101
|
Negrillo-Cárdenas J, Jiménez-Pérez JR, Feito FR. The role of virtual and augmented reality in orthopedic trauma surgery: From diagnosis to rehabilitation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 191:105407. [PMID: 32120088 DOI: 10.1016/j.cmpb.2020.105407] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/22/2019] [Accepted: 02/18/2020] [Indexed: 06/10/2023]
Abstract
Virtual and augmented reality have been used to assist and improve human capabilities in many fields. Most recent advances allow the usage of these technologies for personal and professional purposes. In particular, they have been progressively introduced in many medical procedures since the last century. Thanks to immersive training systems and a better comprehension of the ongoing procedure, their main objectives are to increase patient safety and decrease recovery time. The current and future possibilities of virtual and augmented reality in the context of bone fracture reduction are the main focus of this review. This medical procedure requires meticulous planning and a complex intervention in many cases, hence becoming a promising candidate to be benefited from this kind of technology. In this paper, we exhaustively analyze the impact of virtual and augmented reality to bone fracture healing, detailing each task from diagnosis to rehabilitation. Our primary goal is to introduce novel researchers to current trends applied to orthopedic trauma surgery, proposing new lines of research. To that end, we propose and evaluate a set of qualitative metrics to highlight the most promising challenges of virtual and augmented reality technologies in this context.
Collapse
|
102
|
Manni F, Elmi-Terander A, Burström G, Persson O, Edström E, Holthuizen R, Shan C, Zinger S, van der Sommen F, de With PHN. Towards Optical Imaging for Spine Tracking without Markers in Navigated Spine Surgery. SENSORS (BASEL, SWITZERLAND) 2020; 20:E3641. [PMID: 32610555 PMCID: PMC7374436 DOI: 10.3390/s20133641] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/13/2020] [Accepted: 06/22/2020] [Indexed: 12/18/2022]
Abstract
Surgical navigation systems are increasingly used for complex spine procedures to avoid neurovascular injuries and minimize the risk for reoperations. Accurate patient tracking is one of the prerequisites for optimal motion compensation and navigation. Most current optical tracking systems use dynamic reference frames (DRFs) attached to the spine, for patient movement tracking. However, the spine itself is subject to intrinsic movements which can impact the accuracy of the navigation system. In this study, we aimed to detect the actual patient spine features in different image views captured by optical cameras, in an augmented reality surgical navigation (ARSN) system. Using optical images from open spinal surgery cases, acquired by two gray-scale cameras, spinal landmarks were identified and matched in different camera views. A computer vision framework was created for preprocessing of the spine images, detecting and matching local invariant image regions. We compared four feature detection algorithms, Speeded Up Robust Feature (SURF), Maximal Stable Extremal Region (MSER), Features from Accelerated Segment Test (FAST), and Oriented FAST and Rotated BRIEF (ORB) to elucidate the best approach. The framework was validated in 23 patients and the 3D triangulation error of the matched features was < 0 . 5 mm. Thus, the findings indicate that spine feature detection can be used for accurate tracking in navigated surgery.
Collapse
Affiliation(s)
- Francesca Manni
- Department of Electrical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands; (S.Z.); (F.v.d.S.); (P.H.N.d.W.)
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 46, Sweden & Department of Neurosurgery, Karolinska University Hospital, SE-171 46 Stockholm, Sweden; (A.E.-T.); (G.B.); (O.P.); (E.E.)
| | - Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 46, Sweden & Department of Neurosurgery, Karolinska University Hospital, SE-171 46 Stockholm, Sweden; (A.E.-T.); (G.B.); (O.P.); (E.E.)
| | - Oscar Persson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 46, Sweden & Department of Neurosurgery, Karolinska University Hospital, SE-171 46 Stockholm, Sweden; (A.E.-T.); (G.B.); (O.P.); (E.E.)
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 46, Sweden & Department of Neurosurgery, Karolinska University Hospital, SE-171 46 Stockholm, Sweden; (A.E.-T.); (G.B.); (O.P.); (E.E.)
| | | | - Caifeng Shan
- Philips Research, High Tech Campus 36, 5656 AE Eindhoven, The Netherlands;
| | - Svitlana Zinger
- Department of Electrical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands; (S.Z.); (F.v.d.S.); (P.H.N.d.W.)
| | - Fons van der Sommen
- Department of Electrical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands; (S.Z.); (F.v.d.S.); (P.H.N.d.W.)
| | - Peter H. N. de With
- Department of Electrical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands; (S.Z.); (F.v.d.S.); (P.H.N.d.W.)
| |
Collapse
|
103
|
Hyperspectral Imaging for Skin Feature Detection: Advances in Markerless Tracking for Spine Surgery. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10124078] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In spinal surgery, surgical navigation is an essential tool for safe intervention, including the placement of pedicle screws without injury to nerves and blood vessels. Commercially available systems typically rely on the tracking of a dynamic reference frame attached to the spine of the patient. However, the reference frame can be dislodged or obscured during the surgical procedure, resulting in loss of navigation. Hyperspectral imaging (HSI) captures a large number of spectral information bands across the electromagnetic spectrum, providing image information unseen by the human eye. We aim to exploit HSI to detect skin features in a novel methodology to track patient position in navigated spinal surgery. In our approach, we adopt two local feature detection methods, namely a conventional handcrafted local feature and a deep learning-based feature detection method, which are compared to estimate the feature displacement between different frames due to motion. To demonstrate the ability of the system in tracking skin features, we acquire hyperspectral images of the skin of 17 healthy volunteers. Deep-learned skin features are detected and localized with an average error of only 0.25 mm, outperforming the handcrafted local features with respect to the ground truth based on the use of optical markers.
Collapse
|
104
|
Diffuse reflectance spectroscopy for breach detection during pedicle screw placement: a first in vivo investigation in a porcine model. Biomed Eng Online 2020; 19:47. [PMID: 32532305 PMCID: PMC7291697 DOI: 10.1186/s12938-020-00791-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/04/2020] [Indexed: 11/10/2022] Open
Abstract
Background The safe and accurate placement of pedicle screws remains a critical step in open and minimally invasive spine surgery, emphasizing the need for intraoperative guidance techniques. Diffuse reflectance spectroscopy (DRS) is an optical sensing technology that may provide intraoperative guidance in pedicle screw placement. Purpose The study presents the first in vivo minimally invasive procedure using DRS sensing at the tip of a Jamshidi needle with an integrated optical K-wire. We investigate the effect of tissue perfusion and probe-handling conditions on the reliability of fat fraction measurements for breach detection in vivo. Methods A Jamshidi needle with an integrated fiber-optic K-wire was gradually inserted into the vertebrae under intraoperative image guidance. The fiber-optic K-wire consisted of two optical fibers with a fiber-to-fiber distance of 1.024 mm. DRS spectra in the wavelength range of 450 to 1600 nm were acquired at several positions along the path inside the vertebrae. Probe-handling conditions were varied by changing the amount of pressure exerted on the probe within the vertebrae. Continuous spectra were recorded as the probe was placed in the center of the vertebral body while the porcine specimen was sacrificed via a lethal injection. Results A typical insertion of the fiber-optic K-wire showed a drop in fat fraction during an anterior breach as the probe transitioned from cancellous to cortical bone. Fat fraction measurements were found to be similar irrespective of the amount of pressure exerted on the probe (p = 0.65). The 95% confidence interval of fat fraction determination was found in the narrow range of 1.5–3.6% under various probe-handling conditions. The fat fraction measurements remained stable during 70 min of decreased blood flow after the animal was sacrificed. Discussions These findings indicate that changes in tissue perfusion and probe-handling conditions have a relatively low measureable effect on the DRS signal quality and thereby on the determination of fat fraction as a breach detection signal. Conclusions Fat fraction quantification for intraoperative pedicle screw breach detection is reliable, irrespective of changes in tissue perfusion and probe-handling conditions.
Collapse
|
105
|
Dennler C, Jaberg L, Spirig J, Agten C, Götschi T, Fürnstahl P, Farshad M. Augmented reality-based navigation increases precision of pedicle screw insertion. J Orthop Surg Res 2020; 15:174. [PMID: 32410636 PMCID: PMC7227090 DOI: 10.1186/s13018-020-01690-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background Precise insertion of pedicle screws is important to avoid injury to closely adjacent neurovascular structures. The standard method for the insertion of pedicle screws is based on anatomical landmarks (free-hand technique). Head-mounted augmented reality (AR) devices can be used to guide instrumentation and implant placement in spinal surgery. This study evaluates the feasibility and precision of AR technology to improve precision of pedicle screw insertion compared to the current standard technique. Methods Two board-certified orthopedic surgeons specialized in spine surgery and two novice surgeons were each instructed to drill pilot holes for 40 pedicle screws in eighty lumbar vertebra sawbones models in an agar-based gel. One hundred and sixty pedicles were randomized into two groups: the standard free-hand technique (FH) and augmented reality technique (AR). A 3D model of the vertebral body was superimposed over the AR headset. Half of the pedicles were drilled using the FH method, and the other half using the AR method. Results The average minimal distance of the drill axis to the pedicle wall (MAPW) was similar in both groups for expert surgeons (FH 4.8 ± 1.0 mm vs. AR 5.0 ± 1.4 mm, p = 0.389) but for novice surgeons (FH 3.4 mm ± 1.8 mm, AR 4.2 ± 1.8 mm, p = 0.044). Expert surgeons showed 0 primary drill pedicle perforations (PDPP) in both the FH and AR groups. Novices showed 3 (7.5%) PDPP in the FH group and one perforation (2.5%) in the AR group, respectively (p > 0.005). Experts showed no statistically significant difference in average secondary screw pedicle perforations (SSPP) between the AR and the FH set 6-, 7-, and 8-mm screws (p > 0.05). Novices showed significant differences of SSPP between most groups: 6-mm screws, 18 (45%) vs. 7 (17.5%), p = 0.006; 7-mm screws, 20 (50%) vs. 10 (25%), p = 0.013; and 8-mm screws, 22 (55%) vs. 15 (37.5%), p = 0.053, in the FH and AR group, respectively. In novices, the average optimal medio-lateral convergent angle (oMLCA) was 3.23° (STD 4.90) and 0.62° (STD 4.56) for the FH and AR set screws (p = 0.017), respectively. Novices drilled with a higher precision with respect to the cranio-caudal inclination angle (CCIA) category (p = 0.04) with AR. Conclusion In this study, the additional anatomical information provided by the AR headset superimposed to real-world anatomy improved the precision of drilling pilot holes for pedicle screws in a laboratory setting and decreases the effect of surgeon’s experience. Further technical development and validations studies are currently being performed to investigate potential clinical benefits of the herein described AR-based navigation approach.
Collapse
Affiliation(s)
- Cyrill Dennler
- Spine Division, University Hospital Balgrist, University of Zürich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Laurenz Jaberg
- Spine Division, University Hospital Balgrist, University of Zürich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - José Spirig
- Spine Division, University Hospital Balgrist, University of Zürich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Christoph Agten
- Department of Radiology, University Hospital Balgrist, University of Zürich, Zurich, Switzerland
| | - Tobias Götschi
- Laboratory for Biomechanics, University Hospital Balgrist, University of Zürich, Zurich, Switzerland
| | - Philipp Fürnstahl
- Computer Assisted Research and Development Group, University Hospital Balgrist, University of Zürich, Zurich, Switzerland
| | - Mazda Farshad
- Spine Division, University Hospital Balgrist, University of Zürich, Forchstrasse 340, 8008, Zurich, Switzerland
| |
Collapse
|
106
|
Balicki M, Kyne S, Toporek G, Holthuizen R, Homan R, Popovic A, Burström G, Persson O, Edström E, Elmi-Terander A, Patriciu A. Design and control of an image-guided robot for spine surgery in a hybrid OR. Int J Med Robot 2020; 16:e2108. [PMID: 32270913 DOI: 10.1002/rcs.2108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/17/2020] [Accepted: 03/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Minimally invasive spine (MIS) fusion surgery requires image guidance and expert manual dexterity for a successful, efficient, and accurate pedicle screw placement. Operating room (OR)-integrated robotic solution can provide precise assistance to potentially minimize complication rates and facilitate difficult MIS procedures. METHODS A 5-degrees of freedom robot was designed specifically for a hybrid OR with integrated surgical navigation for guiding pedicle screw pilot holes. The system automatically aligns an instrument following the surgical plan using only instrument tracking feedback. Contrary to commercially available robotic systems, no tracking markers on the robotic arm are required. The system was evaluated in a cadaver study. RESULTS The mean targeting error (N = 34) was 1.27±0.57 mm and 1.62±0.85°, with 100% of insertions graded as clinically acceptable. CONCLUSIONS A fully integrated robotic guidance system, including intra-op imaging, planning, and physical guidance with optimized robot design and control, can improve workflow and provide pedicle screw guidance with less than 2 mm targeting error.
Collapse
Affiliation(s)
- Marcin Balicki
- Philips Research North America, Cambridge, Massachusetts, USA
| | - Sean Kyne
- Philips Research North America, Cambridge, Massachusetts, USA
| | | | | | | | | | - Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Oscar Persson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | | |
Collapse
|
107
|
Burström G, Balicki M, Patriciu A, Kyne S, Popovic A, Holthuizen R, Homan R, Skulason H, Persson O, Edström E, Elmi-Terander A. Feasibility and accuracy of a robotic guidance system for navigated spine surgery in a hybrid operating room: a cadaver study. Sci Rep 2020; 10:7522. [PMID: 32371880 PMCID: PMC7200720 DOI: 10.1038/s41598-020-64462-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 04/15/2020] [Indexed: 12/11/2022] Open
Abstract
The combination of navigation and robotics in spine surgery has the potential to accurately identify and maintain bone entry position and planned trajectory. The goal of this study was to examine the feasibility, accuracy and efficacy of a new robot-guided system for semi-automated, minimally invasive, pedicle screw placement. A custom robotic arm was integrated into a hybrid operating room (OR) equipped with an augmented reality surgical navigation system (ARSN). The robot was mounted on the OR-table and used to assist in placing Jamshidi needles in 113 pedicles in four cadavers. The ARSN system was used for planning screw paths and directing the robot. The robot arm autonomously aligned with the planned screw trajectory, and the surgeon inserted the Jamshidi needle into the pedicle. Accuracy measurements were performed on verification cone beam computed tomographies with the planned paths superimposed. To provide a clinical grading according to the Gertzbein scale, pedicle screw diameters were simulated on the placed Jamshidi needles. A technical accuracy at bone entry point of 0.48 ± 0.44 mm and 0.68 ± 0.58 mm was achieved in the axial and sagittal views, respectively. The corresponding angular errors were 0.94 ± 0.83° and 0.87 ± 0.82°. The accuracy was statistically superior (p < 0.001) to ARSN without robotic assistance. Simulated pedicle screw grading resulted in a clinical accuracy of 100%. This study demonstrates that the use of a semi-automated surgical robot for pedicle screw placement provides an accuracy well above what is clinically acceptable.
Collapse
Affiliation(s)
- Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
| | | | | | - Sean Kyne
- Philips Research North America, Cambridge, USA
| | | | - Ronald Holthuizen
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, the Netherlands
| | - Robert Homan
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, the Netherlands
| | - Halldor Skulason
- Department of Neurosurgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Oscar Persson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
108
|
Rezaii PG, Pendharkar AV, Ho AL, Sussman ES, Veeravagu A, Ratliff JK, Desai AM. Conventional versus stereotactic image guided pedicle screw placement during spinal deformity correction: a retrospective propensity score-matched study of a national longitudinal database. Int J Neurosci 2020; 131:953-961. [PMID: 32364414 DOI: 10.1080/00207454.2020.1763343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE/AIM To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity. METHODS The Thomson Reuters MarketScan national longitudinal database was used to identify patients undergoing osteotomy, posterior instrumentation, and fusion for treatment of spinal deformity with or without image-guided navigation between 2007-2016. Conventional and navigated groups were propensity-matched (1:1) to normalize differences between demographics, comorbidities, and surgical characteristics. Clinical outcomes and charges were compared between matched groups using bivariate analyses. RESULTS A total of 4,604 patients were identified as having undergone deformity correction, of which 286 (6.2%) were navigated. Propensity-matching resulted in a total of 572 well-matched patients for subsequent analyses, of which half were navigated. Rate of mechanical instrumentation-related complications was found to be significantly lower for navigated procedures (p = 0.0371). Navigation was also associated with lower rates of 90-day unplanned readmissions (p = 0.0295), as well as 30- and 90-day postoperative revisions (30-day: p = 0.0304, 90-day: p = 0.0059). Hospital, physician, and total payments favored the conventional group for initial admission (p = 0.0481, 0.0001, 0.0019, respectively); however, when taking into account costs of readmissions, hospital payments became insignificantly different between the two groups. CONCLUSIONS Procedures involving image-guided navigation resulted in decreased instrumentation-related complications, unplanned readmissions, and postoperative revisions, highlighting its potential utility for the treatment of spine deformity. Future advances in navigation technologies and methodologies can continue to improve clinical outcomes, decrease costs, and facilitate widespread adoption of navigation for deformity correction.
Collapse
Affiliation(s)
- Paymon G Rezaii
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | | | - Allen L Ho
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Atman M Desai
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| |
Collapse
|
109
|
McDonnell JM, Ahern DP, Ó Doinn T, Gibbons D, Rodrigues KN, Birch N, Butler JS. Surgeon proficiency in robot-assisted spine surgery. Bone Joint J 2020; 102-B:568-572. [DOI: 10.1302/0301-620x.102b5.bjj-2019-1392.r2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article: Bone Joint J 2020;102-B(5):568–572.
Collapse
Affiliation(s)
| | - Daniel P. Ahern
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Tiarnan Ó Doinn
- National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Denys Gibbons
- School of Medicine, Trinity College Dublin, Dublin, Ireland, National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Nick Birch
- The Chris Moody Rehabilitation and Sports Injury Centre, Northampton, UK
| | - Joseph S. Butler
- National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| |
Collapse
|
110
|
Hu MH, Chiang CC, Wang ML, Wu NY, Lee PY. Clinical feasibility of the augmented reality computer-assisted spine surgery system for percutaneous vertebroplasty. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1590-1596. [DOI: 10.1007/s00586-020-06417-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/16/2020] [Accepted: 04/11/2020] [Indexed: 12/15/2022]
|
111
|
Peh S, Chatterjea A, Pfarr J, Schäfer JP, Weuster M, Klüter T, Seekamp A, Lippross S. Accuracy of augmented reality surgical navigation for minimally invasive pedicle screw insertion in the thoracic and lumbar spine with a new tracking device. Spine J 2020; 20:629-637. [PMID: 31863933 DOI: 10.1016/j.spinee.2019.12.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive approaches are increasingly used in spine surgery. The purpose of navigation systems is to guide the surgeon and to reduce intraoperative x-ray exposure. PURPOSE This study aimed to determine the feasibility and clinical accuracy of a navigation technology based on augmented reality surgical navigation (ARSN) for minimally invasive thoracic and lumbar pedicle screw instrumentation compared with standard fluoroscopy-guided minimally invasive technique. STUDY DESIGN/SETTING Cadaveric laboratory study. METHODS ARSN was installed in a hybrid operating room, consisting of a flat panel detector c-arm with two dimensional/three dimensional imaging capabilities and four integrated cameras in its frame. The surface-referenced navigation device does not require a bony reference but uses video cameras and optical markers applied to the patient's skin for tracking. In four cadavers, a total of 136 pedicle screws were inserted in thoracic and lumbar vertebrae. The accuracy was assessed by three independent raters in postoperative conventional computed tomography. RESULTS The overall accuracy of ARSN was 94% compared with an accuracy of 88% for fluoroscopy. The difference was not statistically significant. In the thoracic region, accuracy with ARSN was 92% compared with 83% with fluoroscopy. With fluoroscopy, unsafe screws were observed in three normal cadavers and one with scoliosis. Using ARSN, unsafe screws were only observed in the scoliotic spine. No significant difference in the median of time for K-wire placement was recorded. As no intraoperative fluoroscopy was necessary in ARSN, the performing surgeon was not exposed to radiation. CONCLUSIONS In this limited cadaveric study minimally invasive screw placement using ARSN was demonstrated to be feasible and as accurate as fluoroscopy. It did not require any additional navigation time or use of any intraoperative x-ray imaging, thereby potentially permitting surgery in a protective lead garment-free environment. A well-powered clinical study is needed to demonstrate a significant difference in the accuracy between the two methods. CLINICAL SIGNIFICANCE ARSN offers real-time imaging of planned insertion paths, instrument tracking, and overlay of three dimensional bony anatomy and surface topography. The referencing procedure, by optical recognition of several skin markers is easy and does not require a solid bony reference as necessary for conventional navigation which saves time. Additionally, ARSN may foster the reduction of intraoperative x-ray exposure to spinal surgeons.
Collapse
Affiliation(s)
- Simon Peh
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany.
| | - Anindita Chatterjea
- Image Guided Therapy Systems, Philips Healthcare, Veenpluis 4-6, 5684 PC, Best, the Netherlands
| | - Julian Pfarr
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Jost Philipp Schäfer
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Matthias Weuster
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Tim Klüter
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Andreas Seekamp
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Sebastian Lippross
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| |
Collapse
|
112
|
Hussain I, Cosar M, Kirnaz S, Schmidt FA, Wipplinger C, Wong T, Härtl R. Evolving Navigation, Robotics, and Augmented Reality in Minimally Invasive Spine Surgery. Global Spine J 2020; 10:22S-33S. [PMID: 32528803 PMCID: PMC7263339 DOI: 10.1177/2192568220907896] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Innovative technology and techniques have revolutionized minimally invasive spine surgery (MIS) within the past decade. The introduction of navigation and image-guided surgery has greatly affected spinal surgery and will continue to make surgery safer and more efficient. Eventually, it is conceivable that fluoroscopy will be completely replaced with image guidance. These advancements, among others such as robotics and virtual and augmented reality technology, will continue to drive the value of 3-dimensional navigation in MIS. In this review, we cover pertinent features of navigation in MIS and explore their evolution over time. Moreover, we aim to discuss the key features germane to surgical advancement, including technique and technology development, accuracy, overall health care costs, operating room time efficiency, and radiation exposure.
Collapse
Affiliation(s)
- Ibrahim Hussain
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
- Ibrahim Hussain and Murat Cosar are equal contributors to this study
| | - Murat Cosar
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
- Ibrahim Hussain and Murat Cosar are equal contributors to this study
| | - Sertac Kirnaz
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Franziska A. Schmidt
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Christoph Wipplinger
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Taylor Wong
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Roger Härtl
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
113
|
Rychen J, Goldberg J, Raabe A, Bervini D. Augmented Reality in Superficial Temporal Artery to Middle Cerebral Artery Bypass Surgery: Technical Note. Oper Neurosurg (Hagerstown) 2020; 18:444-450. [PMID: 31232435 DOI: 10.1093/ons/opz176] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/06/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Augmented reality (AR) applied to surgery refers to the virtual superimposition of computer-generated anatomical information on the surgical field. AR assistance in extracranial-intracranial (EC-IC) bypass revascularization surgery has been reported to be a helpful technical adjunct. OBJECTIVE To describe our experience of using AR in superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery with the additional implementation of new technical processes to improve the safety and efficacy of the procedure. METHODS Data sets from preoperative imaging were loaded and fused in a single 3-dimensional matrix using the neuronavigation system. Anatomical structures of interest (the STA, a selected M4 branch of the MCA, the middle meningeal artery [MMA], and the primary motor cortex [PMC]) were segmented. After the registration of the patient and the operating microscope, the structures of interest were projected into the eyepiece of the microscope and superimposed onto the patient's head, creating the AR surgical field. RESULTS AR was shown to be useful in patients undergoing EC-IC bypass revascularization, mostly during the following 4 surgical steps: (1) microsurgical dissection of the donor vessel (STA); (2) tailoring the craniotomy above the recipient vessel (M4 branch of the MCA); (3) tailoring the craniotomy to spare the MMA; and (4) tailoring the craniotomy and the anastomosis to spare the PMC. CONCLUSION AR assistance in EC-IC bypass revascularization is a versatile technical adjunct for helping surgeons to ensure the safety and efficacy of the procedure.
Collapse
Affiliation(s)
- Jonathan Rychen
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| |
Collapse
|
114
|
Abstract
STUDY DESIGN A prospective, case-based, observational study. OBJECTIVES To investigate how microscope-based augmented reality (AR) support can be utilized in various types of spine surgery. METHODS In 42 spinal procedures (12 intra- and 8 extradural tumors, 7 other intradural lesions, 11 degenerative cases, 2 infections, and 2 deformities) AR was implemented using operating microscope head-up displays (HUDs). Intraoperative low-dose computed tomography was used for automatic registration. Nonlinear image registration was applied to integrate multimodality preoperative images. Target and risk structures displayed by AR were defined in preoperative images by automatic anatomical mapping and additional manual segmentation. RESULTS AR could be successfully applied in all 42 cases. Low-dose protocols ensured a low radiation exposure for registration scanning (effective dose cervical 0.29 ± 0.17 mSv, thoracic 3.40 ± 2.38 mSv, lumbar 3.05 ± 0.89 mSv). A low registration error (0.87 ± 0.28 mm) resulted in a reliable AR representation with a close matching of visualized objects and reality, distinctly supporting anatomical orientation in the surgical field. Flexible AR visualization applying either the microscope HUD or video superimposition, including the ability to selectively activate objects of interest, as well as different display modes allowed a smooth integration in the surgical workflow, without disturbing the actual procedure. On average, 7.1 ± 4.6 objects were displayed visualizing target and risk structures reliably. CONCLUSIONS Microscope-based AR can be applied successfully to various kinds of spinal procedures. AR improves anatomical orientation in the surgical field supporting the surgeon, as well as it offers a potential tool for education.
Collapse
Affiliation(s)
- Barbara Carl
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | - Miriam Bopp
- Department of Neurosurgery, University Marburg, Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | - Benjamin Saß
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | - Mirza Pojskic
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | | | - Christopher Nimsky
- Department of Neurosurgery, University Marburg, Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| |
Collapse
|
115
|
Vadalà G, De Salvatore S, Ambrosio L, Russo F, Papalia R, Denaro V. Robotic Spine Surgery and Augmented Reality Systems: A State of the Art. Neurospine 2020; 17:88-100. [PMID: 32252158 PMCID: PMC7136092 DOI: 10.14245/ns.2040060.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 02/24/2020] [Indexed: 12/26/2022] Open
Abstract
Instrumented spine procedures have been performed for decades to treat a wide variety of spinal disorders. New technologies have been employed to obtain a high degree of precision, to minimize risks of damage to neurovascular structures and to diminish harmful exposure of patients and the operative team to ionizing radiations. Robotic spine surgery comprehends 3 major categories: telesurgical robotic systems, robotic-assisted navigation (RAN) and virtual augmented reality (AR) systems, including AR and virtual reality. Telesurgical systems encompass devices that can be operated from a remote command station, allowing to perform surgery via instruments being manipulated by the robot. On the other hand, RAN technologies are characterized by the robotic guidance of surgeon-operated instruments based on real-time imaging. Virtual AR systems are able to show images directly on special visors and screens allowing the surgeon to visualize information about the patient and the procedure (i.e., anatomical landmarks, screw direction and inclination, distance from neurological and vascular structures etc.). The aim of this review is to focus on the current state of the art of robotics and AR in spine surgery and perspectives of these emerging technologies that hold promises for future applications.
Collapse
Affiliation(s)
- Gianluca Vadalà
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sergio De Salvatore
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Luca Ambrosio
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Fabrizio Russo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| |
Collapse
|
116
|
Jud L, Fotouhi J, Andronic O, Aichmair A, Osgood G, Navab N, Farshad M. Applicability of augmented reality in orthopedic surgery - A systematic review. BMC Musculoskelet Disord 2020; 21:103. [PMID: 32061248 PMCID: PMC7023780 DOI: 10.1186/s12891-020-3110-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/03/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Computer-assisted solutions are changing surgical practice continuously. One of the most disruptive technologies among the computer-integrated surgical techniques is Augmented Reality (AR). While Augmented Reality is increasingly used in several medical specialties, its potential benefit in orthopedic surgery is not yet clear. The purpose of this article is to provide a systematic review of the current state of knowledge and the applicability of AR in orthopedic surgery. METHODS A systematic review of the current literature was performed to find the state of knowledge and applicability of AR in Orthopedic surgery. A systematic search of the following three databases was performed: "PubMed", "Cochrane Library" and "Web of Science". The systematic review followed the Preferred Reporting Items on Systematic Reviews and Meta-analysis (PRISMA) guidelines and it has been published and registered in the international prospective register of systematic reviews (PROSPERO). RESULTS 31 studies and reports are included and classified into the following categories: Instrument / Implant Placement, Osteotomies, Tumor Surgery, Trauma, and Surgical Training and Education. Quality assessment could be performed in 18 studies. Among the clinical studies, there were six case series with an average score of 90% and one case report, which scored 81% according to the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC). The 11 cadaveric studies scored 81% according to the QUACS scale (Quality Appraisal for Cadaveric Studies). CONCLUSION This manuscript provides 1) a summary of the current state of knowledge and research of Augmented Reality in orthopedic surgery presented in the literature, and 2) a discussion by the authors presenting the key remarks required for seamless integration of Augmented Reality in the future surgical practice. TRIAL REGISTRATION PROSPERO registration number: CRD42019128569.
Collapse
Affiliation(s)
- Lukas Jud
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Javad Fotouhi
- Computer Aided Medical Procedure, Johns Hopkins University, 3400 N Charles Street, Baltimore, 21210 USA
| | - Octavian Andronic
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Alexander Aichmair
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Greg Osgood
- Johns Hopkins Hospital, Department of Orthopedics Surgery, 1800 Orleans Street, Baltimore, 21287 USA
| | - Nassir Navab
- Computer Aided Medical Procedure, Johns Hopkins University, 3400 N Charles Street, Baltimore, 21210 USA
- Computer Aided Medical Procedure, Technical University of Munich, Boltzmannstrasse 3, 85748 Munich, Germany
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland
| |
Collapse
|
117
|
Elmi-Terander A, Burström G, Nachabé R, Fagerlund M, Ståhl F, Charalampidis A, Edström E, Gerdhem P. Augmented reality navigation with intraoperative 3D imaging vs fluoroscopy-assisted free-hand surgery for spine fixation surgery: a matched-control study comparing accuracy. Sci Rep 2020; 10:707. [PMID: 31959895 PMCID: PMC6971085 DOI: 10.1038/s41598-020-57693-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/09/2019] [Indexed: 02/06/2023] Open
Abstract
This study aimed to compare screw placement accuracy and clinical aspects between Augmented Reality Surgical Navigation (ARSN) and free-hand (FH) technique. Twenty patients underwent spine surgery with screw placement using ARSN and were matched retrospectively to a cohort of 20 FH technique cases for comparison. All ARSN and FH cases were performed by the same surgeon. Matching was based on clinical diagnosis and similar proportions of screws placed in the thoracic and lumbosacral vertebrae in both groups. Accuracy of screw placement was assessed on postoperative scans according to the Gertzbein scale and grades 0 and 1 were considered accurate. Procedure time, blood loss and length of hospital stay, were collected as secondary endpoints. A total of 262 and 288 screws were assessed in the ARSN and FH groups, respectively. The share of clinically accurate screws was significantly higher in the ARSN vs FH group (93.9% vs 89.6%, p < 0.05). The proportion of screws placed without a cortical breach was twice as high in the ARSN group compared to the FH group (63.4% vs 30.6%, p < 0.0001). No statistical difference was observed for the secondary endpoints between both groups. This matched-control study demonstrated that ARSN provided higher screw placement accuracy compared to free-hand.
Collapse
Affiliation(s)
- Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rami Nachabé
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, the Netherlands.
| | - Michael Fagerlund
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Ståhl
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Anastasios Charalampidis
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Orthopedics, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Paul Gerdhem
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Orthopedics, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
118
|
Fusion of augmented reality imaging with the endoscopic view for endonasal skull base surgery; a novel application for surgical navigation based on intraoperative cone beam computed tomography and optical tracking. PLoS One 2020; 15:e0227312. [PMID: 31945082 PMCID: PMC6964902 DOI: 10.1371/journal.pone.0227312] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 12/16/2019] [Indexed: 01/11/2023] Open
Abstract
Objective Surgical navigation is a well-established tool in endoscopic skull base surgery. However, navigational and endoscopic views are usually displayed on separate monitors, forcing the surgeon to focus on one or the other. Aiming to provide real-time integration of endoscopic and diagnostic imaging information, we present a new navigation technique based on augmented reality with fusion of intraoperative cone beam computed tomography (CBCT) on the endoscopic view. The aim of this study was to evaluate the accuracy of the method. Material and methods An augmented reality surgical navigation system (ARSN) with 3D CBCT capability was used. The navigation system incorporates an optical tracking system (OTS) with four video cameras embedded in the flat detector of the motorized C-arm. Intra-operative CBCT images were fused with the view of the surgical field obtained by the endoscope’s camera. Accuracy of CBCT image co-registration was tested using a custom-made grid with incorporated 3D spheres. Results Co-registration of the CBCT image on the endoscopic view was performed. Accuracy of the overlay, measured as mean target registration error (TRE), was 0.55 mm with a standard deviation of 0.24 mm and with a median value of 0.51mm and interquartile range of 0.39˗˗0.68 mm. Conclusion We present a novel augmented reality surgical navigation system, with fusion of intraoperative CBCT on the endoscopic view. The system shows sub-millimeter accuracy.
Collapse
|
119
|
Lohre R, Wang JC, Lewandrowski KU, Goel DP. Virtual reality in spinal endoscopy: a paradigm shift in education to support spine surgeons. JOURNAL OF SPINE SURGERY 2020; 6:S208-S223. [PMID: 32195429 DOI: 10.21037/jss.2019.11.16] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Minimally invasive spine surgery (MISS) and endoscopic spine surgery have continually evolving indications in the cervical, thoracic, and lumbar spine. Endoscopic spine surgery entails treatment of disc disease, stenosis, spondylolisthesis, radiculopathy, and deformity. MISS involves complex motor skills in regions of variable anatomy. Simulator use has been proposed to aid in training and skill retention, preoperative planning, and intraoperative use. Methods A systematic review of five databases was performed for publications pertaining to the use of virtual (VR), augmented (AR), and mixed (MR) reality in MISS and spinal endoscopic surgery. Qualitative data analysis was undertaken with focus of study design, quality, and reported outcomes. Study quality was assessed using the Medical Education Research Quality Instrument (MERSQI) score and level of evidence (LoE) by a modified Oxford Centre for Evidence-Based Medicine (OCEBM) level for simulation in medicine. Results Thirty-eight studies were retained for data collection. Studies were of intervention-control, clinical application, and pilot or cross-sectional design. Identified articles illustrated use of VR, AR, and MR in all study designs. Procedures included pedicle cannulation and screw insertion, vertebroplasty, kyphoplasty, percutaneous transforaminal endoscopic discectomy (PTED), lumbar puncture and facet injection, transvertebral anterior cervical foraminotomy (TVACF) and posterior cervical laminoforaminotomy. Overall MERSQI score was low-to-medium [M =9.71 (SD =2.60); range, 4.5-13.5], and LoE was predominantly low given the number of purely descriptive articles, or low-quality randomized studies. Conclusions The current scope of VR, AR, and MR surgical simulators in MISS and spinal endoscopic surgery was described. Studies demonstrate improvement in technical skill and patient outcomes in short term follow-up. Despite this, overall study quality and levels of evidence remain low. Cohesive study design and reporting with focus on transfer validity in training scenarios, and patient derived outcome measures in clinical studies are required to further advance the field.
Collapse
Affiliation(s)
- Ryan Lohre
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, USA
| | - Jeffrey C Wang
- USC Spine Center, Keck School of Medicine at University of Southern California, Los Angeles, USA
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson, AZ, USA.,Department of Neurosurgery, UNIRIO, Rio de Janeiro, Brazil
| | - Danny P Goel
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
120
|
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE To assess staff and patient radiation exposure during augmented reality surgical navigation in spine surgery. SUMMARY OF BACKGROUND DATA Surgical navigation in combination with intraoperative three-dimensional imaging has been shown to significantly increase the clinical accuracy of pedicle screw placement. Although this technique may increase the total radiation exposure compared with fluoroscopy, the occupational exposure can be minimized, as navigation is radiation free and staff can be positioned behind protective shielding during three-dimensional imaging. The patient radiation exposure during treatment and verification of pedicle screw positions can also be reduced. METHODS Twenty patients undergoing spine surgery with pedicle screw placement were included in the study. The staff radiation exposure was measured using real-time active personnel dosimeters and was further compared with measurements using a reference dosimeter attached to the C-arm (i.e., a worst-case staff exposure situation). The patient radiation exposures were recorded, and effective doses (ED) were determined. RESULTS The average staff exposure per procedure was 0.21 ± 0.06 μSv. The average staff-to-reference dose ratio per procedure was 0.05% and decreased to less than 0.01% after a few procedures had been performed. The average patient ED was 15.8 ± 1.8 mSv which mainly correlated with the number of vertebrae treated and the number of cone-beam computed tomography acquisitions performed. A low-dose protocol used for the final 10 procedures yielded a 32% ED reduction per spinal level treated. CONCLUSION This study demonstrated significantly lower occupational doses compared with values reported in the literature. Real-time active personnel dosimeters contributed to a fast optimization and adoption of protective measures throughout the study. Even though our data include both cone-beam computed tomography for navigation planning and intraoperative screw placement verification, we find low patient radiation exposure levels compared with published data. LEVEL OF EVIDENCE 3.
Collapse
|
121
|
Samuel N, Berger M. Cultural evolution: a Darwinian perspective on patient safety in neurosurgery. J Neurosurg 2019; 131:1985-1991. [PMID: 31518982 DOI: 10.3171/2019.6.jns191517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nardin Samuel
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada; and
| | - Mitchel Berger
- 2Department of Neurological Surgery, University of California, San Francisco, California
| |
Collapse
|
122
|
Laverdière C, Corban J, Khoury J, Ge SM, Schupbach J, Harvey EJ, Reindl R, Martineau PA. Augmented reality in orthopaedics. Bone Joint J 2019; 101-B:1479-1488. [DOI: 10.1302/0301-620x.101b12.bjj-2019-0315.r1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aims Computer-based applications are increasingly being used by orthopaedic surgeons in their clinical practice. With the integration of technology in surgery, augmented reality (AR) may become an important tool for surgeons in the future. By superimposing a digital image on a user’s view of the physical world, this technology shows great promise in orthopaedics. The aim of this review is to investigate the current and potential uses of AR in orthopaedics. Materials and Methods A systematic review of the PubMed, MEDLINE, and Embase databases up to January 2019 using the keywords ‘orthopaedic’ OR ‘orthopedic AND augmented reality’ was performed by two independent reviewers. Results A total of 41 publications were included after screening. Applications were divided by subspecialty: spine (n = 15), trauma (n = 16), arthroplasty (n = 3), oncology (n = 3), and sports (n = 4). Out of these, 12 were clinical in nature. AR-based technologies have a wide variety of applications, including direct visualization of radiological images by overlaying them on the patient and intraoperative guidance using preoperative plans projected onto real anatomy, enabling hands-free real-time access to operating room resources, and promoting telemedicine and education. Conclusion There is an increasing interest in AR among orthopaedic surgeons. Although studies show similar or better outcomes with AR compared with traditional techniques, many challenges need to be addressed before this technology is ready for widespread use. Cite this article: Bone Joint J 2019;101-B:1479–1488
Collapse
Affiliation(s)
- Carl Laverdière
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Jason Corban
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Jason Khoury
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Susan Mengxiao Ge
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Justin Schupbach
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Edward J. Harvey
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Rudy Reindl
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Paul A. Martineau
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| |
Collapse
|
123
|
Burström G, Swamy A, Spliethoff JW, Reich C, Babic D, Hendriks BHW, Skulason H, Persson O, Elmi Terander A, Edström E. Diffuse reflectance spectroscopy accurately identifies the pre-cortical zone to avoid impending pedicle screw breach in spinal fixation surgery. BIOMEDICAL OPTICS EXPRESS 2019; 10:5905-5920. [PMID: 31799054 PMCID: PMC6865097 DOI: 10.1364/boe.10.005905] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/09/2019] [Accepted: 10/09/2019] [Indexed: 05/03/2023]
Abstract
Pedicle screw placement accuracy during spinal fixation surgery varies greatly and severe misplacement has been reported in 1-6.5% of screws. Diffuse reflectance (DR) spectroscopy has previously been shown to reliably discriminate between tissues in the human body. We postulate that it could be used to discriminate between cancellous and cortical bone. Therefore, the purpose of this study is to validate DR spectroscopy as a warning system to detect impending pedicle screw breach in a cadaveric surgical setting using typical clinical breach scenarios. DR spectroscopy was incorporated at the tip of an integrated pedicle screw and screw driver used for tissue probing during pedicle screw insertions on six cadavers. Measurements were collected in the wavelength range of 400-1600 nm and each insertion was planned to result in a breach. Measurements were labelled as cancellous, cortical or representing a pre-cortical zone (PCZ) in between, based on information from cone beam computed tomographies at corresponding positions. In addition, DR spectroscopy data was recorded after breach. Four typical pedicle breach types were performed, and a total of 45 pedicle breaches were recorded. For each breach direction, the technology was able to detect the transition of the screw tip from the cancellous bone to the PCZ (P < 0.001), to cortical bone (P < 0.001), and to a subsequent breach (P < 0.001). Using support vector machine (SVM) classification, breach could reliably be detected with a sensitivity of 98.3 % [94.3-100 %] and a specificity of 97.7 % [91.0-100 %]. We conclude that DR spectroscopy reliably identifies the area of transition from cancellous to cortical bone in typical breach scenarios and can warn the surgeon of impending pedicle breach, thereby resulting in safer spinal fixation surgeries.
Collapse
Affiliation(s)
- Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Akash Swamy
- Delft University of Technology, Department of Biomechanical Engineering, Delft, The Netherlands
- Department of In-body Systems, Philips Research, Royal Philips NV, Eindhoven, The Netherlands
| | - Jarich W. Spliethoff
- Department of In-body Systems, Philips Research, Royal Philips NV, Eindhoven, The Netherlands
| | - Christian Reich
- Department of In-body Systems, Philips Research, Royal Philips NV, Eindhoven, The Netherlands
| | - Drazenko Babic
- Department of In-body Systems, Philips Research, Royal Philips NV, Eindhoven, The Netherlands
| | - Benno H. W. Hendriks
- Delft University of Technology, Department of Biomechanical Engineering, Delft, The Netherlands
- Department of In-body Systems, Philips Research, Royal Philips NV, Eindhoven, The Netherlands
| | - Halldor Skulason
- Department of Neurosurgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Oscar Persson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
124
|
Carl B, Bopp M, Saß B, Pojskic M, Nimsky C. Augmented reality in intradural spinal tumor surgery. Acta Neurochir (Wien) 2019; 161:2181-2193. [PMID: 31300886 DOI: 10.1007/s00701-019-04005-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/05/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Microscope-based augmented reality (AR) is commonly used in cranial surgery; however, until recently, this technique was not implemented for spinal surgery. We prospectively investigated, how AR can be applied for intradural spinal tumor surgery. METHODS For ten patients with intradural spinal tumors (ependymoma, glioma, hemangioblastoma, meningioma, and metastasis), AR was provided by head-up displays (HUDs) of operating microscopes. User-independent automatic AR registration was established by low-dose intraoperative computed tomography. The objects visualized by AR were segmented in preoperative imaging data; non-linear image registration was applied to consider spine flexibility. RESULTS In all cases, AR supported surgery by visualizing the tumor outline and other relevant surrounding structures. The overall AR registration error was 0.72 ± 0.24 mm (mean ± standard deviation), a close matching of visible tumor outline and AR visualization was observed for all cases. Registration scanning resulted in a low effective dose of 0.22 ± 0.16 mSv for cervical and 1.68 ± 0.61 mSv for thoracic lesions. The mean HUD AR usage in relation to microscope time was 51.6 ± 36.7%. The HUD was switched off and turned on again in a range of 2 to 17 times (5.7 ± 4.4 times). Independent of the status of the HUD, the AR visualization was displayed on monitors throughout surgery. CONCLUSIONS Microscope-based AR can be reliably applied to intradural spinal tumor surgery. Automatic AR registration ensures high precision and provides an intuitive visualization of the extent of the tumor and surrounding structures. Given this setting, all advanced multi-modality options of cranial AR can also be applied to spinal surgery.
Collapse
|
125
|
Satoh M, Nakajima T, Yamaguchi T, Watanabe E, Kawai K. Application of Augmented Reality to Stereotactic Biopsy. Neurol Med Chir (Tokyo) 2019; 59:444-447. [PMID: 31548442 PMCID: PMC6867933 DOI: 10.2176/nmc.tn.2019-0128] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Both frame-based stereotaxy and frameless stereotaxy are established surgical procedures. However, they each have their respective disadvantages when used in the biopsy of a deep-seated lesion. To overcome the drawbacks associated with these procedures, we evaluated the feasibility of applying augmented reality (AR) to stereotactic biopsy. We applied our trans-visible navigator (TVN) to frame-based stereotactic biopsy in five cases of deep-seated lesions. This navigation system uses the AR concept, allowing surgeons to view three-dimensional virtual models of anatomical structures superimposed over the surgical field on a tablet personal computer. Using TVN, we could easily confirm a clear trajectory avoiding the important structures as well as the target point’s location in the lesion. Use of the stereotactic apparatus allowed the surgeon to easily advance the biopsy probe to the target point. Consequently, a satisfactory histopathological diagnosis without complication was achieved in all cases. In conclusion, applying AR to stereotactic biopsy is feasible and may improve the safety of the procedure.
Collapse
Affiliation(s)
- Makoto Satoh
- Department of Neurosurgery, Jichi Medical University
| | | | | | - Eiju Watanabe
- Department of Neurosurgery, Jichi Medical University
| | - Kensuke Kawai
- Department of Neurosurgery, Jichi Medical University
| |
Collapse
|
126
|
Yoo JS, Patel DS, Hrynewycz NM, Brundage TS, Singh K. The utility of virtual reality and augmented reality in spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S171. [PMID: 31624737 DOI: 10.21037/atm.2019.06.38] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
As the number of advances in surgical techniques increases, it becomes increasingly important to assess and research the technology regarding spine surgery techniques in order to increase surgical accuracy, decrease overall length of surgery, and minimize overall radiation exposure. Currently, augmented reality and virtual reality have shown promising results in regard to their applicability beyond their current functions. At present, VR has been generally applied to a teaching and preparatory role, while AR has been utilized in surgical settings. As such, the following review attempts to provide an overview of both virtual reality and augmented reality, followed by a discussion of their current applications and future direction.
Collapse
Affiliation(s)
- Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Dillon S Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nadia M Hrynewycz
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Thomas S Brundage
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
127
|
Edström E, Burström G, Nachabe R, Gerdhem P, Elmi Terander A. A Novel Augmented-Reality-Based Surgical Navigation System for Spine Surgery in a Hybrid Operating Room: Design, Workflow, and Clinical Applications. Oper Neurosurg (Hagerstown) 2019; 18:496-502. [DOI: 10.1093/ons/opz236] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/31/2019] [Indexed: 12/29/2022] Open
Abstract
Abstract
BACKGROUND
Treatment of several spine disorders requires placement of pedicle screws. Detailed 3-dimensional (3D) anatomic information facilitates this process and improves accuracy.
OBJECTIVE
To present a workflow for a novel augmented-reality-based surgical navigation (ARSN) system installed in a hybrid operating room for anatomy visualization and instrument guidance during pedicle screw placement.
METHODS
The workflow includes surgical exposure, imaging, automatic creation of a 3D model, and pedicle screw path planning for instrument guidance during surgery as well as the actual screw placement, spinal fixation, and wound closure and intraoperative verification of the treatment results. Special focus was given to process integration and minimization of overhead time. Efforts were made to manage staff radiation exposure avoiding the need for lead aprons. Time was kept throughout the procedure and subdivided to reflect key steps. The navigation workflow was validated in a trial with 20 cases requiring pedicle screw placement (13/20 scoliosis).
RESULTS
Navigated interventions were performed with a median total time of 379 min per procedure (range 232-548 min for 4-24 implanted pedicle screws).
The total procedure time was subdivided into surgical exposure (28%), cone beam computed tomography imaging and 3D segmentation (2%), software planning (6%), navigated surgery for screw placement (17%) and non-navigated instrumentation, wound closure, etc (47%).
CONCLUSION
Intraoperative imaging and preparation for surgical navigation totaled 8% of the surgical time. Consequently, ARSN can routinely be used to perform highly accurate surgery potentially decreasing the risk for complications and revision surgery while minimizing radiation exposure to the staff.
Collapse
Affiliation(s)
- Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rami Nachabe
- Image-Guided Therapy, Philips Healthcare, Best, the Netherlands
| | - Paul Gerdhem
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
128
|
Sayadi LR, Naides A, Eng M, Fijany A, Chopan M, Sayadi JJ, Shaterian A, Banyard DA, Evans GRD, Vyas R, Widgerow AD. The New Frontier: A Review of Augmented Reality and Virtual Reality in Plastic Surgery. Aesthet Surg J 2019; 39:1007-1016. [PMID: 30753313 DOI: 10.1093/asj/sjz043] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/12/2019] [Accepted: 02/08/2019] [Indexed: 11/14/2022] Open
Abstract
Mixed reality, a blending of the physical and digital worlds, can enhance the surgical experience, leading to greater precision, efficiency, and improved outcomes. Various studies across different disciplines have reported encouraging results using mixed reality technologies, such as augmented and virtual reality. To provide a better understanding of the applications and limitations of this technology in plastic surgery, we performed a systematic review of the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The initial query of the National Center for Biotechnology Information database yielded 2544 results, and only 46 articles met our inclusion criteria. The majority of studies were in the field of craniofacial surgery, and uses of mixed reality included preoperative planning, intraoperative guides, and education of surgical trainees. A deeper understanding of mixed reality technologies may promote its integration and also help inspire new and creative applications in healthcare.
Collapse
Affiliation(s)
| | | | | | | | - Mustafa Chopan
- Resident, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, FL
| | | | | | | | | | | | - Alan D Widgerow
- Director of the UC Irvine Center for Tissue Engineering, UC Irvine Department of Plastic Surgery, Center for Tissue Engineering, Orange, CA
| |
Collapse
|
129
|
Augmented and Virtual Reality Instrument Tracking for Minimally Invasive Spine Surgery: A Feasibility and Accuracy Study. Spine (Phila Pa 1976) 2019; 44:1097-1104. [PMID: 30830046 DOI: 10.1097/brs.0000000000003006] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaveric animal laboratory study. OBJECTIVE To evaluate the feasibility and accuracy of pedicle cannulation using an augmented reality surgical navigation (ARSN) system with automatic instrument tracking, yielding feedback of instrument position in relation to deep anatomy. SUMMARY OF BACKGROUND DATA Minimally invasive spine surgery (MISS) has the possibility of reducing surgical exposure resulting in shorter hospital stays, lower blood loss and infection rates compared with open surgery but the drawback of limiting visual feedback to the surgeon regarding deep anatomy. MISS is mainly performed using image-guided 2D fluoroscopy, thus exposing the staff to ionizing radiation. METHODS A hybrid operating room (OR) equipped with a robotic C-arm with integrated optical cameras for augmented reality instrument navigation was used. In two pig cadavers, cone beam computed tomography (CBCT) scans were performed, a 3D model generated, and pedicle screw insertions were planned. Seventy-eight insertions were performed. Technical accuracy was assessed on post-insertion CBCTs by measuring the distance between the navigated device and the corresponding pre-planned path as well as the angular deviations. Drilling and hammering into the pedicle were also compared. Navigation time was measured. An independent reviewer assessed a simulated clinical accuracy according to Gertzbein. RESULTS The technical accuracy was 1.7 ± 1.0 mm at the bone entry point and 2.0 ± 1.3 mm at the device tip. The angular deviation was 1.7 ± 1.7° in the axial and 1.6 ± 1.2° in the sagittal plane. Navigation time per insertion was 195 ± 93 seconds. There was no difference in accuracy between hammering and drilling into the pedicle. The clinical accuracy was 97.4% to 100% depending on the screw size considered for placement. No ionizing radiation was used during navigation. CONCLUSION ARSN with instrument tracking for MISS is feasible, accurate, and radiation-free during navigation. LEVEL OF EVIDENCE 3.
Collapse
|
130
|
Swamy A, Burström G, Spliethoff JW, Babic D, Ruschke S, Racadio JM, Edström E, Terander AE, Dankelman J, Hendriks BHW. Validation of diffuse reflectance spectroscopy with magnetic resonance imaging for accurate vertebral bone fat fraction quantification. BIOMEDICAL OPTICS EXPRESS 2019; 10:4316-4328. [PMID: 31453013 PMCID: PMC6701522 DOI: 10.1364/boe.10.004316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/09/2019] [Accepted: 06/11/2019] [Indexed: 05/12/2023]
Abstract
Safe and accurate placement of pedicle screws remains a critical step in open and minimally invasive spine surgery. The diffuse reflectance spectroscopy (DRS) technique may offer the possibility of intra-operative guidance for pedicle screw placement. Currently, Magnetic Resonance Imaging (MRI) is one of the most accurate techniques used to measure fat concentration in tissues. Therefore, the purpose of this study is to compare the accuracy of fat content measured invasively in vertebrae using DRS and validate it against the Proton density fat fraction (PDFF) derived via MRI. Chemical shift-encoding-based water-fat imaging of the spine was first performed on six cadavers. PDFF images were computed and manually segmented. 23 insertions using a custom-made screw probe with integrated optical fibers were then performed under cone beam computer tomography (CBCT). DR spectra were recorded at several positions along the trajectory as the optical screw probe was inserted turn by turn into the vertebral body. Fat fractions determined via DRS and MRI techniques were compared by spatially correlating the optical screw probe position within the vertebrae on CBCT images with respect to the PDFF images. The fat fraction determined by DRS was found to have a high correlation with those determined by MRI, with a Pearson coefficient of 0.950 (P< 0.001) as compared with PDFF measurements calculated from the MRI technique. Additionally, the two techniques were found to be comparable for fat fraction quantification within vertebral bodies (R2 = 0.905).
Collapse
Affiliation(s)
- Akash Swamy
- Department of Biomechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, the Netherlands
- Department of In-body Systems, Philips Research, Royal Philips NV, High Tech Campus 34, 5656 AE, Eindhoven, the Netherlands
| | - Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurosurgery, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Jarich W. Spliethoff
- Department of In-body Systems, Philips Research, Royal Philips NV, High Tech Campus 34, 5656 AE, Eindhoven, the Netherlands
| | - Drazenko Babic
- Department of In-body Systems, Philips Research, Royal Philips NV, High Tech Campus 34, 5656 AE, Eindhoven, the Netherlands
| | - Stefan Ruschke
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675 München, Germany
| | - John M. Racadio
- Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio, USA
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurosurgery, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Adrian Elmi Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurosurgery, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Jenny Dankelman
- Department of Biomechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, the Netherlands
| | - Benno H. W. Hendriks
- Department of Biomechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, the Netherlands
- Department of In-body Systems, Philips Research, Royal Philips NV, High Tech Campus 34, 5656 AE, Eindhoven, the Netherlands
| |
Collapse
|
131
|
Zhao JX, Li C, Ren H, Hao M, Zhang LC, Tang PF. Evolution and Current Applications of Robot-Assisted Fracture Reduction: A Comprehensive Review. Ann Biomed Eng 2019; 48:203-224. [DOI: 10.1007/s10439-019-02332-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/20/2019] [Indexed: 11/28/2022]
|
132
|
Chytas D, Malahias MA, Nikolaou VS. Augmented Reality in Orthopedics: Current State and Future Directions. Front Surg 2019; 6:38. [PMID: 31316995 PMCID: PMC6610425 DOI: 10.3389/fsurg.2019.00038] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/12/2019] [Indexed: 12/29/2022] Open
Abstract
Augmented reality (AR) comprises special hardware and software, which is used in order to offer computer-processed imaging data to the surgeon in real time, so that real-life objects are combined with computer-generated images. AR technology has recently gained increasing interest in the surgical practice. Preclinical research has provided substantial evidence that AR might be a useful tool for intra-operative guidance and decision-making. AR has been applied to a wide spectrum of orthopedic procedures, such as tumor resection, fracture fixation, arthroscopy, and component's alignment in total joint arthroplasty. The present study aimed to summarize the current state of the application of AR in orthopedics, in preclinical and clinical level, providing future directions and perspectives concerning potential further benefits from this technology.
Collapse
Affiliation(s)
- Dimitrios Chytas
- 2nd Orthopaedic Department, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Vasileios S Nikolaou
- 2nd Orthopaedic Department, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
133
|
Urakov TM, Wang MY, Levi AD. Workflow Caveats in Augmented Reality-Assisted Pedicle Instrumentation: Cadaver Lab. World Neurosurg 2019; 126:e1449-e1455. [PMID: 30904807 DOI: 10.1016/j.wneu.2019.03.118] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Augmented reality (AR) is gaining popularity in gaming, industrial, military, and medical fields. Neurosurgical applications are currently limited and underdeveloped. METHODS The cadaver lab session was prepared with the currently available AR equipment and software. Pedicle instrumentation was performed from thoracic 1 to the pelvis with either fluoroscopy or AR. RESULTS A total of 38 screws were placed. There were no major breaches on the fluoroscopy-assisted side. Among the AR screws, 3 had a major medial breach and 4 had a major inferior breach. The cause of a 3 breaches appeared to be related to an error in the starting position, as their overall orientation remained correctly parallel to the original trajectory. CONCLUSIONS The article discusses the potential and limitations of AR in its current state and identifies strategies for successful AR application in future surgery.
Collapse
Affiliation(s)
- Timur M Urakov
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan D Levi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|