Benchmarking Distance Control and Virtual Drilling for Lateral Skull Base Surgery

Eduard H.J. Voormolen*, Sander Diederen, Marijn van Stralen, Peter A. Woerdeman, Herke Jan Noordmans, Max A. Viergever, Luca Regli, Pierre A. Robe, JW Berkelbach vd Sprenkel

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background: Novel audiovisual feedback methods were developed to improve image guidance during skull base surgery by providing audiovisual warnings when the drill tip enters a protective perimeter set at a distance around anatomic structures ("distance control") and visualizing bone drilling ("virtual drilling"). Objective: To benchmark the drill damage risk reduction provided by distance control, to quantify the accuracy of virtual drilling, and to investigate whether the proposed feedback methods are clinically feasible. Methods: In a simulated surgical scenario using human cadavers, 12 unexperienced users (medical students) drilled 12 mastoidectomies. Users were divided into a control group using standard image guidance and 3 groups using distance control with protective perimeters of 1, 2, or 3 mm. Damage to critical structures (sigmoid sinus, semicircular canals, facial nerve) was assessed. Neurosurgeons performed another 6 mastoidectomy/trans-labyrinthine and retro-labyrinthine approaches. Virtual errors as compared with real postoperative drill cavities were calculated. In a clinical setting, 3 patients received lateral skull base surgery with the proposed feedback methods. Results: Users drilling with distance control protective perimeters of 3 mm did not damage structures, whereas the groups using smaller protective perimeters and the control group injured structures. Virtual drilling maximum cavity underestimations and overestimations were 2.8 ± 0.1 and 3.3 ± 0.4 mm, respectively. Feedback methods functioned properly in the clinical setting. Conclusion: Distance control reduced the risks of drill damage proportional to the protective perimeter distance. Errors in virtual drilling reflect spatial errors of the image guidance system. These feedback methods are clinically feasible.

Original languageEnglish
Pages (from-to)e217-e228
JournalWorld Neurosurgery
Publication statusPublished - Jan 2018


  • Distance control
  • Mastoidectomy
  • Neuronavigation
  • Skull base
  • Temporal bone
  • Virtual drilling


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