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Background  With the growing incidence of patients receiving surgical treatment for spinal metastatic tumours, there is a need for developing cost-efficient and radiation-free alternatives for spinal interventions. In this paper, we evaluate the capabilities and limitations of an image-guided neurosurgery (IGNS) system that uses intraoperative ultrasound (iUS) imaging for guidance.    Methods  Using a lumbosacral section of a porcine cadaver, we explored the impact of CT image resolution, ultrasound depth and ultrasound frequency on system accuracy, robustness and effectiveness. Preoperative CT images with an isotropic resolution of , and were acquired. During surgery, vertebrae L1 to L6 were exposed. For each vertebra, five iUS scans were acquired using two depth parameters (5 cm and 7 cm) and two frequencies (6 MHz and 12 MHz). A total of 120 acquisition trials were evaluated. Ultrasound-based registration performance is compared to the standard alignment procedure using intraoperative CT. We report target registration error (TRE) and computation time. In addition, the scans’ trajectories were analyzed to identify vertebral regions that provide the most relevant features for the alignment.    Results  For all acquisitions, the median TRE ranged from 1.42 mm to 1.58 mm and the overall computation time was 9.04 s ± 1.58 s. Fourteen out of 120 iUS acquisitions (11.66%) yielded a level-to-level mismatch (and these are included in the accuracy measurements reported). No significant effect on accuracy was found with CT resolution ( F   (2,10)  = 1.70,  p  = 0.232), depth ( F   (1,5)  = 0.22,  p = 0.659) nor frequency ( F   (1,5)  = 1.02,  p  = 0.359). While misalignment increases linearly with the distance from the imaged vertebra, accuracy was satisfactory for directly adjacent levels. A significant relationship was found between iUS scan coverage of laminae and articular processes, and accuracy.    Conclusion  Intraoperative ultrasound can be used for spine surgery neuronavigation. We demonstrated that the IGNS system yield acceptable accuracy and high efficiency compared to the standard CT-based navigation procedure. The flexibility of the iUS acquisitions can have repercussions on the system performance, which are not fully identified. Further investigation is needed to understand the relationship between iUS acquisition and alignment performance.

Evaluation of an Ultrasound-Based Navigation System for Spine Neurosurgery: A Porcine Cadaver Study