Intraoperative CT and cone-beam CT imaging for minimally invasive evacuation of spontaneous intracerebral hemorrhage

Acta Neurochirurgica (2020) 162:3167–3177

Minimally invasive surgery (MIS) for evacuation of spontaneous intracerebral hemorrhage (ICH) has shown promise but there remains a need for intraoperative performance assessment considering the wide range of evacuation effectiveness. In this feasibility study, we analyzed the benefit of intraoperative 3-dimensional imaging during navigated endoscopyassisted ICH evacuation by mechanical clot fragmentation and aspiration.

Methods 18 patients with superficial or deep supratentorial ICH underwent MIS for clot evacuation followed by intraoperative computerized tomography (iCT) or cone-beamCT (CBCT) imaging. Eligibility for MIS required (a) availability of intraoperative iCT or CBCT, (b) spontaneous lobar or deep ICH without vascular pathology, (c) a stable ICH volume (20–90 ml), (d) a reduced level of consciousness (GCS 5–14), and (e) a premorbid mRS ≤ 1. Demographic, clinical, and radiographic patient data were analyzed by two independent observers.

Results Nine female and 9 male patients with a median age of 76 years (42–85) presented with an ICH score of 3 (1–4), GCS of 10 (5–14) and ICH volume of 54 ± 26 ml. Clot fragmentation and aspiration was feasible in all cases and intraoperative imaging determined an overall evacuation rate of 80 ± 19% (residual hematoma volume: 13 ± 17 ml; p < 0.0001 vs. Pre-OP).Based on the intraoperative imaging results, 1/3rd of all patients underwent an immediate re-aspiration attempt. No patient experienced hemorrhagic complications or required conversion to open craniotomy. However, routine postoperative CT imaging revealed early hematoma re-expansion with an adjusted evacuation rate of 59 ± 30% (residual hematoma volume: 26 ± 37 ml; p < 0.001 vs. Pre-OP).

Conclusions Routine utilization of iCTor CBCT imaging in MIS for ICH permits direct surgical performance assessment and the chance for immediate re-aspiration, which may optimize targeting of an ideal residual hematoma volume and reduce secondary revision rates.

Spinal navigation for posterior instrumentation of C1–2 instability using a mobile intraoperative CT scanner

J Neurosurg Spine 27:268–275, 2017

Spinal navigation techniques for surgical fixation of unstable C1–2 pathologies are challenged by complex osseous and neurovascular anatomy, instability of the pathology, and unreliable preoperative registration techniques. An intraoperative CT scanner with autoregistration of C-1 and C-2 promises sufficient accuracy of spinal navigation without the need for further registration procedures. The aim of this study was to analyze the accuracy and reliability of posterior C1–2 fixation using intraoperative mobile CT scanner–guided navigation.

METHODS In the period from July 2014 to February 2016, 10 consecutive patients with instability of C1–2 underwent posterior fixation using C-2 pedicle screws and C-1 lateral mass screws, and 2 patients underwent posterior fixation from C-1 to C-3. Spinal navigation was performed using intraoperative mobile CT. Following navigated screw insertion in C-1 and C-2, intraoperative CT was repeated to check for the accuracy of screw placement. In this study, the accuracy of screw positioning was retrospectively analyzed and graded by an independent observer.

RESULTS The authors retrospectively analyzed the records of 10 females and 2 males, with a mean age of 80.7 ± 4.95 years (range 42–90 years). Unstable pathologies, which were verified by fracture dislocation or by flexion/extension radiographs, included 8 Anderson Type II fractures, 1 unstable Anderson Type III fracture, 1 hangman fracture Levine Effendi Ia, 1 complex hangman-Anderson Type III fracture, and 1 destructive rheumatoid arthritis of C1–2. In 4 patients, critical anatomy was observed: high-riding vertebral artery (3 patients) and arthritis-induced partial osseous destruction of the C-1 lateral mass (1 patient). A total of 48 navigated screws were placed. Correct screw positioning was observed in 47 screws (97.9%). Minor pedicle breach was observed in 1 screw (2.1%). No screw displacement occurred (accuracy rate 97.9%).

CONCLUSION Spinal navigation using intraoperative mobile CT scanning was reliable and safe for posterior fixation in unstable C1–2 pathologies with high accuracy in this patient series.

Minimally invasive transforaminal lumbar interbody fusion with the ROSA Spine robot and intraoperative flat-panel CT guidance

Minimally invasive transforaminal lumbar interbody fusion with the ROSATM Spine robot and intraoperative flat-panel CT guidance

Acta Neurochir (2016) 158:1125–1128

Circumferential arthrodesis is commonly used to treat degenerative lumbar diseases. Minimally invasive techniques may enable faster recovery and reduce the incidence of postoperative infections.

Methods: We report on the surgical technique of a transforaminal lumbar interbody fusion (TLIF) procedure performed with the assistance of a new robotic device (ROSATM Spine) and intraoperative flat-panel CT guidance.

Conclusions: The combined use of this new robotic device and intraoperative CT enables accurate and safe arthrodesis in the treatment of degenerative lumbar disc diseases.