Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis

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OBJECTIVE

The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions.

METHODS

This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance.

RESULTS

The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14–87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62–865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5–7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1–36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden.

CONCLUSIONS

O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

ABBREVIATIONSEBL = estimated blood loss; OR = operating room.

OBJECTIVE

The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions.

METHODS

This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance.

RESULTS

The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14–87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62–865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5–7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1–36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden.

CONCLUSIONS

O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

ABBREVIATIONSEBL = estimated blood loss; OR = operating room.

The treatment paradigms for patients with spinal tumors have evolved with enhanced technology. Advancements in intraoperative imaging have augmented our surgical planning and execution. With better systemic cancer care, the incidence of spinal metastases in oncological patients has become more prevalent. As a result, effective treatment of these tumors has become increasingly important. The approach to treatment of spinal metastases is interdisciplinary, often involving various combinations of chemotherapy, radiation, stereotactic radiosurgery, and surgery. Since the 2005 publication of the study by Patchell et al.,24 surgery has become part of the treatment paradigm for patients with metastatic epidural cord compression in concert with radiation therapy. With radiation therapy in mind, efforts have been made to cause only minimal injury to the adjacent tissue and to prevent destabilization of the spine column that would affect quality of life for these patients.

Recently, intraoperative stereotactic navigation has become more available in spine surgery. Stereotactic navigation with cone-beam fluoroscopy and CT and the use of the O-arm (Medtronic) 3D imaging with stereotactic computer navigation have been well described for the safe and accurate placement of pedicle screws.10,16 Stereotactic navigation may also be used to advance surgical treatment of spinal neoplasms. The use of image guidance has been described in surgical planning for resection of spinal tumors.22,27,35 It has been used to both plan osteotomies and to carry out minimally invasive surgical techniques. The result is to minimize the extent of surgery in the oncological patient. It is proposed that stereotactic intraoperative navigation can be of further utility in tumor resection by aiding in the localization of spinal lesions and intraoperative visualization of margins. Our objective was to assess the utility of the intraoperative CT navigation system in the localization of spinal lesions and as an intraoperative tool to dynamically assess the resection margins.

Methods

This is a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation between 2010 and 2015. Spine tumors included primary and metastatic disease. Metastatic tumors included breast, colorectal, hepatocellular, leiomyosarcoma, lung, prostate, renal, and uterine cancers. Primary lesions included chordoma, chondrosarcoma, fibrous dysplasia, giant cell tumor, hemangioma, lymphoma, meningioma, multiple myeloma, plasma cell tumor, and osteosarcoma. Indications for surgery included worsening findings on neurological examination with or without myelopathy, pathological fractures necessitating decompression and stabilization, progressive kyphosis, and intractable pain.

Surgical Technique With Image Guidance

General Considerations for Image Guidance in Tumor Surgery

The description of surgical technique and use of navigation for tumor surgery can be extremely extensive and depends on the area of the spine as well as the goals of surgery. In the next sections, we will attempt to provide overall considerations for incorporation of navigation into traditional tumor surgery techniques in addition to considerations for different areas of the cervical, thoracic, and lumbosacral spine.

Patient Positioning

All patients were placed prone on a Jackson radiolucent spinal operating table, and pressure points were padded appropriately. For patients undergoing cervical spine surgery, depending on surgeon preference, chest bolsters and a Skytron table were also used. All cervical spine patients had Mayfield pins and tongs attached to the cranium, and the Mayfield reference frame was secured to the operating table with the patient's neck in a neutral position (Fig. 1).

FIG. 1.
FIG. 1.

Photographs showing the Mayfield reference frame secured to the operating table with the patient's neck in a neutral position (left) and the Mayfield reference frame positioned away from the surgical field (right).

When using navigation, we recommend a wide draping area, as it allows for skin surface anatomy identification (occiput, scapula, posterior superior iliac spine, iliac crest, midline spinous processes), providing orientation during the entire procedure and avoiding any line-of-sight issues or workflow disruptions

Navigated reference Frame

The ideal reference frame location is always dependent on the operative goals of the surgeon and the region of the spine being operated on. In cervical surgery, the 2 main options for navigated reference frame are the spinous process clamp and the Mayfield reference frame (Fig. 1). In our earlier experience, we elected to use the spinous process clamp placed at either the C-2 or C-7 spinous process. We found, however, that this resulted in unnecessary exposure of the C-2 and C-7 spinous processes in midcervical tumor cases. In our experience, the Mayfield reference frame was equally rigid and accurate. In addition, the benefit of the Mayfield reference frame positioned away from the direct surgical field translated into less risk of accidental collision and fewer line-of-sight issues (Fig. 1).

For the thoracic spine, the 2 main options for a navigated reference frame are the spinous process clamp and a pedicle screw–based reference frame. In cases in which pedicle screws are already present in the operative field (i.e., revision cases or proximal navigation to previously inserted pedicle screws), we found the preferred reference frame to be the pedicle screw–based system. Compared with placement of clamps on thoracic spinous processes, which tend to be less robust, we found the pedicle screw reference frame to be highly rigid and stable.

For lumbar and sacral tumor surgery, the choice of a percutaneous reference pin in the ilium versus a spinous process reference clamp versus a pedicle screw–based frame is debatable. In our earlier experiences, we found that the percutaneous pin placed in the posterior superior iliac spine often interfered with the surgeon's and/or assistant's operative field and often caused line-of-sight issues. As a result, we preferred the reference clamp placed on a proximal or distal lumbar spinous process, directed away from the surgical area. Additionally, we would elect to use the pedicle screw–based reference frame if pedicle instrumentation was present in the operative field. The Stealth-Station workstation (Medtronic, Inc.) and LED (light-emitting diode) detector camera were placed at either the head of the bed or the foot of the operating table, depending on the direction of the reference frame. Careful attention to navigated reference frame selection and Stealth-Station placement are 2 examples of critical preoperative issues that a surgeon must consider in order to maximize navigated workflow efficiency in tumor surgery.

CT-Image Acquisition

CT images were obtained using a cone-beam mobile CT scanner (O-arm) and were transferred to the computer-assisted StealthStation surgical navigation workstation. 3D reconstruction images were created on the StealthStation for navigation purposes. All navigated instruments were calibrated according to the manufacturers' guidelines. Although it is possible to keep the O-arm in the sterile surgical field during the entire procedure, it was our preference to remove the O-arm and station it in the operating room.

Incision

Midline skin incisions were planned using a navigated probe. Exposure of the spine and determining the extent of the tumor was performed using the navigated probe. Once the bony spine was exposed, depending on the type of resection (e.g., intralesional, wide, en bloc), the margins of the desired tumor resection were marked on the dorsal lamina to guide tumor removal.

Navigated Tumor resection

The navigated probe is the main instrument used to precisely identify and verify exact bony landmarks and tumor margins. As many destructive spinal tumors in the cervical, thoracic, and lumbar spine are either lytic or blastic in nature, the ability of CT imaging–guided navigation to identify normal bone margins makes it an ideal imaging modality for use in resection of these lesions. A second instrument that we commonly use in spinal tumor resection is the SureTrak reference frame attachment on a Midas drill (Medtronic). Once the navigated Midas drill has been calibrated, this instrument allows the surgeon to intraoperatively preplan and make exact bony cuts for osteotomies and perform neural decompression in otherwise distorted anatomy. The ability of CT image–guided navigation tools to visualize deep bony anatomy allows for maximal ability to resect spinal tumors with minimal damage to surrounding soft tissue and can be used in real time to guide the surgical resection.

Navigated Insertion of Instrumentation

All pedicle screw instrumentation (pedicle, lateral mass, occiput pelvic screws) was inserted according to the same technique. Anatomical variations of dorsal vertebral bone surfaces and starting points were easily overcome with navigation guidance. The pilot hole was followed by a navigated awl (e.g., Jamshidi needle, Lenke probe, or pedicle probe) to cannulate the pedicle and navigated tap and navigated screwdriver with the appropriate length and width screw as determined by CT navigation. Prior to final screw insertion, a thin ball probe was used to confirm bony containment of the instrumented channel. The ideal trajectory and insertion of screws were confirmed and visualized on the StealthStation computer screen in real time (Fig. 2).

FIG. 2.
FIG. 2.

StealthStation computer screenshot demonstrating an ideal cervical screw trajectory.

Insertion of instrumentation under navigation guidance in spinal surgery requires a strict adherence to basic rules. In our technique, we always emphasize minimizing “manipulation” or pulling or pushing of the surrounding soft tissue and bony spine. During tap cannulation and screw insertion, significant forces may be applied to the vertebral body, which can move it from its original imaged position. This can lead to significant inaccuracy and malplacement of instrumentation. Current navigation technology is unable to account for shifts in vertebral body position and dynamic changes in the spinal bony anatomy. As a result, we recommend that extreme care be taken to minimize any force that might displace or alter the alignment of the operated spine. Minimizing soft tissue retraction and manipulation of the bony spine minimizes variance in navigation trajectory and ultimately translates into more accurate pedicle screws. Guidewires can be used, if necessary, to confirm and maintain the pedicle trajectory; however, we do not routinely use them in open tumor surgery (Fig. 3).

FIG. 3.
FIG. 3.

Photograph showing a navigated tap being used with a guide-wire to confirm and maintain the pedicle trajectory.

Intraoperative Assessment of Tumor resection

Intraoperative post-resection CT images can be obtained with the mobile cone-beam CT scanner to assess adequacy of tumor margins. This was done routinely in all our spinal tumor cases to confirm wide resection and avoid additional postoperative imaging and the need for revision surgery.

Results

In the total group of 50 patients (27 male, 23 female) undergoing spinal tumor procedures utilizing image-guided navigation, the average age was 61 ± 17 years (range 14–87 years). Twenty-five of the patients had metastatic disease to the spine and the other 25 had primary spine tumors. The average operative time from incision to closure was 311 ± 188 minutes (range 62–865 minutes). The average estimated blood loss (EBL) was 882 ± 1194 ml (range 5–7000 ml). Patients were hospitalized an average of 10 ± 8.9 days (range 1–36 days). Postoperative complications included 2 deaths (4.0%) and 4 cases of radiculopathy (8%) secondary to tumor burden.

In the group with metastatic disease, the patients' average age was 66.2 ± 12.8 years (range 14–87 years) and 12 (48%) of the 25 patients were female. In 7 cases the lesions were metastases from breast cancer; in 5, from prostate cancer; in 3, from colorectal cancer; in 3, from hepatocellular carcinoma; in 3, from lung cancer; in 2, from renal cell carcinoma; in 1, from leiomyosarcoma; and in 1, from uterine cancer. Of the 25 metastatic cases, 19 involved metastases to the thoracic spine (76%), 5 to the cervical spine (20%), and 1 to the lumbar spine (4%). Breast cancer and prostate cancer most frequently metastasized to the thoracic spine (75% and 80%, respectively). Posterior spinal fusion was required at the time of surgery in 23 (92%) of the 25 patients. The average number of spinal levels fused in these 23 patients was 5.7 (range 1–11). Image-guided navigation was instrumental in defining trajectories for pedicle screw placement and for more extensive decompressions. Three patients had a corpectomy, 1 patient had a vertebrectomy, 2 patients had costotransversectomies, and 2 patients required a unilateral transpedicular approach (Table 1). The average length of stay for patients with metastatic disease was 13.8 ± 9.6 days (range 3–36 days), the average EBL was 1061 ± 1410 ml (range 25–7000 ml), and the average operating room (OR) time was 341.2 ± 180.7 minutes (range 84–764 minutes).

TABLE 1.

Summary of cases involving patients with metastatic tumors from the multicenter, comparative review

Case No.Age (yrs), SexDiagnosisOperation PerformedType of IGSLOS (days)EBL (ml)OR Time (mins)Operative ComplicationsNeurological Status (postop)EOR
144, FT-6 metastatic breast cancerT5–7 lami, T-6 partial corpectomy, T3–9 PSFO-arm/C-arm6500188NoneIntactSTR
245, FT-6 metastatic breast cancer, pathologic fractureT5–6 lami, T3–9 PSFO-arm22500376NoneIntactSTR
354, FT-8 metastatic breast cancerT7–9 lami, T5–10 PSFO-arm/C-arm162000299NoneIntactSTR
458, FT-3 metastatic breast cancer, T-3 burst fracture w/severe kyphosisT-3 vertebrectomy, T1–5 PSFO-arm32550372NoneIntactNTR
561, FC1–3 metastatic breast cancerSubocc craniotomy, C1–3 lami, occ to T-4 fusionO-arm13700420NoneIntactSTR
667, FC-2 metastatic breast cancerOcc to C-3 lami & PSFO-arm8200182NoneIntactSTR
770, FT-7 & T-9 metastatic breast cancer, pathological fractures, kyphosisT2–L1 lami, PSF, osteotomyO-arm31500186NoneIntactSTR
856, MT6–10 metastatic colorectal cancerT7–10 lami, T5–12 PSF, T7–8 corpectomyO-arm251000401NoneIntactNTR
966, FT-4 metastatic colorectal cancerT-4 lami, T1–7 PSFO-arm11800570NoneIntactNTR
1074, MT-3 metastatic colorectal cancerCostotransversectomy T-3, T1–6 PSFO-arm5700734Postop death (PE)DeceasedNTR
1149, MT-5 metastatic hepatocellular carcinomaT-4 & T-6 transpedicular tumor resectionO-arm101000764NoneIntactSTR
1266, MC-6 metastatic hepatocellular carcinomaC2–T2 lami, PSFO-arm6750112NoneIntactSTR
1379, MT-9 metastatic hepatocellular carcinomaT-9 lami, T5–12 PSFO-arm8800540NoneIntactSTR
1487, ML-4 metastatic leiomyosarcomaL4–5 laminoforaminotomy decompression, L2–L5 PSFO-arm13200230NoneIntactNTR
1540, FL-2 metastatic lung adenocarcinomaL2–3 laminoforaminotomies, L1–4 PSFO-arm10200165NoneIntactSTR
1668, MT-8 metastatic lung adenocarcinomaT8–9 lami, T6–11 PSFO-arm362000516NoneIntactSTR
1780, MC-7 metastatic NSCLCC3–T5 lami & PSFO-arm7400165DeceasedDeceasedNTR
1867, MT-5 metastatic prostate cancerT4–6 lamiO-arm301500389NoneIntactSTR
1970, MT-4 metastatic prostate cancerT-4 lami & lt transpedicular, T2–6 PSFO-arm3500249NoneIntactNTR
2076, MT-7 metastatic prostate cancerT6–8 lami, T5–9 PSFO-arm5200330NoneIntactSTR
2182, MT-8 metastatic prostate cancerT7–9 lami, T3–12 PSFO-arm8900385NoneIntactSTR
2284, MC-4 metastatic prostate cancerC-4 corpectomy & fusionO-arm132584NoneIntactNTR
2373, FT3–7 metastatic RCCT4–6 lami, T3–7 PSFO-arm113000180NoneIntactSTR
2475, FT4–5 metastatic RCCT4–5 corpectomies, T4–5 left lami, T2–5 costotransversectomy, T2–8 PSFO-arm107000414Loss of bilat lower MEPs, desaturation to 50%Lt arm radiculopathyNTR
2565, FT6–8 metastatic uterine cancerT6–8 lami, T4–10 PSFO-arm7600279NoneIntactSTR
EOR = extent of resection; GTR = gross-total resection; IGS = intraoperative guidance system; lami = laminectomy(-ies); LOS = length of stay; MEP = motor evoked potential; NSCLC = non–small cell lung cancer; NTR = near-total resection; occ = occiput; PE = pulmonary embolism; PSF = posterior spinal fusion; RCC = renal cell carcinoma; STR= subtotal resection.

In the group with primary disease, the patients' average age was 56.2 ± 20.2 years (range 14–86 years) and 11 (44%) of the 25 patients were female. Fibrous or fibrovascular dysplasia (20%) and multiple myeloma (20%) were the most common lesions. Fusion was required in 9 (36%) of the 25 patients. The average number of spinal levels fused in these 9 patients was 2.89 (range 1–8). Interestingly, 80% (4/5) of the multiple myeloma cases required fusion, while only 20% (1/5) of the fibrous or fibrovascular dysplasia required fusion. Image-guided navigation was useful in biopsy, laminectomy, tumor resection, and spine stabilization (Table 2). Follow-up imaging demonstrated fusion in all patients who underwent pedicle screw placement. The average length of stay for patients with primary disease was 6.2 ± 6.3 days (range 1–25 days), the average EBL was 703.4 ± 925.9 ml (range 5–3000 ml), and the average OR time was 281.6 ± 194.4 minutes (range 92–865 minutes).

TABLE 2.

Summary of cases involving patients with primary tumors from the multicenter, comparative review

Case No.Age (yrs), SexDiagnosisOperation PerformedType of IGSLOS (days)EBL (mL)OR Time (mins)Operative ComplicationsNeurological Status (postop)EOR
120, MSacral chondrosarcomaEn bloc radical resection w/partial sacrectomy, partial hemi-pelvectomyO-arm4600353NoneIntactGTR
250, FT10–11 myxoid chondrosarcoma, T-11 burst fractureT10–11 vertebrectomy, T9–12 interbody graft, T9–12 fusionO-arm14600337NoneIntactGTR
358, FSacral chondrosarcomaType II internal hemipelvectomy w/en bloc radical pelvic resection & reconstructionO-arm71000226NoneIntactGTR
467, MSacral chordomaRadical sacrectomy, neurolysis lt S-1, lt S-2, & S-3 rhizotomiesO-arm61300298NoneUrinary retentionGTR
583, MSacral chordomaSacrectomyO-arm211200430NoneIntactGTR
622, FT-10 fibrovascular dysplasiaVideo-assisted thoracoscopy for resection of T-10 massO-arm15120NoneIntactGTR
746, FL-5 fibrovascular dysplasiaL-5 resection of posterior element cystic massO-arm125240NoneIntactGTR
854, FSacral fibrous dysplasiaSacral biopsyO-arm150240NoneIntactBiopsy
958, MT-2 fibrous dysplasiaT2 lamiO-arm555120NoneIntactNTR
1070, FC-5 fibrous dysplasiaC5–6 corpectomy & fusionO-arm210240NoneRadiculopathyNTR
1124, MSacral giant cell tumorBiopsy, curettage, partial lt sacrectomy, neurolysis of S-1 & S-2, lt-sided lami of S-1 & S-2O-arm43000210NoneIntactSTR
1251, FSacral giant cell tumorResection of giant cell tumor w/cryotherapyO-arm42800180NoneRt L-5 radiculopathyGTR
1314, MIntraosseous hemangiomaS-5 partial vertebrectomy, S-6 complete vertebrectomy, coccygectomyO-arm15090NoneIntactNTR
1445, FIntraosseous hemangiomaBiopsy & partial sacrectomyO-arm15062NoneIntactSTR
1538, MT-cell lymphomaC7–1 lami & C3–T11 fusionO-arm11800865NoneIntactSTR
1666, FDiffuse large B-cell lymphomaSacral biopsy, L5–S1 decompressionO-arm1200152NoneIntactBiopsy
1768, MB-cell lymphomaL1–3 percutaneous fusionO-arm925135NoneIntactBiopsy
1857, MMultiple myelomaL-2 corpectomy & fusionO-arm251800570NoneIntactNTR
1959, MMultiple myelomaC-6 corpectomy & fusionO-arm6100299NoneIntactNTR
2074, FMultiple myelomaC-5 corpectomy & fusionO-arm4100725NoneIntactNTR
2175, MMultiple myelomaRt T8–9 foraminotomyO-arm11592NoneIntactSTR
2282, MMultiple myelomaT6–8 lami & T3–11 fusionO-arm31000348NoneIntactSTR
2368, MPlasma cell tumorC-5 corpectomy & fusionO-arm3200171NoneIntactNTR
2486, FMeningiomaT12–L1 lami for intradural tumor removalO-arm8100305NoneIntactNTR
2570, MOsteosarcomaRt S1–3 lami, medial sacral osteotomies of sacral pelvic tumorO-arm122500221NoneRt L-4 radiculopathySTR

Illustrative Cases

Primary Disease Case 3

This 58-year-old woman had a history of right hip pain radiating into her right lower extremity for several months duration. She was sent for radiographs and CT imaging of her pelvis, which showed a 43 mm × 26 mm × 77 mm lytic lesion in the dome of the acetabulum extending into the ileum on the right with surrounding sclerosis. Subsequent MRI revealed that the lesion was lobular (Fig. 4). A biopsy was performed, confirming chondrosarcoma, and the patient was referred to orthopedic oncology for further evaluation and treatment. A nuclear scan was performed and showed intense focal increase in the right iliac crest consistent with the lesion seen on CT (Fig. 4). The patient underwent en bloc resection of the right hemipelvis under O-arm guidance (Fig. 5). The specimen was sent for pathological examination, which confirmed that negative margins were obtained. The final surgical pathology report confirmed the diagnosis of chondrosarcoma (Fig. 4). The patient tolerated the surgical procedure well and had no neurological deficit.

FIG. 4.
FIG. 4.

Primary disease Case 3. A and B: Preoperative anteroposterior pelvic radiograph (A) and coronal T2-weighted MR image (B) showing a lytic lesion to the right acetabulum with a lobular contour. C: Nuclear medicine bone scan showing intense focal abnormality of the right ilium extending from the right acetabulum consistent with a large metastatic focus area. D and E: Photomicrographs of the surgical pathology specimen showing a moderately differentiated, conventional type of chondrosarcoma of the bone. H & E, original magnification ×40 (D) and ×100 (E).

FIG. 5.
FIG. 5.

Primary disease Case 3. Intraoperative O-arm images showing localization of the lesion.

Primary Disease Case 7

This 46-year-old woman initially presented with hematuria and pain. She was found to have a mass in her right kidney and a focal, lytic lesion over the transverse process of L-5 on the right side. She remained neurologically stable. She underwent a laparoscopic nephrectomy without any complication and then was referred for neurosurgical evaluation of the lytic lesion at L-5. Surgery was performed with the patient in the prone position with a stereotactic reference frame positioned via a small incision in the iliac crest. A Medtronic METRx tube was inserted with stereotactic navigation and fluoroscopic guidance. The intraosseus lesion was resected in total without complication (Fig. 6). Histopathological examination demonstrated fibrous dysplasia. The patient had an unremarkable and full recovery from both resections.

FIG. 6.
FIG. 6.

Primary disease Case 7. Upper: Photograph showing a navigated stereotactic tube and percutaneous posterior superior iliac spine reference frame. Lower: Screenshot showing 3D localization of left L-5 transverse process lesion.

Metastatic Disease Case 6

This 67-year-old woman presented with a history of estrogen and progesterone receptor–positive, HER2 (human epithelial growth factor receptor 2)–negative, left-side breast carcinoma with diffuse bone metastases causing a pathological fracture of C-2. MRI of her neck showed obliterated C-1 and C-2 vertebral bodies with extension into the ventral epidural space without cord signal abnormality. Tumor extended posteriorly up to C-7 (Fig. 7). She was referred to the neurosurgery spine team for further evaluation and treatment. She underwent an occiput to C-5 posterior spinal instrumentation and fusion procedure under O-arm guidance without complications (Fig. 8). The surgical pathological specimen was confirmed to be metastatic carcinoma from a primary breast tumor. The patient did well postoperatively and had no neurological deficit.

FIG. 7.
FIG. 7.

Metastatic disease Case 6. Preoperative sagittal T2-weighted (A), sagittal contrast-enhanced T1-weighted (B), and axial contrast-enhanced T1-weighted (C) MR images showing obliteration of the C-1 and C-2 vertebral bodies with extension of the lesion in to the ventral epidural space.

FIG. 8.
FIG. 8.

Metastatic disease Case 6. Intraoperative 3D localization of cervical spine lesion.

Metastatic Disease Case 13

This 79-year-old man who had undergone a partial liver resection for hepatocellular carcinoma developed progressive gait instability and myelopathy. Imaging studies showed a pathological fracture at T-9 with collapse of the vertebral body with epidural extension resulting in spinal cord compression (Fig. 9). We presumed the diagnosis of metastatic cancer and proceeded with a decompression and stabilization procedure via a T-9 laminectomy and T6–12 instrumented pedicle fusion (Fig. 9). Furthermore, a bilateral transpedicular resection of the intraspinal component of the tumor was performed to allow space for the radiation oncologist to proceed with stereotactic radiosurgery. Intraoperatively, the patient had lost approximately 800 ml of blood. He was discharged to a rehabilitation facility 8 days later without complications and underwent radiation shortly thereafter.

FIG. 9.
FIG. 9.

Metastatic disease Case 13. A: Preoperative sagittal contrast-enhanced T1-weighted MR image revealing pathological fracture of T-9. B: Localization of the lesion using frameless stereotactic navigation. C and D: Postoperative sagittal CT images showing left and right pedicle screws placed with frameless navigation.

Discussion

Intraoperative navigation has become increasingly useful in spinal surgery. Unlike 2D fluoroscopy, stereotactic navigation allows for more comprehensive surgical planning.16 It has been well established that this technology assists in the placement of pedicle screws.7,24,38 The use and accuracy of image-guided pedicle screw placement has been widely reported, and studies demonstrate its ability to safeguard against pedicle breach, damage to neural structures, or even CSF leak.1,2,10,30,34 In a meta-analysis by Tian et al., the 95% confidence interval for the odds ratio for incidence of pedicle breach with CT-guided placement of pedicle screws as compared with freehand placement was 0.32–0.60.34 Moreover, a meta-analysis by Shin et al.30 found that in 8539 pedicle screw insertions (4814 with navigation vs 3725 without) there was a 6% pedicle breach rate for screws inserted with navigation compared with a 15% breach rate in those placed without. Shin et al. also reported the accuracy and safety of navigation coupled with the cone-beam fluoroscopy as compared with conventional fluoroscopic guidance.31 Similarly, Rivkin et al.29 reported the accuracy of stereotactic image-guided placement of pedicle screws in the thoracolumbar spine after familiarization with the technique.27

Cone-beam fluoroscopy additionally allows for the confirmation of accurate instrument position once screws are placed. The benefit of navigated pedicle screw placement is particularly apparent in cases where there is deformed anatomy and anatomical landmark–based freehand screw placement is challenging. Jin et al.14 used fluoroscopic cone-beam navigation to facilitate placement of pedicle screws in patients with dystrophic neurofibromatosis Type 1–associated scoliosis and reported 79% accuracy compared with 67% in the freehand group.

Intraoperative use of cone-beam fluoroscopy may be especially valuable in helping to localize lesions on the thoracic spine, where localization can be notoriously difficult with conventional fluoroscopy.13 It is reported that as many as 68% of spine surgeons (both orthopedic and neurosurgical) have admitted to wrong-level localization in thoracic and lumbar spine surgeries, with some cases being corrected intraoperatively; 56% of these surgeons reported using plain radiographs and 44% reported using fluoroscopy for localization when the errors occurred.20 Anatomical variations, obesity, and decreased bone density make localization with fluoroscopy or long-cassette radiographs difficult.36 However, the use of stereotactic navigation for localization allows for precise access to the level of interest.13

Intraoperative navigation has been described as beneficial for applications beyond accurate screw placement, including image-guidance for the resection of spinal tumors. 3D imaging offers superior information compared with traditional fluoroscopy, allowing for accurate intraoperative identification of unexposed spinal anatomy.22,27 We performed a comprehensive review of the English literature on the use of image-guidance for the resection of spinal tumors (Table 3). Kalfas16 described the use of image-guided modalities and noted the efficacy in surgical planning in managing metastatic tumors to the spine; clinical applications for intraoperative spinal navigation using preoperative CT imaging included anterior thoracolumbar surgery and localization of tumor margins in addition to accurate screw placement.

TABLE 3.

Review of the current literature on image-guided navigation and spine tumor surgery

Authors & YearSummary
Kalfas, 2001Review of fundamentals of spine image-guided technology in setting of spinal metastatic disease
Arand et al., 2002Optoelectronic navigation system (SurgiGATE, Medivision) w/a nonmobile spiral CT (MX 8000, Phillips) used in 8 pts w/thoracic spine tumors
Gebhard et al., 2003Optoelectronic navigation system (SurgiGATE) w/a nonmobile spiral CT (MX 8000) used in 12 pts w/thoracolumbar spine tumors
Moore & McLain, 2005Stereotactic image-guidance w/Viewpoint (Z-Kat Systems) in resection of cervicothoracic osteroid osteoma & osteoblastoma in 2 athletes
Van Royen et al., 2005Frameless stereotaxy (Brainlab) & gamma probe–guided high-speed intralesional drill excision for 5 pts w/osteoid osteoma.
Rajasekaran et al., 2008Intraop Iso-C 3D (Siemens) w/VectorVision (Brainlab) in excision of osteoid osteomas in 4 pts
Rajasekaran et al., 2010Intraop Iso-C 3D excision of a cervical osteoblastoma in a child
Hsu et al., 2010Image-guided (Brainlab), Mayfield head reference frame, transcervical endoscopic assistance for a cervical chordoma in 1 elderly pt
Fujibayashi et al., 20103D spinal osteotomy performed w/computer-assisted navigation system (O-arm & StealthStation) in 4 pts; tumors resected en bloc; associated spinal deformity corrected using intraop guidance
Smitherman et al., 2010Frameless stereotaxy (Brainlab) used to assist complex 4-level sagittal vertebral osteotomy of giant cell tumor involving chest wall & thoracic spine.
Nagashima et al., 2010Navigation (StealthStation & O-arm) for an osteoid osteoma of C-2 pedicle
Dasenbrock et al., 2012Frameless stereotaxy (Brainlab) used to assist in safe en bloc resection of sacral chordomas in 3 pts w/adequate margins
Ghostine et al., 2012Image-guided (StealthStation & O-arm) w/video-assisted thoracoscopy for resection of thoracic nerve sheath tumors in 3 pts
Bandiera et al., 2013StealthStation or VectorVision Spine used in surgical treatment of 7 pts w/tumors
Campos et al., 2013Video-assisted thoracoscopic surgery guided by a navigation system (StealthStation & O-arm) for resection of an osteoid osteoma
Johnson et al., 2014Video-assisted thoracoscopic surgery guided by a navigation system (StealthStation & O-arm) in 4 pts w/intrathoracic spinal tumors.
Pt = patient.

These principals in image guidance were further developed by Fujibayashi et al.;7 in planning osteotomies for tumor resection and deformity correction, navigation provided anatomical information and assistance in avoiding neurovascular structures.

The use of image guidance allowed for safe and efficient en-bloc resection of spinal metastatic tumors in their series of image-guided osteotomies.7 Furthermore, Smitherman et al.31 described a similar image-guided osteotomy technique for a giant cell tumor in the thoracic spine. Dasenbrock and colleagues5 also reported the advantage of frameless spine navigation in achieving adequate margins for the en-bloc resection of sacral chordomas. Additionally, the use of image guidance has been underscored in averting the possibility of seeding of oncological lesions.12

In addition to improving localization and surgical planning, image guidance in the spine has also been increasingly used in minimally invasive procedures. Nagashima et al.22 and Campos et al.4 described the use of stereotactic guidance for curetting the nidus of an osteoid osteoma. The use of navigation made it possible for them to safely curette the nidus through a small hole, thus providing symptomatic relief without the destabilization or limitation of movement that might have resulted from a larger fusion surgery.4,22 The ability to perform minimally invasive surgeries and ultimately create smaller incisions than are required with conventional open techniques is of particular concern in patients with metastatic disease who are undergoing adjuvant therapy. Patients with metastatic disease may have multiple comorbidities and are at high risk for postoperative complication. Furthermore, these patients often have nutritional deficiencies and impaired wound healing.23,38,39 Radiation treatment as part of adjuvant therapy may further predispose these patients to wound breakdown. When patients undergo conventional open decompression and fusion procedures, radiation and chemotherapy are withheld for 4–5 weeks, depending on the institution.39 In contrast, Zairi et al.39 described adjuvant therapy being initiated within 10–12 days after a minimally invasive approach for metastatic lesions to the spine. Furthermore, Tancioni et al.33 also reported expedient administration of adjuvant therapy with a mean hospital stay of 6 days.

Our review of the literature indicated increasing use of intraoperative navigation for resection of tumors as it aids in identifying appropriate anatomy and enables the use of minimally invasive techniques. However, in each case, the images used for navigation were only preoperatively acquired. Cone-beam fluoroscopy has demonstrated that images with navigation can be used to place pedicle screws and then to confirm adequate positioning; we propose that intraoperative CT or cone-beam fluoroscopy can be used for rapid and accurate localization of lesions and confirmation of extent of resection.

In the current paper, we present 4 cases (of 50 reviewed) illustrating the use of intraoperative stereotactic navigation to localize tumors and to guide resection in patients with spinal lesions. With the emergence of 3D image guidance systems, we were able to acquire intraoperative CT scans with real-time tracking that allowed for precise targeting of spinal lesions with minimal dissection. In all cases, a diagnostic evaluation of the lesion was imperative and required a highly accurate and targeted approach. This new technique has not been previously reported and represents a novel approach combining the demonstrated advantages of minimally invasive spine surgery with the submillimetric accuracy of image-guided, intraoperative navigation with autoregistration capability. It circumvented the need for open dissection and the associated potential destabilization of the spinal column or injury to adjacent tissue and organs and represents an alternative to open surgery when the need for diagnostic results is imperative for the treatment algorithm. After a desired tumor resection or instrumentation, cone-beam fluoroscopy can assist in acquiring additional intraoperative images to assist in further tumor removal or hardware confirmation. Using image guidance for surgery has been documented by Rajasekaran et al.25 and Arand et al.1 to assist in tumor excision and determining resection margins.

Although the O-arm provides real-time intraoperative navigation, some clinical pitfalls must be avoided. A study conducted by Houten et al.10 confirmed the precision of the O-arm in the thoracic and lumbar spine. However, Santos et al.28 reported that accuracy in the cervical spine was not as reliable. The acquisition of intraoperative imaging in patients with prior hardware placement may prove challenging. The scatter artifact from prior hardware may compromise the navigational accuracy of the O-arm.7 Other circumstances, such as intraoperative vertebroplasty, may pose navigational challenges. Stereotactic guidance certainly augments our surgical ability, but is not a substitute for anatomical knowledge and surgical technique.16 As helpful as this technology has become in the operating room, it must not be relied upon as a substitute for knowledge of and attention to anatomy. Tjardes et al.35 described the importance of the human factor in their review of the literature. Furthermore, the use of the image-guided navigation system can be regarded as an additional operative step that increases the anesthesia time and hence increases the risk for the patient with cancer. In studies by Deutsch et al.6 and Schwab et al.,29 the time for minimally invasive spine techniques compared favorably to the time required for standard open surgery once the surgical teams overcame the learning curves. In addition, a study conducted by Kalfas et al.17 demonstrated that the use of intraoperative navigation actually reduced the time of instrumentation by 30 minutes compared with the use of conventional fluoroscopy.

The use of intraoperative CT scans (such as those obtained with the O-arm) for stereotactic navigation may also pose concerns about radiation dosing in comparison with conventional fluoroscopy. In their review of the literature, Kraus et al.18 reported that the effective dose of radiation was 0.4 mSv for lumbar pedicle screws using O-arm cone-beam CT in comparison to 5.03 mSv with conventional fluoroscopy, although the precise amount of radiation delivered to the patient is somewhat dependent on the body habitus of the patient. For example, a study by Lange et al. compared the amount of radiation from the cone-beam CT in the O-arm to the amount of radiation from a conventional abdominal (fan-beam) CT scan. In a patient with a smaller body habitus, 6 cone-beam CT scans were equivalent to 1 standard abdominal CT scan; however, in a larger patient, 3 cone-beam CT scans were comparable to 1 abdominal CT scan.19 In addition to the lower dosimetric levels of radiation for the patient, this also equated to less radiation for the surgeon and operative staff than with fluoroscopy.40

Conclusions

O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to OR personnel as well as the ability to use minimally invasive approaches that limit tissue injury. Further work may be done to assess the utility of stereotactic guidance in oncological tumor resection, particularly with respect to outcomes for patients.

References

  • 1

    Arand MHartwig EKinzl LGebhard F: Spinal navigation in tumor surgery of the thoracic spine: first clinical results.. Clin Orthop Relat Res 3992112182002

    • Search Google Scholar
    • Export Citation
  • 2

    Baaj AABeckman JSmith DA: O-arm-based image guidance in minimally invasive spine surgery: technical note. Clin Neurol Neurosurg 115:3423452013

    • Search Google Scholar
    • Export Citation
  • 3

    Bandiera SGhermandi RGasbarrini ABarbanti Bròdano GColangeli SBoriani S: Navigation-assisted surgery for tumors of the spine. Eur Spine J 22:Suppl 6S919S9242013

    • Search Google Scholar
    • Export Citation
  • 4

    Campos WKGasbarrini ABoriani S: Case report: Curetting osteoid osteoma of the spine using combined video-assisted thoracoscopic surgery and navigation. Clin Orthop Relat Res 471:6806852013

    • Search Google Scholar
    • Export Citation
  • 5

    Dasenbrock HHClarke MJBydon AMcGirt MJWitham TFSciubba DM: En bloc resection of sacral chordomas aided by frameless stereotactic image guidance: a technical note. Neurosurgery 70:1 Suppl Operative82882012

    • Search Google Scholar
    • Export Citation
  • 6

    Deutsch HBoco TLobel J: Minimally invasive transpedicular vertebrectomy for metastatic disease to the thoracic spine. J Spinal Disord Tech 21:1011052008

    • Search Google Scholar
    • Export Citation
  • 7

    Fujibayashi SNeo MTakemoto MOta MNakayama TToguchida J: Computer-assisted spinal osteotomy: a technical note and report of four cases. Spine (Phila Pa 1976) 35:E895E9032010

    • Search Google Scholar
    • Export Citation
  • 8

    Gebhard FKinzl LHartwig EArand M: [Navigation of tumors and metastases in the area of the thoracolumbar spine.]. Unfallchirurg 106:9499552003. (Ger)

    • Search Google Scholar
    • Export Citation
  • 9

    Ghostine SVaynman SSchoeb JSCambron HKing WASamudrala S: Image-guided thoracoscopic resection of thoracic dumbbell nerve sheath tumors. Neurosurgery 70:4614682012

    • Search Google Scholar
    • Export Citation
  • 10

    Houten JKNasser RBaxi N: Clinical assessment of percutaneous lumbar pedicle screw placement using the O-arm multidimensional surgical imaging system. Neurosurgery 70:9909952012

    • Search Google Scholar
    • Export Citation
  • 11

    Hsu WKosztowski TAZaidi HAGokaslan ZLWolinsky JP: Image-guided, endoscopic, transcervical resection of cervical chordoma. J Neurosurg Spine 12:4314352010

    • Search Google Scholar
    • Export Citation
  • 12

    Iloreta AMNyquist GGFriedel MFarrell CRosen MREvans JJ: Surgical pathway seeding of clivo-cervical chordomas.. J Neurol Surg Rep 75:e246e2502014

    • Search Google Scholar
    • Export Citation
  • 13

    Jeswani SDrazin DHsieh JCShweikeh FFriedman EPashman R: Instrumenting the small thoracic pedicle: the role of intraoperative computed tomography image-guided surgery. Neurosurg Focus 36:3E62014

    • Search Google Scholar
    • Export Citation
  • 14

    Jin MLiu ZLiu XYan HHan XQiu Y: Does intraoperative navigation improve the accuracy of pedicle screw placement in the apical region of dystrophic scoliosis secondary to neurofibromatosis Type I: comparison between O-arm navigation and free-hand technique. Eur Spine J 25:172917372016

    • Search Google Scholar
    • Export Citation
  • 15

    Johnson JPDrazin DKing WAKim TT: Image-guided navigation and video-assisted thoracoscopic spine surgery: the second generation. Neurosurg Focus 36:3E82014

    • Search Google Scholar
    • Export Citation
  • 16

    Kalfas IH: Image-guided spinal navigation: application to spinal metastases. Neurosurg Focus 11:6e52001

  • 17

    Kalfas IHKormos DWMurphy MAMcKenzie RLBarnett GHBell GR: Application of frameless stereotaxy to pedicle screw fixation of the spine. J Neurosurg 83:6416471995

    • Search Google Scholar
    • Export Citation
  • 18

    Kraus MDKrischak GKeppler PGebhard FTSchuetz UH: Can computer-assisted surgery reduce the effective dose for spinal fusion and sacroiliac screw insertion?. Clin Orthop Relat Res 468:241924292010

    • Search Google Scholar
    • Export Citation
  • 19

    Lange JKarellas AStreet JEck JCLapinsky AConnolly PJ: Estimating the effective radiation dose imparted to patients by intraoperative cone-beam computed tomography in thoracolumbar spinal surgery. Spine (Phila Pa 1976) 38:E306E3122013

    • Search Google Scholar
    • Export Citation
  • 20

    Mayer JEDang RPDuarte Prieto GFCho SKQureshi SAHecht AC: Analysis of the techniques for thoracic- and lumbar-level localization during posterior spine surgery and the occurrence of wrong-level surgery: results from a national survey. Spine J 14:7417482014

    • Search Google Scholar
    • Export Citation
  • 21

    Moore TMcLain RF: Image-guided surgery in resection of benign cervicothoracic spinal tumors: a report of two cases. Spine J 5:1091142005

    • Search Google Scholar
    • Export Citation
  • 22

    Nagashima HNishi TYamane KTanida A: Case report: osteoid osteoma of the C2 pedicle: surgical technique using a navigation system. Clin Orthop Relat Res 468:2832882010

    • Search Google Scholar
    • Export Citation
  • 23

    Pascal-Moussellard HBroc GPointillart VSiméon FVital JMSénégas J: Complications of vertebral metastasis surgery. Eur Spine J 7:4384441998

    • Search Google Scholar
    • Export Citation
  • 24

    Patchell RATibbs PARegine WFPayne RSaris SKryscio RJ: Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 366:6436482005

    • Search Google Scholar
    • Export Citation
  • 25

    Rajasekaran SKamath VShetty AP: Intraoperative Iso-C three-dimensional navigation in excision of spinal osteoid osteomas. Spine (Phila Pa 1976) 33:E25E292008

    • Search Google Scholar
    • Export Citation
  • 26

    Rajasekaran SKanna RMKamath VShetty AP: Computer navigation-guided excision of cervical osteoblastoma. Eur Spine J 19:104610472010

    • Search Google Scholar
    • Export Citation
  • 27

    Rivkin MAYocom SS: Thoracolumbar instrumentation with CT-guided navigation (O-arm) in 270 consecutive patients: accuracy rates and lessons learned. Neurosurg Focus 36:3E72014

    • Search Google Scholar
    • Export Citation
  • 28

    Santos ERLedonio CGCastro CATruong WHSembrano JN: The accuracy of intraoperative O-arm images for the assessment of pedicle screw postion. Spine (Phila Pa 1976) 37:E119E1252012

    • Search Google Scholar
    • Export Citation
  • 29

    Schwab JHGasbarrini ACappuccio MBoriani LDe Iure FColangeli S: Minimally invasive posterior stabilization improved ambulation and pain scores in patients with plasmacytomas and/or metastases of the spine.. Int J Surg Oncol 2011:2392302011

    • Search Google Scholar
    • Export Citation
  • 30

    Shin BJJames ARNjoku IUHärtl R: Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. J Neurosurg Spine 17:1131222012

    • Search Google Scholar
    • Export Citation
  • 31

    Shin MHHur JWRyu KSPark CK: Prospective comparison study between the fluoroscopy-guided and navigation coupled with O-arm–guided pedicle screw placement in the thoracic and lumbosacral spines. J Spinal Disord Tech 28:E347E3512015

    • Search Google Scholar
    • Export Citation
  • 32

    Smitherman SMTatsui CERao GWalsh GRhines LD: Image-guided multilevel vertebral osteotomies for en bloc resection of giant cell tumor of the thoracic spine: case report and description of operative technique. Eur Spine J 19:102110282010

    • Search Google Scholar
    • Export Citation
  • 33

    Tancioni FNavarria PPessina FMarcheselli SRognone EMancosu P: Early surgical experience with minimally invasive percutaneous approach for patients with metastatic epidural spinal cord compression (MESCC) to poor prognoses. Ann Surg Oncol 19:2943002012

    • Search Google Scholar
    • Export Citation
  • 34

    Tian NFHuang QSZhou PZhou YWu RKLou Y: Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies. Eur Spine J 20:8468592011

    • Search Google Scholar
    • Export Citation
  • 35

    Tjardes TShafizadeh SRixen DPaffrath TBouillon BSteinhausen ES: Image-guided spine surgery: state of the art and future directions. Eur Spine J 19:25452010

    • Search Google Scholar
    • Export Citation
  • 36

    Upadhyaya CDWu JCChin CTBalamurali GMummaneni PV: Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement. J Neurosurg Spine 16:2802842012

    • Search Google Scholar
    • Export Citation
  • 37

    Van Royen BJBaayen JCPijpers RNoske DPSchakenraad DWuisman PI: Osteoid osteoma of the spine: a novel technique using combined computer-assisted and gamma probe-guided high-speed intralesional drill excision. Spine (Phila Pa 1976) 30:3693732005

    • Search Google Scholar
    • Export Citation
  • 38

    Wise JJFischgrund JSHerkowitz HNMontgomery DKurz LT: Complication, survival rates, and risk factors of surgery for metastatic disease of the spine. Spine (Phila Pa 1976) 24:194319511999

    • Search Google Scholar
    • Export Citation
  • 39

    Zairi FArikat AAllaoui MMarinho PAssaker R: Minimally invasive decompression and stabilization for the management of thoracolumbar spine metastasis. J Neurosurg Spine 17:19232012

    • Search Google Scholar
    • Export Citation
  • 40

    Zhang JWeir VFajardo LLin JHsiung HRitenour ER: Dosimetric characterization of a cone-beam O-arm imaging system. J XRay Sci Technol 17:3053172009

    • Search Google Scholar
    • Export Citation

Disclosures

Dr. Kim reports a consultant relationship with DePuy Synthes and Medtronic and support from Medtronic for non–study-related clinical or research effort. Dr. Johnson reports receipt of grant funding from Medtronic.

Author Contributions

Conception and design: Drazin, Nasser, Nakhla, Brien, Baron, Kim, Johnson, Yassari. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Drazin. Statistical analysis: Drazin, Nakhla, Brien, Baron, Kim, Yassari. Administrative/technical/material support: Nasser, Al-Khouja, Johnson. Study supervision: Drazin, Nasser, Nakhla, Brien, Baron, Kim, Johnson, Yassari.

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Article Information

Contributor Notes

INCLUDE WHEN CITING DOI: 10.3171/2016.5.FOCUS16136.Correspondence Doniel Drazin, Department of Neurosurgery, Cedars-Sinai Medical Center, Advanced Health Sciences Pavilion-Neurosciences, 8700 Beverly Blvd., 6th Fl., Los Angeles, CA 90048. email: doniel.drazin@cshs.org.
Headings
Figures
  • View in gallery

    Photographs showing the Mayfield reference frame secured to the operating table with the patient's neck in a neutral position (left) and the Mayfield reference frame positioned away from the surgical field (right).

  • View in gallery

    StealthStation computer screenshot demonstrating an ideal cervical screw trajectory.

  • View in gallery

    Photograph showing a navigated tap being used with a guide-wire to confirm and maintain the pedicle trajectory.

  • View in gallery

    Primary disease Case 3. A and B: Preoperative anteroposterior pelvic radiograph (A) and coronal T2-weighted MR image (B) showing a lytic lesion to the right acetabulum with a lobular contour. C: Nuclear medicine bone scan showing intense focal abnormality of the right ilium extending from the right acetabulum consistent with a large metastatic focus area. D and E: Photomicrographs of the surgical pathology specimen showing a moderately differentiated, conventional type of chondrosarcoma of the bone. H & E, original magnification ×40 (D) and ×100 (E).

  • View in gallery

    Primary disease Case 3. Intraoperative O-arm images showing localization of the lesion.

  • View in gallery

    Primary disease Case 7. Upper: Photograph showing a navigated stereotactic tube and percutaneous posterior superior iliac spine reference frame. Lower: Screenshot showing 3D localization of left L-5 transverse process lesion.

  • View in gallery

    Metastatic disease Case 6. Preoperative sagittal T2-weighted (A), sagittal contrast-enhanced T1-weighted (B), and axial contrast-enhanced T1-weighted (C) MR images showing obliteration of the C-1 and C-2 vertebral bodies with extension of the lesion in to the ventral epidural space.

  • View in gallery

    Metastatic disease Case 6. Intraoperative 3D localization of cervical spine lesion.

  • View in gallery

    Metastatic disease Case 13. A: Preoperative sagittal contrast-enhanced T1-weighted MR image revealing pathological fracture of T-9. B: Localization of the lesion using frameless stereotactic navigation. C and D: Postoperative sagittal CT images showing left and right pedicle screws placed with frameless navigation.

References
  • 1

    Arand MHartwig EKinzl LGebhard F: Spinal navigation in tumor surgery of the thoracic spine: first clinical results.. Clin Orthop Relat Res 3992112182002

    • Search Google Scholar
    • Export Citation
  • 2

    Baaj AABeckman JSmith DA: O-arm-based image guidance in minimally invasive spine surgery: technical note. Clin Neurol Neurosurg 115:3423452013

    • Search Google Scholar
    • Export Citation
  • 3

    Bandiera SGhermandi RGasbarrini ABarbanti Bròdano GColangeli SBoriani S: Navigation-assisted surgery for tumors of the spine. Eur Spine J 22:Suppl 6S919S9242013

    • Search Google Scholar
    • Export Citation
  • 4

    Campos WKGasbarrini ABoriani S: Case report: Curetting osteoid osteoma of the spine using combined video-assisted thoracoscopic surgery and navigation. Clin Orthop Relat Res 471:6806852013

    • Search Google Scholar
    • Export Citation
  • 5

    Dasenbrock HHClarke MJBydon AMcGirt MJWitham TFSciubba DM: En bloc resection of sacral chordomas aided by frameless stereotactic image guidance: a technical note. Neurosurgery 70:1 Suppl Operative82882012

    • Search Google Scholar
    • Export Citation
  • 6

    Deutsch HBoco TLobel J: Minimally invasive transpedicular vertebrectomy for metastatic disease to the thoracic spine. J Spinal Disord Tech 21:1011052008

    • Search Google Scholar
    • Export Citation
  • 7

    Fujibayashi SNeo MTakemoto MOta MNakayama TToguchida J: Computer-assisted spinal osteotomy: a technical note and report of four cases. Spine (Phila Pa 1976) 35:E895E9032010

    • Search Google Scholar
    • Export Citation
  • 8

    Gebhard FKinzl LHartwig EArand M: [Navigation of tumors and metastases in the area of the thoracolumbar spine.]. Unfallchirurg 106:9499552003. (Ger)

    • Search Google Scholar
    • Export Citation
  • 9

    Ghostine SVaynman SSchoeb JSCambron HKing WASamudrala S: Image-guided thoracoscopic resection of thoracic dumbbell nerve sheath tumors. Neurosurgery 70:4614682012

    • Search Google Scholar
    • Export Citation
  • 10

    Houten JKNasser RBaxi N: Clinical assessment of percutaneous lumbar pedicle screw placement using the O-arm multidimensional surgical imaging system. Neurosurgery 70:9909952012

    • Search Google Scholar
    • Export Citation
  • 11

    Hsu WKosztowski TAZaidi HAGokaslan ZLWolinsky JP: Image-guided, endoscopic, transcervical resection of cervical chordoma. J Neurosurg Spine 12:4314352010

    • Search Google Scholar
    • Export Citation
  • 12

    Iloreta AMNyquist GGFriedel MFarrell CRosen MREvans JJ: Surgical pathway seeding of clivo-cervical chordomas.. J Neurol Surg Rep 75:e246e2502014

    • Search Google Scholar
    • Export Citation
  • 13

    Jeswani SDrazin DHsieh JCShweikeh FFriedman EPashman R: Instrumenting the small thoracic pedicle: the role of intraoperative computed tomography image-guided surgery. Neurosurg Focus 36:3E62014

    • Search Google Scholar
    • Export Citation
  • 14

    Jin MLiu ZLiu XYan HHan XQiu Y: Does intraoperative navigation improve the accuracy of pedicle screw placement in the apical region of dystrophic scoliosis secondary to neurofibromatosis Type I: comparison between O-arm navigation and free-hand technique. Eur Spine J 25:172917372016

    • Search Google Scholar
    • Export Citation
  • 15

    Johnson JPDrazin DKing WAKim TT: Image-guided navigation and video-assisted thoracoscopic spine surgery: the second generation. Neurosurg Focus 36:3E82014

    • Search Google Scholar
    • Export Citation
  • 16

    Kalfas IH: Image-guided spinal navigation: application to spinal metastases. Neurosurg Focus 11:6e52001

  • 17

    Kalfas IHKormos DWMurphy MAMcKenzie RLBarnett GHBell GR: Application of frameless stereotaxy to pedicle screw fixation of the spine. J Neurosurg 83:6416471995

    • Search Google Scholar
    • Export Citation
  • 18

    Kraus MDKrischak GKeppler PGebhard FTSchuetz UH: Can computer-assisted surgery reduce the effective dose for spinal fusion and sacroiliac screw insertion?. Clin Orthop Relat Res 468:241924292010

    • Search Google Scholar
    • Export Citation
  • 19

    Lange JKarellas AStreet JEck JCLapinsky AConnolly PJ: Estimating the effective radiation dose imparted to patients by intraoperative cone-beam computed tomography in thoracolumbar spinal surgery. Spine (Phila Pa 1976) 38:E306E3122013

    • Search Google Scholar
    • Export Citation
  • 20

    Mayer JEDang RPDuarte Prieto GFCho SKQureshi SAHecht AC: Analysis of the techniques for thoracic- and lumbar-level localization during posterior spine surgery and the occurrence of wrong-level surgery: results from a national survey. Spine J 14:7417482014

    • Search Google Scholar
    • Export Citation
  • 21

    Moore TMcLain RF: Image-guided surgery in resection of benign cervicothoracic spinal tumors: a report of two cases. Spine J 5:1091142005

    • Search Google Scholar
    • Export Citation
  • 22

    Nagashima HNishi TYamane KTanida A: Case report: osteoid osteoma of the C2 pedicle: surgical technique using a navigation system. Clin Orthop Relat Res 468:2832882010

    • Search Google Scholar
    • Export Citation
  • 23

    Pascal-Moussellard HBroc GPointillart VSiméon FVital JMSénégas J: Complications of vertebral metastasis surgery. Eur Spine J 7:4384441998

    • Search Google Scholar
    • Export Citation
  • 24

    Patchell RATibbs PARegine WFPayne RSaris SKryscio RJ: Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 366:6436482005

    • Search Google Scholar
    • Export Citation
  • 25

    Rajasekaran SKamath VShetty AP: Intraoperative Iso-C three-dimensional navigation in excision of spinal osteoid osteomas. Spine (Phila Pa 1976) 33:E25E292008

    • Search Google Scholar
    • Export Citation
  • 26

    Rajasekaran SKanna RMKamath VShetty AP: Computer navigation-guided excision of cervical osteoblastoma. Eur Spine J 19:104610472010

    • Search Google Scholar
    • Export Citation
  • 27

    Rivkin MAYocom SS: Thoracolumbar instrumentation with CT-guided navigation (O-arm) in 270 consecutive patients: accuracy rates and lessons learned. Neurosurg Focus 36:3E72014

    • Search Google Scholar
    • Export Citation
  • 28

    Santos ERLedonio CGCastro CATruong WHSembrano JN: The accuracy of intraoperative O-arm images for the assessment of pedicle screw postion. Spine (Phila Pa 1976) 37:E119E1252012

    • Search Google Scholar
    • Export Citation
  • 29

    Schwab JHGasbarrini ACappuccio MBoriani LDe Iure FColangeli S: Minimally invasive posterior stabilization improved ambulation and pain scores in patients with plasmacytomas and/or metastases of the spine.. Int J Surg Oncol 2011:2392302011

    • Search Google Scholar
    • Export Citation
  • 30

    Shin BJJames ARNjoku IUHärtl R: Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. J Neurosurg Spine 17:1131222012

    • Search Google Scholar
    • Export Citation
  • 31

    Shin MHHur JWRyu KSPark CK: Prospective comparison study between the fluoroscopy-guided and navigation coupled with O-arm–guided pedicle screw placement in the thoracic and lumbosacral spines. J Spinal Disord Tech 28:E347E3512015

    • Search Google Scholar
    • Export Citation
  • 32

    Smitherman SMTatsui CERao GWalsh GRhines LD: Image-guided multilevel vertebral osteotomies for en bloc resection of giant cell tumor of the thoracic spine: case report and description of operative technique. Eur Spine J 19:102110282010

    • Search Google Scholar
    • Export Citation
  • 33

    Tancioni FNavarria PPessina FMarcheselli SRognone EMancosu P: Early surgical experience with minimally invasive percutaneous approach for patients with metastatic epidural spinal cord compression (MESCC) to poor prognoses. Ann Surg Oncol 19:2943002012

    • Search Google Scholar
    • Export Citation
  • 34

    Tian NFHuang QSZhou PZhou YWu RKLou Y: Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies. Eur Spine J 20:8468592011

    • Search Google Scholar
    • Export Citation
  • 35

    Tjardes TShafizadeh SRixen DPaffrath TBouillon BSteinhausen ES: Image-guided spine surgery: state of the art and future directions. Eur Spine J 19:25452010

    • Search Google Scholar
    • Export Citation
  • 36

    Upadhyaya CDWu JCChin CTBalamurali GMummaneni PV: Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement. J Neurosurg Spine 16:2802842012

    • Search Google Scholar
    • Export Citation
  • 37

    Van Royen BJBaayen JCPijpers RNoske DPSchakenraad DWuisman PI: Osteoid osteoma of the spine: a novel technique using combined computer-assisted and gamma probe-guided high-speed intralesional drill excision. Spine (Phila Pa 1976) 30:3693732005

    • Search Google Scholar
    • Export Citation
  • 38

    Wise JJFischgrund JSHerkowitz HNMontgomery DKurz LT: Complication, survival rates, and risk factors of surgery for metastatic disease of the spine. Spine (Phila Pa 1976) 24:194319511999

    • Search Google Scholar
    • Export Citation
  • 39

    Zairi FArikat AAllaoui MMarinho PAssaker R: Minimally invasive decompression and stabilization for the management of thoracolumbar spine metastasis. J Neurosurg Spine 17:19232012

    • Search Google Scholar
    • Export Citation
  • 40

    Zhang JWeir VFajardo LLin JHsiung HRitenour ER: Dosimetric characterization of a cone-beam O-arm imaging system. J XRay Sci Technol 17:3053172009

    • Search Google Scholar
    • Export Citation
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