Cervical, thoracic, lumbar spine andscoliosis surgery – with Artis zeego
Ebara Sohei, MD,
Shonan Fujisawa Tokushukai Hospital, Spine and Scoliosis Center, Japan
Overview of spinal workflows in Hybrid Operating Rooms

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Shonan Fujisawa
Tokushukai Hospital,
Spine and Scoliosis Center
SHONAN FUJISAWA TOKUSHUKAI HOSPITAL was
re-opened after reconstruction in October 2012as a key clinical institute in this region.
Tokushukai group is one of the largest, and it
manages 66 hospitals and more than 280 clinicalinstitutes that provide healthcare service in Japan.
In accordance with the fundamental principles of“All living beings are created equal” (President,
Torao Tokuda), the Tokushukai Group Hospitals
ensure the health and livelihood of patients.
A hybrid operating room dedicated for the spineand scoliosis center was set up and equippedwith the Artis zeego robotic imaging system, the
TruSystem 7500 operating table, and the CURVE
navigation system (BrainLab). This hybrid operating
room provides surgeons with the latest technology
for greater surgical precision.
It is the first installation dedicated solely for spinal
surgery worldwide and it plays a pioneering role inorthopedic surgery in Japan.

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Dr. Sohei Ebara, the director of the spine andscoliosis center and vice president of the hospital has been a leader in new technologies overthe last years. He is a pioneer in developing
safer and more advanced procedures using lessinvasive techniques, monitoring equipment andcomputer assisted surgery. Minimally invasive
spine surgery techniques using endoscopes isapplied whenever possible.
He has a long experience with the use ofmobile C-arms. However, to achieve better
images and higher precision he chose to use
a fixed C-arm for his hybrid operating room.
3D imaging and a better workflow provide
more safety for more sophisticated procedures
like adolescent scoliosis surgery for example.
Since the opening more than 360 cases, withover 80 scoliosis cases, have been performed
by Dr. Ebara and his team.

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Cervical spine

The cervical spine involves the vertebral bodies
inferior to the skull. The most important issue
is the proximity to the central nervous systemand the vertebral arteries. In case of injury,
e.g. fractures or dislocation, the damage can bemassive, such as respiratory failure or complete
paralysis.
Surgery in this area is extremely challenging forthe spine surgeon. It demands the highest precision within very little space. This is a situationin which 3D imaging and exact navigation canbe very beneficial both for the surgeon as well
as for the patient.

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Cervical spine

Patient
positioning
The patient is positioned in a stable prone
position with the head safely in a PMI Dororadiolucent headclamp attached to thetable. The position is supported with highcushions underneath the pelvis and the chest
to leave the abdomen free for unobstructedbreathing. The legs are also placed in softcushions to avoid pressure injuries. The arms
with the intravenous lines are placed alongside the patient as is the trachael tube so thatthe anesthesiologist has free access to theequipment.
A test run for 3D imaging is performed before
the start of surgery to confirm the positionof the patient and to make sure there are no
collisions with any surgery equipment. The
Artis zeego and the table including the headclamp are fully integrated and coordinated to
avoid collisions.

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Cervical spine

Surgical
preparation
After the patient is in the final position, he/she
is covered in sterile drapes and surgery begins.
The patient, the Artis zeego and the entire
table are covered with sterile drapes to provide
maximum sterility even underneath the table.
After surgical preparation of the anatomy, the
DRB (dynamic reference base) is placed on thecervical spine for registration with the navigation system.
The DRB needs to be visible to the infrared
camera of the navigation system as well as
the reflective markers on the Artis zeego.
A 5 second syngo DynaCT protocol is performed for a 3D volume. This specific protocol
is configured for this setup with the navigation
system.
The 3D data set and patient data, such asname and age, etc., are automatically transferred to the navigation system so that thesurgeon can move the Artis zeego into a park
position and can start with the navigatedplacement of the screws.

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Cervical spine

Verification ofscrew position
The procedure is performed and the screws
are placed with confidence. The combinationof the intraoperative CT-like imaging and thenavigation system provides the surgeon
precise guidance and visualization of the
anatomy.
With the intraoperative syngo DynaCT, theplacement of the screws is verified right in
the OR. Implants that may not be ideally positioned can be corrected immediately. Patientscan count on optimal postoperative results.
There is no nervously waiting for the postoperative CT scan or deciding how to deal with animperfectly placed screw. The intraoperative
quality control leads to better outcomes andfewer secondary surgeries.

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Lumbar spine

The lumbar spine is the lower end of the spine,consisting of the 5 vertebral bodies between
the pelvis and the thorax. This part of the spine
helps to support the weight of the body andpermits movements of the lower extremities.
It is mostly affected by degenerative diseases.
Demographic or life style issues like being overweight and sedentary lifestyle add to this disease. Most of the worldwide population suffersfrom lower back pain at least once.
The trend toward minimally invasive surgery
is very strong in lumbar spine surgery. Small
incisions compared to open surgery allow thepatient to recover more quickly. High quality
imaging enables the surgeon to place thescrews with confidence.

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Lumbar spine

Surgical
preparation
The patient is positoned and safely supportedwith cushions under the chest and pelvis foran optimal position and unobstructed breathing. The anesthesia equipment is fully acces­
sible in this setup, with the patient’s headplaced in a foamed pillow. The pillow has
cutouts for the eyes and the mouth to avoid
pressure marks and the endotracheal tube isin a safe position. One arm is placed alongside
the patient while the other one is positioned
in an armrest for optimal access to the IV lines.
The integrated OR table allows the sophisticated patient positioning required in an orthopedic OR environment and 2D and 3D imaging
at the same time.
The pedicle screws, cages or other spinal
implants have to be precisely positioned underthe most sterile conditions. The Artis zeego
imaging system fulfills the highest hygienic
standards. Even in a working position with arunning laminar air field, the robotic systemmeets Class 1A standards.

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Lumbar spine

Intraoperative
imaging guidance
The Artis zeego system provides a large fieldof view with a 30 x 40 cm detector size. With
the possibility of a rotation of the detector
from landscape to portrait, a larger segment of
the spine can be visualized in one image shot.
The power generator enables high quality
images to be acquired even in obese patientswhere the anatomy is challenging, like at thethoracolumbar junction.
An image of up to 24x45 cm can be acquired.
This field of view has never been possible
before.

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Scoliosis

Scoliosis is a curved 3-dimensional deformity of theentire spine, often affecting the cervical, thoracic,
and lumbar spine. The origin is either congenital,
idiopathic or results as a secondary condition froma neuromuscular disease. The disease affects young
patients as well as older patients who experience
later onset of the disease. In young patients, scoliosis
can cause severe deformity if untreated, and lead topulmonary malfunction. There are various non-surgical treatment options. However, surgery is recommended in very specific cases or if conservative
methods are insufficient.

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Scoliosis

Lateral approach –patient positioning
The anesthesiologist needs to verify the position of the tube using an endoscope. If surgery
requires a lateral approach through the thorax,
a double luminar tube is necessary. In this casethe patient is positioned on the left side andsurgery is performed through the right thorax.
For better access to the spine, the right lungneeds to be collapsed. Meanwhile, the otherlung is ventilated to maintain a sufficient
oxygen supply to the patient.
The patient is positioned carefully in a lateralposition and metal wires are placed on theskin for better orientation. A syngo DynaCT
run is performed preoperatively. It serves as
an exact surgical planning tool.
A preoperative CT loses its value with a change
in the patient’s position. The anatomy withthe patient positioned laterally is not the sameas with the patient in the supine position in apreoperative CT.

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21Scoliosis

Lateral approach –surgical
preparation
After the exact planning of the procedure,
surgery starts. The thorax is opened throughsmall incisions and an endoscope is used to
guide the surgical instruments. The right lung is
desufflated by the anesthesiologist, and thesurgeon prepares the anatomy.
Intraoperative imaging plays a decisive role.
Using the minimally invasive approach, the surgeon loses tactile sense and natural 3D vision.
He or she has to fully rely on the images provided by the endoscope and the Artis zeego.
As soon as the anatomy is prepared, thedynamic reference base (DRB) of the navigation
system is placed in the region of interest.
Another syngo DynaCT run, now under sterile
conditions, is performed and the 3D data is
automatically transferred to the navigation
system.

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Scoliosis

Lateral approach –placement of
the screws
The first screws are placed with the help of thenavigation system, the referenced instruments
and the endoscope. The DRB and the instruments need to be visible to the camera of thenavigation system to achieve the highest precision. Cross-sectional imaging helps the surgeon
decide whether the screws are placed correctly.
The process of screw placement is checked
regu­larly using fluoroscopy. In this case, theArtis zeego can easily move in and out of thesurgical field without disturbing the workflow
and sterility. If the screw position is correct, thesurgeon continues. The closer the screw placement is to the DRB, the greater the degree ofprecision.
For these long stretches of the spine, the placement of screws is even a bigger challenge.
The large field of view and high image qualityof the Artis zeego support this process.

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Scoliosis

Lateral approach –intraoperative
image guidance
The fixation of the spinal implants is controlled with fluoroscopy. Even with the large
frames and all the surgical instruments,
fluoroscopy can be easily performed with
the C-arm of the robotic system.
The next step is to stabilize the screws. Thispart of the workflow is also checked using
fluoroscopy. When everything is fixated tofull satisfaction and all screws optimally
positioned, surgery is finished. As soon as
the thorax is closed, the lung is insufflated
to allow normal function. For postoperative
quality control, another syngo DynaCT run
is performed in the hybrid OR before thepatient is released to the ward.

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Scoliosis

Dorsal approach –patient positioning
and surgicalpreparation
For the posterior approach the patient is positioned in prone position. Cushions underneaththe pelvis and the chest provide the required
safety and also the needed position of thespine. Again, the head and the arms are alsosafely positioned. For better orientation wires
are placed on the skin and the spine is centered with the help of a laser cross beam.
Surgery is started and the anatomy is prepared.
The DRB is placed on the spine. The reflective
markers of the DRB and the reflective markers
attached to the Artis zeego are detected by
the infrared camera of the navigation system.
The 5sec Body protocol for the syngo DynaCT
is configured for the communication of theArtis zeego and the navigation system. The 3Dvolume and the patient data is automaticallytransferred in a short time period.

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Scoliosis

Dorsal approach –placement of
the screws
The screws are placed one after another. The
surgical instruments, also equipped with reflective markers, are registered with the navigation
system through the infrared camera. The navigation system calculates the distance between
the reflective markers on the DRB as well ason the surgical instruments. This increases theprecision for placement of the screws.
The surgeon follows the placement of thescrews on a separate screen of the navigation
system using the intraoperative 3D volume.
The syngo spine composing software of therobotic C-arm system can be used at the sametime. This allows stitching multiple imagesof segments of the spine into one image.
The surgeon is able to evaluate the severityof the deformity, plan thoroughly and assess
the success of the procedure.

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Scoliosis

Dorsal approach –intraoperative
image guidanceOnce the screws are in place, a metal bar isplaced in the openings to stabilize the spineand fixate it properly. One disadvantage withthis technique is the lack of spinal flexibility
for the patient after surgery. However further
degeneration and other organ impairment
can be prevented, which outweighs the
disadvantage.
Surgical progress is checked regularly. The
Automap function allows positions and angulations of the Artis zeego to be easily stored andreached whenever needed with only a few
clicks. This speeds up the procedure and facilitates surgical workflow.

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Scoliosis

Dorsal approach –intraoperative
image guidance
At the end of the procedure, the surgeon
verifies the position of the screws.
With the help of the Large volume syngo DynaCT
and the image composing option, the surgeon
can visualize the entire spine in a few steps.
Any screw that requires repositioning can be
adjusted right in the OR.
Consequently, the surgeon is able to finish
surgery confidently with all screws properly
positioned and then release the patient to
the ward.

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Configuration of theHybrid Operating Room
Shonan Fujisawa Tokushukai Hospital,
Spine and Scoliosis Center, Japan■

Artis zeego VC21■

Large display with DCS extended■■

 rumpf operating tabletopT(one piece or segmented)
TruSystem 7500
Brainlab Curve (R) navigation system■

Laser crosshair beam■

syngo X Workplace VB21■s yngo iGuide andsyngo iGuide Toolbox■

syngo DynaCT■

syngo spine composing■

Large volume dynaCT■

syngo InSpace 3D■

syngo Large volume DynaCT■

syngo iPilot

!

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The Benefits
at a glance■Large field of view■

Great flexibility■

Good accessibility to work on the patient■Laser guidance for precision■

Integration of navigation systems■

High contrast 3D imaging in the OR■

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Sound decision making■

 oft tissue imaging
S
Image fusion capability(preoperative MRI, etc.)

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