Accuracy and feasibility of a dedicated image guidance solution for endoscopic lateral skull base surgery

Rathgeb, Christoph; Anschuetz, Lukas; Schneider, Daniel; Dür, Cilgia; Caversaccio, Marco; Weber, Stefan; Williamson, Tom

doi:10.1007/s00405-018-4906-7

Cited by 13 publications

(4 citation statements)

References 15 publications

(29 reference statements)

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“…Adding additional, redundant approaches based on pose reconstruction from bone density and drill forces [28] as well as a neuromonitoring-based fail-safe [1] Rathgeb et.al. [18] report a navigation accuracy of 0.22 ± 0.1 mm at the critical facial nerve / 0.11 ± 0.08 mm at the target.…”

Section: Related Workmentioning

confidence: 87%

i3PosNet: instrument pose estimation from X-ray in temporal bone surgery

et al. 2020

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Purpose Accurate estimation of the position and orientation (pose) of surgical instruments is crucial for delicate minimally invasive temporal bone surgery. Current techniques lack in accuracy and/or line-of-sight constraints (conventional tracking systems) or expose the patient to prohibitive ionizing radiation (intra-operative CT). A possible solution is to capture the instrument with a c-arm at irregular intervals and recover the pose from the image. Methods i3PosNet infers the position and orientation of instruments from images using a pose estimation network. Said framework considers localized patches and outputs pseudo-landmarks. The pose is reconstructed from pseudo-landmarks by geometric considerations. Results We show i3PosNet reaches errors $$<\,0.05$$<0.05 mm. It outperforms conventional image registration-based approaches reducing average and maximum errors by at least two thirds. i3PosNet trained on synthetic images generalizes to real X-rays without any further adaptation. Conclusion The translation of deep learning-based methods to surgical applications is difficult, because large representative datasets for training and testing are not available. This work empirically shows sub-millimeter pose estimation trained solely based on synthetic training data.

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Section: Related Workmentioning

confidence: 87%

i3PosNet: instrument pose estimation from X-ray in temporal bone surgery

et al. 2020

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“…While this method allows assessment of the quantitative error, the authors themselves state that it is limited to assessment on the surface of the temporal bone and therefore of limited relevance to neurotology. Other preclinically used measurement methods, such as the measurement of implanted target screws (34)(35)(36)(37) or the geometric comparison of a planned surgical approach vs. its image-guided execution (17,18,38), are not ethically justifiable for use in vivo or require an enormous effort rendering the achievement of statistical significance infeasible.…”

Section: Accuracy Validationmentioning

confidence: 99%

“…We present the first clinical application of freehand stereotactic image-guidance during endoscopic neurotologic surgery. Its use was investigated in preclinical studies by Kempfle et al (54) and Rathgeb et al (35). Both agreed that the possibility to see below the surface using the image-guidance system adds valuable information to the 2-dimensional perception of the anatomy from the endoscope.…”

Section: Endoscopic Neurotologic Surgerymentioning

confidence: 99%

Freehand Stereotactic Image-Guidance Tailored to Neurotologic Surgery

et al. 2021

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Hypothesis: The use of freehand stereotactic image-guidance with a target registration error (TRE) of μTRE + 3σTRE < 0.5 mm for navigating surgical instruments during neurotologic surgery is safe and useful.Background: Neurotologic microsurgery requires work at the limits of human visual and tactile capabilities. Anatomy localization comes at the expense of invasiveness caused by exposing structures and using them as orientation landmarks. In the absence of more-precise and less-invasive anatomy localization alternatives, surgery poses considerable risks of iatrogenic injury and sub-optimal treatment. There exists an unmet clinical need for an accurate, precise, and minimally-invasive means for anatomy localization and instrument navigation during neurotologic surgery. Freehand stereotactic image-guidance constitutes a solution to this. While the technology is routinely used in medical fields such as neurosurgery and rhinology, to date, it is not used for neurotologic surgery due to insufficient accuracy of clinically available systems.Materials and Methods: A freehand stereotactic image-guidance system tailored to the needs of neurotologic surgery–most importantly sub-half-millimeter accuracy–was developed. Its TRE was assessed preclinically using a task-specific phantom. A pilot clinical trial targeting N = 20 study participants was conducted (ClinicalTrials.gov ID: NCT03852329) to validate the accuracy and usefulness of the developed system. Clinically, objective assessment of the TRE is impossible because establishing a sufficiently accurate ground-truth is impossible. A method was used to validate accuracy and usefulness based on intersubjectivity assessment of surgeon ratings of corresponding image-pairs from the microscope/endoscope and the image-guidance system.Results: During the preclinical accuracy assessment the TRE was measured as 0.120 ± 0.05 mm (max: 0.27 mm, μTRE + 3σTRE = 0.27 mm, N = 310). Due to the COVID-19 pandemic, the study was terminated early after N = 3 participants. During an endoscopic cholesteatoma removal, a microscopic facial nerve schwannoma removal, and a microscopic revision cochlear implantation, N = 75 accuracy and usefulness ratings were collected from five surgeons each grading 15 image-pairs. On a scale from 1 (worst rating) to 5 (best rating), the median (interquartile range) accuracy and usefulness ratings were assessed as 5 (4–5) and 4 (4–5) respectively.Conclusion: Navigating surgery in the tympanomastoid compartment and potentially in the lateral skull base with sufficiently accurate freehand stereotactic image-guidance (μTRE + 3σTRE < 0.5 mm) is feasible, safe, and useful.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03852329.

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“…Similar to those in previous decades, clinical applications of freehand image guidance in lateral skull procedures have suggested potential usefulness in otologic, petrous apex, and internal auditory canal surgery (58)(59)(60)(61). Preclinical research has focused on finding accurate yet non-invasive (53,54,62) and automatic (42,63) registration strategies, developing less-invasive access routes to the petrous apex and internal auditory canal (64)(65)(66)(67)(68)(69)(70) and assessing the accuracy of available technology (71,72). The persistent lack of proven effects and absence in routine use indicate, however, that the clinically available systems still do not meet the needs for lateral skull surgery.…”

Section: -2020: Stagnation Of Commercial Development the Use Casmentioning

confidence: 83%

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Accuracy and feasibility of a dedicated image guidance solution for endoscopic lateral skull base surgery

Abstract: Useful surgical navigation is, to a large extent, a result of sufficiently accurate tracking technology. We have demonstrated sufficient accuracy and a potentially suitable integration for surgical application within endoscopic lateral skull base procedures.

Cited by 13 publications

References 15 publications

i3PosNet: instrument pose estimation from X-ray in temporal bone surgery

i3PosNet: instrument pose estimation from X-ray in temporal bone surgery

Freehand Stereotactic Image-Guidance Tailored to Neurotologic Surgery

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