Does image guidance decrease pedicle screw-related complications in surgical treatment of adolescent idiopathic scoliosis: a systematic review update and meta-analysis

  • Andrew Chan
  • Eric ParentEmail author
  • Jason Wong
  • Karl Narvacan
  • Cindy San
  • Edmond Lou
Review Article



Surgical treatment of severe adolescent idiopathic scoliosis (AIS) with posterior spinal instrumentation and fusion with pedicle screws is common, requiring careful screw insertion to prevent pedicle breaches and neurologic complications. Image guidance has been suggested to improve breach rates, though the radiation risk for AIS precludes its common usage. The purpose of this systematic review and meta-analysis was to compare the breach rates and screw-related complications for AIS patients undergoing spine surgery with pedicle screws between freehand screw insertion and image guidance methods.


A comprehensive search of MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science databases was conducted. Two reviewers independently screened abstracts, full-texts, extracted data and performed risk of bias assessment using the QUIPS quality appraisal tool. Level of evidence summary statements were formulated based on consistency and quality of reporting.


Ninety-four studies were found, with 18 studies of moderate risk of bias or better. Moderate evidence from two head-to-head studies shows CT guidance has lower breach rates than freehand methods (OR 0.28 [0.20–0.40, I2 = 1%]), with no complications in either study. From individual studies, moderate evidence showed lower breach rates for image guidance versus freehand methods (13%, I2 = 98% vs. 20%, I2 = 95%). Complication rates were conflicting (0–1.6% for image guidance, 0–1.7% for freehand). Moderate evidence showed increased surgical time for image guidance versus freehand (257.7 min vs. 226.8 min).


Meta-analyzed breach rates show moderate evidence of decreased breaches with CT navigation compared with freehand methods. Complication rates remain unknown due to the low complication rates from small sample sizes.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.


Image guidance Spine surgery Systematic review Meta-analysis Pedicle breaches 



Elizabeth Dennett from the University of Alberta provided guidance on search terms and search strategy. Dr. Marc Moreau and Sarah Southon from Alberta Health Services and the Edmonton Scoliosis Clinic provided search terms and guidance on objectives and key outcomes for this study. Undergraduate student Suzana Trac helped with study de-duplication and study design assessment.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

586_2019_6219_MOESM1_ESM.pptx (171 kb)
Supplementary material 1 (PPTX 171 kb)
586_2019_6219_MOESM2_ESM.pdf (110 kb)
Supplementary material 2 (PDF 110 kb)
586_2019_6219_MOESM3_ESM.pdf (153 kb)
Supplementary material 3 (PDF 153 kb)
586_2019_6219_MOESM4_ESM.pdf (1.3 mb)
Supplementary material 4 (PDF 1320 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Biomedical Engineering, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonCanada
  2. 2.Department of Physical Therapy, Faculty of Rehabilitation MedicineUniversity of AlbertaEdmontonCanada
  3. 3.Faculty of Medicine and DentistryUniversity of AlbertaEdmontonCanada
  4. 4.Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverCanada
  5. 5.Department of Electrical EngineeringUniversity of AlbertaEdmontonCanada

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