Planning, guidance, and quality assurance of pelvic screw placement using deformable image registration.

Percutaneous pelvic screw placement is challenging due to narrow bone corridors surrounded by vulnerable structures and difficult visual interpretation of complex anatomical shapes in 2D x-ray projection images. To address these challenges, a system for planning, guidance, and quality assurance (QA) is presented, providing functionality analogous to surgical navigation, but based on robust 3D-2D image registration techniques using fluoroscopy images already acquired in routine workflow. Two novel aspects of the system are investigated: automatic planning of pelvic screw trajectories and the ability to account for deformation of surgical devices (K-wire deflection). Atlas-based registration is used to calculate a patient-specific plan of screw trajectories in preoperative CT. 3D-2D registration aligns the patient to CT within the projective geometry of intraoperative fluoroscopy. Deformable known-component registration (dKC-Reg) localizes the surgical device, and the combination of plan and device location is used to provide guidance and QA. A leave-one-out analysis evaluated the accuracy of automatic planning, and a cadaver experiment compared the accuracy of dKC-Reg to rigid approaches (e.g. optical tracking). Surgical plans conformed within the bone cortex by 3-4 mm for the narrowest corridor (superior pubic ramus) and >5 mm for the widest corridor (tear drop). The dKC-Reg algorithm localized the K-wire tip within 1.1 mm and 1.4° and was consistently more accurate than rigid-body tracking (errors up to 9 mm). The system was shown to automatically compute reliable screw trajectories and accurately localize deformed surgical devices (K-wires). Such capability could improve guidance and QA in orthopaedic surgery, where workflow is impeded by manual planning, conventional tool trackers add complexity and cost, rigid tool assumptions are often inaccurate, and qualitative interpretation of complex anatomy from 2D projections is prone to trial-and-error with extended fluoroscopy time.

Deformable 3D-2D Registration for Guiding K-Wire Placement in Pelvic Trauma Surgery.

Pelvic Kirschner wire (K-wire) insertion is a challenging surgical task requiring interpretation of complex 3D anatomical shape from 2D projections (fluoroscopy) and delivery of device trajectories within fairly narrow bone corridors in proximity to adjacent nerves and vessels. Over long trajectories (~10-25 cm), K-wires tend to curve (deform), making conventional rigid navigation inaccurate at the tip location. A system is presented that provides accurate 3D localization and guidance of rigid or deformable surgical devices ("components" - e.g., K-wires) based on 3D-2D registration. The patient is registered to a preoperative CT image by virtually projecting digitally reconstructed radiographs (DRRs) and matching to two or more intraoperative x-ray projections. The K-wire is localized using an analogous procedure matching DRRs of a deformably parametrized model for the device component (deformable known-component registration, or dKC-Reg). A cadaver study was performed in which a K-wire trajectory was delivered in the pelvis. The system demonstrated target registration error (TRE) of 2.1 ± 0.3 mm in location of the K-wire tip (median ± interquartile range, IQR) and 0.8 ± 1.4° in orientation at the tip (median ± IQR), providing functionality analogous to surgical tracking/navigation using imaging systems already in the surgical arsenal without reliance on a surgical tracker. The method offers quantitative 3D guidance using images (e.g., inlet/outlet views) already acquired in the standard of care, potentially extending the advantages of navigation to broader utilization in trauma surgery to improve surgical precision and safety.

Analysis of 30 Spinal Angiograms Falsely Reported as Normal in 18 Patients with Subsequently Documented Spinal Vascular Malformations.

BACKGROUND AND PURPOSE: The early diagnosis of spinal vascular malformations suffers from the nonspecificity of their clinical and radiologic presentations. Spinal angiography requires a methodical approach to offer a high diagnostic yield. The prospect of false-negative studies is particularly distressing when addressing conditions with a narrow therapeutic window. The purpose of this study was to identify factors leading to missed findings or inadequate studies in patients with spinal vascular malformations. MATERIALS AND METHODS: The clinical records, laboratory findings, and imaging features of 18 patients with spinal arteriovenous fistulas and at least 1 prior angiogram read as normal were reviewed. The clinical status was evaluated before and after treatment by using the Aminoff-Logue Disability Scale. RESULTS: Eighteen patients with 19 lesions underwent a total of 30 negative spinal angiograms. The lesions included 9 epidural arteriovenous fistulas, 8 dural arteriovenous fistulas, and 2 perimedullary arteriovenous fistulas. Seventeen patients underwent endovascular (11) or surgical (6) treatment, with a delay ranging between 1 week and 32 months; the Aminoff-Logue score improved in 13 (76.5%). The following factors were identified as the causes of the inadequate results: 1) lesion angiographically documented but not identified (55.6%); 2) region of interest not documented (29.6%); or 3) level investigated but injection technically inadequate (14.8%). CONCLUSIONS: All the angiograms falsely reported as normal were caused by correctible, operator-dependent factors. The nonrecognition of documented lesions was the most common cause of error. The potential for false-negative studies should be reduced by the adoption of rigorous technical and training standards and by second opinion reviews.

Multi-stage 3D-2D registration for correction of anatomical deformation in image-guided spine surgery.

A multi-stage image-based 3D-2D registration method is presented that maps annotations in a 3D image (e.g. point labels annotating individual vertebrae in preoperative CT) to an intraoperative radiograph in which the patient has undergone non-rigid anatomical deformation due to changes in patient positioning or due to the intervention itself. The proposed method (termed msLevelCheck) extends a previous rigid registration solution (LevelCheck) to provide an accurate mapping of vertebral labels in the presence of spinal deformation. The method employs a multi-stage series of rigid 3D-2D registrations performed on sets of automatically determined and increasingly localized sub-images, with the final stage achieving a rigid mapping for each label to yield a locally rigid yet globally deformable solution. The method was evaluated first in a phantom study in which a CT image of the spine was acquired followed by a series of 7 mobile radiographs with increasing degree of deformation applied. Second, the method was validated using a clinical data set of patients exhibiting strong spinal deformation during thoracolumbar spine surgery. Registration accuracy was assessed using projection distance error (PDE) and failure rate (PDE > 20 mm-i.e. label registered outside vertebra). The msLevelCheck method was able to register all vertebrae accurately for all cases of deformation in the phantom study, improving the maximum PDE of the rigid method from 22.4 mm to 3.9 mm. The clinical study demonstrated the feasibility of the approach in real patient data by accurately registering all vertebral labels in each case, eliminating all instances of failure encountered in the conventional rigid method. The multi-stage approach demonstrated accurate mapping of vertebral labels in the presence of strong spinal deformation. The msLevelCheck method maintains other advantageous aspects of the original LevelCheck method (e.g. compatibility with standard clinical workflow, large capture range, and robustness against mismatch in image content) and extends capability to cases exhibiting strong changes in spinal curvature.

Spinal pedicle screw planning using deformable atlas registration.

Spinal screw placement is a challenging task due to small bone corridors and high risk of neurological or vascular complications, benefiting from precision guidance/navigation and quality assurance (QA). Implicit to both guidance and QA is the definition of a surgical plan-i.e. the desired trajectories and device selection for target vertebrae-conventionally requiring time-consuming manual annotations by a skilled surgeon. We propose automation of such planning by deriving the pedicle trajectory and device selection from a patient's preoperative CT or MRI. An atlas of vertebrae surfaces was created to provide the underlying basis for automatic planning-in this work, comprising 40 exemplary vertebrae at three levels of the spine (T7, T8, and L3). The atlas was enriched with ideal trajectory annotations for 60 pedicles in total. To define trajectories for a given patient, sparse deformation fields from the atlas surfaces to the input (CT or MR image) are applied on the annotated trajectories. Mean value coordinates are used to interpolate dense deformation fields. The pose of a straight trajectory is optimized by image-based registration to an accumulated volume of the deformed annotations. For evaluation, input deformation fields were created using coherent point drift (CPD) to perform a leave-one-out analysis over the atlas surfaces. CPD registration demonstrated surface error of 0.89 ± 0.10 mm (median ± interquartile range) for T7/T8 and 1.29 ± 0.15 mm for L3. At the pedicle center, registered trajectories deviated from the expert reference by 0.56 ± 0.63 mm (T7/T8) and 1.12 ± 0.67 mm (L3). The predicted maximum screw diameter differed by 0.45 ± 0.62 mm (T7/T8), and 1.26 ± 1.19 mm (L3). The automated planning method avoided screw collisions in all cases and demonstrated close agreement overall with expert reference plans, offering a potentially valuable tool in support of surgical guidance and QA.

Intraoperative evaluation of device placement in spine surgery using known-component 3D-2D image registration.

Intraoperative x-ray radiography/fluoroscopy is commonly used to assess the placement of surgical devices in the operating room (e.g. spine pedicle screws), but qualitative interpretation can fail to reliably detect suboptimal delivery and/or breach of adjacent critical structures. We present a 3D-2D image registration method wherein intraoperative radiographs are leveraged in combination with prior knowledge of the patient and surgical components for quantitative assessment of device placement and more rigorous quality assurance (QA) of the surgical product. The algorithm is based on known-component registration (KC-Reg) in which patient-specific preoperative CT and parametric component models are used. The registration performs optimization of gradient similarity, removes the need for offline geometric calibration of the C-arm, and simultaneously solves for multiple component bodies, thereby allowing QA in a single step (e.g. spinal construct with 4-20 screws). Performance was tested in a spine phantom, and first clinical results are reported for QA of transpedicle screws delivered in a patient undergoing thoracolumbar spine surgery. Simultaneous registration of ten pedicle screws (five contralateral pairs) demonstrated mean target registration error (TRE) of 1.1 ± 0.1 mm at the screw tip and 0.7 ± 0.4° in angulation when a prior geometric calibration was used. The calibration-free formulation, with the aid of component collision constraints, achieved TRE of 1.4 ± 0.6 mm. In all cases, a statistically significant improvement (p < 0.05) was observed for the simultaneous solutions in comparison to previously reported sequential solution of individual components. Initial application in clinical data in spine surgery demonstrated TRE of 2.7 ± 2.6 mm and 1.5 ± 0.8°. The KC-Reg algorithm offers an independent check and quantitative QA of the surgical product using radiographic/fluoroscopic views acquired within standard OR workflow. Such intraoperative assessment could improve quality and safety, provide the opportunity to revise suboptimal constructs in the OR, and reduce the frequency of revision surgery.

Registration of MRI to intraoperative radiographs for target localization in spinal interventions.

Decision support to assist in target vertebra localization could provide a useful aid to safe and effective spine surgery. Previous solutions have shown 3D-2D registration of preoperative CT to intraoperative radiographs to reliably annotate vertebral labels for assistance during level localization. We present an algorithm (referred to as MR-LevelCheck) to perform 3D-2D registration based on a preoperative MRI to accommodate the increasingly common clinical scenario in which MRI is used instead of CT for preoperative planning. Straightforward adaptation of gradient/intensity-based methods appropriate to CT-to-radiograph registration is confounded by large mismatch and noncorrespondence in image intensity between MRI and radiographs. The proposed method overcomes such challenges with a simple vertebrae segmentation step using vertebra centroids as seed points (automatically defined within existing workflow). Forwards projections are computed using segmented MRI and registered to radiographs via gradient orientation (GO) similarity and the CMA-ES (covariance-matrix-adaptation evolutionary-strategy) optimizer. The method was tested in an IRB-approved study involving 10 patients undergoing cervical, thoracic, or lumbar spine surgery following preoperative MRI. The method successfully registered each preoperative MRI to intraoperative radiographs and maintained desirable properties of robustness against image content mismatch and large capture range. Robust registration performance was achieved with projection distance error (PDE) (median ± IQR) = 4.3 ± 2.6 mm (median ± IQR) and 0% failure rate. Segmentation accuracy for the continuous max-flow method yielded dice coefficient = 88.1 ± 5.2, accuracy = 90.6 ± 5.7, RMSE = 1.8 ± 0.6 mm, and contour affinity ratio (CAR) = 0.82 ± 0.08. Registration performance was found to be robust for segmentation methods exhibiting RMSE <3 mm and CAR >0.50. The MR-LevelCheck method provides a potentially valuable extension to a previously developed decision support tool for spine surgery target localization by extending its utility to preoperative MRI while maintaining characteristics of accuracy and robustness.

Performance evaluation of MIND demons deformable registration of MR and CT images in spinal interventions.

Accurate intraoperative localization of target anatomy and adjacent nervous and vascular tissue is essential to safe, effective surgery, and multimodality deformable registration can be used to identify such anatomy by fusing preoperative CT or MR images with intraoperative images. A deformable image registration method has been developed to estimate viscoelastic diffeomorphisms between preoperative MR and intraoperative CT using modality-independent neighborhood descriptors (MIND) and a Huber metric for robust registration. The method, called MIND Demons, optimizes a constrained symmetric energy functional incorporating priors on smoothness, geodesics, and invertibility by alternating between Gauss-Newton optimization and Tikhonov regularization in a multiresolution scheme. Registration performance was evaluated for the MIND Demons method with a symmetric energy formulation in comparison to an asymmetric form, and sensitivity to anisotropic MR voxel-size was analyzed in phantom experiments emulating image-guided spine-surgery in comparison to a free-form deformation (FFD) method using local mutual information (LMI). Performance was validated in a clinical study involving 15 patients undergoing intervention of the cervical, thoracic, and lumbar spine. The target registration error (TRE) for the symmetric MIND Demons formulation (1.3 ± 0.8 mm (median ± interquartile)) outperformed the asymmetric form (3.6 ± 4.4 mm). The method demonstrated fairly minor sensitivity to anisotropic MR voxel size, with median TRE ranging 1.3-2.9 mm for MR slice thickness ranging 0.9-9.9 mm, compared to TRE = 3.2-4.1 mm for LMI FFD over the same range. Evaluation in clinical data demonstrated sub-voxel TRE (<2 mm) in all fifteen cases with realistic deformations that preserved topology with sub-voxel invertibility (0.001 mm) and positive-determinant spatial Jacobians. The approach therefore appears robust against realistic anisotropic resolution characteristics in MR and yields registration accuracy suitable to application in image-guided spine-surgery.

MIND Demons for MR-to-CT Deformable Image Registration In Image-Guided Spine Surgery.

PURPOSE: Localization of target anatomy and critical structures defined in preoperative MR images can be achieved by means of multi-modality deformable registration to intraoperative CT. We propose a symmetric diffeomorphic deformable registration algorithm incorporating a modality independent neighborhood descriptor (MIND) and a robust Huber metric for MR-to-CT registration. METHOD: The method, called MIND Demons, solves for the deformation field between two images by optimizing an energy functional that incorporates both the forward and inverse deformations, smoothness on the velocity fields and the diffeomorphisms, a modality-insensitive similarity function suitable to multi-modality images, and constraints on geodesics in Lagrangian coordinates. Direct optimization (without relying on an exponential map of stationary velocity fields used in conventional diffeomorphic Demons) is carried out using a Gauss-Newton method for fast convergence. Registration performance and sensitivity to registration parameters were analyzed in simulation, in phantom experiments, and clinical studies emulating application in image-guided spine surgery, and results were compared to conventional mutual information (MI) free-form deformation (FFD), local MI (LMI) FFD, and normalized MI (NMI) Demons. RESULT: The method yielded sub-voxel invertibility (0.006 mm) and nonsingular spatial Jacobians with capability to preserve local orientation and topology. It demonstrated improved registration accuracy in comparison to the reference methods, with mean target registration error (TRE) of 1.5 mm compared to 10.9, 2.3, and 4.6 mm for MI FFD, LMI FFD, and NMI Demons methods, respectively. Validation in clinical studies demonstrated realistic deformation with sub-voxel TRE in cases of cervical, thoracic, and lumbar spine. CONCLUSIONS: A modality-independent deformable registration method has been developed to estimate a viscoelastic diffeomorphic map between preoperative MR and intraoperative CT. The method yields registration accuracy suitable to application in image-guided spine surgery across a broad range of anatomical sites and modes of deformation.

Automatic Masking for Robust 3D-2D Image Registration in Image-Guided Spine Surgery.

During spinal neurosurgery, patient-specific information, planning, and annotation such as vertebral labels can be mapped from preoperative 3D CT to intraoperative 2D radiographs via image-based 3D-2D registration. Such registration has been shown to provide a potentially valuable means of decision support in target localization as well as quality assurance of the surgical product. However, robust registration can be challenged by mismatch in image content between the preoperative CT and intraoperative radiographs, arising, for example, from anatomical deformation or the presence of surgical tools within the radiograph. In this work, we develop and evaluate methods for automatically mitigating the effect of content mismatch by leveraging the surgical planning data to assign greater weight to anatomical regions known to be reliable for registration and vital to the surgical task while removing problematic regions that are highly deformable or often occluded by surgical tools. We investigated two approaches to assigning variable weight (i.e., "masking") to image content and/or the similarity metric: (1) masking the preoperative 3D CT ("volumetric masking"); and (2) masking within the 2D similarity metric calculation ("projection masking"). The accuracy of registration was evaluated in terms of projection distance error (PDE) in 61 cases selected from an IRB-approved clinical study. The best performing of the masking techniques was found to reduce the rate of gross failure (PDE > 20 mm) from 11.48% to 5.57% in this challenging retrospective data set. These approaches provided robustness to content mismatch and eliminated distinct failure modes of registration. Such improvement was gained without additional workflow and has motivated incorporation of the masking methods within a system under development for prospective clinical studies.

3D-2D image registration for target localization in spine surgery: investigation of similarity metrics providing robustness to content mismatch.

In image-guided spine surgery, robust three-dimensional to two-dimensional (3D-2D) registration of preoperative computed tomography (CT) and intraoperative radiographs can be challenged by the image content mismatch associated with the presence of surgical instrumentation and implants as well as soft-tissue resection or deformation. This work investigates image similarity metrics in 3D-2D registration offering improved robustness against mismatch, thereby improving performance and reducing or eliminating the need for manual masking. The performance of four gradient-based image similarity metrics (gradient information (GI), gradient correlation (GC), gradient information with linear scaling (GS), and gradient orientation (GO)) with a multi-start optimization strategy was evaluated in an institutional review board-approved retrospective clinical study using 51 preoperative CT images and 115 intraoperative mobile radiographs. Registrations were tested with and without polygonal masks as a function of the number of multistarts employed during optimization. Registration accuracy was evaluated in terms of the projection distance error (PDE) and assessment of failure modes (PDE > 30 mm) that could impede reliable vertebral level localization. With manual polygonal masking and 200 multistarts, the GC and GO metrics exhibited robust performance with 0% gross failures and median PDE < 6.4 mm (±4.4 mm interquartile range (IQR)) and a median runtime of 84 s (plus upwards of 1-2 min for manual masking). Excluding manual polygonal masks and decreasing the number of multistarts to 50 caused the GC-based registration to fail at a rate of >14%; however, GO maintained robustness with a 0% gross failure rate. Overall, the GI, GC, and GS metrics were susceptible to registration errors associated with content mismatch, but GO provided robust registration (median PDE = 5.5 mm, 2.6 mm IQR) without manual masking and with an improved runtime (29.3 s). The GO metric improved the registration accuracy and robustness in the presence of strong image content mismatch. This capability could offer valuable assistance and decision support in spine level localization in a manner consistent with clinical workflow.

Deformable 3D-2D Registration of Known Components for Image Guidance in Spine Surgery.

A 3D-2D image registration method is reported for guiding the placement of surgical devices (e.g., K-wires). The solution registers preoperative CT (and planning data therein) to intraoperative radiographs and computes the pose, shape, and deformation parameters of devices (termed "components") known to be in the radiographic scene. The deformable known-component registration (dKC-Reg) method was applied in experiments emulating spine surgery to register devices (K-wires and spinal fixation rods) undergoing realistic deformation. A two-stage registration process (i) resolves patient pose from individual radiographs and (ii) registers components represented as polygonal meshes based on a B-spline model. The registration result can be visualized as overlay of the component in CT analogous to surgical navigation but without conventional trackers or fiducials. Target registration error in the tip and orientation of deformable K-wires was (1.5±0.9)mm and 0.6∘±0.2∘, respectively. For spinal fixation rods, the registered components achieved Hausdorff distance of 3.4 mm. Future work includes testing in cadaver and clinical data and extension to more generalized deformation and component models.

Known-component 3D-2D registration for quality assurance of spine surgery pedicle screw placement.

A 3D-2D image registration method is presented that exploits knowledge of interventional devices (e.g. K-wires or spine screws-referred to as 'known components') to extend the functionality of intraoperative radiography/fluoroscopy by providing quantitative measurement and quality assurance (QA) of the surgical product. The known-component registration (KC-Reg) algorithm uses robust 3D-2D registration combined with 3D component models of surgical devices known to be present in intraoperative 2D radiographs. Component models were investigated that vary in fidelity from simple parametric models (e.g. approximation of a screw as a simple cylinder, referred to as 'parametrically-known' component [pKC] registration) to precise models based on device-specific CAD drawings (referred to as 'exactly-known' component [eKC] registration). 3D-2D registration from three intraoperative radiographs was solved using the covariance matrix adaptation evolution strategy (CMA-ES) to maximize image-gradient similarity, relating device placement relative to 3D preoperative CT of the patient. Spine phantom and cadaver studies were conducted to evaluate registration accuracy and demonstrate QA of the surgical product by verification of the type of devices delivered and conformance within the 'acceptance window' of the spinal pedicle. Pedicle screws were successfully registered to radiographs acquired from a mobile C-arm, providing TRE 1-4 mm and <5° using simple parametric (pKC) models, further improved to <1 mm and <1° using eKC registration. Using advanced pKC models, screws that did not match the device models specified in the surgical plan were detected with an accuracy of >99%. Visualization of registered devices relative to surgical planning and the pedicle acceptance window provided potentially valuable QA of the surgical product and reliable detection of pedicle screw breach. 3D-2D registration combined with 3D models of known surgical devices offers a novel method for intraoperative QA. The method provides a near-real-time independent check against pedicle breach, facilitating revision within the same procedure if necessary and providing more rigorous verification of the surgical product.

Known-Component 3D-2D Registration for Image Guidance and Quality Assurance in Spine Surgery Pedicle Screw Placement.

PURPOSE: To extend the functionality of radiographic/fluoroscopic imaging systems already within standard spine surgery workflow to: 1) provide guidance of surgical device analogous to an external tracking system; and 2) provide intraoperative quality assurance (QA) of the surgical product. METHODS: Using fast, robust 3D-2D registration in combination with 3D models of known components (surgical devices), the 3D pose determination was solved to relate known components to 2D projection images and 3D preoperative CT in near-real-time. Exact and parametric models of the components were used as input to the algorithm to evaluate the effects of model fidelity. The proposed algorithm employs the covariance matrix adaptation evolution strategy (CMA-ES) to maximize gradient correlation (GC) between measured projections and simulated forward projections of components. Geometric accuracy was evaluated in a spine phantom in terms of target registration error at the tool tip (TRE x ), and angular deviation (TRE ϕ ) from planned trajectory. RESULTS: Transpedicle surgical devices (probe tool and spine screws) were successfully guided with TRE x <2 mm and TRE ϕ <0.5° given projection views separated by at least >30° (easily accommodated on a mobile C-arm). QA of the surgical product based on 3D-2D registration demonstrated the detection of pedicle screw breach with TRE x <1 mm, demonstrating a trend of improved accuracy correlated to the fidelity of the component model employed. CONCLUSIONS: 3D-2D registration combined with 3D models of known surgical components provides a novel method for near-real-time guidance and quality assurance using a mobile C-arm without external trackers or fiducial markers. Ongoing work includes determination of optimal views based on component shape and trajectory, improved robustness to anatomical deformation, and expanded preclinical testing in spine and intracranial surgeries.

Free-hand placement of iliac screws for spinopelvic fixation based on anatomical landmarks: technical note.

BACKGROUND: The placement of iliac screws is a biomechanically sound method for the stabilization of long multi-segment lumbar constructs. Traditional techniques for the placement of iliac screws often involve either substantial iliac muscle dissection for visualization of screw trajectory based on bony landmarks, or alternatively the use of intra-operative imaging to visualize these landmarks and guide screw placement. We describe an alternative free-hand method of iliac screw placement, one that needs neither significant muscle dissection nor intra-operative imaging. METHODS: We performed this technique in 10 consecutive patients. Patient demographics, spinal pathology, post-operative complications, and screw hardware characteristics are described. RESULTS: We have successfully used this technique for the placement 20 iliac screws based on anatomic landmarks in 10 consecutive patients. There were no cortical breeches of the ileum and no penetrations into the acetabulum on post-operative imaging. There were no instances of hardware failure. Two patients developed deep vein thromboses after surgery, 1 had a pulmonary embolism. CONCLUSIONS: Based on our limited experience to date, free-hand placement of iliac screws is both easy to perform and safe for the patient. Further study and validation using this technique is warranted.

Surgical management of metastatic spinal tumors.

BACKGROUND: The spine is the most common site of skeletal metastases. The evolution of surgical methods, medical treatment, and radiation therapy has led to improved survival, functional status, and quality of life for patients with cancer. The role of surgery in the treatment of patients with spinal metastases has evolved over time. METHODS: A review of publications describing the role of open surgery and vertebroplasty was performed and the results are summarized. RESULTS: The treatment goals of spinal metastases include the preservation and restoration of neurologic function and spinal stability. Modern imaging modalities provide accurate methods of tumor diagnosis. A variety of approaches and stabilization techniques are available and should be tailored to the location of the tumor and systemic comorbidities. CONCLUSIONS: As part of multidisciplinary treatment that includes radiation therapy and chemotherapy, surgery provides an effective method of restoration and preservation of neurologic function and spinal stability for patients with metastatic spinal tumors.

Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes?

STUDY DESIGN: Systematic review. OBJECTIVE: The objectives of this systematic review were to determine whether fusion is superior to conservative management in certain psychological subpopulations and to determine the most common psychological screening tests and their ability to predict outcome after treatment in patients with chronic lower back pain. SUMMARY OF BACKGROUND DATA: Many studies have documented the effects of various psychological disorders on outcomes in the treatment of lower back pain. The question of whether patients with certain psychological disorders would benefit more from conservative treatment than fusion is not clear. Furthermore, the most appropriate screening tools for assessing psychological factors in the presence of treatment decision making should be recommended. METHODS: Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of psychological factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain. In the analysis of psychological screening tests, we searched for the most commonly reported questionnaires and those that had been shown to predict lower back pain treatment outcomes. RESULTS: Few studies comparing fusion to conservative management reported differences in outcome by the presence or absence of a psychological disorder. Among those that did, we observed the effect of fusion compared with conservative management was more favorable in patients without a personality disorder, neuroticism, or depression. The most commonly reported, validated psychological screening tests for lower back pain are the Beck Depression Inventory, the Fear Avoidance Belief Questionnaire, the Spielberger Trait Anxiety Inventory, the Zung Depression Scale, and the Distress Risk Assessment Method. CONCLUSION: Psychological disorders affect chronic lower back pain treatment outcomes. Patients with a personality disorder appear to respond more favorably to conservative management and those without a personality disorder more favorably to fusion. Patients with higher depression and neuroticism scores may also respond more favorably to conservative management. CLINICAL RECOMMENDATIONS: Recommendation 1: Chronic LBP patients with depression, neuroticism, and certain personality disorders should preferentially be treated nonoperatively. Strength of recommendation: Weak. Recommendation 2: Consider the use of a validated psychological screening questionnaire such as the BDI, FABQ, DRAM, ZDI or STAI, when treating patients with CLBP. Strength of recommendation: Weak.

The use of expandable cages in patients undergoing multilevel corpectomies for metastatic tumors in the cervical spine.

Expandable cages have been used successfully to reconstruct the anterior spinal column in the treatment of traumatic, neoplastic, infectious, and degenerative spine disease. To the best of our knowledge, no studies report the results of the use of expandable cages in patients undergoing multilevel corpectomies for cervical spine metastatic disease. We report our experience with the use of expandable cages in this subgroup of patients.From August 2006 to May 2008, 5 patients presenting with myelopathy, pain, and/or radiculopathy secondary to metastatic disease of the cervical spine underwent multilevel cervical corpectomies and placement of expandable cages in our institution. All procedures were supplemented with an anterior cervical plate and with posterior instrumentation to achieve a 360 degrees fusion. A visual analog scale (VAS), Nurick grade, Frankel grade, American Spinal Injuries Association (ASIA) grade, and Ranawat grade were used to evaluate patients pre- and postoperatively. The mean follow-up period was 13.2 months. Three patients underwent a 2-level corpectomy, 1 a 3-level corpectomy, and 1 a 4-level corpectomy. Postoperative imaging studies showed that all patients had correction of preoperative kyphosis. The mean VAS score was reduced from 6.4 to 1. All other indices of spinal cord injury measured improved postoperatively or were stabilized. Postoperative imaging studies showed stable constructs in 4 patients.The use of expandable cages in multilevel corpectomies for the treatment of metastatic cervical spine disease appears to be a safe and effective way to reconstruct the anterior column of the cervical spine, preventing further neurologic deterioration.

CT fluoroscopically guided percutaneous placement of transiliosacral rod for sacral insufficiency fracture: case report and technique.

Treatment of sacral insufficiency fractures (SIFs) has traditionally been conservative, but several patients have been treated with percutaneous sacroplasty. Unfortunately, in the setting of severe, bilateral SIFs, cement may not withstand shear forces present at the lumbosacral junction, and surgical hardware may not provide adequate fixation in osteoporotic, cancellous bone of the sacrum, leading to eventual pseudarthrosis. Thus, we propose a novel technique in which guidance with CT fluoroscopy allows placement of a transiliosacral bar in conjunction with sacroplasty.