Targeting accuracy of robot-assisted deep brain stimulation surgery in childhood-onset dystonia: a single-center prospective cohort analysis of 45 consecutive cases

Abstract

OBJECTIVE Deep brain stimulation (DBS) is an established treatment for pediatric dystonia. The accuracy of electrode implantation is multifactorial and remains a challenge in this age group, mainly due to smaller anatomical targets in very young patients compared to adults, and also due to anatomical abnormalities frequently associated with some etiologies of dystonia. Data on the accuracy of robot-assisted DBS surgery in children are limited. The aim of the current paper was to assess the accuracy of robot-assisted implantation of DBS leads in a series of patients with childhood-onset dystonia. METHODS Forty-five children with dystonia undergoing implantation of DBS leads under general anesthesia between 2017 and 2019 were included. Robot-assisted stereotactic implantation of the DBS leads was performed. The final position of the electrodes was verified with an intraoperative 3D scanner (O-arm). Coordinates of the planned electrode target and actual electrode position were obtained and compared, looking at the radial error, depth error, absolute error, and directional error, as well as the euclidean distance. Functional assessment data prospectively collected by a multidisciplinary pediatric complex motor disorders team were analyzed with regard to motor skills, individualized goal achievement, and patients’ and caregivers’ expectations. RESULTS A total of 90 DBS electrodes were implanted and 48.5% of the patients were female. The mean age was 11.0 ± 0.6 years (range 3–18 years). All patients received bilateral DBS electrodes into the globus pallidus internus. The median absolute errors in x-, y-, and z-axes were 0.85 mm (range 0.00–3.25 mm), 0.75 mm (range 0.05–2.45 mm), and 0.75 mm (range 0.00–3.50 mm), respectively. The median euclidean distance from the target to the actual electrode position was 1.69 ± 0.92 mm, and the median radial error was 1.21 ± 0.79. The robot-assisted technique was easily integrated into the authors’ surgical practice, improving accuracy and efficiency, and reducing surgical time significantly along the learning curve. No major perioperative complications occurred. CONCLUSIONS Robot-assisted stereotactic implantation of DBS electrodes in the pediatric age group is a safe and accurate surgical method. Greater accuracy was present in this cohort in comparison to previous studies in which conventional stereotactic frame-based techniques were used. Robotic DBS surgery and neuroradiological advances may result in further improvement in surgical targeting and, consequently, in better clinical outcome in the pediatric population.

Long-Term Outcomes of Deep Brain Stimulation for Pediatric Dystonia

“…The use of interventional MRI-guided DBS using a skull-mounted aiming device in conjunction with dedicated software, which is independent of physiological testing, showed good accuracy and comparable outcomes in pediatric dystonia [29, 61]. Robot-assisted stereotactic implantation may have even greater accuracy [62].…”

Globus Pallidus Internus Deep Brain Stimulation for Dystonic Opisthotonus in Adult-Onset Dystonia: A Personalized Approach

“…Rehabilitation and medical management along with local botulinum toxin injections are the treatment of choice in focal dystonia ( Albanese and Lalli, 2012 ; Ehrlich and Frucht, 2016 ). Since segmental and generalized forms of dystonia may not respond well to pharmacological therapies, there has been growing interest and expansion in the application of bilateral neuromodulation of deep brain structures in the management of these challenging conditions ( Zittel et al, 2009 ; Martínez et al, 2014 ; Shaikh et al, 2014 ; Fox and Alterman, 2015 ; Tambirajoo et al, 2020 ; Furlanetti et al, 2021 ). ATD is more frequently reported in the context of severe segmental and generalized dystonic syndromes, and rarely as an isolated presentation of dystonia ( Bhatia et al, 1997 ; Benecke and Dressler, 2007 ; Albanese et al, 2013 ; Lizarraga and Fasano, 2019 ).…”

Robot-Assisted Minimally Invasive Asleep Single-Stage Deep Brain Stimulation Surgery: Operative Technique and Systematic Review

“…7,[24][25][26] Three studies (including this study) reported the use of a floor-mounted robot with a frameless transient fiducial array, with a target radial error of 0.84 ± 0.54 mm (n = 631 electrodes), operative time of 182.4 ± 47.8 minutes (n = 315), and total procedure time of 311.9 ± 63.0 min (n = 315). 27,28 One study reported their use of a floormounted robot with optical registration, and the only metric recorded was target radial error: 1.28 ± 0.37 (n = 60 electrodes). 29 Our meta-analysis found that the floor-mounted systems are more accurate, with a radial target error of 0.90 ± 0.46 mm (n = 1510 electrodes), compared with skull-mounted systems (1.12 ± 0.54 mm, n = 406) (P = .028).…”