WO1992000702A1 - Stereotaxis system for surgery of the rachis - Google Patents

Stereotaxis system for surgery of the rachis Download PDF

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Publication number
WO1992000702A1
WO1992000702A1 PCT/ES1991/000040 ES9100040W WO9200702A1 WO 1992000702 A1 WO1992000702 A1 WO 1992000702A1 ES 9100040 W ES9100040 W ES 9100040W WO 9200702 A1 WO9200702 A1 WO 9200702A1
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WIPO (PCT)
Prior art keywords
point
target point
surgery
stereotaxy
intervene
Prior art date
Application number
PCT/ES1991/000040
Other languages
Spanish (es)
French (fr)
Inventor
J. Ricardo Dejoz
Original Assignee
Comercial Envisa, S.L.
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Publication date
Application filed by Comercial Envisa, S.L. filed Critical Comercial Envisa, S.L.
Publication of WO1992000702A1 publication Critical patent/WO1992000702A1/en

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Classifications

    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B90/00Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
    • A61B90/10Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges for stereotaxic surgery, e.g. frame-based stereotaxis
    • A61B90/11Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges for stereotaxic surgery, e.g. frame-based stereotaxis with guides for needles or instruments, e.g. arcuate slides or ball joints
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B34/00Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
    • A61B34/70Manipulators specially adapted for use in surgery

Definitions

  • Stereotaxy system for spinal surgery is a system that helps the surgeon in percutaneous interventions.
  • This system is called stereotaxic because it allows access with total precision to a surgical point located over an anatomical area by means of the three-dimensional reconstruction of the same and leads to the construction of an apparatus that will be handled by specialists in this type of surgery.
  • the stereotaxy system conceived will reduce the level of specialization required by surgeons who intervene herniated discs or other interventions suspected of being treated percutaneously, while minimizing radioscopic exposure times, both of the patient and the doctor, during these interventions .
  • the final design covers two basic objectives, on the one hand, its mechanical simplicity, associated with a functional dimensioning with strictly rational tolerances, will facilitate its machining and reduce manufacturing costs. Furthermore, operational simplicity alcan ⁇ Zada avoid typical resistance 'to medical equipment utilizat ⁇ tion novel conception.
  • the spine is a structure that combines the stiffness necessary to support the standing body weight while protecting the delicate spinal cord and spinal nerves while possessing the flexibility demanded by the usual movements in humans (flexion , extension and torsion). It is formed by a series of vertebrae articulated with each other by intervertebral discs.
  • a spine is divided into four zones: cervical, thoracic, lumbar and sacral, consisting of 7, 12, 5 and 5 vertebrae, respectively.
  • Each intervertebral disc is constituted by three parts, two cartilaginous end plates, upper and lower, an outer part of hard but flexible tissue, called a fibrous ring and a softer inner one called the nucleus pulposus.
  • the cartilaginous plates have a millimeter of periphery, being somewhat thinner in their central part, they bind the bone to the fibrous ring through a dense matrix of collagen fibers.
  • the fibrous ring consists of concentric layers of collagen fibers.
  • the fibers of each layer are parallel to each other and surround the axis of the spiral disk, forming angles of 45 s with it.
  • the fibers arranged in adjacent layers form right angles to each other. With this arrangement a great resistance is achieved in the union of the vertebral bodies allowing the interlocking of the fibers the flexion and torsion of the disc, ensuring the resistance to breakage of the fibrous ring.
  • the adjacent layers are separated by a gel rich in proteoglycans that transmits and unifies the pressure generated in the nucleus pulposus.
  • the nucleus pulposus is constituted by a semi-gelatinous tissue that retains about 80% water. Essentially it is a very hydrated mucopolysaccharide gel, wrapped by randomly distributed collagen fibrils. Under normal conditions, the fibrous ring and cartilaginous end plates, supported by adjacent bones, are rigid enough to resist core displacements.
  • the spinal cord is held in its position supported by muscles and ligaments. From it the roots of the nerves are born, as channels of communication between the brain and the rest of the organism.
  • the study of aging processes of the spine and intervertebral discs has given rise to the -degenerative theory, which assumes that all vertebral columns degenerate over time. From this point of view, any medical or surgical treatment involves temporary pain relief and not total restoration to normal spinal behavior.
  • the protrusion disc herniation is called without passing the medullary canal of the nucleus pulposus through the radial cracks that appear in the fibrous ring. There is a tendency to displacement of the nucleus due to the forces acting on it. Although the end plates and the ring are strong enough to prevent these displacements, a protrusion of the core through the most weakened parts of the disk finally appears on the disk.
  • the protrusion usually appears on the back of the ring, which is not only the thinnest, but also the least firmly attached to the bone. In some cases, the protrusion is lateral or anterolateral and, only in a small percentage of occasions, is it anterior.
  • the protrusion of the nucleus through the ring is due to a combination of mechanical and biochemical phenomena of a degenerative nature, such as the progressive loss of water and proteoglycans from the nucleus.
  • the fact that the herniated disc does not only have its origin in the mechanical overloads of the spine is confirmed by the fact that it has not been possible to reproduce, by compression of the cartilaginous plates ter. corpses, the type of herniated disc that - and observed in patients.
  • the intervention of a damaged intervertebral disc consists in the partial or total suppression of the nucleus pulposus of said disc, whose protrusion is causing compression of the nerve roots with - the consequent pain that results from it.
  • Open surgery is performed when the purpose of the operation is to perform a wide exploration of the spinal canal at several intervertebral levels, or when the patient or the pathology is not adequate to perform a nucleotomy / chemo-nucleosis.
  • the technique consists in resecting, totally or partially, the vertebral plate, until obtaining access to the part of the disc where the nucleus pulposus protrudes. Next, the disk fragments are carefully extracted. Having removed one bone portion, a second intervention may be necessary to stabilize the spine by spinal fusion (arthrodesis).
  • Percutaneous nucleotomy is based on the introduction through a small skin incision of a nucleotome 2 millimeters in diameter to reach the nucleus pulposus.
  • Manual guidance in the introduction of the nucleotome, bypassing the bony processes, is performed by radioscopic control of the spine in two planes, vertical (anteroposterior) and horizontal (transverse or lateral), so that its observation allows the area to be reconstructed three-dimensionally.
  • the introduction of the nucleotome requires its longi ⁇ tudinal axis angles form between 45 and 55 s with the sagittal plane so that in its advance not find the transverse apófi ⁇ sis.
  • the nucleotome performs its function consisting of cutting the nuclear material by guillotining between two concentric cylinders with advance and retraction of the interior and simultaneous aspiration of said material.
  • Chemucleucleosis consists " in the introduction of a needle into the nucleus pulposus, and once it has been reached, an enzyme chemopapain from papaya latex is injected, it is a proteolytic enzyme that catalyzes the hydrolysis of the nucleus matrix Octopus until dissolved.
  • chemo-nucleosis is considered as the least invasive lumbar disc herniation intervention technique with the least risk and cost.
  • a stereotaxy system is nothing more than a mechanical design that allows to determine the coordinates in space (x, y, z) of an anatomical point on which it is desired to act (surgery, stimulation, infiltration, etc.) taking this point as center of a casque- spherical te that is defined by the mechanical system itself.
  • machining must be effected by EDM and subsequent filling of the holes of the millimeter by a radio-opaque material such as lead.
  • a radio-opaque material such as lead.
  • the thicknesses of lead must be very well adjusted in order to ensure the sharpness of the radiographic image.
  • the complication of machining is such that the costs of manufacturing the strips involve approximate- mind 50% of the total manufacturing costs of the equipment.
  • the stereotaxy system developed in this patent allows access of an instrument with total precision and quickly, to the target point limiting the use of X-rays to the previous phase of spatial location of the target, reducing therefore the radiation exposure time in addition to the degree of specialization necessary.
  • the system designed to optimize other surgical processes may be to obtain biopsy samples in vertebral bodies at the dorsal level. In this location the technique requires a high degree of accuracy since the access road is limited on one side by the spinal cord and in the other by the pleural leaf.
  • Figures 1 and 2 show a scheme of the developed stereotaxy system.
  • Figures 3 and 4 respectively show a perspective view partially sectioned and with the fixing and sliding mechanism (22) perpendicular to its direction of action, for a better understanding of the total assembly; and a projection in profile.
  • the stereotaxy system proposed here is based on the fact that the location of a point in space requires, at a minimum, the taking of two images in two different planes (usually perpendicular) in which, in addition to the target point, a known reference system. Each of these images confirms that said point is in the line perpendicular to the image plane, which passes through the projection of the real point on this plane.
  • the spatial inter ⁇ section of two of these lines at different normally perpendicular angles determines the X, Y, Z coordinates of the point in question to which it calls. oars target point of target.
  • the described process will generally associate a geometric error, since it over-determines the spatial situation of that point.
  • the geometric error made depends on the radiographic equipment given the conicity with which the object under analysis is irradiated, the precision in the auxiliary reference system and the relative position of the two images.
  • the geometric location error of the cut point of the two lines is smaller when the images are made in planes perpendicular to each other.
  • the operating rooms in which these interventions are performed have an image intensifying X-ray system.
  • This equipment allows a continuous image of the desired area to be obtained on a monitor.
  • the plane on which the image is obtained can be modified at will by simple movements of the intensifier. Thanks to this, its use in obtaining two images perpendicular to each other of the affected area is extremely simple.
  • image intensifier is the starting point for the correct placement of the stereotaxy equipment. With the individual in the prone or lateral recumbency position, these two planes must be, preferably the lateral and the anteropos ⁇ ior.
  • the surgeon manages to locate a specific point of the stereotaxy system (an x-ray image will appear on the x-ray image, which will be the result of the superposition of at least two consecutive points or a linear piece projected longitudinally) in a relative position relative to the target point (default by design).
  • This is simple to achieve since the equipment is equipped with three degrees of freedom (following the coordinates X, Y, Z), as shown in Figure 1.
  • the stereotaxy system is equipped with a pointing mechanism to base of view to achieve its alignment with the objective point (thus specifying its coordinates X, Y, Z).
  • the mechanical system can move continuously and observe these movements with the image intensifier, observing on the screen the displacement of the horizontal references of the equipment established to specify the X, Y coordinates under horizontal (lateral) radiological projection. until the coincidence of those with the target point; in a second moment, and under vertical radiological projection (or perpendicular to the previous one), the vertical references of the system will be matched with the target point, thus specifying the Z coordinate.
  • the equipment will be correctly positioned when the aiming points appear the superimposed objective point, both in the horizontal and vertical projection. In this way we have managed to match the center 0 "(zero) of the spherical cap shown in Figure 2, with the target point.
  • This location of the point to intervene is achieved by sliding on the side (X coordinate) of the bar (1), and the height displacement (Y coordinate) of the bar (4) with the help of a radioscopic control which will determine in the previous screen lateral (horizontal) irradiation, the point that we intend to locate and on which it is desired to intervene, superimposing on it the sights 8 and 8 ' ( Figure 3 and 4), first with a displacement lateral (X), and then with a displacement in height (Y), and all this under radioscopic control.
  • the locks are fixed in the form of levers or screws (5) and (6) that will prevent lateral movement (axis X), and the lock (11) that ' will prevent movement in height (Y axis).
  • the bar (4) will slide horizontally in depth (Z axis) along the part (10), until the point to intervene is shown on the screen of the image intensifier super ⁇ placed with the references vertical (3 and 3 ' ) that have moved until they coincide in the image with the target point; with this we have managed to match the coordinate Z of the line that joins 3 and 3 ' , and which in turn coincides with that of point 0 (zero) of the spherical cap of the figure (2), with the coordinate Z of the target point.
  • the safety lock (7) that prevents the displacement of the bar (4) will be fixed, with the Z coordinate being set.
  • the X, Y, Z coordinates of the target point will be obtained.
  • the locks (19 and 20) respectively fix the rotation on the A axis of the arc (15), and the instrument holder (28) or guide for the penetration of the instrument to be introduced, (which is interchangeable depending on the type of intervention To make).
  • the fixing and sliding mechanisms act directly on the sprockets (14, 13 and 12), or with eccentrics, sliding by means of sprockets that act on a rack system (25), as well as on the dovetails of the bars (1 and 4) respectively, on which two zippers have been installed.
  • the Zippers will be capable of being replaced by another system, such as endless screws.
  • the surgical instrument (18) If in the introduction of the surgical instrument (18) that is to reach the target point, it makes contact with an obstacle, for example with a bone process, a slight variation of the last two degrees of freedom (both simultaneously) or only one of them), first removing the instrument (18) and subsequently varying the angulation slightly on the A axis, and / or Aemisagain by introducing the surgical instrument through a different point on the skin penetrating later, and unfailingly, towards the target point.
  • an obstacle for example with a bone process, a slight variation of the last two degrees of freedom (both simultaneously) or only one of them)
  • the equipment is essentially formed by a series of basic parts, defined above, designed to allow easy disassembly.
  • the zipper sliding system allows fine adjustments of great precision while the fixing means are constituted by parts without edges and clean and ergonomic design.
  • the Y coordinate will be concretized, under lateral radiological projection (horizontal), locating in the image the Puntodiana that you want to access surgically, on which the sights 8 and 8 'must be superimposed, which will be done by shifting in height (ascent - descent) bar 4 until the three points (8, 8 'and target point) coincide.

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Abstract

Stereotaxis system for surgery of the rachis which allows to localise and approach anatomical points and comprising a mechanical device having three and two degrees of freedom for displacement, in the first place, longitudinally, transversally and in elevation with respect to the operation table and, in the second place, a rotation with respect to the sagittal plane and a final introduction towards the target point which the surgeon wants to operate. To this effect, and in order to localise the point of intervention, the system uses sights adaptable to the X ray apparatus and which allow to determine with high precision the spatial coordinates of the target point which is desired to be operated.

Description

Sistema de estereotaxia para cirugia del raquis. El ob/jeto de la presente invención es un sistema que ayuda al cirujano en intervenciones percutáneas. Este sistema se denomina estereotáxico por permitir el acceso con total precisión a un punto quirúrgico situado sobre un área anatómica mediante la reconstruc¬ ción tridimensional de la misma y desemboca en la construcción de un aparato que será manejado por espe¬ cialistas en este tipo de cirugía. El sistema de estereotaxia concebido reducirá el nivel de especialización requerido por los cirujanos que intervienen hernias discales u otras intervenciones suspectibles de ser abordadas percutáneamente, a la vez que minimizará los tiempos de exposición radioscó- pica, tanto del paciente como del médico, durante estas intervenciones. Stereotaxy system for spinal surgery. The object of the present invention is a system that helps the surgeon in percutaneous interventions. This system is called stereotaxic because it allows access with total precision to a surgical point located over an anatomical area by means of the three-dimensional reconstruction of the same and leads to the construction of an apparatus that will be handled by specialists in this type of surgery. . The stereotaxy system conceived will reduce the level of specialization required by surgeons who intervene herniated discs or other interventions suspected of being treated percutaneously, while minimizing radioscopic exposure times, both of the patient and the doctor, during these interventions .
El diseño final cubre dos objetivos básicos, por una parte, su sencillez mecánica, asociada a un acotado funcional con tolerancias estrictamente racio- nales, facilitará su mecanizado y reducirá los costes de fabricación. Por otra, la sencillez operativa alcan¬ zada evitará la típica resistencia' médica a la utiliza¬ ción de equipos de concepción novedosa.The final design covers two basic objectives, on the one hand, its mechanical simplicity, associated with a functional dimensioning with strictly rational tolerances, will facilitate its machining and reduce manufacturing costs. Furthermore, operational simplicity alcan¬ Zada avoid typical resistance 'to medical equipment utiliza¬ tion novel conception.
La columna vertebral es una estructura que combi- na la rigidez necesaria para soportar el peso corporal en bipedestación a la vez que protege la delicada médula espinal y los nervios raquídeos poseyendo al mismo tiempo la flexibilidad que exigen los movimientos habituales en el ser humano (flexión, extensión y torsión). Está formada por una serie de vértebras articuladas entre sí mediante discos intervertebrales.The spine is a structure that combines the stiffness necessary to support the standing body weight while protecting the delicate spinal cord and spinal nerves while possessing the flexibility demanded by the usual movements in humans (flexion , extension and torsion). It is formed by a series of vertebrae articulated with each other by intervertebral discs.
Una columna vertebral se divide en cuatro zonas: cervical, torácica, lumbar y sacra, formada por 7, 12, 5 y 5 vértebras, respectivamente. Cada disco intervertebral está constituido por tres partes, dos placas terminales cartilaginosas, superior e inferior, una parte exterior de tejido duro pero flexible, denominada anillo fibroso y una interior más blanda denominada núcleo pulposo. Las placas cartilaginosas presentan un milímetro de periferia, siendo algo más delgadas en su parte central, unen el hueso al anillo fibroso mediante una matriz densa de fibras de colágeno.A spine is divided into four zones: cervical, thoracic, lumbar and sacral, consisting of 7, 12, 5 and 5 vertebrae, respectively. Each intervertebral disc is constituted by three parts, two cartilaginous end plates, upper and lower, an outer part of hard but flexible tissue, called a fibrous ring and a softer inner one called the nucleus pulposus. The cartilaginous plates have a millimeter of periphery, being somewhat thinner in their central part, they bind the bone to the fibrous ring through a dense matrix of collagen fibers.
El anillo fibroso está constituido por capas concéntricas de fibras de colágeno. Las fibras de cada capa son paralelas entre sí y rodean al eje del disco en espiral, formando ángulos de 45s con el mismo.The fibrous ring consists of concentric layers of collagen fibers. The fibers of each layer are parallel to each other and surround the axis of the spiral disk, forming angles of 45 s with it.
Las fibras dispuestas en capas contiguas forman ángulos rectos entre sí. Con esta disposición se logra una gran resistencia en la unión de los cuerpos vertebrales permitiendo el entrecuzamiento de las fibras la flexión y torsión del disco, asegurando la resistencia a la rotura del anillo fibroso. Las capas adyacentes están separadas por un gel rico en proteoglicanos que trans- mite y uniformiza la presión generada en el núcleo pulposo.The fibers arranged in adjacent layers form right angles to each other. With this arrangement a great resistance is achieved in the union of the vertebral bodies allowing the interlocking of the fibers the flexion and torsion of the disc, ensuring the resistance to breakage of the fibrous ring. The adjacent layers are separated by a gel rich in proteoglycans that transmits and unifies the pressure generated in the nucleus pulposus.
El núcleo pulposo está constituido por un tejido semi-gelatinoso que retiene alrededor de un 80% de agua. Esencialmente es un gel de mucopolisacáridos muy hidratado, envuelto por fibrillas de colágeno distribuidas al azar. En condiciones normales el anillo fibroso y las placas terminales cartilaginosas, sopor¬ tadas por los huesos adyacentes, son lo suficientemente rígidas como para resistir los deplazamientos del núcleo.The nucleus pulposus is constituted by a semi-gelatinous tissue that retains about 80% water. Essentially it is a very hydrated mucopolysaccharide gel, wrapped by randomly distributed collagen fibrils. Under normal conditions, the fibrous ring and cartilaginous end plates, supported by adjacent bones, are rigid enough to resist core displacements.
La médula espinal se mantiene en su posición soportada por músculos y ligamentos. De ella nacen las raices de los nervios, como canales de comunicación entre el cerebro y el resto del organismo. El estudio de los procesos de envejecimiento de la columna y discos intervertebrales ha dado origen a la teoria -degenerativa, la cual asume que todas las columnas vertebrales degeneran con el tiempo. Desde este punto de vista, cualquier tratamiento médico o quirúrgico supone un alivio temporal del dolor y no la restauración total al comportamiento normal del raquis.The spinal cord is held in its position supported by muscles and ligaments. From it the roots of the nerves are born, as channels of communication between the brain and the rest of the organism. The study of aging processes of the spine and intervertebral discs has given rise to the -degenerative theory, which assumes that all vertebral columns degenerate over time. From this point of view, any medical or surgical treatment involves temporary pain relief and not total restoration to normal spinal behavior.
Se denomina hernia discal a la protrusión sin pasar al canal medular del núcleo pulposo a través de las grietas radiales que aparecen en el anillo fibroso. Existe una tendencia al desplazamiento del núcleo debido a las fuerzas que actúan sobre él. Aunque las placas terminales y el anillo son lo suficientemen¬ te resistentes como para impedir estos desplazamientos, finalmente aparece en el disco una protrusión del núcleo a través de las partes más debilitadas de aquel. La protrusión suele aparecer por la parte posterior del anillo, la cual es no sólo la más delgada, sino también la menos firmemente unida al hueso. En algunas ocasiones, la protrusión es lateral o anterolateral y, sólo en un pequeño porcentaje de ocasiones, es anterior.The protrusion disc herniation is called without passing the medullary canal of the nucleus pulposus through the radial cracks that appear in the fibrous ring. There is a tendency to displacement of the nucleus due to the forces acting on it. Although the end plates and the ring are strong enough to prevent these displacements, a protrusion of the core through the most weakened parts of the disk finally appears on the disk. The protrusion usually appears on the back of the ring, which is not only the thinnest, but also the least firmly attached to the bone. In some cases, the protrusion is lateral or anterolateral and, only in a small percentage of occasions, is it anterior.
La protrusión del núcleo a través del anillo se debe a una combinación de fenómenos mecánicos y bioquímicos de naturaleza degenerativa, como es la pérdida progresiva de agua y proteoglicanos del núcleo. El hecho de que la hernia discal no tenga únicamente su origen en las sobrecargas mecánicas de la columna lo constata el que no se haya logrado reproducir, mediante compresión de las placas cartilaginosas ter. nales de cadáveres, el tipo de hernia discal que -,e observa en los pacientes.The protrusion of the nucleus through the ring is due to a combination of mechanical and biochemical phenomena of a degenerative nature, such as the progressive loss of water and proteoglycans from the nucleus. The fact that the herniated disc does not only have its origin in the mechanical overloads of the spine is confirmed by the fact that it has not been possible to reproduce, by compression of the cartilaginous plates ter. corpses, the type of herniated disc that - and observed in patients.
La intervención de un disco intervertebral her¬ niado consiste en la supresión parcial o total del núcleo pulposo de dicho disco, cuya protrusión está causando la compresión de las raices nerviosas con - el consiguiente dolor que de ello se deriva. Existen va rias técnicas alternativas:The intervention of a damaged intervertebral disc consists in the partial or total suppression of the nucleus pulposus of said disc, whose protrusion is causing compression of the nerve roots with - the consequent pain that results from it. There are several alternative techniques:
- Intervención quirúrgica a cielo abierto con laminectomía o hemilaminectonía. Dentro de este grupo englobaremos a la microcirugía.- Open surgery surgery with laminectomy or hemilaminectonia. Within this group we will include microsurgery.
- Cirugía percutánea:- Percutaneous surgery:
- Nucleotomía percutánea.- Percutaneous nucleotomy.
- Quimionucleosis El porcentaje de éxitos medidos como alivio del dolor es similar en los tres métodos. Las dos últimas técnicas tienen la ventaja, sobre la cirugía a cielo abierto de se métodos que casi no entrañan riesgo quirúrgico. Tanto la nucleotomía como la quimio- nucleosis están siendo cada vez más utilizadas frente a la cirugía abierta ya que son menos agresivas, redu¬ cen el tiempo de quirófano, aminoran el periodo de hospitalización, disminuyen el tiempo de convalecencia y exigen únicamente anestesia local. Todas las técnicas de intervención están condi¬ cionadas por la dificultad que supone llegar a través de los extremos óseos (apófisis") de las vértebras al núcleo que se va a intervenir máxime teniendo en cuenta las delicadas estructuras ubicadas en las cerca- nias.- Chemonucleosis The percentage of successes measured as pain relief is similar in all three methods. The last two techniques have the advantage, over open-pit surgery of methods that almost do not involve surgical risk. Both nucleotomy and chemo-nucleosis are being increasingly used in the face of open surgery since they are less aggressive, reduce the operating room time, reduce the period of hospitalization, reduce convalescence time and demand only local anesthesia. All intervention techniques are conditioned by the difficulty of reaching through the bone ends (apophysis " ) of the vertebrae to the nucleus that will be intervened, taking into account the delicate structures located in the vicinity.
La cirugía abierta se efectúa cuando el propósito de operación es realizar una amplia exploración del canal medular en varios niveles intervertebrales, o bien cuando el paciente o la patología no sea la adecuada para realizar una nucleotomía/quimionucleosis. La técnica consiste en resecar, total o parcial¬ mente la lámina vertebral, hasta conseguir el acceso a la parte del disco por donde protruye el núcleo pulposo. A continuación, son extraídos cuidadosamente los fragmentos del disco. Al haber extirpado una porción ósea, puede resultar necesaria una segunda intervención para estabilizar la columna mediante una fusión espinal (artrodesis) .Open surgery is performed when the purpose of the operation is to perform a wide exploration of the spinal canal at several intervertebral levels, or when the patient or the pathology is not adequate to perform a nucleotomy / chemo-nucleosis. The technique consists in resecting, totally or partially, the vertebral plate, until obtaining access to the part of the disc where the nucleus pulposus protrudes. Next, the disk fragments are carefully extracted. Having removed one bone portion, a second intervention may be necessary to stabilize the spine by spinal fusion (arthrodesis).
La nucleotomía percutánea se basa en la introduc- ción a través de una pequeña incisión en piel de un nucleotomo de 2 milímetros de diámetro exterior hasta llegar al núcleo pulposo. El guiado manual en la intro¬ ducción del nucléotomo, sorteando las apófisis óseas, se realiza mediante control radioscópico del raquis en dos planos, vertical (anteroposterior) y horizontal (transversal o lateral), de forma que su observación permita reconstruir tridimensionalmente la zona. La introducción del nucléotomo requiere que su eje longi¬ tudinal forma ángulos entre 45e y 55s con el plano sagital para que, en su avance, no encuentre las apófi¬ sis transversas.Percutaneous nucleotomy is based on the introduction through a small skin incision of a nucleotome 2 millimeters in diameter to reach the nucleus pulposus. Manual guidance in the introduction of the nucleotome, bypassing the bony processes, is performed by radioscopic control of the spine in two planes, vertical (anteroposterior) and horizontal (transverse or lateral), so that its observation allows the area to be reconstructed three-dimensionally. The introduction of the nucleotome requires its longi¬ tudinal axis angles form between 45 and 55 s with the sagittal plane so that in its advance not find the transverse apófi¬ sis.
Una vez alcanzado el punto diana, el nucleotomo realiza su función consistente en el corte del material nuclear mediante guillotinado entre dos cilindros concéntricos con avance y retroceso del interior y aspiración simultanea de dicho material.Once the target point has been reached, the nucleotome performs its function consisting of cutting the nuclear material by guillotining between two concentric cylinders with advance and retraction of the interior and simultaneous aspiration of said material.
La quimionucleosis consiste " en la introducción de una aguja en el núcleo pulposo, y una vez se ha alcanzado éste, se inyecta un enzima la quimopapaína procedente del látex de papaya, se trata de un enzima proteolítico que cataliza la hidrólisis de la matriz del núcleo pulposo hasta disolverlo.Chemucleucleosis consists " in the introduction of a needle into the nucleus pulposus, and once it has been reached, an enzyme chemopapain from papaya latex is injected, it is a proteolytic enzyme that catalyzes the hydrolysis of the nucleus matrix Octopus until dissolved.
Actualmente la quimionucleosis es considerada como la técnica de intervención de hernia discal lumbar menos invasiva y de menos riesgo y coste.Currently, chemo-nucleosis is considered as the least invasive lumbar disc herniation intervention technique with the least risk and cost.
Un sistema de estereotaxia no es sino un diseño mecánico que permite determinar las coordenadas en el espacio (x, y,z) de un punto anatómico sobre el que se desea actuar (cirugía, estimulación, infiltra- ción, etc) tomando este punto como centro de un casque- te esférico que queda definido por el propio sistema mecánico.A stereotaxy system is nothing more than a mechanical design that allows to determine the coordinates in space (x, y, z) of an anatomical point on which it is desired to act (surgery, stimulation, infiltration, etc.) taking this point as center of a casque- spherical te that is defined by the mechanical system itself.
En consecuencia, la utilización de un sistema de estereotaxia se desarrolla en dos etapas sucesivas: -Ia etapa: Determinación de las coordenadas del punto anatómico sobre el que se desea actuar.Consequently, the use of a stereotaxy system is developed in two successive stages: -I a stage: Determination of the coordinates of the anatomical point on which it is desired to act.
2 - etapa: Generación de un mecanismo que describa la superficie de un casquete esférico cuyo centro coincida con el punto anatómico previamente localizado. Los sistemas de localización espacial de un punto parten de la técnica de estereofotogrametría desarrollada por Hindmarsh (1.973), su adaptación al campo médico para localización de puntos anatómicos internos fue desarrollada por Bro n (1.973) dando origen a la técnica de radiografía biplanar.2 - stage: Generation of a mechanism that describes the surface of a spherical cap whose center coincides with the previously located anatomical point. The systems of spatial location of a point start from the stereophotogrammetry technique developed by Hindmarsh (1973), its adaptation to the medical field for localization of internal anatomical points was developed by Bro n (1.973) giving rise to the biplanar radiography technique.
Si intentásemos fijar un sistema de coordenadas con regletas milimetradas, radiografiar la zona en la que se encuentra el punto a localizar y medir sobre la radiografía la posición del punto con la ayuda de las regletas que aparecerían en la radiografía cometeríamos un error debido a que las regletas y el punto a localizar no se encuentran en el mismo plano y, como el tubo de rayos X es una fuente puntual, la imagen habría sufrido una distorsión cónica. Los equipos de estereotaxia convencionales que operan según se ha descrito presentan dos inconvenien¬ tes:If we try to set a coordinate system with millimeter strips, radiograph the area in which the point to be located is located and measure the position of the point on the radiograph with the help of the strips that would appear on the radiograph we would make an error because strips and the point to be located are not in the same plane and, since the X-ray tube is a point source, the image would have suffered a conical distortion. Conventional stereotaxy equipment operating as described has two drawbacks:
- Parte del mecanizado debe ser efectuado por electroerosión y posterior relleno de los huecos del milimetrado por un material radio-opaco como el plomo. Además de lo difícil del mecanizado, los espesores de plomo deben estar muy bien ajustados con el fin de asegurar la nitidez de la imagen radiográfica. La complicación del mecanizado es tal que los costes de la fabricación de las regletas suponen aproximada- mente un 50% de los costes totales de fabricación del equipo.- Part of the machining must be effected by EDM and subsequent filling of the holes of the millimeter by a radio-opaque material such as lead. In addition to the difficult machining, the thicknesses of lead must be very well adjusted in order to ensure the sharpness of the radiographic image. The complication of machining is such that the costs of manufacturing the strips involve approximate- mind 50% of the total manufacturing costs of the equipment.
Si se emplea el sistema de estereotaxia durante una intervención quirúrgica, la necesidad de efectuar cálculos matemáticos en mitad de la misma, tanto por problemas de tiempo como por la posibilidad de incurrir en errores de medida o de cálculo, la entorpecen consi¬ derablemente.If the stereotaxy system is used during a surgical intervention, the need to perform mathematical calculations in the middle of it, both due to time problems and the possibility of incurring measurement or calculation errors, significantly hinders it.
Estas limitaciones han propiciado que el uso de sistemas de estereotaxia se haya circunscrito prefe¬ rentemente a cirugía cerebral. Un equipo mecánico de estereotaxia para cirugía cerebral tiene un coste muy elevado.These limitations have led to the use of stereotaxy systems that have been limited mainly to brain surgery. A stereotaxy mechanical equipment for brain surgery has a very high cost.
El elevado coste comercial final de estos equipos impide la aplicación de los sistemas de estereotaxia existentes en el mercado a un campo como el de las intervenciones de hernia discal, debido a que, mal que bien existen 3 técnicas quirúrgicas que, solucionan esta patología. Para paliar todos estos problemas, el sistema de estereotaxia desarrollado en esta patente, permite el acceso de un instrumento con total precisión y de forma rápida, al punto diana limitando el uso de los rayos X a la fase previa de localización espacial del objetivo, reduciéndose por lo tanto el tiempo de exposición a la radiación además del grado de espe- cialización necesario.The high final commercial cost of these equipment prevents the application of existing stereotaxy systems in the market to a field such as herniated disc interventions, because, badly there are 3 surgical techniques that solve this pathology. To alleviate all these problems, the stereotaxy system developed in this patent, allows access of an instrument with total precision and quickly, to the target point limiting the use of X-rays to the previous phase of spatial location of the target, reducing therefore the radiation exposure time in addition to the degree of specialization necessary.
Como ya se indicó en párrafos anteriores además de la utilización en el tratamiento de las hernias discales, el sistema diseñado permite optimizar otros procesos quirúrgicos, uno de ellos puede ser el de la obtención de muestras de biopsias en cuerpos verte¬ brales a nivel dorsal. En esta localización la técnica requiere un alto grado de precisión puesto que la via de acceso se encuentra limitada en un lado por la médula espinal y en el otro por la hoja pleural.As indicated in previous paragraphs, in addition to the use in the treatment of herniated discs, the system designed to optimize other surgical processes, one of them may be to obtain biopsy samples in vertebral bodies at the dorsal level. In this location the technique requires a high degree of accuracy since the access road is limited on one side by the spinal cord and in the other by the pleural leaf.
Otras zonas anatómicas requieren asimismo un elevado grado de precisión en el abordaje. Una de ellas es el cuello del fémur, el acceso al cual, para la obtención percutáneamente de piezas de biopsia puede quedar definitivamente facilitado con este sis¬ tema.Other anatomical areas also require a high degree of accuracy in the approach. One of them is the neck of the femur, the access to which, for percutaneously obtaining biopsy pieces can be definitely facilitated with this system.
En definitiva, la utilidad del presente desarro¬ llo no se limita a la cirugía del raquis; su flexibili- dad hace de él un sistema completamente abierto y susceptible de ser utilizado por otras especialidades como la cirugía general, urología, ginecología, etc.In short, the usefulness of this development is not limited to spinal surgery; its flexibility makes it a completely open system and can be used by other specialties such as general surgery, urology, gynecology, etc.
Con objeto de comprender más fácilmente el diseño del sistema de estereotaxia desarrollado, anexos a esta memoria se adjuntan planos que muestran:In order to more easily understand the design of the developed stereotaxy system, annexes to this report are attached showing:
Las figuras 1 y 2 muestran un esquema del sistema desarrollado de estereotaxia.Figures 1 and 2 show a scheme of the developed stereotaxy system.
Las figuras 3 y 4 muestran respectivamente, una vista en perspectiva seccionada parcialmente y con el mecanismo de fijación y deslizamiento (22) perpendicular a su dirección de acción, para mayor comprensión del conjunto total; y una proyección en perfil.Figures 3 and 4 respectively show a perspective view partially sectioned and with the fixing and sliding mechanism (22) perpendicular to its direction of action, for a better understanding of the total assembly; and a projection in profile.
El sistema de estereotaxia aquí propuesto parte del hecho de que la localización de un punto en el espacio exige, como mínimo, la toma de dos imágenes en dos planos diferentes (habitualmente perpendicu¬ lares) en las que, además del punto diana, aparezca un sistema de referencia conocido. Cada una de estas imágenes confirma que dicho punto se halla en la recta perpendicular al plano de la imagen, que pasa por la proyección del punto real sobre este plano. La inter¬ sección espacial de dos de estas rectas en diferentes ángulos normalmente perpendiculares, determina las coordenadas X, Y, Z del punto en cuestión al que llama- remos punto objetivo de diana.The stereotaxy system proposed here is based on the fact that the location of a point in space requires, at a minimum, the taking of two images in two different planes (usually perpendicular) in which, in addition to the target point, a known reference system. Each of these images confirms that said point is in the line perpendicular to the image plane, which passes through the projection of the real point on this plane. The spatial inter¬ section of two of these lines at different normally perpendicular angles determines the X, Y, Z coordinates of the point in question to which it calls. oars target point of target.
Puesto que la localización del punto objetivo a partir de dos imágenes exige la determinación de sólo tres grados de libertad, el proceso descrito asociará, en general, un error geométrico, ya que sobredetermina la situación espacial de dicho punto. El error geométrico cometido depende del equipo radio¬ gráfico dada la conicidad con que se irradia el objeto bajo análisis, la precisión en el sistema de referencia auxiliar y la posición relativa de las dos imágenes. El error de localización geométrica del punto de corte de las dos rectas es menor cuando las imágenes se realizan en planos perpendiculares entre sí.Since the location of the objective point from two images requires the determination of only three degrees of freedom, the described process will generally associate a geometric error, since it over-determines the spatial situation of that point. The geometric error made depends on the radiographic equipment given the conicity with which the object under analysis is irradiated, the precision in the auxiliary reference system and the relative position of the two images. The geometric location error of the cut point of the two lines is smaller when the images are made in planes perpendicular to each other.
Los quirófanos en los que se realizan estas intervenciones cuentan con un sistema de rayos X inten- sificador de imágenes. Este equipo permite obtener en un monitor una imagen continua de la zona deseada. Mediante sencillos movimientos del intensificador se puede modificar a voluntad el plano sobre el que se obtiene la imagen. Gracias a ello, su utilización en la obtención de dos imágenes perpendiculares entre sí de la zona afectada es sumamente simple.The operating rooms in which these interventions are performed have an image intensifying X-ray system. This equipment allows a continuous image of the desired area to be obtained on a monitor. The plane on which the image is obtained can be modified at will by simple movements of the intensifier. Thanks to this, its use in obtaining two images perpendicular to each other of the affected area is extremely simple.
La utilización del intensificador de imágenes es el punto de partida para el emplazamiento correcto del equipo de estereotaxia. Con el individuo en posi¬ ción de decúbito prono o lateral, estos dos planos han de ser, preferentemente el lateral y el anteropos¬ terior .The use of the image intensifier is the starting point for the correct placement of the stereotaxy equipment. With the individual in the prone or lateral recumbency position, these two planes must be, preferably the lateral and the anteropos¬ior.
Con la ayuda de la técnica descrita anteriormente el cirujano logra situar un punto concreto del sistema de estereotaxia (en la imagen de rayos X aparecerá una proyección o imagen puntual, que será fruto de la superposición de, al menos dos puntos consecutivos o una pieza lineal proyectada en sentido longitudinal) en una posición relativa respecto del punto diana (predeterminada por diseño). Ello es sencillo de lograr ya que el equipo está dotado con tres grados de liber¬ tad (siguiendo las coordenadas X, Y, Z) , tal como se muestra en la figura 1. El sistema de estereotaxia está dotado de un mecanismo de puntería a base de miras para conseguir su alineación con el punto objeti¬ vo (concretando así sus coordenadas X, Y, Z) . El siste¬ ma mecánico se puede mover de forma continua y observar estos movimientos con el intensificador de imágenes, observádose en la pantalla el desplazamiento de las referencias horizontales del equipo establecidas para concretar las coordenadas X, Y bajo proyección radioló¬ gica horizontal (lateral) hasta la coincidencia de aquellas con el punto diana; en un segundo momento, y bajo proyección radiológica vertical (o perpendicular al anterior), se harán coincidir las referencias verti¬ cales del sistema con el punto diana, concretándose así la coordenada Z. El equipo estará correctamente situado cuando sobre las miras de puntería aparezca el punto objetivo superpuesto, tanto en la proyección horizontal como en la vertical. De esta forma hemos logrado hacer coincidir el centro 0" (cero) del casquete esférico representado en la figura 2, con el punto diana. Una vez lograda la posición de diseño A respecto de 0, el cirujano puede anclar los tres pares cinemáti¬ cos B, C y D de la figura 1. A partir de aquí ya no es necesaria la exposición a la radiación X puesto que la posición relativa A-0 es fija y no depende de las características antropométricas del sujeto que se interviene.With the help of the technique described above, the surgeon manages to locate a specific point of the stereotaxy system (an x-ray image will appear on the x-ray image, which will be the result of the superposition of at least two consecutive points or a linear piece projected longitudinally) in a relative position relative to the target point (default by design). This is simple to achieve since the equipment is equipped with three degrees of freedom (following the coordinates X, Y, Z), as shown in Figure 1. The stereotaxy system is equipped with a pointing mechanism to base of view to achieve its alignment with the objective point (thus specifying its coordinates X, Y, Z). The mechanical system can move continuously and observe these movements with the image intensifier, observing on the screen the displacement of the horizontal references of the equipment established to specify the X, Y coordinates under horizontal (lateral) radiological projection. until the coincidence of those with the target point; in a second moment, and under vertical radiological projection (or perpendicular to the previous one), the vertical references of the system will be matched with the target point, thus specifying the Z coordinate. The equipment will be correctly positioned when the aiming points appear the superimposed objective point, both in the horizontal and vertical projection. In this way we have managed to match the center 0 "(zero) of the spherical cap shown in Figure 2, with the target point. Once the design position has been achieved With respect to 0, the surgeon can anchor the three kinematic pairs B, C and D of Figure 1. From here, exposure to radiation X is no longer necessary since the relative position A-0 is fixed and does not depend on the anthropometric characteristics of the subject being intervened.
Supongamos ahora que en A se ha dispuesto un sistema tal que permita mover el punto "a" del segmento móvil a-b sobre una superficie esférica, centrada en el punto 0 y de radio la distancia 0A, y que se diseña de tal forma que el segmento a-b apunta siempre hacia el punto 0. Para permitir este tipo de movimiento es preciso colocar a partir del punto A un par cinemᬠtico de tipo II (2 grados de libertad), tal como se esquematiza en la figura 2.Suppose now that in A a system has been arranged that allows moving the point "a" of the mobile segment ab over a spherical surface, centered at point 0 and radius the distance 0A, and that It is designed in such a way that segment ab always points towards point 0. To allow this type of movement it is necessary to place a type II kinematic pair (2 degrees of freedom) from point A, as outlined in the figure 2.
Para abordar una intervención quirúrgica con el sistema de estereotaxia de esta patente se procede¬ ría a, bajo proyección radiolδgical horizontal (lateral o transversal), al deslizamiento de la barra (1), a lo largo de la guía (2) perteneciente al lateral de la mesa de intervenciones, y el ascenso o descenso de la barra (4) (y por tanto de las miras 8 y 8' ), hasta la superposición o alineamiento del punto diana a intervenir, sobre las miras 8 y 8'(así logramos hacer coincidir las coordenadas X e Y de la línea que une 8 y 8'que, por diseño, son las mismas que las del centro 0(cero) del casquete esférico (figura 2), con las coordenadas X e Y del punto diana; el ascenso o descenso de 8 y 8'es solidario con el mismo movimiento de la barra (4), por estar unidos a (10) y a (4).In order to approach a surgical intervention with the stereotaxy system of this patent, we would proceed, under horizontal radiolδgical projection (lateral or transverse), to the sliding of the bar (1), along the guide (2) belonging to the lateral of the table of interventions, and the ascent or descent of the bar (4) (and therefore of the sights 8 and 8 '), until the superposition or alignment of the target point to intervene, on the sights 8 and 8' (thus we managed to match the X and Y coordinates of the line that joins 8 and 8'which, by design, are the same as those of the center 0 (zero) of the spherical cap (figure 2), with the X and Y coordinates of the target point ; the ascent or descent of 8 and 8 'is in solidarity with the same movement of the bar (4), for being connected to (10) and (4).
Esta localización del punto a intervenir, se consigue mediante el deslizamiento en lateral (coorde¬ nada X) de la barra (1), y el desplazamiento en altura (coordenada Y) de la barra (4) contando con la ayuda de un control radioscδpico que' determinará en la panta¬ lla previa irradiación lateral (horizontal), el punto que pretendemos localizar y sobre el que se desea intervenir, superponiendo sobre él las miras 8 y 8'(fi- gura 3 y 4), primero con un desplazamiento lateral (X) , y luego con un desplazamiento en altura (Y), y todo ello bajo constrol radioscópico. De esta manera y una vez localizado el objetivo en un plano se procede a fijar los seguros en forma de palancas o tornillos (5) y (6) que evitarán el movimiento lateral (eje X), y el seguro (11) que 'evitará el movimiento en altura (eje Y). Como se trata de determinar un punto en el espacio, necesitamos una tercera coordenada la Z, por lo que se procederá a observar con el inten- sificador de imágenes el punto a intervenir a través de unas miras (3 y 3'), que se desplazan horizontalmen- te en profundidad (coordenada Z) por mediación de una guia (Gn)que circula a través de la cola de milano (9), situada en la barra (4). Se procederá, pues, a deslizar horizontalmente en profundidad (eje Z) la barra (4) a lo largo de la pieza (10), hasta que se vea en la pantalla del intensificador de imágenes el punto a intervenir super¬ puesto con las referencias verticales (3 y 3') que se han desplazado hasta hacerlas coincidir en la imagen con el punto diana; con ello hemos conseguido hacer coincidir la coordenada Z de la línea que une 3 y 3', y que a su vez coincide con la del punto 0 (cero) del casquete esférico de la figura (2), con la coorde- nada Z del punto diana. En ese momento se fijará el seguro (7) que impide el desplazamiento de la barra (4), quedando fijada la coordenada Z. Se obtendrán así las coordenadas X, Y, Z del punto diana.This location of the point to intervene is achieved by sliding on the side (X coordinate) of the bar (1), and the height displacement (Y coordinate) of the bar (4) with the help of a radioscopic control which will determine in the previous screen lateral (horizontal) irradiation, the point that we intend to locate and on which it is desired to intervene, superimposing on it the sights 8 and 8 ' (Figure 3 and 4), first with a displacement lateral (X), and then with a displacement in height (Y), and all this under radioscopic control. In this way and once the objective is located in a plane, the locks are fixed in the form of levers or screws (5) and (6) that will prevent lateral movement (axis X), and the lock (11) that ' will prevent movement in height (Y axis). Since it is a question of determining a point in space, we need a third coordinate of the Z, so we will proceed to observe with the image intensifier the point to intervene through a view (3 and 3 ' ), which they move horizontally in depth (Z coordinate) by means of a guide (Gn) that circulates through the dovetail (9), located in the bar (4). Therefore, the bar (4) will slide horizontally in depth (Z axis) along the part (10), until the point to intervene is shown on the screen of the image intensifier super¬ placed with the references vertical (3 and 3 ' ) that have moved until they coincide in the image with the target point; with this we have managed to match the coordinate Z of the line that joins 3 and 3 ' , and which in turn coincides with that of point 0 (zero) of the spherical cap of the figure (2), with the coordinate Z of the target point. At that time, the safety lock (7) that prevents the displacement of the bar (4) will be fixed, with the Z coordinate being set. The X, Y, Z coordinates of the target point will be obtained.
Para una perfecta localización del punto a inter- venir, los movimientos se han realizado mediante los ajustadores (12, 13, 14) que actúan a lo largo, ancho y alto de la mesa de operaciones, en un principio manualmente, aunque serán susceptibles de ser motoriza¬ dos. Una vez perfectamente determinado el punto diana y fijados estos tres grados de libertad, se hace inne¬ cesaria la utilización del sistema de rayos X evitándo¬ se así la peligrosa exposición del enfermo y del ciru¬ jano puesto que el instrumento quirúrgico a introducir a través de la guia en todo momento se mantendrá en la dirección del punto diana, independientemente de la movilización de la guía de introducción (segmento a-b de las figuras 1 y 2) en cualquiera de los puntos constituyentes de un casquete esférico (figura 2), habida cuenta del modelo de par cinemático tipo II, representado en la figura 2.For a perfect location of the point to intervene, the movements have been made using the adjusters (12, 13, 14) that act along the length, width and height of the operating table, initially manually, although they will be susceptible to Be motorized. Once the target point has been perfectly determined and these three degrees of freedom have been fixed, the use of the X-ray system becomes unnecessary, thus avoiding the dangerous exposure of the patient and the surgeon since the surgical instrument to be introduced through of the guide at all times will remain in the direction of the target point, regardless of the mobilization of the introduction guide (segment ab of figures 1 and 2) at any of the constituent points of a spherical cap (figure 2), taking into account the type II kinematic torque model, represented in figure 2.
Se procederá pues en este término a actuar sobre los dos grados de libertad que aún no habíamos conside¬ rado, con lo cual se efectuará un giro en un rango de grados más o menos amplio, dependiendo de la utili- zación concreta, en referencia al plano sagital del arco (15) que describe una rotación alrededor del eje Aj (figura 3) y se fija con el seguro (16). La pieza 15 (y, por lo tanto la 17 guía 28 fijada a ésta), es posible girarla alrededor el eje A2» con 1° cual queda configurado el segundo grado de libertad del par cinemático de tipo II representado en la figura 2, y comentado anteriormente. A partir de este momento la barra (17) puede ascender o descender siguiendo la dirección del radio del arco (15), y ser fijada a ella por el seguro (23). Tras ello se efectúa la introducción del instrumento (aguja, pinza, nucleotomo, cánula, trocar, etc.) (18), necesario para la inte _ vención.In this term, we will proceed to act on the two degrees of freedom that we had not yet considered, with which a turn will be made in a more or less wide range of degrees, depending on the specific use, in reference to the Sagittal plane of the arc (15) that describes a rotation around the axis A j (figure 3) and is fixed with the lock (16). The piece 15 (and, therefore, the 17 guide 28 fixed thereto), it is possible to rotate it around the axis A2 » with 1 ° which is configured the second degree of freedom of the kinematic pair of type II represented in figure 2, and commented above. From this moment the bar (17) can rise or fall following the direction of the radius of the arc (15), and be fixed to it by the safety (23). After that, the instrument is introduced (needle, clamp, nucleotome, cannula, trocar, etc.) (18), necessary for the intervention.
Los seguros (19 y 20) fijan respectivamente el giro en el eje A del arco (15), y el portainstru- mentos (28) o guía para la penetración del instrumento a introducir, (la cual es intercambiable en función del tipo de intervención a realizar).The locks (19 and 20) respectively fix the rotation on the A axis of the arc (15), and the instrument holder (28) or guide for the penetration of the instrument to be introduced, (which is interchangeable depending on the type of intervention To make).
Los mecanismos de fijación y deslizamiento ac- túan directamente sobre las ruedas dentadas (14, 13 y 12), o bien con excéntricas efectuándose deslizamien¬ tos mediante ruedas dentadas que actúan sobre un siste¬ ma de cremallera (25), así como sobre las colas de milano de las barras (1 y 4) respectivamente, sobre las cuales hav instaladas sendas cremalleras. Las cremalleras serán susceptibles de ser sustituidas por otro sistema, como por ejemplo tornillos sin-fin.The fixing and sliding mechanisms act directly on the sprockets (14, 13 and 12), or with eccentrics, sliding by means of sprockets that act on a rack system (25), as well as on the dovetails of the bars (1 and 4) respectively, on which two zippers have been installed. The Zippers will be capable of being replaced by another system, such as endless screws.
Si en la introducción del instrumento (18) qui¬ rúrgico que ha de llegar al punto diana, aquél hace contacto con un obstáculo, por ejemplo con una apófisis ósea se procedería a una ligera variación de los dos últimos grados de libertad (los dos simultáneamente o solo uno de ellos), primero extrayendo el instrumento (18) y subsiguientemente variando la angulación ligera- mente sobre el eje A, y/o A„ procediéndose de nuevo a la introducción del instrumento quirúrgico a través de un punto diferente en la piel penetrando posterior¬ mente, y de forma indefectible, hacia el punto diana.If in the introduction of the surgical instrument (18) that is to reach the target point, it makes contact with an obstacle, for example with a bone process, a slight variation of the last two degrees of freedom (both simultaneously) or only one of them), first removing the instrument (18) and subsequently varying the angulation slightly on the A axis, and / or A „again by introducing the surgical instrument through a different point on the skin penetrating later, and unfailingly, towards the target point.
El equipo está en esencia formado por una serie de piezas básicas, definidas anteriormente, diseñadas de forma que permita un fácil desmontaje. El sistema de deslizamiento de cremallera permite ajustes finos de gran precisión al tiempo que los medios de fijación están constituidos por piezas sin aristas y de diseño limpio y ergonómico.The equipment is essentially formed by a series of basic parts, defined above, designed to allow easy disassembly. The zipper sliding system allows fine adjustments of great precision while the fixing means are constituted by parts without edges and clean and ergonomic design.
Por último mencionar que los dispositivos de deslizamiento y fijación de los tres y dos grados de libertad pueden realizarse manualmente como en la descripción anteriormente efectuada o mediante la incorporación de motores eléctricos a los mecanismos de desplazamientos provistos del correspondiente mando a distancia, con lo cual el cirujano evitará incluso la corta exposición a las radiaciones X dispersas o reflejadas que tienen lugar en el momento de ajuste del sistema.Finally, mention that the sliding and fixing devices of the three and two degrees of freedom can be carried out manually as in the description previously made or by incorporating electric motors to the movement mechanisms provided with the corresponding remote control, whereby the The surgeon will avoid even short exposure to scattered or reflected X radiation that occurs at the time of system adjustment.
Evidentemente estas y otras mejoras podrán in¬ cluirse en el objeto aquí preconizado, el cual se ha representado exclusivamente a título representativo y no limitativo. Descrita suficientemente la naturaleza del pre- senté invento, así como una forma de llevarlo a la práctica, sólo nos queda por añadir que en su conjunto y partes que lo componen es posible introducir cambios de forma, materiales, de disposición, siempre y cuando dichas alteraciones no varíen sustancialmente las características del invento que se reivindican.Obviously, these and other improvements may be included in the object here recommended, which has been represented exclusively on a representative and non-limiting basis. Describe sufficiently the nature of the pre I set up an invention, as well as a way of putting it into practice, we only have to add that as a whole and its component parts it is possible to introduce changes in shape, materials, layout, as long as these alterations do not substantially vary the characteristics of the invention that are claimed.
Finalmente, decir que en el proceso de concreción de las coordenadas del punto de diana se puede alterar el orden de las proyecciones, realizando inicialmente una proyección radiológica vertical, en la cual se concretarán las coordenadas X, Z del punto diana proce¬ diendo a la superposición en la imagen radiológica, del punto diana sobre las miras 3 y 3' a través del movimiento a lo largo de la mesa de intervenciones -guia 2- (coordenada X), y horizontalmente en profundi¬ dad de la barra 4 (coordenada Z) . Posteriormente se concretará la coordenada Y, bajo proyección radiológica lateral (horizontal), localizando en la imagen el puntodiana al cual se quiere acceder quirúrgicamente, sobre el cual se deberán superponer las miras 8 y 8', lo cual se realizará desplazando en altura (ascenso -descenso) la barra 4 hasta conseguir la coincidencia de los tres puntos (8, 8' y punto diana).Finally, to say that in the process of specifying the coordinates of the target point the order of the projections can be altered, initially carrying out a vertical radiological projection, in which the X, Z coordinates of the target point will be specified by proceeding to the superimposition in the radiological image of the target point on sights 3 and 3 'through the movement along the table of interventions -guide 2- (coordinate X), and horizontally in depth of bar 4 (coordinate Z ). Subsequently, the Y coordinate will be concretized, under lateral radiological projection (horizontal), locating in the image the Puntodiana that you want to access surgically, on which the sights 8 and 8 'must be superimposed, which will be done by shifting in height (ascent - descent) bar 4 until the three points (8, 8 'and target point) coincide.
Durante el proceso de concreción de las coordena- das, aún si los movimientos no están motorizados, los miembros superiores del cirujano no quedan expues¬ tos directamente a la irradiación X, puesto que las ruedasde desplazamiento sobre las que actuarán las manos del operador, se encuentran lejos del flujo de rayos X. During the process of concreting the coordinates, even if the movements are not motorized, the upper members of the surgeon are not directly exposed to the X irradiation, since the displacement wheels on which the hands of the operator will act are found far from the flow of X-rays.

Claims

R E I V I N D I C A C I O N E S
1.- Sistema de estereotaxia para cirugía del raquis, que permite la localización y abordaje de punto anatómi- eos y que se materializa en un dispositivo mecánico que comporte tres y dos grados de libertad con los cuales se desplaza, en primer lugar, a lo largo, ancho y alto de la mesa de operaciones, y en segundo lugar, una rotación alrededor del eje horizontal (movimiento en el plano vertical) y alrededor del eje vertical (movimiento en el plano horizontal), y una introducción final hacia el punto diana sobre el que se desea actuar; asimismo se caracteriza porque para la localización del punto a intervenir utiliza unas miras dispuestas perpendicularmente, adaptables al aparato de rayos X, intensificador de imágenes, que permiten determinar con precisión las coordenadas espaciales del punto diana "U" sobre el que se desea intervenir. 1.- Stereotaxy system for spinal surgery, which allows the location and approach of anatomical point and which is materialized in a mechanical device that behaves three and two degrees of freedom with which it moves, first, to the length, width and height of the operating table, and secondly, a rotation around the horizontal axis (movement in the vertical plane) and around the vertical axis (movement in the horizontal plane), and a final introduction towards the target point on which you want to act; It is also characterized in that, for the location of the point to intervene, it uses perpendicularly arranged sights, adaptable to the X-ray apparatus, image intensifier, which allow to accurately determine the spatial coordinates of the target point "U" on which it is desired to intervene.
2.- Sistema de estereotaxia para cirugía del raquis, 2.- Stereotaxy system for spinal surgery,
PCT/ES1991/000040 1990-07-04 1991-07-04 Stereotaxis system for surgery of the rachis WO1992000702A1 (en)

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Application Number Priority Date Filing Date Title
ES9001837A ES2025894A6 (en) 1990-07-04 1990-07-04 Stereotaxis system for surgery of the rachis
ES9001837 1990-07-04

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Cited By (6)

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US5483961A (en) * 1993-03-19 1996-01-16 Kelly; Patrick J. Magnetic field digitizer for stereotactic surgery
EP0761177A2 (en) * 1995-09-08 1997-03-12 Armstrong Healthcare Limited A goniometric robotic arrangement
US5787886A (en) * 1993-03-19 1998-08-04 Compass International Incorporated Magnetic field digitizer for stereotatic surgery
US7208260B2 (en) 1998-12-31 2007-04-24 Hynix Semiconductor Inc. Cross-linking monomers for photoresist, and process for preparing photoresist polymers using the same
US7245958B1 (en) * 1996-09-30 2007-07-17 Siemens Corporate Research, Inc. Trigonometric depth gauge for biopsy needle
US8838199B2 (en) 2002-04-04 2014-09-16 Medtronic Navigation, Inc. Method and apparatus for virtual digital subtraction angiography

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US4723544A (en) * 1986-07-09 1988-02-09 Moore Robert R Hemispherical vectoring needle guide for discolysis

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Publication number Priority date Publication date Assignee Title
FR910078A (en) * 1945-04-03 1946-05-27 Femoral neck nailing goniometer
US4722336A (en) * 1985-01-25 1988-02-02 Michael Kim Placement guide
US4723544A (en) * 1986-07-09 1988-02-09 Moore Robert R Hemispherical vectoring needle guide for discolysis

Cited By (7)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US5483961A (en) * 1993-03-19 1996-01-16 Kelly; Patrick J. Magnetic field digitizer for stereotactic surgery
US5787886A (en) * 1993-03-19 1998-08-04 Compass International Incorporated Magnetic field digitizer for stereotatic surgery
EP0761177A2 (en) * 1995-09-08 1997-03-12 Armstrong Healthcare Limited A goniometric robotic arrangement
EP0761177A3 (en) * 1995-09-08 1998-01-07 Armstrong Healthcare Limited A goniometric robotic arrangement
US7245958B1 (en) * 1996-09-30 2007-07-17 Siemens Corporate Research, Inc. Trigonometric depth gauge for biopsy needle
US7208260B2 (en) 1998-12-31 2007-04-24 Hynix Semiconductor Inc. Cross-linking monomers for photoresist, and process for preparing photoresist polymers using the same
US8838199B2 (en) 2002-04-04 2014-09-16 Medtronic Navigation, Inc. Method and apparatus for virtual digital subtraction angiography

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