The Accuracy of Pedicle Screw Placement in Thoracolumbar Fractures: A Comparative Study of intraoperative 3D image guided Navigation and Conventional Fluoroscopy

Introduction: Pedicle screw fixation is a standard technique for stabilizing unstable thoracolumbar fractures. Conventional fluoroscopy offers two-dimensional guidance, whereas intraoperative three-dimensional (3D) image-guided navigation provides real-time visualization. This study aimed to compare pedicle screw accuracy and perioperative and postoperative outcomes between conventional fluoroscopy and intraoperative 3D navigation in thoracolumbar fracture fixation. Methods: This single centre cohort study included adult patients with unstable injuries of the thoracolumbar spine treated with posterior pedicle screw fixation using either intraoperative 3D navigation or conventional fluoroscopy over a period of six years. Perioperative and postoperative variables were compared. All screw positions were classified according to the Gertzbein–Robbins grading system. Results: Forty-six patients were included: 25 treated with intraoperative 3D navigation and 21 with conventional fluoroscopy. Among the 345 inserted screws, 313 were suitable for accuracy assessment; 96% were graded Gertzbein–Robbins A or B, and no grade E breaches occurred. Navigation cases involved longer constructs and a higher proportion of thoracic-level instrumentation. Operative time and blood loss were higher in the navigation group, and although these differences were reduced when adjusted per instrumented vertebra and per screw, they remained statistically significant. Two screws required revision in the fluoroscopy group, whereas no screw revisions were necessary in the navigation group. Conclusions: Intraoperative 3D navigation and conventional fluoroscopy provided similarly high pedicle screw accuracy and comparable perioperative outcomes in thoracolumbar fracture fixation. Both techniques were safe and effective, and the findings support intraoperative navigation as a precise and reliable adjunct in modern spine trauma surgery.