Intraoperative Cone-Beam Computed Tomography Assessment of Spinal Pedicle Screws Placement Precision Is in Full Agreement with Postoperative Computed Tomography Assessment

■ OBJECTIVE: To assess agreement between pedicle screw placement evaluated on postoperative computed tomography (CT) and on intraoperative cone-beam CT (CBCT) and compare procedure characteristics when using first-generation and second-generation robotic C-arm sys-tems in the hybrid operating room. ■ METHODS: All patients who received pedicle screws for spinal fusion at our institution between June 2009 and September 2019 and underwent intraoperative CBCT and postoperative CT were included. The CBCT and CT images were reviewed by 2 surgeons to assess the screw place-ment using the Gertzbein-Robbins and the Heary classifi-cations. Intermethod agreement of screw placement classifications as well as interrater agreement were assessed using Brennan-Prediger and Gwet agreement coefficients. Procedure characteristics using first -generation and second-generation generation robotic C-arm systems were compared. ■ RESULTS: Fifty-seven patients were treated with 315 pedicle screws at thoracic, lumbar, and sacral levels. No screw had to be repositioned. On CBCT, accurate place-ment was found for 309 screws (98.1%) using the Gertzbein-Robbins classification and 289 (91.7%) using the Heary classification and on CT, these were 307 (97.4%) and 293 (93.0%), respectively. Intermethod between CBCT and CT and interrater agreements between the 2 raters were almost perfect (>0.90) for all assessment. There were no significant differences in mean radiation dose (P = 0.83) and fluoroscopy time (P = 0.82), but length of surgery using the second-generation system was estimated at 107.7 mi -n utes (95% confidence interval, 31.9e183.5 minutes; P = 0.006) shorter. ■ CONCLUSIONS: Intraoperative CBCT provides accurate assessment of pedicle screw placement and enables intraoperative repositioning of misplaced screws.