The accuracy of pedicle screw placement in thoracolumbar fractures: A comparative study of automated cone-beam CT-based navigation and conventional fluoroscopy.

Introduction: Pedicle screw fixation is a standard technique for stabilizing unstable thoracolumbar fractures. Mobile cone-beam CT (CBCT) systems with robotic image acquisition enable automated navigation workflows, but clinical data in spine trauma remain limited. Research question: To compare pedicle screw accuracy and perioperative outcomes between automated CBCT-based navigation and conventional fluoroscopy in thoracolumbar fracture fixation. Material and methods: This single-centre retrospective cohort study included adults with unstable thoracolumbar spine injuries undergoing pedicle screw fixation during a 5.5-year period. In the CBCT group, intraoperative 3D navigation was performed using an automated CBCT system. Perioperative and postoperative variables were recorded, and screw placement was assessed using the Gertzbein-Robbins classification. Outcomes were compared between groups. Results: Forty-six patients were included: 25 treated with automated CBCT-based navigation and 21 with conventional fluoroscopy. Among 313 evaluable screws, 96.8% were graded Gertzbein-Robbins A or B, and no grade E breaches were observed. In CBCT screws, no grade D or E breach occurred, and no screw-related early reoperations were required. Total operative time was longer with CBCT (154 vs. 119 min; p = 0.018), and blood loss was numerically higher (259 vs. 179 mL; p = 0.272), although operative time and blood loss per pedicle screw did not differ significantly between groups. Length of hospital stay and early clinical outcomes were comparable. Conclusion: Automated CBCT-based intraoperative 3D navigation provides high pedicle screw accuracy and comparable perioperative outcomes. CBCT-based navigation enables real-time 3D visualization and intraoperative verification, supporting its role as a reliable imaging modality in spine trauma surgery.