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BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a widely utilized technique in spine surgery. This study compares the efficacy and safety of MIS-TLIF performed with traditional C-arm fluoroscopy and C-arm-free O-arm navigation. To the best of our knowledge, our study is the first to compare cage positioning between C-arm-free and C-arm techniques for MIS- TLIF. METHODS: A retrospective, comparative analysis was conducted on 43 patients undergoing MIS-TLIF. The group was divided based on the utilization of C-arm fluoroscopy or C-arm-free O-arm navigation. Key parameters analyzed included cage orientation, screw insertion accuracy, operative efficiency, and postoperative recovery. Radiographic measurements were used to assess surgical precision and perioperative complications were documented. RESULTS: The study encompassed 43 patients, with no significant differences in demographic characteristics between the two groups. Surgical time and blood loss were comparable between C-arm-free and C-arm groups. O-arm navigation significantly reduced pedicle screw misplacement (p=0.024). Cage positioning differed between groups (p=0.0063): O-arm cages were mostly mid-center, while C-arm cages were more anterior-center. Such differences in the cage location did not cause any impact on clinical outcome. No significant differences were observed in postoperative complications (screw loosenings, dural tears, surgical site infections) between groups. The Oswestry Disability Index scores at the final follow-up showed no significant difference between the O-arm and C-arm groups, indicating similar levels of postoperative disability. CONCLUSION: Despite the clinically insignificant difference in cage placement between C-arm-free and C-arm dependent, C-arm-free MIS-TLIF significantly improves screw placement accuracy and reduces radiation exposure to operating stuff. This suggests its potential as a valuable tool for safer and more precise spinal fusion surgery.

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OBJECTIVE: In spine surgery, ensuring the safety of vital structures is crucial, and various instruments contribute to the surgeon's confidence. This study aims to present outcomes from spinal cases operated on using the freehand technique and neuronavigation with an O-arm in our clinic. Additionally, we investigate the impact of surgical experience on outcomes by comparing early and late cases operated on with neuronavigation. METHOD: We conducted a retrospective analysis of spinal patients operated on with the freehand technique and neuronavigation in our clinic between 2019 and 2020, with a minimum follow-up of 2 years. Cases operated on with neuronavigation using the O-arm were categorized into early and late groups. RESULTS: This study included 193 patients, with 110 undergoing the freehand technique and 83 operated on utilizing O-arm navigation. The first 40 cases with neuronavigation formed the early group, and the subsequent 43 cases comprised the late group. The mean clinical follow-up was 29.7 months. In the O-arm/navigation group, 796 (99%) of 805 pedicle screws were in an acceptable position, while the freehand group had 999 (89.5%) of 1117 pedicle screws without damage. This rate was 98% in the early neuronavigation group and 99.5% in the late neuronavigation group. CONCLUSIONS: The use of O-arm/navigation facilitates overcoming anatomical difficulties, leading to significant reductions in screw malposition and complication rates. Furthermore, increased experience correlates with decreased surgical failure rates.

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PURPOSE: Fractures and dislocations of the pelvic ring are complex injuries that when treating require meticulous attention to detail and often specialized technical skill. These injuries can be the result of high-energy trauma, particularly in younger patients, or low energy trauma more often found in the elderly. Regardless of mechanism, these injuries lie on a spectrum of severity and can be treated conservatively or surgically. Percutaneous fixation under fluoroscopic guidance is the preferred standard technique when treating these fractures. This technique can be challenging for a variety of reasons including patient characteristics, intra-operative image quality, fracture morphology, among others. METHODS: This retrospective study evaluated the use of intra-operative computed tomography (CT) using an O-arm imaging system for critical evaluation of fluoroscopic-guided screw placement in twenty-three patients. We retrospectively reviewed all cases of patients who were treated by three fellowship-trained orthopaedic traumatologists during a one-year span. Patients undergoing percutaneous pelvis fixation using both standard fluoroscopy and intraoperative CT with the Medtronic O-arm® (Minneapolis, MN) imaging system. Additionally, procedures performed included open reduction internal fixation (ORIF) of the pelvic ring, acetabulum, and associated extremity fractures. RESULTS: Twenty-three patients were included in this study. On average, the use of intraoperative CT added 24.4 min in operative time. Five patients (21.7%) required implant adjustment after O-arm spin. Fourteen patients underwent additional post-operative CT. No secondary revision surgeries were attempted after any post-operative CT. CONCLUSIONS: Our study suggests that intra-operative CT scan, compared to post-operative CT scan, can be utilized to prevent take-back surgery for misplaced implants and allow for adjustment in real-time.

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Trans-sulcal minimally invasive parafascicular surgery is an emerging technique to approach deep lesions with minimal brain retraction. Localization of the tubular retractor during surgery is critical, and intraoperative magnetic resonance imaging and neuronavigation present limitations. We describe the intraoperative use of O-Arm® coupled with pre-operative tractography to precisely localize the tubular retractor. With air acting as contrast, the tubular retractor was localized in three dimensions, without any additional disruption to white matter tracts or nearby vascular structures. We conclude that visualization of tubular retractor using an intraoperative computerized tomography scan is a safe and feasible adjunct in resection of deep lesions via a minimally invasive approach.

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Background: Pediatric orthopedic conditions present unique challenges due to ongoing skeletal growth and development. Managing these cases requires addressing both structural anomalies and functional deficits. Care presentation: This case report discusses a 13-year-old male with recurrent left knee pain exacerbated by physical activity. The patient's history of a left knee infection at 1.5 years of age, possibly septic arthritis or osteomyelitis, underscores the long-term consequences of early pathology on skeletal growth and alignment. Imaging studies revealed a distal lateral femur physis bar and genu valgum, necessitating surgical intervention. Management and Outcomes: The surgery involved medial distal femur hemiepiphysiodesis and lateral distal femur bar excision to correct anatomical deformities and restore optimal limb alignment and function. Postoperative rehabilitation, including targeted exercises to improve quadriceps strength, was crucial for functional recovery and reducing the risk of complications such as medial patellofemoral pain. Conclusion: This case highlights the importance of a multidisciplinary approach in managing complex pediatric orthopedic cases.

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OBJECTIVE: To compare the differences between Ultrasound Volume Navigation (UVN), O-arm Navigation, and conventional X-ray fluoroscopy-guided screw placement in Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) surgeries. METHODS: A total of 90 patients who underwent MIS-TLIF due to lumbar disc herniation from January 2022 to January 2023 were randomly assigned to the UVN group, O-arm group, and X-ray group. UVN, O-arm navigation, and X-ray guidance were used for screw placement in the respective groups, while the remaining surgical procedures followed routine MIS-TLIF protocols. Intraoperative data including average single screw placement time, total radiation dose, and average effective radiation dose per screw were recorded and calculated. On the 10th day after surgery, postoperative X-ray and CT examinations were conducted to assess screw placement accuracy and facet joint violation. RESULTS: There were no significant differences in general characteristics among the three groups, ensuring comparability. Firstly, the average single screw placement time in the O-arm group was significantly shorter than that in the UVN group and X-ray group (P<0.05). Secondly, in terms of total radiation dose during surgery, for single-level MIS-TLIF, the O-arm group had a significantly higher radiation dose compared to the UVN group and X-ray group (P<0.05). However, for multi-level MIS-TLIF, the X-ray group had a significantly higher radiation dose than the O-arm group and UVN group (P<0.05). In terms of average single screw radiation dose, the O-arm group and X-ray group were similar (P>0.05), while the UVN group was significantly lower than the other two groups (P<0.05). Furthermore, no significant differences were found in screw placement assessment grades among the three groups (P>0.05). However, in terms of facet joint violation rate, the UVN group (10.3%) and O-arm group (10.7%) showed no significant difference (P>0.05), while the X-ray group (26.7%) was significantly higher than both groups (P<0.05). Moreover, in the UVN group, there were significant correlations between average single screw placement time and placement grade with BMI index (r = 0.637, P<0.05; r = 0.504, P<0.05), while no similar significant correlations were found in the O-arm and X-ray groups. CONCLUSION: UVN-guided screw placement in MIS-TLIF surgeries demonstrates comparable efficiency, visualization, and accuracy to O-arm navigation, while significantly reducing radiation exposure compared to both O-arm navigation and X-ray guidance. However, UVN may be influenced by factors like obesity, limiting its application.

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Background: Abdominal vascular injury, a fatal complication of lumbar disc surgery, should concern spine surgeons. This study aimed to compare the position of the abdominal arteries in the supine and prone positions and the factors involved. Thirty patients who underwent lumbar surgery by posterior approach were included. Methods: All patients underwent computed tomography (CT) preoperatively in the supine position and intraoperatively in the prone position. In the CT axial image, at the L4, L4/5 disc, L5, and L5/S1 disc level, we measured the shortest distance between the abdominal arteries and the vertebral body (SDA: shortest distance to the aorta), and the amount of abdominal arterial translation, defined as "SDA on intraoperative CT" minus "SDA on preoperative CT". Additionally, the preoperative CT axial images were evaluated for the presence of aortic calcification. Results: No significant difference in SDA values based on patients' positions was observed at each level. In males, the supine position brought the abdominal artery significantly closer to the spine at the left side of the L5/S level (p = 0.037), and, in cases of calcification of the abdominal artery, the abdominal artery was found to be closer to the spine at the left side of the L4/5 level (p = 0.026). Conclusions: It is important to confirm preoperative images correctly to prevent great vessel injuries in lumbar spine surgery using a posterior approach.

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Intra-operative navigation has revolutionized spinal instrumentation. The O-arm (a mobile X-ray system; Medtronic, Minneapolis, MN) is uniquely capable of enabling visualization of the spine in axial planes. The application of this technology is wide yet underutilized in terms of its capacity to image spinal vascular anatomy. We completed a retrospective chart review of the following case studies. A 24-year-old neurologically intact female presented with a Jefferson fracture without vertebral artery dissection after a motor vehicle accident. After the failure of conservative management due to pseudoarthrosis, the patient opted for fusion. Prior to the procedure, bilateral 5 French femoral sheaths were placed. After exposure, intraarterial (IA) contrast was injected prior to the O-arm spin to visualize both vertebral arteries, which were stretched and adjacent to a mobile boney segment. In the second case, a 71-year-old male presented with right shoulder pain and a flaccid left deltoid secondary to a large enhancing epidural lesion spanning C4-C7. Further work-up confirmed a diagnosis of metastatic intrahepatic cholangiocarcinoma. Prior to resection with cervical spinal stabilization, a right radial artery 4 French Glidesheath was placed. Prior to the O-arm spin, the right vertebral artery was selected, and intravenous contrast was injected to permit visualization of the vertebral artery, which was encased within the tumor and at significant risk for iatrogenic injury. Both patients tolerated the endovascular and spinal procedures well without vertebral artery injury. This is the first series to report the effective use of the O-arm for improved visualization of vascular anatomy during surgery for cervical spinal trauma and oncology.

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Surgical approaches directed toward craniovertebral junction (CVJ) can be addressed to the ventral, dorsal, and lateral aspects through a variety of 360° surgical corridors Herein, we report features, advantages, and limits of the updated technical support in CVJ surgery in clinical setting and dissection laboratories enriched by our preliminary surgical results of the simultaneous application of O-arm intraoperative neuronavigation and imaging system along with the 3D-4K EX in TOA for the treatment of CVJ pathologies.In the past 4 years, eight patients harboring CVJ compressive pathologies underwent one-step combined anterior neurosurgical decompression and posterior instrumentation and fusion technique with the aid of exoscope and O-arm. In our equipped Cranio-Vertebral Junction Laboratory, we use fresh cadavers (and injected "head and neck" specimens) whose policy, protocols, and logistics have already been elucidated in previous works. Five fresh-frozen adult specimens were dissected adopting an FLA. In these specimens, a TOA was also performed, as well as a neuronavigation-assisted comparison between transoral and transnasal explorable distances.A complete decompression along with stable instrumentation and fusion of the CVJ was accomplished in all the cases at the maximum follow-up (mean: 25.3 months). In two cases, the O-arm navigation allowed the identification of residual compression that was not clearly visible using the microscope alone. In four cases, it was not possible to navigate C1 lateral masses and C2 isthmi due to the angled projection unfitting with the neuronavigation optical system, so misleading the surgeon and strongly suggesting changing surgical strategy intraoperatively. In another case (case 4), it was possible to navigate and perform both C1 lateral masses and C2 isthmi screwing, but the screw placement was suboptimal at the immediate postoperative radiological assessment. In this case, the hardware displacement occurred 2 months later requiring reoperation.

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The objective is to compare the clinical efficacy and safety of the S8 navigation system and the Tinavi orthopaedic surgery robot in the treatment of upper cervical instability. The research methods adopted are as follows. The clinical data of patients with upper cervical instability who underwent surgery from May 2021 to December 2021 were analysed retrospectively. Patients were divided into a navigation group (assisted by the S8 navigation system) and a tinavi group (assisted by the Tinavi robot) according to the auxiliary system used. Computed tomography and digital radiography were performed after the operation. The accuracy of pedicle screw placement was evaluated using the criteria put forward by Rampersaud. Degree of facet joint violation, visual analogue scale score, neck disability index and Japanese orthopaedic association score were recorded and assessed during follow-up examinations in both groups. Record two groups of surgery-related indicators. Record the complications of the two groups. A total of 50 patients were included. 21 patients in the navigation group and 29 in the tinavi group. The results of the study are as follows. The average follow-up time was 12.1 months. There was no significant difference in nail placement accuracy between the navigation and tinavi groups (P > 0.05); however, the navigation group had a significantly higher rate of facet joint violation than that of tinavi group (P < 0.05), and the screws were placed closer to the anterior cortex (P < 0.05). Significantly more intraoperative fluoroscopies were performed in the tinavi group than in the navigation group, and the operation time was significantly longer in the tinavi group than in the navigation group (P < 0.05). The time of single nail implantation, intraoperative blood loss and incision length in navigation group were significantly longer than those in tinavi group. There were no statistically significant differences in other indicators between the two groups (P > 0.05). We come to the following conclusion. The Stealth Station S8 navigation system (Medtronic, USA), which also uses an optical tracking system, and the Tinavi Orthopedic robot have shown the same high accuracy and satisfactory clinical results in the treatment of upper cervical instability. Although the S8 navigation system still has many limitations, it still has good application prospects and is a new tool for spine surgery.

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BACKGROUND: Schwannomas are the most common intrathoracic neurogenic tumors. In the past, they were often treated by traditional open surgery. Video-assisted thoracic surgery (VATS) has also been used for some large tumors. Recently, minimally invasive posterior neurosurgical technique provides a new option for some of these tumors. METHOD: Here, we describe the specific steps involved in the O-arm guided minimally invasive removal of intrathoracic epidural schwannoma, as well as its advantages and limitations. CONCLUSION: O-arm guided minimally invasive resection of intrathoracic epidural schwannoma is safe and effective and causes little damage.

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OBJECTIVE: The objective of this study was to evaluate the surgical effectiveness of posterior procedure with long segment stabilization for treating thoracolumbar pseudarthrosis associated with ankylosing spinal disorders (ASDs) without anterior fusion or osteotomy. METHODS: Twelve patients with thoracolumbar pseudarthrosis in ASD were enrolled. All patients underwent posterior long-segment stabilization procedures. In some patients, the percutaneous technique or the aid of a robot or O-arm navigation was utilized for pedicle screw implantation. The clinical results were evaluated by means of the visual analog scale and Oswestry Disability Index. Radiological outcomes were evaluated for bone fusion, anterior column defect, local kyphotic correction, and position of the pedicle screws. RESULTS: All patients experienced effective bone fusion at the sites of pseudarthrosis. The mean operative time was 161.7 ± 57.1 minutes, and the average amount of blood loss was 305.8 ± 293.2 mL. For 6 patients who underwent surgery with the assistance of a robot or O-arm navigation, there was no statistically significant difference observed in terms of operative time and mean blood loss compared to those who used the freehand technique (P > 0.05). The visual analog scale score, Oswestry Disability Index value, and mean local kyphotic angle showed significant improvements at the final follow-up (P < 0.05). The accuracy of pedicle screw placement was 96%. CONCLUSIONS: Posterior surgery with long-segment fixation, without anterior fusion or osteotomy, can achieve satisfactory outcomes in ASD patients with thoracolumbar pseudarthrosis. The application of percutaneous techniques, as well as the assistance of robots or navigation technique may be a good choice for the treatment of pseudarthrosis in ASD patients.

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Objective: To compare the effectiveness of O-arm navigation and C-arm navigation for guiding percutaneous long sacroiliac screws in treatment of Denis type Ⅱ sacral fractures. Methods: A retrospective study was conducted on clinical data of the 46 patients with Denis type Ⅱ sacral fractures between April 2021 and October 2022. Among them, 19 patients underwent O-arm navigation assisted percutaneous long sacroiliac screw fixation (O-arm navigation group), and 27 patients underwent C-arm navigation assisted percutaneous long sacroiliac screw fixation (C-arm navigation group). There was no significant difference in gender, age, causes of injuries, Tile classification of pelvic fractures, combined injury, the interval from injury to operation between the two groups ( P>0.05). The intraoperative preparation time, the placement time of each screw, the fluoroscopy time of each screw during placement, screw position accuracy, the quality of fracture reduction, and fracture healing time were recorded and compared, postoperative complications were observed. Pelvic function was evaluated by Majeed score at last follow-up. Results: All operations were completed successfully, and all incisions healed by first intention. Compared to the C-arm navigation group, the O-arm navigation group had shorter intraoperative preparation time, placement time of each screw, and fluoroscopy time, with significant differences ( P<0.05). There was no significant difference in screw position accuracy and the quality of fracture reduction ( P>0.05). There was no nerve or vascular injury during screw placed in the two groups. All patients in both groups were followed up, with the follow-up time of 6-21 months (mean, 12.0 months). Imaging re-examination showed that both groups achieved bony healing, and there was no significant difference in fracture healing time between the two groups ( P>0.05). During follow-up, there was no postoperative complications, such as screw loosening and breaking or loss of fracture reduction. At last follow-up, there was no significant difference in pelvic function between the two groups ( P>0.05). Conclusion: Compared with the C-arm navigation, the O-arm navigation assisted percutaneous long sacroiliac screws for the treatment of Denis typeⅡsacral fractures can significantly shorten the intraoperative preparation time, screw placement time, and fluoroscopy time, improve the accuracy of screw placement, and obtain clearer navigation images.

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Study design: Prospective experimental study. Objective: To compare the accuracy of O-Arm-acquired radiographic and computed tomography (CT) evaluation of thoracic pedicle screw placement with open laminectomy in a simulation laboratory. Summary of background data: Improving surgical safety and procedural efficiency during thoracic posterior spine instrumentation is essential for decreasing complication rates and possible related risks. The most common way of verifying the position of pedicle screws during the surgical procedure and immediately postoperatively is to acquire intraoperative fluoroscopic images and plain radiographs of the spine, respectively. Laboratory simulated surgery is a valuable tool to evaluate the accuracy of those exams. Methods: Twenty simulation models of scoliosis from T3 to T7 were instrumented by five spine fellows (total of 200 pedicle screws), followed by radiographic and CT images acquired with the assistance of the O-Arm which were evaluated by three independent raters. A fellowship-trained spine neurosurgeon performed laminectomies on the instrumented levels and assessed pedicle integrity (gold standard). Results: Forty-eight breaches were identified in the axial direct view after laminectomy. Of those, eighteen breaches were classified as unacceptable. Regarding the sagittal direct view, four breaches were observed, three of which were classified as unacceptable. Overall, both O-arm radiographic and CT evaluations had a significantly high negative predicted value but a low positive predicted value to identify unacceptable breaches, especially in the sagittal plane. The frequency of missed breaches by all three examiners was high, particularly in the sagittal plane. Conclusion: Postoperative evaluation of pedicle screws using O-arm-acquired radiographic or CT images may underdiagnose the presence of breaches. In our study, sagittal breaches were more difficult to diagnose than axial breaches. Although most breaches do not have clinical repercussions, this study suggests that this modality of postoperative radiographic assessment may be inaccurate. Level of evidence: 4.

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PURPOSE: Utilization of navigation improves pedicle screw accuracy in adolescent idiopathic scoliosis (AIS). Our center switched from intraoperative CT (ICT) to an optical navigation system that utilizes pre-operative CT (PCT). We aim to evaluate the radiation dose and operative time for low-dose ICT compared to standard and low-dose PCT used for optical navigation in AIS patients undergoing posterior spinal fusion. METHODS: A single-center matched-control cohort study of 38 patients was conducted. Nineteen patients underwent ICT navigation (O-arm) and were matched by sex, age, and weight to 19 patients who underwent PCT for use with an optical-guided navigation (7D, Seaspine). A total of 418 levels were instrumented and reviewed. PCT was either a standard dose (N = 7) or a low dose (N = 12). The mean volume CT dose index, dose-length product, overall effective dose (ED), ED per level instrumented, and operative time per level were compared. RESULTS: ED per level instrumented was 0.061 ± 0.029 mSv in low-dose PCT and 0.14 ± 0.05 mSv in low-dose ICT (p < 0.0001). ED per level instrumented was significantly higher in standard PCT (1.46 ± 0.39 vs. 0.14 ± 0.03 mSv; p < 0.0001). Mean operative time per level was 31 ± 7 min for ICT and 33 ± 3 min for PCT (p = 0.628). CONCLUSION: Low-dose PCT resulted in 0.70 mSv exposure per case and 31 min per level, standard-dose was 16.95 mSv, while ICT resulted in 1.34-1.62 mSv and a similar operative time. Use of a standard-dose PCT involves radiation exposure about 9 times higher than ICT and 23 times higher than low-dose PCT per level instrumented. LEVEL OF EVIDENCE: Level III.

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INTRODUCTION: Recent advancements in stereotactic neurosurgical techniques have become increasingly reliant on image-based target planning. We devised a case-phantom comparative analysis to evaluate the target registration errors arising during the magnetic resonance imaging (MRI)-computed tomography (CT) image fusion process. METHODS: For subjects whose preoperative MRI and CT images both contained fiducial frame localizers, we investigated discrepancies in target coordinates derived from frame registration based on either MRI or CT. We generated a phantom target through an image fusion process, merging the framed CT images with their corresponding reference MRIs after masking their fiducial indicators. This phantom target was then compared with the original during each instance of target planning. RESULTS: In our investigative study with 26 frame registrations, a systematic error in the y-axis was observed as -0.89 ± 0.42 mm across cases using either conventional CT and/or cone-beam CT (O-arm). For the z-axis, errors varied on a case-by-case basis, recording at +0.64 ± 1.09 mm with a predominant occurrence in those merged with cone-beam CT. Collectively, these errors resulted in an average Euclidean error of 1.33 ± 0.93 mm. CONCLUSION: Our findings suggest that the accuracy of frame-based stereotactic planning is potentially compromised during MRI-CT fusion process. Practitioners should recognize this issue, underscoring a pressing need for strategies and advancements to optimize the process.

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OBJECTIVE@#To compare the effectiveness of O-arm navigation and C-arm navigation for guiding percutaneous long sacroiliac screws in treatment of Denis type Ⅱ sacral fractures.@*METHODS@#A retrospective study was conducted on clinical data of the 46 patients with Denis type Ⅱ sacral fractures between April 2021 and October 2022. Among them, 19 patients underwent O-arm navigation assisted percutaneous long sacroiliac screw fixation (O-arm navigation group), and 27 patients underwent C-arm navigation assisted percutaneous long sacroiliac screw fixation (C-arm navigation group). There was no significant difference in gender, age, causes of injuries, Tile classification of pelvic fractures, combined injury, the interval from injury to operation between the two groups ( P>0.05). The intraoperative preparation time, the placement time of each screw, the fluoroscopy time of each screw during placement, screw position accuracy, the quality of fracture reduction, and fracture healing time were recorded and compared, postoperative complications were observed. Pelvic function was evaluated by Majeed score at last follow-up.@*RESULTS@#All operations were completed successfully, and all incisions healed by first intention. Compared to the C-arm navigation group, the O-arm navigation group had shorter intraoperative preparation time, placement time of each screw, and fluoroscopy time, with significant differences ( P<0.05). There was no significant difference in screw position accuracy and the quality of fracture reduction ( P>0.05). There was no nerve or vascular injury during screw placed in the two groups. All patients in both groups were followed up, with the follow-up time of 6-21 months (mean, 12.0 months). Imaging re-examination showed that both groups achieved bony healing, and there was no significant difference in fracture healing time between the two groups ( P>0.05). During follow-up, there was no postoperative complications, such as screw loosening and breaking or loss of fracture reduction. At last follow-up, there was no significant difference in pelvic function between the two groups ( P>0.05).@*CONCLUSION@#Compared with the C-arm navigation, the O-arm navigation assisted percutaneous long sacroiliac screws for the treatment of Denis typeⅡsacral fractures can significantly shorten the intraoperative preparation time, screw placement time, and fluoroscopy time, improve the accuracy of screw placement, and obtain clearer navigation images.

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Introduction: Intraoperative three-dimensional (3D) imaging guide technology, such as the O-arm surgical imaging system, is a beneficial tool in spinal surgery that provides real-time 3D images of a patient's spine. This study aims to determine the exposure dose from intraoperative O-arm imaging. Methods: A consecutive retrospective review of all patients undergoing spinal surgery was conducted between June 2019 and August 2022. Demographic and operative data were collected from electronic medical records. Results: Intraoperative O-arm imaging was conducted in 206 (12.9%) of 1599 patients, ranging from one to 4 scans per patient (1.17±0.43 scans). Single O-arm imaging enabled navigation of seven vertebrae in the cervical spine, seven in the thoracic spine, five in the thoracolumbar spine, and four in the lumbar spine on average. The number of O-arm shots per surgery was 1.15±0.36, 1.06±0.24, 1.61±0.7, and 1.07±0.25 for cervical, thoracic, thoracolumbar, and lumbar spinal cases, respectively. The exposure doses represented by dose length products in single O-arm imaging were 377±19 mGy-cm, 243±22 mGy-cm, 378±38 mGy-cm, and 258±11 mGy-cm for cervical, thoracic, thoracolumbar, and lumbar spine cases, respectively. We observed a weak positive correlation between the number of fused spinal levels and the exposure dose. Conclusions: Intraoperative radiation exposure from O-arm imaging was lower than the national diagnostic reference levels in Japan established based on the International Commission on Radiological Protection publication, demonstrating its safety from the standpoint of radiological protection in most cases. In surgeries with a large range of fixations, such as corrective deformity surgery, the number of imaging sessions and the amount of intraoperative radiation exposure would increase, leading surgeons to pay attention to the risk of radiation in spinal surgery.

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PURPOSE: This study aims to compare the effect of using O-arm and C-arm fluoroscopy on the surgical outcomes of occipitocervical fixation. METHODS: The study included patients who underwent occipitocervical fixation using O-arm or C-arm between 2005 and 2021. Of 56 patients, 34 underwent O-arm-assisted surgery (O-group) and 22 underwent C-arm-assisted surgery (C-group). We assessed surgical outcomes, including operative time, intraoperative blood loss, perioperative complications, and bone union. RESULTS: Almost half of the patients had rheumatoid arthritis-related disorders in both groups. Sixteen cases (47.1%) in the O-group and 12 cases (54.5%) in the C-group were fixed from occipito (Oc) to C3, 12 cases (38.2%) in the O-group and 7 cases (31.8%) in the C-group from Oc to C4-7, 5 cases (14.7%) in the O-group, and 3 cases (13.6%) in the C-group from Oc to T2 (p = 0.929). There was no significant difference in operative time (p = 0.239) and intraoperative blood loss (p = 0.595) between the two groups. Dysphagia was the most common complication in both groups (O-group vs. C-group, 11.7% vs. 9.1%). Regarding implant-related complications, occipital plate dislodgement was observed in four cases (18.2%) in the C-group (p = 0.02). The bone union rate was 96.3% in the O-group and 93.3% in the C-group (P = 1). CONCLUSIONS: O-arm use is associated with a reduced rate of occipital plate dislodgment and has a similar complication incidence compared with C-arm-assisted surgery and does not prolong operative time despite the time needed for setting and scanning. Accordingly, an O-arm is safe and useful for occipitocervical fixation surgery.

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Percutaneous balloon compression (PBC) is a safe and effective procedure in the treatment of trigeminal neuralgia (TN) due to its simplicity, low cost and the possibility of being repeated in case of pain recurrence. Foramen ovale (FO) cannulation is accomplished with the assistance of intraoperative C-arm fluoroscopy. Recently, several authors have reported successful application of intraoperative CT navigation as well. The reported advantages of CT navigation are linked to better spatial orientation and the low rate of attempts for FO cannulation. However, these advantages should be considered in the face of concerns regarding increased radiation dose to the patient and its possible adverse effects. Here we compared the fluoroscopic guided and neuronavigated PBC techniques in terms of efficacy and radiological exposure. We retrospectively analyzed 37 patients suffering for TN and submitted to PBC. We observed a significant improvement of pain at 1 month FU compared with the pre-operative in both groups (p < 0.0001 and p < 0.0001, respectively). A significant increase in radiation exposure was found in the neuronavigated group compared with the fluoroscopy group (p < 0.0001). We suggest the use of neuronavigated PBC only in selected cases, such as patients with multiple previous operations, in whom a difficult access can be pre-operatively hypothesized.

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