Stereotactic Surgery with the Radionics Frame
Michael Schulder
New Jersey Medical School, Newark, New Jersey, U.S.A.



In the early 1980s Radionics, Inc. (Burlington, MA) was approached with a design for an innovative stereotactic frame that used computed tomography (CT) to directly target points within the brain. This device, the BrownRoberts-Wells (BRW) frame, used a polar coordinate concept to define stereotactic space. A small computer with a simple menu was part of the system, thereby eliminating the need for strict orthogonality of the CT scan (a requirement of the Leksell arc-centered concept). The ‘‘picket-fence’’ configuration of the localizer was the key feature in this regard, as it allowed for calculation of the Z-coordinate (the height from the frame base, as opposed to the X and Y coordinates, which can be derived directly from a CT image). The BRW frame was a great success, but further change was spurred by certain limitations. A direct approach to the posterior fossa was difficult because of the round base of the head ring. The polar coordinate system required the setting of four different angles on the arc itself, a process that could be cumbersome. A separate calculation was required for each new entry point. In 1988, introduction of the Cosman-Roberts-Wells (CRW)

Copyright 2003 by Marcel Dekker, Inc. All Rights Reserved.

stereotactic frames still have their place. 3 IMAGING AND TARGETING Scanning. this tool was somewhat clumsy to use. It is important to ensure that the patient’s nose will clear the ring and the overlying localizer after application is completed. The CRW frame is applied to awake adult patients (children younger than age 12 and the rare uncooperative adult are given general anesthesia). including placement of deep brain stimulators [2]. Stereotactic radiosurgery is always done with a frame except in the unique case of the CyberKnife [3]. The surgeon must keep the target in mind and adjust the frame location accordingly. An assistant stands behind the patient. although frameless stereotaxy is much more suitable for this purpose [4]. if a lesion is known to enhance with contrast. Brain biopsies arguably are done with the most accuracy and least time using a frame. The scan field of view should be 34. A gentle tug on the frame checks the placement. and Radionics now makes one frame that is suitable for CT and MRI targeting. They are necessary for the performance of functional surgery. Axial scans with 3-mm slice thickness are obtained. holds the stereotactic base ring. and the pins are inserted until finger tight. Inc.5 to ensure inclusion of the Copyright 2003 by Marcel Dekker.g. At about the same time. is not necessary but may make scan interpretation and targeting easier. Oral sedation (2 tablets of Percocet and 5 mg of Valium) are administered 30 minutes before the procedure. Craniotomies may be done in the frame. and use of the arc in the operating room are essentially the same as with the CRW frame. this is given as well. An adapter to the scan table. All Rights Reserved. most often with CT. 2 FRAME APPLICATION In this era of frameless stereotaxy and emerging intraoperative imaging technologies. which usually eliminates much of the discomfort of frame application. is done. stabilizing his hands on the patient’s shoulders. imaging. usually 1 mm [5]. Although functional. The patient remains alert with this regimen. Application of the head ring.. The scalp is cleaned with alcohol swabs and the patient sits up. . needed for radiosurgery image acquisition.frame solved these problems. Imaging for localization for functional surgery (e. and the CRW design became the standard stereotactic frame made by Radionics [1]. targeting the Vim nucleus of the thalamus) should use the thinnest possible slices. Local anesthesia (1% lidocaine without epinephrine) is injected through the posts. and these will be described in this chapter. a separate head ring for use with magnetic resonance imaging (MRI) scanners was introduced.

position emission tomography (PET). . then the gantry may be angled to optimize target visualization. Inc. usually supine (or lateral for an occipital or posterior fossa approach) (Fig. Copyright 2003 by Marcel Dekker. and vertical settings for the stereotactic arc are derived. the patient is positioned. functional MRI. FIGURE 1 Patient positioned. Gantry tilt should be avoided if a surgical navigation (SN) computer or the Radionics Stereo Calc program is to be used for image processing. registration with a nonstereotactic digital image [MRI. lateral. 1). This will be of use mainly for identifying the AC-PC line for functional targeting. If the MC is used. If need be. although children will require general anesthesia. In the meantime.) is done. Anteroposterior. then the surgeon must enter the coordinates for each rod and for the target on the slice of interest. All Rights Reserved. etc.localizer rods in the image. 4 SURGERY The images are transferred to the operating room computer and the rods identified. Local anesthesia with intravenous sedation is preferred for most patients. if the dedicated Radionics ‘‘mini-computer’’ (MC) is used.

mounting the arc 90Њ to the usual orientation will give complete exposure of the area of interest). such as the instrument holder. Copyright 2003 by Marcel Dekker. 2). When the accuracy of the targeting is verified and the surgical field prepped and draped. possibly shorter or longer than the arc radius. (Note that for temporal approaches. or craniotomy is then made. the arc is transferred to the base ring. Sterilizing the base adds a measure of protection against infection. again depending on the clinical situation. 3). stimulation of a functional target) are done. A twist drill hole.g.Use of the phantom base will add 5 or 10 minutes to the procedure but will give the surgeon assurance that the target will be reached using the spatial settings (Fig. as long as it can be accessed through the arc and instrument holder. The biopsy cannula or other instrument is fixed to the appropriate length. Coordinates are set on the phantom and arc. then with a ruler held in place. burr hole. The arc-centered design of the CRW system allows for any entry point to be used. To move the stereotactic instrument a set depth. Biopsies are then taken. All Rights Reserved. The instrument is introduced to the desired depth and the patient is examined to rule out new neurological deficits (Fig. Inc. measure to the protruding top of the tool from a fixed object. FIGURE 2 The arc on the phantom base in the operating room. and a pointer is adjusted to the fixed depth from the probe holder to the target (17 cm). depending on the target and the surgeon’s preference.. . or other manipulations (e.

If the minicomputer was used. irrigate patiently through the cannula. All Rights Reserved. the biopsy instrument must be withdrawn and the settings adjusted on the arc. although reconfirmation with the phantom base is not necessary. if not. versatile tool for stereotactic neurosurgery. he or she is observed in a regular hospital room overnight. Re-examine the patient after each change of instrument position. If a stereotactic biopsy is being done. Periodically reinsert the stylet to dislodge any clot that may have formed at the cannula tip and that might falsely indicate that the hemorrhage has stopped. 5 CONCLUSION The CRW frame from Radionics remains a durable. If a different site needs to be targeted. a CT scan is obtained. this can be done quickly with an SN computer. . Of course. advance or withdraw the tool until the desired level is reached. Inc. specimens should be taken from different depths. coordinates will need to be obtained during the surgery from the CT console—doable but cumbersome and time-consuming.FIGURE 3 Insertion of a DBS electrode. withdraw the instrument. and obtain an emergency CT scan. and if no untoward findings are seen. close the incision. from frame application through Copyright 2003 by Marcel Dekker. If a new deficit is noted. After the incision is closed. the patient is observed for several hours in the recovery room. frozen section confirmation that a lesional area has been targeted should be obtained. If bleeding is encountered during the procedure. Attention to detail.

Neurosurg Clin N Am. Inc. Copyright 2003 by Marcel Dekker. 2. I Germano. All Rights Reserved. Neurosurgery 35:682–695. F Bova. P Gildenberg. R Galloway. Surg Neurol 32:334–342. RA Bakay. 3.imaging and the completion of surgery. R Maciunas. 1995. Neurosurgery 37:348–350. 1994. 1990. will ensure a system that is safe and user friendly. 1:765–781. The University of Florida radiosurgery system. 1989. 1998. Ablative surgery and deep brain stimulation for Parkinson’s disease [see comments]. JL Vitek. The NeuroStation System for image-guided frameless stereotaxy. Neurosurgery 43(5):989–1013. . The history of stereotactic neurosurgery. The application accuracy of stereotactic frames. 4. J Lattimer. discussion 1013–1015. 5. PA Starr. REFERENCES 1. W Friedman.