Minim Invasive Neurosurg 2010; 53(4): 184-190
DOI: 10.1055/s-0030-1267926
Original Article

© Georg Thieme Verlag KG Stuttgart · New York

Iso-C/3-Dimensional Neuronavigation versus Conventional Fluoroscopy for Minimally Invasive Pedicle Screw Placement in Lumbar Fusion

J. Fraser1 , H. Gebhard1 , 2 , D. Irie1 , K. Parikh1 , R. Härtl1
  • 1Department of Neurosurgery, Weill Cornell Medical College, New York, New York, USA
  • 2Department of Trauma Surgery, Technical University Munich, Munich, Germany
Further Information

Publication History

Publication Date:
07 December 2010 (online)


Background: Minimally invasive spinal surgery (MISS) has evolved over the past years due to the combination of microsurgery, minimal access strategies and neuronavigation. Percutaneous or mini-open pedicle screw placement is a challenge, especially for surgeons not experienced in the use of biplanar fluoroscopy or stereotactic imaging techniques. The aim of the study was to compare the precision of pedicle screw fixation for lumbar fusion procedures using Iso-C/stereotactic 3D neuronavigation (3D NAV) vs. standard AP/lateral fluoroscopy (2D NAV).

Methods: Our first 42 patients undergoing MISS for one- or 2-level lumbar or lumbosacral fusion procedures for degenerative lumbar pathology were included in this study. Either 3D NAV (n=29) or standard fluoroscopy (n=13) was used to aid screw placement. Demographics, operative time, blood loss, and screw placement accuracy were evaluated. Screw placement was evaluated postoperatively using lumbar CT scanning. Accuracy of 3D NAV was evaluated by comparing intraoperative planning screenshots to postoperative CT placement of screws.

Results: There were no significant differences between groups for mean age, gender or intraoperative blood loss. 90.9% of 3D NAV screws and 73.7% of fluoroscopy screws had no pedicle perforation (p=0.04). Intraoperative navigation screenshots accurately predicted pedicle screw placement in 90.9% of cases. There was a positive correlation between 3D NAV accuracy and better screw grade (rs 0.45, p=0.036).

Conclusions: Utilization of 3D NAV for percutaneous or mini-open lumbar screw placement during the early learning curve for MISS was associated with higher screw accuracy. This study demonstrates that the use of 3D navigation can facilitate the learning curve for MISS.


  • 1 Perez-Cruet MJ, Foley KT, Isaacs RE. et al . Microendoscopic lumbar discectomy: technical note.  Neurosurgery. 2002;  51 S129-S136
  • 2 Hsieh PC, Koski TR, Sciubba DM. et al . Maximizing the potential of minimally invasive spine surgery in complex spinal disorders.  Neurosurg Focus. 2008;  25 E19
  • 3 O’Toole JE, Eichholz KM, Fessler RG. Minimally invasive far lateral microendoscopic discectomy for extraforaminal disc herniation at the lumbosacral junction: cadaveric dissection and technical case report.  Spine J. 2007;  7 414-421
  • 4 Tredway TL, Santiago P, Hrubes MR. et al . Minimally invasive resection of intradural-extramedullary spinal neoplasms.  Neurosurgery. 2006;  58 ONS52-ONS58 discussion ONS52–ONS58
  • 5 Kawaguchi Y, Yabuki S, Styf J. et al . Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery.  Spine. 1996;  21 2683-2688
  • 6 Kawaguchi Y, Matsui H, Tsuji H. Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis.  Spine. 1996;  21 941-944
  • 7 Weber BR, Grob D, Dvorak J. et al . Posterior surgical approach to the lumbar spine and its effect on the multifidus muscle.  Spine. 1997;  22 1765-1772
  • 8 Sihvonen T, Herno A, Paljarvi L. et al . Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome.  Spine. 1993;  18 575-581
  • 9 Berlemann U, Monin D, Arm E. et al . Planning and insertion of pedicle screws with computer assistance.  J Spinal Disord. 1997;  10 117-124
  • 10 Laine T, Schlenzka D, Makitalo K. et al . Improved accuracy of pedicle screw insertion with computer-assisted surgery. A prospective clinical trial of 30 patients.  Spine. 1997;  22 1254-1258
  • 11 Schwarzenbach O, Berlemann U, Jost B. et al . Accuracy of computer-assisted pedicle screw placement. An in vivo computed tomography analysis.  Spine. 1997;  22 452-458
  • 12 Nolte L, Zamorano L, Arm E. et al . Image-guided computer-assisted spine surgery: a pilot study on pedicle screw fixation.  Stereotact Funct Neurosurg. 1996;  66 108-117
  • 13 Nolte LP, Zamorano L, Visarius H. et al . Clinical evaluation of a system for precision enhancement in spine surgery.  Clin Biomech (Bristol, Avon). 1995;  10 293-303
  • 14 Merloz P, Tonetti J, Pittet L. et al . Pedicle screw placement using image guided techniques.  Clin Orthop Relat Res. 1998;  39-48
  • 15 Richter M, Cakir B, Schmidt R. Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws.  Spine. 2005;  30 2280-2287
  • 16 Richter M, Mattes T, Cakir B. Computer-assisted posterior instrumentation of the cervical and cervico-thoracic spine.  Eur Spine J. 2004;  13 50-59
  • 17 Rajasekaran S, Vidyadhara S, Ramesh P. et al . Randomized clinical study to compare the accuracy of navigated and non-navigated thoracic pedicle screws in deformity correction surgeries.  Spine. 2007;  32 E56-E64
  • 18 Parikh K, Tomasino A, Knopman J. et al . Operative results and learning curve: microscope-assisted tubular microsurgery for 1- and 2-level discectomies and laminectomies.  Neurosurg Focus. 2008;  25 E14
  • 19 Palmer S, Turner R, Palmer R. Bilateral decompression of lumbar spinal stenosis involving a unilateral approach with microscope and tubular retractor system.  J Neurosurg. 2002;  97 213-217
  • 20 Palmer S. Use of a tubular retractor system in microscopic lumbar discectomy: 1 year prospective results in 135 patients.  Neurosurg Focus. 2002;  13 E5
  • 21 Hott JS, Deshmukh VR, Klopfenstein JD. et al . Intraoperative Iso-C C-arm navigation in craniospinal surgery: the first 60 cases.  Neurosurgery. 2004;  54 1131-1136 ; discussion 1136-1137
  • 22 Hott JS, Papadopoulos SM, Theodore N. et al . Intraoperative Iso-C C-arm navigation in cervical spinal surgery: review of the first 52 cases.  Spine. 2004;  29 2856-2860
  • 23 Braun V, Rath SA, Antoniadis G. et al . In vivo experiences with frameless stereotactically guided screw placement in the spine − results from 75 consecutive cases.  Neurosurg Rev. 2001;  24 74-79


R. Härtl

Departent of Neurosurgery

Brain and Spine Center

Weill Cornell Medical College

1300 York Ave

10065 New York


Phone: +1/212/746 5543

Fax: +1/212/746-8947