Tharindu De Silva

Automatic Localization of Target Vertebrae in Spine Surgery: Clinical Evaluation of the LevelCheck Registration Algorithm

Study Design. A 3-dimensional-2-dimensional (3D-2D) image registration algorithm, “LevelCheck,” was used to automatically label vertebrae in intraoperative mobile radiographs obtained during spine surgery. Accuracy, computation time, and potential failure modes were evaluated in a retrospective study of 20 patients. Objective. To measure the performance of the LevelCheck algorithm using clinical images acquired during spine surgery. Summary of Background Data. In spine surgery, the potential for wrong level surgery is significant due to the difficulty of localizing target vertebrae based solely on visual impression, palpation, and fluoroscopy. To remedy this difficulty and reduce the risk of wrong-level surgery, our team introduced a program (dubbed LevelCheck) to automatically localize target vertebrae in mobile radiographs using robust 3D-2D image registration to preoperative computed tomographic (CT) scan. Methods. Twenty consecutive patients undergoing thoracolumbar spine surgery, for whom both a preoperative CT scan and an intraoperative mobile radiograph were available, were retrospectively analyzed. A board-certified neuroradiologist determined the “true” vertebra levels in each radiograph. Registration of the preoperative CT scan to the intraoperative radiograph was calculated via LevelCheck, and projection distance errors were analyzed. Five hundred random initializations were performed for each patient, and algorithm settings (viz, the number of robust multistarts, ranging 50–200) were varied to evaluate the trade-off between registration error and computation time. Failure mode analysis was performed by individually analyzing unsuccessful registrations (>5 mm distance error) observed with 50 multistarts. Results. At 200 robust multistarts (computation time of ∼26 s), the registration accuracy was 100% across all 10,000 trials. As the number of multistarts (and computation time) decreased, the registration remained fairly robust, down to 99.3% registration accuracy at 50 multistarts (computation time ∼7 s). Conclusion. The LevelCheck algorithm correctly identified target vertebrae in intraoperative mobile radiographs of the thoracolumbar spine, demonstrating acceptable computation time, compatibility with routinely obtained preoperative CT scans, and warranting investigation in prospective studies. Level of Evidence: N/A

Utility of the LevelCheck Algorithm for Decision Support in Vertebral Localization.

Study Design. An automatic radiographic labeling algorithm called “LevelCheck” was analyzed as a means of decision support for target localization in spine surgery. The potential clinical utility and scenarios in which LevelCheck is likely to be the most beneficial were assessed in a retrospective clinical data set (398 cases) in terms of expert consensus from a multi-reader study (three spine surgeons). Objective. The aim of this study was to evaluate the potential utility of the LevelCheck algorithm for vertebrae localization. Summary of Background Data. Three hundred ninety-eight intraoperative radiographs and 178 preoperative computed tomographic (CT) images for patients undergoing spine surgery in cervical, thoracic, lumbar regions. Methods. Vertebral labels annotated in preoperative CT image were overlaid on intraoperative radiographs via 3D-2D registration. Three spine surgeons assessed the radiographs and LevelCheck labeling according to a questionnaire evaluating performance, utility, and suitability to surgical workflow. Geometric accuracy and registration run time were measured for each case. Results. LevelCheck was judged to be helpful in 42.2% of the cases (168/398), to improve confidence in 30.6% of the cases (122/398), and in no case diminished performance (0/398), supporting its potential as an independent check and assistant to decision support in spine surgery. The clinical contexts for which the method was judged most likely to be beneficial included the following scenarios: images with a lack of conspicuous anatomical landmarks; level counting across long spine segments; vertebrae obscured by other anatomy (e.g., shoulders); poor radiographic image quality; and anatomical variations/abnormalities. The method demonstrated 100% geometric accuracy (i.e., overlaid labels within the correct vertebral level in all cases) and did not introduce ambiguity in image interpretation. Conclusion. LevelCheck is a potentially useful means of decision support in vertebral level localization in spine surgery. Level of Evidence: N/A

MIND Demons: Symmetric Diffeomorphic Deformable Registration of MR and CT for Image-Guided Spine Surgery

Intraoperative localization of target anatomy and critical structures defined in preoperative MR/CT images can be achieved through the use of multimodality deformable registration. We propose a symmetric diffeomorphic deformable registration algorithm incorporating a modality-independent neighborhood descriptor (MIND) and a robust Huber metric for MR-to-CT registration. The method, called MIND Demons, finds a deformation field between two images by optimizing an energy functional that incorporates both the forward and inverse deformations, smoothness on the integrated velocity fields, a modality-insensitive similarity function suitable to multimodality images, and smoothness on the diffeomorphisms themselves. Direct optimization without relying on the exponential map and stationary velocity field approximation used in conventional diffeomorphic Demons is carried out using a Gauss-Newton method for fast convergence. Registration performance and sensitivity to registration parameters were analyzed in simulation, phantom experiments, and clinical studies emulating application in image-guided spine surgery, and results were compared to mutual information (MI) free-form deformation (FFD), local MI (LMI) FFD, normalized MI (NMI) Demons, and MIND with a diffusion-based registration method (MIND-elastic). The method yielded sub-voxel invertibility (0.008 mm) and nonzero-positive Jacobian determinants. It also showed improved registration accuracy in comparison to the reference methods, with mean target registration error (TRE) of 1.7 mm compared to 11.3, 3.1, 5.6, and 2.4 mm for MI FFD, LMI FFD, NMI Demons, and MIND-elastic methods, respectively. Validation in clinical studies demonstrated realistic deformations with sub-voxel TRE in cases of cervical, thoracic, and lumbar spine.

Robust 2-D–3-D Registration Optimization for Motion Compensation During 3-D TRUS-Guided Biopsy Using Learned Prostate Motion Data

In magnetic resonance (MR)-targeted, 3-D transrectal ultrasound (TRUS)-guided biopsy, prostate motion during the procedure increases the needle targeting error and limits the ability to accurately sample MR-suspicious tumor volumes. The robustness of the 2-D–3-D registration methods for prostate motion compensation is impacted by local optima in the search space. In this paper, we analyzed the prostate motion characteristics and investigated methods to incorporate such knowledge into the registration optimization framework to improve robustness against local optima. Rigid motion of the prostate was analyzed adopting a mixture-of-Gaussian (MoG) model using 3-D TRUS images acquired at bilateral sextant probe positions with a mechanically assisted biopsy system. The learned motion characteristics were incorporated into Powell’s direction set method by devising multiple initial search positions and initial search directions. Experiments were performed on data sets acquired during clinical biopsy procedures, and registration error was evaluated using target registration error (TRE) and converged image similarity metric values after optimization. After incorporating the learned initialization positions and directions in Powell’s method, 2-D–3-D registration to compensate for motion during prostate biopsy was performed with rms ± std TRE of 2.33 ± 1.09 mm with ~3 s mean execution time per registration. This was an improvement over 3.12 ± 1.70 mm observed in Powell’s standard approach. For the data acquired under clinical protocols, the converged image similarity metric value improved in ≥8% of the registrations whereas it degraded only ≤1% of the registrations. The reported improvements in optimization indicate useful advancements in robustness to ensure smooth clinical integration of a registration solution for motion compensation that facilitates accurate sampling of the smallest clinically significant tumors.

Real‐time registration of 3D to 2D ultrasound images for image‐guided prostate biopsy

Purpose During image‐guided prostate biopsy, needles are targeted at tissues that are suspicious of cancer to obtain specimen for histological examination. Unfortunately, patient motion causes targeting errors when using an MR‐transrectal ultrasound (TRUS) fusion approach to augment the conventional biopsy procedure. This study aims to develop an automatic motion correction algorithm approaching the frame rate of an ultrasound system to be used in fusion‐based prostate biopsy systems. Two modes of operation have been investigated for the clinical implementation of the algorithm: motion compensation using a single user initiated correction performed prior to biopsy, and real‐time continuous motion compensation performed automatically as a background process. Methods Retrospective 2D and 3D TRUS patient images acquired prior to biopsy gun firing were registered using an intensity‐based algorithm utilizing normalized cross‐correlation and Powells method for optimization. 2D and 3D images were downsampled and cropped to estimate the optimal amount of image information that would perform registrations quickly and accurately. The optimal search order during optimization was also analyzed to avoid local optima in the search space. Error in the algorithm was computed using target registration errors (TREs) from manually identified homologous fiducials in a clinical patient dataset. The algorithm was evaluated for real‐time performance using the two different modes of clinical implementations by way of user initiated and continuous motion compensation methods on a tissue mimicking prostate phantom. Results After implementation in a TRUS‐guided system with an image downsampling factor of 4, the proposed approach resulted in a mean ± std TRE and computation time of 1.6 ± 0.6 mm and 57 ± 20 ms respectively. The user initiated mode performed registrations with in‐plane, out‐of‐plane, and roll motions computation times of 108 ± 38 ms, 60 ± 23 ms, and 89 ± 27 ms, respectively, and corresponding registration errors of 0.4 ± 0.3 mm, 0.2 ± 0.4 mm, and 0.8 ± 0.5° The continuous method performed registration significantly faster (P < 0.05) than the user initiated method, with observed computation times of 35 ± 8 ms, 43 ± 16 ms, and 27 ± 5 ms for in‐plane, out‐of‐plane, and roll motions, respectively, and corresponding registration errors of 0.2 ± 0.3 mm, 0.7 ± 0.4 mm, and 0.8 ± 1.0° Conclusions The presented method encourages real‐time implementation of motion compensation algorithms in prostate biopsy with clinically acceptable registration errors. Continuous motion compensation demonstrated registration accuracy with submillimeter and subdegree error, while performing < 50 ms computation times. Image registration technique approaching the frame rate of an ultrasound system offers a key advantage to be smoothly integrated to the clinical workflow. In addition, this technique could be used further for a variety of image‐guided interventional procedures to treat and diagnose patients by improving targeting accuracy.

Real-time, image-based slice-to-volume registration for ultrasound-guided spinal intervention

Real-time fusion of magnetic resonance (MR) and ultrasound (US) images could facilitate safe and accurate needle placement in spinal interventions. We develop an entirely image-based registration method (independent of or complementary to surgical trackers) that includes an efficient US probe pose initialization algorithm. The registration enables the simultaneous display of 2D ultrasound image slices relative to 3D pre-procedure MR images for navigation. A dictionary-based 3D-2D pose initialization algorithm was developed in which likely probe positions are predefined in a dictionary with feature encoding by Haar wavelet filters. Feature vectors representing the 2D US image are computed by scaling and translating multiple Haar basis filters to capture scale, location, and relative intensity patterns of distinct anatomical features. Following pose initialization, fast 3D-2D registration was performed by optimizing normalized cross-correlation between intra- and pre-procedure images using Powells method. Experiments were performed using a lumbar puncture phantom and a fresh cadaver specimen presenting realistic image quality in spinal US imaging. Accuracy was quantified by comparing registration transforms to ground truth motion imparted by a computer-controlled motion system and calculating target registration error (TRE) in anatomical landmarks. Initialization using a 315-length feature vector yielded median translation accuracy of 2.7 mm (3.4 mm interquartile range, IQR) in the phantom and 2.1 mm (2.5 mm IQR) in the cadaver. By comparison, storing the entire image set in the dictionary and optimizing correlation yielded a comparable median accuracy of 2.1 mm (2.8 mm IQR) in the phantom and 2.9 mm (3.5 mm IQR) in the cadaver. However, the dictionary-based method reduced memory requirements by 47×  compared to storing the entire image set. The overall 3D error after registration measured using 3D landmarks was 3.2 mm (1.8 mm IQR) mm in the phantom and 3.0 mm (2.3 mm IQR) mm in the cadaver. The system was implemented in a 3D Slicer interface to facilitate translation to clinical studies. Haar feature based initialization provided accuracy and robustness at a level that was sufficient for real-time registration using an entirely image-based method for ultrasound navigation. Such an approach could improve the accuracy and safety of spinal interventions in broad utilization, since it is entirely software-based and can operate free from the cost and workflow requirements of surgical trackers.

Clustered iterative sub-atlas registration for improved deformable registration using statistical shape models.

Purpose: Statistical atlases provide a valuable basis for registration and guidance in orthopaedic surgery – for example, automatic anatomical segmentation and planning via atlas-to-patient registration. We report the construction of a statistical shape model for the pelvis containing annotations of common surgical trajectories and investigate a novel method for deformable registration that takes advantage of sub-types that may exist within the atlas and uses them in active shape model registration according to sub-atlas similarity of principal components between atlas members and the target (patient) pelvis. Methods: CT images from 41 subjects (21 males, 20 females) were derived from the Cancer Imaging Archive (TCIA) and segmented using manual/semi-automatic methods. A statistical shape model was constructed and incorporated in an active shape model (ASM) registration framework for atlas-to-patient registration. Further, we introduce a registration method that exploits clusters in the underlying distribution to iteratively perform registrations after selecting a patient relevant cluster (sub-atlas) that represents similar shape characteristics to the image being registered. Experiments were performed to evaluate surface-to-surface and atlas-to patient registration algorithms using this clustered iterative model. Initial investigation of improved registration based on using similar shapes, was first explored through the use of gender as a categorical way of selecting a possible sub-atlas for registration. Results: The RMSE surface-to-surface registration error (mean ± std) was reduced from (2.1 ± 0.2) mm when registering according to the entire atlas (N=40 members) to (1.8 ± 0.1) mm when registering within clusters based on similarity of principal components (N=20 members), showing improved accuracy (p<0.001) with fewer atlas members – an efficiency gained by virtue of the proposed approach. The atlas showed clear clusters in the first two principal components corresponding to gender, and the proposed method demonstrated improved accuracy when using ASM registration as well as when applied to a coherent-point drift (CPD) non-rigid deformable registration. Conclusions: The proposed framework improved atlas-to-patient registration accuracy and increased the efficiency of statistical shape models (i.e., equivalent registration using fewer atlas members) by guiding member selection according to similarity in principal components.

Technical note: design and validation of an open-source library of dynamic reference frames for research and education in optical tracking.

Purpose: Dynamic reference frames (DRFs) are a common component of surgical tracking systems, but there is a limited number of commercially available, valid tool designs, presenting a limitation to researchers in image-guided surgery and other communities. This work presents the development and validation of a large, open-source library of DRFs for passive optical tracking systems. Methods: Ten groups of DRF designs were generated according to an algorithm based on intra- and inter-tool design constraints. Validation studies were performed using a Polaris Vicra tracker (NDI) to compare the performance of each DRF in group A to a standard commercially available reference tool, including: tool-tip pivot calibration and measurement of fiducial registration error (FRE) on a computercontrolled bench Results: The resulting library of DRFs includes 10 groups - one with 10 DRFs and nine with 6. Each group includes one tool geometrically equivalent to a common commercially available DRF (NDI #8700339). Fiducial registration error (FRE) was 0.15 ± 0.03 mm, indistinguishable from the reference. Conclusions: The library of custom DRF designs perform equivalently to common, commercially available reference DRFs and present a multitude of distinct, simultaneously-trackable DRF designs. The open-source library contains files suitable to 3D printing as well as tool definition files ready to download for research purposes.

Real-time, image-based 3D-2D registration for ultrasound-guided spinal interventions.

Introduction: Ultrasound (US) is a promising low-cost, real-time, portable imaging modality suitable for guidance in spine pain procedures. However, suboptimal image quality and US artifacts confound visualization of deep bony anatomy and have limited its widespread use. Real-time fusion of US images with pre-procedure MRI could provide valuable assistance to guide needle targeting in 3D. To achieve this goal, we propose a fast, entirely image-based 3D-2D rigid registration framework that operates without external hardware tracking and can estimate US probe pose relative to patient position in real-time. Method: Registration of 2D US (slice) images is performed via the initialization obtained from a fast dictionary search that determines probe pose within a predefined set of pose configurations. 2D slices are extracted from a static 3D US (volume) image to construct a feature dictionary representing different probe poses. Haar features are computed in a fourlevel pyramid that transforms 2D image intensities to a 1D feature vector, which are in turn matched to the 2D target image. 3D-2D registration was performed with the Haar-based initialization with normalized cross-correlation as the metric and Powell’s method as the optimizer. Reduction to 1D feature vectors presents the potential for major gains in speed compared to registration of the 3D and 2D images directly. The method was validated in experiments conducted in a lumbar spine phantom and a cadaver specimen with known translations imparted by a computerized motion stage. Results: The Haar feature matching method demonstrated initialization accuracy (mean ± std) = (1.9 ± 1.4) mm and (2.1 ± 1.2) mm in phantom and cadaver studies, respectively. The overall registration accuracy was (2.0 ± 1.3) mm and (1.7 ± 0.9) mm, and the initialization was a necessary and important step in the registration process. Conclusions: The proposed image-based registration method demonstrated promising results for compensating motion of the US probe. This image-based solution could be an important step toward an entirely image-based, real-time registration method of 2D US to 3D US and pre-procedure MRI, eliminating hardware-based tracking systems in a manner more suitable to clinical workflow.

A statistical model for image registration performance: effect of tissue deformation.

Purpose: The accuracy of image registration is a critical factor in image-guidance systems, so it is important to quantifiably understand factors that fundamentally limit performance of the registration task. In this work, we extend a recently derived model for the effect of quantum noise on registration error to a more “generalized” model in which tissue deformation is incorporated as an additional source of “noise” described by a power-law distribution, analogous to “anatomical clutter” in signal detection theory. Methods: We apply a statistical framework that incorporates objective image quality factors such as spatial resolution and image noise combined with a statistical representation of anatomical clutter to predict the root-mean-squared error (RMSE) of transformation parameters in a rigid registration. Model predictions are compared to simulation studies in CT-to-CT slice registration using the cross-correlation (CC) similarity metric. Results: RMSE predictions are shown to accurately model the impact of dose and soft-tissue clutter on measured RMSE performance. Further, these predictions reveal dose levels at which the registration becomes soft-tissue clutter limited, where further increase provides no improvement in registration performance. Conclusions: Incorporating tissue deformation into a statistical registration model is an important step in understanding the limits of image registration performance and selecting pertinent registration methods for a particular registration task. The generalized noise model and RMSE analysis provide insight on how to optimize registration tasks with respect to image acquisition protocol (e.g., dose, reconstruction parameters) and registration method (e.g., level of blur).