Warum ist Neuro Navigation in der Wirbelsäulenchirurgie ein Erfolgsfaktor?

Transkript

1 Warum ist Neuro Navigation in der Wirbelsäulenchirurgie ein Erfolgsfaktor? Markus F. Oertel, Christian T. Ulrich Universitätsklinik für Neurochirurgie, Inselspital, Universität Bern

2 Neuronavigation

3 Wirbelsäulenchirurgie Wirbelsäuleneingriffe pro Einwohner Verdoppelung der Patientenzahl seit 2005 Notwendigkeit, Sicherheit und Wirtschaftlichkeit zunehmend im Fokus

4 Was ist (Neuro-)Navigation und wozu der Aufwand?

5 Navigation Steuermannkunst zu Wasser, zu Lande und in der Luft. Ihr Ziel ist, das Fahr- bzw. Flugzeug sicher zum gewünschten Zielpunkt zu steuern. Dem Steuern gehen zwei geometrische Aufgaben voraus: das Feststellen der momentanen Position und das Ermitteln der besten Route zum Zielpunkt.

6 Navigation

7 Cristofo Colombo Sebastiano del Piombo 1519

8 3. August 1492: Aufbruch nach Indien

9 3. August Oktober 1492

10 12. Oktober 1492: Ankunft in Amerika

11 Seeweg nach Indien?

12 Amerika

13 Neuronavigation

14 Damals

15 Damals

16 Heute OP Star Trek

17 Neuronavigation Computergestütztes Operationsverfahren aus der Neurochirurgie, das die Planung von Operationen und die räumliche Orientierung während des Eingriffes ermöglicht.

18 Kraniale Neuronavigation

19 Universitätsklinik für Neurochirurgie, Inselspital Bern Kraniale Neuronavigation Workflow Nr Zeitpunkt Schritt 1 Monat bis Tag präoperativ 2 Monat bis Stunden präoperativ Strukturelle und funktionelle Bildgebung (MRT, MR-A, CCT, fmrt, DTI) Navigations-Planung und Transfer der Planung an das Navigationssystem 3 OP Einleitung Lagerung und Fixierung Referenzrahmen an Kopf oder Mayfield-Kopfhalterung 4 Direkt präoperativ Co-Registrierung 5 Intraoperativ Anschluss und Kalibrierung OP-Mikroskop, Kalibrierung anderer Instrumente für Navigation 6 Intraoperativ Navigation der Kraniotomiegrenzen 7 Intraoperativ Funktionelle Navigation Neuronavigation / Lennart Stieglitz 10

20 Spinale Neuronavigation 2D/3D Navigation Intraoperatives Imaging 3D-Fluoroskope CT Robotic

21 Spinale Neuronavigation Darstellung von Objekte Anatomie Instrumente in einem Bilddatensatz

22 Bilddatensatz Präoperativ Intraoperativ 2D Einzelbilder 3D Datensatz

23 Bilddatensatz Richter PH et al. Chirurg 2014;85:

24 Fusion Richter PH et al. Chirurg 2014;85:

25 Referenzierung

26 Referenzierung Richter PH et al. Chirurg 2014;85:

27 Navigation Richter PH et al. Chirurg 2014;85:

28 Indikationen > Instrumentierung Standardprozeduren Komplexe Anatomie > Tumorchirurgie Biopsien Resektionen

29 Freihandtechnik Genauigkeit abhängig von Anatomische Region Erfahrung des Operateurs

30 Indikationen Schraubenfehllage 14-55% Neurologische Schäden 7% Vaccaro AR et al. J Bone Joint Surg Am 1995;77: Amiot LP et al. Spine 2000;25: Laine T et al. Eur Spine J 2000;9:

31 Pedikelschraubenimplantationen Anwendung intraoperativer Navigation erhöht Präzision Laine T et al. Eur Spine J 2000;9: Kosmopoulos V, Schizas C. Spine 2007;32:E111-E120 Rajasekaran S et al. Spine 2007;32:E56-64 Tian NF et al. Int Orthop 2009;33: Han W et al. Orthopedics 2010;33:DOI / Verma R et al. Eur Spine J 2010;19: Wu H et al. Chin J Traumatol 2010;13: Tian NF et al. Eur Spine J 2011;20: Shin BJ et al. J Neurosurg Spine 2012;17: Mason A et al. J Neurosurg Spine 2014;20: Pirris SM et al. Int J Med Robotics Comput Assist Surg 2015;DOI /res.166

32 Wirbelsäulendeformitäten Anwendung intraoperativer Navigation erhöht Präzision Larson AN et al. Spine 2012;37:E Luther N et al. J Spinal Disord Tech 2015;28:E298-E303

33 Tumorresektionen Anwendung intraoperativer Navigation vereinfacht vollständige Entfernung Bandiera S et al. Eur Spine J 2013;22(Suppl 6): Satcher RL Jr et al. Orthop Clin North Am 2013;44:

34 Operationszeiten Anwendung intraoperativer Navigation verlängert Operationszeiten nicht Kraus M et al. Clin Orthop Relat Res 2010;468: Kraus M et al. Int J Med Robot 2013;10:

35 Strahlenexposition Anwendung intraoperativer Navigation reduziert Strahlenbelastung Kraus M et al. Clin Orthop Relat Res 2010;468: Kraus M et al. Int J Med Robot 2013;10: Villard J et al. Spine 2014;39:

36 Wirtschaftlichkeit Anwendung intraoperativer Navigation ist kosteneffektiv Watkins RG et al. Open Orthop J 2010;4: Abe Y et al. J Neurosurg Spine 2011;15:

37 Lernkurve Anwendung intraoperativer Navigation assoziiert mit Lernkurve Bay YS et al. Chin Med J 2010;123: Ryang YM et al. Spine J 2015;

38 Lernkurve The Spine Clinical Journal 15 Study (2015) Learning curve of 3D fluoroscopy Clinical image guided Study pedicle screw placement in the thoracolumbar spine Yu-Mi Ryang, MD, PhD a, *, Jimmy Villard, MD, MSc a, Thomas Oberm uller a, Benjamin Friedrich, MD b, Petra Wolf c, Jens Gempt, MD a, Florian Ringel, MD, PhD a, in the Bernhard thoracolumbar Meyer, MD, PhD spine a a Department of Neurosurgery, Klinikum rechts der Isar, Technische Universit at M unchen, Ismaninger Str. 22, Abstract M unchen, Germany BACKGROUND CONTEXT: During the past decade, a disproportionate increase of spinal fusion b Department of Neuroradiology, Klinikum rechts der Isar, Technische Universit at M unchen, Ismaninger Str. 22, M unchen, Germany c Institute of Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universit at M unchen, Ismaninger Str. 22, M unchen, Germany min Friedrich, MD b Received, Petra 4 MarchWolf c 2014; revised, 10 Jens September Gempt, 2014; accepted MD a procedures has 7 October, Florian 2014 Ringel, MD, PhD a been observed. Along with this trend, image-guided spine surgery has been experiencing a renaissance, in the recent years. A wide range of different navigation systems are available Bernhard Meyer, MD, PhD a on the market today. However, only few published studies assess the learning curves concerning these new spinal navigation techniques. So far, a study on the learning curve for intraoperative tment Abstract of Neurosurgery, BACKGROUND Klinikum rechts CONTEXT: der Isar, During Technische the past decade, Universit at a disproportionate M unchen, increase Ismaninger of spinal Str. fusion 22, M unchen, three-dimensional Germany fluoroscopy (3DFL) navigated pedicle screw (PS) placement isstill lacking. ment of Neuroradiology, procedures Klinikum has been rechts observed. der Along Isar, Technische with this trend, Universit at image-guided M unchen, spine surgery Ismaninger has been Str. experi- Epidemiology, a renaissance Klinikum the recent rechts years. der AIsar, widetechnische range of different Universit at navigation M unchen, systems Ismaninger are available Str. 22, thoracolumbar M unchen, Germany PS placement. 22, M unchen, PURPOSE: Germany The purpose of the study was to analyze the learning curve for 3DFL-navigated dical Statistics andencing on the market today. However, only few published studies assess the learning curves concerning STUDY DESIGN/SETTING: The study design included a prospective case series. these Received new spinal 4 March navigation 2014; techniques. revised So 10far, September a study on 2014; the learning accepted curve 7 October for intraoperative 2014 PATIENT SAMPLE: A cohort of 145 patients were recruited from January 2011 to June three-dimensional fluoroscopy (3DFL) navigated pedicle screw (PS) placement isstill lacking. OUTCOME MEASURES: The outcome measures were duration of intraoperative 3D scans, PS PURPOSE: The purpose of the study was to analyze the learning curve for 3DFL-navigated placement, PS accuracy on postoperative computed tomography (CT) scans, and PS-related revisions and complications. thoracolumbar PS placement. BACKGROUND STUDY DESIGN/SETTING: CONTEXT: During The study the past design decade, included a disproportionate prospective case series. increase of spinal fusion PATIENT SAMPLE: A cohort of 145 patients were recruited from January 2011 to June METHODS: From the introduction of spinal navigation to our department in January 2011 until procedures has been observed. Along with this trend, image-guided spine surgery has been experiencing a renaissance placement, PSinaccuracy the recent on postoperative years. A wide computed range tomography of different (CT) scans, navigation and PS-related systems revi- are available control scan) and placement time per screw, intraoperative screw revisions, screw-related compli- OUTCOME MEASURES: The outcome measures were duration of intraoperative 3D scans, PS June 2012, the learning curve for the duration of intraoperative 3D scan acquisition (navigation or on the market sions today. and complications. However, only few published studies assess the learning curves concerning cations, revision surgeries, and PS accuracy on postoperative CT scans were assessed in 145 patients undergoing dorsal navigated instrumentation for 928 PS (736 lumbosacral and 192 METHODS: From the introduction of spinal navigation to our department January 2011 until these new spinal navigation techniques. So far, a study on the learning curve for intraoperative June 2012, the learning curve for the duration of intraoperative 3D scan acquisition (navigation or three-dimensional control scan) fluoroscopy and placement (3DFL) navigated time per screw, intraoperative pedicle screw revisions, (PS) placement screw-relatedisstill complications, Therevision purpose surgeries, of the andstudy PS accuracy was on topostoperative analyze the CT learning scans were curve assessed for in 145 3DFL-navigated pa- and last periods were compared with the first (reference) period, respectively. lacking. thoracic). The observed time span was divided into four intervals. Results of the second, third, PURPOSE: tients undergoing dorsal navigated instrumentation for 928 PS (736 lumbosacral and 192 RESULTS: The mean navigation 3D scan time decreased (first and fourth periods) from thoracolumbar PS placement. thoracic). The observed time span was divided into four intervals. Results of the second, third, (range, 4 40) to (3 15) minutes (p!.001). The mean control 3D scan time (after PS placement) decreased from (5 25) to (3 15) minutes (p!.001). The mean PS inser- STUDY DESIGN/SETTING: and last periods were compared The with study thedesign first (reference) included period, a prospective respectively. case series. PATIENT RESULTS: SAMPLE: TheA mean cohort navigation of 145 3D scan patients time decreased were recruited (first and fourth from periods) January from to 7.8 June tion time decreased from (1 15) to (1 17) minutes (p!.001). The mean (range, 4 40) to (3 15) minutes (p!.001). The mean control 3D scan time (after PS placement) decreased from (5 25) to (3 15) minutes (p!.001). The mean PS inser- OUTCOME MEASURES: The outcome measures were duration of intraoperative 3D scans, PSproportion of correctly positioned PS (all 928) according to the Gertzbein and Robbins classification grades A and B increased initially from 83.1% (first period) to 95.1% (second period, p5.001), placement, tion PS time accuracy decreased on from postoperative (1 15) computed to 3.26 tomography 2.3 (1 17) minutes (CT) (p! scans,.001). and The PS-related mean revisions and complications. proportion of correctly positioned PS (all 928) according to the Gertzbein and Robbins classification grades A and B increased initially from 83.1% (first period) to 95.1% (second period, p5.001), with respect to intraoperative screw revisions. There was one revision surgery. 96.4% (third period, p5.002), and 92.4% (fourth period, p5.049). No learning effect was found METHODS: From the introduction of spinal navigation to our department in January 2011 until 96.4% (third period, p5.002), and 92.4% (fourth period, p5.049). No learning effect was found June 2012, with the respect learning to intraoperative curve for the screw duration revisions. of There intraoperative was one revision 3Dsurgery. scan acquisition (navigation or Y-MR and JV contributed equally to the manuscript. FDA device/drug status: Approved (BrainLAB VectorVisionsky navigation system). The Spine Journal 15 (2015) g curve of 3D fluoroscopy image guided pedicle screw placement u-mi Ryang, MD, PhD a, *, Jimmy Villard, MD, MSc a, Thomas Oberm uller a, control scan) and placement time per screw, intraoperative screw revisions, screw-related complications, revision surgeries, and PS accuracy on postoperative CT scans were assessed in 145 patients undergoing dorsal navigated instrumentation for 928 PS (736 lumbosacral and 192 thoracic). The observed time span was divided into four intervals. Results of the second, third, Y-MR and JV contributed equally to the manuscript. Consulting: DepuySynthes (C), Medtronic (C), FDAUlrich device/drug (D), Reliviant status: (B, Paid directly to institution); Speaking and/or navigation Teaching system). Arrangements: Approved (BrainLAB VectorVisionsky DepuySynthes (C), Medtronic (C), Ulrich (D), Author Reliviant disclosures: (B, Paid directly Y-MR: Speaking and/or Teaching Arrangements: The Spine Journal 15 (2015) Clinical Study Learning curve of 3D fluoroscopy image guided pedicle screw pl in the thoracolumbar spine Yu-Mi Ryang, MD, PhD a, *, Jimmy Villard, MD, MSc a, Thomas Oberm ulle Benjamin Friedrich, MD b, Petra Wolf c, Jens Gempt, MD a, Florian Ringel, MD, Bernhard Meyer, MD, PhD a a Department of Neurosurgery, Klinikum rechts der Isar, Technische Universit at M unchen, Ismaninger Str. 22, M unchen, b Department of Neuroradiology, Klinikum rechts der Isar, Technische Universit at M unchen, Ismaninger Str. 22, M unchen c Institute of Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universit at M unchen, Ismaninger Str. 22, M Received 4 March 2014; revised 10 September 2014; accepted 7 October 2014 Consulting: DepuySynthes (C), Medtronic (C), Ulri (B, Paid directly to institution); Speaking and/or Teach DepuySynthes (C), Medtronic (C), Ulrich (D), Relivian to institution).

39 Wirbelsäulenchirurgie Neuronavigation Assoziiert mit relevanter Lernkurze Sollte in die tägliche Routine integriert werden

40 Wirbelsäulenchirurgie Neuronavigation Optimierung Schraubenlage Maximierung Tumorresektion Optimierung Biopsieentnahme Reduzierung Komplikationen Reduzierung Strahlenexposition Maximierung Sicherheit Reduzierung Kosten Reduzierung Operationsdauer

41 Neuronavigation

42 Merci Bern