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THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY

Int J Med Robotics Comput Assist Surg 2006; 2: 107–113.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/rcs.88

ORIGINAL ARTICLE

Use of the NeuroMate stereotactic robot in a
frameless mode for functional neurosurgery†

T. R. K. Varma*
P. Eldridge

Abstract

The Walton Centre for Neurology and
Neurosurgery, Liverpool, UK

Background The aim of this paper is to describe the use of the NeuroMate
stereotactic robot for functional neurosurgery with a novel frameless
ultrasound registration system.

*Correspondence to: T. R. K. Varma,
The Walton Centre for Neurology
and Neurosurgery, Lower Lane,
Liverpool L9 7LJ, UK. E-mail:
tv.varma@thewaltoncentre.nhs.uk

Methods A retrospective review of the evaluation and clinical use of the
NeuroMate stereotactic robot in a frameless mode for functional neurosurgery.

† No

conflict of interest was declared.

Results Prior to its clinical use a phantom study was undertaken to
demonstrate an application accuracy of 1.29 mm. Subsequently the robot
has been used in 153 functional neurosurgical procedures including 113 deep
brain stimulator implantations.
Conclusions The NeuroMate stereotactic robot in a frameless mode has
sufficient accuracy for a range of functional neurosurgical procedures,
including movement disorder surgery. Copyright  2006 John Wiley &
Sons, Ltd.
Keywords

NeuroMate robot; frameless robot; functional neurosurgery

Introduction
The NeuroMate stereotactic robot (Schaerer Mayfield NeuroMate, Sarl,
France) comprises an electromechanical multi-joint arm which can be moved
to a position in space with an accuracy of 0.7 mm, a precision of 0.15 mm and
a payload stability of 7 kg (Figure 1). There are six joints in all and in each joint
a potentiometer measures the angle, thereby feeding positional information
back to a computer which controls the motion. The computer houses software
for the control of robotic movement, the registration process and stereotactic
planning. It has been designed for use in stereotactic neurosurgery and its
use in conjunction with conventional stereotactic localizer frames has been
described (1–3). However, it can also be used with a unique frameless
ultrasound registration system. We have previously described the use of the
robot in a frameless mode for movement disorder surgery (4) and in this
paper we describe the preclinical evaluation of the application accuracy of
the system, followed by a review of our experience of its use in functional
neurosurgery.

Materials and methods
Accepted: 26 March 2006

Copyright  2006 John Wiley & Sons, Ltd.

The NeuroMate stereotactic robot was developed from the initial work at
Grenoble University of Benabid and colleagues (1–3). It was designed for use

which has MRI.and CT-visible markers at the end of each spoke. A T1 volume scan was used in implantation of Int J Med Robotics Comput Assist Surg 2006.108 T. The base plate fixed to the skull and the fiducial system in place prior to imaging (Gpi) were directly targeted. while the subthalamic nucleus (STN) and globus pallidus interna Copyright  2006 John Wiley & Sons. but later an ultrasonic registration system was developed which dispensed with the need for a conventional stereotactic localizer system. 2: 107–113. K. In this frameless mode a unique detachable localizer is used and registration is performed using an ultrasonic system. is mounted to the base plate (Figure 2). A single base plate is implanted into the skull under local anaesthesia and during imaging the detachable fourspoked fiducial system. The NeuroMate stereotactic robot during phantom studies of application accuracy with a conventional stereotactic localizer. Eldridge Figure 1. Varma and P. The area covered by the imaging includes the surgical target and the fiducial markers.1002/rcs . DOI: 10. T1 axial images were used to plan thalamic targets indirectly with reference to the anterior commisure to the posterior commisure (AC–PC) line. Figure 2. R. MRI was the only imaging modality used for functional neurosurgery and was generally performed about 24 h before surgery. using axially acquired T2 data. Ltd.

The base plate for the localizer system was fixed in a wooden phantom. using two slice thicknesses. Int J Med Robotics Comput Assist Surg 2006. DOI: 10. in three dimensions. phantom with the localizer was then scanned with CT. Measurement of this distance was performed by use of a Polaris infra-red tracker system (Northern Digital Inc. along with seven asymmetrically placed screws capable of carrying fiducial markers that are visible on cross-sectional imaging. we undertook a series of phantom studies to assess the application accuracy of the frameless system (5). as the geometry of the marker construct is known and optimized to the application. At surgery the patient’s head is held in a rigid pin headrest attached to the robot and an ultrasound microphone array with a similar geometry to the fiducial system is attached to the base plate on the patient’s head. The Copyright  2006 John Wiley & Sons. An array of four ultrasound emitters is attached to the working arm of the robot (Figure 3) and the position of the microphones is then automatically co-registered to the position of fiducials in the imaging dataset. resulting in high errors in registration and application accuracy. Clinical applications Intracranial mass lesions The early clinical material with intracranial mass lesions comprised biopsy in 19 cases of tumour and catheter placements into intracranial cysts in three cases.5 mm slice thickness was avoided in the clinical cases because of the high radiation dose and time constraints) and MRI in the others. CT scanning was used in seven cases. 2: 107–113. Imaging data was transferred to the robot planning station and the planning software used to identify targets and plan trajectories. the actual position of the target and the point reached by the robot. using a T1 volume gadolinium-enhanced scan with 1 mm3 isotropic voxels. Ltd. each of the seven fiducials was targeted and the application accuracy calculated by measuring.1002/rcs . After the registration procedure. Waterloo. Phantom Studies Prior to clinical use. 1. Canada) and a specially designed pointer with mounted infra-red emitters (Figure 4).5 mm and 3 mm. Ontario. The ultrasonic registration process with the ultrasonic emitters attached to the robot arm and the microphones replacing the fiducial array depth electrodes as part of the presurgical evaluation for epilepsy surgery. In two patients there was motion artefact in the imaging data. The positions of the four markers of the fiducial system are identified in the dataset and. using 3 mm slice thickness (1. it can be compared to the position of the fiducial markers extracted from the image to obtain an estimate of the errors attributable to the imaging process.109 Functional Neurosurgery with a Frameless Robot Figure 3..

DOI: 10. Eldridge (a) (b) Figure 4. Ltd. Int J Med Robotics Comput Assist Surg 2006. Varma and P. R. Pointer with mounted infrared emitters at (A) the robot-calculated target and (B) the true target Copyright  2006 John Wiley & Sons.110 T. K. 2: 107–113.1002/rcs .

This allowed ample time for image analysis to be undertaken prior to the surgical procedure and also reduced operation time.27 mm. The functionality of the NeuroMate robot in a frameless mode has been assessed in both laboratory and clinical settings. MRI to confirm electrode position was carried out in all patients prior to removal of the electrodes. DOI: 10. or better than. with slice thicknesses of 1. The high registration Copyright  2006 John Wiley & Sons.6 mm (range 0.5 mm). MRI was the only imaging used in all but one of the MDS procedures and was undertaken under general anaesthesia the day before the stereotactic procedure (CT was used in one patient for implantation of GpiDBS. that of conventional stereotactic frames (7. Video EEG recording was carried out for a period of 7–14 days until at least three clinical seizures were captured.1 mm (range 0. In this instance the accuracy obtained varied with the CT slice thickness in the expected manner and was comparable to.5mm 3mm 2 1 0 RM RF CF LF LM Oc RP fiducials Figure 5. In all cases a single microelectrode trajectory was used initially but. 2: 107–113. patient-dependent distortion of the image and the difficulties of identifying the position of a biological target rather than a fiducial target. Application accuracy in the phantom studies showed average errors of 1. Two or three electrodes were placed from a lateral approach in each temporal lobe with the deepest contact targeted to be in the mesial temporal structures. Functional neurosurgery using the NeuroMate stereotactic robot in a frameless mode Movement disorder Deep brain stimulators (DBS) Subthalamic nucleus (STN) Globus pallidus (Gpi) Thalamus (Vim) Thalamotomy Chronic pain Thalamic and periventricular grey (PVG) DBS Epilepsy Temporal depth electrodes Total 63 21 22 2 Part IV. and thalamic stimulators (Vim-DBS) in patients with tremor. Depth electrodes for presurgical evaluation in epilepsy surgery A retrospective study of the case records of the 22 patients was undertaken to confirm histological diagnosis and the results of catheter placement. Activities of daily living (ADL) were assessed using UPDRS Part II.0 mm for the CT datasets. 40 patients being considered for epilepsy surgery underwent implantation of depth electrodes for seizure recordings.5 mm and 3. mean registration error was 1. off and on medication and with the stimulator on and off. the pixel dimensions being 0. Drug requirements were measured before and 12–18 months after surgery (6). Motor scores were assessed using the Unified Parkinson’s Disease Rating Scale (UPDRS) Part III. in clinical practice. as he had a cardiac pacemaker which precluded him from undergoing MRI). Clinical fluctuations and dyskinesia were assessed using UPDRS Application accuracy of the system was assessed using a phantom and also in clinical use.1 mm) and mean maximum error was 2. The clinical effectiveness of the technique was verified by the postoperative assessments of a group of patients who underwent STN-DBS for Parkinson’s disease.29 and 2. multiple concentrically arranged parallel trajectories were explored. One patient with Parkinson’s disease underwent Gpi-DBS and two patients with tremor underwent unilateral thalamotomy. 40 153 3-D error 4 3 mm 5 1. The application accuracy was also measured in a series of 22 patients undergoing stereotactic surgery for mass lesions. electrodes were placed simultaneously in the periventricular grey (PVG) and the appropriate sensory nucleus of the thalamus (PVM or PVL). Phantom studies are a reasonable measure of accuracy of registration but underestimate errors which.111 Functional Neurosurgery with a Frameless Robot Table 1.1002/rcs . Ltd. Patients were assessed at 12–18 months after surgery. may arise from patient movement. as shown in Table 1. Movement disorder surgery Assessment of application accuracy Deep brain stimulators (DBS) were implanted in 106 patients with movement disorder: subthalamic stimulators (STN-DBS) in patients with Parkinson’s disease. In the five patients with chronic pain.5 mm2 (Figure 5).3–5. In this series of cases. if satisfactory localization was not obtained.31–6. Functional neurosurgery Results The NeuroMate stereotactic robot in the frameless mode has been used for Functional Neurosurgery in 153 cases. Application accuracy in phantom studies Int J Med Robotics Comput Assist Surg 2006.8). globus pallidus (Gpi-DBS) in patients with generalized or segmental dystonia.

the improvement was maintained except for postural stability. and calculated the position of the STN as identified by microelectrode recordings with the position of the STN as targeted by the NeuroMate on imaging. 54: (suppl): 93–97. Catheters were successfully placed in all the intracranial cysts. K. Cinquin P.7%) compared to preoperatively (p < 0. Acta Neurochir (Wien) 1992.01). ADL scores were improved by surgery at 6 months (26. Hoffman D. Forster A. Surgery for mass lesions Satisfactory recordings were obtained in all patients using depth electrodes. 37 of 50 STN targets were satisfactorily identified using a single microelectrode trajectory and a mean of 1. This degree of accuracy allows the NeuroMate to be used in a frameless mode for functional neurosurgery.5–4.7 mm. In one case the tissue obtained was not diagnostic but a postoperative scan confirmed that the biopsy had been obtained from the area of abnormality as indicated by the imaging. In previous studies (4.01). with results comparable to those reported in the literature for frame-based surgery (6. Potential use of robots in endoscopic neurosurgery.2 mm). Technological design and preliminary results. et al. Stereotact Funct Neurosurg 2003.1002/rcs .7–3. Using implanted skull fiducials. gait and postural stability were all significantly improved at 6 months (p < 0. diagnostic tissue was obtained.5. 2: 107–113. Symon L (ed. DOI: 10. 2. There was a significant improvement in UPDRS Part III motor scores (off medication) at 6 months (43%) and 18 months (51.05 for all scores). Ltd.8%) and 18 months (29. This compares well with reported results from frame-based procedures (10–12). with a mean disease duration of 10. and the current study demonstrates that the method can be reliably used for DBS procedures.2%) (p < 0. References 1. and in only three cases did this exceed 3 mm. The reliability and accuracy of the Neuromate robot in the frameless mode has been validated in previous studies (4.6 trajectories were used. Benabid AL. we have used the system for the placement of recording electrodes in the presurgical evaluation for epilepsy surgery. Varma TR. R. we did not routinely undertake postoperative MRI to assess the accuracy of electrode placement. Preoperative clinical fluctuations were reduced by 58% at 6 months and 53% at 18 months (p < 0. We have been able to demonstrate an application accuracy in phantom and clinical settings that is comparable to frame-based systems.9) we reported a cohort of patients undergoing STN-DBS surgery using the NeuroMate in frameless mode. Preoperative Hoehn and Yahr score off medication was 4–5 and on medication 2.05). et al. The NeuroMate was used in the frameless mode both for biopsies and for the placement of catheters in intracranial cysts. Computer driven robot for stereotactic surgery connected to CT scan and magnetic resonance imaging. Munari C. et al. Int J Med Robotics Comput Assist Surg 2006. with the greatest variation being in the Z axis. There was a significant reduction in motor fluctuations. 1991. Movement disorder surgery The NeuroMate was used in the frameless mode in patients with movement disorders for DBS placements in 111 patients and thalamotomy in two patients. Our largest use of the system has been in movement disorder surgery. et al. At 18 months. Springer: Vienna.8). Eldridge PR. Depth electrodes for presurgical evaluation in epilepsy surgery Discussion Functional neurosurgery is traditionally undertaken using stereotactic frames with localizer systems attached to large base plates that cannot be removed between imaging and the surgical procedure. application accuracy was calculated using the same technique as in the phantom study and mean application accuracy was found to be 2.8 (4–19) years.05). 4. Offmedication sub-scores of the UPDRS Part III for tremor. Detailed analysis of the position of the electrodes in comparison to the calculated target is the subject of an on-going study. Maciunas and Galloway (7) assessed several frames and showed the variability in the application accuracy of these systems. Appl Neurophysiol 1987. Benabid AL. with the deepest contact in the mesial temporal structures. There was a significant reduction in medication by 29% Copyright  2006 John Wiley & Sons. The final electrode position varied from the planned trajectory by a mean of 1. 3–35. In addition. High-resolution imaging is undertaken under general anaesthesia 24 hours prior to surgery and ample time is available for detailed image analysis and trajectory planning. bradykinesia. A major advantage in our experience has been the ability to separate the imaging from the surgical procedure. Eldridge error in two cases was found to be due to patient movement during image acquisition. rigidity. Lavallee S. 50(1–6): 153–154. 80(1–4): 132–135. Is there a future for robots in neurosurgery? In Advances and Technical Standards in Neurosurgery. Dyskinesia duration and severity was also significantly reduced by 71% at 6 months and 68% at 18 months (p < 0.10–12). Hoffmann D. Use of the NeuroMate stereotactic robot in a frameless mode for movement disorder surgery. Because of the potential risks to the patient and the degree of artefact caused by the electrode. and postoperative imaging showed all the electrodes to be placed appropriately.112 T.). Lavallee S. In 18 of the 19 biopsies. Varma and P.9 mm (range 0. at 6 months and 33% at 18 months. Benabid AL. 3.

Lozano AM. Zamorano l. 35(4): 682–694. 51: 850–855. Int J Med Robotics Comput Assist Surg 2006. Guridi J. Varma TR. Neurology 1998. 6. et al. 55(suppl 6): S21–S28. et al. Eldridge PR. et al. Chronic subthalamic nucleus stimulation reduces medication requirements in Parkinson’s disease. Lang AE. 80(1–4): 82–87. 10. 7. 12. Acta Neurochir (Wien) 2000. Latimer JW. Rodriguez-Oroz MC. 3-D error measurement for checking the application accuracy of a stereotactic robotic system with an infrared space digitisation technique: a phantom study and clinical use. 2: 107–113. 7(2): 90–98. 53: 85–90. Lozano AM. 11. Kim YK. The application accuracy of stereotactic frames. Pandya A.Functional Neurosurgery with a Frameless Robot 5. et al. Brain 2005. 113 9. et al. Stereotact Funct Neurosurg 2003. Rodriguez-Oroz MC. Littlechild P. 128: 2240–2249. 8. Ltd.1002/rcs . Li QH. Double-blind evaluation of subthalamic nucleus deep brain stimulation in advanced Parkinson’s disease. Kumar R. Bilateral deep brain stimulation in Parkinson’s disease: a multicentre study with 4 years follow-up. Maciunas RJ. Obeso JA. Eldridge PR. Scerrati M. 142: 1169–1210. Galloway RL Jr. Golash A. The application accuracy of the NeuroMate robot – a quantitative comparison with frameless and frame based surgical localization systems. Varma TRK. DOI: 10. Neurosurgery 1994. Moro E. Neurology 2000. Romito LMA. et al. Variability in position of the subthalamic nucleus targeted by magnetic resonance imaging and microelectrode recordings as compared to atlas coordinates. Comput Aided Surg 2002. Neurology 1999. Copyright  2006 John Wiley & Sons. Targeting the basal ganglia for deep brain stimulation in Parkinson’s disease.