AUTHOR=Eltes Peter Endre , Bartos Marton , Hajnal Benjamin , Pokorni Agoston Jakab , Kiss Laszlo , Lacroix Damien , Varga Peter Pal , Lazary Aron 

TITLE=Development of a Computer-Aided Design and Finite Element Analysis Combined Method for Affordable Spine Surgical Navigation With 3D-Printed Customized Template

JOURNAL=Frontiers in Surgery

VOLUME=7

YEAR=2021

URL=https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2020.583386

DOI=10.3389/fsurg.2020.583386

ISSN=2296-875X

ABSTRACT=<p><bold>Introduction:</bold> Revision surgery of a previous lumbosacral non-union is highly challenging, especially in case of complications, such as a broken screw at the first sacral level (S1). Here, we propose the implementation of a new method based on the CT scan of a clinical case using 3D reconstruction, combined with finite element analysis (FEA), computer-assisted design (CAD), and 3D-printing technology to provide accurate surgical navigation to aid the surgeon in performing the optimal surgical technique by inserting a pedicle screw at the S1 level.</p><p><bold>Materials and Methods:</bold> A step-by-step approach was developed and performed as follows: (1) Quantitative CT based patient-specific FE model of the sacrum was created. (2) The CAD model of the pedicle screw was inserted into the sacrum model in a bicortical convergent and a monocortical divergent position, by overcoming the geometrical difficulty caused by the broken screw. (3) Static FEAs (Abaqus, Dassault Systemes) were performed using 500 N tensile load applied to the screw head. (4) A template with two screw guiding structures for the sacrum was designed and manufactured using CAD design and 3D-printing technologies, and investment casting. (5) The proposed surgical technique was performed on the patient-specific physical model created with the FDM printing technology. The patient-specific model was CT scanned and a comparison with the virtual plan was performed to evaluate the template accuracy</p><p><bold>Results:</bold> FEA results proved that the modified bicortical convergent insertion is stiffer (6,617.23 N/mm) compared to monocortical divergent placement (2,989.07 N/mm). The final template was created via investment casting from cobalt-chrome. The template design concept was shown to be accurate (grade A, Gertzbein-Robbins scale) based on the comparison of the simulated surgery using the patient-specific physical model and the 3D virtual surgical plan.</p><p><bold>Conclusion:</bold> Compared to the conventional surgical navigation techniques, the presented method allows the consideration of the patient-specific biomechanical parameters; is more affordable, and the intraoperative X-ray exposure can be reduced. This new patient- and condition-specific approach may be widely used in revision spine surgeries or in challenging primary cases after its further clinical validation.</p>