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Degulmadi D, Dave BR, Chauhan V, Krishnan A, Mayi SC, Rai R, Dave MB, Bali S, Charde P, Anil A. Comparative Study on Accuracy of Intra-Operative Computed Tomography-Navigation Based Pedicle Screw Placement With Skin vs Bone Fixed Dynamic Reference Frame in Minimally Invasive Transforaminal Lumbar Interbody Fusion. Global Spine J 2023:21925682231181884. [PMID: 37279918 DOI: 10.1177/21925682231181884] [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: 06/08/2023] Open
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To compare the accuracy of intra-operative navigation-assisted percutaneous pedicle screw insertion between bone fixed and skin fixed dynamic reference frame (DRF) in Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS Between October 2018 and September 2022, patients who underwent MIS-TLIF were included in this study with DRF fixed either on bone (group B) or skin (group S). Pedicle screws were inserted under the guidance of intra-operative Cone bean Computed tomography (cbCT) based navigation. Accuracy of pedicle screw placement was immediately checked by a final intra-operative cbCT Spin. RESULTS Among 170 patients, group B included 91 patients and group S included 79 patients. Out of total 680 screws, 364 screws (group B) and 316 screws (group S) were placed. Patient's demographic data and distribution of screws showed no statistically significant difference. The accuracy showed no significant difference between both the groups (94.5% in group B and 94.3% in group S). CONCLUSION Skin fixed DRF can serve as an alternate way for placement and avoids extra incision with similar accuracy in pedicle screw insertions with bone fixed DRF using intra-operative CT guided navigation in MIS TLIF.
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Affiliation(s)
- Devanand Degulmadi
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Bharat R Dave
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Vikrant Chauhan
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Ajay Krishnan
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Shivanand C Mayi
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Ravi Rai
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Mirant Bharat Dave
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Shivkumar Bali
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Pranav Charde
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
| | - Abhijith Anil
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Nr Nagari Hospital, Ahmedabad, India
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Yi M, Song J, Zhang Y, Lin W, Yao M, Fan Y, Ding L. Effects of tracer position on screw placement technique in robot-assisted posterior spine surgery: a case-control study. BMC Musculoskelet Disord 2023; 24:421. [PMID: 37231398 DOI: 10.1186/s12891-023-06547-y] [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: 11/14/2022] [Accepted: 05/18/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Robot-assisted spine surgery is increasingly used in clinical work, and the installation of tracers as a key step in robotic surgery has rarely been studied. OBJECTIVE To explore the potential effects of tracers on surgical outcomes in robot-assisted posterior spine surgery. METHODS We reviewed all patients who underwent robotic-assisted posterior spine surgery at Beijing Shijitan Hospital over a 2-year period from September 2020 to September 2022. Patients were divided into two groups based on the location of the tracer (iliac spine or vertebral spinous process) during robotic surgery and a case-control study was conducted to determine the potential impact of tracer location on the surgical procedure. Data analysis was performed using SPSS.25 statistical software (SPSS Inc., Chicago, Illinois). RESULTS A total of 525 pedicle screws placed in 92 robot-assisted surgeries were analyzed. The rate of perfect screw positioning was 94.9% in all patients who underwent robot-assisted spine surgery (498/525). After grouping studies based on the location of tracers, we found there was no significant difference in age, sex, height and body weight between the two groups. The screw accuracy (p < 0.01)was significantly higher in the spinous process group compared to the iliac group (97.5% versus 92.6%), but the operation time (p = 0.09) was longer in comparison. CONCLUSION Placing the tracer on the spinous process as opposed to the iliac spine may result in longer procedure duration or increased bleeding, but enhanced satisfaction of screw placement.
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Affiliation(s)
- Meng Yi
- Department of Spine, Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, People's Republic of China
| | - Jipeng Song
- Department of Spine, Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, People's Republic of China
| | - Yao Zhang
- Department of Spine, Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, People's Republic of China
| | - Wancheng Lin
- Department of Spine, Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, People's Republic of China
| | - Mingtao Yao
- Department of Spine, Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, People's Republic of China
| | - Yuyu Fan
- Department of Spine, Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, People's Republic of China
| | - Lixiang Ding
- Department of Spine, Beijing Shijitan Hospital, Capital Medical University, No.10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, People's Republic of China.
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Sheth N, Vagdargi P, Sisniega A, Uneri A, Osgood G, Siewerdsen JH. Preclinical evaluation of a prototype freehand drill video guidance system for orthopedic surgery. J Med Imaging (Bellingham) 2022; 9:045004. [PMID: 36046335 PMCID: PMC9411797 DOI: 10.1117/1.jmi.9.4.045004] [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: 01/28/2022] [Accepted: 08/09/2022] [Indexed: 08/28/2023] Open
Abstract
Purpose: Internal fixation of pelvic fractures is a challenging task requiring the placement of instrumentation within complex three-dimensional bone corridors, typically guided by fluoroscopy. We report a system for two- and three-dimensional guidance using a drill-mounted video camera and fiducial markers with evaluation in first preclinical studies. Approach: The system uses a camera affixed to a surgical drill and multimodality (optical and radio-opaque) markers for real-time trajectory visualization in fluoroscopy and/or CT. Improvements to a previously reported prototype include hardware components (mount, camera, and fiducials) and software (including a system for detecting marker perturbation) to address practical requirements necessary for translation to clinical studies. Phantom and cadaver experiments were performed to quantify the accuracy of video-fluoroscopy and video-CT registration, the ability to detect marker perturbation, and the conformance in placing guidewires along realistic pelvic trajectories. The performance was evaluated in terms of geometric accuracy and conformance within bone corridors. Results: The studies demonstrated successful guidewire delivery in a cadaver, with a median entry point error of 1.00 mm (1.56 mm IQR) and median angular error of 1.94 deg (1.23 deg IQR). Such accuracy was sufficient to guide K-wire placement through five of the six trajectories investigated with a strong level of conformance within bone corridors. The sixth case demonstrated a cortical breach due to extrema in the registration error. The system was able to detect marker perturbations and alert the user to potential registration issues. Feasible workflows were identified for orthopedic-trauma scenarios involving emergent cases (with no preoperative imaging) or cases with preoperative CT. Conclusions: A prototype system for guidewire placement was developed providing guidance that is potentially compatible with orthopedic-trauma workflow. First preclinical (cadaver) studies demonstrated accurate guidance of K-wire placement in pelvic bone corridors and the ability to automatically detect perturbations that degrade registration accuracy. The preclinical prototype demonstrated performance and utility supporting translation to clinical studies.
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Affiliation(s)
- Niral Sheth
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Prasad Vagdargi
- Johns Hopkins University, Department of Computer Science, Baltimore, Maryland, United States
| | - Alejandro Sisniega
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Ali Uneri
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Gregory Osgood
- Johns Hopkins Medicine, Department of Orthopedic Surgery, Baltimore, Maryland, United States
| | - Jeffrey H. Siewerdsen
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
- Johns Hopkins University, Department of Computer Science, Baltimore, Maryland, United States
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Rossi VJ, Wells-Quinn TA, Malham GM. Negotiating for new technologies: guidelines for the procurement of assistive technologies in spinal surgery: a narrative review. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:254-265. [PMID: 35875618 PMCID: PMC9263739 DOI: 10.21037/jss-21-107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE This is a narrative review with the objective to discuss available assistive technologies for spinal surgery. Characteristics, costs, and compatibility of the different systems are summarized and recommendations made regarding acquiring these technologies. The availability of assistive technologies in spine surgery continues to evolve rapidly. The literature is lacking a collective summary of the available technologies and guidelines for acquisition. This is a narrative review which (I) presents an up-to-date summary of the currently available assistive technologies in spinal surgery; (II) makes comment on the utility of imaging, navigation, and robotics; (III) makes recommendations for the utility of the platform based on hospital size and (IV) discuss factors involved in negotiating for the purchase of these new technologies. METHODS We assemble the most up-to-date collection of description, characteristics and pricing of assistive technologies in spinal surgery. We compare and contrast these technologies and make recommendations regarding acquisition. KEY CONTENT AND FINDINGS These technologies require a learning-curve for the surgeon and the operating room staff to understand how to use them efficiently. Surgeons need to be involved in the process of purchase decisions. Surgeons occupy a unique position in the health care infrastructure as their approach to care has significant ramifications on both the quality and cost of care. Surgeons should maintain conviction that their training and practice has allowed the use of these technologies to provide safer and more effective care for patients. CONCLUSIONS Assistive technologies and prostheses for spinal fusion are evolving rapidly. This article serves as an encompassing reference to the current technologies. These technologies will play a significant role in the delivery of spinal health care in the future. All stakeholders stand to benefit from the increased value these technologies bring to patient care.
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Affiliation(s)
- Vincent J. Rossi
- Epworth Hospital, Melbourne, Australia
- Carolina Neurosurgery & Spine Associates, Charlotte, NC, USA
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | | | - Gregory M. Malham
- Epworth Hospital, Melbourne, Australia
- Swinburne University of Technology, Melbourne, Australia
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Malham GM, Munday NR. Comparison of novel machine vision spinal image guidance system with existing 3D fluoroscopy-based navigation system: a randomized prospective study. Spine J 2022; 22:561-569. [PMID: 34666179 DOI: 10.1016/j.spinee.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The use of spinal image guidance systems (IGS) has increased patient safety, accuracy, operative efficiency, and reduced revision rates in pedicle screw placement procedures. Traditional intraoperative 3D fluoroscopy or CT imaging produces potentially harmful ionizing radiation and increases operative time to register the patient. An IGS, FLASH Navigation, uses machine vision through high resolution stereoscopic cameras and structured visible light to build a 3D topographical map of the patient's bony surface anatomy enabling navigation use without ionizing radiation. PURPOSE We aimed to compare FLASH navigation system to a widely used 3D fluoroscopic navigation (3D) platform by comparing radiation exposure and pedicle screw accuracy. DESIGN A randomized prospective comparative cohort study of consecutive patients undergoing open posterior lumbar instrumented fusion. PATIENT SAMPLE Adults diagnosed with spinal pathology requiring surgical treatment and planning for open posterior lumbar fusion with pedicle screws implanted into 1-4 vertebral levels. OUTCOME MEASURES Outcome measures included mean intraoperative fluoroscopy time and dose, mean CT dose length product (DLP) for preoperative and day 2 CT, pedicle screw accuracy by CT, estimated blood loss and revision surgery rate. METHODS Consecutive patients were randomized 1:1 to FLASH or 3D and underwent posterior lumbar instrumented fusion. Radiation doses were recorded from pre- and postoperative CT and intraoperative 3D fluoroscopy. 2 independent blinded radiologists reviewed pedicle screw accuracy on CT. RESULTS A total of 429 (n=210 FLASH, n=219 3D) pedicle screws were placed in 90 patients (n=45 FLASH, n=45 3D) over the 18-month study period. Mean age and indication for surgery were similar between both groups, with a non-significantly higher ratio of males in the 3D group. Mean intraoperative fluoroscopy time and doses were significantly reduced in FLASH compared to 3D (4.51±3.71s vs 79.6±23.0s, p<.001 and 80.9±68.1cGycm2 vs 3704.1±3442.4 cGycm2, p<.001, respectively). This represented a relative reduction of 94.3% in the total intraoperative radiation time and a 97.8% reduction in the total intraoperative radiation dose. Mean preoperative CT DLP and mean day 2 postoperative CT DLP were significantly reduced in FLASH compared to 3D (662.0±440.4mGy-cm vs 1008.9±616.3 mGy-cm, p<.001 and 577.9±294.3 mGy-cm vs 980.7±441.6 mGy-cm, p<.001, respectively). This represented relative reductions of 34.4% and 41.0% in the preoperative CT dose and postoperative total DLP, respectively. The FLASH group required an average of 1.2 registrations in each case with an average of 2447 (±961.3) data points registered with a mean registration time of 106s (±52.1). A rapid re-registration mechanism was utilized in 22% (n=10/45) of cases and took 22.7s (±11.3). Re-registration was used in 7% (n=3/45) in the 3D group. Pedicle screw accuracy was high in FLASH (98.1%) and 3D (97.3%) groups with no pedicle breach >2mm in either group (p<.001). EBL was not statistically different between the groups (p=.38). No neurovascular injuries occurred, and no patients required return to theatre for screw repositioning. CONCLUSIONS FLASH and 3D IGS demonstrate high accuracy for pedicle screw placement. FLASH showed significant reduction in intraoperative radiation time and dose with lower but non-significant blood loss. FLASH showed significant reduction in preoperative and postoperative radiation, but this may be associated to the lower number of males/females preponderance in this group. FLASH provides similar accuracy to contemporary IGS without requiring 3D-fluoroscopy or radiolucent operating tables. Reducing registration time and specialized equipment may reduce costs.
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Affiliation(s)
- Gregory M Malham
- Epworth Hospital, Richmond, Melbourne, Australia; Swinburne University of Technology, Melbourne, Australia.
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Alluri RK, Sivaganesan A, Vaishnav AS, Dupont M, Qureshi SA. Surface Navigation and the Influence of Navigation on MIS Surgery. Global Spine J 2022; 12:19S-26S. [PMID: 35393880 PMCID: PMC8998479 DOI: 10.1177/21925682211028587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Literature review. OBJECTIVES To review the evidence for surface-based navigation in minimally-invasive spine surgery (MIS), provide an outline for its workflow, and present a wide range of MIS case examples in which surface-based navigation may be advantageous. METHODS A comprehensive review of the literature and compilation of findings related to surface-based navigation in MIS was performed. Workflow and case examples utilizing surface-based navigation were described. RESULTS The nascent literature regarding surface-based intraoperative navigation (ION) in spine surgery is encouraging and initial studies have shown that surface-based navigation can allow for accurate pedicle screw placement and decreased operative time, fluoroscopy time, and radiation exposure when compared to traditional fluoroscopic imaging. Surface-based navigation may be particularly useful in MIS cervical and lumbar decompressions and MIS lumbar instrumentation cases. CONCLUSIONS Overall, it is possible that surface-based ION will become a mainstay in the armamentarium of enabling technologies utilized by minimally-invasive spine surgeons, but further studies are needed assessing its accuracy, complications, and cost-effectiveness.
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Affiliation(s)
| | | | | | | | - Sheeraz A. Qureshi
- Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
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Vaishnav AS, Gang CH, Qureshi SA. Time-demand, Radiation Exposure and Outcomes of Minimally Invasive Spine Surgery With the Use of Skin-Anchored Intraoperative Navigation: The Effect of the Learning Curve. Clin Spine Surg 2022; 35:E111-E120. [PMID: 33769982 PMCID: PMC11296386 DOI: 10.1097/bsd.0000000000001167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE The aim was to evaluate the learning curve of skin-anchored intraoperative navigation (ION) for minimally invasive lumbar surgery. SUMMARY OF BACKGROUND DATA ION is increasingly being utilized to provide better visualization, improve accuracy, and enable less invasive procedures. The use of noninvasive skin-anchored trackers for navigation is a novel technique, with the few reports on this technique demonstrating safety, feasibility, and significant reductions in radiation exposure compared with conventional fluoroscopy. However, a commonly cited deterrent to wider adoption is the learning curve. METHODS Retrospective review of patients undergoing 1-level minimally invasive lumbar surgery was performed. Outcomes were: (1) time for ION set-up and image-acquisition; (2) operative time; (3) fluoroscopy time; (4) radiation dose; (5) operative complications; (6) need for repeat spin; (7) incorrect localization.Chronologic case number was plotted against each outcome. Derivative of the nonlinear curve fit to the dataset for each outcome was solved to find plateau in learning. RESULTS A total of 270 patients [114 microdiscectomy; 79 laminectomy; 77 minimally invasive transforaminal lumbar interbody fusion (MI-TLIF)] were included. (1) ION set-up and image-acquisition: no learning curve for microdiscectomy. Proficiency at 23 and 31 cases for laminectomy and MI-TLIF, respectively. (2) Operative time: no learning curve for microdiscectomy. Proficiency at 36 and 31 cases for laminectomy and MI-TLIF, respectively. (3) Fluoroscopy time: no learning curve. (4) Radiation dose: proficiency at 42 and 33 cases for microdiscectomy and laminectomy, respectively. No learning curve for MI-TLIF. (5) Operative complications: unable to evaluate for microdiscectomy and MI-TLIF. Proficiency at 29 cases for laminectomy. (6) Repeat spin: unable to evaluate for microdiscectomy and laminectomy. For MI-TLIF, chronology was not associated with repeat spins. (7) Incorrect localization: none. CONCLUSIONS Skin-anchored ION did not result in any wrong level surgeries. Learning curve for other parameters varied by surgery type, but was achieved at 25-35 cases for a majority of outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Sheeraz A. Qureshi
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
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Vaishnav AS, Louie P, Gang CH, Iyer S, McAnany S, Albert T, Qureshi SA. Technique, Time Demand, Radiation Exposure, and Outcomes of Skin-anchored Intraoperative 3D Navigation in Minimally Invasive Posterior Cervical Laminoforaminotomy. Clin Spine Surg 2022; 35:31-37. [PMID: 33633002 DOI: 10.1097/bsd.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective review. OBJECTIVE The objective of this study was to describe our technique and evaluate the time demand, radiation exposure, and outcomes of minimally invasive posterior cervical laminoforaminotomy (MI-PCLF) using skin-anchored intraoperative navigation (ION). BACKGROUND Although bone-anchored trackers are most commonly used for ION, a novel technique utilizing noninvasive skin-anchored trackers has recently been described for lumbar surgery and has shown favorable results. There are currently no reports on the use of this technology for cervical surgery. METHODS Time demand, radiation exposure, and perioperative outcomes of MI-PCLF using skin-anchored ION were evaluated. RESULTS Twenty-one patients with 36 operative levels were included. Time for ION setup and operative time were a median of 34 and 62 minutes, respectively. Median radiation to the patient was 2.5 mGy from 10 seconds of fluoroscopy time. Radiation exposure to operating room personnel was negligible because they are behind a protective lead shield during ION image acquisition. There were no intraoperative complications or wrong-level surgeries. One patient required a repeat ION spin, and in 2 patients, ION was abandoned and standard fluoroscopy was used. CONCLUSIONS Skin-anchored ION for MI-PCLF is feasible, safe, and accurate. It results in short operative times, minimal complications, low radiation to the patient, and negligible radiation to operating room personnel.
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Affiliation(s)
| | | | | | - Sravisht Iyer
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | - Steven McAnany
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | - Todd Albert
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
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García-Sevilla M, Moreta-Martinez R, García-Mato D, Arenas de Frutos G, Ochandiano S, Navarro-Cuéllar C, Sanjuán de Moreta G, Pascau J. Surgical Navigation, Augmented Reality, and 3D Printing for Hard Palate Adenoid Cystic Carcinoma En-Bloc Resection: Case Report and Literature Review. Front Oncol 2022; 11:741191. [PMID: 35059309 PMCID: PMC8763795 DOI: 10.3389/fonc.2021.741191] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/26/2021] [Indexed: 12/18/2022] Open
Abstract
Adenoid Cystic Carcinoma is a rare and aggressive tumor representing less than 1% of head and neck cancers. This malignancy often arises from the minor salivary glands, being the palate its most common location. Surgical en-bloc resection with clear margins is the primary treatment. However, this location presents a limited line of sight and a high risk of injuries, making the surgical procedure challenging. In this context, technologies such as intraoperative navigation can become an effective tool, reducing morbidity and improving the safety and accuracy of the procedure. Although their use is extended in fields such as neurosurgery, their application in maxillofacial surgery has not been widely evidenced. One reason is the need to rigidly fixate a navigation reference to the patient, which often entails an invasive setup. In this work, we studied three alternative and less invasive setups using optical tracking, 3D printing and augmented reality. We evaluated their precision in a patient-specific phantom, obtaining errors below 1 mm. The optimum setup was finally applied in a clinical case, where the navigation software was used to guide the tumor resection. Points were collected along the surgical margins after resection and compared with the real ones identified in the postoperative CT. Distances of less than 2 mm were obtained in 90% of the samples. Moreover, the navigation provided confidence to the surgeons, who could then undertake a less invasive and more conservative approach. The postoperative CT scans showed adequate resection margins and confirmed that the patient is free of disease after two years of follow-up.
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Affiliation(s)
- Mónica García-Sevilla
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rafael Moreta-Martinez
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - David García-Mato
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Gema Arenas de Frutos
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Servicio de Cirugía Oral y Maxilofacial, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Santiago Ochandiano
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Servicio de Cirugía Oral y Maxilofacial, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Carlos Navarro-Cuéllar
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Servicio de Cirugía Oral y Maxilofacial, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Guillermo Sanjuán de Moreta
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Servicio de Otorrinolaringología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Pascau
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Charles YP, Cazzato RL, Nachabe R, Chatterjea A, Steib JP, Gangi A. Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Augmented Reality Surgical Navigation for Percutaneous Pedicle Screw Placement. Clin Spine Surg 2021; 34:E415-E424. [PMID: 33560011 DOI: 10.1097/bsd.0000000000001132] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective observational study. OBJECTIVE The aim of this study was to evaluate the accuracy of percutaneous pedicle screw placement using augmented reality surgical navigation during minimally invasive transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA Augmented reality-based navigation is a new type of computer-assisted navigation where video cameras are used instead of infrared cameras to track the operated patients and surgical instruments. This technology has not so far been clinically evaluated for percutaneous pedicle screw placement. MATERIALS AND METHODS The study assessed percutaneous pedicle screw placement in 20 consecutive patients who underwent single-level minimally invasive TLIF using augmented reality surgical navigation. Facet joint violation and depression by the inserted pedicle screws were evaluated. Secondary outcome such as radiation dose exposure, fluoroscopy time, and operative time were collected for 3 phases of surgery: preparation phase, pedicle screw placement, and decompression with cage placement. RESULTS A clinical accuracy for screw placement within the pedicle (Gertzbein 0 or 1) of 94% was achieved. One screw violated the facet joint with a transarticular pathway. The screw head did not depress the facet in 54%. The use of fluoroscopy during navigation correlated with patient body-mass index (r=0.68, P<0.0001). The pedicle screw placement time corresponded to 36±5% of the total operative time of 117±11 minutes. A statistically significant decrease of 10 minutes in operative time was observed between the first and last 10 procedures which corresponded to the pedicle screw placement time decrease (48±9 vs. 38±7 min, P=0.0142). The learning curve model suggests an ultimate operative time decrease to 97 minutes. CONCLUSION Augmented reality surgical navigation can be clinically used to place percutaneous screws during minimally invasive TLIF. However, the lack of tracking of the location of the device requires intraoperative fluoroscopy to monitor screw insertion depth especially in obese patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Roberto L Cazzato
- Interventional Radiology, University Hospital of Strasbourg, Strasbourg, France
| | - Rami Nachabe
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, The Netherlands
| | - Anindita Chatterjea
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, The Netherlands
| | | | - Afshin Gangi
- Interventional Radiology, University Hospital of Strasbourg, Strasbourg, France
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Use of intraoperative navigation for posterior spinal fusion in adolescent idiopathic scoliosis surgery is safe to consider. Spine Deform 2021; 9:403-410. [PMID: 33025389 DOI: 10.1007/s43390-020-00218-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/21/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE The use of image-guided stereotactic navigation is increasing in use in treating AIS; however, no studies have investigated perioperative outcomes and short-term adverse events compared with non-navigated procedures. The aim of the present study is to use a large national pediatric database to assess the rate of utilization of intraoperative navigation in pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) and to compare thirty-day outcomes of navigated vs. non-navigated surgery. METHODS The NSQIP-Pediatric database was queried for cases of posterior fusion for AIS. Patients were stratified by whether or not a concurrent code for stereotactic navigation was used (CPT 61,783). Year of procedure, demographics, comorbidities, operative variables and perioperative adverse outcomes were abstracted and assessed using univariate and multivariate analysis. RESULTS Overall, 12,739 non-navigated patients and 340 navigated patients were identified. The use of navigation increased from 0.5% of cases in 2012 to 5.2% of cases in 2018. Demographics, comorbidities, and number of levels fused did not differ between navigated and non-navigated patients. Navigated cases were on average 41 min longer than non-navigated cases (268.6 vs. 309.6 min p < 0.001), with 9.84% more cases requiring transfusion (65.0% vs 75.6%, p < 0.001). Hospital stay for navigated cases was an average of 0.4 days shorter (3.9 days vs 4.3 days, p = 0.001). On multivariate analysis, navigated cases had higher odds of prolonged surgery (OR = 2.13, p < 0.001) and lower odds of prolonged length of stay (OR = 0.28, p < 0.001). CONCLUSION Although the use of navigation for AIS posterior fusion was associated with longer operative time, post-operative hospital stay was shorter and other perioperative adverse outcomes were not significantly different between groups.
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Accuracy and technical limits of percutaneous pedicle screw placement in the thoracolumbar spine. Surg Radiol Anat 2021; 43:843-853. [PMID: 33449140 DOI: 10.1007/s00276-020-02673-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The two-dimensional fluoroscopic method of percutaneous pedicle screw instrumentation has been clinically described as reliable method in the caudal thoracic and lumbosacral spine. Its accuracy has not been clearly reported in the cranial thoracic spine. The aim of this in vitro study was to investigate percutaneous pedicle screw placement accuracy according to pedicle dimensions and vertebral levels. METHODS Six fresh-frozen human specimens were instrumented with 216 screws from T1 to S1. Pedicle isthmus widths, heights, transversal pedicles and screws were measured on computed tomography. Pedicle cortex violation ≥ 2 mm was defined as screw malposition. RESULTS The narrowest pedicles were at T3-T5. A large variability between transversal pedicle axes and percutaneous pedicle screw was present, depending on the spinal level. Screw malposition rates were 36.1% in the cranial thoracic spine (T1-T6), 16.7% in the caudal thoracic spine (T7-T12), and 6.9% in the lumbosacral spine (L1-S1). The risk for screw malposition was significantly higher at cranial thoracic levels compared to caudal thoracic (p = 0.006) and lumbosacral (p < 0.0001) levels. Cortex violation ≥ 2 mm was constantly present if the pedicle width was < 4.8 mm. CONCLUSION Percutaneous pedicle screw placement appears safe in the caudal thoracic and lumbosacral spine. The two-dimensional fluoroscopic method has a limited reliability above T7 because of smaller pedicle dimensions, difficulties in visualizing radiographic pedicle landmarks and kyphosis.
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Manni F, Mamprin M, Holthuizen R, Shan C, Burström G, Elmi-Terander A, Edström E, Zinger S, de With PHN. Multi-view 3D skin feature recognition and localization for patient tracking in spinal surgery applications. Biomed Eng Online 2021; 20:6. [PMID: 33413426 PMCID: PMC7792004 DOI: 10.1186/s12938-020-00843-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/19/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Minimally invasive spine surgery is dependent on accurate navigation. Computer-assisted navigation is increasingly used in minimally invasive surgery (MIS), but current solutions require the use of reference markers in the surgical field for both patient and instruments tracking. PURPOSE To improve reliability and facilitate clinical workflow, this study proposes a new marker-free tracking framework based on skin feature recognition. METHODS Maximally Stable Extremal Regions (MSER) and Speeded Up Robust Feature (SURF) algorithms are applied for skin feature detection. The proposed tracking framework is based on a multi-camera setup for obtaining multi-view acquisitions of the surgical area. Features can then be accurately detected using MSER and SURF and afterward localized by triangulation. The triangulation error is used for assessing the localization quality in 3D. RESULTS The framework was tested on a cadaver dataset and in eight clinical cases. The detected features for the entire patient datasets were found to have an overall triangulation error of 0.207 mm for MSER and 0.204 mm for SURF. The localization accuracy was compared to a system with conventional markers, serving as a ground truth. An average accuracy of 0.627 and 0.622 mm was achieved for MSER and SURF, respectively. CONCLUSIONS This study demonstrates that skin feature localization for patient tracking in a surgical setting is feasible. The technology shows promising results in terms of detected features and localization accuracy. In the future, the framework may be further improved by exploiting extended feature processing using modern optical imaging techniques for clinical applications where patient tracking is crucial.
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Affiliation(s)
- Francesca Manni
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.
| | - Marco Mamprin
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | | | - Caifeng Shan
- Shandong University of Science and Technology, Qingdao, China
| | - Gustav Burström
- Department of Neurosurgery, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Neurosurgery, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Erik Edström
- Department of Neurosurgery, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Svitlana Zinger
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Peter H N de With
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
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Virk S, Qureshi S. Narrative review of intraoperative imaging guidance for decompression-only surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:88. [PMID: 33553381 PMCID: PMC7859763 DOI: 10.21037/atm-20-5854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Decompression of the spine is defined as removal of bony and soft tissue structures in order to provide space for the spinal cord and/or nerve roots. This definition, however, underscores the dangers and complexity of safely providing anatomical space for these neurologic structures. Complications such as neurologic injury, vascular injury, and durotomy can make these procedures hazardous for the patient and surgeon. Furthermore, inability to fully decompress the neural elements will result in continued symptoms for patients. Intraoperative image guidance can provide important anatomical landmarks to perform these decompressive surgeries safely and efficiently. In particular, performing decompression surgery utilizing minimally invasive techniques with image guidance can allow for the least amount of muscle/soft tissue trauma possible. Within our article we outline research on the forefront of use of intra-operative imaging guidance for spine surgery and implications for decompression surgery. We also outline a case from the senior author to illustrate an example of image-guided spine decompression for cervical radiculopathy. Future technology, such as augmented reality and robotics, is also discussed in the context of image guided decompression. The authors hope this article shows surgeons that use of image guidance in specific clinical situations can allow for better/safer spinal decompression procedures.
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Affiliation(s)
- Sohrab Virk
- Department of Orthopedic Surgery, Northwell Health, Great Neck, NY, USA
| | - Sheeraz Qureshi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Klingler JH, Hubbe U, Scholz C, Volz F, Hohenhaus M, Vasilikos I, Masalha W, Watzlawick R, Naseri Y. Noninvasive patient tracker mask for spinal 3D navigation: does the required large-volume 3D scan involve a considerably increased radiation exposure? J Neurosurg Spine 2020; 33:838-844. [PMID: 32858517 DOI: 10.3171/2020.5.spine20530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/15/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative 3D imaging and navigation is increasingly used for minimally invasive spine surgery. A novel, noninvasive patient tracker that is adhered as a mask on the skin for 3D navigation necessitates a larger intraoperative 3D image set for appropriate referencing. This enlarged 3D image data set can be acquired by a state-of-the-art 3D C-arm device that is equipped with a large flat-panel detector. However, the presumably associated higher radiation exposure to the patient has essentially not yet been investigated and is therefore the objective of this study. METHODS Patients were retrospectively included if a thoracolumbar 3D scan was performed intraoperatively between 2016 and 2019 using a 3D C-arm with a large 30 × 30-cm flat-panel detector (3D scan volume 4096 cm3) or a 3D C-arm with a smaller 20 × 20-cm flat-panel detector (3D scan volume 2097 cm3), and the dose area product was available for the 3D scan. Additionally, the fluoroscopy time and the number of fluoroscopic images per 3D scan, as well as the BMI of the patients, were recorded. RESULTS The authors compared 62 intraoperative thoracolumbar 3D scans using the 3D C-arm with a large flat-panel detector and 12 3D scans using the 3D C-arm with a small flat-panel detector. Overall, the 3D C-arm with a large flat-panel detector required more fluoroscopic images per scan (mean 389.0 ± 8.4 vs 117.0 ± 4.6, p < 0.0001), leading to a significantly higher dose area product (mean 1028.6 ± 767.9 vs 457.1 ± 118.9 cGy × cm2, p = 0.0044). CONCLUSIONS The novel, noninvasive patient tracker mask facilitates intraoperative 3D navigation while eliminating the need for an additional skin incision with detachment of the autochthonous muscles. However, the use of this patient tracker mask requires a larger intraoperative 3D image data set for accurate registration, resulting in a 2.25 times higher radiation exposure to the patient. The use of the patient tracker mask should thus be based on an individual decision, especially taking into considering the radiation exposure and extent of instrumentation.
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Affiliation(s)
- Jan-Helge Klingler
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
| | - Ulrich Hubbe
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
| | - Christoph Scholz
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
| | - Florian Volz
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
| | - Marc Hohenhaus
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
| | - Ioannis Vasilikos
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
| | - Waseem Masalha
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
| | - Ralf Watzlawick
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
| | - Yashar Naseri
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and
- 2Department of Neurosurgery, Cantonal Hospital St. Gallen, Switzerland
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Frameless Patient Tracking With Adhesive Optical Skin Markers for Augmented Reality Surgical Navigation in Spine Surgery. Spine (Phila Pa 1976) 2020; 45:1598-1604. [PMID: 32756274 DOI: 10.1097/brs.0000000000003628] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational study. OBJECTIVE The aim of this study was to evaluate the accuracy of a new frameless reference marker system for patient tracking by analyzing the effect of vertebral position within the surgical field. SUMMARY OF BACKGROUND DATA Most modern navigation systems for spine surgery rely on a dynamic reference frame attached to a vertebra for tracking the patient. This solution has the drawback of being bulky and obstructing the surgical field, while requiring that the dynamic reference frame is moved between vertebras to maintain accuracy. METHODS An augmented reality surgical navigation (ARSN) system with intraoperative cone beam computed tomography (CBCT) capability was installed in a hybrid operating room. The ARSN system used input from four video cameras for tracking adhesive skin markers placed around the surgical field. The frameless reference marker system was evaluated first in four human cadavers, and then in 20 patients undergoing navigated spine surgery. In each CBCT, the impact of vertebral position in the surgical field on technical accuracy was analyzed. The technical accuracy of the inserted pedicle devices was determined by measuring the distance between the planned position and the placed pedicle device, at the bone entry point. RESULTS The overall mean technical accuracy was 1.65 ± 1.24 mm at the bone entry point (n = 366). There was no statistically significant difference in technical accuracy between levels within CBCTs (P ≥ 0.12 for all comparisons). Linear regressions showed that null- to negligible parts of the effect on technical accuracy could be explained by the number of absolute levels away from the index vertebrae (r ≤ 0.007 for all, β ≤ 0.071 for all). CONCLUSION The frameless reference marker system based on adhesive skin markers is unobtrusive and affords the ARSN system a high accuracy throughout the navigated surgical field, independent of vertebral position. LEVEL OF EVIDENCE 3.
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Hyperspectral Imaging for Skin Feature Detection: Advances in Markerless Tracking for Spine Surgery. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10124078] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In spinal surgery, surgical navigation is an essential tool for safe intervention, including the placement of pedicle screws without injury to nerves and blood vessels. Commercially available systems typically rely on the tracking of a dynamic reference frame attached to the spine of the patient. However, the reference frame can be dislodged or obscured during the surgical procedure, resulting in loss of navigation. Hyperspectral imaging (HSI) captures a large number of spectral information bands across the electromagnetic spectrum, providing image information unseen by the human eye. We aim to exploit HSI to detect skin features in a novel methodology to track patient position in navigated spinal surgery. In our approach, we adopt two local feature detection methods, namely a conventional handcrafted local feature and a deep learning-based feature detection method, which are compared to estimate the feature displacement between different frames due to motion. To demonstrate the ability of the system in tracking skin features, we acquire hyperspectral images of the skin of 17 healthy volunteers. Deep-learned skin features are detected and localized with an average error of only 0.25 mm, outperforming the handcrafted local features with respect to the ground truth based on the use of optical markers.
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Vaishnav AS, Merrill RK, Sandhu H, McAnany SJ, Iyer S, Gang CH, Albert TJ, Qureshi SA. A Review of Techniques, Time Demand, Radiation Exposure, and Outcomes of Skin-anchored Intraoperative 3D Navigation in Minimally Invasive Lumbar Spinal Surgery. Spine (Phila Pa 1976) 2020; 45:E465-E476. [PMID: 32224807 PMCID: PMC11097676 DOI: 10.1097/brs.0000000000003310] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To describe our technique for and evaluate the time demand, radiation exposure and outcomes of skin-anchored intraoperative three-dimensional navigation (ION) in minimally invasive (MIS) lumbar surgery, and to compare these parameters to 2D fluoroscopy for MI-TLIF. SUMMARY OF BACKGROUND DATA Limited visualization of anatomic landmarks and narrow access corridor in MIS procedures result in greater reliance on image guidance. Although two-dimensional fluoroscopy has historically been used, ION is gaining traction. METHODS Patients who underwent MIS lumbar microdiscectomy, laminectomy, or MI-TLIF using skin-anchored ION and MI-TLIF by the same surgeon using 2D fluoroscopy were selected. Operative variables, radiation exposure, and short-term outcomes of all procedures were summarized. Time-demand and radiation exposure of fluoroscopy and ION for MI-TLIF were compared. RESULTS Of the 326 patients included, 232 were in the ION cohort (92 microdiscectomies, 65 laminectomies, and 75 MI-TLIFs) and 94 in the MI-TLIF using 2D fluoroscopy cohort. Time for ION setup and image acquisition was a median of 22 to 24 minutes. Total fluoroscopy time was a median of 10 seconds for microdiscectomy, 9 for laminectomy, and 26 for MI-TLIF. Radiation dose was a median of 15.2 mGy for microdiscectomy, 16.6 for laminectomy, and 44.6 for MI-TLIF, of this, 93%, 95%, and 37% for microdiscectomy, laminectomy, and MI-TLIF, respectively were for ION image acquisition, with the rest attributable to the procedure. There were no wrong-level surgeries. Compared with fluoroscopy, ION for MI-TLIF resulted in lower operative times (92 vs. 108 min, P < 0.0001), fluoroscopy time (26 vs. 144 s, P < 0.0001), and radiation dose (44.6 vs. 63.1 mGy, P = 0.002), with equivalent time-demand and length of stay. ION lowered the radiation dose by 29% for patients and 55% for operating room personnel. CONCLUSION Skin-anchored ION does not increase time-demand compared with fluoroscopy, is feasible, safe and accurate, and results in low radiation exposure. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | | | - Harvinder Sandhu
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Steven J. McAnany
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Sravisht Iyer
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | - Todd J. Albert
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Sheeraz A. Qureshi
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
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El Saman A, Meier SL, Marzi I. A minimally invasive, 3D-fluoroscopy-navigation-guided, 3D-controlled pedicle approach in spine surgery: first reliable results and impact on patient safety. Eur J Trauma Emerg Surg 2020; 47:739-748. [PMID: 32123950 PMCID: PMC8187224 DOI: 10.1007/s00068-020-01332-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/15/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Safe pedicle screw placement is a daily challenge to every spine surgeon. Introduction of minimally invasive approaches in spinal surgery led to an impaired facility of inspection of the surgical field increasing the importance of intraoperative imaging and navigation. During the past years, we established a minimally invasive, navigated approach in our clinical setting. METHODS We retrospectively reviewed the accuracy of pedicle approaches in patients treated due to traumatic or osteoporotic fractures, spondylitis/discitis, and tumoral lesions. Guide wires for pedicle screws or kyphoplasty cannulas were inserted in a 3D-navigation-guided, minimally invasive technique. Positioning of the guide wires was verified via 3D-scan, and pedicle screws/kyphoplasty cannulas were then visualized via a.p./lateral radiographs. Accuracy data were compared to a standard navigated open approach control group with indications similar to the MIS-group. RESULTS 23 MIS patients were included in this study (25-84 years, mean 70 years) with a total of 154 placed guide wires. Handling of the navigated Jamshidi needle was easy and secure. The guide wires showed correct placement in 151/154 cases. Three wires (1.9%) needed correction of placement after control scan. There were no vascular or neurologic complications due to wire misplacement. In the open-surgery control group, 7/181 screws (3.9%) needed intraoperative correction presenting no significant difference compared to the correction rate of the MIS-group (p = 0.35). CONCLUSION Our study shows the feasibility and reliability of a navigation-guided, minimally invasive pedicle approach in the clinical setting. Therefore, reduced morbidity due to minimized approaches can be combined with higher accuracy of navigated pedicle screw/kyphoplasty cannula placement improving patient safety.
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Affiliation(s)
- André El Saman
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Simon Lars Meier
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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Accuracy of K-Wireless Insertion of Percutaneous Pedicle Screws Using Computer-Assisted Spinal Navigation: A Systematic Review and Single-Center Experience. World Neurosurg 2020; 138:e267-e274. [PMID: 32105880 DOI: 10.1016/j.wneu.2020.02.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study sought to 1) describe the use K-wireless pedicle screw insertion among adults (age ≥18 years) undergoing a minimally invasive fusion and 2) perform a systematic review (SR) of all studies that describe a navigated, K-wireless technique with 3-dimensional fluoroscopy. METHODS Patients undergoing a minimally invasive fusion requiring pedicle screw fixation for any indication were prospectively enrolled in the observational component of this study. An assessment of pedicle breach was performed independently and in duplicate based on a modification of the Belmont grading scale. Articles for the SR were identified from a structured search of Medline from inception to May 8, 2019, without restriction of language. RESULTS A total of 82 pedicle screws were placed in 20 patients who underwent surgery between January and June 2014. There was no significant difference in mean operative time between the cases included in this study and a matched cohort of 20 patients undergoing surgery with 2-dimensional fluoroscopy and K-wire-assisted pedicle screw placement (95 ± 13 vs. 87 ± 20 minutes, respectively; P > 0.05). There were 2 major pedicle breaches (Belmont grade 3) in a single patient, yielding a major breach rate of 2.44%. A total of 6 papers that described the placement of 700 pedicle screws in 160 patients between May 2011 and March 2017 were included in the SR. The overall breach rate was 7.00% (n = 37). CONCLUSIONS Percutaneous pedicle screws can be placed accurately and safely using 3-dimensional navigation without the use of K-wires and may confer benefits to patients and clinicians by reducing K-wire-associated complications and radiation exposure.
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Measuring the performance of patient-specific solutions for minimally invasive transforaminal lumbar interbody fusion surgery. J Clin Neurosci 2019; 71:43-50. [PMID: 31843436 DOI: 10.1016/j.jocn.2019.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 10/07/2019] [Accepted: 11/09/2019] [Indexed: 01/12/2023]
Abstract
Pre-surgical planning using 3D-printed BioModels enables the preparation of a "patient-specific" kit to assist instrumented spinal fusion surgery. This approach has the potential to decrease operating time while also offering logistical benefits and cost savings for healthcare. We report our experience with this method in 129 consecutive patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) over 27 months at a single centre and performed by a single surgeon. Patient imaging and surgical planning software were used to manufacture a 3D-printed patient-specific MIS TLIF kit for each patient consisting of a 1:1 scale spine BioModel, stereotactic K-wire guide, osteotomy guide, and retractors. Pre-selected pedicle screws, rods, and cages were sourced and supplied with the patient-specific kit. Additional implants were available on-shelf to address a size discrepancy between the kit implant and intraoperative measurements. Each BioModel was used pre-operatively for surgical planning, patient consent and education. The BioModel was sterilised for intraoperative reference and navigation purposes. Efficiency measures included operating time (153 ± 44 min), sterile tray usage (14 ± 3), fluoroscopy screening time (57.2 ± 23.7 s), operative waste (19 ± 8 L contaminated, 116 ± 30 L uncontaminated), and median hospital stay (4 days). The pre-selected kit implants exactly matched intraoperative measurements for 597/639 pedicle screws, 249/258 rods, and 46/148 cages. Pedicle screw placement accuracy was 97.8% (625/639) on postoperative CT. Complications included one intraoperative dural tear, no blood products administered, and six reoperations. Our experience demonstrates a viable application of patient-specific 3D-printed solutions and provides a benchmark for studies of efficiency in spinal fusion surgery.
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Pennington Z, Cottrill E, Westbroek EM, Goodwin ML, Lubelski D, Ahmed AK, Sciubba DM. Evaluation of surgeon and patient radiation exposure by imaging technology in patients undergoing thoracolumbar fusion: systematic review of the literature. Spine J 2019; 19:1397-1411. [PMID: 30974238 DOI: 10.1016/j.spinee.2019.04.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive spine techniques are becoming increasingly popular owing to their ability to reduce operative morbidity and recovery times. The downside to these new procedures is their need for intraoperative radiation guidance. PURPOSE To establish which technologies provide the lowest radiation exposure to both patient and surgeon. STUDY DESIGN/SETTING Systematic review OUTCOME MEASURES: Average intraoperative radiation exposure (in mSv per screw placed) to surgeon and patient. Average fluoroscopy time per screw placed. METHODS We reviewed the available English medical literature to identify all articles reporting patient and/or surgeon radiation exposure in patients undergoing image-guided thoracolumbar instrumentation. Quantitative meta-analysis was performed for studies providing radiation exposure or fluoroscopy use per screw placed to determine which navigation modality was associated with the lowest intraoperative radiation exposure. Values on meta-analysis were reported as mean ± standard deviation. RESULTS We identified 4956 unique articles, of which 85 met inclusion/exclusion criteria. Forty-one articles were included in the meta-analysis. Patient radiation exposure per screw placed for each modality was: conventional fluoroscopy without navigation (0.26±0.38 mSv), conventional fluoroscopy with pre-operative CT-based navigation (0.027±0.010 mSv), intraoperative CT-based navigation (1.20±0.91 mSv), and robot-assisted instrumentation (0.04±0.30 mSv). Values for fluoroscopy used per screw were: conventional fluoroscopy without navigation (11.1±9.0 seconds), conventional fluoroscopy with navigation (7.20±3.93 s), 3D fluoroscopy (16.2±9.6 s), intraoperative CT-based navigation (19.96±17.09 s), and robot-assistance (20.07±17.22 s). Surgeon dose per screw: conventional fluoroscopy without navigation (6.0±7.9 × 10-3 mSv), conventional fluoroscopy with navigation (1.8±2.5 × 10-3 mSv), 3D Fluoroscopy (0.3±1.9 × 10-3 mSv), intraoperative CT-based navigation (0±0 mSv), and robot-assisted instrumentation (2.0±4.0 × 10-3 mSv). CONCLUSION All image guidance modalities are associated with surgeon radiation exposures well below current safety limits. Intraoperative CT-based (iCT) navigation produces the lowest radiation exposure to surgeon albeit at the cost of increased radiation exposure to the patient relative to conventional fluoroscopy-based methods.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA.
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23
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Wewel JT, Godzik J, Uribe JS. The utilization of minimally invasive surgery techniques for the treatment of spinal deformity. JOURNAL OF SPINE SURGERY 2019; 5:S84-S90. [PMID: 31380496 DOI: 10.21037/jss.2019.04.22] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Minimally invasive spinal surgery (MISS) has evolved as a formidable alternative to traditional open techniques to address adult spinal deformity (ASD). As technology advances, an increasingly large body of techniques and implants are available for use in MISS deformity correction. MISS deformity correction includes anterior, lateral, and posterior techniques that can be tailored to each patient while capturing the strength of each respective technique. Previous limitations of obtaining sagittal correction have been overcome with anterior column realignment (ACR) and the mini-open pedicle subtraction osteotomy. This article will describe current techniques and their application for ASD correction.
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Affiliation(s)
- Joshua T Wewel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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24
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Vaishnav AS, Othman YA, Virk SS, Gang CH, Qureshi SA. Current state of minimally invasive spine surgery. JOURNAL OF SPINE SURGERY 2019; 5:S2-S10. [PMID: 31380487 DOI: 10.21037/jss.2019.05.02] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Over the past two decades, minimally invasive surgical approaches have become increasingly feasible, efficient and popular for the management of a wide range of spinal disorders, with a growing body of research demonstrating numerous advantages of these techniques over the traditional open approach. In this article, we review the technologies and innovations that are expanding the horizon of minimally invasive spine surgery (MISS), and highlight high-quality peer-reviewed literature in the past year that expands our knowledge and understanding of indications, advantages and limitations of MISS.
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Affiliation(s)
| | - Yahya A Othman
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | | | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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25
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Malham GM, Wells-Quinn T. What should my hospital buy next?-Guidelines for the acquisition and application of imaging, navigation, and robotics for spine surgery. JOURNAL OF SPINE SURGERY 2019; 5:155-165. [PMID: 31032450 DOI: 10.21037/jss.2019.02.04] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The range of assistive technology options available for spinal fusion surgery has significantly increased. However, surgeons and hospital administrators may lack sufficient information to compare options and make purchasing decisions. We summarize currently available navigation, robotics, and imaging technologies for spinal surgery, highlighting key characteristics, utility, differences, price, and compatibility with other technologies and spinal implants. Guidelines for optimal use and combinations are provided based on surgical approach, operative site, patient anatomy, optimal image quality, and workflow efficiency. Key recommendations include the following. (I) Open-platform navigation and robotics systems that provide surgeons with access to all software and hardware features regardless of implant choice are preferred. (II) Imaging systems that have maximum compatibility with navigation and robotics platforms are optimal. (III) Navigation systems that offer a universal registration mechanism should be standard. (IV) 3D fluoroscopy provides the greatest benefit when speed, operative efficiency, and mobility are required. (V) Intraoperative CT is more useful for imaging long constructs, high BMI, or cervicothoracic anatomy. (VI) Radiation safety awareness that new 3D-fluoroscopy units can deliver radiation comparable to that of CT is needed. (VII) New robotic arm platforms require more clinical and health economic data to justify increased costs.
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