Colorado spine surgeon, Donald Corenman, MD provides a training on the benefits, use and technique of the O Arm surgical procedure. O Arm surgical technique benefits the surgeon and his team, along with the patient. Through reduced surgical time, increased accuracy of screw placement and reduction of incision size, O Arm is an effective surgical technique.

1. O Arm Benefits, Uses,O Arm Benefits, Uses,
Techniques and PearlsTechniques and Pearls
Donald S. Corenman, M.D., D.C.Donald S. Corenman, M.D., D.C.
The Steadman ClinicThe Steadman Clinic
Vail, ColoradoVail, Colorado

2. O Arm BenefitsO Arm Benefits
 Surgical time reductionSurgical time reduction
 Reduction of radiation exposure to surgeon and staffReduction of radiation exposure to surgeon and staff
 SafetySafety
 Improvement of surgical skillsImprovement of surgical skills
 Accuracy of screw placementAccuracy of screw placement
 TrainingTraining
 Use in landmark lossUse in landmark loss
 Reduction of incision size- tissue damageReduction of incision size- tissue damage
 Intraoperative hardware placement confirmationIntraoperative hardware placement confirmation
 Pioneering new techniquesPioneering new techniques
– Pars repairPars repair
– Fracture reduction confirmationFracture reduction confirmation
 Reduced surgical invasiveness (avoiding a 360)Reduced surgical invasiveness (avoiding a 360)
 Stress reduction on surgeonStress reduction on surgeon

3. Surgical Time Increased RisksSurgical Time Increased Risks
 Increased surgical time leads to increasedIncreased surgical time leads to increased
chance of:chance of:
– DVTDVT
– Pulmonary edema/ PneumoniaPulmonary edema/ Pneumonia
– Pressure necrosis (nerve and skin)Pressure necrosis (nerve and skin)
– InfectionInfection
– IONION

4. O-Arm/ Stealth Reduces SurgicalO-Arm/ Stealth Reduces Surgical
TimeTime
 Placing andPlacing and
checking everychecking every
screw with C armscrew with C arm
takes significanttakes significant
timetime
 Revising oneRevising one
misplaced screwmisplaced screw
can take as longcan take as long
as 20 minutesas 20 minutes

5. O-Arm Reduces RadiationO-Arm Reduces Radiation
ExposureExposure
 Checking each screwChecking each screw
with C-Arm subjectswith C-Arm subjects
surgeon to significantsurgeon to significant
radiation exposureradiation exposure
 Wearing of leadWearing of lead
apron is hot, heavyapron is hot, heavy
and uncomfortable-and uncomfortable-
does not protectdoes not protect
thyroid or eyesthyroid or eyes

6. Safety of Screw PlacementSafety of Screw Placement
 Percentage ofPercentage of
misplaced screwsmisplaced screws
creating root injurycreating root injury
is underreportedis underreported
 Permanent injury toPermanent injury to
root can occur withroot can occur with
significant disabilitysignificant disability
to patientto patient

7. Screw Placement CreatesScrew Placement Creates
Landmarks for Foramen and DiscLandmarks for Foramen and Disc
SpaceSpace
 Surgeons use screwSurgeons use screw
position for landmarksposition for landmarks
 Incorrect screwIncorrect screw
placement or lack ofplacement or lack of
placement leads toplacement leads to
mistakes in graftmistakes in graft
positioningpositioning
 Incorrect placementIncorrect placement
produces growth inproduces growth in
undesirable locationsundesirable locations
 Lack of screw supportLack of screw support
allows foramenalallows foramenal
collapsecollapse

8. Accuracy of PlacementAccuracy of Placement
 Cerebral Palsy orCerebral Palsy or
Neurogenic ScoliosisNeurogenic Scoliosis
patientspatients
 Dysplastic pediclesDysplastic pedicles
(abnormal curvilinear(abnormal curvilinear
pathway)pathway)
 Atrophic pedicleAtrophic pedicle
diameter 3-4 mmdiameter 3-4 mm
 Rotation of pediclesRotation of pedicles

9. Pedicle Torsion/AtrophicPedicle Torsion/Atrophic
PediclesPedicles

10. Iliac Screw PlacementIliac Screw Placement
 Dysplastic ilium or prior iliac bone grafting makesDysplastic ilium or prior iliac bone grafting makes
iliac screw placement difficult without O-Arm andiliac screw placement difficult without O-Arm and
StealthStealth

11. O-Arm/ StealthO-Arm/ Stealth
Landmark LossLandmark Loss
 Pedicular landmarks arePedicular landmarks are
missing for screwmissing for screw
placement inplacement in
pseudoarthrosis patientspseudoarthrosis patients
 Prior surgery eliminates allPrior surgery eliminates all
landmarks making for alandmarks making for a
““hunt and peckhunt and peck”” techniquetechnique
and exhausting dayand exhausting day

12. No need to use multiple C Arm images to find landmarksNo need to use multiple C Arm images to find landmarks

13. Revision SurgeryRevision Surgery
PseudoarthrosisPseudoarthrosis
Broken screws at S1Broken screws at S1

14. Screw Insertion BipassingScrew Insertion Bipassing
Existing Broken ScrewsExisting Broken Screws

15. Screw InsertionScrew Insertion

16. Residency and Fellowship TrainingResidency and Fellowship Training
 Screw insertion byScrew insertion by
trainee can betrainee can be
performed in typicalperformed in typical
fashion whilefashion while
attending surgeonattending surgeon
can monitor screwcan monitor screw
placement withoutplacement without
fear of pedicle breachfear of pedicle breach
or unintendedor unintended
consequencesconsequences

17. Intraoperative Hardware PlacementIntraoperative Hardware Placement
ConfirmationConfirmation
 Using monitoringUsing monitoring
technique (EMG)-technique (EMG)-
abnormal signal canabnormal signal can
yield false positivesyield false positives
(vascular pedicle(vascular pedicle
channels)channels)
 O-Arm will confirmO-Arm will confirm
appropriate placementappropriate placement
 ““Flow Seal pearlFlow Seal pearl””
 S1 screw anteriorS1 screw anterior
penetrationpenetration

18. Accuracy PearlAccuracy Pearl
Check registration with frameCheck registration with frame
Check accuracy with anatomic landmarkCheck accuracy with anatomic landmark

19. Pioneering NewPioneering New
TechniquesTechniques
 Pars repairPars repair
 Fracture reductionFracture reduction

20. Pars Repair with Pars ScrewPars Repair with Pars Screw
 Current repairCurrent repair
technique consiststechnique consists
of wiring or pedicleof wiring or pedicle
screw fixation withscrew fixation with
hooks- non-rigidhooks- non-rigid
fixation and 50-75%fixation and 50-75%
fusion ratefusion rate

21. Pars ScrewPars Screw
 Pars is 3-4 mm widePars is 3-4 mm wide
 All cortical bone (noAll cortical bone (no
central cancellouscentral cancellous
bone for guide path)bone for guide path)
 There is noThere is no ““feelfeel””
upon insertion ofupon insertion of
screwscrew
 Nerve root isNerve root is
immediately anteriorimmediately anterior
of Parsof Pars
 Must engage lateralMust engage lateral
pedicle wall forpedicle wall for
fixationfixation

22. Success Rate with Pars ScrewsSuccess Rate with Pars Screws
 Small series (22Small series (22
patients and 24patients and 24
levels)levels)
 Fusion rate of 90%Fusion rate of 90%
 Time to solid fusionTime to solid fusion
6 months (two at6 months (two at
one year)one year)

23. Fracture ReductionFracture Reduction
 Fracture fragments inFracture fragments in
canal from burstcanal from burst
fracture below L1fracture below L1
(conus) normally(conus) normally
requires anterior andrequires anterior and
posterior approach toposterior approach to
clear canalclear canal
 Using O-Arm andUsing O-Arm and
Stealth Technology-Stealth Technology-
reduction can bereduction can be
assisted with a guidedassisted with a guided
tamp from posteriortamp from posterior
onlyonly

24. Fracture ReductionFracture Reduction
 Post- reduction canPost- reduction can
be confirmed bybe confirmed by
intraoperative O-intraoperative O-
Arm so no return toArm so no return to
OR is necessary forOR is necessary for
ill-reducedill-reduced
fragmentsfragments

25. Cervical Usage-Odontoid Fx withCervical Usage-Odontoid Fx with
C1 Burst Neurologically IntactC1 Burst Neurologically Intact

26. Eroded Facets- Atrophic C2Eroded Facets- Atrophic C2
PediclesPedicles

27. Ability to Place Hardware inAbility to Place Hardware in
Difficult CircumstancesDifficult Circumstances

28. Stress Reduction of Surgeon !!!Stress Reduction of Surgeon !!!
 ““Mental ExhaustionMental Exhaustion”” isis
the enemy of longerthe enemy of longer
casescases
 Placement of screwsPlacement of screws
requires strong grossrequires strong gross
motor contraction withmotor contraction with
the overlay of finethe overlay of fine
motor precisionmotor precision
 Ease of screwEase of screw
placement along withplacement along with
pre-closure knowledgepre-closure knowledge
of safe hardwareof safe hardware
placement reducesplacement reduces
surgeon stress levelsurgeon stress level

29. O-Arm/Stealth Benefits Out-WeighO-Arm/Stealth Benefits Out-Weigh
CostsCosts
 Reduction of Surgical TimeReduction of Surgical Time
 Improved Safety of Hardware PlacementImproved Safety of Hardware Placement
 Reduction of Radiation ExposureReduction of Radiation Exposure
 Increased Ability of SurgeonIncreased Ability of Surgeon
 Difficult Cases TamedDifficult Cases Tamed
 Improved Resident TrainingImproved Resident Training
 Improved Tissue HandlingImproved Tissue Handling
 Significant Reduction of Surgeon StressSignificant Reduction of Surgeon Stress

30. Thank YouThank You
Donald S. Corenman, M.D.,Donald S. Corenman, M.D.,
D.C.D.C.
The Steadman ClinicThe Steadman Clinic
Vail, ColoradoVail, Colorado
NeckandBack.comNeckandBack.com