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Original Article |

Navigated Surgery at the Lateral Skull Base and Registration and Preoperative Imagery:  Experimental Results FREE

Florian Kral, MD; Herbert Riechelmann, MD; Wolfgang Freysinger, PhD
[+] Author Affiliations

Author Affiliations: Department of Otorhinolaryngology (Drs Kral, Riechelmann, and Freysinger) and 4D Visualization Laboratory (Dr Freysinger), Innsbruck Medical University, Innsbruck, Austria.


Arch Otolaryngol Head Neck Surg. 2011;137(2):144-150. doi:10.1001/archoto.2010.249.
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Published online

Objectives  To assess factors that affect the accuracy of navigated surgery at the human lateral skull base, including the choice of registration procedures and preoperative computed tomography (CT) section thickness, and to compare target registration error, a measure of clinical application accuracy, with root mean square, an accuracy variable provided by several surgical navigation systems.

Design  Experimental cadaver study.

Setting  Medical university.

Participants  Anatomic specimen.

Main Outcome Measures  Target registration error.

Results  A combination of high-resolution CT images, 0.5-mm section thickness, with pair-point matching of a combination of markers on the anatomical specimen, and the registration element was found to be superior (mean [SD], 0.72 [0.28] mm). No correlation was found between target registration error and root mean square. A statistical analysis that considers image registration and acquisition method did not show any correlation between target registration error and root mean square error (r = −0.175, P = .15).

Conclusions  High-resolution CT images, 0.5 mm, of the petrous bone and a pair-point registration using loci on the patient and registration superstructures worked best under experimental conditions. Only target registration error was found to provide reliable information on accuracy intraoperatively. In line with the literature, these data prove that root mean square bears little relevance for clinical application accuracy.

Figures in this Article

Navigation systems are widely accepted and used for different surgical procedures in otorhinolaryngology today.1,2 Whereas navigation is clinically routine for sinus surgery,35 it is not routine for surgery of the lateral skull base, especially regarding microscope-guided navigated interventions. This fact can be attributed partly to the inherent complexity and smallness of the anatomical area under consideration and partly to the technological challenges associated with it.3,68 As a rule of thumb, an application accuracy that resembles the typical dimensions of the surgical targets should be the goal intraoperatively. At the lateral skull base, this would imply submillimetric precision.

Two immediate factors have the most affect on clinical application accuracy: image section thickness9 and the intraoperative registration process. Herein, we do not consider hardware-related aspects, such as the spatial position–sensing power of the 3-dimensional (3-D) camera in use. Registration is the step that links preoperative patient imagery with the physical patient10 by determining the physical coordinates of select patient features using the tracked probe of the navigation system; these coordinates are then used to translate position data into coordinates of preoperative imagery used for navigation so that the tip of the probe can be visualized in the patient's data. For navigated sinus surgery, registration is performed by correlating facial structures to the computed tomography (CT) data.11,12 At the lateral skull base, however, the small area of surgically exposed anatomy and the specific imaging protocols for the petrous bone impede this approach severely.13 Temporal bone high-resolution (HR) scans do not provide enough distinct shapes and structures suitable for registration at the plane of the squamous part of the temporal bone; moreover, the external ear is inadequate for registration. Invasive techniques for registration, such as placing titanium screws in the patient's skull as external landmarks for registration before imaging,14 are performed with the patient under general anesthesia using intraoperative imaging or under local anesthesia before surgery, which is acceptable only in a few patients. Thus, navigating the lateral skull base noninvasively in HR diagnostic images is still an open challenge.

A variety of approaches, including extrinsic registration structures15 and axial CT data sets, have been studied,1620 but none of these approaches could convincingly be used in a real clinical setting. In fact, microscopic surgery is hardly ever navigated. Consequently, no standard for noninvasive, accurate, and clinically practicable registration is available for this surgical problem.16,19,21,22 External superstructures fixed to the patient by means of dental imprints,23,24 implantation of titanium screws before imaging,25,26 and invasive head fixation are described.27,28 However, systematic comparisons of different registration techniques for the lateral skull base are rare.

When intraoperative navigation is accurate, the position of a pointing device (or an instrument) is ideally displayed at exactly the same location on the computer monitor as in the patient. In reality, this is never the case.29,30 The application accuracy of navigation is, however, crucial to surgical acceptance. Frequently, the root mean square (RMS) error of the registration3133 is given and only quantifies the quality of a least-squares optimization process,34 with little, if any, relevance to the surgical process.35 Among the various figures of merit found in the literature is the target registration error (TRE),30,36,37 which describes the difference between the actual probe position on the patient and the calculated position in the data. The TRE is the most important quantity intraoperatively because it reflects clinical accuracy.30

Surgical navigation systems typically provide the RMS of the registration as a type of guideline for application accuracy, although the user is advised to check the accuracy on the patient. The RMS describes the residual error between world and data coordinate systems after registration.38 The TRE30 is the spatial difference between corresponding points after registration, measured using the navigation system. The aim of this work was to assess the performance of different patient registration strategies and image acquisition protocols and to test whether RMS and TRE are correlated in the lateral skull base.

SKULL BASE SPECIMEN

A formaldehyde-fixed anatomical human cadaver (aged 60 years, male) was provided by the Department of Anatomy, Innsbruck Medical University. Access to the internal structures of the left petrous bone was gained by cutting the specimen horizontally in the submaxillary and supraorbital planes after removing the brain. The left posterior fossa was removed (Figure 1 and Figure 2), and fiducials (X-Spots; Beekley Corporation, Bristol, Connecticut) (radiolucent sphere diameter, 1.5 mm) were fixed on the specimen. A locking acrylic dental splint17 external superstructure (VBH [Vogele-Bale-Hohner] head holder; Medical Intelligence Medizintechnik GmbH, Schwabmünchen, Germany) was adapted to the upper jaw of the anatomical specimen39 and was additionally secured with titanium screws on the maxilla. The mouthpiece served to stabilize the specimen on the operating table and carried radio-opaque fiducial markers that were used for registration purposes. Unlike in the intraoperative condition, this configuration allowed direct measurements at the targets of interest inside the temporal bone and then were used to determine the TRE.

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Figure 1.

The measurement setup shows the specimen from the cranio-occipital region held by the 2 hydraulic arms that are securely attached to the Vogele-Bale-Hohner mouthpiece (not visible from this view). The locking acrylic dental splint, in addition, carries an external superstructure in close proximity to the left lateral skull base. Another hydraulic arm was used to eliminate hand tremor during measurements and to keep the pointer in place (shown as an example at measurement point 7).

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Figure 2.

The specimen as viewed from the occipital region. A sample of measurement points (⊕) in and around the petrous bone is shown. The points were selected to provide optimum visibility in the computed tomographic data and on the specimen and comprise pneumatized cells of the mastoid, the vessels, or the most lateral edge of the truncated internal auditory canal. Note the internal auditory canal (IAC plus arrow), the internal carotid artery (ICA), the mastoid (M), and the sigmoid sinus (SS).

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NAVIGATION SYSTEM

An active optical navigation system (Surgical Tool Navigator [STN]; Carl Zeiss Inc, Oberkochen, Germany) was used with an active optical tracking system (Flashpoint 3000; Image Guided Technologies, Boulder, Colorado). The system as a whole is no longer available for purchase, but core components are in clinical use40 and compose parts of commercially available navigation systems.41 For medicolegal reasons, the STN is a closed system and, thus, no direct access to positional 3-D data and CT coordinates is possible.

REGISTRATION STRATEGIES

Three common bases for registration were used: anatomical landmarks, an external superstructure (the VBH system) for pair-point matching, and surface registration. The VBH system carried 5 fiducials; 4 unilateral anatomical landmarks were defined (the tip of the mastoid, the supraorbital foramen, the root of the helix of the pinna, and the supra-aurale). X-Spots were sewn to the anatomical locations to improve identification during the registration process. Note that we were using unilateral registration, which is the only approach suitable for HR data sets. For consistency, the axial data sets were registered similarly. As is well known,37 this approach will yield surgically useful application accuracies in a limited anatomical area only. By design of the registration spots on the anatomy and the external registration element, this limited anatomical area will be the petrous bone. The configuration of the registration points actually encloses the surgical area. For surface matching, 40 points of the surface of the specimen that were visible in the 3-D reconstruction of the CT data were collected using the tracked pointer. The hardware limitations of the Zeiss STN system did not allow us to cover more points for the surface registration. Specifically, we experimentally determined the TRE and studied the performance of registration based on the use of external superstructures only, external superstructures plus anatomical landmarks, and external superstructures plus anatomical landmarks plus surface for the axial data sets only.

IMAGE ACQUISITION

Three different CT data sets with identical scanning variables (140 kV, 220 mA) (Siemens Plus 4 Volume Zoom; Siemens AG, Erlangen, Germany) were obtained: 1 axial data set with 1-mm section thickness (2-mm table feed, 4-mm focus) displaying the whole cadaver head and 2 HR data sets with 1- and 0.5-mm section thickness (1-mm table feed, 2-mm focus) displaying the temporal region only. Three registration approaches and 3 different image data sets allow 9 combinations. However, we could not include surface matching with HR data sets because temporal bone HRCT images have a reduced field of view, providing an inadequate surface for surface matching.

ASSESSMENT OF TRE

Fifteen different target points were defined throughout the specimen, all different from the registration points. Five points were skin-fixed fiducial markers, and the remaining 10 were defined as anatomical landmarks in and around the petrous bone (Table 1). To improve measuring accuracy, a holding device was used to keep the pointer as vertical to the measurement point as possible and to eliminate hand tremor. The deviation of the actual pointer position and the position identified by the navigation system was measured at a zoom level of 400% with the navigation system's ruler at the identical windowing settings of the CT data (Figure 3). Deviations were measured in the axial, coronal, and sagittal views as left/right, anterior/posterior, and cranial/caudal deviations, respectively. Right, anterior, and cranial deviations were assigned positive signs, all other durations were assigned negative signs and all the deviations were assigned x-, y-, and z-axes, respectively. The TRE was calculated as the length of the resulting total deviation vector. In addition, the RMS as provided by the navigation system was recorded for each registration. The complete procedure (registration, TRE measurements, and RMS recordings) was repeated 10 times for each registration and each image acquisition technique. The final TRE at each target point was obtained as the average of 10 measurements. The intraclass correlation coefficient was calculated to assess the consistency of the results of the 10 repeated registration and TRE measurements.

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Figure 3.

Screenshot at a magnification of 400% from the navigation software (StP [Software Through Pictures] 4.0; Atego, San Diego, California). Multiplanar view showing axial, coronal, and sagittal cuts. The tip of the probe is on the most lateral part of the truncated internal auditory canal (measurement point 13) and is visualized as the crosshairs. No deviation in this measurement can be found. This screenshot represents the ideal application accuracy in the petrous bone (high-resolution petrous bone computed tomographic scan and registration with external fiducials plus anatomical landmarks).

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Table Graphic Jump LocationTable 1. Targets Used for Measurement of Target Registration Errora
DATA ANALYSIS

A 2-factorial analysis of variance with interaction was used to analyze the TRE values. The 2 grouping factors in the model were registration strategy (fiducials only, fiducials + anatomical landmarks, and fiducials + anatomical landmarks + surface registration) and image acquisition (1-mm section thickness, low resolution; 1-mm section thickness, HR; and 0.5-mm section thickness, HR). Data were tested for normal distribution using the Anderson-Darling test, and homogeneity of variance was verified using the Levene test. Intraclass correlation was tested using a 1-way random-effects model. Correlation of TRE and RMS was tested using the Pearson correlation coefficient; partial correlation coefficients were calculated using a 2-way mixed-effects model. All the calculations were performed using a statistical software program (SPSS version 16.0; SPSS Inc, Chicago, Illinois).

Of 3149 TRE raw measurements, 114 were discarded because they were greater than 3 SD from the mean. The overall mean (SD) TRE in the lateral skull base was 2.88 (2.09) mm. The TRE data differed significantly depending on the registration technique and the image acquisition method used. As expected, TRE values at bony landmarks in the petrous bone were smaller than those at measurement points located at superficial soft tissue (P < .01; data not shown).

EFFECT OF REGISTRATION STRATEGY

Registration strategies significantly affected TRE values (P < .001). The lowest (most accurate) TRE values were obtained by combining external superstructures and anatomical landmarks (mean [SD], 1.11 [1.0] mm). For low-resolution axial CT data, the addition of a surface registration yielded worse results than did a mouthpiece plus anatomical landmarks without surface registration (Table 2).

Table Graphic Jump LocationTable 2. Target Registration Errors Obtained at 15 Targets at the Lateral Skull Base Using 3 Registration Techniques and 3 Image Acquisition Methods
EFFECT OF IMAGE ACQUISITION

The choice of image acquisition methods had no significant effect on TRE (P = .31). Noticeable differences were observed using the 0.5-mm HRCT scans, which yielded the highest (worst) TRE values using the external superstructure only and the lowest (best) values when anatomical landmarks were used additionally.

INTRACLASS CORRELATION OF REPEATED MEASUREMENTS

Ten repeated measurements were performed at the 15 target points for the available registration strategies and imaging data. The intraclass correlation coefficient for the repeated measurements was 0.62 mm (95% confidence interval, 0.54-0.69 mm).

CORRELATION OF TRE AND RMS

Mean (SD) RMS values (1.88 [0.33] mm) were significantly smaller than were mean (SD) TRE values (2.88 [2.09] mm, P < .001), pretending an unrealistic accuracy. Controlling for the effects of registration and image acquisition methods, no correlation between TRE and RMS was found (r = −0.175, P = .15).

In computer-assisted surgical navigation, accuracy means that the virtual position displayed by the navigation system is consistent with the actual surgical position in the patient. A clinically relevant variable of accuracy is the TRE, that is, the deviation of the displayed position from the actual anatomical target. In this study, a segment of the petrous bone in a human cadaver head was removed to expose 15 targets of potential surgical interest for TRE measurements in the lateral skull base (Table 1). Accuracy is affected by many variables, and, ideally, the effect of each single link in the chain of the workflow of navigated procedures should be subject to investigation. Herein we studied the effect of 3 registration procedures and 3 types of radiologic data. Moreover, information on the consistency of the registration process was gained by evaluating 10 repetitions of the whole registration process. Finally, we correlated TRE with RMS, an accuracy variable provided by several navigation systems.

Across all registration and image acquisition methods used, a mean (SD) TRE of 2.88 (2.09) mm was measured under experimental conditions in the lateral skull base. Considering the dimensions of surgically relevant structures in the petrous bone, this accuracy is considered insufficient for navigated lateral skull base surgery. Registration method had a statistically significant effect on TRE (P < .001), whereas image modality did not (P = .3). The lowest TRE (mean [SD], 0.72 [0.28] mm) was achieved with 0.5-mm HRCT scans and the combination of an external superstructure and intrinsic landmarks for registration. Herein, the TRE is close to the resolution power of the Polaris digitizer.42 However, unlike during surgical procedures, we did not remove and reinsert the bite block in this experimental setup. The external superstructure alone yielded inaccurate results, probably because of the distance of the mouthpiece from the lateral skull base. Other external superstructures, such as reference arrays fixed at the skull or at a Mayfield clamp, may yield more accurate results. Because only a small surface area of the petrous bone is displayed, surface registration was not feasible in HRCT scans. It is still unknown whether surface matching would improve the TRE in this anatomical area. In low-resolution axial CT scans, additional surface registration did not improve but rather deteriorated the TRE.

The low intraclass correlation coefficient of 0.6 in 10 repeated registrations suggests that the registration process is a major cause of inaccuracy in lateral skull base navigation. One probable reason for this inaccuracy is the lack of prominent landmarks at the surface of the lateral skull. Various factors may affect the registration process, including small movements, soft-tissue deformability, reduced skin turgor in elderly patients, and changes in skin properties during general anesthesia.13,43,44 These factors sum to a major source of inaccuracy in lateral skull base navigation.

Finally, no correlation between TRE and RMS was found. To our knowledge, this is the first experimental verification of the prediction by Fitzpatrick35 that RMS and TRE are uncorrelated. Moreover, RMS values were significantly lower than were TRE values, falsely implying a nonexistent accuracy to the surgeon. This finding reinforces that RMS should not be used as a figure of merit for assessing patient-to-image registration intraoperatively.

The present experimental results are in line with those of previous studies45,46 and are comparable with the work of Caversaccio et al,20 Vrionis et al,47 and Labadie et al.17 However, the detailed analysis of the present data allows us to assess the theoretical framework of Fitzpatrick et al30 on a human cadaver.

In previous experimental investigations, we found that submillimetric application accuracy in the petrous bone is possible.45,46 In combination with the known submillimetric repositioning accuracy of maxillary splints for navigation (experimentally determined to be <0.73 mm on 50 human volunteers23 and theoretically determined to be 0.66 mm48 on an anatomical specimen) and the fact that both TREs are uncorrelated, one can assume a significantly better TRE for navigation only.

The most interesting feature of these data regarding the combination of anatomical landmarks with the mouth piece is that we demonstrate the decrease in TRE with increasing CT resolution9,49; thus, better application accuracy can be expected. However, this is limited by the 3-D position-sensing unit's spatial resolution, beyond which any increase in voxel resolution is lost.

In lateral skull base navigation, any measurement taken is affected with unavoidable error that should be considered. Thus, to achieve a 95% probability that a measurement will be “correct,” an interval of ±2 SD has to be considered. Even for the best combination used in this study (0.5-mm HRCT, mouthpiece, and anatomical landmarks) and under favorable experimental conditions, this would imply that the measurements will fall in the interval of 0.16 to 1.28 mm, which is not in the submillimetric precision range. To support microscopic navigated surgery at the lateral skull base or robotic interventions there, registration, tracking, and imaging techniques for lateral skull base surgery should be improved. To locate minute structures in the lateral skull base, the resolution of any measuring tool should be at least 1 order of magnitude better than the characteristic dimension of the problem. Ideally, the tracked instrument can be located with subvoxel precision in isotropic submillimetric radiologic imagery (novel flat-panel technologies provide this with a low radiation dose) so that the still open challenge is to develop submillimetric 3-D tracking and subvoxel application accuracy with noninvasive registration techniques.

In conclusion, navigation at the lateral skull base is proceeding at the borders of practicability as the ultimate surgical goal, submillimetric application accuracy, stretches the dimensions of currently available radiologic imagery and 3-D measurement technology. However, navigation in this delicate anatomical area will definitely be a supplementary tool intraoperatively.

Correspondence: Florian Kral, MD, Department of Otorhinolaryngology, Innsbruck Medical University, Anichstr 35, 6020 Innsbruck, Austria (florian.kral@i-med.ac.at).

Submitted for Publication: December 6, 2009; final revision received July 23, 2010; accepted September 6, 2010.

Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kral and Freysinger. Acquisition of data: Kral. Analysis and interpretation of data: Kral, Riechelmann, and Freysinger. Drafting of the manuscript: Kral and Riechelmann. Critical revision of the manuscript for important intellectual content: Kral, Riechelmann, and Freysinger. Statistical analysis: Kral and Riechelmann. Administrative, technical, and material support: Riechelmann and Freysinger. Study supervision: Riechelmann and Freysinger.

Financial Disclosure: None reported.

Peters  TM Image-guidance for surgical procedures. Phys Med Biol 2006;51 (14) R505- R540
PubMed
Yaniv  ZCleary  K Image-Guided Procedures: A Review.  Washington, DC Imaging Science and Information Systems Center, Georgetown University2006;Technical Report CAIMR TR-2006-3
Citardi  MJBatra  PS Intraoperative surgical navigation for endoscopic sinus surgery: rationale and indications. Curr Opin Otolaryngol Head Neck Surg 2007;15 (1) 23- 27
PubMed
Hemmerdinger  SAJacobs  JBLebowitz  RA Accuracy and cost analysis of image-guided sinus surgery. Otolaryngol Clin North Am 2005;38 (3) 453- 460
PubMed
Sindwani  RBucholz  RD The next generation of navigational technology. Otolaryngol Clin North Am 2005;38 (3) 551- 562
PubMed
Grayeli  ABEsquia-Medina  GNguyen  Y  et al.  Use of anatomic or invasive markers in association with skin surface registration in image-guided surgery of the temporal bone. Acta Otolaryngol 2009;129 (4) 405- 410
PubMed
Majdani  OBartling  SHLeinung  M  et al.  A true minimally invasive approach for cochlear implantation: high accuracy in cranial base navigation through flat-panel-based volume computed tomography. Otol Neurotol 2008;29 (2) 120- 123
PubMed
Schipper  JAschendorff  AArapakis  I  et al.  Navigation as a quality management tool in cochlear implant surgery. J Laryngol Otol 2004;118 (10) 764- 770
PubMed
Bucholz  RDHo  HWRubin  JP Variables affecting the accuracy of stereotactic localization using computerized tomography. J Neurosurg 1993;79 (5) 667- 673
PubMed
Lavallée  SCinquin  PSzeliski  R  et al.  Building a hybrid patient's model for augmented reality in surgery: a registration problem. Comput Biol Med 1995;25 (2) 149- 164
PubMed
Caversaccio  MLanglotz  FNolte  L-PHäusler  R Impact of a self-developed planning and self-constructed navigation system on skull base surgery: 10 years experience. Acta Otolaryngol 2007;127 (4) 403- 407
PubMed
Knott  PDBatra  PSButler  RSCitardi  MJ Contour and paired-point registration in a model for image-guided surgery. Laryngoscope 2006;116 (10) 1877- 1881
PubMed
Woerdeman  PAWillems  PWANoordmans  HJTulleken  CAFvan der Sprenkel  JWB Application accuracy in frameless image-guided neurosurgery: a comparison study of three patient-to-image registration methods. J Neurosurg 2007;106 (6) 1012- 1016
PubMed
Warren  FMBalachandran  RFitzpatrick  JMLabadie  RF Percutaneous cochlear access using bone-mounted, customized drill guides: demonstration of concept in vitro. Otol Neurotol 2007;28 (3) 325- 329
PubMed
Gunkel  ARVogele  MMartin  ABale  RJThumfart  WFFreysinger  W Computer-aided surgery in the petrous bone. Laryngoscope 1999;109 (11) 1793- 1799
PubMed
Labadie  RFFenlon  MCevikalp  HHarris  SGalloway  RFitzpatrick  JM Image-guided otologic surgery. Lemke  HUVannier  MWInamura  KFarman  AGDoi  KReiber  JHCProceedings of the 17th International Congress and Exhibition CARS 2003. Amsterdam, the Netherlands Elsevier Science2003;627- 632
Labadie  RFShah  RJHarris  SS  et al.  In vitro assessment of image-guided otologic surgery: submillimeter accuracy within the region of the temporal bone. Otolaryngol Head Neck Surg 2005;132 (3) 435- 442
PubMed
Strauss  GKoulechov  KHofer  M  et al.  The navigation-controlled drill in temporal bone surgery: a feasibility study. Laryngoscope 2007;117 (3) 434- 441
PubMed
Zheng  GKowal  JGonzalez Ballester  MCaversaccio  MNolte  LP Registration techniques for computer navigation. Curr Orthop 2007;21170- 179
Caversaccio  MZulliger  DBächler  RNolte  LPHäusler  R Practical aspects for optimal registration (matching) on the lateral skull base with an optical frameless computer-aided pointer system. Am J Otol 2000;21 (6) 863- 870
PubMed
Gunkel  ARFreysinger  WThumfart  WF Experience with various 3-dimensional navigation systems in head and neck surgery. Arch Otolaryngol Head Neck Surg 2000;126 (3) 390- 395
PubMed
Caversaccio  MGarcia-Giraldez  JGonzalez-Ballester  MMarti  G Image-guided surgical microscope with mounted minitracker. J Laryngol Otol 2007;121 (2) 160- 162
PubMed
Martin  ABale  RJVogele  MGunkel  ARThumfart  WFFreysinger  W Vogele-Bale-Hohner mouthpiece: registration device for frameless stereotactic surgery. Radiology 1998;208 (1) 261- 265
PubMed
Edwards  PJHawkes  DJHill  DL  et al.  Augmentation of reality using an operating microscope for otolaryngology and neurosurgical guidance. J Image Guid Surg 1995;1 (3) 172- 178
PubMed
Mascott  CRSol  JCBousquet  PLagarrigue  JLazorthes  YLauwers-Cances  V Quantification of true in vivo (application) accuracy in cranial image-guided surgery: influence of mode of patient registration. Neurosurgery 2006;59 (1) ((suppl 1)) ONS146- ONS156
PubMed
Strauss  GDittrich  EBaumberger  C  et al.  Improvement of registration accuracy for navigated-control drill in mastoidectomy (autopilot). Laryngorhinootologie 2008;87 (8) 560- 564
PubMed
Leuthardt  ECFox  DOjemann  GA  et al.  Frameless stereotaxy without rigid pin fixation during awake craniotomies. Stereotact Funct Neurosurg 2002;79 (3-4) 256- 261
PubMed
Majdani  ORau  TSBaron  S  et al.  A robot-guided minimally invasive approach for cochlear implant surgery: preliminary results of a temporal bone study. Int J Comput Assist Radiol Surg 2009;4 (5) 475- 486
PubMed
Labadie  RFDavis  BMFitzpatrick  JM Image-guided surgery: what is the accuracy? Curr Opin Otolaryngol Head Neck Surg 2005;13 (1) 27- 31
PubMed
Fitzpatrick  JMWest  JBMaurer  CR  Jr Predicting error in rigid-body point-based registration. IEEE Trans Med Imaging 1998;17 (5) 694- 702
PubMed
Khadem  RYeh  CCSadeghi-Tehrani  M  et al.  Comparative tracking error analysis of five different optical tracking systems. Comput Aided Surg 2000;5 (2) 98- 107
PubMed
Seno  SSuzuki  MSakurai  H  et al.  Image-guided endoscopic sinus surgery: a comparison of two navigation systems [in Japanese]. Nippon Jibiinkoka Gakkai Kaiho 2005;108 (11) 1101- 1109
PubMed
Schicho  KFigl  MDonat  M  et al.  Stability of miniature electromagnetic tracking systems. Phys Med Biol 2005;50 (9) 2089- 2098
PubMed
Knott  PDMaurer  CRGallivan  RRoh  H-JCitardi  MJ The impact of fiducial distribution on headset-based registration in image-guided sinus surgery. Otolaryngol Head Neck Surg 2004;131 (5) 666- 672
PubMed
Fitzpatrick  JM Fiducial registration error and target registration error are uncorrelated. Proc SPIE 2009;7261726102- 12
Maurer  CR  JrMaciunas  RJFitzpatrick  JM Registration of head CT images to physical space using a weighted combination of points and surfaces. IEEE Trans Med Imaging 1998;17 (5) 753- 761
PubMed
West  JBFitzpatrick  JMToms  SAMaurer  CR  JrMaciunas  RJ Fiducial point placement and the accuracy of point-based, rigid body registration. Neurosurgery 2001;48 (4) 810- 816
PubMed
Labadie  RFMajdani  OFitzpatrick  JM Image-guided technique in neurotology. Otolaryngol Clin North Am 2007;40 (3) 611- 624
PubMed
Bale  RJVogele  MFreysinger  W  et al.  Minimally invasive head holder to improve the performance of frameless stereotactic surgery. Laryngoscope 1997;107 (3) 373- 377
PubMed
Marmulla  REggers  GMühling  J Laser surface registration for lateral skull base surgery. Minim Invasive Neurosurg 2005;48 (3) 181- 185
PubMed
Gellrich  NCSchramm  AHammer  B  et al.  Computer-assisted secondary reconstruction of unilateral posttraumatic orbital deformity. Plast Reconstr Surg 2002;110 (6) 1417- 1429
PubMed
Wiles  ADThompson  DGFrantz  DD Accuracy assessment and interpretation for optical tracking systems. Proc SPIE 2004;5367 (14) 1- 12
Ammirati  MGross  JDAmmirati  GDugan  S Comparison of registration accuracy of skin- and bone-implanted fiducials for frameless stereotaxis of the brain: a prospective study. Skull Base 2002;12 (3) 125- 130
PubMed
Metzger  MCRafii  AHolhweg-Majert  BPham  AMStrong  B Comparison of 4 registration strategies for computer-aided maxillofacial surgery. Otolaryngol Head Neck Surg 2007;137 (1) 93- 99
PubMed
Vogele  MFreysinger  WBale  RGunkel  ARThumfart  WF Use of the ISG viewing wand on the temporal bone: a model study [in German]. HNO 1997;45 (2) 74- 80
PubMed
Kral  FFreysinger  W 3-D navigation in the petrous bone with submillimeter accuracy [in German]. HNO 2004;52 (8) 699- 705
PubMed
Vrionis  FDFoley  KTRobertson  JHShea  JJ  III Use of cranial surface anatomic fiducials for interactive image-guided navigation in the temporal bone: a cadaveric study. Neurosurgery 1997;40 (4) 755- 763
PubMed
Fitzpatrick  JMBalachandran  RLabadie  RF Bite-block relocation error in image-guided otologic surgery. Lect Notes Comput Sci 2004;3217518- 525
Bartling  SHLeinung  MGraute  J  et al.  Increase of accuracy in intraoperative navigation through high-resolution flat-panel volume computed tomography: experimental comparison with multislice computed tomography-based navigation. Otol Neurotol 2007;28 (1) 129- 134
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

The measurement setup shows the specimen from the cranio-occipital region held by the 2 hydraulic arms that are securely attached to the Vogele-Bale-Hohner mouthpiece (not visible from this view). The locking acrylic dental splint, in addition, carries an external superstructure in close proximity to the left lateral skull base. Another hydraulic arm was used to eliminate hand tremor during measurements and to keep the pointer in place (shown as an example at measurement point 7).

Graphic Jump Location
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Figure 2.

The specimen as viewed from the occipital region. A sample of measurement points (⊕) in and around the petrous bone is shown. The points were selected to provide optimum visibility in the computed tomographic data and on the specimen and comprise pneumatized cells of the mastoid, the vessels, or the most lateral edge of the truncated internal auditory canal. Note the internal auditory canal (IAC plus arrow), the internal carotid artery (ICA), the mastoid (M), and the sigmoid sinus (SS).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Screenshot at a magnification of 400% from the navigation software (StP [Software Through Pictures] 4.0; Atego, San Diego, California). Multiplanar view showing axial, coronal, and sagittal cuts. The tip of the probe is on the most lateral part of the truncated internal auditory canal (measurement point 13) and is visualized as the crosshairs. No deviation in this measurement can be found. This screenshot represents the ideal application accuracy in the petrous bone (high-resolution petrous bone computed tomographic scan and registration with external fiducials plus anatomical landmarks).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Targets Used for Measurement of Target Registration Errora
Table Graphic Jump LocationTable 2. Target Registration Errors Obtained at 15 Targets at the Lateral Skull Base Using 3 Registration Techniques and 3 Image Acquisition Methods

References

Peters  TM Image-guidance for surgical procedures. Phys Med Biol 2006;51 (14) R505- R540
PubMed
Yaniv  ZCleary  K Image-Guided Procedures: A Review.  Washington, DC Imaging Science and Information Systems Center, Georgetown University2006;Technical Report CAIMR TR-2006-3
Citardi  MJBatra  PS Intraoperative surgical navigation for endoscopic sinus surgery: rationale and indications. Curr Opin Otolaryngol Head Neck Surg 2007;15 (1) 23- 27
PubMed
Hemmerdinger  SAJacobs  JBLebowitz  RA Accuracy and cost analysis of image-guided sinus surgery. Otolaryngol Clin North Am 2005;38 (3) 453- 460
PubMed
Sindwani  RBucholz  RD The next generation of navigational technology. Otolaryngol Clin North Am 2005;38 (3) 551- 562
PubMed
Grayeli  ABEsquia-Medina  GNguyen  Y  et al.  Use of anatomic or invasive markers in association with skin surface registration in image-guided surgery of the temporal bone. Acta Otolaryngol 2009;129 (4) 405- 410
PubMed
Majdani  OBartling  SHLeinung  M  et al.  A true minimally invasive approach for cochlear implantation: high accuracy in cranial base navigation through flat-panel-based volume computed tomography. Otol Neurotol 2008;29 (2) 120- 123
PubMed
Schipper  JAschendorff  AArapakis  I  et al.  Navigation as a quality management tool in cochlear implant surgery. J Laryngol Otol 2004;118 (10) 764- 770
PubMed
Bucholz  RDHo  HWRubin  JP Variables affecting the accuracy of stereotactic localization using computerized tomography. J Neurosurg 1993;79 (5) 667- 673
PubMed
Lavallée  SCinquin  PSzeliski  R  et al.  Building a hybrid patient's model for augmented reality in surgery: a registration problem. Comput Biol Med 1995;25 (2) 149- 164
PubMed
Caversaccio  MLanglotz  FNolte  L-PHäusler  R Impact of a self-developed planning and self-constructed navigation system on skull base surgery: 10 years experience. Acta Otolaryngol 2007;127 (4) 403- 407
PubMed
Knott  PDBatra  PSButler  RSCitardi  MJ Contour and paired-point registration in a model for image-guided surgery. Laryngoscope 2006;116 (10) 1877- 1881
PubMed
Woerdeman  PAWillems  PWANoordmans  HJTulleken  CAFvan der Sprenkel  JWB Application accuracy in frameless image-guided neurosurgery: a comparison study of three patient-to-image registration methods. J Neurosurg 2007;106 (6) 1012- 1016
PubMed
Warren  FMBalachandran  RFitzpatrick  JMLabadie  RF Percutaneous cochlear access using bone-mounted, customized drill guides: demonstration of concept in vitro. Otol Neurotol 2007;28 (3) 325- 329
PubMed
Gunkel  ARVogele  MMartin  ABale  RJThumfart  WFFreysinger  W Computer-aided surgery in the petrous bone. Laryngoscope 1999;109 (11) 1793- 1799
PubMed
Labadie  RFFenlon  MCevikalp  HHarris  SGalloway  RFitzpatrick  JM Image-guided otologic surgery. Lemke  HUVannier  MWInamura  KFarman  AGDoi  KReiber  JHCProceedings of the 17th International Congress and Exhibition CARS 2003. Amsterdam, the Netherlands Elsevier Science2003;627- 632
Labadie  RFShah  RJHarris  SS  et al.  In vitro assessment of image-guided otologic surgery: submillimeter accuracy within the region of the temporal bone. Otolaryngol Head Neck Surg 2005;132 (3) 435- 442
PubMed
Strauss  GKoulechov  KHofer  M  et al.  The navigation-controlled drill in temporal bone surgery: a feasibility study. Laryngoscope 2007;117 (3) 434- 441
PubMed
Zheng  GKowal  JGonzalez Ballester  MCaversaccio  MNolte  LP Registration techniques for computer navigation. Curr Orthop 2007;21170- 179
Caversaccio  MZulliger  DBächler  RNolte  LPHäusler  R Practical aspects for optimal registration (matching) on the lateral skull base with an optical frameless computer-aided pointer system. Am J Otol 2000;21 (6) 863- 870
PubMed
Gunkel  ARFreysinger  WThumfart  WF Experience with various 3-dimensional navigation systems in head and neck surgery. Arch Otolaryngol Head Neck Surg 2000;126 (3) 390- 395
PubMed
Caversaccio  MGarcia-Giraldez  JGonzalez-Ballester  MMarti  G Image-guided surgical microscope with mounted minitracker. J Laryngol Otol 2007;121 (2) 160- 162
PubMed
Martin  ABale  RJVogele  MGunkel  ARThumfart  WFFreysinger  W Vogele-Bale-Hohner mouthpiece: registration device for frameless stereotactic surgery. Radiology 1998;208 (1) 261- 265
PubMed
Edwards  PJHawkes  DJHill  DL  et al.  Augmentation of reality using an operating microscope for otolaryngology and neurosurgical guidance. J Image Guid Surg 1995;1 (3) 172- 178
PubMed
Mascott  CRSol  JCBousquet  PLagarrigue  JLazorthes  YLauwers-Cances  V Quantification of true in vivo (application) accuracy in cranial image-guided surgery: influence of mode of patient registration. Neurosurgery 2006;59 (1) ((suppl 1)) ONS146- ONS156
PubMed
Strauss  GDittrich  EBaumberger  C  et al.  Improvement of registration accuracy for navigated-control drill in mastoidectomy (autopilot). Laryngorhinootologie 2008;87 (8) 560- 564
PubMed
Leuthardt  ECFox  DOjemann  GA  et al.  Frameless stereotaxy without rigid pin fixation during awake craniotomies. Stereotact Funct Neurosurg 2002;79 (3-4) 256- 261
PubMed
Majdani  ORau  TSBaron  S  et al.  A robot-guided minimally invasive approach for cochlear implant surgery: preliminary results of a temporal bone study. Int J Comput Assist Radiol Surg 2009;4 (5) 475- 486
PubMed
Labadie  RFDavis  BMFitzpatrick  JM Image-guided surgery: what is the accuracy? Curr Opin Otolaryngol Head Neck Surg 2005;13 (1) 27- 31
PubMed
Fitzpatrick  JMWest  JBMaurer  CR  Jr Predicting error in rigid-body point-based registration. IEEE Trans Med Imaging 1998;17 (5) 694- 702
PubMed
Khadem  RYeh  CCSadeghi-Tehrani  M  et al.  Comparative tracking error analysis of five different optical tracking systems. Comput Aided Surg 2000;5 (2) 98- 107
PubMed
Seno  SSuzuki  MSakurai  H  et al.  Image-guided endoscopic sinus surgery: a comparison of two navigation systems [in Japanese]. Nippon Jibiinkoka Gakkai Kaiho 2005;108 (11) 1101- 1109
PubMed
Schicho  KFigl  MDonat  M  et al.  Stability of miniature electromagnetic tracking systems. Phys Med Biol 2005;50 (9) 2089- 2098
PubMed
Knott  PDMaurer  CRGallivan  RRoh  H-JCitardi  MJ The impact of fiducial distribution on headset-based registration in image-guided sinus surgery. Otolaryngol Head Neck Surg 2004;131 (5) 666- 672
PubMed
Fitzpatrick  JM Fiducial registration error and target registration error are uncorrelated. Proc SPIE 2009;7261726102- 12
Maurer  CR  JrMaciunas  RJFitzpatrick  JM Registration of head CT images to physical space using a weighted combination of points and surfaces. IEEE Trans Med Imaging 1998;17 (5) 753- 761
PubMed
West  JBFitzpatrick  JMToms  SAMaurer  CR  JrMaciunas  RJ Fiducial point placement and the accuracy of point-based, rigid body registration. Neurosurgery 2001;48 (4) 810- 816
PubMed
Labadie  RFMajdani  OFitzpatrick  JM Image-guided technique in neurotology. Otolaryngol Clin North Am 2007;40 (3) 611- 624
PubMed
Bale  RJVogele  MFreysinger  W  et al.  Minimally invasive head holder to improve the performance of frameless stereotactic surgery. Laryngoscope 1997;107 (3) 373- 377
PubMed
Marmulla  REggers  GMühling  J Laser surface registration for lateral skull base surgery. Minim Invasive Neurosurg 2005;48 (3) 181- 185
PubMed
Gellrich  NCSchramm  AHammer  B  et al.  Computer-assisted secondary reconstruction of unilateral posttraumatic orbital deformity. Plast Reconstr Surg 2002;110 (6) 1417- 1429
PubMed
Wiles  ADThompson  DGFrantz  DD Accuracy assessment and interpretation for optical tracking systems. Proc SPIE 2004;5367 (14) 1- 12
Ammirati  MGross  JDAmmirati  GDugan  S Comparison of registration accuracy of skin- and bone-implanted fiducials for frameless stereotaxis of the brain: a prospective study. Skull Base 2002;12 (3) 125- 130
PubMed
Metzger  MCRafii  AHolhweg-Majert  BPham  AMStrong  B Comparison of 4 registration strategies for computer-aided maxillofacial surgery. Otolaryngol Head Neck Surg 2007;137 (1) 93- 99
PubMed
Vogele  MFreysinger  WBale  RGunkel  ARThumfart  WF Use of the ISG viewing wand on the temporal bone: a model study [in German]. HNO 1997;45 (2) 74- 80
PubMed
Kral  FFreysinger  W 3-D navigation in the petrous bone with submillimeter accuracy [in German]. HNO 2004;52 (8) 699- 705
PubMed
Vrionis  FDFoley  KTRobertson  JHShea  JJ  III Use of cranial surface anatomic fiducials for interactive image-guided navigation in the temporal bone: a cadaveric study. Neurosurgery 1997;40 (4) 755- 763
PubMed
Fitzpatrick  JMBalachandran  RLabadie  RF Bite-block relocation error in image-guided otologic surgery. Lect Notes Comput Sci 2004;3217518- 525
Bartling  SHLeinung  MGraute  J  et al.  Increase of accuracy in intraoperative navigation through high-resolution flat-panel volume computed tomography: experimental comparison with multislice computed tomography-based navigation. Otol Neurotol 2007;28 (1) 129- 134
PubMed

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