Accuracy of Pedicle Screw Insertion Among 3 Image-Guided Navigation Systems: Systematic Review and Meta-Analysis.

Background: Many retrospective studies of pedicle screw placement have revealed that intraoperative navigation systems provide higher accuracy rates and safety than do free-hand techniques. The accuracy of various image-guided navigation systems has been studied; however, differences have not been well defined due to the lack of adequate evidence-based comparative studies.

Objective: A meta-analysis was conducted to focus on the variation in pedicle screw insertion among 3 navigation systems: a 3-dimensional fluoroscopy-based navigation system (3D FluoroNav), a 2-dimensional fluoroscopy-based navigation system (2D FluoroNav), and a conventional computed tomography navigation system (CT Nav).

Methods: We screened for comparative studies on different pedicle screw insertion navigation systems published through January 2017 using the Cochrane Library, Ovid, Web of Science, PubMed, and EMBASE databases.

Results: From 125 papers that were identified, 10 articles were finally chosen. The present comparative study included 8 retrospective clinical studies, 1 prospective clinical trial, and 1 randomized controlled cadaveric study. The prevalence rate of pedicle violation in the 3D FluoroNav group was significantly lower than the rates of the 2D FluoroNav group (relative risk [RR] 95%, confidence interval [CI]: 0.16-0.61, P < 0.01) and the CT Nav group (RR 95%, CI: 0.42-0.90, P = 0.01), and the rate of the CT Nav group was significantly lower than that of the 2D FluoroNav group (RR 95%, CI: 0.29-0.81, P < 0.01).

Conclusions: Significant differences exist among CT Nav, 3D FluoroNav, and 2D FluoroNav. Our review suggests that 3D FluoroNav may be superior to the other 2 methods in reducing pedicle violation and that clinicians should consider 3D FluoroNav as a better choice.