Bone conductivity and spine fluoroscopy, Hand-Eye-Ear dialogue, during pedicle screw positioning: a new human cognitive system for precision and radiation-decrease; better than artificial intelligence and machine learning system?

Purpose: There is an increasing need for pedicle screw positioning while decreasing radiation exposure. This study compares intra-operative radiation dose using posterior internal fixation using impedancemetry-guided pedicle positioning by the Pediguard system versus standard free-hand sighting when surgery was performed with a trainee or expert surgeon.

Material and methods: Using the electrical properties of bone, the Pediguard detects iatrogenic penetration of the pedicle wall and gives auditory feedback to the surgeon. A single centre, two surgeons (one experienced and the other novice) conducted a continuous prospective randomized study for one year. Twenty patients were randomized into one group (free-hand control group) receiving pedicle instrumentation without the use of the Pediguard and the second group receiving pedicle instrumentation with the use of the Pediguard. The total screw placement times and fluoroscopic times for each screw was recorded and pedicle screw position was analyzed on post-operative CT scan.

Results: Among the 104 screwed pedicles, 22 unrecognized perforations were detected by CT scan, while no perforation signal was observed intra-operatively. Only one perforation was greater than 2 mm. The overall screwing time was 4.33 ± 1.2 minutes per screw for experienced surgeon and 5.84 ± 2.5 minutes per screw for the novice. Pediguard did not increased significantly the time (0.3 mn per screw) for the experienced surgeon, but the time with Pediguard was longer (2 mn more per screw) for the novice surgeon, particularly at the thoracic level. The overall fluoroscopic average time per screw for the experienced surgeon is 5.8 ± 2.3 s and 10.4 ± 4.5 s for the novice surgeon. For the novice surgeon, radiation time reduced from 12 (without Pediguard) to 6 s (with Pediguard). There was no significant difference for the experienced surgeon in terms of improvement in radiation time with the use of Pediguard.

Conclusion: The overall time was longer for the novice surgeon with the Pediguard system, but allowed to decrease by 50% the fluoroscopy time.