Spinal Navigation for Cervical Pedicle Screws: Surgical Pearls and Pitfalls

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: We intend to evaluate the accuracy and safety of cervical pedicle screw (CPS) insertion under O-arm-based 3-dimensional (3D) navigation guidance. METHODS: This is a retrospective study of patients who underwent CPS insertion under intraoperative O-arm-based 3D navigation during the years 2009 to 2018. The radiological accuracy of CPS placement was evaluated using their intraoperative scans. RESULTS: A total of 297 CPSs were inserted under navigation. According to Gertzbein classification, 229 screws (77.1%) were placed without any pedicle breach (grade 0). Of the screws that did breach the pedicle, 51 screws (17.2%) had a minor breach of less than 2 mm (grade 1), 13 screws (4.4%) had a breach of between 2 and 4 mm (grade 2), and 4 screws (1.3%) had a complete breach of 4 mm or more (grade 3). Six screws were revised intraoperatively. There was no incidence of neurovascular injury in this series of patients. 59 of the 68 breaches (86.8%) were found to perforate laterally, and the remaining 9 (13.2%) medially. It was noted that the C5 cervical level had the highest breach rate of 33.3%. CONCLUSIONS: O-arm-based 3D navigation can improve the accuracy and safety of CPS insertion. The overall breach rate in this study was 22.9%. Despite these breaches, there was no incidence of neurovascular injury or need for revision surgery for screw malposition.