Name: Nine-Grid Area Division Method: A New Ideal Bone Puncture Region for Percutaneous Vertebroplasty in Lumbar Spine (Video) | JoVE Journal
Uploaded: 2024-08-09T13:30:00.000+00:00
Duration: 9 min 29 s
Description: Learn the Nine-grid Area Division Method for percutaneous vertebroplasty to enhance puncture accuracy and minimize complications. This technique improves surgical efficiency and reduces intraoperative radiation exposure.

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5 minutes

The study was funded by Beijing Natural Science Foundation-Haidian Original Innovation Joint Fund (L232054) and Capital Health Development Research Special Fund (NO.2024-2-2024).

The present study was approved by the Ethics Committee of Beijing Friendship Hospital Capital Medical University. This method will be introduced via a retrospective case study, utilizing only the preoperative prone-position computed tomography (CT) imaging data of the patient. The &#34;Nine-grid Area Division Method&#34; in assisted percutaneous vertebroplasty (PVP) offers a simpler and more effective approach compared to traditional methods, resulting in reduced surgical and radiation exposure times. This technique may benefit young residents by facilitating easier identification of puncture points and potentially shortening the learning curve for PVP procedures, warranting further investigation. The individual described here is a female of 68 years of age.
1. Diagnosing osteoporotic vertebral compression fracture (OVCF) using X-ray fluoroscopy, magnetic resonance image (MRI), bone scintigraphy, and symptoms
<ol>
	<li>Identify the patient who has OVCF among older patients with symptoms such as back pain, tenderness in the spinous process, and paraspinal muscles at the back. Utilize posteroanterior X-ray fluoroscopy to assess for the presence of a vertebral compression fracture at the L1 level (Figure 2A). Employ MRI imaging to confirm the diagnosis of a newly occurring lumbar vertebral compression fracture and identify the specific vertebra affected, which is determined to be L1 (Figure 2B).</li>
</ol>
2. The preoperative acquisition of CT imaging of the patient in a prone position
<ol>
	<li>Place the patient in a prone position to perform prone CT on the patient. Confirm the target area by x-ray fluoroscopy and a physical examination of the patient&#39;s back while pressing the most painful part.</li>
	<li>Make the patient lie in a prone position on the operation table, place a gradienter on the patient&#39;s back before the prone CT scan, record the patient&#39;s body position, and then remove the gradienter (Figure 3).</li>
	<li>Save the CT images (1 mm scanning layer thickness, 1 mm layer spacing, and either 90 slices (conventional scanning) or 400 slices (thin slice scanning) in DICOM format.</li>
</ol>
3. Establish the 3-D model and simulate the operation in medical imaging processing software
<ol>
	<li>Export the CT images in DICOM format into medical imaging processing software by clicking New Project. Select the desired slices for reconstructing the compressed vertebra.</li>
	<li>Utilize the Threshold Segmentation tool to adjust the threshold range for the target vertebra, specifically within the range of 125-3071 H to create a mask. Employ the Duplicate Mask function to generate two separate masks, Mask A and Mask B.</li>
	<li>Utilize the Mask Edit feature to erase the target vertebra from Mask A. Subsequently, utilize the Boolean Operations tool to subtract Mask A from Mask B, resulting in the formation of a new mask, Mask C. Finally, activate the Calculate 3-D function to reconstruct the target vertebra using the Mask C; name this 3-D model L1 (Figure 4A).</li>
	<li>Right-click on New in the Objects interface, choose Draw, and subsequently select Cylinder. Ensure that the cylinder has the same dimensions as the puncture needle, with a length of 12.5 mm and a radius of 1.25 mm.</li>
	<li>Adjust the positioning of the cylinder using the Move and Rotate function to achieve the ideal position (Figure 4B). Throughout the simulation, take care to maintain needle trajectories consistent with established principles: the puncture needle must be able to traverse the pedicle, preferably in its superior half, and the optimal positioning of the tips is within the anterior one-third of the vertebral body on the lateral view.</li>
	<li>Right-click on L1 in the Objects interface, choose Export STL, and subsequently export the file in STL format.</li>
</ol>
4. Polish the 3-D model in 3-D reverse engineering production software
<ol>
	<li>Import the exported vertebral body solid file into the 3-D reverse engineering production software by clicking Import. Consequently, employ the Mesh Doctor feature to eliminate distortions and spikes from the model.</li>
	<li>As the Grid Doctor function may mistakenly identify normal anatomical structures as distortions or spikes, take care to thoroughly examine the rough model to identify any internal voids, and follow step 4.1 to fill them appropriately (Figure 5A).</li>
	<li>Employ the Precise Surface function to transform the solid model into a triangular mesh surface, opting for the Organic Geometry Material (Figure 5B). Await the completion of the automated surface construction process and subsequently export the file in STP format.</li>
</ol>
5. Reconstruct the vertebral engineering model and confirm the safe entry regions of pedicle projection in 3-D modeling design software
<ol>
	<li>Import the STP format of the precise surface document into 3-D modeling design software to reconstruct the vertebral engineering model by clicking Open. Employ the Section View feature to examine the pedicle&#39;s morphology in horizontal, sagittal, and coronal orientations, providing an initial observation of the pedicle&#39;s morphology and structure (Figure 6A).</li>
	<li>In the Section View panel, adjust the angle of the section for optimal visualization. By utilizing Transparency Section Bodies, observe the narrowest point of the pedicles (Figure 6B) and record the angle parameters at Section 1 in the left panel.</li>
	<li>To adjust the angle of the vertebral model, click on the Insert-Features-Move/Copy function and select the Translate/Rotate button located at the bottom of the left panel. Revisit the Section View panel and adjust the view angle parameter in Section 1 to 0.</li>
	<li>Fine-tune the displacement parameters in the Section 1 panel to attain a satisfactory pedicle section view. Reorient for an improved perspective to observe the pedicle section. Document the confirmed displacement parameters in the panel (Figure 7).</li>
	<li>Utilize the aforementioned Move/Copy function to manipulate the position of the vertebral model. Specify the displacement parameter in the left panel. Employ the Corner Rectangle tool to encompass the entirety of the vertebral body.</li>
	<li>To begin, navigate to the Features-Reference Geometry-Plane option and designate the section view as the First Reference. Modify the offset distance parameter accordingly to relocate the newly created plane to the anterior third of the vertebral body.</li>
	<li>Proceed to generate a Sketch on the aforementioned plane and draw a Point at the midpoint of the vertebral body, signifying the termination point of the puncture.</li>
	<li>Use the Extruded Cut function to perform the cutting of the model. Designate the rectangular sketch generated as the Selected Contours.</li>
	<li>Make adjustments to both the direction and depth to divide the vertebral body model into two halves, namely the vertebral body half and the lamina half (Figure 8A). Save the engineering files in SLDPRT format, specifically as part of the process.</li>
	<li>Open the file containing the vertebral body part, followed by the creation of a sketch based on the section plane. Use the Convert Entities function to convert the left pedicle projection into a curve sketch.</li>
	<li>Repeat the above procedure for the right pedicle projection, resulting in the acquisition of another curve sketch. Employ the Filled Surface function to transform the curve sketches into surfaces, with the left and right pedicle projection curve sketches serving as the boundary (Figure 8B).</li>
	<li>Display the resulting surface after the vertebra has been concealed. Select the Lofted Boss/Base function on the Features panel.</li>
	<li>The superior positioning of the left pedicle surface, with the designation of the puncture endpoint as Profiles, will yield a conical structure delineating the paths for pedicle puncture. Use the left side as a reference for illustrative purposes, with the same process to be replicated on the right side.</li>
	<li>Use the Scale function to magnify the bilateral conical structure, with the centroid serving as the scaling center point and a scale factor of 2. Employ the Move/Copy Body function to individually relocate the conical structures.</li>
	<li>Within the Mate Setting panel interface, select the apex of the structure and the puncture end point, with the matching mode set as Coincident. Eliminate the vertebral body subsequently using the Delete/Keep Body function (Figure 9A).</li>
	<li>The biconical structure is a compilation of bilateral pedicle puncture paths, saved in SLDPRT format. Employ the Insert Part function to reassemble the lamina part and the vertebral body part using the pedicle puncture set. Simply press the OK button to automatically align the insert position of the part with the origin (Figure 9B).</li>
	<li>Employ the Combine Body function for executing Boolean operations on various components. Through the process of subtracting the puncture set from one half of the laminae while retaining all laminae components, the subsequent analysis indicates that the ideal bone puncture region includes regions 1, 4, and 7 on the left side (Figure 9C).</li>
</ol>

Enhancing Pedicle Puncture Precision with 3D Modeling and a Nine-Grid Method

<ol><li>Wenhao, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+comparison+of+percutaneous+kyphoplasty+with+high-viscosity+and+low-viscosity+bone+cement+for+treatment+of+osteoporotic+vertebral+compression+fractures%3A+a+retrospective+study%5BTitle%5D)+AND+%22Geriatr+Orthop+Surg+Rehabil%22%5BJournal%5D)">A comparison of percutaneous kyphoplasty with high-viscosity and low-viscosity bone cement for treatment of osteoporotic vertebral compression fractures: a retrospective study.</a> Geriatr Orthop Surg Rehabil. 13, 21514593221119625(2022).</li>
<li>Xuebiao, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((CT+features+and+risk+factors+of+pulmonary+cement+embolism+after+vertebroplasty+or+kyphoplasty+in+patients+with+vertebral+compression+fracture%3A+a+retrospective+cohort+study%5BTitle%5D)+AND+%22Quant+Imaging+Med+Surg%22%5BJournal%5D)">CT features and risk factors of pulmonary cement embolism after vertebroplasty or kyphoplasty in patients with vertebral compression fracture: a retrospective cohort study.</a> Quant Imaging Med Surg. 13 (4), 2397-2407 (2023).</li>
<li>Liehua, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+study+on+the+puncture+method+of+extrapedicular+infiltration+anesthesia+applied+during+lumbar+percutaneous+vertebroplasty+or+percutaneous+kyphoplasty%5BTitle%5D)+AND+%22Medicine+%28Baltimore%29%22%5BJournal%5D)">A study on the puncture method of extrapedicular infiltration anesthesia applied during lumbar percutaneous vertebroplasty or percutaneous kyphoplasty.</a> Medicine (Baltimore). 98 (33), e16792(2019).</li>
<li>Lo Bianco, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Interventional+pain+procedures%3A+a+narrative+review+focusing+on+safety+and+complications.+PART+2+Interventional+procedures+for+back+pain%5BTitle%5D)+AND+%22J+Pain+Res%22%5BJournal%5D)">Interventional pain procedures: a narrative review focusing on safety and complications. PART 2 Interventional procedures for back pain.</a> J Pain Res. 16, 761-772 (2023).</li>
<li>Jie, W., Qiang, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Beware+of+Brucella+spondylitis+following+vertebroplasty%3A+an+unusual+case+of+osteoporotic+vertebral+compression+fracture%5BTitle%5D)+AND+%22Infect+Drug+Resist%22%5BJournal%5D)">Beware of Brucella spondylitis following vertebroplasty: an unusual case of osteoporotic vertebral compression fracture.</a> Infect Drug Resist. 15, 2565-2572 (2022).</li>
<li>Xinqiang, H., Yongzhen, Z., Zhu, W., Mengpeng, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Case+report%3A+Cement+entrapped+in+the+inferior+vena+cava+filter+after+pedicle+screw+augmentation%5BTitle%5D)+AND+%22Front+Cardiovasc+Med%22%5BJournal%5D)">Case report: Cement entrapped in the inferior vena cava filter after pedicle screw augmentation.</a> Front Cardiovasc Med. 9, 892025(2022).</li>
<li>Saracen, A., Kotwica, Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Complications+of+percutaneous+vertebroplasty%3A+An+analysis+of+1100+procedures+performed+in+616+patients%5BTitle%5D)+AND+%22Medicine+%28Baltimore%29%22%5BJournal%5D)">Complications of percutaneous vertebroplasty: An analysis of 1100 procedures performed in 616 patients.</a> Medicine (Baltimore). 95 (24), e3850(2016).</li>
<li>Peilun, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+novel+%26%2334%3Bthree-dimensional-printed+individual+guide+template-assisted+percutaneous+vertebroplasty%26%2334%3B+for+osteoporotic+vertebral+compression+fracture%3A+a+prospective%2C+controlled+study%5BTitle%5D)+AND+%22J+Orthop+Surg+Res%22%5BJournal%5D)">A novel &#34;three-dimensional-printed individual guide template-assisted percutaneous vertebroplasty&#34; for osteoporotic vertebral compression fracture: a prospective, controlled study.</a> J Orthop Surg Res. 16 (1), 326(2021).</li>
<li>Jiashen, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Impact+of+sarcopenia+and+sagittal+parameters+on+the+residual+back+pain+after+percutaneous+vertebroplasty+in+patients+with+osteoporotic+vertebral+compression+fracture%5BTitle%5D)+AND+%22J+Orthop+Surg+Res%22%5BJournal%5D)">Impact of sarcopenia and sagittal parameters on the residual back pain after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fracture.</a> J Orthop Surg Res. 17 (1), 111(2022).</li>
<li>Songfeng, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+of+percutaneous+vertebroplasty+for+the+relief+of+osteoblastic+spinal+metastasis+pain%5BTitle%5D)+AND+%22Exp+Ther+Med%22%5BJournal%5D)">Efficacy of percutaneous vertebroplasty for the relief of osteoblastic spinal metastasis pain.</a> Exp Ther Med. 22 (1), 727(2021).</li>
<li>Ruszat, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Photoselective+vaporization+of+the+prostate%3A+subgroup+analysis+of+men+with+refractory+urinary+retention%5BTitle%5D)+AND+%22Eur+Urol%22%5BJournal%5D)">Photoselective vaporization of the prostate: subgroup analysis of men with refractory urinary retention.</a> Eur Urol. 50 (5), discussion 1049 1040-1049 (2006).</li>
<li>Junchuan, X., Jisheng, L., Jian, L., Yong, Y., Qi, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((%26%2334%3BTargeted+percutaneous+vertebroplasty%26%2334%3B+versus+traditional+percutaneous+vertebroplasty+for+osteoporotic+vertebral+compression+fracture%5BTitle%5D)+AND+%22Surg+Innov%22%5BJournal%5D)">&#34;Targeted percutaneous vertebroplasty&#34; versus traditional percutaneous vertebroplasty for osteoporotic vertebral compression fracture.</a> Surg Innov. 26 (5), 551-559 (2019).</li>
</ol>

The authors have no conflict of interest regarding any drugs, materials, or devices described in this study.

Percutaneous vertebroplasty (PVP) has demonstrated favorable clinical efficacy in managing painful osteoporotic vertebral compression fractures (OVCF)9. The utilization of precise percutaneous pedicle puncture technology by surgeons plays a crucial role in determining the optimal insertion point, direction, and depth of the puncture needle, thereby significantly reducing the occurrence of complications10. Currently, C-arm X-ray machines are widely employed in the domestic and international practice of traditional PVP surgery to facilitate the adjustment of the surgical path of the puncture needle11. The crucial aspect lies in identifying the ideal bone puncture point, which is conventionally situated at the projection &#34;left 10 points, right 2 points&#34; of the pedicle in the lumbar spine. The &#34;Nine-grid Area Division Method&#34; has the capability to identify the optimal bone puncture region.
The rationale for selecting the Nine-grid as the preferred division method over alternatives like the &#34;Four-grid &#34; and &#34;Sixteen-grid &#34; warrants explicit clarification. This decision stems from preliminary experiments, which have demonstrated that segmenting the pedicle projection into a Nine-grid Area aligns most closely with clinical practice while also considering the reference value. The &#34;Four-grid Area Division Method&#34; is characterized by ease of operation; however, its limited reference value arises from the imprecise regional division, making it challenging to discern the safety of the bone puncture entry point. Conversely, the &#34;Sixteen-grid Area Division Method&#34;&#160;offers an accurate determination of the puncture point&#39;s safety, yet its complexity during surgical procedures hinders observation and judgment, rendering it incongruous with clinical practice. Consequently, the &#34;Nine-grid Area Division Method&#34; was selected as it combines clinical feasibility with the provision of satisfactory reference value.
Upon further analysis of the clinical imaging data from our previous research subjects12, it was discovered that the precise lumbar spine PVP bone puncture points, as projected by the ideal pedicle projection of &#34;left 10 points, right 2 points&#34;, are not consistently observed. However, it was observed that certain alternative puncture points can still yield satisfactory puncture outcomes near the aforementioned ideal bone puncture point. These deviations from the ideal do not compromise surgical safety or accuracy. Based on the assumptions, we introduce the novel notion of the ideal bone puncture region for the PVP pedicle, which involves segmenting the pedicle projection into a Nine-grid Area on the X-ray anteroposterior image. By employing the X-ray projection of the lumbar pedicle as an anatomical reference, we establish the ideal bone puncture region for PVP through the division of the pedicle into a Nine-grid Area, thereby surpassing the limitations of a singular point.
Theoretical innovation has the potential to enhance the PVP puncture surgical pathway by using the &#34;Nine-grid Area Division Method&#34;-assisted PVP surgery in the lumbar spine. This advancement may decrease the dosage of intraoperative projection and minimize the duration of surgical procedures required for adjusting the bone entry point of the puncture needle, ultimately improving surgical efficiency and efficacy. It is noteworthy that the ideal bone puncture region for the &#34;Nine-grid Area Division Method&#34; may vary across different segments of the vertebral body. For illustrative purposes, the L1 vertebral body is solely utilized as an exemplar in this context. Our future research will incorporate additional case studies, broader sample segments, and investigations into robot learning to enhance the validity and objectivity of the indications and methodologies for PVP puncture.
However, there are some limitations of the &#34;Nine-grid Area Division Method&#34;-assisted PVP in the lumbar spine. There is a learning curve for learning to use the medical imaging software. Any mistake made during template design by surgeons unfamiliar with the software may lead to an unsuccessful result. Furthermore, larger-scale studies are imperative to validate the reliability and practicability of this finding.

Osteoporotic vertebral compression fracture (OVCF) is the most prevalent type of fracture among osteoporotic fractures and poses a significant clinical concern in contemporary healthcare1. According to current guidelines, percutaneous vertebroplasty is recognized as one of the most efficacious minimally invasive treatment modalities for OVCF2. The predominant method for performing percutaneous vertebroplasty (PVP) involves the pedicle puncture approach, which encompasses three key parameters: the identification of the bone puncture entry point, puncture angle, and puncture depth. Of these parameters, the selection of the bone puncture entry point is considered the most crucial.
Currently, C-arm X-ray machines are widely employed in the domestic and international practice of traditional PVP surgery to facilitate the adjustment of the surgical path of the puncture needle. The crucial aspect lies in identifying the &#34;ideal bone puncture point,&#34; which is conventionally situated at the projection &#34;left 10 points, right 2 points&#34; of the pedicle in the lumbar spine (Figure 1A)3. Despite their experience, even seasoned surgeons may make mistakes when determining appropriate puncture points based solely on personal experience. This can lead to puncture-related complications such as cement leakage into surrounding tissues, nerve root injury, and intra-spinal hematoma4,5,6. Additionally, nearly half of patients experience local complications from traditional PVP, with 95% of these complications attributed to cement leakage into surrounding tissue or embolization of paravertebral veins7. Our preliminary research found that the actual PVP bone puncture points in the lumbar spine are not always located at the ideal pedicle projection &#34;left 10 points and right 2 points&#34;8. Some actual puncture points can also achieve satisfactory puncture results near the &#34;ideal bone puncture point,&#34; which does not affect surgical safety and accuracy.
Based on the above assumptions, we propose, for the first time, the concept of the &#34;ideal bone puncture region&#34; for PVP in the lumbar spine and divide the projection of the pedicle into a &#34;Nine-grid Area&#34;. The concept of the ideal bone puncture region pertains to specific anatomical regions where the puncture entry point can successfully and securely reach the puncture ideal endpoint through the pedicle.The term &#34;Nine-grid Area Division Method&#34; refers to a technique in the X-ray anteroposterior image whereby the longest and shortest diameters of the pedicle projection are divided into three equal parts, resulting in the division of the area into nine regions (Figure 1B). These regions are sequentially numbered from 1 to 9, progressing from the outermost to the innermost and from top to bottom. Using the X-ray projection of the lumbar pedicle as an anatomical marker, we establish the &#34;ideal bone puncture region&#34; for PVP through the &#34;Nine-grid Area Division Method&#34; instead of being confined to a single point. We use computer simulation to explore a safe puncture path during the puncture process.
Hence, we suggest the implementation of the &#34;Nine-grid Area Division Method&#34; as a potential method for enhancing the convenience, efficiency, and safety of auxiliary puncture techniques in PVP surgery, with the aim of enhancing procedural accuracy and minimizing puncture-related complications. It is important to note that this study presents a theoretical approach that requires validation through extensive research to ascertain its efficacy and safety.

<table><tbody><tr><td>Computer tomography&amp;nbsp;</td><td>Company GE</td><td></td><td>machine</td></tr><tr><td>Geomagic Wrap (3-D reverse engineering production software)</td><td>Oqton software</td><td></td><td>software</td></tr><tr><td>Magnetic resonance image machine</td><td>Company GE</td><td></td><td>machine</td></tr><tr><td>Solidworks (3-D modeling design software)</td><td>Dassault Syst&amp;egrave;mes&amp;nbsp;-&amp;nbsp;SolidWorks Corporation</td><td></td><td>software</td></tr><tr><td>Spirit Level Plus</td><td>IOS App store</td><td></td><td>gradientor</td></tr><tr><td>X-ray machine</td><td>Company Philips</td><td></td><td>machine</td></tr></tbody></table>

nine-grid area division method: a new ideal bone puncture region for percutaneous vertebroplasty in lumbar spine

Nine-Grid Area Division Method: A New Ideal Bone Puncture Region for Percutaneous Vertebroplasty in Lumbar Spine

Percutaneous vertebroplasty (PVP) is widely recognized as an efficacious intervention for alleviating low back pain resulting from osteoporotic vertebral compression fractures. The ideal bone puncture point is conventionally situated at the projection "left 10 points, right 2 points" of the pedicle in the lumbar spine. Determining the optimal bone puncture point represents a critical and complex challenge. The accuracy of percutaneous vertebroplasty (PVP) is primarily influenced by the proficiency of the operating surgeons and the utilization of multiple fluoroscopes during the conventional procedure. Incidences of puncture-related complications have been documented globally. In an effort to enhance the precision of the surgical technique and reduce the occurrence of puncture-related complications, our team applied the "Nine-grid Area Division Method" for PVP in the lumbar spine to modify the traditional procedure. There is potential to decrease the number of puncture times, the radiation exposure dosage, and the duration of surgical procedures.
This protocol introduces the definition of the "Nine-grid Area Division Method" and describes the process of modeling target vertebrae DICOM imaging data within medical imaging processing software, simulating operations within a 3-D model, refining the 3-D model using reverse engineering production software, reconstructing the vertebral engineering model within 3-D modeling design software, and utilizing surgical data to determine safe entry regions for pedicle projection. By employing this methodology, surgeons can effectively identify appropriate puncture points with precision and ease, thereby reducing the intricacies associated with puncturing and enhancing the overall accuracy of surgical procedures.

CT imaging and digital modeling were performed in the hospital. It took 30 min to build the 3-D model from the CT images, ~10 min to polish the 3-D model in 3-D reverse engineering production software, and 15 min to reconstruct the vertebral engineering model and confirm the safe entry regions of pedicle projection in 3-D modeling design software. The ideal bone puncture region includes regions 1, 4, and 7 on the left side in this case. The notion of the ideal bone puncture region refers to distinct anatomical regions where the entry point for puncture can effectively and safely access the desired endpoint through the pedicle. Put differently, by adjusting the direction and depth of the puncture needle, the ideal puncture endpoint can be attained as long as the bone puncture entry point falls within these specified areas, rather than being restricted to the " left 10 points". This technique can significantly increase the surgeon's error tolerance during the puncture procedure. A minimal amount of fluoroscopy is necessary to identify an appropriate bone puncture site, leading to a reduction in the frequency of adjustments, radiation exposure, and duration of surgery.
The ideal bone puncture point is conventionally situated at the projection "left 10 points, right 2 points" of the pedicle in the lumbar spine as shown in Figure 1A. Figure 1B presents a detailed overview of the division details and methodologies employed in the Nine-grid Area Division Method. The preoperative images of the target vertebra are shown in Figure 2. A gradienter was placed on the patient's back before the prone CT scan and the patient's body position was recorded (Figure 3). The CT vertebra image was reconstructed into a 3-D model from the coronal, transverse, and the sagittal planes (Figure 4). Figure 4 also shows the simulation of the PVP operation procedure in the image processing software. Figure 5 shows the procedures to repair the mesh and transform the solid model into a triangular mesh surface. Figure 6 illustrates the methodology for observing and documenting the narrowest point of the pedicle through the utilization of the Section View function. Figure 7 illustrates the steps involved in adjusting the model displacement parameters and determining the final puncture target location. Figure 8 illustrates the partitioning of the model into two distinct components: the vertebral body half and the lamina half (A), followed by the generation of the pedicle projection using the Convert Entities function (B). Figure 9 depicts the array of puncture paths within the vertebral body. The lamina and vertebral body components were reassembled using the pedicle puncture set, with the puncture set subsequently removed from the laminae portion while preserving all laminae components. The Combine Body function was utilized to perform Boolean operations on multiple components, leading to the identification of the ideal bone puncture region comprising regions 1, 4, and 7. 
<img alt="Vertebrae static equilibrium diagram; points labeled for analysis." class="xfigimg" src="/files/ftp_upload/66906/66906fig01.jpg" data-altupdatedat="1788304762000" data-alt="Figure 1"> 
Figure 1: A. Traditional "ideal bone puncture point." The "ideal bone puncture point" is conventionally situated at the projection "left 10 points, right 2 points" of the pedicle in the lumbar spine. B. Introduction to the "Nine-grid Area Division Method." A detailed overview of the division details and methodologies employed in the "Nine-grid Area Division Method." <a href="https://www.jove.com/files/ftp_upload/66906/66906fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="X-ray and MRI scans of spine, illustrating vertebral alignment and potential disc anomalies for analysis." class="xfigimg" src="/files/ftp_upload/66906/66906fig02.jpg" data-altupdatedat="1788304762000" data-alt="Figure 2"> 
Figure 2: Preoperative images of the target vertebra. (A) X-ray of the patient with osteoporotic vertebral compression fracture.The pre-operation X-ray images of the target vertebra of the patient. (A1: Posteroanterior view; A2: Lateral view). (B) MRI of the patient with osteoporoticvertebral compression fracture.The preoperative MRI images of the target vertebra of the patient. (B1: T1WI view; B2: T2WI view). <a href="https://www.jove.com/files/ftp_upload/66906/66906fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Smartphone-based spinal posture monitoring; clinical setup; patient alignment measurement." class="xfigimg" src="/files/ftp_upload/66906/66906fig03.jpg" data-altupdatedat="1788304762000" data-alt="Figure 3"> 
Figure 3: CT scan in the prone position. Use a gradienter on the patient's back to measure the horizontal and sagittal angles of the patient's body while undergoing a prone position CT scan. <a href="https://www.jove.com/files/ftp_upload/66906/66906fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Spinal anatomy 3D reconstruction, diagram; CT scans; vertebrae segmentation; medical imaging analysis." class="xfigimg" src="/files/ftp_upload/66906/66906fig04.jpg" data-altupdatedat="1788304762000" data-alt="Figure 4"> 
Figure 4: Reconstruction of the vertebra and simulation of the operation. (A) Reconstruction of vertebra in medical imaging processing software from the CT vertebra image from (A1) the coronal plane, (A2) the transverse plane, (A3) the sagittal plane, and (A4) the 3-D model. (B) Simulation of PVP operation procedure in medical imaging processing software. <a href="https://www.jove.com/files/ftp_upload/66906/66906fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="3D vertebrae models comparison; surface analysis, anatomical study, simulation results." class="xfigimg" src="/files/ftp_upload/66906/66906fig05.jpg" data-altupdatedat="1788304762000" data-alt="Figure 5"> 
Figure 5: Polishing the 3-D model in 3-D reverse engineering production software. The procedure of refining the 3-D model. (A) Repairing the mesh and (B) transforming the solid model into a triangular mesh surface. <a href="https://www.jove.com/files/ftp_upload/66906/66906fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Solid modeling comparison; 3D mesh diagrams of vertebral reconstruction techniques; design analysis." class="xfigimg" src="/files/ftp_upload/66906/66906fig06.jpg" data-altupdatedat="1788304762000" data-alt="Figure 6"> 
Figure 6: Utilize the Section View function to observe and document the pedicle. Utilizing the Section View function to observe the (A) pedicle projection and (B) document angle parameters. <a href="https://www.jove.com/files/ftp_upload/66906/66906fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="3D vertebra model diagram, CAD design, geometry analysis for anatomical study." class="xfigimg" src="/files/ftp_upload/66906/66906fig07.jpg" data-altupdatedat="1788304762000" data-alt="Figure 7"> 
Figure 7: Modifying the parameters of the model's displacement. Adjust the model displacement parameters and determine the final puncture target location. <a href="https://www.jove.com/files/ftp_upload/66906/66906fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="3D spine modeling, finite element analysis, vertebrae structure diagram, biomechanical study." class="xfigimg" src="/files/ftp_upload/66906/66906fig08.jpg" data-altupdatedat="1788304762000" data-alt="Figure 8"> 
Figure 8: Creating a representation of the projection of the pedicle. (A) Partitioning of the model into two distinct components, followed by (B) the generation of the pedicle projection using the Convert Entities function. <a href="https://www.jove.com/files/ftp_upload/66906/66906fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="3D anatomy model comparison; surface mesh diagrams for visualization; structural analysis." class="xfigimg" src="/files/ftp_upload/66906/66906fig09.jpg" data-altupdatedat="1788304762000" data-alt="Figure 9"> 
Figure 9: Puncture paths and the identification of the ideal puncture region. (A) Set of puncture paths traversing the pedicle. The array of puncture paths within the vertebral body through the pedicle. (B) Reconstructing models comprising diverse components. Reconstruct the lamina and vertebral body segments by means of the pedicle puncture set. (C) Acquisition of the "ideal bone puncture region". An area is deemed an ideal bone puncture region only when it is completely blue. The ideal bone puncture region encompasses regions 1, 4, and 7 through the application of Boolean operations. <a href="https://www.jove.com/files/ftp_upload/66906/66906fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Herein, we present a "Nine-grid Area Division Method" for percutaneous vertebroplasty. A patient with an L1 vertebral compression fracture was selected as a case study.

Percutaneous vertebroplasty (PVP) is widely recognized as an efficacious intervention for alleviating low back pain resulting from osteoporotic vertebral ...

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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

Herein, we present a three-dimensional printing guide template for percutaneous vertebraplasty. A patient with a T11 vertebral compression fracture was selected as a case study.

Three-Dimensional Printing Guide Template Assisted Percutaneous Vertebroplasty (PVP)

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Here, we present a protocol for the "isolation zone" technique in the treatment of lumbar disc herniation (LDH) under full-endoscopic spine surgery (FESS), including intervertebral foramen formation, targeted catheterization, nucleus pulposus resection, and annulus fibrosus formation, which together completely block the pain from the nerve conduction pathway.

Full-Endoscopic Isolation Zone Technique for the Treatment of Lumbar Disc Herniation

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

We developed an in vitro model of dormancy in the bone marrow for estrogen-sensitive breast cancer cells. The goal of this protocol is to demonstrate use of the model for the study of the molecular and cellular biology of dormancy and for generation of hypotheses for subsequent testing in vivo.

An In Vitro Dormancy Model of Estrogen-sensitive Breast Cancer in the Bone Marrow: A Tool for Molecular Mechanism Studies and Hypothesis Generation

Here, we introduce a method to evaluate transpedicular screws by using an in vivo porcine lumbar spine model.

An Anesthesia, Surgery, and Harvest Method for the Evaluation of Transpedicular Screws Using an In Vivo Porcine Lumbar Spine Model

Currently any kind of vascularized composite allotransplantation depends on long-term-immunosuppression, difficult to support for non-life-critical indications. We present a new porcine tibial VCA model that can be used to study bone VCA and demonstrate the use of surgical angiogenesis to maintain bone viability without the need of long-term immune-modulation.

Surgical Angiogenesis in Porcine Tibial Allotransplantation: A New Large Animal Bone Vascularized Composite Allotransplantation Model

Here we present a protocol of a novel outside-in technique of transforaminal endoscopic discectomy for lumbar disc herniations. The technical aspects of the technique, the wide indications of use, and the results of the treatment in 184 patients are described in detail.

A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

Learn the Nine-grid Area Division Method for percutaneous vertebroplasty to enhance puncture accuracy and minimize complications. This technique improves surgical efficiency and reduces intraoperative radiation exposure.

Nine-Grid Area Division Method: A New Ideal Bone Puncture Region for Percutaneous Vertebroplasty in Lumbar Spine

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