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Frameless Navigation
Elyne Kahn , Kevin S. Chen , and Paul Park
1 1
11.1 Introduction
In spine procedures, radiographic imaging is
necessary for localization and is often used to
guide instrumentation placement. Fluoroscopy is
commonly used; however, its frequent use can be
associated with signifi cant intraoperative radiation exposure [ 3 , 4 ]. More so than in traditional
open procedures, minimally invasive procedures
typically result in greater radiation exposure, as
fl uoroscopy is used in place of visual cues due to
the decreased spine exposure. In minimally invasive LLIFs, signifi cant fl uoroscopy is used to
accurately localize the disc space and ensure
appropriate placement of the interbody cage. As
LLIF continues to gain popularity, spine surgeons
must fi nd ways to reduce associated radiation
exposure.
CaSN is one validated method that can
minimize the use of intraoperative fluoroscopy, thereby reducing the radiation burden to
the surgeon and other operating room personnel [
1 ]. Most commonly used for posterior
instrumentation, CaSN can also be applied to
LLIF.
In this chapter, we describe the surgical
technique associated with successful use of the
E. Kahn , MD • K. S. Chen , MD • P. Park , MD (*)
Department of Neurosurgery , University of Michigan ,
3552 Taubman Center, Box 0338, 1500 East Medical
Center Drive , Ann Arbor , MI , USA
ppark@med.umich.edu
e-mail:
O-arm Surgical Imaging System combined with
the StealthStation CaSN (Medtronic, Minneapolis,
MN) for LLIF.
11.2 Technique
11.2.1 Positioning
After induction of general anesthesia,
neuro- monitoring leads are placed. Somatosensory
evoked potentials and electromyography are monitored. The patient is turned to the lateral position
on a Jackson fl at table (Fig. 11.1 ). Typically, a
left-sided approach is performed unless there is a
signifi cant deformity present, in which case the
approach is dictated by the concavity of the curve.
Positioning includes placement of an axillary roll
and a large roll underneath the fl ank to open the
space between the lower rib cage and iliac crest.
The legs are fl exed. This maneuver, along with
keeping the bed fl at rather than “breaking” or
“jackknifi ng” the table, avoids potential stretch
injury to the femoral nerve [
table also allows easier positioning of the O-arm
unit. The patient’s position is secured with tape at
multiple points, so that tilting of the table can be
performed safely.
The skin is prepped and draped in the standard
manner. When draping, the anterior superior iliac
spine (ASIS) is included in the fi eld. The ASIS
will serve as the fi xation point for the stereotactic
2 ]. The use of the fl at
© Springer International Publishing Switzerland 2017
M.Y. Wang et al. (eds.), Lateral Access Minimally Invasive Spine Surgery,
DOI 10.1007/978-3-319-28320-3_11
81
82
Fig. 11.1 Patient is
positioned on a Jackson fl at
table, secured at multiple
points with taping, with a
large roll underlying the fl ank
E. Kahn et al.
frame. The screen and camera for CaSN are
placed at the foot of the bed.
11.2.2 Image Acquisition and Registration to CaSN
An initial stab incision is made over the ASIS,
followed by impaction of an iliac pin into the
bone. The StealthStation reference arc is then fi xated to the iliac pin (Fig. 11.2 ). Additional sterile
drapes are placed to cover the fi eld, leaving the
reference arc exposed. The O-arm fl uoroscopy
unit is then positioned to acquire a 3D image of
the targeted spinal levels, which is auto- registered
to the StealthStation CaSN system (Fig. 11.3 ).
After registration, the O-arm unit is removed
from the surgical fi eld.
11.2.3 Surgical Approach and Cage Placement with CaSN
The initial dilator serves multiple purposes. It is
used as a nerve stimulator via a clip electrode as
well as for navigation when a tracking arc is
attached (Fig. 11.4 ). This navigated dilator is
used to determine the incision site on the fl ank.
Typically, for a one-level procedure, a one-to-one
and a half-inch incision is made. After dissection
through the subcutaneous tissues, the fascia over
the abdominal muscles is opened. The abdominal
wall muscles (external oblique, internal oblique,
and transversus abdominis) are split, and blunt
dissection is used to enter the retroperitoneal
space (Fig. 11.5 ). The psoas muscle can be pal-
pated. A clip electrode for nerve stimulation is
attached to the navigated dilator, which is guided
11 Frame les s N avi gat ion
83
Fig. 11.4 Dilator with nerve stimulation clip and tracking frame attached
Fig. 11.2 An iliac pin is impacted into the ASIS, with
subsequent attachment of reference frame
Fig. 11.3 Positioning of O-arm fl uoroscopic unit in preparation for acquisition of a 3D image
into the retroperitoneal space by CaSN
(Fig. 11.6 ). The dilator is navigated through the
psoas muscle while being stimulated to prevent
nerve injury and advanced into the disc space.
The clip electrode and tracking frame are then
Fig. 11.5 Split abdominal musculature
removed, at which point sequential dilation is
performed and an appropriate length expandable
retractor is placed (Figs. 11.7 and 11.8 ). Note that
fl uoroscopy has not been used.
The retractor is expanded and the light source
positioned to optimize visualization. Typically,
there is residual psoas muscle present, which is
carefully split and retracted. The disc space is
visualized, and the navigated dilator is used to
confi rm adequate positioning of the retractor over
the disc space. A knife is used to incise the annulus and discectomy is performed. At this stage,
the fl uoroscopy unit is positioned in the surgical
fi eld to obtain anterior-posterior spot images as
84
E. Kahn et al.
Fig. 11.6 CaSN screenshot showing path of the navigated dilator with clip electrode attached
Fig. 11.8 Placement of expandable tubular retractor
insertion of the Cobb elevator completely through
the contralateral side. The endplates are prepared
Fig. 11.7 Removal of tracking frame after dilator has
been advanced into the disc space using CaSN
for grafting (Fig. 11.9 ).
At this point, a trial spacer is navigated into
the disc space under CaSN (Fig. 11.10 ). Allograft
needed. Frequently a Cobb elevator, which is not
navigated, is used to release the contralateral
annulus. Spot fl uoroscopy is used to confi rm
bone is packed into the disc space and interbody
cage. Cage selection is based on the size of trial
spacer used. The cage is attached to a navigated
11 Frame les s N avi gat ion
85
Fig. 11.9 Disc space after discectomy
holder, which allows placement of the cage under
CaSN (Fig. 11.11 ). Spot fl uoroscopy is used to
confi rm appropriate placement (Fig. 11.12 ).
After cage placement, hemostasis is obtained.
The fascia overlying the abdominal musculature
is re-approximated, and the remaining incision is
closed in layers, with the skin closed with tissue
glue. The iliac pin is removed, and this incision is
closed with absorbable deep dermal stitches and
tissue glue (Fig. 11.13 ).
Fig. 11.10 CaSN screenshot as interbody trial spacer is navigated into the disc space
86
E. Kahn et al.
Fig. 11.11 CaSN screenshot as interbody implant is navigated into the disc space
Fig. 11.12 Preoperative lateral x-ray ( left ) and intraoperative fl uoroscopic lateral x-ray ( right ) illustrating appropriate
placement of interbody cage by CaSN
11 Frame les s N avi gat ion
87
Fig. 11.13 Postoperative closed incisions
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