Introduction to haptics for neurosurgeons

Simulators with Haptic Feedback in Neurosurgery: Are We Reaching the "Aviator" Type of Training? Narrative Review and Future Perspectives

Over the last decade, the quality of neurosurgical procedures dramatically improved, also thanks to the development and increased accessibility of several technological recourses (e.g., imaging, neuronavigation, neurophysiology, microscopy), allowing to plan increasingly complex approaches, while reducing the risk of postoperative complications. Among these resources, three-dimensional rendering and simulation systems, such as virtual and augmented reality, provide a high-quality visual reconstruction of brain structures and interaction with advanced anatomical models. Although the usefulness of these systems is now widely recognized, the additional availability of proprioceptive (haptic) feedback might help to further enhance the realism of surgical simulation. A systematic literature review on the application of haptic technology in simulation of cranial neurosurgical procedures was made. Inclusion criteria were the usage of simulators with haptic feedback for specific neurosurgical procedures whereas the studies that did not include an evaluation of the surgical simulation system by a surgeon were excluded. According to inclusion and exclusion criteria, 10 studies were selected. Simulation in neurosurgery still lacks a system capable of rehearsing the entire procedure-from skin incision to skin closure-while providing both visual and proprioceptive feedback. Consequently, further advancements in this area are necessary.

Use of a High-Fidelity Training Simulator for Minimally Invasive Lumbar Decompression Increases Working Knowledge and Technical Skills Among Orthopedic and Neurosurgical Trainees

STUDY DESIGN

Prospective comparative study.

OBJECTIVE

To quantify the educational benefit to surgical trainees of using a high-fidelity simulator to perform minimally invasive (MIS) unilateral laminotomy for bilateral decompression (ULBD) for lumbar stenosis.

METHODS

Twelve orthopedic and neurologic surgery residents performed three MIS ULBD procedures over 2 weeks on a simulator guided by established AO Spine metrics. Video recording of each surgery was rated by three blinded, independent experts using a global rating scale. The learning curve was evaluated with attention to technical skills, skipped steps, occurrence of errors, and timing. A knowledge gap analysis evaluating participants' current vs desired ability was performed after each trial.

RESULTS

From trial 1 to 3, there was a decrease in average procedural time by 31.7 minutes. The cumulative number of skipped steps and surgical errors decreased from 25 to 6 and 24 to 6, respectively. Overall surgical proficiency improved as indicated by video rating of efficiency and smoothness of surgical maneuvers, most notably with knowledge and handling of instruments. The greatest changes were noted in junior rather than senior residents. Average knowledge gap analysis significantly decreased by 30% from the first to last trial (P = .001), signifying trainees performed closer to their desired technical goal.

CONCLUSION

Procedural metrics for minimally invasive ULBD in combination with a realistic surgical simulator can be used to improve the skills and confidence of trainees. Surgical simulation may offer an important educational complement to traditional methods of skill acquisition and should be explored further with other MIS techniques.

Comparison of accuracy and safety between robot-assisted and conventional fluoroscope assisted placement of pedicle screws in thoracolumbar spine: A meta-analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis is to explore the screw positioning accuracy, complications related to pedicle screw implantation, revision rate and radiation exposure between robot screw placement and traditional fluoroscopic screw placement.

METHODS

We searched several databases, including CNKI, Wanfang database, cqvip datebase, PubMed, Cochrane library and EMBASE, to identify articles that might meet the criteria. Meta-analysis was performed using Revman 5.3 software.

RESULTS

A total of 13 randomized controlled trial were included. The results showed that the pedicle screw accuracy of the robot assisted group was significantly better than that of the conventional freehand (FH) group (OR = 3.5, 95% confidence interval [CI] [2.75,4.45], P < .0001). There was no significant difference in the complications caused by pedicle screw implantation between the robot-assisted group and the conventional FH group [OR = 0.39, 95%CI (0.10,1.48), P = .17]. The rate of facet joint invasion in the robot-assisted group was significantly lower than that in the conventional FH group (OR = 0.06, 95%CI [0.01,0.29], P = .0006). The revision rate in the robot-assisted group was significantly lower than that in the conventional FH group (OR = 0.19, 95%CI [0.05,0.71], P = 0.0.01). There was no significant difference in the average radiation of pedicle screws implantation between the robot-assisted group and the conventional FH (mean difference = -7.94, 95%CI [-20.18,4.30], P = .20).

CONCLUSION

The robot-assisted group was significantly better than the conventional FH in the accuracy of pedicle screw placement and facet joint invasion rate and revision rate. There was no significant difference in the complication and fluoroscopy time between the two groups.

Design and Kinematics of a Comanipulated Robot Dedicated to Prostate Brachytherapy

In brachytherapy, the manual implantation of seeds is not accurate leading to side effects and limiting the use of new procedures. Robotics solutions have to be fully suitable for medical applications especially considering the operating room. This paper investigates a delta robot solution for improving the accuracy of the prostate brachytherapy procedure by proposing a compact and lightweight robot. In addition, the design was thought as a comanipulated robot for a better acceptability and human–machine interaction. The robot kinematics and singularities were determined and the theoretical capability in term of resolution and force feedback was evaluated. A prototype was built in order to experimentally measure the capability of this first prototype.

Dynamic Reconfiguration of Redundant Haptic Interfaces for Rendering Soft and Hard Contacts

There are conflicting objectives between required characteristics of haptic interfaces such as maximum force feedback capability versus back-drive friction, which can be optimally traded-off in a redundant haptic interface; a redundant haptic interface has more degrees of freedom than minimally required ones for a given task. In this article, a contact-aware null-space control approach for redundant haptic interfaces is proposed to address these trade-offs. First, we introduce a task-dependent null-space controller in which the internal motion of the redundant haptic interface is appropriately controlled to achieve a desired performance; i.e., low back-drive friction in case of free-space motion and soft contact or large force feedback capability in case of stiff contact. Next, a transition method is developed to facilitate the adaptation of the null-space controller's varying objectives according to the varying nature of the task. The transition method prevents discontinuities in the null-space control signal. This transition method is informed by a proposed actuator saturation observer that monitors the distance of joint torques from their saturation levels. The overall outcome is an ability to recreate the feelings of soft contacts and hard contacts with higher fidelity compared to what a conventional non-redundant haptic interface can achieve. Simulations are provided throughout the paper to illustrate the concepts. Moreover, experimental results are reported to verify the effectiveness of the proposed control strategies. It is shown that the proposed controller can perform well in the soft-contact, hard-contact, and transition phases.

Radiological and Clinical Differences between Tinavi Orthopedic Robot and O-Arm Navigation System in Thoracolumbar Screw Implantation for Reconstruction of Spinal Stability

Background

Pedicle screw fixation is one of the most commonly used methods in spine surgery. We introduce a surgical robot system from China based on 3-dimensional fluoroscopy imaging and compare it with the commonly used O-arm navigation system. We study the differences in accuracy, safety, and clinical effect in auxiliary pedicle screw fixation.

Material/Methods

Patients who underwent thoracolumbar internal fixation in our hospital from 2017 to 2019 were divided into a robot and navigation group according to whether surgery was assisted by the Tinavi orthopedic robot or O-arm navigation system. Imaging data of patients were searched from the image system and accuracy of screw implantation was measured by Rampersaud A to D grade classification. Deviation sagittal, deviation transversal, and facet joint violation were also measured and calculated.

Results

In total, 306 patients were included: 136 patients in the robot group with 760 screws implanted; 166 patients in the navigation group with 908 screws implanted. The accuracy of “perfect” and “clinically acceptable” pedicle screw implantation was 96.2% and 99.6%, respectively, in the robot group and 90.5% and 96.7%, respectively, in the navigation group, with a significant difference between the 2 groups (P<0.05). The sagittal and transversal deviations in the robot group were significantly less than those in the navigation group (P<0.05).

Conclusions

The Tinavi orthopedic robot can significantly improve surgical accuracy and safety of pedicle screw fixation, as compared with that of O-arm navigation technology, without increasing complications. It shows great potential in clinical application.

Pierre Curie: the anonymous neurosurgical contributor

Pierre Curie, best known as a Nobel Laureate in Physics for his co-contributions to the field of radioactivity alongside research partner and wife Marie Curie, died suddenly in 1906 from a street accident in Paris. Tragically, his skull was crushed under the wheel of a horse-drawn carriage. This article attempts to honor the life and achievements of Pierre Curie, whose trailblazing work in radioactivity and piezoelectricity set into motion a wide range of technological developments that have culminated in the advent of numerous techniques used in neurological surgery today. These innovations include brachytherapy, Gamma Knife radiosurgery, focused ultrasound, and haptic feedback in robotic surgery.

Simulation Training Curricula for Neurosurgical Residents: Cervical Foraminotomy and Durotomy Repair Modules

INTRODUCTION

Since 2010, the Congress of Neurological Surgeons (CNS) has offered a neurosurgical skills simulation course for residents and medical students. The authors describe their experience with incorporation of two neurosurgical skills simulation modules into the dedicated resident training curriculum of a single ACGME-accredited training program, using lumbar dural repair (5) and posterior cervical laminoforaminotomy modules from the CNS simulation initiative (6).

METHODS

Each of the available 22 neurosurgery residents at a single residency program was given two 20-question pretests for a cervical laminoforaminotomy and durotomy repair module as a basic test of regional anatomy, general disease knowledge, surgical decision making, and recently published literature. This was followed by a faculty-directed skills simulation course and concluded with a final 20 question post-test.

RESULTS

Posterior cervical laminoforaminotomy was performed once by each resident, and grading was conducted using the predetermined OSATs. The overall score was 56.1 (70%, range 26-76, maximum 80 points) with a trend towards higher scores with advanced levels of training. All residents completed the durotomy repair OSATs for a total of three trials. Of a maximum composite score of 60, a mean 37.2 (62%, range 15-58) was scored by the residents (Table 3). The mean OSAT scores for each durotomy trial was 2.66, 3.15, and 3.48 on each success test. A trend towards higher scores in advanced years of training was observed, but did not reach statistical significance (Figure 3).

CONCLUSIONS

Duty hour limitations and regulatory pressure for enhanced quality and outcomes may limit access of neurosurgical residents to fundamental skills training. Fundamental skills training as part of a validated simulation curriculum can mitigate this challenge to residency education. National development of effective technical simulation modules for use in individual residency training programs is a promising strategy to achieve these goals.

Urovision 2020: The future of urology

Urology, as a specialty, has always been at the forefront of innovation and research. Newer technologies have been rapidly embraced and, in many cases, improved upon in order to achieve better patient outcomes. This review addresses the possible future directions that technological advances in urology may take. The role of further miniaturization of urolithiasis treatment, robotic surgery and other minimally invasive techniques is addressed. The potential for enhanced imaging and diagnostic techniques like magnetic resonance imaging and ultrasonography modifications, as well as the potential applications of nanotechnology and tissue engineering, are reviewed.

This article is based on the Dr. Sitharaman Best Essay award of the Urological Society of India for 2013.

Simulation and resident education in spinal neurosurgery

BACKGROUND

A host of factors have contributed to the increasing use of simulation in neurosurgical resident education. Although the number of simulation-related publications has increased exponentially over the past two decades, no studies have specifically examined the role of simulation in resident education in spinal neurosurgery.

METHODS

We performed a structured search of several databases to identify articles detailing the use of simulation in spinal neurosurgery education in an attempt to catalogue potential applications for its use.

RESULTS

A brief history of simulation in medicine is given, followed by current trends of spinal simulation utilization in residency programs. General themes from the literature are identified that are integral for implementing simulation into neurosurgical residency curriculum. Finally, various applications are reported.

CONCLUSION

The use of simulation in spinal neurosurgery education is not as ubiquitous in comparison to other neurosurgical subspecialties, but many promising methods of simulation are available for augmenting resident education.

Frameless robotic stereotactic biopsies: a consecutive series of 100 cases

OBJECT

Stereotactic biopsy procedures are an everyday part of neurosurgery. The procedure provides an accurate histological diagnosis with the least possible morbidity. Robotic stereotactic biopsy needs to be an accurate, safe, frameless, and rapid technique. This article reports the clinical results of a series of 100 frameless robotic biopsies using a Medtech ROSA device.

METHODS

The authors retrospectively analyzed their first 100 frameless stereotactic biopsies performed with the robotic ROSA device: 84 biopsies were performed by frameless robotic surface registration, 7 were performed by robotic bone fiducial marker registration, and 9 were performed by scalp fiducial marker registration. Intraoperative flat-panel CT scanning was performed concomitantly in 25 cases. The operative details of the robotic biopsies, the diagnostic yield, and mortality and morbidity data observed in this series are reported.

RESULTS

A histological diagnosis was established in 97 patients. No deaths or permanent morbidity related to surgery were observed. Six patients experienced transient neurological worsening. Six cases of bleeding within the lesion or along the biopsy trajectory were observed on postoperative CT scans but were associated with transient clinical symptoms in only 2 cases. Stereotactic surgery was performed with patients in the supine position in 93 cases and in the prone position in 7 cases. The use of fiducial markers was reserved for posterior fossa biopsy via a transcerebellar approach, via an occipital approach, or for pediatric biopsy.

CONCLUSIONS

ROSA frameless stereotactic biopsies appear to be accurate and safe robotized frameless procedures.

Current state-of-the-art and future perspectives of robotic technology in neurosurgery

Neurosurgery is one of the most demanding surgical specialties in terms of precision requirements and surgical field limitations. Recent advancements in robotic technology have generated the possibility of incorporating advanced technological tools to the neurosurgical operating room. Although previous studies have addressed the specific details of new robotic systems, there is very little literature on the strengths and drawbacks of past attempts, currently available platforms and prototypes in development. In this review, the authors present a critical historical analysis of the development of robotic technology in neurosurgery as well as a comprehensive summary of the currently available systems that can be expected to be incorporated to the neurosurgical armamentarium in the near future. Finally, the authors present a critical analysis of the main technical challenges in robotic technology development at the present time (such as the design of improved systems for haptic feedback and the necessity of incorporating intraoperative imaging data) as well as the benefits which robotic technology is expected to bring to specific neurosurgical subspecialties in the near future.

A robot-assisted surgical system using a force-image control method for pedicle screw insertion

Objective

To introduce a robot-assisted surgical system for spinal posterior fixation that can automatically recognize the drilling state and stop potential cortical penetration with force and image information and to further evaluate the accuracy and safety of the robot for sheep vertebra pedicle screw placement.

Methods

The Robotic Spinal Surgery System (RSSS) was composed of an optical tracking system, a navigation and planning system, and a surgical robot equipped with a 6-DOF force/torque sensor. The robot used the image message and force signals to sense the different operation states and to prevent potential cortical penetration in the pedicle screw insertion operation. To evaluate the accuracy and safety of the RSSS, 32 screw insertions were conducted. Furthermore, six trajectories were deliberately planned incorrectly to explore whether the robot could recognize the different drilling states and immediately prevent cortical penetration.

Results

All 32 pedicle screws were placed in the pedicle without any broken pedicle walls. Compared with the preoperative planning, the average deviations of the entry points in the axial and sagittal views were 0.50±0.33 and 0.65±0.40 mm, and the average deviations of the angles in the axial and sagittal views were 1.9±0.82° and 1.48±1.2°. The robot successfully recognized the different drilling states and prevented potential cortical penetration. In the deliberately incorrectly planned trajectory experiments, the robot successfully prevented the cortical penetration.

Conclusion

These results verified the RSSS’s accuracy and safety, which supported its potential use for the spinal surgery.