Current innovation in virtual and augmented reality in spine surgery

Surgeon perspectives on a virtual reality platform for preoperative planning in complex bone sarcomas

Background and objectives

Treatment of primary bone and soft tissue sarcomas typically includes complete surgical resection with or without adjunctive modalities. Despite best efforts, for the most challenging clinical scenarios such as axial or pelvic sarcoma, five-year survival rates are reported to be between 27 and 40 %. Since quality of resection is a key determinant of oncologic outcomes, it is critical to preoperatively plan the surgical approach to improve resection accuracy, ensure sufficient surgical margins, and reduce the risk of local or metastatic recurrence. The computer conversion of 2-dimensional (2D) computerized tomography (CT) and magnetic resonance imaging (MRI) to a three-dimensional (3D) virtual reality (VR) avatar image may allow improved preoperative estimation of tumor size, location, adjacent anatomy, and spatial understanding of the tumor without relying on surgeon experience, memory, and imagination. The purpose of this study is to investigate the utility of a virtual reality platform in preoperative planning and surgical approach in a retrospective cohort of pelvic bone sarcoma cases.

Methods

The histopathology database at our institution was queried for all historical cases of bone and soft tissue sarcoma with surgical resection failure, defined as positive gross or microscopic margins. Four cases of pelvic bone sarcoma were chosen for retrospective review by fellowship-trained orthopedic tumor specialists. For each case, participants first studied conventional 2D preoperative CT images and answered a questionnaire pertaining to objective case parameters. Participants then interacted with case-specific 3D models while wearing a VR headset and answered the same questionnaire. The VR 'avatar' was created with custom-developed software. After using both modalities, participants completed a Likert-scale survey aiming to evaluate the VR technology's subjective impact on understanding tumor environment, surgical plan confidence, and its ability to improve communication with colleagues and patients. Four attending orthopedic oncologists, one orthopedic oncology fellow, and one senior orthopedic oncology resident participated in the study.

Results

Four cases of failed resection were evaluated by a group of both attending surgeons and a group of trainees composed of both residents and fellows. Tumor borders were clearly delineated in 0 % and 66.6 % cases when evaluating with conventional 2D imaging and VR, respectively. Participants changed adjacent structure involvement grade 22.2 % of the time after assessing involvement grade on the VR technology, with adjacent ligamentous structure grading changed most frequently in 55.5 % of cases. Users reported they would change the surgical approach or margins 44.4 % of the time after reviewing with VR technology. Initial 6 plane resection plans were changed in every user case. Subjective responses indicated that surgeons expressed more confidence in their approach, confidence with obtaining negative margins, and provided more detail regarding structures to be resected in specific planes.

Conclusion

Pelvic tumors present unique surgical challenges due to complex 3D anatomy, the proximity of vital structures, consistency of the tumor, and the need to alter patient position during resection procedures. Using examples of failed pelvic bone sarcoma resections, our study found that VR imaging increased understanding of the tumor environment, characteristics, and ability to communicate with patients and colleagues.

Framework for Adoption of Enabling Technologies for Improved Outcomes in Spine Surgery

STUDY DESIGN

Narrative Review.

OBJECTIVES

We aim to investigate the integration and impact of enabling technologies, such as augmented reality, virtual reality, mixed reality, navigation, robotics, and artificial intelligence within the domain of spinal surgery.

METHODS

We made a literature review for articles that examined the progression of adoption from initial to subsequent adopters. We also analysed the key determinants that influence adopting these technologies into clinical settings. These include cost-effectiveness, ease of integration, patient acceptance, learning curves, and availability of training resources. Based on the available data a suggestion has been made on the adoption framework for clinical utility.

RESULTS

These technological advancements have the potential to transform surgical practice, offering improved precision and efficiency. The journey toward widespread adoption presents challenges, which include the financial implications, the necessity for specialized training, and the complexities associated with integration. To navigate these hurdles, the study proposes recommendations aimed at improving cost efficiency, streamlining technology integration, investing in professional development, and nurturing a culture of innovation and research.

CONCLUSIONS

A framework has been established for the evaluation and integration of state-of-the-art technologies in spinal surgery, thereby maximizing their potential impact on surgical outcomes and patient welfare.

Optimizing Single-Position Prone Lateral Lumbar Interbody Fusion with Exoscopic Technology: A Review of Key Innovations

Minimally invasive spine surgery has advanced significantly over the past decade, integrating technologies such as intraoperative navigation, robotics, and artificial intelligence with innovative techniques such as single-position prone lateral transpsoas lumbar interbody fusion (proLIF). While proLIF offers excellent clinical outcomes for a wide range of lumbar pathologies, the lateral approach to lumbar spine presents technical and ergonomic challenges, including an increased need for soft-tissue dissection and unfavorable ergonomics for surgeons. This review details how the combination of emerging technologies has been applied in minimally invasive lumbar spine surgery. It also describes the novel application of an exoscope during navigation-guided proLIF. The benefits offered by the exoscope included high-resolution, three-dimensional visualization, enhanced maneuverability, and improved surgeon ergonomics. By combining emerging technologies with novel surgical approaches, this review demonstrates the recent advancements in minimally invasive spine surgery and underscores the exoscope's potential to enhance visualization and optimize ergonomics for surgeons.

A Novel Pedicle Screw Placement Surgery Based on Integration of Surgical Guides and Augmented Reality

BACKGROUND

 Augmented reality is a new technology that, when applied to spinal surgery, offers the potential for efficient, safe, and accurate placement of pedicle screws. This study investigated whether augmented reality combined with a guide board improved the safety and accuracy of pedicle screw placement compared to traditional freehand screw placement.

METHODS

 Four trainers were divided into augmented reality navigation and freehand groups. Each group consisted of a novice and an experienced spine surgeon. A total of 80 pedicle screws were implanted. First, the AR group reconstructed the three-dimensional (3D) model and planned the screw insertion route according to the computed tomography (CT) data of L2 lumbar vertebrae. Next, the Microsoft HoloLens 2 was used to identify the vertebral model, and the planned virtual path was superimposed on the real cone model. Then, the screw was placed according to the projected trajectory. Finally, Micron Tracker was used to measure the deviation of screws from the preoperatively planned trajectory, and pedicle screws were evaluated using the Gertzbein-Robbins scale.

RESULTS

 In the augmented reality group, the linear deviation of the experienced doctors and novices was 1.59 ± 0.39 and 1.73 ± 0.52 mm, respectively, and the deviation angle was 2.72 ± 0.61 and 2.87 ± 0.63 degrees, respectively. In the freehand group, the linear deviation of the experienced doctors and novices was 2.88 ± 0.58 and 5.25 ± 0.62 mm, respectively, and the deviation angle was 4.41 ± 1.18 and 7.15 ± 1.45 degrees, respectively. The screw placement accuracy rate was 97.5% in the augmented reality navigation group and 77.5% in the freehand group.

CONCLUSIONS

 Augmented reality navigation improves the accuracy and safety of pedicle screw implantation compared with the traditional freehand method and can assist inexperienced doctors in successfully completing the surgery.

A Self-Developed Mobility Augmented Reality System Versus Conventional X-rays for Spine Positioning in Intraspinal Tumor Surgery: A Case-Control Study

OBJECTIVE

To evaluate the efficacy of a self-developed mobile augmented reality navigation system (MARNS) in guiding spinal level positioning during intraspinal tumor surgery based on a dual-error theory.

METHODS

This retrospective study enrolled patients diagnosed with intraspinal tumors admitted to Fujian Provincial Hospital between May and November 2023. The participants were divided into conventional x-rays and self-developed MARNS groups according to the localization methods they received. Position time, length of intraoperative incision variation, and location accuracy were systematically compared.

RESULTS

A total of 41 patients (19 males) with intraspinal tumors were included, and MARNS was applied to 21 patients. MARNS achieved successful lesion localization in all patients with an error of 0.38±0.12 cm. Compared to x-rays, MARNS significantly reduced positioning time (129.00±13.03 seconds vs. 365.00±60.43 seconds, p<0.001) and length of intraoperative incision variation (0.14 cm vs. 0.67 cm, p=0.009).

CONCLUSION

The self-developed MARNS, based on augmented reality technology for lesion visualization and perpendicular projection, offers a radiation-free complement to conventional x-rays.

Integrating Augmented Reality in Spine Surgery: Redefining Precision with New Technologies

INTRODUCTION

The integration of augmented reality (AR) in spine surgery marks a significant advancement, enhancing surgical precision and patient outcomes. AR provides immersive, three-dimensional visualizations of anatomical structures, facilitating meticulous planning and execution of spine surgeries. This technology not only improves spatial understanding and real-time navigation during procedures but also aims to reduce surgical invasiveness and operative times. Despite its potential, challenges such as model accuracy, user interface design, and the learning curve for new technology must be addressed. AR's application extends beyond the operating room, offering valuable tools for medical education and improving patient communication and satisfaction.

MATERIAL AND METHODS

A literature review was conducted by searching PubMed and Scopus databases using keywords related to augmented reality in spine surgery, covering publications from January 2020 to January 2024.

RESULTS

In total, 319 articles were identified through the initial search of the databases. After screening titles and abstracts, 11 articles in total were included in the qualitative synthesis.

CONCLUSION

Augmented reality (AR) is becoming a transformative force in spine surgery, enhancing precision, education, and outcomes despite hurdles like technical limitations and integration challenges. AR's immersive visualizations and educational innovations, coupled with its potential synergy with AI and machine learning, indicate a bright future for surgical care. Despite the existing obstacles, AR's impact on improving surgical accuracy and safety marks a significant leap forward in patient treatment and care.

Evolution of the meta-neurosurgeon: A systematic review of the current technical capabilities, limitations, and applications of augmented reality in neurosurgery

Background

Augmented reality (AR) applications in neurosurgery have expanded over the past decade with the introduction of headset-based platforms. Many studies have focused on either preoperative planning to tailor the approach to the patient's anatomy and pathology or intraoperative surgical navigation, primarily realized as AR navigation through microscope oculars. Additional efforts have been made to validate AR in trainee and patient education and to investigate novel surgical approaches. Our objective was to provide a systematic overview of AR in neurosurgery, provide current limitations of this technology, as well as highlight several applications of AR in neurosurgery.

Methods

We performed a literature search in PubMed/Medline to identify papers that addressed the use of AR in neurosurgery. The authors screened three hundred and seventy-five papers, and 57 papers were selected, analyzed, and included in this systematic review.

Results

AR has made significant inroads in neurosurgery, particularly in neuronavigation. In spinal neurosurgery, this primarily has been used for pedicle screw placement. AR-based neuronavigation also has significant applications in cranial neurosurgery, including neurovascular, neurosurgical oncology, and skull base neurosurgery. Other potential applications include operating room streamlining, trainee and patient education, and telecommunications.

Conclusion

AR has already made a significant impact in neurosurgery in the above domains and has the potential to be a paradigm-altering technology. Future development in AR should focus on both validating these applications and extending the role of AR.

Innovations in Spine Surgery: A Narrative Review of Current Integrative Technologies

Neurosurgical technologies have become increasingly more adaptive, featuring real-time and patient-specific guidance in preoperative, intraoperative, and postoperative settings. This review offers insight into how these integrative innovations compare with conventional approaches in spine surgery, focusing on machine learning (ML), artificial intelligence, augmented reality and virtual reality, and spinal navigation systems. Data on technology applications, diagnostic and procedural accuracy, intraoperative times, radiation exposures, postoperative outcomes, and costs were extracted and compared with conventional methods to assess their advantages and limitations. Preoperatively, augmented reality and virtual reality have applications in surgical training and planning that are more immersive, case specific, and risk-free and have been shown to enhance accuracy and reduce complications. ML algorithms have demonstrated high accuracy in predicting surgical candidacy (up to 92.1%) and tailoring personalized treatments based on patient-specific variables. Intraoperatively, advantages include more accurate pedicle screw insertion (96%-99% with ML), enhanced visualization, reduced radiation exposure (49 μSv with O-arm navigation vs. 556 μSv with fluoroscopy), increased efficiency, and potential for fewer intraoperative complications compared with conventional approaches. Postoperatively, certain ML and artificial intelligence models have outperformed conventional methods in predicting all postoperative complications of >6000 patients as well as predicting variables contributing to in-hospital and 90-day mortality. However, applying these technologies comes with limitations, such as longer operative times (up to 35.6% longer) with navigation, dependency on datasets, costs, accessibility, steep learning curve, and inherent software malfunctions. As these technologies advance, continuing to assess their efficacy and limitations will be crucial to their successful integration within spine surgery.

Augmented Reality and Virtual Reality in Spine Surgery: A Comprehensive Review

Augmented reality (AR) and virtual reality (VR) are powerful technologies with proven utility and tremendous potential. Spine surgery, in particular, may benefit from these developing technologies for resident training, preoperative education for patients, surgical planning and execution, and patient rehabilitation. In this review, the history, current applications, challenges, and future of AR/VR in spine surgery are examined.

Using Augmented Reality Technology to Optimize Transfacet Lumbar Interbody Fusion: A Case Report

The transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a novel approach available for the management of lumbar spondylolisthesis. It avoids the need to manipulate either of the exiting or traversing nerve roots, both protected by the bony boundaries of the approach. With the advancement in operative technologies such as navigation, mapping, segmentation, and augmented reality (AR), surgeons are prompted to utilize these technologies to enhance their surgical outcomes. A 36-year-old male patient was complaining of chronic progressive lower back pain. He was found to have grade 2 L4/5 spondylolisthesis. We studied the feasibility of a trans-Kambin or a transfacet MIS-TLIF, and decided to proceed with the latter given the wider corridor it provides. Preoperative trajectory planning and level segmentation in addition to intraoperative navigation and image merging were all utilized to provide an AR model to guide us through the surgery. The use of AR can build on the safety and learning of novel surgical approaches to spine pathologies. However, larger high-quality studies are needed to further objectively analyze its impact on surgical outcomes and to expand on its application.

Virtual, Augmented, and Mixed Reality Applications for Surgical Rehearsal, Operative Execution, and Patient Education in Spine Surgery: A Scoping Review

Background and Objectives: Advances in virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies have resulted in their increased application across many medical specialties. VR's main application has been for teaching and preparatory roles, while AR has been mostly used as a surgical adjunct. The objective of this study is to discuss the various applications and prospects for VR, AR, and MR specifically as they relate to spine surgery. Materials and Methods: A systematic review was conducted to examine the current applications of VR, AR, and MR with a focus on spine surgery. A literature search of two electronic databases (PubMed and Scopus) was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The study quality was assessed using the MERSQI score for educational research studies, QUACS for cadaveric studies, and the JBI critical appraisal tools for clinical studies. Results: A total of 228 articles were identified in the primary literature review. Following title/abstract screening and full-text review, 46 articles were included in the review. These articles comprised nine studies performed in artificial models, nine cadaveric studies, four clinical case studies, nineteen clinical case series, one clinical case-control study, and four clinical parallel control studies. Teaching applications utilizing holographic overlays are the most intensively studied aspect of AR/VR; the most simulated surgical procedure is pedicle screw placement. Conclusions: VR provides a reproducible and robust medium for surgical training through surgical simulations and for patient education through various platforms. Existing AR/MR platforms enhance the accuracy and precision of spine surgeries and show promise as a surgical adjunct.

The Integration of 3D Virtual Reality and 3D Printing Technology as Innovative Approaches to Preoperative Planning in Neuro-Oncology

Our study explores the integration of three-dimensional (3D) virtual reality (VR) and 3D printing in neurosurgical preoperative planning. Traditionally, surgeons relied on two-dimensional (2D) imaging for complex neuroanatomy analyses, requiring significant mental visualization. Fortunately, nowadays advanced technology enables the creation of detailed 3D models from patient scans, utilizing different software. Afterwards, these models can be experienced through VR systems, offering comprehensive preoperative rehearsal opportunities. Additionally, 3D models can be 3D printed for hands-on training, therefore enhancing surgical preparedness. This technological integration transforms the paradigm of neurosurgical planning, ensuring safer procedures.

Augmented reality in spine surgery - past, present, and future

BACKGROUND CONTEXT

Augmented reality (AR) is increasingly recognized as a valuable tool in spine surgery. Here we provides an overview of the key developments and technological milestones that have laid the foundation for AR applications in this field. We also assess the quality of existing studies on AR systems in spine surgery and explore potential future applications.

PURPOSE

The purpose of this narrative review is to examine the role of AR in spine surgery. It aims to highlight the evolution of AR technology in this context, evaluate the existing body of research, and outline potential future directions for integrating AR into spine surgery.

STUDY DESIGN

Narrative review.

METHODS

We conducted a thorough literature search to identify studies and developments related to AR in spine surgery. Relevant articles, reports, and technological advancements were analyzed to establish the historical context and current state of AR in this field.

RESULTS

The review identifies significant milestones in the development of AR technology for spine surgery. It discusses the growing body of research and highlights the strengths and weaknesses of existing investigations. Additionally, it presents insights into the potential for AR to enhance spine surgical education and speculates on future applications.

CONCLUSIONS

Augmented reality has emerged as a promising adjunct in spine surgery, with notable advancements and research efforts. The integration of AR into the spine surgery operating room holds promise, as does its potential to revolutionize surgical education. Future applications of AR in spine surgery may include real-time navigation, enhanced visualization, and improved patient outcomes. Continued development and evaluation of AR technology are essential for its successful implementation in this specialized surgical field.

Spine Surgery with Electronic Conductivity Device: A Prospectively Multicenter Randomized Clinical Trial and Literature Review

OBJECTIVE

Improving accuracy and safety of pedicle screw placement is of great clinical importance. Electronic conductivity device (ECD) can be a promising technique with features of affordability, portability, and real-time detection capabilities. This study aimed to validate the safety and effectiveness of a modified ECD.

METHODS

The ECD underwent a modification where six lamps of various colors, and it was utilized in a prospectively multicenter randomized controlled clinical trial involving 96 patients across three hospitals from June 2018 to December 2018. The trial incorporated a self-control randomization with an equal distribution of left or right side of vertebral pedicle among two groups: the free-hand group and the ECD group. A total of 496 pedicle screws were inserted, with 248 inserted in each group. The primary outcomes focused on the accuracy of pedicle screw placement and the frequency of intraoperative X-rays. Meanwhile, the secondary indicator measured the time required for pedicle screw placement. Results were presented as means ± SD. Paired samples t-test and χ2 -test were used for comparison. Furthermore, an updated review was conducted, which included studies published from 2006 onwards.

RESULTS

Baseline patient characteristics were recorded. The primary accuracy outcome revealed a 96.77% accuracy rate in the ECD group, compared to a 95.16% accuracy rate in the free-hand group, with no significant differences noted. In contrast, ECD demonstrated a significant reduction in radiation exposure frequency when compared to the free-hand group (1.11 ± 0.32 vs. 1.30 ± 0.53; p < 0.001), resulting in a 14.6% reduction. Moreover, ECD displayed a decrease of 30.38% in insertion time (70.88 ± 30.51 vs. 101.82 ± 54.00 s; p < 0.001). According to the results of the 21 studies, ECD has been utilized in various areas of the spine such as the atlas, thoracic and lumbar spine, as well as sacral 2-alar-iliac. The accuracy of ECD ranged from 85% to 100%.

CONCLUSION

The prospectively randomized trial and the review indicate that the use of ECD presents a secure and precise approach to the placement of pedicle screws, with the added benefit of reducing both procedure time and radiation exposure.

Augmented Reality in Neurosurgery: A New Paradigm for Training

Augmented reality (AR) involves the overlay of computer-generated images onto the user's real-world visual field to modify or enhance the user's visual experience. With respect to neurosurgery, AR integrates preoperative and intraoperative imaging data to create an enriched surgical experience that has been shown to improve surgical planning, refine neuronavigation, and reduce operation time. In addition, AR has the potential to serve as a valuable training tool for neurosurgeons in a way that minimizes patient risk while facilitating comprehensive training opportunities. The increased use of AR in neurosurgery over the past decade has led to innovative research endeavors aiming to develop novel, more efficient AR systems while also improving and refining present ones. In this review, we provide a concise overview of AR, detail current and emerging uses of AR in neurosurgery and neurosurgical training, discuss the limitations of AR, and provide future research directions. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 386 articles were initially identified. Two independent reviewers (GH and AC) assessed article eligibility for inclusion, and 31 articles are included in this review. The literature search included original (retrospective and prospective) articles and case reports published in English between 2013 and 2023. AR assistance has shown promise within neuro-oncology, spinal neurosurgery, neurovascular surgery, skull-base surgery, and pediatric neurosurgery. Intraoperative use of AR was found to primarily assist with surgical planning and neuronavigation. Similarly, AR assistance for neurosurgical training focused primarily on surgical planning and neuronavigation. However, studies included in this review utilize small sample sizes and remain largely in the preliminary phase. Thus, future research must be conducted to further refine AR systems before widespread intraoperative and educational use.

Augmented Reality-Assisted Spine Surgery: An Early Experience Demonstrating Safety and Accuracy with 218 Screws

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

In spine surgery, accurate screw guidance is critical to achieving satisfactory fixation. Augmented reality (AR) is a novel technology to assist in screw placement and has shown promising results in early studies. This study aims to provide our early experience evaluating safety and efficacy with an Food and Drug Administration-approved head-mounted (head-mounted device augmented reality (HMD-AR)) device.

METHODS

Consecutive adult patients undergoing AR-assisted thoracolumbar fusion between October 2020 and August 2021 with 2 -week follow-up were included. Preoperative, intraoperative, and postoperative data were collected to include demographics, complications, revision surgeries, and AR performance. Intraoperative 3D imaging was used to assess screw accuracy using the Gertzbein-Robbins (G-R) grading scale.

RESULTS

Thirty-two patients (40.6% male) were included with a total of 222 screws executed using HMD-AR. Intraoperatively, 4 (1.8%) were deemed misplaced and revised using AR or freehand. The remaining 218 (98.2%) screws were placed accurately. There were no intraoperative adverse events or complications, and AR was not abandoned in any case. Of the 208 AR-placed screws with 3D imaging confirmation, 97.1% were considered clinically accurate (91.8% Grade A, 5.3% Grade B). There were no early postoperative surgical complications or revision surgeries during the 2 -week follow-up.

CONCLUSIONS

This early experience study reports an overall G-R accuracy of 97.1% across 218 AR-guided screws with no intra or early postoperative complications. This shows that HMD-AR-assisted spine surgery is a safe and accurate tool for pedicle, cortical, and pelvic fixation. Larger studies are needed to continue to support this compelling evolution in spine surgery.

Augmented Reality in Minimally Invasive Spinal Surgery: A Narrative Review of Available Technology

INTRODUCTION

Spine surgery has undergone significant changes in approach and technique. With the adoption of intraoperative navigation, minimally invasive spinal surgery (MISS) has arguably become the gold standard. Augmented reality (AR) has now emerged as a front-runner in anatomical visualization and narrower operative corridors. In effect, AR is poised to revolutionize surgical training and operative outcomes. Our study examines the current literature on AR-assisted MISS, synthesizes findings, and creates a narrative highlighting the history and future of AR in spine surgery.

MATERIAL AND METHODS

Relevant literature was gathered using the PubMed (Medline) database from 1975 to 2023. Pedicle screw placement models were the primary intervention in AR. These were compared to the outcomes of traditional MISS RESULTS: We found that AR devices on the market show promising clinical outcomes in preoperative training and intraoperative use. Three prominent systems were as follows: XVision, HoloLens, and ImmersiveTouch. In the studies, surgeons, residents, and medical students had opportunities to operate AR systems, showcasing their educational potential across each phase of learning. Specifically, one facet described training with cadaver models to gauge accuracy in pedicle screw placement. AR-MISS exceeded free-hand methods without unique complications or contraindications.

CONCLUSIONS

While still in its infancy, AR has already proven beneficial for educational training and intraoperative MISS applications. We believe that with continued research and advancement of this technology, AR is poised to become a dominant player within the fundamentals of surgical education and MISS operative technique.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

The Role of Augmented Reality in the Advancement of Minimally Invasive Surgery Procedures: A Scoping Review

The purpose of this review was to analyze the evidence on the role of augmented reality (AR) in the improvement of minimally invasive surgical (MIS) procedures. A scoping literature search of the PubMed and ScienceDirect databases was performed to identify articles published in the last five years that addressed the direct impact of AR technology on MIS procedures or that addressed an area of education or clinical care that could potentially be used for MIS development. A total of 359 studies were screened and 31 articles were reviewed in depth and categorized into three main groups: Navigation, education and training, and user-environment interfaces. A comparison of studies within the different application groups showed that AR technology can be useful in various disciplines to advance the development of MIS. Although AR-guided navigation systems do not yet offer a precision advantage, benefits include improved ergonomics and visualization, as well as reduced surgical time and blood loss. Benefits can also be seen in improved education and training conditions and improved user-environment interfaces that can indirectly influence MIS procedures. However, there are still technical challenges that need to be addressed to demonstrate added value to patient care and should be evaluated in clinical trials with sufficient patient numbers or even in systematic reviews or meta-analyses.

Clip Ligation and Disconnection of a Ruptured Ventral Subaxial Cervical Isolated Spinal Aneurysm Using Tailored Access Osteotomies: An Operative Technique

BACKGROUND

Isolated spinal aneurysms (iSAs) are lesions of the spinal vasculature with no associated vascular malformation with difficult management paradigms limited by safe access.

OBJECTIVE

To describe a case of an irregular fusiform ruptured distal subaxial cervical spine iSA with a complex angioarchitecture intimately associated with the ventral pial plexus (VPP), treated using open clip ligation and disconnection.

METHODS

A 51-year-old woman presented with complete spinal cord injury with a C8 sensory level and ventral subarachnoid hemorrhage at the C6-T1 vertebral levels. After emergent anterior evacuation and fusion, angiography revealed a small iSA around the VPP. A total laminectomy spanning C5 to T3 was completed, and bilateral C7 pedicle resections were performed. A temporary clip was placed from the left for proximal control, and a permanent clip was placed across the dome of the distal vessel for disconnection. The dura was then closed, and a cervicothoracic fusion completed.

RESULTS

Postoperative angiography confirmed iSA disconnection and obliteration with anterior spinal artery preservation. The patient had intermittent numbness in the right C8 dermatome. On postoperative day 1, she regained proprioception in the right foot and movement in the lower extremities on command. On postoperative day 3, she regained full sensation and voluntary movement in both lower extremities.

CONCLUSION

iSA is a rare and morbid condition with nonstandardized guidelines regarding management. We promote the concept of using tailored osteotomies to establish safe corridors for the open treatment of difficult subaxial cervical ventral lesions not amenable to transarterial treatment. Multidisciplinary collaboration is promising, and further investigation is highly warranted.

Spatial Computing for preoperative planning and postoperative evaluation of single-position lateral approaches in spinal revision surgery

Spatial computing (SC) in a surgical context offers reconstructed interactive four-dimensional models of radiological imaging. Preoperative and postoperative assessment with SC can offer more insight into personalized surgical approaches. Spine surgery has benefitted from the use of perioperative SC assessment. Herein, we describe the use of SC to perform a perioperative assessment of a revision spinal deformity surgery. A 79-year-old wheelchair-bound male presented to the neurosurgery clinic with a history of chronic lumbar pain associated with bilateral lower extremity weakness. His surgical history is significant for an L2-L5 lumbar decompression with posterior fixation 1 year prior. On examination, there were signs of thoracic myelopathy. Imaging revealed his previous instrumentation, pseudoarthrosis, and cord compression. We perform a two-staged operation to address the thoracic spinal cord compression and myelopathy, pseudoarthrosis, and malalignment with a lack of global spinal harmony. His imaging is driven by a spatial computing and SC environment and offers support for the diagnosis of his L2-3 and L4-5 pseudoarthrosis on the reconstructed SC-based computed tomography scan. SC enabled the assessment of the configuration of the psoas muscle and course of critical neurovascular structures in addition to graft sizing, trajectory and approach, evaluation of the configuration and durability of the anterior longitudinal ligament, and the overlying abdominal viscera. SC increases the familiarity of the patient's specific anatomy and enhances perioperative assessment. As such, SC can be used to preoperatively plan for spinal revision surgery.

The Role and Future of Endoscopic Spine Surgery: A Narrative Review

Many types of surgeries are changing from conventional to minimally invasive techniques. Techniques in spine surgery have also changed, with endoscopic spine surgery (ESS) becoming a major surgical technique. Although ESS has advantages such as less soft tissue dissection and normal structure damage, reduced blood loss, less epidural scarring, reduced hospital stay, and earlier functional recovery, it is not possible to replace all spine surgery techniques with ESS. ESS was first used for discectomy in the lumbar spine, but the range of ESS has expanded to cover the entire spine, including the cervical and thoracic spine. With improvements in ESS instruments (optics, endoscope, endoscopic drill and shaver, irrigation pump, and multiportal endoscopic), limitations of ESS have gradually decreased, and it is possible to apply ESS to more spine pathologies. ESS currently incorporates new technologies, such as navigation, augmented and virtual reality, robotics, and 3-dimentional and ultraresolution visualization, to innovate and improve outcomes. In this article, we review the history and current status of ESS, and discuss future goals and possibilities for ESS through comparisons with conventional surgical techniques.

Augmented reality for minimally invasive spinal surgery

Background

Augmented reality (AR) is an emerging technology that can overlay computer graphics onto the real world and enhance visual feedback from information systems. Within the past several decades, innovations related to AR have been integrated into our daily lives; however, its application in medicine, specifically in minimally invasive spine surgery (MISS), may be most important to understand. AR navigation provides auditory and haptic feedback, which can further enhance surgeons' capabilities and improve safety.

Purpose

The purpose of this article is to address previous and current applications of AR, AR in MISS, limitations of today's technology, and future areas of innovation.

Methods

A literature review related to applications of AR technology in previous and current generations was conducted.

Results

AR systems have been implemented for treatments related to spinal surgeries in recent years, and AR may be an alternative to current approaches such as traditional navigation, robotically assisted navigation, fluoroscopic guidance, and free hand. As AR is capable of projecting patient anatomy directly on the surgical field, it can eliminate concern for surgeon attention shift from the surgical field to navigated remote screens, line-of-sight interruption, and cumulative radiation exposure as the demand for MISS increases.

Conclusion

AR is a novel technology that can improve spinal surgery, and limitations will likely have a great impact on future technology.

Practical Use of Augmented Reality Modeling to Guide Revision Spine Surgery: An Illustrative Case of Hardware Failure and Overriding Spondyloptosis

BACKGROUND AND IMPORTANCE

Augmented reality (AR) is a novel technology with broadening applications to neurosurgery. In deformity spine surgery, it has been primarily directed to the more precise placement of pedicle screws. However, AR may also be used to generate high fidelity three-dimensional (3D) spine models for cases of advanced deformity with existing instrumentation. We present a case in which an AR-generated 3D model was used to facilitate and expedite the removal of embedded instrumentation and guide the reduction of an overriding spondyloptotic deformity.

CLINICAL PRESENTATION

A young adult with a remote history of a motor vehicle accident treated with long-segment posterior spinal stabilization presented with increasing back pain and difficulty sitting upright in a wheelchair. Imaging revealed pseudoarthrosis with multiple rod fractures resulting in an overriding spondyloptosis of T6 on T9. An AR-generated 3D model was useful in the intraoperative localization of rod breaks and other extensively embedded instrumentation. Real-time model thresholding expedited the safe explanation of the defunct system and correction of the spondyloptosis deformity.

CONCLUSION

An AR-generated 3D model proved instrumental in a revision case of hardware failure and high-grade spinal deformity.

Augmented Reality in Surgery: A Scoping Review

Augmented reality (AR) is an innovative system that enhances the real world by superimposing virtual objects on reality. The aim of this study was to analyze the application of AR in medicine and which of its technical solutions are the most used. We carried out a scoping review of the articles published between 2019 and February 2022. The initial search yielded a total of 2649 articles. After applying filters, removing duplicates and screening, we included 34 articles in our analysis. The analysis of the articles highlighted that AR has been traditionally and mainly used in orthopedics in addition to maxillofacial surgery and oncology. Regarding the display application in AR, the Microsoft HoloLens Optical Viewer is the most used method. Moreover, for the tracking and registration phases, the marker-based method with a rigid registration remains the most used system. Overall, the results of this study suggested that AR is an innovative technology with numerous advantages, finding applications in several new surgery domains. Considering the available data, it is not possible to clearly identify all the fields of application and the best technologies regarding AR.

First in-human report of the clinical accuracy of thoracolumbar percutaneous pedicle screw placement using augmented reality guidance

OBJECTIVE

Augmented reality (AR) is an emerging technology that has great potential for guiding the safe and accurate placement of spinal hardware, including percutaneous pedicle screws. The goal of this study was to assess the accuracy of 63 percutaneous pedicle screws placed at a single institution using an AR head-mounted display (ARHMD) system.

METHODS

Retrospective analyses were performed for 9 patients who underwent thoracic and/or lumbar percutaneous pedicle screw placement guided by ARHMD technology. Clinical accuracy was assessed via the Gertzbein-Robbins scale by the authors and by an independent musculoskeletal radiologist. Thoracic pedicle subanalysis was also performed to assess screw accuracy based on pedicle morphology.

RESULTS

Nine patients received thoracic or lumbar AR-guided percutaneous pedicle screws. The mean age at the time of surgery was 71.9 ± 11.5 years and the mean number of screws per patient was 7. Indications for surgery were spinal tumors (n = 4, 44.4%), degenerative disease (n = 3, 33.3%), spinal deformity (n = 1, 11.1%), and a combination of deformity and infection (n = 1, 11.1%). Presenting symptoms were most commonly low-back pain (n = 7, 77.8%) and lower-extremity weakness (n = 5, 55.6%), followed by radicular lower-extremity pain, loss of lower-extremity sensation, or incontinence/urinary retention (n = 3 each, 33.3%). In all, 63 screws were placed (32 thoracic, 31 lumbar). The accuracy for these screws was 100% overall; all screws were Gertzbein-Robbins grade A or B (96.8% grade A, 3.2% grade B). This accuracy was achieved in the thoracic spine regardless of pedicle cancellous bone morphology.

CONCLUSIONS

AR-guided surgery demonstrated a 100% accuracy rate for the insertion of 63 percutaneous pedicle screws in 9 patients (100% rate of Gertzbein-Robbins grade A or B screw placement). Using an ARHMS system for the placement of percutaneous pedicle screws showed promise, but further validation using a larger cohort of patients across multiple surgeons and institutions will help to determine the true accuracy enabled by this technology.

Evaluation of the effect of standard neuronavigation and augmented reality on the integrity of the perifocal structures during a neurosurgical approach

OBJECTIVE

Intracranial minimally invasive procedures imply working in a restricted surgical corridor surrounded by critical structures, such as vessels and cranial nerves. Any damage to them may affect patient outcome. Neuronavigation systems may reduce the risk of such complications. In this study, the authors sought to compare standard neuronavigation (NV) and augmented reality (AR)-guided navigation with respect to the integrity of the perifocal structures during a neurosurgical approach using a novel model imitating intracranial vessels.

METHODS

A custom-made box, containing crisscrossing hard metal wires, a hidden nail at its bottom, and a wooden top, was scanned, fused, and referenced for the purpose of the study. The metal wires and an aneurysm clip applier were connected to a controller, which counted the number of contacts between them. Twenty-three naive participants were asked to 1) use NV to define an optimal entry point on the top, perform the smallest craniotomy possible on the wooden top, and to use a surgical microscope when placing a clip on the nail without touching the metal wires; and 2) use AR to preoperatively define an ideal trajectory, navigate the surgical microscope, and then perform the same task. The primary outcome was the number of contacts made between the metal wires and the clip applier. Secondary outcomes were craniotomy size, and trust in NV and AR to help avoid touching the metal wires, as assessed by a 9-level Likert scale.

RESULTS

The median number of contacts tended to be lower with the use of AR than with NV (AR, median 1 [Q1: 1, Q3: 2]; NV, median 3 [Q1: 1, Q3: 6]; p = 0.074). The size of the target-oriented craniotomy was significantly lower with the use of AR compared with NV (AR, median 4.91 cm2 [Q1: 4.71 cm2, Q3: 7.55 cm2]; and NV, median 9.62 cm2 [Q1: 7.07 cm2; Q3: 13.85 cm2]). Participants had more trust in AR than in NV (the differences posttest minus pretest were mean 0.9 [SD 1.2] and mean -0.3 [SD 0.2], respectively; p < 0.05).

CONCLUSIONS

The results of this study show a trend favoring the use of AR over NV with respect to reducing contact between a clip applier and the perifocal structures during a simulated clipping of an intracranial aneurysm. Target-guided craniotomies were smaller with the use of AR. AR may be used not only to localize surgical targets but also to prevent complications associated with damage to structures encountered during the surgical approach.

Augmented Reality, Virtual Reality and Artificial Intelligence in Orthopedic Surgery: A Systematic Review

Background: The application of virtual and augmented reality technologies to orthopaedic surgery training and practice aims to increase the safety and accuracy of procedures and reducing complications and costs. The purpose of this systematic review is to summarise the present literature on this topic while providing a detailed analysis of current flaws and benefits. Methods: A comprehensive search on the PubMed, Cochrane, CINAHL, and Embase database was conducted from inception to February 2021. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to improve the reporting of the review. The Cochrane Risk of Bias Tool and the Methodological Index for Non-Randomized Studies (MINORS) was used to assess the quality and potential bias of the included randomized and non-randomized control trials, respectively. Results: Virtual reality has been proven revolutionary for both resident training and preoperative planning. Thanks to augmented reality, orthopaedic surgeons could carry out procedures faster and more accurately, improving overall safety. Artificial intelligence (AI) is a promising technology with limitless potential, but, nowadays, its use in orthopaedic surgery is limited to preoperative diagnosis. Conclusions: Extended reality technologies have the potential to reform orthopaedic training and practice, providing an opportunity for unidirectional growth towards a patient-centred approach.