Augmented Reality Integration in Skull Base Neurosurgery: A Systematic Review

Abstract

Background and Objectives: To investigate the role of augmented reality (AR) in skull base (SB) neurosurgery. Materials and Methods: Utilizing PRISMA methodology, PubMed and Scopus databases were explored to extract data related to AR integration in SB surgery. Results: The majority of 19 included studies (42.1%) were conducted in the United States, with a focus on the last five years (77.8%). Categorization included phantom skull models (31.2%, n = 6), human cadavers (15.8%, n = 3), or human patients (52.6%, n = 10). Microscopic surgery was the predominant modality in 10 studies (52.6%). Of the 19 studies, surgical modality was specified in 18, with microscopic surgery being predominant (52.6%). Most studies used only CT as the data source (n = 9; 47.4%), and optical tracking was the prevalent tracking modality (n = 9; 47.3%). The Target Registration Error (TRE) spanned from 0.55 to 10.62 mm. Conclusion: Despite variations in Target Registration Error (TRE) values, the studies highlighted successful outcomes and minimal complications. Challenges, such as device practicality and data security, were acknowledged, but the application of low-cost AR devices suggests broader feasibility.

Single-Center Experience in Microsurgical Resection of Acoustic Neurinomas and the Benefit of Microscope-Based Augmented Reality

“…Retrosigmoid craniotomy planning was described in a cadaveric study [21], with projection of outlines of the dural sinuses on the skin and tailoring of the craniotomy. A recent literature review on the use of AR in skull base surgery identified nine clinical studies with 292 patients which thematized the use of this technology [22]. The primary data source was CT with optical tracking as the main modality (each 47.4%) and target registration error (TRE) which spanned from 0.55 to 10.62 mm [22].…”

“…A recent literature review on the use of AR in skull base surgery identified nine clinical studies with 292 patients which thematized the use of this technology [22]. The primary data source was CT with optical tracking as the main modality (each 47.4%) and target registration error (TRE) which spanned from 0.55 to 10.62 mm [22]. Feasibility studies for AR use in lateral skull base surgery, which included the creation of a head-up display platform which allowed manual alignment of incorporated fiducial markers in real-time on a phantom model of a temporal bone using only CT rendering in the AR environment, were published in 2020 [23]; however, although AR visualization of CT could be transferred to surface landmarks of the patient, the target registration error was too high for proper use in surgery.…”

“…A study on 3D models with defects involving the anterior skull base, with modeling of AR-assisted and manually shaped implants for the repair of the defect from PMMA (Palacos ® R + G, Heraeus Medical GmbH, Wehrheim, Germany), has shown reduced deviation of the median volume from the profile of the surface of the original model in the case of an AR-assisted procedure compared to a "freehand" technique, with improved cosmetic results [29], which made this technique a viable and cost-effective alternative to patient-specific implants. Operative videos which depict the use of AR for resection of skull base meningiomas have been published, depicting its use in intraoperative orientation through estimation of tumor size, estimation of tumor remnant throughout the resection, as well as relations to neurovascular structures, especially in surgery in and around bony structures, such as for estimation of the extent of drilling in extradural clinoidectomy [22,[30][31][32]. One important advantage of AR is that, even in cases of shift and slight registration inaccuracy, the size of a segmented object such as a tumor remains unchanged, which allows for estimation of the extent of resection.…”

“…Overall complications included shunt-dependent hydrocephalus (Patient Nos. 1, 14, 25 and 27), CSF leak with wound healing deficit (Patient Nos 2,3,17,22,27,33,. 39 and 42, in Patient Nos.…”

Augmented Reality-Assisted Transcanal Endoscopic Ear Surgery for Middle Ear Cholesteatoma

“…In addition to projecting onto endoscopic images, AR glasses can be used to project information into the clinician’s field of vision. This has already been applied in spine, hip, and skull base surgeries [ 18 , 19 , 20 ]. In otologic surgery, there have been reports of cochlear implantation using AR with robotic assistance for cadavers [ 21 ] and preoperative AR projection in lateral temporal bone surgery to confirm the location of critical structures [ 22 ].…”