Korean J Pain.  2012 Apr;25(2):81-88. 10.3344/kjp.2012.25.2.81.

Evaluation of an Experimentally Designed Stereotactic Guidance System for Determining Needle Entry Point during Uniplanar Fluoroscopy-guided Intervention

• Lee JH
• Jeon GR
• Ro JH
• Byoen GJ
• Kim TK
• Kim KH

• KMID: 1778990
• DOI: http://doi.org/10.3344/kjp.2012.25.2.81

Abstract

BACKGROUND
In discography performed during percutaneous endoscopic lumbar discectomy (PELD) via the posterolateral approach, it is difficult to create a fluoroscopic tunnel view because a long needle is required for discography and the guide-wire used for consecutive PELD interrupts rotation of fluoroscope. A stereotactic system was designed to facilitate the determination of the needle entry point, and the feasibility of this system was evaluated during interventional spine procedures.
METHODS
A newly designed stereotactic guidance system underwent a field test application for PELD. Sixty patients who underwent single-level PELD at L4-L5 were randomly divided into conventional or stereotactic groups. PELD was performed via the posterolateral approach using the entry point on the skin determined by premeasured distance from the midline and angles according to preoperative magnetic resonance imaging (MRI) findings. Needle entry accuracy provided by the two groups was determined by comparing the distance and angle measured by postoperative computed tomography with those measured by preoperative MRI. The duration and radiation exposure for determining the entry point were measured in the groups.
RESULTS
The new stereotactic guidance system and the conventional method provided similarly accurate entry points for discography and consecutive PELD. However, the new stereotactic guidance system lowered the duration and radiation exposure for determining the entry point.
CONCLUSIONS
The new stereotactic guidance system under fluoroscopy provided a reliable needle entry point for discography and consecutive PELD. Furthermore, it reduced the duration and radiation exposure associated with determining needle entry.

Keyword

equipment design; fluoroscopy; needle; percutaneous discectomy; stereotactic technique

MeSH Terms

Diskectomy
Diskectomy, Percutaneous
Equipment Design
Fluoroscopy
Humans
Magnetic Resonance Imaging
Needles
Skin
Spine
Stereotaxic Techniques

Figure

• 

  Fig. 1 A conventional method for determining of needle entry on preoperative magnetic resonance image and under fluoroscopy. (A) (Left) Using picture archiving and communication system drawing tool, an angle and the distance from the midline to the skin of the needle entry point are determined preoperatively over an axial film of MRI. The first line is drawn from the skin of the midline via the spinous process to the posterior 1/3 of the intervertebral disc (IVD), and the second line is drawn from the posterior 1/3 of the IVD passing through the herniated disc to the skin. (Right) A line is drawn from the skin to the posterior IVD via the herniated nucleus pulposus on the sagittal view. (B) A conventional method for determining needle entry: (Left) A K-wire is placed between the upper and lower endplate and a line is drawn over the K-wire. The midline is marked between the adjacent spinous processes under fluoroscope. The distance from the midline, which has already been measured from preoperative MRI, is marked using a ruler. (Right) It is important to adjust the lateral view so that both the upper and lower endplate of the targeted disc are clearly seen. It is better to first place a needle to touch the upper endplate for upward migration or to touch the lower endplate for downward migration. According to up- or down-migration, another K-wire is placed on the lateral view. The meeting point of the 2 K-wires is the destination of needle entry.

• 

  Fig. 2 A stereotactic system for needle entry for percutaneous endoscopic lumbar discectomy. (A) (Left) A computer-aided design was created with a scale for mimicking a stereotactic system. (Middle) A stereotactic system was designed without a scale. A 15 cm-long transparent ruler (x axis: coronal plane) attaching a wire below its bottom with a 90° protractor movable from 5 to 15 cm (angle to coronal plane) has a perpendicular movable wing which has also a wire (angle within sagittal plane). (Right) A case for the body, 2 K-wires, and protractor allowed the system to be easily carried and sterilized. The stereotactic system was made of acryl, wire, and screws. A tiny roller was applied on the middle and both ends to adjust the insertion angles of the needle. (B) The stereotactic system was applied to patients that underwent a single-level percutaneous endoscopic lumbar discectomy at L4-L5. (Left) The system was placed on the patient to confirm the midline of the spine and the intervertebral space from the anteroposterior view (Middle) and the intervertebral space from the lateral view (Right). A protractor was subsequently placed on the anticipated skin entry point, normally from 8 to 12 cm, according to preoperative magnetic resonance image.

• 

  Fig. 3 The accuracy of needle entry by the guidance system was evaluated by comparing the distance and angles between preoperative magnetic resonance image (MRI) and the trace of postoperative computed tomography (CT). (A) Preoperative MRI, (B) Postoperative CT.

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