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Langston T. Holly, Orin Bloch, Chinyere Obasi, and J. Patrick Johnson

the practicality, efficacy, and accuracy of anterior spinal stereotaxy in a cadaveric model. Materials and Methods Three embalmed adult cadavers were used for this study. Following posterior soft-tissue exposure, unilateral pedicle screws were placed posteriorly from C-4 to L-4 to serve as unknown markers within each VB. The specimens then underwent CT scanning (General Electric, Milwaukee, WI). Data were obtained in 1-mm slices in the cervical region and 3-mm slices in the thoracic and lumbar regions on data-acquisition tapes and then transferred to the

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Pierre Bourdillon, Caroline Apra, and Marc Lévêque

techniques. Whereas in the second half of the 19th century extensive studies were published about the use of external anatomical landmarks to locate deep anatomical structures ( Fig. 1 ), Gaston Contremoulins (1869–1950) was the first to introduce radiography as an improvement to the concept of stereotaxy; this improvement allowed a spectacular surgical premiere, that is, successfully extracting intracranial foreign bodies from patients. Fig. 1. Diagram of the stages of the main stereotactic developments before Spiegel. The blue boxes indicate clinical human applications

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Jay Jagannathan, Daniel M. Prevedello, Vivek S. Ayer, Aaron S. Dumont, John A. Jane Jr., and Edward R. Laws

Object

In this study the authors address the efficacy and safety of frameless stereotaxy in transsphenoidal surgery.

Methods

One thousand transsphenoidal operations were performed at the authors' institution between June 2000 and July 2005. This series consists of a retrospective review of 176 patients entered in a prospectively obtained database who underwent frameless stereotactic transsphenoidal surgery in which magnetic resonance (MR) imaging, computerized tomography (CT) scanning, or fluoroscopic guidance was used. Of the 176 patients, 104 (59%) had suprasellar extension of their tumor, 70 (40%) had involvement of the visual apparatus, and 65 (37%) had cavernous sinus involvement. All patients underwent detailed pre- and postoperative neurological, endocrinological, radiographic, and ophthalmological follow-up evaluations. Records were reviewed retrospectively for intraoperative and postoperative complications related to the surgical approach.

No instances of visual deterioration, carotid artery (CA) stenosis, or stroke were observed following transsphenoidal surgery. Only one patient sustained damage to the CA intraoperatively, and this was controlled in the operating room. Five patients (3%) required an intensive care unit stay postoperatively. Intraoperative cerebrospinal fluid leakage was encountered in 112 patients (64%) and was more frequently observed in tumors with suprasellar involvement.

Conclusions

Frameless stereotaxy is a safe and effective modality for the treatment of recurrent or invasive sellar masses. All three frameless stereotaxy modalities provided accurate information regarding the anatomical midline and the trajectory to the sella turcica. The MR imaging, CT scanning, and fluoroscopic stereotaxy modalities all have unique advantages as well as specific limitations.

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Eric M. Gabriel and Blaine S. Nashold Jr

intracranial neurosurgical procedures. Spinal Cord Stereotaxy Stereotaxis has not been limited in its use to intracranial operations. Interestingly, long before Horsley and Clarke's 17 landmark paper appeared in Brain in 1908, the first attempts at localization of specific points in the central nervous system began with experimental studies of the spinal cord. The earliest documented use of the principle of guiding devices for directing probes to their targets appeared in the work of Dittmar 6 in 1873. 1 While working at The Physiological Institute of Professor

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Neil L. Dorward, Olaf Alberti, James D. Palmer, Neil D. Kitchen, and David G. T. Thomas

. Although image guidance of a tracked instrument can be achieved relatively simply, 3, 17, 27 hand-held devices cannot satisfy the requirements of stereotaxy. Therefore, for frameless stereotaxy to be achieved, an instrument guide is required. This should reach all parts of the cranial vault, lock in place rigidly to provide robust support, allow fine correction of trajectory settings, adapt to a variety of instruments, and be compatible with image guidance tracking. Although attempts to adapt traditional neurosurgical devices to this task have been reported, 11 none

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Florian Grimm, Georgios Naros, Angelika Gutenberg, Naureen Keric, Alf Giese, and Alireza Gharabaghi

guidance and provided frameless stereotaxy. 7 However, because it could perform only single-dimension incursions and the patient had to be inside a CT scanner, the project was discontinued in 1993. Several other robotic systems were designed and tested, and some were marketed (e.g., SurgiScope; Elekta). However, these surgical robots have not successfully overcome the inherent limitations of current localization systems, because they are still susceptible to human interference errors during either manual setting of the frame (in frame-based approaches) or intraoperative

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Orin Bloch, Langston T. Holly, Jongsoo Park, Chinyere Obasi, Kee Kim, and J. Patrick Johnson

pars interarticularis in real time, allowing the surgeon to avoid the VA safely. This in vitro study was conducted to determine whether frameless stereotaxy would improve the accuracy of C1–2 transarticular screw placement in healthy patients as well as in those with anatomy deemed unsuitable by previous criteria for such a procedure. Materials and Methods Seventeen cadaveric specimens underwent preoperative spiral CT scanning (General Electric, Milwaukee, WI). The data were obtained in 1-mm slices and transferred on digital audio tape to a workstation (Optical

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Iain H. Kalfas, Donald W. Kormos, Michael A. Murphy, Rick L. McKenzie, Gene H. Barnett, Gordon R. Bell, Charles P. Steiner, Mary Beth Trimble, and Joseph P. Weisenberger

I nteractive frameless stereotaxy using surface reference marks in place of a stereotactic frame has been successfully applied to intracranial surgery. 1, 2, 8, 10, 11, 13, 14, 17 The method provides an accurate and reliable means of localizing lesions within the brain to reduce operative time, costs, and morbidity. However, the application of this technology to other areas of neurosurgery, particularly spinal surgery, is not as direct. Localization in spinal surgery is not as significant a problem as it is in the removal of deep-seated intracranial lesions

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Martin J. Ryan, Robert K. Erickson, David N. Levin, Charles A. Pelizzari, R. Loch Macdonald, and George J. Dohrmann

extraneous ultrasonic noise and echoes in the operating room. In recent years, 3-D digitizers based on optical tracking have become available for use in frameless stereotaxy. Arrays of charge-coupled device (CCD) cameras track a stylus by localizing the infrared light-emitting diodes (LEDs) on its handle; 2 alternatively, an array of video cameras is used to monitor the movements of the wand by detecting lights or a characteristic pattern on its handle. 3, 5 These systems can be adapted for interactive tracking of surgical tools and they are not significantly

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Benjamin Yim, M. Reid Gooch, John C. Dalfino, Matthew A. Adamo, and Tyler J. Kenning

imaging. Traditionally at our institution, frameless stereotaxy has been used for shunt placement in patients with small ventricular size, such as in cases of IIH. This has some inherent limitations, however, including the need for rigid head fixation and constraints on patient positioning in patients who are often morbidly obese, the added cost of compatible preoperative imaging and intraoperative disposable equipment, and added time in the operating room. Additionally, final intraventricular catheter location is not confirmed until a CT scan is obtained