Standard navigation versus intraoperative computed tomography navigation in upper cervical spine trauma

  • Barbara CarlEmail author
  • Miriam Bopp
  • Mirza Pojskic
  • Benjamin Voellger
  • Christopher Nimsky
Original Article



In surgery of C1–C2 fractures, standard navigation for screw placement based on preoperative image data was compared with intraoperative imaging guidance applying intraoperative computed tomography (iCT) with a special focus on accuracy of screw placement, workflow, and radiation exposure.


A single surgeon series of 16 consecutive patients with C1–C2 trauma was retrospectively analyzed. Seven patients were operated with standard navigation; preoperative image data were registered by a 20-point surface-matching process for each vertebra. Nine patients were operated with iCT guidance, allowing automatic navigation registration. Screw placement was examined and graded with either iCT or postoperative CT. Dose length product of CT and dose area products of fluoroscopy scans were assessed; effective radiation doses were estimated based on conversion factors. Radiation doses of intraoperative and postoperative X-ray and/or CT diagnostics for each group were summarized to compare the total effective doses.


A total number of 72 screws were placed, 26 in the standard navigation group including 24 screws in C1 and C2, and 46 screws in the iCT group including 34 screws in C1 and C2. 15.38% (n = 4) of the C2 screws showed a grade 1 deviation and 3.8% (n = 1) a grade 2 deviation applying standard navigation. There was no misplacement of screws in the iCT group. Mean operating time in the standard navigation group was 186.57 min versus 157.11 min in the iCT group, while the mean summarized effective dose was 1.129 mSv in the standard navigation and 2.129 mSv in the iCT group.


iCT navigated surgery can lead to higher accuracy and shorter operating time compared to standard navigated operations. iCT is a safe and straightforward procedure allowing reduction in radiation exposure of the medical staff, while modified scan protocols resulted in a radiation exposure that is lower than in standard diagnostic neck CT.


Spinal navigation Intraoperative computed tomography Navigation registration Radiation exposure Effective dose C2 fracture Screw placement 



We would like to thank J.W. Bartsch for thoroughly proofreading the manuscript.

Compliance with ethical standards

Conflict of interest

Ch. Nimsky has received a speaker honorarium from Brainlab. B. Carl, M. Bopp, M. Pojskic, and B. Voellger declare that they have no conflict of interest.

Human and animal rights

For this type of study, formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Harms J, Melcher RP (2001) Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976) 26(22):2467–2471CrossRefGoogle Scholar
  2. 2.
    Vergara P, Bal JS, Hickman Casey AT, Crockard HA, Choi D (2012) C1–C2 posterior fixation: are 4 screws better than 2? Neurosurgery 71(1 Suppl Operative):86–95. Google Scholar
  3. 3.
    Rahmathulla G, Nottmeier EW, Pirris SM, Deen HG, Pichelmann MA (2014) Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance. Neurosurg Focus 36(3):E3. CrossRefGoogle Scholar
  4. 4.
    Uehara M, Takahashi J, Hirabayashi H, Hashidate H, Ogihara N, Mukaiyama K, Kato H (2012) Computer-assisted C1–C2 Transarticular Screw Fixation “Magerl Technique” for Atlantoaxial Instability. Asian Spine J 6(3):168–177. CrossRefGoogle Scholar
  5. 5.
    Yang Y, Wang F, Han S, Wang Y, Dong J, Li L, Zhou D (2015) Isocentric C-arm three-dimensional navigation versus conventional C-arm assisted C1–C2 transarticular screw fixation for atlantoaxial instability. Arch Orthop Trauma Surg 135(8):1083–1092. CrossRefGoogle Scholar
  6. 6.
    Yang YL, Zhou DS, He JL (2013) 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 26(3):127–134. CrossRefGoogle Scholar
  7. 7.
    Barsa P, Frohlich R, Benes V 3rd, Suchomel P (2014) Intraoperative portable CT-scanner based spinal navigation: a feasibility and safety study. Acta Neurochir (Wien) 156(9):1807–1812. CrossRefGoogle Scholar
  8. 8.
    Czabanka M, Haemmerli J, Hecht N, Foehre B, Arden K, Liebig T, Woitzik J, Vajkoczy P (2017) Spinal navigation for posterior instrumentation of C1-2 instability using a mobile intraoperative CT scanner. J Neurosurg Spine 27(3):268–275. CrossRefGoogle Scholar
  9. 9.
    Hecht N, Kamphuis M, Czabanka M, Hamm B, Konig S, Woitzik J, Synowitz M, Vajkoczy P (2016) Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO(®) CT scanner. Eur Spine J 25(3):716–723. CrossRefGoogle Scholar
  10. 10.
    Navarro-Ramirez R, Lang G, Lian X, Berlin C, Janssen I, Jada A, Alimi M, Hartl R (2017) Total navigation in spine surgery; a concise guide to eliminate fluoroscopy using a portable intraoperative computed tomography 3-dimensional navigation system. World Neurosurg 100:325–335. CrossRefGoogle Scholar
  11. 11.
    Laine T, Lund T, Ylikoski M, Lohikoski J, Schlenzka D (2000) Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients. Eur Spine J 9(3):235–240CrossRefGoogle Scholar
  12. 12.
    The 2007 Recommendations of the international commission on radiological protection. ICRP publication 103 (2007). Ann ICRP 37(2–4):1–332.
  13. 13.
    Manninen AL, Isokangas JM, Karttunen A, Siniluoto T, Nieminen MT (2012) A comparison of radiation exposure between diagnostic CTA and DSA examinations of cerebral and cervicocerebral vessels. AJNR Am J Neuroradiol 33(11):2038–2042. CrossRefGoogle Scholar
  14. 14.
    Huda W, Magill D, He W (2011) CT effective dose per dose length product using ICRP 103 weighting factors. Med Phys 38(3):1261–1265. CrossRefGoogle Scholar
  15. 15.
    Huda W, Ogden KM, Khorasani MR (2008) Converting dose-length product to effective dose at CT. Radiology 248(3):995–1003. CrossRefGoogle Scholar
  16. 16.
    Kraus M, von dem Berge S, Perl M, Krischak G, Weckbach S (2014) Accuracy of screw placement and radiation dose in navigated dorsal instrumentation of the cervical spine: a prospective cohort study. Int J Med Robot 10(2):223–229. CrossRefGoogle Scholar
  17. 17.
    Tjardes T, Shafizadeh S, Rixen D, Paffrath T, Bouillon B, Steinhausen ES, Baethis H (2010) Image-guided spine surgery: state of the art and future directions. Eur Spine J 19(1):25–45. CrossRefGoogle Scholar
  18. 18.
    Singh PK, Garg K, Sawarkar D, Agarwal D, Satyarthi G, Gupta D, Sinha S, Kale S, Sharma B (2014) CT-guided C2 pedicle screw placement for treatment of unstable hangman’s fractures. Spine (Phila Pa 1976). Google Scholar
  19. 19.
    Smith JD, Jack MM, Harn NR, Bertsch JR, Arnold PM (2016) Screw placement accuracy and outcomes following o-arm-navigated atlantoaxial fusion: a feasibility study. Global Spine J 6(4):344–349. CrossRefGoogle Scholar
  20. 20.
    Ling JM, Tiruchelvarayan R, Seow WT, Ng HB (2013) Surgical treatment of adult and pediatric C1/C2 subluxation with intraoperative computed tomography guidance. Surg Neurol Int 4(Suppl 2):S109–S117. Google Scholar
  21. 21.
    Villas C, Arriagada C, Zubieta JL (1999) Preliminary CT study of C1–C2 rotational mobility in normal subjects. Eur Spine J 8(3):223–228CrossRefGoogle Scholar
  22. 22.
    Dvorak J, Penning L, Hayek J, Panjabi MM, Grob D, Zehnder R (1988) Functional diagnostics of the cervical spine using computer tomography. Neuroradiology 30(2):132–137CrossRefGoogle Scholar
  23. 23.
    Monckeberg JE, Tome CV, Matias A, Alonso A, Vasquez J, Zubieta JL (2009) CT scan study of atlantoaxial rotatory mobility in asymptomatic adult subjects: a basis for better understanding C1–C2 rotatory fixation and subluxation. Spine (Phila Pa 1976) 34(12):1292–1295. CrossRefGoogle Scholar
  24. 24.
    White AA 3rd, Panjabi MM (1978) The clinical biomechanics of the occipitoatlantoaxial complex. Orthop Clin North Am 9(4):867–878Google Scholar
  25. 25.
    Rampersaud YR, Foley KT, Shen AC, Williams S, Solomito M (2000) Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976) 25(20):2637–2645CrossRefGoogle Scholar
  26. 26.
    Dewey P, Incoll I (1998) Evaluation of thyroid shields for reduction of radiation exposure to orthopaedic surgeons. Aust N Z J Surg 68(9):635–636CrossRefGoogle Scholar
  27. 27.
    Berrington de Gonzalez A, Darby S (2004) Risk of cancer from diagnostic x-rays: estimates for the UK and 14 other countries. Lancet 363(9406):345–351. CrossRefGoogle Scholar
  28. 28.
    Health risks from exposure to low levels of ionizing radiation: BEIR VII, Phase I, Letter Report (1998). Washington (DC).
  29. 29.
    Gebhard FT, Kraus MD, Schneider E, Liener UC, Kinzl L, Arand M (2006) Does computer-assisted spine surgery reduce intraoperative radiation doses? Spine (Phila Pa 1976) 31(17):2024–2027. (discussion 2028) CrossRefGoogle Scholar
  30. 30.
    Hadelsberg UP, Harel R (2016) Hazards of ionizing radiation and its impact on spine surgery. World Neurosurg 92:353–359. CrossRefGoogle Scholar
  31. 31.
    Mendelsohn D, Strelzow J, Dea N, Ford NL, Batke J, Pennington A, Yang K, Ailon T, Boyd M, Dvorak M, Kwon B, Paquette S, Fisher C, Street J (2016) Patient and surgeon radiation exposure during spinal instrumentation using intraoperative computed tomography-based navigation. Spine J 16(3):343–354. CrossRefGoogle Scholar
  32. 32.
    Fazel R, Krumholz HM, Wang Y, Ross JS, Chen J, Ting HH, Shah ND, Nasir K, Einstein AJ, Nallamothu BK (2009) Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 361(9):849–857. CrossRefGoogle Scholar
  33. 33.
    Mettler FA Jr, Huda W, Yoshizumi TT, Mahesh M (2008) Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 248(1):254–263. CrossRefGoogle Scholar
  34. 34.
    Greffier J, Pereira FR, Viala P, Macri F, Beregi JP, Larbi A (2017) Interventional spine procedures under CT guidance: How to reduce patient radiation dose without compromising the successful outcome of the procedure? Phys Med 35:88–96. CrossRefGoogle Scholar
  35. 35.
    Pireau N, Cordemans V, Banse X, Irda N, Lichtherte S, Kaminski L (2017) Radiation dose reduction in thoracic and lumbar spine instrumentation using navigation based on an intraoperative cone beam CT imaging system: a prospective randomized clinical trial. Eur Spine J 26(11):2818–2827. CrossRefGoogle Scholar

Copyright information

© CARS 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryUniversity of MarburgMarburgGermany

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