Individualized Treatment For Thoracolumbar Burst Fractures Based On ICT With Integrated Navigation System

Objective：Our study investigate how the intraoperative computed tomography(iCT) using amobile scanner with integrated navigation system (NS) wasapplied for individualized treatment for thoracolumbar burst fractures.The aim of this article is to determine the standard workflow ofintraoperative CT integrated with NS in microsurgery, to estimate thefeasibility and safety, as well as the accuracy of the NS. Retrospectiveanalysis of the prognosis of patients was used to investigate the clinicalapplication of iCT and integrated NNS in congenital thoracolumbar burstfractures. Meanwhile, since there’s a high risk was in the fix of thepedicle screws in thoracolumbar vertebra, which may induce injuries ofspinal cord and vascellum around pedicle, the method of intraoperativecomputed tomography (iCT) scan and navigation system (NS) reconstruction assisting thoracolumbar pedicle fixation was established,with which the reconstruct in the virtual surgery system with realisticthree-dimensional images and the3-D would improve the prognosisMethods：This study was divided into three parts.1. Preoperative assessment of patients after surgical planning. Into thelumbar burst fractures in patients90cases from March2009toMarch2012, all patients in the preoperative X-ray examination of thethree-dimensional CT scan, MRI, three high qualification, deputy directorof the above physician surgical standard for surgical plan, including theposterior distraction reduction surgery decompression the posteriordistraction reset directly, and posterior distraction reset indirectdecompression, posterior distraction reset transpedicular anteriordecompression, posterior distraction reduction anterior interbody fixation.And propose feasible specific programs and technical route.2. Establish the the intraoperative CT observation group and X-rayobservations surgery group. Siemens and BrainLab jointly launched the whole operating room, through retrospective analysis of the hospitalhospital from the composition of the90cases from March2009to March2013, odd and even numbers grouped according to the treatmentsequence,90patients were in indirect reduction surgery, preoperative,intraoperative CT scan after the completion of surgery. Surgical reductionresults according to the three-dimensional reconstruction of CT to assesshow their specific surgery surgical divided into A, B groups: A group thatsurgery A group of45patients, according to the AO classification, whichthe A3.1type of11cases, A3.2type25, A3.3type nine cases; accordingto the traditional X-ray group B that surgery is lateral to judge the resultsof surgical reduction A3.115cases, A3.224cases A3.36cases. Thestatistical analysis of the two sets of data are comparable, and aftersurgery were retrospectively analyzed by the same group of surgeons,recording two surgical time, blood loss. The two groups were16monthsof follow-up June1postoperative neurologic recovery assessed inaccordance with the ASIA neurological function evaluation.3. Establish pedicle screw intraoperative CT navigation placement group and intraoperative X-ray placement group.45routine real-timenavigation of pedicle screw fixation (A group),27males and18females,aged19-59years old, with an average age of35, the cause of his injuries:15cases of fall injury, injured five cases, traffic The accident injury25cases; injury site: T119cases, T1214cases, Lll6cases, L28cases.45traditional routine X-ray fluoroscopy pedicle volume reconstruction byspiral CT technology in VR and multi-planar reconstruction the MPRtechnique of pedicle screw reference indicators individualizedmeasurement and screw placed in the navigation screw fixation (B group),26males and14females, aged17to55years old, with an average of37years of age, cause of injury: fall injury cases, injured six cases,26casesof traffic accident injury; injury site: TI16cases、T1213cases、L114cases、L29cases、L33cases. statistical analysis, the two sets of data arecomparable, and after surgery were retrospectively analyzed by the samegroup of surgeons, recorded two surgical time, blood loss, evaluation ofplacement quality. The two groups were16months of follow-up June1postoperative neurologic recovery assessed in accordance with the ASIA neurological function evaluation.Results：1.Experiment found that24patients in group A patients by indirectreduction and spinal bone Replies to achieve the established requirements,without further processing;6patients first reset spinal bone imperfectreduction, adjust the reset method re-Reset, iCT re-scan display goodreduction;11patients imperfect reduction, based on direct decompressionbone morphology and placeholder size or indirect decompression of thespinal canal to reach the established requirements;4patients after resetvertebral bone block sustained spinal cord compression and cauda equinachange postural underwent anterior decompression and fusion;22patients in all patients under surgery after reset change preoperativesurgical planning.17cases of group B patients preoperative planningindirect reduction underwent decompression surgery, but CT scansshowed postoperative evaluation after reset,4patients was reset afterbone has good reduction, no need for further decompression, false Thepositive rate of23%.2patients CT scans showed postoperative evaluation after reset the bone reset unsatisfactory in15cases of patientsaccording to the preoperative plan indirect reduction withoutdecompression required posterior decompression, the false-negative rateof13%.16patients in all patients should be changed according to thesituation after the surgery reset preoperative surgical planning. Differencebetween two groups in operative time, blood loss, postoperative recoveryof neurological function was significant (P <0.05)2. Navigation verify accuracy average of1.6mm (1.6:1.2-2.0mm);navigation Steering Group204, placed screws, two screws (1.2%) inviolation of the pedicle cortex. The two screws in the thoracic spine.1case, right unilateral T11screws breakthrough the cortical medial,because only the threaded portion invasive pedicle cortex, not more than2mm not close to the nerve, vascular damage. The second patient the leftof the T-12screws minimally invasive pedicle outer sidewall, the twocases none of the spinal canal and adjacent structures damage, there is nodanger therefore decided screws remain in its initial position. TheSteering Group of the picture, the overall accuracy of98.8%. X-ray fluoroscopic guidance group, placed screws198errors (3.5%) observedseven screws. The screw dislocation in the distribution of each group arelisted in Table1according to statistics, X-ray guided group than in thefrequent occurrence of the screw in the wrong place than navigationguidance group (P <0.05, χ2test). Cases invasive spinal surgery CT scandoes not require revision.(Table2). The perspective group apostoperative wound infection healed after requiring surgicaldebridement. Screws average placement in operative time, the timedifference between the two groups was significant (P <0.05)Conclusions：1. Intraoperative CT scanning system for real-time detection reset effectcan significantly improve the reset accuracy rate and the guidance of adoctor at any time to adjust to the surgery program, to avoid secondarysurgery does not increase the blood vessels and nerve injury, a significantimprovement in the quality of life of the patients;2. Cases must be decompression, iCT can also provide a clear imagevacuum to help determine whether a thorough and fundamentally improve the therapeutic effect of lumbar spine surgery. Compared with nointraoperative CT, iCT allows doctors treatment effect can be captured inreal time, to determine whether surgery program needs to be changed orfurther treatment, helps to get the best effect for improving surgicalpositioning accuracy and reduce surgical injury, optimize the surgicalpath and treatment programs, improve the success rate of surgery, etc. hasa very important significance;3. Using image-guidance technology the auxiliary push pedicle screwplacement relative to conventional X-ray fluoroscopy, navigationtechnology reduces the patient and surgeon X-ray radiation, to favorsurgery smoothly; greatly reduce the failure rate of surgery; make pediclescrew surgery more accurate, simple, fast, safe, reduce operative time andblood loss, can reduce the incidence of postoperative complications;4. Navigation instantaneous tracking capabilities, real-time monitoring,precision-guided within the plant to enable the operator to image,multi-dimensional, real strong sense of to avoid the error ofthoracolumbar fractures in patients with postural changes brought navigation is an ideal plant boot mode, the clinical application of theconcept of minimally invasive spine surgery.Contributions and innovations：1. The first time by intraoperative CT and navigation systems ofthoracolumbar burst fractures study, not only was whether the judgmentdecompression surgery completely, and further changes may be based onthe degree of spinal reset surgical, and fundamentally improve thethoracolumbar spine surgery the therapeutic effect;2. Exploration of thoracolumbar burst the bone morphology typing andintegration fractures, different methods of fracture fragments of thedifferent types of treatment, may inspire new ideas in the treatmentCT-based typing methods;3. Summed up the establishment of intraoperative CT reconstructiontechnique assisted thoracolumbar pedicle fixation, virtual surgery systemfor three-dimensional image reconstruction, intraoperative3Dimaging-guided surgery, improving the efficacy involved in the surgery in depth for the next robot The study provides important scientific evidence.