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Mayer R, Desai K, Aguiar RSDT, McClure JJ, Kato N, Kalman C, Pilitsis JG. Evolution of Deep Brain Stimulation Techniques for Complication Mitigation. Oper Neurosurg (Hagerstown) 2024; 27:148-157. [PMID: 38315020 DOI: 10.1227/ons.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/07/2023] [Indexed: 02/07/2024] Open
Abstract
Complication mitigation in deep brain stimulation has been a topic matter of much discussion in the literature. In this article, we examine how neurosurgeons as individuals and as a field generated and adapted techniques to prevent infection, lead fracture/lead migration, and suboptimal outcomes in both the acute period and longitudinally. The authors performed a MEDLINE search inclusive of articles from 1987 to June 2023 including human studies written in English. Using the Rayyan platform, two reviewers (J.P. and R.M.) performed a title screen. Of the 776 articles, 252 were selected by title screen and 172 from abstract review for full-text evaluation. Ultimately, 124 publications were evaluated. We describe the initial complications and inefficiencies at the advent of deep brain stimulation and detail changes instituted by surgeons that reduced them. Furthermore, we discuss the trend in both undesired short-term and long-term outcomes with emphasis on how surgeons recognized and modified their practice to provide safer and better procedures. This scoping review adds to the literature as a guide to both new neurosurgeons and seasoned neurosurgeons alike to understand better what innovations have been trialed over time as we embark on novel targets and neuromodulatory technologies.
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Affiliation(s)
- Ryan Mayer
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton , Florida , USA
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Spennato P, Di Costanzo M, Mirone G, Cicala D, De Martino L, Onorini N, Ruggiero C, Cinalli G. Image-guided biopsy of intracranial lesions in children, with a small robotic device: a case series. Childs Nerv Syst 2024; 40:1681-1688. [PMID: 38441630 DOI: 10.1007/s00381-024-06349-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/28/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND AND OBJECTIVES Robot-assisted biopsies have gained popularity in the last years. Most robotic procedures are performed with a floor-based robotic arm. Recently, Medtronic Stealth Autoguide, a miniaturized robotic arm that work together with an optical neuronavigation system, was launched. Its application in pediatric cases is relatively unexplored. In this study, we retrospectively report our experience using the Stealth Autoguide, for frameless stereotactic biopsies in pediatric patients. METHODS Pediatric patients who underwent stereotactic biopsy using the Stealth Autoguide cranial robotic platform from July 2020 to May 2023 were included in this study. Clinical, neuroradiological, surgical, and histological data were collected and analyzed. RESULTS Nineteen patients underwent 20 procedures (mean age was 9-year-old, range 1-17). In four patients, biopsy was part of a more complex surgical procedure (laser interstitial thermal therapy - LITT). The most common indication was diffuse intrinsic brain stem tumor, followed by diffuse supratentorial tumor. Nine procedures were performed in prone position, eight in supine position, and three in lateral position. Facial surface registration was adopted in six procedures, skull-fixed fiducials in 14. The biopsy diagnostic tissue acquisition rate was 100% in the patients who underwent only biopsy, while in the biopsy/LITT group, one case was not diagnostic. No patients developed clinically relevant postoperative complications. CONCLUSION The Stealth Autoguide system has proven to be safe, diagnostic, and highly accurate in performing stereotactic biopsies for both supratentorial and infratentorial lesions in the pediatric population.
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Affiliation(s)
- Pietro Spennato
- Department of Neurosciences, Division of Neurosurgery, Santobono-Pausilipon Children's Hospital, Via Mario Fiore 6, 80121, Naples, Italy.
| | - Marianna Di Costanzo
- Department of Neurosciences, Division of Neurosurgery, Santobono-Pausilipon Children's Hospital, Via Mario Fiore 6, 80121, Naples, Italy
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giuseppe Mirone
- Department of Neurosciences, Division of Neurosurgery, Santobono-Pausilipon Children's Hospital, Via Mario Fiore 6, 80121, Naples, Italy
| | - Domenico Cicala
- Department of Neurosciences, Division of Neuroradiology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Lucia De Martino
- Department of Onco-Hematology, Unit of Neuro-oncology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Nicola Onorini
- Department of Neurosciences, Division of Neurosurgery, Santobono-Pausilipon Children's Hospital, Via Mario Fiore 6, 80121, Naples, Italy
| | - Claudio Ruggiero
- Department of Neurosciences, Division of Neurosurgery, Santobono-Pausilipon Children's Hospital, Via Mario Fiore 6, 80121, Naples, Italy
| | - Giuseppe Cinalli
- Department of Neurosciences, Division of Neurosurgery, Santobono-Pausilipon Children's Hospital, Via Mario Fiore 6, 80121, Naples, Italy
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Sharma A, Song R, Sarmey N, Harasimchuk S, Bulacio J, Pucci F, Rammo R, Bingaman W, Serletis D. Validation and Safety Profile of a Novel, Noninvasive Fiducial Attachment for Stereotactic Robotic-Guided Stereoelectroencephalography: A Case Series. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01137. [PMID: 38651866 DOI: 10.1227/ons.0000000000001148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/06/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES We developed, tested, and validated a novel, noninvasive, Leksell G frame-based fiducial attachment, for use in stereotactic registration for stereoelectroencephalography (sEEG). Use of the device increased the number of fixed reference points available for registration, while obviating the need for additional scalp incisions. We report here on our experience and safety profile of using the device. METHODS We collected registration data using the fiducial device across 25 adult and pediatric patients with epilepsy consecutively undergoing robotic-guided sEEG for invasive epilepsy monitoring, treated between May 2022 and July 2023. ROSA One Brain was used for trajectory planning and electrode implantation. Postoperative clinical and radiographic data were computed and quantified, including mean registration error for all patients. Entry point, target point (TP), and angular errors were measured. Descriptive statistics and correlation coefficients for error were calculated. RESULTS Twenty-five patients underwent robotic-guided sEEG implantation (11 patients, bilateral; 10 patients, left unilateral; 4 patients, right). The mean number of electrodes per patient was 18 ± 3. The average mean registration error was 0.77 ± 0.11 mm. All patients were implanted with Ad-Tech depth electrodes. No clinically relevant complications were reported. Analysis of trajectory error was performed on 446 electrodes. The median entry point error was 1.03 mm (IQR 0.69-1.54). The median TP error was 2.26 mm (IQR 1.63-2.93). The mean angular error was 0.03 radians (IQR 0.02-0.05). There was no significant correlation between root mean square error and lead error. Root mean square error did not appreciably change over time, nor were there any significant changes in average angular, entry point, or TP error metrics. CONCLUSION A novel, noninvasive, Leksell G frame-based fiducial attachment was developed, tested, and validated, facilitating O-arm-based stereotactic registration for sEEG. This simple innovation maintained an excellent accuracy and safety profile for sEEG procedures in epilepsy patients, with the added advantages of providing additional reference points for stereotactic registration, without requiring additional scalp incisions.
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Affiliation(s)
- Akshay Sharma
- Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ryan Song
- Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Nehaw Sarmey
- Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stephen Harasimchuk
- Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Juan Bulacio
- Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francesco Pucci
- Department of Neurosurgery, University of Illinois, Chicago, Chicago, Illinois, USA
| | - Richard Rammo
- Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - William Bingaman
- Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Demitre Serletis
- Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
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Kaewborisutsakul A, Chernov M, Yokosako S, Kubota Y. Usefulness of Robotic Stereotactic Assistance (ROSA ®) Device for Stereoelectroencephalography Electrode Implantation: A Systematic Review and Meta-analysis. Neurol Med Chir (Tokyo) 2024; 64:71-86. [PMID: 38220166 PMCID: PMC10918457 DOI: 10.2176/jns-nmc.2023-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/17/2023] [Indexed: 01/16/2024] Open
Abstract
The aim of this study was to systematically review and meta-analyze the efficiency and safety of using the Robotic Stereotactic Assistance (ROSA®) device (Zimmer Biomet; Warsaw, IN, USA) for stereoelectroencephalography (SEEG) electrode implantation in patients with drug-resistant epilepsy. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature search was carried out. Overall, 855 nonduplicate relevant articles were determined, and 15 of them were selected for analysis. The benefits of the ROSA® device use in terms of electrode placement accuracy, as well as operative time length, perioperative complications, and seizure outcomes, were evaluated. Studies that were included reported on a total of 11,257 SEEG electrode implantations. The limited number of comparative studies hindered the comprehensive evaluation of the electrode implantation accuracy. Compared with frame-based or navigation-assisted techniques, ROSA®-assisted SEEG electrode implantation provided significant benefits for reduction of both overall operative time (mean difference [MD], -63.45 min; 95% confidence interval [CI] from -88.73 to -38.17 min; P < 0.00001) and operative time per implanted electrode (MD, -8.79 min; 95% CI from -14.37 to -3.21 min; P = 0.002). No significant differences existed in perioperative complications and seizure outcomes after the application of the ROSA® device and other techniques for electrode implantation. To conclude, the available evidence shows that the ROSA® device is an effective and safe surgical tool for trajectory-guided SEEG electrode implantation in patients with drug-resistant epilepsy, offering benefits for saving operative time and neither increasing the risk of perioperative complications nor negatively impacting seizure outcomes.
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Affiliation(s)
- Anukoon Kaewborisutsakul
- Neurological Surgery Unit, Division of Surgery, Faculty of Medicine, Prince of Songkla University
- Department of Neurosurgery, Tokyo Women's Medical University Adachi Medical Center
| | - Mikhail Chernov
- Department of Neurosurgery, Tokyo Women's Medical University Adachi Medical Center
| | - Suguru Yokosako
- Department of Neurosurgery, Tokyo Women's Medical University Adachi Medical Center
| | - Yuichi Kubota
- Department of Neurosurgery, Tokyo Women's Medical University Adachi Medical Center
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Niznik T, Grossen A, Shi H, Stephens M, Herren C, Desai VR. Learning Curve in Robotic Stereoelectroencephalography: Single Platform Experience. World Neurosurg 2024; 182:e442-e452. [PMID: 38030071 DOI: 10.1016/j.wneu.2023.11.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Learning curve, training, and cost impede widespread implementation of new technology. Neurosurgical robotic technology introduces challenges to visuospatial reasoning and requires the acquisition of new fine motor skills. Studies detailing operative workflow, learning curve, and patient outcomes are needed to describe the utility and cost-effectiveness of new robotic technology. METHODS A retrospective analysis was performed of pediatric patients who underwent robotic stereoelectroencephalography (sEEG) with the Medtronic Stealth Autoguide. Workflow, total operative time, and time per electrode were evaluated alongside target accuracy assessed via error measurements and root sum square. Patient demographics and clinical outcomes related to sEEG were also assessed. RESULTS Robot-assisted sEEG was performed in 12 pediatric patients. Comparison of cases over time demonstrated a mean operative time of 363.3 ± 109.5 minutes for the first 6 cases and 256.3 ± 59.1 minutes for the second 6 cases, with reduced operative time per electrode (P = 0.037). Mean entry point error, target point error, and depth point error were 1.82 ± 0.77 mm, 2.26 ± 0.71 mm, and 1.27 ± 0.53 mm, respectively, with mean root sum square of 3.23 ± 0.97 mm. Error measurements between magnetic resonance imaging and computed tomography angiography found computed tomography angiography to be more accurate with significant differences in mean entry point error (P = 0.043) and mean target point error (P = 0.035). The epileptogenic zone was identified in 11 patients, with therapeutic surgeries following in 9 patients, of whom 78% achieved an Engel class I. CONCLUSIONS This study demonstrated institutional workflow evolution and learning curve for the Autoguide in pediatric sEEG, resulting in reduced operative times and increased accuracy over a small number of cases. The platform may seamlessly and quickly be incorporated into clinical practice, and the provided workflow can facilitate a smooth transition.
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Affiliation(s)
- Taylor Niznik
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Neurosurgery, Section of Pediatric Neurosurgery, Oklahoma Children's Hospital, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma, USA
| | - Audrey Grossen
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Neurosurgery, Section of Pediatric Neurosurgery, Oklahoma Children's Hospital, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma, USA
| | - Helen Shi
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Neurosurgery, Section of Pediatric Neurosurgery, Oklahoma Children's Hospital, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma, USA
| | - Mark Stephens
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Neurosurgery, Section of Pediatric Neurosurgery, Oklahoma Children's Hospital, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma, USA
| | - Cherie Herren
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Virendra R Desai
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Neurosurgery, Section of Pediatric Neurosurgery, Oklahoma Children's Hospital, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma, USA.
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Anderson W, Ponce FA, Kinsman MJ, Sani S, Hwang B, Ghinda D, Kogan M, Mahoney JM, Amin DB, Van Horn M, McGuckin JP, Razo-Castaneda D, Bucklen BS. Robotic-Assisted Navigation for Stereotactic Neurosurgery: A Cadaveric Investigation of Accuracy, Time, and Radiation. Oper Neurosurg (Hagerstown) 2023; 26:01787389-990000000-00991. [PMID: 38054727 PMCID: PMC11008650 DOI: 10.1227/ons.0000000000001024] [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: 08/14/2023] [Accepted: 10/18/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite frequent use, stereotactic head frames require manual coordinate calculations and manual frame settings that are associated with human error. This study examines freestanding robot-assisted navigation (RAN) as a means to reduce the drawbacks of traditional cranial stereotaxy and improve targeting accuracy. METHODS Seven cadaveric human torsos with heads were tested with 8 anatomic coordinates selected for lead placement mirrored in each hemisphere. Right and left hemispheres of the brain were randomly assigned to either the traditional stereotactic arc-based (ARC) group or the RAN group. Both target accuracy and trajectory accuracy were measured. Procedural time and the radiation required for registration were also measured. RESULTS The accuracy of the RAN group was significantly greater than that of the ARC group in both target (1.2 ± 0.5 mm vs 1.7 ± 1.2 mm, P = .005) and trajectory (0.9 ± 0.6 mm vs 1.3 ± 0.9 mm, P = .004) measurements. Total procedural time was also significantly faster for the RAN group than for the ARC group (44.6 ± 7.7 minutes vs 86.0 ± 12.5 minutes, P < .001). The RAN group had significantly reduced time per electrode placement (2.9 ± 0.9 minutes vs 5.8 ± 2.0 minutes, P < .001) and significantly reduced radiation during registration (1.9 ± 1.1 mGy vs 76.2 ± 5.0 mGy, P < .001) compared with the ARC group. CONCLUSION In this cadaveric study, cranial leads were placed faster and with greater accuracy using RAN than those placed with conventional stereotactic arc-based technique. RAN also required significantly less radiation to register the specimen's coordinate system to the planned trajectories. Clinical testing should be performed to further investigate RAN for stereotactic cranial surgery.
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Affiliation(s)
- William Anderson
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Francisco A. Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael J. Kinsman
- Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sepehr Sani
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian Hwang
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
- Current Affiliation: Orange County Neurosurgical Associates, Laguna Hills, California, USA
| | - Diana Ghinda
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Michael Kogan
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Jonathan M. Mahoney
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, Pennsylvania, USA
| | - Dhara B. Amin
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, Pennsylvania, USA
| | - Margaret Van Horn
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, Pennsylvania, USA
| | - Joshua P. McGuckin
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, Pennsylvania, USA
| | - Dominic Razo-Castaneda
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | - Brandon S. Bucklen
- Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, Pennsylvania, USA
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Mahmoudian B, Dalal H, Lau J, Corrigan B, Abbas M, Barker K, Rankin A, Chen ECS, Peters T, Martinez-Trujillo JC. A method for chronic and semi-chronic microelectrode array implantation in deep brain structures using image guided neuronavigation. J Neurosci Methods 2023; 397:109948. [PMID: 37572883 DOI: 10.1016/j.jneumeth.2023.109948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/17/2023] [Accepted: 08/09/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Accurate targeting of brain structures for in-vivo electrophysiological recordings is essential for basic as well as clinical neuroscience research. Although methodologies for precise targeting and recording from the cortical surface are abundant, such protocols are scarce for deep brain structures. NEW METHOD We have incorporated stable fiducial markers within a custom cranial cap for improved image-guided neuronavigation targeting of subcortical structures in macaque monkeys. Anchor bolt chambers allowed for a minimally invasive entrance into the brain for chronic recordings. A 3D-printed microdrive allowed for semi-chronic applications. RESULTS We achieved an average Euclidean targeting error of 1.6 mm and a radial error of 1.2 mm over three implantations in two animals. Chronic and semi-chronic implantations allowed for recording of extracellular neuronal activity, with single-neuron activity examples shown from one macaque monkey. COMPARISON WITH EXISTING METHOD(S) Traditional stereotactic methods ignore individual anatomical variability. Our targeting approach allows for a flexible, subject-specific surgical plan with targeting errors lower than what is reported in humans, and equal to or lower than animal models using similar methods. Utilizing an anchor bolt as a chamber reduced the craniotomy size needed for electrode implantation, compared to conventional large access chambers which are prone to infection. Installation of an in-house, 3D-printed, screw-to-mount mechanical microdrive is in contrast to existing semi-chronic methods requiring fabrication, assembly, and installation of complex parts. CONCLUSIONS Leveraging commercially available tools for implantation, our protocol decreases the risk of infection from open craniotomies, and improves the accuracy of chronic electrode implantations targeting deep brain structures in large animal models.
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Affiliation(s)
- Borna Mahmoudian
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Robarts Research Institute and Brain and Mind Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada
| | - Hitarth Dalal
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Robarts Research Institute and Brain and Mind Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada
| | - Jonathan Lau
- Department of Clinical Neurological Sciences, Division of Neurosurgery, London Health Sciences Centre, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada; School of Biomedical Engineering, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada; Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada
| | - Benjamin Corrigan
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Robarts Research Institute and Brain and Mind Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada
| | - Mohamad Abbas
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Robarts Research Institute and Brain and Mind Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada; Department of Clinical Neurological Sciences, Division of Neurosurgery, London Health Sciences Centre, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada
| | | | - Adam Rankin
- Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada
| | - Elvis C S Chen
- School of Biomedical Engineering, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada; Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada; Department of Medical Biophysics, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada; Lawson Health Research Institute, 750 Base Line Road East Suite 300, London, ON N6C2R5, Canada; Department of Electrical and Computer Engineering, Thompson Engineering Building, University of Western Ontario, London, ON, N6A 5B9, Canada
| | - Terry Peters
- Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada; Center for Functional and Metabolic Mapping, Robarts Research Institute, Department of Medical Biophysics and Brain and Mind Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada
| | - Julio C Martinez-Trujillo
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Robarts Research Institute and Brain and Mind Institute, University of Western Ontario, 1151 Richmond St. N., London, ON N6A 5B7, Canada; Lawson Health Research Institute, 750 Base Line Road East Suite 300, London, ON N6C2R5, Canada.
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Pivazyan G, Sandhu FA, Beaufort AR, Cunningham BW. Basis for error in stereotactic and computer-assisted surgery in neurosurgical applications: literature review. Neurosurg Rev 2022; 46:20. [PMID: 36536143 DOI: 10.1007/s10143-022-01928-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 11/29/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
Technological advancements in optoelectronic motion capture systems have allowed for the development of high-precision computer-assisted surgery (CAS) used in cranial and spinal surgical procedures. Errors generated sequentially throughout the chain of components of CAS may have cumulative effect on the accuracy of implant and instrumentation placement - potentially affecting patient outcomes. Navigational integrity and maintenance of fidelity of optoelectronic data is the cornerstone of CAS. Error reporting measures vary between studies. Understanding error generation, mechanisms of propagation, and how they relate to workflow can assist clinicians in error mitigation and improve accuracy during navigation in neurosurgical procedures. Diligence in planning, fiducial positioning, system registration, and intra-operative workflow have the potential to improve accuracy and decrease disparity between planned and final instrumentation and implant position. This study reviews the potential errors associated with each step in computer-assisted surgery and provides a basis for disparity in intrinsic accuracy versus achieved accuracy in the clinical operative environment.
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Affiliation(s)
- Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA.
- Musculoskeletal Education Center, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA.
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | | | - Bryan W Cunningham
- Musculoskeletal Education Center, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Abstract
The transition to performing procedures robotically generally entails a period of adjustment known as a learning curve as the surgeon develops a familiarity with the technology. However, no study has comprehensively examined robotic learning curves across the field of neurosurgery. We conducted a systematic review to characterize the scope of literature on robotic learning curves in neurosurgery, assess operative parameters that may involve a learning curve, and delineate areas for future investigation. PubMed, Embase, and Scopus were searched. Following deduplication, articles were screened by title and abstract for relevance. Remaining articles were screened via full text for final inclusion. Bibliographic and learning curve data were extracted. Of 746 resultant articles, 32 articles describing 3074 patients were included, of which 23 (71.9%) examined spine, 4 (12.5%) pediatric, 4 (12.5%) functional, and 1 (3.1%) general neurosurgery. The parameters assessed for learning curves were heterogeneous. In total, 8 (57.1%) of 14 studies found reduced operative time with increased cases, while the remainder demonstrated no learning curve. Six (60.0%) of 10 studies reported reduced operative time per component with increased cases, while the remainder indicated no learning curve. Radiation time, radiation time per component, robot time, registration time, setup time, and radiation dose were assessed by ≤ 4 studies each, with 0-66.7% of studies demonstrated a learning curve. Four (44.4%) of 9 studies on accuracy showed improvement over time, while the others indicated no improvement over time. The number of cases required to reverse the learning curve ranged from 3 to 75. Learning curves are common in robotic neurosurgery. However, existing studies demonstrate high heterogeneity in assessed parameters and the number of cases that comprise the learning curve. Future studies should seek to develop strategies to reduce the number of cases required to reach the learning curve.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL, 60611, USA.
| | - Jonathan Huang
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL, 60611, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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Del Bene M, Carone G, Porto E, Barbotti A, Messina G, Tringali G, Rossi D, Lanteri P, Togni R, Demichelis G, Aquino D, Doniselli FM, DiMeco F, Casali C. Neurophysiology-Guided Laser Interstitial Thermal Therapy: A Synergistic Approach For Motor Function Preservation. Technical Note. World Neurosurg 2022; 168:165-172. [DOI: 10.1016/j.wneu.2022.09.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/22/2022]
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11
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Secoli R, Matheson E, Pinzi M, Galvan S, Donder A, Watts T, Riva M, Zani DD, Bello L, Rodriguez y Baena F. Modular robotic platform for precision neurosurgery with a bio-inspired needle: System overview and first in-vivo deployment. PLoS One 2022; 17:e0275686. [PMID: 36260553 PMCID: PMC9581417 DOI: 10.1371/journal.pone.0275686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/22/2022] [Indexed: 11/23/2022] Open
Abstract
Over the past 10 years, minimally invasive surgery (MIS) has shown significant benefits compared to conventional surgical techniques, with reduced trauma, shorter hospital stays, and shorter patient recovery times. In neurosurgical MIS procedures, inserting a straight tool (e.g. catheter) is common practice in applications ranging from biopsy and laser ablation, to drug delivery and fluid evacuation. How to handle tissue deformation, target migration and access to deep-seated anatomical structures remain an open challenge, affecting both the preoperative planning phase and eventual surgical intervention. Here, we present the first neurosurgical platform in the literature, able to deliver an implantable steerable needle for a range of diagnostic and therapeutic applications, with a short-term focus on localised drug delivery. This work presents the system's architecture and first in vivo deployment with an optimised surgical workflow designed for pre-clinical trials with the ovine model, which demonstrate appropriate function and safe implantation.
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Affiliation(s)
- Riccardo Secoli
- The Mechatronics in Medicine Lab, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
- * E-mail:
| | - Eloise Matheson
- The Mechatronics in Medicine Lab, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Marlene Pinzi
- The Mechatronics in Medicine Lab, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Stefano Galvan
- The Mechatronics in Medicine Lab, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Abdulhamit Donder
- The Mechatronics in Medicine Lab, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Thomas Watts
- The Mechatronics in Medicine Lab, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Marco Riva
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Istituto di Ricovero e Cura a Carattere Scientifico Humanitas Research Hospital Rozzano, Rozzano, Italy
| | - Davide Danilo Zani
- Department of Veterinary Medicine, Universitá degli Studi di Milano, Lodi, Italy
| | - Lorenzo Bello
- Department of Oncology and Hematology-Oncology, Universitá degli Studi di Milano, Milan, Italy
| | - Ferdinando Rodriguez y Baena
- The Mechatronics in Medicine Lab, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
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12
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Singh R, Wang K, Qureshi MB, Rangel IC, Brown NJ, Shahrestani S, Gottfried ON, Patel NP, Bydon M. Robotics in neurosurgery: Current prevalence and future directions. Surg Neurol Int 2022; 13:373. [PMID: 36128120 PMCID: PMC9479589 DOI: 10.25259/sni_522_2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/31/2022] [Indexed: 12/03/2022] Open
Abstract
Background: The first instance of a robotic-assisted surgery occurred in neurosurgery; however, it is now more common in other fields such as urology and gynecology. This study aims to characterize the prevalence of robotic surgery among current neurosurgery programs as well as identify trends in clinical trials pertaining to robotic neurosurgery. Methods: Each institution’s website was analyzed for the mention of a robotic neurosurgery program and procedures. The future potential of robotics in neurosurgery was assessed by searching for current clinical trials pertaining to neurosurgical robotic surgery. Results: Of the top 100 programs, 30 offer robotic cranial and 40 offer robotic spinal surgery. No significant differences were observed with robotic surgical offerings between geographic regions in the US. Larger programs (faculty size 16 or over) had 20 of the 30 robotic cranial programs (66.6%), whereas 21 of the 40 robotic spinal programs (52.5%) were at larger programs. An initial search of clinical trials revealed 223 studies, of which only 13 pertained to robotic neurosurgery. Spinal fixation was the most common intervention (six studies), followed by Deep Brain Stimulation (DBS, two studies), Cochlear implants (two studies), laser ablation (LITT, one study), and endovascular embolization (one study). Most studies had industry sponsors (9/13 studies), while only five studies had hospital sponsors. Conclusion: Robotic neurosurgery is still in its infancy with less than half of the top programs offering robotic procedures. Future directions for robotics in neurosurgery appear to be focused on increased automation of stereotactic procedures such as DBS and LITT and robot-assisted spinal surgery.
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Affiliation(s)
- Rohin Singh
- Alix School of Medicine, Mayo Clinic, Scottsdale,
| | - Kendra Wang
- Department of Osteopathic Medicine, A. T. Still University, Mesa,
| | | | | | | | | | | | | | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Rochester, United States
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13
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Raguž M, Dlaka D, Orešković D, Kaštelančić A, Chudy D, Jerbić B, Šekoranja B, Šuligoj F, Švaco M. Frameless stereotactic brain biopsy and external ventricular drainage placement using the RONNA G4 system. J Surg Case Rep 2022; 2022:rjac151. [PMID: 35665400 PMCID: PMC9156034 DOI: 10.1093/jscr/rjac151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/20/2022] [Indexed: 11/17/2022] Open
Abstract
Robot-assisted stereotactic procedures are among the latest technological improvements in neurosurgery. Herein, to the best of our knowledge, we report a first external ventricular drainage (EVD) placement using the RONNA G4 robotic system preformed together with brain biopsy, all in one procedure. A patient was presented with progressive drowsiness, cognitive slowing, poor mobility and incontinent. Magnetic resonance imaging brain scans revealed multicentric process located in the basal ganglia right with extensive vasogenic edema and dilatated ventricular system. Using the RONNAplan software two trajectories were planned: one for brain biopsy on the left side and one for EVD implantation on the right side; the procedures went without complications. The RONNA G4 robotic system is an accurate neurosurgical tool for performing frameless brain biopsies and EVD placement. Further studies are needed in order to enroll a larger patient sample and to calculate the possible placement deviation, and to perform the comparison with other robotic systems.
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Affiliation(s)
- Marina Raguž
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Catholic University of Croatia, School of Medicine, Zagreb, Croatia
| | - Domagoj Dlaka
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Darko Orešković
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Anđelo Kaštelančić
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Darko Chudy
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Department of Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Bojan Jerbić
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Bojan Šekoranja
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Filip Šuligoj
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Marko Švaco
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
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14
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Robertson FC, Wu KC, Sha RM, Amich JM, Lal A, Lee BH, Kirollos RW, Chen MW, Gormley WB. Stereotactic Neurosurgical Robotics With Real-Time Patient Tracking: A Cadaveric Study. Oper Neurosurg (Hagerstown) 2022; 22:425-432. [DOI: 10.1227/ons.0000000000000155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022] Open
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15
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El Ganainy SO, Cijsouw T, Ali MA, Schoch S, Hanafy AS. Stereotaxic-assisted gene therapy in Alzheimer's and Parkinson's diseases: therapeutic potentials and clinical frontiers. Expert Rev Neurother 2022; 22:319-335. [PMID: 35319338 DOI: 10.1080/14737175.2022.2056446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Alzheimer's disease (AD) and Parkinson's disease (PD) are neurodegenerative disorders causing cognitive deficits and motor difficulties in the elderly. Conventional treatments are mainly symptomatic with little ability to halt disease progression. Gene therapies to correct or silence genetic mutations predisposing to AD or PD are currently being developed in preclinical studies and clinical trials, relying mostly on systemic delivery, which reduces their effectiveness. Imaging-guided stereotaxic procedures are used to locally deliver therapeutic cargos to well-defined brain sites, hence raising the question whether stereotaxic-assisted gene therapy has therapeutic potentials. AREAS COVERED The authors summarize the studies that investigated the use of gene therapy in PD and AD in animal and clinical studies over the past five years, with a special emphasis on the combinatorial potential with stereotaxic delivery. The advantages, limitations and futuristic challenges of this technique are discussed. EXPERT OPINION Robotic stereotaxis combined with intraoperative imaging has revolutionized brain surgeries. While gene therapies are bringing huge innovations to the medical field and new hope to AD and PD patients and medical professionals, the efficient and targeted delivery of such therapies is a bottleneck. We propose that careful application of stereotaxic delivery of gene therapies can improve PD and AD management. [Figure: see text].
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Affiliation(s)
- Samar O El Ganainy
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt
| | - Tony Cijsouw
- Institute of Neuropathology, Section for Translational Epilepsy Research, Medical Faculty, University of Bonn, Bonn, Germany
| | - Mennatallah A Ali
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt
| | - Susanne Schoch
- Institute of Neuropathology, Section for Translational Epilepsy Research, Medical Faculty, University of Bonn, Bonn, Germany
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16
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Spyrantis A, Woebbecke T, Rueß D, Constantinescu A, Gierich A, Luyken K, Visser-Vandewalle V, Herrmann E, Gessler F, Czabanka M, Treuer H, Ruge M, Freiman TM. Accuracy of Robotic and Frame-Based Stereotactic Neurosurgery in a Phantom Model. Front Neurorobot 2022; 16:762317. [PMID: 35515711 PMCID: PMC9063629 DOI: 10.3389/fnbot.2022.762317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 03/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background The development of robotic systems has provided an alternative to frame-based stereotactic procedures. The aim of this experimental phantom study was to compare the mechanical accuracy of the Robotic Surgery Assistant (ROSA) and the Leksell stereotactic frame by reducing clinical and procedural factors to a minimum. Methods To precisely compare mechanical accuracy, a stereotactic system was chosen as reference for both methods. A thin layer CT scan with an acrylic phantom fixed to the frame and a localizer enabling the software to recognize the coordinate system was performed. For each of the five phantom targets, two different trajectories were planned, resulting in 10 trajectories. A series of five repetitions was performed, each time based on a new CT scan. Hence, 50 trajectories were analyzed for each method. X-rays of the final cannula position were fused with the planning data. The coordinates of the target point and the endpoint of the robot- or frame-guided probe were visually determined using the robotic software. The target point error (TPE) was calculated applying the Euclidian distance. The depth deviation along the trajectory and the lateral deviation were separately calculated. Results Robotics was significantly more accurate, with an arithmetic TPE mean of 0.53 mm (95% CI 0.41–0.55 mm) compared to 0.72 mm (95% CI 0.63–0.8 mm) in stereotaxy (p < 0.05). In robotics, the mean depth deviation along the trajectory was −0.22 mm (95% CI −0.25 to −0.14 mm). The mean lateral deviation was 0.43 mm (95% CI 0.32–0.49 mm). In frame-based stereotaxy, the mean depth deviation amounted to −0.20 mm (95% CI −0.26 to −0.14 mm), the mean lateral deviation to 0.65 mm (95% CI 0.55–0.74 mm). Conclusion Both the robotic and frame-based approach proved accurate. The robotic procedure showed significantly higher accuracy. For both methods, procedural factors occurring during surgery might have a more relevant impact on overall accuracy.
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Affiliation(s)
- Andrea Spyrantis
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
- *Correspondence: Andrea Spyrantis
| | - Tirza Woebbecke
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Daniel Rueß
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anne Constantinescu
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Andreas Gierich
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Klaus Luyken
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modeling, Goethe University, Frankfurt am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Medical Center Rostock, Rostock, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Harald Treuer
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Maximilian Ruge
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas M. Freiman
- Department of Neurosurgery, Center of Neurology and Neurosurgery (ZNN), University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
- Department of Neurosurgery, University Medical Center Rostock, Rostock, Germany
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17
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Insights into Infusion-Based Targeted Drug Delivery in the Brain: Perspectives, Challenges and Opportunities. Int J Mol Sci 2022; 23:ijms23063139. [PMID: 35328558 PMCID: PMC8949870 DOI: 10.3390/ijms23063139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 01/31/2023] Open
Abstract
Targeted drug delivery in the brain is instrumental in the treatment of lethal brain diseases, such as glioblastoma multiforme, the most aggressive primary central nervous system tumour in adults. Infusion-based drug delivery techniques, which directly administer to the tissue for local treatment, as in convection-enhanced delivery (CED), provide an important opportunity; however, poor understanding of the pressure-driven drug transport mechanisms in the brain has hindered its ultimate success in clinical applications. In this review, we focus on the biomechanical and biochemical aspects of infusion-based targeted drug delivery in the brain and look into the underlying molecular level mechanisms. We discuss recent advances and challenges in the complementary field of medical robotics and its use in targeted drug delivery in the brain. A critical overview of current research in these areas and their clinical implications is provided. This review delivers new ideas and perspectives for further studies of targeted drug delivery in the brain.
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18
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Robot-assisted stereotactic multiple brain abscesses' puncture: technical case report. Acta Neurochir (Wien) 2022; 164:845-851. [PMID: 34410501 DOI: 10.1007/s00701-021-04955-4] [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: 05/19/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
We report a case of multiple brain abscesses' puncture, employing the ROSA™ Brain surgical robot (Zimmer Biomet) and the O-arm® O2 Imaging System (Medtronic). A 51-year-old man was diagnosed with multiple supratentorial ring enhancing cystic lesions consistent with brain abscesses. A neurological deterioration occurred despite broad spectrum antibiotic therapy, due to mass effect of the abscesses. Stereotactic aspiration was performed using the described technique, allowing a single stage puncture of the cerebral lesions. In this case, the robot-assisted and image-guided procedure permitted an accurate, quick, and efficient targeting of the multiple abscesses for drainage.
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19
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Mazur-Hart DJ, Yaghi NK, Shahin MN, Raslan AM. Stealth Autoguide for robotic-assisted laser ablation for lesional epilepsy: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21556. [PMID: 36130560 PMCID: PMC9379759 DOI: 10.3171/case21556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Laser interstitial thermal therapy has been used in tumor and epilepsy surgery to maximize clinical treatment impact while minimizing morbidity. This intervention places a premium on accuracy. With the advent of robotics, neurosurgery is entering a new age of improved accuracy. Here, the authors described the use of robotic-assisted laser placement for the treatment of epileptiform lesions.
OBSERVATIONS
The authors presented a case of a 21-year-old woman with medically intractable epilepsy, localized to left mesial temporal sclerosis and left temporal encephalocele by way of stereotactic electroencephalography, who presented for consideration of surgical intervention. When presented with resection versus laser ablation, the patient opted for laser ablation. The patient received robotic-assisted stereotactic laser ablation (RASLA) using a Stealth Autoguide. The patient was seizure free (10 weeks) after surgical ablation.
LESSONS
RASLA is an effective way to treat epilepsy. Here, the authors reported the first RASLA procedure with a Stealth Autoguide to treat epilepsy. The procedure can be performed effectively and efficiently for multiple epileptic foci without the need for bulkier robotic options or head frames that may interfere with the use of magnetic resonance imaging for heat mapping.
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Affiliation(s)
- David J. Mazur-Hart
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Nasser K. Yaghi
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Maryam N. Shahin
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Ahmed M. Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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20
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Mallereau CH, Chibbaro S, Ganau M, Benmekhbi M, Cebula H, Dannhoff G, Santin MDN, Ollivier I, Chaussemy D, Hugo Coca A, Proust F, Todeschi J. Pushing the boundaries of accuracy and reliability during stereotactic procedures: A prospective study on 526 biopsies comparing the frameless robotic and Image-Guided Surgery systems. J Clin Neurosci 2021; 95:203-212. [PMID: 34933231 DOI: 10.1016/j.jocn.2021.11.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 11/10/2021] [Accepted: 11/27/2021] [Indexed: 01/13/2023]
Abstract
INTRODUCTION A 12-year long, prospective, single center study was conducted, comparing two frameless systems for brain biopsies: ROSA robotic-assisted stereotaxy and BrainLab Varioguide image-guided stereotaxy (Image Guided Surgery, IGS). METHOD All consecutive adult and pediatric patients undergoing frameless brain biopsies were included. Successfully achieving diagnosis was the primary endpoint, analysis of all periprocedural complications was the secondary endpoint, and the tertiary endpoint was the length of the procedure, with the aim of assessing of the learning curve for each operator over time. The results for the ROSA robot and the Varioguide system were compared and benchmarked to data from the literature. RESULTS We performed 526 on 516 patients, 314 with the ROSA robot (Group A) and 212 with the IGS Varioguide (Group B). Histological diagnosis was achieved in 97.4% of cases in Group A, versus 93.3% in Group B (p < 0.05). No statistically significant difference was found for secondary and tertiary endpoints. The complication rate appeared similar between the 2 frameless systems, with a hemorrhagic complications rate of 3.5% in Group A and 4.7% in Group B. Permanent neurological deterioration was only recorded in 0.8% of cases from Group B. Mortality was recorded in 0.3% in Group A and 0.4% in Group B. CONCLUSION This study provides evidence to confirm that robotic surgery lives up to its promises of increased safety, accuracy, and reliability.
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Affiliation(s)
| | - Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Mario Ganau
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Mustapha Benmekhbi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Helene Cebula
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Guillaume Dannhoff
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | | | - Irène Ollivier
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Dominique Chaussemy
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Andres Hugo Coca
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - François Proust
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Julien Todeschi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
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21
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Koizumi S, Shiraishi Y, Makita I, Kadowaki M, Sameshima T, Kurozumi K. A novel technique for fence-post tube placement in glioma using the robot-guided frameless neuronavigation technique under exoscope surgery: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21466. [PMID: 35855488 PMCID: PMC9281438 DOI: 10.3171/case21466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/22/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Robotic technology is increasingly used in neurosurgery. The authors reported a new technique for fence-post tube placement using robot-guided frameless stereotaxic technology with neuronavigation in patients with glioma. OBSERVATIONS Surgery was performed using the StealthStation S8 linked to the Stealth Autoguide cranial robotic guidance platform and a high-resolution three-dimensional (3D) surgical microscope. A surgical plan was created to determine the removal area using fence-post tube placement at the tumor and normal brain tissue boundary. Using this surgical plan, the robotic system allowed quick and accurate fence-post tube positioning, automatic alignment of the needle insertion and measurement positions in the brain, and quick and accurate puncture needle insertion into the brain tumor. Use of a ventricular drainage tube for the outer needle cylinder allowed placement of the puncture needle in a single operation. Furthermore, use of a high-resolution 3D exoscope allowed the surgeon to simultaneously view the surgical field image and the navigation screen with minimal line-of-sight movement, which improved operative safety. The position memory function of the 3D exoscope allowed easy switching between the exoscope and the microscope and optimal field of view adjustment. LESSONS Fence-post tube placement using robot-guided frameless stereotaxic technology, neuronavigation, and an exoscope allows precise glioma resection.
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Affiliation(s)
- Shinichiro Koizumi
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yuki Shiraishi
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Ippei Makita
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Makoto Kadowaki
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Tetsuro Sameshima
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kazuhiko Kurozumi
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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22
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Wang TY, Park C, Dalton T, Rajkumar S, McCray E, Owolo E, Than KD, Abd-El-Barr MM. Robotic navigation in spine surgery: Where are we now and where are we going? J Clin Neurosci 2021; 94:298-304. [PMID: 34863454 DOI: 10.1016/j.jocn.2021.10.034] [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: 04/26/2021] [Revised: 08/31/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
Robotic navigation is a new and rapidly emerging niche within minimally invasive spine surgery. The robotic arms-race began in 2004 and has resulted in no less than four major robotic surgical adjuncts. Current Food and Drug Administration (FDA)-approved applications of robotic navigation are limited to pedicle screw instrumentation, but new indications and experimental applications are rapidly emerging. As with any new technology, robotic navigation must be vetted for clinical efficacy, efficiency, safety, and cost-effectiveness. Given the rapid advancements made on a yearly basis, it is important to make frequent and objective assessments of the available technology. Thus, the authors seek to provide the most up-to-date review of the history, currently available technology, learning curve, novel applications, and cost effectiveness of today's available robotic systems as it relates to spine surgery.
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Affiliation(s)
- Timothy Y Wang
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA.
| | | | - Tara Dalton
- School of Medicine, Duke University, Durham, NC, USA
| | | | - Edwin McCray
- School of Medicine, Duke University, Durham, NC, USA
| | - Edwin Owolo
- School of Medicine, Duke University, Durham, NC, USA
| | - Khoi D Than
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
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23
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Robot assisted laser-interstitial thermal therapy with iSYS1 and Visualase: how I do it. Acta Neurochir (Wien) 2021; 163:3465-3471. [PMID: 34148147 DOI: 10.1007/s00701-021-04883-3] [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: 02/03/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Laser-interstitial thermal therapy (LITT) is an ablative treatment based on a surgically implanted laser-emitting catheter to induce a focal ablation of the pathological tissue. The main indications in neurosurgery are primary brain tumors, metastases, radiation necrosis, and pediatric brain tumors. Several approaches have been proposed to implant the laser-emitting catheter, both in frameless and frame-based conditions. METHODS We report our approach for Robot assisted laser-interstitial thermal therapy of brain lesions with iSYS1 and Visualase (Medtronic). CONCLUSIONS iSYS1 represents a significant adjunct to LITT procedures and may be safely implemented in routine laser-catheter positioning.
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24
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Bichsel O, Oertel MF, Stieglitz LH. Mobile intraoperative CT-assisted frameless stereotactic biopsies achieved single-millimeter trajectory accuracy for deep-seated brain lesions in a sample of 7 patients. BMC Neurol 2021; 21:285. [PMID: 34294075 PMCID: PMC8296727 DOI: 10.1186/s12883-021-02322-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 07/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background Brain biopsies are crucial diagnostic interventions, providing valuable information for treatment and prognosis, but largely depend on a high accuracy and precision. We hypothesized that through the combination of neuronavigation-based frameless stereotaxy and MRI-guided trajectory planning with intraoperative CT examination using a mobile unit, one can achieve a seamlessly integrated approach yielding optimal target accuracy. Methods We analyzed a total of 7 stereotactic biopsy trajectories for a variety of deep-seated locations and different patient positions. After rigid head fixation, an intraoperative pre-procedural scan using a mobile CT unit was performed for automatic image fusion with the planning MRI images and a peri-procedural scan with the biopsy cannula in situ for verification of the definite target position. We then evaluated the radial trajectory error. Results Intraoperative scanning, surgery, computerized merging of MRI and CT images as well as trajectory planning were feasible without difficulties and safe in all cases. We achieved a radial trajectory deviation of 0.97 ± 0.39 mm at a trajectory length of 60 ± 12.3 mm (mean ± standard deviation). Repositioning of the biopsy cannula due to inaccurate targeting was not required. Conclusion Intraoperative verification using a mobile CT unit in combination with frameless neuronavigation-guided stereotaxy and pre-operative MRI-based trajectory planning was feasible, safe and highly accurate. The setting enabled single-millimeter accuracy for deep-seated brain lesions and direct detection of intraoperative complications, did not depend on a dedicated operating room and was seamlessly integrated into common stereotactic procedures.
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Affiliation(s)
- Oliver Bichsel
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland. .,Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lennart H Stieglitz
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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25
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Rubino F, Eichberg DG, Cordeiro JG, Di L, Eliahu K, Shah AH, Luther EM, Lu VM, Komotar RJ, Ivan ME. Robotic guidance platform for laser interstitial thermal ablation and stereotactic needle biopsies: a single center experience. J Robot Surg 2021; 16:549-557. [PMID: 34258748 PMCID: PMC8276839 DOI: 10.1007/s11701-021-01278-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/04/2021] [Indexed: 11/28/2022]
Abstract
While laser ablation has become an increasingly important tool in the neurosurgical oncologist's armamentarium, deep seated lesions, and those located near critical structures require utmost accuracy during stereotactic laser catheter placement. Robotic devices have evolved significantly over the past two decades becoming an accurate and safe tool for stereotactic neurosurgery. Here, we present our single center experience with the MedTech ROSA ONE Brain robot for robotic guidance in laser interstitial thermal therapy (LITT) and stereotactic biopsies. We retrospectively analyzed the first 70 consecutive patients treated with ROSA device at a single academic medical center. Forty-three patients received needle biopsy immediately followed by LITT with the catheter placed with robotic guidance and 27 received stereotactic needle biopsy alone. All the procedures were performed frameless with skull bone fiducials for registration. We report data regarding intraoperative details, mortality and morbidity, diagnostic yield and lesion characteristics on MRI. Also, we describe the surgical workflow for both procedures. The mean age was 60.3 ± 15 years. The diagnostic yield was positive in 98.5% (n = 69). Sixty-three biopsies (90%) were supratentorial and seven (10%) were infratentorial. Gliomas represented 54.3% of the patients (n = 38). There were two postoperative deaths (2.8%). No permanent morbidity related to surgery were observed. We did not find intraoperative technical problems with the device. There was no need to reposition the needle after the initial placement. Stereotactic robotic guided placement of laser ablation catheters and biopsy needles is safe, accurate, and can be implemented into a neurosurgical workflow.
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Affiliation(s)
- Franco Rubino
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA.
| | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA
| | - Joacir G Cordeiro
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA
| | - Long Di
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA
| | - Karen Eliahu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA
| | - Evan M Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA.,Sylvester Comprehensive Cancer Center, Miami, FL, 33146, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace (D4-6), Miami, FL, 33146, USA.,Sylvester Comprehensive Cancer Center, Miami, FL, 33146, USA
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26
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Ball T, González-Martínez J, Zemmar A, Sweid A, Chandra S, VanSickle D, Neimat JS, Jabbour P, Wu C. Robotic Applications in Cranial Neurosurgery: Current and Future. Oper Neurosurg (Hagerstown) 2021; 21:371-379. [PMID: 34192764 DOI: 10.1093/ons/opab217] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 05/16/2021] [Indexed: 12/19/2022] Open
Abstract
Robotics applied to cranial surgery is a fast-moving and fascinating field, which is transforming the practice of neurosurgery. With exponential increases in computing power, improvements in connectivity, artificial intelligence, and enhanced precision of accessing target structures, robots are likely to be incorporated into more areas of neurosurgery in the future-making procedures safer and more efficient. Overall, improved efficiency can offset upfront costs and potentially prove cost-effective. In this narrative review, we aim to translate a broad clinical experience into practical information for the incorporation of robotics into neurosurgical practice. We begin with procedures where robotics take the role of a stereotactic frame and guide instruments along a linear trajectory. Next, we discuss robotics in endoscopic surgery, where the robot functions similar to a surgical assistant by holding the endoscope and providing retraction, supplemental lighting, and correlation of the surgical field with navigation. Then, we look at early experience with endovascular robots, where robots carry out tasks of the primary surgeon while the surgeon directs these movements remotely. We briefly discuss a novel microsurgical robot that can perform many of the critical operative steps (with potential for fine motor augmentation) remotely. Finally, we highlight 2 innovative technologies that allow instruments to take nonlinear, predetermined paths to an intracranial destination and allow magnetic control of instruments for real-time adjustment of trajectories. We believe that robots will play an increasingly important role in the future of neurosurgery and aim to cover some of the aspects that this field holds for neurosurgical innovation.
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Affiliation(s)
- Tyler Ball
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.,Department of Neurosurgery, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Science, New Delhi, India
| | | | - Joseph S Neimat
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chengyuan Wu
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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27
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Khanna O, Beasley R, Franco D, DiMaio S. The Path to Surgical Robotics in Neurosurgery. Oper Neurosurg (Hagerstown) 2021; 20:514-520. [PMID: 33982116 DOI: 10.1093/ons/opab065] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/25/2021] [Indexed: 11/15/2022] Open
Abstract
Robotic systems may help efficiently execute complicated tasks that require a high degree of accuracy, and this, in large part, explains why robotics have garnered widespread use in a variety of neurosurgical applications, including intracranial biopsies, spinal instrumentation, and placement of intracranial leads. The use of robotics in neurosurgery confers many benefits, and inherent limitations, to both surgeons and their patients. In this narrative review, we provide a historical overview of robotics and its implementation across various surgical specialties, and discuss the various robotic systems that have been developed specifically for neurosurgical applications. We also discuss the relative advantages of robotic systems compared to traditional surgical techniques, particularly as it pertains to integration of image guidance with the ability of the robotic arm to reliably execute pre-planned tasks. As more neurosurgeons adopt the use of robotics in their practice, we postulate that further technological advancements will become available that will help achieve improved technical capabilities, user experience, and overall patient clinical outcomes.
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Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ryan Beasley
- SimQuest Solutions, Inc., Annapolis, Maryland, USA
| | - Daniel Franco
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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28
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Rotim K, Splavski B, Vrban F. THE SAFETY AND EFFICACY OF ROBOT-ASSISTED STEREOTACTIC BIOPSY FOR BRAIN GLIOMA: EARLIEST INSTITUTIONAL EXPERIENCES AND EVALUATION OF LITERATURE. Acta Clin Croat 2021; 60:296-303. [PMID: 34744281 PMCID: PMC8564848 DOI: 10.20471/acc.2021.60.02.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/27/2021] [Indexed: 11/24/2022] Open
Abstract
Robot-assisted brain tumor biopsy is becoming one of the most important innovative technologies in neurosurgical practice. The idea behind its engagement is to advance the safety and efficacy of the biopsy procedure, which is much in demand when planning the management of endocranial tumor pathology. Herein, we provide our earliest institutional experiences in utilizing this mesmerizing technology. Cranial robotic device was employed for stereotactic robot-assisted brain glioma biopsy in three consecutive patients from our series: an anaplastic isocitrate dehydrogenase (IDH) negative astrocytoma (WHO grade III) located in the right trigone region of the periventricular white matter; a low grade diffuse astrocytoma (WHO grade II) of bilateral thalamic region spreading into the right mesencephalic area; and an IDH-wildtype glioblastoma (WHO grade IV) of the right frontal lobe producing a contralateral midline shifting. Robot-assisted tumor biopsy was successfully performed to get tissue samples for histopathologic and immunohistochemical analysis. The adjacent tissue iatrogenic damage of the eloquent cortical areas was minimal, while the immediate postoperative recovery was satisfactory in all patients. In conclusion, considering the preliminary results of our early experiences, robot-assisted tumor biopsy was proven to be a feasible and accurate procedure when surgery for brain glioma was not an option. It may increase safety and precision, without expanding surgical time, being similarly effective when compared to standard stereotactic and manual biopsy. Using this method to provide accurate sampling for histopathologic and immunohistochemical analysis is a safe and easy way to determine management strategies and outcome of different types of brain glioma.
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Affiliation(s)
| | - Bruno Splavski
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Filip Vrban
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia
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29
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Furlanetti L, Ellenbogen J, Gimeno H, Ainaga L, Narbad V, Hasegawa H, Lin JP, Ashkan K, Selway R. Targeting accuracy of robot-assisted deep brain stimulation surgery in childhood-onset dystonia: a single-center prospective cohort analysis of 45 consecutive cases. J Neurosurg Pediatr 2021; 27:677-687. [PMID: 33862592 DOI: 10.3171/2020.10.peds20633] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is an established treatment for pediatric dystonia. The accuracy of electrode implantation is multifactorial and remains a challenge in this age group, mainly due to smaller anatomical targets in very young patients compared to adults, and also due to anatomical abnormalities frequently associated with some etiologies of dystonia. Data on the accuracy of robot-assisted DBS surgery in children are limited. The aim of the current paper was to assess the accuracy of robot-assisted implantation of DBS leads in a series of patients with childhood-onset dystonia. METHODS Forty-five children with dystonia undergoing implantation of DBS leads under general anesthesia between 2017 and 2019 were included. Robot-assisted stereotactic implantation of the DBS leads was performed. The final position of the electrodes was verified with an intraoperative 3D scanner (O-arm). Coordinates of the planned electrode target and actual electrode position were obtained and compared, looking at the radial error, depth error, absolute error, and directional error, as well as the euclidean distance. Functional assessment data prospectively collected by a multidisciplinary pediatric complex motor disorders team were analyzed with regard to motor skills, individualized goal achievement, and patients' and caregivers' expectations. RESULTS A total of 90 DBS electrodes were implanted and 48.5% of the patients were female. The mean age was 11.0 ± 0.6 years (range 3-18 years). All patients received bilateral DBS electrodes into the globus pallidus internus. The median absolute errors in x-, y-, and z-axes were 0.85 mm (range 0.00-3.25 mm), 0.75 mm (range 0.05-2.45 mm), and 0.75 mm (range 0.00-3.50 mm), respectively. The median euclidean distance from the target to the actual electrode position was 1.69 ± 0.92 mm, and the median radial error was 1.21 ± 0.79. The robot-assisted technique was easily integrated into the authors' surgical practice, improving accuracy and efficiency, and reducing surgical time significantly along the learning curve. No major perioperative complications occurred. CONCLUSIONS Robot-assisted stereotactic implantation of DBS electrodes in the pediatric age group is a safe and accurate surgical method. Greater accuracy was present in this cohort in comparison to previous studies in which conventional stereotactic frame-based techniques were used. Robotic DBS surgery and neuroradiological advances may result in further improvement in surgical targeting and, consequently, in better clinical outcome in the pediatric population.
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Affiliation(s)
- Luciano Furlanetti
- 1Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London.,4King's Health Partners Academic Health Sciences Centre, London, United Kingdom
| | | | - Hortensia Gimeno
- 2Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London.,4King's Health Partners Academic Health Sciences Centre, London, United Kingdom
| | - Laura Ainaga
- 2Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London.,4King's Health Partners Academic Health Sciences Centre, London, United Kingdom
| | - Vijay Narbad
- 1Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London
| | - Harutomo Hasegawa
- 1Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London.,4King's Health Partners Academic Health Sciences Centre, London, United Kingdom
| | - Jean-Pierre Lin
- 2Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London.,4King's Health Partners Academic Health Sciences Centre, London, United Kingdom
| | - Keyoumars Ashkan
- 1Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London.,4King's Health Partners Academic Health Sciences Centre, London, United Kingdom
| | - Richard Selway
- 1Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London.,4King's Health Partners Academic Health Sciences Centre, London, United Kingdom
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30
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Lozada-Martínez I, Maiguel-Lapeira J, Torres-Llinás D, Moscote-Salazar L, Rahman MM, Pacheco-Hernández A. Letter: Need and Impact of the Development of Robotic Neurosurgery in Latin America. Neurosurgery 2021; 88:E580-E581. [PMID: 33822187 DOI: 10.1093/neuros/nyab088] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ivan Lozada-Martínez
- Medical and Surgical Research Center School of Medicine University of Cartagena Cartagena, Colombia.,Latinamerican Council of Neurocritical Care (CLaNi) Cartagena, Colombia.,Colombian Clinical Research Group in Neurocritical Care School of Medicine University of Cartagena Cartagena, Colombia
| | - Juan Maiguel-Lapeira
- Medical and Surgical Research Center School of Medicine University of Cartagena Cartagena, Colombia
| | - Daniela Torres-Llinás
- Medical and Surgical Research Center School of Medicine University of Cartagena Cartagena, Colombia
| | - Luis Moscote-Salazar
- Medical and Surgical Research Center School of Medicine University of Cartagena Cartagena, Colombia.,Latinamerican Council of Neurocritical Care (CLaNi) Cartagena, Colombia.,Colombian Clinical Research Group in Neurocritical Care School of Medicine University of Cartagena Cartagena, Colombia
| | - Md Moshiur Rahman
- Neurosurgery Department Holy Family Red Crescent Medical College Dhaka, Bangladesh
| | - Alfonso Pacheco-Hernández
- Medical and Surgical Research Center School of Medicine University of Cartagena Cartagena, Colombia.,Colombian Clinical Research Group in Neurocritical Care School of Medicine University of Cartagena Cartagena, Colombia
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31
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Dlaka D, Švaco M, Chudy D, Jerbić B, Šekoranja B, Šuligoj F, Vidaković J, Romić D, Raguž M. Frameless stereotactic brain biopsy: A prospective study on robot-assisted brain biopsies performed on 32 patients by using the RONNA G4 system. Int J Med Robot 2021; 17:e2245. [PMID: 33591608 DOI: 10.1002/rcs.2245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/12/2021] [Accepted: 02/12/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND We present a novel robotic neuronavigation system (RONNA G4), used for precise preoperative planning and frameless neuronavigation, developed by a research group from the University of Zagreb and neurosurgeons from the University Hospital Dubrava, Zagreb, Croatia. The aim of study is to provide comprehensive error measurement analysis of the system used for the brain biopsy. METHODS Frameless stereotactic robot-assisted biopsies were performed on 32 consecutive patients. Post-operative CT and MRI scans were assessed to precisely measure and calculate target point error (TPE) and entry point error (EPE). RESULTS The application accuracy of the RONNA system for TPE was 1.95 ± 1.11 mm, while for EPE was 1.42 ± 0.74 mm. The total diagnostic yield was 96.87%. Linear regression showed statistical significance between the TPE and EPE, and the angle of the trajectory on the bone. CONCLUSION The RONNA G4 robotic system is a precise and highly accurate autonomous neurosurgical assistant for performing frameless brain biopsies.
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Affiliation(s)
- Domagoj Dlaka
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Marko Švaco
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Darko Chudy
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Croatian Institute for Brain Research, School of Medicine University of Zagreb, Zagreb, Croatia.,Department of Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Bojan Jerbić
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Bojan Šekoranja
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Filip Šuligoj
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Josip Vidaković
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Dominik Romić
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Marina Raguž
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Croatian Institute for Brain Research, School of Medicine University of Zagreb, Zagreb, Croatia
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32
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Fong AJ, Stewart CL, Lafaro K, LaRocca CJ, Fong Y, Femino JD, Crawford B. Robotic assistance for quick and accurate image-guided needle placement. Updates Surg 2021; 73:1197-1201. [PMID: 33394359 DOI: 10.1007/s13304-020-00956-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 11/29/2022]
Abstract
Computed tomography (CT) image-guided procedures including biopsy, drug delivery, and ablation are gaining increasing application in medicine. Robotic technology holds the promise for allowing surgeons, and other proceduralists, access to such CT-guided procedures by potentially shortening training, improving accuracy, decreasing needle passes, and reducing radiation exposure. We evaluated surgeon learning and proficiency for image-guided needle placement with an FDA-cleared robotic arm. Five out of six surgeons had no prior CT-guided procedural experience, while one had prior experience with freehand CT-guided needle placement. All surgeons underwent a 60-min training with the MAXIO robot (Perfint Healthcare, Redmond, WA). The robot was used to place needles into three different pre-specified targets on a spine model. Performance time, procedural errors, and needle placement accuracy were recorded. All participants successfully placed needles into the targets using the robotic arm. The average time for needle placement was 3:44 ± 1:43 min. Time for needle placement decreased with subsequent attempts, with average third placement taking 2:29 ± 1:51 min less than the first attempt. The average vector distance from the target was 2.3 ± 1.2 mm. One error resulted in the need for reimaging by CT scan. No errant needle placement occurred. Surgeons (attending fellows and residents) without previous experience and minimal training could successfully place percutaneous needles under CT guidance quickly, accurately, and reproducibly using a robotic arm. This suggests that robotic technology may be used to facilitate surgeon adoption of CT image-guided needle-based procedures in the future.
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Affiliation(s)
- Abigail J Fong
- Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Camille L Stewart
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Kelly Lafaro
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Christopher J LaRocca
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA.
| | - Joseph D Femino
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
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33
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Zanello M, Roux A, Senova S, Peeters S, Edjlali M, Tauziede-Espariat A, Dezamis E, Parraga E, Zah-Bi G, Harislur M, Oppenheim C, Sauvageon X, Chretien F, Devaux B, Varlet P, Pallud J. Robot-Assisted Stereotactic Biopsies in 377 Consecutive Adult Patients with Supratentorial Diffuse Gliomas: Diagnostic Yield, Safety, and Postoperative Outcomes. World Neurosurg 2021; 148:e301-e313. [PMID: 33412330 DOI: 10.1016/j.wneu.2020.12.127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple biopsy samples are warranted for the histomolecular diagnosis of diffuse gliomas in the current molecular era, which possibly increases morbidity. OBJECTIVE We assessed diagnostic yield, safety, and risk factors of postoperative morbidity after robot-assisted serial stereotactic biopsy sampling along 1 biopsy trajectory for diffuse gliomas. METHODS Observational retrospective analysis of consecutive magnetic resonance imaging-based robot-assisted stereotactic biopsies performed at a single institution to assess the diagnosis of nonresectable newly diagnosed supratentorial diffuse gliomas in adults (2006-2016). RESULTS In 377 patients, 4.2 ± 1.9 biopsy samples were obtained at 2.6 ± 1.2 biopsy sites. The histopathologic diagnosis was obtained in 98.7% of cases. Preoperative neurologic deficit (P = 0.030), biopsy site hemorrhage ≥20 mm (P = 0.004), and increased mass effect on postoperative imaging (P = 0.014) were predictors of a new postoperative neurologic deficit (7.7%). Postoperative neurologic deficit (P < 0.001) and increased mass effect on postoperative imaging (P = 0.014) were predictors of a Karnofsky Performance Status decrease ≥20 points postoperatively (4.0%). Increased intracranial pressure preoperatively (P = 0.048) and volume of the contrast-enhanced area ≥13 cm3 (P = 0.048) were predictors of an increased mass effect on postoperative imaging (4.4%). Preoperative Karnofsky Performance Status <70 (P = 0.045) and increased mass effect on postoperative imaging (P < 0.001) were predictors of mortality 1 month postoperatively (2.9%). Preoperative neurologic deficit (P = 0.005), preoperative Karnofsky Performance Status <70 (P < 0.001), subventricular zone contact (P = 0.004), contrast enhancement (P = 0.018), and steroid use (P = 0.003), were predictors of the inability to discharge to home postoperatively (37.0%). CONCLUSIONS Robot-assisted stereotactic biopsy sampling results in high diagnostic accuracy with low complication rates. Multiple biopsy sites and samples do not increase postoperative complications.
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Affiliation(s)
- Marc Zanello
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France; Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM, IMA-BRAIN, Paris, France
| | - Alexandre Roux
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France; Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM, IMA-BRAIN, Paris, France
| | - Suhan Senova
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France; Neurosurgery Department, Assistance Publique-Hôpitaux de Paris (APHP), Groupe Henri-Mondor Albert-Chenevier, PePsy Department, Créteil, France; INSERM IMR, Université de Paris, Faculté de Médecine, Créteil, France
| | - Sophie Peeters
- Department of Neurosurgery, University of California-Los Angeles, Los Angeles, California, USA
| | - Myriam Edjlali
- Université de Paris, Paris, France; Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM, IMA-BRAIN, Paris, France; Department of Neuroradiology, GHU site Sainte-Anne, Paris, France
| | - Arnault Tauziede-Espariat
- Université de Paris, Paris, France; Department of Neuropathology, GHU site Sainte-Anne, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France
| | - Eduardo Parraga
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France
| | - Gilles Zah-Bi
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France
| | - Marc Harislur
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France
| | - Catherine Oppenheim
- Université de Paris, Paris, France; Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM, IMA-BRAIN, Paris, France; Department of Neurosurgery, University of California-Los Angeles, Los Angeles, California, USA
| | - Xavier Sauvageon
- Université de Paris, Paris, France; Department of Neuro-Anaesthesia and Neuro-Intensive Care, GHU site Sainte-Anne, Paris, France
| | - Fabrice Chretien
- Université de Paris, Paris, France; Department of Neuropathology, GHU site Sainte-Anne, Paris, France
| | - Bertrand Devaux
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France
| | - Pascale Varlet
- Université de Paris, Paris, France; Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM, IMA-BRAIN, Paris, France; Department of Neuropathology, GHU site Sainte-Anne, Paris, France
| | - Johan Pallud
- Department of Neurosurgery, GHU site Sainte-Anne, Paris, France; Université de Paris, Paris, France; Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM, IMA-BRAIN, Paris, France.
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Karas PJ, Giridharan N, Treiber JM, Prablek MA, Khan AB, Shofty B, Krishnan V, Chu J, Van Ness PC, Maheshwari A, Haneef Z, Gavvala JR, Sheth SA. Accuracy and Workflow Improvements for Responsive Neurostimulation Hippocampal Depth Electrode Placement Using Robotic Stereotaxy. Front Neurol 2020; 11:590825. [PMID: 33424745 PMCID: PMC7793880 DOI: 10.3389/fneur.2020.590825] [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] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/19/2020] [Indexed: 01/06/2023] Open
Abstract
Background: Robotic stereotaxy is increasingly common in epilepsy surgery for the implantation of stereo-electroencephalography (sEEG) electrodes for intracranial seizure monitoring. The use of robots is also gaining popularity for permanent stereotactic lead implantation applications such as in deep brain stimulation and responsive neurostimulation (RNS) procedures. Objective: We describe the evolution of our robotic stereotactic implantation technique for placement of occipital-approach hippocampal RNS depth leads. Methods: We performed a retrospective review of 10 consecutive patients who underwent robotic RNS hippocampal depth electrode implantation. Accuracy of depth lead implantation was measured by registering intraoperative post-implantation fluoroscopic CT images and post-operative CT scans with the stereotactic plan to measure implantation accuracy. Seizure data were also collected from the RNS devices and analyzed to obtain initial seizure control outcome estimates. Results: Ten patients underwent occipital-approach hippocampal RNS depth electrode placement for medically refractory epilepsy. A total of 18 depth electrodes were included in the analysis. Six patients (10 electrodes) were implanted in the supine position, with mean target radial error of 1.9 ± 0.9 mm (mean ± SD). Four patients (8 electrodes) were implanted in the prone position, with mean radial error of 0.8 ± 0.3 mm. The radial error was significantly smaller when electrodes were implanted in the prone position compared to the supine position (p = 0.002). Early results (median follow-up time 7.4 months) demonstrate mean seizure frequency reduction of 26% (n = 8), with 37.5% achieving ≥50% reduction in seizure frequency as measured by RNS long episode counts. Conclusion: Prone positioning for robotic implantation of occipital-approach hippocampal RNS depth electrodes led to lower radial target error compared to supine positioning. The robotic platform offers a number of workflow advantages over traditional frame-based approaches, including parallel rather than serial operation in a bilateral case, decreased concern regarding human error in setting frame coordinates, and surgeon comfort.
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Affiliation(s)
- Patrick J Karas
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Nisha Giridharan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Jeffrey M Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Marc A Prablek
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - A Basit Khan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Ben Shofty
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Vaishnav Krishnan
- Department of Neurology, Comprehensive Epilepsy Center, Baylor College of Medicine, Houston, TX, United States
| | - Jennifer Chu
- Department of Neurology, Comprehensive Epilepsy Center, Baylor College of Medicine, Houston, TX, United States
| | - Paul C Van Ness
- Department of Neurology, Comprehensive Epilepsy Center, Baylor College of Medicine, Houston, TX, United States
| | - Atul Maheshwari
- Department of Neurology, Comprehensive Epilepsy Center, Baylor College of Medicine, Houston, TX, United States
| | - Zulfi Haneef
- Department of Neurology, Comprehensive Epilepsy Center, Baylor College of Medicine, Houston, TX, United States
| | - Jay R Gavvala
- Department of Neurology, Comprehensive Epilepsy Center, Baylor College of Medicine, Houston, TX, United States
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
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Stumpo V, Staartjes VE, Klukowska AM, Golahmadi AK, Gadjradj PS, Schröder ML, Veeravagu A, Stienen MN, Serra C, Regli L. Global adoption of robotic technology into neurosurgical practice and research. Neurosurg Rev 2020; 44:2675-2687. [PMID: 33252717 PMCID: PMC8490223 DOI: 10.1007/s10143-020-01445-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/23/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
Recent technological advancements have led to the development and implementation of robotic surgery in several specialties, including neurosurgery. Our aim was to carry out a worldwide survey among neurosurgeons to assess the adoption of and attitude toward robotic technology in the neurosurgical operating room and to identify factors associated with use of robotic technology. The online survey was made up of nine or ten compulsory questions and was distributed via the European Association of the Neurosurgical Societies (EANS) and the Congress of Neurological Surgeons (CNS) in February and March 2018. From a total of 7280 neurosurgeons who were sent the survey, we received 406 answers, corresponding to a response rate of 5.6%, mostly from Europe and North America. Overall, 197 neurosurgeons (48.5%) reported having used robotic technology in clinical practice. The highest rates of adoption of robotics were observed for Europe (54%) and North America (51%). Apart from geographical region, only age under 30, female gender, and absence of a non-academic setting were significantly associated with clinical use of robotics. The Mazor family (32%) and ROSA (26%) robots were most commonly reported among robot users. Our study provides a worldwide overview of neurosurgical adoption of robotic technology. Almost half of the surveyed neurosurgeons reported having clinical experience with at least one robotic system. Ongoing and future trials should aim to clarify superiority or non-inferiority of neurosurgical robotic applications and balance these potential benefits with considerations on acquisition and maintenance costs.
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Affiliation(s)
- Vittorio Stumpo
- Machine Intelligence in Clinical Neuroscience (MICN) Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
- School of Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
- Amsterdam UMC, Neurosurgery, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
| | | | - Aida Kafai Golahmadi
- HARMS (Human-centered Automation, Robotics and Monitoring for Surgery) Laboratory, Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Pravesh S Gadjradj
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Neurosurgery, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Marc L Schröder
- Department of Neurosurgery, Bergman Clinics, Amsterdam, The Netherlands
| | - Anand Veeravagu
- Neurosurgery AI Lab, Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Martin N Stienen
- Machine Intelligence in Clinical Neuroscience (MICN) Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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Abstract
Brain metastases (BrM) affect up to 20% of patients with cancer and represent an increasing portion of patients with surgical brain tumors owing to improving prognoses of cancer patients in general and in many cases even of those with brain metastases. With advances in molecular biology and targeted therapy, the indications for neurosurgical sampling and specifically stereotactic biopsy are likely to change in the future. In this review the authors address some of the scientific advances in BrM biology, the clinical rationale and range of techniques currently used to perform stereotactic biopsy, and how the advent of molecular interrogation may potentially alter the way patients with BrM are managed in the future.
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Affiliation(s)
- Kenny K H Yu
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York City, NY 10065, USA
| | - Ankur R Patel
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York City, NY 10065, USA
| | - Nelson S Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York City, NY 10065, USA.
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Li L, Wu J, Ding H, Wang G. A "eye-in-body" integrated surgery robot system for stereotactic surgery. Int J Comput Assist Radiol Surg 2019; 14:2123-2135. [PMID: 31317475 DOI: 10.1007/s11548-019-02032-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Current stereotactic surgical robots system relies on cumbersome operations such as calibration, tracking and registration to establish the accurate intraoperative coordinate transformation chain, which makes the system not easy to use. To overcome this problem, a novel stereotactic surgical robot system has been proposed and validated. METHODS First, a hand-eye integrated scheme is proposed to avoid the intraoperative calibration between robot arm and motion tracking system. Second, a special reference-tool-based patient registration and tracking method is developed to avoid intraoperative registration. Third, a model-free visual servo method is used to reduce the accuracy requirement of hand-eye relationship and robot kinematic model. Finally, a prototype of the system is constructed and performance tests and a pedicle screw drilling experiment are performed. RESULTS The results show that the proposed system has acceptable accuracy. The target positioning error in the plane was - 0.68 ± 0.52 mm and 0.06 ± 0.41 mm. The orientation error was 0.43 ± 0.25°. The pedicle screw drilling experiment shows that the system can complete accurate stereotactic surgery. CONCLUSIONS The stereotactic surgical robot system described in this paper can perform stereotactic surgery without the intraoperative hand-eye calibration and nor manual registration and can achieve an acceptable position and orientation accuracy while tolerating the errors in the hand-eye coordinate transformation error and the robot kinematics model error.
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Affiliation(s)
- Liang Li
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Room C249, Beijing, 100084, People's Republic of China
| | - Julia Wu
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Room C249, Beijing, 100084, People's Republic of China.,Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Hui Ding
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Room C249, Beijing, 100084, People's Republic of China
| | - Guangzhi Wang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Room C249, Beijing, 100084, People's Republic of China.
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Zhu G, Chen Y, Du T, Liu D, Zhang X, Liu Y, Yuan T, Shi L, Zhang J. The Accuracy and Feasibility of Robotic Assisted Lead Implantation in Nonhuman Primates. Neuromodulation 2019; 22:441-450. [DOI: 10.1111/ner.12951] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/14/2019] [Accepted: 02/27/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Guan‐Yu Zhu
- Department of Neurosurgery Beijing Tiantan Hospital, Capital Medical University Beijing China
| | - Ying‐Chuan Chen
- Department of Neurosurgery Beijing Tiantan Hospital, Capital Medical University Beijing China
| | - Ting‐Ting Du
- Department of Functional Neurosurgery Beijing Neurosurgical Institute, Capital Medical University Beijing China
| | - De‐Feng Liu
- Department of Neurosurgery Beijing Tiantan Hospital, Capital Medical University Beijing China
| | - Xin Zhang
- Department of Functional Neurosurgery Beijing Neurosurgical Institute, Capital Medical University Beijing China
| | - Yu‐Ye Liu
- Department of Neurosurgery Beijing Tiantan Hospital, Capital Medical University Beijing China
| | - Tian‐Shuo Yuan
- Department of Neurosurgery Beijing Tiantan Hospital, Capital Medical University Beijing China
| | - Lin Shi
- Department of Neurosurgery Beijing Tiantan Hospital, Capital Medical University Beijing China
| | - Jian‐Guo Zhang
- Department of Neurosurgery Beijing Tiantan Hospital, Capital Medical University Beijing China
- Department of Functional Neurosurgery Beijing Neurosurgical Institute, Capital Medical University Beijing China
- Beijing Key Laboratory of Neurostimulation Beijing China
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Legnani FG, Franzini A, Mattei L, Saladino A, Casali C, Prada F, Perin A, Cojazzi V, Saini M, Kronreif G, Wolfsberger S, DiMeco F. Image-Guided Biopsy of Intracranial Lesions with a Small Robotic Device (iSYS1): A Prospective, Exploratory Pilot Study. Oper Neurosurg (Hagerstown) 2019; 17:403-412. [DOI: 10.1093/ons/opy411] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 01/04/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Robotic technologies have been used in the neurosurgical operating rooms for the last 30 yr. They have been adopted for several stereotactic applications and, particularly, image-guided biopsy of intracranial lesions which are not amenable for open surgical resection.
OBJECTIVE
To assess feasibility, safety, accuracy, and diagnostic yield of robot-assisted frameless stereotactic brain biopsy with a recently introduced miniaturized device (iSYS1; Interventional Systems Medizintechnik GmbH, Kitzbühel, Austria), fixed to the Mayfield headholder by a jointed arm.
METHODS
Clinical and surgical data of all patients undergoing frameless stereotactic biopsies using the iSYS1 robotized system from October 2016 to December 2017 have been prospectively collected and analyzed. Facial surface registration has been adopted for optical neuronavigation.
RESULTS
Thirty-nine patients were included in the study. Neither mortality nor morbidity related to the surgical procedure performed with the robot was recorded. Diagnostic tissue samples were obtained in 38 out of 39 procedures (diagnostic yield per procedure was 97.4%). All patients received a definitive histological diagnosis. Mean target error was 1.06 mm (median 1 mm, range 0.1-4 mm).
CONCLUSION
The frameless robotic iSYS1-assisted biopsy technique was determined to be feasible, safe, and accurate procedure; moreover, the diagnostic yield was high. The surface matching registration method with computed tomography as the reference image set did not negatively affect the accuracy of the procedure.
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Affiliation(s)
- Federico G Legnani
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
| | - Andrea Franzini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
| | - Luca Mattei
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
| | - Andrea Saladino
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
| | - Cecilia Casali
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
| | - Francesco Prada
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia
| | - Alessandro Perin
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
| | - Vittoria Cojazzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
| | - Marco Saini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
| | - Gernot Kronreif
- Austrian Center for Medical Innovation and Technology, ACMIT Gmbh, Wiener Neustadt, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Università degli Studi, Milan, Italy
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Bourdillon P, Châtillon CE, Moles A, Rheims S, Catenoix H, Montavont A, Ostrowsky-Coste K, Boulogne S, Isnard J, Guénot M. Effective accuracy of stereoelectroencephalography: robotic 3D versus Talairach orthogonal approaches. J Neurosurg 2018; 131:1938-1946. [PMID: 30544338 DOI: 10.3171/2018.7.jns181164] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereoelectroencephalography (SEEG) was first developed in the 1950s by Jean Talairach using 2D angiography and a frame-based, orthogonal approach through a metallic grid. Since then, various other frame-based and frameless techniques have been described. In this study the authors sought to compare the traditional orthogonal Talairach 2D angiographic approach with a frame-based 3D robotic procedure that included 3D angiographic interoperative imaging guidance. MRI was used for both procedures during surgery, but MRI preplanning was done only in the robotic 3D technique. METHODS All study patients suffered from drug-resistant focal epilepsy and were treated at the same center by the same neurosurgical team. Fifty patients who underwent the 3D robotic procedure were compared to the same number of historical controls who had previously been successfully treated with the Talairach orthogonal procedure. The effectiveness and absolute accuracy, as well as safety, of the two procedures were compared. Moreover, in the 3D robotic group, the reliability of the preoperative MRI to avoid vascular structures was evaluated by studying the rate of trajectory modification following the coregistration of the intraoperative 3D angiographic data onto the preoperative MRI-based trajectory plans. RESULTS Effective accuracy (96.5% vs 13.7%) and absolute accuracy (1.15 mm vs 4.00 mm) were significantly higher in the 3D robotic group than in the Talairach orthogonal group. Both procedures showed excellent safety results (no major complications). The rate of electrode modification after 3D angiography was 43.8%, and it was highest for frontal and insular locations. CONCLUSIONS The frame-based, 3D angiographic, robotic procedure described here provided better accuracy for SEEG implantations than the traditional Talairach approach. This study also highlights the potential safety advantage of trajectory planning using intraoperative frame-based 3D angiography over preoperative MRI alone.
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Affiliation(s)
- Pierre Bourdillon
- 1Department of Neurosurgery, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- 2Faculty of Medicine Claude Bernard, University of Lyon, Lyon, France
- 3Faculty of Science & Engineering, Sorbonne University, Paris, France
- 4Brain and Spine Institute, INSERM U1127, CNRS 7225, Paris, France
| | - Claude-Edouard Châtillon
- 5Department of Surgery, Service of Neurosurgery, Centre Hospitalier Affilié Universitaire Régional, Trois-Rivières Hospital, Trois-Rivières, Quebec, Canada
- 6Faculty of Medicine, Division of Neurosurgery, Université de Montréal, Montreal, Quebec, Canada
| | - Alexis Moles
- 1Department of Neurosurgery, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Sylvain Rheims
- 2Faculty of Medicine Claude Bernard, University of Lyon, Lyon, France
- 7Department of Functional Neurology and Epileptology, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- 8TIGER, Neuroscience Research Center of Lyon, INSERM U1028, CNRS 5292, Université de Lyon, Lyon, France; and
| | - Hélène Catenoix
- 7Department of Functional Neurology and Epileptology, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Alexandra Montavont
- 7Department of Functional Neurology and Epileptology, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Karine Ostrowsky-Coste
- 7Department of Functional Neurology and Epileptology, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Sebastien Boulogne
- 2Faculty of Medicine Claude Bernard, University of Lyon, Lyon, France
- 7Department of Functional Neurology and Epileptology, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Jean Isnard
- 7Department of Functional Neurology and Epileptology, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Marc Guénot
- 1Department of Neurosurgery, Neurology & Neurosurgery Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- 2Faculty of Medicine Claude Bernard, University of Lyon, Lyon, France
- 9NEUROPAIN Team, Lyon Neuroscience Research Center, INSERM U1028, CNRS 5292, Université de Lyon, Lyon, France
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Navigation-Supported Stereotaxy by Applying Intraoperative Computed Tomography. World Neurosurg 2018; 118:e584-e592. [DOI: 10.1016/j.wneu.2018.06.246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 06/28/2018] [Accepted: 06/29/2018] [Indexed: 12/22/2022]
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Marcus HJ, Vakharia VN, Ourselin S, Duncan J, Tisdall M, Aquilina K. Robot-assisted stereotactic brain biopsy: systematic review and bibliometric analysis. Childs Nerv Syst 2018; 34:1299-1309. [PMID: 29744625 PMCID: PMC5996011 DOI: 10.1007/s00381-018-3821-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/02/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Stereotactic brain biopsy represents one of the earliest applications of surgical robotics. The aim of the present systematic review and bibliometric analysis was to evaluate the literature supporting robot-assisted brain biopsy and the extent to which the scientific community has accepted the technique. METHODS The Cochrane and PubMed databases were searched over a 30-year period between 1st of January 1988 and 31st of December 2017. Titles and abstracts were screened to identify publications that met the following criteria: (1) featured patients with brain pathology, (2) undergoing stereotactic brain biopsy, (3) reporting robot-assisted surgery, and (4) outcome data were provided. The reference lists of selected studies were also sought, and expert opinion sought to identify further eligible publications. Selected manuscripts were then reviewed, and data extracted on effectiveness and safety. The status of scientific community acceptance was determined using a progressive scholarly acceptance analysis. RESULTS All identified studies were non-randomised, including 1 retrospective cohort study and 14 case series or reports. The diagnostic biopsy rate varied from 75 to 100%, and the average target accuracy varied from 0.9 to 4.5 mm. Use of the robot was aborted in two operations owing to geometric inaccessibility and an error in image registration but no associated adverse events were reported. A compounding progressive scholarly acceptance analysis suggested a trend towards acceptance of the technique by the scientific community. CONCLUSIONS In conclusion, robot-assisted stereotactic brain biopsy is an increasingly mainstream tool in the neurosurgical armamentarium. Further evaluation should proceed along the IDEAL framework with research databases and comparative trials.
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Affiliation(s)
- Hani J Marcus
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.
- Wellcome EPSRC Centre for Interventional and Surgical Sciences, University College London, 8.02 Malet Place Building, Gower Street, London, WC1E 6BT, UK.
| | - Vejay N Vakharia
- Wellcome EPSRC Centre for Interventional and Surgical Sciences, University College London, 8.02 Malet Place Building, Gower Street, London, WC1E 6BT, UK
- UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Sebastien Ourselin
- Wellcome EPSRC Centre for Interventional and Surgical Sciences, University College London, 8.02 Malet Place Building, Gower Street, London, WC1E 6BT, UK
| | - John Duncan
- Wellcome EPSRC Centre for Interventional and Surgical Sciences, University College London, 8.02 Malet Place Building, Gower Street, London, WC1E 6BT, UK
- UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
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