficiency. We are convinced that the navigation-assisted spinal instrumentation will soon become a necessity for spine surgery centres.

Keywords: O-arm, transpedicular fixation, spondylolisthesis, fusion, navigation, learning curve.

Received: May 15, 2024; Revised: May 15, 2024; Accepted: October 7, 2024; Published: February 3, 2025  Show citation

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JABLONSKÝ J, TRNKA ©, STEJSKAL P, HRABÁLEK L, WANEK T, VAVERKA M. O-arm Versus C-arm: Comparison of the Learning Curves and Accuracy in Transpedicular Screw Fixation of Lumbar Spondylolisthesis. Acta Chir Orthop Traumatol Cech. 2024;91(6):355-363. doi: 10.55095/achot2024/057. PubMed PMID: 39781636.
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References

  1. LiteraturaAnnoni E, Joedicke H, Barnett GS . The 3D O-arm surgical imaging system with navigation effectively and economically addresses the challenges of spinal stabilization procedures. Value Health. 2013;16:A556.2. Arand M, Hartwig E, Kinzl L, Gebhard F. Spinal navigation in tumor surgery of the thoracic spine: first clinical results. Clin Orthop Relat Res. 2002;399:211-218.3. Arand M, Schempf M, Kinzl L, Fleiter T, Pless D, Gebhard F. Precision in standardized Iso-C-arm based navigated boring of the proximal femur. Unfallchirurg. 2001;104:1150-1156.4. Aoude AA, Fortin M, Figueiredo R, Jarzem P, Ouellet J, Weber MH. Methods to determine pedicle screw placement accuracy in spine surgery: a systematic review. Eur Spine J. 2015;24:990-1004. doi: 10.1007/s00586-015-3853-x.5. Boriani S, Bandiera S, Donthineni R, Amendola L, Cappuccio M, De Iure F. Morbidity of en bloc resections in the spine. Eur Spine J. 2010;19:231-241.6. Castro WH, Halm H, Jerosch J, Malms J, Steinbeck J, Blasius S. Accuracy of pedicle screw placement in lumbar vertebrae. Spine. 1996;21:1320-1324.7. Chang CC, Chang HK, Wu JC, Tu TH, Cheng H, Huang WC. Comparison of radiation exposure between O-arm navigated and C-arm guided screw placement in minimally invasive transforaminal lumbar interbody fusion. World Neurosurg. 2020;139:e489-e495. doi: 10.1016/j.wneu.2020.04.052.8. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303: 1259-1265.9. Epstein NE. Commentary: utility of the O-arm in spinal surgery. Surg Neurol Int. 2014;5:S517-S519, (Schils F. O-arm guided balloon kyphoplasty: preliminary experience of 16 consecutive patients. Acta Neurochir Suppl. 2011;109: 175-178),10. Feng W, Wang W, Chen S, Wu K, Wang H. O-arm navigation versus C-arm guidance for pedicle screw placement in spine surgery: a systematic review and meta-analysis. Int Orthop. 2020;44:919-926. doi: 10.1007/s00264-019-04470-3.11. Gebhard F, Weidner A, Liener UC, Stockle U, Arand M. Navigation at the spine. Injury 35(Suppl 1):S-A35-S-A45. (Merloz P, Troccaz J, Vouaillat H, Vasile C, Tonetti J, Eid A .(2007) Fluoroscopy-based navigation system in spine surgery. Proc Inst Mech Eng H. 2007;221:813-820),12. Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976). 1990;15:11-14.13. Grob D, Magerl F, McGowan DP. Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine (Phila Pa 1976). 1990;15:251.14. Jaiswal A, Shetty AP, Rajasekaran S. Role of intraoperative iso-c based navigation in challenging spine trauma. Indian J Orthop. 2007;41:312-317.15. Kim YJ, Lenke LG, Bridwell KH, Cho YS, Riew KD. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine (Phila Pa 1976). 2004;29:333-342, discussion 42.16. Knafo S, Mireau E, Bennis S, Baussart B, Aldea S, Gaillard S. Operative and perioperative durations in O-Arm vs C-Arm fluoroscopy for lumbar instrumentation. Oper Neurosurg (Hagerstown). 2018;14:273-278. doi: 10.1093/ons/opx142. PMID: 28973631.17. Lavallee S, Sautot P, Troccaz J, Cinquin P, Merloz P. Computer-assisted spine surgery: a technique for accurate transpedicular screw fixation using CT data and a 3-D optical localizer. J Image Guid Surg. 1995;1:65-73.18. Learch TJ, Massie JB, Pathria MN, Ahlgren BA, Garfin SR. Asessment of pedicle screw placement utilizing convenional radiography and computed tomography: a proposed systematic approach to improve accuracy of interpretation. Spine. 2004; 29:767-773.19. Lekovic GP, Potts EA, Karahalios DG, Hall G. A comparison of two techniques in image-guided thoracic pedicle screw placement: a retrospective study of 37 patients and 277 pedicle screws. J Neurosurg Spine. 2007;7:393-398.20. Liu H, Wang YM, Pi B, Qian ZL, Zhu XY, Yang HL, Comparison of intraoperative O-arm- and conventional fluoroscopy (C-arm)-assisted insertion of pedicle screws in the treatment of fracture of thoracic vertebrae. J Orthop Surg. 2017;25:1-6.21. Merloz P, Tonetti J, Eid A, Faure C, Lavallee S, Troccaz J. Computer assisted spine surgery. Clin Orthop Relat Res. 1997;337:86-96.22. Mirza SK, Wiggins GC, Kuntz C, York JE, Bellabarba C, Knonodi MA. Accuracy of thoracic vertebral body screw placement using standard fluoroscopy, fluoroscopic image guidance, and computed tomographic image guidance: a cadaver study. Spine (Phila Pa 1976). 2003;28:402-413.23. Nakagawa H, Kamimura M, Uchiyama S, Takahara K, Itsubo T, Miyasaka T (2003) The accuracy and safety of image-guidance system using intraoperative fluoroscopic images: an in vitro feasibility study. J Clin Neurosci. 2003;10:226-230.24. Niessen WJ. Accuracy evaluation of direct navigation with an isocentric 3D rotational X-ray system. Med Image Anal. 2006;10:113-124.25. Rajaee SS, Bae HW, Kanim LEA, Delamarter RB. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine 2012;37:67-76.).26. Rampersaud YR, Foley KT, Shen AC, Williams S, Solomito M. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976). 2000;25:2637-2645.27. Reisener MJ, Pumberger M, Shue J, Girardi FP, Hughes AP. Trends in lumbar spinal fusion-a literature review. J Spine Surg. 2020;6:752-761. doi: 10.21037/jss-20-492.28. Ryang YM, Villard J, Obermüller T, Friedrich B, Wolf P, Gempt J, Ringel F, Meyer B. Learning curve of 3D fluoroscopy image-guided pedicle screw placement in the thoracolumbar spine. Spine J. 2015;15:467-476. doi: 10.1016/j.spinee.2014.10.003.29. Sclafani JA, Regev GJ, Webb J, Garfin SR, Kim CW. Use of a quantitative pedicle screw accuracy system to assess new technology: initial studies on O-arm navigation and its effect on the learning curve of percutaneous pedicle screw insertion. SAS J. 2011;5:57-62.30. Schils F. O-arm guided balloon kyphoplasty: preliminary experience of 16 consecutive patients. Acta Neurochir Suppl. 2011;109:175-178.31. Schlenzka D, Laine T, Lund T. Computer-assisted spine surgery. Eur Spine J. 2000;9(Suppl 1):S57-S64.32. Sheikh SR, Thompson NR, Benzel E, Steinmetz M, Mroz T, Tomic D, Machado A, Jehi L. Can we justify it? Trends in the utilization of spinal fusions and associated reimbursement. Neurosurgery. 2020;86:E193-E202.33. Silbermann J, Riese F, Allam Y, Reichert T, Koeppert H, Gutberlet M. Computer tomography assessment of pedicle screw placement in lumbar and sacral spine: comparison between free-hand and O-arm based navigation techniques. Eur Spine J. 2011;20:875-881. doi: 10.1007/s00586-010-1683-4.34. Shin MH, Ryu KS, Park CK. Accuracy and safety in pedicle screw placement in the thoracic and lumbar spines: comparison study between conventional C-arm fluoroscopy and navigation coupled with O-arm® guided methods. J Korean Neurosurg Soc. 2012;52:204-209.35. Shin MH, Hur JW, Ryu KS, Park CK. Prospective comparison study between the fluoroscopy-guided and navigation coupled with O-arm-guided pedicle screw placement in the thoracic and lumbosacral spines. J Spinal Disord Tech. 2015;28:E347-EE51.36. Sun J, Wu D, Wang Q, Wei Y, Yuan F. Pedicle Screw Insertion: Is O-Arm-based navigation superior to the conventional freehand technique? A systematic review and meta-analysis. World Neurosurg. 2020 Dec;144:e87-e99. doi: 10.1016/j.wneu.2020.07.205. Epub 2020 Aug 3. PMID: 32758654.),37. Tajsic T, Patel K, Farmer R, Mannion RJ, Trivedi RA. Spinal navigation for minimally invasive thoracic and lumbosacral spine fixation: implications for radiation exposure, operative time, and accuracy of pedicle screw placement. Eur Spine J. 2018;27:1918-1924.38. Talotta J. Key to the future: O-arm. J Med Imaging Radiat Sci. 2012;43:S63.39. Tjardes T, Shafizadeh S, Rixen D, Paffrath T, Bouillon B, Steinhausen ES. Image-guided spine surgery: state of theart and future directions. Eur Spine J. 2010;19:25-45, (Van de Kraats EB, Van Walsum T, Kendrick L, Noordhoek NJ,40. Tian NF, Xu HZ. Image-guided pedicle screw insertion accuracy: a meta-analysis. Int Orthop. 2009;33:895-903.41. Van Brussel K, Vander Sloten J, Van Audekercke R, Fabry G. Internal fixation of the spine in traumatic and scoliotic cases. The potential of pedicle screws. Technol Health Care. 1996;4:365-384.42. Van de Kelft E, Costa F, Van der Planken D, Schils F. A prospective multicenter registry on the accuracy of pedicle screw placement in the thoracic, lumbar, and sacral levels with the use of the O-arm imaging system and StealthStation navigation. Spine (Phila Pa 1976). 2012;37:E1580-E1587.43. van de Kraats EB, van Walsum T, Kendrick L, Noordhoek NJ, Niessen WJ. Accuracy evaluation of direct navigation with an isocentric 3D rotational X-ray system. Med Image Anal. 2006;10:113-124.44. Weinstein JN, Spratt KF, Spengler D, Brick C, Reid S. Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine (Phila Pa 1976). 1988;13:1012-1018.45. Wood M, Mannion R. A comparison of CT-based navigation techniques for minimally invasive lumbar pedicle screw placement. J Spinal Disord Tech. 2011;24:E1-E5.46. Xu R, Ebraheim NA, Ou Y, Yeasting RA. Anatomic considerations of pedicle screw placement in the thoracic spine. Roy-Camille technique versus open-lamina technique. Spine (Phila Pa 1976). 1998;23:1065-1068.47. Yang YL, Zhou DS, He JL. Comparison of isocentric C-arm 3-dimensional navigation and conventional fluoroscopy for C1 lateral mass and C2 pedicle screw placement for atlantoaxial instability. J Spinal Disord Tech. 2013;26:127-134. Go to original source...