BACKGROUND: Pedicle screws (PS) are routinely used for stabilization to enhance fusion in a variety of spinal pathologies. Although the accuracy of different PS placement methods has been previously reported, the majority of these studies have been limited to one or two techniques.OBJECTIVE: To determine the current accuracy of PS placement among four modalities of PS insertion [free-hand (FH), fluoroscopy-assisted (FA), CT-navigation guided (CTNav), and robot-assisted (RA)] and analyze variables associated with screw misplacement.METHODS: A systematic review of peer-reviewed articles reporting PS accuracy of one technique from January 1990 to June 2018 was performed. Accuracy of PS placement, PS insertion technique, and pedicle breach (PB) data were collected. A meta-analysis was performed to estimate the overall pooled (OP) rates of PS accuracy as a primary outcome, stratified by screw insertion techniques. Potential determinants were analyzed via meta-regression analyses.RESULTS: 78 studies with 7,858 patients, 51,161 PSs, and 3,614 cortical PBs were included. CTNav displayed the highest PS placement accuracy compared to other techniques: OP accuracy rates were 95.5%, 93.1%, 91.5% and 90.5%, via CTNav, FH, FA and RA techniques, respectively. RA and CTNav were associated with the highest PS accuracy in the thoracic spine, compared to FH.CONCLUSIONS: The OP data show that CTNav has the highest PS accuracy rates. Thoracic PSs were associated with lower accuracy rates; however, RA exhibited fewer breaches in the thoracic spine compared to FH and FA. Given the heterogeneity among studies, further standardized and comparative investigations are required to confirm our findings.
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