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Huang Y, Zhang X, Hu Y, Johnston AR, Jones CK, Zbijewski WB, Siewerdsen JH, Helm PA, Witham TF, Uneri A. Deformable registration of preoperative MR and intraoperative long-length tomosynthesis images for guidance of spine surgery via image synthesis. Comput Med Imaging Graph 2024; 114:102365. [PMID: 38471330 DOI: 10.1016/j.compmedimag.2024.102365] [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: 10/04/2023] [Revised: 01/31/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Improved integration and use of preoperative imaging during surgery hold significant potential for enhancing treatment planning and instrument guidance through surgical navigation. Despite its prevalent use in diagnostic settings, MR imaging is rarely used for navigation in spine surgery. This study aims to leverage MR imaging for intraoperative visualization of spine anatomy, particularly in cases where CT imaging is unavailable or when minimizing radiation exposure is essential, such as in pediatric surgery. METHODS This work presents a method for deformable 3D-2D registration of preoperative MR images with a novel intraoperative long-length tomosynthesis imaging modality (viz., Long-Film [LF]). A conditional generative adversarial network is used to translate MR images to an intermediate bone image suitable for registration, followed by a model-based 3D-2D registration algorithm to deformably map the synthesized images to LF images. The algorithm's performance was evaluated on cadaveric specimens with implanted markers and controlled deformation, and in clinical images of patients undergoing spine surgery as part of a large-scale clinical study on LF imaging. RESULTS The proposed method yielded a median 2D projection distance error of 2.0 mm (interquartile range [IQR]: 1.1-3.3 mm) and a 3D target registration error of 1.5 mm (IQR: 0.8-2.1 mm) in cadaver studies. Notably, the multi-scale approach exhibited significantly higher accuracy compared to rigid solutions and effectively managed the challenges posed by piecewise rigid spine deformation. The robustness and consistency of the method were evaluated on clinical images, yielding no outliers on vertebrae without surgical instrumentation and 3% outliers on vertebrae with instrumentation. CONCLUSIONS This work constitutes the first reported approach for deformable MR to LF registration based on deep image synthesis. The proposed framework provides access to the preoperative annotations and planning information during surgery and enables surgical navigation within the context of MR images and/or dual-plane LF images.
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Affiliation(s)
- Yixuan Huang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Xiaoxuan Zhang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Yicheng Hu
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, United States
| | - Ashley R Johnston
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Craig K Jones
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, United States
| | - Wojciech B Zbijewski
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Jeffrey H Siewerdsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States; Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Ali Uneri
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States.
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Sakhrekar R, Shkumat N, Ertl-Wagner B, Lewis S, Lebel D, McVey MJ, Camp M. Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis. Spine Deform 2024; 12:739-746. [PMID: 38413472 DOI: 10.1007/s43390-024-00830-1] [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: 03/10/2023] [Accepted: 01/13/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. METHOD A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). RESULTS 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. CONCLUSION Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.
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Affiliation(s)
- Rajendra Sakhrekar
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Nicholas Shkumat
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Stephen Lewis
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - David Lebel
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - M J McVey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
| | - Mark Camp
- Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Dietz N, Spiessberger A. Consistent anatomical relationships of pedicle, lamina, and superior articulating process in severe idiopathic scoliosis allow for safe freehand pedicle screw placement: A proof-of-concept technical study. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:224-229. [PMID: 38957756 PMCID: PMC11216649 DOI: 10.4103/jcvjs.jcvjs_16_24] [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: 01/29/2024] [Accepted: 03/18/2024] [Indexed: 07/04/2024] Open
Abstract
Introduction Transpedicular screw placement has superior pullout strength compared to alternative forms of spinal fusion and is often performed in deformity correction surgery with navigation for optimal accuracy and reliability. Freehand technique for pedicle screws minimizes operation time and radiation exposure without fluoroscopy but is not widely adopted given the challenge of difficult anatomical corridors and accurate placement, especially in idiopathic scoliosis and advanced deformity. We used a computer-generated model to assess a proof-of-concept and anatomical feasibility of a freehand screw technique in severe scoliosis. Methods Three-dimensional (3D) reconstructions of vertebra from a sample of two male patients with severe idiopathic scoliosis deformity (1 thoracic and 1 lumbar) with Cobb angles of 100° were used for planned placement of 17 levels of thoracolumbar (6.5 mm × 45 mm) pedicle screws. 3D reconstruction of each vertebra was created and measurements of screw entries and trajectories were reproduced with a 3D slicer software image computing platform. Results Accurate transpedicular screw placement is possible with anatomical landmarks based on the 3D reconstructed vertebral levels. A series of 5 figures were assembled to demonstrate sagittal, coronal, and axial planes and key anatomical landmarks and trajectories of thoracic and lumbar freehand pedicle screws in severe idiopathic scoliosis. Conclusions Anatomical landmarks for freehand transpedicular screw placement (between pedicle, lamina, and superior articulating process) are constant and reliable in severe idiopathic scoliosis as evidenced by 3D computer modeling. Preoperative computed tomography modeling may assist appropriate screw entry and trajectory based on anatomical landmarks for spine surgeons, and guide freehand technique for screw placement in adolescent idiopathic scoliosis.
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Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
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Leblond L, Godio-Raboutet Y, Glard Y, La Greca R, Clement T, Evin M. Assessment of the tolerance angle for pedicle screw insertion. Med Biol Eng Comput 2024; 62:1265-1275. [PMID: 38177833 DOI: 10.1007/s11517-023-03002-x] [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: 09/08/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024]
Abstract
Cannulation process intervenes before implantation of pedicle screw and depends on the surgeon's experience. A reliable experimental protocol has been developed for the characterization of the slipping behavior of the surgical tool on the cortical shell simulated by synthetic materials. Three types of synthetic foam samples with three different densities were tested using an MTS Acumen 3 A/T electrodynamic device with a tri-axis 3 kN Kistler load cell mounted on a surgical tool, moving at a constant rotational speed of 10° mm-1 and performing a three-step cannulation test. Cannulation angle varied between 10° and 30°. Synthetic samples were scanned after each tests, and cannulation coefficient associated to each perforation section was computed. Reproducibility tests resulted in an ICC for Sawbone samples of 0.979 (p < 0.001) and of 0.909 (p < 0.001) for Creaplast and Sawbone samples. Cannulation coefficient and maximum force in Z-axis are found the best descriptors of the perforation. Angular threshold for perforation prediction was found to be 17.5° with an area under the curve of the Receiver Operating Characteristic of 89.5%. This protocol characterizes the cannulation process before pedicle screw insertion and identifies the perforation tool angle until which the surgical tool slips on the cortical shell depending on bone quality.
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Affiliation(s)
- Lugdivine Leblond
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France
| | - Yves Godio-Raboutet
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France
| | - Yann Glard
- Department of Paediatric Orthopaedics, Saint Joseph Hospital, Marseille, France
| | - Raphael La Greca
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France
| | - Thomas Clement
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France
| | - Morgane Evin
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR, Faculté de Medecine Secteur-Nord, Aix-Marseille University, University of Gustave Eiffel, LBA, Marseille, France.
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Altorfer FCS, Burkhard MD, Kelly MJ, Avrumova F, Sneag DB, Chazen JL, Tan ET, Lebl DR. Robot-Assisted Lumbar Pedicle Screw Placement Based on 3D Magnetic Resonance Imaging. Global Spine J 2024:21925682241232328. [PMID: 38324511 DOI: 10.1177/21925682241232328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
STUDY DESIGN Human Cadaveric Study. OBJECTIVE This study aims to explore the feasibility of using preoperative magnetic resonance imaging (MRI), zero-time-echo (ZTE) and spoiled gradient echo (SPGR), as source data for robotic-assisted spine surgery and assess the accuracy of pedicle screws. METHODS Zero-time-echo and SPGR MRI scans were conducted on a human cadaver. These images were manually post-processed, producing a computed tomography (CT)-like contrast. The Mazor X robot was used for lumbar pedicle screw-place navigating of MRI. The cadaver underwent a postoperative CT scan to determine the actual position of the navigated screws. RESULTS Ten lumbar pedicle screws were robotically navigated of MRI (4 ZTE; 6 SPGR). All MR-navigated screws were graded A on the Gertzbein-Robbins scale. Comparing preoperative robotic planning to postoperative CT scan trajectories: The screws showed a median deviation of overall 0.25 mm (0.0; 1.3), in the axial plane 0.27 mm (0.0; 1.3), and in the sagittal plane 0.24 mm (0.0; 0.7). CONCLUSION This study demonstrates the first successful registration of MRI sequences, ZTE and SPGR, in robotic spine surgery here used for intraoperative navigation of lumbar pedicle screws achieving sufficient accuracy, showcasing potential progress toward radiation-free spine surgery.
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Affiliation(s)
| | - Marco D Burkhard
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Michael J Kelly
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Fedan Avrumova
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - J Levi Chazen
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Darren R Lebl
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
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Liebmann F, von Atzigen M, Stütz D, Wolf J, Zingg L, Suter D, Cavalcanti NA, Leoty L, Esfandiari H, Snedeker JG, Oswald MR, Pollefeys M, Farshad M, Fürnstahl P. Automatic registration with continuous pose updates for marker-less surgical navigation in spine surgery. Med Image Anal 2024; 91:103027. [PMID: 37992494 DOI: 10.1016/j.media.2023.103027] [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: 03/02/2023] [Revised: 10/29/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Abstract
Established surgical navigation systems for pedicle screw placement have been proven to be accurate, but still reveal limitations in registration or surgical guidance. Registration of preoperative data to the intraoperative anatomy remains a time-consuming, error-prone task that includes exposure to harmful radiation. Surgical guidance through conventional displays has well-known drawbacks, as information cannot be presented in-situ and from the surgeon's perspective. Consequently, radiation-free and more automatic registration methods with subsequent surgeon-centric navigation feedback are desirable. In this work, we present a marker-less approach that automatically solves the registration problem for lumbar spinal fusion surgery in a radiation-free manner. A deep neural network was trained to segment the lumbar spine and simultaneously predict its orientation, yielding an initial pose for preoperative models, which then is refined for each vertebra individually and updated in real-time with GPU acceleration while handling surgeon occlusions. An intuitive surgical guidance is provided thanks to the integration into an augmented reality based navigation system. The registration method was verified on a public dataset with a median of 100% successful registrations, a median target registration error of 2.7 mm, a median screw trajectory error of 1.6°and a median screw entry point error of 2.3 mm. Additionally, the whole pipeline was validated in an ex-vivo surgery, yielding a 100% screw accuracy and a median target registration error of 1.0 mm. Our results meet clinical demands and emphasize the potential of RGB-D data for fully automatic registration approaches in combination with augmented reality guidance.
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Affiliation(s)
- Florentin Liebmann
- Research in Orthopedic Computer Science, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Laboratory for Orthopaedic Biomechanics, ETH Zurich, Zurich, Switzerland.
| | - Marco von Atzigen
- Research in Orthopedic Computer Science, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Laboratory for Orthopaedic Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Dominik Stütz
- Computer Vision and Geometry Group, ETH Zurich, Zurich, Switzerland
| | - Julian Wolf
- Product Development Group, ETH Zurich, Zurich, Switzerland
| | - Lukas Zingg
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Daniel Suter
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Nicola A Cavalcanti
- Research in Orthopedic Computer Science, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Laura Leoty
- Research in Orthopedic Computer Science, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Hooman Esfandiari
- Research in Orthopedic Computer Science, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jess G Snedeker
- Laboratory for Orthopaedic Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Martin R Oswald
- Computer Vision and Geometry Group, ETH Zurich, Zurich, Switzerland; Computer Vision Lab, University of Amsterdam, Amsterdam, Netherlands
| | - Marc Pollefeys
- Computer Vision and Geometry Group, ETH Zurich, Zurich, Switzerland; Microsoft Mixed Reality and AI Zurich Lab, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Oppermann M, Karapetyan V, Gupta S, Ramjist J, Oppermann P, Yang VXD. The pedicle screw accuracy using a robotic system and measured by a novel three-dimensional method. J Orthop Surg Res 2023; 18:706. [PMID: 37730623 PMCID: PMC10510280 DOI: 10.1186/s13018-023-04206-5] [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: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 09/22/2023] Open
Abstract
Robotics in medicine is associated with precision, accuracy, and replicability. Several robotic systems are used in spine surgery. They are all considered shared-control systems, providing "steady-hand" manipulation instruments. Although numerous studies have testified to the benefits of robotic instrumentations, they must address their true accuracy. Our study used the Mazor system under several situations and compared the spatial accuracy of the pedicle screw (PS) insertion and its planned trajectory. We used two cadaveric specimens with intact spinal structures from C7 to S1. PS planning was performed using the two registration methods (preopCT/C-arm or CT-to-fluoroscopy registration). After planning, the implant spatial orientation was defined based on six anatomic parameters using axial and sagittal CT images. Two surgical open and percutaneous access were used to insert the PS. After that, another CT acquisition was taken. Accuracy was classified into optimal, inaccurate and unacceptable according to the degree of screw deviation from its planning using the same spatial orientation method. Based on the type of spatial deviation, we also classified the PS trajectory into 16 pattern errors. Seven (19%) out of 37 implanted screws were considered unacceptable (deviation distances > 2.0 mm or angulation > 5°), and 14 (38%) were inaccurate (> 0.5 mm and ≤ 2.0 mm or > 2.5° and ≤ 5°). CT-to-fluoroscopy registration was superior to preopCT/C-arm (average deviation in 0.9 mm vs. 1.7 mm, respectively, p < 0.003), and percutaneous was slightly better than open but did not reach significance (1.3 mm vs. 1.7 mm, respectively). Regarding pattern error, the tendency was to have more axial than sagittal shifts. Using a quantitative method to categorize the screw 3D position, only 10.8% of the screws were considered unacceptable. However, with a more rigorous concept of inaccuracy, almost half were non-optimal. We also identified that, unlike some previous results, the O-arm registration delivers more accurate implants than the preopCT/C-arm method.
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Affiliation(s)
- Marcelo Oppermann
- Department of Clinical Neurological Science, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Department of Electrical Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada.
| | - Vahagan Karapetyan
- Department of Clinical Neurological Science, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Shaurya Gupta
- Department of Electrical Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada
| | - Joel Ramjist
- Department of Electrical Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada
| | - Priscila Oppermann
- Department of Clinical Neurological Science, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Victor X D Yang
- Department of Clinical Neurological Science, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Electrical Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada
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Karamian BA, DiMaria SL, Sawires AN, Canseco JA, Basques BA, Toci GR, Radcliff KE, Rihn JA, Kaye ID, Hilibrand AS, Lee JK, Kepler CK, Vaccaro AR, Schroeder GD. Clinical Outcomes of Robotic Versus Freehand Pedicle Screw Placement After One-to Three-Level Lumbar Fusion. Global Spine J 2023; 13:1871-1877. [PMID: 34873951 PMCID: PMC10556914 DOI: 10.1177/21925682211057491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The purpose of this study is to compare patient-reported outcome measures (PROMs) for patients undergoing one-to three-level lumbar fusion using robotically assisted vs freehand pedicle screw placement. METHODS Patients who underwent either robotically assisted or freehand pedicle screw placement for one-to three-level lumbar fusion surgery from January 1, 2014 to August 31, 2020 at a single academic institution were identified. Propensity score matching was performed based on demographic variables. Clinical and surgical outcomes were compared between groups. Recovery Ratios (RR) and the proportion of patients achieving the minimally clinically important difference (%MCID) were calculated for Oswestry Disability Index, PCS-12, MCS-12, VAS Back, and VAS Leg at 1 year. Surgical outcomes included complication and revision rates. RESULTS A total of 262 patients were included in the study (85 robotic and 177 freehand). No significant differences were found in ΔPROM scores, RR, or MCID between patients who underwent robotically assisted vs freehand screw placement. The rates of revision (1.70% freehand vs 1.18% robotic, P = 1.000) and complications (.57% freehand vs 1.18% robotic, P = .546) were not found to be statically different between the 2 groups. Controlling for demographic factors, procedure type (robotic vs freehand) did not emerge as a significant predictor of ΔPROM scores on multivariate linear regression analysis. CONCLUSIONS Robotically assisted pedicle screw placement did not result in significantly improved clinical or surgical outcomes compared to conventional freehand screw placement for patients undergoing one-to three-level lumbar fusion.
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Affiliation(s)
- Brian A. Karamian
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Stephen L. DiMaria
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Andrew N. Sawires
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose A. Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Bryce A. Basques
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory R. Toci
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kris E. Radcliff
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeffrey A. Rihn
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - I. David Kaye
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alan S. Hilibrand
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joseph K. Lee
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher K. Kepler
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander R. Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory D. Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Giorgi H, Tomi F, Glard Y, Afonso D, Montanari L, Faure A. Change of vertebral orientation, between the supine position and the prone position. Spine Deform 2023; 11:1079-1092. [PMID: 37221317 DOI: 10.1007/s43390-023-00704-y] [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: 01/06/2023] [Accepted: 05/06/2023] [Indexed: 05/25/2023]
Abstract
PURPOSE Our aim was to assess the change of vertebral orientation, expressed in the sagittal plane, in the transversal plane and in the frontal plane, at each level from T1 to S1 between the supine position (like in in a CT scan) and the prone position lying on bolsters like in an OR. METHODS Thirty-six patients were selected and included for a total number of one hundred and forty-eight vertebral levels. There were 30 females and 6 males. The mean age was 15 years and 9 months. A semi-automatic image processing technique and software (3D slicer), with a custom-made python script add-on, was used for each patient: paired preoperative CT scan and intraoperative cone beam computed tomography (CBCT) scan were processed to acquire complete spinal reconstructions in a consistent 3D coordinate system. The aim was to automatically compute a set of sagittal, transversal, and frontal rotations of each vertebral level of the same patient describing the 3D vertebral rotation between the supine position and the prone position lying on bolsters. RESULTS For sagittal analysis, the results showed a behavior in the evolution of rotation depending on the level. Between T01 and T10, the rotation was between - 14° and - 8°. Between T10 and L05, the sagittal rotation increased from - 10° up to + 10°. For frontal and transversal analysis, the rotations were under 6.5°. CONCLUSION These results could be valuable to perform a safe virtual templating: the information given by the virtual templating seems to be more accurate in the transversal plane than in the sagittal plane.
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Affiliation(s)
- Hadrien Giorgi
- Institut Méditerranéen du Dos, 232 Av. du Prado, 13008, Marseille, France
| | - Florent Tomi
- Laboratoire de Biomécanique Appliquée, Aix-Marseille Univ, Univ Gustave Eiffel, IFSTTAR, LBA, 13016, Marseille, France
| | - Yann Glard
- Hôpital Saint Joseph, Service de Chirurgie Pédiatrique, 13008, Marseille, France.
| | - David Afonso
- Hôpital Saint Joseph, Service de Chirurgie Pédiatrique, 13008, Marseille, France
| | - Lucrezia Montanari
- Hôpital Saint Joseph, Service de Chirurgie Pédiatrique, 13008, Marseille, France
| | - Aymeric Faure
- Institut Méditerranéen du Dos, 232 Av. du Prado, 13008, Marseille, France
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Matinfar S, Salehi M, Suter D, Seibold M, Dehghani S, Navab N, Wanivenhaus F, Fürnstahl P, Farshad M, Navab N. Sonification as a reliable alternative to conventional visual surgical navigation. Sci Rep 2023; 13:5930. [PMID: 37045878 PMCID: PMC10097653 DOI: 10.1038/s41598-023-32778-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/02/2023] [Indexed: 04/14/2023] Open
Abstract
Despite the undeniable advantages of image-guided surgical assistance systems in terms of accuracy, such systems have not yet fully met surgeons' needs or expectations regarding usability, time efficiency, and their integration into the surgical workflow. On the other hand, perceptual studies have shown that presenting independent but causally correlated information via multimodal feedback involving different sensory modalities can improve task performance. This article investigates an alternative method for computer-assisted surgical navigation, introduces a novel four-DOF sonification methodology for navigated pedicle screw placement, and discusses advanced solutions based on multisensory feedback. The proposed method comprises a novel four-DOF sonification solution for alignment tasks in four degrees of freedom based on frequency modulation synthesis. We compared the resulting accuracy and execution time of the proposed sonification method with visual navigation, which is currently considered the state of the art. We conducted a phantom study in which 17 surgeons executed the pedicle screw placement task in the lumbar spine, guided by either the proposed sonification-based or the traditional visual navigation method. The results demonstrated that the proposed method is as accurate as the state of the art while decreasing the surgeon's need to focus on visual navigation displays instead of the natural focus on surgical tools and targeted anatomy during task execution.
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Affiliation(s)
- Sasan Matinfar
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany.
- Nuklearmedizin rechts der Isar, Technical University of Munich, 81675, Munich, Germany.
| | - Mehrdad Salehi
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany
| | - Daniel Suter
- Department of Orthopaedics, Balgrist University Hospital, 8008, Zurich, Switzerland
| | - Matthias Seibold
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist Campus, 8008, Zurich, Switzerland
| | - Shervin Dehghani
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany
- Nuklearmedizin rechts der Isar, Technical University of Munich, 81675, Munich, Germany
| | - Navid Navab
- Topological Media Lab, Concordia University, Montreal, H3G 2W1, Canada
| | - Florian Wanivenhaus
- Department of Orthopaedics, Balgrist University Hospital, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Balgrist Campus, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, 8008, Zurich, Switzerland
| | - Nassir Navab
- Computer Aided Medical Procedures (CAMP), Technical University of Munich, 85748, Munich, Germany
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Altaf S, Rehman L, Javeed F, Ahmed A, Hatif Y. Comparison of the accuracy of intraoperative lateral fluoroscopy versus postoperative computed tomography in spinal fusions. Surg Neurol Int 2023; 14:71. [PMID: 36895236 PMCID: PMC9990634 DOI: 10.25259/sni_73_2023] [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: 01/23/2023] [Accepted: 02/15/2023] [Indexed: 03/11/2023] Open
Abstract
Background This study compared the accuracy of intraoperative lateral fluoroscopic images versus postoperative computed tomography (CT) 3D studies in the treatment of thoracolumbar spinal fusions. Methods In a tertiary care hospital (study duration 6 months), we compared the use of lateral fluoroscopic images with the postoperative CT scans in 64 patients with thoracic or lumbar fractures undergoing spinal fusions. Results Out of the 64 patients, 61% were lumbar followed by 39% thoracic fractures. In the lumbar spine, the accuracy of screw placement utilizing lateral fluoroscopy versus postoperative CT 3D was 97.4%, while in thoracic spine, accuracy was reduced to 84.4%. Of the 64 patients, just 4 (6.2%) patients demonstrated lateral pedicle cortex penetration, 1 (1.5%) patient had a medial pedicle cortex breach, while none exhibited anterior vertebral body cortex penetration. Conclusion This study documented the efficacy of lateral fluoroscopy in intraoperative thoracic and lumbar spinal fixation as confirmed by postoperative CT 3D studies. These findings support the continued use of fluoroscopy rather than CT intraoperatively to lower the risk of radiation exposure to both patients and surgeons.
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Affiliation(s)
- Sehrish Altaf
- Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Lal Rehman
- Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Farrukh Javeed
- Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Anas Ahmed
- Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Yousra Hatif
- Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
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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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13
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Navigation accuracy and assessability of carbon fiber-reinforced PEEK instrumentation with multimodal intraoperative imaging in spinal oncology. Sci Rep 2022; 12:15816. [PMID: 36138117 PMCID: PMC9500029 DOI: 10.1038/s41598-022-20222-7] [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: 07/13/2022] [Accepted: 09/09/2022] [Indexed: 12/03/2022] Open
Abstract
Radiolucent carbon-fiber reinforced PEEK (CFRP) implants have helped improve oncological follow-up and radiation therapy. Here, we investigated the performance of 3D intraoperative imaging and navigation systems for instrumentation and precision assessment of CFRP pedicle screws across the thoraco-lumbar spine. Thirty-three patients with spinal tumors underwent navigated CFRP instrumentation with intraoperative CT (iCT), robotic cone-beam CT (rCBCT) or cone-beam CT (CBCT) imaging. Two different navigation systems were used for iCT-/rCBCT- and CBCT-based navigation. Demographic, clinical and outcome data was assessed. Four blinded observers rated image quality, assessability and accuracy of CFRP pedicle screws. Inter-observer reliability was determined with Fleiss` Kappa analysis. Between 2018 and 2021, 243 CFRP screws were implanted (iCT:93, rCBCT: 99, CBCT: 51), of which 13 were non-assessable (iCT: 1, rCBCT: 9, CBCT: 3; *p = 0.0475; iCT vs. rCBCT). Navigation accuracy was highest using iCT (74%), followed by rCBCT (69%) and CBCT (49%) (*p = 0.0064; iCT vs. CBCT and rCBCT vs. CBCT). All observers rated iCT image quality higher than rCBCT/CBCT image quality (*p < 0.01) but relevant pedicle breaches were reliably identified with substantial agreement between all observers regardless of the imaging modality. Navigation accuracy for CFRP pedicle screws was considerably lower than expected from reports on titanium implants and CT may be best for reliable assessment of CFRP materials.
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14
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Gueziri HE, Georgiopoulos M, Santaguida C, Collins DL. Ultrasound-based navigated pedicle screw insertion without intraoperative radiation: feasibility study on porcine cadavers. Spine J 2022; 22:1408-1417. [PMID: 35523390 DOI: 10.1016/j.spinee.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 04/15/2022] [Accepted: 04/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Navigation systems for spinal fusion surgery rely on intraoperative computed tomography (CT) or fluoroscopy imaging. Both expose patient, surgeons and operating room staff to significant amounts of radiation. Alternative methods involving intraoperative ultrasound (iUS) imaging have recently shown promise for image-to-patient registration. Yet, the feasibility and safety of iUS navigation in spinal fusion have not been demonstrated. PURPOSE To evaluate the accuracy of pedicle screw insertion in lumbar and thoracolumbar spinal fusion using a fully automated iUS navigation system. STUDY DESIGN Prospective porcine cadaver study. METHODS Five porcine cadavers were used to instrument the lumbar and thoracolumbar spine using posterior open surgery. During the procedure, iUS images were acquired and used to establish automatic registration between the anatomy and preoperative CT images. Navigation was performed with the preoperative CT using tracked instruments. The accuracy of the system was measured as the distance of manually collected points to the preoperative CT vertebral surface and compared against fiducial-based registration. A postoperative CT was acquired, and screw placements were manually verified. We report breach rates, as well as axial and sagittal screw deviations. RESULTS A total of 56 screws were inserted (5.50 mm diameter n=50, and 6.50 mm diameter n=6). Fifty-two screws were inserted safely without breach. Four screws (7.14%) presented a medial breach with an average deviation of 1.35±0.37 mm (all <2 mm). Two breaches were caused by 6.50 mm diameter screws, and two by 5.50 mm screws. For vertebrae instrumented with 5.50 mm screws, the average axial diameter of the pedicle was 9.29 mm leaving a 1.89 mm margin in the left and right pedicle. For vertebrae instrumented with 6.50 mm screws, the average axial diameter of the pedicle was 8.99 mm leaving a 1.24 mm error margin in the left and right pedicle. The average distance to the vertebral surface was 0.96 mm using iUS registration and 0.97 mm using fiducial-based registration. CONCLUSIONS We successfully implanted all pedicle screws in the thoracolumbar spine using the ultrasound-based navigation system. All breaches recorded were minor (<2 mm) and the breach rate (7.14%) was comparable to existing literature. More investigation is needed to evaluate consistency, reproducibility, and performance in surgical context. CLINICAL SIGNIFICANCE Intraoperative US-based navigation is feasible and practical for pedicle screw insertion in a porcine model. It might be used as a low-cost and radiation-free alternative to intraoperative CT and fluoroscopy in the future.
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Affiliation(s)
- Houssem-Eddine Gueziri
- McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada.
| | - Miltiadis Georgiopoulos
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada
| | - D Louis Collins
- McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, 3801 University St, Montreal, Quebec, Canada
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15
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Naik RR, Hoblidar A, Bhat SN, Ampar N, Kundangar R. A Hybrid 3D-2D Image Registration Framework for Pedicle Screw Trajectory Registration between Intraoperative X-ray Image and Preoperative CT Image. J Imaging 2022; 8:jimaging8070185. [PMID: 35877629 PMCID: PMC9324544 DOI: 10.3390/jimaging8070185] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/11/2022] [Accepted: 06/19/2022] [Indexed: 12/04/2022] Open
Abstract
Pedicle screw insertion is considered a complex surgery among Orthopaedics surgeons. Exclusively to prevent postoperative complications associated with pedicle screw insertion, various types of image intensity registration-based navigation systems have been developed. These systems are computation-intensive, have a small capture range and have local maxima issues. On the other hand, deep learning-based techniques lack registration generalizability and have data dependency. To overcome these limitations, a patient-specific hybrid 3D-2D registration principled framework was designed to map a pedicle screw trajectory between intraoperative X-ray image and preoperative CT image. An anatomical landmark-based 3D-2D Iterative Control Point (ICP) registration was performed to register a pedicular marker pose between the X-ray images and axial preoperative CT images. The registration framework was clinically validated by generating projection images possessing an optimal match with intraoperative X-ray images at the corresponding control point registration. The effectiveness of the registered trajectory was evaluated in terms of displacement and directional errors after reprojecting its position on 2D radiographic planes. The mean Euclidean distances for the Head and Tail end of the reprojected trajectory from the actual trajectory in the AP and lateral planes were shown to be 0.6–0.8 mm and 0.5–1.6 mm, respectively. Similarly, the corresponding mean directional errors were found to be 4.90 and 20. The mean trajectory length difference between the actual and registered trajectory was shown to be 2.67 mm. The approximate time required in the intraoperative environment to axially map the marker position for a single vertebra was found to be 3 min. Utilizing the markerless registration techniques, the designed framework functions like a screw navigation tool, and assures the quality of surgery being performed by limiting the need of postoperative CT.
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Affiliation(s)
- Roshan Ramakrishna Naik
- Manipal Institute of Technology, Manipal Academy of Higher Education Manipal, Manipal 576104, India;
| | - Anitha Hoblidar
- Manipal Institute of Technology, Manipal Academy of Higher Education Manipal, Manipal 576104, India;
- Correspondence: (A.H.); (S.N.B.)
| | - Shyamasunder N. Bhat
- Kasturba Medical College, Manipal Academy of Higher Education Manipal, Manipal 576104, India; (N.A.); (R.K.)
- Correspondence: (A.H.); (S.N.B.)
| | - Nishanth Ampar
- Kasturba Medical College, Manipal Academy of Higher Education Manipal, Manipal 576104, India; (N.A.); (R.K.)
| | - Raghuraj Kundangar
- Kasturba Medical College, Manipal Academy of Higher Education Manipal, Manipal 576104, India; (N.A.); (R.K.)
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16
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Pijpker PAJ, Kuijlen JMA, Tamási K, Oterdoom DLM, Vergeer RA, Rijtema G, Coppes MH, Kraeima J, Groen RJM. The Accuracy of Patient-Specific Spinal Drill Guides Is Non-Inferior to Computer-Assisted Surgery: The Results of a Split-Spine Randomized Controlled Trial. J Pers Med 2022; 12:jpm12071084. [PMID: 35887581 PMCID: PMC9317516 DOI: 10.3390/jpm12071084] [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: 05/18/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022] Open
Abstract
In recent years, patient-specific spinal drill guides (3DPGs) have gained widespread popularity. Several studies have shown that the accuracy of screw insertion with these guides is superior to that obtained using the freehand insertion technique, but there are no studies that make a comparison with computer-assisted surgery (CAS). The aim of this study was to determine whether the accuracy of insertion of spinal screws using 3DPGs is non-inferior to insertion via CAS. A randomized controlled split-spine study was performed in which 3DPG and CAS were randomly assigned to the left or right sides of the spines of patients undergoing fixation surgery. The 3D measured accuracy of screw insertion was the primary study outcome parameter. Sixty screws inserted in 10 patients who completed the study protocol were used for the non-inferiority analysis. The non-inferiority of 3DPG was demonstrated for entry-point accuracy, as the upper margin of the 95% CI (−1.01 mm−0.49 mm) for the difference between the means did not cross the predetermined non-inferiority margin of 1 mm (p < 0.05). We also demonstrated non-inferiority of 3D angular accuracy (p < 0.05), with a 95% CI for the true difference of −2.30°−1.35°, not crossing the predetermined non-inferiority margin of 3° (p < 0.05). The results of this randomized controlled trial (RCT) showed that 3DPGs provide a non-inferior alternative to CAS in terms of screw insertion accuracy and have considerable potential as a navigational technique in spinal fixation.
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Affiliation(s)
- Peter A. J. Pijpker
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
- 3D-Lab, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands;
- Correspondence:
| | - Jos M. A. Kuijlen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Katalin Tamási
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - D. L. Marinus Oterdoom
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Rob A. Vergeer
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Gijs Rijtema
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Maarten H. Coppes
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
| | - Joep Kraeima
- 3D-Lab, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands;
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Rob J. M. Groen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (J.M.A.K.); (K.T.); (D.L.M.O.); (R.A.V.); (G.R.); (M.H.C.); (R.J.M.G.)
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17
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Zhang X, Uneri A, Huang Y, Jones CK, Witham TF, Helm PA, Siewerdsen JH. Deformable 3D-2D image registration and analysis of global spinal alignment in long-length intraoperative spine imaging. Med Phys 2022; 49:5715-5727. [PMID: 35762028 DOI: 10.1002/mp.15819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Spinal deformation during surgical intervention (caused by patient positioning and/or correction of malalignment) confounds conventional navigation due to assumptions of rigid transformation. Moreover, the ability to accurately quantify spinal alignment in the operating room would provide assessment of the surgical product via metrics that correlate with clinical outcome. PURPOSE A method for deformable 3D-2D registration of preoperative CT to intraoperative long-length tomosynthesis images is reported for accurate 3D evaluation of device placement in the presence of spinal deformation and automated evaluation of global spinal alignment (GSA). METHODS Long-length tomosynthesis ("Long Film", LF) images were acquired using an O-arm™ imaging system (Medtronic, Minneapolis USA). A deformable 3D-2D patient registration was developed using multi-scale masking (proceeding from the full-length image to local subvolumes about each vertebra) to transform vertebral labels and planning information from preoperative CT to the LF images. Automatic measurement of GSA [Main Thoracic Kyphosis (MThK) and Lumbar Lordosis (LL)] was obtained using a spline fit to registered labels. The "Known-Component Registration" (KC-Reg) method for device registration was adapted to the multi-scale process for 3D device localization from orthogonal LF images. The multi-scale framework was evaluated using a deformable spine phantom in which pedicle screws were inserted, and deformations were induced over a range in LL ∼25-80°. Further validation was carried out in a cadaver study with implanted pedicle screws and a similar range of spinal deformation. The accuracy of patient and device registration was evaluated in terms of 3D translational error and target registration error (TRE), respectively, and the accuracy of automatic GSA measurements were compared to manual annotation. RESULTS Phantom studies demonstrated accurate registration via the multi-scale framework for all vertebral levels in both the neutral and deformed spine: median (interquartile range, IQR) patient registration error was 1.1 mm (0.7-1.9 mm IQR). Automatic measures of MThK and LL agreed with manual delineation within -1.1° ± 2.2° and 0.7° ± 2.0° (mean and standard deviation), respectively. Device registration error was 0.7 mm (0.4-1.0 mm IQR) at the screw tip and 0.9° (1.0°-1.5°) about the screw trajectory. Deformable 3D-2D registration significantly outperformed conventional rigid registration (p < 0.05), which exhibited device registration error of 2.1 mm (0.8-4.1 mm) and 4.1° (1.2°-9.5°). Cadaver studies verified performance under realistic conditions, demonstrating patient registration error of 1.6 mm (0.9-2.1 mm); MThK within -4.2° ± 6.8° and LL within 1.7° ± 3.5°; and device registration error of 0.8 mm (0.5-1.9 mm) and 0.7° (0.4°-1.2°) for the multi-scale deformable method, compared to 2.5 mm (1.0-7.9 mm) and 2.3° (1.6°-8.1°) for rigid registration (p < 0.05). CONCLUSION The deformable 3D-2D registration framework leverages long-length intraoperative imaging to achieve accurate patient and device registration over extended lengths of the spine (up to 64 cm) even with strong anatomical deformation. The method offers a new means for quantitative validation of spinal correction (intraoperative GSA measurement) and 3D verification of device placement in comparison to preoperative images and planning data. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Xiaoxuan Zhang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Ali Uneri
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Yixuan Huang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Craig K Jones
- The Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD
| | | | - Jeffrey H Siewerdsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD.,The Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD
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18
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Fan F, Kreher B, Keil H, Maier A, Huang Y. Fiducial marker recovery and detection from severely truncated data in navigation assisted spine surgery. Med Phys 2022; 49:2914-2930. [PMID: 35305271 DOI: 10.1002/mp.15617] [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: 09/07/2021] [Revised: 02/16/2022] [Accepted: 03/06/2022] [Indexed: 11/11/2022] Open
Abstract
PURPOSE Fiducial markers are commonly used in navigation assisted minimally invasive spine surgery and they help transfer image coordinates into real world coordinates. In practice, these markers might be located outside the field-of-view (FOV) of C-arm cone-beam computed tomography (CBCT) systems used in intraoperative surgeries, due to the limited detector sizes. As a consequence, reconstructed markers in CBCT volumes suffer from artifacts and have distorted shapes, which sets an obstacle for navigation. METHODS In this work, we propose two fiducial marker detection methods: direct detection from distorted markers (direct method) and detection after marker recovery (recovery method). For direct detection from distorted markers in reconstructed volumes, an efficient automatic marker detection method using two neural networks and a conventional circle detection algorithm is proposed. For marker recovery, a task-specific data preparation strategy is proposed to recover markers from severely truncated data. Afterwards, a conventional marker detection algorithm is applied for position detection. The networks in both methods are trained based on simulated data. For the direct method, 6800 images and 10000 images are generated respectively to train the U-Net and ResNet50. For the recovery method, the training set includes 1360 images for FBPConvNet and Pix2pixGAN. The simulated data set with 166 markers and 4 cadaver cases with real fiducials are used for evaluation. RESULTS The two methods are evaluated on simulated data and real cadaver data. The direct method achieves 100% detection rates within 1 mm detection error on simulated data with normal truncation and simulated data with heavier noise, but only detect 94.6% markers in extremely severe truncation case. The recovery method detects all the markers successfully in three test data sets and around 95% markers are detected within 0.5 mm error. For real cadaver data, both methods achieve 100% marker detection rates with mean registration error below 0.2 mm. CONCLUSIONS Our experiments demonstrate that the direct method is capable of detecting distorted markers accurately and the recovery method with the task-specific data preparation strategy has high robustness and generalizability on various data sets. The task-specific data preparation is able to reconstruct structures of interest outside the FOV from severely truncated data better than conventional data preparation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Fuxin Fan
- Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, 91058, Germany
| | | | - Holger Keil
- Department of Trauma and Orthopedic Surgery, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, 91054, Germany
| | - Andreas Maier
- Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, 91058, Germany
| | - Yixing Huang
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, 91054, Germany
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19
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Chan A, Parent E, Mahood J, Lou E. 3D ultrasound navigation system for screw insertion in posterior spine surgery: a phantom study. Int J Comput Assist Radiol Surg 2021; 17:271-281. [PMID: 34725774 DOI: 10.1007/s11548-021-02516-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Posterior spinal fusion surgery is required to correct severe idiopathic scoliosis. The surgery involves insertion of screws which requires high accuracy to prevent neurologic damage to the spinal cord. Although conventional CT navigation can reduce this risk, 3D-ultrasound-based navigation could achieve this without added ionizing radiation and usage of expensive and bulky equipment. This study aimed to evaluate the accuracy of a 3D ultrasound navigation system for posterior spine surgery. METHODS A custom 3D ultrasound (3DUS) with model-to-surface registration algorithm was developed and integrated into a 3D navigation environment. A CT scan of an adolescent spine (T3-T11) was segmented and 3D printed for experiments. A probe with reflective markers was placed in vertebral pedicles 684 times in varying levels, positions in the capture space and orientation of vertebra, and the entrypoint and trajectory accuracies were measured. RESULTS Among 684 probe placements in vertebral levels T3 to T11 in the phantom spine, 95.5% were within 1 mm and 5° of accuracy, with an average accuracy of 0.4 ± 0.4 mm and 2.1 ± 0.9°, requiring 8.8 s to process. Accuracies were statistically significantly affected by vertebral orientation and position in the capture volume, though this was still within the targeted accuracies of 1 mm and 5°. CONCLUSION This preliminary ultrasound-based navigation system is accurate and fast enough for guiding placement of pedicle screws into the spine in posterior fusion surgery. The current results are limited to phantom spines, and future study in animal or human cadavers is needed to investigate soft tissue effects on registration accuracy.
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Affiliation(s)
- Andrew Chan
- Department of Biomedical Engineering, University of Alberta, 1098 Research Transition Facility, 8308-114 Street, Edmonton, AB, T6G 2V2, Canada
| | - Eric Parent
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G2G4, Canada
| | - Jim Mahood
- Department of Surgery, University of Alberta, 2D, Walter C Mackenzie Health Sciences Center - 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Edmond Lou
- Department of Biomedical Engineering, University of Alberta, 1098 Research Transition Facility, 8308-114 Street, Edmonton, AB, T6G 2V2, Canada.
- Department of Surgery, University of Alberta, 2D, Walter C Mackenzie Health Sciences Center - 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada.
- Department of Electrical Engineering, University of Alberta, Donadeo ICE 11-263, 9211-116 Street, Edmonton, AB, T6G 1H9, Canada.
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20
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Konovalov NA, Nazarenko AG, Brinyuk ES, Kaprovoy SV, Asyutin DS, Schultz MA, Onoprienko RA, Solenkova AV. [Intraoperative computed tomography and modern navigation in surgical treatment of spine and spinal cord diseases]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:15-28. [PMID: 34156204 DOI: 10.17116/neiro20218503115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgical treatment of spine and spinal cord diseases is one of important objectives in modern neurosurgery. Patient safety is a priority in spine and spinal cord surgery. Intraoperative imaging ensures efficacy and safe surgery with and without stabilization, preoperative marking, control of decompression and correct implant placement. Surgical C-arms and intraoperative cone-beam CT scanners are the most widespread in everyday practice. The latest achievement was intraoperative spiral computed tomography. C-arms and CT scanners with intraoperative navigation increase the efficiency and safety of surgical interventions.
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Affiliation(s)
| | | | - E S Brinyuk
- Burdenko Center of Neurosurgery, Moscow, Russia
| | | | - D S Asyutin
- Burdenko Center of Neurosurgery, Moscow, Russia
| | - M A Schultz
- Burdenko Center of Neurosurgery, Moscow, Russia
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21
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Fan X, Durtschi MS, Li C, Evans LT, Ji S, Mirza SK, Paulsen KD. Hand-Held Stereovision System for Image Updating in Open Spine Surgery. Oper Neurosurg (Hagerstown) 2021; 19:461-470. [PMID: 32365204 DOI: 10.1093/ons/opaa057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 02/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Image guidance in open spinal surgery is compromised by changes in spinal alignment between preoperative images and surgical positioning. We evaluated registration of stereo-views of the surgical field to compensate for vertebral alignment changes. OBJECTIVE To assess accuracy and efficiency of an optically tracked hand-held stereovision (HHS) system to acquire images of the exposed spine during surgery. METHODS Standard midline posterior approach exposed L1 to L6 in 6 cadaver porcine spines. Fiducial markers were placed on each vertebra as "ground truth" locations. Spines were positioned supine with accentuated lordosis, and preoperative computed tomography (pCT) was acquired. Spines were re-positioned in a neutral prone posture, and locations of fiducials were acquired with a tracked stylus. Intraoperative stereovision (iSV) images were acquired and 3-dimensional (3D) surfaces of the exposed spine were reconstructed. HHS accuracy was assessed in terms of distances between reconstructed fiducial marker locations and their tracked counterparts. Level-wise registrations aligned pCT with iSV to account for changes in spine posture. Accuracy of updated computed tomography (uCT) was assessed using fiducial markers and other landmarks. RESULTS Acquisition time for each image pair was <1 s. Mean reconstruction time was <1 s for each image pair using batch processing, and mean accuracy was 1.2 ± 0.6 mm across 6 cases. Mean errors of uCT were 3.1 ± 0.7 and 2.0 ± 0.5 mm on the dorsal and ventral sides, respectively. CONCLUSION Results suggest that a portable HHS system offers potential to acquire accurate image data from the surgical field to facilitate surgical navigation during open spine surgery.
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Affiliation(s)
- Xiaoyao Fan
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | | | - Chen Li
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Linton T Evans
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Songbai Ji
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire.,Department of Biomedical Engineering, Worcester Institute of Polytechnic, Worcester, Massachusetts
| | - Sohail K Mirza
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire.,PEERClinic for Back Pain and Spine Surgery, Fairfax, Virginia
| | - Keith D Paulsen
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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22
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Baba S, Kawaguchi K, Itamoto K, Watanabe T, Hayashida M, Mae T, Nakashima Y, Kato G. Use of an inertial measurement unit sensor in pedicle screw placement improves trajectory accuracy. PLoS One 2020; 15:e0242512. [PMID: 33196657 PMCID: PMC7668595 DOI: 10.1371/journal.pone.0242512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/03/2020] [Indexed: 12/02/2022] Open
Abstract
Ascertaining the accuracy of the pedicle screw (PS) trajectories is important as PS malpositioning can cause critical complications. We aimed to determine the angle range over which estimation is unreliable; build a low-cost PS placement support system that uses an inertial measurement unit (IMU) to enable the monitoring of surgical tools and PS trajectories, and determine the situations where IMU support would be most beneficial. In PS insertion experiments, we used cadaver samples that included lumbar porcine spines. Computed tomography images obtained before and after PS insertion were viewed. Offsets between the planned and implanted PS trajectories in the freehand and IMU-assisted groups were analyzed. The PS cortical bone breaches were classified according to the Gertzbein and Robbins criteria (GRC). Added head-down tilted sample experiments were repeated wherein we expected a decreased rostro-caudal rotational accuracy of the PS according to the angle estimation ability results. Evaluation of the PS trajectory accuracy revealed no significant advantage of IMU-assisted rostro-caudal rotational accuracy versus freehand accuracy. According to the GRC, IMU assistance significantly increased the rate of clinically acceptable PS positions (RoCA) than the freehand technique. In the head-down tilted sample experiments, IMU assist provided increased accuracies with both rostro-caudal and medial rotational techniques when compared with the freehand technique. In the freehand group, RoCA was significantly decreased in samples with rostral tilting relative to that in the samples without. However, In the IMU-assisted group, no significant difference in RoCA between the samples with and without head-down tilting was observed. Even when the planned PS medial and/or rostro-caudal rotational angle was relatively large and difficult to reproduce manually, IMU-support helped maintain the PS trajectory accuracy and positioning safety. IMU assist in PS placement was more beneficial, especially for larger rostro-caudal and/or medial rotational pedicle angles.
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Affiliation(s)
- Satoshi Baba
- Department of Spine Surgery, Saga Medical Center, Koseikan, Saga, Japan
- Trauma Center, Saga Medical Center, Koseikan, Saga, Japan
- Department of Orthopedic Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kenichi Kawaguchi
- Department of Orthopedic Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazuhito Itamoto
- Department of Small Animal Clinical Science, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Takeshi Watanabe
- Department of Orthopedic Surgery, Watanabe Orthopedic Hospital, Itoshima, Fukuoka, Japan
| | - Mitsumasa Hayashida
- Department of Spine Surgery, Saga Medical Center, Koseikan, Saga, Japan
- Trauma Center, Saga Medical Center, Koseikan, Saga, Japan
- Department of Orthopedic Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takao Mae
- Trauma Center, Saga Medical Center, Koseikan, Saga, Japan
- Department of Orthopedic Surgery, Saga Medical Center, Koseikan, Saga, Japan
| | - Yasuharu Nakashima
- Department of Orthopedic Surgery, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Go Kato
- Department of Spine Surgery, Saga Medical Center, Koseikan, Saga, Japan
- Trauma Center, Saga Medical Center, Koseikan, Saga, Japan
- Department of Orthopedic Surgery, Fukuoka Red Cross Hospital, Fukuoka, Japan
- * E-mail:
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23
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Lang SD, Gilmer BB. A Dual-Motor Drill Reduces Plunge, Simultaneously Gauges Depth, and Saves Time When Placing Orthopedic Screws. Orthopedics 2020; 43:e465-e470. [PMID: 32501524 DOI: 10.3928/01477447-20200521-09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/14/2019] [Indexed: 02/03/2023]
Abstract
The technique for placement of orthopedic hardware remains unchanged despite technological advances. The surgeon controls drill bit speed and advancement, which risks drill bit overpenetration, or plunge. Measurement is performed as an additional step, introducing measurement error and increasing operative time. A dual-motor drill was created to control drill variables and combine drilling and measurement into a single step. The purpose of this study was to determine whether a dual-motor drill could reduce drilling and measurement errors while increasing the speed of placement of orthopedic hardware. Five orthopedic surgeons drilled and measured 10 holes with a standard drill and a dual-motor drill in randomized bicortical bone blocks. The bone blocks were placed on standard ballistic gels, which left a defect from drill bit overpenetration that could be measured with a calibrated gauge. The accuracy of drilling was determined by the depth of the defect in the ballistic gel and was compared between groups. Finally, time for drilling and measurement was collected and compared between groups. Overpenetration for the dual-motor drill (0.5±0.3 mm) was significantly less than for the standard drill (8.4±1.9 mm) (P<.0001). Depth measurement error for the dual-motor drill (0.6±0.3 mm) was significantly less than for the standard drill (2.6±0.5 mm) (P<.0001). Drilling and measurement time for the dual-motor drill (6.0±2.2 seconds) was significantly less than for the standard drill (13.4±3.9 seconds) (P<.0001). Use of a dual-motor drill reduced overpenetration, improved measurement accuracy, and reduced time spent during placement of orthopedic hardware. [Orthopedics. 2020;43(5):e465-e470.].
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24
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Gueziri HE, Santaguida C, Collins DL. The state-of-the-art in ultrasound-guided spine interventions. Med Image Anal 2020; 65:101769. [PMID: 32668375 DOI: 10.1016/j.media.2020.101769] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 02/07/2023]
Abstract
During the last two decades, intra-operative ultrasound (iUS) imaging has been employed for various surgical procedures of the spine, including spinal fusion and needle injections. Accurate and efficient registration of pre-operative computed tomography or magnetic resonance images with iUS images are key elements in the success of iUS-based spine navigation. While widely investigated in research, iUS-based spine navigation has not yet been established in the clinic. This is due to several factors including the lack of a standard methodology for the assessment of accuracy, robustness, reliability, and usability of the registration method. To address these issues, we present a systematic review of the state-of-the-art techniques for iUS-guided registration in spinal image-guided surgery (IGS). The review follows a new taxonomy based on the four steps involved in the surgical workflow that include pre-processing, registration initialization, estimation of the required patient to image transformation, and a visualization process. We provide a detailed analysis of the measurements in terms of accuracy, robustness, reliability, and usability that need to be met during the evaluation of a spinal IGS framework. Although this review is focused on spinal navigation, we expect similar evaluation criteria to be relevant for other IGS applications.
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Affiliation(s)
- Houssem-Eddine Gueziri
- McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, Montreal (QC), Canada; McGill University, Montreal (QC), Canada.
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, McGill University Health Center, Montreal (QC), Canada
| | - D Louis Collins
- McConnell Brain Imaging Center, Montreal Neurological Institute and Hospital, Montreal (QC), Canada; McGill University, Montreal (QC), Canada
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25
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Chan A, Coutts B, Parent E, Lou E. Development and Evaluation of CT-to-3D Ultrasound Image Registration Algorithm in Vertebral Phantoms for Spine Surgery. Ann Biomed Eng 2020; 49:310-321. [PMID: 32533392 DOI: 10.1007/s10439-020-02546-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 06/04/2020] [Indexed: 12/18/2022]
Abstract
Posterior spinal fusion surgery requires careful insertion of screws into the spine to avoid neurologic injury. While current systems use CT-scans, three-dimensional ultrasound (3DUS) could provide guidance by reconstructing the vertebral surface, and then registering a pre-operative vertebral model to that surface for localization. The aim of this study was to evaluate the accuracy and processing time of a custom CT-3DUS registration algorithm. A phantom human vertebra was 3D-printed and scanned with a motion capture-based 3D ultrasound (3DUS) system. Image registration was performed that included a pre-alignment phase using vertebral symmetry information, and then comparing Gaussian pyramid intensity-based registration with iterative-closest-point registration for final transformations. Image registration was performed 192 times while surgical registration between CT and real-world position was performed 84 times. The accuracy of image registration (CT-to-3DUS) was 0.3 ± 0.2 mm and 0.9 ± 0.8° completed in 13.3 ± 2.9 s. The surgical navigation accuracy (CT model to real-world position) of the system was 1.2 ± 0.5 mm and 2.2 ± 2.0° completed in 16.2 ± 3.0 s. Both meet accuracy thresholds of < 2 mm and < 5° required for the surgery. A feasibility study on porcine spine qualitatively showed appropriate overlapping anatomy in CT-3DUS registrations. The usage of 3D ultrasound for navigation has demonstrated accuracy to provide radiation-free image guidance for spine surgery.
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Affiliation(s)
- Andrew Chan
- Department of Biomedical Engineering, University of Alberta, 1098 Research Transition Facility, 8308-114 Street, Edmonton, AB, T6G 2V2, Canada
| | - Brendan Coutts
- Department of Electrical and Computer Engineering, University of Alberta, Donadeo ICE 11-203, 9211-116 Street, Edmonton, AB, T6G 1H9, Canada
| | - Eric Parent
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G2G4, Canada
| | - Edmond Lou
- Department of Biomedical Engineering, University of Alberta, 1098 Research Transition Facility, 8308-114 Street, Edmonton, AB, T6G 2V2, Canada. .,Department of Electrical and Computer Engineering, University of Alberta, Donadeo ICE 11-203, 9211-116 Street, Edmonton, AB, T6G 1H9, Canada.
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26
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Raasck K, Khoury J, Aoude A, Beland B, Munteanu A, Weber MH, Golan J. The Effect of Thoracolumbar Pedicle Isthmus on Pedicle Screw Accuracy. Global Spine J 2020; 10:393-398. [PMID: 32435557 PMCID: PMC7222685 DOI: 10.1177/2192568219850143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVES Aberrant pedicle screws can cause serious neurovascular complications. We propose that a predominant factor of pedicle screw breach is the vertebral anatomy at a given spinal level. We aim to investigate the inverse correlation between breach incidence and vertebral isthmus width. METHODS The computed tomography scans of patients undergoing thoracolumbar surgery were retrospectively reviewed. Breaches were categorized as minor (<2 mm) or major (>2 mm). Breach incidence was stratified by spinal level. Average isthmus width was then compared to the collected breach incidences. A regression analysis and Pearson's correlation were performed. RESULTS A total of 656 pedicle screws were placed in 91 patients with 233 detected breaches. Incidence of major breach was 6.3%. Four patients developed post-operative radiculopathy due to breach. Breach incidence was higher in the thoracic than lumbar spine (Fisher's exact test, P < .0001). The 2 spinal levels with the thinnest isthmus width (T4 and T5) were breached most often (73.7% and 73.9%, respectively). The 2 spinal levels with the thickest isthmus width (L4 and L5) were breached least often (20.5% and 11.8%). Breach incidence and isthmus width were shown to have a significant inverse correlation (Pearson's correlation, R 2 = 0.7, P < .0001). CONCLUSIONS Thinner vertebral isthmus width increases pedicle screw breach incidence. Image-guided assistance may be most useful where breach incidence is highest and isthmus width is lowest (T2 to T6). Despite high incidence of cortical bone violation, there was little correlation with clinical symptoms. A breach is not automatically a clinical problem, provided the screw is structurally sound and the patient is symptomless.
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Affiliation(s)
- Kyle Raasck
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada,Kyle Raasck, Division of Orthopaedic Surgery, McGill Faculty of Medicine, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.
| | - Jason Khoury
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ahmed Aoude
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Benjamin Beland
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexander Munteanu
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael H. Weber
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jeff Golan
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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27
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Balicki M, Kyne S, Toporek G, Holthuizen R, Homan R, Popovic A, Burström G, Persson O, Edström E, Elmi-Terander A, Patriciu A. Design and control of an image-guided robot for spine surgery in a hybrid OR. Int J Med Robot 2020; 16:e2108. [PMID: 32270913 DOI: 10.1002/rcs.2108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/17/2020] [Accepted: 03/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Minimally invasive spine (MIS) fusion surgery requires image guidance and expert manual dexterity for a successful, efficient, and accurate pedicle screw placement. Operating room (OR)-integrated robotic solution can provide precise assistance to potentially minimize complication rates and facilitate difficult MIS procedures. METHODS A 5-degrees of freedom robot was designed specifically for a hybrid OR with integrated surgical navigation for guiding pedicle screw pilot holes. The system automatically aligns an instrument following the surgical plan using only instrument tracking feedback. Contrary to commercially available robotic systems, no tracking markers on the robotic arm are required. The system was evaluated in a cadaver study. RESULTS The mean targeting error (N = 34) was 1.27±0.57 mm and 1.62±0.85°, with 100% of insertions graded as clinically acceptable. CONCLUSIONS A fully integrated robotic guidance system, including intra-op imaging, planning, and physical guidance with optimized robot design and control, can improve workflow and provide pedicle screw guidance with less than 2 mm targeting error.
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Affiliation(s)
- Marcin Balicki
- Philips Research North America, Cambridge, Massachusetts, USA
| | - Sean Kyne
- Philips Research North America, Cambridge, Massachusetts, USA
| | | | | | | | | | - Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Oscar Persson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Lumbar Percutaneous Pedicle Screw Breach Rates: A Comparison of Robotic Navigation Platform Versus Conventional Techniques. Clin Spine Surg 2020; 33:E162-E167. [PMID: 32149744 DOI: 10.1097/bsd.0000000000000963] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Cadaveric study. SUMMARY OF BACKGROUND DATA Pedicle screw fixation is an established means of stabilizing the thoracic and lumbar spine. However, there are associated complications including pedicle breach which can result in neurological injury, durotomy, vascular injury, and suboptimal fixation. OBJECTIVE The aim of this study is to determine whether use of a navigated robotic platform results in fewer pedicle breaches and the underlying reasons for any difference in pedicle breach rates. MATERIALS AND METHODS Ten board-certified neuro- and orthopedic spine surgeons inserted 80 percutaneous lumbar screws in 10 unembalmed human cadavers. Forty screws were inserted using conventional fluoroscopic guidance and 40 were inserted using a navigated robotic platform. None of the participating surgeons had any prior experience with navigated robotic spine surgery. At the end of the study each screw was assessed with a computed tomography scan, plain radiographs and visual inspection to determine the presence or absence of pedicle breaches. RESULTS Forty percent (40%) of screws inserted using conventional fluoroscopic guidance breached compared with 2.5% of screws inserted with robot assistance (P=0.00005). Lateral breaches accounted for 88.2% (15/17) of all breaches. Detailed analysis revealed that the starting point of screws that breached laterally were significantly more lateral than that of the contralateral accurate screw (P=0.016). Pedicle screw diameter, length, and angulation in the transverse plane did not differ significantly between accurate screws and those that breached (P>0.05). CONCLUSIONS The use of a navigated robotic platform in the present study resulted in significantly fewer pedicle breaches. This was achieved through correct starting point selection with subsequent safe pedicle screw insertion.
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Lauretti C, Cordella F, Tamantini C, Gentile C, Luzio FSD, Zollo L. A Surgeon-Robot Shared Control for Ergonomic Pedicle Screw Fixation. IEEE Robot Autom Lett 2020. [DOI: 10.1109/lra.2020.2972892] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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30
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Müller F, Roner S, Liebmann F, Spirig JM, Fürnstahl P, Farshad M. Augmented reality navigation for spinal pedicle screw instrumentation using intraoperative 3D imaging. Spine J 2020; 20:621-628. [PMID: 31669611 DOI: 10.1016/j.spinee.2019.10.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/19/2019] [Accepted: 10/21/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Due to recent developments in augmented reality with head-mounted devices, holograms of a surgical plan can be displayed directly in the surgeon's field of view. To the best of our knowledge, three dimensional (3D) intraoperative fluoroscopy has not been explored for the use with holographic navigation by head-mounted devices in spine surgery. PURPOSE To evaluate the surgical accuracy of holographic pedicle screw navigation by head-mounted device using 3D intraoperative fluoroscopy. STUDY DESIGN In this experimental cadaver study, the accuracy of surgical navigation using a head-mounted device was compared with navigation with a state-of-the-art pose-tracking system. METHODS Three lumbar cadaver spines were embedded in nontransparent agar gel, leaving only commonly visible anatomy in sight. Intraoperative registration of preoperative planning was achieved by 3D fluoroscopy and fiducial markers attached to lumbar vertebrae. Trackable custom-made drill sleeve guides enabled real-time navigation. In total, 20 K-wires were navigated into lumbar pedicles using AR-navigation, 10 K-wires by the state-of-the-art pose-tracking system. 3D models obtained from postexperimental CT scans were used to measure surgical accuracy. MF is the founder and shareholder of Incremed AG, a Balgrist University Hospital start-up focusing on the development of innovative techniques for surgical executions. The other authors declare no conflict of interest concerning the contents of this study. No external funding was received for this study. RESULTS No significant difference in accuracy was measured between AR-navigated drillings and the gold standard with pose-tracking system with mean translational errors between entry points (3D vector distance; p=.85) of 3.4±1.6 mm compared with 3.2±2.0 mm, and mean angular errors between trajectories (3D angle; p=.30) of 4.3°±2.3° compared with 3.5°±1.4°. CONCLUSIONS In conclusion, holographic navigation by use of a head-mounted device achieve accuracy comparable to the gold standard of high-end pose-tracking systems. CLINICAL SIGNIFICANCE These promising results could result in a new way of surgical navigation with minimal infrastructural requirements but now have to be confirmed in clinical studies.
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Affiliation(s)
- Fabio Müller
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Simon Roner
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Florentin Liebmann
- Computer Assisted Research and Development Group, Balgrist University Hospital, University of Zurich, Lengghalde 5, 8008 Zurich, Switzerland; Laboratory for Orthopedic Biomechanics, ETH Zurich, Forchstrasse 328, 8008 Zurich, Switzerland
| | - José M Spirig
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Philipp Fürnstahl
- Computer Assisted Research and Development Group, Balgrist University Hospital, University of Zurich, Lengghalde 5, 8008 Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
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Navigated percutaneous versus open pedicle screw implantation using intraoperative CT and robotic cone-beam CT imaging. 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 2019; 29:803-812. [DOI: 10.1007/s00586-019-06242-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/12/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
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Shree Kumar D, Ampar N, Wee Lim L. Accuracy and reliability of spinal navigation: An analysis of over 1000 pedicle screws. J Orthop 2019; 18:197-203. [PMID: 32042226 DOI: 10.1016/j.jor.2019.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/13/2019] [Indexed: 01/01/2023] Open
Abstract
Purpose To estimate the rate of pedicle screw malpositioning associated with placing pedicle screws using intraoperative computed tomography (CT)-guided spinal navigation. Methods We analysed the records of 219 patients who underwent pedicle screw fixation using O-arm-based navigation. Screw placement accuracy was evaluated on intraoperative CT scans acquired after pedicle screw insertion. Breaches were graded according to the Gertzbein classification (grade 0-III). Results Of 1152 pedicle screws included, 47 had pedicle violations noted on intraoperative CT. Pedicle screw violation was noted for 17 of 241 screws placed in the cervical spine (overall breach rate, 7.05%; 3.73% and 3.3% with grade I and II, respectively), for 11 of 300 screws placed in the thoracic spine (overall breach rate, 3.67%; 2%, 1%, and 0.67% with grade I, II, and III, respectively), and for 22 of 611 screws placed in the lumbar spine (overall breach rate, 3.6%; 2.29% and 0.82% with grade I and II, respectively). The rate of accuracy of pedicle screw fixation was 93%, 96.33%, and 96.4% for the cervical, thoracic, and lumbar spine, respectively. Conclusions Using O-arm-based intra-operative three-dimensional scans for navigation can improve the reliability, accuracy, and safety of pedicle screw placement, reducing the risk for reoperation and hospitalization due to implant-related complications. Further improvement may be achieved by adequate consideration of potential sources of errors.
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Affiliation(s)
| | - Nishanth Ampar
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India
| | - Loo Wee Lim
- Department of Orthopaedics, Changi General Hospital, Changi, Singapore
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Solitro GF, Whitlock K, Amirouche F, Mehta AI, McDonnell A. Currently Adopted Criteria for Pedicle Screw Diameter Selection. Int J Spine Surg 2019; 13:132-145. [PMID: 31131212 PMCID: PMC6510178 DOI: 10.14444/6018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Transpedicular screw insertion has become widely accepted for the correction of spinal deformity as well as degenerative and traumatic injury, but adoption of this technique has remained less widespread in the thoracic compared to the lumbar spine. This is thought to be associated with the relative technical difficulty of screw insertion into the narrower widths of the thoracic pedicles and the neurologic and mechanical risks associated with breach of the pedicle wall. The surgical decision making involves determining the appropriate sized screw for maximum fixation strength while simultaneously respecting the structural integrity of the vertebral pedicles to prevent a breach and provide better fixation. This paper presents a systematic review of criteria for thoracic pedicle screw diameter (SD) selection in order to orient inexperienced surgeons on the impact of this selection on pedicle breaching and fixation strength. METHODS We performed a systematic literature review focused on studies reporting SD selection in relation to pedicle dimensions, measures of fixation strength, and breach rate. RESULTS Twenty-nine articles that measured fixation strength, breach rate, and/or provided SD in relation to pedicle width were selected for inclusion. CONCLUSIONS A commonly accepted criteria for pedicle SD selection has not yet been proposed. Screw diameters approximately 80% of the pedicle width have been adopted, but this proportion is rarely reported in the midthoracic vertebrae for which smaller pedicles and inadequate hardware specificity result in higher breach rates. Depending upon the insertion technique adopted, greater specificity in diameter selection by vertebral level should be pursued in order to maximally target cortical bone purchase. CLINICAL RELEVANCE Based on this review of the literature, we believe that proper selection of the SD for individual vertebral level directly affects the insertion technique and the potential breach.
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Affiliation(s)
- Giovanni F Solitro
- Department of Orthopaedics, Louisiana State University Health Science Center, Shreveport, Louisiana
| | - Keith Whitlock
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Farid Amirouche
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Annie McDonnell
- Department of Mechanical Engineering, University of Illinois at Chicago, Chicago, Illinois
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Lin JD, Wei C, Shillingford JN, Beauchamp EC, Tan LA, Kim YJ, Lehman RA, Lenke LG. Evaluation of a more ventral starting point for thoracic pedicle screws: higher maximal insertional arc and more medial and safer screw angulation. J Neurosurg Spine 2019; 30:337-343. [PMID: 30554175 DOI: 10.3171/2018.8.spine18175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 08/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVETo demonstrate that a more ventral starting point for thoracic pedicle screw insertion, produced by aggressively removing the dorsal transverse process bone down to the superior articular facet (SAF), results in a larger margin for error and more medial screw angulation compared to the traditional dorsal starting point (DSP). The margin for error will be quantified by the maximal insertional arc (MIA).METHODSThe study population included 10 consecutive operative patients with adult idiopathic scoliosis who underwent primary surgery. All measurements were performed using 3D visualization software by an attending spine surgeon. The screw starting points were 2 mm lateral to the midline of the SAF in the mediolateral direction and in the center of the pedicle in the cephalocaudal direction. The DSP was on the dorsal cortex. The ventral starting point (VSP) was at the depth of the SAF. Measurements included distance to the pedicle isthmus, MIA, and screw trajectories.RESULTSTen patients and 110 vertebral levels (T1-11) were measured. The patients' average age was 41.4 years (range 18-64 years). The pedicle isthmus was largest at T1 (4.04 ± 1.09 mm), and smallest at T5 (1.05 ± 0.93 mm). The distance to the pedicle isthmus was 7.47 mm for the VSP and 11.92 mm for the DSP (p < 0.001). The MIA was 15.3° for the VSP and 10.1° for the DSP (p < 0.001). Screw angulation was 21.7° for the VSP and 16.8° for the DSP (p < 0.001).CONCLUSIONSA more ventral starting point for thoracic pedicle screws results in increased MIA and more medial screw angulation. The increased MIA represents an increased tolerance for error that should improve the safety of pedicle screw placement. More medial screw angulation allows improved triangulation of pedicle screws.
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Affiliation(s)
- James D Lin
- 1Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian/Allen, New York, New York
| | - Chao Wei
- 2Department of Spine Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China P.R.; and
| | - Jamal N Shillingford
- 1Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian/Allen, New York, New York
| | - Eduardo C Beauchamp
- 1Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian/Allen, New York, New York
| | - Lee A Tan
- 3Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - Yongjung J Kim
- 1Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian/Allen, New York, New York
| | - Ronald A Lehman
- 1Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian/Allen, New York, New York
| | - Lawrence G Lenke
- 1Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian/Allen, New York, New York
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Chan A, Parent E, Lou E. Reconstruction and positional accuracy of 3D ultrasound on vertebral phantoms for adolescent idiopathic scoliosis spinal surgery. Int J Comput Assist Radiol Surg 2018; 14:427-439. [PMID: 30519871 DOI: 10.1007/s11548-018-1894-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Determine the positional, rotational and reconstruction accuracy of a 3D ultrasound system to be used for image registration in navigation surgery. METHODS A custom 3D ultrasound for spinal surgery image registration was developed using Optitrack Prime 13-W motion capture cameras and a SonixTablet Ultrasound System. Temporal and spatial calibration was completed to account for time latencies between the two systems and to ensure accurate motion tracking of the ultrasound transducer. A mock operating room capture volume with a pegboard grid was set up to allow phantoms to be placed at a variety of predetermined positions to validate accuracy measurements. Five custom-designed ultrasound phantoms were 3D printed to allow for a range of linear and angular dimensions to be measured when placed on the pegboard. RESULTS Temporal and spatial calibration was completed with measurement repeatabilities of 0.2 mm and 0.5° after calibration. The mean positional accuracy was within 0.4 mm, with all values within 0.5 mm within the critical surgical regions and 96% of values within 1 mm within the full capture volume. All orientation values were within 1.5°. Reconstruction accuracy was within 0.6 mm and 0.9° for geometrically shaped phantoms and 0.5 and 1.9° for vertebrae-mimicking phantoms. CONCLUSIONS The accuracy of the developed 3D ultrasound system meets the 1 mm and 5° requirements of spinal surgery from this study. Further repeatability studies and evaluation on vertebrae are needed to validate the system for surgical use.
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Affiliation(s)
- Andrew Chan
- Department of Biomedical Engineering, University of Alberta, 1098 Research Transition Facility, 8308-114 Street, Edmonton, AB, T6G 2V2, Canada
| | - Eric Parent
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G2G4, Canada
| | - Edmond Lou
- Department of Biomedical Engineering, University of Alberta, 1098 Research Transition Facility, 8308-114 Street, Edmonton, AB, T6G 2V2, Canada. .,Department of Electrical and Computer Engineering, University of Alberta, Donadeo ICE 11-371, 9211-116 Street, Edmonton, AB, T6G 1H9, Canada.
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Comparison of the Clinical Accuracy Between Point-to-Point Registration and Auto-Registration Using an Active Infrared Navigation System. Spine (Phila Pa 1976) 2018; 43:E1329-E1333. [PMID: 29689003 DOI: 10.1097/brs.0000000000002704] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A model experiment. OBJECTIVE To measure and compare the clinical accuracy of point-to-point registration (PR) and auto-registration (AR) in an operative set using an active infrared navigation system. SUMMARY OF BACKGROUND DATA PR and AR are two major registration methods of navigation assisted spinal surgery. No previous study compared the difference between the two methods with respect to clinical accuracy. METHODS A novel method was used to measure the clinical accuracy of the navigation system under an operative set using a Sawbone model with titanium beads on the surface, which was essential to measure the accuracy numerically, instead of a real patient. Both the operative set and the procedure mimicked a regular surgery. The clinical accuracy was defined as the average distance between the "navigation coordinate" and the "image coordinate." The clinical accuracy of the PR using preoperative computed tomography (CT) images and the AR using intraoperative CT images was measured and compared. RESULTS The average clinical accuracy of PR was different among different segments. The accuracy of the most accurate segment, which provided the reference points during the PR, was 1.10 mm. In the two segments adjacent to the reference segment, the clinical accuracy deteriorated to 1.37 and 1.50 mm. The accuracy of the farther segments was worse. In comparison, the clinical accuracy of different segments of AR was of no significant difference. The average accuracy of AR was 0.74 mm, which was significantly better than the best accuracy of PR. CONCLUSION AR is better than PR with respect to clinical accuracy in navigation assisted spinal surgery. LEVEL OF EVIDENCE N/A.
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Perspective pinhole model with planar source for augmented reality surgical navigation based on C-arm imaging. Int J Comput Assist Radiol Surg 2018; 13:1671-1682. [PMID: 30014167 DOI: 10.1007/s11548-018-1823-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE For augmented reality surgical navigation based on C-arm imaging, accuracy of the overlaid augmented reality onto the X-ray image is imperative. However, overlay displacement is generated when a conventional pinhole model describing a geometric relationship of a normal camera is adopted for C-arm calibration. Thus, a modified model for C-arm calibration is proposed to reduce this displacement, which is essential for accurate surgical navigation. METHOD Based on the analysis of displacement pattern generated for three-dimensional objects, we assumed that displacement originated by moving the X-ray source position according to the depth. In the proposed method, X-ray source movement was modeled as variable intrinsic parameters and represented in the pinhole model by replacing the point source with a planar source. RESULTS The improvement which represents a reduced displacement was verified by comparing overlay accuracy for augmented reality surgical navigation between the conventional and proposed methods. The proposed method achieved more accurate overlay on the X-ray image in spatial position as well as depth of the object volume. CONCLUSION We validated that intrinsic parameters that describe the source position were dependent on depth for a three-dimensional object and showed that displacement can be reduced and become independent of depth by using the proposed planar source model.
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Newell R, Esfandiari H, Anglin C, Bernard R, Street J, Hodgson AJ. An intraoperative fluoroscopic method to accurately measure the post-implantation position of pedicle screws. Int J Comput Assist Radiol Surg 2018; 13:1257-1267. [PMID: 29633081 DOI: 10.1007/s11548-018-1732-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/07/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Pedicle screw malplacement, leading to neurological symptoms, vascular injury, and premature implant loosening, is not uncommon and difficult to reliably detect intraoperatively with current techniques. We propose a new intraoperative post-placement pedicle screw position assessment system that can therefore allow surgeons to correct breaches during the procedure. Our objectives were to assess the accuracy and robustness of this proposed screw location system and to compare its performance to that of 2D planar radiography. METHODS The proposed system uses two intraoperative X-ray shots acquired with a standard fluoroscopic C-arm and processed using 2D/3D registration methods to provide a 3D visualization of the vertebra and screw superimposed on one another. Point digitization and CT imaging of the residual screw tunnel were used to assess accuracy in five synthetic lumbar vertebral models (10 screws in total). Additionally, the accuracy was evaluated with and without correcting for image distortion and for various screw lengths, screw materials, breach directions, and vertebral levels. RESULTS The proposed method is capable of localizing the implanted screws with less than 2 mm of translational error (RMSE: 0.7 and 0.8 mm for the screw head and tip, respectively) and less than [Formula: see text] angular error (RMSE: [Formula: see text]), with minimal change to the errors if image distortion is not corrected. Breaches and their anatomical locations were all correctly visualized and identified for a variety of screw lengths, screw materials, breach locations, and vertebral levels, demonstrating the robustness of this approach. In contrast, one breach, one non-breach, and the anatomical location of three screws were misclassified with 2D X-ray. CONCLUSION We have demonstrated an accurate and low-radiation technique for localizing pedicle screws post-implantation that requires only two X-rays. This intraoperative feedback of screw location and direction may allow the surgeon to correct malplaced screws intraoperatively, thereby reducing postoperative complications and reoperation rates.
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Affiliation(s)
- Robyn Newell
- Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada.
- Department of Mechanical Engineering, University of British Columbia, 2054-6250 Applied Science Lane, Vancouver, BC, V6T 1Z4, Canada.
| | - Hooman Esfandiari
- Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
- Department of Mechanical Engineering, University of British Columbia, 2054-6250 Applied Science Lane, Vancouver, BC, V6T 1Z4, Canada
| | - Carolyn Anglin
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Department of Civil Engineering, University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada
| | - Renee Bernard
- Department of Mechanical Engineering, University of British Columbia, 2054-6250 Applied Science Lane, Vancouver, BC, V6T 1Z4, Canada
| | - John Street
- Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Blusson Spinal Cord Center, Floor 6-818 10 Ave W, Vancouver, BC, V5Z 1M9, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Antony J Hodgson
- Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
- Department of Mechanical Engineering, University of British Columbia, 2054-6250 Applied Science Lane, Vancouver, BC, V6T 1Z4, Canada
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Abstract
STUDY DESIGN A prospective case-series study and a retrospective analysis of historical patients for comparison of data. OBJECTIVE To compare accuracy and limitations of intraoperative computed tomography (iCT)- versus 3D C-arm-based spinal navigation for posterior pedicle screw implantation. SUMMARY OF BACKGROUND DATA Despite the higher accuracy of navigated compared to non-navigated pedicle screw implantation, it remains a matter of debate whether the use of iCT imaging may further benefit navigated spinal instrumentation compared to more commonly used isocentric 3D C-arm imaging. METHODS Between 2013 and 2016, 1527 pedicle screws were implanted in 260 patients with iCT (1219 screws) or 3D C-arm (308 screws)-based spinal navigation. Screw positioning was intraoperatively assessed by a second iCT or 3D C-arm (intraoperative accuracy). If necessary, immediate intraoperative screw revision was performed. Thereafter, a third iCT or 3D C-arm scan was performed to confirm repositioning (final accuracy). Clinical and patient data, intraoperative screw assessability, and accuracy rates were retrospectively reviewed and analyzed by an independent observer. RESULTS Intraoperative CT permitted immediate intraoperative assessment of each implanted screw. In contrast, 39 of the screws visualized with 3D C-arm imaging were intraoperatively not clearly assessable. Regarding the overall precision, iCT and 3D C-arm navigation yielded a comparable intraoperative accuracy (iCT 94.7% vs 3D C-arm 89.4%) and immediate correction of misplaced screws was feasible with both modalities (final accuracy: iCT 95.4% vs 3D C-arm 91.6%). Regarding the region specific performance, however, iCT-based navigation yielded significantly higher final accuracy rates in the cervical (iCT 99.5% vs 3D C-arm 88.9%, P < 0.01) and thoracic (iCT 97.7% vs 3D C-arm 88.8%, P < 0.001) regions. CONCLUSION Both iCT and 3D C-arm-based spinal navigation provides high pedicle screw accuracy rates. Immediate screw assessability and placement accuracy in the cervical-thoracic spine, however, appear to be limited with intraoperative 3D C-arm imaging alone. LEVEL OF EVIDENCE 3.
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Gokcen HB, Erdogan S, Ozturk S, Gumussuyu G, Bayram I, Ozturk C. Sagittal orientation and uniform entry for thoracic pedicle screw placement with free-hand technique: A retrospective study on 382 pedicle screws. Int J Surg 2018; 51:83-88. [PMID: 29367042 DOI: 10.1016/j.ijsu.2018.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 01/04/2018] [Accepted: 01/10/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND One of the most important factors in obtaining a successful outcome in spinal surgery is appropriate placement of the pedicle screw. A number of different techniques are used to achieve successful pedicle screw placement. The free-hand technique has the advantage of no requirement for radiation exposure, but its success is highly dependent on surgeon experience. Here, we describe our entry point and perioperative sagittal orientation method, and evaluate postoperative sagittal alignment of pedicle screws with the free-hand pedicle screw placement technique. MATERIALS AND METHODS Eighty-two patients undergoing spinal surgery between 2015 and 2016 were included in this study. Pedicle screw placement was evaluated retrospectively on postoperative anterior-posterior (A-P) and lateral load-bearing radiographs of the entire spinal column. The vertebral body was divided into five areas in the lateral plane. Sagittal orientation of the pedicle screws on lateral radiographs was evaluated by two spine surgeons with 3 years of experience and one radiologist experienced in musculoskeletal radiology, with each observer evaluating the image twice according to a 1-month interval. RESULTS A total of 382 pedicle screws were evaluated. There was no statistically significant difference between the first and second measurements, performed by individual observers, and there was good concordance among the three observers. CONCLUSIONS Use of a uniform entry point at all levels may increase the effectiveness of the free-hand technique and decrease the pedicle screw misplacement rate. Our technique may standardize the free-hand technique, which does not require radiation exposure, and make it more practical to apply uniformly.
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Affiliation(s)
- H Bahadir Gokcen
- Orthopaedics and Traumatology, Istinye University (Medicalpark Hospital), Bahcelievler, Istanbul, Turkey.
| | - Sinan Erdogan
- Orthopaedics and Traumatology, Istinye University (LIV Hospital), Ulus, Istanbul, Turkey.
| | - Sidar Ozturk
- Orthopaedics and Traumatology, Medicalpark Hospital, Bahcelievler, Istanbul, Turkey.
| | - Gurkan Gumussuyu
- Orthopaedics and Traumatology, Medicalpark Hospital, Bahcelievler, Istanbul, Turkey.
| | - Irem Bayram
- Department of Radiology, LIV Hospital, Ulus, Istanbul, Turkey.
| | - Cagatay Ozturk
- Orthopaedics and Traumatology, Istinye University (LIV Hospital), Ulus, Istanbul, Turkey.
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Szczodry M, Solitro GF, Amirouche F, Patel P. Pedicle Screw With Increased Cortical Purchase Can Be Inserted With Same Accuracy as the Screw in Straightforward Trajectory Using 3D Modeling Landmarks. Spine Deform 2018; 6:20-27. [PMID: 29287813 DOI: 10.1016/j.jspd.2017.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/05/2017] [Accepted: 06/18/2017] [Indexed: 11/29/2022]
Abstract
STUDY DESIGN Comparison, in terms of insertion accuracy and biomechanical performance, between an increased cortical purchase and straightforward pedicle screw trajectory. OBJECTIVE This study aims to compare a trajectory with increased cortical purchase to the more common straightforward trajectory in terms of strength and insertion accuracy using real-time navigation. SUMMARY OF BACKGROUND DATA In previous studies, it was suggested that pedicle screw pullout strength is strongly correlated with bone mineral density, and using a more cortical tract allows a greater portion of the denser bone, the cortex, to be in contact with the screw. In light of this advantage, an insertion technique has been proposed more recently, to increase the cortical purchase to maximize screw thread contact with cortical bone. It is performed inserting the screw with reduced transverse inclination and results in cortical bone purchase in the lateral portion of the pedicle. METHODS Eight T1 and eight T3 vertebra models were reconstructed in Mimics Suite (Materialise, Leuven, Belgium) using CT data obtained with a Medtronic O-arm. Using a previously developed computer algorithm, we calculated all achievable safe trajectories for pedicle screw placement ensuring a minimal distance of 0.5 mm between screw and pedicle edges. For both vertebrae, among these, the straightest and the most convergent trajectories with the calculated insertion region greater than 15% of the total were selected to safely instrument the vertebrae, respectively, as ICP and straightforward techniques. The straightforward technique was planned with a transverse angle of 22.50° in both vertebrae whereas the ICP was planned with a transverse angle of 12.50° for T1 and 2.5° for T3. The screws were implanted by a surgeon experienced in straightforward insertion, and other independent investigators measured placement accuracy and mechanical performance. RESULTS The transverse screw angles for T1 and T3 with straightforward technique had average values of 24.93° ± 2.96° and 23.53° ± 2.70°, respectively. For the ICP technique, the average values were 15.60° ± 2.95° for T1 and 2.29° ± 1.55° for T3. The resultant errors associated with screw placement for T1 and T3 were not significantly different (p > .05). The pullout failure loads with straightforward techniques ranged from 756 ± 164 N in T1 to 703 ± 74 N in T3 and were not significantly different (p > .05) from the values of 699 ± 84 N for T1 and of 732 ± 113 N measured for the ICP. CONCLUSIONS For the upper thoracic vertebrae tested, despite the use of shorter screws, the insertion technique with increased cortical purchase, in biomechanical terms, is comparable with the straightforward trajectory. Using guidance, the proposed ICP technique was performed with the same accuracy as the popular straightforward technique. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Michal Szczodry
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave., Chicago, IL 21287, USA.
| | - Giovanni F Solitro
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave., Chicago, IL 21287, USA
| | - Farid Amirouche
- Department of Orthopaedics, University of Illinois at Chicago, 835 S. Wolcott Ave., Chicago, IL 21287, USA
| | - Priyesh Patel
- Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd, North Chicago, IL 60064, USA
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Tian W, Liu Y, Fan M, Zhao J, Jin P, Zeng C. CAMISS Concept and Its Clinical Application. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1093:31-46. [PMID: 30306470 DOI: 10.1007/978-981-13-1396-7_3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This chapter intends to provide an overview of computer-assisted minimally invasive spine surgery (CAMISS) and its clinical application. Since minimally invasive spine surgery was first brought out, the concept of decreasing the damage to patient was soon become popular. However, without the proper surgical field, the spine surgery can be very dangerous. The minimally invasive concept was restricted in promotion until the computer-assisted navigation system break down the obstacles. The CAMISS technique achieves better clinical outcomes with the advantages of smaller invasion, less injury, and better recovery and also became the gold standard for spine surgery. The spatial distribution concept and the respiration-induced motion concept help in promoting the accuracy and safety of the CAMISS concept. The CAMISS concept also facilitated the developing of robotic techniques, which was considered as the future of orthopedic surgery.
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Affiliation(s)
- Wei Tian
- Spine Department, Beijing Jishuitan Hospital, Beijing, China.
| | - Yajun Liu
- Spine Department, Beijing Jishuitan Hospital, Beijing, China
| | - Mingxing Fan
- Spine Department, Beijing Jishuitan Hospital, Beijing, China
| | - Jingwei Zhao
- Spine Department, Beijing Jishuitan Hospital, Beijing, China
| | - Peihao Jin
- Spine Department, Beijing Jishuitan Hospital, Beijing, China
| | - Cheng Zeng
- Spine Department, Beijing Jishuitan Hospital, Beijing, China
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Robot-assisted and conventional freehand pedicle screw placement: a systematic review and meta-analysis of randomized controlled trials. 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 2017; 27:921-930. [DOI: 10.1007/s00586-017-5333-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/05/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
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Ma L, Zhao Z, Chen F, Zhang B, Fu L, Liao H. Augmented reality surgical navigation with ultrasound-assisted registration for pedicle screw placement: a pilot study. Int J Comput Assist Radiol Surg 2017; 12:2205-2215. [DOI: 10.1007/s11548-017-1652-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 07/21/2017] [Indexed: 11/28/2022]
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Chan A, Aguillon J, Hill D, Lou E. Precision and accuracy of consumer-grade motion tracking system for pedicle screw placement in pediatric spinal fusion surgery. Med Eng Phys 2017; 46:33-43. [PMID: 28602642 DOI: 10.1016/j.medengphy.2017.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 04/12/2017] [Accepted: 05/16/2017] [Indexed: 11/17/2022]
Abstract
Adolescent idiopathic scoliosis (AIS) is a 3-dimensional spinal deformity involving lateral curvature and axial rotation. Surgical intervention involves insertion of pedicle screws into the spine, requiring accuracies of 1mm and 5° in translation and rotation to prevent neural and vascular complications. While commercial CT-navigation is available, the significant cost, bulk and radiation dose hinders their use in AIS surgery. The objective of this study was to evaluate a commercial-grade Optitrack Prime 13W motion capture cameras to determine if they can achieve adequate accuracy for screw insertion guidance in AIS. Static precision, camera and tracked rigid body configurations, translational and rotational accuracy were investigated. A 1-h camera warm-up time was required to achieve precisions of 0.13mm and 0.10°. A three-camera system configuration with cameras at equal height but staggered depth achieved the best accuracy. A triangular rigid body with 7.9mm markers had superior accuracy. The translational accuracy for motions up to 150mm was 0.25mm while rotational accuracy was 4.9° for rotations in two directions from 0° to 70°. Required translational and rotational accuracies were achieved using this motion capture system as well as being comparable to surgical-grade navigators.
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Affiliation(s)
- Andrew Chan
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta T6G 2V2, Canada
| | - Janelle Aguillon
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, Alberta T6G 1H9, Canada
| | - Doug Hill
- Department of Surgery, University of Alberta, Edmonton, Alberta T6G 2B7, Canada; Alberta Health Services - Glenrose Rehabilitation Hospital, Edmonton, Alberta T5G 0B7, Canada
| | - Edmond Lou
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta T6G 2V2, Canada; Department of Surgery, University of Alberta, Edmonton, Alberta T6G 2B7, Canada; Alberta Health Services - Glenrose Rehabilitation Hospital, Edmonton, Alberta T5G 0B7, Canada.
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47
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Guha D, Jakubovic R, Gupta S, Alotaibi NM, Cadotte D, da Costa LB, George R, Heyn C, Howard P, Kapadia A, Klostranec JM, Phan N, Tan G, Mainprize TG, Yee A, Yang VXD. Spinal intraoperative three-dimensional navigation: correlation between clinical and absolute engineering accuracy. Spine J 2017; 17:489-498. [PMID: 27777052 DOI: 10.1016/j.spinee.2016.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/19/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal intraoperative computer-assisted navigation (CAN) may guide pedicle screw placement. Computer-assisted navigation techniques have been reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably and reported in less than a quarter of clinical studies of CAN-guided pedicle screw accuracy. PURPOSE This study aimed to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy. DESIGN/SETTING This is a retrospective review of a prospectively collected cohort. PATIENT SAMPLE We recruited 30 patients undergoing first-time posterior cervical-thoracic-lumbar-sacral instrumented fusion±decompression, guided by intraoperative three-dimensional CAN. OUTCOME MEASURES Clinical or radiographic screw accuracy (Heary and 2 mm classifications) and absolute quantitative navigation accuracy (translational and angular error in axial and sagittal planes). METHODS We reviewed a prospectively collected series of 209 pedicle screws placed with CAN guidance. Each screw was graded clinically by multiple independent raters using the Heary and 2 mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes. RESULTS Acceptable screw accuracy was achieved for significantly fewer screws based on 2 mm grade versus Heary grade (92.6% vs. 95.1%, p=.036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2 mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational-angular accuracies were 1.75 mm-3.13° and 1.20 mm-3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy. CONCLUSIONS Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on postoperative imaging may be more reliable if performed in multiple by radiologist raters.
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Affiliation(s)
- Daipayan Guha
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Raphael Jakubovic
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Department of Biomedical Physics, Ryerson University, 350 Victoria St., Toronto, ON, M5B 2K3, Canada
| | - Shaurya Gupta
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - David Cadotte
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Leodante B da Costa
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Rajeesh George
- JurongHealth, Ng Teng Fong General Hospital, 1 Jurong East Street, Singapore, 609606, Singapore
| | - Chris Heyn
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Peter Howard
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Anish Kapadia
- Department of Medical Imaging, University of Toronto, 263 McCaul St., Toronto, ON, M5T 1W7, Canada
| | - Jesse M Klostranec
- Department of Medical Imaging, University of Toronto, 263 McCaul St., Toronto, ON, M5T 1W7, Canada
| | - Nicolas Phan
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Gamaliel Tan
- JurongHealth, Ng Teng Fong General Hospital, 1 Jurong East Street, Singapore, 609606, Singapore
| | - Todd G Mainprize
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Albert Yee
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 149 College St., Toronto, ON, M5T 1P5, Canada
| | - Victor X D Yang
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Department of Electrical and Computer Engineering, Ryerson University, 350 Victoria St., Toronto, ON, M5B 2K3, Canada.
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48
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Uneri A, De Silva T, Goerres J, Jacobson MW, Ketcha MD, Reaungamornrat S, Kleinszig G, Vogt S, Khanna AJ, Osgood GM, Wolinsky JP, Siewerdsen JH. Intraoperative evaluation of device placement in spine surgery using known-component 3D-2D image registration. Phys Med Biol 2017; 62:3330-3351. [PMID: 28233760 DOI: 10.1088/1361-6560/aa62c5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intraoperative x-ray radiography/fluoroscopy is commonly used to assess the placement of surgical devices in the operating room (e.g. spine pedicle screws), but qualitative interpretation can fail to reliably detect suboptimal delivery and/or breach of adjacent critical structures. We present a 3D-2D image registration method wherein intraoperative radiographs are leveraged in combination with prior knowledge of the patient and surgical components for quantitative assessment of device placement and more rigorous quality assurance (QA) of the surgical product. The algorithm is based on known-component registration (KC-Reg) in which patient-specific preoperative CT and parametric component models are used. The registration performs optimization of gradient similarity, removes the need for offline geometric calibration of the C-arm, and simultaneously solves for multiple component bodies, thereby allowing QA in a single step (e.g. spinal construct with 4-20 screws). Performance was tested in a spine phantom, and first clinical results are reported for QA of transpedicle screws delivered in a patient undergoing thoracolumbar spine surgery. Simultaneous registration of ten pedicle screws (five contralateral pairs) demonstrated mean target registration error (TRE) of 1.1 ± 0.1 mm at the screw tip and 0.7 ± 0.4° in angulation when a prior geometric calibration was used. The calibration-free formulation, with the aid of component collision constraints, achieved TRE of 1.4 ± 0.6 mm. In all cases, a statistically significant improvement (p < 0.05) was observed for the simultaneous solutions in comparison to previously reported sequential solution of individual components. Initial application in clinical data in spine surgery demonstrated TRE of 2.7 ± 2.6 mm and 1.5 ± 0.8°. The KC-Reg algorithm offers an independent check and quantitative QA of the surgical product using radiographic/fluoroscopic views acquired within standard OR workflow. Such intraoperative assessment could improve quality and safety, provide the opportunity to revise suboptimal constructs in the OR, and reduce the frequency of revision surgery.
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Affiliation(s)
- A Uneri
- Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, United States of America. Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21205, United States of America
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Miller CA, Ledonio CG, Hunt MA, Siddiq F, Polly DW. Reliability of the Planned Pedicle Screw Trajectory versus the Actual Pedicle Screw Trajectory using Intra-operative 3D CT and Image Guidance. Int J Spine Surg 2016; 10:38. [PMID: 27909659 DOI: 10.14444/3038] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Technological advances, including navigation, have been made to improve safety and accuracy of pedicle screw fixation. We evaluated the accuracy of the virtual screw placement (Stealth projection) compared to actual screw placement (intra-operative O-Arm) and examined for differences based on the distance from the reference frame. METHODS A retrospective evaluation of prospectively collected data was conducted from January 2013 to September 2013. We evaluated thoracic and lumbosacral pedicle screws placed using intraoperative O-arm and Stealth navigation by obtaining virtual screw projections and intraoperative O-arm images after screw placement. The screw trajectory angle to the midsagittal line and superior endplate was compared in the axial and sagittal views, respectively. Percent error and paired t-test statistics were then performed. RESULTS Thirty-one patients with 240 pedicle screws were analyzed. The mean angular difference between the virtual and actual image in all screws was 2.17° ± 2.20° on axial images and 2.16° ± 2.24° on sagittal images. There was excellent agreement between actual and virtual pedicle screw trajectories in the axial and sagittal plane with ICC = 0.99 (95%CI: 0.992-0.995) (p<0.001) and ICC= 0.81 (95%CI: 0.759-0.855) (p<0.001) respectively. When comparing thoracic and lumbar screws, there was a significant difference in the sagittal angulation between the two distributions. No statistical differences were found distance from the reference frame. CONCLUSION The virtual projection view is clinically accurate compared to the actual placement on intra-operative CT in both the axial and sagittal views. There is slight imprecision (~2°) in the axial and sagittal planes and a minor difference in the sagittal thoracic and lumbar angulation, although these did not affect clinical outcomes. In general, we find that pedicle screw placement using intraoperative cone beam CT and navigation to be accurate and reliable, and as such have made it a routine part of our spine practice. This study was approved by the University of Minnesota IRB (#1303E30544).
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Affiliation(s)
| | | | - Matthew A Hunt
- University of Minnesota Department of Neurosurgery, Minneapolis, MN
| | - Farhan Siddiq
- Jefferson University Department of Neurosurgery, St. Mary Medical Center, Langhorne, PA
| | - David W Polly
- University of Minnesota Department of Orthopaedics, Minneapolis, MN
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50
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Uneri A, Goerres J, De Silva T, Jacobson MW, Ketcha MD, Reaungamornrat S, Kleinszig G, Vogt S, Khanna AJ, Wolinsky JP, Siewerdsen JH. Deformable 3D-2D Registration of Known Components for Image Guidance in Spine Surgery. MEDICAL IMAGE COMPUTING AND COMPUTER-ASSISTED INTERVENTION : MICCAI ... INTERNATIONAL CONFERENCE ON MEDICAL IMAGE COMPUTING AND COMPUTER-ASSISTED INTERVENTION 2016; 9902:124-132. [PMID: 37195053 PMCID: PMC10183252 DOI: 10.1007/978-3-319-46726-9_15] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
A 3D-2D image registration method is reported for guiding the placement of surgical devices (e.g., K-wires). The solution registers preoperative CT (and planning data therein) to intraoperative radiographs and computes the pose, shape, and deformation parameters of devices (termed "components") known to be in the radiographic scene. The deformable known-component registration (dKC-Reg) method was applied in experiments emulating spine surgery to register devices (K-wires and spinal fixation rods) undergoing realistic deformation. A two-stage registration process (i) resolves patient pose from individual radiographs and (ii) registers components represented as polygonal meshes based on a B-spline model. The registration result can be visualized as overlay of the component in CT analogous to surgical navigation but without conventional trackers or fiducials. Target registration error in the tip and orientation of deformable K-wires was (1.5±0.9)mm and 0.6∘±0.2∘, respectively. For spinal fixation rods, the registered components achieved Hausdorff distance of 3.4 mm. Future work includes testing in cadaver and clinical data and extension to more generalized deformation and component models.
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Affiliation(s)
- A Uneri
- Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - J Goerres
- Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - T De Silva
- Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - M W Jacobson
- Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - M D Ketcha
- Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | | | - G Kleinszig
- Siemens Healthcare XP Division, Erlangen, Germany
| | - S Vogt
- Siemens Healthcare XP Division, Erlangen, Germany
| | - A J Khanna
- Orthopaedic Surgery, Johns Hopkins Medical Institute, Baltimore, MD, USA
| | - J-P Wolinsky
- Neurological Surgery, Johns Hopkins Medical Institute, Baltimore, MD, USA
| | - J H Siewerdsen
- Computer Science, Johns Hopkins University, Baltimore, MD, USA
- Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Neurological Surgery, Johns Hopkins Medical Institute, Baltimore, MD, USA
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