1
|
Kastler A, Carneiro I, Perolat R, Rudel A, Pialat JB, Lazard A, Isnard S, Krainik A, Amoretti N, Grand S, Stacoffe N. Combined vertebroplasty and pedicle screw insertion for vertebral consolidation: feasibility and technical considerations. Neuroradiology 2024; 66:855-863. [PMID: 38453715 DOI: 10.1007/s00234-024-03325-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/24/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE To assess the feasibility and technical accuracy of performing pedicular screw placement combined with vertebroplasty in the radiological setting. METHODS Patients who underwent combined vertebroplasty and pedicle screw insertion under combined computed tomography and fluoroscopic guidance in 4 interventional radiology centers from 2018 to 2023 were retrospectively assessed. Patient demographics, vertebral lesion type, and procedural data were analyzed. Strict intra-pedicular screw positioning was considered as technical success. Pain score was assessed according to the Visual Analogue Scale before the procedure and in the 1-month follow-up consultation. RESULTS Fifty-seven patients (38 men and 19 women) with a mean age of 72.8 (SD = 11.4) years underwent a vertebroplasty associated with pedicular screw insertion for the treatment of traumatic fractures (29 patients) and neoplastic disease (28 patients). Screw placement accuracy assessed by post-procedure CT scan was 95.7% (89/93 inserted screws). A total of 93 pedicle screw placements (36 bi-pedicular and 21 unipedicular) in 32 lumbar, 22 thoracic, and 3 cervical levels were analyzed. Mean reported procedure time was 48.8 (SD = 14.7) min and average injected cement volume was 4.4 (SD = 0.9) mL. A mean VAS score decrease of 5 points was observed at 1-month follow-up (7.7, SD = 1.3 versus 2.7, SD = 1.7), p < .001. CONCLUSION Combining a vertebroplasty and pedicle screw insertion is technically viable in the radiological setting, with a high screw positioning accuracy of 95.7%.
Collapse
Affiliation(s)
- Adrian Kastler
- Diagnostic and Interventional Neuroradiology Unit, Grenoble University Hospital, Grenoble, France.
| | - Inês Carneiro
- Neuroradiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Romain Perolat
- Radiology Unit, Carémeau University Hospital, Nimes, France
| | - Alexandre Rudel
- Diagnostic and Interventional MSK Unit, Pasteur II Hospital, Nice, France
| | | | - Arnaud Lazard
- Neurosurgery Unit, Grenoble University Hospital, Grenoble, France
| | - Stephanie Isnard
- Neurosurgery Unit, Grenoble University Hospital, Grenoble, France
| | - Alexandre Krainik
- Diagnostic and Interventional Neuroradiology Unit, Grenoble University Hospital, Grenoble, France
| | - Nicolas Amoretti
- Diagnostic and Interventional MSK Unit, Pasteur II Hospital, Nice, France
| | - Sylvie Grand
- Diagnostic and Interventional Neuroradiology Unit, Grenoble University Hospital, Grenoble, France
| | - Nicolas Stacoffe
- Diagnostic and Interventional Radiology Unit, Lyon Sud Hospital, Lyon, France
| |
Collapse
|
2
|
Burkett D, Brooks N. Advances and Challenges of Endoscopic Spine Surgery. J Clin Med 2024; 13:1439. [PMID: 38592293 PMCID: PMC10932008 DOI: 10.3390/jcm13051439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 02/24/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
The purpose of this paper is to review the data supporting current endoscopic surgical techniques for the spine and the potential challenges and future of the field. The origins of endoscopic spine surgery can be traced back many decades, with many important innovations throughout its development. It can be applied to all levels of the spine, with many robust trials supporting its clinical outcomes. Continued clinical research is needed to explore its expanding indications. Although the limitations of starting an endoscopic program can be justified by its cost effectiveness and positive societal impact, challenges facing its widespread adoption are still present. As more residency and fellowship programs include endoscopy as part of their spine training, it will become more prevalent in hospitals in the United States. Technological advancements in spine surgery will further propel and enhance endoscopic techniques as they become an integral part of a spine surgeon's repertoire.
Collapse
Affiliation(s)
| | - Nathaniel Brooks
- Neurosurgery Department, University of Wisconsin Hospitals and Clinics, Madison, WI 53792, USA;
| |
Collapse
|
3
|
Privalov M, Bullert B, Gierse J, Mandelka E, Vetter SY, Franke J, Grützner PA, Swartman B. Effect of changing the acquisition trajectory of the 3D C-arm (CBCT) on image quality in spine surgery: experimental study using an artificial bone model. J Orthop Surg Res 2023; 18:924. [PMID: 38044441 PMCID: PMC10694912 DOI: 10.1186/s13018-023-04394-0] [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: 07/17/2023] [Accepted: 11/18/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Intraoperative 3D imaging using cone-beam CT (CBCT) provides improved assessment of implant position and reduction in spine surgery, is used for navigated surgical techniques, and therefore leads to improved quality of care. However, in some cases the image quality is not sufficient to correctly assess pedicle screw position and reduction, especially due to metal artifacts. The aim of this study was to investigate whether changing the acquisition trajectory of the CBCT in relation to the pedicle screw position during dorsal instrumentation of the spine can reduce metal artifacts and consequently improve image quality as well as clinical assessability on the artificial bone model. METHODS An artificial bone model was instrumented with pedicle screws in the thoracic and lumbar spine region (Th10 to L5). Then, the acquisition trajectory of the CBCT (Cios Spin, Siemens, Germany) to the pedicle screws was systematically changed in 5° steps in angulation (- 30° to + 30°) and swivel (- 30° to + 30°). Subsequently, radiological evaluation was performed by three blinded, qualified raters on image quality using 9 questions (including anatomical structures, implant position, appearance of artifacts) with a score (1-5 points). For statistical evaluation, the image quality of the different acquisition trajectories was compared to the standard acquisition trajectory and checked for significant differences. RESULTS The angulated acquisition trajectory increased the score for subjective image quality (p < 0.001) as well as the clinical assessability of pedicle screw position (p < 0.001) highly significant with particularly strong effects on subjective image quality in the vertebral pedicle region (d = 1.06). Swivel of the acquisition trajectory significantly improved all queried domains of subjective image quality (p < 0.001) as well as clinical assessability of pedicle screw position (p < 0.001). The data show that maximizing the angulation or swivel angle toward 30° provides the best tested subjective image quality. Angulation and swivel of the acquisition trajectory result in a clinically relevant improvement in image quality in intraoperative 3D imaging (CBCT) during dorsal instrumentation of the spine.
Collapse
Affiliation(s)
- Maxim Privalov
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Benno Bullert
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Jula Gierse
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Eric Mandelka
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Sven Y Vetter
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Jochen Franke
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Paul A Grützner
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany
| | - Benedict Swartman
- BG Klinik Ludwigshafen, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen am Rhein, Germany.
| |
Collapse
|
4
|
Ohara Y. Full Endoscopic Spine Surgery with Image-Guided Navigation System as "Hybrid Endoscopic Spine Surgery": A Narrative Review. World Neurosurg 2023; 179:45-48. [PMID: 37543200 DOI: 10.1016/j.wneu.2023.07.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
Endoscopic surgery is adopted as a minimally invasive technique in several surgical fields. Endoscopic spine surgery (ESS) was performed initially for lumbar discectomy but is currently widely utilized for various pathologies. Similar to other endoscopic techniques, ESS has a steep learning curve that has recently been a topic of discussion. Image-guided navigation systems have been developed for spine surgery. Intraoperative computed tomography enables the use of an image-guided navigation system in ESS, which is a suitable approach for managing complex lesions. Full-ESS is currently being adopted for certain cervical pathologies, and the incorporation of an image-guided navigation system will soon enable surgery for other cervical pathologies.
Collapse
Affiliation(s)
- Yukoh Ohara
- Department of Neurosurgery, Juntendo University, Tokyo, Japan.
| |
Collapse
|
5
|
Zawar A, Chhabra HS, Mundra A, Sharma S, Kalidindi KKV. Robotics and navigation in spine surgery: A narrative review. J Orthop 2023; 44:36-46. [PMID: 37664556 PMCID: PMC10470401 DOI: 10.1016/j.jor.2023.08.007] [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: 06/13/2023] [Revised: 08/12/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction In recent decades, there has been a rising trend of spinal surgical interventional techniques, especially Minimally Invasive Spine Surgery (MIS), to improve the quality of life in an effective and safe manner. However, MIS techniques tend to be difficult to adapt and are associated with an increased risk of radiation exposure. This led to the development of 'computer-assisted surgery' in 1983, which integrated CT images into spinal procedures evolving into the present day robotic-assisted spine surgery. The authors aim to review the development of spine surgeries and provide an overview of the benefits offered. It includes all the comparative studies available to date. Methods The manuscript has been prepared as per "SANRA-a scale for the quality assessment of narrative review articles". The authors searched Pubmed, Embase, and Scopus using the terms "(((((Robotics) OR (Navigation)) OR (computer assisted)) OR (3D navigation)) OR (Freehand)) OR (O-Arm)) AND (spine surgery)" and 68 articles were included for analysis excluding review articles, meta-analyses, or systematic literature. Results The authors noted that 49 out of 68 studies showed increased precision of pedicle screw insertion, 10 out of 19 studies show decreased radiation exposure, 13 studies noted decreased operative time, 4 out of 8 studies showed reduced hospital stay and significant reduction in rates of infections, neurological deficits, the need for revision surgeries, and rates of radiological ASD, with computer-assisted techniques. Conclusion Computer-assisted surgeries have better accuracy of pedicle screw insertion, decreased blood loss and operative time, reduced radiation exposure, improved functional outcomes, and lesser complications.
Collapse
Affiliation(s)
- Amogh Zawar
- Rajiv Gandhi Medical College and CSMH, Thane, Maharashtra. 400605, India
| | | | - Anuj Mundra
- Sri Balaji Action Medical Institute, A4 Block, Paschim Vihar, New Delhi, 110063, India
| | - Sachin Sharma
- Sri Balaji Action Medical Institute, A4 Block, Paschim Vihar, New Delhi, 110063, India
| | | |
Collapse
|
6
|
Beisemann N, Gierse J, Mandelka E, Hassel F, Grützner PA, Franke J, Vetter SY. Radiation exposure for pedicle screw placement with three different navigation system and imaging combinations in a sawbone model. BMC Musculoskelet Disord 2023; 24:752. [PMID: 37742007 PMCID: PMC10517448 DOI: 10.1186/s12891-023-06880-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Studies have shown that pedicle screw placement using navigation can potentially reduce radiation exposure of surgical personnel compared to conventional methods. Spinal navigation is based on an interaction of a navigation software and 3D imaging. The 3D image data can be acquired using different imaging modalities such as iCT and CBCT. These imaging modalities vary regarding acquisition technique and field of view. The current literature varies greatly in study design, in form of dose registration, as well as navigation systems and imaging modalities analyzed. Therefore, the aim of this study was a standardized comparison of three navigation and imaging system combinations in an experimental setting in an artificial spine model. METHODS In this experimental study dorsal instrumentation of the thoracolumbar spine was performed using three imaging/navigation system combinations. The system combinations applied were the iCT/Curve, cCBCT/Pulse and oCBCT/StealthStation. Referencing scans were obtained with each imaging modality and served as basis for the respective navigation system. In each group 10 artificial spine models received bilateral dorsal instrumentation from T11-S1. 2 referencing and control scans were acquired with the CBCTs, since their field of view could only depict up to five vertebrae in one scan. The field of view of the iCT enabled the depiction of T11-S1 in one scan. After instrumentation the region of interest was scanned again for evaluation of the screw position, therefore only one referencing and one control scan were obtained. Two dose meters were installed in a spine bed ventral of L1 and S1. The dose measurements in each location and in total were analyzed for each system combination. Time demand regarding screw placement was also assessed for all system combinations. RESULTS The mean radiation dose in the iCT group measured 1,6 ± 1,1 mGy. In the cCBCT group the mean was 3,6 ± 0,3 mGy and in the oCBCT group 10,3 ± 5,7 mGy were measured. The analysis of variance (ANOVA) showed a significant (p < 0.0001) difference between the three groups. The multiple comparisions by the Kruskall-Wallis test showed no significant difference for the comparison of iCT and cCBCT (p1 = 0,13). Significant differences were found for the direct comparison of iCT and oCBCT (p2 < 0,0001), as well as cCBCT and oCBCT (p3 = 0,02). Statistical analysis showed that significantly (iCT vs. oCBCT p = 0,0434; cCBCT vs. oCBCT p = 0,0083) less time was needed for oCBCT based navigated pedicle screw placement compared to the other system combinations (iCT vs. cCBCT p = 0,871). CONCLUSION Under standardized conditions oCBCT navigation demanded twice as much radiation as the cCBCT for the same number of scans, while the radiation exposure measured for the iCT and cCBCT for one scan was comparable. Yet, time effort was significantly less for oCBCT based navigation. However, for transferability into clinical practice additional studies should follow evaluating parameters regarding feasibility and clinical outcome under standardized conditions.
Collapse
Affiliation(s)
- Nils Beisemann
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Jula Gierse
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Eric Mandelka
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Frank Hassel
- Department of Spine Surgery, Loretto Hospital, Mercystrasse 6, 79100, Freiburg Im Breisgau, Germany
| | - Paul A Grützner
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Jochen Franke
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Sven Y Vetter
- Research Group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), BG Klinik (BG Trauma Center) Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany.
| |
Collapse
|
7
|
Mandelka E, Gierse J, Zimmermann F, Gruetzner PA, Franke J, Vetter SY. Implications of navigation in thoracolumbar pedicle screw placement on screw accuracy and screw diameter/pedicle width ratio. BRAIN & SPINE 2023; 3:101780. [PMID: 38020982 PMCID: PMC10668071 DOI: 10.1016/j.bas.2023.101780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/22/2023] [Accepted: 07/10/2023] [Indexed: 12/01/2023]
Abstract
Introduction There is ample evidence that higher accuracy can be achieved in thoracolumbar pedicle screw placement by using spinal navigation. Still, to date, the evidence regarding the influence of the use of navigation on the screw diameter to pedicle width ratio remains limited. Research question The aim of this study was to investigate the implications of navigation in thoracolumbar pedicle screw placement not only on screw accuracy, but on the screw diameter to pedicle width ratio as well. Material and methods In this single-center single-surgeon study, 45 Patients undergoing navigated thoracolumbar pedicle screw placement were prospectively included. The results were compared with a matched comparison group of patients in which screw placement was performed under fluoroscopic guidance. The screw accuracy and the screw diameter to pedicle width ratio of every screw were compared between the groups. Results Screw accuracy was significantly higher in the navigation group compared to the fluoroscopic guidance group, alongside with a significant increase of the screw diameter to pedicle width ratio by approximately 10%. In addition, both the intraoperative radiation dose and the operating time tended to be lower in the study group. Conclusion This study was able to show that navigated thoracolumbar pedicle screw placement not only increases the accuracy of screw placement but also facilitates the selection of the adequate screw sizes, which according to the literature has positive effects on fixation strength. Meanwhile, the use of navigation did not negatively affect the time needed for surgery or the patient's intraoperative exposure to radiation.
Collapse
Affiliation(s)
- Eric Mandelka
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Jula Gierse
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Felix Zimmermann
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Paul A. Gruetzner
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Jochen Franke
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Sven Y. Vetter
- Research group Medical Imaging and Navigation in Trauma and Orthopedic Surgery (MINTOS), Department of Orthopedics and Trauma Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| |
Collapse
|
8
|
La Rocca G, Mazzucchi E, Pignotti F, Nasto LA, Galieri G, Rinaldi P, De Santis V, Pola E, Sabatino G. Navigated, percutaneous, three-step technique for lumbar and sacral screw placement: a novel, minimally invasive, and maximally safe strategy. J Orthop Traumatol 2023; 24:32. [PMID: 37386233 DOI: 10.1186/s10195-023-00696-5] [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: 10/09/2022] [Accepted: 04/02/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Minimally invasive spine surgery is a field of active and intense research. Image-guided percutaneous pedicle screw (PPS) placement is a valid alternative to the standard free-hand technique, thanks to technological advancements that provide potential improvement in accuracy and safety. Herein, we describe the clinical results of a surgical technique exploiting integration of neuronavigation and intraoperative neurophysiological monitoring (IONM) for minimally invasive PPS. MATERIALS AND METHODS An intraoperative-computed tomography (CT)-based neuronavigation system was combined with IONM in a three-step technique for PPS. Clinical and radiological data were collected to evaluate the safety and efficacy of the procedure. The accuracy of PPS placement was classified according to the Gertzbein-Robbins scale. RESULTS A total of 230 screws were placed in 49 patients. Only two screws were misplaced (0.8%); nevertheless, no clinical sign of radiculopathy was experienced by these patients. The majority of the screws (221, 96.1%) were classified as grade A according to Gertzbein-Robbins scale, seven screws were classified as grade B, one screw was classified as grade D, and one last screw was classified as grade E. CONCLUSIONS The proposed three-step, navigated, percutaneous procedure offers a safe and accurate alternative to traditional techniques for lumbar and sacral pedicle screw placement. Level of Evidence Level 3. Trial registration Not applicable.
Collapse
Affiliation(s)
- Giuseppe La Rocca
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Edoardo Mazzucchi
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Fabrizio Pignotti
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Luigi Aurelio Nasto
- Department of Orthopaedics and Spine Surgery, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università Della Campania Luigi Vanvitelli, Via De Crecchio 4, 80138, Naples, Italy
| | - Gianluca Galieri
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | | | | | - Enrico Pola
- Department of Orthopaedics and Spine Surgery, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università Della Campania Luigi Vanvitelli, Via De Crecchio 4, 80138, Naples, Italy.
| | - Giovanni Sabatino
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| |
Collapse
|
9
|
Kwon H, Park JY. The Role and Future of Endoscopic Spine Surgery: A Narrative Review. Neurospine 2023; 20:43-55. [PMID: 37016853 PMCID: PMC10080412 DOI: 10.14245/ns.2346236.118] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
Many types of surgeries are changing from conventional to minimally invasive techniques. Techniques in spine surgery have also changed, with endoscopic spine surgery (ESS) becoming a major surgical technique. Although ESS has advantages such as less soft tissue dissection and normal structure damage, reduced blood loss, less epidural scarring, reduced hospital stay, and earlier functional recovery, it is not possible to replace all spine surgery techniques with ESS. ESS was first used for discectomy in the lumbar spine, but the range of ESS has expanded to cover the entire spine, including the cervical and thoracic spine. With improvements in ESS instruments (optics, endoscope, endoscopic drill and shaver, irrigation pump, and multiportal endoscopic), limitations of ESS have gradually decreased, and it is possible to apply ESS to more spine pathologies. ESS currently incorporates new technologies, such as navigation, augmented and virtual reality, robotics, and 3-dimentional and ultraresolution visualization, to innovate and improve outcomes. In this article, we review the history and current status of ESS, and discuss future goals and possibilities for ESS through comparisons with conventional surgical techniques.
Collapse
Affiliation(s)
- Hyungjoo Kwon
- Department of Neurosurgery, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
10
|
Chatelain LS, Kourilsky A, Lot G, Rogers A. Airo® navigation versus freehand fluoroscopy technique: A comparative study of accuracy and radiological exposure for thoracolumbar screws placement. Neurochirurgie 2023; 69:101437. [PMID: 36967084 DOI: 10.1016/j.neuchi.2023.101437] [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: 10/21/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE The aim was to compare the accuracy of freehand fluoroscopy and CT based navigation on thoracolumbar screws placement and their respective effects on radiological exposure to the patient. No previous study directly compared the Airo® navigation system to freehand technique. METHODS In this monocentric retrospective study, 156 consecutive patients who underwent thoracolumbar spine surgery were included. Epidemiological data and surgical indications were noted. Heary classification was used for thoracic screws and Gertzbein-Robbins classification for lumbar screws. Radiological exposure was collected for each surgery. RESULTS A total of 918 screws were implanted. We analyzed 725 lumbar screws (Airo® 287; freehand fluoroscopy 438) and 193 thoracic screws (Airo® 49; freehand fluoroscopy 144). Overall, lumbar screws accuracy (Gertzbein-Robbins grade A and B) was good in both groups (freehand fluoroscopy 91.3%; Airo® 97.6%; P<0.05). We found significantly less Grade B and C in the Airo® group. Thoracic accuracy was also good in both groups (Heary 1 and 2; freehand fluoroscopy 77.8%; Airo® 93.9%), without reaching statistical significance. Radiological exposure was significantly higher in the Airo® group with a mean effective dose of 9.69 mSv versus 0.71mSv for freehand fluoroscopy. CONCLUSION Our study confirmed that the use of Airo® navigation yielded good accuracy. It however exposed the patient to higher radiological exposure compared with freehand fluoroscopy technique. LEVEL OF EVIDENCE Level 3.
Collapse
Affiliation(s)
- L S Chatelain
- Fondation Rothschild, Department of Neurosurgery, 25-29, rue Manin, 75019 Paris, France.
| | - A Kourilsky
- Fondation Rothschild, Department of Neurosurgery, 25-29, rue Manin, 75019 Paris, France
| | - G Lot
- Fondation Rothschild, Department of Neurosurgery, 25-29, rue Manin, 75019 Paris, France
| | - A Rogers
- Fondation Rothschild, Department of Neurosurgery, 25-29, rue Manin, 75019 Paris, France; American Hospital of Paris, 55, boulevard du Château, 92200 Neuilly-sur-Seine, France
| |
Collapse
|
11
|
Croci DM, Nguyen S, Streitmatter SW, Sherrod BA, Hardy J, Cole KL, Gamblin AS, Bisson EF, Mazur MD, Dailey AT. O-Arm Accuracy and Radiation Exposure in Adult Deformity Surgery. World Neurosurg 2023; 171:e440-e446. [PMID: 36528322 DOI: 10.1016/j.wneu.2022.12.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE In long thoracolumbar deformity surgery, accurate screw positioning is critical for spinal stability. We assessed pedicle and pelvic screw accuracy and radiation exposure in patients undergoing long thoracolumbar deformity fusion surgery (≥4 levels) involving 3-dimensional fluoroscopy (O-Arm/Stealth) navigation. METHODS In this retrospective single-center cohort study, all patients aged >18 years who underwent fusion in 2016-2018 were reviewed. O-Arm images were assessed for screw accuracy. Effective radiation doses were calculated. The primary outcome was pedicle screw accuracy (Heary grade). Secondary outcomes were pelvic fixation screw accuracy, radiation exposure, and screw-related perioperative and postoperative complications or revision surgery within 3 years. RESULTS Of 1477 pedicle screws placed in 91 patients (mean 16.41 ± 5.6 screws/patient), 1208 pedicle screws (81.8%) could be evaluated by 3-dimensional imaging after placement. Heary Grade I placement was achieved in 1150 screws (95.2%), Grade II in 47 (3.9%), Grade III in 10 (0.82%), Grade IV in 1 (0.08%), and Grade V in 0; Grade III-V were replaced intraoperatively. One of 60 (1.6%) sacroiliac screws placed showed medial cortical breach and was replaced. The average O-Arm-related effective dose was 29.54 ± 14.29 mSv and effective dose/spin was 8.25 ± 2.65 mSv. No postoperative neurological worsening, vascular injuries, or revision surgeries for screw misplacement were recorded. CONCLUSIONS With effective radiation doses similar to those in interventional neuroendovascular procedures, the use of O-Arm in multilevel complex deformity surgery resulted in high screw accuracy, no need for surgical revision because of screw malposition, less additional imaging, and no radiation exposure for the surgical team.
Collapse
Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Sarah Nguyen
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Seth W Streitmatter
- Medical Imaging Physics and Radiation Safety, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Brandon A Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Jeremy Hardy
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Austin S Gamblin
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
| |
Collapse
|
12
|
Märdian S, Maleitzke T, Niemann M, Salmoukas K, Stöckle U. [Imaging examination procedures, navigation and minimally invasive procedures in acetabular surgery]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:89-99. [PMID: 36645450 DOI: 10.1007/s00113-022-01281-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 01/17/2023]
Abstract
Acetabular fractures still pose a special challenge even today. Considering the increasing case numbers, especially in the geriatric patient group, modern imaging examination procedures represent an essential pillar of the diagnostics. Especially in this vulnerable patient group, minimally invasive methods are necessary, which can be guaranteed by intraoperative navigation; however, the choice of surgical access and implants is also made based on the existing morphological characteristics of fractures, which highlights the importance of an imaging modality that is as detailed as possible. Last but not least, new developments concerning the surgical treatment of these injuries are also based on this. This article summarizes the current state of the techniques and the available literature.
Collapse
Affiliation(s)
- Sven Märdian
- Centrum für Muskuloskeletale Chirurgie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - T Maleitzke
- Centrum für Muskuloskeletale Chirurgie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.,Julius Wolff Institut, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.,BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - M Niemann
- Centrum für Muskuloskeletale Chirurgie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.,Julius Wolff Institut, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - K Salmoukas
- Centrum für Muskuloskeletale Chirurgie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - U Stöckle
- Centrum für Muskuloskeletale Chirurgie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| |
Collapse
|
13
|
Kothe R, Schmeiser G. [Intraoperative computed tomography-guided navigation for implant anchorage in spine surgery]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:17-28. [PMID: 36562777 DOI: 10.1007/s00064-022-00794-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Improved accuracy of spinal instrumentation with the use of intraoperative CT (iCT). INDICATIONS All types of posterior spinal instrumentation. CONTRAINDICATIONS None. SURGICAL TECHNIQUE After fixation of the spinal clamp, an intraoperative CT (iCT) is performed. The image data set can then be used for navigation of the spinal implants. The arrangement of the devices, positioning of the patient, and the exact fixation of the clamp depend on the operation technique and the anatomical region. A high level of standardization is necessary for clinical success. In general, the utilization of drill guides over the use of awls and Yamshidi needles is strongly recommended. Thereby the risk of segmental vertebral rotation, especially in multisegmental instrumentation, will be reduced. POSTOPERATIVE MANAGEMENT The postoperative management depends on the type of surgery and is not influenced by the use of navigation with iCT. RESULTS In our patient group of the first 200 surgeries with iCT (AIRO, Brainlab AG, Munich, Germany), we performed 34% cervical instrumentations, 31% percutaneous screw insertions, and 35% multisegmental open procedures including the sacrum or ilium. Two surgeries had to be converted to conventional technique due to technical problems. One misplaced S2/Ala/ilium screw had to be corrected in revision surgery. The infection rate was 2.5% and was not increased compared to conventional procedures. In the literature, a significant reduction of radiation exposure was shown, when iCT and navigation were used. Also, in longer surgical cases the operation time could be reduced. In comparison with 3D C‑arm imaging, the image quality and screw accuracy is improved by iCT. Due to the possibility of 3D intraoperative implant control, the number of revision cases can be reduced.
Collapse
Affiliation(s)
- Ralph Kothe
- Abteilung für spinale Chirurgie, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22083, Hamburg, Deutschland.
| | - Gregor Schmeiser
- Abteilung für spinale Chirurgie, Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22083, Hamburg, Deutschland
| |
Collapse
|
14
|
Spine surgery in a state-of-the-art hybrid operating room: an experience of 1745 implanted pedicle screws in the thoracolumbar spine. J Robot Surg 2023:10.1007/s11701-023-01533-x. [PMID: 36646966 PMCID: PMC10374771 DOI: 10.1007/s11701-023-01533-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/08/2023] [Indexed: 01/18/2023]
Abstract
Hybrid-operating rooms (hybrid-OR) combine high-resolution 2D images and 3D-scans with the possibility of 3D-navigation and allow minimal invasive pedicle screw placement even in the upper thoracic spine. The disadvantage of high cost and increased radiation needs to be compensated with high accuracy and safety. The hybrid operating room consists of a floor-based flat-panel robotic C-arm with 3D-scan capability (Artis Zeego, Siemens; Germany) combined with navigation (BrainLAB Curve, BrainLAB; Germany). Through a minimally invasive incision, a Jamshidi needle was advanced through the pedicle and a K-wire was placed. If 2D image quality did not allow safe placement 3D-navigation was used to place the K-wire. Position was controlled through a 3D-Scan and corrected if necessary before screw placement. Postoperative CTs evaluated screw perforation grade with grade I when completely within the pedicle, II < 2 mm, III 2-4 mm, and IV > 4 mm outside the pedicle. Overall, 354 screws were placed in T1-T6, 746 in the lower thoracic spine T7-T12 and 645 in the L1-L5. Navigation was mainly used in upper thoracic spine cases (31 of 57). In 63 out of 326 cases K-wire was corrected after the 3D-Scan. Overall, 99.1% of the screws showed perforation less than 2 mm. Mean radiation was 13.3 ± 11.7 mSv and significantly higher in the upper thoracic spine and in navigated procedures. Despite higher costs and radiation, the hybrid-OR allows highest accuracy and therefore patient safety in minimal invasive pedicle screw placement in the thoracic and lumbar spine.
Collapse
|
15
|
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: 1] [Impact Index Per Article: 0.5] [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.
Collapse
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
| |
Collapse
|
16
|
Reynolds T, Ma YQ, Kanawati AJ, Constantinidis A, Williams Z, Gang G, Dillon O, Russ T, Wang W, Ehtiati T, Weiss CR, Theodore N, Siewerdsen JH, Stayman JW, O'Brien RT. Extended Intraoperative Longitudinal 3-Dimensional Cone Beam Computed Tomography Imaging With a Continuous Multi-Turn Reverse Helical Scan. Invest Radiol 2022; 57:764-772. [PMID: 35510875 PMCID: PMC9547812 DOI: 10.1097/rli.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Cone beam computed tomography (CBCT) imaging is becoming an indispensable intraoperative tool; however, the current field of view prevents visualization of long anatomical sites, limiting clinical utility. Here, we demonstrate the longitudinal extension of the intraoperative CBCT field of view using a multi-turn reverse helical scan and assess potential clinical utility in interventional procedures. MATERIALS AND METHODS A fixed-room robotic CBCT imaging system, with additional real-time control, was used to implement a multi-turn reverse helical scan. The scan consists of C-arm rotation, through a series of clockwise and anticlockwise rotations, combined with simultaneous programmed table translation. The motion properties and geometric accuracy of the multi-turn reverse helical imaging trajectory were examined using a simple geometric phantom. To assess potential clinical utility, a pedicle screw posterior fixation procedure in the thoracic spine from T1 to T12 was performed on an ovine cadaver. The multi-turn reverse helical scan was used to provide postoperative assessment of the screw insertion via cortical breach grading and mean screw angle error measurements (axial and sagittal) from 2 observers. For all screw angle measurements, the intraclass correlation coefficient was calculated to determine observer reliability. RESULTS The multi-turn reverse helical scans took 100 seconds to complete and increased the longitudinal coverage by 370% from 17 cm to 80 cm. Geometric accuracy was examined by comparing the measured to actual dimensions (0.2 ± 0.1 mm) and angles (0.2 ± 0.1 degrees) of a simple geometric phantom, indicating that the multi-turn reverse helical scan provided submillimeter and degree accuracy with no distortion. During the pedicle screw procedure in an ovine cadaver, the multi-turn reverse helical scan identified 4 cortical breaches, confirmed via the postoperative CT scan. Directly comparing the screw insertion angles (n = 22) measured in the postoperative multi-turn reverse helical and CT scans revealed an average difference of 3.3 ± 2.6 degrees in axial angle and 1.9 ± 1.5 degrees in the sagittal angle from 2 expert observers. The intraclass correlation coefficient was above 0.900 for all measurements (axial and sagittal) across all scan types (conventional CT, multi-turn reverse helical, and conventional CBCT), indicating excellent reliability between observers. CONCLUSIONS Extended longitudinal field-of-view intraoperative 3-dimensional imaging with a multi-turn reverse helical scan is feasible on a clinical robotic CBCT imaging system, enabling long anatomical sites to be visualized in a single image, including in the presence of metal hardware.
Collapse
Affiliation(s)
- Tess Reynolds
- From the The University of Sydney, Sydney, Australia
| | | | | | | | - Zoe Williams
- From the The University of Sydney, Sydney, Australia
| | | | - Owen Dillon
- From the The University of Sydney, Sydney, Australia
| | - Tom Russ
- University of Mannheim, Baden-Württemberg, Germany
| | | | | | | | | | | | | | | |
Collapse
|
17
|
High Accuracy and Safety of Intraoperative CT-Guided Navigation for Transpedicular Screw Placement in Revision Spinal Surgery. J Clin Med 2022; 11:jcm11195853. [PMID: 36233720 PMCID: PMC9573638 DOI: 10.3390/jcm11195853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/27/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Intraoperative CT-guided navigation (iCT-navigation) has been reported to improve the accuracy and safety of transpedicular screw placement in primary spinal surgery. However, due to a disrupted bony anatomy and scarring tissue, revision spinal surgery can be challenging. The purpose of this study was to evaluate the accuracy and safety of iCT-navigation for screw placement at the virgin site versus the revision site in revision thoracolumbar spinal surgery. Method: In total, 254 screws were inserted in 27 revision surgeries, in which 114 (44.9%) screws were inserted at the site with previous laminectomy or posterolateral fusion (the revision site), 64 (25.2%) were inserted at the virgin site, and 76 (29.9%) were inserted to replace the pre-existing screws. CT scans were conducted for each patient after all screws were inserted to intraoperatively confirm the screw accuracy. Results: In total, 248 (97.6%) screws were considered accepted. The rate of accepted screws at the virgin site was 98.4% (63/64) versus 95.6% (109/114) at the revision site (p: 0.422). There were six (2.4%) unaccepted screws, which were immediately revised during the same operation. There was no neurological injury noted in our patients. Conclusion: With the use of iCT-navigation, the rate of accepted screws at the revision site was found to be comparable to that at the virgin site. We concluded that iCT-navigation could achieve high accuracy and safety for transpedicular screw placement in revision spinal surgery and allow for the immediate revision of unaccepted screws.
Collapse
|
18
|
Navigation accuracy and assessability of carbon fiber-reinforced PEEK instrumentation with multimodal intraoperative imaging in spinal oncology. Sci Rep 2022; 12:15816. [PMID: 36138117 PMCID: PMC9500029 DOI: 10.1038/s41598-022-20222-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/09/2022] [Indexed: 12/03/2022] Open
Abstract
Radiolucent carbon-fiber reinforced PEEK (CFRP) implants have helped improve oncological follow-up and radiation therapy. Here, we investigated the performance of 3D intraoperative imaging and navigation systems for instrumentation and precision assessment of CFRP pedicle screws across the thoraco-lumbar spine. Thirty-three patients with spinal tumors underwent navigated CFRP instrumentation with intraoperative CT (iCT), robotic cone-beam CT (rCBCT) or cone-beam CT (CBCT) imaging. Two different navigation systems were used for iCT-/rCBCT- and CBCT-based navigation. Demographic, clinical and outcome data was assessed. Four blinded observers rated image quality, assessability and accuracy of CFRP pedicle screws. Inter-observer reliability was determined with Fleiss` Kappa analysis. Between 2018 and 2021, 243 CFRP screws were implanted (iCT:93, rCBCT: 99, CBCT: 51), of which 13 were non-assessable (iCT: 1, rCBCT: 9, CBCT: 3; *p = 0.0475; iCT vs. rCBCT). Navigation accuracy was highest using iCT (74%), followed by rCBCT (69%) and CBCT (49%) (*p = 0.0064; iCT vs. CBCT and rCBCT vs. CBCT). All observers rated iCT image quality higher than rCBCT/CBCT image quality (*p < 0.01) but relevant pedicle breaches were reliably identified with substantial agreement between all observers regardless of the imaging modality. Navigation accuracy for CFRP pedicle screws was considerably lower than expected from reports on titanium implants and CT may be best for reliable assessment of CFRP materials.
Collapse
|
19
|
Navigation Techniques in Endoscopic Spine Surgery. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8419739. [PMID: 36072476 PMCID: PMC9444441 DOI: 10.1155/2022/8419739] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 07/31/2022] [Accepted: 08/08/2022] [Indexed: 12/04/2022]
Abstract
Endoscopic spine surgery (ESS) advances the principles of minimally invasive surgery, including minor collateral tissue damage, reduced blood loss, and faster recovery times. ESS allows for direct access to the spine through small incisions and direct visualization of spinal pathology via an endoscope. While this technique has many applications, there is a steep learning curve when adopting ESS into a surgeon's practice. Two types of navigation, optical and electromagnetic, may allow for widespread utilization of ESS by engendering improved orientation to surgical anatomy and reduced complication rates. The present review discusses these two available navigation technologies and their application in endoscopic procedures by providing case examples. Furthermore, we report on the future directions of navigation within the discipline of ESS.
Collapse
|
20
|
Mandelka E, Gierse J, Gruetzner PA, Franke J, Vetter SY. First Clinical Experience with a Novel 3D C-Arm-Based System for Navigated Percutaneous Thoracolumbar Pedicle Screw Placement. Medicina (B Aires) 2022; 58:medicina58081111. [PMID: 36013578 PMCID: PMC9414596 DOI: 10.3390/medicina58081111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background and Objectives: Navigated pedicle screw placement is becoming increasingly popular, as it has been shown to reduce the rate of screw misplacement. We present our intraoperative workflow and initial experience in terms of safety, efficiency, and clinical feasibility with a novel system for a 3D C-arm cone beam computed-tomography-based navigation of thoracolumbar pedicle screws. Materials and Methods: The first 20 consecutive cases of C-arm cone beam computed-tomography-based percutaneous pedicle screw placement using a novel navigation system were included in this study. Procedural data including screw placement time and patient radiation dose were prospectively collected. Final pedicle screw accuracy was assessed using the Gertzbein–Robbins grading system. Results: In total, 156 screws were placed. The screw accuracy was 94.9%. All the pedicle breaches occurred on the lateral pedicle wall, and none caused clinical complications. On average, a time of 2:42 min was required to place a screw. The mean intraoperative patient radiation exposure was 7.46 mSv. Conclusions: In summary, the investigated combination of C-arm CBCT-based navigation proved to be easy to implement and highly reliable. It facilitates the accurate and efficient percutaneous placement of pedicle screws in the thoracolumbar spine. The careful use of intraoperative imaging maintains the intraoperative radiation exposure to the patient at a moderate level.
Collapse
|
21
|
Matsuoka A, Toyone T, Okano I, Kudo Y, Ishikawa K, Maruyama H, Ozawa T, Shirahata T, Inagaki K. Comparison of pedicle screw placement accuracy between two types of imaging support (Artis Zeego versus two-dimensional fluoroscopy): a cross-sectional observational study. BMC Musculoskelet Disord 2022; 23:644. [PMID: 35790951 PMCID: PMC9254419 DOI: 10.1186/s12891-022-05602-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/28/2022] [Indexed: 02/07/2023] Open
Abstract
Background The pedicle screw system is widely used in spine surgery, and it provides rigid fixation and leads to successful subsequent deformity correction and bony fusion. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. Artis Zeego is an emerging intraoperative imaging technique that can provide conventional two-dimensional fluoroscopic images and rapid three-dimensional fluoroscopic computed tomography reconstruction imaging. The aim of this study is to compare the insertion accuracies of PS placement using Artis Zeego and conventional 2D X-ray fluoroscopy. Methods In this study, we retrospectively reviewed the postoperative images of thoracolumbar fusion patients who underwent surgery using pedicle screws between 2013 and 2018. Pedicle screw malplacement was assessed using a four-grade classification by Rao et al. Misplacement rates were compared between pedicle screws assisted with Artis Zeego and two-dimensional fluoroscopy. Results A total of 1107 pedicle screws in 153 patients were inserted using Artis Zeego, and 427 pedicle screws in 80 patients were inserted using fluoroscopy. The overall perforation rate was 4.2% (46 perforations of 1106 pedicle screws) in the Artis Zeego group and 7.7% (33 perforations of 427 pedicle screws) in the fluoroscopy group. In the Artis Zeego group, 43 (3.9%) screws were classified as grade 1, and three (0.3%) screws were classified as grade 2. In the fluoroscopy group, 21 (4.9%) screws were classified as grade 1, 10 (2.3%) screws were classified as grade 2, and 2 (0.5%) screws were classified as grade 3. The use of Artis Zeego was associated with a significantly lower screw malplacement rate than was the use of fluoroscopy (p < 0.001). Conclusions Our results demonstrated that pedicle screw placement with Artis Zeego was associated with a lower malplacement rate than was conventional two-dimensional fluoroscopy. No severe malplacement was observed in the Artis Zeego group. Thus, Artis Zeego could be a good option for improving pedicle screw accuracy.
Collapse
|
22
|
Intraoperative imaging and navigated spinopelvic instrumentation: S2-alar-iliac screws combined with tricortical S1 pedicle screw fixation. 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; 31:2587-2596. [PMID: 35771266 DOI: 10.1007/s00586-022-07268-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 04/02/2022] [Accepted: 05/13/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE The present study aimed to assess the feasibility, safety and accuracy of navigated spinopelvic fixation with focus on S2-alar-iliac screws (S2AIS) and tricortical S1 pedicle screw implantation with the use of high-resolution three-dimensional intraoperative imaging and real-time spinal navigation. METHODS Patients undergoing navigated intraoperative CT-based spinopelvic stabilization between January 2016 and September 2019 were included. Pelvic fixation was achieved by implantation of S2AIS or iliac screws (IS). S1 screws were implanted with the goal of achieving tricortical purchase. In all cases, instrumentation was performed with real-time spinal navigation and intraoperative screw positioning was assessed using intraoperative computed tomography (iCT), cone-beam CT (CBCT) and robotic cone-beam CT (rCBCT). Screw accuracy was evaluated based on radiographic criteria. To identify predictors of complications, univariate analysis was performed. RESULTS Overall, 52 patients (85%) received S2AIS and nine patients (15%) received IS instrumentation. Intraoperative imaging and spinal navigation were performed with iCT in 34 patients, CBCT in 21 patients and rCBCT in six patients. A total number of 10/128 (7.8%) iliac screws underwent successful intraoperative correction due to misalignment. Tricortical purchase was successfully accomplished in 58/110 (53%) of the S1 screws with a clear learning curve in the course of time. S2AIS implantation was associated with significantly fewer surgical side infection-associated surgeries. CONCLUSIONS Real-time navigation facilitated spinopelvic instrumentation with increasing accuracy of S2AIS and tricortical S1 screws. Intraoperative imaging by iCT, CBCT or rCBCT permitted screw assessment with the chance of direct navigated revision of misplaced iliac screws to avoid secondary screw revision surgery.
Collapse
|
23
|
Accuracy Assessment of Percutaneous Pedicle Screw Placement Using Cone Beam Computed Tomography with Metal Artifact Reduction. SENSORS 2022; 22:s22124615. [PMID: 35746396 PMCID: PMC9228786 DOI: 10.3390/s22124615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022]
Abstract
Metal artifact reduction (MAR) algorithms are used with cone beam computed tomography (CBCT) during augmented reality surgical navigation for minimally invasive pedicle screw instrumentation. The aim of this study was to assess intra- and inter-observer reliability of pedicle screw placement and to compare the perception of baseline image quality (NoMAR) with optimized image quality (MAR). CBCT images of 24 patients operated on for degenerative spondylolisthesis using minimally invasive lumbar fusion were analyzed retrospectively. Images were treated using NoMAR and MAR by an engineer, thus creating 48 randomized files, which were then independently analyzed by 3 spine surgeons and 3 radiologists. The Gertzbein and Robins classification was used for screw accuracy rating, and an image quality scale rated the clarity of pedicle screw and bony landmark depiction. Intra-class correlation coefficients (ICC) were calculated. NoMAR and MAR led to similarly good intra-observer (ICC > 0.6) and excellent inter-observer (ICC > 0.8) assessment reliability of pedicle screw placement accuracy. The image quality scale showed more variability in individual image perception between spine surgeons and radiologists (ICC range 0.51−0.91). This study indicates that intraoperative screw positioning can be reliably assessed on CBCT for augmented reality surgical navigation when using optimized image quality. Subjective image quality was rated slightly superior for MAR compared to NoMAR.
Collapse
|
24
|
Servello D, Saleh C, Zekaj E. Intraoperative mobile computed tomography in deep brain stimulation: Comparison between Airo CT and O-arm CT. Surg Neurol Int 2022; 13:258. [PMID: 35855166 PMCID: PMC9282795 DOI: 10.25259/sni_349_2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/09/2022] [Indexed: 01/29/2023] Open
Abstract
Background: A new intraoperative mobile device, called Airo computed tomography (CT), is becoming increasingly used in surgery adding to the current most widespread intraoperative imaging in form of the O-arm CT device. Intraoperative CT imaging has the advantage to reduce the discomfort derived from the patient’s transfer from the operative room to the radiological unit and also the time of control or time of reposition in cases of lead misplacement. This is the first rapport on Airo CT device application in DBS surgery. Methods: In our retrospective study, we have evaluated 52 patients who had DBS from October 2020 to November 2021. All patients underwent a preoperative brain magnetic resonance imaging (MRI) and a stereotactic brain CT scan. We performed an intraoperative CT scan with the Airo device. Images were subsequently transferred to the neuronavigation system (BrainLab cranial software) and merged with preoperative planning images to confirm correct position of leads. Five aspects were compared: patient and surgeon comfort, surgical planning, parenchymal visualization, radioscopic lead visualization, and costs. Results: Both imaging devices are easy-to-use, precise, and safe and have their pros and cons. Conclusion: This is the first study reporting on CT-Airo application in DBS. We advise that if only DBS is considered, the O-arm application might be more suitable. If in addition to DBS cranial surgery is performed, the Airo device is more suitable.
Collapse
Affiliation(s)
| | - Christian Saleh
- Department of Neurology, Center for Neurorehabilitation and Paraplegiology, Basel, Switzerland
| | - Edvin Zekaj
- Department of Neurosurgery, IRCCS Galeazzi, Milan, Italy,
| |
Collapse
|
25
|
Mallikarjuna S, Ramakumar N, Gupta B, Chakraborty S. Mobius Airo TruCT Scanner in the Operating Room: An Ergonomic Challenge to Neuroanesthesiologist. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Swathi Mallikarjuna
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nirupa Ramakumar
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Bhavna Gupta
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Siddharth Chakraborty
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| |
Collapse
|
26
|
Hagan MJ, Syed S, Leary OP, Persad-Paisley EM, Lin Y, Zheng B, Shao B, Abdulrazeq H, Yu JYH, Telfeian AE, Gokaslan ZL, Fridley JS, Oyelese AA. Pedicle Screw Placement Using Intraoperative Computed Tomography and Computer-Aided Spinal Navigation Improves Screw Accuracy and Avoids Postoperative Revisions: Single-Center Analysis of 1400 Pedicle Screws. World Neurosurg 2022; 160:e169-e179. [PMID: 34990843 DOI: 10.1016/j.wneu.2021.12.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Intraoperative computed tomography and navigation (iCT-Nav) is increasingly used to aid spinal instrumentation. We aimed to document the accuracy and revision rate of pedicle screw placement across many screws placed using iCT-Nav. We also assess patient-level factors predictive of high-grade pedicle breach. METHODS Medical records of patients who underwent iCT-Nav pedicle screw placement between 2015 and 2017 at a single center were retrospectively reviewed. Screw placement accuracy was individually assessed for each screw using the 2-mm incremental grading system for pedicle breach. Predictors of high-grade (>2 mm) breach were identified using multiple logistic regression. RESULTS In total, 1400 pedicle screws were placed in 208 patients undergoing cervicothoracic (29; 13.9%), thoracic (30; 14.4), thoracolumbar (19; 9.1%) and lumbar (130; 62.5%) surgeries. iCT-Nav afforded high-accuracy screw placement, with 1356 of 1400 screws (96.9%) being placed accurately. In total, 37 pedicle screws (2.64%) were revised intraoperatively during the index surgery across 31 patients, with no subsequent returns to the operating room because of screw malpositioning. After correcting for potential confounders, males were less likely to have a high-grade breach (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.10-0.59, P = 0.003) whereas lateral (OR 6.21; 95% CI 2.47-15.52, P < 0.001) or anterior (OR 5.79; 95% CI2.11-15.88, P = 0.001) breach location were predictive of a high-grade breach. CONCLUSIONS iCT-Nav with postinstrumentation intraoperative imaging is associated with a reduced need for costly postoperative return to the operating room for screw revision. In comparison with studies of navigation without iCT where 1.5%-1.7% of patients returned for a second surgery, we report 0 revision surgeries due to screw malpositioning.
Collapse
Affiliation(s)
- Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Sohail Syed
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Owen P Leary
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Yang Lin
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Belinda Shao
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Hael Abdulrazeq
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - James Y H Yu
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Albert E Telfeian
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA.
| |
Collapse
|
27
|
Comparison of radiation exposure and surgery time between an intraoperative CT with automatic surface registration and a preoperative CT with manual surface registration in navigated spinal surgeries. 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; 31:685-692. [PMID: 34993583 DOI: 10.1007/s00586-021-07082-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 08/22/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This retrospective matched case-control study was conducted to compare two CT based surgery techniques for navigated screw placement in spinal surgery, whether a reduction of radiation exposure and surgery time could be achieved. METHODS We matched cases treated with an intraoperative CT (iCT), regarding the type and number of implants, with cases treated with a preoperative CT (pCT) of one main surgeon. Outcome measures were radiation exposure due to intraoperative control x-rays, radiation exposure due to CT images, and the duration of surgery. RESULTS The required radiation exposure could be significantly reduced in the iCT group. For the intraoperative control X-rays by 69% (median (MED) 88.50/standard deviation (SD) 107.84 and MED 286.00/SD 485.04 for iCT and pCT respectively-in Gycm2; p < 0.001) and for the CT examinations by 25% (MED 317.00/SD 158.62 and MED 424.50/SD 225.04 for iCT and pCT respectively-in mGycm; p < 0.001) with no significant change in surgery time. The correlation between the number of segments fused and the necessary surgery time decreased significantly for the iCT group (Pearson product-moment-correlation: r = 0.569 and r = 0.804 for iCT and pCT respectively; p < 0.05). CONCLUSION The results show that spinal navigation using an intraoperative CT with automatic registration compared to a preoperative CT and intraoperative manual surface registration, allows a significant reduction of radiation exposure, without prolonged surgery time. A significant benefit regarding cut-to-suture-time can be gained with surgeries of a larger scale.
Collapse
|
28
|
Kendlbacher P, Tkatschenko D, Czabanka M, Bayerl S, Bohner G, Woitzik J, Vajkoczy P, Hecht N. Workflow and performance of intraoperative CT, cone-beam CT, and robotic cone-beam CT for spinal navigation in 503 consecutive patients. Neurosurg Focus 2022; 52:E7. [PMID: 34973677 DOI: 10.3171/2021.10.focus21467] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/13/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE A direct comparison of intraoperative CT (iCT), cone-beam CT (CBCT), and robotic cone-beam CT (rCBCT) has been necessary to identify the ideal imaging solution for each individual user's need. Herein, the authors sought to analyze workflow, handling, and performance of iCT, CBCT, and rCBCT imaging for navigated pedicle screw instrumentation across the entire spine performed within the same surgical environment by the same group of surgeons. METHODS Between 2014 and 2018, 503 consecutive patients received 2673 navigated pedicle screws using iCT (n = 1219), CBCT (n = 646), or rCBCT (n = 808) imaging during the first 24 months after the acquisition of each modality. Clinical and demographic data, workflow, handling, and screw assessment and accuracy were analyzed. RESULTS Intraoperative CT showed image quality and workflow advantages for cervicothoracic cases, obese patients, and long-segment instrumentation, whereas CBCT and rCBCT offered independent handling, around-the-clock availability, and the option of performing 2D fluoroscopy. All modalities permitted reliable intraoperative screw assessment. Navigated screw revision was possible with each modality and yielded final accuracy rates > 92% in all groups (iCT 96.2% vs CBCT 92.3%, p < 0.001) without a difference in the accuracy of cervical pedicle screw placement or the rate of secondary screw revision surgeries. CONCLUSIONS Continuous training and an individual setup of iCT, CBCT, and rCBCT has been shown to permit safe and precise navigated posterior instrumentation across the entire spine with reliable screw assessment and the option of immediate revision. The perceived higher image quality and larger scan area of iCT should be weighed against the around-the-clock availability of CBCT and rCBCT technology with the option of single-handed robotic image acquisition.
Collapse
Affiliation(s)
- Paul Kendlbacher
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin.,2Department of Neurosurgery, Goethe Universität Frankfurt, Frankfurt am Main
| | | | - Marcus Czabanka
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin.,2Department of Neurosurgery, Goethe Universität Frankfurt, Frankfurt am Main
| | - Simon Bayerl
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Georg Bohner
- 3Department of Neuroradiology, Charité-Universitätsmedizin Berlin; and
| | - Johannes Woitzik
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin.,4Department of Neurosurgery, University at Oldenburg, Germany
| | - Peter Vajkoczy
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Nils Hecht
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| |
Collapse
|
29
|
Karius A, Karolczak M, Strnad V, Bert C. Technical evaluation of the cone-beam computed tomography imaging performance of a novel, mobile, gantry-based X-ray system for brachytherapy. J Appl Clin Med Phys 2021; 23:e13501. [PMID: 34905285 PMCID: PMC8833290 DOI: 10.1002/acm2.13501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/21/2021] [Accepted: 11/29/2021] [Indexed: 12/11/2022] Open
Abstract
Purpose A novel, mobile cone‐beam computed tomography (CBCT) system for image‐guided adaptive brachytherapy was recently deployed at our hospital as worldwide first site. Prior to the device's clinical operation, a profound characterization of its imaging performance was conducted. This was essential to optimize both the imaging workflow and image quality for achieving the best possible clinical outcomes. We present the results of our investigations. Methods The novel CBCT‐system features a ring gantry with 121 cm clearance as well as a 43.2 × 43.2 cm2 flat‐panel detector, and is controlled via a tablet‐personal computer (PC). For evaluating its imaging performance, the geometric reproducibility as well as imaging fidelity, computed tomography (CT)‐number accuracy, uniformity, contrast‐noise‐ratio (CNR), noise characteristics, and spatial resolution as fundamental image quality parameters were assessed. As dose metric the weighted cone‐beam dose index (CBDIw) was measured. Image quality was evaluated using standard quality assurance (QA) as well as anthropomorphic upper torso and breast phantoms. Both in‐house and manufacturer protocols for abdomen, pelvis, and breast imaging were examined. Results Using the in‐house protocols, the QA phantom scans showed altogether a high image quality, with high CT‐number accuracy (R2 > 0.97) and uniformity (<12 Hounsfield Unit (HU) cupping), reasonable noise and imaging fidelity, and good CNR at bone–tissue transitions of up to 28:1. Spatial resolution was strongly limited by geometric instabilities of the device. The breast phantom scans fulfilled clinical requirements, whereas the abdomen and pelvis scans showed severe artifacts, particularly at air/bone–tissue transitions. Conclusion With the novel CBCT‐system, achieving a high image quality appears possible in principle. However, adaptations of the standard protocols, performance enhancements in image reconstruction referring to artifact reductions, as well as the extinction of geometric instabilities are imperative.
Collapse
Affiliation(s)
- Andre Karius
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Universitätsstraße 27, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Marek Karolczak
- Institute of Medical Physics, Friedrich-Alexander-University Erlangen-Nuremberg, Henkestraße 91, Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Universitätsstraße 27, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Universitätsstraße 27, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| |
Collapse
|
30
|
Pojskić M, Bopp M, Nimsky C, Carl B, Saβ B. Initial Intraoperative Experience with Robotic-Assisted Pedicle Screw Placement with Cirq ® Robotic Alignment: An Evaluation of the First 70 Screws. J Clin Med 2021; 10:jcm10245725. [PMID: 34945020 PMCID: PMC8703981 DOI: 10.3390/jcm10245725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Robot-guided spine surgery is based on a preoperatively planned trajectory that is reproduced in the operating room by the robotic device. This study presents our initial experience with thoracolumbar pedicle screw placement using Brainlab's Cirq® surgeon-controlled robotic arm (BrainLab, Munich, Germany). METHODS All patients who underwent robotic-assisted implantation of pedicle screws in the thoracolumbar spine were included in the study. Our workflow, consisting of preoperative imagining, screw planning, intraoperative imaging with automatic registration, fusion of the preoperative and intraoperative imaging with a review of the preplanned screw trajectories, robotic-assisted insertion of K-wires, followed by a fluoroscopy-assisted insertion of pedicle screws and control iCT scan, is described. RESULTS A total of 12 patients (5 male and 7 females, mean age 67.4 years) underwent 13 surgeries using the Cirq® Robotic Alignment Module for thoracolumbar pedicle screw implantation. Spondylodiscitis, metastases, osteoporotic fracture, and spinal canal stenosis were detected. A total of 70 screws were implanted. The mean time per screw was 08:27 ± 06:54 min. The mean time per screw for the first 7 surgeries (first 36 screws) was 16:03 ± 09:32 min and for the latter 6 surgeries (34 screws) the mean time per screw was 04:35 ± 02:11 min (p < 0.05). Mean entry point deviation was 1.9 ± 1.23 mm, mean deviation from the tip of the screw was 2.61 ± 1.6 mm and mean angular deviation was 3.5° ± 2°. For screw-placement accuracy we used the CT-based Gertzbein and Robbins System (GRS). Of the total screws, 65 screws were GRS A screws (92.85%), one screw was a GRS B screw, and two further screws were grade C. Two screws were D screws (2.85%) and underwent intraoperative revision. There were no perioperative deficits. CONCLUSION Brainlab's Cirq® Robotic Alignment surgeon-controlled robotic arm is a safe and beneficial method for accurate thoracolumbar pedicle screw placement with high accuracy.
Collapse
Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
- Correspondence: ; Tel.: +49-642-1586-9848
| | - Miriam Bopp
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 65199 Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 65199 Marburg, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 65199 Marburg, Germany
- Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, 65199 Wiesbaden, Germany
| | - Benjamin Saβ
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
| |
Collapse
|
31
|
Arnaout MM, ElSheikh MO, Makia MA. Confirmation of accuracy/inaccuracy of lumbar pedicle screw placement using postoperative computed tomography. Surg Neurol Int 2021; 12:518. [PMID: 34754568 PMCID: PMC8571410 DOI: 10.25259/sni_290_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/25/2021] [Indexed: 11/04/2022] Open
Abstract
Background Transpedicular screws are extensively utilized in lumbar spine surgery. The placement of these screws is typically guided by anatomical landmarks and intraoperative fluoroscopy. Here, we utilized 2-week postoperative computed tomography (CT) studies to confirm the accuracy/inaccuracy of lumbar pedicle screw placement in 145 patients and correlated these findings with clinical outcomes. Methods Over 6 months, we prospectively evaluated the location of 612 pedicle screws placed in 145 patients undergoing instrumented lumbar fusions addressing diverse pathology with instability. Routine anteroposterior and lateral plain radiographs were obtained 48 h after the surgery, while CT scans were obtained at 2 postoperative weeks (i.e., ideally these should have been performed intraoperatively or within 24-48 h of surgery). Results Of the 612 screws, minor misplacement of screws (≤2 mm) was seen in 104 patients, moderate misplacement in 34 patients (2-4 mm), and severe misplacement in 7 patients (>4 mm). Notably, all the latter 7 (4.8% of the 145) patients required repeated operative intervention. Conclusion Transpedicular screw insertion in the lumbar spine carries the risks of pedicle medial/lateral violation that is best confirmed on CT rather than X-rays/fluoroscopy alone. Here, we additional found 7 patients (4.8%) who with severe medial/lateral pedicle breach who warranting repeated operative intervention. In the future, CT studies should be performed intraoperatively or within 24-48 h of surgery to confirm the location of pedicle screws and rule in our out medial or lateral pedicle breaches.
Collapse
Affiliation(s)
- Mohamed M Arnaout
- Department of Neurosurgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Magdy O ElSheikh
- Department of Neurosurgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mansour A Makia
- Department of Neurosurgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| |
Collapse
|
32
|
Ille S, Baumgart L, Obermueller T, Meyer B, Krieg SM. Clinical efficiency of operating room-based sliding gantry CT as compared to mobile cone-beam CT-based navigated pedicle screw placement in 853 patients and 6733 screws. 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 2021; 30:3720-3730. [PMID: 34519911 DOI: 10.1007/s00586-021-06981-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/30/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Multiple solutions for navigation-guided pedicle screw placement are available. However, the efficiency with regard to clinical and resource implications has not yet been analyzed. The present study's aim was to analyze whether an operating room sliding gantry CT (ORCT)-based approach for spinal instrumentation is more efficient than a mobile cone-beam CT (CBCT)-based approach. METHODS This cohort study included a random sample of 853 patients who underwent spinal instrumentation using ORCT-based or CBCT-based pedicle screw placement due to tumor, degenerative, trauma, infection, or deformity disorders between November 2015 and January 2020. RESULTS More screws had to be revised intraoperatively in the CBCT group due to insufficient placement (ORCT: 98, 2.8% vs. CBCT: 128, 4.0%; p = 0.0081). The mean time of patients inside the OR (Interval 5 Entry-Exit) was significantly shorter for the ORCT group (ORCT: mean, [95% CI] 256.0, [247.8, 264.3] min, CBCT: 283.0, [274.4, 291.5] min; p < 0.0001) based on shorter times for Interval 2 Positioning-Incision (ORCT: 18.8, [18.1, 19.9] min, CBCT: 33.6, [32.2, 35.5] min; p < 0.0001) and Interval 4 Suture-Exit (ORCT: 24.3, [23.6, 26.1] min, CBCT: 29.3, [27.5, 30.7] min; p < 0.0001). CONCLUSIONS The choice of imaging technology for navigated pedicle screw placement has significant impact on standard spine procedures even in a high-volume spine center with daily routine in such devices. Particularly with regard to the duration of surgeries, the shorter time needed for preparation and de-positioning in the ORCT group made the main difference, while the accuracy was even higher for the ORCT.
Collapse
Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany; School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany.,TUM Neuroimaging Center, Technical University of Munich, Germany, Ismaninger Str. 22, 81675 , Munich, Germany
| | - Lea Baumgart
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany; School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas Obermueller
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany; School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany; School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany; School of Medicine, Ismaninger Str. 22, 81675, Munich, Germany. .,TUM Neuroimaging Center, Technical University of Munich, Germany, Ismaninger Str. 22, 81675 , Munich, Germany.
| |
Collapse
|
33
|
Alqurashi A, Alomar SA, Bakhaidar M, Alfiky M, Baeesa SS. Accuracy of Pedicle Screw Placement Using Intraoperative CT-Guided Navigation and Conventional Fluoroscopy for Lumbar Spondylosis. Cureus 2021; 13:e17431. [PMID: 34462711 PMCID: PMC8389880 DOI: 10.7759/cureus.17431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 11/28/2022] Open
Abstract
Background Transpedicular screws are a common adjunct for lumbar spine fusion. Accurate screw placement to prevent neurological injury has been the subject of many studies. The adoption of spine neuronavigation has shown a significant decrease in screw malposition morbidity. We aim to evaluate the accuracy of pedicle screw insertion using intraoperative CT-guided navigation in lumbar spondylosis. Methods We reviewed a prospective registry-based cohort study. This included patients who underwent transpedicular screws insertion for lumbar spondylosis under intraoperative CT-guided navigation (iCT-Nav) and compared it to another group operated using conventional fluoroscopy (FS) over one year. In addition, the correlation between clinical outcome using the visual analog scale (VAS) and short 12 physical component scores (SF-12 PCS) and hospital stay was reported. Results Fifteen patients were included in the iCT-Nav group compared to 42 patients in the FS group. The median age of the iCT-Nav group was 59.3 years old (27-76 years) versus 45 years old (20-60 years) in the FS group. The number of screws was 98 in the iCT-Nav group and 252 screws in the FS group. Based on more than 2-mm breach increments measured on CT images, lumbar pedicular screw placement accuracy was 100% in the iCT-Nav group and 86.9% in the FS group. None of the patients in the iCT-Nav group had to undergo any postoperative revisions. On the other hand, two patients of the FS group developed new postoperative symptoms related to displaced screws and required readmission and revision surgery. Conclusion In a commonly performed pedicular fixation in lumbar spondylosis, iCT-Nav has been shown to improve the accuracy of pedicle screw placement, hospital stay, and functional outcomes compared to FS.
Collapse
Affiliation(s)
- Ashwaq Alqurashi
- Department of Surgery, King Abdulaziz University Hospital, Jeddah, SAU
| | - Soha A Alomar
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Mohamad Bakhaidar
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Mohammed Alfiky
- Department of Surgery, King Abdulaziz University Hospital, Jeddah, SAU
| | - Saleh S Baeesa
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU.,Department of Surgery, King Abdulaziz University Hospital, Jeddah, SAU
| |
Collapse
|
34
|
Wessels L, Komm B, Bohner G, Vajkoczy P, Hecht N. Spinal alignment shift between supine and prone CT imaging occurs frequently and regardless of the anatomic region, risk factors, or pathology. Neurosurg Rev 2021; 45:855-863. [PMID: 34379226 PMCID: PMC8827393 DOI: 10.1007/s10143-021-01618-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/13/2021] [Accepted: 07/25/2021] [Indexed: 11/05/2022]
Abstract
Computer-assisted spine surgery based on preoperative CT imaging may be hampered by sagittal alignment shifts due to an intraoperative switch from supine to prone. In the present study, we systematically analyzed the occurrence and pattern of sagittal spinal alignment shift between corresponding preoperative (supine) and intraoperative (prone) CT imaging in patients that underwent navigated posterior instrumentation between 2014 and 2017. Sagittal alignment across the levels of instrumentation was determined according to the C2 fracture gap (C2-F) and C2 translation (C2-T) in odontoid type 2 fractures, next to the modified Cobb angle (CA), plumbline (PL), and translation (T) in subaxial pathologies. One-hundred and twenty-one patients (C1/C2: n = 17; C3-S1: n = 104) with degenerative (39/121; 32%), oncologic (35/121; 29%), traumatic (34/121; 28%), or infectious (13/121; 11%) pathologies were identified. In the subaxial spine, significant shift occurred in 104/104 (100%) cases (CA: *p = .044; T: *p = .021) compared to only 10/17 (59%) cases that exhibited shift at the C1/C2 level (C2-F: **p = .002; C2-T: *p < .016). The degree of shift was not affected by the anatomic region or pathology but significantly greater in cases with an instrumentation length > 5 segments (“∆PL > 5 segments”: 4.5 ± 1.8 mm; “∆PL ≤ 5 segments”: 2 ± 0.6 mm; *p = .013) or in revision surgery with pre-existing instrumentation (“∆PL presence”: 5 ± 2.6 mm; “∆PL absence”: 2.4 ± 0.7 mm; **p = .007). Interestingly, typical morphological instability risk factors did not influence the degree of shift. In conclusion, intraoperative spinal alignment shift due to a change in patient position should be considered as a cause for inaccuracy during computer-assisted spine surgery and when correcting spinal alignment according to parameters that were planned in other patient positions.
Collapse
Affiliation(s)
- Lars Wessels
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Bettina Komm
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Georg Bohner
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| |
Collapse
|
35
|
Nazimi AJ, Nabil S. Intraoperative Computed Tomography Image Fusion for Orbital Blowout Fracture Reconstruction. ARCHIVES OF OROFACIAL SCIENCES 2021; 16:1-12. [DOI: 10.21315/aos2021.16.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Intraoperative computed tomography (CT) has been previously described and acknowledged for its use in orbital blowout fracture reconstructions. We described a clinical case series managed by this technique combined with intraoperative image fusion for accuracy in orbital implant position. In total, eight patients who sustained a total number of 19 orbital wall fractures were described. From the total number of 19 blowout orbital fracture reconstructions comprised of medial and inferior (floor) orbital fractures, malposition was identified in a total of four orbital implants by using image fusion. All cases of implant malposition were immediately revised intraoperatively. Subsequent fusion was carried out to confirm whether the revision was satisfactorily achieved. We found that the intraoperative image fusion technique utilised to determine orbital implant position, especially at the posterior ledge, further augmented the role of intraoperative CT scanning. Image fusion conceptually provides an immediate, real-time, and objective solution for intraoperative image analysis and potentially eliminates problems with misaligned CT images. It also reduces the need for the surgeon to ‘eye-ball’ the CT images acquired or the need for additional intraoperative time, since the patient’s head orientation is always axially at random during the acquisition of the CT. Conventional methods for CT image assessment are subjected to one’s own interpretation and may introduce inconsistent or longer intraoperative decision-making. The technique facilitates intraoperative decision-making and reduces the risk of orbital implant malposition in orbital blowout fracture reconstructions. Hence, surgical complication in relation to orbital implant malposition in orbital blowout fracture management could be minimised. In addition, no further postoperative imaging is required.
Collapse
Affiliation(s)
- Abd Jabar Nazimi
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Universiti Kebangsaan Malaysia, 50300 Kuala Lumpur, Malaysia
| | - Syed Nabil
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Universiti Kebangsaan Malaysia, 50300 Kuala Lumpur, Malaysia
| |
Collapse
|
36
|
Lu YJ, Miao YM, Zhu TF, Wu Q, Shen X, Lu DD, Zhu XS, Gan MF. Comparison of the Wiltse Approach and Percutaneous Pedicle Screw Fixation Under O-arm Navigation for the Treatment of Thoracolumbar Fractures. Orthop Surg 2021; 13:1618-1627. [PMID: 34142446 PMCID: PMC8313162 DOI: 10.1111/os.13053] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 03/29/2021] [Accepted: 04/28/2021] [Indexed: 12/25/2022] Open
Abstract
Objectives The aim of this study was to evaluate the clinical outcomes of the Wiltse approach and percutaneous pedicle screw placement under O‐arm navigation for the treatment of thoracolumbar fracture. Methods We enrolled a total of 54 patients with neurologically intact thoracolumbar fracture who received minimally invasive treatments between October 2014 and October 2018 in this retrospective study. Among these, 28 patients (22 males and six females, with a mean age of 48.6 ± 9.6 years) were treated with pedicle screw fixation through the Wiltse approach (WPSF), and another 26 (15 males and 11 females, with a mean age of 45.7 ± 10.6 years) received percutaneous pedicle screw fixation under O‐arm navigation (OPSF). Statistical methods were used to perform a detailed comparison of clinical outcomes, radiologic findings, and complications between the two groups obtained preoperatively, postoperatively, and at last follow‐up. Results All patients underwent surgery successfully and finished a follow‐up of more than 12 months. No serious complications, such as infection, blood vessel injury, or spinal cord or nerve root injury occurred. Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, local Cobb angle (LCA), vertebral wedge angle (VWA), and R value were notably improved after surgery, though there was no clear discrepancy between the groups at each time point (P > 0.05). During the follow‐up period, no patients developed neurological impairment or implant‐related complications, and no patients underwent revision surgery. The WPSF group had a significantly shorter operation time than the OPSF group (68.1 ± 9.8 vs 76.1 ± 9.0 minutes, P = 0.005). Moreover, the WPSF group showed less cost of surgery than the WPSF group (48142.1 ± 1430.1 vs 59035.4 ± 1152.7 CNY, P < 0.001). There were no significant differences between the two groups in terms of the intraoperative bleeding, length of incision, or postoperative hospitalization time (P > 0.05). The accuracy of pedicle screw placement was 95.2% (160/168) in the WPSF group and 96.8% (151/156) in the OPSF group, with no significant difference between the groups (P = 0.432). Conclusion Both WPSF and OPSF were safe and effective for the treatment of thoracolumbar fracture. Although the two groups showed favorable clinical and radiologic outcomes through to final follow‐up, we recommended the minimally invasive WPSF given its shorter operation time and lower cost of surgery.
Collapse
Affiliation(s)
- Ying-Jie Lu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yi-Ming Miao
- Department of Orthopaedic Surgery, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Tian-Feng Zhu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qian Wu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xu Shen
- Department of Orthopaedic Surgery, Suzhou Dushuhu Public Hospital (Dushuhu Public Hospital Affiliated to Soochow University), Suzhou, China
| | - Dong-Dong Lu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xue-Song Zhu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Min-Feng Gan
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| |
Collapse
|
37
|
Use of Intraoperative CT Improves Accuracy of Spinal Navigation During Screw Fixation in Cervico-thoracic Region. Spine (Phila Pa 1976) 2021; 46:530-537. [PMID: 33273435 DOI: 10.1097/brs.0000000000003827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective analysis of a single-center consecutive series of patients. OBJECTIVE To test the hypothesis that using a mobile intraoperative computed tomography in combination with spinal navigation would result in better accuracy of lateral mass and pedicle screws between C3 and T5 levels, compared to cone-beam computed tomography and traditional 2D fluoroscopy. SUMMARY OF BACKGROUND DATA Use of spinal navigation associated with 3D imaging has been shown to improve accuracy of screw positioning in the cervico-thoracic region. However, use of iCT imaging compared to a cone-beam CT has not been fully investigated in these types of surgical interventions. METHODS We retrospectively analyzed a series of patients who underwent posterior cervico-thoracic fixations using different intraoperative imaging systems in a single hospital. We identified three different groups of patients: Group A, operated under 2D-fluoroscopic guidance without navigation; Group B: O-arm guidance with navigation; Group C: iCT AIRO guidance with navigation. Primary outcome was the rate of accurately placed screws, measured on intra or postoperative CT scan with Neo et al. classification for cervical pedicles screws and Gertzbein et al. for thoracic pedicle screws. Screws in cervical lateral masses were evaluated according to a new classification created by the authors. RESULTS Data on 67 patients and 495 screws were available. Overall screw accuracy was 92.8% (95.6% for lateral mass screws, 81.6% for cervical pedicle screws, and 90% for thoracic pedicle screws). Patients operated with iCT AIRO navigation had significantly fewer misplaced screws (2.4%) compared to 2D-fluoroscopic guidance (9.1%) and O-arm navigation (9.7%) (P = 0.0152). Accuracy rate of iCT navigation versus O-arm navigation was significantly higher (P = 0.0042), and there was no statistically significant difference in surgical time between the three Groups (P = 0.5390). CONCLUSION Use of high-quality CT associated with spinal navigation significantly improved accuracy of screw positioning in the cervico-thoracic region.Level of Evidence: 3.
Collapse
|
38
|
Kageyama H, Yoshimura S, Tatebayashi K, Iida T, Yamada K. Accuracy of Pedicle Screw Placement Comparing an Electronic Conductivity Device and a Multi-axis Angiography Unit with C-arm Fluoroscopy in Lumbar Fixation Surgery for Safety. Neurol Med Chir (Tokyo) 2021; 61:334-340. [PMID: 33790131 PMCID: PMC8120099 DOI: 10.2176/nmc.oa.2020-0374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to compare the accuracy, safety, and usefulness of percutaneous pedicle screw (PPS) placement for lumbar fixation using a multi-axis angiography unit (MAU) and an electronic conductivity device (ECD) with a cannulated Jamshidi needle with that using a conventional C-arm. Of 65 cases that underwent lumbar fixation (region between L1-S1) during April 2013 to March 2019, 57 cases that could be followed-up for more than 12 months after the procedure were included. Among them, 31 patients (150 screws) received treatment with MAU and ECD (MAU+ECD group) and 26 (117 screws) were treated with the conventional C-arm. We performed a retrospective study of the surgical techniques used in each group at our institute by assessing the accuracy of PPS using Gertzbin–Robbins classification and the Japanese Orthopedic Association (JOA) score for recovery. There was no significant difference in surgery outcome based on the JOA recovery rate. There was a significant difference between the two groups in terms of Accuracy-1 (Group A indicating accuracy and Groups B–E indicating inaccuracy), where the rates were 85.3% and 72.0% in the MAU+ECD group and C-arm group, respectively (P = 0.008). There was also a significant difference between the two groups in terms of Accuracy-2 (Groups A–B indicating accuracy; Groups C–E indicate inaccuracy), where the rates were 98.0% and 92.4% in the MAU+ECD and C-arm groups, respectively (P = 0.036). A combination of MAU and ECD is a safe and accurate method for inserting screws into the pedicle.
Collapse
Affiliation(s)
| | | | | | - Tomoko Iida
- Department of Neurosurgery, Hyogo College of Medicine
| | | |
Collapse
|
39
|
Senova S, Lefaucheur JP, Brugières P, Ayache SS, Tazi S, Bapst B, Abhay K, Langeron O, Edakawa K, Palfi S, Bardel B. Case Report: Multimodal Functional and Structural Evaluation Combining Pre-operative nTMS Mapping and Neuroimaging With Intraoperative CT-Scan and Brain Shift Correction for Brain Tumor Surgical Resection. Front Hum Neurosci 2021; 15:646268. [PMID: 33716700 PMCID: PMC7947337 DOI: 10.3389/fnhum.2021.646268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/08/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Maximum safe resection of infiltrative brain tumors in eloquent area is the primary objective in surgical neuro-oncology. This goal can be achieved with direct electrical stimulation (DES) to perform a functional mapping of the brain in patients awake intraoperatively. When awake surgery is not possible, we propose a pipeline procedure that combines advanced techniques aiming at performing a dissection that respects the anatomo-functional connectivity of the peritumoral region. This procedure can benefit from intraoperative monitoring with computerized tomography scan (iCT-scan) and brain shift correction. Associated with this intraoperative monitoring, the additional value of preoperative investigation combining brain mapping by navigated transcranial magnetic stimulation (nTMS) with various neuroimaging modalities (tractography and resting state functional MRI) has not yet been reported. Case Report: A 42-year-old left-handed man had increased intracranial pressure (IICP), left hand muscle deficit, and dysarthria, related to an infiltrative tumor of the right frontal lobe with large mass effect and circumscribed contrast enhancement in motor and premotor cortical areas. Spectroscopy profile and intratumoral calcifications on CT-scan suggested an WHO grade III glioma, later confirmed by histology. The aforementioned surgical procedure was considered, since standard awake surgery was not appropriate for this patient. In preoperative time, nTMS mapping of motor function (deltoid, first interosseous, and tibialis anterior muscles) was performed, combined with magnetic resonance imaging (MRI)-based tractography reconstruction of 6 neural tracts (arcuate, corticospinal, inferior fronto-occipital, uncinate and superior and inferior longitudinal fasciculi) and resting-state functional MRI connectivity (rs-fMRI) of sensorimotor and language networks. In intraoperative time, DES mapping was performed with motor evoked response recording and tumor resection was optimized using non-rigid image transformation of the preoperative data (nTMS, tractography, and rs-fMRI) to iCT data. Image guidance was updated with correction for brain shift and tissue deformation using biomechanical modeling taking into account brain elastic properties. This correction was done at crucial surgical steps, i.e., when tumor bulged through the craniotomy after dura mater opening and when approaching the presumed eloquent brain regions. This procedure allowed a total resection of the tumor region with contrast enhancement as well as a complete regression of IICP and dysarthria. Hand paresis remained stable with no additional deficit. Postoperative nTMS mapping confirmed the good functional outcome. Conclusion: This case report and technical note highlights the value of preoperative functional evaluation by nTMS updated intraoperatively with correction of brain deformation by iCT. This multimodal approach may become the optimized technique of reference for patients with brain tumors in eloquent areas that are unsuitable for awake brain surgery.
Collapse
Affiliation(s)
- Suhan Senova
- Department of Neurosurgery, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Translational Psychiatry (Equipe 15), IMRB - INSERM U955, Univ Paris-Est Creteil, Creteil, France
| | - Jean-Pascal Lefaucheur
- Department of Clinical Neurophysiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Excitabilite Nerveuse et Therapeutique, EA 4391, Univ Paris-Est Creteil, Creteil, France
| | - Pierre Brugières
- Department of Neuroradiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France
| | - Samar S Ayache
- Department of Clinical Neurophysiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Excitabilite Nerveuse et Therapeutique, EA 4391, Univ Paris-Est Creteil, Creteil, France
| | - Sanaa Tazi
- Department of Neurosurgery, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Translational Psychiatry (Equipe 15), IMRB - INSERM U955, Univ Paris-Est Creteil, Creteil, France
| | - Blanche Bapst
- Department of Neuroradiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France
| | - Kou Abhay
- Department of Anesthesiology and Critical Care, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France
| | - Olivier Langeron
- Department of Anesthesiology and Critical Care, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Experimental Neuropathology Unit, Institut Pasteur, Paris, France
| | - Kohtaroh Edakawa
- Department of Neurosurgery, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Translational Psychiatry (Equipe 15), IMRB - INSERM U955, Univ Paris-Est Creteil, Creteil, France.,Department of Neurosurgery, Graduate School of Medicine Osaka University, Suita, Japan
| | - Stéphane Palfi
- Department of Neurosurgery, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Translational Psychiatry (Equipe 15), IMRB - INSERM U955, Univ Paris-Est Creteil, Creteil, France
| | - Benjamin Bardel
- Department of Clinical Neurophysiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Excitabilite Nerveuse et Therapeutique, EA 4391, Univ Paris-Est Creteil, Creteil, France
| |
Collapse
|
40
|
Venier A, Croci D, Robert T, Distefano D, Presilla S, Scarone P. Use of Intraoperative Computed Tomography Improves Outcome of Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Single-Center Retrospective Cohort Study. World Neurosurg 2021; 148:e572-e580. [PMID: 33482416 DOI: 10.1016/j.wneu.2021.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To provide data about surgical workflow, accuracy, complications, radiation exposure, and learning curve effect in patients who underwent minimally invasive (MIS) transforaminal lumbar interbody fusion with navigation coupled with mobile intraoperative computed tomography. METHODS A retrospective analysis was performed of data from consecutive patients who underwent single- or double-level MIS transforaminal lumbar interbody fusion at a single institution; mobile intraoperative computed tomography combined with a navigation system was used as the sole intraoperative imaging method to place pedicular screws; decompression and interbody fusion were performed through a 22-mm tubular retractor. Clinical data, perioperative complications, accuracy of pedicular screw placement, and radiation exposure were analyzed. A learning curve effect on surgical time and accuracy was assessed. RESULTS A total of 408 screws in 100 patients were analyzed. In all cases, spinal navigation allowed for identification of pedicular trajectories and greatly facilitated nerve root decompression through the MIS approach. Overall accuracy according to Heary classification was 95.3%. Nineteen screws (4.7%) presented a minor lateral breach (<2 mm), not clinically significant. Surgical time, blood loss, and patient radiation exposure compared favorably with reported values from other series using three-dimensional navigation. A learning curve effect on surgical time, but not on screw accuracy, was identified. CONCLUSIONS MIS transforaminal lumbar interbody fusion can now be performed without any radiation exposure to the surgeon and operating room staff, with almost absolute accuracy during screw positioning and tubular decompression. A learning curve effect on surgical time, but not on overall screw accuracy, may be expected.
Collapse
Affiliation(s)
- Alice Venier
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Davide Croci
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland; Facoltà di scienze biomediche, Università della Svizzera italiana, Lugano, Switzerland
| | - Daniela Distefano
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Stefano Presilla
- Medical Physics Service, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Pietro Scarone
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland.
| |
Collapse
|
41
|
Burman S, Das A, Mahajan C, Rath GP. Radiation Concerns for the Neuroanesthesiologists. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1715354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractWith the advent of minimally invasive neurosurgical techniques and rapid innovations in the field of neurointervention, there has been a sharp rise in diagnostic and therapeutic modalities requiring radiation exposure. Neuroanesthesiologists are currently involved in various procedures inside as well as outside the operating room (OR) like intensive care units, interventional suites, and gamma knife units. The ambit expands from short-lasting diagnostic scans to lengthy therapeutic procedures performed under fluoroscopic guidance. Hence, a modern-day neuroanesthesiologist has to bear the brunt of the radiation exposure in both inside and outside the OR. However, obliviousness and nonadherence to the relevant radiation safety measures are still prevalent. Radiation protection and safety are topics that need to be discussed with new vigor in the light of current practice.
Collapse
Affiliation(s)
- Sourav Burman
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Abanti Das
- Department of Radiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Girija P. Rath
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
42
|
Casiraghi M, Scarone P, Bellesi L, Piliero MA, Pupillo F, Gaudino D, Fumagalli G, Del Grande F, Presilla S. Effective dose and image quality for intraoperative imaging with a cone-beam CT and a mobile multi-slice CT in spinal surgery: A phantom study. Phys Med 2020; 81:9-19. [PMID: 33310424 DOI: 10.1016/j.ejmp.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 09/30/2020] [Accepted: 11/02/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To compare the effective dose (ED) and image quality (IQ) of O-arm cone-beam CT (Medtronic, Minneapolis, MN, USA) and Airo multi-slice CT (Brainlab AG, Munich, Germany) for intraoperative-CT (i-CT) in spinal surgery. METHODS The manufacturer-defined protocols available in the O-arm and Airo systems for three-dimensional lumbar spine imaging were compared. Organ dose was measured both with thermo-luminescent dosimeters and GafChromic films in the Alderson RadiationTherapy anthropomorphic phantom. A subjective analysis was performed by neurosurgeons to compare the clinical IQ of the anthropomorphic phantom images acquired with the different i-CT systems and imaging protocols. Image uniformity, noise, contrast-to-noise-ratio (CNR), and spatial resolution were additionally assessed with the Catphan 504 phantom. RESULTS O-arm i-CT caused 56% larger ED than Airo due to the high definition (HD) imaging protocol. The noise was larger for O-arm images leading to a lower CNR than that measured for Airo. Moreover, scattering and beam hardening effects were observed in the O-arm images. Better spatial resolution was measured for the O-arm system (9 lp/cm) than for Airo (4 lp/cm). For all the investigated protocols, O-arm was found to be better for identifying anatomical features important for accurate pedicle screw positioning. CONCLUSIONS According to phantom measurements, the HD protocol of O-arm offered better clinical IQ than Airo but larger ED. The larger noise of O-arm images did not compromise the clinical IQ while the superior spatial resolution of this system allowed a better visibility of anatomical features important for pedicle screw positioning in the lumbar region.
Collapse
Affiliation(s)
- Margherita Casiraghi
- Medical Physics Division, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Ospedale Regionale di Bellinzona e Valli, 6500 Bellinzona, Switzerland.
| | - Pietro Scarone
- Service of Neurosurgery, Neurocenter of Southern Switzerland, 6900 Lugano, Switzerland.
| | - Luca Bellesi
- Medical Physics Division, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Ospedale Regionale di Bellinzona e Valli, 6500 Bellinzona, Switzerland.
| | - Maria Antonietta Piliero
- Medical Physics Division, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Ospedale Regionale di Bellinzona e Valli, 6500 Bellinzona, Switzerland.
| | - Francesco Pupillo
- Medical Physics Division, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Ospedale Regionale di Bellinzona e Valli, 6500 Bellinzona, Switzerland.
| | - Diego Gaudino
- Medical Physics Division, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Ospedale Regionale di Bellinzona e Valli, 6500 Bellinzona, Switzerland.
| | - Giulia Fumagalli
- Medical Physics Division, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Ospedale Regionale di Bellinzona e Valli, 6500 Bellinzona, Switzerland.
| | - Filippo Del Grande
- Department of Radiology, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, 6900 Lugano, Switzerland.
| | - Stefano Presilla
- Medical Physics Division, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Ospedale Regionale di Bellinzona e Valli, 6500 Bellinzona, Switzerland.
| |
Collapse
|
43
|
Intraoperative CT and cone-beam CT imaging for minimally invasive evacuation of spontaneous intracerebral hemorrhage. Acta Neurochir (Wien) 2020; 162:3167-3177. [PMID: 32193726 PMCID: PMC7593312 DOI: 10.1007/s00701-020-04284-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/04/2020] [Indexed: 01/25/2023]
Abstract
Background Minimally invasive surgery (MIS) for evacuation of spontaneous intracerebral hemorrhage (ICH) has shown promise but there remains a need for intraoperative performance assessment considering the wide range of evacuation effectiveness. In this feasibility study, we analyzed the benefit of intraoperative 3-dimensional imaging during navigated endoscopy-assisted ICH evacuation by mechanical clot fragmentation and aspiration. Methods 18 patients with superficial or deep supratentorial ICH underwent MIS for clot evacuation followed by intraoperative computerized tomography (iCT) or cone-beam CT (CBCT) imaging. Eligibility for MIS required (a) availability of intraoperative iCT or CBCT, (b) spontaneous lobar or deep ICH without vascular pathology, (c) a stable ICH volume (20–90 ml), (d) a reduced level of consciousness (GCS 5–14), and (e) a premorbid mRS ≤ 1. Demographic, clinical, and radiographic patient data were analyzed by two independent observers. Results Nine female and 9 male patients with a median age of 76 years (42–85) presented with an ICH score of 3 (1–4), GCS of 10 (5–14) and ICH volume of 54 ± 26 ml. Clot fragmentation and aspiration was feasible in all cases and intraoperative imaging determined an overall evacuation rate of 80 ± 19% (residual hematoma volume: 13 ± 17 ml; p < 0.0001 vs. Pre-OP). Based on the intraoperative imaging results, 1/3rd of all patients underwent an immediate re-aspiration attempt. No patient experienced hemorrhagic complications or required conversion to open craniotomy. However, routine postoperative CT imaging revealed early hematoma re-expansion with an adjusted evacuation rate of 59 ± 30% (residual hematoma volume: 26 ± 37 ml; p < 0.001 vs. Pre-OP). Conclusions Routine utilization of iCT or CBCT imaging in MIS for ICH permits direct surgical performance assessment and the chance for immediate re-aspiration, which may optimize targeting of an ideal residual hematoma volume and reduce secondary revision rates. Electronic supplementary material The online version of this article (10.1007/s00701-020-04284-y) contains supplementary material, which is available to authorized users.
Collapse
|
44
|
Hussain I, Fu KM, Uribe JS, Chou D, Mummaneni PV. State of the art advances in minimally invasive surgery for adult spinal deformity. Spine Deform 2020; 8:1143-1158. [PMID: 32761477 DOI: 10.1007/s43390-020-00180-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/27/2020] [Indexed: 12/21/2022]
Abstract
Adult spinal deformity (ASD) can be associated with substantial suffering due to pain and disability. Surgical intervention for achieving neural decompression and restoring physiological spinal alignment has shown to result in significant improvement in pain and disability through patient-reported outcomes. Traditional open approaches involving posterior osteotomy techniques and instrumentation are effective based on clinical outcomes but associated with high complication rates, even in the hands of the most experienced surgeons. Minimally invasive techniques may offer benefit while decreasing associated morbidity. Minimally invasive surgery (MIS) for ASD has evolved over the past 20 years, driven by improved understanding of open procedures along with novel technique development and technologic advancements. Early efforts were hindered due to suboptimal outcomes resulting from high pseudarthrosis, inadequate correction, and fixation failure rates. To address this, multi-center collaborative groups have been established to study large numbers of ASD patients which have been vital to understanding optimal patient selection and individualized management strategies. Different MIS decision-making algorithms have been described to better define appropriate candidates and interbody selection approaches in ASD. The purpose of this state of the review is to describe the evolution of MIS surgery for adult deformity with emphasis on landmark papers, and to discuss specific MIS technology for ASD, including percutaneous pedicle screw instrumentation, hyperlordotic grafts, three-dimensional navigation, and robotics.
Collapse
Affiliation(s)
- Ibrahim Hussain
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, Box 99, New York, NY, USA.
| | - Juan S Uribe
- Department of Neurological Surgery, Barrow Neurologic Institute, Phoenix, AZ, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| |
Collapse
|
45
|
Sankey EW, Mehta VA, Wang TY, Than TT, Goodwin CR, Karikari IO, Shaffrey CI, Abd-El-Barr MM, Than KD. The medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the United States. Neurosurg Focus 2020; 49:E20. [PMID: 33130620 DOI: 10.3171/2020.8.focus20600] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. The authors of the current study aimed to describe this impact in the United States, as well as to suggest a potential method for mitigating the problem.This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). Litigation resulted in average payouts of $1,204,422 ± $753,832 between 1995 and 2019, when adjusted for inflation. The median time to case closure was 56.3 (35.2-67.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.4-77.2) months for defendant (surgeon) verdicts (p = 0.117).
Collapse
Affiliation(s)
- Eric W Sankey
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Vikram A Mehta
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Timothy Y Wang
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | | | - C Rory Goodwin
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Isaac O Karikari
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Christopher I Shaffrey
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Muhammad M Abd-El-Barr
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Khoi D Than
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| |
Collapse
|
46
|
Keil H, Luxenhofer M, Vetter SY, Beisemann N, Grützner PA, Franke J. Evaluation of image quality and assessability of a new flat‐panel 3D C‐arm compared to mobile and fixed computed tomography in posterior spinal fixation. Int J Med Robot 2020; 17:e2181. [DOI: 10.1002/rcs.2181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/25/2020] [Accepted: 10/07/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Holger Keil
- Department of Trauma and Orthopaedic Surgery Krankenhausstr Universitätsklinikum Erlangen Erlangen Germany
| | - Miriam Luxenhofer
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| | - Sven Y. Vetter
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| | - Nils Beisemann
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| | - Paul A. Grützner
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| | - Jochen Franke
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| |
Collapse
|
47
|
Zhou LP, Zhang RJ, Sun YW, Zhang L, Shen CL. Accuracy of Pedicle Screw Placement and Four Other Clinical Outcomes of Robotic Guidance Technique versus Computer-Assisted Navigation in Thoracolumbar Surgery: A Meta-Analysis. World Neurosurg 2020; 146:e139-e150. [PMID: 33075574 DOI: 10.1016/j.wneu.2020.10.055] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Robotic guidance (RG) pedicle screw placement has been increasingly used to improve the rate of insertion accuracy. However, the superiority of the RG technique over computer-assisted navigation (CAN) remains debatable. OBJECTIVE To determine whether the Mazor RG technique is superior to CAN in terms of the rate of insertion accuracy and 4 other clinical indices, namely, intraoperative time, blood loss, complications and revision surgery caused by malposition. METHODS A search of PubMed, Embase, Cochrane, Web of Science, CNKI, and WanFang was conducted. We mainly aimed to evaluate the accuracy of pedicle screw placement between the Mazor RG and CAN techniques. The secondary objectives were intraoperative time, blood loss, complications, and revision surgery caused by malposition. The meta-analysis was conducted using the RevMan 5.3 and Stata 15.1 software. RESULTS A randomized controlled trial and 5 comparative cohort studies consisting of 529 patients and 4081 pedicle screws were included in this meta-analysis. The RG technique has a significantly higher accuracy than CAN in terms of optimal (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.85-2.76; P < 0.01) and clinically acceptable (OR, 1.69; 95% CI, 1.22-2.34; P = 0.002) pedicle screw insertions. Furthermore, the RG technique showed significantly less blood loss (mean difference, -42.49; 95% CI, -78.38 to -6.61; P = 0.02) than did the CAN technique but has equivalent intraoperative time (mean difference, 0.75; 95% CI, -5.89 to 7.40; P = 0.82), complications (OR, 0.65; 95% CI, 0.32-1.33, P = 0.24), and revision surgery caused by malposition (OR, 0.46; 95% CI, 0.15-1.43, P = 0.18). CONCLUSIONS The Mazor RG technique is superior to CAN concerning the accuracy of pedicle screw placement. Thus, the Mazor RG technique is accurate and safe in clinical application.
Collapse
Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ren-Jie Zhang
- Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yi-Wei Sun
- Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Lai Zhang
- Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Cai-Liang Shen
- Department of Orthopedics and Spine Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.
| |
Collapse
|
48
|
Mao JZ, Agyei JO, Khan A, Hess RM, Jowdy PK, Mullin JP, Pollina J. Technologic Evolution of Navigation and Robotics in Spine Surgery: A Historical Perspective. World Neurosurg 2020; 145:159-167. [PMID: 32916361 DOI: 10.1016/j.wneu.2020.08.224] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 12/15/2022]
Abstract
Spine surgery is continuously evolving. The synergy between medical imaging and advances in computation has allowed for stereotactic neuronavigation and its integration with robotic technology to assist in spine surgery. The discovery of x-rays in 1895, the development of image intensifiers in 1940, and then advancements in computational science and integration have allowed for the development of computed tomography. In combination with the advancements of stereotaxy in the late 1980s, and manipulation of volumetric and special data for 3-dimensional reconstruction in 1998, computed tomography has revolutionized neuronavigational systems. Integrating all these technologies, robotics in spine surgery was introduced in 2004. Since then, it has become a safe modality that can reproducibly place accurate pedicle screws. Robotics may have the added benefits of improving the surgical workflow and optimizing surgeon ergonomics. Growing at a rapid rate, the second-generation spinal robotics have overcome preliminary limitations and errors. However, comparatively, robotics in spine surgery remains in its infancy. By leveraging technologic advancements in medical imaging, computation, and stereotactic navigation, robotics in spine surgery will continue to mature and expand in utility.
Collapse
Affiliation(s)
- Jennifer Z Mao
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Biomedical Sciences, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Justice O Agyei
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Patrick K Jowdy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA.
| |
Collapse
|
49
|
Ashraf M, Choudhary N, Hussain SS, Kamboh UA, Ashraf N. Role of intraoperative computed tomography scanner in modern neurosurgery - An early experience. Surg Neurol Int 2020; 11:247. [PMID: 32905376 PMCID: PMC7468186 DOI: 10.25259/sni_303_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/16/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Intraoperative imaging addresses the limitations of frameless neuronavigation systems by providing real-time image updates. With the advent of new multidetector intraoperative computed tomography (CT), soft tissue can be visualized far better than before. We report the early departmental experience of our intraoperative CT scanner’s use in a wide range of technically challenging neurosurgical cases. Methods: We retrospectively analyzed the data of all patients in whom intraoperative CT scanner was utilized. Out of 31 patients, 24 (77.4%) were cranial and 8 (22.6%) spinal cases. There were 13 male (41.9%) and 18 (58.1%) female patients, age ranged from 1 to 83 years with a mean age of 34.29 years ±17.54 years. Seven patients underwent spinal surgery, 2 cases were of orbital tumors, and 16 intra-axial brain tumors, including 5 low- grade gliomas, 10 high-grade gliomas, and 1 colloid cyst. There were four sellar lesions and two multiloculated hydrocephalus. Results: The intraoperative CT scan guided us to correct screw placement and was crucial in managing four complex spinal instabilities. In intracranial lesions, 59% of cases were benefitted due to intraoperative CT scan. It helped in the precise placement of ventricular catheter in multiloculated hydrocephalus and external ventricular drain for a third ventricular colloid cyst. Conclusion: Intraoperative CT scan is safe and logistically and financially advantageous. It provides versatile benefits allowing for safe and maximal surgery, requiring minimum changes to an existing neurosurgical setup. Intraoperative CT scan provides clinical benefit in technically difficult cases and has a smooth workflow.
Collapse
Affiliation(s)
- Mohammad Ashraf
- rd Year Medical Student, University of Glasgow, Wolfson School of Medicine, Glasgow, Scotland, United Kingdom.,Visiting Medical Student, Allama Iqbal Medical College, Department of Neurosurgery, Jinnah Hospital, Lahore, Pakistan
| | - Nabeel Choudhary
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Syed Shahzad Hussain
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| |
Collapse
|
50
|
Braun BJ, Grimm B, Hanflik AM, Marmor MT, Richter PH, Sands AK, Sivananthan S. Finding NEEMO: towards organizing smart digital solutions in orthopaedic trauma surgery. EFORT Open Rev 2020; 5:408-420. [PMID: 32818068 PMCID: PMC7407868 DOI: 10.1302/2058-5241.5.200021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
There are many digital solutions which assist the orthopaedic trauma surgeon. This already broad field is rapidly expanding, making a complete overview of the existing solutions difficult.The AO Foundation has established a task force to address the need for an overview of digital solutions in the field of orthopaedic trauma surgery.Areas of new technology which will help the surgeon gain a greater understanding of these possible solutions are reviewed.We propose a categorization of the current needs in orthopaedic trauma surgery matched with available or potential digital solutions, and provide a narrative overview of this broad topic, including the needs, solutions and basic rules to ensure adequate use in orthopaedic trauma surgery. We seek to make this field more accessible, allowing for technological solutions to be clearly matched to trauma surgeons' needs. Cite this article: EFORT Open Rev 2020;5:408-420. DOI: 10.1302/2058-5241.5.200021.
Collapse
Affiliation(s)
- Benedikt J Braun
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Germany
| | | | | | - Meir T Marmor
- Department of Orthopaedic Surgery, University of California, San Francisco, California, USA
| | - Peter H Richter
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Germany
| | - Andrew K Sands
- Weill Cornell Medical College, Foot and Ankle Surgery, Downtown Orthopedic Associates, New York Presbyterian Lower Manhattan Hospital, New York, USA
| | | |
Collapse
|