"Are there any new radiologic studies to locate where to operate for
central stenosis with multiple levels of narrowing. This would not
include CT Myelogram or standard MRI. Who does this and who has the
most sensitive equipment?"
Yes, the newest, state of the art, technology is known as image-guided
surgery (IGS) and it is available in many hospitals across the United
Image-Guided Surgery: Space Age Technology Enters the Operating Room
"One of the greatest advances has been the emergence of image-guided
surgery. Image-guided surgery enables spine surgeons to see and
navigate through the patient's anatomy three-dimensionally (3D) in
real time before and during surgery!"
"Several days before surgery, the necessary images (CT Scans and/or
MRIs) of the patient's spinal anatomy are prepared. The images are
then 'downloaded' into the StealthStation? computer and the system
creates three-dimensional images of the spinal anatomy. The 3D images
can be rotated, enlarged, flipped, angled, or manipulated in a variety
of other important ways. This allows the surgeon to accurately
pre-plan the surgical procedure including determining the type and
size of instrumentation (e.g. screws) and implant placement and
trajectory. Such pre-planning is helpful to ensure a successful
surgical outcome, especially for patients with spinal deformity whose
anatomy often does not match that in a textbook.
During surgery the instruments communicate with the computer and
surgeon in real time. This means the spine surgeon can watch on a
computer monitor as he precisely operates on the spine. Looking at the
computer monitor, the surgeon can see the position of the instrument
as it relates to portions of the patient's anatomy that are beneath
the surface of skin, hidden from the surgeon's direct view."
What is image-guided surgery?
"There are four broad steps in an image-guided surgery procedure. It
begins with an MRI or CAT scan of the patient's head or spine. This
data is downloaded into a computer from which a 3-D model of the
patient's head or spine is made. Just before surgery, the surgeon maps
the patient's anatomy to the 3D model using an image-guided probe.
(For spinal surgery, Medtronic software can build this model and make
the map automatically.) This process (known as registration) enables
the surgeon, using image-guided surgical instruments, to see the
instruments on the computer image and confirm the exact point where
she or he is operating."
The details: How does image-guided surgery work?
There are four broad steps in an image-guided surgery procedure.
"The radiology technician takes a CAT or MRI scan of the patient..."
"The surgeon builds a 3D model on the computer..."
"The surgeon maps the computer model to the patient's body (registration)..."
"The surgeon uses the image-guided system during surgery..."
> Some Centers Who Use Image Guided Surgery:
1) Neurological Surgery - Spine Center
Robert Heary, MD, Director
Ira Goldstein, MD
"The Spine Center offers experienced care in all types of disorders of
the spine including: trauma, with or without an associated spinal cord
injury; tumors (both metastatic and primary spine and spinal cord
tumors); degenerative disorders, such as spinal stenosis, herniated
disks, spondylolisthesis, and 'failed back'; deformity surgery;
infections; inflammatory disorders, such as rheumatoid arthritis and
ankylosing spondylitis; and reoperation for previously unsuccessful
The faculty is fellowship trained in both neurological and orthopaedic
surgery and works in coordination with a wide variety of specialists
and sub-specialists. Particular expertise is available in the
application of image-guided, minimally invasive surgical techniques,
including microendoscopic discectomy."
Appointments: (973) 972-2334
The University Hospital
150 Bergen Street, D209
Newark, New Jersey 07103
2) Outpatient Spine Surgery Center
IMAGE GUIDED TECHNOLOGY
New Technology Provides Navigational Accuracy
"It may at first seem like something out of a science fiction movie,
but surgeons are now using high-tech computer programs in the
operating room to guide their surgical instruments during delicate
surgeries. Without this type of technology, surgeons relied on the
information provided in a two-dimensional x-ray and their own visual
identification to determine their location during some surgical
procedures. Known as the StealthStation? Treatment Guidance Platform,
surgeons are now able to pinpoint with improved accuracy, the location
of certain surgical instruments and anatomic structure during an
operation by incorporating this navigational technology into their
3) Spine Surgery Center
1508 Arizona Ave.
Santa Monica, CA
For Treatment information call:
For General Information contact OSSC:
Phone: (310) 260-1400
Fax: (310) 260-1400
4) "St. Edward Mercy is among 450 hospitals across the U.S. that now
have acquired the StealthStation and is one of only three hospitals in
Arkansas that has the device. St. Edward Mercy was among of the first
40 hospitals in the world to utilize one of the more recent software
programs, FluoroNav?, and surgeons at St. Edward Mercy led in the
development of the software and other instrumentation used with the
5) United Health Services
Stealth technology improves neurosurgery outcomes
"The StealthStationŞ works by using imaging data from computed
tomography and/or magnetic resonance imaging to generate a 3-D model
of a patient?s head or spine. The 3D images can be viewed at many
angles allowing surgeons to plan a procedure. Neurosurgeons use the
system to calculate the shortest, safest route to a tumor. For spinal
fusion surgery, the system directs surgeons toward the perfect angle
for screw placement. Precise planning helps ensure a successful
surgical outcome, especially for patients with anatomical deformities
that may not match textbook examples. "
United Health Services
Bajwa, Saeed A. M.D.
Galyon, Daniel D. M.D.
Garrehy, Joseph P.A.
Gartman, John J. M.D.
Meirelles, Eduardo M.D.
Oney, Larry P.A.
Sethi, Khalid M.D.
6) Spine Specialty Institute
1135 Sunset Avenue
West Covina, CA 91790
Spine Specialty Institute
2300 S Flower St Suite 200
Los Angeles, CA 90007
Spine Specialty Institute
1881 CommerceCenter East Suite 133
San Bernardino, CA 92408
7) Silicon Valley Spine Institute
A Professional Corporation
360 Dardanelli Lane Suite 1F
Los Gatos, CA 95032
Additional Links of Interest:
"One single medical test cannot offer all the necessary information
needed to make a clear diagnosis of a spinal condition. Each test
gives specific information that can help define the medical problem
present. In most cases a physician will start with the most basic test
and proceed to more sophisticated tests until a clear diagnosis has
been made. Some of the common tests and imaging studies performed in
evaluating spinal conditions include: X-Rays, Myelogram, CT Scan
(computer tomography), bone scan, Arteriogram, discogram, MRI
(magnetic resonance images), EMG (electromyograms), Sonogram
(ultrasound tests), and blood tests."
"In some cases it may be difficult to clearly identify a source of
pain in the lower back. In other instances, surgery may be planned and
yet it is uncertain at which level to end a fusion due to concerns
over disc function at the ends of the intended fusion. In both of the
above settings MRI can help make the proper decision. When an MRI is
not offering sufficient information, a discogram may be ordered."
"Discography involves introducing a fine needle through the skin and
muscles of the back directly into the intervertebral disc with the
patient awake. The location of the needle tip is verified by X-Ray
imaging. Once the position is confirmed, a small quantity of special
dye (contrast media) is injected into the disc. The injection
increases the pressure inside the disc and if this maneuver reproduces
the patient's pain, the test is considered positive. With X-Ray
imaging, the outline of the nucleus pulposus in the disc can be
visualized. Often a CT Scan is obtained after the discogram to clearly
see the status of the disc and degree of dye leakage."
Computer Tomography (CT)
"CT imaging of the lumbar spine provides superior anatomic imaging of
the osseous (bony) structures of the spine and good resolution for
disc herniation. Its sensitivity for detecting disc herniation when
used without myelography however is inferior to MRI. CT with
myelography is also not as useful in detecting far lateral or
foraminal pathology. As with MRI, there can be a significant number of
"positive" findings in the asymptomatic population. CT imaging is best
used in the face of suspected fracture, but can be utilized in the
detection of disc injury in patients who cannot undergo MRI scanning.
In addition, for patients when more detailed imaging of the bony
architecture is important, CT imaging is recommended."
Computed tomography (CT)
"Today almost every major hospital in the Western World is equipped
with a CT -scanner and most radiologists have considerable experience
in the diagnosis of lumbar disease with this modality. CT is very
valuable for the evaluation of degenerative disease in the spine for
many reasons: the method is non-invasive, it is quick, it provides
excellent visualization of bone in the axial projection and it shows
the root-canals and paraspinal area. It is usually easy to make a
diagnosis of disc herniation, as well as to detect bony elements
narrowing the spinal canal, recesses and/or root-canals. CT is
therefore especially useful for the diagnosis of the different causes
of spinal stenosis. The draw-backs are that for practical reasons only
a limited number of disk levels are routinely covered at most
institutions, and only direct axial views can be obtained. Projections
other than the axial view can be obtained by using thin slices and
reformatting. However, if a large area is to be visualized, there will
be significant irradiation of the patient. Another, and probably more
important drawback is that the content of the dural sac is not
visualized, unless contrast has been injected into the subarachnoid
space, and therefore intradural pathology, such as a tumor, might be
If all modalities are available the following strategy for evaluation
of patients with low-back pain and sciatica is suggested: Routine
patient: 1) plain films, 2) MRI. Patient with advanced spinal stenosis
or severe scoliosis: 1) plain films, 2) myelography, 3) CT at selected
levels, after myelography.
In the diagnosis of spinal stenosis, a combination of myelography and
CT is very efficient (Fig. 22), because these methods visualize the
bony changes so well. MRI can be used, but is more difficult to
Magnetic Resonance Imaging: MRI
"This test involves placing the patient into the area of a very strong
magnet and then measuring the emitted radiation from the patient as
the magnetic field is turned off. Through this technique very precise
images of the various structures in the body can be obtained. MRI does
not involve X-Rays or other types of projected radiation."
Department of Radiology and Imaging
Spinal Stenosis and Neurogenic Claudication
Precision Diagnostic Disc Injections
Central nervous system imaging
When is CT more appropriate than MRI?
Treatment of lumbar spinal stenosis by extensive unilateral
decompression and contralateral autologous bone fusion: operative
technique and results
I was glad to work on this for you, I hope it helps.
Some Google search terms used: spinal stenosis imaging radiological
tests precision multilevel image-guided surgery