Mobile C-arm cone-beam CT for guidance of spine surgery: Image quality, radiation dose, and integration with interventional guidance.

PURPOSE A flat-panel detector based mobile isocentric C-arm for cone-beam CT (CBCT) has been developed to allow intraoperative 3D imaging with sub-millimeter spatial resolution and soft-tissue visibility. Image quality and radiation dose were evaluated in spinal surgery, commonly relying on lower-performance image intensifier based mobile C-arms. Scan protocols were developed for task-specific imaging at minimum dose, in-room exposure was evaluated, and integration of the imaging system with a surgical guidance system was demonstrated in preclinical studies of minimally invasive spine surgery. METHODS Radiation dose was assessed as a function of kilovolt (peak) (80-120 kVp) and milliampere second using thoracic and lumbar spine dosimetry phantoms. In-room radiation exposure was measured throughout the operating room for various CBCT scan protocols. Image quality was assessed using tissue-equivalent inserts in chest and abdomen phantoms to evaluate bone and soft-tissue contrast-to-noise ratio as a function of dose, and task-specific protocols (i.e., visualization of bone or soft-tissues) were defined. Results were applied in preclinical studies using a cadaveric torso simulating minimally invasive, transpedicular surgery. RESULTS Task-specific CBCT protocols identified include: thoracic bone visualization (100 kVp; 60 mAs; 1.8 mGy); lumbar bone visualization (100 kVp; 130 mAs; 3.2 mGy); thoracic soft-tissue visualization (100 kVp; 230 mAs; 4.3 mGy); and lumbar soft-tissue visualization (120 kVp; 460 mAs; 10.6 mGy) - each at (0.3  ×  0.3  ×  0.9 mm3 ) voxel size. Alternative lower-dose, lower-resolution soft-tissue visualization protocols were identified (100 kVp; 230 mAs; 5.1 mGy) for the lumbar region at (0.3  ×  0.3  ×  1.5 mm3 ) voxel size. Half-scan orbit of the C-arm (x-ray tube traversing under the table) was dosimetrically advantageous (prepatient attenuation) with a nonuniform dose distribution (∼2 ×  higher at the entrance side than at isocenter, and ∼3-4 lower at the exit side). The in-room dose (microsievert) per unit scan dose (milligray) ranged from ∼21 μSv/mGy on average at tableside to ∼0.1 μSv/mGy at 2.0 m distance to isocenter. All protocols involve surgical staff stepping behind a shield wall for each CBCT scan, therefore imparting ∼zero dose to staff. Protocol implementation in preclinical cadaveric studies demonstrate integration of the C-arm with a navigation system for spine surgery guidance-specifically, minimally invasive vertebroplasty in which the system provided accurate guidance and visualization of needle placement and bone cement distribution. Cumulative dose including multiple intraoperative scans was ∼11.5 mGy for CBCT-guided thoracic vertebroplasty and ∼23.2 mGy for lumbar vertebroplasty, with dose to staff at tableside reduced to ∼1 min of fluoroscopy time (∼40-60 μSv), compared to 5-11 min for the conventional approach. CONCLUSIONS Intraoperative CBCT using a high-performance mobile C-arm prototype demonstrates image quality suitable to guidance of spine surgery, with task-specific protocols providing an important basis for minimizing radiation dose, while maintaining image quality sufficient for surgical guidance. Images demonstrate a significant advance in spatial resolution and soft-tissue visibility, and CBCT guidance offers the potential to reduce fluoroscopy reliance, reducing cumulative dose to patient and staff. Integration with a surgical guidance system demonstrates precise tracking and visualization in up-to-date images (alleviating reliance on preoperative images only), including detection of errors or suboptimal surgical outcomes in the operating room.