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Pedicle screw navigation using surface digitization on the Microsoft HoloLens

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International Journal of Computer Assisted Radiology and Surgery Aims and scope Submit manuscript

Abstract

Purpose

In spinal fusion surgery, imprecise placement of pedicle screws can result in poor surgical outcome or may seriously harm a patient. Patient-specific instruments and optical systems have been proposed for improving precision through surgical navigation compared to freehand insertion. However, existing solutions are expensive and cannot provide in situ visualizations. Recent technological advancement enabled the production of more powerful and precise optical see-through head-mounted displays for the mass market. The purpose of this laboratory study was to evaluate whether such a device is sufficiently precise for the navigation of lumbar pedicle screw placement.

Methods

A novel navigation method, tailored to run on the Microsoft HoloLens, was developed. It comprises capturing of the intraoperatively reachable surface of vertebrae to achieve registration and tool tracking with real-time visualizations without the need of intraoperative imaging. For both surface sampling and navigation, 3D printable parts, equipped with fiducial markers, were employed. Accuracy was evaluated within a self-built setup based on two phantoms of the lumbar spine. Computed tomography (CT) scans of the phantoms were acquired to carry out preoperative planning of screw trajectories in 3D. A surgeon placed the guiding wire for the pedicle screw bilaterally on ten vertebrae guided by the navigation method. Postoperative CT scans were acquired to compare trajectory orientation (3D angle) and screw insertion points (3D distance) with respect to the planning.

Results

The mean errors between planned and executed screw insertion were \(3.38^{\circ }\pm {1.73}^{\circ }\) for the screw trajectory orientation and 2.77±1.46 mm for the insertion points. The mean time required for surface digitization was 125±27 s.

Conclusions

First promising results under laboratory conditions indicate that precise lumbar pedicle screw insertion can be achieved by combining HoloLens with our proposed navigation method. As a next step, cadaver experiments need to be performed to confirm the precision on real patient anatomy.

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References

  1. Raciborski F, Gasik R, Kłak A (2016) Disorders of the spine. A major health and social problem. Reumatologia 54(4):196

    Article  PubMed  PubMed Central  Google Scholar 

  2. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V et al (2012) Years lived with disability (ylds) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010. The Lancet 380(9859):2163–2196

    Article  Google Scholar 

  3. Van Tulder MW, Koes BW, Bouter LM (1997) Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine 22(18):2128–2156

    Article  PubMed  Google Scholar 

  4. Mirza SK, Deyo RA (2007) Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine 32(7):816–823

    Article  PubMed  Google Scholar 

  5. Verlaan J, Diekerhof C, Buskens E, Van der Tweel I, Verbout A, Dhert W, Oner F (2004) Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine 29(7):803–814

    Article  CAS  PubMed  Google Scholar 

  6. Maruyama T, Takeshita K (2008) Surgical treatment of scoliosis: a review of techniques currently applied. Scoliosis 3(1):6

    Article  PubMed  PubMed Central  Google Scholar 

  7. Mason A, Paulsen R, Babuska JM, Rajpal S, Burneikiene S, Nelson EL, Villavicencio AT (2014) The accuracy of pedicle screw placement using intraoperative image guidance systems: a systematic review. J Neurosurg Spine 20(2):196–203

    Article  PubMed  Google Scholar 

  8. Modi HN, Suh SW, Fernandez H, Yang JH, Song HR (2008) Accuracy and safety of pedicle screw placement in neuromuscular scoliosis with free-hand technique. Eur Spine J 17(12):1686–1696

    Article  PubMed  PubMed Central  Google Scholar 

  9. Farshad M, Betz M, Farshad-Amacker NA, Moser M (2017) Accuracy of patient-specific template-guided vs. free-hand fluoroscopically controlled pedicle screw placement in the thoracic and lumbar spine: a randomized cadaveric study. Eur Spine J 26(3):738–749

    Article  PubMed  Google Scholar 

  10. Merc M, Drstvensek I, Vogrin M, Brajlih T, Recnik G (2013) A multi-level rapid prototyping drill guide template reduces the perforation risk of pedicle screw placement in the lumbar and sacral spine. Arch Orthop Trauma Surg 133(7):893–899

    Article  PubMed  Google Scholar 

  11. Kantelhardt SR, Martinez R, Baerwinkel S, Burger R, Giese A, Rohde V (2011) Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement. Eur Spine J 20(6):860–868

    Article  PubMed  PubMed Central  Google Scholar 

  12. Tian NF, Huang QS, Zhou P, Zhou Y, Wu RK, Lou Y, Xu HZ (2011) Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies. Eur Spine J 20(6):846–859

    Article  PubMed  Google Scholar 

  13. Narain AS, Hijji FY, Yom KH, Kudaravalli KT, Haws BE, Singh K (2017) Radiation exposure and reduction in the operating room: perspectives and future directions in spine surgery. World J Orthop 8(7):524

    Article  PubMed  PubMed Central  Google Scholar 

  14. Gebhard FT, Kraus MD, Schneider E, Liener UC, Kinzl L, Arand M (2006) Does computer-assisted spine surgery reduce intraoperative radiation doses? Spine 31(17):2024–2027

    Article  PubMed  Google Scholar 

  15. Slomczykowski M, Roberto M, Schneeberger P, Ozdoba C, Vock P (1999) Radiation dose for pedicle screw insertion: fluoroscopic method versus computer-assisted surgery. Spine 24(10):975–983

    Article  CAS  PubMed  Google Scholar 

  16. Nottmeier EW, Crosby TL (2007) Timing of paired points and surface matching registration in three-dimensional (3D) image-guided spinal surgery. Clin Spine Surg 20(4):268–270

    Google Scholar 

  17. Richter M, Cakir B, Schmidt R (2005) Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws. Spine 30(20):2280–2287

    Article  PubMed  Google Scholar 

  18. Chiang CF, Tsai TT, Chen LH, Lai PL, Fu TS, Niu CC, Chen WJ (2012) Computed tomography-based navigation-assisted pedicle screw insertion for thoracic and lumbar spine fractures. Chang Gung Med J 35(4):332–338

    Google Scholar 

  19. Qian L, Unberath M, Yu K, Fuerst B, Johnson A, Navab N, Osgood G (2017) Towards virtual monitors for image guided interventions-real-time streaming to optical see-through head-mounted displays. arXiv preprint arXiv:171000808

  20. Andress S, Johnson A, Unberath M, Winkler AF, Yu K, Fotouhi J, Weidert S, Osgood G, Navab N (2018) On-the-fly augmented reality for orthopedic surgery using a multimodal fiducial. J Med Imaging 5(2):021209

    Article  Google Scholar 

  21. Sielhorst T, Feuerstein M, Navab N (2008) Advanced medical displays: a literature review of augmented reality. J Disp Technol 4(4):451–467

    Article  Google Scholar 

  22. Navab N, Blum T, Wang L, Okur A, Wendler T (2012) First deployments of augmented reality in operating rooms. Computer 45(7):48–55

    Article  Google Scholar 

  23. Ma L, Zhao Z, Chen F, Zhang B, Fu L, Liao H (2017) Augmented reality surgical navigation with ultrasound-assisted registration for pedicle screw placement: a pilot study. Int J Comput Assis Radiol Surg 12(12):2205–2215

    Article  Google Scholar 

  24. Microsoft (2018) HoloLens Research mode. https://docs.microHrBsoft.com/en-us/windows/mixed-reality/research-modeHrB. Accessed 1 Nov 2018

  25. Olson E (2011) Apriltag: a robust and flexible visual fiducial system. In: 2011 IEEE international conference on robotics and automation (ICRA). IEEE, pp 3400–3407

  26. Wang J, Olson E (2016) Apriltag 2: efficient and robust fiducial detection. In: IROS, pp 4193–4198

  27. Microsoft (2018) Locatable camera. https://docs.microsoft.com/en-us/windows/mixed-reality/locatable-camera. Accessed 5 Nov 2018

  28. Garrido-Jurado S, Muñoz-Salinas R, Madrid-Cuevas FJ, Marín-Jiménez MJ (2014) Automatic generation and detection of highly reliable fiducial markers under occlusion. Pattern Recognit 47(6):2280–2292

    Article  Google Scholar 

  29. Garrido-Jurado S, Munoz-Salinas R, Madrid-Cuevas FJ, Medina-Carnicer R (2016) Generation of fiducial marker dictionaries using mixed integer linear programming. Pattern Recognit 51:481–491

    Article  Google Scholar 

  30. Romero-Ramirez FJ, Muñoz-Salinas R, Medina-Carnicer R (2018) Speeded up detection of squared fiducial markers. Image Vis Comput 76:38–47

    Article  Google Scholar 

  31. Kalman RE (1960) A new approach to linear filtering and prediction problems. J Basic Eng 82(1):35–45

    Article  Google Scholar 

  32. Bradski G, Kaehler A (2000) Opencv. Dr Dobbs journal of software tools 3

  33. Horn BK (1987) Closed-form solution of absolute orientation using unit quaternions. JOSA A 4(4):629–642

    Article  Google Scholar 

  34. Microsoft (2017) Use the HoloLens clicker. https://support.micHrBrosoft.com/de-ch/help/12646/hololens-use-the-hololens-clickerHrB. Accessed 3 Nov 2018

  35. Microsoft (2018) HoloToolkit 2017.4.1.0. https://github.com/MicHrBrosoft/MixedRealityToolkit-Unity/releases/tag/2017.4.1.0HrB. Accessed 3 Nov 2018

  36. Besl PJ, McKay ND (1992) Method for registration of 3-D shapes. In: Sensor fusion IV: control paradigms and data structures, vol 1611. International society for optics and photonics, pp 586–607

  37. Pearson K (1901) LIII. On lines and planes of closest fit to systems of points in space. Lond Edinb Dublin Philos Mag J Sci 2(11):559–572

    Article  Google Scholar 

  38. Schweizer A, Mauler F, Vlachopoulos L, Nagy L, Fürnstahl P (2016) Computer-assisted 3-dimensional reconstructions of scaphoid fractures and nonunions with and without the use of patient-specific guides: early clinical outcomes and postoperative assessments of reconstruction accuracy. J Hand Surg 41(1):59–69

    Article  Google Scholar 

  39. Roner S, Vlachopoulos L, Nagy L, Schweizer A, Fürnstahl P (2017) Accuracy and early clinical outcome of 3-dimensional planned and guided single-cut osteotomies of malunited forearm bones. J Hand Surg 42(12):1031–e1

    Article  Google Scholar 

  40. Walti J, Jost GF, Cattin PC (2014) A new cost-effective approach to pedicular screw placement. In: Workshop on augmented environments for computer-assisted interventions. Springer, pp 90–97

  41. Gibby JT, Swenson SA, Cvetko S, Rao R, Javan R (2019) Head-mounted display augmented reality to guide pedicle screw placement utilizing computed tomography. Int J Comput Assis Radiol Surg 14(3):525–535

    Article  Google Scholar 

  42. Vassallo R, Rankin A, Chen EC, Peters TM (2017) Hologram stability evaluation for microsoft hololens. In: Medical imaging 2017: image perception, observer performance, and technology assessment, vol 10136. international society for optics and photonics, p 1013614

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Authors and Affiliations

  1. Computer Assisted Research and Development Group, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland

    Florentin Liebmann, Simon Roner, Marco von Atzigen & Philipp Fürnstahl

  2. Laboratory for Orthopaedic Biomechanics, ETH Zurich, Zurich, Switzerland

    Florentin Liebmann, Marco von Atzigen & Jess Snedeker

  3. Orthopaedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland

    Simon Roner, Jess Snedeker & Mazda Farshad

  4. Department of Informatics, University of Zurich, Zurich, Switzerland

    Davide Scaramuzza

  5. Department of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland

    Davide Scaramuzza

  6. Radiology Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland

    Reto Sutter

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  1. Florentin Liebmann
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  2. Simon Roner
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Correspondence to Florentin Liebmann.

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Liebmann, F., Roner, S., von Atzigen, M. et al. Pedicle screw navigation using surface digitization on the Microsoft HoloLens. Int J CARS 14, 1157–1165 (2019). https://doi.org/10.1007/s11548-019-01973-7

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  • DOI: https://doi.org/10.1007/s11548-019-01973-7

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