Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101278

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Interdisciplinary Neurosurgery: Advanced Techniques

and Case Management
journal homepage: www.elsevier.com/locate/inat

Research Article

Comparative evaluation of screw accuracy and complications of new C-arm

free O-arm navigated minimally invasive cervical pedicle screw fixation
(MICEPS) with conventional cervical screw fixation
Masato Tanaka *, Venkatesh Kadiri , Sumeet Sonawane , Koji Uotani , Shinya Arataki ,
Yoshihiro Fujiwara , Yoshiaki Oda , Taro Yamauchi , Tomoyuki Takigawa
Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan

A R T I C L E I N F O A B S T R A C T

Keywords: Study design: Retrospective comparative study.

MICEPS Objective: Comparative study of C-arm free O-arm navigated minimally invasive cervical pedicle screw (MICEPS)
Cervical pedicle screw fixation fixation with conventional cervical pedicle screw fixation.
O-arm navigation
Methods: Twenty-five patients with different cervical spine pathologies were operated with MICEPS with O-arm
C-arm free
Cervical pedicle breach rate
navigation (group M; 18 patients) and conventional pedicle screw (group C; 7 patients) from June 2017 to
January 2020. Operative time, blood loss were recorded. Preoperative and postoperative radiograms, CT scans
and MRI were evaluated. Postoperatively screw position accuracy and angulation was determined on CT. Breach
rate was evaluated on CT scan and classified according to Neo grading. Complications if any were noted.
Results: The average blood loss in group M and group C was 129 ml and 329 ml, respectively. The average
operative time in group M and group C was 77.4 min and 82.3 min, respectively. A total of 148 screws were
inserted. In group M, no patient showed grade 2 and 3 breach while in group C, grade 0 and 1 breach was found
in 85.7% screws and grade 2 in 14.3% screws. Mean screw medial angulation was 45.2 degrees in group M and
33.4 degrees in group C. There was one dural tear and two C5 palsies in each group.
Conclusion: With C -arm free O-arm navigated MICEPS fixation operative time and blood loss are less though not
statistically significant. It has less pedicle breach rate, less incidence of neurovascular complications than con­
ventional technique. There is no radiation exposure to operating surgeon and staff.

1. Introduction: have higher vertebral artery injury due to lateral placement of screw [7].
Minimally invasive cervical pedicle screw (MICEPS) was recently
Posterior cervical spine fixation is indicated in instability due to described with good outcomes [8]. It requires smaller skin incision and
laminectomy, degenerative, fracture-dislocation, metastatic involve­ good relative horizontal placement of screw can be obtained [9]. Studies
ment of cervical spine. Historically, methods used for cervical spine have found that O-arm navigation improves accuracy of pedicle screw
fixation are spinous process wiring, sublaminar wiring and lateral mass insertion compared to fluoroscopic technique [10,11]. We moved from
screws [1]. Biomechanical studies have shown that there is not much conventional pedicle screw placement to C-arm free O-arm navigated
difference in stability provided by these methods [2,3]. Abumi reported pedicle screw [12]. There is no comparative study between these tech­
cervical pedicle screw fixation for traumatic cervical spine pathologies niques. This is the first study comparing C-arm free O-arm navigated
[4]. A recent study reported that pull-out strength of cervical pedicle MICEPS with conventional pedicle screw.
screw is greater than lateral mass screw [5]. Thus, cervical pedicle
screws provide greater stability and may obviate need of anterior sur­ 2. Materials and methods
gery for patients whom combined anterior and posterior surgery might
be required [6]. This is a retrospective comparative study. Twenty-five patients with
Conventional cervical pedicle screw requires larger midline incision, cervical spine pathologies due to trauma, malignancy or degenerative

* Corresponding author.
E-mail address: [email protected] (M. Tanaka).

https://doi.org/10.1016/j.inat.2021.101278
Received 30 March 2021; Received in revised form 1 May 2021; Accepted 29 May 2021
Available online 5 June 2021
2214-7519/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Tanaka et al. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101278

diseases were included this study. Patients were operated from June reference arc. The diameter and length of each pedicle screw are
2017 to January 2020. Due approval of ethical committee of the insti­ determined on the navigation monitor screen. With navigation-guided
tute was obtained. Patients operated with MICEPS technique were tapping (Fig. 4A), adequate pedicle screws are inserted under naviga­
designated as group M and those operated with conventional cervical tion (Fig. 4B). After the insertion of all pedicle screws, another O-arm-
pedicle screw technique were called group C. based scan should be obtained to check the inserted screws’ locations.

2.1. Indications and contraindication for MICEPS 2.2.4. Rod insertion

The rods are measured, contoured, and placed on the pedicle screws
The indications for MICEPS fixation through the posterolateral and secured. The rod contouring is performed with a preoperative
approach were same as those for conventional posterior cervical fusion radiogram, and if it is necessary to correct deformity, cervical mala­
from C2–C7, such as cervical deformity, trauma, infection, and degen­ lignment is reduced by using the rod contouring technique.
erative diseases. The contraindication for MICEPS and conventional
pedicle screw fixation are congenital anomaly of the cervical pedicles, 2.3. Statistical analysis
traumatic vertebral artery aneurysm, bilateral vertebral artery injuries
(VAI), and difficulty in prone positioning (Table 1). T-test was used for interval data and chi-square test was used for
nominal data. All statistical calculations were performed using Graph­
Pad Prism (version 6.0; GraphPad Software, La Jolla, CA, USA). In all
2.2. Surgical technique
analyses, a p-value of < 0.05 was considered statistically significant.

2.2.1. Patient positioning for C-arm-free MICEPS

2.4. Radiographic parameters
The patient is positioned in the prone position with carbon Mayfield
on a Jackson frame to enable to CT scanning by the O-arm. The feasi­
Pre and postoperative cervical spine radiographs, computer tomog­
bility of cervical pedicle screw insertion should be confirmed before
raphy (CT) scans and magnetic imaging radiography (MRI) of the pa­
surgery because the skin incisions used with this new technique are > 6
tients were obtained.
cm lateral from the cervical midline (Fig. 1A).
2.5. Intra and perioperative data
2.2.2. Incision and muscle exposure
First, the reference frame is attached to the C7 spinous process for
Operative time and blood loss were noted. Any change in intra­
C2–7 pedicle screw insertion (Fig. 1B). For better accuracy when C2–3
operative neuromonitoring, dural tear, vertebral artery injury, nerve
screw insertion is needed, the use of the C2 spinous process is more
palsy, hematoma formation was recorded.
precise. The O-arm® (Medtronic, Memphis, TN, USA) is then positioned,
and 3D reconstructed images are obtained and transmitted to the Stealth
2.6. Assessment of accuracy of pedicle screw placement
station navigation system Spine 7® (Medtronic). After the O-arm scan is
obtained and all of the navigated instruments are calibrated, bilateral
Postoperative CT scans were studied for accuracy and angulation of
skin incisions (approx. 4 cm long) are made under navigation guidance
cervical pedicle screws. Pedicle breach or perforation of the screw was
(Fig. 2). The underlying subcutaneous tissue and nuchal fascia are cut
graded according to Neo classification (Table 2). Neo grade 0 and 1 were
with electrocautery. The targeted lateral masses are exposed with blunt
considered non-significant while grade 2 and 3 were considered
finger dissection between the levator scapulae and splenius muscles. A
significant.
small self-retaining retractor should be applied to maintain a clear sur­
gical field.
2.7. Postoperative protocol and complications
2.2.3. Pedicle screw insertion
Patients were followed up at 3, 6, 12, 24 and 36 months. Radiographs
Neuromonitoring is useful to prevent neurological complications
were taken at follow ups and CT scan was done immediate post­
during this procedure. The entry point of the pedicle screw is determined
operatively and at 1 year follow up. Any complications like infection,
using the navigation system. At least three points on the bone surface
implant failure, reoperation were recorded.
(the tip of the exposed spinous process, and both sides of exposed facet
joints) should be checked before using the navigation-guided high-speed
3. Results
burr. This accuracy check should be performed for every vertebra. A
pilot hole is made on the lateral mass with the navigation-guided high-
3.1. Patient demographics
speed burr (Fig. 3). If the targeted pedicle is relatively narrow, it is much
safer to shave the medial wall of the pedicle because the vertebral artery
Twenty-five patients were included in this study. Sixteen were men
is located laterally. The cervical pedicle is then probed using a
and nine were women. Mean age of patients in group M was 66.9 ± 12.1
navigation-guided pedicle probe. Careful attention must be paid not to
years and that in group C was 64 ± 10.9 years. Mean follow up period in
breach the transverse foramen. If there is no resistance of cancerous
group M was 19.7 ± 8.4 months while that in group C was 29.4 ± 7.6
bone with the probe or if there is any doubt of navigation accuracy,
months. Fifteen had degenerative diseases, nine patients had traumatic
another O-arm scan should be taken with a reference arc attached to the
pathology and one patient had metastasis. A total of 148 screws were
corresponding spinous process, because the navigation accuracy will
inserted in 25 cases. Group M included 18 cases and 106 screws were
worsen due to the distance from the reference or loosening of the
inserted while group C had 7 cases and 42 screws were inserted in them
(Table 3).
Table 1
Surgical Indications and Contraindications for MICEPS.
3.2. Blood loss and operative time
Indication Contraindication

Cervical deformity Congenital anomaly The averege blood loss in group M was 129 ± 33.8 ml while that in
Cervical trauma Traumatic VA aneurysm group C was 329 ± 69.3 ml with p value 0.10. The averge operative time
Cervical infection Bilateral vertebral artery injuries in group M was 77.4 ± 8.2 min while same in group C was 82.3 ± 5.1
Cervical degenerative disease Difficulty concerning the prone position for surgery
min with p value 0.12 the difference between these parameters is not

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M. Tanaka et al. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101278

Fig. 1. Patient and reference frame positioning. A: The patient is positioned in the prone position with a carbon Mayfield on a Jackson frame. B: The reference frame
is attached with C7 spinous process.

Fig. 2. Skin incision. A: Bilateral 4-cm skin incisions are made under navigation guidance. B: Navigation monitor.

Fig. 3. Screw hole preparation A: A navigation-guided high-speed burr is used to make a starting point for a pedicle screw. B: Navigation monitor.

statistically significant. 3.4. Screw angulation

3.3. Pedicle breach rate The mean medial screw angulation at all vertebral levels was
significantly higher in group M (average 45.2 degrees) (Fig. 6A)
Neo grade 0 and 1 were considered non-significant while grade 2 and compared to group C (average 33.4 degrees) (Fig. 6B). These are sum­
3 were considered significant. In group M, 84.9% screws showed grade marised in Table 5
0 breach, 15.1% screws showed grade 1 (grade 0 and 1 non-significant
breach 100%). In group C 59.5% screws showed grade 0 breach, 26.2%
screws showed grade 1 breach (grade 0 and 1 non-significant breach 3.5. Complications
85.7%) and 14.3% screws had grade 2 breach (Table 4 and Fig. 5). The
breach rate was significantly less in group M compared to group C for There was one dural tear in each group which healed without con­
grade 0 and 1 breach and for grade 2 and 3 breach (P < 0.03). sequences. Two patients in each group had C5 palsy which recovered by
2 months. There were no postoperative complications like vertebral
artery injury, epidural hematoma formation, infection or implant
failure.

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M. Tanaka et al. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101278

Fig. 4. Pedicle screw insertion. A: The pilot hole is tapped by the special cervical navigation-guided tap. B: Pedicle screw is accurately inserted under navigation.

in study of conventional cervical pedicle screw reported 10% incomplete

Table 2
perforation and 4% complete perforation. They also reported 1.4%
NEO classification for pedicular breach.
intraoperative complications of one vertebral artery injury and one
Grade 0 Grade 1 Grade 2 Grade 3 nerve injury [7]. Neo reported 29 of 84 screws (25%) breached the
Perforation No <2 mm 2–4 mm ≥4 mm pedicle cortex in study 18 case series of cervical pedicle screw, but
Significant breach − − + + continuity of vertebral artery was noted in all cases after CT angiography
[14]. Even with O-arm navigation, pedicle screw breach rate was from
0.6 to 3.8% [15–18]. In our cases, no screw showed significant breach
Table 3 (G2,3) in group M while in group C 14.3% screws had significant breach.
Patient demographics. One patient in each group had dural tear and 2 patients in each group
MICEPS (N = Conventional (N = Total (N = 25) had C5 palsy which recovered eventually. This shows that MICEPS has
18) 7) less screw perforation and neurovascular injury.
Mean age (range) 66.9±12.1 64.0±10.9 66.2±11.6
It was also reported that, medial angulation at midcervical level was
(years) (38–82) (45–72) (38–82) 52 degrees in MICEPS group and 39 degrees in conventional cervical
M:F 12:6 4:3 16:9 pedicle screw group [19]. In our patients angle of screw insertion was
Pathology 10 5 15 also higher in group M compared to group C with average angle of 45.2
Degenerative
degrees in group M and 33.4 degrees in group C (Table 4). The reasons
Trauma 7 2 9
Metastasis 1 0 1 for less medial angulation in conventional technique are skin and mus­
Follow up (month) 19.7 ± 8.4 29.4 ± 7.6 (12–38) 22.3 ± 9.6 cles not allowing more medial trajectory for instruments, rotation of
(12–43) (12–43) vertebra during probing and thick medial pedicular cortex. It has been
reported that medial cortex of cervical pedicle is up to 3.6 times ticker
than lateral [20]. Thus, screw tends to go more lateral which increases
4. Discussion
incidence of vertebral artery injury. MICEPS allow relatively horizontal
screw placement so risk of lateral perforation decreases [21]. This
Cervical instability due to laminectomy, degeneration, fracture-
medial angulation helps to reduce lateral breach and vertebral artery
dislocation, metastasis may require fixation. Lateral mass screw fixa­
injury in turn. In a study by Tokioka, average blood loss was 162 ml and
tion is conventionally used for cervical spine stabilisation. But it has
560 ml in MICEPS and conventional screw fixation respectively while
been proven that cervical pedicle screw fixation is stronger than lateral
operative time was 166 min and 217 min respectively [9]. Another study
mass screw fixation [5]. Conventional pedicle screw requires a large
reported that blood loss was 180 ml and 780 ml while operative time
incision, cause more blood loss and has high complications like vertebral
was 234 min and 250 min in MICEPS and conventional cervical pedicle
artery injury due to lateral breach of screw [7]. Minimally invasive
screw fixation respectively [19]. In our patients, the average blood loss
cervical pedicle screw (MICEPS) was recently described with good
in group M was 129 ml per level while that in group C was 329 ml per
outcomes [9]. It has benefits like small skin incision, less blood loss,
level and the average operative time in group M was 77.4 min per level
reduced lateral breach, less risk of vertebral artery injury [8]. Compli­
while same in group C was 82.3 min per level. In our study, the differ­
cations related to pedicle breach are vertebral artery injury, spinal cord
ence between blood loss and operative time are not statistically signif­
and nerve root injury, screw loosening, loss of reduction, psuedoarth­
icant. This might be due to various pathological conditions of cervical
rosis [1]. Devastating complication of cerebellar infarct after conven­
spine included in study.
tional cervical pedicle screw fixation have been reported [13]. Yukawa
With use of O-arm, accuracy of pedicle screw insertion can improved

Table 4
Breach rate of pedicle screws.
MICEPS Total Grade 0 Grade 1 Grade 2 Grade 3 Conventional Total Grade 0 Grade 1 Grade 2 Grade 3

C2 2 1 1 0 0 C2 4 2 0 2 0
C3 6 3 3 0 0 C3 2 0 1 1 0
C4 24 22 2 0 0 C4 2 1 0 1 0
C5 28 24 4 0 0 C5 4 1 3 0 0
C6 18 14 4 0 0 C6 10 4 4 2 0
C7 18 17 1 0 0 C7 12 9 3 0 0
T1 10 9 1 0 0 T1 8 8 0 0 0
Total 106 90 16 0 0 Total 42 25 11 6 0

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Fig. 5. Breach rate of screws in two groups.

good medial angulation of screw than conventional technique.

CRediT authorship contribution statement

Masato Tanaka: Conceptualization, Investigation. Venkatesh

Kadiri: Writing - original draft. Sumeet Sonawane: Writing - review &
editing. Koji Uotani: Formal analysis. Shinya Arataki: Data curation.
Yoshihiro Fujiwara: Data curation. Yoshiaki Oda: Data curation. Taro
Yamauchi: Formal analysis. Tomoyuki Takigawa: Writing - review &
editing.

Fig. 6. Postoperative axial CT in two groups. A: MICEPS technique B: Con­

Declaration of Competing Interest
ventional technique.

The authors declare that they have no known competing financial

Table 5 interests or personal relationships that could have appeared to influence
Average angulation of pedicle screws. the work reported in this paper.
Screw level MICEPS average angle Conventional average angle P-value
Acknowledgement
C2 47.5◦ 35.8◦ 0.0205
C3 44.7◦ 34.5◦ 0.0490
C4 52.0◦ 34.5◦ 0.0015 No acknowledgement.
C5 50.1◦ 36.3◦ <0.0001
C6 51.2◦ 33.5◦ <0.0001 Appendix A. Supplementary data
C7 40.9◦ 30.0◦ 0.0150
T1 30.6◦ 29.6◦ 0.7417
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.inat.2021.101278.
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