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Conventional Versus Stereotactic Image-guided Pedicle Screw Placement During Posterior Lumbar Fusions

A Retrospective Propensity Score-matched Study of a National Longitudinal Database

Pendharkar, Arjun V. MD; Rezaii, Paymon G. MS; Ho, Allen L. MD; Sussman, Eric S. MD; Veeravagu, Anand MD; Ratliff, John K. MD; Desai, Atman M. MD

doi: 10.1097/BRS.0000000000003130

Study Design. Retrospective 1:1 propensity score-matched analysis on a national longitudinal database between 2007 and 2016.

Objective. The aim of this study was to compare complication rates, revision rates, and payment differences between navigated and conventional posterior lumbar fusion (PLF) procedures with instrumentation.

Summary of Background Data. Stereotactic navigation techniques for spinal instrumentation have been widely demonstrated to improve screw placement accuracies and decrease perforation rates when compared to conventional fluoroscopic and free-hand techniques. However, the clinical utility of navigation for instrumented PLF remains controversial.

Methods. Patients who underwent elective laminectomy and instrumented PLF were stratified into “single level” and “3- to 6-level” cohorts. Navigation and conventional groups within each cohort were balanced using 1:1 propensity score matching, resulting in 1786 navigated and conventional patients in the single-level cohort and 2060 in the 3 to 6 level cohort. Outcomes were compared using bivariate analysis.

Results. For the single-level cohort, there were no significant differences in rates of complications, readmissions, revisions, and length of stay between the navigation and conventional groups. For the 3- to 6-level cohort, length of stay was significantly longer in the navigation group (P < 0.0001). Rates of readmissions were, however, greater for the conventional group (30-day: P = 0.0239; 90-day: P = 0.0449). Overall complications were also greater for the conventional group (P = 0.0338), whereas revision rate was not significantly different between the 2 groups. Total payments were significantly greater for the navigation group in both the single level and 3- to 6-level cohorts (P < 0.0001).

Conclusion. Although use of navigation for 3- to 6-level instrumented PLF was associated with increased length of stay and payments, the concurrent decreased overall complication and readmission rates alluded to its potential clinical utility. However, for single-level instrumented PLF, no differences in outcomes were found between groups, suggesting that the value in navigation may lie in more complex procedures.

Level of Evidence: 3

Evidence regarding the clinical utility of navigation for instrumented posterior lumbar fusion remains controversial. In this retrospective propensity score-matched analysis on a national database, we found greater lengths of stay, yet decreased complication and readmissions rates associated with navigation compared to conventional multisegmental posterior lumbar instrumentation for degenerative disc disease.

Department of Neurosurgery, Stanford University, Stanford, CA.

Address correspondence and reprint requests to Arjun V. Pendharkar, MD, Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R281, Stanford, CA 94305-5327; E-mail:

Received 17 December, 2018

Revised 15 April, 2019

Accepted 21 May, 2019

AVP and PGR contributed equally to this work.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: grants.

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