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.

Background and Objectives: Augmented reality head-mounted display (AR-HMD) is a novel technology that provides surgeons with a real-time CT-guided 3-dimensional recapitulation of a patient’s spinal anatomy. In this case series, we explore the use of AR-HMD alongside more traditional robotic assistance in surgical spine trauma cases to determine their effect on operative costs and perioperative outcomes. Materials and Methods: We retrospectively reviewed trauma patients who underwent pedicle screw placement surgery guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between 1 January 2021 and 31 December 2022. Outcome distributions were compared using the Mann–Whitney U test. Results: The AR cohort (n = 9) had a mean age of 66 years, BMI of 29.4 kg/m², Charlson Comorbidity Index (CCI) of 4.1, and Surgical Invasiveness Index (SII) of 8.8. In total, 77 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 378 mL, 0.78 units transfused, 398 min spent in the operating room, and a 20-day LOS. The robotic cohort (n = 13) had a mean age of 56 years, BMI of 27.1 kg/m², CCI of 3.8, and SII of 14.2. In total, 128 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 432 mL, 0.46 units transfused units used, 331 min spent in the operating room, and a 10.4-day LOS. No significant difference was found between the two cohorts in any outcome metrics. Conclusions: Although the need to address urgent spinal conditions poses a significant challenge to the implementation of innovative technologies in spine surgery, this study represents an initial effort to show that AR-HMD can yield comparable outcomes to traditional robotic surgical techniques. Moreover, it highlights the potential for AR-HMD to be readily integrated into Level 1 trauma centers without requiring extensive modifications or adjustments.

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Purpose: As the prevalence of adult spinal deformity (ASD) increases, it is crucial to define patient-centered outcome benchmarks to improve understanding of successful surgical intervention. The Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI) is the gold standard for spine surgery, but substantial clinical benefit (SCB) thresholds specific to ASD patients remain undefined. This study aims to establish PROMIS PI SCB values using fixed and dynamic Oswestry Disability Index (ODI) anchors. Methods: This single-center retrospective cohort study included 117 ASD patients who underwent surgery for ASD from 2016 to 2024. PROMIS PI and ODI scores were collected preoperatively and at 6 months postoperatively. The SCB thresholds for PROMIS PI were calculated using both fixed (ODI > 19) and dynamic (≥ 50% improvement) anchors. Optimal cutoffs were identified using receiver operating characteristic (ROC) curves and clinical relevance was assessed using multivariable regressions of the association between the SCB thresholds and PROMIS Physical Function, Depression, and Anxiety scores. Results: PROMIS PI SCB thresholds with a fixed anchor were identified to be 9.6 points (AUC = 0.8563) or a 12.04% improvement when using a dynamic threshold (AUC = 0.8532). When using a dynamic anchor, the SCB thresholds were 8.2 points (AUC = 0.8185) or a 21.24% improvement when using a dynamic threshold (AUC = 0.855). Achieving SCB was associated with significantly greater improvements in physical function (β = 7.1 to 8.6, p < 0.001)) and depression (β=-4.6 to -5.1, p < 0.02) at one year. Conclusion: This is the first study to define ASD-specific SCB thresholds for PROMIS PI. We found that using a 21.24% improvement using a dynamic ODI anchor was a significant and clinically applicable benchmark. These findings will help enhance interpretability of PROMIS PI scores for evaluating surgical outcomes for managing ASD.