Application accuracy in frameless image-guided neurosurgery: a comparison study of three patient-to-image registration methods

Object. The aim of this study was to compare three patient-to-image registration methods in frameless stereotaxy in terms of their application accuracy (the accuracy with which the position of a target can be determined intraoperatively). In frameless stereotaxy, imaging information is transposed to the surgical field to show the spatial position of a localizer or surgical instrument. The mathematical relationship between the image volume and the surgical working space is calculated using a rigid body transformation algorithm, based on point-pair matching or surface matching. Methods. Fifty patients who were scheduled to undergo a frameless image-guided neurosurgical procedure were included in the study. Prior to surgery, the patients underwent either Computerized tomography (CT) scanning or magnetic resonance (MR) imaging with widely distributed adhesive fiducial markers on the scalp. An extra fiducial marker was placed on the head as a target, as near as possible to the intracranial lesion. Prior to each surgical procedure, an optical tracking system was used to perform three separate patient-to-image registration procedures, using anatomical landmarks, adhesive markers, or surface matching. Subsequent to each registration, the target registration error (TRE), defined as the Euclidean distance between the image space coordinates and world space coordinates of the target marker, was determined. Independent of target location or imaging modality, mean application accuracy (+/- standard deviation) was 2.49 +/- 1.07 mm when using adhesive markers. Using the other two registration strategies, mean TREs were significantly larger (surface matching, 5.03 +/- 2.30 mm; anatomical landmarks, 4.97 +/- 2.29 mm; p < 0.001 for both). Conclusions. The results of this study show that skin adhesive fiducial marker registration is the most accurate noninvasive registration method. When images from an earlier study are to be used and accuracy may be slightly compromised, anatomical landmarks and surface matching are equally accurate alternatives.