Abstract
BackgroundEndoscopic endonasal transsphenoidal approaches are broadly used nowadays for a vast spectrum of pathologies sited in the anterior and middle cranial fossa. The usage of neuronavigation systems (neuronavigation) in these surgeries is crucial for improving orientations deeply inside the skull and increasing patient safety.MethodsThe aim of this study was to assess the use of optical neuronavigation, together with an intraoperative O-arm O2 imaging system, in a group of patients with hypophyseal adenoma that underwent a transnasal transsphenoidal surgery, and correlate the accuracy and its deviation during the navigational process against the use of conventional neuronavigation that uses preoperative MRI and CT scans. The overall group consisted of six patients, between 39 and 78 years old, with a diagnosis of hypophyseal adenoma. Patients were treated with an endoscopic transsphenoidal technique and all of them underwent preoperative MRI and CT scans of the brain. These images were used in the neuronavigation system StealthStation S7® during the surgery, where we defined two bony anatomical landmarks, such as a vomer or the origin of an intrasphenoidal septum, in each operated patient. The tip of the navigational instrument, under endoscopic control, pointed to these landmarks and the distance between the tip and the bony structure was measured on the neuronavigation system. Afterwards, intraoperative 3D x-ray imaging was performed via the mobile system O-arm O2® system with automatic transfer into the navigational system. Under endoscopic guidance, we localized the identical bony anatomical landmarks used in the previous measurement and re-measured the distance between the tip and bony landmark in images acquired by the O-arm. The results of both measurements were statistically compared.ResultsThe mean error of accuracy during conventional neuronavigation with usage of preoperative CT and MRI scans was 2.65 mm. During the neuronavigation, with utilization of intraoperative 3D O-arm images, the mean error of accuracy 0 mm. These mean errors of accuracy (both measurement methods were compared by nonparametric Wilcoxon test) had a statistically significant difference (p = 0.043).ConclusionsBased on this preliminary clinical study, we conclude that the O-arm is capable of providing intraoperative x-ray 3D images in sufficient spatial resolution in a clinically feasible acquisition. The mean error of accuracy during intraoperative navigation, based on 3D O-arm scans at the skull base, is significantly lower compared to the usage of navigation using conventional presurgical CT and MRI images. This suggests the suitability of this method for utilization during endoscopic endonasal skull base approaches.
Highlights
Endoscopic endonasal transsphenoidal approaches are broadly used nowadays for a vast spectrum of pathologies sited in the anterior and middle cranial fossa
Despite of a lot of evidence in available literature for utilizing neuronavigation during cranial surgeries, like tumor resections or biopsies, so far there is a lack of reports using intraoperative 3D x-ray imaging systems, like the O-arm, in combination with neuronavigation during transsphenoidal approaches
The usage of neuronavigation that allows the visualization of preoperative scans from magnetic resonance imaging (MRI) and computed tomography (CT) systems decreased the morbidity and mortality rating to under 1% [1]
Summary
Endoscopic endonasal transsphenoidal approaches are broadly used nowadays for a vast spectrum of pathologies sited in the anterior and middle cranial fossa. Despite of a lot of evidence in available literature for utilizing neuronavigation during cranial surgeries, like tumor resections or biopsies, so far there is a lack of reports using intraoperative 3D x-ray imaging systems, like the O-arm, in combination with neuronavigation during transsphenoidal approaches This role is becoming important, especially in situations that need challenging surgical approaches and in situations when anatomical structures are altered by previous surgical or radiological therapy. Used neuronavigation systems have a certain degree of deviation in accuracy (mean error of accuracy), which is more frequently detected in deeply localized anatomical structures [3] These inaccuracies can arise from the registration step during which the neuronavigation’s camera collects points in a 3D coordinate space and fits them onto presurgical CT or MRI images. On the other hand, utilizing an intraoperative CT scan in combination with neuronavigation allows automatic registration of the acquired scan and rules out possible inaccuracies
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