Welch Nicole, Mota Frank, Birch Craig, Hutchinson Lauren, Hedequist Daniel
Department of Orthopaedic Surgery, Boston Children's Hospital.
Harvard Medical School, Boston, MA.
J Pediatr Orthop. 2023;43(5):e337-e342. doi: 10.1097/BPO.0000000000002381. Epub 2023 Mar 21.
This study assesses intraoperative efficacy, accuracy, and complications of pedicle screw placement using robotic-assisted navigation (RAN) in pediatric spine surgery.
A retrospective review of patients who underwent spine deformity surgery using RAN at a single pediatric institution from 2019 to 2021 was conducted. Patient demographics, perioperative metrics, screw execution and accuracy, technical difficulties, and other outcomes were summarized. In cases with postoperative computed tomography scans, screws were classified using the Gertzbein and Robbins classification scale. Fisher exact tests were used to assess the relationship between procedural changes and lateral screw malposition.
One hundred sixty-two cases with an average patient age of 15.1 years (range, 4 to 31 y) were reviewed. The most common diagnosis was adolescent idiopathic scoliosis (n=80) with an average major curve of 65 degrees. Of 1467 screws attempted, 1461 were executed successfully (99.6%). All failures were in Type D pedicles and were lateral deviations recognized with routine intraoperative fluoroscopy. In cases with postoperative computed tomography imaging, 100% of screws (n=197) were placed with complete containment (Grade A). Remaining screws were graded as accurate by mirroring fluoroscopy and planned computer software positions. In 4% of cases, loss of registration was detected by a safety check before drilling at the planned level. There were no neurological deficits or returns to the operating room. Two changes occurred as part of the learning curve associated with this technique. (1) Adoption of a high-speed navigated drill: Change 1 (last 74 cases). (2) Drilling all pilot holes robotically first, then placing screws within the robotically established tracts to avoid motion and subsequent registration disruption: Change 2 (last 39 cases). Change 1 was less likely to result in screw malposition as no screws skived lateral with the technique ( P =0.03). Change 2 trended toward statistical significance for avoidance of screw malposition and loss of registration, as no loss of registration occurred after adopting this technique.
This study highlights the safety and screw accuracy associated with the use of RAN in pediatric patients.
Level III.
本研究评估了在小儿脊柱手术中使用机器人辅助导航（RAN）进行椎弓根螺钉置入的术中疗效、准确性和并发症。
对2019年至2021年在一家小儿专科医院接受使用RAN的脊柱畸形手术的患者进行回顾性研究。总结患者人口统计学、围手术期指标、螺钉操作与准确性、技术难点及其他结果。对于有术后计算机断层扫描的病例，使用格茨贝恩和罗宾斯分类量表对螺钉进行分类。采用费舍尔精确检验评估手术操作变化与外侧螺钉位置不当之间的关系。
共回顾了162例患者，平均年龄15.1岁（范围4至31岁）。最常见的诊断为青少年特发性脊柱侧凸（n = 80），平均主弯角度为65度。在尝试置入的1467枚螺钉中，1461枚成功置入（99.6%）。所有失败均发生在D型椎弓根，且均为术中常规透视发现的外侧偏移。在有术后计算机断层扫描成像的病例中，100%的螺钉（n = 197）置入时完全包容（A级）。其余螺钉通过透视和计划计算机软件位置的镜像对比评定为准确。4%的病例在按计划水平钻孔前的安全检查中检测到注册丢失。未出现神经功能缺损或再次手术情况。作为与该技术相关的学习曲线的一部分，发生了两项改变。（1）采用高速导航钻：改变1（最后74例）。（2）先机器人辅助钻所有导孔，然后在机器人建立的通道内置入螺钉以避免移动及随后的注册中断：改变2（最后39例）。改变1导致螺钉位置不当的可能性较小，因为采用该技术时没有螺钉向外侧偏移（P = 0.03）。改变2在避免螺钉位置不当和注册丢失方面有统计学意义的趋势，因为采用该技术后未发生注册丢失。
本研究强调了在小儿患者中使用RAN的安全性和螺钉置入准确性。
三级。
