Korean J Pain.  2022 Oct;35(4):403-412. 10.3344/kjp.2022.35.4.403.

Development of pre-procedure virtual simulation for challenging interventional procedures: an experimental study with clinical application

• Seong H
• Yun D
• Yoon KS
• Kwak JS
• Koh JC

• KMID: 2533980
• DOI: http://doi.org/10.3344/kjp.2022.35.4.403

Abstract

Background
Most pain management techniques for challenging procedures are still performed under the guidance of the C-arm fluoroscope although it is sometimes difficult for even experienced clinicians to understand the modified threedimensional anatomy as a two-dimensional X-ray image. To overcome these difficulties, the development of a virtual simulator may be helpful. Therefore, in this study, the authors developed a virtual simulator and presented its clinical application cases.
Methods
We developed a computer program to simulate the actual environment of the procedure. Computed tomography (CT) Digital Imaging and Communications in Medicine (DICOM) data were used for the simulations. Virtual needle placement was simulated at the most appropriate position for a successful block. Using a virtual C-arm, the authors searched for the position of the C-arm at which the needle was visualized as a point. The positional relationships between the anatomy of the patient and the needle were identified.
Results
For the simulations, the CT DICOM data of patients who visited the outpatient clinic was used. When the patients revisited the clinic, images similar to the simulated images were obtained by manipulating the C-arm. Transforaminal epidural injection, which was difficult to perform due to severe spinal deformity, and the challenging procedures of the superior hypogastric plexus block and Gasserian ganglion block, were successfully performed with the help of the simulation.
Conclusions
We created a pre-procedural virtual simulation and demonstrated its successful application in patients who are expected to undergo challenging procedures.

Keyword

Computer-Assisted Instruction; Computer Simulation; Humans; Hypogastric Plexus; Injections; Epidural; Pain Management; Simulation Training; Tomography; X-Ray Computed; Trigeminal Ganglion; User-Computer Interface; Virtual Reality

Figure

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  Fig. 1 Process of acquiring the patient’s image in a virtual space. (A) The computed tomographic image is obtained and positioned in the virtual space by using the values of image orientation, image position, and pixel spacing values. (B) When the Hounsfield unit value of 200–400 is only visualized, a bone-like three-dimensional image could be acquired.

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  Fig. 2 Virtual X-ray generation. Virtual X-rays are generated from the generator to the inside of the four corners of the detector, and the spatial coordinates are divided by the desired resolutions (A, 5 × 5) and (B, 10 × 10). The movement of the virtual C-arm is programmed to mimic the movements of the actual C-arm, with adjustments made using a keyboard. After calculating the point on the computed tomography slice where each X-ray collision occurred, the corresponding Hounsfield unit values are obtained. The degree of absorption of the X-rays is calculated and subsequently converted to the pixel value (C, resolution 128 × 128 and D, resolution 512 × 512).

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  Fig. 3 Creation of a procedure needle expressed on a virtual X-ray. (A, B) Patient’s Digital Imaging and Communications in Medicine and polygonal data are positioned in the same virtual space to manipulate the simulation conveniently. (C) Creation of the virtual needle similar to the actual needle. (D) Colliders are set in the handle and the needle shaft. (E, F) When the virtual X-ray collides with the collider of the needle, a value of 2,000 is added so that it can be expressed as a metallic material in the virtual X-ray.

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  Fig. 4 Application of virtual simulation before performing transforaminal epidural injection in a patient with severe spinal deformity. (A) Axial plane of T2-weighted magnetic resonance imaging (MRI). Lumbar MRI of the patient revealed left sided L5 nerve root irritation due to severe spinal deformity seemed to be the cause of pain. (B) Three-dimensional virtual procedural planning. The virtual needle is placed in the most appropriate position. (C) Oblique view of the virtual X-ray image is saved where the needle presents as a pinpoint. (D) Anteroposterior view of the simulated virtual X-ray. (E) The patient’s oblique X-ray image during the procedure. (F) The patient’s X-ray image in the anteroposterior view during the procedure. White asterisk: needle, TP: transverse process, SAP: superior articular process, Dotted lines: contour of anatomical structures.

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  Fig. 5 Application of virtual simulation in performing the superior hypogastric plexus block. (A) Coronal view of the patient’s magnetic resonance image. Metastasis to the right sided L5 vertebra and sacral ala seems to cause the pain. (B) Three-dimensional virtual procedural planning. The virtual needle is placed at the most appropriate position. (C) Oblique view of the virtual X-ray image is saved where the needle presents as a pinpoint. (D) Anteroposterior view of the simulated virtual X-ray. (E) The patient’s oblique X-ray image during the procedure. (F) The patient’s X-ray image in the anteroposterior view during the procedure. White asterisk: needle, TP: transverse process, SAP: superior articular process, Dotted lines: contour of anatomical structures.

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  Fig. 6 Application of virtual simulation in performing the Gasserian ganglion block. (A, B) Three-dimensional virtual procedural planning. The virtual needle is placed at the most appropriate position with reference to the right foramen ovale. (C) Caudal tilted anteroposterior view of the virtual X-ray image is saved where the needle presented as a pinpoint. (D) Lateral view of the simulated virtual X-ray. (E) The patient’s X-ray image in the caudal tilted anteroposterior view during the procedure. (F) The patient’s X-ray image in the lateral view during the procedure. White asterisk: needle, Dotted lines: contour of anatomical structures.

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