Use of O-arm Navigation in Percutaneous Pedicle Screw Fixation for Thoracolumbar Fractures in Patients with Ankylosing Spinal Disorders: Reducing Intraoperative Radiation Exposure-A Retrospective Cohort Study

Use of O-arm Navigation in Percutaneous Pedicle Screw Fixation for Thoracolumbar Fractures in Patients with Ankylosing Spinal Disorders: Reducing Intraoperative Radiation Exposure-A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of O-arm Navigation in Percutaneous Pedicle Screw Fixation for Thoracolumbar Fractures in Patients with Ankylosing Spinal Disorders: Reducing Intraoperative Radiation Exposure-A Retrospective Cohort Study Gentaro Kumagai, Kanichiro Wada, On Takeda, Kazushige Koyama, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7171881/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Surgical intervention for thoracolumbar fractures in patients with ankylosing spinal disorders (ASD), such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, typically requires long-segment fixation, which carries a risk of prolonged radiation exposure. Here, we compared the radiation exposure and accuracy of percutaneous pedicle screw (PPS) fixation guided by O-arm navigation or C-arm fluoroscopy in patients with AS who sustained thoracolumbar fractures. Methods: This retrospective cohort study analyzed 24 patients with AS having thoracolumbar fractures who underwent surgery from July 2015 to September 2022. Patients were divided into two groups: O-arm (11 patients) and C-arm (13 patients). Data collected included patient characteristics, intraoperative fluoroscopic radiation exposure time, and PPS placement accuracy using the Heary and Gertzbein classification. Statistical analyses were performed using the Mann-Whitney U test, paired t-test, and chi-square test. Results: Patient characteristics and PPS accuracy did not differ significantly between groups (O-arm: 88.3%, C-arm: 87.3%). The fluoroscopic radiation exposure time was significantly shorter in the O-arm group (2.5 min) than in the C-arm group (15.7 min, p < 0.001). Conclusion: O-arm navigation significantly reduced the intraoperative radiation exposure for the surgical staff during PPS fixation in patients with AS and thoracolumbar fractures, without compromising the screw placement accuracy. Figures Figure 1 Figure 2 Figure 3 1. Introduction Ankylosing spinal disorders (ASD), such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, increase spinal fragility, placing patients at heightened risk for complex thoracolumbar fractures following even minor trauma[ 1 ]. Surgical intervention in such cases often requires long-segment fixation, which carries the risk of prolonged intraoperative radiation exposure. The harmful effects of radiation on the surgical staff, including potential skin injuries, are well documented[ 2 ]. While traditional intraoperative imaging tools such as C-arm fluoroscopy are commonly used, the O-arm—a computed tomography (CT)-based intraoperative navigation system—offers the potential to reduce radiation exposure while maintaining high surgical precision[ 3 ]. Previous studies reported that O-arm navigation enhances screw placement accuracy and reduces radiation exposure during spinal surgeries[ 4 , 5 ]. The potential application of O-arm navigation in patients with ASD, however, particularly those with thoracolumbar fractures, is underexplored. Compared with conventional fluoroscopic techniques, the use of O-arm navigation for percutaneous pedicle screw (PPS) fixation in the treatment of thoracolumbar fractures improves placement accuracy, reduces the rate of functional pedicle breaches, and minimizes serious perforations[ 6 ]. In the present study, we compared radiation exposure and PPS placement accuracy in patients with ASD who underwent surgery guided by O-arm navigation or C-arm fluoroscopy. 2. Methods 2.1 Participants In this retrospective cohort study, conducted at a single tertiary emergency and critical care center in Japan, we reviewed the medical records of patients with spinal trauma diagnosed by orthopedic spine surgeons. The patient sample included 24 adults with AS who were treated for thoracolumbar fractures at our institution from July 2015 to September 2024. The patients were assigned to the O-arm (n = 11) or C-arm (n = 13) groups. Figure 1 presents the study flow diagram. Our institutional review board provided approval for the study (2018–1002). The medical record data were anonymized, and the requirement for informed consent was therefore waived. Patient characteristics, including age, sex, body mass index; body mass index (BMI), medical history, and American Spinal Injury Association impairment scale, AO Spine Thoracolumbar Injury Classification System (AO Classification)[ 7 ], surgical details (overtime work, time from injury to surgery, operative time, blood loss, number and accuracy of PPS placement, and fluoroscopic radiation exposure time), and postoperative complications (e.g., delirium, venous thrombosis embolism, urinary infection, and surgical site infection) were collected from the medical records. 2.2 Surgical indication The decision to perform surgery was guided by the AO Classification, which categorizes injuries into three main injury types: type A (compression), type B (tension band disruption), and type C (displacement/translation) (Fig. 2 , A and B). Type A and Type B injuries are further divided into five and three subtypes, respectively[ 7 ]. Surgery was performed in cases with an AO score greater than 6. 2.3 Surgical techniques PPS fixation was performed using a C-arm or O-arm. All patients were positioned prone on a radiolucent Jackson spinal table (Mizuho OSI, Union City, CA, USA). In the O-arm group, intraoperative CT (Medtronic Sofamor Daneck, Memphis, TN, USA) and a navigation StealthStation system (Medtronic Sofamor Danek) were used, with the surgical area covered with sterile drapes while scanning. After scanning, well-trained surgeons performed the surgical procedure using a navigation system. The surgical staff exited the operating room during O-arm image acquisition. Surgeons performed PPS insertion under navigation without radiation exposure (Fig. 2 ). For patients in the C-arm group, the surgeon was protected and monitored for radiation exposure. 2.4 Assessment of PPS placement accuracy The PPS placement accuracy was measured in axial CT images the day after surgery (GE Health Care, Waukesha, WI, USA). The accuracy of PPS placement was evaluated based on the Heary and Gertzbein classification system[ 8 , 9 ]. For the thoracic spine, the Heary Classification was used, where Grade I represents screw placement fully within the pedicle with no breach, considered optimal placement. Grade II is a minor breach of the pedicle cortex ( 4 mm), which requires revision. For the lumbar spine, the Gertzbein Classification was applied, with Grade A representing screw placement fully within the pedicle with no deviation. Grade B indicates a minor breach of the pedicle cortex ( 4 mm), requiring revision. In this study, Grades I and II (Heary) or A and B (Gertzbein) were considered acceptable, while Grade III or C and above were considered unacceptable. 2.4 Statistical analysis Values are presented as the mean (standard deviation [SD]) unless otherwise noted. Statistical analysis was conducted with SPSS version 29 (IBM Corporation, 2022, Armonk, NY, USA), with statistical significance set at P < 0.05. We compared quantitative and qualitative data between the two groups using the Mann-Whitney U and Fisher’s exact test tests, respectively. 3. Results Demographic data The demographic data of the two groups are shown in Table 1. No significant differences in patient characteristics, including age, sex, BMI, hypertension, diabetes mellitus, AIS, and the AO spine thoracolumbar Injury classification system, were detected between groups. Surgical information and PPS placement accuracy rate Overtime work was significantly more prevalent in the C-arm group than in the O-arm group (P = 0.033, Table 2). Time from injury to surgery was significantly longer in the O-arm group than in the C-arm group (P = 0.020, Table 2). No significant differences in surgical time, blood loss, and PPS placement accuracy were detected between groups (Table 2). In addition, no significant differences in the PPS accuracy rate were detected between groups (O-arm, 88.3%; C-arm, 87.3; Table 2). No patients experienced neurologic injury as a result of screw misplacement. Postsurgical complications Although surgical complications, including delirium, venous thromboembolism, pneumonia, urinary tract infection, and surgical site infection, were observed, no significant differences in complication rates were detected between groups (Table 3). Intraoperative fluoroscopic radiation exposure time The average fluoroscopic radiation time in the O-arm group (2.5 ± 1.8 min) was significantly shorter than that in the C-arm group (16.9 ± 11.4 min, p < 0.001; Fig. 3 ). 4. Discussion The findings of the present study demonstrated that O-arm navigation significantly reduced intraoperative radiation exposure for the surgical staff, with no significant differences in the PPS placement accuracy between the O-arm and C-arm groups in AS patients. The significantly shorter average fluoroscopic radiation time in the O-arm group highlights its potential to minimize occupational radiation risks. Our findings are consistent with those of previous studies suggesting that O-arm navigation offers high PPS placement accuracy, comparable to C-arm fluoroscopy. While both systems exhibit similar accuracy rates (88.3% for O-arm vs. 87.3% for C-arm), the reduced radiation exposure for the surgical staff is a clear advantage of using the O-arm. Prior studies, including those by Lu et al. (2020)[ 6 ], confirmed that O-arm navigation is a reliable method for PPS fixation in spinal fractures, and our results suggest that this reliability extends to patients with AS, who present with increased spinal fragility. AS confers unique challenges due to increased spinal rigidity and a higher risk of fractures. Liu et al (2021) reported successful results using O-arm navigation in posterior wedge osteotomy for patients with AS presenting with spinal fractures[ 10 ]. Occupational radiation-induced skin injuries are prevalent among orthopedic surgeons[ 2 ]. One study identified being a spine surgeon as an independent risk factor for radiation-induced skin injury, underscoring the importance of minimizing radiation exposure during spinal surgeries[ 2 ]. Our study demonstrated that the radiation exposure time was significantly shorter in the O-arm group than in the C-arm group. This study is the first to compare radiation exposure time in surgeries involving patients with AS. Our results suggest that O-arm navigation can be recommended for trauma cases in patients with AS, as it reduces radiation exposure without compromising surgical outcomes. While radiation exposure time was significantly shorter in the O-arm group, it is important to note that the total surgical time differed substantially between the two groups. Specifically, the C-arm group had a 56-minute longer surgical time compared to the O-arm group. This extended surgical time in the C-arm group can be attributed to several intraoperative factors. The need for frequent radiation exposure and adjustments in the radiographic angles contributed to increased procedural duration. In contrast, the O-arm group required only a single CT scan, followed by navigation-guided surgery, allowing for a more efficient workflow with fewer interruptions. Therefore, the difference in surgical time can largely be explained by these factors. 20Although the radiation exposure time in the C-arm group was longer, with a significant difference of 13 minutes compared to the O-arm group, the overall surgical time discrepancy was much more pronounced. The O-arm group, after a single scan at the beginning of the surgery, was able to perform the procedure more efficiently with fewer interruptions. This reduced need for repeated imaging and adjustments likely contributed to the shorter total surgical time, despite the fact that the radiation exposure time difference was not as large. On the other hand, while the need for overtime work was significantly more common in the C-arm group, the time from injury to surgery was notably longer in the O-arm group than in the C-arm group. Therefore, proper coordination and management of the surgical staff are essential to ensure the efficient use of the O-arm during the additional surgical work. This study has several limitations. First, the retrospective design introduces potential selection bias, which may affect the generalizability of the results. Second, the small sample size limits the statistical power and external applicability of the findings. Future studies should aim to increase the sample size, possibly through multi-center collaborations, to enhance statistical power. If possible, perform a multivariate analysis to control for confounding factors. Third, we measured radiation exposure time. Objective measurements of radiation exposure, such as dosimeter data, would provide more reliable and accurate data. Finally, long-term clinical outcomes, such as functional recovery and quality of life post-surgery, were not assessed, which could provide a more comprehensive understanding of the advantages and limitations of O-arm navigation during surgery for patients with AS. Conclusion O-arm navigation is a promising approach to reduce intraoperative radiation exposure for the surgical staff during PPS fixation in patients with AS who present with thoracolumbar fractures. The accuracy of screw placement is maintained, making the O-arm a valuable tool for enhancing safety and precision in spinal surgery. Additional studies with larger cohorts and long-term follow-up are needed to confirm the effectiveness of O-arm technology in improving clinical outcomes. Declarations Ethical Approval: This study was conducted in accordance with the Declaration of Helsinki. This study was approved by the Institutional Review Board of Hirosaki University Graduate School of Medicine (approval code: 2018-1002, and all participants provided written informed consent. Clinical trial number: not applicable. Consent to Publish declaration: not applicable. Availability of Data and Materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Etics approval and consent to participate: This study was approved by the institutional ethics committee. Approval number is 2018-1002. Consent to publication: Yes Competing interests: No Funding information: None Author Contributions: Conceived and designed the experiments: GK, KW, and YI. Performed the investigation: GK, WK, OT, KK, and YI. Analyzed the data: GK. Wrote the paper: GK. References Ye J, Jiang P, Guan H, Wei C, Li S, Jia M, et al. Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. J Orthop Surg Res. 2022;17:504. Asari T, Rokunohe D, Sasaki E, Kaneko T, Kumagai G, Wada K, et al. Occupational ionizing radiation-induced skin injury among orthopedic surgeons: A clinical survey. J Orthop Sci. 2022;27:266-71. Shirbache K, Heidarzadeh M, Qahremani R, Karami A, Karami S, Madreseh E, et al. A systematic review and meta-analysis of radiation exposure in spinal surgeries: Comparing C-Arm, CT navigation, and O-Arm techniques. J Med Imaging Radiat Sci. 2025;56:101831. Mason A, Paulsen R, Babuska JM, Rajpal S, Burneikiene S, Nelson EL, et al. The accuracy of pedicle screw placement using intraoperative image guidance systems. J Neurosurg Spine. 2014;20:196-203. Santos ER, Ledonio CG, Castro CA, Truong WH, Sembrano JN. The accuracy of intraoperative O-arm images for the assessment of pedicle screw postion. Spine (Phila Pa 1976). 2012;37:E119-25. Lu J, Chen W, Liu H, Yang H, Liu T. Does Pedicle Screw Fixation Assisted by O-Arm Navigation Perform Better Than Fluoroscopy-guided Technique in Thoracolumbar Fractures in Percutaneous Surgery?: A Retrospective Cohort Study. Clin Spine Surg. 2020;33:247-53. Whang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, et al. The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal Disord Tech. 2009;22:77-85. Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976). 1990;15:11-4. Heary RF, Bono CM, Black M. Thoracic pedicle screws: postoperative computerized tomography scanning assessment. J Neurosurg. 2004;100:325-31. Li B, Guo R, Jiang X, Wu J, Zhang D, Yang C, et al. Posterior wedge osteotomy assisted by O-arm navigation for treating ankylosing spondylitis with thoracolumbar fractures: an early clinical evaluation. Ann Palliat Med. 2021;10:6694-705. Tables Table 1. Comparative analysis of demographic data across the two groups C-arm group (n = 13) O-arm group (n = 11) P-value Age (years) # 73.9 ± 13.3 74.9 ± 16.1 1.000 Male, n (%) 9 (69.2) 6 (54.5) 0.675 BMI (kg/m 2 ) # 22.1 ± 3.5 26.2 ± 6.5 0.170 Hypertension, n (%) 8 (61.5) 10 (90.1) 0.166 Diabetes, n (%) 2 (15.4) 5 (45.5) 0.255 AIS 0.525 A 1 (7.7) 0 (0) B 1 (7.7) 0 (0) C 0 (0) 0 (0) D 1 (7.7) 2 (18.2) E 10 (76.9) 9 (81.8) AO Spine Thoracolumbar Injury Classification System 0.236 B1, n (%) 0 (0) 2 (18.2) B2, n (%) 8 (61.5) 3 (27.3) B3, n (%) 4 (30.8) 5 (45.5) C, n (%) 1 (7.7) 1 (9.1) BMI, body mass index; AIS, ASIA impairment scale; ♰Mann–Whitney U test, *Fisher’s exact test, P < 0.05, # mean ± S.D Table 2. Comparative analysis of surgical information across the two groups C-arm group (n = 13) O-arm group (n = 11) P-value Overtime work, n (%) 7 (53.8) 1 (9.1) 0.033 Time from injury, hour # 52.0 ± 95.6 155.3 ± 167.0 0.020 Surgical time, minutes # 158.3 ± 45.4 214.6 ± 63.0 0.170 Bood loss, ml # 194.6 ± 163.4 199.1 ± 249.2 0.648 Total PPS number 147 122 - Average PPS number/case # 11.3 ± 2.1 11.1 ± 2.4 1.000 Grade III, IV, V 0 (0) 1 (0.8) 0.670 Accuracy of PPS position # 86.3 ± 12.1 87.7 ± 12.0 1.000 PPS, percutaneous pedicle screw; # mean ± S.D Table 3. Comparative analysis of surgical complications across groups C-arm group (n = 13) O-arm group (n = 11) P-value Total perioperative complication, n (%) 7 (53.8) 5 (45.5) 0.482 Delirium, n (%) 6 (46.2) 3 (27.3) 0.423 VTE, n (%) 4 (30.8) 6 (54.5) 0.414 Pneumonia, n (%) 2 (15.4) 0 (0) 0.482 UTI, n (%) 0 (0) 1 (9.1) 0.458 SSI, n (%) 1 (7.7) 1 (9.1) 1.000 VTE, venous thrombosis embolism; UTI, urinary tract infection; SSI, surgical site infection. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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The study included 24 patients with ASD in our department who underwent posterior PPS fixation surgery. Patients in the O-arm group underwent surgery using O-arm/navigation. Patients in the C-arm group underwent surgery using C-arm fluoroscopy.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7171881/v1/ebe70d3b72295da45db29e2c.png"},{"id":91953417,"identity":"f1480860-44ed-4165-9ff7-8d13e69bc931","added_by":"auto","created_at":"2025-09-23 06:55:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4469582,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative images of PPS fixation surgery\u003c/p\u003e\n\u003cp\u003eCase of thoracolumbar fracture in a 19-year-old man with diffuse idiopathic skeletal hyperostosis. The AO type was B2. The AO injury score was 6 points. (A) Sagittal computed tomography image showed a vertebral fracture of L1. (B) Sagittal short tau inversion recovery MRI image showed signal changes in T12 and L1 vertebrae, and in the interspinous process ligament at T12/L1. (C and D) Intraoperative photographs after percutaneous pedicle screw fixation: lateral view (C) and anterior-posterior view (D). (E and F) Postoperative X-ray: anterior-posterior view (E) and lateral view (F).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7171881/v1/5f90ab47ef1334ee120a2e4d.png"},{"id":91953837,"identity":"a5d51728-ff4f-4929-a9b7-5d3142cc0b43","added_by":"auto","created_at":"2025-09-23 07:03:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":156266,"visible":true,"origin":"","legend":"\u003cp\u003eRadiation exposure time. *Mann-Whitney U-test, P \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7171881/v1/8e3a7b7c129e4d330d9874b6.png"},{"id":91963816,"identity":"90736001-1dc3-4681-87ad-0d0366cb1423","added_by":"auto","created_at":"2025-09-23 08:10:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7576085,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7171881/v1/78f0c257-176a-4f06-9659-603a5b5ce108.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Use of O-arm Navigation in Percutaneous Pedicle Screw Fixation for Thoracolumbar Fractures in Patients with Ankylosing Spinal Disorders: Reducing Intraoperative Radiation Exposure-A Retrospective Cohort Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAnkylosing spinal disorders (ASD), such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, increase spinal fragility, placing patients at heightened risk for complex thoracolumbar fractures following even minor trauma[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Surgical intervention in such cases often requires long-segment fixation, which carries the risk of prolonged intraoperative radiation exposure. The harmful effects of radiation on the surgical staff, including potential skin injuries, are well documented[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While traditional intraoperative imaging tools such as C-arm fluoroscopy are commonly used, the O-arm\u0026mdash;a computed tomography (CT)-based intraoperative navigation system\u0026mdash;offers the potential to reduce radiation exposure while maintaining high surgical precision[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious studies reported that O-arm navigation enhances screw placement accuracy and reduces radiation exposure during spinal surgeries[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The potential application of O-arm navigation in patients with ASD, however, particularly those with thoracolumbar fractures, is underexplored. Compared with conventional fluoroscopic techniques, the use of O-arm navigation for percutaneous pedicle screw (PPS) fixation in the treatment of thoracolumbar fractures improves placement accuracy, reduces the rate of functional pedicle breaches, and minimizes serious perforations[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e In the present study, we compared radiation exposure and PPS placement accuracy in patients with ASD who underwent surgery guided by O-arm navigation or C-arm fluoroscopy.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 \u003cem\u003eParticipants\u003c/em\u003e\u003c/h2\u003e\u003cp\u003eIn this retrospective cohort study, conducted at a single tertiary emergency and critical care center in Japan, we reviewed the medical records of patients with spinal trauma diagnosed by orthopedic spine surgeons. The patient sample included 24 adults with AS who were treated for thoracolumbar fractures at our institution from July 2015 to September 2024. The patients were assigned to the O-arm (n\u0026thinsp;=\u0026thinsp;11) or C-arm (n\u0026thinsp;=\u0026thinsp;13) groups. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the study flow diagram. Our institutional review board provided approval for the study (2018\u0026ndash;1002). The medical record data were anonymized, and the requirement for informed consent was therefore waived. Patient characteristics, including age, sex, body mass index; body mass index (BMI), medical history, and American Spinal Injury Association impairment scale, AO Spine Thoracolumbar Injury Classification System (AO Classification)[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], surgical details (overtime work, time from injury to surgery, operative time, blood loss, number and accuracy of PPS placement, and fluoroscopic radiation exposure time), and postoperative complications (e.g., delirium, venous thrombosis embolism, urinary infection, and surgical site infection) were collected from the medical records.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 \u003cem\u003eSurgical indication\u003c/em\u003e\u003c/h2\u003e\u003cp\u003eThe decision to perform surgery was guided by the AO Classification, which categorizes injuries into three main injury types: type A (compression), type B (tension band disruption), and type C (displacement/translation) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, A and B). Type A and Type B injuries are further divided into five and three subtypes, respectively[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Surgery was performed in cases with an AO score greater than 6.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 \u003cem\u003eSurgical techniques\u003c/em\u003e\u003c/h2\u003e\u003cp\u003ePPS fixation was performed using a C-arm or O-arm. All patients were positioned prone on a radiolucent Jackson spinal table (Mizuho OSI, Union City, CA, USA). In the O-arm group, intraoperative CT (Medtronic Sofamor Daneck, Memphis, TN, USA) and a navigation StealthStation system (Medtronic Sofamor Danek) were used, with the surgical area covered with sterile drapes while scanning. After scanning, well-trained surgeons performed the surgical procedure using a navigation system. The surgical staff exited the operating room during O-arm image acquisition. Surgeons performed PPS insertion under navigation without radiation exposure (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For patients in the C-arm group, the surgeon was protected and monitored for radiation exposure.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 \u003cem\u003eAssessment of PPS placement accuracy\u003c/em\u003e\u003c/h2\u003e\u003cp\u003e The PPS placement accuracy was measured in axial CT images the day after surgery (GE Health Care, Waukesha, WI, USA). The accuracy of PPS placement was evaluated based on the Heary and Gertzbein classification system[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For the thoracic spine, the Heary Classification was used, where Grade I represents screw placement fully within the pedicle with no breach, considered optimal placement. Grade II is a minor breach of the pedicle cortex (\u0026lt;\u0026thinsp;2 mm), which is considered acceptable. Grade III indicates a moderate breach of the pedicle cortex (2\u0026ndash;4 mm), which is potentially risky, while Grade IV is a severe breach of the pedicle cortex (\u0026gt;\u0026thinsp;4 mm), which requires revision. For the lumbar spine, the Gertzbein Classification was applied, with Grade A representing screw placement fully within the pedicle with no deviation. Grade B indicates a minor breach of the pedicle cortex (\u0026lt;\u0026thinsp;2 mm), which is considered acceptable. Grade C represents a moderate breach of the pedicle cortex (2\u0026ndash;4 mm), which increases the risk, while Grade D is a severe breach of the pedicle cortex (\u0026gt;\u0026thinsp;4 mm), requiring revision. In this study, Grades I and II (Heary) or A and B (Gertzbein) were considered acceptable, while Grade III or C and above were considered unacceptable.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.4 \u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/h2\u003e\u003cp\u003eValues are presented as the mean (standard deviation [SD]) unless otherwise noted. Statistical analysis was conducted with SPSS version 29 (IBM Corporation, 2022, Armonk, NY, USA), with statistical significance set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. We compared quantitative and qualitative data between the two groups using the Mann-Whitney U and Fisher\u0026rsquo;s exact test tests, respectively.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cem\u003eDemographic data\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe demographic data of the two groups are shown in Table\u0026nbsp;1. No significant differences in patient characteristics, including age, sex, BMI, hypertension, diabetes mellitus, AIS, and the AO spine thoracolumbar Injury classification system, were detected between groups.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurgical information and PPS placement accuracy rate\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOvertime work was significantly more prevalent in the C-arm group than in the O-arm group (P\u0026thinsp;=\u0026thinsp;0.033, Table\u0026nbsp;2). Time from injury to surgery was significantly longer in the O-arm group than in the C-arm group (P\u0026thinsp;=\u0026thinsp;0.020, Table\u0026nbsp;2). No significant differences in surgical time, blood loss, and PPS placement accuracy were detected between groups (Table\u0026nbsp;2). In addition, no significant differences in the PPS accuracy rate were detected between groups (O-arm, 88.3%; C-arm, 87.3; Table\u0026nbsp;2). No patients experienced neurologic injury as a result of screw misplacement.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePostsurgical complications\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAlthough surgical complications, including delirium, venous thromboembolism, pneumonia, urinary tract infection, and surgical site infection, were observed, no significant differences in complication rates were detected between groups (Table\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eIntraoperative fluoroscopic radiation exposure time\u003c/p\u003e\u003cp\u003eThe average fluoroscopic radiation time in the O-arm group (2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 min) was significantly shorter than that in the C-arm group (16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe findings of the present study demonstrated that O-arm navigation significantly reduced intraoperative radiation exposure for the surgical staff, with no significant differences in the PPS placement accuracy between the O-arm and C-arm groups in AS patients. The significantly shorter average fluoroscopic radiation time in the O-arm group highlights its potential to minimize occupational radiation risks.\u003c/p\u003e\u003cp\u003eOur findings are consistent with those of previous studies suggesting that O-arm navigation offers high PPS placement accuracy, comparable to C-arm fluoroscopy. While both systems exhibit similar accuracy rates (88.3% for O-arm vs. 87.3% for C-arm), the reduced radiation exposure for the surgical staff is a clear advantage of using the O-arm. Prior studies, including those by Lu et al. (2020)[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], confirmed that O-arm navigation is a reliable method for PPS fixation in spinal fractures, and our results suggest that this reliability extends to patients with AS, who present with increased spinal fragility.\u003c/p\u003e\u003cp\u003eAS confers unique challenges due to increased spinal rigidity and a higher risk of fractures. Liu et al (2021) reported successful results using O-arm navigation in posterior wedge osteotomy for patients with AS presenting with spinal fractures[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Occupational radiation-induced skin injuries are prevalent among orthopedic surgeons[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. One study identified being a spine surgeon as an independent risk factor for radiation-induced skin injury, underscoring the importance of minimizing radiation exposure during spinal surgeries[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Our study demonstrated that the radiation exposure time was significantly shorter in the O-arm group than in the C-arm group. This study is the first to compare radiation exposure time in surgeries involving patients with AS. Our results suggest that O-arm navigation can be recommended for trauma cases in patients with AS, as it reduces radiation exposure without compromising surgical outcomes.\u003c/p\u003e\u003cp\u003eWhile radiation exposure time was significantly shorter in the O-arm group, it is important to note that the total surgical time differed substantially between the two groups. Specifically, the C-arm group had a 56-minute longer surgical time compared to the O-arm group. This extended surgical time in the C-arm group can be attributed to several intraoperative factors. The need for frequent radiation exposure and adjustments in the radiographic angles contributed to increased procedural duration. In contrast, the O-arm group required only a single CT scan, followed by navigation-guided surgery, allowing for a more efficient workflow with fewer interruptions. Therefore, the difference in surgical time can largely be explained by these factors.\u003c/p\u003e\u003cp\u003e20Although the radiation exposure time in the C-arm group was longer, with a significant difference of 13 minutes compared to the O-arm group, the overall surgical time discrepancy was much more pronounced. The O-arm group, after a single scan at the beginning of the surgery, was able to perform the procedure more efficiently with fewer interruptions. This reduced need for repeated imaging and adjustments likely contributed to the shorter total surgical time, despite the fact that the radiation exposure time difference was not as large.\u003c/p\u003e\u003cp\u003eOn the other hand, while the need for overtime work was significantly more common in the C-arm group, the time from injury to surgery was notably longer in the O-arm group than in the C-arm group. Therefore, proper coordination and management of the surgical staff are essential to ensure the efficient use of the O-arm during the additional surgical work.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, the retrospective design introduces potential selection bias, which may affect the generalizability of the results. Second, the small sample size limits the statistical power and external applicability of the findings. Future studies should aim to increase the sample size, possibly through multi-center collaborations, to enhance statistical power. If possible, perform a multivariate analysis to control for confounding factors. Third, we measured radiation exposure time. Objective measurements of radiation exposure, such as dosimeter data, would provide more reliable and accurate data. Finally, long-term clinical outcomes, such as functional recovery and quality of life post-surgery, were not assessed, which could provide a more comprehensive understanding of the advantages and limitations of O-arm navigation during surgery for patients with AS.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eO-arm navigation is a promising approach to reduce intraoperative radiation exposure for the surgical staff during PPS fixation in patients with AS who present with thoracolumbar fractures. The accuracy of screw placement is maintained, making the O-arm a valuable tool for enhancing safety and precision in spinal surgery. Additional studies with larger cohorts and long-term follow-up are needed to confirm the effectiveness of O-arm technology in improving clinical outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. This study was approved by the Institutional Review Board of Hirosaki University Graduate School of Medicine (approval code: 2018-1002, and all participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eEtics approval and consent to participate: This study was approved by the institutional ethics committee. Approval number is 2018-1002.\u003c/p\u003e\n\u003cp\u003eConsent to publication: Yes\u003c/p\u003e\n\u003cp\u003eCompeting interests: No\u003c/p\u003e\n\u003cp\u003eFunding information: None\u003c/p\u003e\n\u003cp\u003eAuthor Contributions: Conceived and designed the experiments: GK, KW, and YI. Performed the investigation: GK, WK, OT, KK, and YI. Analyzed the data: GK. Wrote the paper: GK.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYe J, Jiang P, Guan H, Wei C, Li S, Jia M, et al. Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. J Orthop Surg Res. 2022;17:504.\u003c/li\u003e\n\u003cli\u003eAsari T, Rokunohe D, Sasaki E, Kaneko T, Kumagai G, Wada K, et al. Occupational ionizing radiation-induced skin injury among orthopedic surgeons: A clinical survey. J Orthop Sci. 2022;27:266-71.\u003c/li\u003e\n\u003cli\u003eShirbache K, Heidarzadeh M, Qahremani R, Karami A, Karami S, Madreseh E, et al. A systematic review and meta-analysis of radiation exposure in spinal surgeries: Comparing C-Arm, CT navigation, and O-Arm techniques. J Med Imaging Radiat Sci. 2025;56:101831.\u003c/li\u003e\n\u003cli\u003eMason A, Paulsen R, Babuska JM, Rajpal S, Burneikiene S, Nelson EL, et al. The accuracy of pedicle screw placement using intraoperative image guidance systems. J Neurosurg Spine. 2014;20:196-203.\u003c/li\u003e\n\u003cli\u003eSantos ER, Ledonio CG, Castro CA, Truong WH, Sembrano JN. The accuracy of intraoperative O-arm images for the assessment of pedicle screw postion. Spine (Phila Pa 1976). 2012;37:E119-25.\u003c/li\u003e\n\u003cli\u003eLu J, Chen W, Liu H, Yang H, Liu T. Does Pedicle Screw Fixation Assisted by O-Arm Navigation Perform Better Than Fluoroscopy-guided Technique in Thoracolumbar Fractures in Percutaneous Surgery?: A Retrospective Cohort Study. Clin Spine Surg. 2020;33:247-53.\u003c/li\u003e\n\u003cli\u003eWhang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, et al. The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal Disord Tech. 2009;22:77-85.\u003c/li\u003e\n\u003cli\u003eGertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976). 1990;15:11-4.\u003c/li\u003e\n\u003cli\u003eHeary RF, Bono CM, Black M. Thoracic pedicle screws: postoperative computerized tomography scanning assessment. J Neurosurg. 2004;100:325-31.\u003c/li\u003e\n\u003cli\u003eLi B, Guo R, Jiang X, Wu J, Zhang D, Yang C, et al. Posterior wedge osteotomy assisted by O-arm navigation for treating ankylosing spondylitis with thoracolumbar fractures: an early clinical evaluation. Ann Palliat Med. 2021;10:6694-705.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eComparative analysis of demographic data across the two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC-arm group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eO-arm group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 11)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eAge (years)\u003cem\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e73.9 \u0026plusmn; 13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e74.9 \u0026plusmn; 16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e9 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e6 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.675\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003cem\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e22.1 \u0026plusmn; 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e26.2 \u0026plusmn; 6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eHypertension, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e8 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e10 (90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eDiabetes, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eAIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.525\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp; B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp; C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp; D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp; E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e10 (76.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eAO Spine Thoracolumbar Injury Classification System\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eB1, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eB2, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e8 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eB3, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI, body mass index; AIS, ASIA impairment scale; ♰Mann\u0026ndash;Whitney U test, *Fisher\u0026rsquo;s exact test, P \u0026lt; 0.05, \u003csup\u003e#\u003c/sup\u003emean \u0026plusmn; S.D\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eComparative analysis of surgical information across the two groups\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC-arm group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eO-arm group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 11)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eOvertime work, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e7 (53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eTime from injury, hour\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e52.0 \u0026plusmn; 95.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e155.3 \u0026plusmn; 167.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eSurgical time, minutes\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e158.3 \u0026plusmn; 45.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e214.6 \u0026plusmn; 63.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eBood loss, ml\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e194.6 \u0026plusmn; 163.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e199.1 \u0026plusmn; 249.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.648\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;PPS number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;PPS number/case\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e11.3 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e11.1 \u0026plusmn; 2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eGrade III, IV, V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.670\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAccuracy of PPS position\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e86.3 \u0026plusmn; 12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e87.7 \u0026plusmn; 12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePPS, percutaneous pedicle screw;\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003csup\u003e#\u003c/sup\u003emean \u0026plusmn; S.D\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Comparative analysis of surgical complications across groups\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC-arm group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eO-arm group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 11)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003eTotal perioperative complication, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7 (53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e5 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.482\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003eDelirium, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e6 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e3 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.423\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003eVTE, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e6 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003ePneumonia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.482\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003eUTI, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e1 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.458\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003eSSI, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e1 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eVTE, venous thrombosis embolism; UTI, urinary tract infection; SSI, surgical site infection.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7171881/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7171881/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Surgical intervention for thoracolumbar fractures in patients with ankylosing spinal disorders (ASD), such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, typically requires long-segment fixation, which carries a risk of prolonged radiation exposure. Here, we compared the radiation exposure and accuracy of percutaneous pedicle screw (PPS) fixation guided by O-arm navigation or C-arm fluoroscopy in patients with AS who sustained thoracolumbar fractures.\u003c/p\u003e\n\u003cp\u003eMethods: This retrospective cohort study analyzed 24 patients with AS having thoracolumbar fractures who underwent surgery from July 2015 to September 2022. Patients were divided into two groups: O-arm (11 patients) and C-arm (13 patients). Data collected included patient characteristics, intraoperative fluoroscopic radiation exposure time, and PPS placement accuracy using the Heary and Gertzbein classification. Statistical analyses were performed using the Mann-Whitney U test, paired t-test, and chi-square test.\u003c/p\u003e\n\u003cp\u003eResults: Patient characteristics and PPS accuracy did not differ significantly between groups (O-arm: 88.3%, C-arm: 87.3%). The fluoroscopic radiation exposure time was significantly shorter in the O-arm group (2.5 min) than in the C-arm group (15.7 min, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eConclusion: O-arm navigation significantly reduced the intraoperative radiation exposure for the surgical staff during PPS fixation in patients with AS and thoracolumbar fractures, without compromising the screw placement accuracy.\u003c/p\u003e","manuscriptTitle":"Use of O-arm Navigation in Percutaneous Pedicle Screw Fixation for Thoracolumbar Fractures in Patients with Ankylosing Spinal Disorders: Reducing Intraoperative Radiation Exposure-A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 06:47:53","doi":"10.21203/rs.3.rs-7171881/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad2d0519-9526-4ee6-ab69-dc9e27a9a7fa","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-23T06:47:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 06:47:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7171881","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7171881","identity":"rs-7171881","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}