Intraoperative image guidance for cervical spine surgery

Intraoperative image-guidance in spinal surgery has been influenced by various technological developments in imaging science since the early 1990s. The technology has evolved from simple fluoroscopic-based guidance to state-of-art intraoperative computed tomography (iCT)-based navigation systems. Although the intraoperative navigation is more commonly used in thoracolumbar spine surgery, this newer imaging platform has rapidly gained popularity in cervical approaches. The purpose of this manuscript is to address the applications of advanced image-guidance in cervical spine surgery and to describe the use of intraoperative neuro-navigation in surgical planning and execution. In this review, we aim to cover the following surgical techniques: anterior cervical approaches, atlanto-axial fixation, subaxial instrumentation, percutaneous interfacet cage implantation as well as minimally invasive posterior cervical foraminotomy (PCF) and unilateral laminotomy for bilateral decompression. The currently available data suggested that the use of 3D navigation significantly reduces the screw malposition, operative time, mean blood loss, radiation exposure, and complication rates in comparison to the conventional fluoroscopic-guidance. With the advancements in technology and surgical techniques, 3D navigation has potential to replace conventional fluoroscopy completely.