title: A Neuromonitoring Approach to Facial Nerve Preservation During Image-guided Robotic Cochlear Implantation.
abstract: OBJECTIVE
  A multielectrode probe in combination with an optimized stimulation protocol could provide sufficient sensitivity and specificity to act as an effective safety mechanism for preservation of the facial nerve in case of an unsafe drill distance during image-guided cochlear implantation.
  
  
  BACKGROUND
  A minimally invasive cochlear implantation is enabled by image-guided and robotic-assisted drilling of an access tunnel to the middle ear cavity. The approach requires the drill to pass at distances below 1  mm from the facial nerve and thus safety mechanisms for protecting this critical structure are required. Neuromonitoring is currently used to determine facial nerve proximity in mastoidectomy but lacks sensitivity and specificity necessaries to effectively distinguish the close distance ranges experienced in the minimally invasive approach, possibly because of current shunting of uninsulated stimulating drilling tools in the drill tunnel and because of nonoptimized stimulation parameters. To this end, we propose an advanced neuromonitoring approach using varying levels of stimulation parameters together with an integrated bipolar and monopolar stimulating probe.
  
  
  METHODS
  An in vivo study (sheep model) was conducted in which measurements at specifically planned and navigated lateral distances from the facial nerve were performed to determine if specific sets of stimulation parameters in combination with the proposed neuromonitoring system could reliably detect an imminent collision with the facial nerve. For the accurate positioning of the neuromonitoring probe, a dedicated robotic system for image-guided cochlear implantation was used and drilling accuracy was corrected on postoperative microcomputed tomographic images.
  
  
  RESULTS
  From 29 trajectories analyzed in five different subjects, a correlation between stimulus threshold and drill-to-facial nerve distance was found in trajectories colliding with the facial nerve (distance <0.1  mm). The shortest pulse duration that provided the highest linear correlation between stimulation intensity and drill-to-facial nerve distance was 250  μs. Only at low stimulus intensity values (≤0.3  mA) and with the bipolar configurations of the probe did the neuromonitoring system enable sufficient lateral specificity (>95%) at distances to the facial nerve below 0.5  mm. However, reduction in stimulus threshold to 0.3  mA or lower resulted in a decrease of facial nerve distance detection range below 0.1  mm (>95% sensitivity). Subsequent histopathology follow-up of three representative cases where the neuromonitoring system could reliably detect a collision with the facial nerve (distance <0.1  mm) revealed either mild or inexistent damage to the nerve fascicles.
  
  
  CONCLUSIONS
  Our findings suggest that although no general correlation between facial nerve distance and stimulation threshold existed, possibly because of variances in patient-specific anatomy, correlations at very close distances to the facial nerve and high levels of specificity would enable a binary response warning system to be developed using the proposed probe at low stimulation currents.
authors.affiliation: *ARTORG Center for Biomedical Engineering†Department of ENT, Head and Neck Surgery, Inselspital‡VetSuisse Faculty, University of Bern, Bern§Swiss Centre for Electronics and Microtechnology, CSEM, Neuchâtel||Institute for Surgical Technologies and Biomechanics, ISTB¶Institute of Pathology#Department of Neurology, ENMG-Station, Inselspital, University of Bern, Bern, Switzerland.
authors.forename: Juan
authors.initials: J
authors.lastname: Ansó
authors.forename: Cilgia
authors.initials: C
authors.lastname: Dür
authors.forename: Kate
authors.initials: K
authors.lastname: Gavaghan
authors.forename: Helene
authors.initials: H
authors.lastname: Rohrbach
authors.forename: Nicolas
authors.initials: N
authors.lastname: Gerber
authors.forename: Tom
authors.initials: T
authors.lastname: Williamson
authors.forename: Enric M
authors.initials: EM
authors.lastname: Calvo
authors.forename: Thomas Wyss
authors.initials: TW
authors.lastname: Balmer
authors.forename: Christina
authors.initials: C
authors.lastname: Precht
authors.forename: Damien
authors.initials: D
authors.lastname: Ferrario
authors.forename: Matthias S
authors.initials: MS
authors.lastname: Dettmer
authors.forename: Kai M
authors.initials: KM
authors.lastname: Rösler
authors.forename: Marco D
authors.initials: MD
authors.lastname: Caversaccio
authors.forename: Brett
authors.initials: B
authors.lastname: Bell
authors.forename: Stefan
authors.initials: S
authors.lastname: Weber
mesh_terms: D000818:Animals; D019929:Cochlear Implantation / Q000009:adverse effects*; D020209:Cranial Nerve Injuries / Q000473:pathology* / Q000517:prevention & control*; D004558:Electric Stimulation; D004576:Electromyography; D005154:Facial Nerve / Q000033:anatomy & histology / Q000473:pathology*; D008416:Mastoid / Q000473:pathology / Q000601:surgery; D064926:Neurophysiological Monitoring / Q000379:methods*; D013506:Otologic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control*; D012371:Robotics; D012756:Sheep; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000379:methods*; D013525:Surgical Instruments