Stereotactic surgery
Stereotactic surgery | |
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Other names | Stereotaxy |
Specialty | Neurosurgery |
Stereotactic surgery is a
In theory, any organ system inside the body can be subjected to stereotactic surgery. However, difficulties in setting up a reliable frame of reference (such as
Another accepted form of "stereotactic" is "stereotaxic". The word roots are stereo-, a prefix derived from the Greek word στερεός (stereos, "solid"), and -taxis (a suffix of Neo-Latin and ISV, derived from Greek taxis, "arrangement", "order", from tassein, "to arrange").
Uses
The surgery is used to treat various brain cancers, benign, and functional disorders of the brain.[1] This is sometimes combined with whole brain radiotherapy, and a 2021 systematic review found this combination led to the greatest improvement of survival for those with single brain metastasis.[2]
Amongst the malignant brain disorders are: brain metastasis and glioblastoma.[1] The benign brain disorders are: meningioma, cerebral arteriovenous malformation, vestibular schwannoma, and pituitary adenoma.[1] Functional disorders are: trigeminal neuralgia, Parkinson's disease, and epilepsy.[1]
Procedure
Stereotactic surgery works on the basis of three main components:[citation needed]
- A stereotactic planning system, including atlas, multimodality image matching tools, coordinates calculator, etc.
- A stereotactic device or apparatus
- A stereotactic localization and placement procedure
Modern stereotactic planning systems are computer based. The stereotactic atlas is a series of cross sections of anatomical structure (for example, a human brain), depicted in reference to a two-coordinate frame. Thus, each brain structure can be easily assigned a range of three coordinate numbers, which will be used for positioning the stereotactic device. In most atlases, the three dimensions are: latero-lateral (x), dorso-ventral (y) and rostro-caudal (z).
The stereotactic apparatus uses a set of three coordinates (x, y and z) in an orthogonal frame of reference (
Guide bars in the x, y and z directions (or alternatively, in the polar coordinate holder), fitted with high precision vernier scales allow the neurosurgeon to position the point of a probe (an electrode, a cannula, etc.) inside the brain, at the calculated coordinates for the desired structure, through a small trephined hole in the skull.
Currently, a number of manufacturers produce stereotactic devices fitted for neurosurgery in humans, for both brain and spine procedures, as well as for animal experimentation.
Types frame systems
- Simple orthogonal system: The probe is directed perpendicular to a square base unit fixed to the skull. These provide three degrees of freedom by means of a carriage that moved orthogonally along the base plate or along a bar attached parallel to the base plate of the instrument. Attached to the carriage was a second track that extended across the head frame perpendicularly.
- Burr hole mounted system: This provides a limited range of possible intracranial target points with a fixed entry point. They provided two angular degrees of freedom and a depth adjustment. The surgeon could place the burr hole over nonessential brain tissue and utilize the instrument to direct the probe to the target point from the fixed entry point at the burr hole.
- Arc-quadrant systems: Probes are directed perpendicular to the tangent of an arc (which rotates about the vertical axis) and a quadrant (which rotates about the horizontal axis). The probe, directed to a depth equal to the radius of the sphere defined by the arc-quadrant, will always arrive at the center or focal point of that sphere.
- Arc-phantom systems: An aiming bow attaches to the head ring, which is fixed to the patient's skull, and can be transferred to a similar ring that contains a simulated target. In this system, the phantom target is moved on the simulator to 3D coordinates. After adjusting the probe holder on the aiming bow so that the probe touches the desired target on the phantom, the transferable aiming bow is moved from the phantom base ring to the base ring on the patient. The probe is then lowered to the determined depth in order to reach the target point deep in the patient's brain.[4]
Treatment
Stereotactic radiosurgery
Stereotactic radiosurgery utilizes externally generated ionizing radiation to inactivate or eradicate defined targets in the head or spine without the need to make an incision.[5] This concept requires steep dose gradients to reduce injury to adjacent normal tissue while maintaining treatment efficacy in the target.[6] As a consequence of this definition, the overall treatment accuracy should match the treatment planning margins of 1–2 mm or better.[7] To use this paradigm optimally and treat patients with the highest possible accuracy and precision, all errors, from image acquisition over treatment planning to mechanical aspects of the delivery of treatment and intra-fraction motion concerns, must be systematically optimized.[8] To assure quality of patient care the procedure involves a multidisciplinary team consisting of a radiation oncologist, medical physicist, and radiation therapist.[9][10] Dedicated, commercially available stereotactic radiosurgery programs are provided by the irrespective Gamma Knife,[11] CyberKnife,[12] and Novalis Radiosurgery[13] devices.[14]
Stereotactic radiosurgery provides an efficient, safe, and minimal invasive treatment alternative[15] for patients diagnosed with malignant, benign and functional indications in the brain and spine, including but not limited to both primary and secondary tumors.[16] Stereotactic radiosurgery is a well-described management option for most metastases, meningiomas, schwannomas, pituitary adenomas, arteriovenous malformations, and trigeminal neuralgia, among others.[17]
Irrespective of the similarities between the concepts of stereotactic radiosurgery and fractionated
A second, more recent evolution extrapolates the original concept of stereotactic radiosurgery to extra-cranial targets, most notably in the lung, liver, pancreas, and prostate. This treatment approach, entitled stereotactic body radiotherapy or SBRT, is challenged by various types of motion.[20] On top of patient immobilization challenges and the associated patient motion, extra-cranial lesions move with respect to the patient's position due to respiration, bladder and rectum filling.[21] Like stereotactic radiosurgery, the intent of stereotactic body radiotherapy is to eradicate a defined extra-cranial target. However, target motion requires larger treatment margins around the target to compensate for the positioning uncertainty. This in turn implies more normal tissue exposed to high doses, which could result in negative treatment side effects. As a consequence, stereotactic body radiotherapy is mostly delivered in a limited number of fractions, thereby blending the concept of stereotactic radiosurgery with the therapeutic benefits of fractionated radiotherapy.[22] To monitor and correct target motion for accurate and precise patient positioning prior and during treatment, advanced image-guided technologies are commercially available and included in the radiosurgery programs offered by the CyberKnife and Novalis communities.[23]
Parkinson's disease
Functional neurosurgery comprises treatment of several disorders such as Parkinson's disease, hyperkinesia, disorder of muscle tone, intractable pain, convulsive disorders and psychological phenomena. Treatment for these phenomena was believed to be located in the superficial parts of the CNS and PNS. Most of the interventions made for treatment consisted of cortical extirpation. To alleviate extra pyramidal disorders, pioneer Russell Meyers dissected or transected the head of the caudate nucleus in 1939,[24] and part of the putamen and globus pallidus. Attempts to abolish intractable pain were made with success by transection of the spinothalamic tract at spinal medullary level and further proximally, even at mesencephalic levels.[citation needed]
In 1939-1941 Putnam and Oliver tried to improve Parkinsonism and hyperkinesias by trying a series of modifications of the lateral and antero-lateral cordotomies. Additionally, other scientists like Schurman, Walker, and Guiot made significant contributions to functional neurosurgery. In 1953, Cooper discovered by chance that ligation of the anterior chorioidal artery resulted in improvement of Parkinson's disease. Similarly, when Grood was performing an operation in a patient with Parkinson's, he accidentally lesioned the thalamus. This caused the patient's tremors to stop. From then on, thalamic lesions became the target point with more satisfactory results.[25]
More recent clinical applications can be seen
In Thalamotomy, a needle electrode is placed into the thalamus, and the patient must cooperate with tasks assigned to find the affected area- after this area of the thalamus is located, a small high frequency current is applied to the electrode and this destroys a small part of the thalamus. Approximately 90% of patients experience instantaneous tremor relief.[citation needed]
In Pallidotomy, an almost identical procedure to thalamotomy, a small part of the pallidum is destroyed and 80% of patients see improvement in rigidity and hypokinesia and a tremor relief or improvement comes weeks after the procedure.[citation needed]
History
The stereotactic method was first published in 1908 by two British scientists,
The first stereotactic device used in humans was used by Martin Kirschner, for a method to treat trigeminal neuralgia by inserting an electrode into the trigeminal nerve and ablating it. He published this in 1933.[29]: 13 [32]: 420 [33]
In 1947 and 1949, two neurosurgeons working at Temple University in Philadelphia, Ernest A. Spiegel (who had fled Austria when the Nazis took over[28]) and Henry T. Wycis, published their work on a device similar to the Horsley–Clarke apparatus in using a cartesian system; it was attached to the patient's head with a plaster cast instead of screws. Their device was the first to be used for brain surgery; they used it for psychosurgery. They also created the first atlas of the human brain, and used intracranial reference points, generated by using medical images acquired with contrast agents.[29]: 13 [32]: 72 [34]
The work of Spiegel and Wycis sparked enormous interest and research.[29]: 13 In Paris, Jean Talairach collaborated with Marcel David, Henri Hacaen, and Julian de Ajuriaguerra on a stereotactic device, publishing their first work in 1949 and eventually developing the Talairach coordinates.[28][29]: 13 [32]: 93 In Japan, Hirotaro Narabayashi was doing similar work.[28]
In 1949,
In 1979,
Other localization methods also exist that do not make use of tomographic images produced by CT, MRI, or PET, but instead conventional radiographs.[52]
The stereotactic method has continued to evolve, and at present employs an elaborate mixture of
History in Latin America
In 1970, in the city of Buenos Aires, Argentina, Aparatos Especiales company, produced the first Stereotactic System in Latin America. Antonio Martos Calvo, together with Jorge Candia and Jorge Olivetti through the request of neurosurgeon Jorge Schvarc (1942-2019), developed an equipment based on the principle of Hitchcock Stereotactic System. The patient was seated in an adapted chair with two telescopic arms attached at it base, which fixed the stereotactic frame preventing the patient’s movement.
A double radiopaque ruler attached to the side of the frame made it possible to obtain the antero-posterior and latero-lateral X-ray images without the need of moving the radiopaque ruler. The thermal coagulation lesion was performed using tungsten monopole electrodes of 1,5mm of diameter (without temperature control) with a 3mm active tip, utilizing an electrical bipolar coagulator. The lesion size was previously determined by testing the electrode in egg albumin. Coagulation size was the result of the electrical coagulator power regulation and the application time of the radiofrequency. The first surgery performed with this system was a Trigeminal Nucleotractothomy. Jorge Schvarcz performed more than 700 functional surgeries until 1994 when, due to health problems he stopped exercising his profession. But the equipment developed kept improving on a neurosurgery history.
This was the beginning of the developing of technology to produce stereotactic devices in Latin America. This was the beginning of the first stereotactic manufacturer of Latin America – The Brazilian Micromar.
Research
Stereotactic surgery is sometimes used to aid in several different types of animal research studies. Specifically, it is used to target specific sites of the brain and directly introduce pharmacological agents to the brain which otherwise may not be able to cross the
See also
- Radiosurgery
- CyberKnife
- Gamma knife
- Novalis radiosurgery
- Interventional radiology
- Psychosurgery
- Stereotaxis
References
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- ^ Levy, Robert. "A Short History of Stereotactic Neurosurgery". Cyber Museum of Neurosurgery. Archived from the original on 2017-05-13. Retrieved 2004-11-20.
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Further reading
- Armando Alaminos Bouza, "Imaging, Stereotactic Space and Targeting in Functional Neurosurgery", Functional Neurosurgery, First Edition, Publisher: Alaúde Editorial LTDA, Editor: Arthur Cukiert, pp. 67–79, (2014), ISBN 978-85-7881-248-5
- Philip L. Gildenberg, "Stereotactic Surgery: Present and Past", Stereotactic Neurosurgery (Editor: M. Peter Heilbrun). Baltimore: Williams and Wilkins(1988)
- Patrick J. Kelly, "Introduction and Historical Aspects", Tumor Stereotaxis, Philadelphia: W. B. Saunders Company (1991)
- Robert Levy, A Short History of Stereotactic Surgery Archived 2017-05-13 at the Wayback Machine, Cyber Museum of Neurosurgery.
- William Regine; Lawrence Chin (2008). Principles of Stereotactic Surgery. Berlin: Springer. ISBN 978-0-387-71069-3.
- Steel, G. Gordon (2002). Basic clinical radiobiology (3rd ed.). London: Hodder Arnold. ISBN 978-0340807835.
- Tasker RR, Organ LW, Hawrylyshyn P (1976). "Sensory organization of the human thalamus". Applied Neurophysiology. 39 (3–4): 139–53. PMID 801856.
- Tasker RR, Hawrylyshyn P, Rowe IH, Organ LW (1977). "Computerized Graphic Display of Results of Subcortical Stimulation During Stereotactic Surgery". Advances in Stereotactic and Functional Neurosurgery 2. Acta Neurochirurgica Supplementum. Vol. 24. pp. 85–98. PMID 335811.
- van Manen, Jaap (1967). Stereotactic Methods and their Applications in Disorders of the Motor System. Springfield, IL: Royal Van Gorcum.
- Zapata, A.; Chefer, V.I.; Shippenberg, T.S. (2009). "Microdialysis in Rodents". Current Protocols in Neuroscience. 47: 7.2.1–7.2.29. PMID 19340813.