title: Frameless stereotaxy without rigid pin fixation during awake craniotomies.
abstract: OBJECTIVE
  The accuracy and precision of resection with awake brain mapping is augmented when combined with frameless stereotaxy. Frameless stereotactic assisted surgery, however, typically involves immobilization in Mayfield pins. Rigid fixation, however, may be problematic for individuals undergoing awake craniotomy. We describe an alternate method of frameless stereotaxy without the use of pin fixation.
  
  
  METHODS
  The MRI fiducials are placed in proximity to the proposed incision and prepared and draped in the operative field. After craniotomy, the epidural skull clamp (standardly used to support the electrode holder during corticography) is attached. Using the Stealth Navigational System, a spinal reference arc is then clamped onto the skull clamp base. After the fiducials and arc are registered, the probe is used for frameless guidance.
  
  
  RESULTS
  In 14 of 15 cases (93%), this technique was successful. One case failed because of close proximity of the fiducials to the incision. The accuracy of the 14 successful cases was less than 4 mm. The error within the lesion itself was always less than 2 mm. Overall, these results are comparable to those achieved using a Mayfield head holder. In all tumor cases, postoperative imaging concurred with intraoperative assessment of a total versus subtotal resection.
  
  
  CONCLUSIONS
  By affixing the spinal arc to the skull, the complications and discomfort associated with pin fixation are avoided completely. The patient is free to move without affecting the accuracy. The spine arc, in combination with the skull clamp, provides an efficient, well-tolerated, and accurate method of frameless navigation for the awake patient undergoing craniotomy.
authors.affiliation: Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Mo., USA.
authors.forename: Eric C
authors.initials: EC
authors.lastname: Leuthardt
authors.forename: Douglas
authors.initials: D
authors.lastname: Fox
authors.forename: George A
authors.initials: GA
authors.lastname: Ojemann
authors.forename: Ralph G
authors.initials: RG
authors.lastname: Dacey
authors.forename: Robert L
authors.initials: RL
authors.lastname: Grubb
authors.forename: Keith M
authors.initials: KM
authors.lastname: Rich
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Ojemann
mesh_terms: D001364:Awareness; D001858:Bone Nails; D001931:Brain Mapping; D001932:Brain Neoplasms / Q000601:surgery*; D003399:Craniotomy / Q000379:methods*; D004827:Epilepsy / Q000601:surgery; D005910:Glioma / Q000601:surgery*; D006801:Humans; D038361:Neuronavigation / Q000379:methods*; D012886:Skull; D013116:Spinal Cord; D013525:Surgical Instruments