This study was supported by the Okayama Spine Group.

This study was approved by the ethics committee at Okayama Rosai Hospital (No. 201-3).
1. Patient examination
<ol>
	<li>History taking
	<ol>
		<li>Evaluate a patient with a suspected herniated disc or stenosis by taking their history. Usually, the patient presents with a history of prodromal low back pain. The patient may correlate their symptoms with an episode of trauma.</li>
		<li>Ask the patient to describe the radiating leg pain, its location, and aggravating and relieving activities.</li>
	</ol>
	</li>
	<li>Physical examination
	<ol>
		<li>To determine the level of the affected nerve, look for signs of motor weakness or loss of sensation in the leg. Check the lumbar range of motion, the straight leg raise (SLR) test, deep tendon reflexes, and muscle weakness.</li>
		<li>Perform the Kemp test to check the location of the herniated discs. If the Kemp test yields a positive result, local pain suggests a facet pathology, while radiating pain into the leg is more suggestive of nerve root irritation, which frequently accompanies foraminal disc herniation or stenosis. 
		NOTE: Usually, the SLR test is negative for patients with lumbar canal stenosis and positive for patients with lumbar disc herniation.</li>
	</ol>
	</li>
</ol>
2. Evaluation of images
<ol>
	<li>Magnetic resonance imaging (MRI)
	<ol>
		<li>Perform an MRI. This is the most accurate diagnostic modality for assessing lumbar disc herniation, showing the site of herniation and the nerve roots affected. The L5 nerve root can be compressed by fibrocartilage at the pars interarticularis of L5.</li>
	</ol>
	</li>
	<li>Computed tomography (CT)
	<ol>
		<li>Use CT to check whether the herniated disc is calcified and to rule out nerve compression by any osteophyte.</li>
	</ol>
	</li>
	<li>CT-MRI fusion imaging
	<ol>
		<li>Use the fusion image to evaluate the feasibility of performing OLIF51. The vascular window, made by the common iliac vessels at the L5-S1 disc level, is clearly visualized. A vascular window of less than 20 mm makes OLIF technically difficult (Figure 1).</li>
	</ol>
	</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63572/63572fig01.jpg" /> 
Figure 1: Preoperative image. (A) Midsagittal reconstruction CT, (B) T2 weighted midsagittal image, (C) CT MRI fusion image. CT and MRI show grade 2 isthmic spondylolisthesis. The vascular window is 37 mm. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
3. Patient positioning and neuromonitoring
<ol>
	<li>Patient positioning
	<ol>
		<li>Place the patient in a right lateral decubitus position on a carbon table. Use an O-arm to obtain 3D images of the lumbar spine of the patient (Figure 2).</li>
		<li>To protect the neurovascular structures, place an axillary roll underneath the patient&#39;s right axilla.</li>
		<li>Flex the hip and knee to 20&#176; to relax the psoas muscle and the lumbar nerve. Secure the patient to the table with tape.</li>
		<li>Insert a percutaneous reference pin into the left sacroiliac joint.</li>
		<li>Obtain 3D images of the O-arm and transmit them to the navigation system.</li>
	</ol>
	</li>
	<li>Neuromonitoring
	<ol>
		<li>Whenever possible, neuromonitor the patient to prevent neurological complications (Figure 3).</li>
	</ol>
	</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63572/63572fig02.jpg" /> 
Figure 2: Patient positioning. Right lateral decubitus position secured with tape. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/63572/63572fig03.jpg" /> 
Figure 3: Neuromonitoring. Neuromonitoring is preferable for this technique. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
4. Intraoperative CT and spinal navigation
<ol>
	<li>Intraoperative CT
	<ol>
		<li>Place a navigation reference frame (RF) percutaneously into the contralateral sacroiliac joint or L5 spinous process, and obtain intraoperative CT images (Figure 4).</li>
	</ol>
	</li>
	<li>Navigation
	<ol>
		<li>The navigation system is necessary for this technique. Transmit the CT 3D reconstructed images to the navigation system (Figure 5).</li>
	</ol>
	</li>
</ol>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/63572/63572fig04.jpg" /> 
Figure 4: O-arm. One O-arm scan is just 23 s. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/63572/63572fig05.jpg" /> 
Figure 5: Navigation system. Every instrument is navigated with this system. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
5. Navigated instrument registration
<ol>
	<li>Register every navigated instrument and perform an accuracy check.</li>
</ol>
6. Incision and muscle dissection
<ol>
	<li>Skin incision
	<ol>
		<li>Mark the skin incision using a navigated pointer. Direct the entry point to the center and parallel to the L5-S1 disc space.</li>
		<li>Make a 4 cm long oblique incision on the skin, 4 cm medial to the anterior superior iliac spine and parallel to the pelvis (Figure 6).</li>
	</ol>
	</li>
	<li>Muscle dissection
	<ol>
		<li>Divide the abdominal muscles and dissect along the line of the skin incision. A monopolar cautery is contraindicated due to the risk of injury to the iliohypogastric and ilioinguinal nerves.</li>
		<li>With a retroperitoneal approach, use both index fingers to dissect the retroperitoneal space, following the internal abdominal wall posteriorly down to the psoas muscle, which can then be visualized (Figure 7). 
		CAUTION: If the iliohypogastric nerve is injured, abdominal herniation may occur.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/63572/63572fig06.jpg" /> 
Figure 6: Skin incision. The skin is marked using a navigated pointer, which is directed to the center and parallel to the L5-S1 <a href="https://www.jove.com/files/ftp_upload/63572/63572fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/63572/63572fig07.jpg" /> 
Figure 7: Navigated pointer. The white arrow indicates a navigated pointer. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
7. Disc preparation and trialing
<ol>
	<li>Disc preparation
	<ol>
		<li>After exposing the promontorium, identify the left common iliac vessels and retract laterally (upward) using a special self-retaining retractor under illumination. Take great care to preserve the left ureter. The L5/S1 intervertebral disc is exposed (Figure 8).</li>
		<li>Retract both common iliac vessels and the bifurcation with three self-retaining retractors. A blunt dissection of the adventitial layers on the L5/S1 disc is necessary to not injure the sympathetic chain. Retrograde ejaculation may occur in male patients if the sympathetic chain is injured.</li>
		<li>After the center of the disc is marked with a navigated pointer, incise the annulus with a knife, and perform a discectomy using Kerrison rongeurs, pituitary forceps, a navigated Cobb elevator, a navigated shaver (Figure 10), a navigated combo tool (periosteum elevator), and a navigated curved curette (Figure 11).</li>
		<li>Use the navigated curved curette to remove the posterior part of the disc. 
		NOTE: Since all the instruments are navigated, the use of an intraoperative C-arm is not required.</li>
	</ol>
	</li>
	<li>Trialing
	<ol>
		<li>After disc preparation, sequentially distract the disc space using navigated trials. Determine the size of the cage on a preoperative lateral radiogram. For Asian patients, a disc height of 10-14 mm and an angulation of 12&#176;-18&#176; is advisable.</li>
		<li>At this step, perform intraoperative radiography to check the implant position and the size of the cage. If the cage protrudes beyond the disc space, choose another adequately sized cage (Figure 12). 
		CAUTION: The surgeon should check the accuracy of the navigation system before using the navigation instruments, as the reference frame may sometimes be accidentally altered. Unlike the C-arm, the disc space in the navigation image does not open on insertion of a trial with an adequate height.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/63572/63572fig08.jpg" /> 
Figure 8: Approach to the promontorium. (A) Navigated pedicle probe, (B) navigation monitor.&#160;A navigated pedicle probe (white arrow) is used to check the L5-S1 disc level.&#160;<a href="https://www.jove.com/files/ftp_upload/63572/63572fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/63572/63572fig09.jpg" /> 
Figure 9: Self-retaining retractors. These three retractors retract both common iliac vessels and the bifurcation. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/63572/63572fig10.jpg" /> 
Figure 10: Navigated shaving. (A) Navigated shaver, (B) navigation monitor. Navigated shavers are from 6 mm to 12 mm. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig10large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 11" class="xfigimg" src="/files/ftp_upload/63572/63572fig11.jpg" /> 
Figure 11: Navigated curved curette. (A) Navigated curved curette, (B) navigation monitor. A navigated curved curette is very useful to completely remove the posterior part of the disc. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig11large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 12" class="xfigimg" src="/files/ftp_upload/63572/63572fig12.jpg" /> 
Figure 12: Trialing. After disc preparation, the disc space is sequentially distracted with navigated trials (white arrow). <a href="https://www.jove.com/files/ftp_upload/63572/63572fig12large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
8. Cage placement and screwing
<ol>
	<li>Cage placement
	<ol>
		<li>Insert a mixture of autogenous bone and demineralized bone material into the cage hole. Confirm the angle of insertion for the cage with a navigation pointer to insert the OLIF51 cage accurately.</li>
		<li>Use a mallet to gently insert the OLIF51 cage. After the implant is positioned, take anteroposterior and lateral radiographs to confirm the position of the cage (Figure 13A).</li>
	</ol>
	</li>
	<li>Screwing
	<ol>
		<li>After cage insertion, insert one or two supplemental screws to prevent cage back-out (Figure 13B).</li>
	</ol>
	</li>
</ol>
<img alt="Figure 13" class="xfigimg" src="/files/ftp_upload/63572/63572fig13.jpg" /> 
Figure 13: Cage placement and screwing. (A) OLIF51 cage at the L5-S1 disc, (B) cage with screw. A mixture of autogenous bone and demineralized bone material is inserted into the cage hole. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig13large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
9. Simultaneous percutaneous pedicle screw (PPS) fixation
<ol>
	<li>Have another surgeon insert the PPSs in the same lateral decubitus position of the patient under navigation guidance.</li>
	<li>Make the screw hole with a navigated high-speed burr, navigated pedicle probe, and navigated tap. Measure the length and diameter of the screws by navigation.</li>
	<li>Insert the S1 PPS in a transdiscal manner to enhance the screw pullout strength.</li>
	<li>Take radiograms after the insertion of the screws (Figure 14).</li>
</ol>
<img alt="Figure 14" class="xfigimg" src="/files/ftp_upload/63572/63572fig14.jpg" /> 
Figure 14: Simultaneous PPS fixation. PPSs are inserted in the same single lateral position by another surgeon under navigation guidance. <a href="https://www.jove.com/files/ftp_upload/63572/63572fig14large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
10. Postoperative procedure
<ol>
	<li>Ambulate the patient 1 day after the surgery. The use of a soft brace is recommended for 3 months. Follow-up at 3 months, 6 months, and 12 months after the surgery to assess for solid bony fusion.</li>
</ol>

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The authors declare that there are no conflicts of interest.

Recently, the lateral lumbar approach for interbody fusion has been gaining popularity due to its minimal invasiveness9. Among these approaches, the direct lateral psoas splitting approach has several disadvantages, such as lumbar nerve plexus injury and psoas muscle weakness10. To reduce these complications, prepsoas or OLIF was introduced by Davis et al. in 201411. However, it is difficult to operate at the L5-S1 disc due to its anatomical features...

Spondylosis is regarded as a stress fracture1 and occurs in about 5% of the young adult population2. The most common level of occurrence is at the L5 level due to the unique shearing force applied at the L5-S1 area. The main symptoms of spondylosis and spondylolisthesis are low back pain, leg pain, and numbness. If conservative treatment proves ineffective, surgical treatment is recommended3. Transforaminal lumbar interbody fusion (TLIF) is an effective and established technique4, but the nonunion rate of this procedure is relatively higher at the L5-S1 level5. Furthermore, with TLIF, it is difficult to create adequate lordosis compared to oblique lumbar interbody fusion (OLIF) or anterior lumbar interbody fusion (ALIF)6.
Indirect decompressions such as ALIF or OLIF are currently common methods for treating lumbar stenosis7. However, the conventional ALIF technique causes a large amount of muscle damage. Oblique lateral interbody fusion at the L5-S1 level (OLIF51) was first reported in 20178. Posterior instrument augmentation is usually necessary to ensure solid fusion, but the conventional OLIF technique uses a C-arm, and the patient position is changed from lateral to prone. To overcome these problems, we report herein a novel technique of C-arm-free simultaneous OLIF51 and percutaneous pedicle screws (PPSs) in a single lateral position. 
We introduce the case of a 75-year-old woman with symptomatic L5 spondylolisthesis (grade 2).

<table><tbody><tr><td>Adjustable hinged operating carbon table</td><td>Mizuho OSI</td><td>6988A-PV-ACP</td><td>OSI Axis Jackson table</td></tr><tr><td>CD Horizon Solera Voyager</td><td>Medtronic</td><td>6.4317E+11</td><td>Percutaneous pedicle screw system</td></tr><tr><td>Navigated Cobb elevator</td><td>Medtronic</td><td>NAV2066</td><td></td></tr><tr><td>Navigated combo tool</td><td>Medtronic</td><td>NAV2068</td><td></td></tr><tr><td>Navigated curette</td><td>Medtronic</td><td>NAV2069</td><td></td></tr><tr><td>Navigated high speed bur</td><td>Medtronic</td><td>EM200N</td><td>Stelth</td></tr><tr><td>Navigated passive pointer</td><td>Medtronic</td><td>960-559</td><td></td></tr><tr><td>Navigated pedicle probe</td><td>Medtronic</td><td>9734680</td><td></td></tr><tr><td>Navigated shaver</td><td>Medtronic</td><td>NAV2071</td><td></td></tr><tr><td>NIM Eclipse system</td><td>Medtronic</td><td>ECLC</td><td>Neuromonitouring</td></tr><tr><td>O-arm</td><td>Medtronic</td><td>224ABBZX00042000</td><td>Intraoperative CT</td></tr><tr><td>Radiolucent open spine cramp</td><td>Medtronic</td><td>9731780</td><td></td></tr><tr><td>Self-retaining retractor</td><td>Medtronic</td><td>29B2X10008MDT151</td><td></td></tr><tr><td>Sovereign Spinal System</td><td>Medtronic</td><td>6.4317E+11</td><td>OLIF51 cage</td></tr><tr><td>Spine small passive frame</td><td>Medtronic</td><td>9730605</td><td></td></tr><tr><td>Stealth station navigation system Spine 7&lt;sup&gt;R&lt;/sup&gt;</td><td>Medtronic</td><td>9733990</td><td>Navigation</td></tr><tr><td>U-NavLock Gray</td><td>Medtronic</td><td>9734590</td><td></td></tr><tr><td>U-NavLock Green</td><td>Medtronic</td><td>9734734</td><td></td></tr><tr><td>U-NavLock Orange</td><td>Medtronic</td><td>9734683</td><td></td></tr><tr><td>U-NavLock Violet</td><td>Medtronic</td><td>9734682</td><td></td></tr></tbody></table>

c-arm-free simultaneous olif51 and percutaneous pedicle screw fixation in a single lateral position

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 level (OLIF51) is technically difficult because of the anatomical structures. We present a novel simultaneous technique of OLIF51 with percutaneous pedicle screw fixation without fluoroscopy. The patient is placed in a right lateral decubitus position. A percutaneous reference pin is inserted into the right sacroiliac joint. An O-arm scan is performed, and 3D reconstructed images are transmitted to the spinal navigation system. A 4 cm oblique skin incision is made under navigation guidance along the pelvis. The internal/external and transverse abdominal muscles are divided along the muscle fibers, protecting the iliohypogastric and ilioinguinal nerves. Using a retroperitoneal approach, the left common iliac vessels are identified. Special muscle retractors with illumination are used to expose the L5-S1 intervertebral disc. After disc preparation with navigated instruments, the disc space is distracted with navigated trials. Autogenous bone and demineralized bone material are then inserted into the cage hole. The OLIF51 cage is inserted into the disc space with the help of a mallet. Simultaneously, percutaneous pedicle screws are inserted by another surgeon without changing the lateral decubitus position of the patient.
In conclusion, C-arm-free OLIF51 and simultaneous percutaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This novel technique reduces surgical time and radiation hazards.

Fourteen cases (average age: 71.5 years) were treated using this new technique. They were compared to 40 cases (average age: 74.0 years) of L5-S1 TLIF. L5-S1 lordosis angle and disc height were measured in both groups. The OLIF51 group obtained a better L5-S1 lordosis than the TLIF 51 group (Figure 15).
<img alt="Figure 15" class="xfigimg" src="/files/ftp_upload/63572/63572fig15.jpg" /> 
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Watch this Scientific Journal Video about C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position at JoVE.com

C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

C-arm-free oblique lumbar interbody fusion at the L5-S1 level (OLIF51) and simultaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This technique does not expose the surgeon or operating staff to radiation hazards.

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 ...

c-arm-free-simultaneous-olif51-percutaneous-pedicle-screw-fixation

Research

JoVE Journal

Medicine

3.9K Views.  Okayama Rosai Hospital. Spondylose wordt beschouwd als stressfractuur en komt voor bij ongeveer 5% van de jonge bevolking. Het meest voorkomende niveau van voorkomen is het L5-niveau vanwege de unieke schuifkracht die wordt toegepast op L5-S1-gebied. Het belangrijkste symptoom van spondylose en spondylolisthesis zijn lage rugpijn, pijn in de benen en gevoelloosheid.Als conservatieve behandeling ineffectief blijkt, wordt chirurgische behandeling aanbevolen. Transforaminal Lumbar Interbody Fusion, TLIF is een e...

Video: C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis (ALS)

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression across speech subsystems, and for addressing the critical need for sensitive outcome measures for ongoing experimental treatment trials. To address this need, we are obtaining longitudinal profiles of bulbar impairment in 100 individuals based on a comprehensive instrumentation-based assessment that yield objective measures. Using instrumental approaches to quantify speech-related behaviors is very important in a field that has primarily relied on subjective, auditory-perceptual forms of speech assessment1. Our assessment protocol measures performance across all of the speech subsystems, which include respiratory, phonatory (laryngeal), resonatory (velopharyngeal), and articulatory. The articulatory subsystem is divided into the facial components (jaw and lip), and the tongue. Prior research has suggested that each speech subsystem responds differently to neurological diseases such as ALS. The current protocol is designed to test the performance of each speech subsystem as independently from other subsystems as possible. The speech subsystems are evaluated in the context of more global changes to speech performance. These speech system level variables include speaking rate and intelligibility of speech.
The protocol requires specialized instrumentation, and commercial and custom software. The respiratory, phonatory, and resonatory subsystems are evaluated using pressure-flow (aerodynamic) and acoustic methods. The articulatory subsystem is assessed using 3D motion tracking techniques. The objective measures that are used to quantify bulbar impairment have been well established in the speech literature and show sensitivity to changes in bulbar function with disease progression. The result of the assessment is a comprehensive, across-subsystem performance profile for each participant. The profile, when compared to the same measures obtained from healthy controls, is used for diagnostic purposes. Currently, we are testing the sensitivity and specificity of these measures for diagnosis of ALS and for predicting the rate of disease progression. In the long term, the more refined endophenotype of bulbar ALS derived from this work is expected to strengthen future efforts to identify the genetic loci of ALS and improve diagnostic and treatment specificity of the disease as a whole. The objective assessment that is demonstrated in this video may be used to assess a broad range of speech motor impairments, including those related to stroke, traumatic brain injury, multiple sclerosis, and Parkinson disease.

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis ALS

Objective assessments of the physiological mechanisms that support speech are needed to monitor disease onset and progression in persons with ALS and to quantify treatment effects in clinical trials. In this video, we present a comprehensive, instrumentation-based protocol for quantifying speech motor performance in clinical populations.

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression ...

A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. Transiliac-transsacral screws provide a longer lever arm to withstand the perpendicular vertical shear forces. However, the screw channel is so long that a minor discrepancy can lead to iatrogenic neurovascular injuries. The development of medical robots has improved the precision of surgery. The present protocol describes how to use a new teleoperated robotic system to execute transiliac-transacral screw fixation. The Robot was operated remotely to position the entry point and adjust the orientation of the sleeve. The screw positions were evaluated using postoperative computed tomography (CT). All the screws were safely implanted, as confirmed using intraoperative fluoroscopy. Postoperative CT confirmed that all the screws were in the cancellous bone. This system combines the doctor's initiative with the Robot's stability. The remote control of this procedure is possible. Robot-assisted surgery has a higher position-retention capacity compared with conventional methods. In contrast to active robotic systems, surgeons have full control over the operation. The robot system is fully compatible with operating room systems and does not require additional equipment.

Teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation is a feasible technique. Screw channels can be implemented with high accuracy owing to the excellent freedom of movement and stability of the robotic arms.

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. ...

Engineering

A Spine Robotic-Assisted Navigation System for Pedicle Screw Placement

Pedicle screw implantation has excellent treatment effects and is often used by surgeons in spinal fusion surgery. However, due to the complexity of human body anatomy, this surgical procedure is difficult and challenging, especially in minimally invasive surgery or patients with congenital anomalies and kyphoscoliosis deformity. In addition to the abovementioned factors, the surgical experience and technique of the surgeon also affect the recovery rates and complications of the patients after the surgical operation. Therefore, accurately performing pedicle screw implantation has is a constant topic of common concern for surgeons and patients. In recent years, with the technological development, robot-assisted navigation systems have gradually become adopted. These robot-assisted navigation systems provide surgeons with complete preoperative planning before surgery. The system provides 3D reconstructed images of each vertebra, allowing surgeons to understand the patient&#39;s physiological characteristics more quickly. It also provides 2D images of sagittal, coronal, axial and oblique planes so that surgeons can accurately perform pedicle screw placement plan.
Previous studies have demonstrated the effectiveness of robot-assisted navigation systems for pedicle screw implantation procedures, including accuracy and safety assessments. This step-by-step protocol aims to outline a standardized surgical technique note for robotic-assisted pedicle screw placement.

This article presents a standardized surgical technique for robotic-assisted pedicle screw placement by using robotic-assisted navigational systems. We present a step-by-step protocol and describe the workflow and precautions of this procedure.

Pedicle screw implantation has excellent treatment effects and is often used by surgeons in spinal fusion surgery. However, due to the complexity of human ...

Bioengineering

An Anesthesia, Surgery, and Harvest Method for the Evaluation of Transpedicular Screws Using an In Vivo Porcine Lumbar Spine Model

Pedicle screw fixation is the gold standard for the treatment of spinal diseases. However, many studies have reported the issue of loosening pedicle screws after spinal surgery, which is a serious concern. To address this problem, diverse types of pedicle screws have been examined to identify those with good fixation strength and osseointegration in spine bone. The porcine spine is a good alternative for the human spine in the evaluation of pedicle screws due to the anatomical size, mechanical characteristics, and cost. Although several studies have reported that pedicle screws are efficient in the porcine model, no study has described detailed protocols for the evaluation of a pedicle screw using the porcine model. Here, we describe a detailed method for evaluating transpedicular screws using an in vivo porcine lumbar spine model. The technical details for anesthesia, spine surgery, and harvest provided here will facilitate with the evaluation of the transpedicular screw fixation model.

An Anesthesia, Surgery, and Harvest Method for the Evaluation of Transpedicular Screws Using an In Vivo Porcine Lumbar Spine Model

Here, we introduce a method to evaluate transpedicular screws by using an in vivo porcine lumbar spine model.

Pedicle screw fixation is the gold standard for the treatment of spinal diseases. However, many studies have reported the issue of loosening pedicle ...

Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. Minimally invasive surgery (MIS) approaches have been applied to this technique with an associated decrease in estimated blood loss (EBL), length of hospital stay, and infection rates, while preserving outcomes with traditional open surgery. Previous MIS TLIF techniques involve significant fluoroscopy that subjects the patient, surgeon, and operating room staff to non-trivial levels of radiation exposure, particularly for complex multi-level procedures. We present a technique that utilizes an intraoperative computed tomography (CT) scan to aid in placement of pedicle screws, followed by traditional fluoroscopy for confirmation of cage placement. Patients are positioned in the standard fashion and a reference arc is placed in the posterior superior iliac spine (PSIS) followed by intraoperative CT scan. This allows for image-guidance-based placement of pedicle screws through a one-inch skin incision on each side. Unlike traditional MIS-TLIF that requires significant fluoroscopic imaging during this stage, the operation can now be performed without any additional radiation exposure to the patient or operating room staff. After completion of the facetectomy and discectomy, final TLIF cage placement is confirmed with fluoroscopy. This technique has the potential to decrease operative time and minimize total radiation exposure.

The purpose of this article is to provide image-guidance for minimally invasive transforaminal interbody fusion.

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. ...

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large implant size and optimal implant position. However, current methods for lateral interbody cage placement require either a two-staged procedure or a single lateral decubitus position that precludes surgeons from having either full access to the posterior spine for direct decompression or comfortable pedicle screw placement.
Herein is one institution's experience with 10 cases of a prone single-position approach for simultaneous access to the anterior and posterior lumbar spine. This allows both lateral lumbar interbody cage placement, direct posterior decompression, and pedicle screw placement, all in one position. Three-dimensional (3D) navigation is utilized for increased precision in both approaching the lateral spine and interbody cage placement. The traditional blind psoas muscle tubular dilation was also modified. Tubular retractors and lateral vertebral body retractor pins were used to minimize the risks to the lumbar plexus.

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large ...

Neuroscience

Application of the O-arm Intraoperative Imaging System to Assist Anterior Cervical Screw Fixation for Odontoid Fractures

Odontoid fractures account for a large proportion of cervical spine fractures in the elderly, causing pain in the occiput and the back of the neck and restricting neck movement. Anterior cervical screw fixation is a common surgical procedure to treat odontoid fractures. Due to the special location and complex anatomy of the odontoid, surgeons need to perform intraoperative fluoroscopies repeatedly to ensure correct screw position and avoid damage to the peripheral nerves and vessels of the odontoid. The traditional anterior cervical screw fixation is usually conducted with the assistance of a C-arm. However, compared to the C-arm, an O-arm intraoperative imaging system can provide 3D images during surgery, which improves the accuracy of screw placement. This study retrospectively analyzed patients with anterior cervical odontoid fractures treated in our hospital. The application of the O-arm intraoperative imaging system for assisting screw placement in the treatment of odontoid fractures can reduce intraoperative blood loss, operation time, and trauma to the patients.

This study describes the application of the O-arm intraoperative imaging system in odontoid fractures.

Odontoid fractures account for a large proportion of cervical spine fractures in the elderly, causing pain in the occiput and the back of the neck and ...

Application of Stand-Alone Oblique Lateral Interbody Fusion in L4-5 Lumbar Diseases

Lumbar spine diseases often cause lower back pain, lower extremity pain, numbness, and paresthesia. In severe cases, intermittent claudication may occur, affecting the quality of life of patients. Surgery is often required when conservative treatment fails, or when patients' symptoms become unbearable. Surgical treatments include laminectomy and discectomy, as well as interbody fusion. The main purpose of laminectomy and discectomy is to relieve nerve compression; however, recurrence is common due to spinal instability. Interbody fusion improves stability while relieving nerve compression and significantly reduces the risk of recurrence compared to non-fusion surgery. Nonetheless, conventionally posterior intervertebral fusion requires separation of the muscles to expose the operated segment, which causes more trauma to the patient. In contrast, the oblique lateral interbody fusion (OLIF) technique achieves spinal fusion with minimal trauma to the patients and shortens the recovery time. This article introduces procedures of stand-alone OLIF surgery performed in the lumbar spine, providing a reference for other spine surgeons.

This study describes the application of oblique lateral interbody fusion in lumbar spinal surgeries.

Lumbar spine diseases often cause lower back pain, lower extremity pain, numbness, and paresthesia. In severe cases, intermittent claudication may occur, ...

Pedicle Screw Placement Using an Augmented Reality Head-Mounted Display in a Porcine Model

This protocol helps assess the accuracy and workflow of an augmented reality (AR) hybrid navigation system using the Magic Leap head-mounted display (HMD) for minimally invasive pedicle screw placement. The cadaveric porcine specimens were placed on a surgical table and draped with sterile covers. The levels of interest were identified using fluoroscopy, and a dynamic reference frame was attached to the spinous process of a vertebra in the region of interest. Cone beam computerized tomography (CBCT) was performed, and a 3D rendering was automatically generated, which was used for the subsequent planning of the pedicle screw placements. Each surgeon was fitted with an HMD that was individually eye-calibrated and connected to the spinal navigation system.
Navigated instruments, tracked by the navigation system and displayed in 2D and 3D in the HMD, were used for 33 pedicle cannulations, each with a diameter of 4.5 mm. Postprocedural CBCT scans were assessed by an independent reviewer to measure the technical (deviation from the planned path) and clinical (Gertzbein grade) accuracy of each cannulation. The navigation time for each cannulation was measured. The technical accuracy was 1.0 mm &#177; 0.5 mm at the entry point and 0.8 mm &#177; 0.1 mm at the target. The angular deviation was 1.5&#176; &#177; 0.6&#176;, and the mean insertion time per cannulation was 141 s &#177; 71 s. The clinical accuracy was 100% according to the Gertzbein grading scale (32 grade 0; 1 grade 1). When used for minimally invasive pedicle cannulations in a porcine model, submillimeter technical accuracy and 100% clinical accuracy could be achieved with this protocol.

The augmented reality head-mounted display, Magic Leap, was used in combination with a conventional navigation system to place pedicle screws in a porcine model by adhering to a novel workflow. With a median insertion time of &lt;2.5 min, submillimeter technical accuracy and 100% clinical accuracy were achieved according to Gertzbein.

This protocol helps assess the accuracy and workflow of an augmented reality (AR) hybrid navigation system using the Magic Leap head-mounted display (HMD) ...

Technique of Sagittal Adjusting Screw System for Thoracolumbar Burst Fractures

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the indication for surgical treatment of neurologically intact TL fractures remains under debate, studies have demonstrated that posttraumatic malalignment may lead to a deterioration in the patient&#39;s quality of life. For burst fractures with malalignment or fragments in the spinal canal, a reduction technique using ligamentotaxis is commonly used to improve long-term outcomes.
The sagittal adjusting screw (SAS) system is a monoaxial screw system with a fixed head and concave sliding saddle that allows lordotic sliding of the rod in the sagittal plane after screw insertion. SAS also has a percutaneous option and has been used for TL spine fractures. Notably, the SAS only allows motion on the sagittal plane, allowing both secure fixation and angular reduction. The SAS has certain advantages over the conventional Schanz screw system or normal mono-/multiaxial pedicle screws for TL spine fracture treatment. In addition, specialized trauma reduction devices are available for the SAS system. In this video protocol, we discuss the indication for the SAS system in TL burst fracture and describe a technique of TL burst fracture reduction and fixation using the SAS system. Additionally, we describe our recent case series with radiological evaluation, including regional kyphotic angle and percent loss of anterior vertebral body height, to evaluate the newly introduced trauma reduction device.

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.

C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

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