Neurosurgical focus最新文献

Objective: Robotics in neurosurgery is becoming increasingly prevalent. The integration of intraoperative imaging for patient registration into workflows of newer robotic systems enhances precision and has further driven their widespread adoption. In this study, the authors report on a lightweight, table-mounted robotic system integrating robotic cone-beam CT (CB-CT) for automated patient registration in cranial biopsies and stereotactic electroencephalography (sEEG).

Methods: This prospective cohort study included patients who underwent stereotactic biopsy or sEEG with the Cirq system from January 2023 to August 2024. For patient-to-image registration, an external registration matrix was secured near the patient's head before conducting CB-CT with robotic Artis Pheno. CT was then fused with preoperative planning MRI and used as the navigation dataset. Demographic and clinical data were evaluated, and entry and target errors, as well as vector deviation of sEEG electrodes, were assessed and compared with those of patients who underwent biopsies and sEEG with the frameless VarioGuide system.

Results: In 26 Cirq-assisted surgical procedures, robotic CB-CT was used for image registration in 20 cases. Of these, 15 were biopsies (mean ± SD 7 ± 1 specimens) and 5 were sEEG with 31 depth electrodes, compared to 29 VarioGuide biopsies and 3 VarioGuide sEEG cases with 25 electrodes. The mean age was 56 ± 19 years, with a male/female ratio of 1.9:1. Lesion size averaged 19 ± 17 cm3 on T1-weighted imaging and 61 ± 53 cm3 on T2-weighted imaging for Cirq and 14 ± 14 cm3 and 68 ± 47 cm3 for VarioGuide. The mean surgical times were 117 ± 34 minutes for biopsy and 269 ± 54 minutes for sEEG in the Cirq group, with skin-to-skin times of 40 ± 23 minutes for biopsy and 208 ± 74 minutes for sEEG; in comparison, surgical times of 78 ± 21 minutes for biopsy and 218 ± 33 minutes for sEEG were reported with VarioGuide, with skin-to-skin times of 34 ± 13 and 158 ± 27 minutes. No complications occurred. The mean dosage area product was 983 ± 351 µGym2 for biopsies and 1772 ± 968 µGym2 for sEEG. Cirq-assisted sEEG electrodes had mean entry and target errors of 1.4 ± 1.2 mm and 2.6 ± 1.6 mm, compared to 5.3 ± 3.3 mm and 6.5 ± 2.8 mm with VarioGuide. Mean vector deviation was 1.6 ± 0.9 mm with Cirq versus 4.9 ± 2.9 mm with VarioGuide.

Conclusions: The integration of a lightweight, table-mounted robotic alignment tool with intraoperative CB-CT for automated patient-to-image registration enables high precision and a seamless workflow. This combination is safe, has a manageable learning curve, and holds potential to replace traditional frame-based and frameless procedures. Its efficiency and accuracy are likely to contribute to the increasing adoption of robotics in neurosurgery.

Objective: Robot-assisted (RA) technology is becoming more widely integrated and accepted in spine surgery. The authors sought to evaluate operative and patient-reported outcomes (PROs) in RA versus fluoroscopy-assisted (FA) pedicle screw placement during minimally invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF).

Methods: The authors retrospectively studied elective patients who underwent single- or multilevel MIS TLIF for degenerative indication using FA versus RA pedicle screw placement. Patients were selected from September 2021 to May 2023 at a single institution with multiple surgeons whose practice consists of primarily MIS. Outcomes included fluoroscopy dosage per screw, operative time per screw, anesthesia time per screw, estimated blood loss (EBL), screw revision rate, inpatient surgical complications, and minimal clinically important difference (MCID) of Oswestry Disability Index (ODI) and numeric rating scale (NRS) scores at the 6- and 12-month follow-ups. Comparability of groups was analyzed by univariate analysis. Multivariable analysis modeling fluoroscopy time per screw was performed, adjusting for confounders.

Results: One hundred eighty-three patients (n = 133 in the FA group vs 50 in the RA group) were included. Patients in the RA cohort were significantly younger than those in the FA group (mean age 63.8 ± 11.9 vs 59.8 ± 11.0 years, p = 0.037). A total of 932 pedicle screws were placed (mean 5.1, range 4-8 per patient). The RA cohort demonstrated significantly lower intraoperative fluoroscopy dosage per screw (4.9 ± 7.6 mGy per screw vs 20.3 ± 14.0 mGy per screw, p < 0.001), significantly longer anesthesia time per screw (49.1 ± 12.6 vs 43.6 ± 9.2, p = 0.009), and similar operative time per screw (33.3 vs 30.7 minutes, p = 0.125). The screw revision rate for symptomatic radiculopathy was zero in both groups. Revision surgery requiring screw removal or reposition was performed in 4 total cases (RA group: 1/50 for infection; FA group: 2/133 for infection, 1/133 for foraminotomy). Both groups demonstrated significant improvement in PROs at 6 and 12 months compared with preoperatively. Moreover, both groups achieved MCID at similar rates.

Conclusions: When implementing RA technology, one can expect similar perioperative outcomes as FA techniques in addition to significantly lower radiation exposure. Moreover, there is no statistically significant difference in postoperative PROs between RA and FA. Longer anesthesia times may also be encountered, as in this study, which is likely a result of more complex robotic setup and workflow.

Objective: Stylomastoid foramen (SMF) puncture with radiofrequency ablation (RFA) is a minimally invasive therapy for hemifacial spasm (HFS) with notable therapeutic outcomes. Conventionally, this procedure is performed under CT guidance. The present study highlights the authors' preliminary clinical experience with robot-assisted SMF puncture in 7 patients with HFS using a neurosurgical robot.

Methods: Patients were secured in a skull clamp, and their heads were linked to the Sinovation neurosurgical robot's linkage arms for precise positioning. Bone fiducial registration was conducted using the robotic pointer. Under robotic guidance, a puncture needle was positioned at the skin entry point and then advanced to the target with a surgical blade incision. On target attainment, an RFA electrode was positioned, and the ablation was performed while monitoring facial nerve function. Preoperative and postoperative spasm grading, surgical metrics, and adverse events were meticulously documented.

Results: The puncture trajectories averaged 49.5 mm in length, and the overall operation duration was 27.3 minutes. Guided by the robotic arm, all puncture attempts were successfully achieved without any obstructions, and SMF puncture was completed in a single attempt. Following RFA, immediate spasm relief was achieved, with all patients attaining Cohen spasm grade 0. Over a mean follow-up period of 12 months (range 6-15 months), no recurrence of spasms was reported. Facial paralysis was observed in 85.7% of patients, with 6 cases classified as House-Brackmann (HB) grade II and 1 case as grade III. At the final follow-up, 1 patient remained at HB grade II, while the remaining patients improved to grade I. No other lasting or severe complications were recorded.

Conclusions: SMF puncture and RFA emerge as a potent and minimally invasive treatment option for HFS. The robot-assisted approach, despite necessitating additional time for head fixation and registration, notably reduces the overall puncture time, puncture attempts, and radiation exposure, thereby enhancing the puncture success rate.

Objective: This study aimed to introduce a novel artificial intelligence (AI)-based robotic system for autonomous planning of spinal posterior decompression and verify its accuracy through a cadaveric model.

Methods: Seventeen vertebrae from 3 cadavers were included in the study. Three thoracic vertebrae (T9-11) and 3 lumbar vertebrae (L3-5) were selected from each cadaver. After obtaining CT data, the robotic system independently planned the laminectomy path based on AI algorithms before the surgical procedure and automatically performed the decompression during the procedure. A postoperative CT scan was performed, and the deviation of each cutting plane from the preoperative plan was quantitatively analyzed to evaluate the accuracy and safety of the cuts. The duration of laminectomy was also recorded.

Results: A total of 285 cuts were made on thoracic and lumbar vertebrae. The average duration for unilateral longitudinal cutting was 16.38 ± 4.76 minutes, while for transverse cutting it was 4.44 ± 1.52 minutes. In terms of accuracy assessment, 3 levels were divided based on the distance between the actual cutting plane and the preplanned plane: 77 (84%) were grade A, 15 (16%) were grade B, and none were grade C. Regarding safety assessment, 74 (80%) were designated safe (grade A), with 18 (20%) classified as uncertain (grade B).

Conclusions: The results confirm the accuracy and preliminary safety of the robotic system for autonomous planning and cutting of spinal decompression.

Objective: An increasing number of studies have shown that a robotic guidance system (RGS) can provide accurate cervical pedicle screw (CPS) placement. The accuracy of CPS placement with an RGS has mostly been evaluated according to the magnitude of pedicular cortical violation. However, an RGS assists in pedicle screw (PS) placement by directly indicating the preplanned trajectory in the operative field. Therefore, investigating how accurately the planned trajectory is executed is essential to determine the accuracy of CPS placement using an RGS, in addition to evaluating the clinical accuracy. Hence, this study aimed to evaluate the accuracy of CPS placement using an RGS by comparing the executed trajectory with the planned trajectory.

Methods: This prospective study analyzed 174 CPSs placed between C2 and C6 in 39 consecutive patients who underwent cervical fusion surgery using an RGS. The deviation of the executed CPS trajectory from the planned trajectory was measured at the entry point and at a depth of 20 mm in both the axial and sagittal planes on CT images. Additionally, its direction was noted (lateral or medial in the axial plane and cephalad or caudal in the sagittal plane). These measurements were analyzed according to spinal levels (C2 and C3-C6), laterality (right and left sides), and registration material (preoperative and intraoperative CT images). Furthermore, clinical accuracy was assessed using the Neo classification (grades 0-3).

Results: Overall, the mean (± SD) deviations from the planned trajectory at the entry point and at a depth of 20 mm were 0.79 ± 0.65 mm and 0.86 ± 0.69 mm in the axial plane and 0.88 ± 0.81 mm and 0.82 ± 0.79 mm in the sagittal plane, respectively. When separately examining the deviations according to spinal level, laterality, and registration material, the mean deviations were < 1 mm at any point. Analysis of the deviation direction showed that the CPSs were placed divergently from the planned trajectory in the axial plane. In the sagittal plane, the CPSs were likely to be inserted parallel to the planned trajectory. However, at C2 the CPSs were placed in the caudal direction relative to the planned trajectory. Regarding clinical accuracy, the acceptable rates (grades 0 and 1) were 97.7% and 97.1% in the axial and sagittal planes, respectively, without any CPS-related complications.

Conclusions: This study suggests that an RGS can reliably execute planned trajectories, aiding accurate CPS placement in clinical settings.

Objective: Both robot and computer navigation have significantly improved the accuracy and safety of percutaneous pedicle screw placement compared with a freehand fluoroscopy-guided technique. However, how the two new technologies compare with each other is unknown. The aim of this study was to investigate the accuracy and safety of robot-assisted and navigation-guided percutaneous pedicle screw placement in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

Methods: A multicenter, retrospective study was conducted with patients who underwent 1- to 3-level MIS-TLIF from 2019 to 2022. The surgical indication was symptomatic spinal stenosis and spondylolisthesis that failed conservative management. Screw accuracy and safety were compared between robot and computer navigation systems by obtaining postoperative CT images in all patients. The screw accuracy was determined by the Gertzbein and Robbins classification.

Results: A total of 100 patients were divided into robot-assisted (RA; n = 42) and O-arm navigation (ON; n = 58) groups, with 514 percutaneous pedicle screws placed. Clinically satisfactory accuracy was achieved in 100% of the RA group and 92.1% of the ON group (p < 0.001). There were no medial breaches or revision surgeries for screw malposition in either group. The RA group showed similar overall operation time to the ON group (263.54 ± 114.33 vs 243.4 ± 68.96 minutes, p = 0.2821). Subgroup analyses showed that there was no difference in 1-level MIS-TLIF, but the RA group had significantly more operative time for 2-level MIS-TLIF than the ON group (324.67 ± 101.25 vs 266.4 ± 66.38 minutes, p = 0.0264).

Conclusions: Screw accuracy was significantly better in the RA group, with slightly more operation time, compared with the navigation group. Neither group required revision surgery or reoperation for screw malposition.

Objective: Preclinical studies suggest that robotic carotid artery stenting (CAS) could be superior to manual CAS. However, very limited comparative data exist for patients who have undergone robotic versus manual CAS. In addition, no data exist comparing the costs of manual and robotic CAS.

Methods: All robotic CAS cases at two academic neurosurgery centers were retrospectively reviewed and 1:1 propensity matched with manual CAS cases. Personnel costs, supply costs, and total procedure costs were collected in collaboration with hospital administration by using time-driven activity-based cost analysis.

Results: A total of 24 robotic CAS operations were performed between 2019 and 2023. Comorbidities and baseline procedural characteristics were well matched between robotic and manual cases. Unplanned manual conversion was observed in only 1 robotic case (4.2%). Robotic CAS complications and outcomes were comparable to manual. Robotic CAS was associated with a significantly increased fluoroscopy time (29.0 vs 19.2 minutes; p < 0.001). Robotic procedure time (88.9 ± 18.2 minutes) was significantly (p = 0.003) longer than manual time (68.72 ± 22.4 minutes). Health personnel costs ($1589.71 ± $176.92 vs $1375.99 ± $233.39, p = 0.005); supply costs ($3918.25 ± $421.20 vs $2152.74 ± $1030.26, p < 0.001); and total procedure costs ($5306.11 ± $608.95 vs $3437.56 ± $1165.67, p < 0.001) were greater for robotic CAS.

Conclusions: In the first multicenter study and largest sample to date, the authors show that robotic CAS, with a low rate of procedural failure and postoperative complications, is safe and feasible. In addition, robotic CAS achieves comparable clinical outcomes to manual CAS. Robotic CAS was associated with increased fluoroscopy time, but fluoroscopy time decreased as operators gained familiarity with the CorPath GRX system. Robotic CAS was associated with a greater procedural cost, which was driven by greater personnel and supply costs. Robotic CAS failed to show superiority to manual CAS. These findings set a foundation for randomized controlled trials of robotic CAS, and also highlight the need for further studies to optimize robotic CAS and reduce its associated costs.

Objective: The authors investigated the predictors of cost of admission (CoA) for robot-assisted pedicle screw placement to assess the value of robotic systems in spine operations.

Methods: Demographic, operative, and postoperative variables were retrospectively collected from 506 patients undergoing robot-assisted spine surgery utilizing the ExcelsiusGPS robot at two high-volume tertiary care centers from 2017 to 2023. Perioperative parameters were evaluated against total hospital admission cost utilizing the Kruskal-Wallis and Wilcoxon rank-sum tests followed by multivariable linear regression.

Results: The majority of patients were female (53.6%), 50-80 years of age (77.7%), and White (73.9%); had at least 1 comorbidity (58.1%); and presented with an average functional preoperative Frankel grade (57.5%). The mean CoA was $69,458 ± $47,910. On univariable analysis, demographic data including sex, age, race, and Frankel grade were not associated with CoA. The presence of a comorbidity, however, was associated with increased CoA (p < 0.001). Intraoperatively, one-third of the operations (31.8%) were revisions from prior operations and were subsequently associated with increased CoA (p = 0.021). Thoracic-level operations constituted roughly one-quarter of the cohort (24.1%) and were also associated with increased CoA (p < 0.001). Intraoperative durotomies occurred in 7.7% of patients, leading to increased CoA (p = 0.003). Extended surgical durations also demonstrated elevated CoA (p < 0.001). Postoperatively, the median length of stay (LOS) was 3 days, and an LOS of greater than 3 days was one of the primary drivers of cost (p < 0.001). Postoperative complications occurred in just 6.3% of the cohort but were also associated with increased CoA (p < 0.001). On multivariable analysis, LOS, number of screws placed, operative duration, and postoperative complications were the primary predictors of increased CoA.

Conclusions: Understanding the drivers of cost in robot-assisted pedicle screw placement is crucial to elucidate the value associated with the use of robotic systems in spine surgery. These results indicate that patient and surgical complexity influence cost and that robotic systems may augment management in spine surgery. Further investigation is warranted to determine the long-term benefits and cost-effectiveness of new technologies compared with traditional techniques in spine surgery.

Objective: Innovations in robotics continue to reshape the landscape of neurosurgery. Here, the authors evaluated the safety and efficacy of the ExcelsiusGPS robot in the treatment of neuro-oncological, intracranial lesions.

Methods: The authors conducted a retrospective analysis of 19 consecutive adult patients with a neuro-oncological diagnosis who underwent intracranial biopsy and/or laser interstitial thermal therapy (LITT) with the assistance of the ExcelsiusGPS robot and intraoperative CT. Demographic and clinical data were collected from the electronic medical record and the robot software.

Results: All 19 patients harbored lesions that were deep seated, involving the eloquent cortex, or subcentimeter. Definitive tissue diagnosis was achieved in all cases involving stereotactic biopsy (n = 16), with glioblastoma as the most common diagnosis. The mean ± SD time for setting up the robotic stereotaxis system was 57.4 ± 10.7 minutes. The mean procedural time after that was 71.6 ± 41.0 minutes for stereotactic needle biopsy and 188.4 ± 61.2 minutes for procedures involving LITT. The mean radial errors of the actual trajectory relative to the planned trajectory at the entry and target points were 0.625 ± 0.443 mm and 0.745 ± 0.472 mm, respectively. There were no procedural complications or new postoperative deficits, although routine postoperative CT showed new hyperdensity at the target site in 3/19 patients (15.7%). All patients who underwent elective procedures were discharged by postoperative day 3 (mean 1.38 ± 0.619 days). There were two 30-day readmissions (pulmonary embolus and general weakness), and neither was attributable to the surgical procedure.

Conclusions: The authors' pilot experience with the ExcelsiusGPS robot in neuro-oncology procedures indicates a favorable efficacy and safety profile.