RU2792552C1 - Method for projection marking of surgical access in neurosurgery - Google Patents

Abstract

FIELD: medicine; neurosurgery.

SUBSTANCE: invention can be used to improve the results of treatment during surgical interventions on the brain, reducing the time of surgical intervention. The proposed method includes obtaining a three-dimensional image of the head, including the brain, using medical imaging tools, loading this image into a computer with an existing image processing program, and building a three-dimensional 3D model of the patient's head. The preparatory stage of navigation is performed outside the operating room without the participation of the patient, a digital file is created with an image of the selected projection, transferred to a device for machine reading, brain formations and anatomical landmarks of the head are highlighted in this image with color markers; in the operating room, the projector is fixed on a bracket and the image is projected onto the patient's head, combining the main anatomical landmarks in such a way as to maintain proportion and anatomical correctness by smoothly adjusting the position of the projector, marking the access on the scalp with a contrast marker in accordance with the projection.

EFFECT: invention improves the patient's quality of life, reduces the likelihood of infectious complications.

1 cl, 5 dwg, 1 tbl

Description

The invention relates to medicine, namely to neurosurgery, and can be used to improve the results of treatment during surgical interventions on the brain, reducing the time of surgical intervention.

Surgical intervention on the central nervous system (CNS), and especially on the brain, is an initially high-risk action, since it is performed on an organ that regulates the functions of the body as a whole and ensures the mental activity of a person [A.I. Gaivoronsky, E.N. Kondakov, D.V. Svistov, D.A. Gulyaev Operative approaches in neurosurgery Volume I. Head. Guide for doctors. Under the editorship of Academician of the Russian Academy of Sciences B.V. Gaidar].

Usually, the planning of a surgical intervention involves the study of neuroimaging data (MPT, CT) by the surgeon and the extrapolation of this information to the surface of the patient's head in accordance with the virtual surgical plan. This method is subject to serious errors associated with the experience of the surgeon, the anatomical features of the patient and the peculiarities of volumetric perception of a particular surgeon.

There is a way to project an image on the surface of real objects [US Pat. RU 2667346 dated 2018.09.18]. This includes creating a gobo on dichroic glass from the main image template, installing a gobo with the image in the gobo projector, defining the projection area, determining the location of the projector gobo, determining the type of projector gobo optics used, based on the installation location in relation to the projection area, mounting the mount projector gobo at the installation site, calibrating the projector with the calibration gobo, pointing the projector gobo to the projection area, adjusting the focus of the projector gobo. After setting the value of the opening angle and focus, the distance from the projector gobo to the extreme points of the projection is measured, the data of the set values of the opening angle, focus, distances to the extreme points of the projection and the mounting directions along the axes are recorded, the projections of the calibration gobo are photographed, the projection distortion is calculated according to the data on the opening angle and the distance to the extreme points of the projection, create the primary template in the graphics editor.

Disadvantages of the technique is difficult to use, practically unsuitable for medical purposes, for example, in surgery.

Recently, electromagnetic navigation systems have been actively used in medicine, for example, Medtronic Stealth Station 7, USA or Fiagon GmbH, Germany [found on the Internet www.medtronic.com, www.fiagon.com]. This method is based on the fact that the generator creates an electromagnetic field around the patient's head, which is a coordinate system in which there is a reference and a surgical instrument equipped with a built-in electromagnetic sensor, or on which a special adapter is fixed. However, the cost of this equipment exceeds thirty million rubles and is not available to most clinics, especially in regions remote from federal centers. In addition, the adjustment of these systems takes time and increases the duration of the patient's stay under general anesthesia, since the adjustment of the system is performed when the patient is already under anesthesia. Also, the navigation system cannot be used in patients with electronic devices connected to the brain or nervous system and in patients with pacemakers.

The technical result to which the invention is directed is an increase in the pharmacoeconomic efficiency of the technology of surgical intervention on the brain, an increase in the simplicity and accessibility of using navigation technology in preoperative preparation, and an increase in the patient's quality of life. An important component is the import substitution of expensive electromagnetic navigation.

The technical result is achieved as follows. During the period of preparation for surgery, outside the operating room, a brain image is loaded using the medical industry standard for creating, storing, transmitting and visualizing digital medical images and documents of examined patients (Digital Imaging and Communications in Medicine - DICOM), obtained using imaging tools, for example, MPT, CT (Fig. 1) into a computer with an existing image processing program and build a three-dimensional 3D model of the patient's head, for example, using OsiriX (Fig. 2).

The OsiriX application is known and widely available. It is used to process DICOM images produced by, for example, equipment for MPT, CT, PET, PET-CT and other machines.

OsiriX application complements existing viewers, in particular nuclear medicine viewers, fully complies with the DICOM standard for image transfer and image file formats [Digital Imaging Journal: OsiriX: Open source software for navigating DICOM multidimensional images: http://www osirix-viewer.com/UserManualIntroduction.pdf].

Then, the marking of the proposed access is built on the surface of the three-dimensional model of the head of a particular patient in accordance with the operation plan. A convenient projection of the 3D model is selected, which provides recognizable landmarks on the patient's head, for example, ear, eye, nose, bridge of the nose, parietal tubercle (Fig. 2).

For work, the well-known definition of topographically recognizable landmarks on the head is used [Ostroverkhov G.E., Lubotsky D.N., Bomash Yu.M. Course of operative surgery and topographic anatomy. M.: Medicine, 1964. 743 p.; Ognev B.V., Frauchi V.Kh. Topographic and clinical anatomy / Guide for students and doctors. - M.: MEDGIZ, 1960, - 580 p.].

Next, a digital file is created, which is an image of the selected projection and transferred to a reading device, for example, a projector, a flash drive, or electronic networks, WiFi. At the same time, color markers are used to highlight both brain formations and anatomical landmarks of the head, which allow for optimal marking for access, for example, highlighting the functional area of the brain. Color marking also improves perception, reduces the risk of navigational errors, which is impossible when using monochrome electromagnetic navigation.

After marking, the projector is fixed on the bracket (Fig. 4) and the resulting image is projected onto the patient's head, aligning the main anatomical landmarks in such a way as to maintain proportion and anatomical correctness by smoothly adjusting the position of the projector (Fig. 3). After that, access is marked with a contrast marker, for example, a skin felt-tip pen, brilliant green, methylene blue, on the patient's skin in accordance with the projection (Fig. 5).

Using the proposed marking method, 14 patients with brain neoplasms received surgical treatment. When comparing the time spent on navigation of the tumor in patients (Table 1), a significant reduction in determining the location of the surgical access was obtained when using the projector, in comparison with the use of an electromagnetic navigation system.

Reducing the time to reach the target made it possible to reduce the time of the actual access and, accordingly, the duration of the entire operation from 15 to 30%. Accordingly, the time spent by the patient under anesthesia was also reduced, which, when performing neurosurgical operations, is associated with a significant decrease in the volume of narcotic drugs as a component of anesthesia, a decrease in the time for the patient to wake up after anesthesia, and a more favorable course of the early postoperative period. Decreased the proportion of patients who decreased or completely absent vomiting, improved health, verticalization in the shortest possible time. The risk of infectious complications is also significantly reduced.

The cost of the known and proposed methods differs by at least three orders of magnitude, that is, a thousand times, which allows the proposed method to be used in all neurosurgical departments of the country, while electromagnetic neuronavigation equipment is available only to large neurosurgical centers, requires expenses not only for the purchase equipment, but also for regular updating of consumables, such as a pointer tool, localizer, localizer sticker.

Thus, the proposed method has a number of major advantages, taking into account significant economic efficiency, ease of use, the country's course towards import substitution and the absence of domestic analogues of electromagnetic navigation.

Clinical examples. Clinical case 1.

Patient V., 14 years old, was hospitalized with a brain tumor (tumor of the right temporal lobe). Surgery was performed using a projector for navigation and access calculation. The time spent by the patient under anesthesia (navigation, access and surgical removal of the brain mass) was 2 hours. 10 min. After the operation, the patient was taken to the ward, verticalized the next day, and discharged from the hospital on the 12th day after the operation.

Operation protocol: Under general anesthesia, with the patient in the supine position with head fixation with a Mainfield brace, a typical small craniotomy was performed from a 4.0 cm linear skin incision in the right temporal region (a 3.0 × 3.0 cm flap was sawn out), the dura mater was opened in an X-shape. The brain is swollen. Corticotomy of the middle sections of the middle temporal gyrus was performed under an operating microscope in accordance with MRI data, and a gray-pink soft jelly-like tumor was found at a depth of 1 cm. Its removal was started by a conventional aspirator. As it was removed, the lower horn of the right lateral ventricle opened wide. The tumor occupied most of the laterobasal parts of the right temporal lobe and was gradually removed within the infiltration zone. Hemostasis. The dura mater is sutured, reinforced with a Tachocomb plate. The bone was placed in place and fixed with craniofixes. Soft tissues are sutured in layers. Aseptic label applied.

Clinical case 2.

Patient M., 7 years old, was hospitalized with a brain tumor (a cyst in the right parieto-occipital region). The intervention was carried out using the Fiagon GmbH electromagnetic navigation system. The navigation setup time to the cut took 25 minutes. The time spent by the patient under anesthesia was 3 hours 20 minutes, including the setting of navigation equipment and the surgical intervention itself. It should be noted that at the time of the operation, the navigation system failed due to interference from other equipment in the operating room. The system had to be rebooted, which took 30 minutes.

The navigation system uses an electromagnetic positioning system with interference detection. An electromagnetic field generated by a special generator located on the operating table determines the location of the instrument using passive markers located at the tip of the instruments). When interference occurs, navigation data is not displayed due to possible loss of accuracy.

Due to the length of the child's stay under general anesthesia after the operation, the patient was sent to the intensive care unit, where he stayed for a day. Verticalized on the 3rd day after the operation, discharged home on the 14th day after the operation.

Protocol of the operation: Under general anesthesia in the position of the child lying on his back with the head turned to the left, using a three-point fixation bracket, after processing the surgical field, a 3.0 cm incision was made in the posterior parietal sections on the right. The bone was skeletonized and a 2.0×3.0 cm flap was sawn out with a craniotomy. The dura mater was tense and linearly dissected. Produced encephalotomy to the cavity of the lateral ventricle, set the port of the endoscopic system, held the endoscope. The wall of the cyst protrudes into the cavity of the ventricle. The cyst was opened, its walls were excised within reach. The port has been removed. Hemostasis control. The dura mater is sutured, reinforced with a Tachocomb plate. The bone was placed in place and fixed with a craniofix. Soft tissues are sutured in layers. Aseptic label applied.

Clinical case 3.

Patient S., 4 years old, was hospitalized with a brain tumor (cyst of the posterior cranial fossa). The intervention was carried out without the use of navigation systems. Conducted trefination in the projection of the posterior cranial fossa. From this access, an unsuccessful attempt was made to puncture and drain the cyst. The hole in the bone was enlarged, after which a second attempt was made to puncture and drain the cyst of the brain. The time the child was under anesthesia was 2 hours and 20 minutes. After the operation, the patient was in the intensive care unit for a day. The child was verticalized on the 3rd day, discharged home on the 10th day after the operation.

Operation protocol: under general anesthesia with the child lying on the left side, after processing the surgical field, an incision was made in the occipital region on the right 6.0 cm. A puncture of the cyst of the posterior cranial fossa was made (an unsuccessful attempt, the liquor was not obtained). After expanding the trefination hole downwards by 1.0 cm, a repeated puncture of the cyst was performed - a transparent, colorless liquor was obtained under high pressure. The cyst was drained with a silicone catheter into the subarachnoid space, the catheter was fixed to the dura with one suture. Soft tissues are sutured in layers. Aseptic label applied.

Description for the figures.

Figure 1. MRI of a patient with a brain tumor (axial section).

1 - tumor

2 - lateral ventricle

3 - parietal lobe

4 - occipital lobe

5 - the border of the functional zone of the brain

6 - rear sections of the tumor

Figure 2. 3D image of the patient's head on the computer screen, the main guidelines for positioning the image on the patient's head:

5 - the border of the functional zone of the brain

6 - rear sections of the tumor

7 - nose

8 - outer corner of the eye

9 - ear

10 - parietal tubercle

Figure 3. Preoperative positioning of the image of the model of surgical landmarks, made on the computer, on the patient's head.

5 - the border of the functional zone of the brain,

6 - posterior sections of the tumor,

11 is a computer monitor showing a pre-built model. Figure 4.

The general plan of the process of transferring the image from the projector to the patient's head.

12 - standard operating microscope,

13 - projector,

14 - the path of the beams of the projector.

Figure 5. Comparison of the projection of the 3D model directly onto the patient's head and access marking.

6 - rear sections of the tumor

8 - outer corner of the eye

9 - ear

10 - parietal tubercle

15 - incision line on the skin.

Claims (1)

A method for projection marking of surgical access in neurosurgery, which includes obtaining a three-dimensional image of the head, including the brain, using medical imaging tools, loading this image into a computer with an available image processing program, building a three-dimensional 3D model of the patient's head, characterized in that the preparatory stage of navigation is performed outside the operating room without the participation of the patient, a digital file is created with an image of the selected projection, transferred to a machine reading device, brain formations and anatomical landmarks of the head are highlighted in this image with color markers; in the operating room, the projector is fixed on a bracket and the image is projected onto the patient's head, combining the main anatomical landmarks in such a way as to maintain proportion and anatomical correctness by smoothly adjusting the position of the projector, marking the access on the scalp with a contrast marker in accordance with the projection.

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