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Chumnanvej S, Chumnanvej S, Tripathi S. Assessing the benefits of digital twins in neurosurgery: a systematic review. Neurosurg Rev 2024; 47:52. [PMID: 38236336 DOI: 10.1007/s10143-023-02260-5] [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: 10/09/2023] [Revised: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 01/19/2024]
Abstract
Digital twins are virtual replicas of their physical counterparts, and can assist in delivering personalized surgical care. This PRISMA guideline-based systematic review evaluates current literature addressing the effectiveness and role of digital twins in many stages of neurosurgical management. The aim of this review is to provide a high-quality analysis of relevant, randomized controlled trials and observational studies addressing the neurosurgical applicability of a variety of digital twin technologies. Using pre-specified criteria, we evaluated 25 randomized controlled trials and observational studies on the applications of digital twins, including navigation, robotics, and image-guided neurosurgeries. All 25 studies compared these technologies against usual surgical approaches. Risk of bias analyses using the Cochrane risk of bias tool for randomized trials (Rob 2) found "low" risk of bias in the majority of studies (23/25). Overall, this systematic review shows that digital twin applications have the potential to be more effective than conventional neurosurgical approaches when applied to brain and spinal surgery. Moreover, the application of these novel technologies may also lead to fewer post-operative complications.
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Affiliation(s)
- Sorayouth Chumnanvej
- Neurosurgery Division, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Siriluk Chumnanvej
- Department of Anesthesiology and Operating Room, Phramongkutklao Hospital, Bangkok, Thailand
| | - Susmit Tripathi
- Department of Neurology, New York Presbyterian-Weill Cornell Medical Center, New York, NY, USA.
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Doria-Medina R, Hubbe U, Scholz C, Sircar R, Brönner J, Hoedlmoser H, Klingler JH. Free-Hand MIS TLIF without 3D Navigation-How to Achieve Low Radiation Exposure for Both Surgeon and Patient. J Clin Med 2023; 12:5125. [PMID: 37568527 PMCID: PMC10419541 DOI: 10.3390/jcm12155125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Transforaminal lumbar interbody fusion (TLIF) is one of the most frequently performed spinal fusion techniques, and this minimally invasive (MIS) approach has advantages over the traditional open approach. A drawback is the higher radiation exposure for the surgeon when conventional fluoroscopy (2D-fluoroscopy) is used. While computer-assisted navigation (CAN) reduce the surgeon's radiation exposure, the patient's exposure is higher. When we investigated 2D-fluoroscopically guided and 3D-navigated MIS TLIF in a randomized controlled trial, we detected low radiation doses for both the surgeon and the patient in the 2D-fluoroscopy group. Therefore, we extended the dataset, and herein, we report the radiation-sparing surgical technique of 2D-fluoroscopy-guided MIS TLIF. METHODS Monosegmental and bisegmental MIS TLIF was performed on 24 patients in adherence to advanced radiation protection principles and a radiation-sparing surgical protocol. Dedicated dosemeters recorded patient and surgeon radiation exposure. For safety assessment, pedicle screw accuracy was graded according to the Gertzbein-Robbins classification. RESULTS In total, 99 of 102 (97.1%) pedicle screws were correctly positioned (Gertzbein grade A/B). No breach caused neurological symptoms or necessitated revision surgery. The effective radiation dose to the surgeon was 41 ± 12 µSv per segment. Fluoroscopy time was 64 ± 34 s and 75 ± 43 radiographic images per segment were performed. Patient radiation doses at the neck, chest, and umbilical area were 65 ± 40, 123 ± 116, and 823 ± 862 µSv per segment, respectively. CONCLUSIONS Using a dedicated radiation-sparing free-hand technique, 2D-fluoroscopy-guided MIS TLIF is successfully achievable with low radiation exposure to both the surgeon and the patient. With this technique, the maximum annual radiation exposure to the surgeon will not be exceeded, even with workday use.
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Affiliation(s)
- Roberto Doria-Medina
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Ronen Sircar
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | | | | | - Jan-Helge Klingler
- Department of Neurosurgery, Medical Center, University of Freiburg, 79106 Freiburg, Germany
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Kim JH, Jitpakdee K, Kotheeranurak V, Quillo-Olvera J, Choi KC, Kim YJ, Lee CR, Kim JS. Is navigation beneficial for transforaminal endoscopic lumbar foraminotomy? A preliminary comparison study with fluoroscopic guidance. 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 2023; 32:2808-2818. [PMID: 36920512 DOI: 10.1007/s00586-023-07624-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE The primary purpose of this study was to determine radiation exposure of the surgeon during transforaminal endoscopic lumbar foraminotomy (TELF). Secondary purpose of this study was to compare clinical and radiologic outcomes between TELF under C-arm fluoroscopic guidance (C-TELF) and O-arm navigation-guided TELF (O-TELF). METHODS The author reviewed patients' medical records who underwent TELF at our institute from June 2015 to November 2022. A total of 40 patients were included (18 patients with C-TELF and 22 with O-TELF). Basic demographic data were collected. Preoperative/postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) were recorded at the outpatient clinic. Radiologic features were compared on X-rays at each follow-up. The degree of foraminal expansion was measured/compared through MRI. In the C-TELF group, the amount of exposure was calculated with a dosimeter. RESULTS Average surgeon's effective dose in the C-TELF group was 0.036 mSv. In the case of the O-TELF group, there was no radiation exposure during operation. However, the operation time in the O-TELF group was about 37 min longer than that in the C-TELF group. There were significant improvements in VAS/ODI after operation in both groups. Complications were identified in three patients. CONCLUSION O-TELF showed similarly favorable clinical and radiologic outcomes to C-TELF in lumbar foraminal stenosis, including complication rate. Compared to C-TELF, O-TELF has an advantage of not wearing a lead apron since the operator is not exposed to radiation. However, the operation time was longer with O-TELF due to O-arm setting time. Because there are pros and cons, the choice of surgical method depends on the surgeon's preference.
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Affiliation(s)
- Jung-Hoon Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Khanathip Jitpakdee
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Orthopaedics, Queen Savang Vadhana Memorial Hospital, Thai Red Cross Society, Si Racha, Chonburi, Thailand
| | - Vit Kotheeranurak
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Javier Quillo-Olvera
- The Brain and Spine Care, Minimally Invasive Spine Surgery Group, Hospital H+, Queretaro City, Mexico
| | - Kyung-Chul Choi
- Seoul Top Spine Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Young-Jin Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Cho-Rong Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Klingler JH, Hubbe U, Scholz C, Volz F, Roelz R, Beck J, Watzlawick R, Brönner J, Hoedlmoser H, Krüger MT, Hohenhaus M, Naseri Y. The Impact of Implementing a Radiation-Sparing Protocol for Percutaneous Kyphoplasty-A Prospective Dosemetric Study. Global Spine J 2023; 13:1541-1549. [PMID: 34530629 PMCID: PMC10448088 DOI: 10.1177/21925682211039497] [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: 11/16/2022] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES The purpose of this prospective study was to evaluate a protocol for radiation-sparing kyphoplasty by assessing dosemetrically recorded radiation exposures to both patient and surgeon. METHODS This prospective clinical study examines the radiation exposure to patient and surgeon during single-level kyphoplasty in 32 thoracolumbar osteoporotic vertebral body fractures (12 OF 2, 9 OF 3, 11 OF 4 types) using a radiation aware surgical protocol between May 2017 and November 2019. The radiation exposure was measured at different locations using film, eye lens and ring dosemeters. Dose values are reported under consideration of lower detection limits of each dosemeter type. RESULTS A high proportion of dosemeter readings was below the lower detection limits, especially for the surgeon (>90%). Radiation exposure to the surgeon was highest at the unprotected thyroid gland (0.053 ± 0.047 mSv), however only slightly above the lower detection limit of dosemeters (0.044 mSv). Radiation exposure to the patient was highest at the chest (0.349 ± 0.414 mSv) and the gonad (0.186 ± 0.262 mSv). Fluoroscopy time, dose area product and number of fluoroscopic images were 46.0 ± 17.9 sec, 124 ± 109 cGy×cm2, and 35 ± 13 per kyphoplasty, respectively. Back pain significantly improved from 6.8 ± 1.6 to 2.5 ± 1.7 on the numeric rating scale on the first postoperative day (P < 0.0001). CONCLUSIONS The implementation of a strict intraoperative radiation protection protocol allows for safely performed kyphoplasty with ultra-low radiation exposure for the patient and surgeon without exceeding the annual occupational dose limits. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register (DRKS00011908, registration date 16/05/2017).
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Affiliation(s)
- Jan-Helge Klingler
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Volz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralf Watzlawick
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Brönner
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Herbert Hoedlmoser
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Marie T. Krüger
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marc Hohenhaus
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Yashar Naseri
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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Scarone P, Chatterjea A, Jenniskens I, Klüter T, Weuster M, Lippross S, Presilla S, Distefano D, Chianca V, Sedaghat S, Nelson M, Lampe F, Seekamp A. Percutaneous thoraco-lumbar-sacral pedicle screw placement accuracy results from a multi-center, prospective clinical study using a skin marker-based optical navigation system. 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 2022; 31:3098-3108. [PMID: 36149493 DOI: 10.1007/s00586-022-07387-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/05/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
STUDY DESIGN Prospective multi-center study. OBJECTIVE The study aimed to evaluate the accuracy of pedicle screw placement using a skin marker-based optical surgical navigation system for minimal invasive thoraco-lumbar-sacral pedicle screw placement. METHODS The study was performed in a hybrid Operating Room with a video camera-based navigation system integrated in the imaging hardware. The patient was tracked with non-invasive skin markers while the instrument tracking was via an on-shaft optical marker pattern. The screw placement accuracy assessment was performed by three independent reviewers, using the Gertzbein grading. The screw placement time as well as the staff and patient radiation doses was also measured. RESULTS In total, 211 screws in 39 patients were analyzed for screw placement accuracy. Of these 32.7% were in the thoracic region, 59.7% were in the lumbar region, and 7.6% were in the sacral region. An overall accuracy of 98.1% was achieved. No screws were deemed severely misplaced (Gertzbein grading 3). The average time for screw placement was 6 min and 25 secs (± 3 min 33 secs). The average operator radiation dose per subject was 40.3 µSv. The mean patient effective dose (ED) was 11.94 mSv. CONCLUSION Skin marker-based ON can be used to achieve very accurate thoracolumbarsacral pedicle screw placements.
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Affiliation(s)
- Pietro Scarone
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Ospedale Regionale Di Lugano Civico E Italiano, Lugano, Switzerland
| | - Anindita Chatterjea
- Image Guided Therapy Systems, Philips Healthcare, Veenpluis 6, 5684 PC, Best, The Netherlands.
| | - Inge Jenniskens
- Image Guided Therapy Systems, Philips Healthcare, Veenpluis 6, 5684 PC, Best, The Netherlands
| | - Tim Klüter
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| | - Matthias Weuster
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| | - Sebastian Lippross
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| | - Stefano Presilla
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Ospedale Regionale Di Lugano Civico E Italiano, Lugano, Switzerland
| | - Daniela Distefano
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Ospedale Regionale Di Lugano Civico E Italiano, Lugano, Switzerland
| | - Vito Chianca
- Clinica di Radiologia EOC IIMSI, Lugano, Switzerland
- Ospedale Evangelico Betania, Naples, Italy
| | - Sam Sedaghat
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Ospedale Regionale Di Lugano Civico E Italiano, Lugano, Switzerland
| | - Melissa Nelson
- Image Guided Therapy Systems, Philips Healthcare, Veenpluis 6, 5684 PC, Best, The Netherlands
| | - Finn Lampe
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
| | - Andreas Seekamp
- Klinik Für Orthopädie Und Unfallchirurgie, UKSH, Campus Kiel, Kiel, Germany
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Sivaganesan A, Kim C, Kiran Alluri R, Vaishnav AS, Qureshi S. Advanced Technologies for Outpatient Lumbar Fusion: Barriers and Opportunities. Int J Spine Surg 2022; 16:S37-S43. [PMID: 35831061 PMCID: PMC9808792 DOI: 10.14444/8275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND In recent years, there has been increasing interest in outpatient spine surgery. Minimally invasive techniques have created an opportunity for ambulatory lumbar fusion, and these techniques increasingly involve advanced technologies such as navigation and robotics. OBJECTIVE To explore the barriers, advantages, and future predictions for such technology in the context of outpatient lumbar fusions. METHODS This is a narrative review of studies examining the advantages, limitations, and cost-effectiveness of navigation and spinal robotics in conjunction with the outcomes and costs of outpatient lumbar fusion. RESULTS Outpatient lumbar fusion is a growing trend with ample evidence of its safety, favorable patient outcomes, and cost savings. Navigation and spinal robotics are associated with improved instrumentation accuracy and fewer complications, and the long-term cost savings can make these technologies financially practical in the outpatient setting. Future capabilities with robotics will only increase their value. CONCLUSIONS Advanced technologies such as navigation and robotics are strategic long-term investments in the context of outpatient lumbar fusion. CLINICAL RELEVANCE The favorable outcomes and costs associated with navigation and robotics will be relevant to any spine surgeon interested in developing an outpatient lumbar fusion program. LEVEL OF EVIDENCE: 5
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Affiliation(s)
- Ahilan Sivaganesan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Choll Kim
- Excel Spine Center, San Diego, CA, USA
| | | | | | - Sheeraz Qureshi
- Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA, Sheeraz Qureshi, Weill Cornell Medical College, 535 E 70th St, New York, NY 10021, USA;
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Hohenhaus M, Volz F, Merz Y, Watzlawick R, Scholz C, Hubbe U, Klingler JH. The challenge of measuring spinopelvic parameters: inter-rater reliability before and after minimally invasive lumbar spondylodesis. BMC Musculoskelet Disord 2022; 23:104. [PMID: 35101020 PMCID: PMC8802499 DOI: 10.1186/s12891-022-05055-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The common manual measurement technique of spinal sagittal alignment on X-rays is susceptible to rater-dependent variability, which has not been adequately considered in previous publications. This study investigates the effect of those variations in the characterization of patients receiving lumbar spondylodesis. METHODS General alignment parameters on pre- and postoperative X-rays were evaluated by four raters in 43 prospectively sampled patients undergoing monolevel spondylodesis. The Intra-class Correlation Coefficient (ICC) for each rater pair and all raters together was calculated for inter-rater reliability. For the operation-induced change of the sagittal alignment in every patient the Wilcoxon test was applied to compare for each rater separately. RESULTS The ICCs were "good" (>0.75) to "excellent" (>0.9) for all raters together and for 45 of the 48 single rater pairs (93.75%). All revealed a significant increase of the addressed segmental lordosis and disc height and no significant change for spinopelvic parameters and sagittal vertical axis from pre- to postoperative. The lumbar lordosis showed a significant increase through the operation of +2.5° (p = 0.014) and +3.7° (p = 0.015) in two raters and no difference for the other ones (+2.1°, p = 0.171; -2.2°, p = 0.522). CONCLUSIONS The pre- to postoperative change of lumbar lordosis revealed different significance levels for different raters, although the ICCs were formally good. Accordingly, the evaluation by only one rater would lead to different conclusions. Due to this susceptibility of alignment measurements to rater-dependent variability, the exact evaluation process should be described in every publication and the consistency of significant results be validated through multiple raters. TRIALS REGISTRATION The trial was approved by the local ethics committee and listed at the national clinical trials register ( DRKS00004514 , date of registration: 08/11/2012).
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Affiliation(s)
- Marc Hohenhaus
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Florian Volz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Yorn Merz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Ralf Watzlawick
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Jan-Helge Klingler
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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Campbell DH, McDonald D, Araghi K, Araghi T, Chutkan N, Araghi A. The Clinical Impact of Image Guidance and Robotics in Spinal Surgery: A Review of Safety, Accuracy, Efficiency, and Complication Reduction. Int J Spine Surg 2021; 15:S10-S20. [PMID: 34607916 DOI: 10.14444/8136] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Image guidance (IG) and robotic-assisted (RA) surgery are modern technological advancements that have provided novel ways to perform precise and accurate spinal surgery. These innovations supply real-time, three-dimensional imaging information to aid in instrumentation, decompression, and implant placement. Although nothing can replace the knowledge and expertise of an experienced spine surgeon, these platforms do have the potential to supplement the individual surgeon's capabilities. Specific advantages include more precise pedicle screw placement, minimally invasive surgery with less reliance on intraoperative fluoroscopy, and lower radiation exposure to the surgeon and staff. As these technologies have become more widely adopted over the years, novel uses such as tumor resection have been explored. Disadvantages include the cost of implementing IG and robotics platforms, the initial learning curve for both the surgeon and the staff, and increased patient radiation exposure in scoliosis surgery. Also, given the relatively recent transition of many procedures from inpatient settings to ambulatory surgery centers, access to current devices may be cost prohibitive and not as readily available at some centers. Regarding patient-related outcomes, much further research is warranted. The short-term benefits of minimally invasive surgery often bolster the perioperative and early postoperative outcomes in many retrospective studies on IG and RA surgery. Randomized controlled trials limiting such confounding factors are warranted to definitively show potential independent improvements in patient-related outcomes specifically attributable to IG and RA alone. Nonetheless, irrespective of these current unknowns, it is clear that these technologies have changed the field and the practice of spine surgery. Surgeons should be familiar with the potential benefits and tradeoffs of these platforms when considering adopting IG and robotics in their practices.
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Affiliation(s)
- David H Campbell
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona
| | - Donnell McDonald
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona
| | | | | | - Norman Chutkan
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona.,The CORE Institute, Phoenix, Arizona
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Klingler JH, Scholz C, Hohenhaus M, Volz F, Naseri Y, Krüger MT, Vasilikos I, Roelz R, Brönner J, Hoedlmoser H, Sircar R, Hubbe U. Radiation Exposure to Scrub Nurse, Assistant Surgeon, and Anesthetist in Minimally Invasive Spinal Fusion Surgery Comparing 2D Conventional Fluoroscopy With 3D Fluoroscopy-based Navigation: A Randomized Controlled Trial. Clin Spine Surg 2021; 34:E211-E215. [PMID: 32991363 DOI: 10.1097/bsd.0000000000001077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 07/24/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A randomized controlled trial. OBJECTIVE To compare the radiation exposure with the scrub nurse, assistant surgeon, and anesthetist during minimally invasive transforaminal lumbar interbody fusion using conventional 2-dimensional (2D) fluoroscopy or 3D fluoroscopy-based navigation. SUMMARY OF BACKGROUND DATA Minimally invasive spinal fusion techniques are related to higher radiation exposures compared with open techniques. Especially the routinely exposed surgical staff faces the risks of increased radiation exposure. METHODS In total, 41 patients with planned monosegmental minimally invasive transforaminal lumbar interbody fusion were randomized into the intraoperative imaging techniques 2D fluoroscopy or 3D navigation. Eye lens and film dosemeters were attached to defined locations of the scrub nurse, assistant surgeon, and anesthetist. Mann-Whitney U and Wilcoxon-matched pairs signed-rank test were used to compare dosemeter readings. This study was registered with the German Clinical Trials Register (DRKS00004514). RESULTS The radiation exposure per surgery was low for the scrub nurse, assistant surgeon, and anesthetist in both the 2D fluoroscopy and 3D navigation groups. The maximum average value of 0.057±0.031 mSv was measured on the unprotected chest of the assistant surgeon and was thus slightly above the lower detection limit of the dosemeters (0.044 mSv). The annual occupational dose limit would be exceeded at the earliest after 571 operations for the unprotected eye lens of the assistant surgeon. CONCLUSIONS Minimally invasive lumbar fusion surgery is possible with comparatively low radiation exposure to the assisting operating room personnel without exceeding the annual maximum occupational radiation exposure. However, there is no definite dose value below which ionizing radiation poses no risk. Consequently, radiation sparing work routines should be strictly followed.
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Affiliation(s)
- Jan-Helge Klingler
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marc Hohenhaus
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Volz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Yashar Naseri
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marie T Krüger
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ioannis Vasilikos
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Brönner
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Herbert Hoedlmoser
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Ronen Sircar
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Weiner JA, McCarthy MH, Swiatek P, Louie PK, Qureshi SA. Narrative review of intraoperative image guidance for transforaminal lumbar interbody fusion. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:89. [PMID: 33553382 PMCID: PMC7859762 DOI: 10.21037/atm-20-1971] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Recent advancements in imaging technology have changed the landscape of transforaminal lumbar interbody fusion (TLIF) with the objective of improving safety and efficacy for the patient and surgical team. Spine surgery, and specifically TLIFs, involve challenging anatomy and command precise surgical accuracy, creating an essential role for intraoperative imaging, navigation, and robotics. Traditionally, surgeons have relied upon fluoroscopy for pedicle screw and interbody placement. More recently, intraoperative 3-dimensional navigation (ION) has risen in popularity in TLIF surgery. This technology utilizes intra-operative advanced imaging, such as computed tomography (CT) and 3D-fluroscopy, to accurately track instruments and implants in relation to the patient’s anatomy. ION has demonstrated improved accuracy of pedicle screw placement, decreased operating room times, and lower radiation exposure to the surgeon and staff. However, conventional fluoroscopy, 3D fluoroscopy, intraoperative CT, image-guided navigation, and robot-assisted surgery all have a role in TLIF surgery. Numerous studies have been published regarding the benefits and pitfalls of these intraoperative tools in spine surgery, but there is a relative lack of research regarding some of the newer technologies surrounding TLIF. As future studies are published, and technology continues to evolve, surgeons must stay abreast of novel techniques to maximize patient safety and outcomes. Over the coming decade, we can expect intraoperative navigation and robotics to play a more significant role in spine surgery.
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Affiliation(s)
- Joseph A Weiner
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL, USA
| | - Michael H McCarthy
- Hospital for Special Surgery Department of Orthopedic Surgery, New York, NY, USA
| | - Peter Swiatek
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL, USA
| | - Philip K Louie
- Hospital for Special Surgery Department of Orthopedic Surgery, New York, NY, USA
| | - Sheeraz A Qureshi
- Hospital for Special Surgery Department of Orthopedic Surgery, New York, NY, USA
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Radiation Exposure in Minimally Invasive Lumbar Fusion Surgery: A Randomized Controlled Trial Comparing Conventional Fluoroscopy and 3D Fluoroscopy-based Navigation. Spine (Phila Pa 1976) 2021; 46:1-8. [PMID: 32925679 DOI: 10.1097/brs.0000000000003685] [Citation(s) in RCA: 7] [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 Randomized controlled trial. OBJECTIVE The aim of this study was to compare the dosemetrically determined radiation exposure of surgeon and patient during minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) using conventional 2D fluoroscopy (FLUORO) or 3D fluoroscopy-based navigation (NAV). SUMMARY OF BACKGROUND DATA MIS TLIF was shown to exhibit higher radiation exposures compared to open techniques. In particular, the routinely exposed surgeon encounters the risks of increased radiation doses. With the additional use of intraoperative 3D navigation, major steps of the operation can be performed without exposing the operating room staff to ionizing radiation. METHODS Forty-four patients undergoing monosegmental MIS TLIF were randomized into the two intraoperative imaging technique groups (FLUORO or NAV). The primary endpoint was the radiation exposure of the surgeon; the secondary endpoints were the radiation exposure of the patient and C-arm readings. RESULTS After exclusion of three patients, 41 patients were analyzed. In general, the average radiation exposure of the surgeon was lower in the NAV group without being statistically significant. The radiation exposure of the patient was significantly higher in the NAV group at all dosemeter sites. The average fluoroscopy time was 63 ± 36 versus 109 ± 31 sec (FLUORO versus NAV group, P < 0.001). CONCLUSION The additional use of intraoperative 3D fluoroscopy-based navigation compared to conventional 2D fluoroscopy alone showed a nonsignificant reduction of the radiation exposure of the surgeon in monosegmental MIS TLIF, while increasing the radiation exposure of the patient. LEVEL OF EVIDENCE 1.
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Vasilikos I, Fistouris P, Krüger MT, Scholz C, Kogias E, Roelz R, Sircar R, Beck J, Hubbe U, Klingler JH. How Safe Is Minimally Invasive Transforaminal Lumbar Interbody Fusion for Octogenarians?: A Perioperative Complication Analysis. World Neurosurg 2020; 139:e754-e760. [DOI: 10.1016/j.wneu.2020.04.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022]
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Krüger MT, Naseri Y, Hohenhaus M, Hubbe U, Scholz C, Klingler JH. Impact of morbid obesity (BMI > 40 kg/m2) on complication rate and outcome following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Clin Neurol Neurosurg 2019; 178:82-85. [DOI: 10.1016/j.clineuro.2019.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/29/2022]
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Effects of Preoperative Simulation on Minimally Invasive Hybrid Lumbar Interbody Fusion. World Neurosurg 2017; 106:578-588. [PMID: 28705704 DOI: 10.1016/j.wneu.2017.06.184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/25/2017] [Accepted: 06/28/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The main focus of this study was to evaluate how preoperative simulation affects the surgical work flow, radiation exposure, and outcome of minimally invasive hybrid lumbar interbody fusion (MIS-HLIF). METHODS A total of 132 patients who underwent single-level MIS-HLIF were enrolled in a cohort study design. Dose area product was analyzed in addition to surgical data. Once preoperative simulation was established, 66 cases (SIM cohort) were compared with 66 patients who had previously undergone MIS-HLIF without preoperative simulation (NO-SIM cohort). RESULTS Dose area product was reduced considerably in the SIM cohort (320 cGy·cm2 NO-SIM cohort: 470 cGy·cm2; P < 0.01). Surgical time was shorter for the SIM cohort (155 minutes; NO-SIM cohort, 182 minutes; P < 0.05). SIM cohort had a better outcome in Numeric Rating Scale back at 6 months follow-up compared with the NO-SIM cohort (P < 0.05). CONCLUSIONS Preoperative simulation reduced radiation exposure and resulted in less back pain at the 6 months follow-up time point. Preoperative simulation provided guidance in determining the correct cage height. Outcome controls enabled the surgeon to improve the procedure and the software algorithm.
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Minimally invasive transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion: a technical description and review of the literature. Acta Neurochir (Wien) 2017; 159:1137-1146. [PMID: 28160064 DOI: 10.1007/s00701-017-3078-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 01/10/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Minimally invasive spine surgery (MISS) has been increasingly advocated during the last decade with new studies being reported every year. Minimally invasive spine procedures, such as minimally invasive transforaminal interbody fusion (MI-TLIF), have been introduced to reduce approach-related muscle trauma, to minimise blood loss, and to achieve faster wound healing, quicker ambulation and earlier patient discharge. METHODS The aim of this article was to give a comprehensive review of the available English literature comparing open TLIF with MI-TLIF techniques published or available online between 1990 and 2014 as identified by an electronic database search on http://www.ncbi.nlm.nih.gov/pubmed . Fourteen relevant studies comparing MI-TLIF and open TLIF cohorts could be identified. RESULTS AND CONCLUSION MI-TLIF seems to be a valid alternative to open TLIF. Both methods yield good clinical results with similar improvements of Oswestry Disability Index (ODI) and visual analogue scale (VAS) on follow-up. There seems to be no significant differences in clinical outcome and fusion rates on comparison. These results are consistent throughout all reported studies in this review. The most pronounced benefits of MI-TLIF are a significant reduction of blood loss, shorter lengths of hospital stay (LOHS) and lower surgical site infection rates. On the downside, MI-TLIF seems to be associated with significantly higher intraoperative radiation doses, a shallow learning curve, at least in the beginning, longer operating times and potentially more frequent implant failures/cage displacements and revision surgeries.
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Total 3D Airo® Navigation for Minimally Invasive Transforaminal Lumbar Interbody Fusion. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5027340. [PMID: 27529069 PMCID: PMC4978816 DOI: 10.1155/2016/5027340] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/08/2016] [Indexed: 12/04/2022]
Abstract
Introduction. A new generation of iCT scanner, Airo®, has been introduced. The purpose of this study is to describe how Airo facilitates minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Method. We used the latest generation of portable iCT in all cases without the assistance of K-wires. We recorded the operation time, number of scans, and pedicle screw accuracy. Results. From January 2015 to December 2015, 33 consecutive patients consisting of 17 men and 16 women underwent single-level or two-level MIS-TLIF operations in our institution. The ages ranged from 23 years to 86 years (mean, 66.6 years). We treated all the cases in MIS fashion. In four cases, a tubular laminectomy at L1/2 was performed at the same time. The average operation time was 192.8 minutes and average time of placement per screw was 2.6 minutes. No additional fluoroscopy was used. Our screw accuracy rate was 98.6%. No complications were encountered. Conclusions. Airo iCT MIS-TLIF can be used for initial planning of the skin incision, precise screw, and cage placement, without the need for fluoroscopy. “Total navigation” (complete intraoperative 3D navigation without fluoroscopy) can be achieved by combining Airo navigation with navigated guide tubes for screw placement.
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