Novel Imageguidance Techniques Intraoperative

The development of the intraoperative MRI (iMRI) system by the Brigham and Women's Hospital and General Electric Medical Systems represented a significant advance in surgical navigation. The iMRI system allows neurosurgeons to obtain real-time dynamic imaging during surgery as opposed to relying on preoperative imaging registered with a patient's anatomy (116). The current 0.5-T iMRI (SIGNA SP, Boston, MA) has a vertical gap within its magnet, allowing space for surgeons on either side of the operating table, which is enclosed within the magnet. The iMRI images may be acquired during the surgery and may be obtained in conjunction with optical tracking of surgical instruments. The images are viewed on monitors within the magnet gap. The images are constantly updated to help eliminate errors that can arise during frame-based or frameless navigation systems. Use of the iMRI in cranial surgery has been well described, and it is particularly useful in defining tumor margins during resection and accounting for brain shift, which may occur during tumor debulking.

The first spinal procedure using iMRI guidance was performed in 1996 for the evacuation of an extraaxial cervical cyst, followed shortly thereafter by cervical decompression for myelopathy (116). Since then, other spinal procedures performed in the iMRI have included lumbar discectomies, anterior cervical discectomies with all graft fusion, cervical vertebrectomies with allograft fusion, cervical foraminotomies, and decompressive cervical laminectomy (117). The iMRI was able to provide fast and precise localization in all the listed cases and allowed determination of the degree of neural decompression in more than 80% of cases. Future applications of the iMRI for spine surgery will undoubtedly include its use in the resection of spine and spinal cord tumors and the refinement of trajectory planning for spinal endoscopy or screw fixation.

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