Everine B. van de Kraats

Bone Displacement and the Role of Longitudinal Ligaments During Balloon Vertebroplasty in Traumatic Thoracolumbar Fractures

Study Design. In a human cadaveric burst fracture model with and without longitudinal ligament damage, the amount of anterior and posterior bone displacement (ABD, PBD) during balloon vertebroplasty after pedicle-screw instrumentation was investigated quantitatively. Objectives. To investigate, in a burst fracture model with and without longitudinal ligament damage, the amount of ABD, PBD, and cement leakage at various phases during balloon vertebroplasty in combination with pedicle-screw instrumentation. Summary of Background Data. The role of intact longitudinal ligaments in traumatic spine fractures, for prevention of bone retropulsion and subsequent reduction, has been discussed in several studies but is still up for debate. In a recent human cadaveric burst fracture study, inflatable bone tamps and calcium phosphate cement were used for the augmentation of the anterior column after pedicle-screw instrumentation. The additional balloon vertebroplasty procedure was found to be feasible and safe, but no data pertaining to unwarranted bone displacement or cement leakage during the procedure are available for burst fractures with damaged longitudinal ligaments. Methods. Ten thoracic and 10 lumbar burst fractures, with rotation or flexion components, were created, and balloon vertebroplasty with calcium phosphate cement was performed after pedicle-screw instrumentation. Volumetric datasets (using the 3-dimensional (3D) rotational x-ray imaging technique) of the fractures were obtained during the following phases: intact, fractured, after reduction and stabilization with pedicle-screws, after inflation of the balloons, after deflation and removal of the balloons, and after injection of the cement. The amount of ABD and PBD was measured on reconstructed sagittal images and recorded together with the presence of extracorporal cement leakage. The continuity of the longitudinal ligaments was assessed after anatomic dissection. Results. During the balloon vertebroplasty procedure, a significant (P < 0.05) increase of ABD (at both thoracic and lumbar level) and PBD (thoracic level) occurred after inflation of the balloons. After deflation and subsequent injection of the cement, however, the ABD and PBD returned to the preinflation levels. The absolute amount of ABD and PBD (<1 mm) during inflation was considered of little clinical importance. No differences in ABD or PBD were observed for specimens with or without continuity of the corresponding longitudinal ligament, irrespective of the level, at any of the phases during the experiment (P > 0.5 in all cases). A small amount of cement leakage was observed in the psoas compartment of one specimen with intact longitudinal ligaments. Conclusions. It is suggested that balloon vertebroplasty after pedicle-screw instrumentation may safely be used, in terms of bone displacement and cement leakage, in fracture types where damage to longitudinal ligaments is to be expected.

Accuracy evaluation of direct navigation with an isocentric 3D rotational X-ray system

Minimally invasive interventions are often performed under fluoroscopic guidance. Drawbacks of fluoroscopic guidance are the fact that the presented images are 2D projections and that both the patient and the clinician are exposed to radiation. Image-guided navigation using pre-interventionally acquired 3D MR or CT data is an alternative. However, this often requires invasive anatomical landmark-based, marker-based or surface-based image-to-patient registration. In this paper, a coupling between an image-guided navigation system and an intraoperative C-arm X-ray device with 3D imaging capabilities (3D rotational X-ray (3DRX) system) that enables direct navigation without invasive image-to-patient registration on 3DRX volumes, is described and evaluated. The coupling is established in a one-time preoperative calibration procedure. The individual steps in the registration procedure are explained and evaluated. The acquired navigation accuracy using this coupling is approximately one millimeter.

Three-dimensional rotational X-ray navigation for needle guidance in percutaneous vertebroplasty: an accuracy study.

Study Design. The position of a needle tip displayed on a navigation system after transpedicular introduction into a vertebral body is compared with the real position of the needle tip when using a direct navigation coupling between a three-dimensional rotational X-ray (3DRX) system and a navigation system. Objectives. To assess whether the needle tip position displayed by the navigation system corresponds to the real needle position and to quantitatively determine needle navigation accuracy in a clinically relevant setting. Summary of Background Data. Image-guided navigation has reportedly increased the accuracy and safety of pedicle screw insertion and decreased complication rates. In former studies, the result of image-guided navigation was mainly compared qualitatively with the result of conventional fluoroscopy-guided procedures. Previously, a direct navigation coupling between a 3DRX system and a standard navigation system was introduced that bypasses the need for explicit patient-to-image registration necessary for image-guided orthopedic surgery. In a phantom experiment, the reported accuracy of navigation with the coupling to a 3DRX system was approximately 1 mm. However, in a clinical setting, additional errors can be introduced. Methods. Twenty-three needles were placed transpedicularly into vertebral bodies of embalmed human trunks using 3DRX-guided navigation. The navigated needle tip positions were compared with the real needle tip positions manually extracted from 3DRX volumes acquired after completion of the introduction. Results. The average distance between the navigated needle tip and the real position of the needle tip extracted from a postprocedure 3DRX volume was 2.5 ± 1.5 mm. Conclusions. Accuracy of 3DRX-guided navigation is 2.5 ± 1.5 mm in a clinically relevant setting, which is less than the accuracy determined in phantom experiments.

Three-Dimensional Rotational X-ray Imaging for Spine Surgery : A Quantitative Validation Study Comparing Reconstructed Images with Corresponding Anatomical Sections

Study Design. A validation study was done in which reconstructed three-dimensional rotational x-ray images were quantitatively compared with corresponding anatomic sections. Objectives. To assess the accuracy of reconstructed images acquired on a three-dimensional rotational x-ray imaging device. Summary of Background Data. Minimally invasive procedures have proven quite successful as alternatives for a multitude of open treatments. An unfavorable property of this type of procedure is a lack of direct vision of the operating area. Three-dimensional rotational x-ray imaging may be able to merge the advantages of computed tomography and fluoroscopy: real-time two-dimensional projections for fast visual feedback and three-dimensional reconstructions for detailed volumetric imaging of complex anatomy. Methods. Twenty traumatic thoracolumbar burst fractures were created and underwent pedicle screw instrumentation and balloon vertebroplasty. Subsequently, a three-dimensional dataset was obtained, and the midsagittal image was reconstructed. The specimens were sliced, and photographs were obtained. Multiple parameters on the reconstructed images and photographs were measured two times by two observers using a graphical method. The differences and standard deviations were calculated for the corresponding parameters and for the intraobserver data. Results. The mean difference between the corresponding values ranged between −1.1 and 2.1 mm for all parameters. The standard deviation for the differences per parameter ranged between 1.2 and 3.2 mm. The intraobserver differences ranged from −0.8 to 1.4 mm, and the standard deviation varied between 0.4 and 2.4 mm. Conclusions. The reconstructed midsagittal images were accurate in all measured parameters. The three-dimensional rotational x-ray technique may prove to be valuable for less invasive spine surgery.

Standardized Evaluation of 2D-3D Registration

In the past few years a number of 2D-3D registration algorithms have been introduced. However, these methods have not been directly compared or only work for specific applications. Understanding and evaluating their performance is therefore an open and important issue. To address this challenge we introduce a standard evaluation method, which can be used for all types of methods and different applications. Our method uses the geometry of the 3D Rotational X-ray (3DRX) imaging system in combination with 3D-3D registration for attaining a highly accurate ground truth for 2D multiple X-ray to 3D MR/CT/3DRX registration. The data and ground truth transformations will be made available on the Internet. Furthermore, we propose starting positions and failure criteria to allow future researchers to directly compare their methods. As an illustration, the proposed method has been used to evaluate the performance of two 2D-3D registration techniques, viz. a gradient-based and an intensity-based method, in spinal applications.

Multispectral MR to X-ray registration of vertebral bodies by generating CT-like data

A new method for MR to X-ray registration is presented. Based on training data, consisting of registered multispectral MR and CT data, a function is defined that maps multispectral MR data to CT-like data. For new subjects for which multispectral MR data have been acquired, the mapping function is used to generate a corresponding CT-like dataset. The CT-like image is subsequently used for registration to X-ray data, using gradient-based registration. Preliminary experiments indicate that MR to X-ray registration using this method is more accurate and has a larger capture range than gradient-based registration applied directly to MR data.

Direct navigation on 3D rotational x-ray data acquired with a mobile propeller C-arm: accuracy and application in functional endoscopic sinus surgery

Recently, three-dimensional (3D) rotational x-ray imaging has been combined with navigation technology, enabling direct 3D navigation for minimally invasive image guided interventions. In this study, phantom experiments are used to determine the accuracy of such a navigation set-up for a mobile C-arm with propeller motion. After calibration of the C-arm system, the accuracy is evaluated by pinpointing divots on a special-purpose phantom with known geometry. This evaluation is performed both with and without C-arm motion in between calibration and registration for navigation. The variation caused by each of the individual transformations in the calibration and registration process is also studied. The feasibility of direct navigation on 3D rotational x-ray images for functional endoscopic sinus surgery has been evaluated in a cadaver navigation experiment. Navigation accuracy was approximately 1.0 mm, which is sufficient for functional endoscopic sinus surgery. C-arm motion in between calibration and registration slightly degraded the registration accuracy by approximately 0.3 mm. Standard deviations of each of the transformations were in the range 0.15-0.31 mm. In the cadaver experiment, the navigation images were considered in good correspondence with the endoscopic images by an experienced ENT surgeon. Availability of 3D localization information provided by the navigation system was considered valuable by the ENT surgeon.

Accuracy of Navigation on 3DRX Data Acquired with a Mobile Propeller C-Arm

Recently, 3DRX imaging has been combined with navigation technology, enabling direct 3D navigation, i.e. navigation on volumetric data without an explicit step to register the image data to the patient coordinate system. In this study, the accuracy of such a navigation setup is evaluated for a mobile C-arm with propeller motion

Noninvasive MR to 3D Rotational x-ray registration of vetebral bodies

3D Rotational X-ray (3DRX) imaging can be used to intraoperatively acquire 3D volumes depicting bone structures in the patient. Registration of 3DRX to MR images, containing soft tissue information, facilitates image guided surgery on both soft tissue and bone tissue information simultaneously. In this paper, automated noninvasive registration using maximization of mutual information is compared to conventional interactive and invasive point-based registration using the least squares fit of corresponding point sets. Both methods were evaluated on 3DRX images (with a resolution of 0.62x0.62x0.62 mm3) and MRI images (with resolutions of 2x2x2 mm3, 1.5x1.5x1.5 mm3 and 1x1x1 mm3) of seven defrosted spinal segments implanted with six or seven markers. The markers were used for the evaluation of the registration transformations found by both point- and maximization of mutual information based registration. The root-mean-squared-error on markers that were left out during registration was calculated after transforming the marker set with the computed registration transformation. The results show that the noninvasive registration method performs significantly better (p≤0.01) for all MRI resolutions than point-based registration using four or five markers, which is the number of markers conventionally used in image guided surgery systems.