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Opportunities in

Image-Guided Surgery

Nicholas Theodore, MD, FACS, FAANS Donlin M. Long Professor

Professor of Neurosurgery, Orthopaedics and Biomedical Engineering

Co-Director, Carnegie Center for Surgical Innovation

Johns Hopkins University

Origin of Stereotaxis

•1908: Victor Horsley and

Robert Clarke first published a

3D targeting technique for

neurosurgery in Brain.

•They used a Cartesian

coordinate system used to

lesion targets in monkey

brains from external cranial

land marks and cortical

topography, coining the term

“stereotaxis”.

Historical Perspectives • Roentgen & X-ray (November 8, 1895)*

• Horsley & Clarke, Stereotaxis (1906)

• Dandy & Pneumoencephalography (1919)

• Moniz & Cerebral Angiography (1927)

• Spiegel & Wycis, Stereoencephalotome (1946)

• Leksell & Stereotactic Frame (1949)

• Hounsfield & Cormack, CT (1979)*

• Lauterbur & Mansfield, MRI (2003)*

• *Nobel Prize

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Image Guided Brain Surgery

Evolution of Image Guided Spinal Surgery

•Plain radiography/C-arm

fluoroscopy

•Preoperative CT-based

•Intra-operative CT-based

•Fluoroscopy-based

•Intraoperative mobile 3D

imaging

Percutaneous Pedicle Screws for Trauma

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Registration

Intra-Operative Imaging

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Image Guided Brain Surgery

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State of the Art

• Frameless stereotaxy

• Intraoperative cone beam

imaging

• Intraoperative MRI

• Image-guided robotics

Leaders Followers

1996-2016

Navigation Adoption

Reference: Hartl, Roger, et al. “Worldwide Survey on the Use of Navigation in Spine Surgery.” World Neurosurgery, vol. 79, no. 1, 2013, pp. 162–172., doi:10.1016/j.wneu.2012.03.011.

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Leaders Followers 1996-2016

“Fiddle-Factor” is Too High

Reference: Hartl, Roger, et al. “Worldwide Survey on the Use of Navigation in Spine Surgery.” World Neurosurgery, vol. 79, no. 1, 2013, pp. 162–172., doi:10.1016/j.wneu.2012.03.011.

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Challenges

• Radiation Exposure

• Image Quality

• Image Merge

• Registration

• Automation

Why Image Guidance?

Bad Things Happen

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Meta-Analysis Results Navigation – Conventional vs. 2D vs. 3D

• Conventional Accuracy • Overall – 2532 or 3719 screws (68.1%)

• Cervical 69.4%

• Thoracic 50.8%

• Lumbar 75.9%

• 2D Fluoro Navigation accuracy • Overall – 1031 or 1223 screws (84.3%)

• Cervical 73.3%

• Thoracic 78.4%

• Lumbar 86.8%

• 3D Navigation • Overall – 4170 of 4368 screws (95.5%)

• Cervical 90.3%

• Thoracic 93.2%

• Lumbar 96.7%

•1985: The PUMA surgical robot was used to

position a biopsy cannula as a stable platform

for needle insertion of a brain biopsy

Introduction of Surgical Robots

•4 arms

•7 degrees of

freedom

•Master-slave

DaVinci Surgical System (1999)

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CyberKnifeⓇ (Accuray) 1994

Mako Robot 2015

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BNI, 2002 Theodore, Sonntag

• 1. Middle management

• 2. Salespeople

• 3. Report writers, journalists, authors

• 4. Accountants and bookkeepers

• 5. Doctors

*

*Spinal Surgery

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Robotics in Spinal Surgery

Capture Patients Seeking Less Invasive Surgery

Reduce Radiation Exposure

Surgeons, staff, and patients

Procedural Consistency

Automate trajectory alignment

Pre-Operative and Intra-Operative Planning

Patient Value = Efficacy * Less Invasiveness

Optimize surgical placement

2 -Helm, Patrick A. "Spinal Navigation and Imaging: History, Trends, and Future.” IEEE 34.8 (2015): 1738-1746. 3 –Tian, Nai-Feng, et. al. "Minimally invasive versus open transforaminal lumbar interbody fusion: a meta-analysis based on the current evidence.” Euro Spine J 22 (2013): 1741-1749. 4 – O’Toole, John. “Surgical Site Infection Rates after Minimally Invasive Spine Surgery.” J Neurosurg Spine 11 (2009): 471-476

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Robotics in Spinal Surgery

Real-time visualization of instruments with trajectory guidance

Active feedback on movement of anatomic reference (DRB)

Deflection sensing technology

BNI, 2002 Theodore, Sonntag

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Image Guidance & Robotics

Excelsius GPS™️ Workflow

Imaging, Robotics & Minimally Invasive Surgery

O-Arm

CereTom®

Biopsy Brain

Focal

Therapy

Spine

Confidential

X-ray

MRI

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CT Guided Biopsy

Future Directions • Confocal Microscopy & imaging for virtual

biopsy

• Fully automated surgery

• Artificial intelligence (& big data) for

complex procedures

• Tumor margins, bone density, surgical

planning

• Multi-modality imaging (MRI, ultrasound,

CT)

• Augmented reality for surgery

Future of Imaging

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