Cervical Pedicle Screws: Multicenter Comparison of Freehand, Patient-Specific 3D-Printed Templates, Loop-X Navigation and OARM/CT Navigation Accuracy and Safety

Study Design: Retrospective comparative study. Objective: This multicenter European study aimed to compare the accuracy, complication rates, and incidence of revision surgery associated with three distinct cervical pedicle screw (CPS) insertion techniques: freehand, navigation-assisted (Loop-X/O-arm), and patient-specific 3D-template guided approaches. The primary endpoint was to provide evidence to support decision-making in cervical spine instrumentation. Methods: A retrospective, observational study analyzed prospectively collected data from 97 adult patients who underwent posterior cervical fusion with CPS between January 2019 and August 2024. Screw accuracy was assessed using intraoperative or postoperative CT scans, according to the Gertzbein–Robbins classification. Intraoperative and postoperative complications were systematically evaluated. Results: A total of 369 CPS were implanted, with an overall accuracy (Grade A/B) of 90.7%. Patient-specific 3D-templates yielded the highest accuracy (97.7% of grade A/B screws), significantly superior to navigation-assisted (85.5%) and freehand (80.0%) techniques (P < .001). The lowest accuracy was observed at the C2 level (79.4%; P < .001). Patients over 60 years of age undergoing surgery at the C2 level had a 4.7-fold increased likelihood of suboptimal (Grade > B) screw placement (P = .016). The overall rate of intraoperative and postoperative complications was significantly higher in the freehand and navigation-assisted groups (P < .05). Conclusion: CPSs are safe and effective for cervical fusion, with acceptable complication rates. Patient-specific 3D templates offer superior accuracy and fewer complications, but its applicability is limited in urgent cases. Navigation provides good accuracy, but is associated with higher costs and potential technical inconveniences. Technique selection should consider surgeon expertise, resources, and patient-specific factors.