Role of 3D intraoperative imaging in orthopedic and trauma surgery.
- 作者列表："Tonetti J","Boudissa M","Kerschbaumer G","Seurat O
:Intraoperative three-dimensional (3D) imaging is now feasible because of recent technological advances such as 3D cone-beam CT (CBCT) and flat-panel X-ray detectors (FPDs). These technologies reduce the radiation dose to the patient and surgical team. The aim of this study is to review the advantages of 3D intraoperative imaging in orthopedic and trauma surgery by answering the following 5 questions: What are its technical principles? CBCT with a FPD produces non-distorted digital images and frees up the surgical field. The high quality of these 3D intraoperative images allows them to be integrated into surgical navigation systems. Human-robot comanipulation will likely follow soon after. Conventional multislice CT technology has also improved to the point where it can be used in the operating room. What can we expect from 3D intraoperative imaging and which applications have been validated clinically? We reviewed the literature on this topic for the past 10 years. The expected benefits were determined during the implantation of pedicular screws: more accurate implantation, fewer surgical revisions and time savings. There are few studies in trauma or arthroplasty cases, as robotic comanipulation is a more recent development. What is the tolerance for irradiation to the patient and surgical team? The health drawbacks are the harmful radiation-induced effects. The deterministic effects that we will develop are correlated to the absorbed dose in Gray units (Gy). The stochastic and carcinogenic effects are related to the effective dose in milliSievert (mSv) of linear evolution without threshold. The International Commission on Radiological Protection (ICRP) states that irradiation for medical purposes with risk of detriment is acceptable if it is justified by an optimization attempt. The radioprotection limits must be known but do not constitute opposable restrictions. The superiority of intraoperative 3D imaging over fluoroscopy has been demonstrated for spine surgery and sacroiliac screw fixation. How does the environment need to be adapted? The volume, access, wall protection and floor strength of the operating room must take into account the features of each machine. The instrumentation implants and need for specialized staff result in additional costs. Not every system can track movements during the CBCT acquisition thus transient suspension of assisted ventilation may be required. Is it financially viable? This needs to be calculated based on the expected clinical benefits, which mainly correspond to the elimination of expenses tied to surgical revisions. Our society's search for safety has driven the investments in this technology. LEVEL OF EVIDENCE: V, Expert opinion.
: 由于最近的技术进步，如3D锥形束CT (CBCT) 和平板x射线探测器 (fpd)，术中三维 (3D) 成像现在是可行的。这些技术降低了患者和手术团队的辐射剂量。本研究的目的是通过回答以下5个问题来回顾3D术中成像在骨科和创伤手术中的优势: 它的技术原理是什么？具有FPD的CBCT产生非失真的数字图像并释放手术区域。这些3D术中图像的高质量允许它们被集成到手术导航系统中。人类机器人操作很可能很快就会出现。传统的多层螺旋ct技术也已经提高到可以在手术室中使用的程度。我们可以从3D术中成像中期待什么，哪些应用已经在临床上得到验证？我们回顾了过去10年关于这一主题的文献。在植入椎弓根螺钉期间确定了预期的益处: 更精确的植入，更少的手术修正和时间节省。在创伤或关节成形术病例中很少有研究，因为机器人操作是最近的发展。患者和手术团队对照射的耐受性如何？健康的缺点是有害的辐射引起的影响。我们将开发的确定性效应与灰色单位 (Gy) 的吸收剂量相关。随机效应和致癌效应与无阈值线性进化中毫西弗 (mSv) 的有效剂量有关。国际辐射防护委员会 (辐射防护委员会) 指出，如果以优化尝试为理由，具有损害风险的医疗照射是可以接受的。辐射防护限值必须是已知的，但不构成可反对的限制。在脊柱手术和骶髂螺钉固定中，术中3D成像优于透视。环境需要如何适应？手术室的体积、通道、墙壁保护和地板强度必须考虑每台机器的特点。仪器植入物和专业人员的需要导致额外的成本。不是每个系统都可以在CBCT采集期间跟踪运动，因此可能需要辅助通气的瞬时暂停。它在财务上可行吗？这需要根据预期的临床益处来计算，这主要对应于取消与手术修正相关的费用。我们社会对安全的追求推动了对这项技术的投资。证据级别: V，专家意见。
METHODS:OBJECTIVES:The aim was to evaluate the image quality and sensitivity to artifacts of compressed sensing (CS) acceleration technique, applied to 3D or breath-hold sequences in different clinical applications from brain to knee. METHODS:CS with an acceleration from 30 to 60% and conventional MRI sequences were performed in 10 different applications in 107 patients, leading to 120 comparisons. Readers were blinded to the technique for quantitative (contrast-to-noise ratio or functional measurements for cardiac cine) and qualitative (image quality, artifacts, diagnostic findings, and preference) image analyses. RESULTS:No statistically significant difference in image quality or artifacts was found for each sequence except for the cardiac cine CS for one of both readers and for the wrist 3D proton density (PD)-weighted CS sequence which showed less motion artifacts due to the reduced acquisition time. The contrast-to-noise ratio was lower for the elbow CS sequence but not statistically different in all other applications. Diagnostic findings were similar between conventional and CS sequence for all the comparisons except for four cases where motion artifacts corrupted either the conventional or the CS sequence. CONCLUSIONS:The evaluated CS sequences are ready to be used in clinical daily practice except for the elbow application which requires a lower acceleration. The CS factor should be tuned for each organ and sequence to obtain good image quality. It leads to 30% to 60% acceleration in the applications evaluated in this study which has a significant impact on clinical workflow. KEY POINTS:• Clinical implementation of compressed sensing (CS) reduced scan times of at least 30% with only minor penalty in image quality and no change in diagnostic findings. • The CS acceleration factor has to be tuned separately for each organ and sequence to guarantee similar image quality than conventional acquisition. • At least 30% and up to 60% acceleration is feasible in specific sequences in clinical routine.
METHODS:BACKGROUND:The main surgical techniques for spontaneous basal ganglia hemorrhage include stereotactic aspiration, endoscopic aspiration, and craniotomy. However, credible evidence is still needed to validate the effect of these techniques. OBJECTIVE:To explore the long-term outcomes of the three surgical techniques in the treatment of spontaneous basal ganglia hemorrhage. METHODS:Five hundred and sixteen patients with spontaneous basal ganglia hemorrhage who received stereotactic aspiration, endoscopic aspiration, or craniotomy were reviewed retrospectively. Six-month mortality and the modified Rankin Scale score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of different surgical techniques on patient outcomes. RESULTS:For the entire cohort, the 6-month mortality in the endoscopic aspiration group was significantly lower than that in the stereotactic aspiration group (odds ratio (OR) 4.280, 95% CI 2.186 to 8.380); the 6-month mortality in the endoscopic aspiration group was lower than that in the craniotomy group, but the difference was not significant (OR=1.930, 95% CI 0.835 to 4.465). A further subgroup analysis was stratified by hematoma volume. The mortality in the endoscopic aspiration group was significantly lower than in the stereotactic aspiration group in the medium (≥40-<80 mL) (OR=2.438, 95% CI 1.101 to 5.402) and large hematoma subgroup (≥80 mL) (OR=66.532, 95% CI 6.345 to 697.675). Compared with the endoscopic aspiration group, a trend towards increased mortality was observed in the large hematoma subgroup of the craniotomy group (OR=8.721, 95% CI 0.933 to 81.551). CONCLUSION:Endoscopic aspiration can decrease the 6-month mortality of spontaneous basal ganglia hemorrhage, especially in patients with a hematoma volume ≥40 mL.
METHODS:OBJECTIVE:The primary purpose of this study was to evaluate the effectiveness of a three-dimensional (3D) software tool (smart planes) for displaying fetal brain planes, and the secondary purpose was to evaluate its accuracy in performing automatic measurements. MATERIAL AND METHODS:This prospective study included singleton fetuses with a gestational age (GA) greater than 18 weeks. Transabdominal two-dimensional ultrasound (2DUS) and 3D smart planes images were respectively used to obtain the basic planes of the fetal brain, with five parameters measured. The images, by either two-dimensional (2D) manual or 3D automatic operation, were reviewed by two experienced sonographers. The agreements between two measurements were analyzed. RESULTS:A total of 226 cases were included. The rates of successful detection by automatic display were as high as 80%. There was substantial agreement between the measurements of the biparietal diameter, head circumference and transcerebellar diameter, but poor agreement between the measurements of cisterna magna and lateral ventricle width. CONCLUSIONS:Smart Planes might be valuable for the rapid evaluation of fetal brain, because it simplifies the evaluation process. However, the technology requires improvement. In addition, this technology cannot replace the conventional manual US scans; it can only be used as an additional approach.