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Ziyu Qi, Ye Li, Xinghua Xu, Jiashu Zhang, Fangye Li, Zhichao Gan, Ruochu Xiong, Qun Wang, Shiyu Zhang, and Xiaolei Chen

imaging technologies are emerging that combine real and virtual to create a human-computer interactive environment. In virtual reality, users observe virtual objects in a completely virtual environment. In contrast, in augmented reality, users observe virtual objects in a physical environment. 3 Mixed reality, derived from augmented reality, refers to the input of physical scene information into a virtual environment and enables interactive digital data to be displayed over the physical environment. Commercial head-mounted devices (HMDs), such as HoloLens (Microsoft

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Giselle Coelho, Eberval Gadelha Figueiredo, Nícollas Nunes Rabelo, Manoel Jacobsen Teixeira, and Nelci Zanon

decreasing risks and poor outcomes. 16 The primary goal of this study is to offer a new tool for neurosurgical education that combines virtual and realistic simulation (mixed reality) to create an authentic surgical training environment for craniosynostosis correction (scaphocephaly type). In addition, we validated this new realistic model using experienced surgeons. Methods Study Population Eighteen experienced surgeons with a minimum of 15 years of practice participated in the validation phase of this study (physical model evaluation). Four were craniofacial plastic

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Ye Li, Xiaolei Chen, Ning Wang, Wenyao Zhang, Dawei Li, Lei Zhang, Xin Qu, Weitao Cheng, Yueqiao Xu, Wenjin Chen, and Qiumei Yang

patient, the surgeon can “visualize” the internal structures of the head through the phone lens. 2 A drawback of this method is that the viewing angles are confined to only a fixed direction behind the mobile phone lens, which limits enhancement of the operator’s spatial perception and performance. Mixed-reality technology is a further development that combines augmented reality and virtual reality. It uses digital objects such as holographic projections to provide virtual information in the physical environment, lending immersive realism to users’ experience. The

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Camilo A. Molina, Christopher F. Dibble, Sheng-fu Larry Lo, Timothy Witham, and Daniel M. Sciubba

navigational data on the surgical field. The 2D data provide axial and sagittal projections of the tracked tool trajectory ( Fig. 4 ). The 3D data for 3D segmentation of the bony spine anatomy are overlaid over the real spine in an anatomically matching orientation, location, and size so that the computer spine projection matches the position and size of the real spine ( Fig. 1C ). The mixed-reality 2D and 3D navigational data permit simultaneous visualization of the navigated tool, navigation data, and surgical field—eliminating the distraction and inefficiency of cyclical

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Alexander T. Yahanda, Emelia Moore, Wilson Z. Ray, Brenton Pennicooke, Jack W. Jennings, and Camilo A. Molina


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.


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.


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.


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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Walter C. Jean, Gavin W. Britz, Francesco DiMeco, Adrian Elmi-Terander, and Cameron McIntyre

T echnological advancement in neurosurgery takes a quantum leap forward every 20 years or so. The microscope entered the neurosurgical operating suite in the late 1950s, and the first commercial CT scans became available in the 1970s. 1 , 2 Mixed reality (MR; i.e., virtual and augmented reality) may represent the next iteration of the leap. The term “virtual reality” (VR) was coined by the computer scientist turned philosopher Jaron Lanier in the late 1980s. First used for immersive experience in gaming, VR applications in neurosurgery started in the

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Gorkem Yavas, Kadri Emre Caliskan, and Mehmet Sedat Cagli

planning time of 40.2 minutes in the process of external ventricular drain placement using mixed reality. 14 Incekara et al. used a neuronavigation system with mixed-reality glasses; they reported a preparation time of 5 minutes, 20 seconds, and it was shown that there was a positive learning curve. 11 In our study, it took less than 1 minute to run the app from a mobile device and place the marker. This time will be shorter on computers with higher processing power. The time frame, which was also shown to have a positive learning curve, tended to decrease gradually in

Open access

Giselle Coelho, Eduardo Vieira, Jose Hinojosa, and Hans Delye

: Coelho. Supervision: Coelho. Defining video content/format together with corresponding author: Delye. References 1 Coelho G , Warf B , Lyra M , Zanon N . Anatomical pediatric model for craniosynostosis surgical training . Childs Nerv Syst . 2014 ; 30 ( 12 ): 2009 – 2014 . 2 Coelho G , Figueiredo EG , Rabelo NN , . Development and evaluation of a new pediatric mixed-reality model for neurosurgical training . J Neurosurg Pediatr . 2019 ; 24 ( 4 ): 423 – 432 . 3 Hinojosa J , Esparza J , Muñoz MJ . Endoscopic

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Singh Gagandeep, Kainth Tejasvi, Manjila Nihal, Jain Shubham, Vaysberg Anatoliy, Spektor Vadim, Prasanna Prateek, and Manjila Sunil

C linical practice in neurosurgery has now adapted to support enhanced digital visualizations for training and surgical planning using mixed reality (MR), virtual reality (VR), and augmented reality (AR). These extended reality technologies have been safely used to explore the operative field from different viewpoints, visualizing the neurovascular anatomy hidden from the surgical field, thereby offering an enhanced comprehensive sensory experience, especially in keyhole approaches to deep-lying targets. 1 , 2 Together with the fusion of additional

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Tim Fick, Jesse A. M. van Doormaal, Lazar Tosic, Renate J. van Zoest, Jene W. Meulstee, Eelco W. Hoving, and Tristan P. C. van Doormaal

enhancements in neurosurgery . J Clin Neurosci . 2017 ; 35 : 1 – 4 . 2 Swennen GRJ , Mollemans W , Schutyser F. Three-dimensional treatment planning of orthognathic surgery in the era of virtual imaging . J Oral Maxillofac Surg . 2009 ; 67 ( 10 ): 2080 – 2092 . 3 Preim B , Botha C. Visual Computing for Medicine: Theory, Algorithms, and Applications . 2nd ed. Morgan Kaufmann ; 2014 : 648 – 661 . 4 Li Y , Chen X , Wang N , Zhang W , Li D , Zhang L , A wearable mixed-reality holographic computer for guiding external