Study Design: A prospective, case-based, observational study. Objectives: To investigate how microscope-based augmented reality (AR) support can be utilized in various types of spine surgery. Methods: In 42 spinal procedures (12 intra- and 8 extradural tumors, 7 other intradural lesions, 11 degenerative cases, 2 infections, and 2 deformities) AR was implemented using operating microscope head-up displays (HUDs). Intraoperative low-dose computed tomography was used for automatic registration. Nonlinear image registration was applied to integrate multimodality preoperative images. Target and risk structures displayed by AR were defined in preoperative images by automatic anatomical mapping and additional manual segmentation. Results: AR could be successfully applied in all 42 cases. Low-dose protocols ensured a low radiation exposure for registration scanning (effective dose cervical 0.29 ± 0.17 mSv, thoracic 3.40 ± 2.38 mSv, lumbar 3.05 ± 0.89 mSv). A low registration error (0.87 ± 0.28 mm) resulted in a reliable AR representation with a close matching of visualized objects and reality, distinctly supporting anatomical orientation in the surgical field. Flexible AR visualization applying either the microscope HUD or video superimposition, including the ability to selectively activate objects of interest, as well as different display modes allowed a smooth integration in the surgical workflow, without disturbing the actual procedure. On average, 7.1 ± 4.6 objects were displayed visualizing target and risk structures reliably. Conclusions: Microscope-based AR can be applied successfully to various kinds of spinal procedures. AR improves anatomical orientation in the surgical field supporting the surgeon, as well as it offers a potential tool for education.
Surgical treatment of spondylodiscitis allows for rapid mobilization and shortens hospital stays, which makes surgical treatment the first-line therapy. We aim to describe our experiences with operative treatment on spondylodiscitis and to determine the parameters that are important in the prediction of outcomes. A retrospective review identified 237 patients who were operatively treated for spondylodiscitis in our institution between January 2010 and December 2018. Clinical data were collected through review of electronic records and relevant imaging. In all cases, contrast-enhancing MRI from the infected region of the spine was obtained. Leukocyte count and C-reactive protein concentrations (CRP) were determined in all the patients. We included 237 patients in the study, 87 female (36.7%) and 150 male (63.3%), with a mean age of 71.4 years. Mean follow-up was 31.6 months. Forty-five patients had spondylodiscitis of the cervical, 73 of the thoracic, and 119 of the lumbosacral spine. All the patients with spondylodiscitis of the cervical spine received instrumentation. In thoracic and lumbar spine decompression, surgery without instrumentation was performed in 26 patients as immediate surgery and in a further 28 patients in the early stages following admission, while 138 patients received instrumentation. Eighty-nine patients (37.6%) had concomitant infections. Infection healing occurred in 89% of patients. Favorable outcomes were noted in patients without concomitant infections, with a normalized CRP value and in patients who received antibiotic therapy for more than six weeks (p < 0.05). Unfavorable outcomes were noted in patients with high CRP, postoperative spondylodiscitis, and recurrent spondylodiscitis (p < 0.05). Application of antibiotic therapy for more than six weeks and normalized CRP showed a correlation with favorable outcomes, whereas concomitant infections showed a correlation with unfavorable outcomes. A detailed screening for concomitant infectious diseases is recommended.
Background:Metastases are the most frequent tumors in the brain. Most often used scoring systems to predict the outcome are the RPA (Recursive Partitioning Analysis) classification and the DS-GPA (Diagnosis-Specific Graded Prognostic Assessment) score. The goal of our study was to determine prognostic factors which influence outcome in patients who undergo surgery for brain metastases and to compare different outcome scores.Methods:Two hundred and twenty-nine patients who underwent surgery for brain metastases in our institution between January 2005 and December 2014 were included in the study. Patient data were evaluated retrospectively.Results:The mean survival time was 19.2 months (median survival time, MST: 8 months), for patients with a single metastasis (n = 149) 17.6 months (MST: 8 months), and for patients with multiple metastases (n = 80) 17.9 months (MST: 6 months). Significant influence on MST had age <65 years (9 vs. 5 months, P = 0.002), female sex (10 vs. 6 months, P < 0.001), RPA Class I and II (11 vs. 4 months, P < 0.001), Karnofsky score >70% (11 vs. 4 months, P < 0.001), and postoperative radiotherapy (8 vs. 5 months, P < 0.002). To evaluate the diagnostic power of DS-GPA and RPA score in respect of survival, two Cox regressions were modeled, where the RPA classification showed a better predictive power.Conclusion:Favorable factors for prolonged survival were KPS >70%, RPA Class I and II, age <65 years, female sex, a DS-GPA Score of 2.5–3 and 3.5–4, and adjuvant radiotherapy. The RPA Classification was more accurate in predicting the outcome than the DS-GPA score.
The aim of this study was to report on the clinical experience with microscope-based augmented reality (AR) in transsphenoidal surgery compared to the classical microscope-based approach. AR support was established using the head-up displays of the operating microscope, with navigation based on fiducial-/surface- or automatic intraoperative computed tomography (iCT)-based registration. In a consecutive single surgeon series of 165 transsphenoidal procedures, 81 patients underwent surgery without AR support and 84 patients underwent surgery with AR support. AR was integrated straightforwardly within the workflow. ICT-based registration increased AR accuracy significantly (target registration error, TRE, 0.76 ± 0.33 mm) compared to the landmark-based approach (TRE 1.85 ± 1.02 mm). The application of low-dose iCT protocols led to a significant reduction in applied effective dosage being comparable to a single chest radiograph. No major vascular or neurological complications occurred. No difference in surgical time was seen, time to set-up patient registration prolonged intraoperative preparation time on average by twelve minutes (32.33 ± 13.35 vs. 44.13 ± 13.67 min), but seems justifiable by the fact that AR greatly and reliably facilitated surgical orientation and increased surgeon comfort and patient safety, not only in patients who had previous transsphenoidal surgery but also in cases with anatomical variants. Automatic intraoperative imaging-based registration is recommended.
Background: Robot-guided spine surgery is based on a preoperatively planned trajectory that is reproduced in the operating room by the robotic device. This study presents our initial experience with thoracolumbar pedicle screw placement using Brainlab’s Cirq® surgeon-controlled robotic arm (BrainLab, Munich, Germany). Methods: All patients who underwent robotic-assisted implantation of pedicle screws in the thoracolumbar spine were included in the study. Our workflow, consisting of preoperative imagining, screw planning, intraoperative imaging with automatic registration, fusion of the preoperative and intraoperative imaging with a review of the preplanned screw trajectories, robotic-assisted insertion of K-wires, followed by a fluoroscopy-assisted insertion of pedicle screws and control iCT scan, is described. Results: A total of 12 patients (5 male and 7 females, mean age 67.4 years) underwent 13 surgeries using the Cirq® Robotic Alignment Module for thoracolumbar pedicle screw implantation. Spondylodiscitis, metastases, osteoporotic fracture, and spinal canal stenosis were detected. A total of 70 screws were implanted. The mean time per screw was 08:27 ± 06:54 min. The mean time per screw for the first 7 surgeries (first 36 screws) was 16:03 ± 09:32 min and for the latter 6 surgeries (34 screws) the mean time per screw was 04:35 ± 02:11 min (p < 0.05). Mean entry point deviation was 1.9 ± 1.23 mm, mean deviation from the tip of the screw was 2.61 ± 1.6 mm and mean angular deviation was 3.5° ± 2°. For screw-placement accuracy we used the CT-based Gertzbein and Robbins System (GRS). Of the total screws, 65 screws were GRS A screws (92.85%), one screw was a GRS B screw, and two further screws were grade C. Two screws were D screws (2.85%) and underwent intraoperative revision. There were no perioperative deficits. Conclusion: Brainlab’s Cirq® Robotic Alignment surgeon-controlled robotic arm is a safe and beneficial method for accurate thoracolumbar pedicle screw placement with high accuracy.
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