Intraoperative C-arm cone-beam computed tomography: Quantitative analysis of surgical performance in skull base surgery

Objectives/Hypothesis: To determine whether incorporation of intraoperative imaging via a new cone-beam computed tomography (CBCT) image-guidance system improves accuracy and facilitates resection in sinus and skull-base surgery through quantification of surgical performance. Study Design: Landmark identification and skull base ablation tasks were performed with a CBCT intraoperative image-guidance system in the experimental group and with image-guided surgery (IGS) alone based on preoperative computed tomography (CT) in the control group. Methods: Six cadaveric heads underwent preoperative CT imaging and surgical planning identifying surgical targets. Three types of surgical tasks were planned: landmark point identification, line contour identification, and volume drill-out. Key anatomic structures (carotid artery and optic nerve) were chosen for landmark identification and line contour tasks. Complete ethmoidectomy, vidian corridor drill-out, and clival resection were performed for volume ablation tasks. The CBCT guidance system was used in the experimental group and performance was assessed by metrics of target registration error, sensitivity, and specificity of excision. Results: Significant improvements were seen for point identification and line tracing tasks. Additional resection was performed in 67% of tasks in the CBCT group, and qualitative feedback indicated unequivocal improvement in confidence for all tasks. In review of tasks in the control group, additional resection would have been performed in 35% of tasks if an intraoperative image was available. Conclusions: An experimental prototype C-arm CBCT guidance system was shown to improve surgical precision in the identification of skull base targets and increase accuracy in the ablation of surgical target volumes in comparison to using IGS alone.