Abstract
Background
Ankylosing spinal disorders (ASD), including ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, markedly increase spinal rigidity and susceptibility to highly unstable thoracolumbar fractures. These injuries often require long-segment posterior fixation, which conventionally relies on C-arm fluoroscopy and exposes operating staff to cumulative radiation. O-arm–based intraoperative navigation may reduce radiation exposure while maintaining pedicle screw accuracy; however, evidence in ASD-related fractures remains limited. The aim of this study was to compare intraoperative radiation exposure and pedicle screw placement accuracy between O-arm navigation and C-arm fluoroscopy during percutaneous pedicle screw (PPS) fixation in patients with ASD.
Methods
This single-center retrospective cohort study included 24 consecutive adults with ASD who sustained thoracolumbar fractures between 2015 and 2024. Patients underwent PPS fixation using either O-arm navigation (n=11) or C-arm fluoroscopy (n=13). Demographic characteristics, operative variables, radiation time, and screw accuracy—assessed using the Heary and Gertzbein classification systems—were compared. Fluoroscopy time served as a surrogate marker of radiation exposure because actual dosimeter data were unavailable.
Results
Radiation exposure time was significantly shorter in the O-arm group than in the C-arm group (2.5±1.8 vs. 16.9±11.4 min; P<0.001). Pedicle screw accuracy was comparable (acceptable accuracy: 88.3% vs. 87.3%, respectively; P>0.99). Operative time, blood loss, and complication rates did not differ significantly between groups. Time from injury to surgery was longer in the O-arm group, reflecting workflow constraints and the use of C-arm fluoroscopy for urgent after-hours cases.
Conclusions
O-arm navigation markedly reduces intraoperative radiation exposure without compromising pedicle screw accuracy in ASD-related thoracolumbar fractures. Given the substantial occupational radiation risks faced by spine surgeons, O-arm navigation represents a valuable tool for improving radiation safety while maintaining surgical precision. Larger prospective studies are warranted to validate these findings.
Keywords: Radiation exposure, pedicle screw fixation, O-arm navigation, ankylosing spinal disorders (ASD)
Highlight box.
Key findings
• Fluoroscopy time was reduced from 16.9 to 2.5 minutes with O-arm navigation (P<0.001).
• Screw accuracy remained equivalent between navigation and fluoroscopy groups.
What is known and what is new?
• Patients with ankylosing spinal disorders (ASD) are prone to unstable thoracolumbar fractures and typically require long-segment fixation, which often relies on fluoroscopy and increases occupational radiation exposure to surgical staff.
• This study demonstrates that O-arm navigation reduces intraoperative radiation exposure by more than 80% compared with C-arm fluoroscopy, without compromising pedicle screw accuracy. This is the first study focused specifically on ASD-related thoracolumbar fractures.
What is the implication, and what should change now?
• O-arm navigation should be considered a radiation-sparing alternative to conventional C-arm fluoroscopy in ASD trauma surgery, especially valuable in protecting spine surgeons from cumulative occupational radiation.
• Hospitals should integrate navigation-based workflows to enhance safety and align with ‘As Low As Reasonably Achievable’ (ALARA) recommendations.
Introduction
Ankylosing spinal disorders (ASD), such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, increase spinal fragility, placing patients at heightened risk for complex thoracolumbar fractures following even minor trauma (1). ASD includes two major conditions: ankylosing spondylitis diagnosed according to the modified New York criteria proposed by van der Linden et al. (1984) (2), and diffuse idiopathic skeletal hyperostosis diagnosed based on the Resnick and Niwayama criteria (1976) (3). This increased fragility and susceptibility to unstable spinal fractures in ASD has been emphasized in recent reviews, which note that both ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis predispose patients to highly unstable injuries with elevated morbidity and mortality (4). Surgical intervention in such cases often requires long-segment fixation, which carries the risk of prolonged intraoperative radiation exposure. Current evidence underscores the importance of early computed tomography (CT) and magnetic resonance imaging (MRI) assessment and favors surgical management over conservative treatment because delayed or insufficient stabilization is associated with higher complication rates, particularly cardiopulmonary events (4). The harmful effects of radiation on the surgical staff, including potential skin injuries, are well documented (5). While traditional intraoperative imaging tools such as C-arm fluoroscopy are commonly used, the O-arm—a CT-based intraoperative navigation system—offers the potential to reduce radiation exposure while maintaining high surgical precision (6).
Previous studies reported that O-arm navigation enhances screw placement accuracy and reduces radiation exposure during spinal surgeries (7,8). The potential application of O-arm navigation in patients with ASD, particularly those with thoracolumbar fractures, is underexplored. Compared with conventional fluoroscopic techniques, the use of O-arm navigation for percutaneous pedicle screw (PPS) fixation in the treatment of thoracolumbar fractures improves placement accuracy, reduces the rate of functional pedicle breaches, and minimizes serious perforations (9).
The aim of this study was to compare intraoperative radiation exposure and screw placement accuracy between O-arm navigation and C-arm fluoroscopy during PPS fixation in patients with ASD. We present this article in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-193/rc).
Methods
Participants
This study was designed as a retrospective cohort study conducted at a single tertiary emergency and critical care center in Japan between January 2015 and December 2024. We reviewed the medical records of patients with spinal trauma diagnosed by orthopedic spine surgeons. The patient sample included 24 adults with ASD who were treated for thoracolumbar fractures at our institution from 2015 to 2024. Inclusion criteria were (I) patients aged ≥18 years; (II) diagnosed with ASD (ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis); and (III) presenting with thoracolumbar fractures requiring posterior fixation. Exclusion criteria included (I) incomplete medical records; (II) previous surgery at the same level; or (III) pathological fractures due to tumors or infections. The patients were assigned to the O-arm (n=11) or C-arm (n=13) groups. O-arm cases were performed during regular hours when technologists were available; after-hours emergency surgeries were performed with C-arm fluoroscopy. Figure 1 presents the study flow diagram. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Hirosaki University (No. 2018–1002). The medical record data were anonymized, and the informed consent for this retrospective analysis was therefore waived. Patient characteristics, including age, sex, body mass index (BMI), medical history, and American Spinal Injury Association (ASIA) Impairment Scale (AIS), AO Spine Thoracolumbar Injury Classification System (AO Classification) (10), surgical details (after-hours emergency surgery, time from injury to surgery, operative time, blood loss, number and accuracy of PPS placement, and fluoroscopic radiation exposure time), and postoperative complications [e.g., delirium, venous thromboembolism (VTE), urinary tract infection (UTI), and surgical site infection (SSI)] were collected from the medical records. Actual radiation dose (mSv) and personal dosimeter data were unavailable in our retrospective dataset; thus, fluoroscopy time was used as a surrogate marker of radiation exposure. To minimize selection and measurement bias, data collection and imaging assessment were performed by independent observers.
Figure 1.
Flow diagram of the study. The study included 24 patients with ASD in our department who underwent posterior PPS fixation surgery. Patients in the O-arm group underwent surgery using O-arm/navigation. Patients in the C-arm group underwent surgery using C-arm fluoroscopy. ASD, ankylosing spinal disorders; PPS, percutaneous pedicle screw.
Surgical indication
The decision to perform surgery was guided by the AO Classification, which categorizes injuries into three main injury types: type A (compression), type B (tension band disruption), and type C (displacement/translation) (Figure 2A,2B).
Figure 2.
Representative case of thoracolumbar fracture in a 19-year-old man with diffuse idiopathic skeletal hyperostosis (AO type B2, score 6). (A) Sagittal CT image showing an L1 vertebral fracture (arrow). (B) STIR MRI showing signal changes at T12–L1 and interspinous ligament injury (arrows). (C,D) Intraoperative photographs after percutaneous pedicle screw fixation: lateral (C) and anteroposterior (D) views. (E,F) Postoperative radiographs: anteroposterior (E) and lateral (F) views. CT, computed tomography; MRI, magnetic resonance imaging; STIR, Sagittal Short Tau Inversion Recovery.
Type A and Type B injuries are further divided into five and three subtypes, respectively (10).
Surgical indications were standardized across all patients to ensure consistency. Surgery was indicated for cases with an AO score greater than 6, unstable fractures with neurological symptoms, or progressive deformity. All surgical decisions were reviewed and confirmed by at least two board-certified spine surgeons.
Surgical techniques
PPS fixation was performed using a C-arm or O-arm. All patients were positioned prone on a radiolucent Jackson spinal table (Mizuho OSI, Union City, CA, USA). In the O-arm group, intraoperative CT (Medtronic Sofamor Daneck, Memphis, TN, USA) and a navigation StealthStation system (Medtronic Sofamor Danek) were used, with the surgical area covered with sterile drapes while scanning. After scanning, well-trained surgeons performed the surgical procedure using a navigation system. The surgical staff exited the operating room during O-arm image acquisition. Surgeons performed PPS insertion under navigation without radiation exposure (Figure 2). For patients in the C-arm group, the surgeon was protected and monitored for radiation exposure.
Assessment of PPS placement accuracy
The PPS placement accuracy was measured in axial CT images the day after surgery (GE Health Care, Waukesha, WI, USA). The accuracy of PPS placement was evaluated based on the Heary and Gertzbein classification system (11,12). For the thoracic spine, the Heary Classification was used, where Grade I represents screw placement fully within the pedicle with no breach, considered optimal placement. Grade II is a minor breach of the pedicle cortex (<2 mm), which is considered acceptable. Grade III indicates a moderate breach of the pedicle cortex (2–4 mm), which is potentially risky, while Grade IV is a severe breach of the pedicle cortex (>4 mm), which requires revision. For the lumbar spine, the Gertzbein Classification was applied, with Grade A representing screw placement fully within the pedicle with no deviation. Grade B indicates a minor breach of the pedicle cortex (<2 mm), which is considered acceptable. Grade C represents a moderate breach of the pedicle cortex (2–4 mm), which increases the risk, while Grade D is a severe breach of the pedicle cortex (>4 mm), requiring revision. In this study, Grades I and II (Heary) or A and B (Gertzbein) were considered acceptable, while Grade III or C and above were considered unacceptable.
Statistical analysis
Values are presented as the mean ± standard deviation (SD) unless otherwise noted. Statistical analysis was conducted with SPSS version 29 (IBM Corporation, 2022, Armonk, NY, USA), with statistical significance set at P<0.05. We compared quantitative and qualitative data between the two groups using the Mann-Whitney U and Fisher’s exact tests, respectively. A priori sample size calculation was not performed because this retrospective study included all consecutive eligible patients over the study period.
Results
Demographic data
A total of 24 patients met the inclusion criteria and were included in the analysis. No patients were excluded after eligibility screening. The demographic data of the two groups are shown in Table 1. No significant differences in patient characteristics, including age, sex, BMI, hypertension, diabetes mellitus, AIS, and the AO Classification, were detected between groups.
Table 1. Comparison of patient demographics between the O-arm and C-arm groups.
| Variable | C-arm group (n=13) | O-arm group (n=11) | P value |
|---|---|---|---|
| Age (years) | 73.9±13.3 | 74.9±16.1 | >0.99 |
| Male | 9 (69.2) | 6 (54.5) | 0.68 |
| BMI (kg/m2) | 22.1±3.5 | 26.2±6.5 | 0.17 |
| Hypertension | 8 (61.5) | 10 (90.9) | 0.17 |
| Diabetes | 2 (15.4) | 5 (45.5) | 0.26 |
| AIS | 0.53 | ||
| A | 1 (7.7) | 0 | |
| B | 1 (7.7) | 0 | |
| C | 0 | 0 | |
| D | 1 (7.7) | 2 (18.2) | |
| E | 10 (76.9) | 9 (81.8) | |
| AO Spine Thoracolumbar Injury Classification System | 0.24 | ||
| B1 | 0 | 2 (18.2) | |
| B2 | 8 (61.5) | 3 (27.3) | |
| B3 | 4 (30.8) | 5 (45.5) | |
| C | 1 (7.7) | 1 (9.1) | |
Data are presented as n (%) or mean ± standard deviation. AIS, American Spinal Injury Association Impairment Scale; BMI, body mass index.
Surgical information and PPS placement accuracy rate
After-hours emergency surgery was significantly more prevalent in the C-arm group than in the O-arm group (P=0.03, Table 2). Time from injury to surgery was significantly longer in the O-arm group than in the C-arm group (P=0.02, Table 2). This difference may reflect clinical urgency, because after-hours emergency cases were treated with C-arm fluoroscopy. No significant differences in surgical time, blood loss, and PPS placement accuracy were detected between groups (Table 2). In addition, no significant differences in the PPS accuracy rate were detected between groups (O-arm, 88.3%; C-arm, 87.3%; Table 2). No patients experienced neurologic injury as a result of screw misplacement.
Table 2. Comparative analysis of surgical information across the two groups.
| Variable | C-arm group (n=13) | O-arm group (n=11) | P value |
|---|---|---|---|
| After-hours emergency surgery | 7 (53.8) | 1 (9.1) | 0.03 |
| Time from injury to surgery (h) | 52.0±95.6 | 155.3±167.0 | 0.02 |
| Surgical time (minutes) | 158.3±45.4 | 214.6±63.0 | 0.17 |
| Blood loss (mL) | 194.6±163.4 | 199.1±249.2 | 0.65 |
| Total PPS number | 147 | 122 | – |
| Average PPS number/case | 11.3±2.1 | 11.1±2.4 | >0.99 |
| Unacceptable PPS placement | 0 | 1 (0.8) | 0.67 |
| Accuracy of PPS position (%) | 86.3±12.1 | 87.7±12.0 | >0.99 |
Data are presented as n (%), n, or mean ± standard deviation. P values were calculated using Fisher’s exact test for categorical variables and Mann-Whitney U test for continuous variables. PPS, percutaneous pedicle screw.
Postsurgical complications
Although surgical complications, including delirium, VTE, pneumonia, UTI, and SSI, were observed, no significant differences in complication rates were detected between groups (Table 3).
Table 3. Comparative analysis of surgical complications across groups.
| Variable | C-arm group (n=13) | O-arm group (n=11) | P value |
|---|---|---|---|
| Total perioperative complication | 7 (53.8) | 5 (45.5) | 0.48 |
| Delirium | 6 (46.2) | 3 (27.3) | 0.42 |
| VTE | 4 (30.8) | 6 (54.5) | 0.41 |
| Pneumonia | 2 (15.4) | 0 | 0.48 |
| UTI | 0 | 1 (9.1) | 0.46 |
| SSI | 1 (7.7) | 1 (9.1) | >0.99 |
Data are presented as n (%). SSI, surgical site infection; UTI, urinary tract infection; VTE, venous thromboembolism.
Intraoperative fluoroscopic radiation exposure time
The average fluoroscopic radiation time in the O-arm group (2.5±1.8 min) was significantly shorter than that in the C-arm group (16.9±11.4 min, P<0.001; Figure 3).
Figure 3.
Radiation exposure time. The average fluoroscopic radiation time (2.6 min) in the O-arm group was significantly shorter than the 16.9 min of the C-arm group.
Discussion
This retrospective cohort study, conducted according to the STROBE statement, demonstrated that O-arm navigation significantly reduced intraoperative radiation exposure without compromising screw placement accuracy in patients with ASD. The significantly shorter average fluoroscopic radiation time in the O-arm group highlights its potential to minimize occupational radiation risks.
Our findings are consistent with those of previous studies, suggesting that O-arm navigation offers high PPS placement accuracy, comparable to C-arm fluoroscopy. While both systems exhibit similar accuracy rates (88.3% for O-arm vs. 87.3% for C-arm), the reduced radiation exposure for the surgical staff is a clear advantage of using the O-arm. Prior studies, including those by Lu et al. (2020) (9), confirmed that O-arm navigation is a reliable method for PPS fixation in spinal fractures, and these findings indicate that this reliability extends to patients with ASD, who present with increased spinal fragility.
ASD confers unique challenges due to increased spinal rigidity and a higher risk of fractures. These challenges are consistent with recent trauma literature demonstrating that ASD-related fractures are typically highly unstable, frequently associated with neurological deficits, and require early surgical stabilization for optimal outcomes (4). Li et al. (2021) reported successful results using O-arm navigation in posterior wedge osteotomy for patients with ASD presenting with spinal fractures (13). Occupational radiation-induced skin injuries are prevalent among orthopedic surgeons (5). One study identified being a spine surgeon as an independent risk factor for radiation-induced skin injury, underscoring the importance of minimizing radiation exposure during spinal surgeries (5). Our study demonstrated that the radiation exposure time was significantly shorter in the O-arm group than in the C-arm group. To our knowledge, this is the first study to compare radiation exposure time between O-arm and C-arm in surgeries for patients with ASD. Our results suggest that O-arm navigation can be recommended for trauma cases in patients with ASD, as it reduces radiation exposure without compromising surgical outcomes.
Occupational exposure to ionizing radiation represents a significant long-term hazard for orthopedic surgeons, particularly those who routinely perform spine and trauma procedures requiring fluoroscopy. Cumulative radiation has been associated with chronic dermatitis and, in rare cases, malignant transformation, as demonstrated in recent clinical surveys, including the nationwide study by Asari et al. (2022) (5), which reported a high prevalence of radiation-induced skin injury among orthopedic surgeons. These findings highlight the importance of continuous radiation-safety education and strict adherence to the ‘As Low As Reasonably Achievable’ (ALARA) principles. International guidelines, such as those issued by the International Commission on Radiological Protection (ICRP), recommend annual occupational dose limits of 20 mSv averaged over 5 years (with no single year exceeding 50 mSv) for whole-body exposure, and 500 mSv for the skin and extremities. Although fluoroscopy time does not directly equal radiation dose, shorter fluoroscopy duration generally correlates with reduced occupational exposure. In this context, the marked reduction in fluoroscopic time observed in the O-arm group suggests that O-arm navigation may offer a meaningful advantage in minimizing cumulative exposure for surgical staff. By reducing the need for repeated fluoroscopic imaging and providing a single acquisition followed by navigation-guided instrumentation, O-arm use aligns with ALARA recommendations and contributes to safer workplace practices in spine surgery. This is consistent with fluoroscopy safety principles described in StatPearls (Rednam & Tiwari), which emphasize standardized protocols and ALARA-based practice (14).
While radiation exposure time was significantly shorter in the O-arm group, it is important to note that the total surgical time differed substantially between the two groups. Specifically, the C-arm group required approximately 56 minutes longer operative time than the O-arm group. This extended surgical time in the C-arm group can be attributed to several intraoperative factors. The need for frequent radiation exposure and adjustments in the radiographic angles contributed to increased procedural duration. In contrast, the O-arm group required only a single CT scan, followed by navigation-guided surgery, allowing for a more efficient workflow with fewer interruptions. Therefore, the difference in surgical time can largely be explained by these factors.
Although the radiation exposure time in the C-arm group was longer, with a significant difference of 13 minutes compared to the O-arm group, the overall surgical time discrepancy was much more pronounced. The O-arm group, after a single scan at the beginning of the surgery, was able to perform the procedure more efficiently with fewer interruptions. This reduced need for repeated imaging and adjustments likely contributed to the shorter total surgical time, despite the fact that the radiation exposure time difference was not as large.
On the other hand, while the need for after-hours emergency surgery was significantly more common in the C-arm group, the time from injury to surgery was notably longer in the O-arm group than in the C-arm group. This difference may represent a confounding factor because O-arm navigation was available only during regular daytime hours, whereas urgent after-hours cases requiring immediate surgery were treated with C-arm fluoroscopy. This temporal allocation likely influenced the between-group imbalance in time from injury to surgery. Therefore, proper coordination and management of the surgical staff are essential to ensure the efficient use of the O-arm during the additional surgical work.
This study adheres to the STROBE statement; however, several limitations must be acknowledged. First, the retrospective design introduces potential selection bias, which may affect the generalizability of the results. In addition, allocation bias may have occurred because O-arm navigation was available only during regular daytime hours when radiology technologists were present, whereas after-hours emergency surgeries were performed using C-arm fluoroscopy. Second, the small sample size limits the statistical power and external applicability of the findings. Future studies should aim to increase the sample size, possibly through multi-center collaborations, to enhance statistical power. If possible, perform a multivariate analysis to control for confounding factors. Third, we measured radiation exposure time. Objective measurements of radiation exposure, such as dosimeter data, would provide more reliable and accurate data. Because actual dose (mSv) and dosimeter data were not available, fluoroscopy time may not fully represent true radiation exposure. Finally, long-term clinical outcomes, such as functional recovery and quality of life post-surgery, were not assessed, which could provide a more comprehensive understanding of the advantages and limitations of O-arm navigation during surgery for patients with ASD.
Conclusions
O-arm navigation is a promising approach to reduce intraoperative radiation exposure for the surgical staff during PPS fixation in patients with ASD who present with thoracolumbar fractures. The accuracy of screw placement is maintained, making the O-arm a valuable tool for enhancing safety and precision in spinal surgery. Additional studies with larger cohorts and long-term follow-up are needed to confirm the effectiveness of O-arm technology in improving clinical outcomes.
Supplementary
The article’s supplementary files as
Acknowledgments
We thank all members of the Department of Orthopedics, Hirosaki University Graduate School of Medicine, for their excellent technical assistance.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Hirosaki University (No. 2018-1002) and individual consent for this retrospective analysis was waived.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-193/rc
Funding: None
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-193/coif). The authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-193/dss
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