Low-Dose Radiation 3D Intraoperative Imaging

Vishal Sarwahi, Monica Payares, Stephen Wendolowski, Kathleen Maguire, Beverly Thornhill, Yungtai Lo, Terry D. Amaral

Research output: Contribution to journalArticlepeer-review

17 Scopus citations


Study Design. Cadaveric study. Objective. The objective was to evaluate O-Arm's ability at low-dose (LD) settings to assess intraoperative screw placement. Summary of Background Data. Accurate placement of pedicle screws is crucial because of proximity to vital structures. Malposition of screws may result in significant morbidity and potential mortality. O-arm provides real-time, intraoperative imaging of patient's anatomy and provides higher accuracy in scoliosis surgeries, avoiding risk to vital structures. We hypothesize using LD or ultra-low doses (ULDs) to obtain intraoperative images allow for accurate assessment of screw placement, both minimizing radiation exposure and preventing screw misplacement. Methods. Eight cadavers were instrumented with pedicle screws bilaterally from T1 to S1. Screws were randomly placed using O-arm navigation into three positions: contained within the bone, OUT-anterior/lateral, and OUT-medial. O-arm images were obtained at three dosage settings: LD (kVp120/mAs125 - lowest manufacturer recommended), very-low dose (VLD) (kVp120/mAs63), and ULD (kVp120/mAs39). Computed tomography (CT) scan was performed using institution's LD protocol (kVp100/mAs50) and gross dissection to identify screw positions. Results. LD, VLD, ULD, and CT for identifying "IN" screws relative to gross dissection had, a mean (standard deviation) sensitivity of 84.2% (±5.7), specificity of 76.1% (±9.3), and accuracy of 79.9% (±3.1) from all three observers. Across the three observers, the interobserver agreement was 0.67 (0.61-0.72) for LD, 0.74 (0.69-0.79) for VLD, 0.61 (0.56-0.66) for ULD, and 0.79 (0.74-0.84) for CT. Effective doses of radiation (mSV) for LD O-arm scan was 2.16, VLD 1.08, ULD 0.68, and our LD CT protocol was 1.05. Conclusion. Accuracy of pedicle screw placement is similar for O-arm at all doses and CT compared to gross dissection. Interobserver reliability was substantial for VLD and CT. Approximately 30% of medial screw breaches are, however, misclassified. ULD and VLDs can be used for intraoperative navigation and evaluation purposes within these limitations.

Original languageEnglish (US)
Pages (from-to)E1311-E1317
Issue number22
StatePublished - Nov 15 2017


  • 3D imaging
  • effective dose
  • fluoroscopic imaging
  • image-guided surgery
  • pedicle screw
  • pedicle screw accuracy
  • pedicle screw placement
  • pedicle screw safety
  • radiation exposure
  • reduced radiation

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Clinical Neurology


Dive into the research topics of 'Low-Dose Radiation 3D Intraoperative Imaging'. Together they form a unique fingerprint.

Cite this