OBJECTIVE: Augmented reality–mediated spine surgery (ARMSS) is a minimally invasive novel technology that has the potential to increase the efficiency, accuracy, and safety of conventional percutaneous pedicle screw insertion methods. Visual 3D spinal anatomical and 2D navigation images are directly projected onto the operator’s retina and superimposed over the surgical field, eliminating field of vision and attention shift to a remote display. The objective of this cadaveric study was to assess the accuracy and precision of percutaneous ARMSS pedicle implant insertion.METHODS: Instrumentation was placed in 5 cadaveric torsos via ARMSS with the xvision augmented reality head-mounted display (AR-HMD) platform at levels ranging from T5 to S1 for a total of 113 total implants (93 pedicle screws and 20 Jamshidi needles). Postprocedural CT scans were graded by two independent neuroradiologists using the Gertzbein-Robbins scale (grades A–E) for clinical accuracy. Technical precision was calculated using superimposition analysis employing the Medical Image Interaction Toolkit to yield angular trajectory (°) and linear screw tip (mm) deviation from the virtual pedicle screw position compared with the actual pedicle screw position on postprocedural CT imaging.RESULTS: The overall implant insertion clinical accuracy achieved was 99.1%. Lumbosacral and thoracic clinical accuracies were 100% and 98.2%, respectively. Specifically, among all implants inserted, 112 were noted to be Gertzbein-Robbins grade A or B (99.12%), with only 1 medial Gertzbein-Robbins grade C breach (> 2-mm pedicle breach) in a thoracic pedicle at T9. Precision analysis of the inserted pedicle screws yielded a mean screw tip linear deviation of 1.98 mm (99% CI 1.74–2.22 mm) and a mean angular error of 1.29° (99% CI 1.11°–1.46°) from the projected trajectory. These data compare favorably with data from existing navigation platforms and regulatory precision requirements mandating that linear and angular deviation be less than 3 mm (p < 0.01) and 3° (p < 0.01), respectively.CONCLUSIONS: Percutaneous ARMSS pedicle implant insertion is a technically feasible, accurate, and highly precise method.

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.

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.

En bloc spinal tumor resections are technically demanding procedures with high morbidity because of the conventionally large exposure area and aggressive resection goals. Stereotactic surgical navigation presents an opportunity to perform the smallest possible resection plan while still achieving an en bloc resection. Augmented reality (AR)–mediated spine surgery (ARMSS) via a mounted display with an integrated tracking camera is a novel FDA-approved technology for intraoperative “heads up” neuronavigation, with the proposed advantages of increased precision, workflow efficiency, and cost-effectiveness. As surgical experience and capability with this technology grow, the potential for more technically demanding surgical applications arises. Here, the authors describe the use of ARMSS for guidance in a unique osteotomy execution to achieve an en bloc wide marginal resection of an L1 chordoma through a posterior-only approach while avoiding a tumor capsule breach. A technique is described to simultaneously visualize the navigational guidance provided by the contralateral surgeon’s tracked pointer and the progress of the BoneScalpel aligned in parallel with the tracked instrument, providing maximum precision and safety. The procedure was completed by reconstruction performed with a quad-rod and cabled fibular strut allograft construct, and the patient did well postoperatively. Finally, the authors review the technical aspects of the approach, as well as the applications and limitations of this new technology.

The field of augmented reality mediated spine surgery is growing rapidly and holds great promise for improving surgical capabilities and patient outcomes. Augmented reality can assist with complex ...

BACKGROUND: Rapid growth in smartphone use has expanded opportunities to use mobile health (mHealth) technology to collect real-time patient-reported and objective biometric data. These data may have important implication for personalized treatments of degenerative spine disease. However, no large-scale study has examined the feasibility and acceptability of these methods in spine surgery patients. OBJECTIVE: To evaluate the feasibility and acceptability of a multimodal preoperative mHealth assessment in patients with degenerative spine disease. METHODS: Adults undergoing elective spine surgery were provided with Fitbit trackers and sent preoperative ecological momentary assessments (EMAs) assessing pain, disability, mood, and catastrophizing 5 times daily for 3 weeks. Objective adherence rates and a subjective acceptability survey were used to evaluate feasibility of these methods. RESULTS: The 77 included participants completed an average of 82 EMAs each, with an average completion rate of 86%. Younger age and chronic pulmonary disease were significantly associated with lower EMA adherence. Seventy-two (93%) participants completed Fitbit monitoring and wore the Fitbits for an average of 247 hours each. On average, participants wore the Fitbits for at least 12 hours per day for 15 days. Only worse mood scores were independently associated with lower Fitbit adherence. Most participants endorsed positive experiences with the study protocol, including 91% who said they would be willing to complete EMAs to improve their preoperative surgical guidance. CONCLUSION: Spine fusion candidates successfully completed a preoperative multimodal mHealth assessment with high acceptability. The intensive longitudinal data collected may provide new insights that improve patient selection and treatment guidance.