• Rodrigo Navarro-Ramirez, Gernot Lang, Xiaofeng Lian, Connor Berlin, Insa Janssen, Ajit Jada, Marjan Alimi, and Roger Härtl.
• Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA.
• World Neurosurg. 2017 Apr 1; 100: 325-335.

BackgroundPortable intraoperative computed tomography (iCT) with integrated 3-dimensional navigation (NAV) offers new opportunities for more precise navigation in spinal surgery, eliminates radiation exposure for the surgical team, and accelerates surgical workflows. We present the concept of "total navigation" using iCT NAV in spinal surgery. Therefore, we propose a step-by-step guideline demonstrating how total navigation can eliminate fluoroscopy with time-efficient workflows integrating iCT NAV into daily practice.MethodsA prospective study was conducted on collected data from patients undergoing iCT NAV-guided spine surgery. Number of scans, radiation exposure, and workflow of iCT NAV (e.g., instrumentation, cage placement, localization) were documented. Finally, the accuracy of pedicle screws and time for instrumentation were determined.ResultsiCT NAV was successfully performed in 117 cases for various indications and in all regions of the spine. More than half (61%) of cases were performed in a minimally invasive manner. Navigation was used for skin incision, localization of index level, and verification of implant position. iCT NAV was used to evaluate neural decompression achieved in spinal fusion surgeries. Total navigation eliminates fluoroscopy in 75%, thus reducing staff radiation exposure entirely. The average times for iCT NAV setup and pedicle screw insertion were 12.1 and 3.1 minutes, respectively, achieving a pedicle screw accuracy of 99%.ConclusionsTotal navigation makes spine surgery safer and more accurate, and it enhances efficient and reproducible workflows. Fluoroscopy and radiation exposure for the surgical staff can be eliminated in the majority of cases.Copyright © 2017 Elsevier Inc. All rights reserved.

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