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Ao Y, Esfandiari H, Carrillo F, Laux CJ, As Y, Li R, Van Assche K, Davoodi A, Cavalcanti NA, Farshad M, Grewe BF, Vander Poorten E, Krause A, Fürnstahl P. SafeRPlan: Safe deep reinforcement learning for intraoperative planning of pedicle screw placement. Med Image Anal 2024; 99:103345. [PMID: 39293187 DOI: 10.1016/j.media.2024.103345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 07/11/2024] [Accepted: 09/08/2024] [Indexed: 09/20/2024]
Abstract
Spinal fusion surgery requires highly accurate implantation of pedicle screw implants, which must be conducted in critical proximity to vital structures with a limited view of the anatomy. Robotic surgery systems have been proposed to improve placement accuracy. Despite remarkable advances, current robotic systems still lack advanced mechanisms for continuous updating of surgical plans during procedures, which hinders attaining higher levels of robotic autonomy. These systems adhere to conventional rigid registration concepts, relying on the alignment of preoperative planning to the intraoperative anatomy. In this paper, we propose a safe deep reinforcement learning (DRL) planning approach (SafeRPlan) for robotic spine surgery that leverages intraoperative observation for continuous path planning of pedicle screw placement. The main contributions of our method are (1) the capability to ensure safe actions by introducing an uncertainty-aware distance-based safety filter; (2) the ability to compensate for incomplete intraoperative anatomical information, by encoding a-priori knowledge of anatomical structures with neural networks pre-trained on pre-operative images; and (3) the capability to generalize over unseen observation noise thanks to the novel domain randomization techniques. Planning quality was assessed by quantitative comparison with the baseline approaches, gold standard (GS) and qualitative evaluation by expert surgeons. In experiments with human model datasets, our approach was capable of achieving over 5% higher safety rates compared to baseline approaches, even under realistic observation noise. To the best of our knowledge, SafeRPlan is the first safety-aware DRL planning approach specifically designed for robotic spine surgery.
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Affiliation(s)
- Yunke Ao
- ROCS, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; Department of Computer Science, ETH Zurich, Universitätstrasse 6, 8092 Zürich, Switzerland; ETH AI Center, ETH Zürich, Andreasstrasse 5, 8092 Zürich, Switzerland.
| | - Hooman Esfandiari
- ROCS, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Fabio Carrillo
- ROCS, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Christoph J Laux
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Yarden As
- Department of Computer Science, ETH Zurich, Universitätstrasse 6, 8092 Zürich, Switzerland; ETH AI Center, ETH Zürich, Andreasstrasse 5, 8092 Zürich, Switzerland
| | - Ruixuan Li
- Department of Mechanical Engineering, KU Leuven, Celestijnenlaan 300, 3001 Leuven, Belgium
| | - Kaat Van Assche
- Department of Mechanical Engineering, KU Leuven, Celestijnenlaan 300, 3001 Leuven, Belgium
| | - Ayoob Davoodi
- Department of Mechanical Engineering, KU Leuven, Celestijnenlaan 300, 3001 Leuven, Belgium
| | - Nicola A Cavalcanti
- ROCS, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Benjamin F Grewe
- Department of Information Technology and Electrical Engineering, ETH Zurich, Gloriastrasse 35, 8092 Zürich, Switzerland; ETH AI Center, ETH Zürich, Andreasstrasse 5, 8092 Zürich, Switzerland
| | | | - Andreas Krause
- Department of Computer Science, ETH Zurich, Universitätstrasse 6, 8092 Zürich, Switzerland; ETH AI Center, ETH Zürich, Andreasstrasse 5, 8092 Zürich, Switzerland
| | - Philipp Fürnstahl
- ROCS, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zürich, Switzerland; ETH AI Center, ETH Zürich, Andreasstrasse 5, 8092 Zürich, Switzerland
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Hagan MJ, Syed S, Leary OP, Persad-Paisley EM, Lin Y, Zheng B, Shao B, Abdulrazeq H, Yu JYH, Telfeian AE, Gokaslan ZL, Fridley JS, Oyelese AA. Pedicle Screw Placement Using Intraoperative Computed Tomography and Computer-Aided Spinal Navigation Improves Screw Accuracy and Avoids Postoperative Revisions: Single-Center Analysis of 1400 Pedicle Screws. World Neurosurg 2022; 160:e169-e179. [PMID: 34990843 DOI: 10.1016/j.wneu.2021.12.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Intraoperative computed tomography and navigation (iCT-Nav) is increasingly used to aid spinal instrumentation. We aimed to document the accuracy and revision rate of pedicle screw placement across many screws placed using iCT-Nav. We also assess patient-level factors predictive of high-grade pedicle breach. METHODS Medical records of patients who underwent iCT-Nav pedicle screw placement between 2015 and 2017 at a single center were retrospectively reviewed. Screw placement accuracy was individually assessed for each screw using the 2-mm incremental grading system for pedicle breach. Predictors of high-grade (>2 mm) breach were identified using multiple logistic regression. RESULTS In total, 1400 pedicle screws were placed in 208 patients undergoing cervicothoracic (29; 13.9%), thoracic (30; 14.4), thoracolumbar (19; 9.1%) and lumbar (130; 62.5%) surgeries. iCT-Nav afforded high-accuracy screw placement, with 1356 of 1400 screws (96.9%) being placed accurately. In total, 37 pedicle screws (2.64%) were revised intraoperatively during the index surgery across 31 patients, with no subsequent returns to the operating room because of screw malpositioning. After correcting for potential confounders, males were less likely to have a high-grade breach (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.10-0.59, P = 0.003) whereas lateral (OR 6.21; 95% CI 2.47-15.52, P < 0.001) or anterior (OR 5.79; 95% CI2.11-15.88, P = 0.001) breach location were predictive of a high-grade breach. CONCLUSIONS iCT-Nav with postinstrumentation intraoperative imaging is associated with a reduced need for costly postoperative return to the operating room for screw revision. In comparison with studies of navigation without iCT where 1.5%-1.7% of patients returned for a second surgery, we report 0 revision surgeries due to screw malpositioning.
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Affiliation(s)
- Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Sohail Syed
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Owen P Leary
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Yang Lin
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Belinda Shao
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Hael Abdulrazeq
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - James Y H Yu
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Albert E Telfeian
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA.
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Ho TY, Lin CW, Chang CC, Chen HT, Chen YJ, Lo YS, Hsiao PH, Chen PC, Lin CS, Tsou HK. Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative lumbar kyphoscoliosis patients: an innovative preliminary study. BMC Musculoskelet Disord 2020; 21:734. [PMID: 33172435 PMCID: PMC7656687 DOI: 10.1186/s12891-020-03745-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/26/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The aim of this study is to introduce a new method of percutaneous endoscopic decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative kyphoscoliosis patients without instability or those who with multiple comorbidities. Decompression alone using endoscope for kyphoscoliosis patient is technical demanding and may result in unnecessary bone destruction leading to further instability. The O-arm/StealthStation system is popular for its ability to provide automated registration with intraoperative, postpositioning computed tomography (CT) which results in superior accuracy in spine surgery. METHODS In this study, we presented four cases. All patients were over seventy years old female with variable degrees of kyphoscoliosis and multiple comorbidities who could not endure major spine fusion surgery. Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation were successfully performed. Patients' demographics, image study parameters, and outcome measurements including pre- and post-operative serial Visual analog scale (VAS), and Oswestry Disability Index (ODI) were well documented. The follow-up time was 1 year. RESULTS Pre- and post-operative MRI showed average dural sac cross sectional area (DSCSA) improved from 81.62 (range 67.34-89.07) to 153.27 (range 127.96-189.73). Preoperative neurological symptoms including radicular leg pain improved postoperatively. The mean ODI (%) were 85 (range 82.5-90) at initial visit, 35.875 (range 25-51) at 1 month post-operatively, 26.875 (range 22.5-35) at 6 months post-operatively and 22.5 (range 17.5-30) at 12 months post-operatively (p < 0.05). The mean VAS score were 9 (range 8-10) at initial visit, 2.25 (range 2-3) at 1 month post-operatively, 1.75 (range 1-2) at 6 months post-operatively and 0.25 (range 0-1) at 12 months post-operatively (p < 0.05). There was no surgery-related complication. CONCLUSIONS To the best of our knowledge, this is the first preliminary study of percutaneous endoscopic laminotomy under O-arm navigation with successful outcomes. The innovative technique may serve as a promising solution in treating spinal stenosis patients with lumbar kyphoscoliosis and multiple comorbidities.
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Affiliation(s)
- Tsung-Yu Ho
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan
| | - Chung-Wei Lin
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan
| | - Chien-Chun Chang
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan. .,Spine Center, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan. .,Biological Science and Technology, National Chiao Tung University, No. 75, Bo'ai St., East Dist, Hsinchu City, 300, Taiwan. .,Biomedical Science and Engineering, National Chiao Tung University, No. 75, Bo'ai St., East Dist, Hsinchu City, 300, Taiwan.
| | - Hsien-Te Chen
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan. .,Spine Center, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan. .,Department of Sports Medicine, College of Health Care, China Medical University, No. 91, Xueshi Rd., North Dist, Taichung City, 404, Taiwan.
| | - Yen-Jen Chen
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan.,Spine Center, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan.,Department of Orthopedic Surgery, School of Medicine, China Medical University, No. 91, Xueshi Rd., North Dist, Taichung City, 404, Taiwan
| | - Yuan-Shun Lo
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan.,Spine Center, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan
| | - Pan-Hsuan Hsiao
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan.,Spine Center, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 404, Taiwan
| | - Po-Chen Chen
- Section of Orthopedic Surgery, Department of Surgery, Ministry of Health and Welfare, Changhua Hospital, No. 80, Sec. 2, Zhongzheng Rd., Puxin Township, Changhua County, 513, Taiwan
| | - Chih-Sheng Lin
- Biological Science and Technology, National Chiao Tung University, No. 75, Bo'ai St., East Dist, Hsinchu City, 300, Taiwan.,Biomedical Science and Engineering, National Chiao Tung University, No. 75, Bo'ai St., East Dist, Hsinchu City, 300, Taiwan
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, 407, Taiwan.,Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, No. 79-9 Sha-Luen Hu Xi-Zhou Li Hou-Loung Town, Miaoli County, 356, Taiwan
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Lin CW, Chang CC, Chen HT, Chen YJ, Lin CS, Hsu HC, Tsou HK. 3D Real-Time Image-Guided Navigation Spine Corpectomy with Ultrasonic Bone Cutter: Technical Note. World Neurosurg 2019; 135:197-204. [PMID: 31706972 DOI: 10.1016/j.wneu.2019.10.186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Surgical interventions for congenital scoliosis are challenging for spine surgeons. The coordination of 3-dimensional (3D), real-time, image-guided navigation with an ultrasonic bone cutter allows surgeons to localize the affected area of the spine accurately and remove the lesion without damaging soft tissue structures. The goal of this technical paper is to report a previously undescribed method of hemivertebrectomy that combines 3D, real-time, image-guided navigation and an ultrasonic bone cutter. We highlight the feasibility and safety of this method in spinal surgery. METHODS Three patients with congenital scoliosis were treated with this technique. We present three illustrative cases comprising hemivertebrectomies for congenital scoliosis. Intraoperative photos demonstrating the technique are also provided. RESULTS All surgeries were completed without complications. The hemivertebrae were completely removed, and marked correction of congenital scoliosis was noted. CONCLUSIONS We believe that the combination of 3D, real-time image navigation and an ultrasonic bone cutter improves hemivertebrectomy by increasing accuracy and avoiding dura laceration, major organ damage, or potential vessel damage.
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Affiliation(s)
- Chung-Wei Lin
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan (R.O.C.)
| | - Chien-Chun Chang
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan (R.O.C.); Department of Biological Science and Technology, National Chiao Tung University, Hsinchu City, Taiwan (R.O.C.); Ph.D. Degree Program of Biomedical Science and Engineering, National Chiao Tung University, Hsinchu City, Taiwan (R.O.C.); Spine Center, China Medical University Hospital, China Medical University, Taichung City, Taiwan (R.O.C.)
| | - Hsien-Te Chen
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan (R.O.C.); Department of Sports Medicine, College of Health Care, China Medical University, Taichung City, Taiwan (R.O.C.); Spine Center, China Medical University Hospital, China Medical University, Taichung City, Taiwan (R.O.C.).
| | - Yen-Jen Chen
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan (R.O.C.); Spine Center, China Medical University Hospital, China Medical University, Taichung City, Taiwan (R.O.C.); School of Medicine, China Medical University, Taichung City, Taiwan (R.O.C.)
| | - Chih-Sheng Lin
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu City, Taiwan (R.O.C.); Ph.D. Degree Program of Biomedical Science and Engineering, National Chiao Tung University, Hsinchu City, Taiwan (R.O.C.)
| | - Horng-Chaung Hsu
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan (R.O.C.); School of Medicine, China Medical University, Taichung City, Taiwan (R.O.C.)
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung City, Taiwan (R.O.C.); Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County, Taiwan (R.O.C.)
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Junaid M, Afzal A, Kalsoom A, Bukhari SS. Freehand pedicle screw fixation: A safe recipe for dorsal, lumbar and sacral spine. Pak J Med Sci 2019; 35:680-684. [PMID: 31258575 PMCID: PMC6572961 DOI: 10.12669/pjms.35.3.981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To determine outcome of freehand pedicle screw fixation for dorsal, lumbar and sacral fractures at a tertiary care centre in the developing world. Methods: A retrospective review was performed of 150 consecutive patients who underwent pedicle screw fixation from January 1, 2012 to 31st December 2017. A total of 751 pedicle screws were placed. Incidence and extent of cortical breach by misplaced pedicle screw was determined by review of intra-operative and post-operative radiographs and/or computed tomography. Results: Among the total 751 free hand placed pedicle screws, four screws (0.53%) were repositioned due to a misdirected trajectory towards the disc space. six screws (0.79%) were identified to have cause moderate breach while four screws (0.53%) cause severe breach. There was no occurrence of iatrogenic nerve root damage or violation of the spinal canal. Conclusion: Free hand pedicle screw placement based on external landmarks showed remarkable safety and accuracy in our center. The authors conclude that assiduous adherence to technique and preoperative planning is vital to success.
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Affiliation(s)
- Muhammad Junaid
- Dr. Muhammad Junaid, FCPS IFAANS, Department of Neurosurgery, PNS Shifa Hospital, Karachi, Pakistan
| | - Ali Afzal
- Dr. Ali Afzal, FCPS, Department of Neurosurgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Anisa Kalsoom
- Dr. Anisa Kalsoom, FCPS, Department of Radiology, Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Syed Sarmad Bukhari
- Dr. Syed Sarmad Bukhari, MBBS, Department of Neurological Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Accuracy and Safety in Screw Placement in the High Cervical Spine: Retrospective Analysis of O-arm-based Navigation-assisted C1 Lateral Mass and C2 Pedicle Screws. Clin Spine Surg 2019; 32:E193-E199. [PMID: 30829879 DOI: 10.1097/bsd.0000000000000813] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
STUDY DESIGN This study was a retrospective analysis. OBJECTIVE The purpose of present study was to evaluate accuracy, efficiency, and safety of intraoperative O-arm-based navigation system for the placement of C1 lateral mass screw (C1LMS) and C2 pedicle screws (C2PSs) in high cervical spine operations. SUMMARY OF BACKGROUND DATA High screw misplacement rates, various pedicle morphometry and vertebral body size variations have led to a search of image-guided systems to improve the surgical accuracy of screw insertion in high cervical spine. The use of O-arm has been proposed for more accurate and efficient spinal instrumentation. MATERIALS AND METHODS Between June 2009 and August 2016, a total of 48 patients with atlantoaxial instability were surgically treated using the image-guidance system. To reconstruct atlantoaxial instability, we have been using Harm's technique of C1LMS and C2PS fixations. A frameless, stereotactic O-arm-based image-guidance system was used for correct screw placement. Postoperative computed tomographic scan with multiplanar reconstructions were used to determine the accuracy of the screw placement. RESULTS A total of 182 screws, including 90 C1LMS and 92 C2PSs were inserted using image-guidance system. In total, 4.4% (4/90) of C1LMS and 7.6% (10/92) of C2PS had cortex violation over 2 mm and considered as "significant." Among the significant cortex violations, "unexpected breech" was 3.3% of all the screws inserted. Two (2.1%) screws inserted had perforated the vertebral artery canal and iatrogenic vertebral artery stenosis was proved with postoperative computed tomography angiography. When divided into time periods, 60% of significant breech occurred during the beginning stage, 40% during adaptation stage and none during expert stage. CONCLUSIONS In this study, the authors demonstrated that use of image-guidance system seems to be beneficial for high cervical instrumentation which requires much experience and steep learning curves. However, incidence of cortex violation does not disappear completely due to the close proximity to spinal canal and surrounding vessels.
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Yu JY, Fridley J, Gokaslan Z, Telfeian A, Oyelese AA. Minimally Invasive Thoracolumbar Corpectomy and Stabilization for Unstable Burst Fractures Using Intraoperative Computed Tomography and Computer-Assisted Spinal Navigation. World Neurosurg 2019; 122:e1266-e1274. [DOI: 10.1016/j.wneu.2018.11.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 12/31/2022]
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Abstract
STUDY DESIGN Description of a navigated, single-step, minimally invasive technique for the placement of pedicle screws. OBJECTIVE To describe a new technique for minimally invasive placement of pedicle screws in the lumbar spine using O-arm and StealthStation navigation in combination. SUMMARY OF BACKGROUND DATA Minimally invasive surgical techniques are described in the literature as safe and effective methods for pedicle screw instrumentation. These techniques increase radiation exposure and prompt multiple instrument passes through the pedicle. MATERIALS AND METHODS In total, 35 adult patients (187 screws) underwent lumbar surgery with pedicle screw placement using the 1- (8 patients/48 screws) or 2-step (27 patients/139 screws) technique. Complications associated with instrumentation were noted. Pedicle screw position was evaluated. RESULTS Of 187 screws placed, 181 (96.8%) were found to be fully contained within the pedicle (grade 1) and 4 (2.1%) had a breach of <2 mm. In the 1-step technique, no screws were malpositioned. One screw at S1 with inadequate fixation was replaced with a screw 1 mm larger in diameter. In the 2-step technique, 2 screws (1.06% overall) were revised due to inferior breach of the pedicle. No neurological sequelae were noted. Also, 1 screw was deemed too long at S1 and was replaced with a shorter screw. None of the revised pedicle screws caused neuromonitoring changes and the breaches were found intraoperatively on 3D imaging. CONCLUSIONS Using O-arm and StealthStation navigation with minimally invasive surgical technology for placement of posterior spinal instrumentation is safe, effective, and limits radiation exposure.
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Application of Intraoperative O-Arm-Assisted Real-Time Navigation Technique for Spinal Fixation. ACTA ACUST UNITED AC 2017. [DOI: 10.18679/cn11-6030_r.2017.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study explored the combined use of the O-arm and real-time navigation during spinal fixation. The clinical data for 60 patients undergoing spinal fixation, at Beijing Tsinghua Chang Gung Hospital between May 5, 2015 and May 1, 2017, were retrospectively analyzed. Pre-, intra-, and postoperative imaging findings were assessed. The patients were classified into the occipitocervical fusion (32 cases) and thoracic/lumbar/sacral spine fixation (28 cases, including 6 cases of percutaneous pedicle screw) groups. Lesion resections were performed microscopically. An O-arm, combined with real-time navigation, was used to assess spinal fixation. Efficacy was evaluated using operative times, Xray times, screw positioning, and complications. Within the occipitocervical fusion group, 182 screws were placed in the cervical spine and 96 in the occipital bone. However, 6 screws penetrated the bone cortex and were adjacent to the vertebral arteries, based on O-arm three-dimensional imaging; therefore, the precision rate was 96.7%. Within the thoracic/lumbar/sacral spine fixation group, 148 pedicle screws were implanted, with 4 initially outside the vertebral body, yielding a precision rate of 97.3%. Ten percutaneous pedicle screws were implanted and well positioned. O-arm scans were performed 3 times/patient, with an average of 20–30 min/time. Screw implantation times were 5–7 min (cervical spine), 8–10 min (thoracic spine), and 6–8 min (lumbar spine). Intraoperative O-arm scans, combined with real-time navigation technology, allow real-time observation of screw angles and depths, improving the accuracy and safety of posterior screw fixations and reducing the radiation dose and frequency experienced by patients and surgeons.
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11
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Nasser R, Drazin D, Nakhla J, Al-Khouja L, Brien E, Baron EM, Kim TT, Patrick Johnson J, Yassari R. Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis. Neurosurg Focus 2017; 41:E15. [PMID: 27476839 DOI: 10.3171/2016.5.focus16136] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions. METHODS This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance. RESULTS The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14-87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62-865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5-7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1-36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden. CONCLUSIONS O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.
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Affiliation(s)
- Rani Nasser
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York;
| | | | - Jonathan Nakhla
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York;
| | | | - Earl Brien
- Orthopedics, Cedars-Sinai Medical Center, Los Angeles; and
| | | | - Terrence T Kim
- Departments of 2 Neurosurgery and.,Orthopedics, Cedars-Sinai Medical Center, Los Angeles; and
| | - J Patrick Johnson
- Departments of 2 Neurosurgery and.,Department of Neurosurgery, University of California, Davis, California
| | - Reza Yassari
- Department of Neurosurgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York;
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Nooh A, Lubov J, Aoude A, Aldebeyan S, Jarzem P, Ouellet J, Weber MH. Differences between Manufacturers of Computed Tomography-Based Computer-Assisted Surgery Systems Do Exist: A Systematic Literature Review. Global Spine J 2017; 7:83-94. [PMID: 28451513 PMCID: PMC5400166 DOI: 10.1055/s-0036-1583942] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/21/2016] [Indexed: 11/26/2022] Open
Abstract
STUDY DESIGN Literature review. OBJECTIVE Several studies have shown that the accuracy of pedicle screw placement significantly improves with use of computed tomography (CT)-based navigation systems. Yet, there has been no systematic review directly comparing accuracy of pedicle screw placement between different CT-based navigation systems. The objective of this study is to review the results presented in the literature and compare CT-based navigation systems relative only to screw placement accuracy. METHODS Data sources included CENTRAL, Medline, PubMed, and Embase databases. Studies included were randomized clinical trials, case series, and case-control trials reporting the accuracy of pedicle screws placement using CT-based navigation. Two independent reviewers extracted the data from the selected studies that met our inclusion criteria. Publications were grouped based on the CT-based navigation system used for pedicle screw placement. RESULTS Of the 997 articles we screened, only 26 met all of our inclusion criteria and were included in the final analysis, which showed a significant statistical difference (p < 0.0001, 95% confidence interval 0.92 to 1.23) in accuracy of pedicle screw placement between three different CT-based navigation systems. The mean (weighted) accuracy of pedicle screws placement based on the CT-based navigation system was found to be 97.20 ± 2.1% in StealthStation (Medtronic, United States) and 96.1 ± 3.9% in VectorVision (BrainLab, Germany). CONCLUSION This review summarizes results presented in the literature and compares screw placement accuracy using different CT-based navigation systems. Although certain factors such as the extent of the procedure and the experience and skills of the surgeon were not accounted for, the differences in accuracy demonstrated should be considered by spine surgeons and should be validated for effects on patients' outcome.
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Affiliation(s)
- Anas Nooh
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Canada
- Department of Orthopedic Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
- These authors contributed equally to this article
| | - Joushua Lubov
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Canada
- These authors contributed equally to this article
| | - Ahmed Aoude
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Canada
| | - Sultan Aldebeyan
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Canada
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Peter Jarzem
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Canada
| | - Jean Ouellet
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Canada
| | - Michael H. Weber
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, Canada
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Total Navigation in Spine Surgery; A Concise Guide to Eliminate Fluoroscopy Using a Portable Intraoperative Computed Tomography 3-Dimensional Navigation System. World Neurosurg 2017; 100:325-335. [PMID: 28104526 DOI: 10.1016/j.wneu.2017.01.025] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/05/2017] [Accepted: 01/06/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Portable intraoperative computed tomography (iCT) with integrated 3-dimensional navigation (NAV) offers new opportunities for more precise navigation in spinal surgery, eliminates radiation exposure for the surgical team, and accelerates surgical workflows. We present the concept of "total navigation" using iCT NAV in spinal surgery. Therefore, we propose a step-by-step guideline demonstrating how total navigation can eliminate fluoroscopy with time-efficient workflows integrating iCT NAV into daily practice. METHODS A prospective study was conducted on collected data from patients undergoing iCT NAV-guided spine surgery. Number of scans, radiation exposure, and workflow of iCT NAV (e.g., instrumentation, cage placement, localization) were documented. Finally, the accuracy of pedicle screws and time for instrumentation were determined. RESULTS iCT NAV was successfully performed in 117 cases for various indications and in all regions of the spine. More than half (61%) of cases were performed in a minimally invasive manner. Navigation was used for skin incision, localization of index level, and verification of implant position. iCT NAV was used to evaluate neural decompression achieved in spinal fusion surgeries. Total navigation eliminates fluoroscopy in 75%, thus reducing staff radiation exposure entirely. The average times for iCT NAV setup and pedicle screw insertion were 12.1 and 3.1 minutes, respectively, achieving a pedicle screw accuracy of 99%. CONCLUSIONS Total navigation makes spine surgery safer and more accurate, and it enhances efficient and reproducible workflows. Fluoroscopy and radiation exposure for the surgical staff can be eliminated in the majority of cases.
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Kosterhon M, Gutenberg A, Kantelhardt SR, Archavlis E, Giese A. Navigation and Image Injection for Control of Bone Removal and Osteotomy Planes in Spine Surgery. Oper Neurosurg (Hagerstown) 2017; 13:297-304. [DOI: 10.1093/ons/opw017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 10/31/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE: In contrast to cranial interventions, neuronavigation in spinal surgery is used in few applications, not tapping into its full technological potential. We have developed a method to preoperatively create virtual resection planes and volumes for spinal osteotomies and export 3-D operation plans to a navigation system controlling intraoperative visualization using a surgical microscope's head-up display. The method was developed using a Sawbone® model of the lumbar spine, demonstrating feasibility with high precision. Computer tomographic and magnetic resonance image data were imported into Amira®, a 3-D visualization software. Resection planes were positioned, and resection volumes representing intraoperative bone removal were defined. Fused to the original Digital Imaging and Communications in Medicine data, the osteotomy planes were exported to the cranial version of a Brainlab® navigation system. A navigated surgical microscope with video connection to the navigation system allowed intraoperative image injection to visualize the preplanned resection planes.
CLINICAL PRESENTATION: The workflow was applied to a patient presenting with a congenital hemivertebra of the thoracolumbar spine. Dorsal instrumentation with pedicle screws and rods was followed by resection of the deformed vertebra guided by the in-view image injection of the preplanned resection planes into the optical path of a surgical microscope. Postoperatively, the patient showed no neurological deficits, and the spine was found to be restored in near physiological posture.
CONCLUSION: The intraoperative visualization of resection planes in a microscope's head-up display was found to assist the surgeon during the resection of a complex-shaped bone wedge and may help to further increase accuracy and patient safety.
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Minimally Invasive Spinal Surgery with Intraoperative Image-Guided Navigation. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5716235. [PMID: 27213152 PMCID: PMC4860212 DOI: 10.1155/2016/5716235] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/30/2016] [Indexed: 12/17/2022]
Abstract
We present our perioperative minimally invasive spine surgery technique using intraoperative computed tomography image-guided navigation for the treatment of various lumbar spine pathologies. We present an illustrative case of a patient undergoing minimally invasive percutaneous posterior spinal fusion assisted by the O-arm system with navigation. We discuss the literature and the advantages of the technique over fluoroscopic imaging methods: lower occupational radiation exposure for operative room personnel, reduced need for postoperative imaging, and decreased revision rates. Most importantly, we demonstrate that use of intraoperative cone beam CT image-guided navigation has been reported to increase accuracy.
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Avila MJ, Baaj AA. Freehand Thoracic Pedicle Screw Placement: Review of Existing Strategies and a Step-by-Step Guide Using Uniform Landmarks for All Levels. Cureus 2016; 8:e501. [PMID: 27014535 PMCID: PMC4803536 DOI: 10.7759/cureus.501] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pedicle screw fixation in the thoracic spine presents certain challenges due to the critical regional neurovascular anatomy as well as the narrow pedicular corridor that typically exists. With increased awareness of the dangers of intraoperative radiation, the ability to place pedicle screws with anatomic landmarks alone is paramount. In this study, we reviewed the literature from 1990 to 2015 for studies that included freehand pedicle screw placement in the thoracic spine with special emphasis on entry points and the trajectories of the screws. We excluded studies that used fluoroscopy guidance, navigation techniques, cadaveric and biomechanical articles, case reports, and experimental studies on animals. The search retrieved 40 articles, and after careful selection, seven articles were analyzed. Over 8,000 screws were placed in the different studies. The mean accuracy for placement of the thoracic screws was 93.3%. However, there is little consensus between studies in entry points, sagittal, and axial trajectories of the screws. We complete this review by presenting our step-by-step technique for the placement of freehand pedicle screws in the thoracic spine.
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Affiliation(s)
| | - Ali A Baaj
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical College
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Al-Khouja L, Shweikeh F, Pashman R, Johnson JP, Kim TT, Drazin D. Economics of image guidance and navigation in spine surgery. Surg Neurol Int 2015; 6:S323-6. [PMID: 26167370 PMCID: PMC4496834 DOI: 10.4103/2152-7806.159381] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 03/06/2015] [Indexed: 12/31/2022] Open
Abstract
Background: Image-guidance and navigation in spinal surgery is becoming more widely utilized. Several studies have shown the use of this technology to increase accuracy of pedicle screw placement, decrease the rates of revision surgery, and minimize radiation exposure. In this paper, the authors analyze the economics of image-guided surgery (IGS) and navigation in spine surgery. Methods: A literature review was performed using PubMed, the CEA Registry, and the National Health Service Economic Evaluation Database. Each article was screened for inclusion and exclusion criteria, including costs, reoperation, readmission rates, operating room time, and length of stay. Results: Thirteen studies were included in the analysis. Six studies were identified to meet the inclusion criteria for reporting costs and seven met the criteria for analysis of efficacy. Average costs ranged from $17,650 to $39,643. Pedicle screw misplacement rates using IGS ranged from 1.20% to 15.07% while reoperation rates ranged from 0% to 7.42%. Conclusion: There is currently an insufficient amount of studies reporting on the economics of spinal navigation to accurately conclude on its cost-effectiveness in clinical practice. Although a few of these studies showed less costs associated with intraoperative imaging, none were able to establish a statistically significant difference. Preliminary findings drawn from this study indicate a possible cost-effectiveness advantage with IGS, but more comprehensive data on costs need to be reported in order to validate its utilization.
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Affiliation(s)
- Lutfi Al-Khouja
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Faris Shweikeh
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Robert Pashman
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA ; Department of Neurosurgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Terrence T Kim
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Doniel Drazin
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
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Guppy KH, Chakrabarti I, Banerjee A. The use of intraoperative navigation for complex upper cervical spine surgery. Neurosurg Focus 2014; 36:E5. [PMID: 24580006 DOI: 10.3171/2014.1.focus13514] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Imaging guidance using intraoperative CT (O-arm surgical imaging system) combined with a navigation system has been shown to increase accuracy in the placement of spinal instrumentation. The authors describe 4 complex upper cervical spine cases in which the O-arm combined with the StealthStation surgical navigation system was used to accurately place occipital screws, C-1 screws anteriorly and posteriorly, C-2 lateral mass screws, and pedicle screws in C-6. This combination was also used to navigate through complex bony anatomy altered by tumor growth and bony overgrowth. The 4 cases presented are: 1) a developmental deformity case in which the C-1 lateral mass was in the center of the cervical canal causing cord compression; 2) a case of odontoid compression of the spinal cord requiring an odontoidectomy in a patient with cerebral palsy; 3) a case of an en bloc resection of a C2-3 chordoma with instrumentation from the occiput to C-6 and placement of C-1 lateral mass screws anteriorly and posteriorly; and 4) a case of repeat surgery for a non-union at C1-2 with distortion of the anatomy and overgrowth of the bony structure at C-2.
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Affiliation(s)
- Kern H Guppy
- Department of Neurosurgery, Kaiser Permanente Medical Group, Sacramento, California; and Department of Neurosurgery, University of California, San Francisco, California
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Reaungamornrat S, Wang AS, Uneri A, Otake Y, Khanna AJ, Siewerdsen JH. Deformable image registration with local rigidity constraints for cone-beam CT-guided spine surgery. Phys Med Biol 2014; 59:3761-87. [PMID: 24937093 DOI: 10.1088/0031-9155/59/14/3761] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Image-guided spine surgery (IGSS) is associated with reduced co-morbidity and improved surgical outcome. However, precise localization of target anatomy and adjacent nerves and vessels relative to planning information (e.g., device trajectories) can be challenged by anatomical deformation. Rigid registration alone fails to account for deformation associated with changes in spine curvature, and conventional deformable registration fails to account for rigidity of the vertebrae, causing unrealistic distortions in the registered image that can confound high-precision surgery. We developed and evaluated a deformable registration method capable of preserving rigidity of bones while resolving the deformation of surrounding soft tissue. The method aligns preoperative CT to intraoperative cone-beam CT (CBCT) using free-form deformation (FFD) with constraints on rigid body motion imposed according to a simple intensity threshold of bone intensities. The constraints enforced three properties of a rigid transformation-namely, constraints on affinity (AC), orthogonality (OC), and properness (PC). The method also incorporated an injectivity constraint (IC) to preserve topology. Physical experiments involving phantoms, an ovine spine, and a human cadaver as well as digital simulations were performed to evaluate the sensitivity to registration parameters, preservation of rigid body morphology, and overall registration accuracy of constrained FFD in comparison to conventional unconstrained FFD (uFFD) and Demons registration. FFD with orthogonality and injectivity constraints (denoted FFD+OC+IC) demonstrated improved performance compared to uFFD and Demons. Affinity and properness constraints offered little or no additional improvement. The FFD+OC+IC method preserved rigid body morphology at near-ideal values of zero dilatation (D = 0.05, compared to 0.39 and 0.56 for uFFD and Demons, respectively) and shear (S = 0.08, compared to 0.36 and 0.44 for uFFD and Demons, respectively). Target registration error (TRE) was similarly improved for FFD+OC+IC (0.7 mm), compared to 1.4 and 1.8 mm for uFFD and Demons. Results were validated in human cadaver studies using CT and CBCT images, with FFD+OC+IC providing excellent preservation of rigid morphology and equivalent or improved TRE. The approach therefore overcomes distortions intrinsic to uFFD and could better facilitate high-precision IGSS.
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Affiliation(s)
- S Reaungamornrat
- Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA
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Kim TT, Drazin D, Shweikeh F, Pashman R, Johnson JP. Clinical and radiographic outcomes of minimally invasive percutaneous pedicle screw placement with intraoperative CT (O-arm) image guidance navigation. Neurosurg Focus 2014; 36:E1. [DOI: 10.3171/2014.1.focus13531] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intraoperative CT image–guided navigation (IGN) has been increasingly incorporated into minimally invasive spine surgery (MIS). The vast improvement in image resolution and virtual real-time images with CT-IGN has proven superiority over traditional fluoroscopic techniques. The authors describe their perioperative MIS technique using the O-arm with navigation, and they report their postoperative experience, accuracy results, and technical aspects.
Methods
A retrospective review of 48 consecutive adult patients undergoing minimally invasive percutaneous posterior spinal fusion with intraoperative CT-IGN between July 2010 and August 2013 at Cedars-Sinai Medical Center was performed. Two surgeons assessed 290 screws in a blinded fashion on intraoperative O-arm images and postoperative CT scans for bony pedicle wall breach. Grade 1 breach was defined to be < 2 mm, Grade 2 breach to be between 2 and 4 mm, and a Grade 3 breach to be > 4 mm. Additionally, anterior vertebral body breach was recorded.
Results
Of 290 pedicle screws placed, 280 (96.6%) were in an acceptable position without cortical wall or anterior breach. Of the 10 breaches (3.4%) 5 were lateral (50%), 4 were medial, and 1 was anterior; 90% of breaches were Grade 1–2 and all medial breaches were Grade 1. The one Grade 3 breach was lateral. No vascular or neurological complications were observed intraoperatively, and no significant postoperative complications were noted. The mean clinical follow-up period was 18 months (range 3–39 months). The overall clinical outcomes, measured using the visual analog scale (back pain scores), were improved significantly postoperatively at 3 months compared with preoperatively (visual analog score 6.35 vs 3.57; p < 0.0001). No revision surgery was performed for screw misplacement or neurological deterioration.
Conclusions
New CT-IGN with the mobile O-arm scanner has increased the accuracy of pedicle screw/instrumentation placement using MIS techniques. The authors' high (96.6%) accuracy rate in MIS compares favorably with historical published accuracy rates for fluoroscopy-based techniques. Additional advantages of CT-IGN over fluoroscopic imaging methods are lower occupational radiation exposure for the surgical team, reduced need for postoperative imaging, and decreased rates of revision surgery. For now, the authors simply conclude that use of intraoperative CT-IGN is safe and accurate.
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Affiliation(s)
| | - Doniel Drazin
- 2Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Faris Shweikeh
- 2Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
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Mattei TA, Fassett DR. Letter to the Editor: The O-arm revolution in spine surgery. J Neurosurg Spine 2013; 19:644-7. [DOI: 10.3171/2013.5.spine13474] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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