Feasibility of using EMG for early detection of the facial nerve during robotic direct cochlear access.
OBJECTIVE
Facial nerve monitoring can be used synchronous with a high-precision robotic tool as a functional warning to prevent of a collision of the drill bit with the facial nerve during direct cochlear access (DCA).


BACKGROUND
Minimally invasive direct cochlear access (DCA) aims to eliminate the need for a mastoidectomy by drilling a small tunnel through the facial recess to the cochlea with the aid of stereotactic tool guidance. Because the procedure is performed in a blind manner, structures such as the facial nerve are at risk. Neuromonitoring is a commonly used tool to help surgeons identify the facial nerve (FN) during routine surgical procedures in the mastoid. Recently, neuromonitoring technology was integrated into a commercially available drill system enabling real-time monitoring of the FN. The objective of this study was to determine if this drilling system could be used to warn of an impending collision with the FN during robot-assisted DCA.


METHODS
The sheep was chosen as a suitable model for this study because of its similarity to the human ear anatomy. The same surgical workflow applicable to human patients was performed in the animal model. Bone screws, serving as reference fiducials, were placed in the skull near the ear canal. The sheep head was imaged using a computed tomographic scanner and segmentation of FN, mastoid, and other relevant structures as well as planning of drilling trajectories was carried out using a dedicated software tool. During the actual procedure, a surgical drill system was connected to a nerve monitor and guided by a custom built robot system. As the planned trajectories were drilled, stimulation and EMG response signals were recorded. A postoperative analysis was achieved after each surgery to determine the actual drilled positions.


RESULTS
Using the calibrated pose synchronized with the EMG signals, the precise relationship between distance to FN and EMG with 3 different stimulation intensities could be determined for 11 different tunnels drilled in 3 different subjects.


CONCLUSIONS
From the results, it was determined that the current implementation of the neuromonitoring system lacks sensitivity and repeatability necessary to be used as a warning device in robotic DCA. We hypothesize that this is primarily because of the stimulation pattern achieved using a noninsulated drill as a stimulating probe. Further work is necessary to determine whether specific changes to the design can improve the sensitivity and specificity.
*ARTORG Center for Biomedical Engineering, †VetSuisse Faculty, ‡Department of Neurology, ENMG-Station and §Department of ENT Head and Neck Surgery, Inselspital, University of Bern, Bern, Switzerland.
Juan
J
Ansó
Christina
C
Stahl
Nicolas
N
Gerber
Tom
T
Williamson
Kate
K
Gavaghan
Kai Michael
KM
Rösler
Marco-Domenico
MD
Caversaccio
Stefan
S
Weber
Brett
B
Bell
D000818:Animals; D003051:Cochlea / Q000601:surgery*; D019929:Cochlear Implantation / Q000379:methods*; D004576:Electromyography; D005154:Facial Nerve / Q000502:physiology*; D023421:Models, Animal; D012371:Robotics; D012756:Sheep; D025321:Surgery, Computer-Assisted / Q000379:methods