Abstract
Background Context
The use of intraoperative CT has continued to grow in recent years, as various techniques
leverage the promise of improved instrumentation accuracy and the hope for decreased
complications. Nonetheless, the literature regarding the short- and long-term complications
associated with such techniques remains scant and/or confounded by indication and
selection bias.
Purpose
To use causal inference techniques to determine whether intraoperative CT use is associated
with an improved complication profile as compared to conventional radiography for
single-level lumbar fusions, an increasingly commonplace application for this technology.
Study Design/Setting
Inverse probability weighted retrospective cohort study carried out within a large
integrated health care network.
Patient Sample
Adult patients who underwent surgical treatment of spondylolisthesis via lumbar fusion
from January 2016 to December 2021.
Outcome Measures
Our primary outcome was the incidence rate of revision surgery. Our secondary outcome
was the incidence of composite 90-day complications (deep and superficial surgical
site infection, venous thromboembolic events, and unplanned readmissions).
Methods
Demographics, intraoperative information, and postoperative complications were abstracted
from electronic health records. A propensity score was developed utilizing a parsimonious
model to account for covariate interaction with our primary predictor, intraoperative
imaging technique. This propensity score was utilized in the creation of inverse probability
weights to adjust for indication and selection bias. The rate of revisions within
3 years as well as the rate of revisions at any time-point were compared between cohorts
using Cox regression analysis. The incidence of composite 90-day complications were
compared using negative binomial regression.
Results
Our patient population consisted of 583 patients, with 132 who underwent intraoperative
CT and 451 who underwent conventional radiographic techniques. There were no significant
differences between cohorts following inverse probability weighting. No significant
differences were detected in 3-year revision rates (HR, 0.74 [95% CI 0.29, 1.92];
p=.5), overall revision rates (HR, 0.54 [95% CI 0.20, 1.46]; p=.2), or 90-day complications
(RC -0.24 [95% CI –1.35, 0.87]; p=.7).
Conclusions
Intraoperative CT use was not associated with an improved complication profile in
either the short- or long-term for patients undergoing single-level instrumented fusion.
This observed clinical equipoise should be weighed against resource and radiation-related
costs when considering intraoperative CT for low complexity fusions.
Keywords
Abbreviations:
CT (computed tomography), HR (hazard Ratio), CI (confidence interval), RC (regression coefficient)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The Spine JournalAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Intraoperative spinal navigation.Spine (Phila Pa 1976). 2003; 28: S54-S61https://doi.org/10.1097/01.BRS.0000076899.78522.D9
- Image-guided navigation and robotics in spine surgery.Neurosurg. 2019; 84: 1179-1189https://doi.org/10.1093/neuros/nyy630
- Current state of navigation in spine surgery.Ann Transl Med. 2021; 9: 85
- The clinical impact of image guidance and robotics in spinal surgery: a review of safety, accuracy, efficiency, and complication reduction.Int J Spine Surg. 2021; 15: S10-S20https://doi.org/10.14444/8136
- Augmented reality spine surgery navigation: increasing pedicle screw insertion accuracy for both open and minimally invasive spine surgeries.Spine J. 2022; 47: 865-872https://doi.org/10.1097/BRS.0000000000004338
- Robotic spine surgery: past, present, and future.Spine (Phila Pa 1976. 2022; : 47
- An outcome and cost analysis comparing single-level minimally invasive transforaminal lumbar interbody fusion using intraoperative fluoroscopy versus computed tomography–guided navigation.World Neurosurgery. 2016; 94: 255-260https://doi.org/10.1016/j.wneu.2016.07.014
- Learning curve analysis of 3D-fluoroscopy image-guided pedicle screw insertions in lumbar single-level fusion procedures.Arch Orthop Trauma Surg. 2018; 138: 1501-1509https://doi.org/10.1007/s00402-018-2994-x
- A cost benefit analysis of increasing surgical technology in lumbar spine fusion.Spine J. 2021; 21: 193-201https://doi.org/10.1016/j.spinee.2020.10.012
- The environmental impact of spine surgery and the path to sustainability.Spine (Phila Pa 1976). 2023; 48: 545-551
- Estimating the effective radiation dose imparted to patients by intraoperative cone-beam computed tomography in thoracolumbar spinal surgery.Spine (Phila Pa 1976). 2013; 38: E306-E312https://doi.org/10.1097/BRS.0b013e318281d70b
- Patient and surgeon radiation exposure during spinal instrumentation using intraoperative computed tomography-based navigation.Spine J. 2016; 16: 343-354https://doi.org/10.1016/j.spinee.2015.11.020
Crawford AM, Striano BM, Lightsey IV HM, Zhu JS, Xiong GX, Schoenfeld AJ, et al. Projected lifetime cancer risk for patients undergoing spine surgery for isthmic spondylolisthesis [e-pub ahead of print]. Spine J 2023. S1529-9430(23) 00026-8. https://doi.org/10.1016/j.spinee.2023.01.014
- Safety and accuracy of robot-assisted placement of pedicle screws compared to conventional free-hand technique: a systematic review and meta-analysis.Spine J. 2021; 21: 181-192https://doi.org/10.1016/j.spinee.2020.09.007
- Accuracy of CT-navigated pedicle screw positioning in the cervical and upper thoracic region with and without prior anterior surgery and ventral plating.Bone Joint J. 2017; 99-B: 1373-1380https://doi.org/10.1302/0301-620X.99B10.BJJ-2016-1283.R1
- Computed tomography–guided navigation of thoracic pedicle screws for adolescent idiopathic scoliosis results in more accurate placement and less screw removal.Spine (Phila Pa 1976). 2012; 37: E473-E478https://doi.org/10.1097/BRS.0b013e318238bbd9
- Pedicle screw placement using intraoperative computed tomography and computer-aided spinal navigation improves screw accuracy and avoids postoperative revisions: single-center analysis of 1400 pedicle screws.World Neurosurgery. 2022; 160: e169-e179https://doi.org/10.1016/j.wneu.2021.12.112
- Pediatric pedicle screw placement using intraoperative computed tomography and 3-dimensional image-guided navigation.Spine (Phila Pa 1976). 2012; 37: E188-E194https://doi.org/10.1097/BRS.0b013e31822a2e0a
- Reoperation rates following instrumented lumbar spine fusion.Spine (Phila Pa 1976). 2018; 43: 295-301
- Variability and contributions to cost associated with anterior versus posterior approaches to lumbar interbody fusion.Clin Neurol Neurosurg. 2021; 206106688https://doi.org/10.1016/j.clineuro.2021.106688
- The clinical implications of adding CT angiography in the evaluation of cervical spine fractures: a propensity-matched analysis.J Bone Joint Surg Am. 2018; 100: 1490-1495https://doi.org/10.2106/JBJS.18.00107
- Insurance type is associated with baseline patient-reported outcome measures in patients with lumbar stenosis.Spine (Phila Pa 1976). 2022; 47: 737-744https://doi.org/10.1097/BRS.0000000000004326
- Is intraoperative CT of posterior cervical spine instrumtation cost-effective and does it reduce complications?.Clin Orthop Relat Res. 2011; 469: 1035-1041
- Complications and revision rates in minimally invasive robotic-guided versus fluoroscopic-guided spinal fusions: the MIS ReFRESH prospective comparative study.Spine (Phila Pa 1976). 2021; 46: 1661-1668https://doi.org/10.1097/BRS.0000000000004048
- Revision rate of misplaced pedicle screws of the thoracolumbar spine-comparison of three-dimensional fluoroscopy navigation with freehand placement: a systematic analysis and review of the literature.World Neurosurg. 2018; 109: e24-e32
- Risk factors for infection after spinal surgery.Spine (Phila Pa 1976). 2005; 30: 1460-1465
- The effect of smoking on spinal fusion.Int J Spine Surg. 2017; 11: 29
- Complications in spine surgery: a review.J Neurosurg Spine. 2010; 13: 144-157
Article info
Publication history
Published online: March 02, 2023
Accepted:
February 13,
2023
Received in revised form:
February 1,
2023
Received:
December 12,
2022
Footnotes
FDA device/drug status: Not applicable.
Author disclosures: AMC: Nothing to disclose. BMS: Nothing to disclose. HML: Nothing to disclose. JG: Nothing to disclose. AKS: Nothing to disclose. AJS: Royalties: Wolters Kluwer (B), Royalties: Springer (A), Scientific Advisory Board/Other Office: Commonwealth Fund (A), Grants: Department of Defense (H).
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
