1
|
Tabarestani TQ, Salven DS, Sykes DAW, Bardeesi AM, Bartlett AM, Wang TY, Paturu MR, Dibble CF, Shaffrey CI, Ray WZ, Chi JH, Wiggins WF, Abd-El-Barr MM. Using Novel Segmentation Technology to Define Safe Corridors for Minimally Invasive Posterior Lumbar Interbody Fusion. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-01010. [PMID: 38149852 DOI: 10.1227/ons.0000000000001046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/15/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There has been a rise in minimally invasive methods to access the intervertebral disk space posteriorly given their decreased tissue destruction, lower blood loss, and earlier return to work. Two such options include the percutaneous lumbar interbody fusion through the Kambin triangle and the endoscopic transfacet approach. However, without accurate preoperative visualization, these approaches carry risks of damaging surrounding structures, especially the nerve roots. Using novel segmentation technology, our goal was to analyze the anatomic borders and relative sizes of the safe triangle, trans-Kambin, and the transfacet corridors to assist surgeons in planning a safe approach and determining cannula diameters. METHODS The areas of the safe triangle, Kambin, and transfacet corridors were measured using commercially available software (BrainLab, Munich, Germany). For each approach, the exiting nerve root, traversing nerve roots, theca, disk, and vertebrae were manually segmented on 3-dimensional T2-SPACE magnetic resonance imaging using a region-growing algorithm. The triangles' borders were delineated ensuring no overlap between the area and the nerves. RESULTS A total of 11 patients (65.4 ± 12.5 years, 33.3% female) were retrospectively reviewed. The Kambin, safe, and transfacet corridors were measured bilaterally at the operative level. The mean area (124.1 ± 19.7 mm2 vs 83.0 ± 11.7 mm2 vs 49.5 ± 11.4 mm2) and maximum permissible cannula diameter (9.9 ± 0.7 mm vs 6.8 ± 0.5 mm vs 6.05 ± 0.7 mm) for the transfacet triangles were significantly larger than Kambin and the traditional safe triangles, respectively (P < .001). CONCLUSION We identified, in 3-dimensional, the borders for the transfacet corridor: the traversing nerve root extending inferiorly until the caudal pedicle, the theca medially, and the exiting nerve root superiorly. These results illustrate the utility of preoperatively segmenting anatomic landmarks, specifically the nerve roots, to help guide decision-making when selecting the optimal operative approach.
Collapse
Affiliation(s)
- Troy Q Tabarestani
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - David S Salven
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - David A W Sykes
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anas M Bardeesi
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Alyssa M Bartlett
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Timothy Y Wang
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Mounica R Paturu
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Christopher F Dibble
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | | | - Wilson Z Ray
- Department of Neurosurgery, Washington University, St. Louis, Missouri, USA
| | - John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter F Wiggins
- Department of Radiology, Duke University Hospital, Durham, North Carolina, USA
| | | |
Collapse
|
2
|
Dimensional Changes of the Neuroforamen After Anterior Decompression of the Cervical Spine: An In Vitro Micro-Computed Tomography Investigation. World Neurosurg 2022; 165:e423-e431. [PMID: 35738534 DOI: 10.1016/j.wneu.2022.06.075] [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: 05/13/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of this preliminary cadaveric study was to quantify the dimensional changes of the neuroforamen and area available for the cord (AAC) after implantation of various interbody devices with and without posterior longitudinal ligament (PLL) removal. METHODS Eight cervical spines (C3-T1) underwent micro-computed tomography (micro-CT) scanning of the intact spine, followed by discectomy and reconstruction at 3 contiguous levels (C4-C7). Under conditions of intact and resected PLL, the following interbody device configurations were evaluated: 1) parallel, 2) lordotic, and 3) optimal lordotic. Neuroforaminal measurements were calculated from an oblique angle and the AAC was calculated by quantifying the empty space compared with the total space available for the cord. Posterior disc height and operative range lordosis were measured and compared between groups. RESULTS Neuroforaminal height and area significantly increased for all reconstruction groups compared with intact. The increase in neuroforaminal height and area was greatest after PLL resection and placement of parallel (27.1% and 43.6%, respectively) and optimal lordotic (30.5% and 41.5%, respectively) implants. The AAC increased as a function of implant placement compared with intact and increased further after resection of the PLL (P < 0.05). There were no significant differences in operative range lordosis between parallel and lordotic implants. CONCLUSIONS Similar to the lumbar spine, segmental distraction via placement of an interbody device produces indirect decompression of the cervical neuroforamen. Results indicate that a 34% increase in neuroforaminal area and a 51% increase in AAC are achievable with appropriately sized interbody devices and adequate distraction at the posterior aspect of the vertebral body.
Collapse
|
3
|
McAfee PC, Cunningham BW, Mullinex K, Eisermann L, Brooks DM. Computer Simulated Enhancement and Planning, Robotics and Navigation With Patient Specific Implants and 3-D Printed Cages. Global Spine J 2022; 12:7S-18S. [PMID: 35393879 PMCID: PMC8998477 DOI: 10.1177/21925682211003554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVES Pre and postop Measurement Testing. This is a retrospective study of 33 consecutive interbody spacers in 21 patients who underwent pre, intra, and postoperative measurement of the middle column to determine if this would lead to more precise restoration of middle column height and spacer fit. Scaled transparencies of the pre-operative simulation of angular correction and spacer geometry could be overlayed on the post-operative imaging studies. METHODS Multiple Observers Measurement Testing. 33 consecutive vertebral levels requiring interbody spacers for multilevel deformities had middle column height pre and post operatively measured by 3 blinded observers. The preoperative and postoperative measurements were compared using a linear regression analysis and Pearson product-moment correlation. RESULTS Pre and postop Measurement Testing: Thirty-three interbody devices in 21 patients had pre-operative planning, simulation of cage dimensions to determine the proper cage fit which would provide for the desired correction of foraminal height and sagittal balance parameters. The simulated preoperative plan overlayed the final post-operative radiograph and was a near-perfect match in 20 of 21 patients (95.2%). Multiple Observers Measurement Testing: A Pearson product-moment correlation was run between each individual's pre-op and post-op middle column measurements. There was a strong, positive correlation between pre-operative and post-operative measurements, which was statistically significant (r = 0.903, n = 33, P < 0.001). CONCLUSIONS This consecutive series of 33 cases demonstrated the utility of measuring the preoperative middle column length in predicting the optimal height of the spacers, intervertebral disks, and posterior vertebral body height simultaneously restoring sagittal and coronal plane alignment.
Collapse
Affiliation(s)
- Paul C. McAfee
- MedStar Orthopedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | | | - Ken Mullinex
- MedStar Orthopedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Lukas Eisermann
- MedStar Orthopedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Daina M. Brooks
- MedStar Orthopedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| |
Collapse
|
4
|
Karandikar P, Massaad E, Hadzipasic M, Kiapour A, Joshi RS, Shankar GM, Shin JH. Machine Learning Applications of Surgical Imaging for the Diagnosis and Treatment of Spine Disorders: Current State of the Art. Neurosurgery 2022; 90:372-382. [PMID: 35107085 DOI: 10.1227/neu.0000000000001853] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/10/2021] [Indexed: 01/18/2023] Open
Abstract
Recent developments in machine learning (ML) methods demonstrate unparalleled potential for application in the spine. The ability for ML to provide diagnostic faculty, produce novel insights from existing capabilities, and augment or accelerate elements of surgical planning and decision making at levels equivalent or superior to humans will tremendously benefit spine surgeons and patients alike. In this review, we aim to provide a clinically relevant outline of ML-based technology in the contexts of spinal deformity, degeneration, and trauma, as well as an overview of commercial-level and precommercial-level surgical assist systems and decisional support tools. Furthermore, we briefly discuss potential applications of generative networks before highlighting some of the limitations of ML applications. We conclude that ML in spine imaging represents a significant addition to the neurosurgeon's armamentarium-it has the capacity to directly address and manifest clinical needs and improve diagnostic and procedural quality and safety-but is yet subject to challenges that must be addressed before widespread implementation.
Collapse
Affiliation(s)
- Paramesh Karandikar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- T.H. Chan School of Medicine, University of Massachusetts, Worcester, Massachusetts, USA
| | - Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muhamed Hadzipasic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Kiapour
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rushikesh S Joshi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|