National inventory of authorized diagnostic imaging equipment in Ghana: data as of September 2020.

Introduction: to address the challenge of inadequate and non-equitable distribution of diagnostic imaging equipment, countries are encouraged to evaluate the distribution of installed systems and undertake adequate monitoring to ensure equitability. Ghana´s medical imaging resources have been analyzed in this study and evaluated against the status in other countries. Methods: data on registered medical imaging equipment were retrieved from the database of the Nuclear Regulatory Authority and analyzed. The equipment/population ratio was mapped out graphically for the 16 regions of Ghana. Comparison of the equipment/population ratio was made with the situation in other countries. Results: six hundred and seventy-four diagnostic imaging equipment units from 266 medical imaging facilities (2.5 units/facility), comprising computed tomography (CT), general X-ray, dental X-ray, single-photon emission computed tomography (SPECT) gamma camera, fluoroscopy, mammography and magnetic resonance imaging (MRI) were surveyed nationally. None of the imaging systems measured above the Organization for Economic Co-operation and Development (OECD) average imaging units per million populations (u/mp). The overall equipment/population ratio estimated nationally was 21.4 u/mp. Majority of the imaging systems were general X-ray, installed in the Greater Accra and Ashanti regions. The regional estimates of equipment/population ratios were Greater Accra (49.6 u/mp), Ashanti (22.4 u/mp), Western (21.4 u/mp), Eastern (20.6 u/mp), Bono East (20.0 u/mp), Bono (19.2 u/mp), Volta (17.9 u/mp), Upper West (16.7 u/mp), Oti (12.5 u/mp), Central (11.9 u/mp), Northern (8.9 u/mp), Ahafo (8.9 u/mp), Upper East (6.9 u/mp), Western North (6.7 u/mp), Savannah (5.5 u/mp) and North-East (1.7 u/mp). Conclusion: medical imaging equipment shortfall exist across all imaging modalities in Ghana. A wide inter-regional disparity in the distribution of medical imaging equipment exists contrary to WHO´s recommendation for equitable distribution. A concerted national plan will be needed to address the disparity.

Comparison of the Wiltse Approach and Percutaneous Pedicle Screw Fixation Under O-arm Navigation for the Treatment of Thoracolumbar Fractures.

OBJECTIVES: The aim of this study was to evaluate the clinical outcomes of the Wiltse approach and percutaneous pedicle screw placement under O-arm navigation for the treatment of thoracolumbar fracture. METHODS: We enrolled a total of 54 patients with neurologically intact thoracolumbar fracture who received minimally invasive treatments between October 2014 and October 2018 in this retrospective study. Among these, 28 patients (22 males and six females, with a mean age of 48.6 ± 9.6 years) were treated with pedicle screw fixation through the Wiltse approach (WPSF), and another 26 (15 males and 11 females, with a mean age of 45.7 ± 10.6 years) received percutaneous pedicle screw fixation under O-arm navigation (OPSF). Statistical methods were used to perform a detailed comparison of clinical outcomes, radiologic findings, and complications between the two groups obtained preoperatively, postoperatively, and at last follow-up. RESULTS: All patients underwent surgery successfully and finished a follow-up of more than 12 months. No serious complications, such as infection, blood vessel injury, or spinal cord or nerve root injury occurred. Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, local Cobb angle (LCA), vertebral wedge angle (VWA), and R value were notably improved after surgery, though there was no clear discrepancy between the groups at each time point (P > 0.05). During the follow-up period, no patients developed neurological impairment or implant-related complications, and no patients underwent revision surgery. The WPSF group had a significantly shorter operation time than the OPSF group (68.1 ± 9.8 vs 76.1 ± 9.0 minutes, P = 0.005). Moreover, the WPSF group showed less cost of surgery than the WPSF group (48142.1 ± 1430.1 vs 59035.4 ± 1152.7 CNY, P < 0.001). There were no significant differences between the two groups in terms of the intraoperative bleeding, length of incision, or postoperative hospitalization time (P > 0.05). The accuracy of pedicle screw placement was 95.2% (160/168) in the WPSF group and 96.8% (151/156) in the OPSF group, with no significant difference between the groups (P = 0.432). CONCLUSION: Both WPSF and OPSF were safe and effective for the treatment of thoracolumbar fracture. Although the two groups showed favorable clinical and radiologic outcomes through to final follow-up, we recommended the minimally invasive WPSF given its shorter operation time and lower cost of surgery.

The LungVision navigational platform for peripheral lung nodule biopsy and the added value of cryobiopsy.

BACKGROUND: The LungVision system is a novel augmented-fluoroscopy-based real-time navigation and guidance technology for bronchoscopy that can be integrated with any standard biopsy tool, including the cryoprobe, to enable real-time visualization and localization of pulmonary nodules. OBJECTIVES: To evaluate the diagnostic yield and safety among patients undergoing peripheral pulmonary nodule biopsy with the LungVision system. METHODS: This prospective, single-center study was conducted at Rabin Medical Center in Israel. All patients that underwent peripheral pulmonary nodule biopsy with the LungVision system from January 2016 to August 2020 were included. All procedures were performed under moderate sedation. The primary outcome was tissue diagnosis by either identification of malignant cells or benign diagnosis. Secondary outcomes were safety and the added value of cryobiopsy. RESULTS: Sixty-three procedures were performed during the study period. Median lesion size (interquartile range) was 25.0 mm (18-28 mm). The diagnostic yield overall was 27/33 (81.8%) and for lesions smaller than 20 mm was 13/18 (72.2%). In nine cases the transbronchial cryobiopsy showed tissue with malignant cells that were not found in any other biopsy material taken with other sampling tools. One patient was treated with a chest tube for a pneumothorax. No other major complications were reported. CONCLUSIONS: The LungVision system showed good feasibility and safety for peripheral pulmonary nodule biopsy. The system is compatible with all biopsy tools, including the cryoprobe. Randomized controlled trials are needed to accurately ascertain its diagnostic yield.

A Prospective Comparison of the Effects of Instrument Tracking on Time and Radiation During Minimally Invasive Lumbar Interbody Fusion.

BACKGROUND: Minimally invasive surgical techniques have resulted in improved patient outcomes. One drawback has been the increased reliance on fluoroscopy and subsequent exposure to ionizing radiation. We have previously shown the efficacy of a novel instrument tracking system in cadaveric and preliminary clinical studies for commonplace orthopedic and spine procedures. In the present study, we examined the radiation and operative time using a novel instrument tracking system compared with standard C-arm fluoroscopy for patients undergoing minimally invasive lumbar fusion. METHODS: The radiation emitted, number of radiographs taken, and time required to complete 2 tasks were recorded between the instrument tracking systems and conventional C-arm fluoroscopy. The studied tasks included placement of the initial dilator through Kambin's triangle during percutaneous lumbar interbody fusion and placement of pedicle screws during both percutaneous lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion with or without instrument tracking. RESULTS: A total of 23 patients were included in the analysis encompassing 31 total levels. For the task of placing the initial dilator into Kambin's triangle, an average of 4.21 minutes (2.4 vs. 6.6 minutes; P = 0.002), 15 fluoroscopic images (5.4 vs. 20.5; P = 0.002), and 8.14 mGy (3.3 vs. 11.4; P = 0.011) were saved by instrument tracking. For pedicle screw insertion, an average of 5.69 minutes (3.97 vs. 9.67; P < 0.001), 14 radiographs (6.53 vs. 20.62; P < 0.001), and 7.89 mGy (2.98 vs. 10.87 mGy; P < 0.001) were saved per screw insertion. CONCLUSIONS: Instrument tracking, when used for minimally invasive lumbar fusion, leads to significant reductions in radiation and operative time compared with conventional fluoroscopy.

Extended detail contrasts for TO.10 use on flat panel detector fluoroscopy systems.

OBJECTIVES: Leeds Test Object Ten (TO.10) is routinely used to subjectively estimate Threshold Contrast Detail Detectability (TCDD) as a measure of image quality in fluoroscopy. However, manufacturer guidance provides calibrated contrasts for only limited peak voltage and copper filtration thickness combinations. Prescribed testing conditions are often difficult to attain as modern flat panel fluoroscopic systems independently determine voltage and copper filtration thickness settings. This work aims to extend the range of TO.10 contrasts available for routine testing at peak voltage and copper thickness settings likely to be encountered. METHODS: Two methods are described for generalising the calculation of target contrasts: a three-dimensional interpolation/extrapolation model in MATLAB®, and a multivariate log-polynomial function. Both methods utilise the available calibrated contrasts to estimate contrasts at voltage and copper thickness combinations routinely encountered. RESULTS: Results are presented as Threshold Detection Index [Formula: see text] curves fit by a second-order polynomial of log [Formula: see text] to log [Formula: see text] . Results are found to be more accurate at unprescribed conditions while also reproducible for relatively consistent input air kerma rate (IAKR) expected from automatic dose rate controls (ADRC). CONCLUSIONS: The calculation of TO.10 contrasts at non-standard conditions aids in the determination of an absolute estimate of image quality in fluoroscopy with greater accuracy, reproducibility and efficiency. ADVANCES IN KNOWLEDGE: TO.10 detail contrasts for TCDD testing of fluoroscopy units have been significantly extended beyond those previously available. The described methods will aid the clinical physicist in absolute assessments of fluoroscopic image quality and facilitate inter system comparisons.

C-Arm-Free Anterior Correction for Adolescent Idiopathic Scoliosis (Lenke Type 5C): Analysis of Early Outcomes and Complications.

BACKGROUND: Computer-assisted spinal surgery as a technique for reducing radiation exposure to the operating staff and the complications of spinal deformity are receiving considerable attention. However, no technical reports have described the technique for navigating anterior correction of adolescent idiopathic scoliosis without C-arm fluoroscopy. The purpose of this study was to evaluate the efficacy and safety of this new C-arm-free anterior correction for scoliosis. METHODS: This study investigated 38 consecutive patients with Lenke type 5C curves who underwent selective lumbar or thoracolumbar fusion, comprising 26 patients with conventional anterior correction surgery, and 12 patients with C-arm-free navigation surgery. The 2 groups were evaluated immediately postoperatively and at the 2-year follow-up. RESULTS: No vascular injuries, screw malpositioning, or major complications were associated with the surgical procedure in either group. Correction rates of the lumbar curve were satisfactory with no significant difference between groups (mean, 82.6% ± 5.7% vs. 80.7% ± 10.2%, respectively). However, mean time for fluoroscopy in group C was 133 ± 9.5 seconds (P < 0.0001). No significant differences in intraoperative blood loss (642 ± 123 mL vs. 731 ± 222 mL, respectively) or surgical time (251 ± 13 min vs. 301 ± 38 min, respectively) were seen between groups. Mean final follow-up Scoliosis Research Society Outcomes Questionnaire (SRS-22) was also excellent for both group C (4.2 ± 0.19) and group N (4.3 ± 0.20). CONCLUSIONS: C-arm-free anterior correction offers safe, effective surgery for adolescent idiopathic scoliosis. The advantage of this new technique is no radiation exposure for medical staff at centers performing large numbers of spinal procedures.

Can ultrasound guidance reduce radiation exposure significantly in percutaneous nephrolithotomy in pediatric patients?

In this study, we aimed to compare clinical and technical outcomes between pediatric patients who underwent percutaneous nephrolithotomy (PCNL) under fluoroscopy (FL) and those that underwent this procedure under FL with ultrasound assistance (FLUSA). The data of 66 PCNL patients were analyzed retrospectively. Renal puncture was successful in 22 patients in the FLUSA group and 44 patients in the FL group. In all cases, FL was used for tract dilation and confirmation of ureteral catheter positioning at the beginning of the procedure. The sample consisted of 46 males and 20 females with a mean age of 7.2 ± 2.1 years (range 1-17 years). Stone size varied from 8.0 to 75.4 mm, and 89% of patients achieved a completely stone-free state. The median puncture time was 130.5 ± 25.3 s for FLUSA and 295 ± 82.8 s for FL, the median fluoroscopic screening time was 95 ± 33 and 230 ± 116 s, respectively, and the median radiation dose was 19.04 ± 9.9 dGy/cm2 and 54 ± 21.4 dGy/cm2, respectively. The median puncture time, fluoroscopic screening time, and radiation dose were statistically lower in the FLUSA group (p = 0.001, Mann-Whitney U test). The greatest problem in PCNL is the use of fluoroscopy. Due to some anatomical differences from adults, applying PCNL in pediatric patients using only ultrasound may decrease the success rate. Puncture with ultrasound significantly reduces the radiation dose in children. Puncture with ultrasound and dilation under fluoroscopy is a successful and safe treatment method with low morbidity and high success rates and shorter hospital stay in pediatric patients.

Time Trend of the Radiation Exposure Dose in Endoscopic Retrograde Cholangiopancreatography Over an 8-Year Period: A Single-Center Retrospective Study.

INTRODUCTION: The global needs for a reduction in radiation exposure (RE) are increasing. Endoscopic retrograde cholangiopancreatography (ERCP) is a significant fluoroscopic procedure in the gastrointestinal field. However, the actual RE in ERCP and its annual trend are still unclear. Therefore, we examined the yearly trend of RE in ERCP. METHODS: This retrospective, single-center cohort study included consecutive cases of ERCP from September 2012 to June 2019. We measured the air kerma (AK, mGy), dose area product (DAP, Gycm2), and fluoroscopy time (FT, min). We also evaluated the annual trend of the RE before and after the fluoroscopy device update. RESULTS: In total, 2,174 patients receiving ERCP were enrolled. Among these, the mean age was 74.3 years, and 913 patients were women (42.0%). The median/third quartile values of AK (mGy), DAP (Gycm2), and FT (min) were 109/234 mGy, 13.3/25.8 Gycm2, and 18.2/27.7 minutes. The annual AK, DAP, and FT from 2012 to 2019 were 138, 207, 173, 177, 106, 71.0, 45.0, and 33.3 mGy; 23, 21.4, 19, 18.3, 11.9, 9.0, 6.8, and 6.4 Gycm2; and 12.5, 12.1, 9.7, 9.8, 8.2, 10.8, 9.4, and 10.3 minutes, respectively. The corresponding values before and after the update in July 2016 were 177 and 52 mGy (P < 0.0001), 19.2 and 7.6 Gycm2 (P < 0.0001), and 10.2, and 9.9 minutes (P = 0.05), respectively. DISCUSSION: The RE from ERCP tended to decrease every year, especially after fluoroscopy device updates.

Establishing local diagnostic reference levels for common orthopaedic procedures using the mini C-arm fluoroscope.

OBJECTIVE: Mini C-arm fluoroscopes are widely used by orthopaedic surgeons for intraoperative image guidance without the need for radiographers. This puts the responsibility for radiation exposure firmly with the operating surgeon. In order to maintain safe and best practice under U.K. Ionising Radiation (Medical Exposure) Regulations, one must limit radiation exposure and audit performance using national diagnostic reference levels (DRLs). In the case of the mini C-arm, there are no national DRLs. IR(ME)R, therefore, require the establishment of local DRLs by each hospital to act as an alternative guideline for safe radiation use. The aim of our audit was to establish local DRLs based on our experience operating with the use of the mini C-arm over the last 7 years. METHODS: This retrospective audit evaluates the end dose-area product (DAP) recorded for common trauma and orthopaedic procedures using the mini C-arm in a busy district general hospital.We present the quartile data and have set the cut-off point as the third quartile for formulating the local DRLs, consistent with the methodology for the conventional fluoroscope. RESULTS: For our data set (n = 1664), the third quartile DAP values were lowest for surgeries to the forearm (5.38 cGycm2), hand (7.62 cGycm2), and foot/ankle (8.56 cGycm2), and highest for wrist (10.64 cGycm2) and elbow (14.61 cGycm2) procedures. ADVANCES IN KNOWLEDGE: To our knowledge, this is the largest data set used to establish local DRLs. Other centres may find our guidelines useful whilst they establish their own local DRLs.

The Role of Intraoperative Image Guidance Systems (Three-Dimensional C-arm versus O-arm) in Spinal Surgery: Results of a Single-Center Study.

OBJECTIVE: Spinal dorsal instrumentation is an established treatment option for a range of spinal disorders. In combination with navigation, intraoperative fluoroscopy reduces the risk of incorrectly placing screws. This study aimed to evaluate the efficacy and validity of fluoroscopy (intraoperative navigation with three-dimensional rotation of C-arm vs. O-arm). METHODS: In this retrospective single-center study, 240 patients were included between July 2017 and April 2020. Intraoperative images were acquired using a Siemens-Arcadis Orbic 3D C-arm with a navigation system (Brainlab, AG, Munich, Germany) or using O-arm (Medtronic, Minneapolis, Minnesota, USA) with a navigation system (S7 StealthStation). Finally, we compared mismatches between intraoperative and postoperative computed tomography imaging results using Rampersaud-grade (A-D). RESULTS: A total of 1614 screws were included: 94 patients in the C-arm group (cAG) and 146 in the O-arm group (oAG). In cAG, 3% (n = 20) of the screws had to be replaced directly due to inadequate positioning with median or lateral breaches, and 3.5 % of screws in oAG (n = 35). An A-score was achieved for 85.7% in the cAG and 87.4% in the oAG. A B-score was found in 11.5% in the cAG and 11.9% in the oAG. In the cAG, a C-score was achieved for 2.5% and in oAG for 0.7%. For 0.3% of the screws, a D-score was found in cAG and for none in oAG. CONCLUSIONS: Our study shows that placement of screws using intraoperative imaging in combination with a navigation tool is accurate. Furthermore, navigation coupled with the O-arm had significant advantages in accuracy over navigation with 3D C-arm fluoroscopy. However, both systems offer a high level of accuracy.

Comparison between anteroposterior and oblique "Scotty dog" approach during S1 transforaminal epidural steroid injection: A randomized controlled trial.

BACKGROUND: Traditionally, S1 transforaminal epidural steroid injection (TFESI) has been performed using an anteroposterior (AP) fluoroscopic view. In 2007, the oblique "Scotty dog" (OS) approach was introduced as an alternative technique. We compared passage time of the needle into S1 foramen (Tf) between the anteroposterior (AP) and oblique "Scotty dog" (OS) approach during S1 TFESI. METHODS: In this prospective randomized controlled trial, seventy patients scheduled S1 TFESI were randomly allocated into AP or OS groups. In the AP group, a slight cephalad-caudad tilt was used. In the OS group, the C-arm was rotated ipsilateral oblique degrees to view the S1 Scotty dog. Both groups received injection of steroid mixed with local anesthetics. We measured the passage time of the needle into S1 foramen (Tf), primary outcome, and total procedure time (Tt) between the groups. We also recorded presence of intravascular injection, patients-assessed pain relief for one month and complications. RESULTS: The Tf and Tt were shorter in the OS than in the AP group (24.4 ±â€Š24.0 s vs 47. 8 ±â€Š53.2seconds; 93.3 ±â€Š35.0 seconds vs 160.0 ±â€Š98.7 seconds, P < .001, both). Incidence of intravascular injection (AP, 8 [22.8%]; OS, 4 [11.4%], P = .205), pain score, and complication rates were not statistically different between the two groups. In logistic regression analysis, the body mass index (BMI) was a risk factor for longer Tt (odds ratio [OR] = 1.27, 95% CI: 1.02-1.58, P = .030). CONCLUSION: The passage time of the needle into S1 foramen was shorter in OS approach and the OS approach reduced the procedure time compared with the AP approach during S1 TFESI. The practitioners should note that procedure time can be prolonged in obese patients.

Endobronchial Navigation Guided by Cone-Beam CT-Based Augmented Fluoroscopy without a Bronchoscope: Feasibility Study in Phantom and Swine.

PURPOSE: To evaluate the accuracy of cone-beam computed tomography (CT)-based augmented fluoroscopy (AF) image guidance for endobronchial navigation to peripheral lung targets. METHODS: Prototypic endobronchial navigation AF software that superimposed segmented airways, targets, and pathways based on cone-beam CT onto fluoroscopy images was evaluated ex vivo in fixed swine lungs and in vivo in healthy swine (n = 4) without a bronchoscope. Ex vivo and in vivo (n = 3) phase 1 experiments used guide catheters and AF software version 1, whereas in vivo phase 2 (n = 1) experiments also used an endovascular steerable guiding sheath, upgraded AF software version 2, and lung-specific low-radiation-dose protocols. First-pass navigation success was defined as catheter delivery into a targeted airway segment solely using AF, with second-pass success defined as reaching the targeted segment by using updated AF image guidance based on confirmatory cone-beam CT. Secondary outcomes were navigation error, navigation time, radiation exposure, and preliminary safety. RESULTS: First-pass success was 100% (10/10) ex vivo and 19/24 (79%) and 11/15 (73%) for in vivo phases 1 and 2, respectively. Phase 2 second-pass success was 4/4 (100%). Navigation errors were 2.2 ± 1.2 mm ex vivo and 4.9 ± 3.2 mm and 4.0 ± 2.6 mm for in vivo phases 1 and 2, respectively. No major device-related complications were observed in the in vivo experiments. CONCLUSIONS: Endobronchial navigation is feasible and accurate with cone-beam CT-based AF image guidance. AF can guide endobronchial navigation with endovascular catheters and steerable guiding sheaths to peripheral lung targets, potentially overcoming limitations associated with bronchoscopy.

National Diagnostic Reference Levels for Endovascular Aneurysm Repair and Optimisation Strategies.

OBJECTIVE: The International Commission on Radiological Protection (ICRP) has highlighted the large number of medical specialties using fluoroscopy outside imaging departments without programmes of radiation protection (RP) for patients and staff. Vascular surgery is one of these specialties and endovascular aneurysm repair (EVAR) is one of the most challenging procedures requiring RP guidance and optimisation actions. The recent European Directive on Basic Safety Standards requires the use and regular update of diagnostic reference levels (DRL) for interventional procedures. The objective of the study was to know the doses of patients undergoing EVAR with mobile Xray systems and with hybrid rooms (fixed Xray systems), to obtain national DRLs and suggest optimisation actions. METHODS: The Spanish Chapter of Endovascular Surgery launched a national survey that involved hospitals for 10 autonomous communities representing the 77% of the Spanish population (46.7 million inhabitants). Patient dose values from mobile Xray systems were available from nine hospitals (sample of 165 EVAR procedures) and data from hybrid rooms, from seven hospitals, with dosimetric data from 123 procedures. The initial national DRLs have been obtained, as the third quartile of the median values from the different centres involved in the survey. RESULTS: The proposed national DRLs are 278 Gy cm2 for hybrid rooms and 87 Gy cm2 for mobile Xray systems, and for cumulative air kerma (cumulative AK) at the patient entrance reference point, 1403 mGy for hybrid rooms, and 292 mGy for mobile systems. CONCLUSION: An audit of patient doses for EVAR procedures to identify optimised imaging protocol strategies is needed. It is also appropriate to evaluate the diagnostic information required for EVAR procedures. The increase by a factor of 3.2 (for kerma area product) and 4.8 (for cumulative AK) in the DRLs needs to be justified when the procedures are performed in the hybrid rooms rather than with mobile Xray systems.

Transbronchial biopsy results according to diffuse interstitial lung disease classification. Cryobiopsy versus forceps: MULTICRIO study.

BACKGROUND: In recent years, transbronchial cryobiopsy (TBCB) has come to be increasingly used in interventional pulmonology units as it obtains larger and better-quality samples than conventional transbronchial lung biopsy (TBLB) with forceps. No multicenter studies have been performed, however, that analyse and compare TBCB and TBLB safety and yield according to the interstitial lung disease (ILD) classification. OBJECTIVES: We compared the diagnostic yield and safety of TBCB with cryoprobe sampling versus conventional TBLB forceps sampling in the same patient. METHOD: Prospective multicenter clinical study of patients with ILD indicated for lung biopsy. Airway management with orotracheal tube, laryngeal mask and rigid bronchoscope was according to the protocol of each centre. All procedures were performed using fluoroscopy and an occlusion balloon. TBLB was followed by TBCB. Complications were recorded after both TBLB and TBCB. RESULTS: Included were 124 patients from 10 hospitals. Airway management was orotracheal intubation in 74% of cases. Diagnostic yield according to multidisciplinary committee results for TBCB was 47.6% and for TBLB was 19.4% (p<0.0001). Diagnostic yield was higher for TBCB compared to TBLB for two groups: idiopathic interstitial pneumonias (IIPs) and ILD of known cause or association (OR 2.5; 95% CI: 1.4-4.2 and OR 5.8; 95% CI: 2.3-14.3, respectively). Grade 3 (moderate) bleeding after TBCB occurred in 6.5% of patients compared to 0.8% after conventional TBLB. CONCLUSIONS: Diagnostic yield for TBCB was higher than for TBLB, especially for two disease groups: IIPs and ILD of known cause or association. The increased risk of bleeding associated with TBCB confirms the need for safe airway management and prophylactic occlusion-balloon use. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT02464592.

Does Pedicle Screw Fixation Assisted by O-Arm Navigation Perform Better Than Fluoroscopy-guided Technique in Thoracolumbar Fractures in Percutaneous Surgery?: A Retrospective Cohort Study.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To evaluate the effect of O-arm navigation in percutaneous surgeries for thoracolumbar fracture in comparison to the use of conventional fluoroscopic technique. SUMMARY OF BACKGROUND DATA: O-arm navigation is a progressive surgical tool, with extensive research papers reporting its effects. Whereas, there were not many papers describing its accuracy and facet impingement rate when compared with fluoroscopy-guided technique in percutaneous surgeries, especially at varying fracture levels. MATERIALS AND METHODS: We conducted a retrospective comparative study of 97 consecutive patients of single-level neurological intact thoracolumbar fractures from November 2015 to October 2017 and they were all treated with percutaneous pedicle screw implantation. Screws were classified as 4 grades of perforations and 3 grades of facet joint violation. The association between variables such as anatomic perforation, functional perforation, and facet impingement were investigated by χ test, Fisher exact test or t test. A P-value of <0.05 was considered statistically significant. RESULTS: A total of 573 pedicle screws were implanted and graded. The overall anatomic perforation rate and functional perforation rate were lower in the O-arm group compared with the fluoroscopy group (8.3% vs. 15.0%, P=0.013, 1.1% vs. 4.2%, P=0.024). At fracture level, the rate of grade 2 perforation of the O-arm group was lower than that of the fluoroscopy group (0% vs. 6.1%, P=0.033). Furthermore, the O-arm group obviously reduced the facet impingement rate both at all levels and at fracture levels (P=0.002; 0.02). CONCLUSIONS: In percutaneous pedicle screw placement for neurological intact thoracolumbar fracture, the introduction of O-arm navigation improved accuracy, reduced functional perforations, and minimized serious perforations compared with conventional fluoroscopic technique. It also decreased facet joint violation observably and helped to prevent development of adjacent segment degeneration.

Role of Robotics in Improving Surgical Outcome in Spinal Pathologies.

BACKGROUND: The desire to improve accuracy and safety and to favor minimally invasive techniques has given rise to spinal robotic surgery, which has seen a steady increase in utilization in the past 2 decades. However, spinal surgery encompasses a large spectrum of operative techniques, and robotic surgery currently remains confined to assistance with the trajectory of pedicle screw insertion, which has been shown to be accurate and safe based on class II and III evidence. The role of robotics in improving surgical outcomes in spinal pathologies is less clear, however. METHODS: This comprehensive review of the literature addresses the role of robotics in surgical outcomes in spinal pathologies with a focus on the various meta-analysis and prospective randomized trials published within the past 10 years in the field. RESULTS: It appears that robotic spinal surgery might be useful for increasing accuracy and safety in spinal instrumentation and allows for a reduction in surgical time and radiation exposure for the patient, medical staff, and operator. CONCLUSION: Robotic assisted surgery may thus open the door to minimally invasive surgery with greater security and confidence. In addition, the use of robotics facilitates tireless repeated movements with higher precision compared with humans. Nevertheless, it is clear that further studies are now necessary to demonstrate the role of this modern tool in cost-effectiveness and in improving clinical outcomes, such as reoperation rates for screw malpositioning.

A Proposal for a Standardized Nomenclature of the C-arm Movements.

No formal didactic source exists concerning terminology for movement of the C-arm in the operating room (OR). Many terminologies exist, breeding confusion among OR staff. The objective of this study was to survey the existing C-arm movement terminologies among orthopaedic surgeons and radiologic technologists and propose a standardized nomenclature moving forward. Methods: Forty-six orthopaedic surgeons and 70 radiologic technologists were surveyed. Pertinent product manuals and literature from PubMed were reviewed to find existing terms for the C-arm movement. A focus group of orthopaedic surgeons and radiologic technologists was formed and a standardized nomenclature of the C-arm terminology was developed using the Delphi method. Results: The survey response rate was 71%. The mean percentage of agreement on terms to describe movement was 47% (range, 13% to 83%). Agreement on terms to describe direction was 46% (range, 23% to 73%), and multiple frames of reference were described. No consensus was found by searching the product manuals. Using the Delphi method, we arrived at a standardized nomenclature for the C-arm movement that is reproducible and familiar. Discussion: A standardized terminology for the C-arm movement is described that will help fill a void in OR communication, combat confusion, and provide reproducible results during orthopaedic cases.

The effect of a new universal laser aiming device in C-arm fluoroscopy on the technician's accuracy.

OBJECTIVES: This study aims to introduce a new low-cost universal laser aiming device (LAD) that can be used in existing C-arm fluoroscopy devices, independent of brand and model, and to determine whether this new universal LAD improves technician accuracy in locating the desired region at the midpoint of the fluoroscopic image. MATERIALS AND METHODS: A low-priced universal LAD that is compatible with existing 12-inch C-arm fluoroscopy devices was designed. Eight radiology technicians with varied levels of experience in C-arm fluoroscopy participated in the study. A 12 mm cortical screw with a diameter of 3.5 mm was placed on proximal, diaphyseal, and distal points of femur, tibia, and humerus bones in the anteroposterior plane on L3 vertebrae and the left pubis arm in the pelvis bone model. Technicians were asked to align each screw in the image center 10 times from a distance of 30 cm in the anterolateral plane, first without the LAD and then with the LAD. The distance of the screw head to the center point was measured from the 3,520 images with the help of medical viewer software based on the X- and Y-axis. RESULTS: Each fluoroscopic image was divided into 48 equal parts and the length of a part was taken as one unit for distance measurements. The compliance between technicians without the LAD was 0.347 (95% confidence interval [CI]: 0.208-0.47, p=0.001) and with the LAD was 0.687 (95% CI: 0.621-0.741, p=0.001). The distance between the screw head and the center of the image without the LAD was 19.0±9.8 for technicians with more than 10 years of experience and 28.0±12.9 for those with less than 10 years of experience. This difference was statistically significant (p=0.001). When the LAD was used, the difference between the less experienced (3.1±1.5) and more experienced (3.3±2.0) technicians was statistically reduced, along with the distance (p=0.033). CONCLUSION: The use of the LAD with C-arm fluoroscopy appears to be successful in helping technicians capture the desired point in the center of the fluoroscopic image. The use of the LAD reduces the experience gap between technicians.

[Collected data on freehand technique instrumentation and literature comparison on fluoroscopic and CT-assisted navigation]. / Erhobene Daten zur Instrumentierung in Freihandtechnik und Literaturvergleich zu fluoroskopisch- und CT-gestützter Navigation.

BACKGROUND: A proven and frequently used surgical procedure in patients with idiopathic scoliosis (IS) is posterior transpedicular corrective spondylodesis using the freehand technique. Novel procedures with fluoroscopically and computed tomography (CT)-assisted navigation are presumed to be less risky and more accurate. OBJECTIVE: Is the freehand technique for IS safe with respect to screw-associated complications and intraoperative radiation exposure? MATERIAL AND METHODS: Prospectively collected data (2017-2018) from 39 consecutive patients (average age 18.7 years) with thoracic single curvature IS (61.7°â€¯± 13.9°) from a specialized scoliosis center were evaluated for the following parameters (mean ± standard deviation): total radiation product, fluoroscopy time, fused segments, operative time, blood loss and screw-associated complications. A comparison with data from the literature on intraoperative radiation exposure using navigation procedures was carried out. RESULTS: The total radiation product per patient was 71.7 ± 44.0 cGy*cm2, fluoroscopy time 17.4 ± 8.6 s. (7.8 segments), operative time 183.5 ± 54.2 min and blood loss 379.5 ± 183 ml. There were no screw-associated complications in the entire collective. Correction of the main curvature was 75.7%. Comparison of the data with index data from the literature showed a 1.25-12.5-fold higher radiation exposure for patients with fluoroscopically assisted navigation and 9.25-12.3-fold higher radiation exposure with CT-assisted procedures compared to the present results. CONCLUSION: The results of this study showed that with appropriate experience freehand positioning of pedicle screws is associated with comparable accuracy and less radiation exposure for patients than navigation procedures. With respect to the young age of patients, a radiation-induced long-term risk for malignant diseases should be taken into consideration.