Image guided spine surgery

O-arm, navigation, robotics

• B. Costachescu, L. Eva, C. Apetrei, V.
Dafinescu, C. E. Popescu
• Department of Neurosurgery, Division of
Spine Surgery, University Emergency Hospital
“Prof. Dr. N. Oblu”,
• University of Medicine et Pharmacy “Gr. T.
Popa”, Iasi, Romania
 Bogdan Costachescu, MD, PhD
Consultant - neurosurgery and spine surgery

Membre du Comité Directeur et Scientifique (CDS) - Société de Neurochirurgie de

Langue Française (SNCLF)

National Speaker and Chairperson AO Spine International

• Accuracy/safety

• Complications

• X-rays dose for surgical Quality of life

team/patient

• Confort of the surgeon

 The meaning of navigation in surgery is most accurately defined by the questions
posed:
“Where is my (anatomical) target?”,
“How do I reach my target safely?”,
“Where am I (anatomically)?”, or
“Where and how shall I position my implant?”.

Apart from these important anatomical orientation questions, surgical navigation is

also used as a measurement tool and an information center for providing surgeons
with the right information at the right time.
Principles of surgical navigation/ neuronavigation

• A sort of car navigation system

• Both attempt to localize or determine a position in space in the context of its surroundings.
• The car navigation is using triangulation like a global positioning system with the help of
several geostationary satellites.
Surgical navigation systems use a stereoscopic
camera emitting infrared light which can determine
a 3D position of prominent structures, like reflective
marker spheres.
This allows for real-time tracking of the marker
spheres.

Stereoscopic camera,
computer platform with screen
navigation software.

The marker spheres are attached to the patient and

at surgical instruments (using reference arrays) to
enable an exact localization in space and hence
navigation in the operating room (OR).

In neurosurgery and spinal surgery, navigation is

usually “image-based,” meaning that imaging data
for example preoperative CT or MRI images are
required and can be used for navigation in the OR
(image acquisition)
The O-arm and StealthStation 8 (Medtronic Inc, Minneapolis, MN)
• After standard preparation and surgical exposure, a reference frame was attached to a selected spinous
process for registration and the O-arm was brought in for initial imaging (1st scan.)
• Images were transferred to the StealthStation system for navigation and a navigated probe was used to
verify the pedicle entry point
• The navigation system was used to mark entry points on the skin and incisions were then made down to and
including the fascia. A pre-registered trackable Jamshidi needle was used for pedicle cannulation using axial,
sagittal and coronal plane guidance from the navigation system (PAK needle, Medtronic).
• The navigated pedicle probe was then used to create a path down the pedicle into the vertebral body in the ideal
screw position. This path projection was saved.
K-wires were then left in situ, Jamshidi sheaths were removed and a single 6 mm tapered
dilator used to clear soft tissue at the pedicle entry point.
Screw length was chosen based on the depth marks etched on the probe and based on a projection of a simulated
screw over the probe. The pedicle tract was palpated using a ball-tipped feeler probe and screws were placed with
either a standard or a navigated screwdriver. The projected path of the screw based on the navigated screwdriver was
also saved.
• Pedicle screw placement has evolved since King first described internal fixation
of the spine, Boucher directed these screws into the pedicle, and Roy-Camille
combined screws with plate fixation.
Over time, several techniques for placement of these screws have
been employed:
- the use of anatomic landmarks
- laminotomy with palpation of the pedicle
- plain radiography
- standard fluoroscopic imaging
- fluoroscopic image guidance
- CT image guidance
Grade
A
Completely within the pedicle;

B
Pedicle wall breach less than 2 mm;

C
Pedicle wall breach equal to 2-4 mm

D
Pedicle wall breach more than 4 mm.
 L1
L1fracture
L1 burst
 Iasi, 2018
Spinal level No. of screws Grade A Grade B Grade C Grade D
T3 2 2 - - -
T4 4 3 1 - -
T5 - - - - -
T6 6 4 2 - -
T7 - - - - -
T8 2 1 1 - -
T9 2 2 - -
T10 4 3 1 - -
T11 7 7 - -
T12 13 11 2 - -
L1 10 7 2 1 -
L2 10 8 2 - -
L3 6 5 1 - -
L4 2 2 - - -
L5 - - - - -
S1 - - - - -
Total (%) 68 55 (80,88) 12 (17,64) 1 (1,47) -
Advantages

• Better accuracy/safety

• Lower dose for surgical team/patient

• Confort of the surgeon

 Robotic systems used in today’s surgical applications are still far from human-
independent surgical systems as shown in science-fiction movies.

Therefore, it is a better idea to name these systems “Robotic Assistant Systems”.

Onen MR and Naderi S: Robotic Systems in Spine Surgery, Turk Neurosurg 2014, Vol: 24, No: 3, 305-311
Levels of robot’s “assistance”:

(1) supervisory-controlled systems whereby the machine is programmed with predetermined actions that are carried out
with robotic autonomy and close surgeon supervision;

(2) telesurgical systems, like the Da Vinci robot (Intuitive Surgical, Sunnyvale, California), that afford the surgeon
complete control of the motions of the machine from a remote command station;

(3) shared-control models, a form of co-autonomy allowing both the surgeon and robot to simultaneously control
motions
https://youtu.be/v6mZG8W7Qck
https://www.youtube.com/watch?v=v6mZG8W7Qck
https://www.medtronic.com/us-en/healthcare-
professionals/products/neurological/spine-robotics/mazorx.html
PREDICTABILITY OF PLANNING
Planning is the foundation to a robotic guidance solution.

This plan provides the surgeon with the insight on what they would like to achieve, taking under consideration
the needs of each patient.

Planning provides the ability to make the procedure predictable.

PRECISION OF ROBOTIC GUIDANCE

Once a plan has been created, it is unlikely that a surgeon will be able to execute the plan without additional
help from technology.

The software guides the Surgical Arm into position, translating the Surgical Plan to precision trajectory guidance
in the surgical field.

This technology is designed specifically to help create precision and predictability.

VISIBILITY OF NAVIGATION

Although the robot brings precision, there are two elements that are not provided.

The first is the 5th degree of freedom, or depth of the screw.

Depth of the screw is another variable that needs to be monitored to execute the procedure plan.

Navigation provides this final degree of freedom in addition to that provided by robotic guidance.
Beyond that, the surgeons are looking for assurance and real-time reconciliation of their work back to the
plan.

In simple terms, they would like to see where they are relative to their patient and relative to their plan.

Navigation provides visibility in this step that closes the loop on the execution phase of the process.
 Conclusions
Despite the lack of difference in accuracy in our setting, modern navigation or
robotic techniques carry advantages over classical FH techniques justifying their
use.

Navigation techniques similar to the O-Arm such as 3-D fluoroscopic scans, for
example, are useful in reducing radiation dose to spinal surgeons by as much as
10 times compared with conventional fluoroscopy technique.

Radiation exposure is a health issue for the operating room personnel as well as
the patient.

Radiation carries a risk to orthopedic surgeons and spinal surgeons with a

reported 25-fold increase in thyroid cancer.
Dubito, ergo cogito, cogito, ergo sum”
Je doute donc je pense, je pense donc je suis…
Thank you!