Herein, we present a “Nine-grid Area Division Method” for percutaneous vertebroplasty. A patient with an L1 vertebral compression fracture was selected as a case study.
Percutaneous vertebroplasty (PVP) is widely recognized as an efficacious intervention for alleviating low back pain resulting from osteoporotic vertebral compression fractures. The ideal bone puncture point is conventionally situated at the projection “left 10 points, right 2 points” of the pedicle in the lumbar spine. Determining the optimal bone puncture point represents a critical and complex challenge. The accuracy of percutaneous vertebroplasty (PVP) is primarily influenced by the proficiency of the operating surgeons and the utilization of multiple fluoroscopes during the conventional procedure. Incidences of puncture-related complications have been documented globally. In an effort to enhance the precision of the surgical technique and reduce the occurrence of puncture-related complications, our team applied the “Nine-grid Area Division Method” for PVP in the lumbar spine to modify the traditional procedure. There is potential to decrease the number of puncture times, the radiation exposure dosage, and the duration of surgical procedures.
This protocol introduces the definition of the “Nine-grid Area Division Method” and describes the process of modeling target vertebrae DICOM imaging data within medical imaging processing software, simulating operations within a 3-D model, refining the 3-D model using reverse engineering production software, reconstructing the vertebral engineering model within 3-D modeling design software, and utilizing surgical data to determine safe entry regions for pedicle projection. By employing this methodology, surgeons can effectively identify appropriate puncture points with precision and ease, thereby reducing the intricacies associated with puncturing and enhancing the overall accuracy of surgical procedures.
Osteoporotic vertebral compression fracture (OVCF) is the most prevalent type of fracture among osteoporotic fractures and poses a significant clinical concern in contemporary healthcare1. According to current guidelines, percutaneous vertebroplasty is recognized as one of the most efficacious minimally invasive treatment modalities for OVCF2. The predominant method for performing percutaneous vertebroplasty (PVP) involves the pedicle puncture approach, which encompasses three key parameters: the identification of the bone puncture entry point, puncture angle, and puncture depth. Of these parameters, the selection of the bone puncture entry point is considered the most crucial.
Currently, C-arm X-ray machines are widely employed in the domestic and international practice of traditional PVP surgery to facilitate the adjustment of the surgical path of the puncture needle. The crucial aspect lies in identifying the "ideal bone puncture point," which is conventionally situated at the projection "left 10 points, right 2 points" of the pedicle in the lumbar spine (Figure 1A)3. Despite their experience, even seasoned surgeons may make mistakes when determining appropriate puncture points based solely on personal experience. This can lead to puncture-related complications such as cement leakage into surrounding tissues, nerve root injury, and intra-spinal hematoma4,5,6. Additionally, nearly half of patients experience local complications from traditional PVP, with 95% of these complications attributed to cement leakage into surrounding tissue or embolization of paravertebral veins7. Our preliminary research found that the actual PVP bone puncture points in the lumbar spine are not always located at the ideal pedicle projection "left 10 points and right 2 points"8. Some actual puncture points can also achieve satisfactory puncture results near the "ideal bone puncture point," which does not affect surgical safety and accuracy.
Based on the above assumptions, we propose, for the first time, the concept of the "ideal bone puncture region" for PVP in the lumbar spine and divide the projection of the pedicle into a "Nine-grid Area". The concept of the ideal bone puncture region pertains to specific anatomical regions where the puncture entry point can successfully and securely reach the puncture ideal endpoint through the pedicle.The term "Nine-grid Area Division Method" refers to a technique in the X-ray anteroposterior image whereby the longest and shortest diameters of the pedicle projection are divided into three equal parts, resulting in the division of the area into nine regions (Figure 1B). These regions are sequentially numbered from 1 to 9, progressing from the outermost to the innermost and from top to bottom. Using the X-ray projection of the lumbar pedicle as an anatomical marker, we establish the "ideal bone puncture region" for PVP through the "Nine-grid Area Division Method" instead of being confined to a single point. We use computer simulation to explore a safe puncture path during the puncture process.
Hence, we suggest the implementation of the "Nine-grid Area Division Method" as a potential method for enhancing the convenience, efficiency, and safety of auxiliary puncture techniques in PVP surgery, with the aim of enhancing procedural accuracy and minimizing puncture-related complications. It is important to note that this study presents a theoretical approach that requires validation through extensive research to ascertain its efficacy and safety.
The present study was approved by the Ethics Committee of Beijing Friendship Hospital Capital Medical University. This method will be introduced via a retrospective case study, utilizing only the preoperative prone-position computed tomography (CT) imaging data of the patient. The "Nine-grid Area Division Method" in assisted percutaneous vertebroplasty (PVP) offers a simpler and more effective approach compared to traditional methods, resulting in reduced surgical and radiation exposure times. This technique may benefit young residents by facilitating easier identification of puncture points and potentially shortening the learning curve for PVP procedures, warranting further investigation. The individual described here is a female of 68 years of age.
1. Diagnosing osteoporotic vertebral compression fracture (OVCF) using X-ray fluoroscopy, magnetic resonance image (MRI), bone scintigraphy, and symptoms
2. The preoperative acquisition of CT imaging of the patient in a prone position
3. Establish the 3-D model and simulate the operation in medical imaging processing software
4. Polish the 3-D model in 3-D reverse engineering production software
5. Reconstruct the vertebral engineering model and confirm the safe entry regions of pedicle projection in 3-D modeling design software
CT imaging and digital modeling were performed in the hospital. It took 30 min to build the 3-D model from the CT images, ~10 min to polish the 3-D model in 3-D reverse engineering production software, and 15 min to reconstruct the vertebral engineering model and confirm the safe entry regions of pedicle projection in 3-D modeling design software. The ideal bone puncture region includes regions 1, 4, and 7 on the left side in this case. The notion of the ideal bone puncture region refers to distinct anatomical regions where the entry point for puncture can effectively and safely access the desired endpoint through the pedicle. Put differently, by adjusting the direction and depth of the puncture needle, the ideal puncture endpoint can be attained as long as the bone puncture entry point falls within these specified areas, rather than being restricted to the " left 10 points". This technique can significantly increase the surgeon's error tolerance during the puncture procedure. A minimal amount of fluoroscopy is necessary to identify an appropriate bone puncture site, leading to a reduction in the frequency of adjustments, radiation exposure, and duration of surgery.
The ideal bone puncture point is conventionally situated at the projection "left 10 points, right 2 points" of the pedicle in the lumbar spine as shown in Figure 1A. Figure 1B presents a detailed overview of the division details and methodologies employed in the Nine-grid Area Division Method. The preoperative images of the target vertebra are shown in Figure 2. A gradienter was placed on the patient's back before the prone CT scan and the patient's body position was recorded (Figure 3). The CT vertebra image was reconstructed into a 3-D model from the coronal, transverse, and the sagittal planes (Figure 4). Figure 4 also shows the simulation of the PVP operation procedure in the image processing software. Figure 5 shows the procedures to repair the mesh and transform the solid model into a triangular mesh surface. Figure 6 illustrates the methodology for observing and documenting the narrowest point of the pedicle through the utilization of the Section View function. Figure 7 illustrates the steps involved in adjusting the model displacement parameters and determining the final puncture target location. Figure 8 illustrates the partitioning of the model into two distinct components: the vertebral body half and the lamina half (A), followed by the generation of the pedicle projection using the Convert Entities function (B). Figure 9 depicts the array of puncture paths within the vertebral body. The lamina and vertebral body components were reassembled using the pedicle puncture set, with the puncture set subsequently removed from the laminae portion while preserving all laminae components. The Combine Body function was utilized to perform Boolean operations on multiple components, leading to the identification of the ideal bone puncture region comprising regions 1, 4, and 7.
Figure 1: A. Traditional "ideal bone puncture point." The "ideal bone puncture point" is conventionally situated at the projection "left 10 points, right 2 points" of the pedicle in the lumbar spine. B. Introduction to the "Nine-grid Area Division Method." A detailed overview of the division details and methodologies employed in the "Nine-grid Area Division Method." Please click here to view a larger version of this figure.
Figure 2: Preoperative images of the target vertebra. (A) X-ray of the patient with osteoporotic vertebral compression fracture.The pre-operation X-ray images of the target vertebra of the patient. (A1: Posteroanterior view; A2: Lateral view). (B) MRI of the patient with osteoporoticvertebral compression fracture.The preoperative MRI images of the target vertebra of the patient. (B1: T1WI view; B2: T2WI view). Please click here to view a larger version of this figure.
Figure 3: CT scan in the prone position. Use a gradienter on the patient's back to measure the horizontal and sagittal angles of the patient's body while undergoing a prone position CT scan. Please click here to view a larger version of this figure.
Figure 4: Reconstruction of the vertebra and simulation of the operation. (A) Reconstruction of vertebra in medical imaging processing software from the CT vertebra image from (A1) the coronal plane, (A2) the transverse plane, (A3) the sagittal plane, and (A4) the 3-D model. (B) Simulation of PVP operation procedure in medical imaging processing software. Please click here to view a larger version of this figure.
Figure 5: Polishing the 3-D model in 3-D reverse engineering production software. The procedure of refining the 3-D model. (A) Repairing the mesh and (B) transforming the solid model into a triangular mesh surface. Please click here to view a larger version of this figure.
Figure 6: Utilize the Section View function to observe and document the pedicle. Utilizing the Section View function to observe the (A) pedicle projection and (B) document angle parameters. Please click here to view a larger version of this figure.
Figure 7: Modifying the parameters of the model's displacement. Adjust the model displacement parameters and determine the final puncture target location. Please click here to view a larger version of this figure.
Figure 8: Creating a representation of the projection of the pedicle. (A) Partitioning of the model into two distinct components, followed by (B) the generation of the pedicle projection using the Convert Entities function. Please click here to view a larger version of this figure.
Figure 9: Puncture paths and the identification of the ideal puncture region. (A) Set of puncture paths traversing the pedicle. The array of puncture paths within the vertebral body through the pedicle. (B) Reconstructing models comprising diverse components. Reconstruct the lamina and vertebral body segments by means of the pedicle puncture set. (C) Acquisition of the "ideal bone puncture region". An area is deemed an ideal bone puncture region only when it is completely blue. The ideal bone puncture region encompasses regions 1, 4, and 7 through the application of Boolean operations. Please click here to view a larger version of this figure.
Percutaneous vertebroplasty (PVP) has demonstrated favorable clinical efficacy in managing painful osteoporotic vertebral compression fractures (OVCF)9. The utilization of precise percutaneous pedicle puncture technology by surgeons plays a crucial role in determining the optimal insertion point, direction, and depth of the puncture needle, thereby significantly reducing the occurrence of complications10. Currently, C-arm X-ray machines are widely employed in the domestic and international practice of traditional PVP surgery to facilitate the adjustment of the surgical path of the puncture needle11. The crucial aspect lies in identifying the ideal bone puncture point, which is conventionally situated at the projection "left 10 points, right 2 points" of the pedicle in the lumbar spine. The "Nine-grid Area Division Method" has the capability to identify the optimal bone puncture region.
The rationale for selecting the Nine-grid as the preferred division method over alternatives like the "Four-grid " and "Sixteen-grid " warrants explicit clarification. This decision stems from preliminary experiments, which have demonstrated that segmenting the pedicle projection into a Nine-grid Area aligns most closely with clinical practice while also considering the reference value. The "Four-grid Area Division Method" is characterized by ease of operation; however, its limited reference value arises from the imprecise regional division, making it challenging to discern the safety of the bone puncture entry point. Conversely, the "Sixteen-grid Area Division Method" offers an accurate determination of the puncture point's safety, yet its complexity during surgical procedures hinders observation and judgment, rendering it incongruous with clinical practice. Consequently, the "Nine-grid Area Division Method" was selected as it combines clinical feasibility with the provision of satisfactory reference value.
Upon further analysis of the clinical imaging data from our previous research subjects12, it was discovered that the precise lumbar spine PVP bone puncture points, as projected by the ideal pedicle projection of "left 10 points, right 2 points", are not consistently observed. However, it was observed that certain alternative puncture points can still yield satisfactory puncture outcomes near the aforementioned ideal bone puncture point. These deviations from the ideal do not compromise surgical safety or accuracy. Based on the assumptions, we introduce the novel notion of the ideal bone puncture region for the PVP pedicle, which involves segmenting the pedicle projection into a Nine-grid Area on the X-ray anteroposterior image. By employing the X-ray projection of the lumbar pedicle as an anatomical reference, we establish the ideal bone puncture region for PVP through the division of the pedicle into a Nine-grid Area, thereby surpassing the limitations of a singular point.
Theoretical innovation has the potential to enhance the PVP puncture surgical pathway by using the "Nine-grid Area Division Method"-assisted PVP surgery in the lumbar spine. This advancement may decrease the dosage of intraoperative projection and minimize the duration of surgical procedures required for adjusting the bone entry point of the puncture needle, ultimately improving surgical efficiency and efficacy. It is noteworthy that the ideal bone puncture region for the "Nine-grid Area Division Method" may vary across different segments of the vertebral body. For illustrative purposes, the L1 vertebral body is solely utilized as an exemplar in this context. Our future research will incorporate additional case studies, broader sample segments, and investigations into robot learning to enhance the validity and objectivity of the indications and methodologies for PVP puncture.
However, there are some limitations of the "Nine-grid Area Division Method"-assisted PVP in the lumbar spine. There is a learning curve for learning to use the medical imaging software. Any mistake made during template design by surgeons unfamiliar with the software may lead to an unsuccessful result. Furthermore, larger-scale studies are imperative to validate the reliability and practicability of this finding.
The authors have nothing to disclose.
The study was funded by Beijing Natural Science Foundation-Haidian Original Innovation Joint Fund (L232054) and Capital Health Development Research Special Fund (NO.2024-2-2024).
Computer tomography | Company GE | machine | |
Geomagic Wrap (3-D reverse engineering production software) | Oqton software | software | |
Magnetic resonance image machine | Company GE | machine | |
Materialise Interactive Medical Image Control System (medical imaging processing software) | Materialise Company | software | |
Solidworks (3-D modeling design software) | Dassault Systèmes - SolidWorks Corporation | software | |
Spirit Level Plus | IOS App store | gradientor | |
X-ray machine | Company Philips | machine |
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