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Frameless Patient Tracking With Adhesive Optical Skin Markers for Augmented Reality Surgical Navigation in Spine Surgery. Spine (Phila Pa 1976) 2020; 45:1598-1604. [PMID: 32756274 DOI: 10.1097/brs.0000000000003628] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational study. OBJECTIVE The aim of this study was to evaluate the accuracy of a new frameless reference marker system for patient tracking by analyzing the effect of vertebral position within the surgical field. SUMMARY OF BACKGROUND DATA Most modern navigation systems for spine surgery rely on a dynamic reference frame attached to a vertebra for tracking the patient. This solution has the drawback of being bulky and obstructing the surgical field, while requiring that the dynamic reference frame is moved between vertebras to maintain accuracy. METHODS An augmented reality surgical navigation (ARSN) system with intraoperative cone beam computed tomography (CBCT) capability was installed in a hybrid operating room. The ARSN system used input from four video cameras for tracking adhesive skin markers placed around the surgical field. The frameless reference marker system was evaluated first in four human cadavers, and then in 20 patients undergoing navigated spine surgery. In each CBCT, the impact of vertebral position in the surgical field on technical accuracy was analyzed. The technical accuracy of the inserted pedicle devices was determined by measuring the distance between the planned position and the placed pedicle device, at the bone entry point. RESULTS The overall mean technical accuracy was 1.65 ± 1.24 mm at the bone entry point (n = 366). There was no statistically significant difference in technical accuracy between levels within CBCTs (P ≥ 0.12 for all comparisons). Linear regressions showed that null- to negligible parts of the effect on technical accuracy could be explained by the number of absolute levels away from the index vertebrae (r ≤ 0.007 for all, β ≤ 0.071 for all). CONCLUSION The frameless reference marker system based on adhesive skin markers is unobtrusive and affords the ARSN system a high accuracy throughout the navigated surgical field, independent of vertebral position. LEVEL OF EVIDENCE 3.
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Manni F, Elmi-Terander A, Burström G, Persson O, Edström E, Holthuizen R, Shan C, Zinger S, van der Sommen F, de With PHN. Towards Optical Imaging for Spine Tracking without Markers in Navigated Spine Surgery. SENSORS (BASEL, SWITZERLAND) 2020; 20:E3641. [PMID: 32610555 PMCID: PMC7374436 DOI: 10.3390/s20133641] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/13/2020] [Accepted: 06/22/2020] [Indexed: 12/18/2022]
Abstract
Surgical navigation systems are increasingly used for complex spine procedures to avoid neurovascular injuries and minimize the risk for reoperations. Accurate patient tracking is one of the prerequisites for optimal motion compensation and navigation. Most current optical tracking systems use dynamic reference frames (DRFs) attached to the spine, for patient movement tracking. However, the spine itself is subject to intrinsic movements which can impact the accuracy of the navigation system. In this study, we aimed to detect the actual patient spine features in different image views captured by optical cameras, in an augmented reality surgical navigation (ARSN) system. Using optical images from open spinal surgery cases, acquired by two gray-scale cameras, spinal landmarks were identified and matched in different camera views. A computer vision framework was created for preprocessing of the spine images, detecting and matching local invariant image regions. We compared four feature detection algorithms, Speeded Up Robust Feature (SURF), Maximal Stable Extremal Region (MSER), Features from Accelerated Segment Test (FAST), and Oriented FAST and Rotated BRIEF (ORB) to elucidate the best approach. The framework was validated in 23 patients and the 3D triangulation error of the matched features was < 0 . 5 mm. Thus, the findings indicate that spine feature detection can be used for accurate tracking in navigated surgery.
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Affiliation(s)
- Francesca Manni
- Department of Electrical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands; (S.Z.); (F.v.d.S.); (P.H.N.d.W.)
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 46, Sweden & Department of Neurosurgery, Karolinska University Hospital, SE-171 46 Stockholm, Sweden; (A.E.-T.); (G.B.); (O.P.); (E.E.)
| | - Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 46, Sweden & Department of Neurosurgery, Karolinska University Hospital, SE-171 46 Stockholm, Sweden; (A.E.-T.); (G.B.); (O.P.); (E.E.)
| | - Oscar Persson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 46, Sweden & Department of Neurosurgery, Karolinska University Hospital, SE-171 46 Stockholm, Sweden; (A.E.-T.); (G.B.); (O.P.); (E.E.)
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm SE-171 46, Sweden & Department of Neurosurgery, Karolinska University Hospital, SE-171 46 Stockholm, Sweden; (A.E.-T.); (G.B.); (O.P.); (E.E.)
| | | | - Caifeng Shan
- Philips Research, High Tech Campus 36, 5656 AE Eindhoven, The Netherlands;
| | - Svitlana Zinger
- Department of Electrical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands; (S.Z.); (F.v.d.S.); (P.H.N.d.W.)
| | - Fons van der Sommen
- Department of Electrical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands; (S.Z.); (F.v.d.S.); (P.H.N.d.W.)
| | - Peter H. N. de With
- Department of Electrical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands; (S.Z.); (F.v.d.S.); (P.H.N.d.W.)
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History of degenerative spondylolisthesis: From anatomical description to surgical management. Neurochirurgie 2019; 65:75-82. [DOI: 10.1016/j.neuchi.2019.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/26/2019] [Accepted: 03/20/2019] [Indexed: 01/01/2023]
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Salama H. Direct pedicle visualization and disc space orientation as the only guide for lumbar pedicular screw insertion. EGYPTIAN JOURNAL OF NEUROSURGERY 2018. [DOI: 10.1186/s41984-018-0010-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Zheng G, Nolte LP. Computer-Aided Orthopaedic Surgery: State-of-the-Art and Future Perspectives. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1093:1-20. [DOI: 10.1007/978-981-13-1396-7_1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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Al-Habib AF, Al-Akkad S. Segmental Surface Referencing during Intraoperative Three-dimensional Image-Guided Spine Navigation: An Early Validation with Comparison to Automated Referencing. Global Spine J 2016; 6:765-770. [PMID: 27853660 PMCID: PMC5110353 DOI: 10.1055/s-0036-1582393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 02/16/2016] [Indexed: 11/09/2022] Open
Abstract
Study Design Interventional human cadaver study. Objective Intraoperative three-dimensional (3-D)-guided navigation improves spine instrumentation accuracy. However, image acquisition may need to be repeated with segment hypermobility or distant target from reference frame (RF). The current study evaluates the usefulness of internal metal fiducials (IMFs) as surface references in enhancing registration accuracy and avoiding repeating imaging. Methods Six fresh-frozen cadaveric human torsos were utilized. Posterior C1-T2 exposure was done, and three IMFs were inserted per level; intraoperative 3-D images were then acquired. Two registration methods were utilized: autoregistration (AR, group 1) and point registration using IMF (IMFR, group 2). Registration accuracy was checked by identifying IMFs in both groups. Pedicle screws inserted into C2, C4, C5, and C7 based on the two registration methods (three cadavers each) with RF on C7 and then on C2. Results The mean registration error was lower with IMFR compared with AR (0.35 ± 0.5 mm versus 2.02 ± 0.85 mm, p = 0.0001). Overall, 34 pedicle screws were inserted (AR, 18; IMFR, 16). Final screw placement was comparable using both techniques (p = 0.58). Lateral screws violations were observed in four IMFR screws (1 to 2 mm) as compared with five in AR group (2 to 3 mm). Reregistration after moving RF to C2 was possible using surface screws in IMFR group, thus avoiding new 3-D image acquisition. Conclusion During intraoperative 3-D navigation in spine procedures, surface fiducial registration using IMF provided superior accuracy over automated registration. It allowed repeat registration without repeating radiation during long spine segment instrumentations. More studies are needed to clarify both practical and clinical application of this method.
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Affiliation(s)
- Amro F. Al-Habib
- Division of Neurosurgery, Department of Surgery, King Saud University, Riyadh, Saudi Arabia,Address for correspondence Amro F. Al-Habib, MD, FRCSC, MPH Division of Neurosurgery, Department of Surgery, College of MedicineKing Saud University, PO Box 59220, Riyadh 11525Saudi Arabia
| | - Salah Al-Akkad
- Neurospinal Unit, Department of Surgery, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
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Control of Pedicle Screw Placement with an Electrical Conductivity Measurement Device: Initial Evaluation in the Thoracic and Lumbar Spine. Adv Med 2016; 2016:4296294. [PMID: 27699203 PMCID: PMC5028864 DOI: 10.1155/2016/4296294] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 08/16/2016] [Indexed: 11/17/2022] Open
Abstract
Aim. Transpedicular screw fixation is widely used in spinal surgery. But the insertion of pedicle screws can sometimes be challenging because of the variability in pedicle size and the proximity of nerve roots. Methods. We detected intraoperatively the sensitivity for iatrogenic pedicel perforation with a hand-held electronic conductivity measurement device (ECD) that measures electrical conductivity of tissue-medium surrounding the instrument tip. ECD was used to guide the placement of 84 pedicle screws in 15 patients undergoing surgery for tumor or degenerative spinal disease at various spinal levels from T8 to L5. Additionally a CT-scan controlled screw positioning postoperatively. Results. The placement was "correct" (no mediocaudal pedicle wall penetration) for 78 of 84 (92,8%) screws, "suboptimal but acceptable" (0-2 mm penetration) for 4 of 84 (4,8%) screws, and "misplaced" (penetration > 2 mm) for 2 of 84 (2,4%) screws. Conclusion. Although this study was not designed to compare electronic conductivity technique to other guidance methods, such as fluoroscopy or navigation, a convincing "proof of concept" for ECD use in spinal instrumentation could be demonstrated. Advantages include easy handling without time-consuming setup and reduced X-ray exposure. However, further investigations are necessary to evaluate i.a. the economic aspects for this single-use developed instrument.
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Zheng G, Nolte LP. Computer-Assisted Orthopedic Surgery: Current State and Future Perspective. Front Surg 2015; 2:66. [PMID: 26779486 PMCID: PMC4688391 DOI: 10.3389/fsurg.2015.00066] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/07/2015] [Indexed: 11/13/2022] Open
Abstract
Introduced about two decades ago, computer-assisted orthopedic surgery (CAOS) has emerged as a new and independent area, due to the importance of treatment of musculoskeletal diseases in orthopedics and traumatology, increasing availability of different imaging modalities, and advances in analytics and navigation tools. The aim of this paper is to present the basic elements of CAOS devices and to review state-of-the-art examples of different imaging modalities used to create the virtual representations, of different position tracking devices for navigation systems, of different surgical robots, of different methods for registration and referencing, and of CAOS modules that have been realized for different surgical procedures. Future perspectives will also be outlined.
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Affiliation(s)
- Guoyan Zheng
- Institute for Surgical Technology and Biomechanics, University of Bern , Bern , Switzerland
| | - Lutz P Nolte
- Institute for Surgical Technology and Biomechanics, University of Bern , Bern , Switzerland
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Guedes VDP, Manffra EF, Aguiar LR. IMAGE-GUIDED SURGERY IN THE SPINE: NEURONAVIGATION VS. FLUOROSCOPY. COLUNA/COLUMNA 2015. [DOI: 10.1590/s1808-185120151403122410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objectives:To evaluate the accuracy and the operative complications of implanting pedicle screws in the thoracic and lumbar spine, using computer-assisted surgery compared to the implantation technique using fluoroscopy.Methods:A retrospective study was conducted at the Hospital Universitário Cajuru PUC-PR from January 2000 to January 2009. Two groups of patients undergoing implant pedicle screws were analyzed (n=80). Group I received implant pedicle screws through fluoroscopy technique and group II, through neuronavigation technique. The accuracy of positioning of pedicle screws was evaluated using rating scales.Results:The accuracy was higher in group II, where 77.5% of the screws were correctly positioned, whereas there were only 28.5% in group I (p=0.001). There was a reduction of 95% (CI: 80-97%) in the risk of screws misplacement in group II. The average operation time was 312.2±78.1 minutes in group I and 270.3±41.4 in group II (p=0.004). Blood transfusion was needed in 28 patients in group I and 10 patients in group II (p=0.005), resulting in 64% risk reduction of blood transfusion in group II. Eight patients in group I underwent revision surgery whereas only one patient in the group II, that is, 75% of surgical revision risk reduction.Conclusion:The implantation technique of pedicle screws using neuronavigation is a more accurate method and has less operative complications compared with the technique that uses fluoroscopy.
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Bredow J, Oppermann J, Kraus B, Schiller P, Schiffer G, Sobottke R, Eysel P, Koy T. The accuracy of 3D fluoroscopy-navigated screw insertion in the upper and subaxial cervical spine. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:2967-76. [DOI: 10.1007/s00586-015-3974-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 04/16/2015] [Accepted: 04/16/2015] [Indexed: 11/27/2022]
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Rahmathulla G, Nottmeier EW, Pirris SM, Deen HG, Pichelmann MA. Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance. Neurosurg Focus 2014; 36:E3. [PMID: 24580004 DOI: 10.3171/2014.1.focus13516] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal instrumentation has made significant advances in the last two decades, with transpedicular constructs now widely used in spinal fixation. Pedicle screw constructs are routinely used in thoracolumbar-instrumented fusions, and in recent years, the cervical spine as well. Three-column fixations with pedicle screws provide the most rigid form of posterior stabilization. Surgical landmarks and fluoroscopy have been used routinely for pedicle screw insertion, but a number of studies reveal inaccuracies in placement using these conventional techniques (ranging from 10% to 50%). The ability to combine 3D imaging with intraoperative navigation systems has improved the accuracy and safety of pedicle screw placement, especially in more complex spinal deformities. However, in the authors' experience with image guidance in more than 1500 cases, several potential pitfalls have been identified while using intraoperative spinal navigation that could lead to suboptimal results. This article summarizes the authors' experience with these various pitfalls using spinal navigation, and gives practical tips on their avoidance and management.
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Johnson JP, Drazin D, King WA, Kim TT. Image-guided navigation and video-assisted thoracoscopic spine surgery: the second generation. Neurosurg Focus 2014; 36:E8. [DOI: 10.3171/2014.1.focus13532] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Video-assisted thoracoscopic surgery (VATS) has evolved for treatment of a variety of spinal disorders. Early incorporation with image-guided surgery (IGS) was challenged due to reproducibility and adaptability, limiting the procedure's acceptance. In the present study, the authors report their experience with second-generation IGS and VATS technologies for anterior thoracic minimally invasive spinal (MIS) procedures.
Methods
The surgical procedure is described in detail including operating room set-up, patient positioning (a lateral decubitus position), placement of the spinal reference frame and portal, radiographic localization, registration, surgical instruments, and the image-guided thoracoscopic discectomy.
Results
Combined IGS and VATS procedures were successfully performed and assisted in anatomical localization in 14 patients. The mean patient age was 59 years (range 32–73 years). Disc herniation pathology represented the most common indication for surgery (n = 8 patients); intrathoracic spinal tumors were present in 4 patients and the remaining patients had infection and ossification of the posterior longitudinal ligament. All patients required chest tube drainage postoperatively, and all but 1 patient had drainage discontinued the following day. The only complication was a seroma that was presumed to be due to steroid therapy for postoperative weakness. At the final follow-up, 11 of the patients were improved neurologically, 2 patients had baseline neurological status, and the 1 patient with postoperative weakness was able to ambulate, albeit with an assistive device.
The evolution of thoracoscopic surgical procedures occurring over 20 years is presented, including their limitations. The combination of VATS and IGS technologies is discussed including their safety and the importance of 3D imaging. In cases of large open thoracotomy procedures, surgeries require difficult, extensive, and invasive access through the chest cavity; using a MIS procedure can potentially eliminate many of the complications and morbidities associated with large open procedures. The authors report their experience with thoracic spinal surgeries that involved MIS procedures and the new technologies.
Conclusions
The most significant advance in IGS procedures has resulted from intraoperative CT scanning and automatic registration with the IGS workstation. Image guidance can be used in conjunction with VATS techniques for thoracic discectomy, spinal tumors, infection, and ossification of the posterior longitudinal ligament. The authors' initial experience has revealed this technique to be useful and potentially applicable to other MIS procedures.
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Affiliation(s)
- J. Patrick Johnson
- 1Departments of Neurosurgery and
- 3Department of Neurosurgery, UC Davis Medical Center, Sacramento, California
| | | | | | - Terrence T. Kim
- 2Orthopaedics, Cedars-Sinai Medical Center, Los Angeles; and
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Lehman RA, Kang DG, Lenke LG, Gaume RE, Paik H. The ventral lamina and superior facet rule: a morphometric analysis for an ideal thoracic pedicle screw starting point. Spine J 2014; 14:137-44. [PMID: 24268391 DOI: 10.1016/j.spinee.2013.06.092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 05/12/2013] [Accepted: 06/24/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT With the increasing popularity of thoracic pedicle screws, the freehand technique has been espoused to be safe and effective. However, there is currently no objective, definable landmark to assist with freehand insertion of pedicle screws in the thoracic spine. With our own increasing surgical experience, we have noted a reproducible and unique anatomic structure known as the ventral lamina. PURPOSE We set out to define the morphologic relationship of the ventral lamina to the superior articular facet (SAF) and pedicle, and describe an optimal medial-lateral pedicle screw starting point in the thoracic spine. STUDY DESIGN We conducted an in vitro fresh-frozen human cadaveric study. METHODS One hundred fifteen thoracic spine vertebral levels were evaluated. After the vertebral body was removed, Kirschner wires were inserted retrograde along the four boundaries of the pedicle. Using digital calipers, we measured width of the SAF and pedicle at the isthmus, and from the borders of the SAF to the boundaries of the pedicle. We calculated the morphologic relationship of the ventral lamina and the center of the pedicle (COP) to the SAF. RESULTS Two hundred twenty-nine pedicles were measured, with one pedicle excluded because of fracture of the SAF during disarticulation. The ventral lamina was clearly identifiable at all levels, forming the roof of the spinal canal and confluent with the medial pedicle wall (MPW). The mean distance from the SAF midline to the MPW was 1.36±1.23 mm medial. The MPW was lateral to SAF midline in 34 pedicles (14.85%) and, on average, was a distance of 0.52±0.51 mm lateral. The mean distance from the SAF midline to the COP was 2.17±1.38 mm lateral. The COP was medial to SAF midline in only 11 pedicles (4.80%). CONCLUSIONS The ventral lamina is an anatomically reproducible structure located consistently medial to the SAF midline (85%). We also found the COP consistently lateral to the SAF midline (95%). Based on these morphologic findings, the medial-lateral starting point for thoracic pedicle screws should be 2 to 3 mm lateral to the SAF midline (superior facet rule), allowing screw placement in the COP and avoiding penetration into the spinal canal.
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Affiliation(s)
- Ronald A Lehman
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA.
| | - Daniel G Kang
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8233, St. Louis, MO 63110, USA
| | - Rachel E Gaume
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Haines Paik
- Department of Orthopaedic Surgery and Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
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Jarvers JS, Franck A, Glasmacher S, Josten C. Minimally Invasive Posterior C1/2 Screw Fixation Using C1 Lateral Mass Screws and C2 Pedicle Screws With 3D C-Arm-Based Navigation. ACTA ACUST UNITED AC 2013. [DOI: 10.1053/j.oto.2013.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Wang M, Song Z. Optimal number and distribution of points selected on the vertebra for surface matching in CT-based spinal navigation. ACTA ACUST UNITED AC 2013; 18:93-100. [DOI: 10.3109/10929088.2012.761728] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ammirati M, Salma A. Placement of thoracolumbar pedicle screws using O-arm-based navigation: technical note on controlling the operational accuracy of the navigation system. Neurosurg Rev 2012; 36:157-62; discussion 162. [PMID: 22956149 DOI: 10.1007/s10143-012-0421-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 06/26/2012] [Accepted: 07/29/2012] [Indexed: 10/27/2022]
Abstract
Suboptimal placements of pedicle screws may lead to neurological and vascular complications. Computer-assisted image guidance has been shown to improve accuracy in spinal instrumentation. Checking the accuracy of the navigation system during pedicle screw placement is fundamental. We describe a novel technique of using continuous accuracy check of the navigation system during O-arm-based neuronavigation to instrument the thoracolumbar region. Forty thoracic and 42 lumbar screws were inserted in 12 patients. The Mirza evaluation system was used to evaluate the accuracy of the inserted screws. There was no neurological injury and no need to reposition any screw. The accuracy of the screws placement was excellent. Our technique of continuous at will operational accuracy check of the neuronavigation system is associated with extreme accuracy of screw placement, no need to bring a patient back to the operating room to reposition a pedicle screw, and with excellent outcome.
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Affiliation(s)
- Mario Ammirati
- Department of Neurological Surgery, Ohio State University Medical Center, N1025 Doan Hall, 410 W. 10th Avenue, Columbus, OH 43210, USA.
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Ultrasound-CT registration of vertebrae without reconstruction. Int J Comput Assist Radiol Surg 2012; 7:901-9. [DOI: 10.1007/s11548-012-0771-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 05/31/2012] [Indexed: 10/28/2022]
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Zhang HL, Zhou DS, Jiang ZS. Analysis of accuracy of computer-assisted navigation in cervical pedicle screw installation. Orthop Surg 2012; 3:52-6. [PMID: 22009981 DOI: 10.1111/j.1757-7861.2010.00110.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To observe the accuracy of computer-assisted navigation (CAN) in cervical pedicle screw installation and to analyze the reasons for screw malposition. METHODS From October 2004 to December 2009, 144 cervical pedicle screws were installed in 25 patients with cervical spinal diseases using CAN. Screw position and direction were measured on sagittal and transection images from intraoperative navigation and postoperative CTs. RESULTS Among 144 screws inserted from C3 to C7, two perforated the upper pedicle wall and three deviated from the lateral pedicle wall. The rate of accurate cervical pedicle screw placement with CAN was 96.5% (139/144) in our group. There was no statistical difference in the position and direction of the pedicle screws according to navigation images and CT scans. CONCLUSION CAN can result in high accuracy of cervical pedicle installation. The excursion phenomenon is responsible for malposition of pedicle screws. Only by understanding the navigational principles of CAN and the characteristics of cervical spinal surgery, together with personal experience, can good use be made of CAN.
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Affiliation(s)
- Hong-lei Zhang
- Department of Orthopaedics, Liaocheng People's Hospital, Shandong, China.
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Yashar P, Hopkins LN. Instrumentation in neurosurgery: nurturing the trend toward minimalism. World Neurosurg 2012; 80:240-2. [PMID: 22381330 DOI: 10.1016/j.wneu.2011.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 11/18/2011] [Indexed: 11/16/2022]
Affiliation(s)
- Parham Yashar
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA
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Navigation-assisted surgery for bone and soft tissue tumors with bony extension. Clin Orthop Relat Res 2012; 470:275-83. [PMID: 22009710 PMCID: PMC3238002 DOI: 10.1007/s11999-011-2094-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 09/01/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND The navigation system was introduced to orthopaedic surgery in the 1990s. More recently, CT-based navigation systems have been used more commonly in spine and joint replacement surgery because of their precision. QUESTIONS/PURPOSES The aim of our study was to evaluate the accuracy and efficacy of navigation-assisted excision of bone and soft tissue tumors. METHODS From 2006 to 2009, we performed navigation-assisted surgery in 16 patients, 11 males and five females, with a mean age of 39 years (range, 13-70 years). We diagnosed nine benign bone tumors and seven malignant bone and soft tissue tumors. In two patients, the malignant soft tissue tumors infiltrated the adjacent bones. Nine excisional biopsies for benign tumors and seven en bloc excisions for malignant tumors were performed. In all cases, the point registration method was performed using 10 skin markers, which were placed around the tumor. Each excisional difference between the preoperative and postoperative plans was evaluated histologically or by postoperative CT. RESULTS The mean accuracy of this system, which was determined using skin markers, was 0.93 mm (range, 0.6-1.2 mm). All biopsy and excision samples were evaluated by pathologic examination and postoperative CT imaging. The mean difference between the planned margin and postoperative CT or excised histologic specimen was 0 mm to 4 mm. The mean followup was 34 months (range, 10-54 months). There were no local recurrences, except for excision of skip metastases in a patient with a chordoma. CONCLUSION We report our experience with navigation-assisted surgery for bone and soft tissue tumors. Navigation-assisted surgery could be indicated for sufficiently reliable, accurate, and minimally invasive resections.
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Towards accurate, robust and practical ultrasound-CT registration of vertebrae for image-guided spine surgery. Int J Comput Assist Radiol Surg 2010; 6:523-37. [DOI: 10.1007/s11548-010-0536-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 10/11/2010] [Indexed: 10/18/2022]
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Tormenti MJ, Kostov DB, Gardner PA, Kanter AS, Spiro RM, Okonkwo DO. Intraoperative computed tomography image-guided navigation for posterior thoracolumbar spinal instrumentation in spinal deformity surgery. Neurosurg Focus 2010; 28:E11. [PMID: 20192656 DOI: 10.3171/2010.1.focus09275] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECT Placement of thoracolumbar pedicle screws in spinal deformity surgery has a reported inaccuracy rate as high as 30%. At present, image-guided navigation systems designed to improve instrumentation accuracy typically use intraoperative fluoroscopy or preoperative CT scans. The authors report the prospective evaluation of the accuracy of posterior thoracolumbar spinal instrumentation using a new intraoperative CT operative suite with an integrated image guidance system. They compare the accuracy of thoracolumbar pedicle screw placement using intraoperative CT image guidance with instrumentation placement utilizing fluoroscopy. METHODS Between December 2007 and July 2008, 12 patients underwent posterior spinal instrumentation for spinal deformity correction using intraoperative CT-based image guidance. An intraoperative CT scan of the sterile surgical field was obtained after decompression and before instrumentation. Instrumentation was placed, and a postinstrumentation CT scan was obtained before wound closure to assess the accuracy of instrumentation placement and the potential need for revision. The accuracy of pedicle screw placement was later reviewed and recorded by independent observers. A comparison group of 14 patients who underwent thoracolumbar instrumentation utilizing fluoroscopy and postoperative CT scanning during the same time period was evaluated and included in this analysis. RESULTS In the intraoperative CT-based image guidance group, a total of 164 thoracolumbar pedicle screws were placed. Two screws were found to have breached the pedicle wall (1.2%). Neither screw was deemed to need revision due to misplacement. In the comparison group, 211 pedicle screws were placed. Postoperative CT scanning revealed that 11 screws (5.2%) had breached the pedicle. One patient in the fluoroscopy group awoke with a radiculopathy attributed to a misplaced screw, which required revision. The difference in accuracy was statistically significant (p = 0.031). CONCLUSIONS Intraoperative CT-based image guidance for placement of thoracolumbar instrumentation has an accuracy that exceeds reported rates with other image guidance systems, such as virtual fluoroscopy and 3D isocentric C-arm-based stereotactic systems. Furthermore, with the use of intraoperative CT scanning, a postinstrumentation CT scan allows the surgeon to evaluate the accuracy of instrumentation before wound closure and revise as appropriate.
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Affiliation(s)
- Matthew J Tormenti
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Pompeo E, Mancini F, Ippolito E, Mineo TC. Videothoracoscopic Approach to the Spine in Idiopathic Scoliosis. Thorac Surg Clin 2010; 20:311-21. [DOI: 10.1016/j.thorsurg.2010.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Winkler D, Vitzthum HE, Seifert V. Spinal Markers: a New Method for Increasing Accuracy in Spinal Navigation. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/10929089909148165] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Muratore DM, Russ JH, Dawant BM, Galloway RL. Three-Dimensional Image Registration of Phantom Vertebrae for Image-Guided Surgery: A Preliminary Study. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/10929080209146523] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Haberland N, Ebmeier K, Grunewald JP, Hliscs R, Kalff RL. Incorporation of Intraoperative Computerized Tomography in a Newly Developed Spinal Navigation Technique. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/10929080009148868] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Barrick EF, O'mara JW, Lane HE. Iliosacral Screw Insertion Using Computer-Assisted CT Image Guidance: a Laboratory Study. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/10929089809148149] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Geerling J, Gösling T, Gösling A, Ortega G, Kendoff D, Citak M, Krettek C, Hüfner T. Navigated pedicle screw placement: Experimental comparison between CT- and 3D fluoroscopy-based techniques. ACTA ACUST UNITED AC 2010; 13:157-66. [DOI: 10.3109/10929080802102110] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Thomale UW, Kneissler M, Hein A, Maetzig M, Kroppenstedt SN, Lueth T, Woiciechowsky C. A spine frame for intra-operative fixation to increase accuracy in spinal navigation and robotics. ACTA ACUST UNITED AC 2010; 10:151-5. [PMID: 16321912 DOI: 10.3109/10929080500229744] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Intra-operative movements due to mechanical ventilation or manipulations are a limiting factor for accurate spinal navigation or robotic-assisted spinal surgery. The purpose of this study was to assess the accuracy of an intra-operative spinal fixation device in an experimental setup. MATERIALS AND METHODS We developed a fixation device, attached to the operating table, that combines soft tissue retraction with spinal process fixation. Using a lumbar spine cadaver, tightness of fixation was evaluated using two measurement systems. Accuracy measurements using changes in spatial co-ordinates of implanted reference markers were performed in three segments, following different manipulations of the spine. In addition, for intra-operative movements of the spine during mechanical ventilation, the range of motion was determined in 10 patients during lumbar interbody fusion. RESULTS The spine frame was easy to use and did not restrict screw insertion. Mean deviations of the markers' in all segments were measured at between 0.35 and 0.8 mm, following pedicle screw insertion and lateral traction. Intra-operative range of motion of the spine was measured with a mean value of 8.7 +/- 3.3 mm. CONCLUSION Using our spine frame, a rigid fixation following manipulation of the spine was demonstrated. By overcoming the intra-operative movement-dependent inaccuracy, safety in navigated spine surgery and robotic-assisted procedures might be improved.
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Affiliation(s)
- Ulrich-W Thomale
- Department of Neurosurgery, Charité, Virchow Medical Center, Universitätsmedizin of Berlin, Germany.
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Çelik SE, Kelten B, Gökcan R, Yildiz AC. The accuracy of multi-slice three-dimensional computerized tomography on the verification of the pedicle screw trajectory. Orthop Rev (Pavia) 2009; 1:e22. [PMID: 21808684 PMCID: PMC3143979 DOI: 10.4081/or.2009.e22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 09/23/2009] [Accepted: 09/23/2009] [Indexed: 11/22/2022] Open
Abstract
The purpose of our study was to determine the diagnostic power of three-dimensional reformatted multi-slice computerized tomography (CT) images on misplaced pedicle screws in spinal surgery. Eighty-four consecutive patients with 458 screws in situ were investigated prospectively using both axial CT slices and reformatted images after operation by two blinded investigators. All the screw misplacements were documented and the differences between the two imaging modalities were recorded. Axial CT slices were able to show only 23 of 60 misplaced pedicle screws; multislice CT was three times more powerful in the diagnosis of pedicle screw complications in spinal surgery (p<0.05). We concluded that multi-slice CT reconstruction should be the primary diagnostic tool after screw implantation in the human spine.
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Affiliation(s)
| | | | - Recai Gökcan
- Department of Radiology, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Cevri Yildiz
- Department of Radiology, Ümraniye Training and Research Hospital, Istanbul, Turkey
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Image-guided spine surgery: state of the art and future directions. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 19:25-45. [PMID: 19763640 DOI: 10.1007/s00586-009-1091-9] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Revised: 04/23/2009] [Accepted: 06/24/2009] [Indexed: 10/20/2022]
Abstract
Navigation technology is a widely available tool in spine surgery and has become a part of clinical routine in many centers. The issue of where and when navigation technology should be used is still an issue of debate. It is the aim of this study to give an overview on the current knowledge concerning the technical capabilities of image-guided approaches and to discuss possible future directions of research and implementation of this technique. Based on a Medline search total of 1,462 publications published until October 2008 were retrieved. The abstracts were scanned manually for relevance to the topics of navigated spine surgery in the cervical spine, the thoracic spine, the lumbar spine, as well as ventral spine surgery, radiation exposure, tumor surgery and cost-effectivity in navigated spine surgery. Papers not contributing to these subjects were deleted resulting in 276 papers that were included in the analysis. Image-guided approaches have been investigated and partially implemented into clinical routine in virtually any field of spine surgery. However, the data available is mostly limited to small clinical series, case reports or retrospective studies. Only two RCTs and one metaanalysis have been retrieved. Concerning the most popular application of image-guided approaches, pedicle screw insertion, the evidence of clinical benefit in the most critical areas, e.g. the thoracic spine, is still lacking. In many other areas of spine surgery, e.g. ventral spine surgery or tumor surgery, image-guided approaches are still in an experimental stage. The technical development of image-guided techniques has reached a high level as the accuracies that can be achieved technically meet the anatomical demands. However, there is evidence that the interaction between the surgeon ('human factor') and the navigation system is a source of inaccuracy. It is concluded that more effort needs to be spend to understand this interaction.
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von Jako RA, Cselik Z. Percutaneous laser discectomy guided with stereotactic computer-assisted surgical navigation. Lasers Surg Med 2009; 41:42-51. [PMID: 19143018 DOI: 10.1002/lsm.20728] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVE Percutaneous laser discectomy at various wavelengths has been used for minimally invasive surgery of herniated intervertebral discs. Using a high-intensity diode laser at 980-nm wavelength, we aimed to improve the safe insertion of the laser trocar with the aid of a stereotactic computer-assisted surgical navigation system. STUDY DESIGN/MATERIALS AND METHODS The experiments were performed on ex vivo porcine spines with intact soft tissue. Before laser irradiation, each specimen was imaged by computed tomography (CT) with fiduciary markers. The Digital Imaging and Communications in Medicine (DICOM standard) data sets were retrieved into the GE Healthcare Surgery InstaTRAK3500 Plus computer-assisted surgical navigation platform via the hospital Ethernet using a picture archiving and communication system. A special trocar with quartz waveguide connected to the navigation system was inserted into a total of 12 lumbar discs of two fresh intact porcine specimens. Various laser energies (200-700 J) with different exposure times were delivered. Pre- and post-irradiation magnetic resonance (MR) imaging and postoperative macroscopic and histologic studies were carried out. RESULTS A navigation system accuracy of better than 2 mm was achieved. Tracking of the instrument from pre-acquired formatted CT reconstructed images reduced overall radiation exposure by limiting the need for continuous intraoperative C-arm fluoroscopy. The use of surgical navigation by CT images enhanced the precision insertion of the laser trocar. Irradiation with the 980-nm wavelength diode laser resulted in tissue evaporation changes of the intervertebral disc material as demonstrated by comparing pre- and post-irradiation changes of MR images and macro- and microscopic changes of the dissected disc material. CONCLUSION This preclinical study demonstrates the clinical utility of a 980-nm diode laser delivered through a fiber-optic waveguide trocar in which precise insertion was enabled by the use of surgical navigation. This in turn decreases the exposure to ionizing radiation during the procedure.
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Patel AA, Whang PG, Vaccaro AR. Overview of Computer-Assisted Image-Guided Surgery of the Spine. ACTA ACUST UNITED AC 2008. [DOI: 10.1053/j.semss.2008.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kim CW, Lee YP, Taylor W, Oygar A, Kim WK. Use of navigation-assisted fluoroscopy to decrease radiation exposure during minimally invasive spine surgery. Spine J 2008; 8:584-90. [PMID: 18586198 DOI: 10.1016/j.spinee.2006.12.012] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 12/20/2006] [Accepted: 12/30/2006] [Indexed: 02/03/2023]
Abstract
BACKGROUND Minimally invasive surgery decreases postoperative pain and disability. However, limited views of the surgical field require extensive use of intraoperative fluoroscopy that may expose the surgical team to higher levels of ionizing radiation. PURPOSE To assess the feasibility and safety of navigation-assisted fluoroscopy during minimally invasive spine surgery. STUDY DESIGN A combined cadaveric and human study comparing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) using navigation-assisted fluoroscopy with standard intraoperative fluoroscopy to determine differences in surgical times and radiation exposures. METHODS Eighteen fresh cadaveric spines underwent unilateral MIS TLIF by using either navigation-assisted fluoroscopy or standard fluoroscopy. Times for specific surgical steps were compared. In addition, a prospective short-term evaluation of the intraoperative and perioperative results of 10 patients undergoing navigation-assisted MIS TLIF (NAV group) compared with a retrospective review of 8 patients undergoing MIS TLIF performed by using standard fluoroscopy (FLUORO group). RESULTS In the cadaveric study, the times were similar between the NAV group and the FLUORO group for most key steps. No statistically significant differences were obtained for approach, exposure, screw insertion, facetectomy/decompression, or total surgical times. Statistically significant differences were obtained for the setup time and total fluoroscopy time. The setup time for the NAV group averaged 9.67 (standard deviation [SD], 3.74) minutes compared with 4.78 (SD, 2.11) minutes for the FLUORO group (p=.034). The total fluoroscopy time was higher for the FLUORO group compared with the NAV group (41.9 seconds vs. 28.7 seconds, p=.042). Radiation exposure was undetectable when navigation-assisted fluoroscopy is used (NAV group). In contrast, an average 12.4 milli-REM (mREM) of radiation exposure is delivered to the surgeon during unilateral MIS TLIF procedure without navigation (FLUORO group). In the clinical series, the total fluoro time for the NAV group was 57.1 seconds (SD, 37.3; range, 18-120) compared with 147.2 seconds (SD, 73.3; range, 73-295) for FLUORO group (p=.02). No statistically significant differences are noted for operating time, estimated blood loss, or hospital stay. No inadvertent durotomies, postoperative weakness, or new radiculopathy were noted in the NAV group. One inadvertent durotomy was encountered in the FLUORO group that was repaired intraoperatively without clinical sequelae. CONCLUSION The use of navigation-assisted fluoroscopy is feasible and safe for minimally invasive spine surgery. Radiation exposure is decreased to the patient as well as the surgical team.
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Affiliation(s)
- Choll W Kim
- Department of Orthopaedic Surgery, University of California, San Diego VA Healthcare System, 200 West Arbor Drive #8894, San Diego, CA 92103 USA.
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Computer-assisted surgical planning and image-guided surgical navigation in refractory adult scoliosis surgery: case report and review of the literature. Spine (Phila Pa 1976) 2008; 33:E287-92. [PMID: 18427309 DOI: 10.1097/brs.0b013e31816d256e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report and literature review. OBJECTIVE In this case report, we present the utility of computer-assisted surgical planning and image-guided surgical navigation in the planning and execution of a major osteotomy to correct severe kyphoscoliosis. SUMMARY OF BACKGROUND DATA Computer-assisted surgical planning is useful to appreciate the three-dimensional nature of scoliotic deformities and allows for operative maneuvers to be simulated on a computer before their implementation in the operating room. Image-guided surgical navigation improves surgical accuracy and can help translate a virtual surgical plan to the operative setting. METHODS We report the case of a 38-year-old woman with severe, congenital kyphoscoliosis refractory to many previous surgeries, who presents with moderate progressive myelopathy and severe pain attributable to a sharp angular deformity at T12. Three-dimensional computed tomography reconstruction and computer-assisted surgical planning were used to determine the optimal corrective osteotomy. The surgical plan was translated to the operating room where a posterior vertebrectomy and instrumented correction were executed with the aid of image-guided surgical navigation. RESULTS The osteotomy was safely performed resulting in improved sagittal and coronal alignments, as well as, correction of the sharp kyphoscoliotic deformity at the thoracolumbar junction. At 6-month follow-up, the patient's myelopathy and pain had largely resolved and she expressed high satisfaction with the procedure. CONCLUSION We advocate this novel application of virtual surgical planning and intraoperative surgical navigation to improve the safety and efficacy of complex spinal deformity corrections.
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ROSSOL MELANIE, GYGAX DIEGO, ANDRITZKY-WAAS JULIANE, ZHENG GUOYAN, LISCHER CHRISTOPHJ, ZHANG XUAN, AUER JOERGA. Comparison of Computer Assisted Surgery with Conventional Technique for Treatment of Abaxial Distal Phalanx Fractures in Horses: An In Vitro Study. Vet Surg 2008; 37:32-42. [DOI: 10.1111/j.1532-950x.2007.00346.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Togawa D, Kayanja MM, Reinhardt MK, Shoham M, Balter A, Friedlander A, Knoller N, Benzel EC, Lieberman IH. Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: part 2--Evaluation of system accuracy. Neurosurgery 2007; 60:ONS129-39; discussion ONS139. [PMID: 17297375 DOI: 10.1227/01.neu.0000249257.16912.aa] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To evaluate the accuracy of a novel bone-mounted miniature robotic system for percutaneous placement of pedicle and translaminar facet screws. METHODS Thirty-five spinal levels in 10 cadavers were instrumented. Each cadaver's entire torso was scanned before the procedure. Surgeons planned optimal entry points and trajectories for screws on reconstructed three-dimensional virtual x-rays of each vertebra. Either a clamp or a minimally invasive external frame was attached to the bony anatomy. Anteroposterior and lateral fluoroscopic images using targeting devices were obtained and automatically registered with the virtual x-rays of each vertebra generated from the computed tomographic scan obtained before the procedure. A miniature robot was mounted onto the clamp and external frame and the system controlled the robot's motions to align the cannulated drill guide along the planned trajectory. A drill bit was introduced through the cannulated guide and a hole was drilled through the cortex. Then, K-wires were introduced and advanced through the same cannulated guide and left inside the cadaver. The cadavers were scanned with computed tomography after the procedure and the system's accuracy was evaluated in three planes, comparing K-wire positions with the preoperative plan. A total of fifty-five procedures were evaluated. RESULTS Twenty-nine of 32 K-wires and all four screws were placed with less than 1.5 mm of deviation; average deviation was 0.87 +/- 0.63 mm (range, 0-1.7 mm) from the preoperative plan in this group. Sixteen of 19 K-wires were placed with less than 1.5 mm of deviation. There was one broken and one bent K-wire. Another K-wire was misplaced because of collision with the previously placed wire on the contralateral side of the same vertebra because of a mistake in planning, resulting in a 6.5-mm deviation. When this case was excluded, average deviation was 0.82 +/- 0.65 mm (range, 0-1.5 mm). CONCLUSION These results verify the system's accuracy and support its use for minimally invasive spine surgery in selected patients.
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Affiliation(s)
- Daisuke Togawa
- Cleveland Clinic Spine Institute, Minimally Invasive Surgery Center, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Nottmeier EW, Crosby TL. Timing of Paired Points and Surface Matching Registration in Three-Dimensional (3D) Image-guided Spinal Surgery. ACTA ACUST UNITED AC 2007; 20:268-70. [PMID: 17538349 DOI: 10.1097/01.bsd.0000211282.06519.ab] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Image-guidance can increase the safety and accuracy of spinal instrumentation placement. However, many spine surgeons are reluctant to incorporate spinal image-guidance into their surgical practice due to the perception that it is time-consuming and tedious, especially the task of vertebral registration. The authors evaluated the time required for paired points and surface matching registration when using the BrainLAB (BrainLAB, Westchester, IL) image-guided spine application for spinal surgery cases. The time required to register vertebral segments using paired points and surface matching techniques was assessed in 13 consecutive patients undergoing spinal fusions by the senior author. Overall, 23 vertebral segments were registered spanning from T1 to S1. Note was made of the vertebral segments that required reregistration due to poor accuracy. The average time required to register a single vertebral segment using the paired points and surface matching technique was 117 seconds (1 min 57 s). Average accuracy obtained was 0.9 mm. Inaccurate registration occurred in 3/23 (13%) of the segments requiring a second attempt at registration. In 3/23 (13%) of segments, adequate navigation accuracy was maintained on an adjacent vertebral segment thereby allowing for instrumentation to be placed in that adjacent segment without having to register that segment. Though associated with a learning curve, image-guidance can be used effectively and efficiently in spinal surgery. Average time required for registration of a vertebral segment using the BrainLAB spine application in this study was less than 2 minutes. The average accuracy obtained was 0.9 mm.
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Affiliation(s)
- Eric W Nottmeier
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL 32224, USA.
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Rajasekaran S, Vidyadhara S, Ramesh P, Shetty AP. Randomized clinical study to compare the accuracy of navigated and non-navigated thoracic pedicle screws in deformity correction surgeries. Spine (Phila Pa 1976) 2007; 32:E56-64. [PMID: 17224800 DOI: 10.1097/01.brs.0000252094.64857.ab] [Citation(s) in RCA: 246] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Randomized clinical trial (level I evidence). OBJECTIVE To compare the accuracy of non-navigation and Iso-C based navigation in pedicle screw fixation in thoracic spine deformities. SUMMARY OF BACKGROUND DATA Thoracic pedicle screw insertion for spinal deformity correction can be associated with increased pedicle breaches. Iso-C based navigation has been reported to improve the accuracy of pedicle screw placement, but its use in the presence of deformity has not been reported. METHODS Twenty-seven patients with scoliosis and 6 patients with kyphosis had a total of 478 thoracic pedicle screws. The average Cobb angle was 58.4 degrees +/- 8 degrees (range 50 degrees -80 degrees), and the mean kyphotic angle was 54.6 degrees +/- 4 degrees (range 51 degrees -76 degrees). By random allocation, 17 patients had screw insertion under navigation (242 screws) and 16 under fluoroscopic control (236 screws). The 2 groups were compared for accuracy of screw placement, time for screw insertion, and the number of times the C-arm had to be brought into the field. Two independent blinded observers determined accuracy using postoperative computed tomography assessments. RESULTS There were 54 (23%) pedicle breaches in the non-navigation group as compared to only 5 (2%) in the navigation group (P < 0.001). Thirty-eight screws (16%) in the non-navigation group had penetrated the anterior or lateral cortex compared to 2 screws (0.8%) in the navigation group. Average screw insertion time in the non-navigation group was 4.61 +/- 1.05 minutes (range 1.8-6.5) compared to 2.37 +/- 0.72 minutes (range 1.16-4.5) in navigation group (P < 0.01). The C-arm had to be moved into the operation field on an average of 1.5 +/- 0.25 times (range 1-3) per screw. With single screening data, an average of 11.4 pedicles (range 9-14) could be visualized without necessity to bring the C-arm into operating field again. CONCLUSIONS Iso-C navigation increases accuracy, and reduces surgical time and radiation in thoracic deformity correction surgeries.
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Affiliation(s)
- S Rajasekaran
- Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India.
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Lieberman IH, Togawa D, Kayanja MM, Reinhardt MK, Friedlander A, Knoller N, Benzel EC. Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: Part I--Technical development and a test case result. Neurosurgery 2006; 59:641-50; discussion 641-50. [PMID: 16955046 DOI: 10.1227/01.neu.0000229055.00829.5b] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To introduce a new miniature robot (SpineAssist; MAZOR Surgical Technologies, Caesarea, Israel) that has been developed and tested as a surgical assistant for accurate percutaneous placement of pedicle screws and translaminar facet screws. METHODS Virtual projections in three planes-axial, lateral, and anteroposterior-are reconstructed for each vertebra from a preoperative computed tomographic (CT) scan. On a specially designed graphic user interface with proprietary software, the surgeon plans the trajectory of the screws. Intraoperative fluoroscopic x-rays with targeting devices are then matched with the CT-based virtual images, as well as the surgeon's plan. A clamp is attached to the spinous process or a minimally invasive frame (Hover-T frame; MAZOR Surgical Technologies) is mounted to the iliac crest and one spinous process. The miniature robot is then attached to the clamp and/or frame. On the basis of combined CT scan and fluoroscopic data, the robot aligns itself to the desired entry point and trajectory, as dictated by the surgeon's preoperative plan. RESULTS A test case in a cadaver lumbar spine was performed in which four screws and two rods were inserted, using a minimally invasive technique, combining the SpineAssist system and Hover-T frame in conjunction with the PathFinder system (Spinal Concept Inc., Austin, TX). The discrepancy between the planned and actual screw trajectories was measured by means of postprocedural CT scan. Overall, the four screws were implanted with an average deviation of 1.02 +/- 0.56 mm (range, 0-1.5 mm) from the surgeon's plan. CONCLUSION These preliminary results confirm the system's accuracy and support its use in minimally invasive spine surgery applications.
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Affiliation(s)
- Isador H Lieberman
- Cleveland Clinic Spine Institute, Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Quiñones-Hinojosa A, Robert Kolen E, Jun P, Rosenberg WS, Weinstein PR. Accuracy Over Space and Time of Computer-Assisted Fluoroscopic Navigation in the Lumbar Spine In Vivo. ACTA ACUST UNITED AC 2006; 19:109-13. [PMID: 16760784 DOI: 10.1097/01.bsd.0000168513.68975.8a] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The integration of digital image-guided surgical navigation with C-arm fluoroscopy, known as virtual fluoroscopy (VF), has been shown to enhance the safety of spine surgery in vitro. Few clinical studies have assessed the accuracy of VF during actual spinal surgery, and no studies have investigated variations in accuracy over the course of a series of measurements obtained during operative cases. We sought to study the intraoperative accuracy of VF over time and space during lumbar pedicle screw placement in human patients. METHODS Fluoroscopic images of the lumbar spine were obtained, calibrated, and saved to the Stealth Station (FluoroNav) on seven patients undergoing lumbar fusion surgery. The tracking arc was attached to an exposed lumbar spinous process, which was designated the index level. With use of anatomic surface irregularities in the laminae and spinous processes, several points were identified and registered on three different vertebrae directly adjacent to the index level vertebra. Every 15 minutes, throughout the operative case, the probe was brought to each point and the apparent distance from the original location recorded (as measured by the FluoroNav system). Measurements were collected from three vertebral levels adjacent to the index level over a time course of 120 minutes during the operation. RESULTS At the index, index +1, index +2, and index +3 levels, 89%, 81%, 92%, and 64% of measurements were within <2 mm, whereas 97%, 96%, 97%, and 91% were within <3 mm, respectively. At 15, 30, 45, 60, 75, 90, 105, and 120 minutes, 96%, 89%, 85%, 61%, 85%, 90%, 93%, and 50% of measurements were within <2 mm, whereas 100%, 93%, 100%, 83%, 100%, 90%, 100%, and 100% of measurements were within <3 mm, respectively. The error in millimeters tended to increase as the distance from the index level increased (R = 0.19, P < 0.05) and as operative time increased (R = 0.26, P < 0.01). Calibration studies of intraoperative VF (IoVF) in the lumbar spine documented a reasonable degree of accuracy. The majority of sequential measurements obtained during IoVF in the lumbar spine were within an error range of <3 mm. CONCLUSIONS Our results suggest that the use of VF is a reliable method of verifying the use of anatomic and/or radiographic landmarks for guidance during lumbar pedicle screw placement.
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Holly LT, Bloch O, Johnson JP. Evaluation of registration techniques for spinal image guidance. J Neurosurg Spine 2006; 4:323-8. [PMID: 16619680 DOI: 10.3171/spi.2006.4.4.323] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Paired point matching alone and paired point matching combined with surface matching are the two techniques used for the registration step in preoperative computerized tomography–based spinal image guidance. In the present study the authors sought to compare paired point–matching registration alone with paired point matching supplemented with surface matching to determine if the addition of surface matching improves navigational accuracy.
Methods
Pedicle screws were placed in three embalmed human cervicothoracic spinal specimens during image guidance to serve as a reference points. The specimens were then rescanned, and each level was registered using paired point matching alone and then by paired point supplemented with surface matching. Navigational accuracy was assessed by placing the stereotactic probe in the center of the screw head, and measuring the apparent distance between the screw head and probe on the computer monitor. Statistical analysis was used to compare the registration error and navigational error between the two techniques.
Seventy-five screws were placed at 46 vertebral levels. The mean registration error for the paired point matching/surface matching technique (0.5 mm) was significantly lower (p < 0.001) than that of the paired point matching alone technique (1.2 mm); however, the intertechnique difference in navigational error was nearly equivalent (1.3 mm compared with 1.4 mm) and statistically insignificant (p > 0.05).
Conclusions
Although the addition of surface matching to paired point registration significantly decreased the mean registration error, the actual navigational accuracy between the two techniques was equivalent when easily distinguishable points were meticulously selected. The use of paired point matching alone did not compromise the accuracy of navigation and is likely to result in decreased operating time.
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Affiliation(s)
- Langston T Holly
- University of California at Los Angeles Medical Center, Los Angeles, California, USA
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Barzilay Y, Liebergall M, Fridlander A, Knoller N. Miniature robotic guidance for spine surgery — introduction of a novel system and analysis of challenges encountered during the clinical development phase at two spine centres. Int J Med Robot 2006; 2:146-53. [PMID: 17520625 DOI: 10.1002/rcs.90] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Instrumented spinal fusion surgery is increasingly performed. Breaching of the pedicle occurs in 3-55% of screws; clinically significant screw misplacements occur in 0-7% of all transpedicular screw placements. Several techniques have reduced this incidence but none gained popularity due to cost as well as staff issues. Surgical robots offer distinct added value in accuracy and minimal invasiveness. The aim of this study is to introduce the SpineAssist--a novel spine surgery miniature robot, to discuss the various reasons that had prevented full success with its use, to identify patients related, technical related, and surgeon related issues, and to offer ways to avoid them. METHODS The SpineAssist miniature robotic system is presented, including a short description of the system, its mode of action and a short summary of the surgical procedure.15 patients had undergone lumbar fusion procedures using the robotic system as part of clinical trials in two Israeli spine centres. A group of 9 procedures was identified within this prospective cohort. This group represents a wide array of technical challenges and human errors which were encountered during the clinical development phase of the SpineAssist. These 9 cases were conducted in two different sites by different surgical teams, over a period of 9 months, with an average interval of 7 weeks between consecutive cases. The cases were analysed for patient, system, surgeon and technical issues causing the difficulty. Conclusions were drawn as to how to avoid these hurdles in the future. RESULTS In six cases the system operated smoothly, resulting in accurate screws placement according to the pre-operative plan, this was confirmed by a post-operative CT scan. Technical and surgical challenges which are associated with the system early development stage were encountered during 9 procedures. On the technical side, the following phenomena were evident: 1) failure of the software to automatically achieve satisfying CT-to-fluoro image registration and 2) failure of the hospital's peripheral equipment/logistics preventing registration. On the clinical side of things, the following issues were encountered: 1) failure to avoid excessive pressure on the guiding arm caused by surrounding soft tissues, leading to a shift in the entry point and trajectory of the tool guide. 2) a surgeon applying too much force on the tool guide at the tip of the robotic arm, causing deviation from plan. 3) pre-operative plan out of the reach of the robot arm and 4) attachment of the clamp to the spinous process in a suboptimal orientation. CONCLUSIONS It is expected that following a steep learning curve in the range of 5-10 cases, recommended to take place within 2-3 weeks time, the surgical team will gain sufficient experience in operating the SpineAssist miniature robotic device in order to achieve excellent surgical results. The system may be used for wide range of applications including but not limited to pedicle screws, trans-facet and trans-laminar screws, biopsy needles, vertebroplasty or kyphoplasty tools and more. The preoperative plan has to be logical, intraoperative fluoro images taken with care, gentle surgical technique must be kept - maintaining the integrity of the posterior elements, and avoiding pressure between the robot arms and the soft tissues. During the clinical development phase discussed in this study, both teams used an early version of the system. Based on the results of this study several significant software and hardware improvements have already been implemented. It is our hope that describing and analysing our findings will help in planning and preparing for the clinical utilization of the SpineAssist system in future sites and will shorten their learning curve. By the time this article is published wider clinical experience will have been gathered and we expect to soon follow up with an analysis of clinical utilization of this system in a larger study group.
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Affiliation(s)
- Y Barzilay
- Spine Unit, Department of Orthopaedic Surgery, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
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Accuracy of image guided placement of iliosacral lag screws. ACTA ACUST UNITED AC 2005. [DOI: 10.1007/bfb0029284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Richter M, Cakir B, Schmidt R. Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws. Spine (Phila Pa 1976) 2005; 30:2280-7. [PMID: 16227890 DOI: 10.1097/01.brs.0000182275.31425.cd] [Citation(s) in RCA: 158] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective clinical study with postoperative radiologic control of pedicle screw placement in the cervical spine. OBJECTIVES To evaluate whether cervical pedicle screws can be placed safely in a conventional technique when using cannulated screws and separate stab incisions. Also, to evaluate if accuracy and safety of pedicle screw placement can be improved using a computer-assisted surgery (CAS) system (VectorVision; BrainLAB AG, Heimstetten, Germany). SUMMARY OF BACKGROUND DATA Pedicle screws are rarely used in the cervical spine compared to the use in lumbar and thoracic spine. The main reason is probably the potential risk of iatrogenic damage to the spinal cord, nerve roots, or vertebral artery caused by screw misplacement as well as the more demanding technique of pedicle screw placement in the cervical spine. METHODS A total of 52 consecutive patients with posterior cervical or cervicothoracic instrumentations using pedicle screws were evaluated prospectively. For the first 20 patients, 93 pedicle screws were implanted using the conventional technique with the image intensifier in the lateral view, and for the next 32 patients (167 screws), a CAS system was additionally used. For registration of the vertebra, surface-matching algorithms were used. For evaluation of screw placement, postoperative computerized tomography with multiplanar reconstructions in the screw axis was performed for each screw. RESULTS No implant-related complications were observed. No neurologic or vascular complications were found related to pedicle screws. The rate of pedicle perforations was 8.6% (8 screws) in the conventional group and 3.0% (5 screws) in the CAS group, and in all cases, less than 2-mm displacement. None of the screws with pedicle perforation had to be revised as a result of nonsufficient biomechanical stability or compression of neural/vascular structures. CONCLUSIONS Transpedicular screws in the cervical spine and cervicothoracic junction can be applied safely and with high accuracy in a conventional technique. Cannulated screws and the use of separate stab incisions from C3-C6 with a trocar system allow for reduced screw misplacement rates. The CAS system leads to significantly reduced screw misplacement rates. Therefore, because of the potential risk of injury to the vertebral artery and neural elements, the use of a CAS system seems to be beneficial, especially for pedicle instrumentation C3-C6.
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Bolger C, Carozzo C, Roger T, McEvoy L, Nagaria J, Vanacker G, Bourlion M. A preliminary study of reliability of impedance measurement to detect iatrogenic initial pedicle perforation (in the porcine model). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2005; 15:316-20. [PMID: 16222529 PMCID: PMC3489289 DOI: 10.1007/s00586-005-1024-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 06/27/2005] [Accepted: 08/12/2005] [Indexed: 11/25/2022]
Abstract
Accidental perforation of the vertebral pedicle wall is a well-known complication associated with standard approach of pedicle screw insertion. Depending on detection criteria, more than 20% of screws are reported misplaced. Serious clinical consequences, from dysesthesia to paraplegia, although not common, may result from these misplaced screws. Many techniques have been described to address this issue such as somatosensory evoked potentials, electromyography, surgical navigation, etc. Each of these techniques presents advantages and drawbacks, none is simple and ergonomic. A new drilling tool was evaluated which allows for instant detection of pedicle perforation by emission of variable beeps. This new device is based on two original principles: the device is integrated in the drilling or screwing tool, the technology allows real-time detection of perforation through two independent parameters, impedance variation and evoked muscular contractions. A preliminary animal study was conducted to assess the safety and efficacy of this system based upon electrical conductivity. A total of 168 manual pedicle drillings followed by insertion of implants were performed in 11 young porcine lumbar and thoracic spines. The presence or absence of perforation detection, which defines the reliability of the device, was correlated with necropsic examination of the spines. Using this protocol the device demonstrated 100% positive predictive value, 96% negative predictive value, 100% specificity, and 97% sensitivity. Of 168 drillings there were three (1.79%) false-negatives, leading to a minor effraction, cranially in the intervertebral disks, nine (5.36%) screw threads breaching the vertebral cortex when inserting screws, although preparation of the holes did not indicate any perforation, 34 (36%) breaches detected by the instrument and not detected by the surgeon. These results confirm that the impedance variation detection capability of this device offers a simple and effective means to detect perforation in vertebral pedicle, prior to insertion of pedicle screws. Due to the porcine nerve root anatomy, it was not possible to evaluate the added benefit of cross-linking impedance and EMG detection. A future clinical study may further explore the subject of current study.
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Affiliation(s)
- Ciaran Bolger
- Neurosurgical Research and Development Unit, National Department for Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - C. Carozzo
- NeurosEcole Nationale Vétérinaire de Lyonurgical Research and Development Unit, Beaumont 69280 Marcy l’EtoileHospital, 5201 Lyon, France
| | - T. Roger
- NeurosEcole Nationale Vétérinaire de Lyonurgical Research and Development Unit, Beaumont 69280 Marcy l’EtoileHospital, 5201 Lyon, France
| | - Linda McEvoy
- Neurosurgical Research and Development Unit, National Department for Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - Jabir Nagaria
- Neurosurgical Research and Development Unit, National Department for Neurosurgery, Beaumont Hospital, Dublin, Ireland
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Johnson JP, Stokes JK, Oskouian RJ, Choi WW, King WA. Image-guided thoracoscopic spinal surgery: a merging of 2 technologies. Spine (Phila Pa 1976) 2005; 30:E572-8. [PMID: 16205331 DOI: 10.1097/01.brs.0000180475.20002.15] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective clinical and intraoperative navigational data review. OBJECTIVE To evaluate quantitatively the application of frameless stereotactic image guidance in thoracoscopic discectomy procedures. SUMMARY OF BACKGROUND DATA Thoracoscopic spinal surgery has technical and anatomic challenges that result in difficult orientation with a 2-dimensional imaging procedure in a complex 3-dimensional structure. METHODS There were 16 patients who underwent image-guided thoracoscopic discectomy procedures that combine these 2 technologies. Accuracy was determined by the registration (calculated) error and actual navigation (intraoperative) error. The clinical outcomes and complications were reviewed. RESULTS Accuracy determined by registration (calculated) and navigation (intraoperative) was 1.7 and 1.2 mm, respectively. The additional time required for the image guidance portion of the procedure was countered by the efficiency of the remaining procedure. Clinical outcomes and complication were comparable with previous experience. CONCLUSIONS Image-guided thoracoscopic spinal surgery can provide 3-dimensional orientation to a 2-dimensional imaging procedure that ultimately improves accuracy, efficiency, and safety. Future developments in combining guidance technology with standard surgical procedures will likely continue.
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Rampersaud YR, Pik JHT, Salonen D, Farooq S. Clinical accuracy of fluoroscopic computer-assisted pedicle screw fixation: a CT analysis. Spine (Phila Pa 1976) 2005; 30:E183-90. [PMID: 15803068 DOI: 10.1097/01.brs.0000157490.65706.38] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational cohort study with computerized tomography (CT) analysis of in vivo pedicle screw placement. OBJECTIVE To evaluate the clinical accuracy of computer-assisted fluoroscopy for the placement of thoracic and lumbosacral (LS) pedicle screws. SUMMARY OF BACKGROUND DATA Computer-assisted fluoroscopy is an adjunct for the placement of pedicle screws. METHODS Postoperative CT of 360 titanium pedicle screws (281 LS [L1-S1]; 79 thoracic [T2-T12]) were independently assessed. All screws were placed using the FluoroNav system (Medtronic Surgical Navigation Technologies, Louisville, CO). The relative position of the screw to the pedicle was graded as follows: A = completely in; B = <2 mm breach; C = 2-4 mm breach; and D = >4 mm breach. If an osseous breach occurred, the direction of the breach was further classified. RESULTS Eight-five percent of screws were completely contained within the pedicle. Fifty-five-pedicle breaches (25 medial; 30 lateral) occurred. Pedicle breaches were graded B in 13.1% (47 breaches), C in 1.9% (7), and D in 0.3% (1) of screws. Pedicle breach was significantly higher in the thoracic compared to the LS spine, 31.6% (25/79) and 10.6% (30/281), respectively (P < 0.0001). In the thoracic spine, 72% of pedicle breaches were lateral. In 49% of breaches, the screw diameter was larger than the pedicle diameter. None of the pedicle breaches were associated with neurologic or other clinical sequelae. CONCLUSIONS The clinical pedicle breach rate in this study is comparable to those reported using conventional techniques with or without fluoroscopic assistance. FluoroNav appears to be a safe adjunct for the placement of thoracic and LS pedicle screws.
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Affiliation(s)
- Y Raja Rampersaud
- Division of Orthopaedic, University of Toronto, Toronto, Ontario, Canada.
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Mahadewa T, Mizuno J, Inoue T, Song J, Nakagawa H. Traumatic C6-7 subluxation associated with C-7 fracture treated with a pedicle screw system under navigation guidance--case report. Neurol Med Chir (Tokyo) 2005; 45:87-91. [PMID: 15722606 DOI: 10.2176/nmc.45.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 51-year-old female presented with traumatic C6-7 subluxation associated with C-7 fracture due to an automobile accident. She underwent pedicle screw fixation at C-6, C-7, and T-1 for stabilization of the spinal column. A neuronavigation system was used to obtain accurate placement of the pedicle screws. The patient recovered well without further neurological compromise. Postoperative cervical radiography showed reasonable restoration of the vertebral column without delayed kyphotic deformity.
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Affiliation(s)
- Tjokorda Mahadewa
- Department of Neurosurgery, Padjadjaran University School of Medicine, Bandung, Republic of Indonesia
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