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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5225_Библиотеки_им_академика_М_И_Перельмана.pdf
2 Image-Based Spinal Navigation: Current Technology andFuture Applications
13
concern as the radiation dosage is largely xed with cone-beam technology. The
O-arm, however, has the option for dose modication allowing for low-dose imaging, which has been shown to decrease patient radiation exposure by half [22].
Future Technologies forSpinal Navigation
The eld of spinal navigation has seen an explosion in technological incorporation
over the last two decades, a trend which is expected to continue to advance in the
years to come. Several areas of growth include alternative imaging modalities as
well as augmented reality technology. One of the alternative imaging modalities
currently on the market is cone-beam tomosynthesis (nView Medical Inc., Salt Lake
City, UT). Cone-beam tomosynthesis alters the current framework in that the uoroscopic source rotates on a xed access to generate a cone of tomosynthesis
through which high-delity axial, sagittal, and coronal images are generated with
articial intelligence-enabled system. Preclinical application in spinal navigation
has shown cone-beam tomosynthesis to achieve consistently accurate assessment of
spinal anatomy at half the time and one-tenth the radiation exposure of traditional
fan-beam CT imaging [23]. This modality is currently available for clinical application, and although no clinical studies are currently published, it shows great promise
including the application for treatment of pediatric spinal deformity.
With so many of the described techniques involving ionizing radiation, the possibility of linking spinal navigation systems to MRI is tantalizing. The technique of
stereotactic surgery utilizing MRI was described by Leksell etal. [24] for brain
tumors, with Nabavi etal. [25] describing the use of open conguration intraoperative MRI for neurosurgical biopsies; however, there is a paucity of literature on the
use of intraoperative MRIs for spinal navigation applications. Despite this, however,
MRI has the distinct advantage of avoiding ionizing radiation that are inherent in all
previously discussed navigation techniques. Su etal. [26] outlined some of the challenges to implementing MRI-guided spinal navigation, including strong and rapid
switching magnetic elds and constrained space to operate within the scanner bore.
The potential advantages of this type of imaging for navigation included excellent
soft tissue contrast and tissue perfusion scanning. Potential co-registration of CT
and MRI modalities may prove helpful in the future, as described by Kamagowa
etal. [27] in looking at cervical root compression.
Augmented reality technology represents a promising future application for
intraoperative spinal navigation. At the writing of this chapter, few systems have
approval for clinical application in the United States. These systems, in their current
use, require intraoperative 3D imaging with either cone-beam or fan-beam CT technology to interface. Following imaging registration, the images can then be relayed
to head-mounted displays to allow for instantaneous overlay of the surgical anatomy without the use of external display screens. Previous studies have demonstrated
the viability of these head-mounted display-based systems for pedicle screw placement [28, 29], with high clinical accuracy and precision [30, 31]. Clinical studies
14
K. A. Shaw et al.
have also validated the accuracy of these systems while achieving high operative
efciency for pedicle screw placement with minimal learning curve for clinical utilization [32]. Future advances in technology will further enhance the clinical application by extending the imaging system interfaces to include preoperative imaging
studies and uoroscopic validation.
Conclusion
There are many new innovations in spinal navigation that have widely expanded the
options spine surgeons have in safely inserting pedicle screws. While spinal navigation is not the gold standard for inserting pedicle screws, this may change over the
next decade. Surgeons may choose to use spinal navigation systems that utilize
preoperative CT imaging in order to decrease intraoperative radiation exposure to
the surgical team. For cases where the spine position may shift signicantly or
where the anatomy is not amenable to relying on preoperative imaging, spinal navigation using intraoperative CT guidance is available. These intraoperative modalities include fan-beam CT navigation systems and cone-beam CT navigation, which
is also referred to as 3D uoroscopy. The future of spinal navigation will likely
include incorporating augmented reality into virtual goggles, allowing surgeons to
never take their eyes off the surgical eld. Other future advancements will include
the use of preoperative or intraoperative MRIs linked to spinal navigation systems.
References
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3. Du JP, etal. Accuracy of pedicle screw insertion among 3 image-guided navigation systems:
systematic review and meta-analysis. World Neurosurg. 2018;109:24–30.
4. Liu H, Chen W, Liu T, Meng B, Yang H.Accuracy of pedicle screw placement based on preoperative computed tomography versus intraoperative data set acquisition for spinal navigation
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2 Image-Based Spinal Navigation: Current Technology andFuture Applications
9. Chou LB, etal. Increased prevalence of breast and all-cause cancer in female orthopaedic
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dose delivered between two differing CT imaging modalities. Cureus. 2016;8:e778.
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patients. J Neurosurg Spine. 2018;29:397–406.
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xation in cervico-thoracic region. Spine. 2021;46:530–7.
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19. Hecht N, etal. Intraoperative computed tomography versus 3D C-arm imaging for navigated
spinal instrumentation. Spine. 2018;43:370–7.
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22. Su AW, et al. Switching to a pediatric dose O-arm protocol in spine surgery signicantly
reduced patient radiation exposure. J Pediatr Orthop. 2016;36:621–6.
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24. Leksell L, Leksell D, Schwebel J. Stereotaxis and nuclear magnetic resonance. J Neurol
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27. Kamogawa J, Kato O, Morizane T, Hato T.Virtual pathology of cervical radiculopathy based
on 3D MR/CT fusion images: impingement, attening or twisted condition of the compressed
nerve root in three cases. Springerplus. 2015;4:123.
28. Yanni DS, etal. Real-time navigation guidance with intraoperative CT imaging for pedicle
screw placement using an augmented reality head-mounted display: a proof-of-concept study.
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SPINE181142.
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K. A. Shaw et al.
Chapter 3
Image-Based Navigation: Room
andPatient Positioning, Reference Frame
Types andApplication
FelicityFisk andNolanWessell
Surgical Set UpandRoom Layout
While proper operative suite layout and setup does not ensure the success of a procedure, failure to appropriately consider the location of surgical equipment, patient
position, and the integration of navigation systems may lead to a procedure’s failure
or, at the very least, introduce unnecessary challenge to an operation. Critics of
navigation systems often cite increased operative times and reduced surgical efciency, but proper room set up can help streamline the use of navigation and actually
increase the efciency of many procedures [1–3]. The type of navigation system
being used will help determine the best strategy for room layout.
Intraoperative CT-Based Navigation Systems
Intraoperative navigation using traditional 32-slice computed tomography (CT)
scanners such as Airo (BrainLAB, Munich, Germany) or BodyTom (NeuroLogica
Corp; Danvers, MA) require the use of a specialized carbon-made operating
table that is attached to the CT gantry [4]. During image acquisition, the gantry
will slide over the patient while the patient remains stationary [5]. This reduces
the risk of endotracheal tube or anesthetic line disruption as the patient’s position does not change. The large inner diameter of the gantry seen with these
F. Fisk (*)
Department of Orthopaedic Surgery, West Virginia University, Morgantown, WV, USA
N. Wessell
Department of Orthopaedic Surgery, University of Colorado, Aurora, CO, USA
Switzerland AG 2024
S. Garg, C. J. Kleck (eds.), Navigation, Robotics and 3D Printing in Spine
Surgery, https://doi.org/10.1007/978-3-031-68678-8_3
17© The Author(s), under exclusive license to Springer Nature
18
F. Fisk and N. Wessell
systems can accommodate patient positioning with pillows or radiolucent
frames, as well as provide the ability to safely image patients with obesity
(Fig.3.1) [6].
Cone-beam CT systems such as O-Arm (Medtronic, Louisville, CO), Arcadis
Orbic 3D Isocentric C-arm (Siemens AG, Malvern, PA), and Ziehm Vision FD
Vario 3D (Ziehm, Orlando, FL) utilize a scanner that is brought in for image
acquisition after the surgical exposure has been completed. These systems
require a dynamic reference array (DRA) that is rmly attached to the patient’s
skeleton to be visualized during image acquisition. The DRA is tracked throughout the imaging and completes automatic registration for these systems. A direct
line of sight between the infrared camera and the DRA is required at all times
during image acquisition and navigation, which is readily accomplished via two
commonly described room layouts: camera at head (Fig.3.2) and camera at foot
(Fig.3.3). It is important to consider which surgery will be performed and what
will be the most ergonomic layout for the surgeon [7]. The camera at head layout has been described for many open procedures, while the camera at foot
layout has been described for use with minimally invasive procedures done in
lateral decubitus or prone positions where a percutaneous DRA will be
employed. Either layout can be used during most procedures depending on surgeon preference; however, care must be taken to ensure the DRA lies between
the navigated surgical instrument and the camera, in a linear trajectory, throughout the entirety of the procedure. Each manufacturer notes an optimal distance
between the camera and DRA and often the system will contain a function to
help guide camera placement. Operating table selection must be carefully considered as the gantry must be able to encircle the patient and table. Tables must
be radiolucent and without a large central base. Radiolucent Jackson frames or
Allegro (Mizuho, Union City, CA) tables work well for most applications. Most
reference frames used for cone-beam CT systems use infrared optical tracking
systems. Care should be taken to limit direct light from overhead lights, microscopes, or surgeon headlights shining on to reference frames as this can interfere with the accuracy of navigation.
Fig. 3.1 BrainLAB Airo
CT image courtesy of
Rawicki etal.
3 Image-Based Navigation: Room and Patient Positioning, Reference Frame Types…
Fig. 3.2 Camera at head
layout, image courtesy of
Michael Fabien
19
Fluoroscopy-Based Navigation Systems
Fluoroscopy-based image guidance systems are calibrated with spatial and uoroscopic information based on saved uoroscopic images. Often times, intraoperative images can be merged with preoperative CT or MRI scans to reconstruct
a 3D model of the spine. These systems also employ a DRA that is rmly
secured to the patient’s skeleton, in addition to a calibration target attached to
the portable uoroscopy machine. A camera then tracks the position of the DRA
in reference to the C-arm and calibration target during image acquisition, which
eliminates the need for anatomic registration [4, 8]. The C-arm can be removed
from the surgical area after imaging is completed; however, the camera must be
able to see the DRA throughout the procedure for navigation to occur. These
systems can be used on any radiolucent operating table as long as the C-arm is
free to move around the area to be navigated, and patients can be in prone, lateral, or supine positions.
20
Fig. 3.3 Camera at foot
layout, image courtesy of
Michael Fabien
F. Fisk and N. Wessell
Machine Vision-Based Navigation Systems
Machine vision-based image guidance systems employ a specic type of machine
vision called structured light imaging [9]. The currently available machine visionbased system, FLASH Navigation System (7D Surgical/SeaSpine, San Diego, CA),
utilizes a mobile surgical light source tted with two stereoscopic video cameras, a
structured light projector, and an infrared camera system and an attached computer
workstation (Fig.3.4). This system requires a CT scan for registration, which can be
acquired preoperatively or intraoperatively using one of the previously described
systems. After surgical exposure is completed, a DRA tted with reective spheres
is attached to the patient in preparation for the registration process. All other light
sources must be removed from the eld prior to registration. Initiation of registration is initiated by the surgeon by either a foot pedal or surgical light handle.
Registration begins with a ash of light and a projection of a light grid pattern by
the structured light projector. The stereoscopic cameras then create a threedimensional topographical map of the exposed surface anatomy based on the degree
of grid line distortion. The dataset from this topographical map is then registered
with the CT scan. The registration process takes less than 30 seconds and can be
repeated at any time. The infrared camera system allows for tracking of navigational
3 Image-Based Navigation: Room and Patient Positioning, Reference Frame Types…
21
ab
Fig. 3.4 (a) Example of FLASH surgical light. (b) Use of system in operative setting, image
courtesy of Kalfas etal.
Table 3.1 Inner diameter or opening sizes of commonly used image-guidance systems
System Opening (cm) Inner diameter (cm)
O-Arm (Medtronic) 70 97
Ziehm Vision FD Vario 3D (Ziehm) 87 87
Iso-C (Siemens AG) 73 73
Airo (BrainLAB) n/a 107
tools via reective spheres [9, 10]. This system does not require intraoperative
radiographic image acquisition for use and has been demonstrated to reduce intraoperative radiation time and dose [10, 11].
Patient Positioning
In general, image guidance systems can be used with whatever patient position the
procedure to be performed requires, but there are several factors to consider that can
increase efciency. It is critical for a surgeon to be informed of gantry diameters for
the system to be used as this can limit certain aspects of positioning. Some of the
more commonly used systems are noted in Table3.1. Care must be taken to ensure
the system can move freely within the surgical suite and around the patient after
positioning and draping to ensure patient safety, preservation of sterility, and preservation of optimal image quality. With regards to image quality and subsequent
navigation accuracy, the surgeon must attempt to limit motion artifact during image
acquisition. It is recommended that a member of the anesthesia team hold respirations during image acquisition. If intraoperative neuromonitoring is being used, it
may be best to suspend the collection of somatosensory evoked potentials (SSEPs)
during image capture.
22
F. Fisk and N. Wessell
Supine Positioning
In order to improve ease of image acquisition, arms should be secured at the
patient’s side. Minimizing the use of arm boards can help ensure the system has
enough clearance to freely rotate or close around the patient in order to image the
area of interest. When using a skull clamp such as a Mayeld or Gardner-Wells
tongs with a larger prole, the surgeon must make sure that its position will not
interfere with image acquisition [1] or that imaging systems do not disrupt the
alignment or stability of vital anatomic structures or otherwise jeopardize
patient safety.
Prone Positioning
Arm position is critical for use of image guidance systems in the prone position.
In procedures addressing the middle or upper thoracic or cervical spines, it is
recommended that the arms be tucked securely at the patient’s side. This positioning technique, with the arms in an adducted position, may not be amenable to
uoroscopically-based guidance systems as the additional density may negatively
affect image quality. For procedures involving the lower thoracic or lumbar spine,
the arms can frequently be placed on arm boards in the “superman” position
(externally rotated and abducted) provided that the patient’s torso length and
shoulder mobility allows for adequate clearance during the machine’s closure or
rotation [1].
Lateral Positioning
Arms are typically placed in a forward elevated position and secured to arm boards
during these procedures. It is important to consider location of trunk holding devices
for machine closure or rotation. Use of radiolucent holding devices or tape will help
reduce the effect of metal artifact on image quality. The patient’s location on the bed
can help with ease of instrument placement. For any posterior procedures to be done
with the patient in a lateral decubitus position, positioning the patient as close to the
posterior edge of the bed will minimize bed interference during implant placement
(Fig.3.5) [1, 8, 12]. With the patient’s back positioned ush with the posterior edge
of the operating table, single-position, 360-degree fusion procedures can be done
safely [13].