Image guidance in spine tumor surgery

Abstract

Beginning with basic stereotactic operative methods in neurosurgery, intraoperative navigation and image guidance systems have since become the norm in that field. Following the introduction of image guidance into spinal surgery, there has been a dramatic increase in its utilization across disciplines and pathologies. Spine tumor surgery encompasses a wide range of complex surgical techniques and treatment strategies. Similarly to deformity correction and trauma surgery, spine navigation holds potential to improve outcomes and optimize surgical technique for spinal tumors. Recent data demonstrate the applicability of neuro-navigation in the field of spinal oncology, particularly for spinal stabilization, maximizing extent of resection and integration of minimally invasive therapies. The rapid introduction of new, less invasive, and ablative surgical techniques in spine oncology coupled with the rising incidence of spinal metastatic disease make it imperative for spine surgeons to be familiar with the indications for and limitations of imaging guidance. Herein, we provide a practical, current concepts narrative review on the use of spinal navigation in three areas of spinal oncology: (a) extent of tumor resection, (b) spinal column stabilization, and (c) focal ablation techniques.

Keywords: Image guidance; Minimally invasive; Navigation; Spinal metastases; Spinal tumors.

Fig. 1

Intraoperative navigation used to optimize extent of resection. Representative case of a 22 year-old male with a T4-5 chondrosarcoma. (a) Chest x-ray at diagnosis, (b) axial T1 post-contrast MRI demonstrating invasion into the T4 vertebral body, (c) post-operative axial CT scan depicting partial corpectomy achieved with navigation assistance.

Fig. 2

Navigational assistance and ultrasound for resection of spinal metastasis. Intraoperative photographs and ultrasound images during separation surgery for a renal cell carcinoma metastasis at T4 with high-grade epidural spinal cord compression. (a) Photograph of decompression of the posterior most portion of the tumor, (b) photograph of ventral decompression portion of the procedure, using intraoperative navigation, (c) intraoperative axial ultrasound view demonstrating echodense material surrounding the spinal cord, (d) post-resection axial ultrasound indicating successful decompression of the thecal sac and sufficient separation.

Fig. 3

Stabilization and cement augmentation using navigation. Use of fenestrated percutaneous pedicle screws for cement augmentation. (a) coronal pre-operative CT scan demonstrating a right-sided pathologic compression fracture, (b) axial CT slice at the level of the L4 compression fracture, (c) post-operative AP x-ray depicting pedicle screw construct with evidence of cement administration through fenestrated screws, (d) post-operative lateral x-ray of the same construct which provides a better view of the kyphoplasty cement injected into the L4 vertebral body.

Fig. 4

Use of intraoperative navigation for delivery of brachytherapy. (Left) multi-plane view of trajectory planning using intraoperative navigational system, (Right, Top) simulated positioning of brachytherapy source at the tip of the afterloading catheter (Right, Bottom) guided placement of trocar.