Evolution and Stagnation of Image Guidance for Surgery in the Lateral Skull: A Systematic Review 1989–2020

Schneider, Daniel; Hermann, Jan; Mueller, Fabian; Braga, Gabriela O’Toole Bom; Anschuetz, Lukas; Caversaccio, Marco; Nolte, Lutz P.; Weber, Stefan; Klenzner, Thomas

doi:10.3389/fsurg.2020.604362

Cited by 8 publications

(12 citation statements)

References 67 publications

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“…There have been various preceding clinical studies using freehand stereotactic image-guidance during neurotologic surgery (5). A common study endpoint is the TRE.…”

Section: Accuracy Validationmentioning

confidence: 99%

“…Potential reasons for the lack of accuracy are inaccurate spatial tracking systems, imaging with limited resolution, and inaccurate registration methods (5). The previously mentioned studies used (1) tracking cameras with a maximum spatial tracking error of 0.2-0.5 mm (Polaris systems, NDI, Canada) (6-10, 16, 25, 27, 29-31, 33, 42-47), (2) imaging with a slice thickness of 0.3 mm (48), 0.4 mm (49, 50) or higher (6-10, 12-14, 16, 25-30, 32, 33, 44-47, 51), and (3) registration based on paired-point matching using anatomical (8,10,13,27,28,36,47) or skin-affixed landmarks (7,11,14,27,28,30,42,43,51), or surface matching (12,13).…”

Section: Accuracy Requirementsmentioning

confidence: 99%

“…Significant benefit of freehand stereotactic image-guidance for neurotologic surgery has not been demonstrated to date (5). However, various studies reported potential usefulness and thereby corroborate an unmet clinical need for accurate and precise instrument localization in neurotologic surgery (5).…”

Section: Usefulness Assessmentmentioning

confidence: 99%

“…However, after 30 years of intensive preclinical and clinical research on freehand stereotactic image-guidance, other surgical domains such as sinus surgery (3) and neurosurgery (4) benefit from the standard application of the technology. Despite the clinical availability of systems with negligible system-associated costs, freehand stereotactic image-guidance is not routinely used in neurotologic surgery (5). Custom (6) and commercially (7)(8)(9)(10)(11)(12)(13) available freehand stereotactic image-guidance systems were used in numerous clinical research applications.…”

Section: Introductionmentioning

confidence: 99%

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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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“…There have been various preceding clinical studies using freehand stereotactic image-guidance during neurotologic surgery (5). A common study endpoint is the TRE.…”

Section: Accuracy Validationmentioning

confidence: 99%

Section: Accuracy Requirementsmentioning

confidence: 99%

Section: Usefulness Assessmentmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Freehand Stereotactic Image-Guidance Tailored to Neurotologic Surgery

et al. 2021

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“…The screws must be rigidly fixed to the skull and remain immovable on the bone. Failure to do so can result in registration error, inaccurate targeting, or damage to the related structures at the implantation and surgical sites ( 2 , 5 ). The length and the number of the screws used vary according to the technology applied (e.g.…”

Section: Introductionmentioning

confidence: 99%

In Silico Assessment of Safety and Efficacy of Screw Placement for Pediatric Image-Guided Otologic Surgery

et al. 2021

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Introduction: Current high-accuracy image-guided systems for otologic surgery use fiducial screws for patient-to-image registration. Thus far, these systems have only been used in adults, and the safety and efficacy of the fiducial screw placement has not yet been investigated in the pediatric population.Materials and Methods: In a retrospective study, CT image data of the temporal region from 11 subjects meeting inclusion criteria (8–48 months at the time of surgery) were selected, resulting in n = 20 sides. These datasets were investigated with respect to screw stability efficacy in terms of the cortical layer thickness, and safety in terms of the distance of potential fiducial screws to the dura mater or venous sinuses. All of these results are presented as distributions, thickness color maps, and with descriptive statistics. Seven regions within the temporal bone were analyzed individually. In addition, four fiducial screws per case with 4 mm thread-length were placed in an additively manufactured model according to the guidelines for robotic cochlear implantation surgery. For all these screws, the minimal distance to the dura mater or venous sinuses was measured, or if applicable how much they penetrated these structures.Results: The cortical layer has been found to be mostly between 0.7–3.3 mm thick (from the 5th to the 95th percentile), while even thinner areas exist. The distance from the surface of the temporal bone to the dura mater or the venous sinuses varied considerably between the subjects and ranged mostly from 1.1–9.3 mm (from the 5th to the 95th percentile). From all 80 placed fiducial screws of 4 mm thread length in the pediatric subject younger than two years old, 22 touched or penetrated either the dura or the sigmoid sinus. The best regions for fiducial placement would be the mastoid area and along the petrous pyramid in terms of safety. In terms of efficacy, the parietal followed by the petrous pyramid, and retrosigmoid regions are most suited.Conclusion: The current fiducial screws and the screw placement guidelines for adults are insufficiently safe or effective for pediatric patients.

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A Self‐Configuring Deep Learning Network for Segmentation of Temporal Bone Anatomy in Cone‐Beam CT Imaging

Ding

et al. 2023

Otolaryngol.--head neck surg.

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ObjectivePreoperative planning for otologic or neurotologic procedures often requires manual segmentation of relevant structures, which can be tedious and time‐consuming. Automated methods for segmenting multiple geometrically complex structures can not only streamline preoperative planning but also augment minimally invasive and/or robot‐assisted procedures in this space. This study evaluates a state‐of‐the‐art deep learning pipeline for semantic segmentation of temporal bone anatomy.Study DesignA descriptive study of a segmentation network.SettingAcademic institution.MethodsA total of 15 high‐resolution cone‐beam temporal bone computed tomography (CT) data sets were included in this study. All images were co‐registered, with relevant anatomical structures (eg, ossicles, inner ear, facial nerve, chorda tympani, bony labyrinth) manually segmented. Predicted segmentations from no new U‐Net (nnU‐Net), an open‐source 3‐dimensional semantic segmentation neural network, were compared against ground‐truth segmentations using modified Hausdorff distances (mHD) and Dice scores.ResultsFivefold cross‐validation with nnU‐Net between predicted and ground‐truth labels were as follows: malleus (mHD: 0.044 ± 0.024 mm, dice: 0.914 ± 0.035), incus (mHD: 0.051 ± 0.027 mm, dice: 0.916 ± 0.034), stapes (mHD: 0.147 ± 0.113 mm, dice: 0.560 ± 0.106), bony labyrinth (mHD: 0.038 ± 0.031 mm, dice: 0.952 ± 0.017), and facial nerve (mHD: 0.139 ± 0.072 mm, dice: 0.862 ± 0.039). Comparison against atlas‐based segmentation propagation showed significantly higher Dice scores for all structures (p < .05).ConclusionUsing an open‐source deep learning pipeline, we demonstrate consistently submillimeter accuracy for semantic CT segmentation of temporal bone anatomy compared to hand‐segmented labels. This pipeline has the potential to greatly improve preoperative planning workflows for a variety of otologic and neurotologic procedures and augment existing image guidance and robot‐assisted systems for the temporal bone.

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Evolution and Stagnation of Image Guidance for Surgery in the Lateral Skull: A Systematic Review 1989–2020

Cited by 8 publications

References 67 publications

Freehand Stereotactic Image-Guidance Tailored to Neurotologic Surgery

Freehand Stereotactic Image-Guidance Tailored to Neurotologic Surgery

In Silico Assessment of Safety and Efficacy of Screw Placement for Pediatric Image-Guided Otologic Surgery

A Self‐Configuring Deep Learning Network for Segmentation of Temporal Bone Anatomy in Cone‐Beam CT Imaging

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