Original ArticleComparison of Operative Time with Conventional Fluoroscopy Versus Spinal Neuronavigation in Instrumented Spinal Tumor Surgery
Introduction
Spinal metastases occur in approximately 30% of patients with cancer.1, 2, 3 Primary sites such as the breast and the prostate have even higher rates of spinal metastases.4 Surgical management is an integral part of the care for patients with spinal metastatic disease.5 Operative decompression before radiotherapy in patients with myelopathy results in improved ambulation, decreased need for opioids, and prolonged survival.6 Further, instrumented spinal stabilization in patients with spinal metastatic disease results in improved neurologic outcomes, including a higher chance of recovery of ambulation after presentation with paraplegia.7, 8 Recent studies also support separation surgery followed by stereotactic radiosurgery for epidural decompression, stabilization, and disease control without requiring extensive vertebral body resection.9, 10
Multiple myeloma accounts for 10% of all hematologic malignancies and frequently results in osteolytic bone disease, with the spine being the most commonly affected site.11, 12 Vertebral body destruction as part of the multiple myeloma disease process can lead to pain, spinal deformity, and neural element compression.13 Surgical management of multiple myeloma-related vertebral column disease includes kyphoplasty for pathologic vertebral compression fractures, with resection and instrumentation recommended for cases of instability.14, 15, 16
Misplacement of pedicle screws during spinal stabilization surgery can result in an injury to an adjacent nerve root or the spinal cord itself, cerebrospinal fluid leak, and hemorrhage.17, 18, 19, 20 Freehand pedicle screw placement is based on anatomic landmarks and is subject to a learning curve; misplacement rates, as defined by perforation of the pedicle, vary with technique and have been reported as high as 55%.17, 18, 21, 22, 23 Fluoroscopic guidance is a common surgical tool for the placement of spinal instrumentation. Intraoperative two-dimensional (2D) fluoroscopy, three-dimensional (3D) fluoroscopy, and computed tomography (CT)-based neuronavigation allow for greater accuracy than does conventional fluoroscopy.21, 24 The reported screw misplacement rates using spinal neuronavigation are lower than with freehand placement or use of traditional fluoroscopy.17, 18, 21, 22, 25, 26, 27, 28, 29, 30
Both advantages and disadvantages have been reported for the use of spinal neuronavigation. Radiation exposure to the surgical team has been found to be decreased with 3D neuronavigation compared with traditional fluoroscopy.17 Radiation exposure to the patient also is likely decreased, especially when guidance and confirmatory imaging are obtained intraoperatively, thereby eliminating preoperative and postoperative imaging. Still, some studies have found increased radiation exposure in patients with 3D navigation.17, 29, 31, 32, 33, 34, 35, 36, 37, 38 A major reason that surgeons have given for not implementing neuronavigation in spine surgery is concern regarding an increase in operative time.39 Studies addressing this concern are mixed, because some centers report a longer operative time with 3D spinal navigation and others report an insignificant operative time difference.37, 40, 41, 42
There is limited literature regarding the use of 3D neuronavigation in spinal tumor surgery, and there is no report on conventional fluoroscopy versus spinal neuronavigation operative time comparisons for this cohort of patients. Spinal oncology surgery is more likely to be performed in the thoracic spine with smaller pedicles and feature longer constructs incorporating more pedicle screws than do degenerative spinal operations. Thus, any spinal neuronavigation effect on operative time has the potential to be more pronounced in this surgical group. Because of the medical complexities and increased comorbidities of patients with metastatic disease to the spine,43 any increase in operative time and thus anesthesia time could be detrimental. Further, increased operative time could result in increased blood loss during an oncologic procedure. The purpose of our study was to examine and compare operative time in a cohort of consecutive patients requiring laminectomy and posterior instrumentation for spinal column tumors (metastatic disease or multiple myeloma) before and after the integration of 3D-based spinal neuronavigation at our institution.
Section snippets
Methods
This study was approved by our institutional review board. Consecutive spinal operations performed by a single neurosurgeon (A.J.F.) between 2012 and 2014 were retrospectively identified with data collected and managed using the REDCap system (Research Electronic Data Capture, licensed by Vanderbilt University Medical Center). Patients undergoing oncologic instrumented spinal surgery were included in the study. Patients were excluded if they had a primary diagnosis other than metastasis from a
Results
A total of 52 consecutive spinal operations performed between 2012 and 2014 were reviewed. Five patients underwent surgery for diagnoses other than metastatic disease or multiple myeloma and were therefore excluded. An additional 2 patients were excluded because they had previously undergone surgery at the same level. Of the remaining 45 cases, 6 procedures did not require instrumentation and were excluded. This process resulted in inclusion of 39 operative cases. Of these cases, 14 were
Discussion
This study was carried out to compare the operative times of patients requiring laminectomy and posterior instrumentation using 2D fluoroscopy and 3D spinal neuronavigation for spinal tumor surgery. No significant difference in the length of the operation was found between the 2 groups in our cohort. The patients in each group were of similar age, required a similar number of pedicle screws placed for stabilization, and required laminectomies at a similar number of levels, with there being no
Conclusions
The use of spinal neuronavigation during posterior instrumentation can provide a benefit for oncologic patients requiring this procedure. The potential drawback of increased operative time and increased time under anesthesia is not supported by our results, because the operative time with neuronavigation did not significantly differ from the operative time before its implementation at our center. Further, our results suggest that using spinal neuronavigation in oncologic spinal instrumentation
Acknowledgments
The authors thank Paul H. Dressel, B.F.A., for preparation of the illustrations and Carrie Owens, M.S.I.L.S., and Elaine C. Mosher, M.L.S., for editorial assistance. Conception and design, both authors; acquisition of data, both authors; analysis and interpretation of data, both authors; drafting the manuscript, J.A.M.; critically revising the manuscript, both authors; reviewed final version of the manuscript and approved it for submission, both authors.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.