Augmented Reality Surgical Navigation in Spine Surgery to Minimize Staff Radiation Exposure

Abstract

Study Design. Prospective observational study. Objective. To assess staff and patient radiation exposure during augmented reality surgical navigation in spine surgery. Summary of Background Data. Surgical navigation in combination with intraoperative three-dimensional imaging has been shown to significantly increase the clinical accuracy of pedicle screw placement. Although this technique may increase the total radiation exposure compared with fluoroscopy, the occupational exposure can be minimized, as navigation is radiation free and staff can be positioned behind protective shielding during three-dimensional imaging. The patient radiation exposure during treatment and verification of pedicle screw positions can also be reduced. Methods. Twenty patients undergoing spine surgery with pedicle screw placement were included in the study. The staff radiation exposure was measured using real-time active personnel dosimeters and was further compared with measurements using a reference dosimeter attached to the C-arm (i.e., a worst-case staff exposure situation). The patient radiation exposures were recorded, and effective doses (ED) were determined. Results. The average staff exposure per procedure was 0.21 ± 0.06 μSv. The average staff-to-reference dose ratio per procedure was 0.05% and decreased to less than 0.01% after a few procedures had been performed. The average patient ED was 15.8 ± 1.8 mSv which mainly correlated with the number of vertebrae treated and the number of cone-beam computed tomography acquisitions performed. A low-dose protocol used for the final 10 procedures yielded a 32% ED reduction per spinal level treated. Conclusion. This study demonstrated significantly lower occupational doses compared with values reported in the literature. Real-time active personnel dosimeters contributed to a fast optimization and adoption of protective measures throughout the study. Even though our data include both cone-beam computed tomography for navigation planning and intraoperative screw placement verification, we find low patient radiation exposure levels compared with published data. Level of Evidence: 3

Feasibility and accuracy of a robotic guidance system for navigated spine surgery in a hybrid operating room: a cadaver study

“…In this study, no lead aprons were used as all use of radiation was done with all staff outside of the OR. Meanwhile, the patient radiation exposure from the CBCT with the ARSN system is lower than the radiation dose from comparable intraoperative 3-dimensional image systems 22,47 .…”

“…A 3D Cone Beam Computed Tomography (CBCT) was performed to capture the desired spinal levels (XperCT, Philips Healthcare). Typically 4 to 6 spinal levels are imaged using the 48 cm field of view imaging mode used in this study 22 . The C-arm rotates 180° in 8 seconds during acquisition, creating a 3D volume with 0.45 mm voxel size, as has been previously described 17 .…”

“…We investigate whether the addition of a robotic arm to identify and maintain entry position and planned trajectory, increases accuracy and if it adds surgical time compared to non-robot-assisted pedicle screw placement using the same ARSN system and reported rates for robot-assisted surgery in the literature. Using the ARSN, the radiation exposure to the staff is negligible and no lead aprons are required 21,22 .…”

Augmented reality navigation with intraoperative 3D imaging vs fluoroscopy-assisted free-hand surgery for spine fixation surgery: a matched-control study comparing accuracy

“…Furthermore, intraoperative 3D imaging may prevent repeat surgeries and reduce the need for follow-up imaging, thereby reducing the cumulative patient dose. Using a low-dose CBCT-protocol could also reduce the patient radiation exposure 24 .…”

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

“…54 Furthermore, the mean radiation exposure of the surgical staff was significantly lower due to the absence of intraoperative fluoroscopic imaging. 55 The same system was recently utilized in a pilot randomized clinical trial to test AR during percutaneous vertebroplasty. In this study, the virtual trajectory for the injection was superimposed to live images to guide vertebroplasty trocar placement.…”