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Chen H. Application progress of artificial intelligence and augmented reality in orthopaedic arthroscopy surgery. J Orthop Surg Res 2023; 18:775. [PMID: 37838695 PMCID: PMC10576364 DOI: 10.1186/s13018-023-04280-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/11/2023] [Indexed: 10/16/2023] Open
Abstract
In today's rapidly developing technological era, the technological revolution triggered by the rapid iteration of artificial intelligence and augmented reality has provided brand-new digital intelligent empowerment for orthopaedic clinical operation. Although traditional arthroscopy has been widely promoted globally due to its advantages such as minimally invasive, safety and early functional exercise, it still has deficiencies in precision and personalization. The assistance of artificial intelligence and augmented reality enables precise positioning and navigation in arthroscopic surgery, as well as personalized operations based on patient conditions, which lifts the objective limitations of traditional sports medicine surgery. The integration of artificial intelligence and augmented reality with orthopaedic arthroscopy surgery is still in infancy, even though there are still some insufficient to be solved, but its prospect is bright.
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Affiliation(s)
- Haojie Chen
- Department of Orthopaedics, The First People's Hospital of Xiaoshan District, No. 199, Shixin South Road, Chengxiang Street, Xiaoshan District, Hangzhou, China.
- Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang, China.
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Oppermann M, Karapetyan V, Gupta S, Ramjist J, Oppermann P, Yang VXD. The pedicle screw accuracy using a robotic system and measured by a novel three-dimensional method. J Orthop Surg Res 2023; 18:706. [PMID: 37730623 PMCID: PMC10510280 DOI: 10.1186/s13018-023-04206-5] [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: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 09/22/2023] Open
Abstract
Robotics in medicine is associated with precision, accuracy, and replicability. Several robotic systems are used in spine surgery. They are all considered shared-control systems, providing "steady-hand" manipulation instruments. Although numerous studies have testified to the benefits of robotic instrumentations, they must address their true accuracy. Our study used the Mazor system under several situations and compared the spatial accuracy of the pedicle screw (PS) insertion and its planned trajectory. We used two cadaveric specimens with intact spinal structures from C7 to S1. PS planning was performed using the two registration methods (preopCT/C-arm or CT-to-fluoroscopy registration). After planning, the implant spatial orientation was defined based on six anatomic parameters using axial and sagittal CT images. Two surgical open and percutaneous access were used to insert the PS. After that, another CT acquisition was taken. Accuracy was classified into optimal, inaccurate and unacceptable according to the degree of screw deviation from its planning using the same spatial orientation method. Based on the type of spatial deviation, we also classified the PS trajectory into 16 pattern errors. Seven (19%) out of 37 implanted screws were considered unacceptable (deviation distances > 2.0 mm or angulation > 5°), and 14 (38%) were inaccurate (> 0.5 mm and ≤ 2.0 mm or > 2.5° and ≤ 5°). CT-to-fluoroscopy registration was superior to preopCT/C-arm (average deviation in 0.9 mm vs. 1.7 mm, respectively, p < 0.003), and percutaneous was slightly better than open but did not reach significance (1.3 mm vs. 1.7 mm, respectively). Regarding pattern error, the tendency was to have more axial than sagittal shifts. Using a quantitative method to categorize the screw 3D position, only 10.8% of the screws were considered unacceptable. However, with a more rigorous concept of inaccuracy, almost half were non-optimal. We also identified that, unlike some previous results, the O-arm registration delivers more accurate implants than the preopCT/C-arm method.
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Affiliation(s)
- Marcelo Oppermann
- Department of Clinical Neurological Science, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Department of Electrical Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada.
| | - Vahagan Karapetyan
- Department of Clinical Neurological Science, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Shaurya Gupta
- Department of Electrical Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada
| | - Joel Ramjist
- Department of Electrical Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada
| | - Priscila Oppermann
- Department of Clinical Neurological Science, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Victor X D Yang
- Department of Clinical Neurological Science, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Electrical Computer and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada
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Delcont MR, Ou-Yang DC, Burger EL, Patel VV, Wessell NM, Kleck CJ. Alternative Uses of O-Arm and Stealth Navigation Technology Over 10 Years: The University of Colorado Experience. Orthopedics 2023; 46:e89-e97. [PMID: 35876781 DOI: 10.3928/01477447-20220719-04] [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] [Indexed: 02/03/2023]
Abstract
Intraoperative computed tomography scanning with O-arm and use of Stealth navigation can improve surgical outcomes in a variety of orthopedic subspecialties. In spine surgery, the accuracy, precision, and safety of pedicle screw and interbody implant placement has improved. This technology is now routinely used in percutaneous pedicle screw placement and minimally invasive sacroiliac joint fusion. Other applications include, but are not limited to, isthmic pars defect repair, lumbosacral pseudoarticulation resection in Bertolotti's syndrome, radiofrequency ablation, and en bloc tumor resection. Intraoperative navigation has numerous applications, and use of this technology should continue to evolve as the technology advances. [Orthopedics. 2023;46(2):e89-e97.].
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Cammarata G, Scalia G, Costanzo R, Umana GE, Furnari M, Ponzo G, Giuffrida M, Maugeri R, Iacopino DG, Nicoletti GF, Graziano F. Fluoroscopy-Assisted Freehand Versus 3D-Navigated Imaging-Assisted Pedicle Screw Insertion: A Multicenter Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:425-430. [PMID: 38153504 DOI: 10.1007/978-3-031-36084-8_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Pedicle screw placement is a widely accepted surgical procedure for spinal fixation. Despite increases in knowledge about and expertise in pedicle screw insertion techniques, overall reported screw misplacement rates are still high. Spinal neuronavigation and intraoperative computed tomography (CT) imaging improves the accuracy and safety of pedicle screw placement through the continuous monitoring of screw trajectory. The purpose of this study is to compare pedicle screw placement under an O-arm intraoperative imaging system assisted by the StealthStation navigation system with screw placement under conventional fluoroscopy (C-arm). METHODS For 222 patients, 1288 implanted pedicle screws in total were evaluated between 2018 and 2020. All patients underwent pedicle screw placement in the thoracic and lumbosacral regions through a posterior approach. Moreover, 107 patients (48.2%), 48 men and 59 women, underwent freehand screw placement under conventional fluoroscopy (C-arm group), whereas 115 patients (51.8%), 53 men and 62 women, underwent pedicle screw insertion under O-arm guidance with the help of the StealthStation neuronavigation system (Medtronic Navigation, Louisville, CO, USA) (O-arm group). Data were recorded and retrospectively analyzed. The accuracy of pedicle screw placement was postoperatively examined by using CT imaging and analyzed according to the Gertzbein-Robbins classification. RESULTS Of the 1288 pedicle screws, 665 (51.6%) were placed with C-arm image-guided assistance with a mean of 6.21 ± 2.1 screws per patient and 643 (48.4%) with O-arm image-guided assistance with a mean of 5.59 ± 1.6 screws. The average time for the screw placement procedure was 3:57 ± 1:07 h in the C-arm group and 4:21 ± 1:41 h in the O-arm group. A correct screw placement was detected in 92.78% of patients in the C-arm group and in 98.13% of patients in the O-arm group. Medial cortical breach was shown in 13 Grade B screws (1.95%), 19 Grade C (2.86%), 14 Grade D (2.11%), and two Grade E (0.3%) in the C-arm group, whereas this was shown in 11 Grade B screws (1.71%) and one Grade C (0.16%) in the O-arm group. Lateral breach occurred in eight screws in both groups. Anterior vertebral body breach was shown in eight screws in the C-arm group, whereas it was shown in four screws in the O-arm group. Reoperation for screw misplacement was mandatory in five patients in the C-arm group and two patients in the O-arm group. CONCLUSION Pedicle screw placement under an O-arm intraoperative imaging system assisted by spinal navigation showed greater accuracy compared with placement under conventional fluoroscopic control, thus avoiding the onset of major postoperative complications. Notably, a reduction in medial and anterior breaches has been demonstrated.
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Affiliation(s)
| | - Gianluca Scalia
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Roberta Costanzo
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone", Palermo, Italy
| | - Giuseppe Emmanuele Umana
- Division of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy
| | - Massimo Furnari
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Giancarlo Ponzo
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Massimiliano Giuffrida
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone", Palermo, Italy
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone", Palermo, Italy
| | | | - Francesca Graziano
- Division of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone", Palermo, Italy
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Rozaire J, Naaim A, Dubuis L, Lamblin G. Development of an innovative surgical navigation system for sacrospinous fixation in pelvic surgery. J Minim Invasive Gynecol 2021; 29:549-558. [PMID: 34958953 DOI: 10.1016/j.jmig.2021.12.012] [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: 11/02/2021] [Revised: 12/13/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE To validate the use of an innovative navigation method for sacrospinous fixation in surgery-like conditions as a new teaching tool and surgical method. DESIGN 2-month-experiment prospective pilot study between July and August 2021. SETTING Biomechanics laboratory academic research. POPULATION 29 participants: 9 gynecological surgeons and 20 participants with no medical background. MEASUREMENT AND MAIN RESULTS The experiment was composed of two training phases dedicated to improve the hand-eye coordination and suture skills on a training mock-up, and of a suturing phase on a pelvic mock-up designed to recreate the surgery-like conditions of a sacrospinous fixation. The surgeons provided qualitative feedback on the bio-accuracy of the mock-ups and evaluated the ease-of-use of the navigation software. Non-surgeons were included to assess the progression of the suture performance between two experiments performed one week apart (Session 1 & 2). The main objective for participants was to reach a virtual target and to stitch sacrospinous ligaments. For Session 1, an overall comfort score of 7.2/10 was attributed to the tool; 14 (42%) surgeon suture attempts and 63 (65%) non-surgeon suture attempts were accurate (i.e. below the 5-mm threshold). 22 (67%) surgeon suture attempts and 28 (34%) non-surgeon suture attempts were fast (i.e. in the first two quantiles of the duration dataset). An improvement of the non-surgeon performance was observed between the two sessions in terms of duration (Session 1: 46±20 sec; Session 2: 37±18 sec; p=0.047) and distance (Session 1: 3.8±1.3 mm; Session 2: 3.2±1.4 mm; p=10-5) for the last suturing exercise. CONCLUSION This new motion-capture-based navigation method for sacrospinous fixation tested under surgery-like conditions seemed to be accurate and effective. The next step will be to design a pelvis model more adapted to the constraints of a sacrospinous fixation and to validate the benefits of this method compared to current techniques.
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Affiliation(s)
- Julie Rozaire
- Univ Lyon, Univ Gustave Eiffel, Université Claude Bernard Lyon 1, LBMC UMR_T9406, F69622, Lyon, France
| | - Alexandre Naaim
- Univ Lyon, Univ Gustave Eiffel, Université Claude Bernard Lyon 1, LBMC UMR_T9406, F69622, Lyon, France
| | - Laura Dubuis
- Univ Lyon, Univ Gustave Eiffel, Université Claude Bernard Lyon 1, LBMC UMR_T9406, F69622, Lyon, France
| | - Gery Lamblin
- Univ Lyon, Univ Gustave Eiffel, Université Claude Bernard Lyon 1, LBMC UMR_T9406, F69622, Lyon, France; Hôpital Femme Mère Enfant, Service de Chirurgie Urogynécologique, Hospices Civils de Lyon, Bron, France.
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6
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Cewe P, Vorbau R, Omar A, Elmi-Terander A, Edström E. Radiation distribution in a hybrid operating room, utilizing different X-ray imaging systems: investigations to minimize occupational exposure. J Neurointerv Surg 2021; 14:1139-1144. [PMID: 34750111 PMCID: PMC9606514 DOI: 10.1136/neurintsurg-2021-018220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/31/2021] [Indexed: 01/10/2023]
Abstract
Objectives To reduce occupational radiation exposure in a hybrid operating room (OR) used for three-dimensional (3D) image guided spine procedures. The effects of staff positioning, different X-ray imaging systems, and freestanding radiation protection shields (RPSs) were considered. Methods An anthropomorphic phantom was imaged with a robotic ceiling mounted hybrid OR C-arm cone beam CT (hCBCT), a mobile O-arm CBCT (oCBCT), and a mobile two-dimensional C-arm fluoroscopy system. The resulting scatter doses were measured at different positions in the hybrid OR using active personal dosimeters and an ionization chamber. Two types of RPSs were evaluated. Results Using the hCBCT system instead of the oCBCT system reduced the occupational radiation dose on average by 22%. At 200 cm from the phantom, scatter doses from the hCBCT were 27% lower compared with the oCBCT. One rotational acquisition with hCBCT or oCBCT corresponded to 12 or 16 min of fluoroscopy with the C-arm, respectively. The scatter dose decreased by more than 90% behind an RPS. However, the protection was slightly less effective at 60 cm behind the RPS, due to tertiary scatter from the surroundings. Conclusions For 3D image guided spine procedures in the hybrid OR, occupational radiation exposure is lowered by using hCBCT rather than oCBCT. Radiation exposure can also be decreased by optimal staff positioning in the OR, considering distance to the source and positioning relative to the walls, ceiling, and RPS. In this setting and workflow, staff can use RPSs instead of heavy aprons during intraoperative CBCT imaging, to achieve effective whole body dose reduction with improved comfort.
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Affiliation(s)
- Paulina Cewe
- Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden .,Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Robert Vorbau
- Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Artur Omar
- Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Edström
- Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Molina CA, Sciubba DM, Greenberg JK, Khan M, Witham T. Clinical Accuracy, Technical Precision, and Workflow of the First in Human Use of an Augmented-Reality Head-Mounted Display Stereotactic Navigation System for Spine Surgery. Oper Neurosurg (Hagerstown) 2021; 20:300-309. [PMID: 33377137 DOI: 10.1093/ons/opaa398] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Augmented reality mediated spine surgery is a novel technology for spine navigation. Benchmark cadaveric data have demonstrated high accuracy and precision leading to recent regulatory approval. Absence of respiratory motion in cadaveric studies may positively bias precision and accuracy results and analogous investigations are prudent in live clinical scenarios. OBJECTIVE To report a technical note, accuracy, precision analysis of the first in-human deployment of this technology. METHODS A 78-yr-old female underwent an L4-S1 decompression, pedicle screw, and rod fixation for degenerative spine disease. Six pedicle screws were inserted via AR-HMD (xvision; Augmedics, Chicago, Illinois) navigation. Intraoperative computed tomography was used for navigation registration as well as implant accuracy and precision assessment. Clinical accuracy was graded per the Gertzbein-Robbins (GS) scale by an independent neuroradiologist. Technical precision was analyzed by comparing 3-dimensional (3D) (x, y, z) virtual implant vs real implant position coordinates and reported as linear (mm) and angular (°) deviation. Present data were compared to benchmark cadaveric data. RESULTS Clinical accuracy (per the GS grading scale) was 100%. Technical precision analysis yielded a mean linear deviation of 2.07 mm (95% CI: 1.62-2.52 mm) and angular deviation of 2.41° (95% CI: 1.57-3.25°). In comparison to prior cadaveric data (99.1%, 2.03 ± 0.99 mm, 1.41 ± 0.61°; GS accuracy 3D linear and angular deviation, respectively), the present results were not significantly different (P > .05). CONCLUSION The first in human deployment of the single Food and Drug Administration approved AR-HMD stereotactic spine navigation platform demonstrated clinical accuracy and technical precision of inserted hardware comparable to previously acquired cadaveric studies.
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Affiliation(s)
- Camilo A Molina
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jacob K Greenberg
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Majid Khan
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Peltonen JI, Kaasalainen T, Kortesniemi M. Metal artifacts in intraoperative O-arm CBCT scans. BMC Med Imaging 2021; 21:2. [PMID: 33407232 PMCID: PMC7789607 DOI: 10.1186/s12880-020-00538-4] [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] [Received: 08/18/2020] [Accepted: 12/14/2020] [Indexed: 08/23/2023] Open
Abstract
Background Cone-beam computed tomography (CBCT) has become an increasingly important medical imaging modality in orthopedic operating rooms. Metal implants and related image artifacts create challenges for image quality optimization in CBCT. The purpose of this study was to develop a robust and quantitative method for the comprehensive determination of metal artifacts in novel CBCT applications. Methods The image quality of an O-arm CBCT device was assessed with an anthropomorphic pelvis phantom in the presence of metal implants. Three different kilovoltage and two different exposure settings were used to scan the phantom both with and without the presence of metal rods. Results The amount of metal artifact was related to the applied CBCT imaging protocol parameters. The size of the artifact was moderate with all imaging settings. The highest applied kilovoltage and exposure level distinctly increased artifact severity. Conclusions The developed method offers a practical and robust way to quantify metal artifacts in CBCT. Changes in imaging parameters may have nonlinear effects on image quality which are not anticipated based on physics.
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Affiliation(s)
- Juha I Peltonen
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, P.O. Box 340, 00029, Helsinki, Finland.
| | - Touko Kaasalainen
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, P.O. Box 340, 00029, Helsinki, Finland
| | - Mika Kortesniemi
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, P.O. Box 340, 00029, Helsinki, Finland
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Sabri SA, York PJ. Preoperative planning for intraoperative navigation guidance. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:87. [PMID: 33553380 PMCID: PMC7859791 DOI: 10.21037/atm-20-1369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intraoperative navigation for spinal procedures has continued to gain popularity. Numerous platforms are currently on the market and offer a spectrum of features. Preoperative considerations when utilizing this technology begin with understanding the fundamental concepts and methods of navigation. Several key factors including patient positioning, reference array placement, and sequence of instrumentation can help improve intraoperative navigation workflow when planned appropriately. The authors review current literature to help guide surgeon decision making when utilizing navigation. Additionally, tips and techniques for use of navigation are detailed to help avoid common surgeon pitfalls. In general, navigation platforms are classified based on image acquisition and degree of surgeon motion restriction during instrumentation. Imageless platforms often require preoperative images to be uploaded into the navigation system. Image-based systems rely on intraoperative imaging to ensure accuracy of its referencing software. The system then creates a three-dimensional model that allows for visualization of the navigated instrument within the surgical field. Active and passive navigation describe the degree of surgeon free-motion restriction when utilizing navigated instruments. Active navigation platforms, such as most robotic systems, prevent the deviation of the surgeon's instrument from a predetermined trajectory. Passive navigation does not restrict surgeon motion and the projected trajectory of the instrumented can be displayed on a three-dimensional model.
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Affiliation(s)
- Shahbaaz A Sabri
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Philip J York
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Frameless Patient Tracking With Adhesive Optical Skin Markers for Augmented Reality Surgical Navigation in Spine Surgery. Spine (Phila Pa 1976) 2020; 45:1598-1604. [PMID: 32756274 DOI: 10.1097/brs.0000000000003628] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational study. OBJECTIVE The aim of this study was to evaluate the accuracy of a new frameless reference marker system for patient tracking by analyzing the effect of vertebral position within the surgical field. SUMMARY OF BACKGROUND DATA Most modern navigation systems for spine surgery rely on a dynamic reference frame attached to a vertebra for tracking the patient. This solution has the drawback of being bulky and obstructing the surgical field, while requiring that the dynamic reference frame is moved between vertebras to maintain accuracy. METHODS An augmented reality surgical navigation (ARSN) system with intraoperative cone beam computed tomography (CBCT) capability was installed in a hybrid operating room. The ARSN system used input from four video cameras for tracking adhesive skin markers placed around the surgical field. The frameless reference marker system was evaluated first in four human cadavers, and then in 20 patients undergoing navigated spine surgery. In each CBCT, the impact of vertebral position in the surgical field on technical accuracy was analyzed. The technical accuracy of the inserted pedicle devices was determined by measuring the distance between the planned position and the placed pedicle device, at the bone entry point. RESULTS The overall mean technical accuracy was 1.65 ± 1.24 mm at the bone entry point (n = 366). There was no statistically significant difference in technical accuracy between levels within CBCTs (P ≥ 0.12 for all comparisons). Linear regressions showed that null- to negligible parts of the effect on technical accuracy could be explained by the number of absolute levels away from the index vertebrae (r ≤ 0.007 for all, β ≤ 0.071 for all). CONCLUSION The frameless reference marker system based on adhesive skin markers is unobtrusive and affords the ARSN system a high accuracy throughout the navigated surgical field, independent of vertebral position. LEVEL OF EVIDENCE 3.
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11
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Molina CA, Phillips FM, Colman MW, Ray WZ, Khan M, Orru' E, Poelstra K, Khoo L. A cadaveric precision and accuracy analysis of augmented reality-mediated percutaneous pedicle implant insertion. J Neurosurg Spine 2020; 34:316-324. [PMID: 33126206 DOI: 10.3171/2020.6.spine20370] [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: 03/16/2020] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Augmented reality-mediated spine surgery (ARMSS) is a minimally invasive novel technology that has the potential to increase the efficiency, accuracy, and safety of conventional percutaneous pedicle screw insertion methods. Visual 3D spinal anatomical and 2D navigation images are directly projected onto the operator's retina and superimposed over the surgical field, eliminating field of vision and attention shift to a remote display. The objective of this cadaveric study was to assess the accuracy and precision of percutaneous ARMSS pedicle implant insertion. METHODS Instrumentation was placed in 5 cadaveric torsos via ARMSS with the xvision augmented reality head-mounted display (AR-HMD) platform at levels ranging from T5 to S1 for a total of 113 total implants (93 pedicle screws and 20 Jamshidi needles). Postprocedural CT scans were graded by two independent neuroradiologists using the Gertzbein-Robbins scale (grades A-E) for clinical accuracy. Technical precision was calculated using superimposition analysis employing the Medical Image Interaction Toolkit to yield angular trajectory (°) and linear screw tip (mm) deviation from the virtual pedicle screw position compared with the actual pedicle screw position on postprocedural CT imaging. RESULTS The overall implant insertion clinical accuracy achieved was 99.1%. Lumbosacral and thoracic clinical accuracies were 100% and 98.2%, respectively. Specifically, among all implants inserted, 112 were noted to be Gertzbein-Robbins grade A or B (99.12%), with only 1 medial Gertzbein-Robbins grade C breach (> 2-mm pedicle breach) in a thoracic pedicle at T9. Precision analysis of the inserted pedicle screws yielded a mean screw tip linear deviation of 1.98 mm (99% CI 1.74-2.22 mm) and a mean angular error of 1.29° (99% CI 1.11°-1.46°) from the projected trajectory. These data compare favorably with data from existing navigation platforms and regulatory precision requirements mandating that linear and angular deviation be less than 3 mm (p < 0.01) and 3° (p < 0.01), respectively. CONCLUSIONS Percutaneous ARMSS pedicle implant insertion is a technically feasible, accurate, and highly precise method.
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Affiliation(s)
- Camilo A Molina
- 1Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Frank M Phillips
- 3Department of Orthopedic Surgery, Rush University School of Medicine, Chicago, Illinois
| | - Matthew W Colman
- 3Department of Orthopedic Surgery, Rush University School of Medicine, Chicago, Illinois
| | - Wilson Z Ray
- 1Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Majid Khan
- 2Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emanuele Orru'
- 4Department of Neurointerventional Radiology, Lahey Clinic Tufts University School of Medicine, Boston, Massachusetts
| | - Kornelis Poelstra
- 5The Robotic Spine Institute of Silicon Valley at OrthoNorCal, Los Gatos, California; and
| | - Larry Khoo
- 6The Spine Clinic of Los Angeles, California
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Burström G, Balicki M, Patriciu A, Kyne S, Popovic A, Holthuizen R, Homan R, Skulason H, Persson O, Edström E, Elmi-Terander A. Feasibility and accuracy of a robotic guidance system for navigated spine surgery in a hybrid operating room: a cadaver study. Sci Rep 2020; 10:7522. [PMID: 32371880 PMCID: PMC7200720 DOI: 10.1038/s41598-020-64462-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 04/15/2020] [Indexed: 12/11/2022] Open
Abstract
The combination of navigation and robotics in spine surgery has the potential to accurately identify and maintain bone entry position and planned trajectory. The goal of this study was to examine the feasibility, accuracy and efficacy of a new robot-guided system for semi-automated, minimally invasive, pedicle screw placement. A custom robotic arm was integrated into a hybrid operating room (OR) equipped with an augmented reality surgical navigation system (ARSN). The robot was mounted on the OR-table and used to assist in placing Jamshidi needles in 113 pedicles in four cadavers. The ARSN system was used for planning screw paths and directing the robot. The robot arm autonomously aligned with the planned screw trajectory, and the surgeon inserted the Jamshidi needle into the pedicle. Accuracy measurements were performed on verification cone beam computed tomographies with the planned paths superimposed. To provide a clinical grading according to the Gertzbein scale, pedicle screw diameters were simulated on the placed Jamshidi needles. A technical accuracy at bone entry point of 0.48 ± 0.44 mm and 0.68 ± 0.58 mm was achieved in the axial and sagittal views, respectively. The corresponding angular errors were 0.94 ± 0.83° and 0.87 ± 0.82°. The accuracy was statistically superior (p < 0.001) to ARSN without robotic assistance. Simulated pedicle screw grading resulted in a clinical accuracy of 100%. This study demonstrates that the use of a semi-automated surgical robot for pedicle screw placement provides an accuracy well above what is clinically acceptable.
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Affiliation(s)
- Gustav Burström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
| | | | | | - Sean Kyne
- Philips Research North America, Cambridge, USA
| | | | - Ronald Holthuizen
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, the Netherlands
| | - Robert Homan
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, the Netherlands
| | - Halldor Skulason
- Department of Neurosurgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Oscar Persson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Minimally Invasive Percutaneous C1-C2 Fixation Using an Intraoperative Three-Dimensional Imaging–Based Navigation System for Management of Odontoid Fractures. World Neurosurg 2020; 137:266-271. [DOI: 10.1016/j.wneu.2019.12.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 12/10/2019] [Indexed: 11/23/2022]
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14
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Nicoletti G, Furnari M, Giuffrida M, Ponzo G, Iacopino DG, Cammarata G, Scalia G, Graziano F. A new tool to improve pedicle screw placement accuracy in navigated spine surgery: a monocentric study. J Neurosurg Sci 2020; 65:348-353. [PMID: 32347680 DOI: 10.23736/s0390-5616.20.04957-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Navigated instrumented spine surgery is burden by a low but significant screw mispositioning risks, respectively, for the 2D imaging system from 15% to 40% and, for the 3D imaging system, ranging from 4.1% to 11.5%. The primary objective of this study was to demonstrate the efficacy of a new screw-like tool in order to further decrease pedicle screws mispositioning rate during vertebral navigated spine surgery. METHODS Between January and June 2019 an initial case series of 18 patients were enrolled. All patients underwent a pedicle screw fixation, both in thoracic (Th10-Th12) and lumbosacral (L1-S1) spine, using O-arm (Medtronic Navigation, Louisville, CO, USA) and StealthStation S7 surgical navigation system (Medtronic Navigation). Evaluation of pedicle screws placement accuracy using the new tool in adjunct to the classic reference frame, was performed following the Gertzbein and Robbins classification. RESULTS A total of 94 screws have been placed. Among them, 98.9% were completely inside cortical bone (grade A) and only 1.1% with a breach of less than 2 mm (grade B). CONCLUSIONS Our new "screw-like" tool coupled to the classic reference frame device could improve accuracy during navigated spine surgery and potentially reducing to zero the risks for screw mispositioning.
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Affiliation(s)
| | | | | | | | - Domenico G Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, AOUP Paolo Giaccone, Palermo, Italy
| | - Giacomo Cammarata
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, AOUP Paolo Giaccone, Palermo, Italy
| | - Gianluca Scalia
- Division of Neurosurgery, ARNAS Garibaldi, Catania, Italy.,Division of Neurosurgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Francesca Graziano
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, AOUP Paolo Giaccone, Palermo, Italy -
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15
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Müller F, Roner S, Liebmann F, Spirig JM, Fürnstahl P, Farshad M. Augmented reality navigation for spinal pedicle screw instrumentation using intraoperative 3D imaging. Spine J 2020; 20:621-628. [PMID: 31669611 DOI: 10.1016/j.spinee.2019.10.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/19/2019] [Accepted: 10/21/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Due to recent developments in augmented reality with head-mounted devices, holograms of a surgical plan can be displayed directly in the surgeon's field of view. To the best of our knowledge, three dimensional (3D) intraoperative fluoroscopy has not been explored for the use with holographic navigation by head-mounted devices in spine surgery. PURPOSE To evaluate the surgical accuracy of holographic pedicle screw navigation by head-mounted device using 3D intraoperative fluoroscopy. STUDY DESIGN In this experimental cadaver study, the accuracy of surgical navigation using a head-mounted device was compared with navigation with a state-of-the-art pose-tracking system. METHODS Three lumbar cadaver spines were embedded in nontransparent agar gel, leaving only commonly visible anatomy in sight. Intraoperative registration of preoperative planning was achieved by 3D fluoroscopy and fiducial markers attached to lumbar vertebrae. Trackable custom-made drill sleeve guides enabled real-time navigation. In total, 20 K-wires were navigated into lumbar pedicles using AR-navigation, 10 K-wires by the state-of-the-art pose-tracking system. 3D models obtained from postexperimental CT scans were used to measure surgical accuracy. MF is the founder and shareholder of Incremed AG, a Balgrist University Hospital start-up focusing on the development of innovative techniques for surgical executions. The other authors declare no conflict of interest concerning the contents of this study. No external funding was received for this study. RESULTS No significant difference in accuracy was measured between AR-navigated drillings and the gold standard with pose-tracking system with mean translational errors between entry points (3D vector distance; p=.85) of 3.4±1.6 mm compared with 3.2±2.0 mm, and mean angular errors between trajectories (3D angle; p=.30) of 4.3°±2.3° compared with 3.5°±1.4°. CONCLUSIONS In conclusion, holographic navigation by use of a head-mounted device achieve accuracy comparable to the gold standard of high-end pose-tracking systems. CLINICAL SIGNIFICANCE These promising results could result in a new way of surgical navigation with minimal infrastructural requirements but now have to be confirmed in clinical studies.
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Affiliation(s)
- Fabio Müller
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Simon Roner
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Florentin Liebmann
- Computer Assisted Research and Development Group, Balgrist University Hospital, University of Zurich, Lengghalde 5, 8008 Zurich, Switzerland; Laboratory for Orthopedic Biomechanics, ETH Zurich, Forchstrasse 328, 8008 Zurich, Switzerland
| | - José M Spirig
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Philipp Fürnstahl
- Computer Assisted Research and Development Group, Balgrist University Hospital, University of Zurich, Lengghalde 5, 8008 Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
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El Saman A, Meier SL, Marzi I. A minimally invasive, 3D-fluoroscopy-navigation-guided, 3D-controlled pedicle approach in spine surgery: first reliable results and impact on patient safety. Eur J Trauma Emerg Surg 2020; 47:739-748. [PMID: 32123950 PMCID: PMC8187224 DOI: 10.1007/s00068-020-01332-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/15/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Safe pedicle screw placement is a daily challenge to every spine surgeon. Introduction of minimally invasive approaches in spinal surgery led to an impaired facility of inspection of the surgical field increasing the importance of intraoperative imaging and navigation. During the past years, we established a minimally invasive, navigated approach in our clinical setting. METHODS We retrospectively reviewed the accuracy of pedicle approaches in patients treated due to traumatic or osteoporotic fractures, spondylitis/discitis, and tumoral lesions. Guide wires for pedicle screws or kyphoplasty cannulas were inserted in a 3D-navigation-guided, minimally invasive technique. Positioning of the guide wires was verified via 3D-scan, and pedicle screws/kyphoplasty cannulas were then visualized via a.p./lateral radiographs. Accuracy data were compared to a standard navigated open approach control group with indications similar to the MIS-group. RESULTS 23 MIS patients were included in this study (25-84 years, mean 70 years) with a total of 154 placed guide wires. Handling of the navigated Jamshidi needle was easy and secure. The guide wires showed correct placement in 151/154 cases. Three wires (1.9%) needed correction of placement after control scan. There were no vascular or neurologic complications due to wire misplacement. In the open-surgery control group, 7/181 screws (3.9%) needed intraoperative correction presenting no significant difference compared to the correction rate of the MIS-group (p = 0.35). CONCLUSION Our study shows the feasibility and reliability of a navigation-guided, minimally invasive pedicle approach in the clinical setting. Therefore, reduced morbidity due to minimized approaches can be combined with higher accuracy of navigated pedicle screw/kyphoplasty cannula placement improving patient safety.
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Affiliation(s)
- André El Saman
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Simon Lars Meier
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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Chen L, Zhang F, Zhan W, Gan M, Sun L. Optimization of virtual and real registration technology based on augmented reality in a surgical navigation system. Biomed Eng Online 2020; 19:1. [PMID: 31915014 PMCID: PMC6950982 DOI: 10.1186/s12938-019-0745-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 12/30/2019] [Indexed: 12/19/2022] Open
Abstract
Background The traditional navigation interface was intended only for two-dimensional observation by doctors; thus, this interface does not display the total spatial information for the lesion area. Surgical navigation systems have become essential tools that enable for doctors to accurately and safely perform complex operations. The image navigation interface is separated from the operating area, and the doctor needs to switch the field of vision between the screen and the patient’s lesion area. In this paper, augmented reality (AR) technology was applied to spinal surgery to provide more intuitive information to surgeons. The accuracy of virtual and real registration was improved via research on AR technology. During the operation, the doctor could observe the AR image and the true shape of the internal spine through the skin. Methods To improve the accuracy of virtual and real registration, a virtual and real registration technique based on an improved identification method and robot-assisted method was proposed. The experimental method was optimized by using the improved identification method. X-ray images were used to verify the effectiveness of the puncture performed by the robot. Results The final experimental results show that the average accuracy of the virtual and real registration based on the general identification method was 9.73 ± 0.46 mm (range 8.90–10.23 mm). The average accuracy of the virtual and real registration based on the improved identification method was 3.54 ± 0.13 mm (range 3.36–3.73 mm). Compared with the virtual and real registration based on the general identification method, the accuracy was improved by approximately 65%. The highest accuracy of the virtual and real registration based on the robot-assisted method was 2.39 mm. The accuracy was improved by approximately 28.5% based on the improved identification method. Conclusion The experimental results show that the two optimized methods are highly very effective. The proposed AR navigation system has high accuracy and stability. This system may have value in future spinal surgeries.
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Affiliation(s)
- Long Chen
- School of Mechanical and Electrical Engineering, Soochow University, Suzhou, 215006, China
| | - Fengfeng Zhang
- School of Mechanical and Electrical Engineering, Soochow University, Suzhou, 215006, China. .,Collaborative Innovation Center of Suzhou Nano Science and Technology, Soochow University, Suzhou, 215123, China.
| | - Wei Zhan
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Minfeng Gan
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lining Sun
- School of Mechanical and Electrical Engineering, Soochow University, Suzhou, 215006, China.,Collaborative Innovation Center of Suzhou Nano Science and Technology, Soochow University, Suzhou, 215123, China
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18
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Augmented and Virtual Reality Instrument Tracking for Minimally Invasive Spine Surgery: A Feasibility and Accuracy Study. Spine (Phila Pa 1976) 2019; 44:1097-1104. [PMID: 30830046 DOI: 10.1097/brs.0000000000003006] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaveric animal laboratory study. OBJECTIVE To evaluate the feasibility and accuracy of pedicle cannulation using an augmented reality surgical navigation (ARSN) system with automatic instrument tracking, yielding feedback of instrument position in relation to deep anatomy. SUMMARY OF BACKGROUND DATA Minimally invasive spine surgery (MISS) has the possibility of reducing surgical exposure resulting in shorter hospital stays, lower blood loss and infection rates compared with open surgery but the drawback of limiting visual feedback to the surgeon regarding deep anatomy. MISS is mainly performed using image-guided 2D fluoroscopy, thus exposing the staff to ionizing radiation. METHODS A hybrid operating room (OR) equipped with a robotic C-arm with integrated optical cameras for augmented reality instrument navigation was used. In two pig cadavers, cone beam computed tomography (CBCT) scans were performed, a 3D model generated, and pedicle screw insertions were planned. Seventy-eight insertions were performed. Technical accuracy was assessed on post-insertion CBCTs by measuring the distance between the navigated device and the corresponding pre-planned path as well as the angular deviations. Drilling and hammering into the pedicle were also compared. Navigation time was measured. An independent reviewer assessed a simulated clinical accuracy according to Gertzbein. RESULTS The technical accuracy was 1.7 ± 1.0 mm at the bone entry point and 2.0 ± 1.3 mm at the device tip. The angular deviation was 1.7 ± 1.7° in the axial and 1.6 ± 1.2° in the sagittal plane. Navigation time per insertion was 195 ± 93 seconds. There was no difference in accuracy between hammering and drilling into the pedicle. The clinical accuracy was 97.4% to 100% depending on the screw size considered for placement. No ionizing radiation was used during navigation. CONCLUSION ARSN with instrument tracking for MISS is feasible, accurate, and radiation-free during navigation. LEVEL OF EVIDENCE 3.
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19
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Knez D, Nahle IS, Vrtovec T, Parent S, Kadoury S. Computer‐assisted pedicle screw trajectory planning using CT‐inferred bone density: A demonstration against surgical outcomes. Med Phys 2019; 46:3543-3554. [DOI: 10.1002/mp.13585] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/28/2019] [Accepted: 05/03/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Dejan Knez
- Faculty of Electrical Engineering University of Ljubljana Tržaška c. 25 Ljubljana 1000Slovenia
| | - Imad S. Nahle
- CHU Sainte‐Justine Hospital Research Center 3175 Cote‐Sainte‐Catherine Rd. Montréal H3T 1C5QuébecCanada
| | - Tomaž Vrtovec
- Faculty of Electrical Engineering University of Ljubljana Tržaška c. 25 Ljubljana 1000Slovenia
| | - Stefan Parent
- CHU Sainte‐Justine Hospital Research Center 3175 Cote‐Sainte‐Catherine Rd. Montréal H3T 1C5QuébecCanada
| | - Samuel Kadoury
- CHU Sainte‐Justine Hospital Research Center 3175 Cote‐Sainte‐Catherine Rd. Montréal H3T 1C5QuébecCanada
- Department of Computer and Software Engineering Polytechnique Montreal P.O. Box 6079, Succ. Centre‐ville Montréal H3C 3A7QuébecCanada
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Pedicle Screw Placement Using Augmented Reality Surgical Navigation With Intraoperative 3D Imaging: A First In-Human Prospective Cohort Study. Spine (Phila Pa 1976) 2019; 44:517-525. [PMID: 30234816 PMCID: PMC6426349 DOI: 10.1097/brs.0000000000002876] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE The aim of this study was to evaluate the accuracy of pedicle screw placement using augmented reality surgical navigation (ARSN) in a clinical trial. SUMMARY OF BACKGROUND DATA Recent cadaveric studies have shown improved accuracy for pedicle screw placement in the thoracic spine using ARSN with intraoperative 3D imaging, without the need for periprocedural x-ray. In this clinical study, we used the same system to place pedicle screws in the thoracic and lumbosacral spine of 20 patients. METHODS The study was performed in a hybrid operating room with an integrated ARSN system encompassing a surgical table, a motorized flat detector C-arm with intraoperative 2D/3D capabilities, integrated optical cameras for augmented reality navigation, and noninvasive patient motion tracking. Three independent reviewers assessed screw placement accuracy using the Gertzbein grading on 3D scans obtained before wound closure. In addition, the navigation time per screw placement was measured. RESULTS One orthopedic spinal surgeon placed 253 lumbosacral and thoracic pedicle screws on 20 consenting patients scheduled for spinal fixation surgery. An overall accuracy of 94.1% of primarily thoracic pedicle screws was achieved. No screws were deemed severely misplaced (Gertzbein grade 3). Fifteen (5.9%) screws had 2 to 4 mm breach (Gertzbein grade 2), occurring in scoliosis patients only. Thirteen of those 15 screws were larger than the pedicle in which they were placed. Two medial breaches were observed and 13 were lateral. Thirteen of the grade 2 breaches were in the thoracic spine. The average screw placement time was 5.2 ± 4.1 minutes. During the study, no device-related adverse event occurred. CONCLUSION ARSN can be clinically used to place thoracic and lumbosacral pedicle screws with high accuracy and with acceptable navigation time. Consequently, the risk for revision surgery and complications could be minimized. LEVEL OF EVIDENCE 3.
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Morphometric Analysis of the Lumbar Vertebrae Concerning the Optimal Screw Selection for Transpedicular Stabilization. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1133:83-96. [PMID: 30680647 DOI: 10.1007/5584_2018_324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Transpedicular stabilization is a frequently used spinal surgery for fractures, degenerative changes, or neoplastic processes. Improper screw fixation may cause substantial vascular or neurological complications. This study seeks to define detailed morphometric measurements of the pedicle (height, width, and surface area) in the aspects of screw length and girth selection and the trajectory of its implantation, i.e., sagittal and transverse angle of placement. The study was based on CT examinations of 100 Caucasian patients (51 women and 49 men) aged 27-75 with no anatomical, degenerative, or post-traumatic spine changes. The results were stratified by gender and body side, and they were counter compared with the available literature database. Pedicle height decreased from L1 to L4, ranging from 15.9 to 13.3 mm. Pedicle width increased from L1 to L5, extending from 6.1 to 13.2 mm. Pedicle surface area increased from L1 to L5, ranging from 63 to 140 mm2. Distance from the point of entry into the pedicle to the anterior surface of the vertebral body, defining the maximum length of a transpedicular screw, varied from 54.0 to 50.2 mm. Variations concerning body sides were inappreciable. A transverse angle of screw trajectory extended from 20° to 32°, shifting caudally from L1 to L5, with statistical differences in the L3-L5 segments. A sagittal angle varied from 10° to 12°, without such definite relations. We conclude that the L1 and L2 segments display the most distinct morphometric similarities, while the greatest differences, in both genders, are noted for L3, L4, and L5. The findings enable the recommendation of the following screw diameters: 4 mm for L1-L2, 5 mm for L3, 6 mm for L4-L5, and the length of 50 mm. We believe the study has extended clinical knowledge on lumbar spine morphometry, essential in the training physicians engaged in transpedicular stabilization.
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Variability Analysis of Manual and Computer-Assisted Preoperative Thoracic Pedicle Screw Placement Planning. Spine (Phila Pa 1976) 2018; 43:1487-1495. [PMID: 30325346 DOI: 10.1097/brs.0000000000002659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A comparison among preoperative pedicle screw placement plans, obtained from computed tomography (CT) images manually by two spine surgeons and automatically by a computer-assisted method. OBJECTIVE To analyze and compare the manual and computer-assisted approach to pedicle screw placement planning in terms of the inter- and intraobserver variability. SUMMARY OF BACKGROUND DATA Several methods for computer-assisted pedicle screw placement planning have been proposed; however, a systematic variability analysis against manual planning has not been performed yet. METHODS For 256 pedicle screws, preoperative placement plans were determined manually by two experienced spine surgeons, each independently performing two sets of measurements by using a dedicated software for surgery planning. For the same 256 pedicle screws, preoperative placement plans were also obtained automatically by a computer-assisted method that was based on modeling of the vertebral structures in 3D, which were used to determine the pedicle screw size and insertion trajectory by maximizing its fastening strength through the underlying bone mineral density. RESULTS A total of 1024 manually (2 observers × 2 sets × 256 screws) and 256 automatically (1 computer-assisted method × 256 screws) determined preoperative pedicle screw placement plans were obtained and compared in terms of the inter- and intraobserver variability. A large difference was observed for the pedicle screw sagittal inclination that was, in terms of the mean absolute difference and the corresponding standard deviation, equal to 18.3° ± 7.6° and 12.3° ± 6.5°, respectively for the intraobserver variability of the second observer and for the interobserver variability between the first observer and the computer-assisted method. CONCLUSION The interobserver variability among the observers and the computer-assisted method is within the intraobserver variability of each observer, which indicates on the potential use of the computer-assisted approach as a useful tool for spine surgery that can be adapted according to the preferences of the surgeon. LEVEL OF EVIDENCE 3.
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Feasibility and Accuracy of Thoracolumbar Minimally Invasive Pedicle Screw Placement With Augmented Reality Navigation Technology. Spine (Phila Pa 1976) 2018; 43:1018-1023. [PMID: 29215500 PMCID: PMC6039394 DOI: 10.1097/brs.0000000000002502] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaveric laboratory study. OBJECTIVE To assess the feasibility and accuracy of minimally invasive thoracolumbar pedicle screw placement using augmented reality (AR) surgical navigation. SUMMARY OF BACKGROUND DATA Minimally invasive spine (MIS) surgery has increasingly become the method of choice for a wide variety of spine pathologies. Navigation technology based on AR has been shown to be feasible, accurate, and safe in open procedures. AR technology may also be used for MIS surgery. METHODS The AR surgical navigation was installed in a hybrid operating room (OR). The hybrid OR includes a surgical table, a motorized flat detector C-arm with intraoperative 2D/3D imaging capabilities, integrated optical cameras for AR navigation, and patient motion tracking using optical markers on the skin. Navigation and screw placement was without any x-ray guidance. Two neurosurgeons placed 66 Jamshidi needles (two cadavers) and 18 cannulated pedicle screws (one cadaver) in the thoracolumbar spine. Technical accuracy was evaluated by measuring the distance between the tip of the actual needle position and the corresponding planned path as well as the angles between the needle and the desired path. Time needed for navigation along the virtual planned path was measured. An independent reviewer assessed the postoperative scans for the pedicle screws' clinical accuracy. RESULTS Navigation time per insertion was 90 ± 53 seconds with an accuracy of 2.2 ± 1.3 mm. Accuracy was not dependent on operator. There was no correlation between navigation time and accuracy. The mean error angle between the Jamshidi needles and planned paths was 0.9° ± 0.8°. No screw was misplaced outside the pedicle. Two screws breached 2 to 4 mm yielding an overall accuracy of 89% (16/18). CONCLUSION MIS screw placement directed by AR with intraoperative 3D imaging in a hybrid OR is accurate and efficient, without any fluoroscopy or x-ray imaging during the procedure. LEVEL OF EVIDENCE N/A.
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Bohoun CA, Naito K, Yamagata T, Tamrakar S, Ohata K, Takami T. Safety and accuracy of spinal instrumentation surgery in a hybrid operating room with an intraoperative cone-beam computed tomography. Neurosurg Rev 2018; 42:417-426. [PMID: 29663092 DOI: 10.1007/s10143-018-0977-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/20/2018] [Accepted: 03/28/2018] [Indexed: 11/25/2022]
Abstract
Although spinal instrumentation technique has undergone revolutionary progress over the past few decades, it may still carry significant surgery-related risks. The purpose of the present study was to assess the radiological accuracy of spinal screw instrumentation using a hybrid operating room (OR) and quantify the related radiation exposure. This retrospective study included 33 cases of complex spine fusion surgeries that were conducted using a hybrid OR with a flat panel detector (FPD) angiography system. Twelve cases (36.4%) were cervical, and 21 (63.6%) were thoracolumbar. The average number of spine fusion levels was 3 and 4.8, respectively, at the cervical and thoracolumbar spine levels. A FPD angiography system was used for intraoperative cone-beam computed tomography (CBCT) to obtain multi-slice spine images. All operations were conducted under optimized radiation shielding. Entrance surface doses (ESDs) and exposure times were recorded in all cases. A total of 313 screws were placed. Satisfactory screw insertion could be achieved in all cases with safe screw placement in 97.4% and acceptable placement in 2.6%. None of the cases showed any significant anatomical violation by the screws. The radiation exposure to the patients was absolutely consistent with the desired ESD value, and that to the surgeons, under the annual dose limit. These results suggest that the hybrid OR with a FPD angiography system is helpful to achieve safe and precise spinal fusion surgery, especially in complex cases.
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Affiliation(s)
- Christian A Bohoun
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kentaro Naito
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Toru Yamagata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
- Department of Neurosurgery, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 531-0021, Japan
| | - Samantha Tamrakar
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
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Intraoperative Navigation Is Associated with Reduced Blood Loss During C1-C2 Posterior Cervical Fixation. World Neurosurg 2017; 107:574-578. [PMID: 28842229 DOI: 10.1016/j.wneu.2017.08.051] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Traumatic injuries, degenerative/rheumatologic conditions, tumors, or infections of the upper cervical spine may in certain circumstances require surgical stabilization. C1 lateral mass screws (Harms technique) in combination with C2 instrumentation (pars, pedicle, translaminar screws) have become a mainstay of surgical treatment. The surgical anatomy of the C1 lateral mass can be challenging especially with the robust venous plexus that often causes significant bleeding with exposure of the C1-C2 articular complex. The purpose of this study was to examine whether the use of navigation reduced intraoperative blood loss during atlantoaxial fixation. METHODS We reviewed our institutional experience with atlantoaxial instrumentation with and without navigation from 2007 to 2016. We limited our cases to those requiring C1-C2 stabilization in traumatic and degenerative cases and not as part of more extensive surgical stabilizations. We identified 45 consecutive patients and compared intraoperative blood loss, need for transfusion, and time of procedure with and without the use of navigation. RESULTS There was a significant reduction in the amount of intraoperative blood loss in the navigated (n = 20) versus non-navigated cases (n = 25). In addition, although the navigated cases initially were longer, currently there is no significant difference in the length of the cases. CONCLUSIONS In our series, surgical navigation significantly reduced blood loss compared with non-navigated cases without increasing surgical time or risk of complication. Furthermore, navigation has the potential to reduce operative times due to a reduction in blood loss.
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26
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Radiation dose reduction in thoracic and lumbar spine instrumentation using navigation based on an intraoperative cone beam CT imaging system: a prospective randomized clinical trial. 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 2017; 26:2818-2827. [DOI: 10.1007/s00586-017-5229-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 07/09/2017] [Accepted: 07/18/2017] [Indexed: 02/06/2023]
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27
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Pedicle screw insertion accuracy in terms of breach and reposition using a new intraoperative cone beam computed tomography imaging technique and evaluation of the factors associated with these parameters of accuracy: a series of 695 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 2017. [DOI: 10.1007/s00586-017-5195-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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28
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Rate and mode of screw misplacements after 3D-fluoroscopy navigation-assisted insertion and 3D-imaging control of 1547 pedicle screws in spinal levels T10-S1 related to vertebrae and spinal sections. 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 2017; 26:2898-2905. [DOI: 10.1007/s00586-017-5108-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 03/18/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
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29
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Guha D, Jakubovic R, Gupta S, Alotaibi NM, Cadotte D, da Costa LB, George R, Heyn C, Howard P, Kapadia A, Klostranec JM, Phan N, Tan G, Mainprize TG, Yee A, Yang VXD. Spinal intraoperative three-dimensional navigation: correlation between clinical and absolute engineering accuracy. Spine J 2017; 17:489-498. [PMID: 27777052 DOI: 10.1016/j.spinee.2016.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/19/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal intraoperative computer-assisted navigation (CAN) may guide pedicle screw placement. Computer-assisted navigation techniques have been reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably and reported in less than a quarter of clinical studies of CAN-guided pedicle screw accuracy. PURPOSE This study aimed to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy. DESIGN/SETTING This is a retrospective review of a prospectively collected cohort. PATIENT SAMPLE We recruited 30 patients undergoing first-time posterior cervical-thoracic-lumbar-sacral instrumented fusion±decompression, guided by intraoperative three-dimensional CAN. OUTCOME MEASURES Clinical or radiographic screw accuracy (Heary and 2 mm classifications) and absolute quantitative navigation accuracy (translational and angular error in axial and sagittal planes). METHODS We reviewed a prospectively collected series of 209 pedicle screws placed with CAN guidance. Each screw was graded clinically by multiple independent raters using the Heary and 2 mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes. RESULTS Acceptable screw accuracy was achieved for significantly fewer screws based on 2 mm grade versus Heary grade (92.6% vs. 95.1%, p=.036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2 mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational-angular accuracies were 1.75 mm-3.13° and 1.20 mm-3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy. CONCLUSIONS Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on postoperative imaging may be more reliable if performed in multiple by radiologist raters.
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Affiliation(s)
- Daipayan Guha
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Raphael Jakubovic
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Department of Biomedical Physics, Ryerson University, 350 Victoria St., Toronto, ON, M5B 2K3, Canada
| | - Shaurya Gupta
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - David Cadotte
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Leodante B da Costa
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Rajeesh George
- JurongHealth, Ng Teng Fong General Hospital, 1 Jurong East Street, Singapore, 609606, Singapore
| | - Chris Heyn
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Peter Howard
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Anish Kapadia
- Department of Medical Imaging, University of Toronto, 263 McCaul St., Toronto, ON, M5T 1W7, Canada
| | - Jesse M Klostranec
- Department of Medical Imaging, University of Toronto, 263 McCaul St., Toronto, ON, M5T 1W7, Canada
| | - Nicolas Phan
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Gamaliel Tan
- JurongHealth, Ng Teng Fong General Hospital, 1 Jurong East Street, Singapore, 609606, Singapore
| | - Todd G Mainprize
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Albert Yee
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 149 College St., Toronto, ON, M5T 1P5, Canada
| | - Victor X D Yang
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Department of Electrical and Computer Engineering, Ryerson University, 350 Victoria St., Toronto, ON, M5B 2K3, Canada.
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30
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Knez D, Mohar J, Cirman RJ, Likar B, Pernuš F, Vrtovec T. Manual and Computer-Assisted Pedicle Screw Placement Plans: A Quantitative Comparison. LECTURE NOTES IN COMPUTER SCIENCE 2016. [DOI: 10.1007/978-3-319-55050-3_10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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