Preoperative Diffusion Tensor Imaging Guided Surgical Planning Versus Standard MRI for Reducing Iatrogenic Nerve Injury in Spinal Fusion Surgery
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Background: Iatrogenic neurological injury remains an important complication of complex lumbar and lumbosacral spinal fusion. Conventional magnetic resonance imaging (MRI) provides detailed anatomical information but limited characterization of the microstructural organization and trajectories of compressed or displaced nerve fibers. Diffusion tensor imaging (DTI) may provide additional patient-specific information for surgical planning. Objective: To evaluate whether preoperative DTI-guided surgical planning reduces postoperative neurological deficits and improves early clinical outcomes compared with standard MRI-based planning. Methods: This prospective parallel-group randomized controlled trial included 92 adults undergoing elective multilevel lumbar or lumbosacral spinal fusion. Participants were randomized 1:1 to DTI-guided planning (n=46) or standard MRI planning (n=46). Four participants were lost to six-week follow-up, leaving 44 participants per group for postoperative analysis. Outcomes included neurological deficits, Medical Research Council (MRC) motor scores, sensory recovery, visual analog scale (VAS) pain scores, and Oswestry Disability Index (ODI). Results: Neurological deficits occurred in 1/44 participants (2.3%) in the DTI group and 8/44 (18.2%) in the standard MRI group, corresponding to a risk difference of −15.9 percentage points (95% CI −28.1 to −3.7), relative risk 0.13 (95% CI 0.02–0.96), and p=0.030. Mean postoperative MRC scores were 4.82±0.39 and 4.38±0.65, respectively (mean difference 0.44; 95% CI 0.21–0.67; p<0.001). At six weeks, VAS pain was 15.2 mm lower and ODI 11.8 percentage points lower in the DTI group. Conclusion: DTI-guided planning was associated with fewer short-term neurological deficits and greater early functional recovery than standard MRI planning
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