Balling Horst
Department for Spine Surgery and Traumatology, Orthopaedische Fachklinik Schwarzach, Dekan-Graf-Str. 2-6, 94374, Schwarzach, Germany.
Neckar-Odenwald-Kliniken gGmbH Buchen, Center for Spine Surgery, Dr.-Konrad-Adenauer-Str. 37, 74722, Buchen, Germany.
Arch Orthop Trauma Surg. 2018 Nov;138(11):1501-1509. doi: 10.1007/s00402-018-2994-x. Epub 2018 Jul 7.
The implementation of 3D-navigation in the operating theater is reported to be complex, time consuming, and radiation intense. This prospective single-center cohort study was performed to objectify these assumptions by determining navigation-related learning curves in lumbar single-level posterior fusion procedures using 3D-fluoroscopy for real-time image-guided pedicle screw (PS) insertions.
From August 2011 through July 2016, a total of 320 navigated PSs were inserted during 80 lumbar single-level posterior fusion procedures by a single surgeon without any prior experience in image-guided surgery. PS misplacements, navigation-related pre- and intraoperative time demand, and procedural 3D-radiation dose (dose-length-product, DLP) were prospectively recorded and congregated in 16 subgroups of five consecutive procedures to evaluate improving PS insertion accuracy, decreasing navigation-related time demand, and reduction of 3D-radiation dose.
After PS insertion and intraoperative O-arm control scanning, 11 PS modifications were performed sporadically without showing "learning curve dependencies" (PS insertion accuracies in subgroups 96.6 ± 6.3%). Average navigation-related pre-surgical time from patient positioning on the operating table to skin incision decreased from 61 ± 6 min (subgroup 1) to 28 ± 2 min (subgroup 16, p < 0.00001). Average 3D-radiation dose per surgery declined from 919 ± 225 mGycm (subgroup 1) to 66 ± 4 mGycm (subgroup 16, p < 0.0001).
In newly inaugurated O-arm based image-guidance, lumbar PS insertions can be performed at constantly high accuracy, even without prior experience in navigated techniques. Navigation-related time demand decreases considerably due to accelerating workflow preceding skin incision. Procedural 3D-radiation dose is reducible to a fraction (13.2%) of a lumbar diagnostic non-contrast-enhanced computed tomography scan's radiation dose.
据报道，手术室中3D导航的实施复杂、耗时且辐射量大。本前瞻性单中心队列研究旨在通过确定在腰椎单节段后路融合手术中使用3D荧光透视进行实时图像引导椎弓根螺钉（PS）植入时与导航相关的学习曲线，来验证这些假设。
2011年8月至2016年7月，一名此前无图像引导手术经验的外科医生在80例腰椎单节段后路融合手术中总共植入了320枚导航PS。前瞻性记录PS误置、与导航相关的术前和术中时间需求以及手术3D辐射剂量（剂量长度乘积，DLP），并将其汇总到由连续五个手术组成的16个亚组中，以评估提高PS植入准确性、减少与导航相关的时间需求以及降低3D辐射剂量的情况。
在PS植入和术中O型臂控制扫描后，偶尔进行了11次PS调整，未显示出“学习曲线依赖性”（各亚组中PS植入准确率为96.6±6.3%）。从患者在手术台上定位到皮肤切开的平均与导航相关的术前时间从61±6分钟（第1亚组）降至28±2分钟（第16亚组，p<0.00001）。每次手术的平均3D辐射剂量从919±225mGycm（第1亚组）降至66±4mGycm（第16亚组，p<0.0001）。
在新启用的基于O型臂的图像引导中，即使没有导航技术的先验经验，腰椎PS植入也能以持续的高精度进行。由于皮肤切开前工作流程的加快，与导航相关的时间需求大幅减少。手术3D辐射剂量可降低至腰椎诊断性非增强计算机断层扫描辐射剂量的一小部分（13.2%）。
