3D cone-beam tomosynthesis provides axial imaging of the spine with lower radiation compared to computed tomography

Study designThree imaging techniques were compared using porcine spines.ObjectivesTo compare image acquisition time, radiation exposure, pedicle width measurement, assessment of screw breach, and image artifact between cone-beam tomosynthesis (CBT) single mode, CBT dual mode (stereotactic CBT), and computed tomography (CT) imaging with and without spinal implants.Summary of background dataCT is the standard for axial imaging of orthopedic procedures. CBT technology is being developed, allowing real-time intraoperative imaging and 3D surgical guidance. CBT may deliver useful axial imaging quicker with less radiation than current technologies.MethodsSix porcine spines were instrumented with bilateral pedicle screws at six levels connected with 5.5 mm rods. Dosimeters were attached to four surfaces of spines. CT, CBT single and CBT dual images were acquired pre-implant and post-implant. Image acquisition and 3D reconstruction times were recorded. Pedicle widths were measured before and after instrumentation. Screw medial breaches were graded (0: no breach, 1:<2 mm, 2: 2-4 mm, 3: >4 mm). Artifact and/or distortion of each image was ranked (0=none, 1=mild, 2=moderate, 3=large). Image acquisition and reconstruction times, radiation dose, pedicle width, screw breach and artifact were compared between techniques.ResultsTotal image acquisition and reconstruction times of CBT was significantly less (single: 9.90.2 s, p<0.001; dual: 60.0 +/- 8.7 s, p<0.001) than CT (250.3 +/- 36.7 s). CBT had significantly less radiation exposure than CT (CT: 0.7 +/- 0.1 rad, single: 0.03 +/- 0.02 rad, dual: 0.07 +/- 0.03 rad; p<0.001). No difference in pedicle width change pre-implant to post-implant was found (CT: p=0.449, single: p=0.430, dual: p=0.528). Pedicle width (pre-implant: p>0.5, post-implant: p>0.9) and pedicle width change (p>0.4) was similar amongst all techniques. Breach assessment was not different between groups (p=0.257). CBT images had consistently lower artifact grades than CT. Conclusions Although CBT axial image quality appeared subjectively inferior to CT, it enabled consistent assessment of pedicle width and screw breach, at half time and 10x lower radiation exposure. With continued refinements, CBT technology may allow for adequate intra-operative axial imaging using low radiation exposure.