Cone-beam CT with a flat-panel detector on a mobile C-arm: Pre-clinical investigation in image-guided surgery of the head and neck

A promising imaging platform for combined low-dose fluoroscopy and cone-beam CT (CBCT) guidance of interventional procedures has been developed in our laboratory. Based on a mobile isocentric C-arm (Siemens PowerMobil) incorporating a high-performance flat-panel detector (Varian PaxScan 4030CB), the system demonstrates sub-mm 3D spatial resolution and soft-tissue visibility with field of view sufficient for head and body sites. For preclinical studies in head neck tumor surgery, we hypothesize that the 3D intraoperative information provided by CBCT permits precise, aggressive techniques with improved avoidance of critical structures. The objectives include: 1) quantify improvement in surgical performance achieved with CBCT guidance compared to open and endoscopic techniques; and 2) investigate specific, challenging surgical tasks under CBCT guidance. Investigations proceed from an idealized phantom model to cadaveric specimens. A novel surgical performance evaluation method based on statistical decision theory is applied to excision and avoidance tasks. Analogous to receiver operating characteristic (ROC) analysis in medical imaging, the method quantifies surgical performance in terms of Lesion-Excised (True-Positve), Lesion-Remaining (False-Negative), Normal-Excised (False-Positive), and Normal-Remaining (True-Negative) fractions. Conservative and aggressive excision and avoidance tasks are executed in 12 cadaveric specimens with and without CBCT guidance, including: dissection through dura, preservation of posterior lamina, ethmoid air cells removal, exposure of peri-orbita, and excision of infiltrated bone in the skull base (clivus). Intraoperative CBCT data was found to dramatically improve surgical performance and confidence in the execution of such tasks. Pre-clinical investigation of this platform in head and neck surgery, as well as spinal, trauma, biopsy, and other nonvascular procedures, is discussed.