Generating patient-matched 3D-printed pedicle screw and laminectomy drill guides from Cone Beam CT images: Studies in ovine and porcine cadavers

Background The emergence of robotic Cone Beam Computed Tomography (CBCT) imaging systems in trauma departments has enabled 3D anatomical assessment of musculoskeletal injuries, supplementing conventional 2D fluoroscopic imaging for examination, diagnosis, and treatment planning. To date, the primary focus has been on trauma sites in the extremities. Purpose To determine if CBCT images can be used during the treatment planning process in spinal instrumentation and laminectomy procedures, allowing accurate 3D-printed pedicle screw and laminectomy drill guides to be generated for the cervical and thoracic spine. Methods The accuracy of drill guides generated from CBCT images was assessed using animal cadavers (ovine and porcine). Preoperative scans were acquired using a robotic CBCT C-arm system, the Siemens ARTIS pheno (Siemens Healthcare, GmbH, Germany). The CBCT images were imported into 3D-Slicer version 4.10.2 () where vertebral models and specific guides were developed and subsequently 3D-printed. In the ovine cadaver, 11 pedicle screw guides from the T1-T5 and T7-T12 vertebra and six laminectomy guides from the C2-C7 vertebra were planned and printed. In the porcine cadaver, nine pedicle screw guides from the C3-T4 vertebra were planned and printed. For the pedicle screw guides, accuracy was assessed by three observers according to pedicle breach via the Gertzbein-Robbins grading system as well as measured mean axial and sagittal screw error via postoperative CBCT and CT scans. For the laminectomies, the guides were designed to leave 1 mm of lamina. The average thickness of the lamina at the mid-point was used to assess the accuracy of the guides, measured via postoperative CBCT and CT scans from three observers. For all measurements, the intraclass correlation coefficient (ICC) was calculated to determine observer reliability. Results Compared with the planned screw angles for both the ovine and porcine procedures (n = 32), the mean axial and sagittal screw error measured on the postoperative CBCT scans from three observers were 3.9 +/- 1.9 degrees and 1.8 +/- 0.8 degrees, respectively. The ICC among the observes was 0.855 and 0.849 for the axial and sagittal measurements, respectively, indicating good reliability. In the ovine cadaver, directly comparing the measured axial and sagittal screw angle of the visible screws (n = 14) in the postoperative CBCT and conventional CT scans from three observers revealed an average difference 1.9 +/- 1.0 degrees in axial angle and 1.8 +/- 1.0 degrees in the sagittal angle. The average thickness of the lamina at the middle of each vertebra, as measured on-screen in the postoperative CBCT scans by three observes was 1.6 +/- 0.2 mm. The ICC among observers was 0.693, indicating moderate reliability. No lamina breaches were observed in the postoperative images. Conclusion Here, CBCT images have been used to generate accurate 3D-printed pedicle screw and laminectomy drill guides for use in the cervical and thoracic spine. The results demonstrate sufficient precision compared with those previously reported, generated from standard preoperative CT and MRI scans, potentially expanding the treatment planning capabilities of robotic CBCT imaging systems in trauma departments and operating rooms.