Intraoperative computed tomography registration and electromagnetic neuronavigation for transsphenoidal pituitary surgery: accuracy and time effectiveness

Clinical article

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Object

The authors assessed the feasibility, anatomical accuracy, and cost effectiveness of frameless electromagnetic (EM) neuronavigation in conjunction with portable intraoperative CT (iCT) registration for transsphenoidal adenomectomy (TSA).

Methods

A prospective database was established for data obtained in 208 consecutive patients who underwent TSA in which the iCT/EM navigation technique was used. Data were compared with those acquired in a retrospective cohort of 65 consecutive patients in whom fluoroscope-assisted TSA had been performed by the same surgeon. All patients in both groups underwent transnasal removal of pituitary adenomas or neuroepithelial cysts, using identical surgical techniques with an operating microscope. In the iCT/EM technique–treated cases, a portable iCT scan was obtained immediately prior to surgery for registration to the EM navigation system, which did not require rigid head fixation. Preexisting (nonnavigation protocol) MR imaging studies were fused with the iCT scans to enable 3D navigation based on MR imaging data. The accuracy of the navigation system was determined in the first 50 iCT/EM cases by visual concordance of the navigation probe location to 5 preselected bony landmarks. For all patients in both cohorts, total operating room time, incision-to-closure time, and relative costs of imaging and surgical procedures were determined from hospital records.

Results

In every case, iCT registration was successful and preoperative MR images were fused to iCT scans without affecting navigation accuracy. There was 100% concordance between probe tip location and predetermined bony loci in the first 50 cases involving the iCT/EM technique. Total operating room time was significantly less in the iCT/EM cases (mean 108.9 ± 24.3 minutes [208 patients]) compared with the fluoroscopy group (mean 121.1 ± 30.7 minutes [65 patients]; p < 0.001). Similarly, incision-to-closure time was significantly less for the iCT/EM cases (mean 61.3 ± 18.2 minutes) than for the fluoroscopy cases (mean 71.75 ± 19.0 minutes; p < 0.001). Relative overall costs for iCT/EM technique and intraoperative C-arm fluoroscopy were comparable; increased costs for navigation equipment were offset by savings in operating room costs for shorter procedures.

Conclusions

The use of iCT/MR imaging–guided neuronavigation for transsphenoidal surgery is a time-effective, cost-efficient, safe, and technically beneficial technique.

Abbreviations used in this paper: iCT = intraoperative CT; EM = electromagnetic; TSA = transsphenoidal adenomectomy.

Article Information

Address correspondence to: Marc R. Mayberg, M.D., Swedish Neuroscience Institute, 500 17th Avenue, Suite #500, Seattle, Washington 98122. email: marc.mayberg@swedish.org.

Please include this information when citing this paper: published online June 18, 2010; DOI: 10.3171/2010.5.JNS091821.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Setup for EM neuronavigation. An EM localizer is attached to the forehead and an EM generator placed adjacent to the head. Note that the head and generator are not rigidly fixed and can be repositioned after the registration is completed.

  • View in gallery

    Electromagnetic navigation probes. Note that the probe can be bent behind the EM transmitters (red) to provide nonlinear navigation.

  • View in gallery

    Intraoperative verification of accuracy. The navigation probe tip is touching the apex of the sphenoid rostrum, which is delineated in axial (C), coronal (A), and sagittal (B) views on the navigation display derived from CT data set. The 3D rendering (D) is used for surface fiducial tracing.

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