Augmented reality for pedicle screw insertion

Augmented reality for pedicle screw insertion

Cadaveric studies have shown improved accuracy for pedicle screw placement in the thoracic spine using augmented reality with intraoperative 3D imaging, without the need for periprocedural x-ray. In this clinical study, Elmi-Terander et al., used the same system to place pedicle screws in the thoracic and lumbosacral spine of 20 patients.

The study was performed in a hybrid operating room with an integrated augmented realitysystem encompassing a surgical table, a motorized flat detector C-arm with intraoperative 2D/3D capabilities, integrated optical cameras for augmented reality navigation, and noninvasive patient motion tracking. Three independent reviewers assessed screw placement accuracy using the Gertzbein-Robbins classification on 3D scans obtained before wound closure. In addition, the navigation time per screw placement was measured.

One orthopedic spinal surgeon placed 253 lumbosacral and thoracic pedicle screws on 20 consenting patients scheduled for spinal fixation surgery. An overall accuracy of 94.1% of primarily thoracic pedicle screws was achieved. No screws were deemed severely misplaced (Gertzbein grade 3). Fifteen (5.9%) screws had 2 to 4 mm breach (Gertzbein grade 2), occurring in scoliosis patients only. Thirteen of those 15 screws were larger than the pedicle in which they were placed. Two medial breaches were observed and 13 were lateral. Thirteen of the grade 2 breaches were in the thoracic spine. The average screw placement time was 5.2 ± 4.1 minutes. During the study, no device-related adverse event occurred.

Augmented reality can be clinically used to place thoracic and lumbosacral pedicle screws with high accuracy and with acceptable navigation time. Consequently, the risk for revision surgery and complications could be minimized 1).

Molina et al., studied the use of an augmented reality head-mounted display (AR-HMD) in the placement of thoracolumbar pedicle screw spinal instrumentation in cadaver specimens. The AR-HMD system has the potential to reduce important limitations of conventional manual and robotic computer navigation for pedicle screw placement 2).

In 2017 Ma et al., presented a novel augmented reality (AR) surgical navigation system based on ultrasound-assisted registration for pedicle screw placement. This system provides the clinically desired targeting accuracy and reduces radiation exposure.

Ultrasound (US) is used to perform registration between preoperative computed tomography (CT) images and patient, and the registration is performed by least-squares fitting of these two three-dimensional (3D) point sets of anatomical landmarks taken from US and CT images. An integral videography overlay device is calibrated to accurately display naked-eye 3D images for surgical navigation. We use a 3.0-mm Kirschner wire (K-wire) instead of a pedicle screw in this study, and the K-wire is calibrated to obtain its orientation and tip location. Based on the above registration and calibration, naked-eye 3D images of the planning path and the spine are superimposed onto patient in situ using our AR navigation system. Simultaneously, a 3D image of the K-wire is overlaid accurately on the real one to guide the insertion procedure. The targeting accuracy is evaluated postoperatively by performing a CT scan.

An agar phantom experiment was performed. Eight K-wires were inserted successfully after US-assisted registration, and the mean targeting error and angle error were 3.35 mm and [Formula: see text], respectively. Furthermore, an additional sheep cadaver experiment was performed. Four K-wires were inserted successfully. The mean targeting error was 3.79 mm and the mean angle error was [Formula: see text], and US-assisted registration yielded better targeting results than skin markers-based registration (targeting errors: 2.41 vs. 5.18 mm, angle errors: [Formula: see text] vs. [Formula: see text].

Experimental outcomes demonstrated that the proposed navigation system has acceptable targeting accuracy. In particular, the proposed navigation method reduces repeated radiation exposure to the patient and surgeons. Therefore, it has promising prospects for clinical use 3).



Elmi-Terander A, Burström G, Nachabe R, Skulason H, Pedersen K, Fagerlund M, Ståhl F, Charalampidis A, Söderman M, Holmin S, Babic D, Jenniskens I, Edström E, Gerdhem P. Pedicle Screw Placement Using Augmented Reality Surgical Navigation With Intraoperative 3D Imaging: A First In-Human Prospective Cohort Study. Spine (Phila Pa 1976). 2019 Apr 1;44(7):517-525. doi: 10.1097/BRS.0000000000002876. PubMed PMID: 30234816.

Molina CA, Theodore N, Ahmed AK, Westbroek EM, Mirovsky Y, Harel R, Orru’ E, Khan M, Witham T, Sciubba DM. Augmented reality-assisted pedicle screw insertion: a cadaveric proof-of-concept study. J Neurosurg Spine. 2019 Mar 29:1-8. doi: 10.3171/2018.12.SPINE181142. [Epub ahead of print] PubMed PMID: 30925479.

Ma L, Zhao Z, Chen F, Zhang B, Fu L, Liao H. Augmented reality surgical navigation with ultrasound-assisted registration for pedicle screw placement: a pilot study. Int J Comput Assist Radiol Surg. 2017 Dec;12(12):2205-2215. doi: 10.1007/s11548-017-1652-z. Epub 2017 Aug 5. PubMed PMID: 28779275.

Virtual reality in neurosurgery

Virtual reality (VR), sometimes referred to as immersive multimedia, is a computer-simulated environment that can simulate physical presence in places in the real world or imagined worlds. Virtual reality can recreate sensory experiences, including virtual taste, sight, smell, sound, touch, etc.
Chan et al., highlights a selection of recent developments in research areas related to virtual reality simulation, including anatomic modeling, computer graphics and visualization, haptics, and physics simulation, and discusses their implication for the simulation of neurosurgery 1).

Medicine and surgery are turning towards simulation to improve on limited patient interaction during residency training. Many simulators today utilize virtual reality with augmented haptic feedback with little to no physical elements.
To optimize the learning exercise, it is essential that both visual and haptic simulators are presented to best present a real-world experience. Many systems attempt to achieve this goal through a total virtual interface.
Bova et al., approach has been to create a mixed-reality system consisting of a physical and a virtual component. A physical model of the head or spine is created with a 3-dimensional printer using deidentified patient data. The model is linked to a virtual radiographic system or an image guidance platform. A variety of surgical challenges can be presented in which the trainee must use the same anatomic and radiographic references required during actual surgical procedures.
Using the aforementioned techniques, they have created a ventriculostomy simulators, percutaneous radiofrequency trigeminal rhizotomy, and spinal instrumentation.
The system has provided the residents an opportunity to understand and appreciate the complex 3-dimensional anatomy of the 3 neurosurgical procedures simulated. The systems have also provided an opportunity to break procedures down into critical segments, allowing the user to concentrate on specific areas of deficiency 2).

Shakur et al., developed a real-time augmented reality simulator for percutaneous trigeminal rhizotomy using the ImmersiveTouch platform. Ninety-two neurosurgery residents tested the simulator at American Association of Neurological Surgeons Top Gun 2014. Postgraduate year (PGY), number of fluoroscopy shots, the distance from the ideal entry point, and the distance from the ideal target were recorded by the system during each simulation session. Final performance score was calculated considering the number of fluoroscopy shots and distances from entry and target points (a lower score is better). The impact of PGY level on residents’ performance was analyzed.
Seventy-one residents provided their PGY-level and simulator performance data; 38% were senior residents and 62% were junior residents. The mean distance from the entry point (9.4 mm vs 12.6 mm, P = .01), the distance from the target (12.0 mm vs 15.2 mm, P = .16), and final score (31.1 vs 37.7, P = .02) were lower in senior than in junior residents. The mean number of fluoroscopy shots (9.8 vs 10.0, P = .88) was similar in these 2 groups. Linear regression analysis showed that increasing PGY level is significantly associated with a decreased distance from the ideal entry point (P = .001), a shorter distance from target (P = .05), a better final score (P = .007), but not number of fluoroscopy shots (P = .52).
Because technical performance of percutaneous rhizotomy increases with training, they proposed that the skills in performing the procedure in there virtual reality model would also increase with PGY level, if this simulator models the actual procedure. The results confirm this hypothesis and demonstrate construct validity 3).

Alaraj et al., developed a real-time sensory haptic feedback virtual reality aneurysm clipping simulator using the ImmersiveTouch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomographic angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-dimensional immersive virtual reality environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from 3 residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery.
Residents thought that the simulation would be useful in preparing for real-life surgery. About two-thirds of the residents thought that the 3-dimensional immersive anatomic details provided a close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They thought the simulation was useful for preoperative surgical rehearsal and neurosurgical training. A third of the residents thought that the technology in its current form provided realistic haptic feedback for aneurysm surgery.
Neurosurgical residents thought that the novel immersive VR simulator is helpful in their training, especially because they do not get a chance to perform aneurysm clippings until late in their residency programs 4).

Lemole et al., use the ImmersiveTouch (ImmersiveTouch, Inc., Chicago, IL) virtual reality platform, developed at the University of Illinois at Chicago, to simulate the task of ventriculostomy catheter placement as a proof-of-concept. Computed tomographic data are used to create a virtual anatomic volume.
Haptic feedback offers simulated resistance and relaxation with passage of a virtual three-dimensional ventriculostomy catheter through the brain parenchyma into the ventricle. A dynamic three-dimensional graphical interface renders changing visual perspective as the user’s head moves. The simulation platform was found to have realistic visual, tactile, and handling characteristics, as assessed by neurosurgical faculty, residents, and medical students.
They developed a realistic, haptics-based virtual reality simulator for neurosurgical education. The first module recreates a critical component of the ventriculostomy placement task. This approach to task simulation can be assembled in a modular manner to reproduce entire neurosurgical procedures 5).

1) Chan S, Conti F, Salisbury K, Blevins NH. Virtual reality simulation in neurosurgery: technologies and evolution. Neurosurgery. 2013 Jan;72 Suppl 1:154-64. doi: 10.1227/NEU.0b013e3182750d26. PubMed PMID: 23254804.
2) Bova FJ, Rajon DA, Friedman WA, Murad GJ, Hoh DJ, Jacob RP, Lampotang S, Lizdas DE, Lombard G, Lister JR. Mixed-reality simulation for neurosurgical procedures. Neurosurgery. 2013 Oct;73 Suppl 1:138-45. doi: 10.1227/NEU.0000000000000113. PubMed PMID: 24051877.
3) Shakur SF, Luciano CJ, Kania P, Roitberg BZ, Banerjee PP, Slavin KV, Sorenson J, Charbel FT, Alaraj A. Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training. Neurosurgery. 2015 Sep;11 Suppl 3:420-5; discussion 425. doi: 10.1227/NEU.0000000000000853. PubMed PMID: 26103444.
4) Alaraj A, Luciano CJ, Bailey DP, Elsenousi A, Roitberg BZ, Bernardo A, Banerjee PP, Charbel FT. Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback. Neurosurgery. 2015 Mar;11 Suppl 2:52-8. doi: 10.1227/NEU.0000000000000583. PubMed PMID: 25599200; PubMed Central PMCID: PMC4340784.
5) Lemole GM Jr, Banerjee PP, Luciano C, Neckrysh S, Charbel FT. Virtual reality in neurosurgical education: part-task ventriculostomy simulation with dynamic visual and haptic feedback. Neurosurgery. 2007 Jul;61(1):142-8; discussion 148-9. Review. PubMed PMID: 17621029.
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