Clin Orthop Surg.  2019 Jun;11(2):170-175. 10.4055/cios.2019.11.2.170.

Spinal Navigation during Orthopedic Residency Training: A Double-Edged Sword?

• Kaliya-Perumal AK
• Soh T
• Tan M
• Nolan CP
• Yu CS
• Oh JY

• KMID: 2445051
• DOI: http://doi.org/10.4055/cios.2019.11.2.170

Abstract

BACKGROUND
Orthopedic residents in our institute have the opportunity to participate in navigation-assisted spine surgery during their residency training. This paves the way for a new dimension of learning spine surgery, which the previous generation was not exposed to. To study this in detail, we conducted a cross-sectional descriptive survey among our residents to analyse their perception, understanding, and competency regarding pedicle screw application using spinal navigation.
METHODS
We selected orthopedic residents (n = 20) who had completed 3 years of training that included at least one rotation (4-6 months) in our spine division. They were asked to respond to a four-part questionnaire that included general and Likert scale-based questions. The first two parts dealt with various parameters regarding spinal navigation and free-hand technique for applying pedicle screws. The third part dealt with residents' opinion regarding the advantages and disadvantages of spinal navigation. The final part was an objective analysis of residents' ability to identify the pedicle screw entry points in selected segments.
RESULTS
We found that our residents were better trained to apply pedicle screws using spinal navigation. The mean Likert scale score for perception regarding their competency to apply pedicle screws using spinal navigation was 3.65 ± 0.81, compared to only 2.8 ± 0.77 when using the free-hand technique. All residents agreed that spinal navigation is an excellent teaching tool with higher accuracy and greater utility in anatomically critical cases. However, 35% of the residents were not able to identify the entry points correctly in the given segments.
CONCLUSIONS
All selected residents were perceived to be competent to apply pedicle screws using spinal navigation. However, some of them were not able to identify the entry points correctly, probably due to overreliance on spinal navigation. Therefore, we encourage residents to concentrate on surface anatomy and tactile feedback rather than completely relying on the navigation display monitor during every screw placement. In addition, incorporating cadaveric and saw bone workshops as a part of teaching program can enhance better understanding of surgical anatomy.

Keyword

Computer-assisted surgery; Internship and residency; Neuronavigation; Pedicle screws; Spine

Reference

1. Fehlings MG, Ahuja CS, Mroz T, Hsu W, Harrop J. Future advances in spine surgery: the AOSpine North America perspective. Neurosurgery. 2017; 80(3S):S1–S8.

2. Overley SC, Cho SK, Mehta AI, Arnold PM. Navigation and robotics in spinal surgery: where are we now? Neurosurgery. 2017; 80(3S):S86–S99. PMID: 28350944.

3. DiGiorgio AM, Edwards CS, Virk MS, Mummaneni PV, Chou D. Stereotactic navigation for the prepsoas oblique lateral lumbar interbody fusion: technical note and case series. Neurosurg Focus. 2017; 43(2):E14.

4. Zhu W, Sun W, Xu L, et al. Minimally invasive scoliosis surgery assisted by O-arm navigation for Lenke Type 5C adolescent idiopathic scoliosis: a comparison with standard open approach spinal instrumentation. J Neurosurg Pediatr. 2017; 19(4):472–478. PMID: 28186473.

5. Kosterhon M, Gutenberg A, Kantelhardt SR, Archavlis E, Giese A. Navigation and image injection for control of bone removal and osteotomy planes in spine surgery. Oper Neurosurg (Hagerstown). 2017; 13(2):297–304. PMID: 28927210.

6. Nasser R, Drazin D, Nakhla J, et al. Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis. Neurosurg Focus. 2016; 41(2):E15.

7. Mohan AL, Das K. History of surgery for the correction of spinal deformity. Neurosurg Focus. 2003; 14(1):e1.

8. Fan Chiang CY, Tsai TT, Chen LH, et al. Computed tomography-based navigation-assisted pedicle screw insertion for thoracic and lumbar spine fractures. Chang Gung Med J. 2012; 35(4):332–338. PMID: 22913860.

9. Liu Z, Jin M, Qiu Y, Yan H, Han X, Zhu Z. The superiority of intraoperative O-arm navigation-assisted surgery in instrumenting extremely small thoracic pedicles of adolescent idiopathic scoliosis: a case-control study. Medicine (Baltimore). 2016; 95(18):e3581. PMID: 27149486.

10. Navarro-Ramirez R, Lang G, Lian X, et al. Total navigation in spine surgery: a concise guide to eliminate fluoroscopy using a portable intraoperative computed tomography 3-dimensional navigation system. World Neurosurg. 2017; 100:325–335. PMID: 28104526.

11. Feng SW, Yang YJ, Li CZ, Lin MC, Chung TT, Chen YH. Accuracy of spinal screw fixation using intraoperative O-arm navigation: consecutive series of 118 screws. J Med Sci. 2016; 36(1):6–13.

12. Jaiswal A, Shetty AP, Rajasekaran S. Role of intraoperative Iso-C based navigation in challenging spine trauma. Indian J Orthop. 2007; 41(4):312–317. PMID: 21139784.

13. Kotani T, Akazawa T, Sakuma T, et al. Accuracy of pedicle screw placement in scoliosis surgery: a comparison between conventional computed tomography-based and O-arm-based navigation techniques. Asian Spine J. 2014; 8(3):331–338. PMID: 24967047.

14. Avila MJ, Baaj AA. Freehand thoracic pedicle screw placement: review of existing strategies and a step-by-step guide using uniform landmarks for all levels. Cureus. 2016; 8(2):e501. PMID: 27014535.

15. Chung KJ, Suh SW, Desai S, Song HR. Ideal entry point for the thoracic pedicle screw during the free hand technique. Int Orthop. 2008; 32(5):657–662. PMID: 17437109.

16. Puvanesarajah V, Liauw JA, Lo SF, Lina IA, Witham TF. Techniques and accuracy of thoracolumbar pedicle screw placement. World J Orthop. 2014; 5(2):112–123. PMID: 24829874.

17. Villard J, Ryang YM, Demetriades AK, et al. Radiation exposure to the surgeon and the patient during posterior lumbar spinal instrumentation: a prospective randomized comparison of navigated versus non-navigated freehand techniques. Spine (Phila Pa 1976). 2014; 39(13):1004–1009. PMID: 24732833.

18. Fransen P. Fluoroscopic exposure in modern spinal surgery. Acta Orthop Belg. 2011; 77(3):386–389. PMID: 21846009.

19. Gang C, Haibo L, Fancai L, Weishan C, Qixin C. Learning curve of thoracic pedicle screw placement using the free-hand technique in scoliosis: how many screws needed for an apprentice? Eur Spine J. 2012; 21(6):1151–1156. PMID: 22081239.

20. Choo AD, Regev G, Garfin SR, Kim CW. Surgeons' perceptions of spinal navigation: analysis of key factors affecting the lack of adoption of spinal navigation technology. SAS J. 2008; 2(4):189–194. PMID: 25802621.