A wearable headset for monitoring electromyography responses within spinal surgery

An Augmented Vision of Our Medical and Surgical Future, Today?

Incorporating consumer electronics into the operating room, we evaluated the Apple Vision Pro (AVP) during limb preservation surgeries, just as we evaluated Google Glass and FaceTime more than a decade ago. Although AVP's real-time mixed-reality data overlay and controls offer potential enhancements to surgical precision and team communication, our assessment recognized limitations in adapting consumer technology to clinical environments. The initial use facilitated intraoperative decision-making and educational interactions with trainees. The current mixed-reality pass-through resolution allows for input but not for highly dexterous surgical interactions. These early observations indicate that while AVP may soon improve aspects of surgical performance and education, further iteration, evaluation, and experience are needed to fully understand its impact on patient outcomes and to refine its integration into clinical practice.

XR (Extended Reality: Virtual Reality, Augmented Reality, Mixed Reality) Technology in Spine Medicine: Status Quo and Quo Vadis

In recent years, with the rapid advancement and consumerization of virtual reality, augmented reality, mixed reality, and extended reality (XR) technology, the use of XR technology in spine medicine has also become increasingly popular. The rising use of XR technology in spine medicine has also been accelerated by the recent wave of digital transformation (i.e., case-specific three-dimensional medical images and holograms, wearable sensors, video cameras, fifth generation, artificial intelligence, and head-mounted displays), and further accelerated by the COVID-19 pandemic and the increase in minimally invasive spine surgery. The COVID-19 pandemic has a negative impact on society, but positive impacts can also be expected, including the continued spread and adoption of telemedicine services (i.e., tele-education, tele-surgery, tele-rehabilitation) that promote digital transformation. The purpose of this narrative review is to describe the accelerators of XR (VR, AR, MR) technology in spine medicine and then to provide a comprehensive review of the use of XR technology in spine medicine, including surgery, consultation, education, and rehabilitation, as well as to identify its limitations and future perspectives (status quo and quo vadis).

"Disruptive Technology" in Spine Surgery and Education: Virtual and Augmented Reality

BACKGROUND

Technological advancements are the drivers of modern-day spine care. With the growing pressure to deliver faster and better care, surgical-assist technology is needed to harness computing power and enable the surgeon to improve outcomes. Virtual reality (VR) and augmented reality (AR) represent the pinnacle of emerging technology, not only to deliver higher quality education through simulated care, but also to provide valuable intraoperative information to assist in more efficient and more precise surgeries.

OBJECTIVE

To describe how the disruptive technologies of VR and AR interface in spine surgery and education.

METHODS

We review the relevance of VR and AR technologies in spine care, and describe the feasibility and limitations of the technologies.

RESULTS

We discuss potential future applications, and provide a case study demonstrating the feasibility of a VR program for neurosurgical spine education.

CONCLUSION

Initial experiences with VR and AR technologies demonstrate their applicability and ease of implementation. However, further prospective studies through multi-institutional and industry-academic partnerships are necessary to solidify the future of VR and AR in spine surgery education and clinical practice.

Augmented Reality Navigation for Stereoscopic Laparoscopic Anatomical Hepatectomy of Primary Liver Cancer: Preliminary Experience

Background

Accurate determination of intrahepatic anatomy remains challenging for laparoscopic anatomical hepatectomy (LAH). Laparoscopic augmented reality navigation (LARN) is expected to facilitate LAH of primary liver cancer (PLC) by identifying the exact location of tumors and vessels. The study was to evaluate the safety and effectiveness of our independently developed LARN system in LAH of PLC.

Methods

From May 2018 to July 2020, the study included 85 PLC patients who underwent three-dimensional (3D) LAH. According to whether LARN was performed during the operation, the patients were divided into the intraoperative navigation (IN) group and the non-intraoperative navigation (NIN) group. We compared the preoperative data, perioperative results and postoperative complications between the two groups, and introduced our preliminary experience of this novel technology in LAH.

Results

There were 44 and 41 PLC patients in the IN group and the NIN group, respectively. No significant differences were found in preoperative characteristics and any of the resection-related complications between the two groups (All P > 0.05). Compared with the NIN group, the IN group had significantly less operative bleeding (P = 0.002), lower delta Hb% (P = 0.039), lower blood transfusion rate (P < 0.001), and reduced postoperative hospital stay (P = 0.003). For the IN group, the successful fusion of simulated surgical planning and operative scene helped to determine the extent of resection.

Conclusions

The LARN contributed to the identification of important anatomical structures during LAH of PLC. It reduced vascular injury and accelerated postoperative recovery, showing a potential application prospects in liver surgery.

A systematic review of emerging information technologies for sustainable data-centric health-care

BACKGROUND

Of the Sustainable Development Goals (SDGs), the third presents the opportunity for a predictive universal digital healthcare ecosystem, capable of informing early warning, assisting in risk reduction and guiding management of national and global health risks. However, in reality, the existing technology infrastructure of digital healthcare systems is insufficient, failing to satisfy current and future data needs.

OBJECTIVE

This paper systematically reviews emerging information technologies for data modelling and analytics that have potential to achieve Data-Centric Health-Care (DCHC) for the envisioned objective of sustainable healthcare. The goal of this review is to: 1) identify emerging information technologies with potential for data modelling and analytics, and 2) explore recent research of these technologies in DCHC.

FINDINGS

A total of 1619 relevant papers have been identified and analysed in this review. Of these, 69 were probed deeply. Our analysis found that the extant research focused on elder care, rehabilitation, chronic diseases, and healthcare service delivery. Use-cases of the emerging information technologies included providing assistance, monitoring, self-care and self-management, diagnosis, risk prediction, well-being awareness, personalized healthcare, and qualitative and/or quantitative service enhancement. Limitations identified in the studies included vendor hardware specificity, issues with user interface and usability, inadequate features, interoperability, scalability, and compatibility, unjustifiable costs and insufficient evaluation in terms of validation.

CONCLUSION

Achievement of a predictive universal digital healthcare ecosystem in the current context is a challenge. State-of-the-art technologies demand user centric design, data privacy and protection measures, transparency, interoperability, scalability, and compatibility to achieve the SDG objective of sustainable healthcare by 2030.

Smart glasses display device for fluoroscopically guided minimally invasive spinal instrumentation surgery: a preliminary study

OBJECTIVE

Most surgeons are forced to turn their heads away from the surgical field to see various intraoperative support monitors. These movements may result in inconvenience to surgeons and lead to technical difficulties and potential errors. Wearable devices that can be attached to smart glasses or any glasses are novel visualization tools providing an alternative screen in front of the user's eyes, allowing surgeons to keep their attention focused on the operative task without taking their eyes off the surgical field. The aim of the present study was to examine the feasibility of using glasses equipped with a wearable display device that transmits display monitor data during fluoroscopically guided minimally invasive spinal instrumentation surgery.

METHODS

In this pilot prospective randomized study, 20 consecutively enrolled patients who underwent single-segment posterior lumbar interbody fusion (PLIF) at L5-S1 performed using the percutaneous pedicle screw technique were randomly divided into two groups, a group for which the surgeon used a wearable display device attached to regular glasses while performing surgery (smart glasses group) and a group for which the surgeon did not use such a device (nonglasses group). Real-time intraoperative fluoroscopic images were wirelessly transmitted to the display device attached to the surgeon's glasses. The number of head turns performed by the surgeon to view the standard fluoroscopic monitor during procedures and the operative time, estimated blood loss, radiation exposure time, screw placement accuracy, and intraoperative complication rate were evaluated for comparison between the two groups.

RESULTS

The number of surgeon head turns to view the fluoroscopic monitor in the smart glasses group was 0.10 ± 0.31 times, which was significantly fewer than the head turns in the nonglasses group (82.4 ± 32.5 times; p < 0.001). The operative and radiation exposure times in the smart glasses group were shorter than those in the nonglasses group (operative time 100.2 ± 10.4 vs 105.5 ± 14.6 minutes, radiation exposure time 38.6 ± 6.6 vs 41.8 ± 16.1 seconds, respectively), although the differences were not significant. Postoperative CT showed one screw perforation in the nonglasses group, and no intraoperative complications were observed in either group.

CONCLUSIONS

This is, to the authors' knowledge, the first report on the feasibility of using this wearable display device attached to glasses for fluoroscopically guided minimally invasive spinal instrumentation surgery. Smart glasses display devices such as this one may be a valid option to facilitate better concentration on operative tasks by improving ergonomic efficiency during surgery.

Muscle responses to radicular stimulation during lumbo-sacral dorsal rhizotomy for spastic diplegia: Insights to myotome innervation

OBJECTIVE

Most of knowledge on muscle radicular innervation was from explorations in root/spinal cord pathologies. Direct and individual access to each of the lumbar-sacral -ventral and dorsal- nerve roots during dorsal rhizotomy for spastic diplegia allows precise study of the corresponding muscle innervation. Authors report the lumbo-sacral segmental myotomal organization obtained from recordings of muscle responses to root stimulation in a 20-children prospective series.

METHODS

Seven key-muscles in each lower limb and anal sphincter were Electromyography (EMG)-recorded and clinically observed by physiotherapist during L2-to-S2 dorsal rhizotomy. Ventral roots (VR), for topographical mapping, and dorsal roots (DR), for segmental excitability testing, were stimulated, just above threshold for eliciting muscular response.

RESULTS

In 70% of the muscles studied, VR innervation was pluri-radicular, from 2-to-4 roots, with 1 or 2 roots being dominant at each level. Overlapping was important. Muscle responses to DR stimulation were 1.75 times more extended compared to VR stimulation. Inter-individual variability was important.

CONCLUSIONS

Accuracy of root identification and stimulation with the used method brings some more precise information to radicular functional anatomy.

SIGNIFICANCE

Those neurophysiological findings plead for performing Intra-Operative Neuromonitoring when dealing with surgery in the lumbar-sacral roots.

A Systematic Review of the Use of Google Glass in Graduate Medical Education

BACKGROUND

Graduate medical education (GME) has emphasized the assessment of trainee competencies and milestones; however, sufficient in-person assessment is often constrained. Using mobile hands-free devices, such as Google Glass (GG) for telemedicine, allows for remote supervision, education, and assessment of residents.

OBJECTIVE

We reviewed available literature on the use of GG in GME in the clinical learning environment, its use for resident supervision and education, and its clinical utility and technical limitations.

METHODS

We conducted a systematic review in accordance with 2009 PRISMA guidelines. Applicable studies were identified through a review of PubMed, MEDLINE, and Web of Science databases for articles published from January 2013 to August 2018. Two reviewers independently screened titles, abstracts, and full-text articles that reported using GG in GME and assessed the quality of the studies. A systematic review of these studies appraised the literature for descriptions of its utility in GME.

RESULTS

Following our search and review process, 37 studies were included. The majority evaluated GG in surgical specialties (n = 23) for the purpose of surgical/procedural skills training or supervision. GG was predominantly used for video teleconferencing, and photo and video capture. Highlighted positive aspects of GG use included point-of-view broadcasting and capacity for 2-way communication. Most studies cited drawbacks that included suboptimal battery life and HIPAA concerns.

CONCLUSIONS

GG shows some promise as a device capable of enhancing GME. Studies evaluating GG in GME are limited by small sample sizes and few quantitative data. Overall experience with use of GG in GME is generally positive.

Head-Mounted Display Use in Surgery: A Systematic Review

Purpose. We analyzed the literature to determine (1) the surgically relevant applications for which head-mounted display (HMD) use is reported; (2) the types of HMD most commonly reported; and (3) the surgical specialties in which HMD use is reported. Methods. The PubMed, Embase, Cochrane Library, and Web of Science databases were searched through August 27, 2017, for publications describing HMD use during surgically relevant applications. We identified 120 relevant English-language, non-opinion publications for inclusion. HMD types were categorized as “heads-up” (nontransparent HMD display and direct visualization of the real environment), “see-through” (visualization of the HMD display overlaid on the real environment), or “non–see-through” (visualization of only the nontransparent HMD display). Results. HMDs were used for image guidance and augmented reality (70 publications), data display (63 publications), communication (34 publications), and education/training (18 publications). See-through HMDs were described in 55 publications, heads-up HMDs in 41 publications, and non–see-through HMDs in 27 publications. Google Glass, a see-through HMD, was the most frequently used model, reported in 32 publications. The specialties with the highest frequency of published HMD use were urology (20 publications), neurosurgery (17 publications), and unspecified surgical specialty (20 publications). Conclusion. Image guidance and augmented reality were the most commonly reported applications for which HMDs were used. See-through HMDs were the most commonly reported type used in surgically relevant applications. Urology and neurosurgery were the specialties with greatest published HMD use.

The Past, Present, and Future of Virtual Reality in Pharmacy Education

Objective. To characterize how virtual reality (VR) has been and is being used in pharmacy education, and evaluate the projected utility of VR technology in pharmacy education in the future. Findings. Virtual reality technology has been used in pharmacy education for many years to provide engaging learning experiences. Although these learning experiences were not available in the three-dimensional digital environments provided by current VR, they demonstrated improvements in learning. Recent technological advancements have substantially increased the potential usefulness of VR for pharmacy education by providing immersive educational activities that mimic real world experiences to reinforce didactic and laboratory concepts. Virtual reality training that uses head-mounted displays is just beginning in pharmacy education, but more educational VR programs are becoming available. Further research will be necessary to fully understand the potential impact of VR on pharmacy education. Summary. Virtual reality technology can provide an immersive and interactive learning environment, overcoming many of the early challenges faced by instructors who used virtual activities for pharmacy education. With further technological and software development, VR has the potential to become an integral part of pharmacy education.

X-ray vision: the accuracy and repeatability of a technology that allows clinicians to see spinal X-rays superimposed on a person's back

Objective

Since the discovery of ionizing radiation, clinicians have evaluated X-ray images separately from the patient. The objective of this study was to investigate the accuracy and repeatability of a new technology which seeks to resolve this historic limitation by projecting anatomically correct X-ray images on to a person’s skin.

Methods

A total of 13 participants enrolled in the study, each having a pre-existing anteroposterior lumbar X-ray. Each participant’s image was uploaded into the Hololens Mixed reality system which when worn, allowed a single examiner to view a participant’s own X-ray superimposed on the participant’s back. The projected image was topographically corrected using depth information obtained by the Hololens system then aligned via existing anatomic landmarks. Using this superimposed image, vertebral levels were identified and validated against spinous process locations obtained by ultrasound. This process was repeated 1–5 days later. The projection of each vertebra was deemed to be “on-target” if it fell within the known morphological dimensions of the spinous process for that specific vertebral level.

Results

The projection system created on-target projections with respect to individual vertebral levels 73% of the time with no significant difference seen between testing sessions. The average repeatability for all vertebral levels between testing sessions was 77%.

Conclusion

These accuracy and repeatability data suggest that the accuracy and repeatability of projecting X-rays directly on to the skin is feasible for identifying underlying anatomy and as such, has potential to place radiological evaluation within the patient context. Future opportunities to improve this procedure will focus on mitigating potential sources of error.

Effect of problem and scripting-based learning combining wearable technology on orthopedic operating room nurses' learning outcomes

BACKGROUND

Orthopedic operating room (OR) nurses entail specialized skills and training, which are not part of the regular curricula at most nursing college. Instead, many nursing students' exposure to orthopedic care in the orthopedic range is limited to occasional observational assignments. Additionally, teamwork is an important factor affecting the performance of the orthopedic OR nurses. This results in a knowledge gap in clinical nursing education. Problem and scripting based learning (PSBL) method is a crucial tool of pre-operative prepared improvement. It is easy for surgeon to record surgical video from his own field of vision by wearable technology (WT). Nevertheless, few studies related to combine WT and PSBL been done to investigate features underlying efficiency in training of novice orthopedic OR nurses.

OBJECTIVE

This study aimed to evaluate the feasibility of combining WT with PSBL in training of novice orthopedic OR nurses.

METHODS

20 operating room post-graduate-year-1 nurses from the First Hospital of China Medical University were randomly divided into two groups ("conventional training (CT)" group and "WT combining with PSBL" group). Initially the superior orthopedic operating room nurses who immediately followed each procedure filled out a feedback questionnaire of the novice nurses. After finished procedure, novice nurses had a basic understanding of each training method benefits and then filled out the questionnaires. Statistical analysis of the results was performed.

RESULTS

Novice nurses of WT&PSBL Group got the better score in most of the preparedness and performance feedback statement. Mean scores of overall total preparedness and performance feedback statement of WT&PSBL Group was higher than CT Group (P ≤ 0.05). Based on summarizing the questionnaires, the novice nurse in WT- PSBL Group also made significantly better total score than "Conventional training" Group (P ≤ 0.05).

CONCLUSIONS

WT&PSBL method, as a crucial tool for improving pre-operative preparedness and intra-operative performance, can cultivate novice orthopedic operating room nurses' ability to use prior knowledge and cognitive frameworks flexibly to deal with problems during performance. It plays a crucial role in training confident and safe orthopedic operating room nurses.

DESIGN

Randomized controlled trial (RCT).

Dorsal rhizotomy for children with spastic diplegia of cerebral palsy origin: usefulness of intraoperative monitoring

OBJECTIVE The utility of intraoperative neuromonitoring (ION), namely the study of muscle responses to radicular stimulation, remains controversial. The authors performed a prospective study combining ventral root (VR) stimulation for mapping anatomical levels and dorsal root (DR) stimulation as physiological testing of metameric excitability. The purpose was to evaluate to what extent the intraoperative data led to modifications in the initial decisions for surgical sectioning established by the pediatric multidisciplinary team (i.e., preoperative chart), and thus estimate its practical usefulness. METHODS Thirteen children with spastic diplegia underwent the following surgical protocol. First, a bilateral intradural approach was made to the L2-S2 VRs and DRs at the exit from or entry to their respective dural sheaths, through multilevel interlaminar enlarged openings. Second, stimulation-just above the threshold-of the VR at 2 Hz to establish topography of radicular myotome distribution, and then of the DR at 50 Hz as an excitability test of root circuitry, with independent identification of muscle responses by the physiotherapist and by electromyographic recordings. The study aimed to compare the final amounts of root sectioning-per radicular level, established after intraoperative neuromonitoring guidance-with those determined by the multidisciplinary team in the presurgical chart. RESULTS The use of ION resulted in differences in the final percentage of root sectioning for all root levels. The root levels corresponding to the upper lumbar segments were modestly excitable under DR stimulation, whereas progressively lower root levels displayed higher excitability. The difference between root levels was highly significant, as evaluated by electromyography (p = 0.00004) as well as by the physiotherapist (p = 0.00001). Modifications were decided in 11 of the 13 patients (84%), and the mean absolute difference in the percentage of sectioning quantity per radicular level was 8.4% for L-2 (p = 0.004), 6.4% for L-3 (p = 0.0004), 19.6% for L-4 (p = 0.00003), 16.5% for L-5 (p = 0.00006), and 3.2% for S-1 roots (p = 0.016). Decreases were most frequently decided for roots L-2 and L-3, whereas increases most frequently involved roots L-4 and L-5, with the largest changes in terms of percentage of sectioning. CONCLUSIONS The use of ION during dorsal rhizotomy led to modifications regarding which DRs to section and to what extent. This was especially true for L-4 and L-5 roots, which are known to be involved in antigravity and pelvic stability functions. In this series, ION contributed significantly to further adjust the patient-tailored dorsal rhizotomy procedure to the clinical presentation and the therapeutic goals of each patient.

Using Google Glass in Surgical Settings: Systematic Review

Background

In recent years, wearable devices have become increasingly attractive and the health care industry has been especially drawn to Google Glass because of its ability to serve as a head-mounted wearable device. The use of Google Glass in surgical settings is of particular interest due to the hands-free device potential to streamline workflow and maintain sterile conditions in an operating room environment.

Objective

The aim is to conduct a systematic evaluation of the literature on the feasibility and acceptability of using Google Glass in surgical settings and to assess the potential benefits and limitations of its application.

Methods

The literature was searched for articles published between January 2013 and May 2017. The search included the following databases: PubMed MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO (EBSCO), and IEEE Xplore. Two reviewers independently screened titles and abstracts and assessed full-text articles. Original research articles that evaluated the feasibility, usability, or acceptability of using Google Glass in surgical settings were included. This review was completed following the Preferred Reporting Results of Systematic Reviews and Meta-Analyses guidelines.

Results

Of the 520 records obtained, 31 met all predefined criteria and were included in this review. Google Glass was used in various surgical specialties. Most studies were in the United States (23/31, 74%) and all were conducted in hospital settings: 29 in adult hospitals (29/31, 94%) and two in children’s hospitals (2/31, 7%). Sample sizes of participants who wore Google Glass ranged from 1 to 40. Of the 31 studies, 25 (81%) were conducted under real-time conditions or actual clinical care settings, whereas the other six (19%) were conducted under simulated environment. Twenty-six studies were pilot or feasibility studies (84%), three were case studies (10%), and two were randomized controlled trials (6%). The majority of studies examined the potential use of Google Glass as an intraoperative intervention (27/31, 87%), whereas others observed its potential use in preoperative (4/31, 13%) and postoperative settings (5/31, 16%). Google Glass was utilized as a videography and photography device (21/31, 68%), a vital sign monitor (6/31, 19%), a surgical navigation display (5/31, 16%), and as a videoconferencing tool to communicate with remote surgeons intraoperatively (5/31, 16%). Most studies reported moderate or high acceptability of using Google Glass in surgical settings. The main reported limitations of using Google Glass utilization were short battery life (8/31, 26%) and difficulty with hands-free features (5/31, 16%).

Conclusions

There are promising feasibility and usability data of using Google Glass in surgical settings with particular benefits for surgical education and training. Despite existing technical limitations, Google Glass was generally well received and several studies in surgical settings acknowledged its potential for training, consultation, patient monitoring, and audiovisual recording.

Towards X-ray free endovascular interventions - using HoloLens for on-line holographic visualisation

A major challenge during endovascular interventions is visualising the position and orientation of the catheter being inserted. This is typically achieved by intermittent X-ray imaging. Since the radiation exposure to the surgeon is considerable, it is desirable to reduce X-ray exposure to the bare minimum needed. Additionally, transferring two-dimensional (2D) X-ray images to 3D locations is challenging. The authors present the development of a real-time navigation framework, which allows a 3D holographic view of the vascular system without any need of radiation. They extract the patient's surface and vascular tree from pre-operative computed tomography data and register it to the patient using a magnetic tracking system. The system was evaluated on an anthropomorphic full-body phantom by experienced clinicians using a four-point questionnaire. The average score of the system (maximum of 20) was found to be 17.5. The authors' approach shows great potential to improve the workflow for endovascular procedures, by simultaneously reducing X-ray exposure. It will also improve the learning curve and help novices to more quickly master the required skills.

Augmented-reality integrated robotics in neurosurgery: are we there yet?

Surgical robots have captured the interest—if not the widespread acceptance—of spinal neurosurgeons. But successful innovation, scientific or commercial, requires the majority to adopt a new practice. “Faster, better, cheaper” products should in theory conquer the market, but often fail. The psychology of change is complex, and the “follow the leader” mentality, common in the field today, lends little trust to the process of disseminating new technology. Beyond product quality, timing has proven to be a key factor in the inception, design, and execution of new technologies. Although the first robotic surgery was performed in 1985, scant progress was seen until the era of minimally invasive surgery. This movement increased neurosurgeons’ dependence on navigation and fluoroscopy, intensifying the drive for enhanced precision. Outside the field of medicine, various technology companies have made great progress in popularizing co-robots (“cobots”), augmented reality, and processor chips. This has helped to ease practicing surgeons into familiarity with and acceptance of these technologies. The adoption among neurosurgeons in training is a “follow the leader” phenomenon, wherein new surgeons tend to adopt the technology used during residency. In neurosurgery today, robots are limited to computers functioning between the surgeon and patient. Their functions are confined to establishing a trajectory for navigation, with task execution solely in the surgeon’s hands. In this review, the authors discuss significant untapped technologies waiting to be used for more meaningful applications. They explore the history and current manifestations of various modern technologies, and project what innovations may lie ahead.