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User Manual SpineMap® 3D

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1. Warning Reduction of the resolution may lead to inadequate image qual ity Do not reduce the subvolume or resolution in regions in which medical indications require the available image quality Only reduce the subvolume or reso lution according to established medical standards It is the surgeon s responsibility to set the subvolume and resolution In case of an unintended reduc tion of the subvolume or of the resolution import the original scan again FE gt Click to convert image set to half resolution roo 5 430 mage of iwert AO ER SPIE 4 349 Ga The radja ore far LAVAS Mona ty Lead VCT han OU MOOCA Ss brege tar 2122582 pools cow pi a 0 468 mm The velkem e to bo iengortod h rocker od by sie on inap ee ea Import Image Sets 10 Import Image Sets Ai Reni Pi tear LE Bee ERE BAE perth one poet a Da r ee ee DADA SPIN 55 ta MN psi sd Confirmation a importing 130 images of patient 78698 Dc6b687 Dea etd ty The images are from HEGP scanned with LightSpeed VCT fram GE MEDICAL SYSTEMS image size is 12 512 pixels one pixel is 0 684 mm Image orientation is LIP Click Accept F you have already visually verified the patient orientation labels ensuring they are correct Othevase click Cancel and verify the orientation labels first Accept CT 2005 0 5 CT R090 15 1 2000 5 15 ST 60D 1 15 CT MO MAS Cancel Step 4 Import images T
2. B seeettes om eves IX one By default planned screws are dis didata A ae played supporting efficient entry isc point identification and instru ment alignment gt The Rotate 3 D function select the S icon can be used to point to an entry and to rotate the selected point to ska the front in the 3 D scene i Base Set eTo gt The Show Hide Screw func aie tion select the amp icon can man Se PN be used to display or to hide all planned screws Open pedicle pathway Step 1 Initialize tool 1 Insert a sterile battery into a sterile Navigated Pedicle Feeler 2 Make sure that the pedicle feeler s LEDs face towards the camera and press and hold the SELECT button to initialize Upon initialization the Vali date Straight Pedicle Feeler Window is displayed 3 Touch the center of any of the VCD s validation disks with the pedicle feeler s tip and press the SELECT button to confirm Step 2 Open pedicle pathway A pathway can be opened by using the Navigated Pedicle Feeler Pedicle Screw Navigation Validate Straight Pedicle Feeler Back Net 59 60 Pedicle Screw Navigation LJ 1 An additional tracker is switched on Do you want to use it Tor instrument or patent tracking Track Instrument Track Patient Cancel Calibrate Universal Tracker Integrate and calibrate conventional instrumen tation exemplified by pedicle pathway prepara tio
3. On cTO1 Surface matching facilitates to improve the accuracy of the initial mandatory point registration The surface matching process reguires a well defined surface level of the 3 D CT image The 3 D CT image must match the bony surface of the patient s anatomy as exactly as possible Step 1 Activate tool panel 1 Double click the Surface Matching item and select the CT base image series listed underneath Oats Narayan Adjust the surface level to define the 2 Upon selection the Define sy lt ge SL ha eat Matching Surface Tool Panel Image Set CTOI appears Matching on Bone Step 2 Surface Definition Adjust surface level matching on bone lt 1 Select Bone as the surface on which the matching is to be done 2 Use the slider to optimize the 3 D image display of the bony surface Note For 3 D image optimization it is recommended to first increase the surface level until noise appears above the bony structures of the 3 D image Then to decrease the surface level until the noise disap pears Registration Planning 43 44 Registration Planning Note By clicking the Save as Default button the current surface level setting can be saved as default for further CT image series b Select the Next button to proceed 7 Set Up System Position system For navigated pedicle screw inser tion with posterior approach and patient in prone position the system is commonly placed at foot
4. constrant STW Hige Standard Advanced If the image orientation label is incorrect 1 Move the mouse over the orientation label requiring correction 2 Select the correct orientation from the pull down menu Import Image Sets Import Image Sets Step 3 Reduce image set size optional If necessary the file size of the image set to be imported can be reduced The RAM indicator shows the used main memory of the image set to be imported The following procedures help you to reduce the image set file size Set local import bounding box The software provides the selec tion of an import area of the image set gt Use the mouse to set the bounding box over the import area The software imports only the part inside of the bounding box We or 0 Select and deselect single slices In the Slices view single slices can be deselected 1 Click the Slices tab to switch to the Slices view 2 Move the mouse over the desired slice The Import pop up appears Deactivate the checkbox to deselect slice Import Select and deselect all every even every odd every third slice In the Slices view single slices can be deselected 1 Click the Slices tab to switch to the Slices view 2 Click to select all every even every odd or every third slice Import image set with half resolu tion The half resolution feature enables image sets to be imported in half resolution
5. Step 1 Initialize spine tracker VCD and navi gated awl 1 Load a sterile battery into the battery housing of the Spine Tracker 2 Make sure that the LEDs of the Spine Tracker face towards the camera and press and hold the battery housing s SELECT button to initialize 3 Repeat battery insertion and tool initialization for the ster ile VCD and the sterile Navig tated Awl Registration The initialization of any tool is confirmed by an audible chime and a check mark in front of the software button Step 2 Validate navigated awl Upon initialization of the Navi gated Awl the Validate Tool atm validate Awl Window appears on the screen EER I OTE rai device with te pointers fp and press gt Touch the center of one of the VCD s validation disks with the tip of the awl and press the awl s SELECT button to confirm Step 3 Align camera 1 Align the camera in such a way that the Spine Tracker is visible and in the center of the camera s working space 2 Click the Next button to pro ceed with point registration 49 50 Registration pen m Point registration SANGE Overview Step 1 Select reference point set 1 Highlight and select the refer ence point set defined for the vertebra where the Spine Tracker is currently attached by using the awl s control but tons 2 Upon selection the Digitize Points Tool Panel is activated Step 2 Point Digitization
6. s Eye 3 D view consists of three 2 D images reconstructed with respect to the tool axis One 2 D image is reconstructed along 0 the second is recon structed along 90 and the third is reconstructed perpendicular to the tool axis In addition one 3 D image with opaque or translucent surface properties is displayed Create user defined view The software provides creation of user defined view 1 Go to the Home page 2 Click the User defined view settings 3 Select view pattern e g 3x2 4 Create the desired view by using the pull down menus of the images boxes 5 Rename the view Views Tool s Eye 3D No Anatomical Sys Empty Sagittal Axial Coronal Along 0 Along 90 Perpendicular Screw Along 0 Screw Along 90 Screw Perpendicular Screw Guidance Image Target Coronal Target Sagittal Target Axial Target Guidance Image Video Volume Rendering stryker Virtual Length 50 0 mm Navigation Views Shorten o Finish or press and hold to reset v Extend SU Navigation Back Back Next gt Net 9 93 Additional Navigation and Documentation Tools 14 Additional Navigation and Documentation Tools 94 3 D Image Tools Navigation tools For navigation the system offers a range of tools The 2 D and 3 D image tools can be operated with the mouse The tool buttons situ ated on top of the image box can be operated with the mouse and navigated
7. 1 Trajectories fe Compositions i Screenshots 0 Planes Ty a E Ax n Axis 3 Points Image Set TOi Mame 7 Pama E MRO1 T2 TSEAXIALS SFOV HRPE i Planes creation There are two options for resec tion plane planning digitizing an initial axis perpendicular to the desired resection plane or digi tizing three points to define the desired plane Planes are commonly planned for pelvectomies sacrectomies and long bone resections For long bones the axis based resection plane enables easy align ment of perpendicular cutting planes to the bone shaft Step 1 Create new plane 1 Select the image set in which a plane is to be defined by click ing the image set item in the patient record tree 2 Double click the Planes item and select New Plane Upon selection the Planes tool panel is displayed Step 2 Select method for plane creation gt Select the desired plane cre ation method from the pull down menu Axis or 3 Points The tool panel is expanded for the selected plane functional ity Step 3 Create new planes 1 Axis Method 1 Set the crosshair cursor on the first point of a virtual axis that lies perpendicular to the desired plane for example the proximal center point of a bone shaft Select the Set Axis Point 1 button to record the position Id Set the crosshair cursor on the second point of the vir tual axis perpendicular to the desired plane for examp
8. For point registration LI Digitize the reference points If required U Perform surface matching to improve the point registration Prepare entry point Caution Tool s Eye 3D For accuracy and the patient s Multiplanar 3 D safety navigation should only be Screw View used for the registered vertebra Target View Step 1 Select view Tool s Eye Video optional Multiplanar Video The Tool s Eye 3 D view is com monly used for pedicle screw Compositions navigation Base Set CT01 Tool s Eye 3 D view consists of All Segments three 2 D images reconstructed with respect to the tool axis along 0 along 90 and perpendicular to the tool axis and one 3 D image User Defined gt Select the desired view by using the awl s control but tons Step 2 Select composi tion optional By default the CT base image set is active If required gt Call up correlated image sets or an already planned com position by using the awl s control buttons Alternatively gt Click the Compose button to create compostions on the fly by selecting any of the avail able fused images segments planes or trajectories not illustrated Pedicle Screw Navigation i Sermi DIA AE aa a w T Husigatkn Navigation Ira Mo Trajectory Toofs Eye 30 No Anatomical Sya 57 58 Pedicle Screw Navigation Step 3 Prepare entry point The entry point can be identified and prepared by using the awl
9. matching confirmation Step 4 Caution Always confirm registration accu racy by using multiple landmark tests The surgeon must be com fortable with the accuracy before proceeding If one or several of the points appears red then that point was not registered on the surface level and therefore was rejected by the system and is not included in the surface matching Registration 55 Pedicle Screw Navigation 9 Pedicle Screw Navigation Pedicle screw navigation preoperative checklist System startup Import image sets Patient Planning optional Registration planning System setup Registration 56 U Plug in the Navigation System turn it on and log in and start the SpineMap 3 D application U Select Start new case and select the CT base image set LI Verify the CT image set and import the images U Select the features required for surgical planning If required Ul Change or add patient data If desired LI Use any of the planning tools for surgery planning For point registration LI Define one reference set for each vertebra to be instrumented For surface matching U Define the matching surface LI Position the system and align the camera Q Position and prepare the patient If the system was shut down after planning LI Repeat the system startup and select the patient entry in the Ready for sur gery section on the Home page Q Initialize the tools requested by the software
10. or head of the OR table Depending on the situation in the OR the approach and the type of surgery other system positions are supported Independently of the system posi tion it is recommended to gt Position the camera 1 65 m 5 5 feet away facing towards the working area ie Set Up System 45 set Up System Start up system 1 Plug in the main power cable of the navigation system J ON NIA Pi ii ai ha 5 5 J To boot the system 2 Press the main power button on the front panel of the navi gation system To log in 3 Enter the user name naviga tion and press the Enter key or use the left mouse button and click the OK button To start the SpineMap 3 D navi gation software 4 Use the mouse to select the SpineMap 3 D button from aian the Application Manager Navigation System If all mandatory pre operative image import and planning tasks have already been completed Ready for Surgery 5 Select the desired patient from John Miller 001 All patients the section Ready for surgery on the Home page Upon selection the System Setup dialog will be initialized automati cally If image import and planning is still required gt Proceed with Image Sets 8 Registration Prepare Patient For intraoperative registration a Patient Tracker must be fix ated to the spinous process After Spine Tracker fixation de
11. Set Entry Point button to record the position If required gt Change the parameters of the Trajectory by adjusting the Diameter Target and or Entry slider Step 4 Assess trajecto ries 1 Select the Trajectory Ori ented tab 2 Grab and move the handles of the red line in the Along 90 or Along 0 window and assess the trajectory slice by slice through a perpendicular cut If required gt Change the planned trajectory by grabbing and moving the entry or target point Note Click the icon to hide or display all trajectories In the 3 D image the displayed trajectory is extended beyond the digitized entry point to provide guidance if the entry point is subcutaneous The position of the digitized entry point is marked with a staged ring on the 3 D approach mips Toa et A RM mani 2 sere om ito 7 x E CTS foyer Sisiane Pearce Karmela Planning Features 29 30 Planning Features Ab spenktes teri aceon ey ot le 3 D model display The 3 D model can be used in existing correlations and compo sitions Colors of the 3 D models can be changed for optimum visualiza tion Note Each imported 3 D model belongs to only one correspond ing series When a series is deleted the corresponding 3 D models are deleted too Step 1 Import model 1 Double click 3 D Model and select Import 3 D Model in the patient record tree 2 Select the image set in which a 3 D m
12. bara Vorify Annotation Point Weny the new annotation point and change its name F desked New name i Pointer Small Back Net Documentation tools Create annotation points intraoperatively To create annotation points intra operatively 1 Place the instrument tip or the virtually extended tip on the point of interest 2 Highlight and select the icon to digitize the position and to open the Verify Anno tation Point dialog 3 Highlight and select the Accept button to close the dialog Additional Navigation and Documentation Tools Browse images intraoperatively Browse Images The intraoperative image browser se the enables an additional view of the original image set slices or on the created screenshots 1 Highlight and select the jl icon to open Browse Images dialog a tos buttor i to the de ed la Qe 2 Highlight and select the image set of interest 3 Use the tool s Up down but tons to scroll the original image set slices or the created screenshots Export screenshots To export single screenshots the single screenshots must be selected in the patient record tree view To export the created screenshots 1 Select the Planning tab 2 Double click the Screenshot item in the patient record tree view Note With the selection of Export all screenshots link a Windows dialog box opens that enables the user to export all screenshots to a folder hard dr
13. ee te Point to Point Registration on CTO1 1 Place the tip of the awl onto the vertebral landmark dis played as registration point by the software and press the awl s SELECT button to digitize 2 Upon successful digitization the reference point number is checked 3 Digitize the remaining regis tration points 4 Click the Enable Registration button to activate registration Up on completion Point to Point Registration on CTO1 E P gt Highlight and select the gt button to proceed with point registration confirmation Step 3 Step 3 Confirm point registration To verify the registration accu racy 1 Touch distinct anatomical landmarks with the awl s tip 2 Compare the actual tip loca tion with the reported loca tion on the images If the accuracy is satisfactory in order to navigate or acceptable as initial registration followed by surface matching 3 Highlight and confirm Accept If required gt Highlight and select the omtto pamtRessratononcr0 Reregister button AAN gt Repeat point digitization Accept Step 2 and point registration Reregister confirmation Step 3 Caution Always confirm registration accu racy by using multiple landmark tests The surgeon must be com fortable with the accuracy before proceeding Accept Reregister Registration 51 Registration aa Do you want to mp3ove the point to point registration with muta
14. including the plane has to be cre ated and recalled for navigation 27 28 Planning Features o CT01 ARTERIEL PORTAL 3 New Segment Local Correlations New Local Correlation Anatomical System Screws Measurements f Annotation Points Planes Trajectories New Trajectory Trajectory 1 m 3 D Model Compositions gi Screenshots o HH amp O 8 Delete Trajectories Name Trajectory 1 Image Set CTO1 Diameter lt Target lt Entry lt v Target Point Set Target Point Show v Entry Point Set Entry Point Show Length 162 2 mm su Trajectories creation E CTS foyer fastens Pearce E Local Comeon A trajectory connects a target and an entry point Trajectories can also be used to measure total limb length and to define an axis for implant alignment Step 1 Create trajectory 1 Select the image set in which a trajectory is to be defined by clicking the image set item in the patient record tree 2 Double click Trajectories and select New Trajectory Upon selection the Trajectories tool panel is displayed A Seret Oh rtm F oe Step 2 Define target point E CT Sober fawbene Frans lor 1 Set the crosshair cursor on the target point of the desired trajectory 2 Select the Set Target Point button to record the position Step 3 Define entry point 1 Set the crosshair cursor on the entry point of the trajectory 2 Select the
15. vertebra or the sacrum is included For adequate correlation results a local correlation for a vertebra should be defined similar to the following pictures Planning Features 17 18 Planning Features 3 ct cm sue Serene cue NI _ x CTOt arget CTO 3D sean JIO MAGES te 2105 10 sean 30 IMAOET 12064 mages D W Lord Conreintons wy KMI LA 1 BOOP lt A LP Serena crane lm X crot imaget CTO em JOJMASES CTit 20 sean J0 MAGEI Cree mages D Local Correlation 1 3 ang pr eu cthecw 7 a ceci 7 F S amp Anatomical System ie ni A Screw f BEB ie anta ee amp ct ern sie Serene cr 2 2 X CTO meget CTO 30 sean JO MABES MN 21705 10 sean 30 WAGES 12064 aw beg o W Loca Coareintona Land Core Step 1 Select series 1 Select New Local Correlation 2 Position the cursor on the vertebra of interest 3 Select the base image series for correlation 4 Define the correlation region with the adjustable box 5 Select the second image series for correlation 6 Adjust the second image series for correlation Note Parts outside of the correla tion region are dimly displayed When a local correlation region is selected the system shows the image set on which the region s adjustable box has been defined Step 2 Start automatic matching gt Click the Automatic Match ing link to star
16. 2 Select Start Registration on the registration screen 3 Select the reference point set for the segment where the Spine Tracker is currently attached 4 Perform the registration Step 3 Navigate gt Navigate the newly registered segment not illustrated Caution Patient position during preopera tive imaging and surgery is not the same The relative position of the individual vertebral segments on the images and during surgery may differ During surgery there might be relative movement of the indi vudual vertebral segments Due to these potential deviations and movements safe and accurate navigation of additional vertebral segments requires both repositioning and fixation of the Spine Tracker onto the segment to be instrumented next and e new registration of this seg ment Insert Pedicle Screw 65 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging 11 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging PELL Navigation System System Positioning amp Start Up For navigated pedicle screw inser tion with posterior approach and patient in prone position the system is commonly placed at foot or head of the OR table Depending on the situation in the OR the approach and the type of surgery other system positions are supported Independently of the system posi tion 1 Position the camera 1 65 m 5 5 feet away fac
17. Calibrate tap a straight tip 1 Make sure that Straight Tip is highlighted and press the VCD s SELECT button to confirm 2 Insert the tap into the opening of the VCD as indicated Make sure that the tap is centered and touches the base of the device NA Tan 3 Make sure that both tools are visible and centered in the working space of the camera 4 Press the VCD s SELECT button to calibrate the tap straight tip To verify the tap straight tip calibration 5 Touch the center of any of the VCD s validation discs with tip of the tap and press the VCD s SELECT button to Calibrate Universal Tracker confirm 62 Step 5 Prepare navigated pedicle pathway With the calibrated tap pedicle pathway preparation can be navi gated Pedicle Screw Navigation i eto ore tenan ey oe ce T Husigahan Navigation Toots Eye 30 Mo Anatomical Sys Pointer Small Back Net 63 64 Insert Pedicle Screw 10 Insert Pedicle Screw After pedicle pathway prepara tion the pedicle screw can be inserted Note If screws have not been planned screw length and diameter can be determined on the fly Additional vertebral Segments Step 1 Re position spine tracker gt Fixate the Spine Clamp and Spine Tracker firmly onto the spineous process of the seg ment that shall be navigated next Step 2 Registrate 1 Select the Back button on the navigation screen
18. Features 21 Planning Features Automatic Bone Segmentation z5 E Automatic Bone Segmentation 4 Check ifthe cross hair cursor is located in a bone area and click Calculate Calculate Automatic Bone Segmentation E Automatic Bone Segmentation 2 You may optimize the result by adjusting the slider below or change the starting point by clicking Replace Bone tissue starts at Hounsfield unit 216 Replace Finish Cancel raman bms wa demo Bana dey arte Step 2 Start automatic segmentation 1 Bone Segmentation 1 If required limit the segmen tation space by moving the boundaries of the rectangular segmentation box displayed in the 2 D and 3 D views 2 Set the crosshair cursor in an area displaying the bone to be segmented 3 Select the Calculate button The bone is segmented 4 Assess the visibility and bor ders of the segmented bone in the 2 D and 3 D views If the bone is segmented insuf ficiently gt Lower the Hounsfield thresh old to add more cartilage or thin bone to the bony structures by moving the Hounsfield unit slider If the bone is satisfactorily seg mented gt Click the Finish button to finalize and save the bone seg ment Note Automatic bone segmentation works only with CT image sets 2 Tumor Vasculature Automatic Tumor Segmentation User Defined Segmentation 1 Set the cross hair cursor into an area showing tissue to segment and cli
19. acker Universal Adapter gt Highlight and select Universal Adapter by using the VCD s SELECT button Step 3 Calibrate Jam Shidi needle straight tip 1 Make sure that Straight Tip is highlighted and press the VCD s SELECT button to confirm 2 Insert the Jam Shidi needle into the opening of the VCD as indicated Make sure the al Saab a Jam Shidi needle is centered Pa Ee and touches the base of the N a LL device PEK ps e 3 Make sure that both tools are isi si L visible and centered in the TO working space of the camera 4 Press the VCD s SELECT button to calibrate the Jam Shidi needle straight tip ae mara Calibrate Universal Tracker 82 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging To verify the Jam Shidi needle PRA straight tip calibration 5 Touch the center of any of the VCD validation discs with tip of the Jam Shidi needle and press the VCD s SELECT button to confirm Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Shonen Virtual Length 50 0 mm Finish or press and hold to reset Y Extend m MAN O Prepare pedicle Mo Trajectory Multiplanar 3 D ayan Screw View Target View Tool s Eye Video Multiplanar Video Tool s Eye 30 Muttiplanar D Serma View Target View u Tools Eye Video Mukttplanar Video Back Next 3 Shorten Virtual Length 50 0 mm Fin
20. air cursor on a distinct anatomical landmark STEN Pan of this vertebra The landmark should be be easily identifiable on both the patient s images and the patient s anatomy and reachable with the tip of the awl during surgery 3 Click the Set button to select the landmark as reference point 4 Digitize a minimum of three to four additional landmarks on this vertebra Make sure that the digitized points are distributed non linear 41 Registration Planning After reference point set defini tion for one vertebra is complete are E it is recommended to rename the Define a minimum of 3 reference points for reference point set in accordance egistration To increase registration accuracy eee with the anatomical level for connected structures in the image set including points close to the target of surgery example L4 Sef Point 2 gt Define additional reference Set Point 3 point sets for each vertebra to Set Point 4 be instrumented Start defini Set Point 5 tion of an additional set by oor Point 6 selecting the item New Refer ence Point Set underneath the r E E Parl CT base image series link EE Cth Temi a i _ Reference Points Set Point 7 The following landmarks are commonly used as registration points e Most cranial and caudal points of the spinous process e Facet joints Surface matchin 8 CTO1 Nema 8 1 03 BWS LWS 1 0 planning overview a Surface Matching
21. ated chapter 6 Registration Planning page 41 ee SpineMapf 3D Navigation Image Acquisition SIEMENSJO gt 4 ehmimaging Start C arm 3D scan Laman 7 SS 1 To perform a new scan click Scan Intra Ciperatise To transfer Images without a new scan choose Transfer Images scan Intra Operatve Transfer Images 69 70 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 4 Prepare C Arm ji 1 Position the C Arm 2 Connect the C Arm to the network receptacle of the Stryker Navigation System by using an Ethernet crossover cable For Siemens C Arms gt Attach a C Arm Tracker onto the C Arm 3 Prepare and drape the C Arm Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Initialize tool Intraoperative 3 D imaging and automatic registration require the initialization of sterile tools Following tools are recom mended e Patient tracker e VCD e Small Pointer Step 1 Initialize patient tracker VCD and pointer 1 Load a sterile battery into the battery housing of the patient tracker 2 Make sure that the LEDs of the patient tracker face towards the camera and press and hold the SELECT button for three seconds on the bat tery housing to initialize 3 Repeat battery insertion and tool initialization for the sterile VCD and the sterile Pointer Note The initialization of any tool is c
22. ation disc with the point tip of the tool and press SELECT on the VCD to con firm Upon completion the tool is ready for navigation Calibrate Conventional Instruments 91 92 Navigation Views 13 Navigation Views A kna ge rey BIX E Hepie F Wri Navigation Irajectorie oe Taj No Trajectory MUN Phwiar 3 0 No anatomical Sys Pointer Smali Navigation x i No Trajectory Pack Nat Multiplanar views The Multiplanar 3 D view dis plays an additional 3 D image with opague or translucent sur face properties The Multiplanar Video view displays an additional image from a defined video input device not illustrated Target view The Target view reguires a planned and active trajectory with target point The target point position of the currently active trajectory is shown in a Multiplanar view The location of the tool axis is projected onto the fixed image planes In addition a cone displays the position and alignment of the tool axis with respect to the target Screw view The Screw view requires a planned and active screw The three 2 D images of the Screw view are based on the active screw and display image planes along 0 of the screw axis along 90 of the screw axis and an image plane perpendicular to the screw tip In addition a cone displays the position and alignment of the tool axis with respect to the target Tool s Eye 3 D The Tool
23. ce refmement es NN J It adunata Do you want to improve the point to point registration with surface refinement 52 Step 4 Select surface refinement Surface refinement surface matching is recommended in order to improve registration accuracy To proceed with surface refine ment gt Confirm Yes by using the awl s SELECT button Surface matching overview Surface matching surface refine ment is an additional registra tion option Surface matching can be selected after the inital point registration process is completed With surface matching the accu racy of the initial point registra tion can be improved Step 1 Select image set gt Select the CT base image series with bone surface by using the awl s control but tons Step 2 Adjust surface level optional gt Make sure that the displayed 3 D image matches the bony surface of the spinal column If required gt Hightlight and confirm the Adjust Surface Level button To adjust the surface level gt Hightlight and select the or the button Upon completion gt Highlight and select the gt button to proceed with surface point digitization Step 3 gt e Surface Retinement Registration saja Image Set Selection gt et l la Surface Refinement gt e ye meme Surface Refinement on CTO1 2 3 4 a Image Set Selection Adjust Surface Level 4 Cancel Adju
24. ck 1 If required limit the segmen HAH tation space by moving the boundaries of the rectangular segmentation box displayed in the 2 D and 3 D views Use tolerance 2 Set the crosshair cursor into an area showing tissue to seg ment 3 Select the Start button The structure of interest is seg mented Finish 4 Assess the visibility and bor ders of the segmented struc ture in the 2 D and 3 D views If the structure of interest is seg Automatic Tumor Segmentation mented with imperfect borders 2 To change the size of segmented gt Move the Tolerance slider tissue adjust the tolerance A Tolerance 10 until the structure of interest 55 has reached its optimal Vis 3 To change the current area click Replace To segment another area ibility click More Replace If the structure of interest is seg mented partially and not suffi ciently connected to be segmented in one instance gt Add a new portion to the structure already segmented by clicking the More button and by repeating the Segmen tation dialog Finish gt Once the structure is satis factorily segmented click the Finish button to finalize and save the segment More Cancel Planning Features ad as Mana Tomes epee sree 23 Planning Features CT01 THORAX W 3 0 B41 Soft Tiss A EH Image Correlations Screws Measurements f Annotation Points H A AH Planes a New Plane Plane
25. d straight tip calibration in combi nation with the rotational adapter Step 1 Prepare tools l Select the required conven tional tool Mount a NavLock adapter onto the tool Attach a tracker onto the NavLock Insert a sterile battery into the tracker not illustrated Make sure that the tracker s LEDs face towards the camera and press SELECT on the tracker to initialize Upon initialization an information box appears Highlight and select Track Instrument The Calibrate Tracker dialog starts Step 2 Initialize calibra tion device l Insert a sterile battery into the VCD not illustrated Make sure that the VCD s LEDs face toward the camera and press the SELECT button for three seconds on the VCD to initialize it Step 3 Select adapter gt Highlight and select Universal Adapter by pressing SELECT on the VCD Calibrate Conventional Instruments 1 An additional tracker is switched on Do you want to use it for Instrument or patient tracking ick Instrument Track Patient Cancel m e Calibrate Universal Tracker 1 2 Calibration Device Calibrate Femoral Tracker E S Sa Alversal Adapter Rotation Adapte 89 Calibrate Conventional Instruments 90 j Calibrate Universal Tracker OS a Calibrate Universal Tracker I 1 4 Calibration of straight tool tips Step 4a Select calibra tion method gt High
26. dicated instruments have to be initialized In order to correlate the images with the patient s anatomy the registration points defined during registration planning have to be digitized at the site of operation Step 1 Position patient prepare patient and Incision 1 Position and prepare the patient in accordance with the standard protocol 2 Verify the surgical levels clini cally or radiographically and make the incision ensuring adequate exposure Step 2 Fixate spine clamp and spine tracker 1 Fixate the Spine Clamp firmly onto the spinous process of the vertebra that will be regis tered and instrumented first 2 Attach the Spine Tracker onto the Spine Clamp and align it line of sight to the camera 3 Verify the stability of the con nection between the Spine Clamp and the spinous pro cess again Registration 47 Registration 48 When attaching and aligning the Spine Tracker gt Ensure that the Spine Tracker set up is not a tower for mation The Spine Tracker should be turned down towards the patient s back gt Ensure that the LEDs of the Spine Tracker are facing towards the camera Set up system The System Setup Dialog requests the initialization of sterile tools for the registration process The following tools are recommended e Spine Tracker e Vector Calibration Device VCD e Navigated Awl Instead of the Navigated Awl a Long Pointer can be used
27. e Tracker and the segment to be instrumented If the connec tion between Spine Tracker and the instrumented segment is not rigid navigation accuracy may be compromised It is recommended to verify the calibration accuracy of the adapted Jam Shidi needle between each k wire insertion using Hot Spot validation To perform a Hot Spot validation touch the center of one of the VCD s validation discs with the tip of the Jam Shidi needle and press the SELECT button of the Universal Tracker 87 Calibrate Conventional Instruments 12 Calibrate Conventional Instruments Overview SpineMap 3 D software facilitates the integration of conventional instruments e NavLock Adapter e Screwdriver e Tracker e Universal Tracker or e Femur Tracker or e Tibia Pelvis Tracker e Calibration Device e Vector Calibration Device VCD or e Point Calibration Device PCD There are two different calibration methods Straight Tip Calibration for tools with a straight tip e Angle Tip Calibration for tools with an angled tip or for tools with a tip shaft too wide for the opening of the VCD Note The VCD supports straight tip calibration of rigid instruments with an axis diameter varying from a minimum of 2 mm to a maximum of 15 mm The mini mal length of the straight part of the instrument s shaft to be straight calibrated is 45 mm The PCD supports angle tip cali bration of rigid instruments an
28. e Change button and change the weight of the fused image sets in the 2 D view available only from the 2 D tab gt Deselect image sets and other items from the 2 D or 3 D view b Change the selected item s opacity in the 2 D and 3 D view gt Change the selected item s brightness in the 3 D view available only from the 3 D tab Anatomical system cre ation The anatomical system feature provides the possibility to create multiple anatomical systems per each series Step 1 Select image set gt Click the New button and select the required image set Step 2 Rename and store anatomical system 1 Type in a anatomical system name 2 Click the Rename button Planning Features AB rece cement age rr te 7 T Seer Se 0 Ss aan 7 daa fe Tanoe Ra An ah DC S101 JATERIEL PORTAL o B MLoedtariaa a Anaa kab fanm ET OS Sern B Marine Di imiia Feet Da Planes E Tremi a 3D Modal Sh Cepia E Iarsamihbesi 39 40 Planning Features Joe Step 3 Adjust anatomical 0 Say aan i system BC 6101 AATERIEL PORTAL careless The software allows the current position of the cursor to be taken as the center point of the anatom ical system 1 Set the cursor to the desired position and click Set Origin to set the center point of the anatomical system 2 Click and move the arrows in the 2 D views to adjust the anatomical system Reset and delete anatomical system
29. e not to puncture the C Arm drape 2 Digitize the remaining marked inserts Image Acgulsiticn 13 74 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Note The digitization accuracy is displayed on the C Arm s control panel If the digitization accuracy is within the accepted tolerance the system is ready for image acquisition Acceptable digitiza tion accuracy values are lt 0 5 mm Step 4 Acquire image gt Start and complete the scan without interruption Caution Do not move the camera or C Arm during image acquisition For accurate C Arm digitiza tion and uncompromised image quality patient movement has to be avoided during C Arm digitization and image acquisi tion In certain cases it might be appropriate to control patient movement by initiating a brief non ventilated phase for the time of C Arm digitization and image acquisition It is the responsibility of the surgeon to consider the particular conditions of the patient and to decide whether such actions are necessary appropriate and safe Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 5 Transfer and reg Image Acquisition ister images are a pe For Ziehm 3 D C Arms the 4 Digitized images are transferred automati ag arm ready for d cally to the navigation system as soon as the scan is complete E mn acquisition has been finished The images are registe
30. ed ae compositions can be recalled for navigation during surgery Volume By default the software automati cally creates a composition named All segments that incorporates all segments trajectories planes and a fusion composition for each pair of correlated image sets Step 1 Select image set and segment gt Click the Compose button mma and select the image sets and Ae acon note other items required for the Sane image composition cari Step 2 Rename and store composition 1 Select the Store button and type in a composition name 2 Select the OK button to confirm Upon confirmation the composition is stored and available for navigation Planning Features pE cTit lusii Bean 37 Planning Features E CT01 ARTERIEL PORTAL MI Local Correlations iP Anatomical System A Screws Measurements E Annotation Points om Planes Trajectories i ID Modal fe Compositions BE Store as a new composition fe All Segments Hi Screenshots 2 E EF rm p E fff bs fe Compositions All Segments 3D CTO1 ARTERIEL PORTAL Volume Bone i Opacity Bnghtness 38 Step 3 Adjust composi tion The software enables a detailed adjustment of the intensity of the image sets and the opacity and brightness of the selected items gt Double click Compositions in the patient record tree and select the desired composi tion In the Compositions tool panel b Select th
31. ed by Stryker Navigation 4100 East Milham Avenue Kalamazoo MI 49001 USA t 1269 323 7700 f 800 999 3811 USA only toll free 800 253 3210 USA only ml Manufactured and distributed by Stryker Leibinger GmbH amp Co KG Botzinger Stra e 41 D 79111 Freiburg Germany t 49 761 4512 0 f 49 761 4512 120 www stryker com C 1275
32. eon should consider the particular condition of the patient and perform the necessary adjustments if reguired Safety and caution should always be utilized before proceeding Table of Contents 10 11 12 13 14 15 16 Set Up System and Log In Refer to Imaging Protocol Import Image Sets Confirm Patient Data Planning Features Registration Planning Set Up System Registration Pedicle Screw Navigation Insert Pedicle screw Navigated Minimal Invasive Spine Surgery with Intraoperative Calibrate Conventional Instruments Navigation Views Additional Navigation and Documentation Tools Part List Index 11 12 41 45 47 56 64 66 88 92 94 98 101 Set Up System and Log In 1 Set Up System and Log In Knee Navigation Hip Navigation gt iNtellect Cranial Navigation gt OrthoMap 3D gt SpineMap 3D Navigation System 1 Plug in the main power cable of the navigation system 2 Press the main power button on the front panel of the navi gation system 3 Enter the user name naviga tion and press the Enter key or use the left mouse button to click the OK button 4 After Application Manager start up use the mouse to select SpineMap 3 D Note The system setup can be com pleted by the OR support staff prior to operation Refer to Imaging Protocol 2 Refer to Imaging Protocol Stryker SpineMap 3 D naviga tio
33. eon to consider the particular condi tions of the patient and to decide whether such actions are neces sary appropriate and safe Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 4 Transfer and EEA 7 register image Dipitize C anm 1 Digitized 2 Digitized For Siemens Arcadis Orbic 3 D 2 Digitized the images are transferred auto 5 matically as soon as the scan is complete Nae und fan Image transfer Is in progress acquisition has been finished For Siemens Siremobil Iso C 3 D the scans have to be trans ferred manually using the C arm s control panel The images are registered auto matically After image transfer the Confirmation dialog starts Step 5 Adjust window level width optional If required gt Highlight and select the lt icon to change the window level of the 3 D image while touching the patient s anat Image Acquisition Pe eH omy with the pointer i gt Highlight and select the 4 a Ld icon to change the window E width of the 3 D image while touching the patient s anat KS Nias omy with the pointer 19 80 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 6 Confirm image To verify the registration accu racy 1 Touch accessible bony land marks with the pointer s tip 2 Compare the actual tip loca tion with the reported loca tion on the images If the accuracy
34. gt Click the Reset button to set the anatomical system back to the initial status gt Click the Delete button to delete the current anatomical system Note All anatomical systems created by the user can be deleted Registration Planning 6 Registration Planning Image based navigation requires a CTO1 Nema8 1 03 BWSI LWS 1 0 to correlate the image series and von io 2 New Reference Point Set Point Set 1 the patient s anatomy This pro y Surface Matching cess is called registration The mandatory point registration planning process requires the definition of reference point sets on the CT base image series Point registration planning overview Step 1 Tool Panel Activation gt In the Patient Record Tree P7 Delete View double click the CT base image series and select Biana Be i F arma derah oi D romances GD i the New Reference Point Set as ina oTrence Points item 1 i Name Point Set 1 3 s Define a minimum of 3 reference points for i i registration To increase registration accuracy gt Upon selection the Refer ence T J 4 Henna Shy ate ae ine a i 5 connected structures in the image set P oints Tool P anel app ears i m i 1 Y including points close to the target of surgery Step 2 EKA ee Reference Point Definition 5 3 ay Taa al Set Point 3 1 Determine the first vertebra to Nei ma Set Point 4 be instrumented 2 Set the cross h
35. ic matching gt Visually verify the suggested result of the automatic match ing process by using well known landmarks If the correlation is acceptable gt Confirm the result by clicking the checkbox If automatic image correlation is not acceptable gt Perform the Manual match ing or activate the Landmark matching dialog and repeat the image correlation In order to become w Planning Features Confirmed 15 Planning Features 8 ct cm tere Serene cue 2 2 X Local correlations It is also possible to define corre lation regions that are correlated to the selected navigation base series Warning Different patient positions during imaging and movement of soft tissue may result in compromised image correlation accuracy To achieve adequate correlation for the bony structures of interest manual matching correction may be required by a method such as landmark matching Guidelines for local correlation regions For adequate results follow these guidelines Do not include any adjacent anatomy into the region that is connected by a joint to the target anatomy The position of the adjacent anatomy may be different in each image set Only include bony anatomy in the target region because the position of soft tissue may be different in each image set The bounding box for defin ing the local correlation should be scaled down in all space directions so that only a
36. ight tip calibration T Tap Target View Tibia Pelvis Tracker Tolerance slider Tool s Eye View Tracker Track Instrument Trajectories Tumor Vasculature User Defined Segmentation U Universal Tracker USB User defined view User name V Vector Calibration Device Virtual Tip Length 21 46 90 60 92 88 23 93 88 89 12 28 23 88 93 4 46 88 84 W Window Width Level Index 103 The information presented in this brochure is intended to demonstrate a Stryker product Always refer to the package insert product label and or user instructions before using any Stryker product Products may not be available in all markets Product availability is subject to the regulatory or medical practices that govern individual markets Please contact your Stryker representative if you have questions about the availability of Stryker products in your area Stryker Corporation or its divisions or other corporate affiliated entities own use or have applied for the following trademarks or service marks SpineMap Stryker OrthoLock Literature Number 6002 660 790 Rev A 2010 07 15 Copyright 2010 Stryker Printed in USA stryker Joint Replacements Trauma Extremities amp Deformities Craniomaxillofacial Spine Biologics Surgical Products Neuro amp ENT Interventional Spine Navigation Endoscopy Communications Imaging Patient Care amp Handling Equipment Distribut
37. ing towards the working area 2 Plug in the main power cable of the navigation system 3 Press the main power button on the front panel of the navi gation system 4 Enter the user name naviga tion and press the Enter key or use the left mouse button and click the OK button 5 After Application Manager start up use the mouse to select the SpineMap 3 D button Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Prepare patient For 3 D image acquisition and automatic image registration a Spine Tracker must be fixated to the spinous process of the verte bra that will be instrumented first Step 1 Position patient prepare patient and inci sion 1 Position and prepare the patient in accordance with the standard protocol 2 Identify the correct level that will be instrumented first for example by acquiring an AP image 3 Make a minimal invasive key hole incision above the spinous process of the iden tified level to enable Spine Clamp fixation 67 68 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 2 Fixate spine clamp and spine tracker 1 Fixate the Spine Clamp firmly onto the spinous process of the identified vertebra 2 Attach the Spine Tracker onto the Spine Clamp and align it line of sight to the camera 3 Verify the stability of the con nection between the Spine Clamp and the spinous pro cess again AN Cauti
38. instruments Navigation tools icon overview Zoom In Zoom Out To zoom in out the images Additional Navigation and Documentation Tools Rotate 3 D To rotate the 3 D model to the side where the tool is pointing to Cut 3 D Image To cut open the 3 D image at the current tool tip position Set Annotation To set an annotation point Show Hide Annotations To show or hide annotation Show Hide Measurement To show or hide measurements Intraoperative Distance Measurement To set an intraoperative distance measurement Intraoperative Angle 3 Point Measurement To set an intraoperative angle measurement by three points Intraoperative Angle 2 Line Measurement To set an intraoperative angle measurement by two lines Show Hide Screws To show or hide screws Show Hide Plane To show or hide planes Freeze Image To freeze unfreeze the image A frozen image is static without the tool position being updated not illustrated Screenshot To capture the image box The image is stored in the patient s archive directory Browse Images To browse through all 2 D images of the selected image set 95 Additional Navigation and Documentation Tools 96 Navigation tools icon overview Flip To flip images Rotate To rotate images Rendering Setting of the rendering method iso phong x ray Ab Santi me een PIC Navigation x Trajectorias Mo Trajectory ir dp
39. is satisfactory gt Highlight and select the Accept button and proceed AN Caution Always confirm registration accu racy by using multiple landmark tests The surgeon must be com fortable with the accuracy before proceeding Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Minimal invasive pedicle screw navigation Calibrate Jam Shidi needle SpineMap 3 D software facilitates the integration of conventional instruments such as a spinal needle For conventional instru ment integration a NavLock adapter a Universal Tracker and a calibration device are required Step 1 Prepare tool 1 Select the required Jam Shidi needle 2 Mount a NavLock adapter onto the Jam Shidi needle not illustrated 3 Attach a Universal Tracker onto the NavLock 4 Insert a sterile battery into the Univeral Tracker not illus trated 5 Make sure that the Universal Tracker s LEDs face towards the camera and press and hold the tracker s SELECT button to initialize Upon initializa tion an information box appears 6 Press the tracker s SELECT button to confirm Track Instrument The Calibrate Universal Tracker Dialog starts An additional tracker sweched on Do you want 10 use it for Instrument or patient tracking Track tument Track Patient Cancel 81 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 2 Select adapter Calibrate Femoral Tr
40. ish or press and hold to reset v Extend P J aes I Trajectories No Trajectory APU Define Ent A A Target dist Hi 4 d l fu Fa T Y Oi w Virtual Tip Tool s Eye 3D No Anatomical Sys g Compositions Base Set CTO1 Compose Pointer Small Back Net 84 Step 1 Select view optional gt Select the desired view by using the VCD s SELECT button The Tool s Eye 3 D View is com monly used for minimal invasive screw navigation Tool s Eye 3 D View consists of three 2 D images reconstructed with respect to the tool axis along 0 along 90 and perpendicular to the tool axis and one 3 D image Step 2 Extense virtual tip optional For navigating Jam Shidi needle insertion Step 3 virtual tip extension might be helpful 1 Use the VCD s SELECT button to select the Virtual Tip Length button An adjust ment bar will appear 2 Turn the VCD s SELECT button down to extend the virtual tip 3 Press the VCD s SELECT button to finish the virtual tip extension Note Extending the virtual tip is per formed in 5 mm steps shortening is performed in 1 mm steps Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 3 Insert Jam Shidi needle With the calibrated Jam Shidi needle the insertion can be navi gated The virtually extended tip allows the user targeting of the the desired pedicle entry point and alignment and inser
41. ive network drive or media such as a USB memory stick 98 Part List 15 Part List Anchoring devices Percutaneous Spine Clamp Short Percutnaeous Spine Clamp Long Short Spine Clamp 4 inch Long Spine Clamp 6 inch Revision Pin 12 mm Revision Pin 18 mm ji OrthoLock Anchoring device area OrthoLock Ex Pins 3 110 4 150 me 6007 00x xxx Navigation Pins 3 100 3 150 4 100 Navigation locking adapters 6000 999 002 NavLock 2 7 6000 999 003 NavLock 7 13 6000 999 004 NavLock 13 20 6000 999 005 NavLock 20 27 6002 050 000 Rotational Navigation Adapter SpineMap 3 D Navigation Software 2 0 6002 660 000 Navigation platform Navigation System II 7700 100 000 eNlite 7700 300 000 Remote Planning Station 7700 010 000 Navigated tools 6000 012 000 Short Pointer Pedicle Feeler 6002 300 000 Thoracic Pedicle Feeler 6002 350 000 Spine Tracker 6002 005 000 Universal Tracker 6000 005 000 Part List 99 Part List Calibration devices 6000 008 000 Vector Calibration Device VCD 6000 010 000 Pointer Calibration Device PCD Accessories 100 16 Index Symbols 3 D C Arm image 3 D Model 3 Point Method A Anatomical system Angle 2 lines Angle 2 Lines Measurement Angle 3 point Angle 3 Point Measurement Angled tool tips calibration Angle Tip Calibration Annotation points Annotation Points Application Manager Automatic adjust Automatic
42. le the distal center point of a bone shaft Select the Set Axis Point 2 button to record the position A plane perpendicular to the digitized axis is displayed P Select the Plane Oriented tab A 3 Make sure that the plane and bony intersection mark the resection line appropriately If required gt Adjust the shape Ellipse Rectangle the size Size X Size Y the opacity and the rotation of the plane using the radio buttons and the sliders Planes Type Name Plane 1 Image Set CTO1 Set Axis Point 1 Set Axis Point 2 Move plane along axis Shape e Ellipse Rectangle Size X size Y Opacity Rotation Planning Features ap aw oe FF ry E Toni E S HO Mada uA piap W 44 2 en brpa x 25 Planning Features To assess plane position and ori entation gt Grab and move the handles of the red dotted line and assess the margins of the planned resection plane If reguired gt Move the plane along the digitized axis to the desired position using the Move plane along the axis slider or by grabbing the plane gt Change the orientation of the plane by grabbing and moving the axis points Note Click the icon to hide or display all planes To navigate planes a composition including the plane has to be cre ated and recalled for navigation 2 3 Point Method a PI ee TA ee BD a a 0 Opera yg a e 1 Set the crosshair curs
43. light and select Straight Tip using SELECT on the VCD Step 5a Straight tip calibration 1 Insert the straight tool into the opening of the VCD 2 Make sure that the tool is centered and touches the base of the device 3 Make sure that both the VCD and the tool are visible and centered in the working space of the camera 4 Press SELECT on the VCD to calibrate the straight tool tip To validate the straight tool tip calibration gt Touch the center of any of the VCD s validation discs with the tip of the tool and press SELECT on the VCD to con firm Upon completion the tool is ready for navigation Note In case of a chisel tip make sure that the chisel tip is centered in one of the validation disc s crosshair slots for validation If the chisel tip is not centered cali bration may fail Calibrate angled tool tips Calibrate Universal Tracker Step 4b Select calibra DN tion method For point tip calibration of angled tools gt Highlight and select Angled Tip using SELECT on the VCD Step 5b Calibrate point tip 1 Touch the center of one of the VCD s validation discs with the point tip of the angled tool 2 Ensure that both the VCD and the tool are visible and cen tered in the working space of the camera 3 Press SELECT on the VCD to calibrate the point tip of the angled tool To validate the point tip calibra tion gt Touch the center of the other valid
44. matching Automatic segmentation Automatic Segmentation button Axis Method Bone Segmentation Bounding box 73 12 30 26 13 39 33 34 2 34 91 88 35 96 13 15 19 22 21 29 22 C C Arm 3 D scan Composition Compositions CT image set Documentation tools Entry point Femur Tracker Image browser Image orientation Image orientation label Image set Image Set Correlations Image Sets dialog Image set size Import 3 D Model Import button Index 69 37 13 96 58 88 97 30 10 101 Index J Jam Shidi Needle K K Wire L Landmark matching dialog Length Length measurement Local Correlation Manual matching Measurement Measurements Media Memory stick Minimal invasive Multiplanar Views Navigation tools NavLock Adapter Network 102 85 86 86 15 20 33 34 12 16 15 20 33 13 66 92 94 88 P Patient data Patient dialog Pedicle pathway Pedicle screw Pedicle screw navigation Plane creation method Planes Planning dialog Point Calibration Device Point tip Position system Power button Ram indicator Registration S Screenshots Screwdriver Screw Oriented Tab Screws Screw View Segmentation 11 12 59 64 56 24 12 24 12 88 91 45 47 97 88 32 13 31 93 12 21 Segment types Slices view Start up system Stra
45. n software requires a CT image set as a basis for navigation If required additional image sets of different modalities can be fused with the CT base images gt For navigation efficiency and accuracy follow the recom mendations for image acquisi tion as depicted in the Stryker SpineMap 3 D Imaging Protocol Stryker SpineMap 3D Navigation CT MRI Imaging Protocol Scan Basics stryker Uk No obligue angle of Axial scan from INFERIOR to SUPERIOR Scan including one vertebra locator survey lines DO NOT above and below vertebra e No gantry tilt CT scan from SUPERIOR to INFERIOR of interest Scan Parameters All images must have same series ID Field of View FOV to encompass the region of interest Slice thickness 1 mm best 3 mm maximum contiguous no gap no overlapping Pixel Matrix MUST be square 512 x 512 best 256 x 256 minimum CT soft tissue windows if helical reconstruct in axial slices MRI TI or T2 Axial 2D SINGLE echo ONLY Patient Positioning Patient SUPINE FEET FIRST Contrast agents may be used before scanning The information in this brochure is intended to demonstrate a Stryker product Always refer to the package insert product label and or user instructions before using any Stryker product Products may not be available in all markets Product availability i
46. n the Plan ning dialog depend on the selec tion made in the Patient dialog Image Set Correlations Fuse multi modal images such as CT and MRI Local Correlations Select a local correlation region with an adjustable box Segmentation Accentuate anatomical struc tures of interest such as aberrant anatomy soft tissue tumors bone surfaces and vessels Planes Plan and assess resection planes and the required margins Trajectories Plan and assess surgical trajecto ries 3 D Model Display imported 3 D models inserted into section and 3 D images Planning Features Anatomical System Anatomical System ryker Create multiple anatomical sys tems per series Screws Plan and assess screws that may be required for reconstruction Measurements Measure distances and angles Annotation Points Measurements Stryker Mark points of interest and add personal notes Compositions Create image sets displaying image modalities segments and planned items in a way best suited for the intended intervention TTT ara 25 CJ es E i pe i 13 14 Planning Features Image Set Correlation oe a Verify if the anatomy contained in each series corresponds precisely with the anatomy in the overlay display To correct the correlation use one of the following methods Automatic matching Landmark matchinc Identity matchinc Indirect correlation Manual matching is pos
47. n these lines Aen Name A Oi a an gt Define and record the start Image Set CTOT 4 HAN and end points of two lines Set Line 1 Start Point Show For angle calculation the two Set Line 1 End Point Show lines are projected in one plane Set Line 2 Start Point Show Set Line 2End Point Show 6 PM ng i i 4 If required s merane RE gt Redefine the Angle 2 lines Outer angle 967 0 da measurement by grabbing and moving the start and end point of the two lines 3 Angle 3 Point Measurement P4 Measurements gt Define and record the vertex he Sere Oe eo cone a the start and the end point of measure an angle the angle Name ART i sh dh Jet Image Set CTO1 TE If required Set Vertex Point Show j re N gt Redefine the Angle 3 point SetEnd Point Show An Si roe n measurement by grabbing and SetEnd Point Show gee fp NP ee wi moving the start the vertex and the end point of the angle Inner angle 136 4 Be ega poate Jans Outer angle 223 6 q 2 y 5 id a 4 i tart Tn nee an Note Use the icon to hide or display all measurements Annotation points cre ation CT01 ARTERIEL PORTAL Local Correlations Anatomical System Screws 2 Measurements f Annotation Points B New Annotation Point DHAA ew Step 1 Activate tool panel Trajectories 3 D Model Compositions gi Screenshots HE sl E 1 Select the image set in which an annotation
48. n with a tap SpineMap 3 D software facilitates the integration of conventional instruments For conventional instrument integration a NavLock adapter a Universal Tracker and a calibration device are required Step 1 Prepare tool 1 Select the required tap 2 Mount a NavLock adapter onto the tap not illustrated 3 Attach a Universal Tracker onto the NavLock 4 Insert a sterile battery into the Univeral Tracker not illus trated 5 Make sure that the Universal Tracker s LEDs face towards the camera and press and hold the tracker s SELECT button to initialize Upon initializa tion an information box appears 6 Press the tracker s SELECT button to confirm Track Instrument The Calibrate Universal Tracker Dialog starts Step 2 Initialize calibra tion device 1 Insert a sterile battery into the Vector Calibration Device VCD not illustrated 2 Make sure that the VCD s LEDs face towards the camera and press and hold the VCD s SELECT button to initialize Note VCD initialization is only nec essary if the Point Calibration Device PCD has been used for system set up If the VCD has already been intialized and used this step is automatically skipped by the software Step 3 Select adapter gt Highlight and select Universal Adapter by using the VCD s SELECT button Pedicle Screw Navigation 61 Pedicle Screw Navigation Calibrate Universal rocker Step 4
49. o import the selected image set 1 Select the Import button 2 Accept the confirmation mes sage gt Proceed to Planning gt Import more image sets If required import additional image sets for this particular patient gt Select the desired additional image set from the media content tree gt Repeat steps 1 and 2 If all required image sets are imported b Select the Next button to proceed 4 Confirm Patient Data Step 1 Confirm patient data gt Confirm patient data listed at top of the screen John Miler If patient data needs to be changed or added 1856 01 01 1 Select the Update Patient Data link The Update Patient Related Data window is opened ame Of Smith 2009 04 22 11 40 33 2 Change or add patient data Note Date of birth is mandatory in order to ensure unique patient identification If required add the correct date of birth Step 2 Select surgery direction 1 Select the surgery direc tion required for the current patient Step 3 Select planning features 1 Select the planning features required for the current patient 2 Select the Next button to proceed Confirm Patient Data 11 12 Planning Features 5 Planning Features Stryker 3 D Model Overview SpineMap 3 D software offers a vast selection of dedicated plan ning features The planning features add functionality to navigation The features available i
50. odel should be imported in the drop down menu 3 Click Import Model and choose the 3 D model that should be imported 4 Move crosshair cursor to the desired position and click Set Rotation Center to set the rotation center of the 3 D model 5 Check the size and geometry of the 3 D model If necessary position the 3 D model to the desired position 6 Click the Confirmed checkbox to confirm 3 D model Screw creation Step 1 Activate tool panel 1 Select the image set in which a screw is to be defined by click ing the image set item in the patient record tree 2 Double click Screws and select New Screw Upon selec tion the Screws tool panel is displayed Step 2 Define head and axis point 1 Set the crosshair cursor on the desired screw head position 2 Select the Set Head Point button to record The view changes automatically to Screw Oriented 3 Set the crosshair cursor on the desired screw axis position 4 Select the Set Axis Point button to record Note Click the icon to hide or dis play all screws S CTO1 Bekken 0 6 B10s CTO2 Bekken 0 6 B60s Image Correlations Screws New Screw Screw 1 Measurements Annotation Points Planes Trajectories te Compositions gi Screenshots E A o a E A E aA Ha Create v Delete Screws Length lt gt 40mm Diameter gt 6 5mm Suggested L40mm D65mm Set Head Point Set Axis Point Planning Featu
51. oft tissue movement may result in errone ous navigational information of the segmented soft tissue anat omy For each segment a safety margin can be defined During navigation the software warns surgeons visually and audibly as soon as the navigated tool tip enters this safety margin Step 1 Define segment type 1 Double click the image set that best shows the volume of interest for example CT for bone segmentation and MR for tumor segmentation 2 Select New Segment below the selected image set Upon selection the Segmentation tool panel is displayed gt Select one of the pre defined segment types from the pull down menu Bone Tumor Vasculature or User Defined The Segmentation tool panel is expanded gt Select the Automatic Segmen tation button stryker Pte Ti Sb a v O H H A 4 Dee ee 1 Plowing f A P CT01 ARTERIEL PORTAL SF New Segment Local Correlations Anatomical System Screws Measurements Annotation Points Planes Trajectories 3 D Model Compositions Te All Segments m Screenshots KI Segments Ty H B Choose Choose Type Please sele PONE Tumor Depending Vascul atu re provide the User Defined segmentation kill Segments Ty a E Name Margin Volume Bone 1 Automatic Segmentation Varn if navigated tip is about to collide with this segment Ka TA THs i ai grr Teh TA me a ii ir a at j Planning
52. on The metal of the Spine Clamp and Spine Tracker may compromise the intraoperative 3 D C arm image quality When attaching and aligning the Spine Clamp and the Spine Tracker Ensure that they do not block the intraoperative x ray beam imaging the pedicles to be treated If the field of view of the x ray beam contains the entire Spine Clamp and Spine Tracker a tower set up and alignment inbetween the disc space of the vertebra used for Spine Clamp fixation and the inferior neigh boring vertebra might be appro priate Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Start up C Arm 3 D scan Stryker SpineMap 3 D naviga tion software supports automatic registration of intraoperative 3 D images of the following C Arms e Siemens Siremobil Iso C 3 D e Siemens Arcadis Orbic 3 D e Ziehm Vision Vario 3 D e Ziehm Vision Vario FD 3 D Step 1 Initiate 3 D scan To start navigation with intraop erative 3 D C Arm images b Select the Start C Arm 3 D scan link from the Home page Step 2 Select 3 D C Arm gt Select the C Arm manufac turer Siemens or Ziehm Note Step 2 is skipped by the software if the Navigated 3 D scan option is selected on the C Arm s con trol panel With this setting the C Arm type is detected automati cally by the software Step 3 Confirm 3 D scan gt Select Scan Intra operative to initiate intraoperative 3 D C Arm image acquisition Rel
53. onfirmed by an audible chime and a check mark in front of the software button For a Siemens 3 D C Arm a C Arm Tracker has also to be initialized 71 72 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Validate Pointer Small Step 2 Validate pointer Upon initialization of the pointer the Validate Tool window appears on the screen gt Touch the center of one of the VCD s or PCD s valida tion disks with the tip of the pointer and press SELECT on the pointer to confirm Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Acquire Ziehm 3 D C Arm image Step 1 Position C Arm 1 Bring the C Arm into position for image acquisition 2 Follow the instructions on the C Arm control panel and perform a collision check for the complete rotation of the C Arm Note The collision check is mandatory and requested by the 3 D work flow of the C Arm Step 2 Align camera gt Align the camera in sucha way that the patient tracker is visible and that the C Arm s image intensifier is within the camera s working space Step 3 Digitize C Arm Before starting gt Ensure that the patient does not move during C Arm digitization and image acqui sition On the image intensifier there are three marked inserts to be digi tized 1 Using the pointer touch the center of a marked insert and press SELECT on the pointer to record Make sur
54. or on 5 the first point of the intended ane 1 1 gt Anaomba Image Set CTOI N 5 Penuaan plane SetPlanePointf S gt ae 2 Select the Set Plane Point 1 Set Plane Point 2 Z a ee a button to record the position 3 Points Set Plane Point 3 3 Define and record the second and third points of the intended plane A plane defined by the three digitized points is displayed 4 Select the Plane Oriented tab 5 Make sure that the plane and bony intersection mark the resection line appropriately 26 Planning Features If required gt Adjust the shape Ellipse fo Rectangle the size Size X mage Set CTOI Size Y the opacity and the Set Plane Point 1 rotation of the plane using the Set Plane Point 2 radio buttons and the sliders Set Plane Point 3 To assess plane position and ori entation gt Ensure that the crosshair cursor does lie on the plane by clicking any Show button of the tool panel gt Grab and move the handles of the red dotted line and assess the margins of the planned resection plane Move the plane along the digitized axis to the desired position using the Move plane along the Ellipse Rectangle JIZe axis slider or by grabbing the 5 plane ee Rotation If required gt Change position and orienta tion of the plane by grabbing and moving the plane points Note Click the icon to hide or display all planes To navigate planes a composition
55. point is to be defined by clicking the image set item in the patient record tree Create v Delete 2 Double click Annotation Points and select New Anno tation Point The Annotation Points tool panel is displayed Planning Features 35 36 Planning Features Pe Annotation Points Name Point 1 Rename Image Set CTO1 Set Point Show Point Warn if navigated tip is about to collide with this annotation Margin Value Description Description BOE 6101 Lumbar Bean Step 2 Define annotation point 1 Set the cross hair cursor on the landmark or area of inter est to be annotated 2 Select the Set Point button to record If required gt Rename and add values or descriptions to the annotation point Note The Value and Description fields can be used for any purpose The information stored in these fields has no further function in the software For each annotation point a safety margin can be defined During navigation the software warns surgeons visually and audibly as soon as the navigated tool tip enters this safety margin Click the icon to hide or dis play all annotation points Composition creation pg KA Compose M Store TA Pa CT01 THORAX VV 3 0 B41 Soft Tissue The compositions feature facili tates overlaying fused image valine sets segments trajectories and bate planes in a way most suited for MRO1 T2 TSE AXIALS SFOV HR PEL the intended procedure Creat
56. red auto matically After image transfer the Confirmation dialog starts Step 6 Adjust window level width optional If required gt Highlight and select the x icon for changing the window level of the 3 D image while touching the patient s anat omy with the pointer image Acquisition 2 45 i Pe eH gt Highlight and select the 4 peel icon for changing the window width of the 3 D image while l n r P Ea i Ke i touching the patient s anat ii f rp omy with the pointer TAT f Fe ee Dectease Finish of prese and hold to reset v Increase Note a jer To adjust window level width is ge PA RB also possible by using the right ks ae n mouse button and move the cursor up down or left right 15 76 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 7 Confirm image To verify the registration accu racy 1 Touch accessible bony land marks with the pointer s tip 2 Compare the actual tip loca tion with the reported loca tion on the images If the accuracy is satisfactory gt Highlight and select the Accept button and proceed Caution Always confirm registration accu racy by using multiple landmark tests The surgeon must be com fortable with the accuracy before proceeding Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Acquire Siemens 3 D C arm image Step 1 Position C arm 1 Bring
57. res A Sara om een Peake CTENI Parka Kambang Fe tee L Correlations 4 iamais Spee Sere CTO Siryker Seabeone Phantom local Correlates 2 gt tamieried bye Serva ve lt i Screw o4 bo Aments Perr Trepectertes 31 Planning Features 32 Step 3 Adjust screw i CT rier Geabens Phares a wars Gita gt Grab and move the handles of the red line in Along 90 or Along 0 window and assess the screw position and orien tation slice by slice through a perpendicular cut If required gt Redefine the screw position and orientation by first select ing the Screw Oriented tab then grabbing and moving the screw tip the screw head or the entire screw gt Adjust the screw size the screw length and the screw head size using the sliders of the tool panel Note Click the icon to hide or display all screws Measurement creation There are three measurement tools One to measure lengths one to measure the angle between two lines and one to measure the angle created by three points Measurements can also be per formed intraoperatively during navigation by using the tracked instrument tip Measurements performed during navigation are added and stored similar to pre operative measurements Step 1 Activate tool panel 1 Select the image set in which a measurement is to be done by clicking the image set item in the patient record tree 2 Double click Meas
58. s subject to the regulatory or medical practices that govern individual markets Please contact your Stryker representative if you have questions about the availability of Stryker products in your area Stryker Corporation or its divisions or other corporate affiliated entities own use or have applied for the following trademarks or service marks Stryker Ali otar tradem aria are Lradeenario of Us arapaki awia of bolder Article Mimika ann asa Tao Bee F Data Archiving Archive image data in an UNCOMPRESSED DICOM ONLY format on CD DVD Network Optical Disk or USB thumb drive Exclude scout localizer on archive Scan Review No motion artifact The region of interest is visible Patient image orientation is correct Technical ort US only t 877 IGS STRYKER 877 447 7879 Stryker Navigation 4100 East Milham Avenue Kalamazoo MI 49001 USA t 800 253 3210 800 999 3811 JE Stephen Leibing GmbH amp Ce KG Kiri Sex dl PAI Feur German a IHE Eri 731 iE 130 an at Import Image Sets 3 Import Image Sets Step 1 Select media Image data can be read from CD DVD Sony Maxoptix MO Disk USB memory stick or network Read image data from media gt Insert the media into the appropriate drive of the navi gation system SpineMap i P3D Navigation m eaa a AnA OE tT The software detects the media and new image sets automatically To start a new case using new image sets g
59. sible by dragging the handles in the images if the correlation is not confirmed T01 coronals S New Segment Tibia amp Fibula Bone Tumor CTO2 sagittal 7 MRO1 T2 STIR COR Image Set Correlations Pri nie E CTO1 MRO1 CTOL MRO i Local Correlations Anatomical System Measurements Planes fe Compositions Ki Screenshots AA A Image set correlations If two or more image series for the same patient have been imported the image correlation process can be started Warning Different patient positions during imaging and movement of soft tissue may result in compromised image correlation accuracy To achieve adequate correlation for the bony structures of interest manual matching correction may be required Step 1 Select series gt Select or deselect the pairs of series to correlate Note Only pairs of image sets can be correlated Automatic Lerrelation Dialog E Automatic Matching Step 2 Start automatic OTON MRO matching ylation in progress this wali take a ie ru Correlating The complete automatic matching process may take a few minutes For better visualization of the ongoing process the two image series are displayed in different colors gt Click the Automatic Match ing link to start the automatic matching process Note The matching process can be terminated manually if no further alignment takes place Step 3 Confirm automat
60. st the surface level to define the anatomical surface for registration refinement using and Cancel 53 Registration wae mar daa NN wakai wan Step 3 Digitize surface ae Yigitize Surface Poin point 1 Make sure that the Add Point button is highlighted 2 Move the tip of the awl along the surface of the vertebra on which the initial point reg istration was performed and press the awl s SELECT button repeatedly 3 Digitize at least 30 points Ensure that e The points cover prominent areas such as spinous process articular processes and trans verse processes e The points only cover the ver tebra with the Spine Tracker attached to and are spreaded out across all three dimen sions After a sufficient number of points are digitized gt Highlight and select the gt button to start surface match ing Step 4 Confirm surface Surface Refinement on CTM matching To verify the registration accu racy 1 Touch distinct landmarks of the registered vertebra with the awls s tip 2 Compare the actual tip loca tion with the reported loca tion on the images If the accuracy is satisfactory 3 Make sure that the Accept button is highlighted 4 Press the awl s SELECT button to confirm and to proceed with the surgery If required 5 Use the awl s control buttons to highlight and select the Reregister button 6 Repeat surface point digiti zation Step 3 and surface
61. stryker SpineMap 3D User Manual SpineMap 3D Navigation Software 2 0 Introduction Description of Symbols vy This user manual provides gen eral instructions on the use of the Stryker Navigation System soft ware for image guided computer assisted orthopaedic surgery It contains information on the planning navigation functions and the general concept of opera tions for SpineMap 3 D Naviga tion Symbol used in this document symbol AN Marks a warning or caution message MAA AM MMA Symbols used in the software Symbol il Marks an information message C Marks an error message A Marks a warning message User Group Medical Professional surgeon resident radiologist nurse professional caregiver For the reguired safety information and contraindications please refer to the SpineMap 3 D 2 0 Safety Information and the Imaging Protocol supplied with the software package as well as the instructions for use supplied with the system components Refer to documentation For detailed instructions and the reguired safety information related to the Anchoring systems Anchoring Pins Point and Vector Calibration Devices refer to the instructions for use supplied with these instruments For information related to the use of conventional instrumentation please refer to the user documentation supplied with each company s conventional instrumentation As with any technical guide the surg
62. t Select the Start New Case link from the Home page Jahn Mer 1955101 eae The Image Sets dialog is acti sera vated by the software and the new image series are automatically listed 28 Asesymiza Read image data from network The software automatically detects the image files available on the network To retrieve new image sets from the network gt Select the There are lt n gt new image sets link from the Home page The Image Sets dialog is acti vated by the software and the new John Miller 19560101 10 honed image series from the network are automatically listed To preview images gt Select the required image set from the desired patient listed in the media content tree Step 2 Verify image set Image set verification enables you to adjust the contrast and the surface level of the image set to confirm the image orientation and to select the preferred viewing direction of images Adjust contrast and surface level 1 Click the icon and open the Window Width Level box 2 Click the Automatic Adjust button or use the sliders to adjust contrast window level width of the images and surface level of the 3 D ren dering Confirm image orientation gt Verify that the Image orienta fa tion labels are correct on each Pompa FORE sce of the planes Aa X Warning Ensure proper image orientation Severe accuracy errors result from incorrect orientation X
63. t the automatic matching process The complete automatic matching process may take a few minutes For better visualization of the ongoing process the two image series are displayed in different colors To check the result during the matching process gt Click the icon and use the image box functionality Note The matching process can be terminated manually if no further alignment is needed Pe e a Musi ear tree Set Era twee 40 ng mw Planning Features Sarana crore e 7 IX Cot imaget CTR 3D em JOJMAGES 11006 Cie 20 sean JO IMAGES thios Cie mages SMe Loca be gt ww ecw 4 tan eu cilectw creche m gt Anatomi cal Sy shew E A Serem Sarana C lm 71 1x Cot imaget CTI MROI sang Coloul sion in progress this Will tak tea menutes Correlating 03a you are already satished with the result press Finest Mi ia 19 20 Planning Features v Contirmed Step 3 Confirm automatic matching gt Visually verify the accuracy of the automatic matching process by using well known landmarks If the correlation is accurate gt Confirm the result by clicking the Confirmed checkbox If automatic image correlation is not satisfactory gt Perform the Manual match ing or activate the Landmark matching dialog and repeat the image correlation Segmentation There are two segmentation workflows Warning During navigation s
64. the C arm into position for image acquisition 2 Follow the instructions on the C arm control panel and perform a collision check for the complete rotation of the C arm Note The collision check is mandatory and requested by the 3 D work flow of the C arm Step 2 Align camera 1 Align the camera in such a way that the patient tracker and C arm tracker are visible and within the camera s work ing space 2 Assure that the patient tracker and C arm Tracker do not move Note If patient tracker and C arm Tracker are visible and in a stable position the green light indicates that the system is ready for image acquisition C Arm Tracker Patent racker Sointer Align Camera 77 78 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Image Acquisition Cm Tracker Patient Tracker Pointer Align Camera Step 3 Acquire image Before starting gt Assure that the patient does not move during imaging Note The scan should be completed without interruption Incomplete scans cannot be used for naviga tion Caution Do not move the camera or C arm during image acquisition For uncompromised image qual ity patient movement has to be avoided during image acquisi tion In certain cases it might be appropriate to control patient movement by initiating a brief non ventilated phase for the time of image acquisition It is the responsibility of the surg
65. tion of the Jam Shidi needle in accordance with the desired screw trajectory Step 4 Navigate entry point After the Jam Shidi needle is inserted the virtual tip extension can be reset and the pedicle entry point can be prepared by using the navigation control Bac Het Y 85 86 Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 5 Advance Jam Shidi needle After entry point preparation the Jam Shidi needle may be advanced partially through the pedicle by using navigation control Step 6 Insert K Wire The inner trocar of the Jam Shidi needle can be removed and a K wire can be inserted into the pedicle Once the K wire is inserted the outer shaft of the Jam Shidi needle may be removed while keeping the K wire in place Navigated Minimal Invasive Spine Surgery with Intraoperative 3 D Imaging Step 7 Prepare pedicle pathway The pedicle pathway can be pre pared by first placing a cannulated awl over the K wire and twisting the awl into the pedicle If necessary a cannulated tap can be used in the same manner to prepare the pedicle screw canal Step 8 Insert screw After pedicle pathway preparation and the screw length and diam eter determination a cannulated pedicle screw driver with screw can be placed over the K wire and the screw can be inserted AN Caution Additional segments may only be navigated if there is a rigid connection between the Spin
66. urements and select New Measurement Upon selection the Measure ments tool panel is displayed Step 2 Select measure ment gt Select the desired measure ment from the pull down menu Length Angle 3 point or Angle 2 lines The tool panel is expanded for the selected measurement func tionality De ee H H H H H Mame E CTO1 ARTERIEL PORTAL MI Local Correlations Anatomical System Screws Measurements New Measurement f Annotation Points a Planes Trajectories Is 3 D Model fe Compositions i Screenshots Measurements Type Length Set two poi Length gth Angle 3 point Angle lines Image Set CTO Planning Features 33 Planning Features AN Ann Step 3 Create measure P4 Measurements a 4 a amp 9 Tam p Coriri EAER ment types Type Set two points to measure length 1 Length Measurement Name L 1 Image Set CTOI pg A SS incre 1 Set the crosshair cursor on the start point of the line Set Start Point Show SerEnd Poni Show an 5 Na Lean 2 si B 3 ne 2 Click the Set Start Point Pa button to record Distance 466 4 mm 3 Define and record the end point of the line If required gt Redefine the length measure ment by grabbing and moving the start and end point of the Measurements r A 2 amas z a line Type pir gede mn he Set start and end points of two Ines to p Gea conan 2 Angle 2 Lines Measurement measure the angle betwee

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