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Augmented and Virtual Reality Navigation for Interventions in the Musculoskeletal System

Purpose of Review: Augmented reality (AR) and virtual reality (VR) are cutting-edge technologies that offer advanced navigational solutions. These systems are just starting to be used in interventional radiology and the literature has been limited to pre-clinical and translational experiments. In this paper, we present a review of AR and VR for musculoskeletal interventions. Recent Findings: Mixed reality systems have evolved from costly research systems to fully commercialized clinical instruments designed to facilitate operators in navigating complex anatomy. Studies within interventional radiology have demonstrated safety, improved accuracy, and decreased exposure to ionizing radiation. Summary: We review the progression of mixed reality systems from their early origins in computer science through their current day surgical applications, with a special focus on landmark studies within radiologic interventions for the musculoskeletal system. We highlight the instrumentation, clinical workflow, benefits and drawbacks, and suggested future directions for the two main AR systems: head-mounted display and image-overlay.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Processing system of jaws tomograms for pathology identification and surgical guide modeling

The aim of the study is to create an image processing system, which allows dentists to find pathological resorption and to build surgical guide surface automatically. X-rays images of jaws from cone beam tomography or spiral computed tomography are the initial data for processing. One patient’s examination always includes up to 600 images (or tomograms), that’s why the development of processing system for fast automation search of pathologies is necessary. X-rays images can be useful not for only illness diagnostic but for treatment planning too. We have studied the case of dental implantation – for successful surgical manipulations surgical guides are used. We have created a processing system that automatically builds jaw and teeth boundaries on the x-ray image. After this step, obtained teeth boundaries used for surgical guide surface modeling and jaw boundaries limit the area for further pathologies search. Criterion for the presence of pathological resorption zones inside the limited area is based on statistical investigation. After described actions, it is possible to manufacture surgical guide using 3D printer and apply it in surgical operation.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

Fluid handling 2: Surgical applications

The methods proposed for managing fluids and particulate debris during minor surgery on Space Station Freedom (SSF) were investigated and demonstrated. A KC-135 parabolic flight test was performed, in which the flight followed the standard 40 parabola profile with 20 to 25 seconds in near-zero gravity in each parabola. The equipment (suction and laminar flow device) was evaluated. While this equipment performed satisfactorily previously in the dental simulation, the purpose of the current flight was to reconfigure the equipment in support of a minor surgical situation in order to evaluate its efficacy and establish clear requirements for the actual flight hardware. To accomplish the study the Health Maintenance Facility medical restraint system was deployed as for surgical use and mannequin suture arm was restrained to its surface. The surgical area was established as for performing minor surgery with standard tray and suture instruments employed.

Billica, Roger↗

Robotic Surgery

The Automated Endoscopic System for Optimal Positioning, or AESOP, was developed by Computer Motion, Inc. under a SBIR contract from the Jet Propulsion Lab. AESOP is a robotic endoscopic positioning system used to control the motion of a camera during endoscopic surgery. The camera, which is mounted at the end of a robotic arm, previously had to be held in place by the surgical staff. With AESOP the robotic arm can make more precise and consistent movements. AESOP is also voice controlled by the surgeon. It is hoped that this technology can be used in space repair missions which require precision beyond human dexterity. A new generation of the same technology entitled the ZEUS Robotic Surgical System can make endoscopic procedures even more successful. ZEUS allows the surgeon control various instruments in its robotic arms, allowing for the precision the procedure requires.

Source record↗

Dental equipment test during zero-gravity flight

The overall objectives of this program were to establish performance criteria and develop prototype equipment for use in the Health Maintenance Facility (HMF) in meeting the needs of dental emergencies during space missions. The primary efforts during this flight test were to test patient-operator relationships, patent (manikin) restraint and positioning, task lighting systems, use and operation of dental rotary instruments, suction and particle containment system, dental hand instrument delivery and control procedures, and the use of dental treatment materials. The initial efforts during the flight focused on verification of the efficiency of the particle containment system. An absorptive barrier was also tested in lieu of the suction collector. To test the instrument delivery system, teeth in the manikin were prepared with the dental drill to receive restorations, some with temporary filling materials and another with definitive filling material (composite resin). The best particle containment came from the combination use of the laminar-air/suction collector in concert with immediate area suction from a surgical high-volume suction tip. Lighting in the treatment area was provided by a flexible fiberoptic probe. This system is quite effective for small areas, but for general tasks ambient illumination is required. The instrument containment system (elastic cord network) was extremely effective and easy to use. The most serious problem with instrument delivey and actual treatment was lack of time during the microgravity sequences. The restorative materials handled and finished well.

Young, John↗

Simulation System for Training in Laparoscopic Surgery

A computer-based simulation system creates a visual and haptic virtual environment for training a medical practitioner in laparoscopic surgery. Heretofore, it has been common practice to perform training in partial laparoscopic surgical procedures by use of a laparoscopic training box that encloses a pair of laparoscopic tools, objects to be manipulated by the tools, and an endoscopic video camera. However, the surgical procedures simulated by use of a training box are usually poor imitations of the actual ones. The present computer-based system improves training by presenting a more realistic simulated environment to the trainee. The system includes a computer monitor that displays a real-time image of the affected interior region of the patient, showing laparoscopic instruments interacting with organs and tissues, as would be viewed by use of an endoscopic video camera and displayed to a surgeon during a laparoscopic operation. The system also includes laparoscopic tools that the trainee manipulates while observing the image on the computer monitor (see figure). The instrumentation on the tools consists of (1) position and orientation sensors that provide input data for the simulation and (2) actuators that provide force feedback to simulate the contact forces between the tools and tissues. The simulation software includes components that model the geometries of surgical tools, components that model the geometries and physical behaviors of soft tissues, and components that detect collisions between them. Using the measured positions and orientations of the tools, the software detects whether they are in contact with tissues. In the event of contact, the deformations of the tissues and contact forces are computed by use of the geometric and physical models. The image on the computer screen shows tissues deformed accordingly, while the actuators apply the corresponding forces to the distal ends of the tools. For the purpose of demonstration, the system has been set up to simulate the insertion of a flexible catheter in a bile duct. [As thus configured, the system can also be used to simulate other endoscopic procedures (e.g., bronchoscopy and colonoscopy) that include the insertion of flexible tubes into flexible ducts.] A hybrid approach has been followed in developing the software for real-time simulation of the visual and haptic interactions (1) between forceps and the catheter, (2) between the forceps and the duct, and (3) between the catheter and the duct. The deformations of the duct are simulated by finite-element and modalanalysis procedures, using only the most significant vibration modes of the duct for computing deformations and interaction forces. The catheter is modeled as a set of virtual particles uniformly distributed along the center line of the catheter and connected to each other via linear and torsional springs and damping elements. The interactions between the forceps and the duct as well as the catheter are simulated by use of a ray-based haptic-interaction- simulating technique in which the forceps are modeled as connected line segments.

Basdogan, Cagatay↗

Multimodality instrument for tissue characterization

A system with multimodality instrument for tissue identification includes a computer-controlled motor driven heuristic probe with a multisensory tip. For neurosurgical applications, the instrument is mounted on a stereotactic frame for the probe to penetrate the brain in a precisely controlled fashion. The resistance of the brain tissue being penetrated is continually monitored by a miniaturized strain gauge attached to the probe tip. Other modality sensors may be mounted near the probe tip to provide real-time tissue characterizations and the ability to detect the proximity of blood vessels, thus eliminating errors normally associated with registration of pre-operative scans, tissue swelling, elastic tissue deformation, human judgement, etc., and rendering surgical procedures safer, more accurate, and efficient. A neural network program adaptively learns the information on resistance and other characteristic features of normal brain tissue during the surgery and provides near real-time modeling. A fuzzy logic interface to the neural network program incorporates expert medical knowledge in the learning process. Identification of abnormal brain tissue is determined by the detection of change and comparison with previously learned models of abnormal brain tissues. The operation of the instrument is controlled through a user friendly graphical interface. Patient data is presented in a 3D stereographics display. Acoustic feedback of selected information may optionally be provided. Upon detection of the close proximity to blood vessels or abnormal brain tissue, the computer-controlled motor immediately stops probe penetration. The use of this system will make surgical procedures safer, more accurate, and more efficient. Other applications of this system include the detection, prognosis and treatment of breast cancer, prostate cancer, spinal diseases, and use in general exploratory surgery.

Mah, Robert W.↗

Exercise Countermeasures for Bone Loss During Space Flight: A Method for the Study of Ground Reaction Forces and their Implications for Bone Strain

Effective countermeasures to prevent loss of bone mineral during long duration space flight remain elusive. Despite an exercise program on MIR flights, the data from LeBlanc et al. (1996) indicated that there was still a mean rate of loss of bone mineral density in the proximal femur of 1.58% per month (n=18, flight duration 4 - 14.4 months). The specific mechanisms regulating bone mass are not known, but most investigators agree that bone maintenance is largely dependent upon mechanical demand and the resultant local bone strains. A plausible hypothesis is that bone loss during space flight, such as that reported by LeBlanc et al. (1996), may result from failure to effectively load the skeleton in order to generate localized bone strains of sufficient magnitude to prevent disuse osteoporosis. A variety of methods have been proposed to simulate locomotor exercise in reduced gravity. In such simulations, and in an actual microgravity environment, a gravity replacement load (GRL) must always be added to return the exercising subject to the support surface and the resulting skeletal load is critically dependent upon the magnitude of the GRL. To our knowledge, GRLs during orbital flight have only been measured once (on STS 81) and it is likely that most or all prior treadmill exercise in space has used GRLs that were less than one body weight. McCrory (1997) has shown that subjects walking and running in simulated zero-G can tolerate GRLs of 1 if an appropriate harness is used. Several investigators have attempted to measure in vivo strains and forces in the bones of humans, but have faced ethical and technical limitations. The anteromedial aspect of the tibial midshaft has been a common site for the placement of strain gauges; one reason to measure strains in the anterior tibia is that this region is surgically accessible. Aamodt et al. (1997) were able to measure strains on the lateral surface of the proximal femur only because their experimental subjects were already scheduled for hip surgery. Lu et al. (1997) used an instrumented massive proximal femoral prosthesis along with electromyographic measurements to demonstrate that femoral forces depend on muscular activity. These analyses of in vivo bone mechanics are valuable. The invasive nature of the procedures involved, however, limits both the number of subjects and the number of strain gauge locations. Further, the results of these studies may be confounded by the inclusion of subjects with pathological conditions. Gross et al. (1992) measured strain at three locations on the equine third metacarpal and used those data to construct a computer model of the internal strain environment of the bone. An analogous placement of multiple gauges in living humans would be difficult and potentially hazardous because of the depth of soft tissue overlying the tibia and femur.

Peterman, M.↗

Multimodality Instrument for Tissue Characterization

A system with multimodality instrument for tissue identification includes a computer-controlled motor driven heuristic probe with a multisensory tip is discussed. For neurosurgical applications, the instrument is mounted on a stereotactic frame for the probe to penetrate the brain in a precisely controlled fashion. The resistance of the brain tissue being penetrated is continually monitored by a miniaturized strain gauge attached to the probe tip. Other modality sensors may be mounted near the probe tip to provide real-time tissue characterizations and the ability to detect the proximity of blood vessels, thus eliminating errors normally associated with registration of pre-operative scans, tissue swelling, elastic tissue deformation, human judgement, etc., and rendering surgical procedures safer, more accurate, and efficient. A neural network, program adaptively learns the information on resistance and other characteristic features of normal brain tissue during the surgery and provides near real-time modeling. A fuzzy logic interface to the neural network program incorporates expert medical knowledge in the learning process. Identification of abnormal brain tissue is determined by the detection of change and comparison with previously learned models of abnormal brain tissues. The operation of the instrument is controlled through a user friendly graphical interface. Patient data is presented in a 3D stereographics display. Acoustic feedback of selected information may optionally be provided. Upon detection of the close proximity to blood vessels or abnormal brain tissue, the computer-controlled motor immediately stops probe penetration.

Mah, Robert W.↗

Digital X-Ray Imager Final Report CRADA No. TSB-1161-95

The global objective of this cooperation was to lower the cost and improve the quality of breast health care in the United States. We planned to achieve it by designing a very high performance digital radiography unit for breast surgical specimen radiography in the operating room. These technical goals needed to be achieved at reasonable manufacturing costs to enable MedOptics to achieve high market penetration at a profit.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

Single Channel Silicon Photomultiplier Based Surgical Probe

The goal of the project was to develop and test a prototype single-use probe that can reduce the chance of infection of patients during lymph node surgery by incorporating a newly developed light detector, a silicon photomultiplier (SiPM), into a non-imaging gamma-ray detection platform. Sentinel lymph node biopsy is a vital component of surgical oncology in the process of establishing the extent of disease and likelihood of metastasis. The team was successful in the development and testing of the device.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

Bio-medical telemetry - Sensing and transmitting biological information from animals and man.

Several examples are presented of radio transmitters swallowed, surgically implanted, or carried externally to study animal and human objects with minimum disturbance to normal activity patterns. Particular attention is given to the method of using satellite-borne receivers for determining the position of animals or other objects carrying fixed-frequency transmitters. The design and operation of the instrumentation necessary for this purpose are described.

Mackay, S.↗

Spatially Tracked Hand-held Gamma Camera for Surgery

The goal of the project was to develop and test a 3-dimensional (3D) imaging technology designed to overcome limitations of current non-imaging lymph node mapping methods by integrating a newly developed, unique hand-held gamma camera (HGC) into a platform for freehand SPECT (single photon emission computed tomography). Sentinel lymph node biopsy is a vital component of surgical oncology in the process of establishing the extent of disease and likelihood of metastasis. The team was successful in the development and testing of the device.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

Hearing is Believing

This paper presents a discussion on the cochlear implant. This device was developed by Adam Kissiah, who suffers from hearing loss. Driven by his own hearing problem and three failed corrective surgeries, Kissiah started working in the mid-1970s on this surgically implantable device that provides hearing sensation to persons with severe-to-profound hearing loss who receive little or no benefit from hearing aids. Uniquely, the cochlear implant concept was not based on theories of medicine, as Kissiah had no medical background whatsoever. Instead, he utilized the technical expertise he learned while working as an electronics instrumentation engineer at NASA s Kennedy Space Center for the basis of his invention. This took place over 3 years, when Kissiah would spend his lunch breaks and evenings in Kennedy s technical library, studying the impact of engineering principles on the inner ear. In April of 2003, Kissiah was inducted into the Space Foundation's U.S. Space Technology Hall of Fame for his invention

Source record↗

Medical and surgical applications of space biosensor technology

Researchers in space life sciences are rapidly approaching a technology impasse. Many of the critical questions on the impact of spaceflight on living systems simply cannot be answered with the limited available technologies. Research subjects, particularly small animal models like the rat, must be allowed to function relatively untended and unrestrained for long periods to fully reflect the impact of microgravity and spaceflight on their behavior and physiology. These requirements preclude the use of present hard-wired instrumentation techniques and limited data acquisition systems. Implantable sensors and miniaturized biotelemetry are the only means of capturing the fundamental and critical data. This same biosensor and biotelemetry technology has direct application to Earth-based medicine and surgery. Continuous, on-line data acquisition and improved measurement capabilities combined with the ease and flexibility offered by automated, wireless, and portable instruments and data systems, should provide a boon to the health care industry. Playing a key role in this technology revolution is the Sensors 2000! (S2K!) Program at NASA Ames Research Center. S2K!, in collaboration with space life sciences researchers and managers, provides an integrated capability for sensor technology development and applications, including advanced biosensor technology development, spaceflight hardware development, and technology transfer and commercialization. S2K! is presently collaborating on several spaceflight projects with dual-use medical applications. One prime example is a collaboration with the Fetal Treatment Center (FTC) at the University of California at San Francisco. The goal is to develop and apply implantable chemical sensor and biotelemetry technology to continuously monitor fetal patients during extra-uterine surgery, replacement into the womb, through birth and beyond. Once validated for ground use, the method will be transitioned to spaceflight applications to remotely monitor key biochemical parameters in flight animals. Successful application of NASA implantable biosensor and biotelemetry technologies should accelerate the advancement of this and other modern medical procedures while furthering the exploration of life in space.

NASA Discipline General Space Life Sciences↗

A Tool for Medical Research

California Measurements, Inc.'s PC-2 Aerosol Particle Analyzer, developed by William Chiang, a former Jet Propulsion Laboratory (JPL) engineer, was used in a study to measure the size of particles in the medical environment. Chiang has a NASA license for the JPL crystal oscillator technology and originally built the instrument for atmospheric research. In the operating room, it enabled researchers from the University of California to obtain multiple sets of data repeatedly and accurately. The study concluded that significant amounts of aerosols are generated during surgery when power tools are employed, and most of these are in the respirable size. Almost all contain blood and are small enough to pass through surgical masks. Research on the presence of blood aerosols during oral surgery had similar results. Further studies are planned to determine the possibility of HIV transmission during surgery, and the PC-2H will be used to quantify blood aerosols.

Source record↗

Rapid custom prototyping of soft poroelastic biosensor for simultaneous epicardial recording and imaging

Abstract The growing need for the implementation of stretchable biosensors in the body has driven rapid prototyping schemes through the direct ink writing of multidimensional functional architectures. Recent approaches employ biocompatible inks that are dispensable through an automated nozzle injection system. However, their application in medical practices remains challenged in reliable recording due to their viscoelastic nature that yields mechanical and electrical hysteresis under periodic large strains. Herein, we report sponge-like poroelastic silicone composites adaptable for high-precision direct writing of custom-designed stretchable biosensors, which are soft and insensitive to strains. Their unique structural properties yield a robust coupling to living tissues, enabling high-fidelity recording of spatiotemporal electrophysiological activity and real-time ultrasound imaging for visual feedback. In vivo evaluations of custom-fit biosensors in a murine acute myocardial infarction model demonstrate a potential clinical utility in the simultaneous intraoperative recording and imaging on the epicardium, which may guide definitive surgical treatments.

36 MATERIALS SCIENCE↗