Name: nine-grid area division method: a new ideal bone puncture region for percutaneous vertebroplasty in lumbar spine
Uploaded: 2024-08-09T13:30:00.000+00:00
Duration: 9 min 29 s
Description: Percutaneous vertebroplasty (PVP) is widely recognized as an efficacious intervention for alleviating low back pain resulting from osteoporotic vertebral ...

The study was funded by Beijing Natural Science Foundation-Haidian Original Innovation Joint Fund (L232054) and Capital Health Development Research Special Fund (NO.2024-2-2024).

The present study was approved by the Ethics Committee of Beijing Friendship Hospital Capital Medical University. This method will be introduced via a retrospective case study, utilizing only the preoperative prone-position computed tomography (CT) imaging data of the patient. The &#34;Nine-grid Area Division Method&#34; in assisted percutaneous vertebroplasty (PVP) offers a simpler and more effective approach compared to traditional methods, resulting in reduced surgical and radiation exposure times. This technique may benefit young residents by facilitating easier identification of puncture points and potentially shortening the learning curve for PVP procedures, warranting further investigation. The individual described here is a female of 68 years of age.
1. Diagnosing osteoporotic vertebral compression fracture (OVCF) using X-ray fluoroscopy, magnetic resonance image (MRI), bone scintigraphy, and symptoms
<ol>
	<li>Identify the patient who has OVCF among older patients with symptoms such as back pain, tenderness in the spinous process, and paraspinal muscles at the back. Utilize posteroanterior X-ray fluoroscopy to assess for the presence of a vertebral compression fracture at the L1 level (Figure 2A). Employ MRI imaging to confirm the diagnosis of a newly occurring lumbar vertebral compression fracture and identify the specific vertebra affected, which is determined to be L1 (Figure 2B).</li>
</ol>
2. The preoperative acquisition of CT imaging of the patient in a prone position
<ol>
	<li>Place the patient in a prone position to perform prone CT on the patient. Confirm the target area by x-ray fluoroscopy and a physical examination of the patient&#39;s back while pressing the most painful part.</li>
	<li>Make the patient lie in a prone position on the operation table, place a gradienter on the patient&#39;s back before the prone CT scan, record the patient&#39;s body position, and then remove the gradienter (Figure 3).</li>
	<li>Save the CT images (1 mm scanning layer thickness, 1 mm layer spacing, and either 90 slices (conventional scanning) or 400 slices (thin slice scanning) in DICOM format.</li>
</ol>
3. Establish the 3-D model and simulate the operation in medical imaging processing software
<ol>
	<li>Export the CT images in DICOM format into medical imaging processing software by clicking New Project. Select the desired slices for reconstructing the compressed vertebra.</li>
	<li>Utilize the Threshold Segmentation tool to adjust the threshold range for the target vertebra, specifically within the range of 125-3071 H to create a mask. Employ the Duplicate Mask function to generate two separate masks, Mask A and Mask B.</li>
	<li>Utilize the Mask Edit feature to erase the target vertebra from Mask A. Subsequently, utilize the Boolean Operations tool to subtract Mask A from Mask B, resulting in the formation of a new mask, Mask C. Finally, activate the Calculate 3-D function to reconstruct the target vertebra using the Mask C; name this 3-D model L1 (Figure 4A).</li>
	<li>Right-click on New in the Objects interface, choose Draw, and subsequently select Cylinder. Ensure that the cylinder has the same dimensions as the puncture needle, with a length of 12.5 mm and a radius of 1.25 mm.</li>
	<li>Adjust the positioning of the cylinder using the Move and Rotate function to achieve the ideal position (Figure 4B). Throughout the simulation, take care to maintain needle trajectories consistent with established principles: the puncture needle must be able to traverse the pedicle, preferably in its superior half, and the optimal positioning of the tips is within the anterior one-third of the vertebral body on the lateral view.</li>
	<li>Right-click on L1 in the Objects interface, choose Export STL, and subsequently export the file in STL format.</li>
</ol>
4. Polish the 3-D model in 3-D reverse engineering production software
<ol>
	<li>Import the exported vertebral body solid file into the 3-D reverse engineering production software by clicking Import. Consequently, employ the Mesh Doctor feature to eliminate distortions and spikes from the model.</li>
	<li>As the Grid Doctor function may mistakenly identify normal anatomical structures as distortions or spikes, take care to thoroughly examine the rough model to identify any internal voids, and follow step 4.1 to fill them appropriately (Figure 5A).</li>
	<li>Employ the Precise Surface function to transform the solid model into a triangular mesh surface, opting for the Organic Geometry Material (Figure 5B). Await the completion of the automated surface construction process and subsequently export the file in STP format.</li>
</ol>
5. Reconstruct the vertebral engineering model and confirm the safe entry regions of pedicle projection in 3-D modeling design software
<ol>
	<li>Import the STP format of the precise surface document into 3-D modeling design software to reconstruct the vertebral engineering model by clicking Open. Employ the Section View feature to examine the pedicle&#39;s morphology in horizontal, sagittal, and coronal orientations, providing an initial observation of the pedicle&#39;s morphology and structure (Figure 6A).</li>
	<li>In the Section View panel, adjust the angle of the section for optimal visualization. By utilizing Transparency Section Bodies, observe the narrowest point of the pedicles (Figure 6B) and record the angle parameters at Section 1 in the left panel.</li>
	<li>To adjust the angle of the vertebral model, click on the Insert-Features-Move/Copy function and select the Translate/Rotate button located at the bottom of the left panel. Revisit the Section View panel and adjust the view angle parameter in Section 1 to 0.</li>
	<li>Fine-tune the displacement parameters in the Section 1 panel to attain a satisfactory pedicle section view. Reorient for an improved perspective to observe the pedicle section. Document the confirmed displacement parameters in the panel (Figure 7).</li>
	<li>Utilize the aforementioned Move/Copy function to manipulate the position of the vertebral model. Specify the displacement parameter in the left panel. Employ the Corner Rectangle tool to encompass the entirety of the vertebral body.</li>
	<li>To begin, navigate to the Features-Reference Geometry-Plane option and designate the section view as the First Reference. Modify the offset distance parameter accordingly to relocate the newly created plane to the anterior third of the vertebral body.</li>
	<li>Proceed to generate a Sketch on the aforementioned plane and draw a Point at the midpoint of the vertebral body, signifying the termination point of the puncture.</li>
	<li>Use the Extruded Cut function to perform the cutting of the model. Designate the rectangular sketch generated as the Selected Contours.</li>
	<li>Make adjustments to both the direction and depth to divide the vertebral body model into two halves, namely the vertebral body half and the lamina half (Figure 8A). Save the engineering files in SLDPRT format, specifically as part of the process.</li>
	<li>Open the file containing the vertebral body part, followed by the creation of a sketch based on the section plane. Use the Convert Entities function to convert the left pedicle projection into a curve sketch.</li>
	<li>Repeat the above procedure for the right pedicle projection, resulting in the acquisition of another curve sketch. Employ the Filled Surface function to transform the curve sketches into surfaces, with the left and right pedicle projection curve sketches serving as the boundary (Figure 8B).</li>
	<li>Display the resulting surface after the vertebra has been concealed. Select the Lofted Boss/Base function on the Features panel.</li>
	<li>The superior positioning of the left pedicle surface, with the designation of the puncture endpoint as Profiles, will yield a conical structure delineating the paths for pedicle puncture. Use the left side as a reference for illustrative purposes, with the same process to be replicated on the right side.</li>
	<li>Use the Scale function to magnify the bilateral conical structure, with the centroid serving as the scaling center point and a scale factor of 2. Employ the Move/Copy Body function to individually relocate the conical structures.</li>
	<li>Within the Mate Setting panel interface, select the apex of the structure and the puncture end point, with the matching mode set as Coincident. Eliminate the vertebral body subsequently using the Delete/Keep Body function (Figure 9A).</li>
	<li>The biconical structure is a compilation of bilateral pedicle puncture paths, saved in SLDPRT format. Employ the Insert Part function to reassemble the lamina part and the vertebral body part using the pedicle puncture set. Simply press the OK button to automatically align the insert position of the part with the origin (Figure 9B).</li>
	<li>Employ the Combine Body function for executing Boolean operations on various components. Through the process of subtracting the puncture set from one half of the laminae while retaining all laminae components, the subsequent analysis indicates that the ideal bone puncture region includes regions 1, 4, and 7 on the left side (Figure 9C).</li>
</ol>

Enhancing Pedicle Puncture Precision with 3D Modeling and a Nine-Grid Method

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PART 2 Interventional procedures for back pain.</a> J Pain Res. 16, 761-772 (2023).</li><li>Jie, W., Qiang, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Beware+of+Brucella+spondylitis+following+vertebroplasty:+an+unusual+case+of+osteoporotic+vertebral+compression+fracture.">Beware of Brucella spondylitis following vertebroplasty: an unusual case of osteoporotic vertebral compression fracture.</a> Infect Drug Resist. 15, 2565-2572 (2022).</li><li>Xinqiang, H., Yongzhen, Z., Zhu, W., Mengpeng, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Case+report:+Cement+entrapped+in+the+inferior+vena+cava+filter+after+pedicle+screw+augmentation.">Case report: Cement entrapped in the inferior vena cava filter after pedicle screw augmentation.</a> Front Cardiovasc Med. 9, 892025 (2022).</li><li>Saracen, A., Kotwica, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+of+percutaneous+vertebroplasty:+An+analysis+of+1100+procedures+performed+in+616+patients.">Complications of percutaneous vertebroplasty: An analysis of 1100 procedures performed in 616 patients.</a> Medicine (Baltimore). 95 (24), e3850 (2016).</li><li>Peilun, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+novel+&amp;#34;three-dimensional-printed+individual+guide+template-assisted+percutaneous+vertebroplasty&amp;#34;+for+osteoporotic+vertebral+compression+fracture:+a+prospective,+controlled+study.">A novel &amp;#34;three-dimensional-printed individual guide template-assisted percutaneous vertebroplasty&amp;#34; for osteoporotic vertebral compression fracture: a prospective, controlled study.</a> J Orthop Surg Res. 16 (1), 326 (2021).</li><li>Jiashen, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+sarcopenia+and+sagittal+parameters+on+the+residual+back+pain+after+percutaneous+vertebroplasty+in+patients+with+osteoporotic+vertebral+compression+fracture.">Impact of sarcopenia and sagittal parameters on the residual back pain after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fracture.</a> J Orthop Surg Res. 17 (1), 111 (2022).</li><li>Songfeng, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+percutaneous+vertebroplasty+for+the+relief+of+osteoblastic+spinal+metastasis+pain.">Efficacy of percutaneous vertebroplasty for the relief of osteoblastic spinal metastasis pain.</a> Exp Ther Med. 22 (1), 727 (2021).</li><li>Ruszat, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Photoselective+vaporization+of+the+prostate:+subgroup+analysis+of+men+with+refractory+urinary+retention.">Photoselective vaporization of the prostate: subgroup analysis of men with refractory urinary retention.</a> Eur Urol. 50 (5), 1040-1049 (2006).</li><li>Junchuan, X., Jisheng, L., Jian, L., Yong, Y., Qi, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=&amp;#34;Targeted+percutaneous+vertebroplasty&amp;#34;+versus+traditional+percutaneous+vertebroplasty+for+osteoporotic+vertebral+compression+fracture.">&amp;#34;Targeted percutaneous vertebroplasty&amp;#34; versus traditional percutaneous vertebroplasty for osteoporotic vertebral compression fracture.</a> Surg Innov. 26 (5), 551-559 (2019).</li></ol>

The authors have no conflict of interest regarding any drugs, materials, or devices described in this study.

Percutaneous vertebroplasty (PVP) has demonstrated favorable clinical efficacy in managing painful osteoporotic vertebral compression fractures (OVCF)9. The utilization of precise percutaneous pedicle puncture technology by surgeons plays a crucial role in determining the optimal insertion point, direction, and depth of the puncture needle, thereby significantly reducing the occurrence of complications10. Currently, C-arm X-ray machines are widely employed in the domestic and international practice of traditional PVP surgery to facilitate the adjustment of the surgical path of the puncture needle11. The crucial aspect lies in identifying the ideal bone puncture point, which is conventionally situated at the projection &#34;left 10 points, right 2 points&#34; of the pedicle in the lumbar spine. The &#34;Nine-grid Area Division Method&#34; has the capability to identify the optimal bone puncture region.
The rationale for selecting the Nine-grid as the preferred division method over alternatives like the &#34;Four-grid &#34; and &#34;Sixteen-grid &#34; warrants explicit clarification. This decision stems from preliminary experiments, which have demonstrated that segmenting the pedicle projection into a Nine-grid Area aligns most closely with clinical practice while also considering the reference value. The &#34;Four-grid Area Division Method&#34; is characterized by ease of operation; however, its limited reference value arises from the imprecise regional division, making it challenging to discern the safety of the bone puncture entry point. Conversely, the &#34;Sixteen-grid Area Division Method&#34;&#160;offers an accurate determination of the puncture point&#39;s safety, yet its complexity during surgical procedures hinders observation and judgment, rendering it incongruous with clinical practice. Consequently, the &#34;Nine-grid Area Division Method&#34; was selected as it combines clinical feasibility with the provision of satisfactory reference value.
Upon further analysis of the clinical imaging data from our previous research subjects12, it was discovered that the precise lumbar spine PVP bone puncture points, as projected by the ideal pedicle projection of &#34;left 10 points, right 2 points&#34;, are not consistently observed. However, it was observed that certain alternative puncture points can still yield satisfactory puncture outcomes near the aforementioned ideal bone puncture point. These deviations from the ideal do not compromise surgical safety or accuracy. Based on the assumptions, we introduce the novel notion of the ideal bone puncture region for the PVP pedicle, which involves segmenting the pedicle projection into a Nine-grid Area on the X-ray anteroposterior image. By employing the X-ray projection of the lumbar pedicle as an anatomical reference, we establish the ideal bone puncture region for PVP through the division of the pedicle into a Nine-grid Area, thereby surpassing the limitations of a singular point.
Theoretical innovation has the potential to enhance the PVP puncture surgical pathway by using the &#34;Nine-grid Area Division Method&#34;-assisted PVP surgery in the lumbar spine. This advancement may decrease the dosage of intraoperative projection and minimize the duration of surgical procedures required for adjusting the bone entry point of the puncture needle, ultimately improving surgical efficiency and efficacy. It is noteworthy that the ideal bone puncture region for the &#34;Nine-grid Area Division Method&#34; may vary across different segments of the vertebral body. For illustrative purposes, the L1 vertebral body is solely utilized as an exemplar in this context. Our future research will incorporate additional case studies, broader sample segments, and investigations into robot learning to enhance the validity and objectivity of the indications and methodologies for PVP puncture.
However, there are some limitations of the &#34;Nine-grid Area Division Method&#34;-assisted PVP in the lumbar spine. There is a learning curve for learning to use the medical imaging software. Any mistake made during template design by surgeons unfamiliar with the software may lead to an unsuccessful result. Furthermore, larger-scale studies are imperative to validate the reliability and practicability of this finding.

Osteoporotic vertebral compression fracture (OVCF) is the most prevalent type of fracture among osteoporotic fractures and poses a significant clinical concern in contemporary healthcare1. According to current guidelines, percutaneous vertebroplasty is recognized as one of the most efficacious minimally invasive treatment modalities for OVCF2. The predominant method for performing percutaneous vertebroplasty (PVP) involves the pedicle puncture approach, which encompasses three key parameters: the identification of the bone puncture entry point, puncture angle, and puncture depth. Of these parameters, the selection of the bone puncture entry point is considered the most crucial.
Currently, C-arm X-ray machines are widely employed in the domestic and international practice of traditional PVP surgery to facilitate the adjustment of the surgical path of the puncture needle. The crucial aspect lies in identifying the &#34;ideal bone puncture point,&#34; which is conventionally situated at the projection &#34;left 10 points, right 2 points&#34; of the pedicle in the lumbar spine (Figure 1A)3. Despite their experience, even seasoned surgeons may make mistakes when determining appropriate puncture points based solely on personal experience. This can lead to puncture-related complications such as cement leakage into surrounding tissues, nerve root injury, and intra-spinal hematoma4,5,6. Additionally, nearly half of patients experience local complications from traditional PVP, with 95% of these complications attributed to cement leakage into surrounding tissue or embolization of paravertebral veins7. Our preliminary research found that the actual PVP bone puncture points in the lumbar spine are not always located at the ideal pedicle projection &#34;left 10 points and right 2 points&#34;8. Some actual puncture points can also achieve satisfactory puncture results near the &#34;ideal bone puncture point,&#34; which does not affect surgical safety and accuracy.
Based on the above assumptions, we propose, for the first time, the concept of the &#34;ideal bone puncture region&#34; for PVP in the lumbar spine and divide the projection of the pedicle into a &#34;Nine-grid Area&#34;. The concept of the ideal bone puncture region pertains to specific anatomical regions where the puncture entry point can successfully and securely reach the puncture ideal endpoint through the pedicle.The term &#34;Nine-grid Area Division Method&#34; refers to a technique in the X-ray anteroposterior image whereby the longest and shortest diameters of the pedicle projection are divided into three equal parts, resulting in the division of the area into nine regions (Figure 1B). These regions are sequentially numbered from 1 to 9, progressing from the outermost to the innermost and from top to bottom. Using the X-ray projection of the lumbar pedicle as an anatomical marker, we establish the &#34;ideal bone puncture region&#34; for PVP through the &#34;Nine-grid Area Division Method&#34; instead of being confined to a single point. We use computer simulation to explore a safe puncture path during the puncture process.
Hence, we suggest the implementation of the &#34;Nine-grid Area Division Method&#34; as a potential method for enhancing the convenience, efficiency, and safety of auxiliary puncture techniques in PVP surgery, with the aim of enhancing procedural accuracy and minimizing puncture-related complications. It is important to note that this study presents a theoretical approach that requires validation through extensive research to ascertain its efficacy and safety.

<table><tbody><tr><td>Computer tomography&amp;nbsp;</td><td>Company GE</td><td></td><td>machine</td></tr><tr><td>Geomagic Wrap (3-D reverse engineering production software)</td><td>Oqton software</td><td></td><td>software</td></tr><tr><td>Magnetic resonance image machine</td><td>Company GE</td><td></td><td>machine</td></tr><tr><td>Solidworks (3-D modeling design software)</td><td>Dassault Syst&amp;egrave;mes&amp;nbsp;-&amp;nbsp;SolidWorks Corporation</td><td></td><td>software</td></tr><tr><td>Spirit Level Plus</td><td>IOS App store</td><td></td><td>gradientor</td></tr><tr><td>X-ray machine</td><td>Company Philips</td><td></td><td>machine</td></tr></tbody></table>

nine-grid area division method: a new ideal bone puncture region for percutaneous vertebroplasty in lumbar spine

Percutaneous vertebroplasty (PVP) is widely recognized as an efficacious intervention for alleviating low back pain resulting from osteoporotic vertebral compression fractures. The ideal bone puncture point is conventionally situated at the projection "left 10 points, right 2 points" of the pedicle in the lumbar spine. Determining the optimal bone puncture point represents a critical and complex challenge. The accuracy of percutaneous vertebroplasty (PVP) is primarily influenced by the proficiency of the operating surgeons and the utilization of multiple fluoroscopes during the conventional procedure. Incidences of puncture-related complications have been documented globally. In an effort to enhance the precision of the surgical technique and reduce the occurrence of puncture-related complications, our team applied the "Nine-grid Area Division Method" for PVP in the lumbar spine to modify the traditional procedure. There is potential to decrease the number of puncture times, the radiation exposure dosage, and the duration of surgical procedures.
This protocol introduces the definition of the "Nine-grid Area Division Method" and describes the process of modeling target vertebrae DICOM imaging data within medical imaging processing software, simulating operations within a 3-D model, refining the 3-D model using reverse engineering production software, reconstructing the vertebral engineering model within 3-D modeling design software, and utilizing surgical data to determine safe entry regions for pedicle projection. By employing this methodology, surgeons can effectively identify appropriate puncture points with precision and ease, thereby reducing the intricacies associated with puncturing and enhancing the overall accuracy of surgical procedures.

CT imaging and digital modeling were performed in the hospital. It took 30 min to build the 3-D model from the CT images, ~10 min to polish the 3-D model in 3-D reverse engineering production software, and 15 min to reconstruct the vertebral engineering model and confirm the safe entry regions of pedicle projection in 3-D modeling design software. The ideal bone puncture region includes regions 1, 4, and 7 on the left side in this case. The notion of the ideal bone puncture region refers to distinct anatomical regions where the entry point for puncture can effectively and safely access the desired endpoint through the pedicle. Put differently, by adjusting the direction and depth of the puncture needle, the ideal puncture endpoint can be attained as long as the bone puncture entry point falls within these specified areas, rather than being restricted to the &#34; left 10 points&#34;. This technique can significantly increase the surgeon&#39;s error tolerance during the puncture procedure. A minimal amount of fluoroscopy is necessary to identify an appropriate bone puncture site, leading to a reduction in the frequency of adjustments, radiation exposure, and duration of surgery.
The ideal bone puncture point is conventionally situated at the projection &#34;left 10 points, right 2 points&#34; of the pedicle in the lumbar spine as shown in Figure 1A. Figure 1B presents a detailed overview of the division details and methodologies employed in the Nine-grid Area Division Method. The preoperative images of the target vertebra are shown in Figure 2. A gradienter was placed on the patient&#39;s back before the prone CT scan and the patient&#39;s body position was recorded (Figure 3). The CT vertebra image was reconstructed into a 3-D model from the coronal, transverse, and the sagittal planes (Figure 4). Figure 4 also shows the simulation of the PVP operation procedure in the image processing software. Figure 5 shows the procedures to repair the mesh and transform the solid model into a triangular mesh surface. Figure 6 illustrates the methodology for observing and documenting the narrowest point of the pedicle through the utilization of the Section View function. Figure 7 illustrates the steps involved in adjusting the model displacement parameters and determining the final puncture target location. Figure 8 illustrates the partitioning of the model into two distinct components: the vertebral body half and the lamina half (A), followed by the generation of the pedicle projection using the Convert Entities function (B). Figure 9 depicts the array of puncture paths within the vertebral body. The lamina and vertebral body components were reassembled using the pedicle puncture set, with the puncture set subsequently removed from the laminae portion while preserving all laminae components. The Combine Body function was utilized to perform Boolean operations on multiple components, leading to the identification of the ideal bone puncture region comprising regions 1, 4, and 7. 
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66906/66906fig01.jpg" /> 
Figure 1: A. Traditional &#34;ideal bone puncture point.&#34; The &#34;ideal bone puncture point&#34; is conventionally situated at the projection &#34;left 10 points, right 2 points&#34; of the pedicle in the lumbar spine. B. Introduction to the &#34;Nine-grid Area Division Method.&#34; A detailed overview of the division details and methodologies employed in the &#34;Nine-grid Area Division Method.&#34; <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66906/66906fig02.jpg" /> 
Figure 2: Preoperative images of the target vertebra. (A) X-ray of the patient with osteoporotic&#160;vertebral compression fracture.The pre-operation X-ray images of the target vertebra of the patient. (A1: Posteroanterior view; A2: Lateral view). (B) MRI of the patient with osteoporoticvertebral compression fracture.The preoperative MRI images of the target vertebra of the patient. (B1: T1WI view; B2: T2WI view). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/66906/66906fig03.jpg" /> 
Figure 3: CT scan in the prone position. Use a gradienter on the patient&#39;s back to measure the horizontal and sagittal angles of the patient&#39;s body while undergoing a prone position CT scan. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/66906/66906fig04.jpg" /> 
Figure 4: Reconstruction of the vertebra and simulation of the operation. (A) Reconstruction of&#160;vertebra in medical imaging processing software from the CT vertebra image from (A1) the coronal plane, (A2) the transverse plane, (A3) the sagittal plane, and (A4) the 3-D model. (B) Simulation of PVP operation procedure in medical imaging processing&#160;software. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/66906/66906fig05.jpg" /> 
Figure 5: Polishing the 3-D model in 3-D reverse engineering production software. The procedure of refining the 3-D model. (A) Repairing the mesh and (B) transforming the solid model into a triangular mesh surface. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/66906/66906fig06.jpg" /> 
Figure 6: Utilize the Section View function to observe and document the pedicle. Utilizing the Section View function to observe the (A) pedicle projection and (B) document angle parameters. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/66906/66906fig07.jpg" /> 
Figure 7: Modifying the parameters of the model&#39;s displacement. Adjust the model displacement parameters and determine the final puncture target location. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/66906/66906fig08.jpg" /> 
Figure 8: Creating a representation of the projection of the pedicle. (A) Partitioning of the model into two distinct components, followed by (B) the generation of the pedicle projection using the Convert Entities function. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/66906/66906fig09.jpg" /> 
Figure 9: Puncture paths and the identification of the ideal puncture region. (A) Set of puncture&#160;paths traversing the pedicle. The array of puncture paths within the vertebral body through the pedicle. (B) Reconstructing models comprising diverse components. Reconstruct the lamina and vertebral body segments by means of the pedicle puncture set. (C) Acquisition of the &#34;ideal bone&#160;puncture region&#34;. An area is deemed an ideal bone puncture region only when it is completely blue. The ideal bone puncture region encompasses regions 1, 4, and 7 through the application of Boolean operations. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66906/66906fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Author Spotlight: Improving Percutaneous Vertebroplasty Surgical Accuracy and Efficiency Through Advanced Puncture Techniques

Herein, we present a "Nine-grid Area Division Method" for percutaneous vertebroplasty. A patient with an L1 vertebral compression fracture was selected as a case study.

Nine-Grid Area Division Method: A New Ideal Bone Puncture Region for Percutaneous Vertebroplasty in Lumbar Spine

Percutaneous vertebroplasty (PVP) is widely recognized as an efficacious intervention for alleviating low back pain resulting from osteoporotic vertebral ...

nine-grid-area-division-method-new-ideal-bone-puncture-region-for

Nanyang Technological University

Research

JoVE Journal

Medicine

189 Views.  Capital Medical University. Ons onderzoek gaat over de priktechnieken in PVP-chirurgie. We proberen te beantwoorden hoe we de nauwkeurigheid van de procedure kunnen verbeteren en punctiegerelateerde complicaties tijdens PVP-chirurgie kunnen minimaliseren. Met MGC van nieuwe technologieën ontwikkelen verschillende punctietechnieken zich snel, zoals het inwisselen van het navigatiesysteem voor het maken van een begeleide sjabloon, en dus is er een leercurve voor het leren gebruiken van m...

Video: Auteur in de schijnwerpers: verbetering van chirurgische nauwkeurigheid en efficiëntie van percutane vertebroplastiek door middel van geavanceerde punctietechnieken

An Anesthesia, Surgery, and Harvest Method for the Evaluation of Transpedicular Screws Using an In Vivo Porcine Lumbar Spine Model

Pedicle screw fixation is the gold standard for the treatment of spinal diseases. However, many studies have reported the issue of loosening pedicle screws after spinal surgery, which is a serious concern. To address this problem, diverse types of pedicle screws have been examined to identify those with good fixation strength and osseointegration in spine bone. The porcine spine is a good alternative for the human spine in the evaluation of pedicle screws due to the anatomical size, mechanical characteristics, and cost. Although several studies have reported that pedicle screws are efficient in the porcine model, no study has described detailed protocols for the evaluation of a pedicle screw using the porcine model. Here, we describe a detailed method for evaluating transpedicular screws using an in vivo porcine lumbar spine model. The technical details for anesthesia, spine surgery, and harvest provided here will facilitate with the evaluation of the transpedicular screw fixation model.

An Anesthesia, Surgery, and Harvest Method for the Evaluation of Transpedicular Screws Using an In Vivo Porcine Lumbar Spine Model

Here, we introduce a method to evaluate transpedicular screws by using an in vivo porcine lumbar spine model.

Pedicle screw fixation is the gold standard for the treatment of spinal diseases. However, many studies have reported the issue of loosening pedicle ...

Three-Dimensional Printing Guide Template Assisted Percutaneous Vertebroplasty (PVP)

Percutaneous vertebroplasty (PVP) is considered an effective treatment for the back pain caused by osteoporotic vertebral compression fracture. The accuracy of PVP mainly depends on the surgeons&#39; experience and multiple fluoroscopes during a traditional procedure. Puncture related complications were reported all over the world. To make the surgical procedure more precise and decrease the rate of puncture-related complications, our team applied a three-dimensional printing guide template to PVP to modify the traditional procedure. This protocol introduces how to model target vertebrae DICOM imaging data into three-dimensions in the software, how to simulate operation in this 3-D model, and how to use all of the surgical data to reconstruct a patient specific template for application. Using this template, surgeons can identify suitable puncture points accurately to improve the accuracy of the operation. The whole protocol includes: 1) diagnosis of the osteoporotic vertebral compression fracture; 2) acquisition of CT imaging of the target vertebra; 3) simulation of the operation in the software; 4) design and fabrication of the 3-D printing guide template; and 5) application of the template into an operation procedure.

Three-Dimensional Printing Guide Template Assisted Percutaneous Vertebroplasty PVP

Herein, we present a three-dimensional printing guide template for percutaneous vertebraplasty. A patient with a T11 vertebral compression fracture was selected as a case study.

Percutaneous vertebroplasty (PVP) is considered an effective treatment for the back pain caused by osteoporotic vertebral compression fracture. The ...

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large implant size and optimal implant position. However, current methods for lateral interbody cage placement require either a two-staged procedure or a single lateral decubitus position that precludes surgeons from having either full access to the posterior spine for direct decompression or comfortable pedicle screw placement.
Herein is one institution's experience with 10 cases of a prone single-position approach for simultaneous access to the anterior and posterior lumbar spine. This allows both lateral lumbar interbody cage placement, direct posterior decompression, and pedicle screw placement, all in one position. Three-dimensional (3D) navigation is utilized for increased precision in both approaching the lateral spine and interbody cage placement. The traditional blind psoas muscle tubular dilation was also modified. Tubular retractors and lateral vertebral body retractor pins were used to minimize the risks to the lumbar plexus.

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large ...

Neuroscience

C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 level (OLIF51) is technically difficult because of the anatomical structures. We present a novel simultaneous technique of OLIF51 with percutaneous pedicle screw fixation without fluoroscopy. The patient is placed in a right lateral decubitus position. A percutaneous reference pin is inserted into the right sacroiliac joint. An O-arm scan is performed, and 3D reconstructed images are transmitted to the spinal navigation system. A 4 cm oblique skin incision is made under navigation guidance along the pelvis. The internal/external and transverse abdominal muscles are divided along the muscle fibers, protecting the iliohypogastric and ilioinguinal nerves. Using a retroperitoneal approach, the left common iliac vessels are identified. Special muscle retractors with illumination are used to expose the L5-S1 intervertebral disc. After disc preparation with navigated instruments, the disc space is distracted with navigated trials. Autogenous bone and demineralized bone material are then inserted into the cage hole. The OLIF51 cage is inserted into the disc space with the help of a mallet. Simultaneously, percutaneous pedicle screws are inserted by another surgeon without changing the lateral decubitus position of the patient.
In conclusion, C-arm-free OLIF51 and simultaneous percutaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This novel technique reduces surgical time and radiation hazards.

C-arm-free oblique lumbar interbody fusion at the L5-S1 level (OLIF51) and simultaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This technique does not expose the surgeon or operating staff to radiation hazards.

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

Treating Osteoporotic Spinal Fractures in Elderly Patients via a Modified Clinical Bone Cement Injection Technique

The minimally invasive injection of bone cement (MIIBC) is an effective way to treat senile osteoporotic spinal fractures (OSF) in clinical practice. However, the intraspinal dura and nerves may be damaged when the puncture needle passes through the pedicle. Therefore, in this protocol, the puncture site was optimized during the surgery, selecting the same 1-2 cm away from the surface projection of the diseased vertebra. The needle was punctured along the lateral cortex of the pedicle from the junction of the pedicle and the vertebral body into the vertebral body. Meanwhile, bone cement was used as a filling material, and the MIIBC was performed by a percutaneous puncture at the external edge of the pedicle under C-arm fluoroscopy. This modified puncture site is far away from the spinal canal as possible, thereby reducing the risk of the puncture needles penetrating the spinal canal and damaging the nerves and dura mater. In conclusion, a modified MIIBC by percutaneous lateral pedicle puncture can effectively relieve pain in elderly patients with OSF.

Treating Osteoporotic Spinal Fractures in Elderly Patients via a Modified Clinical Bone Cement Injection Technique

Presented here is a modified procedure for minimally invasive injections of bone cement to treat osteoporotic spinal fractures in elderly patients.

The minimally invasive injection of bone cement (MIIBC) is an effective way to treat senile osteoporotic spinal fractures (OSF) in clinical practice. ...

Full-Endoscopic Isolation Zone Technique for the Treatment of Lumbar Disc Herniation

Lumbar disc herniation (LDH) is a type of serious sinus or sciatic nerve dysfunction caused by nucleus pulposus protrusion and annulus fibrosus tears. Its clinical symptoms often include severe low back pain, limited lumbar movement, sciatic nerve pain in the lower limbs, and even cauda equina syndrome. The common treatment for LDH is a conservative treatment scheme involving medicine, rest, and physical therapy. However, if the conservative treatment scheme is ineffective, a surgical treatment approach is adopted. Traditional open lumbar surgery has some disadvantages, including the potential for severe surgical trauma, severe blood loss during the operation, instability of the lumbar spine, and loss of the lumbar motor unit. Among the minimally invasive surgical schemes, full-endoscopic spine surgery (FESS) is undoubtedly the most appropriate and has the advantages of minimal trauma, high safety, quick postoperative recovery, and the retention of the stable structure and the motor unit of the lumbar spine. However, simultaneously, incomplete removal of the nucleus pulposus and residual nerve dysfunction after surgery can occur. To avoid these shortcomings, we studied a specific spinal endoscopy technique, the "isolation zone" surgical strategy, which can effectively block the pain from the nerve conduction pathway by completely relieving the nerve compression and nerve dysfunction through the orderly treatment of the protruding nucleus pulposus, the fissure of the annulus fibrosus, the sinus nerve, and the surrounding inflammatory soft tissues.

Here, we present a protocol for the &#34;isolation zone&#34; technique in the treatment of lumbar disc herniation (LDH) under full-endoscopic spine surgery (FESS), including intervertebral foramen formation, targeted catheterization, nucleus pulposus resection, and annulus fibrosus formation, which together completely block the pain from the nerve conduction pathway.

Lumbar disc herniation (LDH) is a type of serious sinus or sciatic nerve dysfunction caused by nucleus pulposus protrusion and annulus fibrosus tears. Its ...

Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for minimally invasive anterior lumbar interbody fusion (Mini-ALIF). This article is a technical description of anterior lumbar spine surgery under a microscope. We retrospectively collected information on patients who underwent microscope-assisted Mini-ALIF surgery at our hospital between July 2020 and August 2022. A repeated-measures ANOVA was used to compare imaging indicators between periods. Forty-two patients were included in the study. The mean volume of intraoperative bleeding was 180 mL, and the mean operative time was 143 min. The mean follow-up time was 18 months. Apart from one case of peritoneal rupture, no other serious complications occurred. The postoperative foramen and disc height were both higher on average than before surgery. The spreader-assisted micro-Mini-ALIF is simple and easy to use. It can provide good intraoperative disc exposure, good discrimination of important structures, adequate spreading of the intervertebral space, and the restoration of the necessary intervertebral height, which is very helpful for less experienced surgeons.

The technique described in this article is well-suited to the Mini-ALIF procedure, allows for excellent exposure and decompression, and facilitates microscope-assisted manipulation.

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for ...

Biomechanical Analysis of Adjacent Segments after Spinal Fusion Surgery Using a Geometrically Parametric Patient-Specific Finite Element Model

This study aimed to perform a mechanical analysis of adjacent segments after spinal fusion surgery using a geometrically parametric patient-specific finite element model to elucidate the mechanism of adjacent segment degeneration (ASD), thereby providing theoretical evidence for early disease prevention. Fourteen parameters based on patient-specific spinal geometry were extracted from a patient's preoperative computed tomography (CT) scan, and the relative positions of each spinal segment were determined using the image match method. A preoperative patient-specific model of the spine was established through the above method. The postoperative model after L4-L5 posterior lumbar interbody fusion (PLIF) surgery was constructed using the same method except that the lamina and intervertebral disc were removed, and a cage, 4 pedicle screws, and 2 connecting rods were inserted. Range of motion (ROM) and stress changes were determined by comparing the values of each anatomical structure between the preoperative and postoperative models. The overall ROM of the lumbar spine decreased after fusion, while the ROM, stress in the facet joints, and stress in the intervertebral disc of adjacent segments all increased. An analysis of the stress distribution in the annulus fibrosus, nucleus pulposus, and facet joints also showed that not only was the maximum stress in these tissues elevated, but the areas of moderate-to-high stress were also expanded. During torsion, the stress in the facet joints and annulus fibrosus of the proximal adjacent segment (L3-L4) increased to a larger extent than that in the distal adjacent segment (L5-S1). While fusion surgery causes an overall restriction of motion in the lumbar spine, it also causes more load sharing by the adjacent segments to compensate for the fused segment, thus increasing the risk of ASD. The proximal adjacent segment is more prone to degeneration than the distal adjacent segment after spinal fusion due to the significant increase in stress.

Here, we used a patient-specific finite element model to analyze the mechanical changes in adjacent segments after spinal fusion surgery. The results showed that fusion surgery reduced the overall motion of the lumbar spine but increased the load on and stress in adjacent segments, especially the proximal segment.

This study aimed to perform a mechanical analysis of adjacent segments after spinal fusion surgery using a geometrically parametric patient-specific ...

Application of Separation Surgery Combined with Radiofrequency Ablation and Bone Cement Strengthening in Thoracolumbar Metastasis

The spine is a common site for metastatic tumors, with 5%-10% of patients developing epidural spinal cord compression (ESCC), which significantly reduces their quality of life and accelerates the process of death. When total en-bloc spondylectomy (TES) radical surgery does not achieve the desired tumor control, palliative care remains the primary treatment option. Traditional laminar decompression or partial tumor resection can only relieve local compression. Although the surgical trauma and complications are less, these methods cannot effectively address tumor recurrence and secondary compression. Therefore, separation surgery combined with radiofrequency ablation and bone cement strengthening was used to treat thoracolumbar metastatic tumors, aiming to achieve good clinical results. In this protocol, the steps and key points of separation surgery combined with radiofrequency ablation and bone cement reinforcement for thoracolumbar metastatic tumors are introduced in detail. Meanwhile, the clinical data of 67 cases of thoracolumbar metastatic tumors in our hospital meeting the inclusion criteria were retrospectively analyzed. Different treatment methods divided the patients into two groups: separation surgery combined with radiofrequency ablation and bone cement strengthening (group A, 33 cases) and the radiotherapy group (group B, 34 cases). All patients were evaluated using improved Tokuhashi, Tomita, SINS, and ESCC scores before treatment. VAS score, Frankel grading, and Karnofsky scores during different periods of the two treatments were compared to assess the clinical outcomes. Studies have shown that separation surgery combined with radiofrequency ablation and bone cement strengthening can significantly reduce pain, promote neurological function recovery, enhance mobility, and improve quality of life in treating thoracolumbar metastatic tumors.

This study investigates the efficacy of combining separation surgery with radiofrequency ablation and radiotherapy in treating thoracolumbar metastatic tumors.

The spine is a common site for metastatic tumors, with 5%-10% of patients developing epidural spinal cord compression (ESCC), which significantly reduces ...

Nine-Grid Area Division Method: A New Ideal Bone Puncture Region for Percutaneous Vertebroplasty in Lumbar Spine

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