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The use of physical biomodelling in complex spinal surgery

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Abstract

Prior studies have suggested that biomodels enhance patient education, preoperative planning and intra-operative stereotaxy; however, the usefulness of biomodels compared to regular imaging modalities such as X-ray, CT and MR has not been quantified. Our objective was to quantify the surgeon’s perceptions on the usefulness of biomodels compared to standard visualisation modalities for preoperative planning and intra-operative anatomical reference. Physical biomodels were manufactured for a series of 26 consecutive patients with complex spinal pathologies using a stereolithographic technique based on CT data. The biomodels were used preoperatively for surgical planning and customising implants, and intra-operatively for anatomical reference. Following surgery, a detailed biomodel utility survey was completed by the surgeons, and informal telephone interviews were conducted with patients. Using biomodels, 21 deformity and 5 tumour cases were performed. Surgeons stated that the anatomical details were better visible on the biomodel than on other imaging modalities in 65% of cases, and exclusively visible on the biomodel in 11% of cases. Preoperative use of the biomodel led to a different decision regarding the choice of osteosynthetic materials used in 52% of cases, and the implantation site of osteosynthetic material in 74% of cases. Surgeons reported that the use of biomodels reduced operating time by a mean of 8% in tumour patients and 22% in deformity procedures. This study supports biomodelling as a useful, and sometimes essential tool in the armamentarium of imaging techniques used for complex spinal surgery.

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Author information

Authors and Affiliations

  1. Paediatric Spine Research Group, Level 2, Mater Children’s Hospital, Queensland University of Technology and Mater Health Services Brisbane Ltd, Raymond Terrace, South Brisbane, QLD, 4101, Australia

    Maree T. Izatt, Paul L. P. J. Thorpe, Clayton J. Adam, John W. S. Earwaker, Robert D. Labrom & Geoffrey N. Askin

  2. Anatomics Pty Ltd, Melbourne, Australia

    Robert G. Thompson

  3. Department of Neurosurgery, Victorian Neuroscience Centre, Epworth Hospital, Melbourne, Australia

    Paul S. D’Urso

Authors
  1. Maree T. Izatt
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  2. Paul L. P. J. Thorpe
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  3. Robert G. Thompson
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  4. Paul S. D’Urso
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  5. Clayton J. Adam
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  6. John W. S. Earwaker
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  7. Robert D. Labrom
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  8. Geoffrey N. Askin
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Corresponding author

Correspondence to Clayton J. Adam.

Additional information

Sources of support: No financial support was received for this study.

Appendices

Appendix 1: Biomodel utility survey

(Note: Possible responses for each question are given in parentheses)

Part A: Case information

Patient demographics, Surgeon, Surgery date, Hospital, Clinical problem, Type of procedure.

Part B: Preoperative planning

  • B1 Which visualisation modalities were used preoperatively for this case? (X-ray, 2DCT, 3DCT, 2DMRI, 3DMRI, other)

  • B2 Was the biomodel used preoperatively for this patient? (Yes/No)

    • B2.2 How did the information from the biomodel compare with that from other visualisation modalities?

    • (Information needed was visible only on the images, not on the biomodel.)

    • (Information needed was more visible on the images than on the biomodel.)

    • (No difference.)

    • (Information needed was better visible on the biomodel than on the images.)

    • (Information needed was exclusively visible on the biomodel.)

  • B3 Did the preoperative use of this biomodel lead to a different decision for:

    1. (a)

      whether to operate or not (Yes/No)

    2. (b)

      composition of the surgical team (Yes/No)

    3. (c)

      skin incision (Yes/No)

    4. (d)

      patient’s position on the operating table (Yes/No)

    5. (e)

      choice of osteosynthetic material (Yes/No)

    6. (f)

      choice of instrumentation/devices (Yes/No)

    7. (g)

      implantation site of osteosynthetic material (Yes/No)

    8. (h)

      sequence of surgery (Yes/No)

    9. (i)

      other? please specify (Yes/No)

  • B4 Was surgery simulated preoperatively on the biomodel? (Yes/No)

    • B4.1 To what extent did the preoperative simulation affect the surgical outcome? (Much worse, Worse, Same, Better, Much better)

    • B4.2 How was the outcome affected?

  • B5 Was an off-the-shelf implantable device customised preoperatively using this biomodel? (Yes/No)

    • B5.1 What type of implantable device was customised? How was the implantable device customised?

  • B6 Was a custom implant made preoperatively using this biomodel? (Yes/No)

    • B6.1 What type of implant was made? How well did the implant fit? (Poor, Fair, Good, Excellent, Perfect)

Part C: Surgical procedure

  • C1 How long did it take to perform this surgical procedure? (time spent performing the primary operation, min)

  • C2 Was the biomodel used intra-operatively for this patient? (Yes/No)

    • C2.1 How would you compare the use of this biomodel intra-operatively to other visualisation modalities with respect to (a) your diagnosis, (b) your surgical plan, (c) communication between members of the surgical team? (Much Worse, Worse, Same, Better, Much Better)

  • C3 Was the biomodel sterilised? (Yes/No)

    • C3.1 How was the biomodel sterilised? (Autoclave, Liquid Sterilised, ETO, Plasma, Gamma radiation, Other)

  • C4 To what extent were intra-operative findings accurately represented by the biomodel? (Totally different, Somewhat different, Similar, Almost the same, Exactly the same)

  • C5 How many times were the following modalities used intra-operatively? (a) Biomodel. (b) Other visualisation modalities. (0,1–2,3–5,6–10,10+)

  • C6 Did the use of the biomodel have an effect on the time it took to perform the surgical procedure (compared to not using a biomodel)? (Yes/No)

    • C6.1 What effect did the use of the biomodel have? (a) Estimated reduced time in min. How? (b) Estimated increased time in min. How? Was the increase justified? (Yes/No)

  • C7 How does the accuracy of the biomodel compare to that needed for this type of procedure? (Much less than needed, Less than needed, Adequate, More than needed, Much more than needed)

Part D: Outcomes

  • D1 In comparison to other visualisation modalities, how did the use of the biomodel affect (a) accuracy or quality of bone grafts, (b) accuracy or quality of osteotomy, (c) communication with colleagues, (d) communication with the patient, (e) degree of confidence during surgery? (Does not apply, Much less, Less, Same, More, Much more)

  • D2 In comparison to other visualisation modalities, how did the use of the biomodel change the outcome of this procedure? (Much worse, Worse, Same, Better, Much Better, Unachievable without the biomodel)

  • D3 How would you rate the usefulness of the biomodel? (Misleading, No real use, Useful, Very useful, Essential)

  • D4 What effect do you think the biomodel had on the total cost of this procedure? (Significantly higher cost, Higher cost, Same cost, Lower cost, Significantly lower cost) Why?

  • D5 To what extent do you think patient care was affected by the use of the biomodel? (Much worse, Worse, Same, Better, Much Better)

  • D6 Did the use of the biomodel affect your estimate of the total number of surgical interventions that will be needed for this patient (compared to that made using other visualisation modalities)? (No/More/Fewer)

    • D6.1 If more, more surgical interventions will be needed because (a) the biomodel indicated the problem was more complex than indicated by other visualisation modalities, (b) the biomodel indicated that the problem was more widespread than indicated by other visualisation modalities, (c) other.

    • D6.2 If fewer, fewer surgical interventions will be needed because (a) the biomodel indicated the problem was less complex than indicated by other visualisation modalities, (b) the biomodel indicated that the problem was less widespread than indicated by other visualisation modalities, (c) the use of the biomodel allowed a number of interventions to be combined into one procedure, (d) other.

  • D7 What were the three most important outcomes arising from the use of the biomodel?

Part E: General

  • E1 What were your reasons for using a biomodel for this case? (a) Visualisation aid (to improve diagnosis, to improve surgical planning, to obtain informed patient consent). (b) Preoperative action (to simulate surgery preoperatively, to prepare an implant preoperatively, to prepare a template for resections). (c) For intra-operative reference. (d) Other.

  • E2 How much did the use of a biomodel for this patient affect the choice of materials, instruments or devices used or made available during surgery? (Not at all, Slightly, Moderately, Significantly, Extremely) How?

  • E3 Rate the most useful (1) to least useful (6) visualisation modalities used (a) preoperatively, (b) intra-operatively? (Frameless stereotaxy, X-ray, 2D CT, 3D CT, 2D MRI, 3D MRI, Biomodel)

  • E4 How did the biomodel compare to other visualisation modalities for the following? (a) Detection of the problem, (b) localisation of the problem, (c) diagnosis of the problem, (d) rectification of the problem. (Significantly inferior, Not as useful, Same, More useful, Provided unique info)

  • E5 Rank from most important (1) to least important (8) the importance of the following attributes in making your decision to use a biomodel for this patient. (Hardness, Density, Colour, Translucency, accuracy, Can sterilise, Price, Delivery time)

  • E6 Who will meet the cost of the biomodel? (Patient, Surgeon, Hospital, Insurance, Other)

  • E7 When treatment of this patient is completed, who will keep the biomodel? (Patient, Surgeon, Hospital, Other, Unsure)

  • E8 If another patient required similar surgery, would you use a biomodel again? (Yes/No) Why?

  • E9 In what ways could the biomodel be improved?

Appendix 2

Table 2

Table 2 Tumour subgroup detailing the surgical procedure, follow-up, results and complications
Full size table

Appendix 3

Table 3

Table 3 Spinal deformity subgroup detailing the surgical procedure, follow-up, results and complications
Full size table

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Izatt, M.T., Thorpe, P.L.P.J., Thompson, R.G. et al. The use of physical biomodelling in complex spinal surgery. Eur Spine J 16, 1507–1518 (2007). https://doi.org/10.1007/s00586-006-0289-3

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