Daniel P. Borschneck

Spinal Needle Navigation by Tracked Ultrasound Snapshots

Purpose: Ultrasound (US) guidance in facet joint injections has been reported previously as an alternative to imaging modalities with ionizing radiation. However, this technique has not been adopted in the clinical routine, due to difficulties in the visualization of the target joint in US and simultaneous manipulation of the needle. Methods: We propose a technique to increase targeting accuracy and efficiency in facet joint injections. This is achieved by electromagnetically tracking the positions of the US transducer and the needle, and recording tracked US snapshots (TUSS). The needle is navigated using the acquired US snapshots. Results: In cadaveric lamb model, the success rate of facet joint injections by five orthopedic surgery residents significantly increased from 44.4% (p <; 0.05) with freehand US guidance to 93.3% with TUSS guidance. Needle insertion time significantly decreased from 47.9 ± 34.2 s to 36.1 ± 28.7 s (mean ± SD). In a synthetic human spine model, a success rate of 96.7% was achieved with TUSS. The targeting accuracy of the presented system in a gel phantom was 1.03 ± 0.48 mm (mean ± SD). Conclusion: Needle guidance with TUSS improves the success rate and time efficiency in spinal facet joint injections. This technique readily translates also to other spinal needle placement applications.

Spinal Curvature Measurement by Tracked Ultrasound Snapshots

Monitoring spinal curvature in adolescent kyphoscoliosis requires regular radiographic examinations; however, the applied ionizing radiation increases the risk of cancer. Ultrasound imaging is favored over radiography because it does not emit ionizing radiation. Therefore, we tested an ultrasound system for spinal curvature measurement, with the help of spatial tracking of the ultrasound transducer. Tracked ultrasound was used to localize vertebral transverse processes as landmarks along the spine to measure curvature angles. The method was tested in two scoliotic spine models by localizing the same landmarks using both ultrasound and radiographic imaging and comparing the angles obtained. A close correlation was found between tracked ultrasound and radiographic curvature measurements. Differences between results of the two methods were 1.27 ± 0.84° (average ± SD) in an adult model and 0.96 ± 0.87° in a pediatric model. Our results suggest that tracked ultrasound may become a more tolerable and more accessible alternative to radiographic spine monitoring in adolescent kyphoscoliosis.

A global CT to US registration of the lumbar spine

During percutaneous lumbar spine needle interventions, alignment of the preoperative computed tomography (CT) with intraoperative ultrasound (US) can augment anatomical visualization for the clinician. We propose an approach to rigidly align CT and US data of the lumbar spine. The approach involves an intensity-based volume registration step, followed by a surface segmentation and a point-based registration of the entire lumbar spine volume. A clinical feasibility study resulted in mean registration error of approximately 3 mm between CT and US data.

Visualization of scoliotic spine using ultrasound-accessible skeletal landmarks

PURPOSE: Ultrasound imaging is an attractive alternative to X-ray for scoliosis diagnosis and monitoring due to its safety and inexpensiveness. The transverse processes as skeletal landmarks are accessible by means of ultrasound and are sufficient for quantifying scoliosis, but do not provide an informative visualization of the spine. METHODS: We created a method for visualization of the scoliotic spine using a 3D transform field, resulting from thin-spline interpolation of a landmark-based registration between the transverse processes that we localized in both the patient’s ultrasound and an average healthy spine model. Additional anchor points were computationally generated to control the thin-spline interpolation, in order to gain a transform field that accurately represents the deformation of the patient’s spine. The transform field is applied to the average spine model, resulting in a 3D surface model depicting the patient’s spine. We applied ground truth CT from pediatric scoliosis patients in which we reconstructed the bone surface and localized the transverse processes. We warped the average spine model and analyzed the match between the patient’s bone surface and the warped spine. RESULTS: Visual inspection revealed accurate rendering of the scoliotic spine. Notable misalignments occurred mainly in the anterior-posterior direction, and at the first and last vertebrae, which is immaterial for scoliosis quantification. The average Hausdorff distance computed for 4 patients was 2.6 mm. CONCLUSIONS: We achieved qualitatively accurate and intuitive visualization to depict the 3D deformation of the patient’s spine when compared to ground truth CT.

Clinical workflow for spinal curvature measurement with portable ultrasound

PURPOSE: Spinal curvature monitoring is essential in making treatment decisions in scoliosis. Monitoring entails radiographic examinations, however repeated ionizing radiation exposure has been shown to increase cancer risk. Ultrasound does not emit ionizing radiation and is safer for spinal curvature monitoring. We investigated a clinical sonography protocol and challenges associated with position-tracked ultrasound in spinal curvature measurement in scoliosis. METHODS: Transverse processes were landmarked along each vertebra using tracked ultrasound snapshots. The transverse process angle was used to determine the orientation of each vertebra. We tested our methodology on five patients in a local pediatric scoliosis clinic, comparing ultrasound to radiographic curvature measurements. RESULTS: Despite strong correlation between radiographic and ultrasound curvature angles in phantom studies, we encountered new challenges in the clinical setting. Our main challenge was differentiating transverse processes from ribs and other structures during landmarking. We observed up to 13° angle variability for a single vertebra and a 9.85° ± 10.81° difference between ultrasound and radiographic Cobb angles for thoracic curvatures. Additionally, we were unable to visualize anatomical landmarks in the lumbar region where soft tissue depth was 25–35mm. In volunteers with large Cobb angles (greater than 40° thoracic and 60° lumbar), we observed spinal protrusions resulting in incomplete probe-skin contact and partial ultrasound images not suitable for landmarking. CONCLUSION: Spinal curvature measurement using tracked ultrasound is viable on phantom spine models. In the clinic, new challenges were encountered which must be resolved before a universal sonography protocol can be developed.

Comparison of portable and conventional ultrasound imaging in spinal curvature measurement

PURPOSE: In scoliosis monitoring, tracked ultrasound has been explored as a safer imaging alternative to traditional radiography. The use of ultrasound in spinal curvature measurement requires identification of vertebral landmarks, but bones have reduced visibility in ultrasound imaging and high quality ultrasound machines are often expensive and not portable. In this work, we investigate the image quality and measurement accuracy of a low cost and portable ultrasound machine in comparison to a standard ultrasound machine in scoliosis monitoring. METHODS: Two different kinds of ultrasound machines were tested on three human subjects, using the same position tracker and software. Spinal curves were measured in the same reference coordinate system using both ultrasound machines. Lines were defined by connecting two symmetric landmarks identified on the left and right transverse process of the same vertebrae, and spinal curvature was defined as the transverse process angle between two such lines, projected on the coronal plane. RESULTS: Three healthy volunteers were scanned by both ultrasound configurations. Three experienced observers localized transverse processes as skeletal landmarks and obtained transverse process angles in images obtained from both ultrasounds. The mean difference per transverse process angle measured was 3.00 ±2.1°. 94% of transverse processes visualized in the Sonix Touch were also visible in the Telemed. Inter-observer error in the Telemed was 4.5° and 4.3° in the Sonix Touch. CONCLUSION: Price, convenience and accessibility suggest the Telemed to be a viable alternative in scoliosis monitoring, however further improvements in measurement protocol and image noise reduction must be completed before implementing the Telemed in the clinical setting.