Accuracy and safety of navigated pedicle screw insertion in cervical spine fractures

Jalal Mirzamohammadi; Tor Arnøy Austad; Vidar Stenset; Donata Iwona Biernat; Mads Aarhus; Eirik Helseth; Hege Linnerud

doi:10.3389/fsurg.2026.1773142

Accuracy and safety of navigated pedicle screw insertion in cervical spine fractures

Front Surg. 2026 Feb 20:13:1773142. doi: 10.3389/fsurg.2026.1773142. eCollection 2026.

Authors

Jalal Mirzamohammadi^#¹, Tor Arnøy Austad^#¹, Vidar Stenset¹, Donata Iwona Biernat², Mads Aarhus^{1

3}, Eirik Helseth^{1

3}, Hege Linnerud¹

Affiliations

¹ Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.
² Department of Neuroradiology, Oslo University Hospital, Oslo, Norway.
³ Faculty of Medicine, University of Oslo, Oslo, Norway.

^# Contributed equally.

Abstract

Background: Pedicle screw (PS) fixation provides superior biomechanical stability compared with lateral mass screw (LMS) fixation for unstable cervical spine fractures (CS-Fx) but is associated with a risk of neurovascular injury. Navigation systems have improved PS placement accuracy, although most published studies remain small and underpowered to assess rare complications.

Objective: To evaluate the accuracy and safety of navigation-assisted PS fixation for unstable CS-Fx in a population-based cohort.

Methods: All consecutive patients with unstable CS-Fx who underwent navigated PS fixation at Oslo University Hospital between 2015 and 2024 were included in this study. Navigation was performed using preoperative CT-based surface matching. Postoperative CT scans obtained within 24 h were used to grade PS accuracy as Grade 1 (<2 mm breach), Grade 2 (2-4 mm), or Grade 3 (>4 mm). Complications related to PS placement were recorded.

Results: A total of 345 patients (median age 68 years; 75% males) underwent fixation with 1,347 navigated PSs. Screw accuracy was Grade 1 in 90% of cases, Grade 2 in 8% of cases, and Grade 3 in 2% of cases. Surgery-related complications occurred in 23 patients (6.7%), of whom 11 experienced complications directly related to PS placement. The per-screw complication risk was 0.8%, increasing with decreasing accuracy: 0.1% (Grade 1), 6% (Grade 2), and 14% (Grade 3). Vertebral artery injury occurred in seven patients; two patients experienced new-onset nerve root injury, one had a misplaced screw breaching the atlanto-occipital joint, and one developed significant perioperative bleeding. No cases of new-onset spinal cord injury or screw pull-out were observed. Surgical site infections occurred in 3.5% of patients and were successfully treated with debridement and antibiotics in all cases, without the need for implant removal.

Conclusion: Navigated cervical PS fixation is accurate and associated with a low rate of serious complications. Meticulous planning and surgical technique remain essential despite the use of navigation assistance.

Keywords: cervical; navigation; neurovascular injury; pedicle screw; spinal fracture; traumatic.