The Use of Intraoperative Navigation for Complex Upper Cervical Spine Surgery: Report of 4 Cases

Kern H. Guppy, M.D., Ph.D; Indro Chakrabarti, M.D., M.P.H; Ami t Banerjee, M.D.

Disclosures

Neurosurg Focus. 2014;36(3):e5 

In This Article

Abstract and Introduction

Abstract

Imaging guidance using intraoperative CT (O-arm surgical imaging system) combined with a navigation system has been shown to increase accuracy in the placement of spinal instrumentation. The authors describe 4 complex upper cervical spine cases in which the O-arm combined with the StealthStation surgical navigation system was used to accurately place occipital screws, C-1 screws anteriorly and posteriorly, C-2 lateral mass screws, and pedicle screws in C-6. This combination was also used to navigate through complex bony anatomy altered by tumor growth and bony overgrowth. The 4 cases presented are: 1) a developmental deformity case in which the C-1 lateral mass was in the center of the cervical canal causing cord compression; 2) a case of odontoid compression of the spinal cord requiring an odontoidectomy in a patient with cerebral palsy; 3) a case of an en bloc resection of a C2–3 chordoma with instrumentation from the occiput to C-6 and placement of C-1 lateral mass screws anteriorly and posteriorly; and 4) a case of repeat surgery for a non-union at C1–2 with distortion of the anatomy and overgrowth of the bony structure at C-2.

Introduction

Placement of instrumentation from the occiput to the upper cervical spine has been challenging because of the complex anatomy and the need for a high degree of accuracy to avoid complications. The cervical region is prone to inflammatory, neoplastic, and traumatic conditions that can distort familiar anatomy, particularly due to the intimate relationship with the vertebral artery and spinal cord in limited bony structures. For the placement of instrumentation in the cervical spine, early use of direct visualization, serial radiography, and C-arm fluoroscopy have provided somewhat acceptable accuracy, but with the advent of intraoperative spinal navigation this accuracy has evolved.[7] This has been enhanced with intraoperative CT combined with spinal navigation for the cervical spine[10,17,19,24,25] and in particular the O-arm surgical imaging system (Medtronic).[9,15,18] Nottmeier and Young[15] described techniques for the placement of screws in the occiput, C-1 lateral masses, C-2 pars, and C-2 laminae, using the O-arm, and Ishikawa et al.[9] described their experience with the O-arm in the placement of cervical pedicle screws.

In this paper, we present 4 complex upper cervical spine cases in which the O-arm combined with the Medtronic StealthStation surgical navigation system was used. Not only did this combination provide accurate placement of spinal instrumentation, but it also aided in bony decompression. The 4 cases involved 1) resection of a deformed C-1 lateral mass that was in the center of the cervical canal causing cord compression; 2) a transoral odontoidectomy; 3) an en bloc resection of a C2–3 chordoma; and 4) repeat surgery for a C1–2 nonunion in which the anatomy was distorted by bony overgrowth at C-2.

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