Optical Topographic Imaging for Spinal Intraoperative 3-Dimensional Navigation in the Cervical Spine: Initial Preclinical and Clinical Feasibility.

OF BACKGROUND DATA: Computer-assisted 3-dimensional navigation may guide spinal instrumentation. Optical topographic imaging (OTI) is a novel navigation technique offering comparable accuracy and significantly faster registration workflow relative to current navigation systems. It has previously been validated in open posterior thoracolumbar exposures. OBJECTIVE: To validate the utility and accuracy of OTI in the cervical spine. STUDY DESIGN: This is a prospective preclinical cadaveric and clinical cohort study. METHODS: Standard midline open posterior cervical exposures were performed, with segmental OTI registration at each vertebral level. In cadaveric testing, OTI navigation guidance was used to track a drill guide for cannulating screw tracts in the lateral mass at C1, pars at C2, lateral mass at C3-6, and pedicle at C7. In clinical testing, translaminar screws at C2 were also analyzed in addition. Planned navigation trajectories were compared with screw positions on postoperative computed tomographic imaging, and quantitative navigation accuracies, in the form of absolute translational and angular deviations, were computed. RESULTS: In cadaveric testing (mean±SD) axial and sagittal translational navigation errors were (1.66±1.18 mm) and (2.08±2.21 mm), whereas axial and sagittal angular errors were (4.11±3.79 degrees) and (6.96±5.40 degrees), respectively.In clinical validation (mean±SD) axial and sagittal translational errors were (1.92±1.37 mm) and (1.27±0.97 mm), whereas axial and sagittal angular errors were (3.68±2.59 degrees) and (3.47±2.93 degrees), respectively. These results are comparable to those achieved with OTI in open thoracolumbar approaches, as well as using current spinal neuronavigation systems in similar applications. There was no radiographic facet, canal or foraminal violations, nor any neurovascular complications. CONCLUSIONS: OTI is a novel navigation technique allowing efficient initial and repeat registration. Accuracy even in the more mobile cervical spine is comparable to current spinal neuronavigation systems.

Optical Topographic Imaging for Spinal Intraoperative Three-Dimensional Navigation in Mini-Open Approaches: A Prospective Cohort Study of Initial Preclinical and Clinical Feasibility.

OBJECTIVE: Computer-assisted three-dimensional navigation often guides spinal instrumentation. Optical topographic imaging (OTI) offers comparable accuracy and significantly faster registration relative to current navigation systems in open posterior thoracolumbar exposures. We validate the usefulness and accuracy of OTI in minimally invasive spinal approaches. METHODS: Mini-open midline posterior exposures were performed in 4 human cadavers. Square exposures of 25, 30, 35, and 40 mm were registered to preoperative computed tomography imaging. Screw tracts were fashioned using a tracked awl and probe with instrumentation placed. Navigation data were compared with screw positions on postoperative computed tomography imaging, and absolute translational and angular deviations were computed. In vivo validation was performed in 8 patients, with mini-open thoracolumbar exposures and percutaneous placement of navigated instrumentation. Navigated instrumentation was performed in the previously described manner. RESULTS: For 37 cadaveric screws, absolute translational errors were (1.79 ± 1.43 mm) and (1.81 ± 1.51 mm) in the axial and sagittal planes, respectively. Absolute angular deviations were (3.81 ± 2.91°) and (3.45 ± 2.82°), respectively (mean ± standard deviation). The number of surface points registered by the navigation system, but not exposure size, correlated positively with the likelihood of successful registration (odds ratio, 1.02; 95% confidence interval, 1.009-1.024; P < 0.001). Fifty-five in vivo thoracolumbar pedicle screws were analyzed. Overall (mean ± standard deviation) axial and sagittal translational errors were (1.79 ± 1.41 mm) and (2.68 ± 2.26 mm), respectively. Axial and sagittal angular errors were (3.63° ± 2.92°) and (4.65° ± 3.36°), respectively. There were no radiographic breaches >2 mm or any neurovascular complications. CONCLUSIONS: OTI is a novel navigation technique previously validated for open posterior exposures and in this study has comparable accuracy for mini-open minimally invasive surgery exposures. The likelihood of successful registration is affected more by the geometry of the exposure than by its size.

Robotic laser osteotomy through penscriptive structured light visual servoing.

PURPOSE: Planning osteotomies is a task that surgeons do as part of standard surgical workflow. This task, however, becomes more difficult and less intuitive when a robot is tasked with performing the osteotomy. In this study, we aim to provide a new method for surgeons to allow for highly intuitive trajectory planning, similar to the way an attending surgeon would instruct a junior. METHODS: Planning an osteotomy, especially during a craniotomy, is performed intraoperatively using a sterile surgical pen or pencil directly on the exposed bone surface. This paper presents a new method for generating osteotomy trajectories for a multi-DOF robotic manipulator using the same method and relaying the penscribed cut path to the manipulator as a three-dimensional trajectory. The penscribed cut path is acquired using structured light imaging, and detection, segmentation, optimization and orientation generation of the Cartesian trajectory are done autonomously after minimal user input. RESULTS: A 7-DOF manipulator (KUKA IIWA) is able to follow fully penscribed trajectories with sub-millimeter accuracy in the target plane and perpendicular to it (0.46 mm and 0.36 mm absolute mean error, respectively). CONCLUSIONS: The robot is able to precisely follow cut paths drawn by the surgeon directly onto the exposed boney surface of the skull. We demonstrate through this study that current surgical workflow does not have to be drastically modified to introduce robotic technology in the operating room. We show that it is possible to guide a robot to perform an osteotomy in much the same way a senior surgeon would show a trainee by using a simple surgical pen or pencil.

Beam-shifting technique for speckle reduction and flow rate measurement in optical coherence tomography.

In this Letter, we propose a beam-shifting optical coherence tomography scheme for speckle reduction and blood flow rate calculation, where variations of the speckle pattern and Doppler angle were generated by parallel shifting of the sample beam incident on the objective lens. The resultant optical coherent tomography images could then be averaged for speckle noise reduction and simultaneously analyzed for flow rate measurement. The performance of the proposed technique was verified by both phantom and in vivo experiments.

High Speed, High Density Intraoperative 3D Optical Topographical Imaging with Efficient Registration to MRI and CT for Craniospinal Surgical Navigation.

Intraoperative image-guided surgical navigation for craniospinal procedures has significantly improved accuracy by providing an avenue for the surgeon to visualize underlying internal structures corresponding to the exposed surface anatomy. Despite the obvious benefits of surgical navigation, surgeon adoption remains relatively low due to long setup and registration times, steep learning curves, and workflow disruptions. We introduce an experimental navigation system utilizing optical topographical imaging (OTI) to acquire the 3D surface anatomy of the surgical cavity, enabling visualization of internal structures relative to exposed surface anatomy from registered preoperative images. Our OTI approach includes near instantaneous and accurate optical measurement of >250,000 surface points, computed at >52,000 points-per-second for considerably faster patient registration than commercially available benchmark systems without compromising spatial accuracy. Our experience of 171 human craniospinal surgical procedures, demonstrated significant workflow improvement (41 s vs. 258 s and 794 s, p < 0.05) relative to benchmark navigation systems without compromising surgical accuracy. Our advancements provide the cornerstone for widespread adoption of image guidance technologies for faster and safer surgeries without intraoperative CT or MRI scans. This work represents a major workflow improvement for navigated craniospinal procedures with possible extension to other image-guided applications.

Multilevel Spondylolysis Repair Using the "Smiley Face" Technique with 3-Dimensional Intraoperative Spinal Navigation.

BACKGROUND/OBJECTIVE: Multilevel spondylolysis is a rare cause of progressive lower back pain, and patients who fail conservative management are treated surgically. Direct repair methods can maintain mobility and lead to decreased morbidity compared with spinal fusion in single-level spondylolysis. In this paper, we present a patient with nonadjacent multilevel spondylolysis who underwent the "smiley face" technique of direct multilevel repair without fusion using 3-dimensional intraoperative spinal navigation. METHODS: Bilateral spondylolysis at L3 and L5 with associated spondylolisthesis in a 50-year-old male was repaired using the "smiley face" technique. Patient-reported outcomes, including the Oswestry Disability Index (ODI) and visual analog scale scores for back and leg pain, were assessed preoperatively along with 6 weeks and 4 months postoperatively. RESULTS: Postoperative computed tomography imaging showed precise screw insertion and rod placement along with stable hardware alignment in follow-up imaging. The patient's ODI and lower back visual analog scale scores decreased from 25 to 8 and 7.5 to 4, respectively, correlating to an excellent outcome on ODI. CONCLUSION: Direct repair and avoidance of fusion is possible and can provide good functional outcomes in patients with nonadjacent multilevel spondylolysis and associated spondylolisthesis.

High speed, wide velocity dynamic range Doppler optical coherence tomography (Part V): Optimal utilization of multi-beam scanning for Doppler and speckle variance microvascular imaging.

In this paper, a multi-beam scanning technique is proposed to optimize the microvascular images of human skin obtained with Doppler effect based methods and speckle variance processing. Flow phantom experiments were performed to investigate the suitability for combining multi-beam data to achieve enhanced microvascular imaging. To our surprise, the highly variable spot sizes (ranging from 13 to 77 µm) encountered in high numerical aperture multi-beam OCT system imaging the same target provided reasonably uniform Doppler variance and speckle variance responses as functions of flow velocity, which formed the basis for combining them to obtain better microvascular imaging without scanning penalty. In vivo 2D and 3D imaging of human skin was then performed to further demonstrate the benefit of combining multi-beam scanning to obtain improved signal-to-noise ratio (SNR) in microvascular imaging. Such SNR improvement can be as high as 10 dB. To our knowledge, this is the first demonstration of combining different spot size, staggered multiple optical foci scanning, to achieve enhanced SNR for blood flow OCT imaging.