Patent Publication Number: US-2023149112-A1

Title: System and method for a navigated procedure

Description:
FIELD 
     The subject disclosure relates generally to a system and method for determining and/or selecting a position, including location and orientation, of a member in space and/or relative to a subject. 
     BACKGROUND 
     This section provides background information related to the present disclosure which is not necessarily prior art. 
     In a navigation system for various procedures, such as surgical procedures, assembling procedures, and the like, an instrument or object may be tracked. The instrument may be tracked by one or more tracking systems of various operation modes, such as by measuring an effect of a magnetic field on a sensor coil and/or determining a location with optical sensors. The sensor coil may include a conductive material that is placed within a magnetic field where a current is induced in the sensor coil. The measured induced current may be used to identify or determine a position of the instrument or object. 
     The electro-magnetic field may be generated with a plurality of coils, such as three orthogonally placed coils. Various transmitter or field generation systems include the AxiEM™ electro-magnetic navigation system sold by Medtronic Navigation, Inc., having a place of business in Louisville, Colorado. The AxiEM™ electro-magnetic navigation system may include a plurality of coils that are used to generate an electro-magnetic field that is sensed by a tracking device, which may be the sensor coil, to allow a navigation system, such as a Stealthstation® surgical navigation system, to be used to track and/or illustrate a tracked position of an instrument. 
     The tracking system may also, or alternatively, include an optical tracking system. Optical tracking systems include those such as the Stealthstation® S7® tracking system. The optical tracking system includes a set of cameras with a field of vision to triangulate a position of the instrument. 
     SUMMARY 
     This section provides a general summary of the disclosure and is not a comprehensive disclosure of its full scope or all of its features. 
     A system for performing and/or preparing for a procedure is disclosed. The procedure may be performed on a living subject such as an animal, human, or other selected patient. The procedure may include any appropriate type of procedure, such as one being performed on an inanimate object (e.g. an enclosed structure, airframe, chassis, etc.). Nevertheless, the procedure may be performed using a navigation system where a tracking system is able to track a selected one or more items. 
     A navigation system may be used to navigate an instrument relative to a subject for performing a procedure. In various embodiments, the procedure may include a procedure on a spine such as a spinal fusion where two or more vertebrae are connected together with a selected implant system or assembly. The procedure may also be to obtain or gain access to a volume, such a cranial volume. In various embodiments, for example, and implant may be placed in a brain of subject. 
     The disclosed system includes an alignment guide that may be positioned relative to the subject. The alignment guide may include a member that may be fixed to the subject. Further the alignment guide may be moved with a selected system, such as a mechanical or robotic system relative to the subject. Appropriate robotic systems may include the Stealth Autoguide® cranial robotic guidance platform sold by Medtronic, Inc., having a place of business in Louisville, CO. 
     Further areas of applicability will become apparent from the description provided herein. The description and specific examples in this summary are intended for purposes of illustration only and are not intended to limit the scope of the present disclosure. 
    
    
     
       DRAWINGS 
       The drawings described herein are for illustrative purposes only of selected embodiments and not all possible implementations, and are not intended to limit the scope of the present disclosure. 
         FIG.  1    is an environmental view of a navigation system; 
         FIG.  2    is an adjustable guide system of the alignment system, according to various embodiments; 
         FIG.  3    is an assembled view of an alignment system including a guide member and an adjustable base, according to various embodiments; 
         FIG.  3 A  is a detail view of the guide system and an adjustable base; 
         FIG.  4    is a flow chart of a procedure using an alignment system; 
         FIGS.  5 A,  5 B, and  5 C  show in series the use of the alignment system, according to various embodiments; and 
         FIGS.  6 A and  6 B  illustrate use of an alignment system, according to various embodiments. 
     
    
    
     Corresponding reference numerals indicate corresponding parts throughout the several views of the drawings. 
     DETAILED DESCRIPTION 
     Example embodiments will now be described more fully with reference to the accompanying drawings. 
     With initial reference to  FIG.  1   , a navigation system  10  is illustrated. The navigation system  10  may be used for various purposes or procedures by one or more users, such as a user  12 . The navigation system  10  may be used to determine or navigate a position (also referred to as a pose) of an instrument  16  in a volume. The position may include at least six degrees of freedom, including three dimensional X,Y,Z location and one or more degrees of orientation. Orientation may include one or more degree of freedom, such as three degrees of freedom including yaw, pitch, and roll. It is understood, however, that any appropriate degree of freedom position information, such as less than six-degree of freedom position information, may be determined and/or presented to the user  12 . 
     Navigating the position of the instrument  16  may be done with a first or instrument tracking device  56  and may assist the user  12  in knowing and/or understanding a position of the instrument  16 , even if the instrument  16  is not directly viewable by the user  12 , relative to a selected frame of reference, such as an image frame of reference and, therefore, relative to a subject  20 . Various procedures may block the view of the user  12 , such as performing a repair or assembling an inanimate system, such as a robotic system, assembling portions of an airframe or an automobile, or the like. Various other procedures may include a surgical procedure, such as performing a spinal procedure, neurological procedure, positioning a deep brain simulation probe, or other surgical procedures on a living subject. In various embodiments, for example, the subject  20  may be a human subject  20  and the procedure may be performed on the human subject  20 . It is understood, however, that the instrument  16  may be tracked and/or navigated relative to any subject for any appropriate procedure. Tracking or navigating an instrument for a procedure, such as a surgical procedure, on a human or living subject is merely exemplary. 
     In various embodiments, the surgical navigation system  10 , as discussed further herein, may incorporate various portions or systems, such as those disclosed in U.S. Pat. Nos. RE44,305; 7,697,972; 8,644,907; and 8,842,893; and U.S. Pat. App. Pub. No. 2004/0199072, all incorporated herein by reference. Various components that may be used with or as a component of the surgical navigation system  10  may include an imaging system  24  that is operable to image the subject  20 , such as an O-arm® imaging system, magnetic resonance imaging (MRI) system, computed tomography system, etc. A subject support  26  may be used to support or hold the subject  20  during imaging and/or during a procedure. The same or different supports may be used for different portions of a procedure. 
     In various embodiments, the imaging system  24  may include a source  24   s . The source may emit and/or generate X-rays. The X-rays may form a cone  24   c , such as in a cone beam, that impinge on the subject  20 . Some of the X-rays pass though and some are attenuated by the subject  20 . The imaging system  24  may further include a detector  24   d  to detect the X-rays that are not completely attenuated, or blocked, by the subject  20 . Thus, the image data may include X-ray image data. Further, the image data may be two-dimensional (2D) image data. 
     Image data may be acquired, such as with one or more of the imaging systems discussed above, during a surgical procedure or acquired prior to a surgical procedure for displaying an image  30  on a display device  32 . In various embodiments, the acquired image data may also be used to form or reconstruct selected types of image data, such as three-dimensional volumes, even if the image data is 2D image data. The instrument  16  may be tracked in a trackable volume or a navigational volume (also referred to as subject space defined relative to the subject  20 ) by one or more tracking systems. Tracking systems may include one or more tracking systems that operate in an identical manner or more and/or different manner or mode. For example, the tracking system may include an electro-magnetic (EM) localizer  40 , as illustrated in  FIG.  1   . In various embodiments, it is understood by one skilled in the art, that other appropriate tracking systems may be used including optical tracking system that may include an optional tracking system localizer  82 , radar, ultrasonic, etc. The discussion herein of the EM localizer  40  and tracking system is merely exemplary of tracking systems operable with the navigation system  10 . 
     The position of the instrument  16  may be tracked in the tracking volume relative to the subject  20  and then illustrated as a graphical representation, also referred to as an icon,  16   i  with the display device  32 . In various embodiments, the icon  16   i  may be superimposed on the image  30  and/or adjacent to the image  30 . As discussed herein, the navigation system  10   may incorporate the display device  30  and operate to render the image  30  from selected image data, display the image  30 , determine the position of the instrument  16 , determine the position of the icon  16   i , etc. 
     The EM localizer  40  (and or alternative localizer  40 ′) is operable to generate electro-magnetic fields with a transmitting coil array (TCA)  42  which is incorporated into the localizer  40 . The TCA  42  may include one or more coil groupings or arrays. In various embodiments, more than one group is included and each of the groupings may include three coils, also referred to as trios or triplets. The coils may be powered to generate or form an electro-magnetic field by driving current through the coils of the coil groupings. As the current is driven through the coils, the electro-magnetic fields generated will extend away from the coils  42  and form a navigation domain or volume  50 , such as encompassing all or a portion of a head  20   h , spinal vertebrae  20   v , or other appropriate portion. The coils may be powered through a TCA controller and/or power supply  52 . It is understood, however, that more than one of the EM localizers  40  may be provided and each may be placed at different and selected locations. 
     The navigation domain or volume  50  generally defines a navigation space or patient space. As is generally understood in the art, the instrument  16 , such as a drill, lead, guide tube, guide member, lead, etc., may be tracked in the navigation space that is defined by a navigation domain relative to a patient or subject  20  with the instrument tracking device  56 . For example, the instrument  16  may be freely moveable, such as by the user  12 , relative to a dynamic reference frame (DRF) or patient reference frame tracker  60  that is fixed relative to the subject  20 . Both the tracking devices  56 ,  60  may include tracking portions that are tracking with appropriate tracking systems, such as sensing coils (e.g. conductive material formed or placed in a coil) that senses and are used to measure a magnetic field strength, optical reflectors and/or emitters, ultrasonic emitters, etc. Due to the tracking device  56  connected or associated with the instrument  16 , relative to the DRF  60 , the navigation system  10  may be used to determine the position of the instrument  16  relative to the DRF  60 . 
     The navigation of a moveable portion relative to the subject  20  (which may include determining and illustrating a position of a tracked portion) may be made due to a registration of the subject space relative to an image space. The navigation volume or patient space may be registered to an image space defined by the image  30  of the subject  20  and the icon  16   i  representing the instrument  16  may be illustrated at a navigated (e.g. determined) and tracked position with the display device  32 , such as superimposed on the image  30 . Registration of the patient space to the image space and determining a position of a tracking device, such as with the tracking device  56 , relative to a DRF, such as the DRF  60 , may be performed as generally known in the art, including as disclosed in U.S. Pat. Nos. RE44,305; 7,697,972; 8,644,907; and 8,842,893; and U.S. Pat. App. Pub. No. 2004/0199072, all incorporated herein by reference. Generally, registration includes a translation between the subject space and the image space. This may be done by identifying points in the subject space (i.e. fiducial portions) and identifying the same points in the image (i.e. image fiducials). A translation map of the image space to the subject space may then be made, such as by the navigation system  10 . 
     The navigation system  10  may further include a navigation processor system  66 . The navigation processor system  66  may include the display device  32 , the TCA  40 , the TCA controller  52 , and other portions and/or connections thereto. For example, a wire connection may be provided between the TCA controller  52  and a navigation processing unit or module  70 . Further, the navigation processor system  66  may have one or more user control inputs, such as a keyboard  72 , and/or have additional inputs such as from communication with one or more memory systems  74 , either integrated or via a communication system. The navigation processor system  66  may, according to various embodiments include those disclosed in U.S. Pat. Nos. RE44,305; 7,697,972; 8,644,907; and 8,842,893; and U.S. Pat. App. Pub. No. 2004/0199072, all incorporated herein by reference, or may also include the commercially available Stealthstation® or Fusion™ surgical navigation systems sold by Medtronic Navigation, Inc. having a place of business in Louisville, CO. 
     Tracking information, including information regarding the magnetic fields sensed with the tracking devices  56 ,  60 , may be delivered via a communication system, such as the TCA controller, which also may be a tracking device controller  52 , to the navigation processor system  66  including the navigation processor  70 . Thus, the tracked position of the instrument  16  may be illustrated as the icon  16   i  relative to the image  30 . Various other memory and processing systems may also be provided with and/or in communication with the processor system  66 , including the memory system  72  that is in communication with the navigation processor  70  and/or an imaging processing unit  76  including an imaging or image memory  112 . The image memory  112  may store or be used for recall of images or image data acquired of the subject  20 , such as by the imaging system  24  or other appropriate imaging system. 
     The image processing unit  76  may be incorporated into the imaging system  24 , such as the O-arm® imaging system, as discussed above. The imaging system  24  may, therefore, include various portions such as a source and an x-ray detector that are moveable within a gantry  78 . The imaging system  24  may also be tracked with an imaging tracking device  80 . It is understood, however, that the imaging system  24  need not be present while tracking the tracking devices, including the instrument tracking device  56 . Also, the imaging system  24  may be any appropriate imaging system including a MRI, CT, etc. 
     In various embodiments, the tracking system may include the optical localizer  82 . The optical localizer  82  may include one or more cameras that view or have a field of view that defines or encompasses the navigation volume  50 . The optical localizer  82  may receive light (e.g. infrared or ultraviolet) input to determine a position or track the tracking device, such as the instrument tracking device  56 . It is understood that the optical localizer  82  may be used in conjunction with and/or alternatively to the EM localizer  40  for tracking the instrument  16 . 
     Information from all of the tracking devices may be communicated to the navigation processor  70  for determining a position of the tracked portions relative to each other and/or for localizing the instrument  16  relative to the image  30 . The imaging system  24  may be used to acquire image data to generate or produce the image  30  of the subject  20 . It is understood, however, that other appropriate imaging systems may also be used. The TCA controller  52  may be used to operate and power the EM localizer  40 , as discussed above. 
     The image  30  that is displayed with the display device  32  may be based upon image data that is acquired of the subject  20  in various manners. For example, the imaging system  24  may be used to acquire image data that is used to generate the image  30 . It is understood, however, that other appropriate imaging systems may be used to generate the image  30  using image data acquired with the selected imaging system. Imaging systems may include magnetic resonance imagers, computed tomography imagers, and other appropriate imaging systems. Further the image data acquired may be two dimensional or three dimensional data and may have a time varying component, such as imaging the patient during a heart rhythm and/or breathing cycle. 
     In various embodiments, the image data is a 2D image data that is generated with a cone beam. The cone beam that is used to generate the 2D image data may be part of an imaging system, such as the O-arm® imaging system. The 2D image data may then be used to reconstruct a 3D image or model of the imaged subject, such as the patient  20 . The reconstructed 3D image and/or an image based on the 2D image data may be displayed. Thus, it is understood by one skilled in the art that the image  30  may be generated using the selected image data. 
     Further, the icon  16   i , determined as a tracked position of the instrument  16 , may be displayed on the display device  32  relative to the image  30 . In addition, the image  30  may be segmented, for various purposes, including those discussed further herein. Segmentation of the image  30  may be used determine and/or delineate objects or portions in the image. In various embodiments, the image may include a segmented brain for assisting or performing a selected procedure relative to the brain such as placement of a deep brain stimulation (DBS) lead. 
     As discussed above, the navigation system  10  may be used to navigate, such as by tracking devices, various portions, such as with the localizer  40 . The various portions may be navigated for purposes of identifying positions of the tracked portions relative to the subject  20 , registration of image data to the subject  20 , and other appropriate purposes. In various embodiments, a guide assembly or system  200  may be used relative to the subject  20  for a selected portion of the procedure. 
     With continuing reference to  FIG.  1    and additional reference to  FIG.  2   , the alignment system  200  may be positioned relative to the subject  20 , such as with a mounting system or construct  204  that may be fixed to the bed or support  26 . The guide system  200  may be positioned and/or fixed relative to the subject  20 . The support structure  20  may be a rigid structure and/or a movable and fixable support structure, such as the Vertek® flexible support arm system sold by Medtronic Navigation, Inc., having a place of business in Louisville, Colorado. The flexible or moveable support  204  may also be fixed relative to the subject  20  in a selected location after being moved to the selected location. Thus, the guide system  200  may be fixed relative to the subject  20  and/or moved relative to the subject  20 . 
     At an appropriate position, the guide system  200  may have a first or fixed portion  220  that may be connected directly to the support  204 . The guide system  200  may further include a second or movable portion  224  that may move relative to the base or first portion  220 . The movable portion  224  may move or translate in a plane in any appropriate position or translation amount relative to the fixed portion  220 . Accordingly, the movable portion  224  may generally move in a planar or axis system  230  relative to the base portion  220 . The guide system  200  may include the Stealth Autoguide® cranial robotic guidance platform sold by Medtronic, Inc., having a place of business in Louisville, CO. Thus, the guide system may be controlled by the user  12  and/or other appropriate portion to move relative to the subject  20 . 
     The guide system  200  may further include a guide member. The guide member may be a guide tube  234  that may have a bore or through bore, as discussed herein. The guide tube  234  may be held relative to the base portion  220  with a first holding or fixation portion  238 . The guide tube  234  may also be fixed or held relative to the second portion  224  with a second holding or fixation portion  242 . The respective holding portions  238 ,  242  may fixedly hold two portions of the guide tube  234 , such as near a first end or entry portion  244  of the guide tube and near a second end  248 . The fixation portions  238 ,  242  may have a fixed length relative to the respective members  220 ,  224  and the tube  234 . Accordingly, the respective ends of the tube  244 ,  248  are fixed at respective distances from the respective members  220 ,  224 . 
     The fixation members  238 ,  242 , however, may include joints to allow movement of the second member  224  relative to the first member  220  and thereby also moving the tube  234 . As illustrated in  FIG.  2   , the tube  234  may extend along an axis  252 . The guide tube  234  may be at a first position  252   a . The second member  224  may translate relative to the first member  220 , such as any of the directions  230 , and this may cause the tube  234  and the respective axis  252  to move from the first position  252   a  to a second position  252   b . Thus, movement between the second member  224  and the first member  220  may move the tube  234  to move the long axis  252  relative to the subject  20 . Therefore, the position or trajectory of the alignment of the tube  234  may be adjusted relative to the subject  20 . 
     The position of the tube  234  may be determined. The position of the tube  234  may also be illustrated on the display device  32 , as discussed above, due to the determined position. In various embodiments, affixed to and/or associated with the tube  234  may be a tube or alignment guide tracking device  270 . The tracking device may be tracked to determine the position of the tube  234 . 
     The tracking device  270  may be any appropriate tracking device such as an EM tracking device and/or an optical tracking device. In various embodiments, the tracking device  270  may include optical trackable portions, such as reflective spheres  272  and/or may include one or more coils operable with the EM localizer  40 . As discussed above, the tracking device  270  may be tracked with the navigation system  10  to navigate or determine a position of the guide  234  relative to the subject  20 . Again, the tracking device  270  may be tracked and the position of the tube  234 , associated with the guide tracking device  270 , may be illustrated with the display device  32 , such as with an icon  234 ′ relative to the image  30 . The alignment system  200 , therefore, may move the long axis  252  of the tube within a selected cone relative to the subject  20 . The apex of the cone may be moved by moving the support  204  and/or the subject  20 . 
     In various embodiments, the position of the guide  234  may be tracked or determined with other tracking portions. For example, the alignment system may include internal or selected sensors, such as encoders, to determine movement and position of the guide  234 . Thus, the tracking device  270  may not be required to track the guide  234 . The determined movement or position of the alignment system  200  may be used to navigate the guide  234 . 
     With continuing reference to  FIG.  2   , and additional reference to  FIG.  3   , the alignment system  200  may include the movable portion or adjustable portion including the first and second members  220 ,  224  and the guide  234  that may be moved thereby, as discussed above. In addition to the movable portions, as discussed above, the alignment system  200  may include a base assembly  280 . The base assembly may include a selected number of portions, such as a base portion or member  284  that may be fixed to the skull  20   h  of the subject  20 . In various embodiments, the base portion  284  may be fixed to the skull  20   h  or selected fixation members, such as bone screws  288 . An appropriate number of the screws  288 , or other appropriate fixation members, may be used to fix the base  284  to the skull  20   h . 
     Extending or associated with the base portion  284  may be an adjustable member  292 . The adjustable member  292  may extend along a long axis  298  that may be fixed and/or selectively fixed relative to the base portion  284 . Thus, the adjustable member  292  may be positioned relative to a base surface  302  of the base portion  284 . A fixation system or member may selectively fix the adjustable member  292  relative to the base portion  284 . For example, a locking member or set screw  293  may engage the adjustable member  292  relative to the base portion  284 . Thus, the locking member  293  may be selectable between and engaged or locked position and an unengaged or unlocked position. In the unlocked position, the adjustable member  292  may be moved relative to the base portion  284 . In the locked position, the adjustable member  292  may be fixed relative to the base portion  284 . 
     The adjustable member  292  may include an external surface or wall  306  and an internal surface  308 . The alignment guide  234  may be positioned within the adjustable member  292  and may selectively engage the internal wall  308 . Accordingly, the guide tube  234  may be aligned with the adjustment system  200  and may engage the internal surface or portion  308  of the base tube  292  to at least assist in fixing or holding the guide tube  234  relative to the skull  20   h . As discussed above, the adjustable member  292  may be fixed relative to the base portion  280  and the base portion  280  may be fixed relative to the skull  20   h . Therefore, the alignment tube  234  may be held in a selected position with the adjustable or robotic portions  220 ,  224  and/or the lockable base  280  relative to the skull  20   h . 
     In various embodiments, the internal surface  308  of the adjustable tube  292  may include a dimension  312  that may be an internal dimension of the adjustment tube  292 . The guide tube  234  may include an external dimension  316  that is smaller than the internal dimension  312 . Thus, the alignment tube  234  may be adjusted relative to the adjustment base  280 . 
     In various embodiments, the alignment tube  234  may be moved to a selected position that may be pre-planned or pre-determined. The tracking device  270  may be used to track the position of the alignment tube or device  234  to the pre-determined position. The adjustable base  280  may be moved to a position and engage the guide tube  234  in a selected manner, such as with a friction or contact fit. Therefore, the alignment guide  234  may be held relative to the adjustable base  280 . The adjustable base  280  may then be fixed relative to the skull  20   h , such as with the fixation members  288  and/or selected adjustable locking features. In various embodiments, the adjustable tube portion  292  may be locked relative to the base portion  284  with appropriate locking features or portions  293 , such as thumb screws or the like, similar to those included in the Nexframe® trajectory guide sold by Medtronic, Inc., having a place of business in Minnesota. The adjustable member  292  may, therefore, be engaged in a selected manner to the guide tube  234  and then fixed in the appropriate or selected position relative to the base  284 , which, in turn, is fixed to the skull  20   h . Accordingly, the adjustable base  280  may assist in fixing the guide tube  234  relative to the skull  20   h , for a selected period, such as during a procedure. 
     With continuing reference to  FIGS.  2  and  3   , and additional reference to  FIG.  4    and  FIGS.  5 A- 5 C , the alignment system  200 , which may include the guide tube  234  and the base  280  may be used to assist or guide a procedure on the subject  20 . The procedure or process may be included or described in the flow chart  360  illustrated in  FIG.  4   . The process may begin in block  364 , which may include various features or processes, such as diagnosing the subject, identifying a possible diagnosis, determining a possible treatment plan, or other appropriate procedures. Accordingly, the procedure may start in block  264 . Following the starting of the procedure in block  364 , the procedure  360  may include a plurality of paths including a first path to acquire and/or access image data in block  368 . The image data may be acquired of the subject  20  to assist in performing a procedure on the subject  20  and/or diagnosing the subject, planning a procedure for the subject, or the like. The image data may include image data of a selected portion of the subject, such as of the head  20   h . The image data may include the image data acquired with the imaging system  24 , or any appropriate imaging system, such as a magnetic resonance imaging system (MRI), or the like. In various embodiments, the image data may be used to generate images that may be displayed on the display device  32 . The image data may be acquired of the subject  20  at any appropriate time, such as prior to positioning the alignment system  200  relative to the subject. For example, a procedure may be planned relative to the subject  20 , including a pose or position/location of the guide in block  372 . For example, an entry point and trajectory may be determined to perform a procedure, such as for a tumor resection, DBS placement, or the like. Accordingly, a procedure may be planned, such as with using image data acquired and/or accessed of the subject  20 . 
     A plan may be recalled in block  378  of a guide pose, in addition to or alternatively to performing the planning procedure in block  368 . Accordingly, the procedure  360  need not include planning a procedure. Rather a procedure may be planned in any appropriate time and the user  12  may recall the plan for the procedure when the subject  20  is prepared for the procedure, such as in an operating room with the navigation system  10 . Accordingly, the plan may be developed and saved for a later use which may then be recalled. The plan may be saved in an appropriate memory, such as the navigation memory  74  and may be recalled with the processor module  70 . 
     The guide system  200  may be positioned relative to the subject in block  382 . The guide system  200  may be used to move the guide tube  234  to the planned pose for the guide. The guide may be positioned, such as in an initial position relative to the subject  26  and moved further thereafter. With reference to  FIG.  5 A , for example, the alignment system  200  may be fixed with the stand  204 , which may be fixed to the patient support  26 , relative to the subject head  20   h . The second portion  224  may move relative to the first portion  220  to move the guide  234  relative to the subject head  20   h . The tracking device  270  may be used to track the guide tube  234 . The tracking system may track the position of the guide member  234  such as with the tracking device  270 . The position of the guide tube  234  may be illustrated on the display device with the icon  234 ′ due to registration of the subject space, such as the subject head  20   h  to the image  30  in block  386 , as discussed above. 
     Therefore, the guide tube  234  may be navigated relative to the subject head  20   h . The pose of the guide tube may be illustrated with the graphical representation  234 ′ relative to the image  30  on the display device  32 . Due to navigation of the guide tube  234 , the planned position may be determined or identified such as with an output on the display  32  at a selected time. Therefore, the guide tube may be moved and navigated to the planned pose in block  390 . 
     Once the guide tube  234  is at the predetermined or planned position, an indication or alert  396  may be given to the user  12 , such as with an alert on the display device  32 , an audible alert, or other appropriate alert. Accordingly, the user  12  may move or operate the alignment system  200  to move the guide tube  234  to the planned position. It is further understood that the alignment system may be substantially automatic and operated by the processor module  70  to move the guide tube  234  due to the plan. As the plan may be recalled and/or determined and the navigation system may navigate the guide tube  234 , the alignment system  200  may move due to automatic movement of the robotic system to move the guide tube  234  substantially automatically to the planned position. Accordingly, the guide tube  234  may be manually moved, such as operation of the alignment system  200  by the user  12 , and/or automatically by operating the alignment system  200  with the appropriate system, such as the navigation system  10 . 
     Once the alignment tube  234  is at the pre-planned position, a marking device  396  may be used to mark a position  400  on the subject head  20   h  in block  404 . Marking the position on the subject head  20   h  may be optional, but may be useful for positioning the adjustable base  280  relative to the subject head  20   h . 
     Accordingly, with continuing reference to  FIG.  4    and reference to  FIG.  5 B , the adjustable base  280  may be positioned relative to the subject head  20   h  in block  410 . The adjustable base  280  may be moved to the head  20   h  and fixed relative thereto with the appropriate fixation devices  288 . As discussed above, the base  280  may be positioned on the head  20   h  at the position of the mark  400 , or due to the identified gross position of the alignment tube  234 . 
     During positioning of the base  280 , the alignment system  200  may be moved relative to the subject  20 . As discussed above, the support portion  204  may be movable or adjustable and, therefore, the movable members  220 ,  224  may be moved to a second location to allow for efficient and fast application and fixation of the adjustable base  280  relative to the subject  20 . If the alignment system  200  is moved relative to the subject, therefore, re-alignment of the guide to the planned pose in block  420  may occur. 
     Accordingly, whether the guide is re-aligned in block  420 , where the base  280  is fixed to the subject  20   h  with the guide tube  234  in place, the guide tube  234  may engage the base guide tube  292 . When the guide tube  234  is at the planned position and engages the base guide tube  292  the alignment through the guide tube  234  and the base guide  292  is understood to be along the planned pose or trajectory. Thus, engaging the guide tube  234  into the base guide tube  292  in block  424  may align the guide tube  234  relative to the subject  20   h . Further engaging the base system  280  in a substantially fixed position, such as fixing the base  284  to the head and fixing the base tube  292  relative to the base  284 , provides a mechanical fixation of the guide tube  234  relative to the subject head  20   h . Therefore, the guide tube  234  may be secondarily and/or mechanically fixed relative to the subject  20   h  for a selected procedure. 
     Further, the display device  32  may display an indication, such as the indication  396 , that the alignment is at the appropriate position. The display device  32  may thus display an icon of the guide tube  234 ′. 
     Once the alignment is in the appropriate or pre-planned position, the instrument  16  may be positioned relative to the guide tube  234  to assist in performing the procedure. The instrument  16  may be and move and/or track relative to the subject  20   h  in block  430 . The display device  32  may display the graphical representation 16′ of the instrument during navigation and use of the instrument, even within the guide tube  234 . It is understood, however, that illustration of the instrument icon 16′ when in the guide tube  234  is not required. 
     The instrument  16  may then be used to perform the procedure in block  434 . Performing the procedure may include positioning an appropriate portion through the guide  234 , such as a DBS lead, or resection instrument, or the like. It is understood that any appropriate procedure may be performed with the instrument  16  and the instrument  16  may be any appropriate instrument. The method  360  may then end in block  438 . Ending the procedure in block  438  may include any appropriate steps such as completing navigation, performing a resection, performing an implantation, or the like. 
     The procedure  360 , therefore, may use the alignment system  200  to assist in performing a procedure relative to the subject  20 . In various portions of the procedure  360 , the navigation system or any appropriate processor module may be used to navigate the guide tube  234 , determine and identify that the guide tube is at a planned pose, automatically move the guide tube  234 , or other appropriate portions. It is also understood that the user  12  may be used or operate portions of the alignment system  200  and/or move instruments relative to the guide tube  234 . 
     It is understood by one skilled in the art, the procedure  360  does not require all portions identified therein. Generally, the procedure may include moving the guide to the planned pose in block  390  and engaging the guide to the base in block  424 . The guide tube  234  may be moved in an appropriate manner to the planned pose and may be tracked, as discussed above. The base system  280  may then be used to assist in holding (e.g. mechanically fix) the guide tube  234  relative to the subject. 
     Further, while the procedure is illustrated relative to the head  20   h  of the subject  20 , it is understood that the alignment system  200  may be used for other appropriate procedures. In various embodiments, the guide system  200  may be used to guide or align the guide tube  234  relative to a spinal procedure, a biopsy procedure in any appropriate organ (e.g. heart, lung, liver, etc.). Further, the procedure  360  and the alignment system  200  may be used for appropriate procedures on non-living or inanimate objects, such as moving an instrument or driving movement of an instrument into an inanimate object. Therefore, the alignment system  200  may be used to perform a procedure on any appropriate subject. 
     Turning reference to  FIG.  6 A  and  FIG.  6 B , the alignment system  200 , as discussed above, may be provided with an adjustable base  500  in an alignment system  200 ′. The alignment system  200 ′ may be substantially similar or include identical portions or similar portions to those discussed above, and/or alternative or different portions, as discussed further herein. Similar portions will be identified with similar reference numerals augmented by a prime (′). 
     With initial reference to  FIG.  6 A , the subject may have the alignment system  200 ′ positioned relative to the head  20   h . The alignment system  200 ′ may include a first portion  224 ′ that may move relative to a base or second portion  220 ′. Again, as discussed above, a support  204 ′ may be fixed relative to the patient support  26  and assist in holding the alignment system  200 ′ in a relative position to the subject head  20   h . The alignment system  200 ′ may include a guide member  504 . The guide member may be a guide tube with a bore. The guide tube  504  may include the tracking device or tracking device  270 ′. The tracking device  270 ′ may be used to track a pose of the guide tube  504  relative to the subject  20   h  and may be displayed on the display device  32 , similar to the guide tube  234  as discussed above. 
     The adjustable base  500  may include a base portion  510  that may be fixed to the subject head  20   h  with the fixation devices  288 ′, as discussed above. The adjustable base  500  may further include an adjustable portion  514  that may move relative to the base  510  and/or be fixed relative to the base  510 , as discussed above. Accordingly, the adjustable portion  514  may move relative to the base  510  for achieving a selected alignment of the guide tube  504  relative to the subject  20   h . 
     The adjustable base  500 , however, may be movably fixed relative to the guide tube  504 . For example, the guide tube  504  may include an external thread and the adjustable portion  514  may include an internal thread. By rotating the base tube  514  and/or the guide tube  504 , the adjustable base  500  may move axially along an axis  520  relative to the guide tube  504  generally in the direction of the double headed arrow  524 . In various embodiments, the axis  520  may be a longitudinal axis of the guide tube  504 . 
     During a gross or initial alignment of the guide tube  504  relative to the head  20   h , the adjustable base  500  may be in a first position, as illustrated in  FIG.  6 A , that is not in contact with the head  20   h . Once the alignment is determined to be in an appropriate position, such as with an output  530  on the display device  32 , the adjustable base  500  may be moved relative to the head  20   h . Therefore, the initial alignment or alignment of the guide tube  504  may be made with the adjustable base  500  attached thereto, but not in contact with the head  20   h . 
     With reference to  FIG.  6 B , once the guide tube  504  is in the appropriate or pre-planned position, the adjustable base may be moved toward the head  20   h , such as in the direction of arrow  524   a . Movement of the base  500  relative to or toward the head  20   h  may be due to rotation of the base tube  514  and/or rotation of the guide tube  504 . Accordingly, the adjustable base  500  may then be move relative to, such as within contact, with the head  20   h  and fixed relative thereto, such as with the patient fixation portions  288 . 
     It is understood that the adjustable base  500  may be moved relative to the guide tube  504  with any appropriate mechanism, such as with the turning mechanism, as discussed above, a ratchet and pawl, a detent, or other appropriate mechanism. It is further understood that appropriate connection or movement mechanisms may include a set screw that may be engaged and disengaged from between the two guide tubes  504 ,  514  to allow for movement of the adjustable base  500  relative to the head  20   h . 
     Accordingly, as discussed above, the guide tube, according to various embodiments  234 ,  504 , may be moved to a planned or selected pose relative to the subject  20 . The adjustable base, according to various embodiments  280 ,  500  may then be fixed relative to the head  20   h  and engage the guide tube  234 ,  504  to provide for a mechanical and/or secondary fixation relative to the subject  20 . The respective guide tubes  234 ,  504  may be used to assist in guiding the instrument  16  relative to the subject  20  for performing a procedure. 
     Example embodiments are provided so that this disclosure will be thorough, and will fully convey the scope to those who are skilled in the art. Numerous specific details are set forth such as examples of specific components, devices, and methods, to provide a thorough understanding of embodiments of the present disclosure. It will be apparent to those skilled in the art that specific details need not be employed, that example embodiments may be embodied in many different forms and that neither should be construed to limit the scope of the disclosure. In some example embodiments, well-known processes, well-known device structures, and well-known technologies are not described in detail. 
     The foregoing description of the embodiments has been provided for purposes of illustration and description. It is not intended to be exhaustive or to limit the disclosure. Individual elements or features of a particular embodiment are generally not limited to that particular embodiment, but, where applicable, are interchangeable and can be used in a selected embodiment, even if not specifically shown or described. The same may also be varied in many ways. Such variations are not to be regarded as a departure from the disclosure, and all such modifications are intended to be included within the scope of the disclosure. 
     It should be understood that various aspects disclosed herein may be combined in different combinations than the combinations specifically presented in the description and accompanying drawings. It should also be understood that, depending on the example, certain acts or events of any of the processes or methods described herein may be performed in a different sequence, may be added, merged, or left out altogether (e.g., all described acts or events may not be necessary to carry out the techniques). In addition, while certain aspects of this disclosure are described as being performed by a single module or unit for purposes of clarity, it should be understood that the techniques of this disclosure may be performed by a combination of units or modules associated with, for example, a medical device. 
     In one or more examples, the described techniques may be implemented in hardware, software, firmware, or any combination thereof. If implemented in software, the functions may be stored as one or more instructions or code on a computer-readable medium and executed by a hardware-based processing unit. Computer-readable media may include non-transitory computer-readable media, which corresponds to a tangible medium such as data storage media (e.g., RAM, ROM, EEPROM, flash memory, or any other medium that can be used to store desired program code in the form of instructions or data structures and that can be accessed by a computer). 
     Instructions may be executed by one or more processors, such as one or more digital signal processors (DSPs), general purpose microprocessors, graphic processing units (GPUs), application specific integrated circuits (ASICs), field programmable logic arrays (FPGAs), or other equivalent integrated or discrete logic circuitry. Accordingly, the term “processor” as used herein may refer to any of the foregoing structure or any other physical structure suitable for implementation of the described techniques. Also, the techniques could be fully implemented in one or more circuits or logic elements.