Improving accuracy and safety in Posterior Cervical Fusion procedures


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Discover how
intra-operative navigation can improve accuracy and safety 

for the placement of screws in the cervical spine1,2

Challenges of Posterior Cervical Fusion (PCF) procedures

The treatment of cervical spine pathologies can pose considerable challenges, especially when treating complex cases. When performing PCF procedures, Lateral Mass Screws (LMS) are the most common method of fixation used. However, these can have an increased screw loosening or avulsion rate when compared to Cervical Pedicle Screws (CPS)3,4

On the other hand, while CPS offer higher axial load to failure and lower rate of loosening compared to LMS5, it can be a demanding technique. The reported rate of misplaced CPS in procedures with conventional fluoroscopy can be as high as 29.7%6,7.

Challenges of screw placement in PCF
  • Complex screw positioning due to presence of critical neurological and vascular structures2,8
  • Frequent anatomical variations of cervico-thoracic junctional segment9
  • Lack of anatomical landmarks (e.g., in patients with Ankylosing Spondilitys or in revision surgery)9,10,11
  • Decreased pedicle dimensions2,9
Misplacement of CPS may injure1,9
  • Vertebral artery
  • Nerve root
  • Spinal cord

Benefits of 3D Navigation on PCF procedures

In posterior cervical surgical approaches, 3D Navigation is a reliable tool, improving efficiency, accuracy and safety1,2,12

The navigated screw insertion has a significantly lower risk of pedicle perforation events compared to non-navigated screw insertion.13


3D Navigation shows a higher accuracy rate compared to fluoroscopy12

Additional advantages of using 3D Navigated tools combined in the navigated PCF workflow

Expand All

Minimize unwanted cervical movement such as axial rotation 1

The use of Stealth-Midas™ High-Speed drilling system reveals a lower number of misplaced screws compared to the use of a cervical probe1


Reduce radiation exposure to patients and OR personnel 12, 14

Reduce intraoperative blood loss 12, 15

Reduce operative time in cervical procedures 12, 16, 17, 18

Lower risk of Neurovascular injuries 2, 12, 16, 18, 19

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1. Wada K. et al. Cervical Pedicle Screw Insertion Using O-Arm-Based 3D Navigation: Technical Advancement to Improve Accuracy of Screws. World Neurosurg. 2020, 139:e182-e188..
2. Gan G. et al. Spinal navigation for cervical pedicle screws: surgical pearls and pitfalls. global spine journal, 2021.
3. McAllister B.D. et al. Is posterior necessary with laminectomy in the cervical spine? Surg Neurol. Int 2012.
4. Jones E. et al. cervical pedicle screws versus lateral mass screws : anatomic feasibility and biomechanical comparison. Spine 1997, 22, (9).
5. Teologis A.A et al.. Safety and efficacy of reconstruction of complex cervical spine pathology using pedicle screws inserted with stealth navigation and 3D image-guided (O-Arm) technology. SPINE 2015. 40 ,(18): p. 1397 – 1406.
6. Abumi et al. Complications of Pedicle Screw Fixation in Reconstructive Surgery of the Cervical Spine. Spine 2000 25(8): p 962–969.
7. Neo et al. The Clinical Risk of Vertebral Artery Injury From Cervical Pedicle Screws Inserted in degenerative Vertebrae. Spine 2005. 30 (24):pp 2800– 2805.
8. Chachan S. et al. cervical pedicle screw instrumentation is more reliable with O-arm-based 3D navigation: analysis of cervical pedicle screw placement accuracy with O-arm-based 3D navigation. European Spine Journal 2018.
9. Barsa P. et al. The intraoperative portable CT scanner-based spinal navigation: a viable option for instrumentation in the region of cervicothoracic junction. Eur Spine J,2016, 25: p.1643–1650.
10. Hoh et al. Management of cervical deformity in ankylosing spondylitis. Neurosurg Focus 2008, 24 (1):E9.
11. Seichi et al. Revision cervical spine surgery using transarticular or pedicle screws under a computer-assisted image-guidance system. J Orthop Sci. 2005 Jul;10(4):385-90. 
12. Yang L.Y. et al. Comparison of Isocentric C-Arm 3-Dimensional Navigation and Conventional Fluoroscopy for C1 Lateral Mass and C2 Pedicle Screw Placement for Atlantoaxial Instability. J Spinal Disord Tech, 2013, 26, (3).
13. Shin JK. Et al. Pedicle screw navigation.: a systematic review and metaanalysis of perforation risk for computer-navigated versus freehand insertion. J neurosurg spine, 2012.17: p. 113-122.
14. Verhofste B.P. et al. Intraoperative Use of O-arm in Pediatric Cervical Spine Surgery. J Pediatr Orthop 2019.
15. Hitti F.L et al. Intraoperative Navigation Is Associated with Reduced Blood Loss During C1eC2 Posterior Cervical Fixation. World Neurosurg. 2017, 107:p.574-578.
16. Lee S.J. et al. Comparative Analysis of Surgical Outcomes of C1–2 Fusion Spine Surgery between Intraoperative Computed Tomography Image Based Navigation-Guided Operation and Fluoroscopy-Guided Operation. J Korean Neurosurg Soc, 2020 63 (2) :p.237-247.
17. Tokioka et al. . Minimally Invasive Cervical Pedicle Screw Fixation (MICEPS) via a Posterolateral Approach. Clin Spine Surg. 2019;32(7):p.279-284.
18. Ishikawa Y. et al. Intraoperative, full-rotation, three-dimensional image (O-arm)–based navigation system for cervical pedicle screw insertion. J Neurosurg Spine 2011, 15 :p.472–478.
19. Nottmeier et al. Image-Guided Placement of Occipitocervical Instrumentation Using a Reference Arc Attached to the Headholder. Neurosurgery, 2010. 66:p. 138-142.