Name: Intraoperative Ultrasound in Spinal Surgery (Video) | JoVE Journal
Uploaded: 2022-08-17T12:30:00.000+00:00
Duration: 5 min 53 s
Description: Learn intraoperative ultrasound for spinal surgery to visualize intradural lesions in real-time before dura opening. This technique enhances surgical precision and confirms adequate decompression.

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5 minutes

The authors have no acknowledgements.

The protocol illustrated here follows the guidelines of the human research ethics committee at Brigham and Women&#39;s Hospital.
1. Preoperative Protocol
<ol>
	<li>Assess patients with spinal pathology in clinic and determine eligibility for spinal surgery. Perform neurological assessment and obtain CT or MRI scan to identify spinal lesion.</li>
	<li>Include patients who have an intradural pathology such as schwannoma, ependymoma, meningioma, astrocytoma, etc.; or patients who have a ventral compressive extradural pathology, such as a ventral thoracic herniated disc, fracture fragments ventrally, or a spinal bony tumor with ventral compression. 
	NOTE: Pathology is determined by spinal imaging with CT or MRI. Exclusion criteria includes the patients who cannot tolerate surgery, or patients with an extremely poor prognosis.</li>
</ol>
2. Preparation for Surgery
<ol>
	<li>Do not allow the patient to consume anything by mouth after the midnight before surgery. 
	NOTE: The patient will be placed under general anesthesia and intubated by the anesthesiologist.</li>
	<li>Position patient with their back exposed according to surgeon&#39;s preference for the spinal surgery.</li>
	<li>Sterilize the surgical area with povidone-iodine by scrubbing the area.</li>
</ol>
3. Surgery
Note: This section of the protocol follows general spine surgery techniques that can be referenced from any reputable spine surgery technique textbook19.
<ol>
	<li>Make an incision with a scalpel along the length of the spine over the appropriate vertebrae levels and continue to make a straight incision down until the bone is reached. 
	NOTE: The size of the incision will depend on the size of the pathology. For example, if the tumor spans two vertebral levels, then at least two vertebral levels will need to be exposed. When the bone is exposed, an X-ray with a portable X-ray machine can be performed to verify the correct vertebrae.</li>
	<li>Perform subperiosteal dissection by electrosurgical cautery and expose the spinous process which is visualized as a bulbous bony process. Turn the cutting edge ventrally and sweep across the laminar.</li>
	<li>Use a combination of a Leksell bone plier and a highspeed drill to remove the bony lamina and spinous process to expose the ligamentum flavum underneath.</li>
	<li>Use an angled Curette and Kerrison bone punch to remove the ligamentum flavum to reveal the dura mater underneath.</li>
	<li>Use bipolar and hemostatic matrix to achieve hemostasis. 
	NOTE: The success of a good ultrasound image relies upon a clean surgical field.</li>
</ol>
4. Intraoperative Ultrasound
<ol>
	<li>Use a mobile ultrasound machine and a transducer probe with a 20 mm diameter. 
	NOTE: The probe should have a 10 to 4.4 MHz frequency range. Any comparable device with similar probe diameter and frequency range should suffice.</li>
	<li>After the bony removal and dura exposure, fill the surgical field with sufficient saline solution such that the ultrasound transducer probe can be submerged. 
	NOTE: Generally, a range of 100-500 mL of saline solution is needed. The saline solution allows for acoustic coupling.</li>
	<li>Turn on the ultrasound machine and place the ultrasound probe within the saline bath at the level of interest to begin acquiring images. 
	NOTE: It is not necessary to place the probe directly touching the dura or spinal cord. Images are acquired on the ultrasound screen in real-time and can be interpreted immediately by the surgeon. Images on the screen can be captured at any time by pressing the Freeze button and can be saved by pressing the Save button.</li>
	<li>Acquire real time images in the longitudinal plane by placing the ultrasound probe in line with the direction of the spinal canal to visualize the spinal cord and the lesion similar to the sagittal images from the MRI.</li>
	<li>Acquire real time images in the transverse plane by placing the ultrasound probe perpendicular to the spinal canal to visualize the spinal cord and the lesion like the axial images from the MRI.</li>
	<li>Acquire real-time images to verify the location of lesions that cannot be directly visualized, to correlate with the preoperative CT or MRI images, to guide surgical tool placement, and/or to confirm the resolution of pathology. 
	NOTE: When needed, a small piece of sterile compressed sponge approximately 0.5 cm x 0.5 cm can be used as a hyperechoic surgical marker to be placed in the surgical field and help correlate the surgical location with the image location. This helps to locate the lesion during the surgery and also helps to identify the margin of the tumor.</li>
</ol>
5. Postoperative Follow-up
<ol>
	<li>After discharge, have the patient return to the clinic within one month for follow-up.</li>
	<li>Perform a neurological assessment and CT or MRI scans to confirm the resolution of the symptoms and pathology.</li>
</ol>

<ol><li>Reid, M. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ultrasonic+visualization+of+a+cervical+cord+cystic+astrocytoma%5BTitle%5D)+AND+%22AJR.+American+Journal+of+Roentgenology%22%5BJournal%5D)">Ultrasonic visualization of a cervical cord cystic astrocytoma.</a> AJR. American Journal of Roentgenology. 131 (5), 907-908 (1978).</li>
<li>Dohrmann, G. J., Rubin, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+ultrasound+imaging+of+the+spinal+cord%3A+syringomyelia%2C+cysts%2C+and+tumors--a+preliminary+report%5BTitle%5D)+AND+%22Surgical+Neurology%22%5BJournal%5D)">Intraoperative ultrasound imaging of the spinal cord: syringomyelia, cysts, and tumors--a preliminary report.</a> Surgical Neurology. 18 (6), 395-399 (1982).</li>
<li>Rubin, J. M., Dohrmann, G. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Use+of+ultrasonically+guided+probes+and+catheters+in+neurosurgery%5BTitle%5D)+AND+%22Surgical+Neurology%22%5BJournal%5D)">Use of ultrasonically guided probes and catheters in neurosurgery.</a> Surgical Neurology. 18 (2), 143-148 (1982).</li>
<li>Braun, I. F., Raghavendra, B. N., Kricheff, I. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Spinal+cord+imaging+using+real-time+high-resolution+ultrasound%5BTitle%5D)+AND+%22Radiology%22%5BJournal%5D)">Spinal cord imaging using real-time high-resolution ultrasound.</a> Radiology. 147 (2), 459-465 (1983).</li>
<li>Hutchins, W. W., Vogelzang, R. L., Neiman, H. L., Fuld, I. L., Kowal, L. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Differentiation+of+tumor+from+syringohydromyelia%3A+intraoperative+neurosonography+of+the+spinal+cord%5BTitle%5D)+AND+%22Radiology%22%5BJournal%5D)">Differentiation of tumor from syringohydromyelia: intraoperative neurosonography of the spinal cord.</a> Radiology. 151 (1), 171-174 (1984).</li>
<li>Juthani, R. G., Bilsky, M. H., Vogelbaum, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+Management+and+Treatment+Modalities+for+Intramedullary+Spinal+Cord+Tumors%5BTitle%5D)+AND+%22Current+Treatment+Options+in+Oncology%22%5BJournal%5D)">Current Management and Treatment Modalities for Intramedullary Spinal Cord Tumors.</a> Current Treatment Options in Oncology. 16 (8), 39(2015).</li>
<li>Knake, J. E., Gabrielsen, T. O., Chandler, W. F., Latack, J. T., Gebarski, S. S., Yang, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Real-time+sonography+during+spinal+surgery%5BTitle%5D)+AND+%22Radiology%22%5BJournal%5D)">Real-time sonography during spinal surgery.</a> Radiology. 151 (2), 461-465 (1984).</li>
<li>Montalvo, B. M., Quencer, R. M., Green, B. A., Eismont, F. J., Brown, M. J., Brost, P. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/6473773">Intraoperative sonography in spinal trauma.</a> Radiology. 153 (1), 125-134 (1984).</li>
<li>Montalvo, B. M., Quencer, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+sonography+in+spinal+surgery%3A+current+state+of+the+art%5BTitle%5D)+AND+%22Neuroradiology%22%5BJournal%5D)">Intraoperative sonography in spinal surgery: current state of the art.</a> Neuroradiology. 28 (5-6), 551-590 (1986).</li>
<li>Pasto, M. E., Rifkin, M. D., Rubenstein, J. B., Northrup, B. E., Cotler, J. M., Goldberg, B. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Real-time+ultrasonography+of+the+spinal+cord%3A+intraoperative+and+postoperative+imaging%5BTitle%5D)+AND+%22Neuroradiology%22%5BJournal%5D)">Real-time ultrasonography of the spinal cord: intraoperative and postoperative imaging.</a> Neuroradiology. 26 (3), 183-187 (1984).</li>
<li>Mari, A. R., Shah, I., Imran, M., Ashraf, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Role+of+intraoperative+ultrasound+in+achieving+complete+resection+of+intra-axial+solid+brain+tumours%5BTitle%5D)+AND+%22JPMA.+The+Journal+of+the+Pakistan+Medical+Association%22%5BJournal%5D)">Role of intraoperative ultrasound in achieving complete resection of intra-axial solid brain tumours.</a> JPMA. The Journal of the Pakistan Medical Association. 64 (12), 1343-1347 (2014).</li>
<li>Ivanov, M., Budu, A., Sims-Williams, H., Poeata, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Using+Intraoperative+Ultrasonography+for+Spinal+Cord+Tumor+Surgery%5BTitle%5D)+AND+%22World+Neurosurgery%22%5BJournal%5D)">Using Intraoperative Ultrasonography for Spinal Cord Tumor Surgery.</a> World Neurosurgery. 97, 104-111 (2017).</li>
<li>Blumenkopf, B., Daniels, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+ultrasonography+%28IOUS%29+in+thoracolumbar+fractures%5BTitle%5D)+AND+%22Journal+of+Spinal+Disorders%22%5BJournal%5D)">Intraoperative ultrasonography (IOUS) in thoracolumbar fractures.</a> Journal of Spinal Disorders. 1 (1), 86-93 (1988).</li>
<li>McGahan, J. P., Benson, D., Chehrazi, B., Walter, J. P., Wagner, F. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+sonographic+monitoring+of+reduction+of+thoracolumbar+burst+fractures%5BTitle%5D)+AND+%22AJR.+American+Journal+of+roentgenology%22%5BJournal%5D)">Intraoperative sonographic monitoring of reduction of thoracolumbar burst fractures.</a> AJR. American Journal of roentgenology. 145 (6), 1229-1232 (1985).</li>
<li>Quencer, R. M., Montalvo, B. M., Eismont, F. J., Green, B. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+spinal+sonography+in+thoracic+and+lumbar+fractures%3A+evaluation+of+Harrington+rod+instrumentation%5BTitle%5D)+AND+%22AJR.+American+Journal+of+roentgenology%22%5BJournal%5D)">Intraoperative spinal sonography in thoracic and lumbar fractures: evaluation of Harrington rod instrumentation.</a> AJR. American Journal of roentgenology. 145 (2), 343-349 (1985).</li>
<li>Sosna, J., Barth, M. M., Kruskal, J. B., Kane, R. A. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/16301724">Intraoperative sonography for neurosurgery.</a> Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine. 24 (12), 1671-1682 (2005).</li>
<li>Raymond, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Brain%2C+spine+surgeons+say+yes+to+ultrasound%5BTitle%5D)+AND+%22JAMA%22%5BJournal%5D)">Brain, spine surgeons say yes to ultrasound.</a> JAMA. 255 (17), 2258-2262 (1986).</li>
<li>Toktas, Z. O., Sahin, S., Koban, O., Sorar, M., Konya, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Is+intraoperative+ultrasound+required+in+cervical+spinal+tumors%3F+A+prospective+study%5BTitle%5D)+AND+%22Turkish+Neurosurgery%22%5BJournal%5D)">Is intraoperative ultrasound required in cervical spinal tumors? A prospective study.</a> Turkish Neurosurgery. 23 (5), 600-606 (2013).</li>
<li><a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=%22Surgical+Approaches+to+the+Spine%22">Surgical Approaches to the Spine</a>. , Springer-Verlag. New York. (2015).</li>
<li>Friedman, J. A., Wetjen, N. M., Atkinson, J. L. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Utility+of+intraoperative+ultrasound+for+tumors+of+the+cauda+equina%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">Utility of intraoperative ultrasound for tumors of the cauda equina.</a> Spine. 28 (3), discussion 291 288-290 (2003).</li>
<li>Zhou, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+ultrasound+assistance+in+treatment+of+intradural+spinal+tumours%5BTitle%5D)+AND+%22Clinical+Neurology+and+Neurosurgery%22%5BJournal%5D)">Intraoperative ultrasound assistance in treatment of intradural spinal tumours.</a> Clinical Neurology and Neurosurgery. 113 (7), 531-537 (2011).</li>
<li>Harrop, J. S., Ganju, A., Groff, M., Bilsky, M. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/19829279">Primary intramedullary tumors of the spinal cord.</a> Spine. 34, 22 Suppl 69-77 (2009).</li>
<li>Quencer, R. M., Montalvo, B. M. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/6388284">Normal intraoperative spinal sonography.</a> AJR. American journal of roentgenology. 143 (6), 1301-1305 (1984).</li>
<li>Aoyama, T., Hida, K., Akino, M., Yano, S., Iwasaki, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Detection+of+residual+disc+hernia+material+and+confirmation+of+nerve+root+decompression+at+lumbar+disc+herniation+surgery+by+intraoperative+ultrasound%5BTitle%5D)+AND+%22Ultrasound+in+Medicine+%26+Biology%22%5BJournal%5D)">Detection of residual disc hernia material and confirmation of nerve root decompression at lumbar disc herniation surgery by intraoperative ultrasound.</a> Ultrasound in Medicine & Biology. 35 (6), 920-927 (2009).</li>
<li>Bose, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Thoracic+extruded+disc+mimicking+spinal+cord+tumor%5BTitle%5D)+AND+%22The+Spine+Journal%3A+Official+Journal+of+the+North+American+Spine+Society%22%5BJournal%5D)">Thoracic extruded disc mimicking spinal cord tumor.</a> The Spine Journal: Official Journal of the North American Spine Society. 3 (1), 82-86 (2003).</li>
<li>Harel, R., Knoller, N. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/26342702">Intraoperative spine ultrasound: application and benefits.</a> European Spine Journal: Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 25 (3), 865-869 (2016).</li>
<li>Lazennec, J. Y., Saillant, G., Hansen, S., Ramare, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+ultrasonography+evaluation+of+posterior+vertebral+wall+displacement+in+thoracolumbar+fractures%5BTitle%5D)+AND+%22Neurologia+Medico-Chirurgica%22%5BJournal%5D)">Intraoperative ultrasonography evaluation of posterior vertebral wall displacement in thoracolumbar fractures.</a> Neurologia Medico-Chirurgica. 39 (1), 8-15 (1999).</li>
<li>Matsuyama, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Cervical+myelopathy+due+to+OPLL%3A+clinical+evaluation+by+MRI+and+intraoperative+spinal+sonography%5BTitle%5D)+AND+%22Journal+of+Spinal+Disorders+%26+Techniques%22%5BJournal%5D)">Cervical myelopathy due to OPLL: clinical evaluation by MRI and intraoperative spinal sonography.</a> Journal of Spinal Disorders & Techniques. 17 (5), 401-404 (2004).</li>
<li>Mueller, L. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ultrasound-guided+spinal+fracture+repositioning%2C+ligamentotaxis%2C+and+remodeling+after+thoracolumbar+burst+fractures%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">Ultrasound-guided spinal fracture repositioning, ligamentotaxis, and remodeling after thoracolumbar burst fractures.</a> Spine. 31 (20), 739-747 (2006).</li>
<li>Nishimura, Y., Thani, N. B., Tochigi, S., Ahn, H., Ginsberg, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Thoracic+discectomy+by+posterior+pedicle-sparing%2C+transfacet+approach+with+real-time+intraoperative+ultrasonography%3A+Clinical+article%5BTitle%5D)+AND+%22Journal+of+Neurosurgery.+Spine%22%5BJournal%5D)">Thoracic discectomy by posterior pedicle-sparing, transfacet approach with real-time intraoperative ultrasonography: Clinical article.</a> Journal of Neurosurgery. Spine. 21 (4), 568-576 (2014).</li>
<li>Randel, S., Gooding, G. A., Dillon, W. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Sonography+of+intraoperative+spinal+arteriovenous+malformations%5BTitle%5D)+AND+%22Journal+of+Ultrasound+in+Medicine%3A+Official+Journal+of+the+American+Institute+of+Ultrasound+in+Medicine%22%5BJournal%5D)">Sonography of intraoperative spinal arteriovenous malformations.</a> Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine. 6 (9), 539-544 (1987).</li>
<li>Seichi, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+ultrasonographic+evaluation+of+posterior+decompression+via.+laminoplasty+in+patients+with+cervical+ossification+of+the+posterior+longitudinal+ligament%3A+correlation+with+2-year+follow-up+results%5BTitle%5D)+AND+%22Journal+of+Neurosurgery.+Spine%22%5BJournal%5D)">Intraoperative ultrasonographic evaluation of posterior decompression via. laminoplasty in patients with cervical ossification of the posterior longitudinal ligament: correlation with 2-year follow-up results.</a> Journal of Neurosurgery. Spine. 13 (1), 47-51 (2010).</li>
<li>Tian, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+3-dimensional+navigation+and+ultrasonography+during+posterior+decompression+with+instrumented+fusion+for+ossification+of+the+posterior+longitudinal+ligament+in+the+thoracic+spine%5BTitle%5D)+AND+%22Journal+of+Spinal+Disorders+%26+Techniques%22%5BJournal%5D)">Intraoperative 3-dimensional navigation and ultrasonography during posterior decompression with instrumented fusion for ossification of the posterior longitudinal ligament in the thoracic spine.</a> Journal of Spinal Disorders & Techniques. 26 (6), 227-234 (2013).</li>
<li>Tokuhashi, Y., Matsuzaki, H., Oda, H., Uei, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effectiveness+of+posterior+decompression+for+patients+with+ossification+of+the+posterior+longitudinal+ligament+in+the+thoracic+spine%3A+usefulness+of+the+ossification-kyphosis+angle+on+MRI%5BTitle%5D)+AND+%22Spine%22%5BJournal%5D)">Effectiveness of posterior decompression for patients with ossification of the posterior longitudinal ligament in the thoracic spine: usefulness of the ossification-kyphosis angle on MRI.</a> Spine. 31 (1), 26-30 (2006).</li>
<li>Vasudeva, V. S., Abd-El-Barr, M., Pompeu, Y. A., Karhade, A., Groff, M. W., Lu, Y. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/28989844">Use of Intraoperative Ultrasound During Spinal Surgery.</a> Global Spine Journal. 7 (7), 648-656 (2017).</li>
<li>Alaqeel, A., Abou Al-Shaar, H., Alaqeel, A., Al-Habib, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+utility+of+ultrasound+for+surgical+spinal+decompression%5BTitle%5D)+AND+%22Medical+Ultrasonography%22%5BJournal%5D)">The utility of ultrasound for surgical spinal decompression.</a> Medical Ultrasonography. 17 (2), 211-218 (2015).</li>
<li>Della Pepa, G. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Real-time+intraoperative+contrast-enhanced+ultrasound+%28CEUS%29+in+vascularized+spinal+tumors%3A+a+technical+note%5BTitle%5D)+AND+%22Acta+Neurochirurgica%22%5BJournal%5D)">Real-time intraoperative contrast-enhanced ultrasound (CEUS) in vascularized spinal tumors: a technical note.</a> Acta Neurochirurgica. 160 (6), 1259-1263 (2018).</li>
<li>Della Pepa, G. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Integration+of+Real-Time+Intraoperative+Contrast-Enhanced+Ultrasound+and+Color+Doppler+Ultrasound+in+the+Surgical+Treatment+of+Spinal+Cord+Dural+Arteriovenous+Fistulas%5BTitle%5D)+AND+%22World+Neurosurgery%22%5BJournal%5D)">Integration of Real-Time Intraoperative Contrast-Enhanced Ultrasound and Color Doppler Ultrasound in the Surgical Treatment of Spinal Cord Dural Arteriovenous Fistulas.</a> World Neurosurgery. 112, 138-142 (2018).</li>
</ol>

The authors have nothing to disclose.

Intraoperative ultrasound in the spinal surgery has largely fallen out of favor with the advent of newer technology, however, it continues to provide several advantages over the other available imaging modalities such as MRI and CT6,9,16,17,18. In addition to being inexpensive, in this protocol we also show that it is simple to use and can provide visualizatio...

Ultrasound is one of the most common diagnostic tools in medicine, particularly for visualizing pathology in the abdomen, limbs, and neck. However, its use to investigate cranial and spinal lesions is not currently widely utilized. In 1978, Reid was the first to report the use of ultrasound to visualize cervical cord cystic astrocytoma1. Here, scans were performed with the patient&#39;s neck flexed to allow opening of the intralaminar window. Four years later, in 1982, Dohrmann and Rubin reported the use of ultrasound intraoperatively to visualize the intradural space in 10 patients2. Pathologies identified with intraoperative ultrasound among the 10 patients included syringomyelia, spinal cord cysts, and intramedullary and extramedullary tumors. They further demonstrated the use of intraoperative ultrasound to guide catheters and probes for biopsy of tumors, drainage of cysts, and ventricular shunt catheter placement3. This allowed the real-time monitoring and precise positioning of probes/catheters, reducing inaccuracy and errors in placement. Following these initial reports, several others have published the use of intraoperative ultrasound for guiding spinal cord cyst drainage, intramedullary and extramedullary tumor resection, and syringo-subarachnoid shunt catheter placement4,5,6,7,8,9,10. Additionally, it has been shown to also increase rate of complete resection of intra-axial solid brain tumors and spinal intradural tumors11,12. Intraoperative ultrasound has also proven to be useful for the intraoperative surgical planning before manipulation of the tissue and subsequent visualization of adequate neural element decompression in patients with spine fractures7,9,13,14,15.
With the advent of newer intraoperative technology allowing clearer visualization of soft tissues, such as magnetic resonance imaging (MRI) and computed tomography (CT), intraoperative ultrasound has become less common and a less favored intraoperative imaging modality among neurosurgeons today16. However, intraoperative ultrasound can have advantages over these newer technologies in certain operative cases (Table 1). Intraoperative ultrasound has shown to demonstrate better soft tissue visualization of intradural structures when compared with intraoperative CT (iCT) or cone-beam CT (cbCT)9,17. While intraoperative MRI (iMRI) is useful where available because of the higher soft tissue resolution it provides, it is costly, time consuming and does not provide real-time images6, 16,18. An example is in the circumstance of an intradural mass ventral to the thecal sac that the surgeon is unable to directly visualize. Additionally, despite being operator dependent, from our experience, intraoperative ultrasound is fairly simple to use and can be easily read without a radiologist.

<table><tbody><tr><td>Aloka Prosound 5 mobile ultrasound machine</td><td>Hitachi</td><td>N/A</td><td>any comparable devices on the market should suffice</td></tr><tr><td>UST-9120 transducer probe.</td><td>Hitachi</td><td>UST-9120</td><td>Has a 20mm diameter with 10 to 4.4 MHz frequency range (any comparable compatible transducer should suffice).</td></tr></tbody></table>

intraoperative ultrasound in spinal surgery

Intraoperative Ultrasound in Spinal Surgery

Since the 1980s, there have been several reports for the use of intraoperative ultrasound as a useful adjunct in spinal surgery. However, with the advent of newer cutting-edge imaging modalities, the use of intraoperative ultrasound in spine surgery has largely fallen out of favor. Despite this, intraoperative ultrasound continues to provide several advantages over other intraoperative techniques such as magnetic resonance imaging and computed tomography including being more cost-effective, efficient, and easy to operate and interpret. Additionally, it remains the only method for the real-time visualization of soft tissue and pathologies. This paper focuses on the advantages of using intraoperative ultrasound, especially in cases of intradural lesions and lesions ventral to the thecal sac when approaching posteriorly.

On normal spine ultrasound imaging, the dura is an echogenic layer that surrounds the anechoic spinal fluid. The spinal cord is distinguished by its homogenous appearance and low echogenicity which is surrounded by an echogenic rim. This echogenic rim is due to the density shift from the spinal fluid to the spinal cord. The central canal appears as a bright central echo, while exiting nerve roots appear highly echogenic, particularly at the cauda equina16. Intraope...

Here, we present a protocol on the use of intraoperative ultrasound in spinal surgery, particularly in cases of intradural lesions and lesions in the ventral spinal canal when using a posterior approach.

Since the 1980s, there have been several reports for the use of intraoperative ultrasound as a useful adjunct in spinal surgery. However, with the advent ...

intraoperative-ultrasound-in-spinal-surgery

Research

JoVE Journal

Medicine

The purpose of this article is to provide image-guidance for minimally invasive transforaminal interbody fusion.

Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion

This article presents a standardized surgical technique for robotic-assisted pedicle screw placement by using robotic-assisted navigational systems. We present a step-by-step protocol and describe the workflow and precautions of this procedure.

A Spine Robotic-Assisted Navigation System for Pedicle Screw Placement

The protocol described here provides the basics of spine sonoanatomy and a quick, straightforward method for performing ultrasound-guided neuraxial anesthesia. Additionally, two handheld devices that enhance portability are presented, one of which uses pattern recognition software to aid in epidural space localization.

Spinal Sonography for Ultrasound-Guided Lumbar Neuraxial Anesthesia

This protocol describes an ultrasound transducer fixation system specifically designed for ultrasound stimulation of the spinal cord in awake mice. The method employs a fixation system to ensure accurate positioning of the ultrasound transducer while simultaneously allowing the experimental subjects to move freely without compromising the precision of stimulation.

Fixation of Ultrasound Transducers for Spinal Cord Neuromodulation in Mice

Fluorescence imaging is a promising innovative modality for image-guided surgery in surgical oncology. In this video we describe the technical procedure for detection of the sentinel lymph node using fluorescence imaging as showcased in gynecologic oncologicy. A multispectral fluorescence camera system, together with the fluorescent agent indocyanine green, is applied.

Multispectral Real-time Fluorescence Imaging for Intraoperative Detection of the Sentinel Lymph Node in Gynecologic Oncology

We describe two tactile sensory testing methods for acute or chronic periods of spinal cord injury in rats.  These validated procedures can detect the development and maintenance of allodynia-like sensations.

Acute and Chronic Tactile Sensory Testing after Spinal Cord Injury in Rats

Traumatic brain injuries (TBIs) remain a serious health problem. Using the controlled cortical impact surgery model, research on the effects of TBI and possible treatment methods may be performed.

Controlled Cortical Impact Model for Traumatic Brain Injury

Contrast Enhanced Ultrasound imaging is a reliable in-vivo tool for quantifying spinal cord blood flow in an experimental rat spinal cord injury model. This paper contains a comprehensive protocol for application of this technique in association with a contusion model of thoracic spinal cord injury.

Contrast Enhanced Ultrasound Imaging for Assessment of Spinal Cord Blood Flow in Experimental Spinal Cord Injury

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

The goal of this protocol is to provide a clear overview of specimen-driven intraoperative assessment of resection margins. It is encouraged to implement this protocol to improve patient care at other institutes.

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

Learn intraoperative ultrasound for spinal surgery to visualize intradural lesions in real-time before dura opening. This technique enhances surgical precision and confirms adequate decompression.

Intraoperative Ultrasound in Spinal Surgery

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