Multi-Modality guidance based surgical navigation for percutaneous endoscopic transforaminal discectomy

A robotic system for transthoracic puncture of pulmonary nodules based on gated respiratory compensation

BACKGROUND AND OBJECTIVE

With the urgent demands for rapid and precise localization of pulmonary nodules in procedures such as transthoracic puncture biopsy and thoracoscopic surgery, many surgical navigation and robotic systems are applied in the clinical practice of thoracic operation. However, current available positioning methods have certain limitations, including high radiation exposure, large errors from respiratory, complicated and time-consuming procedures, etc. METHODS: To address these issues, a preoperative computed tomography (CT) image-guided robotic system for transthoracic puncture was proposed in this study. Firstly, an algorithm for puncture path planning based on constraints from clinical knowledge was developed. This algorithm enables the calculation of Pareto optimal solutions for multiple clinical targets concerning puncture angle, puncture length, and distance from hazardous areas. Secondly, to eradicate intraoperative radiation exposure, a fast registration method based on preoperative CT and gated respiration compensation was proposed. The registration process could be completed by the direct selection of points on the skin near the sternum using a hand-held probe. Gating detection and joint optimization algorithms are then performed on the collected point cloud data to compensate for errors from respiratory motion. Thirdly, to enhance accuracy and intraoperative safety, the puncture guide was utilized as an end effector to restrict the movement of the optically tracked needle, then risky actions with patient contact would be strictly limited.

RESULTS

The proposed system was evaluated through phantom experiments on our custom-designed simulation test platform for patient respiratory motion to assess its accuracy and feasibility. The results demonstrated an average target point error (TPE) of 2.46 ± 0.68 mm and an angle error (AE) of 1.49 ± 0.45° for the robotic system.

CONCLUSIONS

In conclusion, our proposed system ensures accuracy, surgical efficiency, and safety while also reducing needle insertions and radiation exposure in transthoracic puncture procedures, thus offering substantial potential for clinical application.

How to predict the culprit segment in percutaneous transforaminal endoscopic surgery under local anesthesia for surgical treatment of lumbar degenerative diseases? Radiologic images or clinical symptoms

Objective

Percutaneous transforaminal endoscopic surgery (PTES) is a novel, minimally invasive technique used to treat lumbar degenerative diseases (LDDs). PTES under local anesthesia was performed to treat the culprit segment of LDDs predicted by radiologic images or clinical symptoms, and the efficacy, security, and feasibility were evaluated.

Methods

Eighty-seven cases of LDDs with nerve root symptoms, which were not consistent with lumbar degenerative levels and degrees on MRI and CT, were treated with PTES under local anesthesia in a day surgery ward from January 2015 to December 2019. Forty-two patients, whose culprit segments were predicted by radiologic images, were included in group A. The other 45 patients, whose culprit segments were predicted by clinical symptoms, were included in group B. Leg pain VAS and ODI scores before and after PTES were recorded. The outcome was defined according to the MacNab grade at the 2-year follow-up. Postoperative complications were recorded.

Results

In group A, 2 patients underwent PTES for one segment, 37 patients underwent PTES for two segments, and 3 patients underwent PTES for three segments. One of the one-segment PTES patients had no relief from symptoms and underwent another PTES for other culprit segments 3 months after surgery. In group B, 44 of 45 patients were treated using PTES for one segment and 1 patient was treated for two segments. Group B showed significantly less operative duration, less blood loss, and less fluoroscopy frequency than group A (p < 0.001). The leg pain VAS score and the ODI score significantly decreased after the operation in both groups (p < 0.001), and the excellent and good rates were 97.6% (41/42) in group A and 100% (45/45) in group B at the 2-year follow-up. The leg pain VAS score of group B was significantly lower than that of group A immediately and 1 week, 1 month, 2 months, and 3 months after surgery (p < 0.001). There was no statistical difference in ODI scores and the excellent and good rates between the two groups. No complications, such as wound infection or permanent nerve injury, were observed.

Conclusion

It is much more accurate to predict the culprit segment according to clinical symptoms than radiologic images in PTES under local anesthesia for surgical treatment of LDDs.