intraoperative iso-c c-arm navigation surgery for spinal and pelvic trauma kobe red cross hospital...
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Intraoperative Iso-C C-arm navigation surgery for spinal and pelvic trauma
Kobe Red Cross Hospital
Yasuo Ito
K. Koshimune, T. Takigawa, S. Nakahara, T. MoritaDept. of Orthopaedic Surgery, Kobe Red Cross Hospita
l
JAPAN
Conflict of Interest
• I (or a member of my immediate family) have not received anything of value from or stock in a commercial company or institution related directly or indirectly to the subject of this presentation.
Kobe Red Cross Hospital
Disclosure information
We (or a member of our immediate family) have not received anything of value from or stock in a commercial company or institution related directly or indirectly to the subject of this presentation.
Background Cervical pedicle screw has been shown to provide
excellent mechanical strength. Abumi et al
Screw misplacement leads to injury of the spinal cord, root, and vertebral artery.
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Studies recommend navigation-assisted surgery for cervical pedicle screw fixation in order to prevent complications and increase accuracy.
Limitations of conventional CT-based navigation system
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Special markers or anatomic landmarks are needed.
Manual matching (registration) is subject to poten
tial errors and time-consuming.
Repeated and segmented registration must be needed for each vertebra.
Changes in the anatomy cannot be detected intra-operatively.
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2D projections in DR mode (50 in 1 minute / 100 in 1-2 minutes)
3D reconstruction
3D volume data256 slices/scan
approx. (12 cm)3
Iso-C 3D with navigation system
No manual registration !
Entire spine is matched to navi. images !
3D images of intraoperative anatomy can be detected ! Real Time Navigation !!
Objectives
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To evaluate prospectively the accuracy, feasibility, advantages and applications of intra-operative Iso-C 3D
in cervical spinal surgery
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Patients and Methods
290 cases
131:cervical, 126:thoracolumbar, 33:pelvic trauma
Pedicle Screws 1435 screws cervical : 553 screws, thoracolumbar: 882 screws Lateral mass screws 86 screwsOdontoid screws 6 screws Iliac screws 112 screwsIliosacral screws 10 screws
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Grade 1: screw threads cut into the cortex Grade 2: screw perforation of the cortex by up to 2 mmGrade 3: screw perforation of the cortex by more than 2 mm
Grade 1 Grade ３
Post-operative evaluation of pedicle screws (Thin-cut CT, 1.25mm)
Grade 2 and Grade 3 regarded as misplacements
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Grade 2 ( < 2 mm): 10 screws 22 screwsGrade 3 ( > 2 mm): 4 screws 7 screws
Cortical perforation up to 2 mm
cervical
43 / 1435 screws ( 3.0 %)
thoracolumbar
No deterioration in the initial neurological statusNo injured or irritated nerve rootNo vascular injury
Results – pedicle screw
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The patient is positioned on a non-metallic carbon table to maximize image quality and to minimize artifacts.
Clinical workflow in registration-free 3D navigation surgery
A reference arc is placed on a spinous processCarbon table and Mayfield cramp
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It takes 120 seconds to obtain and reconstruct the 3D data.
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The image data is transferred directly to the navigation system.
The screw trajectory is prepared using a cervical awl by Kotani et al
Intraoperative images of Iso-C Images of the navigated awl
Case PresentationCase 1 55 y.o. Male Odontoid fracture
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Intraoperative images of Iso-C Postoperative sagittal image
Case PresentationCase 1 55 y.o. Male Odontoid fracture
Case PresentationCase 2 76 y.o. Female Hangman fracture
Percutaneous awling Percutaneous insertion of the osteosythesis screw
Case PresentationCase 2 76 y.o. Female Hangman fracture
Intraoperative images of Iso-C
Postoperative images
Advantages of Iso-C 3D C-arm
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1． Accurate correlation between 3D
images and current patient anatomy２． Navigational support based on
updated image data
Educational tool for mastering surgical techniqueApplicable to minimally invasive surgery
Review of cervical or thoracic pedicle screw literature
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Thoracic Weinstein et al (1988) 32 screws 21% Vaccaro et al (1995) 90 41% Abitol et al (1996) 48 50% Liljenqvist et al (1997) 120 25% Xu et al (1998) 95 54.7% Cinotti et al (1999) 126 24%Cervical Abumi et al (2000) 669 6.7%With Navi. ( Thoracic ) Youkilis et al (2001) 224 8.5%
With Navi. and Iso-C (trauma) Our cases 1435 3.0 %
“Miss” Percentage
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Disadvantages and Pitfalls
(Iso-C3D , navigation surgery) • Image quality• Cost Navigation system, Iso-C3D, Carbon bed, Mayfield headholder• Operating staff for navigation surgery • Mechanical or Human error Interference between reference arc and probe Blurring of navigation images Eye movement between the operative field and monitor
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Conclusions
Registration-free navigation surgery with the Iso-C was successfully used in 100 consecutive initial patients with cervical lesions
Intraoperative 3D navigation showed significant advance in the safety and accuracy of operative procedures. This system will assist in performing truly minimally invasive surgeries.