A cadaveric precision and accuracy analysis of augmented reality–mediated percutaneous pedicle implant insertion

Presented at the 2020 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

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  • 1 Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri;
  • 2 Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
  • 3 Department of Orthopedic Surgery, Rush University School of Medicine, Chicago, Illinois;
  • 4 Department of Neurointerventional Radiology, Lahey Clinic Tufts University School of Medicine, Boston, Massachusetts;
  • 5 The Robotic Spine Institute of Silicon Valley at OrthoNorCal, Los Gatos, California; and
  • 6 The Spine Clinic of Los Angeles, California
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OBJECTIVE

Augmented reality–mediated spine surgery (ARMSS) is a minimally invasive novel technology that has the potential to increase the efficiency, accuracy, and safety of conventional percutaneous pedicle screw insertion methods. Visual 3D spinal anatomical and 2D navigation images are directly projected onto the operator’s retina and superimposed over the surgical field, eliminating field of vision and attention shift to a remote display. The objective of this cadaveric study was to assess the accuracy and precision of percutaneous ARMSS pedicle implant insertion.

METHODS

Instrumentation was placed in 5 cadaveric torsos via ARMSS with the xvision augmented reality head-mounted display (AR-HMD) platform at levels ranging from T5 to S1 for a total of 113 total implants (93 pedicle screws and 20 Jamshidi needles). Postprocedural CT scans were graded by two independent neuroradiologists using the Gertzbein-Robbins scale (grades A–E) for clinical accuracy. Technical precision was calculated using superimposition analysis employing the Medical Image Interaction Toolkit to yield angular trajectory (°) and linear screw tip (mm) deviation from the virtual pedicle screw position compared with the actual pedicle screw position on postprocedural CT imaging.

RESULTS

The overall implant insertion clinical accuracy achieved was 99.1%. Lumbosacral and thoracic clinical accuracies were 100% and 98.2%, respectively. Specifically, among all implants inserted, 112 were noted to be Gertzbein-Robbins grade A or B (99.12%), with only 1 medial Gertzbein-Robbins grade C breach (> 2-mm pedicle breach) in a thoracic pedicle at T9. Precision analysis of the inserted pedicle screws yielded a mean screw tip linear deviation of 1.98 mm (99% CI 1.74–2.22 mm) and a mean angular error of 1.29° (99% CI 1.11°–1.46°) from the projected trajectory. These data compare favorably with data from existing navigation platforms and regulatory precision requirements mandating that linear and angular deviation be less than 3 mm (p < 0.01) and 3° (p < 0.01), respectively.

CONCLUSIONS

Percutaneous ARMSS pedicle implant insertion is a technically feasible, accurate, and highly precise method.

ABBREVIATIONS AR-HMD = augmented reality head-mounted display; ARMSS = augmented reality–mediated spine surgery; LOS = line of sight; MITK = Medical Image Interaction Toolkit; UBL = upper-bound limit.

Supplementary Materials

    • Supplementary Tables and Appendix 1 (PDF 548 KB)

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Contributor Notes

Correspondence Camilo A. Molina: Washington University School of Medicine in St. Louis, MO. molina.a.camilo@gmail.com.

INCLUDE WHEN CITING Published online October 30, 2020; DOI: 10.3171/2020.6.SPINE20370.

Disclosures All of the operators have financial relationships with Augmedics Ltd. as listed below. However, radiological and statistical analysis were completed by authors free of any financial relationship or bias related to Augmedics Ltd.

Dr. Molina: consultant for Augmedics and SurgeonMR. Dr. Phillips: direct stock ownership in Augmedics. Dr. Colman: direct stock ownership in Augmedics. Dr. Khan: consultant for Stryker Medical and MedWaves AveCure. Dr. Poelstra: clinical or research support for the study described from Augmedics. Dr. Khoo: direct stock ownership in Augmedics.

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