ABSTRACT
Spatial accuracy in electrophysiological investigations is paramount, as precise localization and reliable access to specific brain regions help the advancement of our understanding of the brain's complex neural activity. Here, we introduce a novel, multi camera-based, frameless neuronavigation technique for precise, 3-dimensional electrode positioning in awake monkeys. The investigation of neural functions in awake primates often requires stable access to the brain with thin and delicate recording electrodes. This is usually realized by implanting a chronic recording chamber onto the skull of the animal that allows direct access to the dura. Most recording and positioning techniques utilize this implanted recording chamber as a holder of the microdrive or to hold a grid. This in turn reduces the degrees of freedom in positioning. To solve this problem, we require innovative, flexible, but precise tools for neuronal recordings. We instead mount the electrode microdrive above the animal on an arch, equipped with a series of translational and rotational micromanipulators, allowing movements in all axes. Here, the positioning is controlled by infrared cameras tracking the location of the microdrive and the monkey, allowing precise and flexible trajectories. To verify the accuracy of this technique, we created iron deposits in the tissue that could be detected by MRI. Our results demonstrate a remarkable precision with the confirmed physical location of these deposits averaging less than 0.5 mm from their planned position. Pilot electrophysiological recordings additionally demonstrate the accuracy and flexibility of this method. Our innovative approach could significantly enhance the accuracy and flexibility of neural recordings, potentially catalyzing further advancements in neuroscientific research.
Subject(s)
Brain , Electrodes, Implanted , Animals , Brain/physiology , Neuronavigation/methods , Neuronavigation/instrumentation , Macaca mulatta , Imaging, Three-Dimensional/methods , Imaging, Three-Dimensional/instrumentation , Male , Wakefulness/physiology , MacacaABSTRACT
BACKGROUND: Ventriculoscopic neuronavigation has been described in several articles. However, there are different ventriculoscopes and navigation systems. Due to these different combinations, it is difficult to find detailed neuronavigation protocols. We describe, step-by-step, a simple method to navigate both the trajectory until reaching the ventricular system, as well as the intraventricular work. METHODS: We use a rigid ventriculoscope (LOTTA, KarlStorz) with an electromagnetic stylet (S8-StealthSystem, Medtronic). The protocol is based on a modified or 3-dimensionally printed trocar for navigating the extraventricular step and on a modified pediatric nasogastric tube for the intraventricular navigation. RESULTS: This protocol can be set up in less than 10 minutes. The extraventricular part is navigated by introducing the electromagnetic stylet inside the modified or 3-dimensionally printed trocar. Intraventricular navigation is done by combining a modified pediatric nasogastric tube with the electromagnetic stylet inside the endoscope's working channel. The most critical point is to obtain a blunt-bloodless ventriculostomy while achieving perfect alignment of all targeted structures via pure straight trajectories. CONCLUSIONS: This protocol is easy-to-set-up, avoids head rigid-fixation and bulky optical-based attachments to the ventriculoscope, and allows continuous navigation of both parts of the surgery. Since we have implemented this protocol, we have noticed a significant enhancement in both simple and complex ventriculoscopic procedures because the surgery is dramatically simplified.
Subject(s)
Neuroendoscopes , Neuroendoscopy , Neuronavigation , Ventriculostomy , Workflow , Humans , Neuronavigation/methods , Neuronavigation/instrumentation , Neuroendoscopy/methods , Neuroendoscopy/instrumentation , Ventriculostomy/methods , Ventriculostomy/instrumentation , Electromagnetic Phenomena , Printing, Three-DimensionalABSTRACT
BACKGROUND AND OBJECTIVES: To assess the feasibility, accuracy, and safety of 3-dimensional (3D) structure light robot-assisted frameless stereotactic brain biopsy. METHODS: Five consecutive patients (3 males, 2 females) were included in this study. The patients' clinical, imaging, and histological data were analyzed, and all patients received a 3D structure light robot-assisted frameless stereotactic brain biopsy. The raw and/or analyzed data of the study are available from the corresponding author. RESULTS: The statistical results showed a mean age of 59.6 years (range 40-70 years), a mean target depth of 60.9 mm (range 53.5-65.8 mm), a mean radial error of 1.2 ± 0.7 mm (mean ± SD), a mean depth error of 0.7 ± 0.3 mm, and a mean absolute tip error of 1.5 ± 0.6 mm. The calculated Pearson product-moment correlation coefficient ( r = 0.23) revealed no correlation between target depth and absolute tip error. All biopsy needles were placed in line with the planned trajectory successfully, and diagnostic specimens were harvested in all cases. Histopathological analysis revealed lymphoma (2 cases), lung adenocarcinoma (1 case), glioblastoma multiforme (1 case), and oligodendroglioma (1 case). CONCLUSION: Surface registration using the 3D structure light technique is fast and precise because of the achievable million-scale point cloud data of the head and face. 3D structure light robot-assisted frameless stereotactic brain biopsy is feasible, accurate, and safe.
Subject(s)
Imaging, Three-Dimensional , Stereotaxic Techniques , Humans , Middle Aged , Female , Male , Adult , Aged , Imaging, Three-Dimensional/methods , Brain Neoplasms/diagnostic imaging , Brain Neoplasms/pathology , Robotic Surgical Procedures/methods , Robotic Surgical Procedures/instrumentation , Brain/pathology , Brain/diagnostic imaging , Feasibility Studies , Biopsy/methods , Biopsy/instrumentation , Neuronavigation/methods , Neuronavigation/instrumentationABSTRACT
BACKGROUND AND OBJECTIVES: Robot-assisted biopsies have gained popularity in the last years. Most robotic procedures are performed with a floor-based robotic arm. Recently, Medtronic Stealth Autoguide, a miniaturized robotic arm that work together with an optical neuronavigation system, was launched. Its application in pediatric cases is relatively unexplored. In this study, we retrospectively report our experience using the Stealth Autoguide, for frameless stereotactic biopsies in pediatric patients. METHODS: Pediatric patients who underwent stereotactic biopsy using the Stealth Autoguide cranial robotic platform from July 2020 to May 2023 were included in this study. Clinical, neuroradiological, surgical, and histological data were collected and analyzed. RESULTS: Nineteen patients underwent 20 procedures (mean age was 9-year-old, range 1-17). In four patients, biopsy was part of a more complex surgical procedure (laser interstitial thermal therapy - LITT). The most common indication was diffuse intrinsic brain stem tumor, followed by diffuse supratentorial tumor. Nine procedures were performed in prone position, eight in supine position, and three in lateral position. Facial surface registration was adopted in six procedures, skull-fixed fiducials in 14. The biopsy diagnostic tissue acquisition rate was 100% in the patients who underwent only biopsy, while in the biopsy/LITT group, one case was not diagnostic. No patients developed clinically relevant postoperative complications. CONCLUSION: The Stealth Autoguide system has proven to be safe, diagnostic, and highly accurate in performing stereotactic biopsies for both supratentorial and infratentorial lesions in the pediatric population.
Subject(s)
Image-Guided Biopsy , Robotic Surgical Procedures , Humans , Child , Male , Female , Child, Preschool , Adolescent , Robotic Surgical Procedures/methods , Robotic Surgical Procedures/instrumentation , Retrospective Studies , Image-Guided Biopsy/instrumentation , Image-Guided Biopsy/methods , Infant , Brain Neoplasms/surgery , Brain Neoplasms/pathology , Brain Neoplasms/diagnostic imaging , Neuronavigation/methods , Neuronavigation/instrumentation , Stereotaxic Techniques/instrumentationABSTRACT
BACKGROUND: Endoscopic transnasal transclival intradural surgery is limited by a high postoperative cerebrospinal fluid leak rate. The aim of this study was to investigate the role of three-dimensional printing to create a personalized, rigid scaffold for clival reconstruction. METHODS: Two different types of clivectomy were performed in 5 specimens with the aid of neuronavigation, and 11 clival reconstructions were simulated. They were repaired with polylactide, three-dimensional-printed scaffolds that were manually designed in a computer-aided environment based either on the real or on the predicted defect. Scaffolds were printed with a fused filament fabrication technique and different offsets. They were positioned and fixed either following the gasket seal technique or with screws. Postdissection radiological evaluation of scaffold position was performed in all cases. In 3 specimens, the cerebrospinal fluid leak pressure point was measured immediately after reconstruction. RESULTS: The production process took approximately 30 hours. The designed scaffolds were satisfactory when no offset was added. Wings were added during the design to allow for screw positioning, but broke in 30% of cases. Radiological assessment documented maximal accuracy of scaffold positioning when the scaffold was created on the real defect; accuracy was satisfactory when the predicted clivectomy was performed under neuronavigation guidance. The cerebrospinal fluid leak pressure point was significantly higher when the scaffold was fixed with screws compared with the gasket technique. CONCLUSIONS: In this preclinical setting, additive manufacturing allows the creation of customized scaffolds that are effective in reconstructing even large and geometrically complex clival defects.
Subject(s)
Cranial Fossa, Posterior/diagnostic imaging , Cranial Fossa, Posterior/surgery , Neuroendoscopy/methods , Plastic Surgery Procedures/methods , Precision Medicine/methods , Proof of Concept Study , Bone Screws/adverse effects , Cerebrospinal Fluid Leak/diagnostic imaging , Cerebrospinal Fluid Leak/etiology , Computer Simulation , Humans , Imaging, Three-Dimensional/methods , Neuroendoscopy/instrumentation , Neuronavigation/instrumentation , Neuronavigation/methods , Precision Medicine/instrumentation , Printing, Three-Dimensional/instrumentation , Plastic Surgery Procedures/instrumentation , Skull Base/diagnostic imaging , Skull Base/surgery , Tomography, X-Ray Computed/methodsABSTRACT
BACKGROUND: Neurosurgeons have limited tools in their armamentarium to visualize critical brain networks during surgical planning. Quicktome was designed using machine-learning to generate robust visualization of important brain networks that can be used with standard neuronavigation to minimize those deficits. We sought to see whether Quicktome could help localize important cerebral networks and tracts during intracerebral surgery. METHODS: We report on all patients who underwent keyhole intracranial surgery with available Quicktome-enabled neuronavigation. We retrospectively analyzed the locations of the lesions and determined functional networks at risks, including chief executive network, default mode network, salience, corticospinal/sensorimotor, language, neglect, and visual networks. We report on the postoperative neurologic outcomes of the patients and retrospectively determined whether the outcomes could be explained by Quicktome's functional localizations. RESULTS: Fifteen high-risk patients underwent craniotomies for intra-axial tumors, with the exception of one meningioma and one case of leukoencephalopathy. Eight patients were male. The median age was 49.6 years. Quicktome was readily integrated in our existing navigation system in every case. New postoperative neurologic deficits occurred in 8 patients. All new deficits, except for one resulting from a postoperative stroke, were expected and could be explained by preoperative findings by Quicktome. In addition, in those who did not have new neurologic deficits, Quicktome offered explanations for their outcomes. CONCLUSIONS: Quicktome helps to visualize complex functional connectomic networks and tracts by seamlessly integrating into existing neuronavigation platforms. The added information may assist in reducing neurological deficits and offer explanations for postsurgical outcomes.
Subject(s)
Brain Mapping/methods , Brain Neoplasms/diagnostic imaging , Brain Neoplasms/surgery , Magnetic Resonance Imaging/methods , Neuronavigation/instrumentation , Neuronavigation/methods , Adult , Aged , Craniotomy , Female , Humans , Male , Middle Aged , Proof of Concept Study , Retrospective Studies , Treatment OutcomeABSTRACT
BACKGROUND: Minimally invasive surgical techniques have resulted in improved patient outcomes. One drawback has been the increased reliance on fluoroscopy and subsequent exposure to ionizing radiation. We have previously shown the efficacy of a novel instrument tracking system in cadaveric and preliminary clinical studies for commonplace orthopedic and spine procedures. In the present study, we examined the radiation and operative time using a novel instrument tracking system compared with standard C-arm fluoroscopy for patients undergoing minimally invasive lumbar fusion. METHODS: The radiation emitted, number of radiographs taken, and time required to complete 2 tasks were recorded between the instrument tracking systems and conventional C-arm fluoroscopy. The studied tasks included placement of the initial dilator through Kambin's triangle during percutaneous lumbar interbody fusion and placement of pedicle screws during both percutaneous lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion with or without instrument tracking. RESULTS: A total of 23 patients were included in the analysis encompassing 31 total levels. For the task of placing the initial dilator into Kambin's triangle, an average of 4.21 minutes (2.4 vs. 6.6 minutes; P = 0.002), 15 fluoroscopic images (5.4 vs. 20.5; P = 0.002), and 8.14 mGy (3.3 vs. 11.4; P = 0.011) were saved by instrument tracking. For pedicle screw insertion, an average of 5.69 minutes (3.97 vs. 9.67; P < 0.001), 14 radiographs (6.53 vs. 20.62; P < 0.001), and 7.89 mGy (2.98 vs. 10.87 mGy; P < 0.001) were saved per screw insertion. CONCLUSIONS: Instrument tracking, when used for minimally invasive lumbar fusion, leads to significant reductions in radiation and operative time compared with conventional fluoroscopy.
Subject(s)
Fluoroscopy/methods , Minimally Invasive Surgical Procedures/methods , Neuronavigation/methods , Operative Time , Radiation Exposure/prevention & control , Spinal Fusion/methods , Adult , Aged , Aged, 80 and over , Female , Fluoroscopy/instrumentation , Humans , Male , Middle Aged , Minimally Invasive Surgical Procedures/instrumentation , Neuronavigation/instrumentation , Pedicle Screws , Prospective Studies , Spinal Fusion/instrumentation , Tomography, X-Ray Computed/instrumentation , Tomography, X-Ray Computed/methodsABSTRACT
Historically, neoplasms which are located in the subcortical region of the brain are considered technically difficult to access. As such, tumours in these locations are usually avoided, due to the risks associated with traversing eloquent cortex, the disrupting of white matter tracts, or the need to use narrow corridors to approach the lesion. Tubular retractors are able to gently displace brain parenchyma and white matter in an atraumatic fashion to access these deep regions. We demonstrate a minimally invasive trans-sulcal parafascicular approach using the Brainpath system (NICO Corp, Indianapolis, Indiana) to a caudate head metastasis as a representative case.
Subject(s)
Brain Neoplasms/surgery , Neuronavigation/instrumentation , Neuronavigation/methods , Adenocarcinoma of Lung/secondary , Brain Neoplasms/secondary , Humans , Lung Neoplasms/pathology , Male , Microsurgery , Neoplasms, Multiple Primary/pathology , Urinary Bladder Neoplasms/pathologyABSTRACT
Obtaining intraoperative images of the spine in the obese patient and at the cervicothoracic junction have historically been technically difficult due to variable penetration and x-ray scatter. This is particularly true for spinal deformity cases, where clear visualization of the end plates is needed to determine if functional alignment has been restored to the spine. The novel "2D long film" functionality for the Medtronic O-arm is capable of capturing the x-ray backscatter, producing enhanced intraoperative images. Furthermore, images can be obtained along the gantry translation of the O-arm and combined into a single long image, optimizing the workflow of surgeons who use the O-arm for intraoperative navigation. The purpose of this report is to highlight 2 example spinal deformity cases that underscore the utility of this imaging technology. In both cases, standard intraoperative fluoroscopy visualization was unacceptable, so 2D long film images were obtained to assess postcorrection spinal alignment.
Subject(s)
Fluoroscopy , Neuronavigation/instrumentation , Neuronavigation/methods , Spinal Diseases/diagnostic imaging , Spinal Diseases/surgery , Adult , Humans , Male , Treatment OutcomeABSTRACT
BACKGROUND: We report on the first use of a digital 3-dimensional (3D) exoscope equipped with a 5-aminolevulinic acid (5-ALA) fluorescence visual system. METHODS: We conducted a prospective clinical trial to evaluate the utility and sensitivity/specificity of the Olympus Orbeye 3D digital exoscope when used to visualize 5-ALA-induced fluorescence in patients with high-grade glioma undergoing a clinically indicated craniotomy. At least 2 tissue samples were each obtained from regions of strong, weak. and no fluorescence and evaluated in a blinded manner by a neuropathologist. RESULTS: Twenty patients were enrolled. Intraoperative fluorescence was observed in 100% of subjects. One hundred twenty-one surgical specimens were collected for histopathological analysis; 40 with strong, 40 weak, and 41 with no visible fluorescence. Histopathology demonstrated 62.8% of samples (n = 76) contained abundant, 20.7% (n = 25) scarce, and 16.5% (n = 20) no tumor cells. Thirty-three of the 40 specimens (82.5%) in the strong fluorescence group correlated with abundant tumor cells and 7 (17.5%) with scarce. Twenty-nine of the 40 specimens (72.5%) in the weak fluorescence group correlated with abundant tumor cells, 7 (17.5%) with scarce, and 4 (10%) with none. Fourteen of the 41 (34.2%) specimens in the no fluorescence group had abundant tumor cells, 11 (26.8%) had scarce, and 16 (39%) had none. The sensitivity was 75% and specificity was 80%. The positive predictive value was 95% and negative predictive value was 39%. CONCLUSIONS: Visualization of 5-ALA-induced tumor fluorescence with use of the Orbeye 3D digital exoscope was feasible and associated with a high positive predictive value.
Subject(s)
Aminolevulinic Acid/metabolism , Brain Neoplasms/metabolism , Glioma/metabolism , Monitoring, Intraoperative/methods , Optical Imaging/methods , Photosensitizing Agents/metabolism , Adult , Aged , Brain Neoplasms/diagnostic imaging , Brain Neoplasms/surgery , Female , Follow-Up Studies , Glioma/diagnostic imaging , Glioma/surgery , Humans , Imaging, Three-Dimensional/instrumentation , Imaging, Three-Dimensional/methods , Imaging, Three-Dimensional/standards , Male , Middle Aged , Monitoring, Intraoperative/instrumentation , Monitoring, Intraoperative/standards , Neoplasm Grading/instrumentation , Neoplasm Grading/methods , Neuronavigation/instrumentation , Neuronavigation/methods , Neuronavigation/standards , Optical Imaging/instrumentation , Optical Imaging/standards , Prospective StudiesABSTRACT
Recently, spine surgery has gradually evolved from conventional open surgery to minimally invasive surgery, and endoscopic spine surgery (ESS) has become an important procedure in minimally invasive spine surgery. With improvements in the optics, spine endoscope, endoscopic burr, and irrigation pump, the indications of ESS are gradually widening from lumbar to cervical and thoracic spine. ESS was not only used previously for disc herniations that were contained without migration but is also used currently for highly migrated disc herniations and spinal stenosis; thus, the indications of ESS will be further expanded. Although ESS has certain advantages such as less soft tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent less epidural fibrosis and scarring, reduced hospital stay, early functional recovery, and improvement of quality of life as well as better cosmesis, several obstacles remain for ESS to be widespread because it has a steep learning curve and surgical outcome is strongly dependent on the surgeon's skillfulness. A solid surgical technique requires reproducibility and ensured safety in addition to surgical outcomes. In this review article, how to improve ESS was investigated by grafting novel technologies such as navigation, robotics, and 3-dimensional and ultraresolution visualization.
Subject(s)
Endoscopy/instrumentation , Endoscopy/trends , Neuroendoscopy/instrumentation , Neuroendoscopy/trends , Neuronavigation/instrumentation , Neuronavigation/trends , Neurosurgical Procedures/instrumentation , Neurosurgical Procedures/trends , Robotics/trends , Spine/surgery , Humans , Intervertebral Disc Displacement/surgery , Spinal Stenosis/surgery , Surgery, Computer-AssistedABSTRACT
Minimally invasive spine surgery techniques for pedicle screw instrumentation are being more frequently used. They offer shorter operative times, shorter hospital stays for patients, faster recovery, less blood loss, and less damage to surrounding tissues. However, they may rely heavily on fluoroscopic imaging, and confer radiation exposure to the surgeon and team members. Use of the AIRO Mobile Intraoperative CT by Brainlab during surgery is a way to eliminate radiation exposure to staff and may improve accuracy rates for pedicle screw instrumentation. We designed a retrospective analysis of our first 12 patients who had a total of 59 pedicle screws inserted when we began to incorporate the AIRO iCT scanner to our surgical workflow. During pedicle screw insertion, projection images were saved, and compared to CT scans gone at the end of the case. We measured the distances between the projected and postprocedural screw locations, at both the screw tips and tulip heads. We observed a mean of 2.8â¯mm difference between the projection and postprocedural images. None of the screws inserted had any clinically significant complications, and no patient required revision surgery. Overall, iCT guided navigation with the AIRO system is a safe adjunct to spinal surgery. It decreased operator and staff radiation exposure, and helped facilitate successful MIS surgery without fluoroscopic imaging. Additional studies and research can be done to further improve accuracy and reliability.
Subject(s)
Intraoperative Neurophysiological Monitoring/instrumentation , Intraoperative Neurophysiological Monitoring/methods , Neuronavigation/instrumentation , Neuronavigation/methods , Pedicle Screws , Spinal Cord Diseases/surgery , Spinal Fusion/methods , Tomography, X-Ray Computed , Adult , Aged , Humans , Middle Aged , Minimally Invasive Surgical Procedures/methods , Retrospective Studies , Young AdultABSTRACT
OBJECTIVE: Electromagnetic (EM) navigation provides the advantages of continuous guidance and tip-tracking of instruments. The current solutions for patient reference trackers are suboptimal, as they are either invasively screwed to the bone or less accurate if attached to the skin. The authors present a novel EM reference method with the tracker rigidly but not invasively positioned inside the nasal cavity. METHODS: The nasal tracker (NT) consists of the EM coil array of the AxiEM tracker plugged into a nasal tamponade, which is then inserted into the inferior nasal meatus. Initially, a proof-of-concept study was performed on two cadaveric skull bases. The stability of the NT was assessed in simulated surgical situations, for example, prone, supine, and lateral patient positioning and skin traction. A deviation ≤ 2 mm was judged sufficiently accurate for clinical trial. Thus, a feasibility study was performed in the clinical setting. Positional changes of the NT and a standard skin-adhesive tracker (ST) relative to a ground-truth reference tracker were recorded throughout routine surgical procedures. The accuracy of the NT and ST was compared at different stages of surgery. RESULTS: Ex vivo, the NT proved to be highly stable in all simulated surgical situations (median deviation 0.4 mm, range 0.0-2.0 mm). In 13 routine clinical cases, the NT was significantly more stable than the ST (median deviation at procedure end 1.3 mm, range 0.5-3.0 mm vs 4.0 mm, range 1.2-11.2 mm, p = 0.002). The loss of accuracy of the ST was highest during draping and flap fixation. CONCLUSIONS: Application of the EM endonasal patient tracker was found to be feasible with high procedural stability ex vivo as well as in the clinical setting. This innovation combines the advantages of high precision and noninvasiveness and may, in the future, enhance EM navigation for neurosurgery.
Subject(s)
Electromagnetic Phenomena , Nasal Cavity/diagnostic imaging , Neuronavigation/methods , Neurosurgical Procedures/methods , Patient Identification Systems/methods , Adult , Aged , Feasibility Studies , Female , Humans , Male , Middle Aged , Nasal Cavity/surgery , Neuronavigation/instrumentation , Neurosurgical Procedures/instrumentation , Surgery, Computer-Assisted/instrumentation , Surgery, Computer-Assisted/methodsABSTRACT
BACKGROUND: Comparative evaluation of long sheath performance in stroke thrombectomy has not been performed. OBJECTIVE: To review an initial experience with the new Ballast 6F long sheath compared with the NeuronMax, to evaluate comparative benchmarks in trackability, navigability, and procedural outcomes. METHODS: A prospectively maintained thrombectomy database was evaluated over a 6-month period to compare procedural and angiographic results between a cohort of patients treated with the historical institutional standard long sheath (NeuronMax) and another with the new Ballast long sheath via a transfemoral approach. RESULTS: Of 156 stroke thrombectomy cases, 69 were performed using NeuronMax and 40 using Ballast via a transfemoral approach; the remainder of cases employed alternative long sheaths or were performed via initial radial access. There was no significant difference in patient age, medical history, baseline National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, arch type, tissue plasminogen activator use, and clot location between the two groups. Single-pass case frequency (41% for NeuronMax vs 44% for Ballast, p=0.84), and final successful revascularization (TICI 2b or greater) were similar between the two cohorts (91% vs 98%, p=0.42). Good 90-day outcome (modified Rankin Scale score 0-2) was also similar (33% for NeuronMax, 43% for Ballast, p=0.41). Excluding tandem occlusions, mean procedural time was 31 min for NeuronMax and 25 min for Ballast (p=0.09). Puncture to long sheath access and angiography in the base target vessel was faster for Ballast than NeuronMax (6.5 min vs 9.2 min, p=0.04). CONCLUSION: Among a cohort of practitioners with historical, preferential experience with NeuronMax for stroke thrombectomy, faster procedural times were achieved with Ballast with similar final angiographic results.
Subject(s)
Catheters , Neuronavigation/instrumentation , Stroke/diagnostic imaging , Stroke/surgery , Thrombectomy/instrumentation , Aged , Aged, 80 and over , Brain Ischemia/diagnostic imaging , Brain Ischemia/surgery , Cohort Studies , Female , Humans , Male , Middle Aged , Neuronavigation/methods , Prospective Studies , Radial Artery/diagnostic imaging , Radial Artery/surgery , Thrombectomy/methods , Treatment OutcomeABSTRACT
Frame-based stereotaxy is widely used for planning and implanting deep-brain electrodes. In 2013, as part of a clinical study on deep-brain stimulation for treatment-resistant depression, our group identified a need for software to simulate and plan stereotactic procedures. Shortcomings in extant commercial systems encouraged us to develop Tactics. Tactics is purpose-designed for frame-based stereotactic placement of electrodes. The workflow is far simpler than commercial systems. By simulating specific electrode placement, immediate in-context view of each electrode contact, and the cortical entry site are available within seconds. Post implantation, electrode placement is verified by linearly registering post-operative images. Tactics has been particularly helpful for invasive electroencephalography electrodes where as many as 20 electrodes are planned and placed within minutes. Currently, no commercial system has a workflow supporting the efficient placement of this many electrodes. Tactics includes a novel implementation of automated frame localization and a user-extensible mechanism for importing electrode specifications for visualization of individual electrode contacts. The system was systematically validated, through comparison against gold-standard techniques and quantitative analysis of targeting accuracy using a purpose-built imaging phantom mountable by a stereotactic frame. Internal to our research group, Tactics has been used to plan over 300 depth-electrode targets and trajectories in over 50 surgical cases, and to plan dozens of stereotactic biopsies. Source code and pre-built binaries for Tactics are public and open-source, enabling use and contribution by the extended community.
Subject(s)
Software , Stereotaxic Techniques , Surgery, Computer-Assisted , Brain/surgery , Computer Simulation , Deep Brain Stimulation/instrumentation , Deep Brain Stimulation/methods , Electrodes, Implanted , Electroencephalography/instrumentation , Electroencephalography/methods , Humans , Imaging, Three-Dimensional , Neuronavigation/instrumentation , Neuronavigation/methods , Phantoms, Imaging , Preoperative Care , Stereotaxic Techniques/instrumentation , Surgery, Computer-Assisted/instrumentation , Surgery, Computer-Assisted/methods , WorkflowABSTRACT
BACKGROUND: Optical neuronavigation-guided intracranial surgery has become increasingly common in veterinary medicine, but its use has not yet been described in horses. OBJECTIVES: To determine the feasibility of optical neuronavigation-guided intracranial biopsy procedures in the horse, compare the use of the standard fiducial array and anatomic landmarks for patient registration, and evaluate surgeon experience. ANIMALS: Six equine cadaver heads. METHODS: Computed tomography images of each specimen were acquired, with the fiducial array rigidly secured to the frontal bone. Six targets were selected in each specimen. Patient registration was performed separately for 3 targets using the fiducial array, and for 3 targets using anatomic landmarks. In lieu of biopsy, 1 mm diameter wire seeds were placed at each target. Postoperative images were coregistered with the planning scan to calculate Euclidian distance from the tip of the seed to the target. RESULTS: No statistical difference between registration techniques was identified. The impact of surgeon experience was examined for each technique using a Mann-Whitney U test. The experienced surgeon was significantly closer to the intended target (median = 2.52 mm) than were the novice surgeons (median = 6.55 mm) using the fiducial array (P = .001). Although not statistically significant (P = .31), for the experienced surgeon the median distance to target was similar when registering with the fiducial array (2.47 mm) and anatomic landmarks (2.58 mm). CONCLUSIONS AND CLINICAL IMPORTANCE: Registration using both fiducial arrays and anatomic landmarks for brain biopsy using optical neuronavigation in horses is feasible.
Subject(s)
Biopsy/veterinary , Brain/surgery , Horses/surgery , Neuronavigation/veterinary , Anatomic Landmarks , Animals , Biopsy/methods , Neuronavigation/instrumentation , Neuronavigation/methods , Pilot ProjectsABSTRACT
BACKGROUND: Precise insertion of pedicle screws is important to avoid injury to closely adjacent neurovascular structures. The standard method for the insertion of pedicle screws is based on anatomical landmarks (free-hand technique). Head-mounted augmented reality (AR) devices can be used to guide instrumentation and implant placement in spinal surgery. This study evaluates the feasibility and precision of AR technology to improve precision of pedicle screw insertion compared to the current standard technique. METHODS: Two board-certified orthopedic surgeons specialized in spine surgery and two novice surgeons were each instructed to drill pilot holes for 40 pedicle screws in eighty lumbar vertebra sawbones models in an agar-based gel. One hundred and sixty pedicles were randomized into two groups: the standard free-hand technique (FH) and augmented reality technique (AR). A 3D model of the vertebral body was superimposed over the AR headset. Half of the pedicles were drilled using the FH method, and the other half using the AR method. RESULTS: The average minimal distance of the drill axis to the pedicle wall (MAPW) was similar in both groups for expert surgeons (FH 4.8 ± 1.0 mm vs. AR 5.0 ± 1.4 mm, p = 0.389) but for novice surgeons (FH 3.4 mm ± 1.8 mm, AR 4.2 ± 1.8 mm, p = 0.044). Expert surgeons showed 0 primary drill pedicle perforations (PDPP) in both the FH and AR groups. Novices showed 3 (7.5%) PDPP in the FH group and one perforation (2.5%) in the AR group, respectively (p > 0.005). Experts showed no statistically significant difference in average secondary screw pedicle perforations (SSPP) between the AR and the FH set 6-, 7-, and 8-mm screws (p > 0.05). Novices showed significant differences of SSPP between most groups: 6-mm screws, 18 (45%) vs. 7 (17.5%), p = 0.006; 7-mm screws, 20 (50%) vs. 10 (25%), p = 0.013; and 8-mm screws, 22 (55%) vs. 15 (37.5%), p = 0.053, in the FH and AR group, respectively. In novices, the average optimal medio-lateral convergent angle (oMLCA) was 3.23° (STD 4.90) and 0.62° (STD 4.56) for the FH and AR set screws (p = 0.017), respectively. Novices drilled with a higher precision with respect to the cranio-caudal inclination angle (CCIA) category (p = 0.04) with AR. CONCLUSION: In this study, the additional anatomical information provided by the AR headset superimposed to real-world anatomy improved the precision of drilling pilot holes for pedicle screws in a laboratory setting and decreases the effect of surgeon's experience. Further technical development and validations studies are currently being performed to investigate potential clinical benefits of the herein described AR-based navigation approach.
Subject(s)
Augmented Reality , Imaging, Three-Dimensional/methods , Neuronavigation/methods , Pedicle Screws , Surgery, Computer-Assisted/methods , Vertebral Body/surgery , Humans , Lumbar Vertebrae/anatomy & histology , Lumbar Vertebrae/surgery , Neuronavigation/instrumentation , Random Allocation , Surgery, Computer-Assisted/instrumentation , Vertebral Body/anatomy & histologyABSTRACT
OBJECTIVE: This study aimed to report the technical advancement to improve the accuracy of cervical pedicle screw (CPS) placement using O-arm-based 3D navigation. METHODS: Sixty-four patients who underwent CPS using O-arm in the spine level of C2 to C7 between June 2013 and February 2020 were involved. In the first phase, a reference frame was placed onto the spinous process of the cranial vertebrae and used it at a maximum of 3 vertebral levels. The navigation guide sleeve was used to drill a screw hole. In the second phase, a reference frame that can hold 3 vertebrae was introduced. In the third phase, a drill guide sleeve to minimize bending of the drill tip was developed. In the fourth phase, navigated surgical drill was introduced. Screw accuracy was assessed using Neo classification: grade (G) 0, no perforation; G1, perforation <2 mm; G2, perforation 2-4 mm; and G3, perforation >4 mm. RESULTS: Mean age at surgery was 67 (19-88) years. A total of 317 CPSs were inserted. In total, 83 screws were inserted in the first phase, 60 in the second phase, 87 in the third phase, and 87 in the fourth phase. The total proportion of malpositioning was 3.8% (12/317 screws) and all were G1; 6.0% (5/83 screws) in the first phase, 8.3% (5/60 screws) in the second phase, 1.2% (1/87 screws) in the third phase, and 1.2% (1/87 screws) in the fourth phase (P < 0.05). CONCLUSIONS: O-arm use improved CPS placement accuracy with the advancement of techniques and instruments.
Subject(s)
Imaging, Three-Dimensional/methods , Neuronavigation/instrumentation , Neuronavigation/methods , Spinal Fusion/instrumentation , Spinal Fusion/methods , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Pedicle Screws , Spinal Diseases/surgery , Young AdultABSTRACT
This article emphasizes the role of the technological progress in changing the landscape of epilepsy surgery and provides a critical appraisal of robotic applications, laser interstitial thermal therapy, intraoperative imaging, wireless recording, new neuromodulation techniques, and high-intensity focused ultrasound. Specifically, (a) it relativizes the current hype in using robots for stereo-electroencephalography (SEEG) to increase the accuracy of depth electrode placement and save operating time; (b) discusses the drawback of laser interstitial thermal therapy (LITT) when it comes to the need for adequate histopathologic specimen and the fact that the concept of stereotactic disconnection is not new; (c) addresses the ratio between the benefits and expenditure of using intraoperative magnetic resonance imaging (MRI), that is, the high technical and personnel expertise needed that might restrict its use to centers with a high case load, including those unrelated to epilepsy; (d) soberly reviews the advantages, disadvantages, and future potentials of neuromodulation techniques with special emphasis on the differences between closed and open-loop systems; and (e) provides a critical outlook on the clinical implications of focused ultrasound, wireless recording, and multipurpose electrodes that are already on the horizon. This outlook shows that although current ultrasonic systems do have some limitations in delivering the acoustic energy, further advance of this technique may lead to novel treatment paradigms. Furthermore, it highlights that new data streams from multipurpose electrodes and wireless transmission of intracranial recordings will become available soon once some critical developments will be achieved such as electrode fidelity, data processing and storage, heat conduction as well as rechargeable technology. A better understanding of modern epilepsy surgery will help to demystify epilepsy surgery for the patients and the treating physicians and thereby reduce the surgical treatment gap.
Subject(s)
Epilepsy/surgery , Robotic Surgical Procedures/instrumentation , Brain/physiopathology , Brain/surgery , Electroencephalography/instrumentation , Electroencephalography/methods , High-Intensity Focused Ultrasound Ablation/instrumentation , High-Intensity Focused Ultrasound Ablation/methods , Humans , Laser Coagulation/instrumentation , Laser Coagulation/methods , Laser Therapy/instrumentation , Laser Therapy/methods , Magnetic Resonance Imaging, Interventional/instrumentation , Magnetic Resonance Imaging, Interventional/methods , Neuronavigation/instrumentation , Neuronavigation/methods , Robotic Surgical Procedures/methods , RoboticsABSTRACT
BACKGROUND: Electromagnetic (EM) localization has typically been used to direct shunt catheters into the ventricle. The objective of this study was to determine if this method of EM tracking could be used in a deep brain stimulation (DBS) electrode cannula to accurately predict the eventual location of the electrode contacts. METHODS: The Medtronic AxiEMTM system was used to generate the cannula tip location directed to the planned target site. Prior to clinical testing, a series of phantom modelling observations were made. RESULTS: Phantom trials (n = 23) demonstrated that the cannula tip could be accurately located at the target site with an error of between 0.331 ± 0.144 and 0.6 ± 0.245 mm, depending on the orientation of the delivery system to the axis of the phantom head. Intraoperative EM localization of the DBS cannula was performed in 84 trajectories in 48 patients. The average difference between the planned target and the EM stylet location at the cannula tip was 1.036 ± 0.543 mm. The average error between the planned target coordinates and the actual target electrode location (by CT) was 1.431 ± 0.607 and 1.145 ± 0.636 mm for the EM stylet location in the cannula (p = 0.00312), indicating that EM localization reflected the position of the target electrode more accurately than the planned target. CONCLUSIONS: EM localization can be used to verify the position of DBS electrodes intraoperatively with a high accuracy.