Upper lumbar pedicle screw insertion using three-dimensional fluoroscopy navigation: assessment of clinical accuracy.

We used a navigation system to insert 128 pedicle screws into 69 vertebrae (L1 to L3) of 49 consecutive patients. We assessed the pedicle isthmic width and the permission angle for pedicle screw insertion. The permission angle is the angle defined by the greatest medial and lateral trajectories allowable when placing the screw through the center of the pedicle. The rate of narrow-width pedicles (isthmic width less than 5 mm) was 5 of 60 pedicles (8%) at L1, 4 of 60 pedicles (7%) at L2, and none (0%) at L3, L4 and L5. The rate of narrow-angle pedicles (a permission angle less than 15 degrees) was 21 of 60 pedicles (35%) at L1, 7 of 60 (12%) at L2, 3 of 60 (5%) at L3, and none (0%) at L4 and L5. Of 128 pedicle screws inserted into 69 vertebrae from L1 to L3, 125 (97.7%) were classified as Grade 1 (no pedicle perforation). In general, the upper lumbar vertebrae have more narrow-width and -angle pedicles. However, we could reduce the rate of pedicle screw misplacement in upper lumbar vertebra using a three-dimensional fluoroscopy and navigation system.