Robotic pedicle screw placement

Robotic pedicle screw placement

Robotic spinal fixation is associated with increased screw placement accuracy and similar operative blood loss, length of stay, and operative duration. These findings support the safety and cost-effectiveness of robotic spinal surgery across the spectrum of robotic systems and screw types 1).


In addition to demonstrating excellent pedicle screw accuracy, early studies have explored the impact of robot-assisted spine surgery on reducing radiation time, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. The Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic’s Stealth navigation technology into the Mazor X platform, which was introduced in 2016. It is unclear what the impact of these advancements have made on clinical outcomes.


In a multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, using Stealth led to significantly less fluoroscopic radiation time, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including length of stay, and 90-day complications were similar 2)

Ha Y. Robot-Assisted Spine Surgery: A Solution for Aging Spine Surgeons. Neurospine. 2018 Sep;15(3):187-188. doi: 10.14245/ns.18edi.003. Epub 2018 Sep 11. PubMed PMID: 30196675.


In three cadavers 12 pedicle screws were implanted in thoraco-lumbar segments with the robotic surgery assistant. 3D-fluoroscopy was performed for preoperative referencing, planning and identification of postoperative screw position. The radiation exposure of fluoroscopy and a CT scanner was compared, measuring the Computed Tomography Dose Index (CTDIw ).

Pedicle screw positioning was graded according to the Gertzbein-Robbins classification: Eleven of 12 pedicle screws showed optimal transpedicular position (Grade 1), one was positioned less than 2 mm outside (Grade 2). No major deviations were observed. Referencing with 3D-fluoroscopy resulted in a CTDIw reduction of 84% in the cervical- and 33% in the lumbar spine.

Robot-guided PS placement, using 3D-fluoroscopy for referencing, is a reliable tool for minimally invasive PS implantation; radiation exposure can be reduced 3).


Menger et al., investigated the cost effectiveness of adding robotic technology in spine surgery to an active neurosurgical practice.

The time of operative procedures, infection rates, revision rates, length of stay, and possible conversion of open to minimally invasive spine surgery (MIS) secondary to robotic image guidance technology were calculated using a combination of institution-specific and national data points. This cost matrix was subsequently applied to 1 year of elective clinical case volume at an academic practice with regard to payor mix, procedural mix, and procedural revenue.

A total of 1,985 elective cases were analyzed over a 1-year period; of these, 557 thoracolumbar cases (28%) were analyzed. Fifty-eight (10.4%) were MIS fusions. Independent review determined an additional ~10% cases (50) to be candidates for MIS fusion. Furthermore, 41.4% patients had governmental insurance, while 58.6% had commercial insurance. The weighted average diagnosis-related group reimbursement for thoracolumbar procedures for the hospital system was calculated to be $25,057 for Medicare and $42,096 for commercial insurance. Time savings averaged 3.4 minutes per 1-level MIS procedure with robotic technology, resulting in annual savings of $5,713. Improved pedicle screw accuracy secondary to robotic technology would have resulted in 9.47 revisions being avoided, with cost savings of $314,661. Under appropriate payor mix components, robotic technology would have converted 31 Medicare and 18 commercial patients from open to MIS. This would have resulted in 140 fewer total hospital admission days ($251,860) and avoided 2.3 infections ($36,312). Robotic surgery resulted in immediate conservative savings estimate of $608,546 during a 1-year period at an academic center performing 557 elective thoracolumbar instrumentation cases.

Application of robotic spine surgery is cost-effective, resulting in lesser revision surgery, lower infection rates, reduced length of stay, and shorter operative time. Further research is warranted, evaluating the financial impact of robotic spine surgery 4).


Several randomized controlled trials (RCTs) and cohort studies involving robotic-assisted (RA) and free-hand with fluoroscopy-guided (FH) and published before January 2017 were searched for using the Cochrane LibraryOvidWeb of SciencePubMed, and EMBASE databases. A total of 55 papers were selected. After the full-text assessment, 45 clinical trials were excluded. The final meta-analysis included 10 articles.

The accuracy of pedicle screw placement within the RA group was significantly greater than the accuracy within the FH group (odds ratio 95%, “perfect accuracy” confidence interval: 1.38-2.07, P < .01; odds ratio 95% “clinically acceptable” Confidence Interval: 1.17-2.08, P < .01).

There are significant differences in accuracy between RA surgery and FH surgery. It was demonstrated that the RA technique is superior to the conventional method in terms of the accuracy of pedicle screw placement 5).


In 2013 a study evaluated the outcomes of robotic-assisted screw placement in a consecutive series of 102 patients.

Data were recorded from technical notes and operative records created immediately following each surgery case, in which the robotic system was used to guide pedicle screw placement. All cases were performed at the same hospital by a single surgeon. The majority of patients had spinal deformity and/or previous spine surgery. Each planned screw placement was classified as: (1) successful/accurately placed screw using robotic guidance; (2) screw malpositioned using robot; (3) use of robot aborted and screw placed manually; (4) planned screw not placed as screw deemed non essential for construct stability. Data from each case were reviewed by two independent researchers to indentify the diagnosis, number of attempted robotic guided screw placements and the outcome of the attempted placement as well as complications or reasons for non-placement.

Robotic-guided screw placement was successfully used in 95 out of 102 patients. In those 95 patients, 949 screws (87.5 % of 1,085 planned screws) were successfully implanted. Eleven screws (1.0 %) placed using the robotic system were misplaced (all presumably due to “skiving” of the drill bit or trocar off the side of the facet). Robotic guidance was aborted and 110 screws (10.1 %) were manually placed, generally due to poor registration and/or technical trajectory issues. Fifteen screws (1.4 %) were not placed after intraoperative determination that the screw was not essential for construct stability. The robot was not used as planned in seven patients, one due to severe deformity, one due to very high body mass index, one due to extremely poor bone quality, one due to registration difficulty caused by previously placed loosened hardware, one due to difficulty with platform mounting and two due to device technical issues.

Of the 960 screws that were implanted using the robot, 949 (98.9 %) were successfully and accurately implanted and 11 (1.1 %) were malpositioned, despite the fact that the majority of patients had significant spinal deformities and/or previous spine surgeries. “Tool skiving” was thought to be the inciting issue with the misplaced screws. Intraoperative anteroposterior and oblique fluoroscopic imaging for registration is critical and was the limiting issue in four of the seven aborted cases 6).

Robotic pedicle screw placement learning curve.


1)

Himstead AS, Shahrestani S, Brown NJ, Produturi G, Shlobin NA, Al Jammal O, Choi EH, Ransom SC, Daniel Diaz-Aguilar L, Sahyouni R, Abraham M, Pham MH. Bony fixation in the era of spinal robotics: A systematic review and meta-analysis. J Clin Neurosci. 2022 Jan 19;97:62-74. doi: 10.1016/j.jocn.2022.01.005. Epub ahead of print. PMID: 35065405.
2)

Lee NJ, Zuckerman SL, Buchanan IA, Boddapati V, Mathew J, Leung E, Park PJ, Pham MH, Buchholz AL, Khan A, Pollina J, Mullin JP, Jazini E, Haines C, Schuler TC, Good CR, Lombardi JM, Lehman RA. Is There a Difference Between Navigated and Non-Navigated Robot Cohorts in Robot-Assisted Spine Surgery? A Multicenter, Propensity-Matched Analysis of 2,800 Screws and 372 Patients. Spine J. 2021 May 19:S1529-9430(21)00253-9. doi: 10.1016/j.spinee.2021.05.015. Epub ahead of print. PMID: 34022461.
3)

Spyrantis A, Cattani A, Seifert V, Freiman TM, Setzer M. Minimally invasive percutaneous robotic thoracolumbar pedicle screw implantation combined with three-dimensional-fluoroscopy can reduce radiation: a cadaver and phantom study. Int J Med Robot. 2019 Jun 19:e2022. doi: 10.1002/rcs.2022. [Epub ahead of print] PubMed PMID: 31216120.
4)

Menger RP, Savardekar AR, Farokhi F, Sin A. A Cost-Effectiveness Analysis of the Integration of Robotic Spine Technology in Spine Surgery. Neurospine. 2018 Aug 29. doi: 10.14245/ns.1836082.041. [Epub ahead of print] PubMed PMID: 30157583.
5)

Fan Y, Du JP, Liu JJ, Zhang JN, Qiao HH, Liu SC, Hao DJ. Accuracy of pedicle screw placement comparing robot-assisted technology and the free-hand with fluoroscopy-guided method in spine surgery: An updated meta-analysis. Medicine (Baltimore). 2018 Jun;97(22):e10970. doi: 10.1097/MD.0000000000010970. Review. PubMed PMID: 29851848; PubMed Central PMCID: PMC6392558.
6)

Hu X, Ohnmeiss DD, Lieberman IH. Robotic-assisted pedicle screw placement: lessons learned from the first 102 patients. Eur Spine J. 2013 Mar;22(3):661-6. doi: 10.1007/s00586-012-2499-1. Epub 2012 Sep 14. PubMed PMID: 22975723; PubMed Central PMCID: PMC3585630.

Subdural drain for chronic subdural hematoma

Subdural drain for chronic subdural hematoma

see also Subdural Evacuating Port System.

Little is known about the best type of drainage system and its relationship with recurrence. In a study, Takroni et al. compared the use of two drainage systems on the recurrence rate of CSDH. They retrospectively analyzed the charts of 180 CSDH patients treated with bedside twist drill craniostomy (TDC) and subdural drain insertion. Patients were divided into two groups: Group A (n=123) received our traditional drain (pediatric size nasogastric tube (NGT), while group B (n=49) had the external ventricular drain (EVD). Various demographic and radiological data were collected. Our main outcome was recurrence, defined as symptomatic re-accumulation of hematoma on the previously operated side within 3 months. Results 212 cases of subdural hematoma were treated in 172 patients. Majority of patients were male (78%) and had a history of previous head trauma (73%). 17 cases had recurrence, 11 in the NGT group drain and 6 in the EVD group. The use of antiplatelet or anticoagulation agents was associated with recurrence (P= 0.038 and 0.05, respectively). There was no difference between both groups in terms of recurrence [OR=1.42, 95% CI:0.49 to 4.08, P=0.573].

Chronic subdural hematoma is a common disease with a high rate of recurrence. Although using a drain postoperatively has shown to improve the incidence of recurrence, little remains known about the best type of drain to use. The analysis showed no difference in the recurrent rate between using the pediatric size NGT and the EVD catheter post TDC 1).


There is some evidence that postoperative drainage is effective in reducing the symptomatic recurrence of chronic subdural hematoma surgery. Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate. Due to the low quality of the evidence for the secondary outcomes, the effect of drainage on the occurrence of surgical complications, mortality and poor functional outcome is uncertain. This uncertainty can be clarified with data from high-quality studies which may be conducted in the future. There is no strong evidence of any increase in complications when drains are used 2).


Soleman et al. administered a survey to neurosurgeons worldwide with questions relating to the surgical treatment of chronic subdural hematoma, with an emphasis on their practices concerning the use of a drain.

The preferred surgical technique was burr-hole drainage (89%). Most surgeons prefer to place a drain (80%), whereas in 56% of the cases the reason for not placing a drain was brain expansion after evacuation. Subdural drains are placed by 50% and subperiosteal drains by 27% of the responders, whereas 23% place primarily a subdural drain if possible and otherwise a subperiosteal drain. Three quarters of the responders leave the drain for 48 hours and give prophylactic antibiotic treatment, mostly a single-shot dose intraoperatively (70%). Routine postoperative computed tomography is done by 59% mostly within 24-48 hours after surgery (94%). Adjunct treatment to surgery rarely is used (4%).

The publication of grade I evidence in favor of drain use influenced positively this practice worldwide. Some surgeons are still reluctant to insert a drain, especially when the subdural space is narrow after drainage of the hematoma. The insertion of a subperiosteal drain could be a good alternative solution. However, its outcome and efficacy must be evaluated in larger studies 3).


Tommiska et al., conducted a retrospective observational study including consecutive patients undergoing burr hole trephinations for chronic subdural hematomas (CSDHs). They compared outcomes between a six-month time period when the SD placement was arbitrary (July to December 2015) and a time period when subdural drain (SD) placement for 48 h was routine (July to December 2017). The primary outcome of interest was recurrences requiring reoperation within six months. Furthermore, patient outcomeinfections and other complications were assessed.

A total of 161 patients were included, of which 71 (44%) were in the SD group and 90 (56%) in the non-drain group. There were no differences in age, comorbidities, history of trauma or use of antithrombotic medication between the groups (p>0.05). Recurrences within six months occurred in 18% of patients in the non-drain group compared to 6% in the SD group (p=0.028; OR 0.28; 95% CI 0.09-0.87). There were no differences in neurological outcome (p=0.72), mortality rate (p=0.55), infection rate (p=0.96) or other complications (p=0.20).

The change in practice from no drain to SD after burr-hole craniostomies for CSDHs effectively reduced the six-month recurrence rate without any effect on patient outcome, infections or other complications 4).

Subdural drain for chronic subdural hematoma complications.


1)

Takroni R, Zagzoog N, Patel N, Martyniuk A, Farrokhyar F, Singh S, Trivedi A, Alotaibi M, Algird A. Comparison of two drainage systems on chronic subdural hematoma (CSDH) recurrence. J Neurol Surg A Cent Eur Neurosurg. 2021 Nov 16. doi: 10.1055/a-1698-6212. Epub ahead of print. PMID: 34784622.
2)

Peng D, Zhu Y. External drains versus no drains after burr-hole evacuation for the treatment of chronic subdural haematoma in adults. Cochrane Database Syst Rev. 2016 Aug 31;(8):CD011402. doi: 10.1002/14651858.CD011402.pub2. Review. PubMed PMID: 27578263.
3)

Soleman J, Kamenova M, Lutz K, Guzman R, Fandino J, Mariani L. Drain Insertion in Chronic Subdural Hematoma: An International Survey of Practice. World Neurosurg. 2017 Aug;104:528-536. doi: 10.1016/j.wneu.2017.04.134. Epub 2017 Apr 28. PubMed PMID: 28461277.
4)

Tommiska P, Lönnrot K, Raj R, Luostarinen T, Kivisaari R. Transition of a clinical practice to use of subdural drains after burr-hole evacuation of chronic subdural haematomas: The Helsinki experience. World Neurosurg. 2019 May 31. pii: S1878-8750(19)31507-4. doi: 10.1016/j.wneu.2019.05.230. [Epub ahead of print] PubMed PMID: 31158547.

Gelatin Sponge

Gelatin Sponge

see Spongostan.

see also Hemostat.


Expanding the range of medical sponges and researching new excipients for their manufacture are a promising area of modern medicine and pharmacy 1).


Gelatin sponge is a non-antigenic protein that can absorb 45 times its weight in blood, and, when wet, is plastered to the irregularities of the bleeding surface. It enables the repair of torn veins, such as the superior sagittal sinus, without compromising the patency of the vessel 2).


Many ablative procedures are effective for hemifacial spasm (HFS) (including sectioning of divisions of the facial nerve), however, this leaves the patient with some degree of facial paresis. The current procedure of choice for HFS is microvascular decompression (MVD) wherein the offending vessel is physically moved off of the nerve, and a sponge (e.g. Ivalon®, polyvinyl formyl alcohol foam) is interposed as a cushion.


For Chang et al. from the Department of Neurosurgery Xinhua Hospital in hemifacial spasm (HFS) patients undergoing microvascular decompression (MVD) , using Teflon plus gelatin sponge can remarkably reduce the incidence of recurrence, facial palsy, and hearing loss compared with those using Teflon alone 3).


A study proves that, during the dural closure, placing a thin layer of gelatin sponge in the subdural space is a safe and effective method for preventing meningocerebral adhesions 4)


1)

Pavliuk B, Chubka M, Hroshovyi T, Stechyshyn I. Characteristics of structured medical hemostatic sponges as a medical devices for stop bleeding and for close the wound. Pol Merkur Lekarski. 2020 Dec 22;48(288):422-426. PMID: 33387430.
2)

Signorelli F, Montano N. Use and Efficacy of Hemostats in Neurosurgery. Surg Technol Int. 2020 Nov 28;37:414-419. PMID: 32944921.
3)

Chang B, Tang Y, Wei X, Li S. A New Application of Gelatin Sponge in the Treatment of Hemifacial Spasm by Microvascular Decompression: A Technical Note. J Neurol Surg A Cent Eur Neurosurg. 2021 May 19. doi: 10.1055/s-0040-1720994. Epub ahead of print. PMID: 34010981.
4)

Gonzalez-Lopez P, Harput MV, Türe H, Atalay B, Türe U. Efficacy of placing a thin layer of gelatin sponge over the subdural space during dural closure in preventing meningo-cerebral adhesion. World Neurosurg. 2015 Jan;83(1):93-101. doi: 10.1016/j.wneu.2014.02.032. Epub 2014 Feb 19. PubMed PMID: 24560706.
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