O Arm Benefits, Uses, O Arm Benefits, Uses, Techniques and Techniques and

PearlsPearls

Donald S. Corenman, M.D., Donald S. Corenman, M.D., D.C.D.C.

The Steadman ClinicThe Steadman Clinic

Vail, ColoradoVail, Colorado

O Arm BenefitsO Arm Benefits Surgical time reductionSurgical time reduction Reduction of radiation exposure to surgeon and staffReduction of radiation exposure to surgeon and staff SafetySafety Improvement of surgical skillsImprovement of surgical skills Accuracy of screw placementAccuracy of screw placement TrainingTraining Use in landmark lossUse in landmark loss Reduction of incision size- tissue damageReduction of incision size- tissue damage Intraoperative hardware placement confirmationIntraoperative hardware placement confirmation Pioneering new techniquesPioneering new techniques

– Pars repairPars repair– Fracture reduction confirmationFracture reduction confirmation

Reduced surgical invasiveness (avoiding a 360)Reduced surgical invasiveness (avoiding a 360) Stress reduction on surgeonStress reduction on surgeon

Surgical Time Increased Surgical Time Increased RisksRisks

Increased surgical time leads to Increased surgical time leads to increased chance of:increased chance of:– DVTDVT– Pulmonary edema/ PneumoniaPulmonary edema/ Pneumonia– Pressure necrosis (nerve and skin)Pressure necrosis (nerve and skin)– InfectionInfection– IONION

O-Arm/ Stealth Reduces O-Arm/ Stealth Reduces Surgical TimeSurgical Time

Placing and Placing and checking every checking every screw with C screw with C arm takes arm takes significant time significant time

Revising one Revising one misplaced screw misplaced screw can take as long can take as long as 20 minutesas 20 minutes

O-Arm Reduces Radiation O-Arm Reduces Radiation ExposureExposure

Checking each Checking each screw with C-Arm screw with C-Arm subjects surgeon subjects surgeon to significant to significant radiation exposureradiation exposure

Wearing of lead Wearing of lead apron is hot, heavy apron is hot, heavy and and uncomfortable- uncomfortable- does not protect does not protect thyroid or eyesthyroid or eyes

Safety of Screw PlacementSafety of Screw Placement

Percentage of Percentage of misplaced screws misplaced screws creating root creating root injury is injury is underreportedunderreported

Permanent injury Permanent injury to root can occur to root can occur with significant with significant disability to disability to patientpatient

Screw Placement Creates Screw Placement Creates Landmarks for Foramen and Landmarks for Foramen and

Disc SpaceDisc Space Surgeons use screw Surgeons use screw

position for landmarks position for landmarks Incorrect screw Incorrect screw

placement or lack of placement or lack of placement leads to placement leads to mistakes in graft mistakes in graft positioningpositioning

Incorrect placement Incorrect placement produces growth in produces growth in undesirable locationsundesirable locations

Lack of screw support Lack of screw support allows foramenal allows foramenal collapsecollapse

Accuracy of PlacementAccuracy of Placement

Cerebral Palsy or Cerebral Palsy or Neurogenic Scoliosis Neurogenic Scoliosis patientspatients

Dysplastic pedicles Dysplastic pedicles (abnormal curvilinear (abnormal curvilinear pathway)pathway)

Atrophic pedicle Atrophic pedicle diameter 3-4 mmdiameter 3-4 mm

Rotation of pediclesRotation of pedicles

Pedicle Torsion/Atrophic Pedicle Torsion/Atrophic PediclesPedicles

Iliac Screw PlacementIliac Screw Placement

Dysplastic ilium or prior iliac bone grafting Dysplastic ilium or prior iliac bone grafting makes iliac screw placement difficult makes iliac screw placement difficult without O-Arm and Stealthwithout O-Arm and Stealth

O-Arm/ Stealth O-Arm/ Stealth Landmark Landmark

Loss Loss Pedicular landmarks are Pedicular landmarks are

missing for screw missing for screw placement in placement in pseudoarthrosis pseudoarthrosis patientspatients

Prior surgery eliminates Prior surgery eliminates all landmarks making all landmarks making for a for a ““hunt and peckhunt and peck”” technique and technique and exhausting dayexhausting day

No need to use multiple C Arm images to find No need to use multiple C Arm images to find

landmarkslandmarks

Revision SurgeryRevision SurgeryPseudoarthrosisPseudoarthrosis

Broken screws at S1Broken screws at S1

Screw Insertion Bipassing Screw Insertion Bipassing Existing Broken ScrewsExisting Broken Screws

Screw InsertionScrew Insertion

Residency and Fellowship Residency and Fellowship TrainingTraining

Screw insertion by Screw insertion by trainee can be trainee can be performed in typical performed in typical fashion while fashion while attending surgeon attending surgeon can monitor screw can monitor screw placement without placement without fear of pedicle fear of pedicle breach or breach or unintended unintended consequencesconsequences

Intraoperative Hardware Intraoperative Hardware Placement ConfirmationPlacement Confirmation

Using monitoring Using monitoring technique (EMG)- technique (EMG)- abnormal signal can abnormal signal can yield false positives yield false positives (vascular pedicle (vascular pedicle channels)channels)

O-Arm will confirm O-Arm will confirm appropriate appropriate placementplacement

““Flow Seal pearlFlow Seal pearl”” S1 screw anterior S1 screw anterior

penetrationpenetration

Accuracy PearlAccuracy PearlCheck registration with frameCheck registration with frame

Check accuracy with anatomic landmark Check accuracy with anatomic landmark

Pioneering New Pioneering New TechniquesTechniques

Pars repairPars repair Fracture Fracture

reductionreduction

Pars Repair with Pars ScrewPars Repair with Pars Screw

Current repair Current repair technique technique consists of wiring consists of wiring or pedicle screw or pedicle screw fixation with fixation with hooks- non-rigid hooks- non-rigid fixation and 50-fixation and 50-75% fusion rate75% fusion rate

Pars ScrewPars Screw Pars is 3-4 mm widePars is 3-4 mm wide All cortical bone (no All cortical bone (no

central cancellous central cancellous bone for guide bone for guide path)path)

There is no There is no ““feelfeel”” upon insertion of upon insertion of screwscrew

Nerve root is Nerve root is immediately immediately anterior of Parsanterior of Pars

Must engage lateral Must engage lateral pedicle wall for pedicle wall for fixationfixation

Success Rate with Pars ScrewsSuccess Rate with Pars Screws

Small series (22 Small series (22 patients and 24 patients and 24 levels)levels)

Fusion rate of Fusion rate of 90%90%

Time to solid Time to solid fusion 6 months fusion 6 months (two at one year)(two at one year)

Fracture ReductionFracture Reduction Fracture fragments in Fracture fragments in

canal from burst canal from burst fracture below L1 fracture below L1 (conus) normally (conus) normally requires anterior and requires anterior and posterior approach to posterior approach to clear canalclear canal

Using O-Arm and Using O-Arm and Stealth Technology- Stealth Technology- reduction can be reduction can be assisted with a guided assisted with a guided tamp from posterior tamp from posterior onlyonly

Fracture ReductionFracture Reduction

Post- reduction Post- reduction can be confirmed can be confirmed by intraoperative by intraoperative O-Arm so no O-Arm so no return to OR is return to OR is necessary for ill-necessary for ill-reduced reduced fragments fragments

Cervical Usage-Odontoid Fx Cervical Usage-Odontoid Fx with C1 Burst Neurologically with C1 Burst Neurologically

IntactIntact

Eroded Facets- Atrophic C2 Eroded Facets- Atrophic C2 PediclesPedicles

Ability to Place Hardware in Ability to Place Hardware in Difficult CircumstancesDifficult Circumstances

Stress Reduction of Surgeon !!!Stress Reduction of Surgeon !!!

““Mental ExhaustionMental Exhaustion”” is is the enemy of longer the enemy of longer casescases

Placement of screws Placement of screws requires strong gross requires strong gross motor contraction motor contraction with the overlay of with the overlay of fine motor precisionfine motor precision

Ease of screw Ease of screw placement along with placement along with pre-closure pre-closure knowledge of safe knowledge of safe hardware placement hardware placement reduces surgeon reduces surgeon stress levelstress level

O-Arm/Stealth Benefits Out-O-Arm/Stealth Benefits Out-Weigh CostsWeigh Costs

Reduction of Surgical TimeReduction of Surgical Time Improved Safety of Hardware PlacementImproved Safety of Hardware Placement Reduction of Radiation ExposureReduction of Radiation Exposure Increased Ability of SurgeonIncreased Ability of Surgeon Difficult Cases TamedDifficult Cases Tamed Improved Resident TrainingImproved Resident Training Improved Tissue HandlingImproved Tissue Handling Significant Reduction of Surgeon StressSignificant Reduction of Surgeon Stress

Thank YouThank You

Donald S. Corenman, M.D., Donald S. Corenman, M.D., D.C.D.C.

The Steadman ClinicThe Steadman ClinicVail, ColoradoVail, Colorado

NeckandBack.comNeckandBack.com