Image Guidance in Cervical Pedicle Screw Fixation: A Review of the Meta-Analytic Evidence for 3D-Printed Templates and Computer-Assisted Navigation

Abstract

Cervical pedicle screw fixation provides greater biomechanical stability than lateral mass screw techniques, but the narrow pedicle diameter and proximity to the vertebral artery, nerve roots, and spinal cord make freehand insertion technically demanding and carry a nontrivial risk of vascular or neurologic injury. Two image-guidance strategies have emerged to reduce this risk: patient-specific 3D-printed drill templates and intraoperative computer-assisted navigation (CT- or O-arm-based). This review synthesizes the current body of systematic reviews and meta-analyses on the topic, anchored by a 2026 network meta-analysis in the Journal of Minimally Invasive Spine Surgery & Technique, and contrasts its favorable conclusions with an earlier, larger, and more skeptical 2024 meta-analysis that found no significant accuracy benefit for navigation over freehand technique. Across the literature, image guidance is associated with higher screw-placement accuracy in most individual series, with the strongest evidence at the atlantoaxial (C1–C2) level; however, pooled estimates vary considerably depending on which studies and accuracy thresholds are used, and no study has directly compared 3D-printed templates against computer-assisted navigation. The evidence base overall remains small, retrospective, and institutionally clustered, and long-term clinical outcome data are scarce. Navigation-assisted cervical pedicle screw fixation should therefore be regarded as a promising, increasingly well-supported adjunct rather than a proven, universally superior standard of care.