Augmented and Virtual Reality Instrument Tracking for Minimally Invasive Spine Surgery

Abstract

Study Design. Cadaveric animal laboratory study. Objective. To evaluate the feasibility and accuracy of pedicle cannulation using an augmented reality surgical navigation (ARSN) system with automatic instrument tracking, yielding feedback of instrument position in relation to deep anatomy. Summary of Background Data. Minimally invasive spine surgery (MISS) has the possibility of reducing surgical exposure resulting in shorter hospital stays, lower blood loss and infection rates compared with open surgery but the drawback of limiting visual feedback to the surgeon regarding deep anatomy. MISS is mainly performed using image-guided 2D fluoroscopy, thus exposing the staff to ionizing radiation. Methods. A hybrid operating room (OR) equipped with a robotic C-arm with integrated optical cameras for augmented reality instrument navigation was used. In two pig cadavers, cone beam computed tomography (CBCT) scans were performed, a 3D model generated, and pedicle screw insertions were planned. Seventy-eight insertions were performed. Technical accuracy was assessed on post-insertion CBCTs by measuring the distance between the navigated device and the corresponding pre-planned path as well as the angular deviations. Drilling and hammering into the pedicle were also compared. Navigation time was measured. An independent reviewer assessed a simulated clinical accuracy according to Gertzbein. Results. The technical accuracy was 1.7 ± 1.0 mm at the bone entry point and 2.0 ± 1.3 mm at the device tip. The angular deviation was 1.7 ± 1.7° in the axial and 1.6 ± 1.2° in the sagittal plane. Navigation time per insertion was 195 ± 93 seconds. There was no difference in accuracy between hammering and drilling into the pedicle. The clinical accuracy was 97.4% to 100% depending on the screw size considered for placement. No ionizing radiation was used during navigation. Conclusion. ARSN with instrument tracking for MISS is feasible, accurate, and radiation-free during navigation. Level of Evidence: 3

Fusion of augmented reality imaging with the endoscopic view for endonasal skull base surgery; a novel application for surgical navigation based on intraoperative cone beam computed tomography and optical tracking

“…The ARSN system has its own proprietary software for planning, segmentation and image processing. The system is composed of two parts: a C-arm for CBCT image acquisition and an optical tracking system (OTS), which makes use of four small highresolution cameras in the flat-panel X-ray detector of the C-arm [20]. The use of four cameras increases robustness, since only two cameras are needed for marker detection and tracking.…”

“…Thus, a computer-generated image of a pre-planned surgical target, path or risk organ, can be integrated in the endoscope's real-world view. In this way, sub-surface structures can be visualized and a pointer tool is not needed [20][21][22]. AR navigation systems have been successfully applied in several surgical fields, including microsurgery and spine surgery [23][24][25][26].…”

“…In this study, we present a novel navigation technique for endoscopic endonasal skull base surgery, based on an augmented reality surgical navigation (ARSN) system, previously presented in [20]. Integrating an endoscope into the system allows us to augment intraoperative CBCT imaging data onto the endoscope view during surgery.…”

Robotic Spine Surgery and Augmented Reality Systems: A State of the Art

“…Such implementation led to an improved identification of the bone screw entry point and angulation, with a 97.4%-100% accuracy of the virtual screw placement as extrapolated from positional data. 53 Given the promising results, the same authors recently published the outcomes of a small prospective cohort study on 20 patients undergoing pedicle screw positioning with ARSN. In Fig.…”

Design of a robot-assisted system for transforaminal percutaneous endoscopic lumbar surgeries: study protocol

“…In the past decades, the use of robotics in surgeries has been successfully employed across many surgical subspecialties, and is considered to set the trend for future surgical development. [15,16]. However, application of robotic technology in percutaneous endoscopic spinal surgery has not been reported up to now.…”