Intraoperative Navigation Techniques Research Articles

Mapping Lymph Node during Indocyanine Green Fluorescence-Imaging Guided Gastric Oncologic Surgery: Current Applications and Future Directions.

Simple SummaryThe intraoperative navigation techniques develop rapidly, we present an update on current use and research on indocyanine green enhanced fluorescence imaging (ICG-FI) guided lymphangiography in gastric oncological surgery. ICG serves as a promising tattooed agent for lymphangiography, its application was restricted by the false negative lymph nodes and loss of specificity in targeting tumor cells. Besides, we summarized the current approaches for gain in sensitivity and specificity of ICG-FI guided lymphangiography in gastric oncological surgery. The next direction for reinforced ICG-FI was quantification of ICG intensity and detection of ICG distribution pattern, combining with intraoperative biopsy method.Huge strides have been made in the navigation of gastric cancer surgery thanks to the improvement of intraoperative techniques. For now, the use of indocyanine green (ICG) enhanced fluorescence imaging has received promising results in detecting sentinel lymph nodes (SLNs) and tracing lymphatic drainages, which make it applicable for limited and precise lymphadenectomy. Nevertheless, issues of the lack of specificity and unpredictable false-negative lymph nodes were encountered in gastric oncologic surgery practice using ICG-enhanced fluorescence imaging (ICG-FI), which restrict its application. Here, we reviewed the current application of ICG-FI and assessed potential approaches to improving ICG-FI.

Percutaneous, Navigated Minimally Invasive Posterior Cervical Pedicle Screw Fixation.

Cervical pedicle screws provide significant biomechanical advantage but can be technically challenging and associated with morbid exposure. Improvements in intraoperative navigation guidance and instrumentation have made feasible this biomechanically robust, but technically challenging procedure. We present our initial experience with minimally invasive (MIS) percutaneous pedicle screw fixation in the cervical atlantoaxial and subaxial spine. A retrospective review was performed on 27 cases that involved a novel MIS percutaneous cervical pedicle screw technique. Small lateral skin incisions were made bilaterally on the neck using intraoperative navigation guidance. Subsequently, navigated, percutaneous screws were placed using the Proficient Minimally Invasive System (PROMIS; Spine Wave, Shelton, CT). Computed tomography (CT)-guided navigation was used for cervical pedicle screw placement with subsequent placement of percutaneous rods. Indications for surgery included type II odontoid fractures, subaxial fracture dislocations and burst fracture, metastatic pathological burst fracture, and degenerative spondylosis with stenosis. There were 15 men and 12 women, with an average age 63.5 years. Follow-up ranged from 3 to 24 months (average = 16.7 months). One screw was revised intraoperatively. Two patients (7.7%) required reoperation, 1 patient required repositioning of a C5 pedicle screw, and 1 suffered a C7 body fracture. No nerve root injury, spinal cord injury, or vertebral artery injuries were reported. Percutaneous cervical pedicle screw fixation is a feasible and safe technique when performed with CT-guided intraoperative navigation techniques. Cervical pedicle screw fixation provides a biomechanically superior construct in comparison with a lateral mass technique. In addition, the lack of paraspinal muscle disruption preserves important stabilizers of the posterior ligamentous complex and may reduce wound-healing issues in high-risk cases (eg, trauma patients). Although the current role for percutaneous instrumentation is relatively narrow, the advancement of MIS posterior cervical techniques may provide expanded opportunities in the future.

A Standard Method for Performance Detection of Fluorescence Imaging System

Fluorescence imaging now becomes an intraoperative navigation technique that gaining popularity in surgery and clinical research. However, at present, there is no mature and reliable method or other related guidance documents for the detection of fluorescence imaging performance. The performance analysis and quality supervision of products on the market could not be performed, which affects their clinical use and image quality. In this paper, a standard method of fluorescence imaging performance testing for fluorescence imaging system is proposed. Several kinds of fluorescence imaging performance parameters affecting fluorescence images are defined strictly. We also recommend scientific and feasible methods for their detections and analyses, which are verified by practical examples. This paper aims to provide a feasible reference standard for fluorescence performance evaluation.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: 2-Dimensional Surgical Video.

This operative video is a detailed look at minimally invasive transforaminal lumbar interbody fusion. We provide a step-by-step guide with appropriate narration and operative video to enhance the educational experience. We review clinical and radiographic evaluation, patient positioning, intraoperative navigation, localization, percutaneous pedicle screw placement, minimally invasive approach, disc space preparation, placement of interbody device, and closure. By presenting up-to-date minimally invasive and intraoperative navigation techniques, this video provides educational benefit to all neurosurgeons regardless of training level.

Separation of Craniopagus Twins by a Multidisciplinary Team

SummaryConjoined twins who are classified as craniopagus (joined at the cranium) have a rare congenital anomaly. Despite advances in surgical techniques and critical care, the rate of complications and death is still high among twins with total fusion in which the superior sagittal sinus is shared. Here, we describe total-fusion craniopagus twins who at 10 months of age underwent successful surgical separation performed by a multidisciplinary team. Computer-aided design and modeling with a three-dimensional printer, custom-designed cranial distraction and constriction devices, and intraoperative navigation techniques were used. These techniques allowed for separation of the twins at an early age and harnessed the regenerative capacity of their young brains.

The role of lipid metabolism disorders, atypical isoforms of protein kinase C, and mutational status of cytosolic and mitochondrial forms of isocitrate dehydrogenase in carcinogenesis of glial tumors

The relationship between molecular genetic and metabolic disorders is one of the challenges of modern oncology. In this review, we consider lipid metabolism and its changes as one of the factors of oncogenesis of glial tumors. Also, we demonstrate that the genome and the metabolome are interconnected by a large number of links, and the metabolic pathways, during their reorganization, are able to drastically affect the genetic structure of the cell and, in particular, cause its tumor transformation. Our own observations and analysis of the literature data allow us to conclude that mass spectrometry is a highly accurate current method for assessing metabolic disorders at the cellular level. The use of mass spectrometry during surgery allows the neurosurgeon to obtain real-time data on the level of specific molecular markers in the resected tissue, thereby bringing intraoperative navigation techniques to the molecular level. The generation of molecular fingerprints for each tumor significantly complements the available neuroimaging, molecular genetic, and immunohistochemical data.

Risk-benefit analysis of navigation techniques for vertebral transpedicular instrumentation: a prospective study

Background ContextPedicle screws in spinal surgery have allowed greater biomechanical stability and higher fusion rates. However, malposition is very common and may cause neurologic, vascular, and visceral injuries and compromise mechanical stability. PurposeThe purpose of this study was to compare the malposition rate between intraoperative computed tomography (CT) scan assisted-navigation and free-hand fluoroscopy-guided techniques for placement of pedicle screw instrumentation. Study Design/SettingThis is a prospective, randomized, observational study. Patient SampleA total of 114 patients were included: 58 in the assisted surgery group and 56 in the free-hand fluoroscopy-guided surgery group. Outcome MeasuresAnalysis of screw position was assessed using the Heary classification. Breach severity was defined according to the Gertzbein classification. Radiation doses were evaluated using thermoluminescent dosimeters, and estimates of effective and organ doses were made based on scan technical parameters. MethodsConsecutive patients with degenerative disease, who underwent surgical procedures using the free-hand, or intraoperative navigation technique for placement of transpedicular instrumentation, were included in the study. ResultsForty-four out of 625 implanted screws were malpositioned: 11 (3.6%) in the navigated surgery group and 33 (10.3%) in the free-hand group (p<.001). Screw position according to the Heary scale was Grade II (4 navigated surgery, 6 fluoroscopy guided), Grade III (3 navigated surgery, 11 fluoroscopy guided), Grade IV (4 navigated surgery, 16 fluoroscopy guided), and Grade V (1 fluoroscopy guided). There was only one symptomatic case in the conventional surgery group. Breach severity was seven Grade A and four Grade B in the navigated surgery group, and eight Grade A, 24 Grade B, and one Grade C in free-hand fluoroscopy-guided surgery group. Radiation received per patient was 5.8 mSv (4.8–7.3). The median dose received in the free-hand fluoroscopy group was 1 mGy (0.8–1.1). There was no detectable radiation level in the navigation-assisted surgery group, whereas the effective dose was 10 µGy in the free-hand fluoroscopy-guided surgery group. ConclusionsMalposition rate, both symptomatic and asymptomatic, in spinal surgery is reduced when using CT-guided placement of transpedicular instrumentation compared with placement under fluoroscopic guidance, with radiation values within the safety limits for health. Larger studies are needed to determine risk-benefit in these patients.

Pedicle subtraction osteotomy in the thoracic spine and thoracolumbar junction: a retrospective series of 28 cases.

Pedicle subtraction osteotomy is a well-described surgical technique for treatment of kyphotic deformity in the spine. It is not widely used for treatment of thoracic kyphosis. We present the first documented series of 28 patients who underwent this procedure in 3 international centers. These patients presented with severe deformity with a wide range of aetiologies. Kyphosis larger than 70 degrees, which is demonstrably rigid based on dynamic imaging. 28 patients underwent surgery following pre-op neurological and radiographic assessment to fully assess the deformity. A triangular osteotomy was carried out using intraoperative navigation techniques. The patients were assessed post-operatively again with clinical and radiographic parameters at regular follow-up. The mean ODI score after surgery was 24.7 (16-42) while the pre-op was 53.4 (38-76). Mean thoracic kyphosis was improved from 64.2° (±20.1°) to 41.1° (±17.4°) resulting in a mean sagittal correction of 23.1°. Mean segmental correction at the PSO for all 28 cases was 17.8° (±8.1°). Stratified by region we found different values for the PSO correction: between T1 and T5 (6 cases) it was 17.5° (±5.4°) and between T6 and T9 (4 cases) 18.2° (±4.7°) and between T10 and L1 (18 cases) 26.2° (±5.2°). FBI index was 22.3° pre-op and improved to 7.8° post-op. Calculations were performed with Microsoft excel (2011 Microsoft, Redmond, WA). Global sagittal balance was statistically improved in this series as demonstrated by FBI and C7 SVA correction.

Computed tomography for preoperative planning in total hip arthroplasty: what radiologists need to know

The number of total hip arthroplasties is continuously rising. Although less invasive surgical techniques, sophisticated component design, and intraoperative navigation techniques have been introduced, the rate of peri- and postoperative complications, including dislocations, fractures, nerve palsies, and infections, is still a major clinical problem. Better patient outcome, faster recovery and rehabilitation, and shorter operation times therefore remain to be accomplished. A promising strategy is to use minimally invasive techniques in conjunction with modular implants, aimed at independently reconstructing femoral offset and leg length on the basis of highly accurate preoperative planning. Plain radiographs have clear limitations for the correct estimation of hip joint geometry and bone quality. Three-dimensional assessment based on computed tomography (CT) allows optimizing the choice and positions of implants and anticipating difficulties to be encountered during surgery. Postoperative CT is used to monitor operative translation and plays a role in arthroplastic quality management. Radiologists should be familiar with the needs of orthopedic surgeons in terms of CT acquisition, post-processing, and data transfer. The CT protocol should be optimized to enhance image quality and reduce radiation exposure. When dedicated orthopedic CT protocols and state-of-the-art scanner hardware are used, radiation exposure can be decreased to a level just marginally higher than that of conventional preoperative radiography. Surgeons and radiologists should use similar terminology to avoid misunderstanding and inaccuracies in the transfer of preoperative planning.

Mid-flexion laxity is greater after posterior-stabilised total knee replacement than with cruciate-retaining procedures

There are several methods for evaluating stability of the joint during total knee replacement (TKR). Activities of daily living demand mechanical loading to the knee joint, not only in full extension, but also in mid-flexion. The purpose of this study was to compare the varus-valgus stability throughout flexion in knees treated with either cruciate-retaining or posterior-stabilised TKR, using an intra-operative navigation technique. A total of 34 knees underwent TKR with computer navigation, during which the investigator applied a maximum varus-valgus stress to the knee while steadily moving the leg from full extension to flexion both before and after prosthetic implantation. The femorotibial angle was measured simultaneously by the navigation system at every 10° throughout the range of movement. It was found that posterior-stabilised knees had more varus-valgus laxity than cruciate-retaining knees at all angles examined, and the differences were statistically significant at 10° (p = 0.0093), 20° (p = 0.0098) and 30° of flexion (p = 0.0252).

Increased galectin-3 expression and intra-epithelial neutrophils in small airways in severe COPD

Galectins-1 and -3 regulate epithelial proliferation/apoptosis and neutrophil activation, and are implicated in lung cancer and asthma. The role of galectins in chronic obstructive pulmonary disease (COPD), characterised by epithelial changes and neutrophil infiltration, remains unknown. In the present study, galectin-1 and -3 expression was assessed by immunohistology in the bronchial epithelium of lung specimens from eight severe COPD patients and compared with nine nonsmokers and six smokers without COPD. Findings were related to epithelial proliferation (Ki-67), tissue inflammation and lung function. Epithelial galectin-3 immunostaining was increased only in the small airways of COPD patients when compared with nonsmokers and smokers. In contrast, galectin-1 was only significantly increased in the small airways of the group of smokers. Ki-67+ epithelial cells and neutrophils were increased in the small airways of COPD patients when compared with smokers. Furthermore, intra-epithelial neutrophils correlated in the small airways with Ki-67+ epithelial cells and with the forced expiratory volume in one second/forced vital capacity ratio. However, no correlation was observed with galectin expression. The present study supports the hypothesis that distal airways represent an important site for detecting changes in chronic obstructive pulmonary disease. In patients with severe disease, an increased galectin-3 expression and neutrophil accumulation in the small airway epithelium was demonstrated, correlating with epithelial proliferation and airway obstruction.

Intra-operative stereotactic accuracy of computer-assisted robot orthopaedic trauma surgery planning system

To investigate the feasibility and accuracy of the software computer-assisted robot orthopaedic trauma surgery planning system (CAOTS). The software CAOTS was developed and used on 85 cases of stereotactic operation, 24 model bones, 21 cadaveric extremity bones, and 40 patients. 307 groups of directional targets in these cases were randomly sampled. The distribution of error sources for evaluating system performance was embodied using Monte-Carlo method in order to derive the theoretic guarantees for further optimizing and enhancing the system performance, then the software SPSS 2.0 was used to analyze the errors. The statistical area of deviation number was 0.0408 +/- 0.4578 mm, corresponding to the result by Monte-Carlo method. Punching succeeded at the first run for all 307 cases without wrong locking and other clinical complications. Accurate and reliable, CAOTS improves the intra-operative navigation techniques and facilitates the orthopedists to perform operation.

Klinische Anwendung C-Arm-basierter registrierungsfreier Navigation

Computerassistierte Operationsverfahren in der Unfallchirurgie finden eine zunehmende Verbreitung. Das Prinzip liegt in einer Verknüpfung von Bildinformationen mit intraoperativen Instrumenten und Implantatpositionen. Ohne Navigationshilfe erfolgt diese Verknüpfung der teilweise sehr komplexen Bilddaten mit der Position des Instruments im Kopf des Operateurs. Die Bildinformationen können aus präoperativ angefertigten Bildern, wie z. B. der Computertomographie oder der Magnetresonanztomographie aber auch aus intraoperativ angefertigten Bildern mithilfe eines konventionellen C‐Bogens bestehen. Zur Bildgebung steht im Operationssaal in der Regel ein Röntgenbildverstärker, der eine Instrumentenposition in Echtzeit nur in einer Ebene verfolgen kann, zur Verfügung. Nur wenigen Zentren ist es vorbehalten, intraoperativ Schnittbilddiagnostik mit Computertomographie oder MRT, mit einem entsprechend erheblichen logistischen und personellen Aufwand, durchzuführen. In der unfallchirurgischen Routine kann ein für die Navigation ausgestatteter C-Bogen zu einer Verbesserung der Präzision und zu einer drastischen Reduktion der Strahlenbelastung für OP-Personal und den Patienten führen. Im folgenden Beitrag sollen das Prinzip, das Spektrum und der logistische und personelle Aufwand der C-Bogen-basierten Navigation dargestellt werden.