Study Design. Collectively, seven cadavers were instrumented with 124 thoracolumbar pedicle screws using VisAR augmented reality/guidance. Sixty-five screws were inserted into four donors using open dissection spine surgery. Fifty-nine screws were positioned in three donors with a minimally invasive spine surgery (MISS) procedure. For both open and MISS, VisAR was used exclusively for pedicle screw navigation.Objective. The objective of this study was to determine the accuracy of pedicle screw placement using VisAR for open spine and MISS procedures. Summary of Background Data. Pedicle screw placement can be challenging depending on anatomical location and a surgeon's experience. AR may minimize fluoroscopy use and speed screw insertion. Methods. Prior to computed tomography (CT) a series of four image visible April Tag optical fiducials were attached to the backs' of the donors. Resulting images were used preoperatively for planned virtual pedicle screw pathways including entry point, trajectory, and depth. The study link was encrypted on a quick response (QR) code, printed, and viewed in the operating room (OR) by the surgeon using VisAR (HoloLens 2 headset). Viewing the code wirelessly uploads and launches the study, converting the DICOM data to holographic images which register to the fiducials on the donor's back. The annotated pathways for each pedicle were called up by voice command and the surgeon positioned each screw by aligning with the virtual guidance hologram. Results. Overall, 124 pedicle screws were inserted with VisAR navigation with 96% accuracy (Gertzbein-Robbins grades A and B). The combined angle of error was 2.48 and the distance error was 1.9 mm. Conclusion. Augmented reality is a highly accurate, emerging technology for navigating both open and minimally invasive spine surgery techniques with off-the-shelf headset hardware.
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INTRODUCTION:The spine surgery market is moving away from open dissection to minimally invasive spine surgery (MISS). Precise operative navigation is imperative for MISS to achieve its potential. Guidance systems have been available for years, but adoption is limited by laborious set-up, costs and intraoperative imaging requirements. Herein is described the use of OpEyes-Augmented Reality (Novarad, American Fork, UT) for navigation and guidance of MISS for highly accurate insertion of pedicle screws.METHODS:A Microsoft HoloLens 2 (Microsoft, Redmond, WA) was used as the hardware platform for OpEyes-AR software. AprilTags, printed with CT visible ink, were either adhered to the skin, anchored to the iliac crests, or a vertebra. Following CT, the radiologist identified virtual pathways for ideal placement of pedicle screws for each vertebra.The annotated studies were wirelessly uploaded to the software/visor combination by viewing an encrypted QR code assigned by the pre-op system. The studies were registered to the AprilTags captured during CT. The virtual pathways were called by voice command for each vertebra and were used to establish skin entry point, trajectory, and depth with target bullseyes. Fluoroscopy was not required for navigation. Excella MIS hardware was used for placement of the screws into the pedicles of a donor torso (Innovasis, Salt Lake City, UT).RESULTS:Pedicle screws were instrumented through levels L5-T9 for a total of 15 screws. There were no breaches. Many of the thoracic pedicles were narrow with little or no tolerance. Guidance and navigation were performed solely with OpEyes-AR.CONCLUSION:OpEyes-AR is a tether-less, holographic visor and software combination offering the potential for precise navigation of MISS percutaneous insertion of pedicle screws with a nominal OR footprint and elimination of OR imaging.
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