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Use of a quantitative pedicle screw accuracy system to assess new technology: Initial studies on O-arm navigation and its effect on the learning curve of percutaneous pedicle screw insertion

Joseph A. Sclafani, MD,1 Gilad J. Regev, MD,2 Jonathan Webb, MD,1 Steven R. Garfin, MD,1 Choll W. Kim, MD, PhD1,3

1Department of Orthopaedic Surgery, University of California, San Diego, CA 2Spine Surgery Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel 3Spine Institute of San Diego, Center for Minimally Invasive Spine Surgery at Alvarado Hospital, San Diego, CA



A quantitative screw accuracy system is proposed that allows for high-fidelity discrimination between various methods of pedicle screw insertion. Our purpose was to study the utility of a quantitative screw accuracy scoring system to assess new imaging technologies and their effects on the minimally invasive spine learning curve.


By use of a hypothetical “perfect screw,” a scoring system is proposed that may be used to compare the position of a small number of screws inserted according to a desired optimal position. This study incorporates a retrospective review of imaging studies for 10 patients who underwent percutaneous pedicle screw placement with either navigation-assisted O-arm imaging or navigation-assisted C-arm imaging. For the learning-curve portion of the study, 2 cadaveric adult torsos were used for instrumentation. Computed tomography imaging studies were used in both studies to assess screw position in the pedicle and vertebral body in relation to an optimal screw by use of a quantitative scoring system to rate accuracy.


The quantitative scoring system allowed a statistically significant accuracy difference to be ascertained between 2 different technologies using fewer data points than previously published methods. When this screw scoring system is applied to minimally invasive percutaneous pedicle screw insertion, an optimal screw position can be achieved with greater accuracy through navigation-assisted technology (O-arm with computer-assisted navigation). When the O-arm with computer-assisted navigation was used by a novice surgeon learning the technique of percutaneous screw insertion, screws were inserted in a shorter period without loss of accuracy. In contrast, use of the traditional C-arm fluoroscopy leads to a loss of accuracy with faster insertion times. Increased accuracy can be seen clinically when compared with fluoroscopic navigation.


The use of a quantitative scoring system allows for rapid assessment of screw accuracy. As additional technologies and new teaching techniques for pedicle screw insertion are developed, this scoring system may be useful as an early assessment tool.

Navigation, Image guidance, Minimally invasive surgery, Spinal Instrumentation, Scoring system
Volume 5 Issue 3