The present disclosure relates to brain surgery and more specifically to the field of trajectory array guides for placement of surgical tools used for delivery of therapeutic agents or measurement devices to specific locations in the brain.
Precise access to brain structures is frequently required for an assortment of indications, including tissue sampling, catheter or electrode placement, and localized drug delivery. The most common means of performing these procedures is to use either frame based or frameless stereotaxy. In either case, a preoperative imaging session is performed to characterize and localize the specific brain target. Magnetic resonance imaging (MRI) is the preferred technique for preoperative demarcation of brain structures due to the quality and range of tissue contrast that can be achieved. Utilization of previously acquired imaging information during surgery requires some system for registering the image data to the patient on the operating table. This may be achieved with an external frame that is visible on imaging or the identification of implanted markers or characteristic features in the frameless case. In either situation, target points are determined based on the previously acquired images and are used to guide the surgical procedure. This has disadvantages, as the registration process is imperfect and prone to error, and there is no ability to update the images to compensate for dynamic effects such as brain shift. Moreover, there is no opportunity to either confirm that the surgical goals have been met or to monitor deposition of a delivered therapeutic agent, physiological change or instrument operation during the procedure (Martin et al. J. Magn. Reson. Imaging, 2008, 27, 737-743).
An alternative to this traditional means of accessing brain structure is to immobilize the patient's head during imaging and perform the surgery within the magnetic resonance bore. This approach also has obvious disadvantages, most notably the physical presence of the magnet and the corresponding magnetic field. However, it overcomes the need for registration and permits intraprocedural image updates. It also may provide novel insight into the guidance, administration, and evaluation of interventions and therapies. There are several different means of performing stereotactic procedures within an MRI system. Lower field, open systems, afford some degree of line-of-site and therefore instruments can be tracked in a manner analogous to conventional frameless stereotaxy without moving the head out of the MRI system. The orientation of these tracked devices can further be used to prescribe the slice in which imaging is to be performed. In closed bore systems it is much less practical to track devices via optical means. The magnetic resonance environment itself, however, permits opportunities to track and visualize devices either by passive or active means. The latter is achieved by integrating microcoils into the appropriate surgical tools and tracking their position within the bore via MR methods. Passive methods simply require that the device be visible within acquired images either by positive or negative contrast.
Prospective stereotaxy is a technique for aligning a trajectory array guide within a magnetic resonance system. The general approach requires that a patient be immobilized within the magnetic resonance scanner and a trajectory array guide be mounted on a rigid surface such as the skull. Imaging is then performed to define the desired trajectory, usually in two orthogonal planes, from the entry point to the remote target. The trajectory array guide is aligned with real-time imaging followed by confirmatory scans to assure the intended path will be followed. This approach has been used to guide brain biopsy and the insertion of deep brain stimulator electrodes (Martin et al. J. Magn. Reson. Imaging, 2008, 27, 737-743).
The optimal trajectory is established by analyzing the magnetic resonance images of the brain, considering the location of the targeted segment of the brain, suitable entry point on the skull, and critical organs and vessels that need to be avoided (e.g. blood vessels) to minimize the risk of complications. Once the trajectory is established, a mounting system external to the head of the patient is used to position the catheter along the trajectory and guide the insertion of the catheter into the brain. This process tends to be iterative and involves image analysis of the actual trajectory of the mounting system versus the desired trajectory. Repositioning of the mounting system is typically required until the actual trajectory coincides with the desired trajectory.
A number of efforts have been made to develop trajectory array guide systems for delivery of elongated tools such as catheters to target locations in the brain. Examples of such systems and related tools are disclosed in U.S. Pat. Nos. 9,042,958, 8,845,665, 7,981,120, 8,845,656, and 8,591,522 and in published U.S. Patent Application Nos. 20150100064 and 20010014771, each of which is incorporated herein by reference in its entirety.
Many challenges remain with regard to development of trajectory array guide systems. A number of such challenges are addressed by various embodiments of the present disclosure.
The present disclosure provides a trajectory array guide system and kit as well as a method for delivering an elongated tool to a target location in the brain of a subject.
The present disclosure provides a trajectory array guide system for defining a trajectory to a target location in the brain of a subject and for guiding an elongated tool along the trajectory. In some embodiments, the trajectory array guide system includes: a combination of a base and an array guide in a lockable ball-socket pivoting mechanism, wherein the base is configured for attachment to the skull of a subject and the array guide is defined by a series of lumens or is defined by a bore configured to hold a separate array unit defined by a series of lumens; an imaging unit configured for engagement with the array guide and configured to hold and direct imaging fluid along passages which are co-axial with the lumens of the array guide for the purpose of defining a series of trajectories; and an elongated handle having sufficient length for connection to an image-guided stereotaxic navigation system, the handle configured for attachment to either the array guide or the imaging unit.
In some embodiments, the trajectory array guide system includes an array guide. In some embodiments, the array guide includes a ball component. In some embodiments, the trajectory array guide system also includes a base which includes a socket configured to receive and hold the ball of the array guide. In some embodiments, the socket has a central axis orthogonal to a plane formed by the bottom of the base. In some embodiments, the socket has a central axis which is non-orthogonal with respect to the plane formed by the bottom of the base, thereby providing a tilted socket. In some embodiments, the tilted socket increases the angle range of a series of trajectories. In some embodiments, the central axis of the socket is angled by about 10 to about 30 degrees from the axis orthogonal to the plane formed by the bottom of the base.
In some embodiments, the trajectory array guide system includes a socket which has an outer sidewall. In some embodiments, the outer sidewall includes threads or one or more grooves configured for attachment to a locking element. In some embodiments, the locking element prevents pivoting movement of a ball within the socket when the locking element is engaged to the outer sidewall of the socket. In some embodiments, the locking element is a ring-clamp configured for connection to the one or more grooves. In some embodiments, the locking element is a locking nut configured for connection to the threads.
In some embodiments, the trajectory array guide system includes a base which includes a plurality of attachment members. In some embodiments, the plurality of attachment members are accessible by an attachment tool for attaching the base to the skull of a subject.
In some embodiments, the trajectory array guide system includes an array guide which is a generally cylindrical or funnel-shaped member with openings at both ends, having a ball formed at one end and a series of lumens extending longitudinally along the length of the array guide between the openings at both ends. In some embodiments, the series of lumens includes seven substantially parallel lumens with six lumens arranged in a symmetrical hexagonal pattern and a seventh lumen located in the center of the symmetrical hexagonal pattern. In some embodiments, the trajectory array guide system further includes an imaging unit which includes an upper reservoir in fluid communication with a series of lower extensions which are co-axial with the lumens of the array guide. In some embodiments, the lower extensions are tubes configured to fit inside the lumens of the array guide. In some embodiments, the array guide includes an outer groove and the imaging unit includes an index tube configured to slide into the outer groove when the imaging unit is engaged with the array guide. In some embodiments, the index tube is provided as a reference point for identification of each of the tubes in magnetic resonance images. In some embodiments, the imaging unit includes a cap to seal the imaging fluid inside the imaging unit. In some embodiments, the array guide includes a locking mechanism for locking the tubes in place within the array guide. In some embodiments, the locking mechanism includes at least one set-screw which penetrates the array guide and makes tightening contact with at least one of the tubes. In some embodiments, the locking system includes three set-screws, each penetrating the body of the array guide to enter two different lumens as well as the seventh lumen. In some embodiments, the three set-screws are placed closer to the ball of the ball array guide than to the upper end of the ball array guide.
In some embodiments, the trajectory array guide system includes a handle. In some embodiments, the handle includes a connector end configured for attachment to the outside or the inside of an imaging unit. In some embodiments, the connector end is configured for attachment to the outside of the imaging unit and includes an opening for a connector set-screw to lock the handle on the imaging unit. In some embodiments, the handle includes an end spike for insertion into one of the lumens of a ball array guide for direct connection of the handle to the ball array guide. In some embodiments, the handle is at least partially hollow and has an outer end opening at the end opposite the end spike, the outer end opening configured for connection to a navigation pointer of an image guided surgery system.
In some embodiments, the trajectory array guide system includes a reducer tube for insertion into one of the lumens of an array guide. In some embodiments, the reducer tube provides a reduced diameter in the lumen for insertion of an elongated tool. In some embodiments, the reducer tube includes an adjustable stop for restraining movement of an elongated tool.
In some embodiments, the trajectory array guide system includes an array guide defined by a bore configured to hold a guide unit defined by a series of passages which are co-axial with the lumens of the array guide. In some embodiments, the guide unit includes an upper lock tab for connection of the guide unit to the array guide. In some embodiments, the trajectory array guide system includes an imaging unit configured for connection to the array guide at the upper lock tab. In some embodiments, the trajectory array guide system further includes a locking slider configured for insertion into the body of the guide unit to hold an elongated tool in place in one of the lumens.
In some embodiments, the trajectory array guide system includes an imaging unit engaged with a ball array guide. In some embodiments, the imaging unit includes a series of passages connected to a plenum located at about the center of rotation of the ball in a ball array guide. In some embodiments, the trajectory array guide system includes a handle with a channel for injecting imaging fluid into a central passage of the series of passages. In some embodiments, the imaging fluid flows through the central passage into the plenum, with subsequent upward filling of remaining passages of the series of passages via the plenum. In some embodiments, the passages are seven substantially parallel passages with six passages arranged in a symmetrical hexagonal pattern around the central passage. In some embodiments, one of the six passages is extended downward past the plenum for providing an index passage for identification of individual passages.
The present disclosure provides a method for delivering an elongated tool to a target location in the brain of a subject. In some embodiments, the method includes: a) providing a trajectory array guide system which includes a base plate, an array guide, an imaging unit, a handle and an image-guided stereotaxic navigation system connected to the handle; b) performing a craniotomy at an entry location; c) connecting the base of the trajectory array guide system to the entry location and engaging the array guide with the base plate; d) engaging the imaging unit with the array guide and aligning the array guide to the target; e) imaging a series of trajectories towards the target location with magnetic resonance imaging; f) locking the trajectory array guide system and selecting a trajectory from the series of trajectories: g) removing the imaging unit and delivering the elongated tool to the target location using the selected trajectory; and h) removing the trajectory array guide system from the skull of the subject. In some embodiments, the base of the trajectory array guide system is connected to the entry location using bone screws through bottom tabs in the base. In some embodiments, the method includes adding MRI contrast imaging reagent to the imaging unit before the step for imaging the series of trajectories. In some embodiments, the method includes using the stereotaxic navigation system to orient the series of trajectories toward the target location. In some embodiments, the elongated tool is a catheter. In some embodiments, the catheter is configured to deliver a drug to the target location.
In some embodiments, the method for delivering an elongated tool to a target location in the brain of a subject uses a trajectory array guide system of the present disclosure.
The present disclosure provides a kit for assembling a trajectory array guide system. In some embodiments, the kit includes: a base and an array guide which can be connected to form a lockable ball-socket pivoting mechanism, wherein the base is configured for attachment to the skull of a subject, and wherein the array guide is defined by a series of lumens or is defined by a bore configured to hold a separate guide unit defined by a series of lumens; an imaging unit configured for engagement with the array guide and configured to hold and direct imaging fluid along axes which are co-axial with the lumens for the purpose of defining a series of trajectories; and an elongated handle having sufficient length for connection to an image-guided stereotaxic navigation system, wherein the handle is configured for attachment to either the array guide or the imaging unit.
In some embodiments, the kit further comprises instructions for assembly of the array guide system.
In some embodiments, the kit further comprises a container of imaging reagent.
In some embodiments, the kit is for assembly of a trajectory array guide system of the present disclosure. In some embodiments, the trajectory array guide system includes a guide unit for insertion into the bore of the array guide. In some embodiments, the kit includes a plurality of guide units configured for guiding elongated tools of different diameters. In some embodiments, the elongated tools include a catheter.
In some embodiments of the kit, all components of the trajectory array guide system are contained in one or more sterilized packages.
The present disclosure provides trajectory array guide system which can function to provide or assist with the stereotactic guidance, placement and fixation of surgical instruments or devices during the planning and operation of neurological procedures performed in conjunction with preoperative and perioperative MR imaging. In some embodiments, the procedures can include laser coagulation, biopsies, catheter placement, or electrode placement procedures.
The present disclosure describes embodiments of a trajectory array guide system which is configured to address a number of shortcomings of known trajectory array guide systems. For example, many such trajectory array guide systems currently in use or under active investigation for use in clinical settings tend to be large, cumbersome and have many separate parts which may be expensive to manufacture and which are prone to damage. Such systems tend to have complicated mechanisms for altering and locking the trajectory paths and as such, tend to require more time to make adjustments than is desirable. In some instances, a contributing factor is that trajectory array guide systems are used while a patient is placed in an MRI system outside of an operating room. This situation increases risk of infection and it is thus desirable to complete the surgical procedure as quickly as possible to minimize patient transportation. It is desirable to have the capability to complete the mounting of the trajectory array guide system and establish an optimal locked trajectory within less than one hour.
The present presents embodiments of a trajectory array guide system as well as methods and kits to address these and other disadvantages of presently known systems.
As used herein, the term “array guide” refers to a component used to create a series of images of trajectories for insertion of an elongated tool into the brain of a subject and for guiding a path for the elongated tool. The array guide can be adjustable to adjust the angles of the trajectories. The array guide may have an array of lumens formed in its body or alternatively be provided with a wide bore configured for insertion of one or more separate units for creating the trajectories for imaging and guiding of the elongated tool.
As used herein, the term “ball array guide” is an array guide having a ball formed at one end for the purpose of creating a pivoting ball and socket joint for adjustment of the angles of the trajectories.
As used herein, the terms “cannula” and “catheter” are considered synonymous, each referring to a tube constructed for insertion into the body for surgical treatment or for delivers of an external substance or extraction of an internal substance.
As used herein, the term “imaging fluid” refers to a fluid having properties for providing contrast images under a mode of analysis such as magnetic resonance imaging, for example. This term is synonymous with the term “MRI contrast agent.” The most commonly used imaging fluids in magnetic resonance imaging include gadolinium-based compounds.
As used herein, the term “imaging unit” refers to a component intended for use with an array guide for the purpose of directing imaging fluid to generate images representing an array of trajectories.
As used herein, the term “image-guided stereotaxic navigation” indicates that images generated by an imaging technology such as magnetic resonance imaging, for example, are used to guide stereotaxic navigation.
As used herein, the term “lumen” refers to an opening or cavity within a body of a system component. More specifically, this term is used to identify channels of an array in an array guide which are provided for guiding the insertion of an elongated tool.
As used herein, the term “passage,” like the term “lumen” above refers to an opening or cavity within a body if a system component. More specifically, this term is used to identify channels of an array in an array guide which are provided to deliver imaging fluid to provide trajectory images.
As used herein, the term “plenum” refers to an open space within an otherwise solid body.
As used herein, the term “stereotaxic navigation” refers to provision of three-dimensional navigation within a surgical site using a three-dimensional coordinate system to locate targets within the body and to perform an action such as ablation, biopsy, lesion, injection, stimulation, implantation, radiosurgery or any other surgical procedure.
As used herein, the term “trajectory” refers to a potential pathway. More specifically herein, the term is used to identify potential pathways for insertion of a catheter or cannula into the brain.
Overview of One Embodiment of a Ball Trajectory Array Guide System
The present description presents a ball trajectory array guide system with reference to
A magnified perspective view of the trajectory array guide system 10 is shown in
The base plate 50 can include a hollow cup-shaped interior (not shown) acting as a socket to receive the ball 21 of the ball array guide 20. The socket may be designed to provide resistance to the ball such that the array will only move under an externally applied force. One of the advantages of using a ball and socket arrangement is that the socket holds the array in an unlocked state and requires intentional force to adjust the trajectory.
The interior of the ball array guide 20 can include a series of parallel channels or lumens (not shown) which are parallel to the main axis of the ball array guide 20. These parallel channels or lumens can establish an array of parallel trajectories for an elongated surgical instrument, such as a catheter, to enter the brain on a selected trajectory and to reach a desired target location within the brain for delivery of a drug.
The ball-and-socket arrangement allows pivotable movement of the stem 22 of the ball array guide 20. A locking nut 330 with inner threads is provided in this embodiment to be threaded and tightened against outer threads of the base plate 50. Engagement of the locking nut 330 with the out threads of the base plate 50 can compress the socket and prevent pivoting motion of the ball array guide 20 when the desired orientation of the stem is attained.
Also seen in
The locking nut 130 is passed over the ball array guide 120 and fixed to the upper portion of the outer sidewall of the base plate 150 to lock the orientation of the ball array guide 120. Before or after this step, the imaging unit 60 may be connected to or engaged with the ball array guide 120. The lower portion of the imaging unit 60 has a series of tubes generally labelled in
In certain modes of operation, the trajectory array guide system 11 uses the imaging unit 60, In certain modes of operation, the trajectory array guide system 11 does not use the imaging unit 60. In certain modes of operation, both modes (with and without imaging unit 60) will be employed at different points during the procedure.
The connector 41 of the handle 40 is placed over the top of the inserted imaging unit 60 (or without the unit 60 in place) and fixed to the top portion of the ball array guide 120 by threading or another connection mechanism.
As noted above, MRI images of the patient's brain are obtained to guide the overall procedure. Surgical planning is performed by the surgeon using preferred planning software to pre-plan entry sites and catheter trajectories to the target locations in the brain. In addition, MRI systems typically include software for 3D reconstruction of the images and further image analysis including dimensional analysis to obtain locations, dimensions, planes, and trajectories for catheter insertion to the target location. Standard image-guided stereotactic platforms available to neurosurgeons in combination with software provided by the manufacturer are used to guide the entire procedure. From the analysis of the MI scans the following dimensions and landmarks are identified: target location(s): entry point on the skull; a preferred trajectory from the entry point to the target location(s); and insertion depth, which is defined as the distance from the entry point to the target location(s).
The entry point and trajectory are selected to avoid potential damage to blood vessels and brain sections by the catheter. In some cases, the trajectory is chosen to allow for multiple injections into the target along the pathway of the catheter as illustrated in
In some embodiments, components of a trajectory array guide system are sterilized. Suitable sterilization methods for the components include high heat, steam, ethylene oxide or radiation such as gamma sterilization. In some embodiments, components of a trajectory array guide system are made of medical grade materials, including medical grade plastics, medical grade polymers, and medical grade metals. Specific examples of medical grade materials include, but are not limited to: medical grade polyether ether ketone (PEEK); medical grade silicon, medical grade steel (such as medical grade stainless steel); and medical grade aluminum.
Overview of Operation of One Embodiment of the Trajectory Array Guide System
The present disclosure provides a system and method for delivering n elongated tool to a target location in the brain of a subject which uses a trajectory array guide system of the present disclosure. An example describing the operation of a trajectory array guide system 11 is presented with reference to components illustrated in
A patient receives general anesthesia in preparation for the procedure. A head stabilization system is used to avoid head motion during the procedure. The placement of the trajectory array guide system 11 is performed in a sterile environment in a surgical operating room or a hybrid operating room with MRI capabilities. The head is shaven and the desired entry point is marked. The incision site is draped and a skin flap is created with a scalpel to expose the skull for placement of the trajectory array guide system 11. A craniotomy C can be made either at this time (see
Once a suitable orientation of the trajectory array guide system 11 is established, it is lowered to the surface of the skull and the base plate 150 is secured onto the skull by securing up to four bone screws into the four holes 152a-d of the tabs 151a-d of the base plate 150. If a craniotomy was not previously made, the upper portion of the trajectory array guide system 11 including the handle 40 is removed from the socket of the base plate 150 to allow access through the base plate 150 to make a burr hole in the skull according to known surgical procedures. The trajectory array guide system 11 is then reattached to the base plate 150 with proper alignment confirmed by the stereotactic navigation system. The locking nut 130 is then tightened to preserve the orientation and prevent any further movement between the system components. The handle 40 is disconnected from the stereotactic navigation system and removed, as shown in
As an alternative workflow, it is envisioned that the entire procedure could be performed within an MRI scanner without use of an alternative imaging system to align the trajectory array guide system 11. Some alternative navigation system, or MRI sequences, will be needed to identify the entry point for attachment of the base plate but alignment of the trajectory array guide system 11 would be performed entirely as described below for refinement of the trajectory.
MRI scans of the patient's brain are performed to confirm that the correct entry point and trajectory have been established.
When the optimal trajectory is confirmed, the imaging unit 60 is removed from the ball array guide 120. From the MRI images the initial and maximum depth of insertion of the catheter 170 is measured using the base of the reservoir of the imaging unit 60 as the datum (a correction equal to the thickness of the imaging unit base must be made). A depth insertion-stop 171 is mounted on the drug delivery catheter 170 at a distance from the tip of the catheter 170 equal to the maximum insertion depth as shown in
The trajectory array guide system 11 is removed from the skull by removing the bone screws. The wound is closed using standard surgical techniques.
One embodiment of a procedure sequence will now be briefly outlined. This procedure sequence assumes that the entire system 11 may be assembled prior to mounting to the skull of the subject.
First the entire trajectory array guide system 11, including the imaging unit 60 and the handle 40, is assembled. Then a surgical navigation system is connected to the handle 40. The entry location on the skull is identified and a craniotomy C is performed to expose the entry location. Then the base plate 150 is connected to the skull. The handle 40 is removed to add imaging reagent IR to the trajectory array guide system 1ii. MRI scans are then performed to view the projected trajectories T and the optimal trajectory OT is selected. The handle 40 is reattached to facilitate additional manipulation of the optimal trajectory OT, if required. The imaging unit 60 is then removed with confirmation that the selected optimal trajectory OT remains locked in place. The catheter procedure is performed using the optimal trajectory OT and then the system 11 is removed from the subject.
In some embodiments, the screw holes of the base plate can be directly accessed by a screwdriver during the process of assembly and disassembly.
Commonly used magnetic resonance imaging has a spatial resolution of about 1 mm. Therefore, in some embodiments, the trajectories in the array are spaced between about 1 mm to about 3 mm apart; between about 1.5 mm to about 2.5 mm apart; about 2 mm apart; about 2.15 mm apart; about 2.25 mm apart; or about 2.35 mm apart.
Base Plate and Locking Nut Combination
In certain embodiments, a trajectory array guide system can be assembled prior to mounting onto a skull. In certain embodiments, the trajectory array guide system provides unobstructed access to the screw holes in the base plate to place the bone screws. The images in
In
In
In
In
Tilted Base Plate
In certain procedures, it is favorable to enter the skull at angles of up to about 45 degrees from the central orthogonal axis of a base plate.
For comparison.
In some embodiments, a base plate of the present disclosure can have a bore diameter of between about 20 mm to about 50 mm, between about 30 mm to about 40 mm, or a bore diameter of about 35 mm.
In some embodiments, a kit of the present disclosure includes a trajectory array guide system which includes only a tilted base plate. In some embodiments, the trajectory array guide system includes only a flat base plate.
Locking Nut Modifications and Alternatives
In some embodiments, a ball locking mechanisms can use radial inward compression of the base plate socket to lock the ball of the ball array guide into the socket. In some embodiments, the inward compression of the socket does not create any motion between the parts that could misalign the ball array guide.
In some embodiments, the ring clamp has a low profile which increases the maximum deflection angles of the trajectory array from the centerline. In some embodiments, the ring clamp has a low profile which allows direct access to the screw holes without the need to extend the footprint of the base plate.
Embodiments of the present disclosure describe trajectory array guide systems which generally include a ball unit configured to fit into a socket of a base plate. In some embodiments, a trajectory array guide system can be reconfigured to include a base plate having a ball unit and an array guide having a socket configured to receive the ball unit of the base plate.
Handle
In some embodiments, the orientation of the ball array guide and corresponding series of parallel trajectories is facilitated by a commercially available MRI or CT image-guided navigation system. In some embodiments, a handle can be used to connect the ball array guide with a navigation system. The handle can be engaged directly with the ball array guide. The handle can also be engaged with an imaging unit connected to the ball array guide.
In some embodiments, the handle has a total length of between about 12 to about 18 cm. In some embodiments, the arm portion of the handle has a diameter of between about 6 to about 10 mm.
In some embodiments, the handle is similar to the embodiment of
Imaging Unit
An imaging unit can be configured for connection to or engagement with a ball array guide and a handle. In some embodiments where the ball array guide uses an offset index tube (such as tube 66 of
In some embodiments, the process of using the imaging unit 360 to produce images for calculation of trajectories to an identified target in the brain will include insertion of tubes 465a-g and 466 into each of the passages 361a-g and 362 of the imaging unit 360, followed by attachment of the imaging unit 360 to the upper end of the ball array guide 620 with the tubes 465a-g and 466 extending into the corresponding lumens 625a-g and outer groove 624.
Ball Array Guide and Lumens
In some embodiments, the ball array guide provides for the placement and accuracy of a catheter. The catheter is passed through a selected lumen of the ball array guide to reach a target. To allow for smooth insertion, the array guide can provide sufficient clearance between the outer diameter of the catheter and the inner diameter of each lumen of the trajectory array. The accuracy of catheter placement can be increased by increasing the length of the lumens. In some embodiments, a ball array guide and corresponding lumens have a length between about 30 mm to about 60 mm, between about 40 mm to about 50 mm, or a length of about 45 mm. In some embodiments, a ball array guide includes two parts each having a defined length that are bonded together. Such a combination of parts could be machined, 3D-printed parts, or molded parts.
The openings of the lumens 625a-g are at a flat bottom part 628 of the ball. Near the top of the stem are three set-screw holes 627a-c for insertion of set screws (not shown) to fix tubes of an imaging unit (not shown) engaged with the ball array guide.
Embodiments of a Trajectory Array Guide System
The president disclosure illustrates how compatible components can be assembled in different combinations to produce various embodiments of a trajectory array guide system.
Imaging unit 360 is attached to the top of the stem 222, The center passage 361g and the index passage 362 of the imaging unit 360 are aligned with the center lumen 225g and the outer groove 224 of the ball array guide 220 (the tubes are omitted in an effort to preserve clarity). The cap 364 of the imaging unit 360 is engaged with the top of the imaging unit to isolate the reservoir 363. Handle 140 is engaged with the outer circumference of the imaging unit 360 and a set screw (not shown) can be used to lock the connector 141 of the handle 140 via the opening 143 in the sidewall of the connector 141. Arm 142 extends outward from the connector 141,
Embodiments of a Trajectory Array Guide System with Separate Imaging Units and Guide Units
In some embodiments, a trajectory array guide system can include an array guide in the form of a wide bore sleeve (instead of a series of lumens). This wide-bore array guide includes a ball joint for connection to a base plate. The bore of the array guide is configured to receive an imaging unit and a matched array catheter guide unit (i.e. the arrangement of imaging unit passages and catheter guide unit lumens are matched such that trajectory images generated by the imaging unit will be co-axial with the lumens in order to ensure that the pathway followed by the catheter matches the selected trajectory). This embodiment of a trajectory array guide system provides a capability to provide independent diameter sizing of the lumens used for imaging (i.e. containing imaging reagent) and the lumens used for guiding the catheter. This embodiment also provides for height alignment of the top of the catheter guide lumens with the bottom of the top imaging chamber. This embodiment can provide more reliable general alignment of components while being less delicate than embodiments using an imaging unit with imaging trajectory tubes. In general terms, the ball portion of the array guide of this embodiment is expected be larger than the ball portion of other embodiments described herein. The use of a ring-clamp as a locking mechanism is particularly amenable for use with trajectory array guide systems having separate imaging array and catheter array units because it allows greater angles of tilting of the array guide.
One embodiment of a trajectory array guide system is shown in
An example describing the operation of a trajectory array guide system is presented with reference to components illustrated in
The system is assembled with the array guide 90 connected to a base plate, such as base plate 450 for example, and with the imaging unit 960 inserted and locked into the bore 92 of the array guide 90 using the lock bolt 95a. The imaging reagent contained within the passages 961a-g and 962 is used to visualize the series of trajectories towards the target and the optimal trajectory is selected. With the array guide 90 locked in place in the base plate 450, the imaging unit 960 is removed and the catheter guide unit 920 is inserted into the bore 92 of the array guide 90 and locked in place using the lock bolt 95a. The locking slider 926 is placed in the catheter guide unit 920 and held in place using lock bolt 95b to retain the catheter in place in the selected lumen which represents the selected optimal trajectory.
Trajectory array guide systems which include a funnel-shaped array guide and corresponding funnel-shaped units can have advantages over other embodiments of the trajectory array guide system. For example, the array of tubes of imaging units can be difficult to insert into corresponding lumens of a ball array guide. There is also a manufacturing challenge in sealing tubes to an imaging unit. There can also a degree of movement between the ball array guide and the tubes which cause a degree of flexure of the system when a handle is connected. In addition, a reducer (see for example reducer 70 in
Trajectory Array Guide System with Alternative Imaging Fluid Injection Path and Handle Connection
This trajectory array guide system 18 includes base plate 450 with its tilted socket and a ring clamp 80. This base locking combination is used to retain an embodiment of a ball array guide 290 which like the ball array guide 90 of
In this embodiment, the handle 340 is provided with an injection passage 348 along the axis of the arm 342 through to the connector 341 which fits into a cavity in the upper chamber 663 of the imaging unit 660. The injection passage 348 in the arm 342 of the handle 340 is for injection of imaging fluid via a port (not shown) in the arm 342. The port may be located at any position along the arm 342 of the handle 340 as long as imaging fluid may be effectively injected into the injection passage 348. When continuously injected, the imaging fluid moves down the injection passage 348 and enters the center passage 661g. When the injected imaging fluid reaches the plenum 669, the imaging fluid then disperses in the plenum 669 and fills the remaining passages 661a-f from the bottom upwards. The imaging fluid also fills the lower extension 661a′ of passage 661a. In this manner, all passages 661a-g are appropriately filled with imaging fluid for identification of the array of parallel trajectories. The lower passage extension 661a′ is easily identified and distinguished from the remaining passages under magnetic resonance imaging and serves as an index image for identification of the trajectory images (this would otherwise be impossible due to the symmetrical hexagonal arrangement of the passages 661a-g). This arrangement obviates the need for an eighth passage used as an index passage as in the previous embodiments.
As a result of this arrangement of features, all passages 661a-g and 661a′ can be filled with imaging fluid via a port (such as a Luer taper injection port) in the handle 340 which is conveniently accessible (see for example,
In some embodiments, the connector 341 of the handle 340 slides into the upper chamber 663 of the imaging unit. This provides an improved sealing arrangement and eliminates the need for a cap for the imaging unit 660. An alternative of this embodiment is an arrangement where the handle 340 is bonded or integrally formed with the upper chamber of the imaging unit 660 during manufacture. This could allow the entire assembly of the imaging unit 660 with the monolithically formed handle 340 to be discarded with the imaging fluid contained therein.
The handle is provided with distance markers (markers 349a-c are shown in this partial view and more would be visible in a complete illustration of the handle 340) which indicate the distance from the center of rotation of the ball 291. This feature provides a means of identifying sideways movement of the handle 340 at a given distance from the center of rotation of the ball 291, which creates a known opposite movement of a trajectory of the same length as that distance.
Trajectory Array Guide System Having Separate Imaging Unit and Guide Units with Slanted Arrays
A trajectory array guide system can include a funnel-shaped ball array guide which includes matched arrays of lumens and imaging passages which are angled with respect to the longitudinal axis of the ball array guide. Such angled or slanted arrays may be designed to expand the range of possible trajectories outside of the typical straight array in which all lumens and passages are aligned with the longitudinal axis of the array guide. This can create a “footprint” three times the size of the single straight array. The advantage of this approach is that the ball-joint can remain in the locked position (i.e. adjustments of the ball-joint are not required). A single slanted imaging array could provide a wide range of additional trajectories arranged circumferentially around the central array when locked in various positions.
The placement of the single lock tab 1169 of the imaging unit (with locking using lock bolt 595a) in a position other than the index position shown in
The catheter guide unit 1120 also includes a locking slider 1126 with openings 1128a-g for locking a catheter in place within one of the selected lumens 1125a-g, This locking slider 1126 is shown by itself in a top view in
As noted hereinabove,
In accordance with the angular direction of the passages 1161a-g and lumens 1121a-g away from the index lock tab 593a (12:00 position), it is understood that the trajectories are directed in the opposite direction (towards the 6:00 position). Therefore, according to this arrangement, it is seen in
The use of ball array guide 590 may be combined with imaging units and catheter guide units with straight arrays such as those illustrated in
Trajectory Array Guide System with Alternative Handle for Connection to Navigation Pointer for Image-Guided Surgery
An embodiment of a trajectory array guide system 19 is shown in
In some embodiments, the position and orientation of a trajectory array guide system can be tracked by an image guided neuronavigational system via instrument trackers clamped to a handle or array guide. In certain embodiments, the trajectory array guide system will have general compatibility with image guided surgery systems including, but not limited to, Varioguide™ and StarLINK™ (Brainlab, AG, Munich, Germany), as well as Vertek™ and SureTrak™ (Medtronic).
Kits
The present disclosure provides kits for assembly of various embodiments of the trajectory array guide system of the present disclosure. In some embodiments, components of a kit may be separately packaged or packaged together in any configuration rendering a package suitable for sterilization. Steam, ethylene oxide, or gamma sterilization are preferred sterilization methods for the kits.
In some embodiments, the kit includes instructions for assembly of a trajectory array guide system.
In some embodiments, the kit includes the following: instructions for assembly of a trajectory array guide system; a container of imaging reagent; and one or more catheters which are compatible with the trajectory array guide system.
In some embodiments, the kit includes multiple imaging units or guide units for insertion into an array guide. In some embodiments, the kit includes a plurality of separate array units or reducers configured for guiding elongated tools of different diameters.
Base plates resembling base plate 550 of
The base plates were held in a vise at one of the attachment tabs. A ball array guide resembling the ball array guide 220 in
The ring-clamp embodiment (similar to base plate 450 in combination with ring clamp 80 of
A gadolinium-based contrast solution is prepared by aspirating a gadolinium-based contrast agent into a 0.3 mL syringe. 0.04 mL of the gadolinium-based contrast agent is injected into a 10 mL pre-filled sterile saline syringe. A 2.0 to 5.0 inch, 25- to 30-gauge needle is attached to the sterile saline syringe and inverted multiple times to ensure mixing of the contrast agent with the sterile saline.
An imagining cartridge is provided which includes 7 imaging tubes in a symmetrical hexagonal pattern and an additional reference imagining tube. The 10 mL syringe containing the gadolinium imaging solution is used to sequentially fill the lumen of each tube by injecting imaging solution into the tube. The tip of the syringe is placed at the bottom of the tube, and the injection begins from the bottom of the tube. To ensure optimum MR visibility of the imaging cartridge tubes, the injection of the gadolinium imaging solution is continued while the syringe is slowly withdrawn from the tube, thereby preventing air from re-entering the tube. Each tube is visually inspected for air bubbles. If air bubbles are observed, the needle is reinserted to the base of the tube and additional gadolinium imaging solution is injected to push out the air bubbles.
Once all tubes have been filled with the gadolinium imaging solution, a reservoir at the top of the imaging cartridge is filled. An O-ring and sealing cap are then engaged with the top opening of the imaging cartridge to seal the imaging solution into the cartridge.
A trajectory array guide system resembling the system shown in
A component of an image guided surgery system, such as an instrument tracker, is attached to the handle of the trajectory array guide system in a manner resembling the configuration shown in
The trajectory array guide system can then be adjusted as necessary, with the tension screw of the ring clamp being fully tightened once the system has been properly aligned.
A trajectory array guide system resembling the system shown in
A component of an image guided surgery system, such as an instrument tracker, is attached directly to a guide array of the trajectory array guide system, similar to the configuration shown in
The trajectory array guide system can then be adjusted as necessary, with the tension screw of the ring clamp being fully tightened once the system has been properly aligned.
A cranial entry point is identified using image guided neuronavigational systems and MRI scans. The target head area is prepared for cranial entry according to standard medical practice, including cleaning and shaving the scalp around the cranial entry point. A craniotomy is conducted using standard surgical procedures to form a cranial entry at least 14 mm diameter at the planned cranial entry site.
A trajectory array guide system is provided, such as the system described in Example 3. The base plate is placed against the skull at the cranial entry point, with the bore of the base plate being located directly over the cranial entry hole. The base is rotated to a suitable orientation for attachment to the skull and to ensure that the tilt of the base is aligned with the surgical target. The base is then attached to the skull using self-drilling titanium bone screws through the holes on the base feet. The ring clamp and array guide are rotated and adjusted as necessary to provide access to the screw holes.
A trajectory array guide system attached to a skull is provided, such as the arrangement described in Example 5.
The ring clamp is maintained in a loose position to allow the array guide to be freely rotated and adjusted as necessary. Using standard surgical procedures, an image guided surgery system is used to align the array guide in the direct of the surgical target. The trajectory and position of the array guide is then secured by gently hand-tightening the tension screw of the ring clamp.
A surgical probe is used to measure the distance from the top of the array guide to the surgical target, thereby providing the necessary insertion depth of the surgical instrument.
An imagining cartridge, such as the imaging cartridge prepared in Example 2, is carefully inserted into the array guide. The system is inspected to ensure that there is no gap between the top of the guide and the body of the imaging cartridge. Set-screws in the array guide are tightened to secure the engagement of the imaging cartridge and array guide.
All MRI unsafe tools, such as a metal handle or metal calibration rod are removed, and the head is placed within an MRI suite. The MRI equipment is turned on, and the resulting images are inspected to ensure that the entire trajectory array guide system and target surgical area are included in the MR images. Each of the seven trajectories is evaluated relative to the reference tube, and the best trajectory for the surgical target is selected. The channel corresponding to the selected trajectory is noted, and the imagining cartridge is removed.
The surgical procedure is then performed using the array channel of the selected trajectory. If the tube is a 14-gauge tube and the surgical instrument is a 16-gauge instrument, a reduce can be used to adjust the diameter of the array channel.
Once the surgical procedure is complete, the bone screws are withdrawn, and the trajectory array guide system is removed from the skull and disassembled. The trajectory array guide system can then be discarded as a single-use system, or it can be sterilized for reuse.
Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments in accordance with the disclosure described herein.
In the claims, articles such as “a,” “an,” and “the” may mean one or more than one unless indicated to the contrary or otherwise evident from the context. Claims or descriptions that include “or” between one or more members of a group are considered satisfied if one, more than one, or all of the group members are present in, employed in, or otherwise relevant to a given product or process unless indicated to the contrary or otherwise evident from the context. members are present in, employed in, or otherwise relevant to a given product or process.
It is also noted that the term “comprising” is intended to be open and permits but does not require the inclusion of additional elements or steps. When the term “comprising” is used herein, the term “consisting of” is thus also encompassed and disclosed.
Methods of the present disclosure are exemplified through discussion of certain embodiments which are not intended to be limiting to the scope of the general methods disclosed herein. Certain embodiments of the methods are discussed with different combinations of steps and different orders of steps. The combinations and order in which steps are presented are not intended to be limiting to the scope of the general methods presently disclosed. Individual steps disclosed herein can be combined in any combination and in any order within operable embodiments of the methods according to the knowledge and skill of those with ordinary skill in the art.
Where ranges are given, endpoints are included. Furthermore, it is to be understood that unless otherwise indicated or otherwise evident from the context and understanding of one of ordinary skill in the art, values that are expressed as ranges can assume any specific value or subrange within the stated ranges in different embodiments of the invention, to the tenth of the unit of the lower limit of the range, unless the context clearly dictates otherwise.
Any particular embodiment of the present disclosure that falls within the prior art may be explicitly excluded from any one or more of the claims. Since such embodiments are deemed to be known to one of ordinary skill in the art, they may be excluded even if the exclusion is not set forth explicitly herein. Any particular embodiment of the compositions of the invention (e.g., any nucleic acid or protein encoded thereby; any method of production; any method of use; etc.) can be excluded from any one or more claims, for any reason, whether or not related to the existence of prior art.
All cited sources, for example, references, publications, databases, database entries, and art cited herein, are incorporated into this application by reference, even if not expressly stated in the citation. In case of conflicting statements of a cited source and the instant application, the statement in the instant application shall control.
Section and table headings are not intended to be limiting. Figures included with the present disclosure are intended to be non-limiting depictions of general concepts of the present disclosure.
This application is a 35 U.S.C. § 371 U.S. National Stage Entry of International Application No. PCT/US2018/042391 filed Jul. 17, 2018, which claims priority to U.S. Provisional Patent Application No. 62/533,207, entitled Trajectory Array Guide System, filed Jul. 17, 2017 and International Patent Application No. PCT/US2017/049191, entitled Trajectory Array Guide System, filed Aug. 29, 2017; the contents of each of which are herein incorporated by reference in their entirety.
Filing Document | Filing Date | Country | Kind |
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PCT/US2018/042391 | 7/17/2018 | WO |
Publishing Document | Publishing Date | Country | Kind |
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WO2019/018342 | 1/24/2019 | WO | A |
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20200229889 A1 | Jul 2020 | US |
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62533207 | Jul 2017 | US |