BACKGROUND CONTEXT

An increasing number of medical centers are adopting an intraoperative computed tomography (iCT) navigation system (iCT-Navi) to provide three-dimensional navigation for pediatric scoliosis surgery. While iCT-Navi has been reported to provide higher pedicle screw (PS) insertion accuracy, it may also result in higher radiation exposure to the patient. What innovations and studies have been introduced to reduce radiation exposure and further improve PS insertion?

PURPOSE

Evaluate the level of evidence and quality of papers while categorizing the tips and pitfalls regarding pediatric scoliosis surgery using iCT-Navi. Compare iCT-Navi with other methods, including preoperative CT navigation.

STUDY DESIGN

Systematic review.

PATIENT SAMPLE

Articles on pediatric scoliosis surgery with iCT-Navi published through to June 2022.

OUTCOME MEASURES

PS perforation rate and patient intraoperative radiation dose.

METHODS

Following PRISMA guidelines, the Cochrane Library, Google Scholar, and PubMed databases were searched for articles satisfying the criteria of iCT-Navi use and pediatric scoliosis surgery. The level of evidence and quality of the articles meeting the criteria were evaluated according to the guidelines of the North American Spine Society and American Academy of Orthopedic Surgeons, respectively. The articles were also categorized by theme and summarized in terms of PS insertion accuracy and intraoperative radiation dose. The origins and characteristics of five major classification methods of PS perforation grade were summarized as well.

RESULTS

The literature search identified 811 studies, of which 20 papers were included in this review. Overall, 513 pediatric scoliosis patients (381 idiopathic, 44 neuromuscular, 39 neurofibromatosis type 1, 28 congenital, 14 syndromic, seven other) were evaluated for PS perforations among 6,209 iCT-Navi insertions. We found that 232 (3.7%) screws were judged as major perforations (G2 or G3), 55 (0.9%) screws were judged as dangerous deviations (G3), and seven (0.1%) screws were removed. There were no reports of neurovascular injury caused by PSs. The risk factors for PS perforation included more than six vertebrae distance from the reference frame, more than nine consecutive insertions, upper thoracic level, thinner pedicle, upper instrumented vertebra proximity, short stature, and female. The accuracy of PS insertion did not remarkably decrease when the radiation dose was reduced to 1/5 or 1/10 by altering the iCT-Navi protocol.

CONCLUSIONS

iCT-Navi has the potential to reduce PS perforation rates compared with other methods. The use of low-dose radiation protocols may not significantly affect PS perforation rates. Although several risk factors for PS perforation and measures to reduce radiation dose have been reported, the current evidence is limited by a lack of consistency in classifying PS perforation and evaluating patient radiation dose among studies. The standardization of several outcome definitions is recommended in this rapidly developing field.

中文翻译：

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小儿脊柱侧弯术中 CT 导航提高准确性和减少辐射暴露的技巧和陷阱：系统评价

背景语境

越来越多的医疗中心采用术中计算机断层扫描 (iCT) 导航系统 (iCT-Navi) 为小儿脊柱侧凸手术提供三维导航。虽然据报道 iCT-Navi 可提供更高的椎弓根螺钉 (PS) 插入精度，但它也可能导致患者受到更高的辐射。引入了哪些创新和研究来减少辐射暴露并进一步改善 PS 插入？

目的

评估证据水平和论文质量，同时使用 iCT-Navi 对有关小儿脊柱侧凸手术的技巧和陷阱进行分类。比较 iCT-Navi 与其他方法，包括术前 CT 导航。

学习规划

系统审查。

患者样本

截至 2022 年 6 月，关于使用 iCT-Navi 进行小儿脊柱侧弯手术的文章已发表。

结果测量

PS 穿孔率和患者术中辐射剂量。

方法

按照 PRISMA 指南，在 Cochrane 图书馆、谷歌学术搜索和 PubMed 数据库中搜索了满足 iCT-Navi 使用和小儿脊柱侧弯手术标准的文章。符合标准的文章的证据水平和质量分别根据北美脊柱学会和美国骨科医师学会的指南进行评估。这些文章还按主题分类，并根据 PS 插入准确性和术中辐射剂量进行了总结。总结了PS穿孔等级五种主要分类方法的起源和特点。

结果

文献检索确定了 811 项研究，其中 20 篇论文被纳入本综述。总体而言，513 名儿童脊柱侧凸患者（381 名特发性、44 名神经肌肉性、39 名神经纤维瘤病 1 型，28 个先天性，14 个综合征，7 个其他）在 6,209 个 iCT-Navi 插入中评估 PS 穿孔。我们发现 232 颗 (3.7%) 螺钉被判断为主要穿孔（G2 或 G3），55 颗（0.9%）螺钉被判断为危险偏差（G3），7 颗（0.1%）螺钉被移除。没有关于 PSs 引起神经血管损伤的报道。PS 穿孔的危险因素包括与参考框架的椎骨距离超过 6 个、连续插入超过 9 个、上胸椎水平、椎弓根较薄、上仪表椎接近、身材矮小和女性。当通过改变 iCT-Navi 协议将辐射剂量减少到 1/5 或 1/10 时，PS 插入的准确性没有显着降低。

结论

与其他方法相比，iCT-Navi 具有降低 PS 穿孔率的潜力。使用低剂量辐射方案可能不会显着影响 PS 穿孔率。尽管已经报道了 PS 穿孔的几个危险因素和减少辐射剂量的措施，但目前的证据受到在 PS 穿孔分类和评估患者辐射剂量方面缺乏一致性的限制。在这个快速发展的领域中，建议对几个结果定义进行标准化。