Clinical Accuracy, Technical Precision, and Workflow of the First in Human Use of an Augmented-Reality Head-Mounted Display Stereotactic Navigation System for Spine Surgery

Molina, Camilo A.; Sciubba, Daniel M.; Greenberg, Jacob K.; Khan, Majid; Witham, Timothy F.

doi:10.1093/ons/opaa398

Cited by 72 publications

(54 citation statements)

References 33 publications

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“…A small number of solutions for AR-based intraoperative surgical guidance have been successfully demonstrated in humans, e.g., for spine [ 12 ] and hip [ 13 ] surgery. Nevertheless, AR has not been widely adopted and the vast majority of surgeries are still performed manually, without any computer-assisted aids.…”

Section: Introductionmentioning

confidence: 99%

Augmented-Reality-Assisted K-Wire Placement for Glenoid Component Positioning in Reversed Shoulder Arthroplasty: A Proof-of-Concept Study

Schlueter-Brust

Henckel

Katinakis

et al. 2021

JPM

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The accuracy of the implant’s post-operative position and orientation in reverse shoulder arthroplasty is known to play a significant role in both clinical and functional outcomes. Whilst technologies such as navigation and robotics have demonstrated superior radiological outcomes in many fields of surgery, the impact of augmented reality (AR) assistance in the operating room is still unknown. Malposition of the glenoid component in shoulder arthroplasty is known to result in implant failure and early revision surgery. The use of AR has many promising advantages, including allowing the detailed study of patient-specific anatomy without the need for invasive procedures such as arthroscopy to interrogate the joint’s articular surface. In addition, this technology has the potential to assist surgeons intraoperatively in aiding the guidance of surgical tools. It offers the prospect of increased component placement accuracy, reduced surgical procedure time, and improved radiological and functional outcomes, without recourse to the use of large navigation or robotic instruments, with their associated high overhead costs. This feasibility study describes the surgical workflow from a standardised CT protocol, via 3D reconstruction, 3D planning, and use of a commercial AR headset, to AR-assisted k-wire placement. Post-operative outcome was measured using a high-resolution laser scanner on the patient-specific 3D printed bone. In this proof-of-concept study, the discrepancy between the planned and the achieved glenoid entry point and guide-wire orientation was approximately 3 mm with a mean angulation error of 5°.

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Section: Introductionmentioning

confidence: 99%

Augmented-Reality-Assisted K-Wire Placement for Glenoid Component Positioning in Reversed Shoulder Arthroplasty: A Proof-of-Concept Study

Schlueter-Brust

Henckel

Katinakis

et al. 2021

JPM

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“…5,6 However, in patients, the same ARHMD system enabled 100% accuracy for pedicle screw placement, although this was only for 6 screws placed in 1 patient. 7 It also was shown to provide excellent clinical accuracy for osteotomies, discectomies, and pedicle screw placement during posterior en bloc L1 corpectomy for a chordoma. 8 A different AR system was used for percutaneous pedicle screw placement during transforaminal lumbar interbody fusion with 94% accuracy; however, this system relies on remote displays and does not use a head-mounted AR display.…”

Section: Discussionmentioning

confidence: 99%

“…That is, we did not determine whether these screws were placed exactly where the surgeon intended them to be placed. The precision of this particular ARHMD system has been examined previously in both cadavers and patients, 6,7 and as our institution's experience with ARHMD-guided surgery increases, we are keenly interested in determining both the accuracy and precision of pedicle screws placed using AR on a larger number of patients and among multiple surgeons.…”

Section: Limitationsmentioning

confidence: 99%

“…3,4 AR has been shown previously, both in cadaver studies and in real patients, to be of clinical utility for guiding the placement of spinal hardware. [4][5][6][7][8] These studies have suggested that pedicle screw placement and tumor resection guided by AR have the potential to be highly accurate and precise. AR thus may be a meaningful surgical adjunct to conventional freehand pedicle screw placement or other spinal procedures and may enable comparable accuracy to robotic pedicle screw placement.…”

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confidence: 99%

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First in-human report of the clinical accuracy of thoracolumbar percutaneous pedicle screw placement using augmented reality guidance

Yahanda¹,

Moore

Ray³

et al. 2021

Neurosurgical Focus

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OBJECTIVE Augmented reality (AR) is an emerging technology that has great potential for guiding the safe and accurate placement of spinal hardware, including percutaneous pedicle screws. The goal of this study was to assess the accuracy of 63 percutaneous pedicle screws placed at a single institution using an AR head-mounted display (ARHMD) system. METHODS Retrospective analyses were performed for 9 patients who underwent thoracic and/or lumbar percutaneous pedicle screw placement guided by ARHMD technology. Clinical accuracy was assessed via the Gertzbein-Robbins scale by the authors and by an independent musculoskeletal radiologist. Thoracic pedicle subanalysis was also performed to assess screw accuracy based on pedicle morphology. RESULTS Nine patients received thoracic or lumbar AR-guided percutaneous pedicle screws. The mean age at the time of surgery was 71.9 ± 11.5 years and the mean number of screws per patient was 7. Indications for surgery were spinal tumors (n = 4, 44.4%), degenerative disease (n = 3, 33.3%), spinal deformity (n = 1, 11.1%), and a combination of deformity and infection (n = 1, 11.1%). Presenting symptoms were most commonly low-back pain (n = 7, 77.8%) and lower-extremity weakness (n = 5, 55.6%), followed by radicular lower-extremity pain, loss of lower-extremity sensation, or incontinence/urinary retention (n = 3 each, 33.3%). In all, 63 screws were placed (32 thoracic, 31 lumbar). The accuracy for these screws was 100% overall; all screws were Gertzbein-Robbins grade A or B (96.8% grade A, 3.2% grade B). This accuracy was achieved in the thoracic spine regardless of pedicle cancellous bone morphology. CONCLUSIONS AR-guided surgery demonstrated a 100% accuracy rate for the insertion of 63 percutaneous pedicle screws in 9 patients (100% rate of Gertzbein-Robbins grade A or B screw placement). Using an ARHMS system for the placement of percutaneous pedicle screws showed promise, but further validation using a larger cohort of patients across multiple surgeons and institutions will help to determine the true accuracy enabled by this technology.

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“…5 Although AR displays are used to show stereotactic information such as pedicle screw trajectories, current AR systems do not dynamically interact with the surgeon and the environment, and any performance metric is derived from imaging studies evaluating the outcome of the AR system. 49 This is a serious limitation to the current status of AR for surgeon performance improvement. AR systems could display relevant case information, metrics, distances, force measurements, etc., that would be automatically collected and analyzed, which would provide peerless assessments of technical skill in a true operative setting.…”

Section: Augmented Realitymentioning

confidence: 99%

A systematic review of virtual reality for the assessment of technical skills in neurosurgery

Chan

Pangal

Cardinal

et al. 2021

Neurosurgical Focus

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OBJECTIVE Virtual reality (VR) and augmented reality (AR) systems are increasingly available to neurosurgeons. These systems may provide opportunities for technical rehearsal and assessments of surgeon performance. The assessment of neurosurgeon skill in VR and AR environments and the validity of VR and AR feedback has not been systematically reviewed. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted through MEDLINE and PubMed. Studies published in English between January 1990 and February 2021 describing the use of VR or AR to quantify surgical technical performance of neurosurgeons without the use of human raters were included. The types and categories of automated performance metrics (APMs) from each of these studies were recorded. RESULTS Thirty-three VR studies were included in the review; no AR studies met inclusion criteria. VR APMs were categorized as either distance to target, force, kinematics, time, blood loss, or volume of resection. Distance and time were the most well-studied APM domains, although all domains were effective at differentiating surgeon experience levels. Distance was successfully used to track improvements with practice. Examining volume of resection demonstrated that attending surgeons removed less simulated tumor but preserved more normal tissue than trainees. More recently, APMs have been used in machine learning algorithms to predict level of training with a high degree of accuracy. Key limitations to enhanced-reality systems include limited AR usage for automated surgical assessment and lack of external and longitudinal validation of VR systems. CONCLUSIONS VR has been used to assess surgeon performance across a wide spectrum of domains. The VR environment can be used to quantify surgeon performance, assess surgeon proficiency, and track training progression. AR systems have not yet been used to provide metrics for surgeon performance assessment despite potential for intraoperative integration. VR-based APMs may be especially useful for metrics that are difficult to assess intraoperatively, including blood loss and extent of resection.

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Clinical Accuracy, Technical Precision, and Workflow of the First in Human Use of an Augmented-Reality Head-Mounted Display Stereotactic Navigation System for Spine Surgery

Cited by 72 publications

References 33 publications

Augmented-Reality-Assisted K-Wire Placement for Glenoid Component Positioning in Reversed Shoulder Arthroplasty: A Proof-of-Concept Study

Augmented-Reality-Assisted K-Wire Placement for Glenoid Component Positioning in Reversed Shoulder Arthroplasty: A Proof-of-Concept Study

First in-human report of the clinical accuracy of thoracolumbar percutaneous pedicle screw placement using augmented reality guidance

A systematic review of virtual reality for the assessment of technical skills in neurosurgery

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