Image-guided Needle Placement Research Articles

Robotic Assistance System for Cone-Beam Computed Tomography-Guided Percutaneous Needle Placement

PurposeThe study aimed to evaluate a new robotic assistance system (RAS) for needle placement in combination with a multi-axis C-arm angiography system for cone-beam computed tomography (CBCT) in a phantom setting.Materials and MethodsThe RAS consisted of a tool holder, dedicated planning software, and a mobile platform with a lightweight robotic arm to enable image-guided needle placement in conjunction with CBCT imaging. A CBCT scan of the phantom was performed to calibrate the robotic arm in the scan volume and to plan the different needle trajectories. The trajectory data were sent to the robot, which then positioned the tool holder along the trajectory. A 19G needle was then manually inserted into the phantom. During the control CBCT scan, the exact needle position was evaluated and any possible deviation from the target lesion measured.ResultsIn total, 16 needle insertions targeting eight in- and out-of-plane sites were performed. Mean angular deviation from planned trajectory to actual needle trajectory was 1.12°. Mean deviation from target point and actual needle tip position was 2.74 mm, and mean deviation depth from the target lesion to the actual needle tip position was 2.14 mm. Mean time for needle placement was 361 s. Only differences in time required for needle placement between in- and out-of-plane trajectories (337 s vs. 380 s) were statistically significant (p = 0.0214).ConclusionUsing this RAS for image-guided percutaneous needle placement with CBCT was precise and efficient in the phantom setting.

Robotic assistance for quick and accurate image-guided needle placement.

Computed tomography (CT) image-guided procedures including biopsy, drug delivery, and ablation are gaining increasing application in medicine. Robotic technology holds the promise for allowing surgeons, and other proceduralists, access to such CT-guided procedures by potentially shortening training, improving accuracy, decreasing needle passes, and reducing radiation exposure. We evaluated surgeon learning and proficiency for image-guided needle placement with an FDA-cleared robotic arm. Five out of six surgeons had no prior CT-guided procedural experience, while one had prior experience with freehand CT-guided needle placement. All surgeons underwent a 60-min training with the MAXIO robot (Perfint Healthcare, Redmond, WA). The robot was used to place needles into three different pre-specified targets on a spine model. Performance time, procedural errors, and needle placement accuracy were recorded. All participants successfully placed needles into the targets using the robotic arm. The average time for needle placement was 3:44 ± 1:43min. Time for needle placement decreased with subsequent attempts, with average third placement taking 2:29 ± 1:51min less than the first attempt. The average vector distance from the target was 2.3 ± 1.2mm. One error resulted in the need for reimaging by CT scan. No errant needle placement occurred. Surgeons (attending fellows and residents) without previous experience and minimal training could successfully place percutaneous needles under CT guidance quickly, accurately, and reproducibly using a robotic arm. This suggests that robotic technology may be used to facilitate surgeon adoption of CT image-guided needle-based procedures in the future.

Photoacoustic Image-Guided Delivery of Plasmonic-Nanoparticle-Labeled Mesenchymal Stem Cells to the Spinal Cord.

Regenerative therapies using stem cells have great potential for treating neurodegenerative diseases and traumatic injuries in the spinal cord. In spite of significant research efforts, many therapies fail at the clinical phase. As stem cell technologies advance toward clinical use, there is a need for a minimally invasive, safe, affordable, and real-time imaging technique that allows for the accurate and safe monitoring of stem cell delivery in the operating room. In this work, we present a combined ultrasound and photoacoustic imaging tool to provide image-guided needle placement and monitoring of nanoparticle-labeled stem cell delivery into the spinal cord. We successfully tagged stem cells using gold nanospheres and provided image-guided delivery of stem cells into the spinal cord in real-time, detecting as few as 1000 cells. Ultrasound and photoacoustic imaging was used to guide needle placement for direct stem cell injection to minimize the risk of needle shear and accidental injury and to improve therapeutic outcomes with accurate, localized stem cell delivery. Following injections of various volumes of cells, three-dimensional ultrasound and photoacoustic images allowed the visualization of stem cell distribution along the spinal cord, showing the potential to monitor the migration of the cells in the future. The feasibility of quantitative imaging was also shown by correlating the total photoacoustic signal over the imaging volume to the volume of cells injected. Overall, the presented method may allow clinicians to utilize imaged-guided delivery for more accurate and safer stem cell delivery to the spinal cord.

Foamed bleomycin sclerosis of airway venous malformations: The role of interspecialty collaboration

To assess clinical outcomes of patients with airway venous malformations treated with percutaneous sclerotherapy (VMPS). We highlight the role of foamed bleomycin as a less inflammatory sclerosant and the importance of collaboration between interventional radiology and otolaryngology-head and neck surgery (OHNS). Retrospective, consecutive, single-center series. Sixteen airway VMPS treatment sessions were performed (5 patients). Endoscopic needle guidance was performed by OHNS. Sclerosants included ethanol and foamed bleomycin. The following data were tabulated for each patient: hospital length of stay (LOS), clinical response, and the presence/absence of airway swelling requiring prolonged intubation. Univariate analysis was performed. P < 0.05 was considered significant. Thirty-one percent (5 of 16) of treatments required endoscopic guidance. Eighty-seven percent (7 of 8) of airway VMs treated with ethanol caused significant airway swelling compared to 0% (0 of 8) of airway VMs treated with bleomycin (P = 0.0004). The LOS was significantly greater for ethanol (5 ± 0.3 days) than for bleomycin (1 day, P = 0.001). Ninety-four percent (15 of 16) of airway VM treatments had at least a partial clinical response. There was no significant difference in clinical response between ethanol and bleomycin (P = 0.30). Endoscopic and image-guided needle placement may be necessary to treat deep airway VMs. Bleomycin may cause less significant airway swelling than ethanol. This may reduce hospital LOS and prolonged intubation. Our results should be interpreted with caution because this is a very small retrospective study. Additional investigation is needed to establish safety and efficacy of foamed bleomycin. 4. Laryngoscope, 126:2726-2732, 2016.

On the Fabric of the Human Body and Modern Ultrasound Imaging

Andreas Vesalius1 (1514–1564), Professor of Anatomy at the University of Padua, Imperial Physician to Holy Roman Emperor Charles V, and author of the seven-volume De Humani Corporis Fabrica (On the Fabric of the Human Body), is noted for his hands-on direct observation of human anatomy and the meticulous drawings of his work he prepared for his students. In the current era of genomics and proteomics, the study of basic human anatomy may seem antiquated and unimportant. However, for interventional pain treatments, precise understanding of the relevant anatomy remains the foundation for safety and effectiveness. In the field of pain medicine, the present-day physician and anatomist Nikolai Bogduk, M.D., Ph.D. (Professor, University of Newcastle, Newcastle, Australia) advanced our knowledge of the sensory innervation of the vertebral column and then built on that work to demonstrate the safe and effective use of radiofrequency treatment for spinal pain.2 Our knowledge of anatomy and how it relates to many painful conditions remains inadequate. We perform interventions for sacroiliac joint pain routinely, yet the innervation of the sacroiliac joint and how to use our knowledge of that anatomy remain the center of controversy.3 In this edition of Anesthesiology, van Eerd et al.4 in Maastricht present a meticulous and detailed study on the sonographic anatomy and landmarks of the cervical spine. They constructed an anatomical model of the cervical spine and a laser-precise, three-dimensional measurement device that allowed them to correlate ultrasound images and specific gross anatomical features of the spine. With this model, they developed a clear and reproducible technique for accurately identifying each of the cervical vertebral levels using ultrasound. Test–retest analysis demonstrated that their technique identifying each cervical vertebral level with ultrasound is extremely reproducible. They describe useful and distinct sonographic landmarks: the cranial base, the mastoid process, the arch of C1, the transverse process of C1, and several more. They note that C6 can be distinguished from C7 on ultrasound because C6 has both an anterior and posterior tubercle and C7 has only a posterior tubercle. They also confirmed that these same landmarks are visible in vivo. Throughout their article, the authors provide high-quality sonographic images and corresponding anatomic drawings of the cervical spine that are clear and instructive. Although others have provided some description of the sonographic anatomy,5,6 this new article stands out for its precision, rigor, and reproducibility. Their anatomic work sets the stage for meaningful application of ultrasound for image-guided needle placement during cervical interventions. Equally important, their model and measuring device can help us to provide better training in use of ultrasound.Caution is in order. We cannot assume that van Eerd’s findings can be generalized to all humans. They used a single human cervical vertebral column embedded in a medium that allowed for realistic ultrasonographic imaging. They and others will likely expand on this work by assuring that their findings can be generalized to populations and used in performing treatments like radiofrequency treatment of the cervical facets. We will also have to learn how their recommendations must be modified to account for common anatomic variations. This work describes only the bony anatomy, but a major advantage of ultrasound is the ability to visualize vessels, nerves, and other relevant soft tissue structures. Thus, a much needed extension of this work will be to develop ultrasound techniques that incorporate descriptions of all relevant bony and soft tissue structures and how they are best imaged. For now, we applaud van Eerd et al. for their careful study, like Vesalius, of basic human anatomy to guide the optimal use of ultrasound to visualize the cervical spine, and we encourage others to return to the anatomy lab as they investigate how best to apply modern imaging techniques in clinical practice.

This Month In: Anesthesiology

This Month In: Anesthesiology

MR Imaging-guided Lumbosacral Spinal Injection Procedures

Magnetic resonance (MR)-guided spinal injection procedures describe techniques for percutaneous drug delivery procedures in which MR imaging is used for visualization of the anatomic target, for accurate image-guided needle placement, monitoring of the injectant, and for visualization of the distrib

Perk Tutor: An Open-Source Training Platform for Ultrasound-Guided Needle Insertions

Image-guided needle placement, including ultrasound (US)-guided techniques, have become commonplace in modern medical diagnosis and therapy. To ensure that the next generations of physicians are competent using this technology, efficient and effective educational programs need to be developed. This paper presents the Perk Tutor: a configurable, open-source training platform for US-guided needle insertions. The Perk Tutor was successfully tested in three different configurations to demonstrate its adaptability to different procedures and learning objectives. 1) The Targeting Tutor, designed to develop US-guided needle targeting skills, 2) the Lumbar Tutor, designed for practicing US-guided lumbar spinal procedures, and (3) the Prostate Biopsy Tutor, configured for US-guided prostate biopsies. The Perk Tutor provides the trainee with quantitative feedback on progress toward the specific learning objectives of each configuration. Configurations were implemented through simple rearrangement of hardware and software components, attesting to the modularity and ease of configuration. The Perk Tutor is provided as a free resource to enable research and development of educational programs for US-guided intervention.

Three‐dimensional ultrasound‐guided robotic needle placement: an experimental evaluation

Clinical use of image-guided needle placement robots has lagged behind laboratory-demonstrated robotic capability. Bridging this gap requires reliable and easy-to-use robotic systems. Our system for image-guided needle placement requires only simple, low-cost components and minimal, entirely off-line calibration. It rapidly aligns needles to planned entry paths using 3D ultrasound (US) reconstructed from freehand 2D scans. We compare system accuracy against clinical standard manual needle placement. The US-guided robotic system is significantly more accurate than single manual insertions. When several manual withdrawals and reinsertions are allowed, accuracy becomes equivalent. In ex vivo experiments, robotic repeatability was 1.56 mm, compared to 3.19 and 4.63 mm for two sets of manual insertions. In an in vivo experiment with heartbeat and respiratory effects, robotic system accuracy was 5.5 mm. A 3D US-guided robot can eliminate error bias and reduce invasiveness (the number of insertions required) compared to manual needle insertion. Remaining future challenges include target motion compensation.

Robotically assisted ablative treatment guided by freehand 3D ultrasound

Robots can improve the accuracy of image-guided needle placement over traditional freehand techniques. While many research groups have demonstrated this, widespread clinical adoption of needle placement robots has not immediately followed, because (1) robots are generally expensive and (2) they are difficult to calibrate and register to the patient in a manner fast and user-friendly enough to be practical in the operating room. Our solution to these considerations is a novel, clinically applicable, low-cost system consisting of a robot (manipulating the needle through a surgeon-specified trajectory), guided by tracked freehand three-dimensional ultrasound (3DUS). We address cost by algorithmically enabling the robot to be unencoded, uncalibrated, and mechanically simple. We address ease of use by eliminating pre-operative registration, and nearly eliminating calibration. The surgical tool is tracked and thereby registered imager intra-operatively. A structured 3DUS volume, created using a tracked conventional 2DUS probe, provides the basis for accurate and reliable volumetric visualization, simulation, and planning. The system components are integrated using a 3D Slicer-based software package. Experiments have been conducted on both mechanical and calf liver phantoms (with embedded olives simulating tumors) with an overall accuracy of 2.54 mm and a targeting success rate of 100%.

Percutaneous Radiofrequency Ablation of Liver Metastases: Applications and Potential Indications

Background: Percutaneous liver tumour ablation has received increased attention as an effective treatment and has been published by a large number of groups. A minimally invasive, percutaneous approach requires fewer resources, less time, recovery and cost, and often offers reduced morbidity and mortality compared with more invasive methods. To be beneficial, however, image-guided percutaneous radiofrequency (RF) therapy will have to meet those criteria without sacrificing efficacy. Methods: Image-guided, local liver tumour treatment relies on the assumption that local disease control may improve survival. Recent developments in ablative techniques are being applied to patients with inoperable, small, or solitary and recurrent metachronous liver tumours. Results: RF ablation of liver tumours with image-guided needle placement, either percutaneously, laparoscopically, or with open surgery, has proven to be effective and encouraging results have been reported. Both intraoperative and percutaneous techniques, however, are complementary options to successfully treat patients with liver tumours. Conclusions: In this article, the authors review the technical developments and current status of liver tumour ablation using radiofrequency ablation techniques, and conclude with a discussion of challenges and opportunities for the future.

Percutaneous tumor ablation with radiofrequency.

Radiofrequency thermal ablation (RFA) is a new minimally invasive treatment for localized cancer. Minimally invasive surgical options require less resources, time, recovery, and cost, and often offer reduced morbidity and mortality, compared with more invasive methods. To be useful, image-guided, minimally invasive, local treatments will have to meet those expectations without sacrificing efficacy. Image-guided, local cancer treatment relies on the assumption that local disease control may improve survival. Recent developments in ablative techniques are being applied to patients with inoperable, small, or solitary liver tumors, recurrent metachronous hereditary renal cell carcinoma, and neoplasms in the bone, lung, breast, and adrenal gland. Recent refinements in ablation technology enable large tumor volumes to be treated with image-guided needle placement, either percutaneously, laparoscopically, or with open surgery. Local disease control potentially could result in improved survival, or enhanced operability. Consensus indications in oncology are ill-defined, despite widespread proliferation of the technology. A brief review is presented of the current status of image-guided tumor ablation therapy. More rigorous scientific review, long-term follow-up, and randomized prospective trials are needed to help define the role of RFA in oncology.