Letter to the Editor. Pedicle screw placement: head-mounted display-based augmented reality for better precision

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  • 1 Salmaniya Medical Complex, Manama, Bahrain
  • | 2 Independent University–Bangladesh, Dhaka, Bangladesh
  • | 3 Holy Family Red Crescent Medical College, Dhaka, Bangladesh
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TO THE EDITOR: We read with great interest the article by Liu et al.1 (Liu A, Jin Y, Cottrill E, et al. Clinical accuracy and initial experience with augmented reality–assisted pedicle screw placement: the first 205 screws. J Neurosurg Spine. 2022;36[3]:351-357). The authors performed a retrospective study aimed at reporting on the accuracy of pedicle screw placement using augmented reality (AR) assistance with a head-mounted display (HMD) navigation system. Here, we add our contribution, which may help to better understand the use of AR technology.

To begin, we provide some historical context: the virtual retinal display was created in 1991 at the University of Washington’s human interface technology laboratory.2 The objective was to create a virtual display with full color, a broad field of vision, high resolution, high brightness, and a low cost.2While there is undoubtedly a lot of excitement about AR right now, this technology has been available for decades, and researchers have been working on it for 30–40 years.

Indeed, current emphasis on AR and the framing of pedicle screw placement accuracy can be explained as the common currency and language in terms of verifying a navigation system and establishing a more accurate system for pedicle screw placement since, in fact, it is not about fixing a problem that does not exist, but this is the barrier to entry for developing a completely new navigational system.3,4

Surgeons are familiar with the remote 2D display that is utilized in conventional manual computer navigation or surgical suites.5However, certain technological disadvantages have been noted, such as line-of-sight interference. It is not a genuine 3D display since it is created using a remote tracking camera that can only observe the patient’s reference frame and the instrument’s tracking.36 A second disadvantage is the learning curve. There is concern that individuals learning how to use this kind of technology may be unable to perform freehand instrumentation.36 Third are the hazards of diverting the surgeon’s focus away from the patient and his or her failure to pay attention to the patient, as well as many risks associated with minimally invasive surgery tool placements.5

Despite technological developments such as robotics, we continue to see surgeons staring at a distant screen, unable to connect what is happening in the surgical field with what is happening on the remote screen. To summarize, no technology other than HMD is superior for pedicle screw placement.1,7 It does not require the use of a traditional network device interface camera, which is required for accuracy by all other navigation systems. Instead, it depends on the distance between the tracking frame and the instrument being navigated or tracked or on tracking cameras directly mounted on the surgeon’s headset.1,7 These are intelligent, advanced, high-resolution tracking cameras that are able to perform surface-active matching registration of the patients, allowing the surgeon to see active movements and deformity corrections while receiving objective data via artificial intelligence into the HMD.7 Additionally, they may be used to guide osteotomies, decompression, and soft-tissue surgeries. Thus, research on AR assistance with an HMD navigation system is not about pedicle screw placement. Instead, it is about demonstrating the system’s accuracy via pedicle screw placement so that surgeons may experiment with all the available AR options.

HMD represents a natural progression of spinal navigation technology.1,7 It is clinically accurate and precise, intended to minimize inaccuracies during operations that are potentially very technically deleterious to a patient.1,7 It is intuitive and has a relatively low learning curve. Not to compete with robots, but when robotics advances and image-guided robotics data are put on the surgeon’s head, the experience will be quite similar to wearing a headlamp. It is ultimately cost-conscious and a lot cheaper than any of the other options.1

Disclosures

The authors report no conflict of interest.

References

  • 1

    Liu A, Jin Y, Cottrill E, et al. Clinical accuracy and initial experience with augmented reality–assisted pedicle screw placement: the first 205 screws. J Neurosurg Spine. 2022;36(3):351357.

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  • 2

    Viirre E, Pryor H, Nagata S, Furness TA III. The virtual retinal display: a new technology for virtual reality and augmented vision in medicine. Stud Health Technol Inform. 1998;50:252257.

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  • 3

    Kosmopoulos V, Schizas C. Pedicle screw placement accuracy: a meta-analysis. Spine (Phila Pa 1976). 2007;32(3):E111E120.

  • 4

    Perdomo-Pantoja A, Ishida W, Zygourakis C, et al. Accuracy of current techniques for placement of pedicle screws in the spine: a comprehensive systematic review and meta-analysis of 51,161 screws. World Neurosurg. 2019;126:664-678.e3.

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    • PubMed
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  • 5

    Bourgeois AC, Faulkner AR, Bradley YC, et al. Improved accuracy of minimally invasive transpedicular screw placement in the lumbar spine with 3-dimensional stereotactic image guidance. J Spinal Disord Tech. 2015;28(9):324329.

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    • PubMed
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    • Export Citation
  • 6

    Phillips FM, Cheng I, Rampersaud YR, et al. Breaking through the “glass ceiling” of minimally invasive spine surgery. Spine (Phila Pa 1976). 2016;41(Suppl 8):S39S43.

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    • Export Citation
  • 7

    Frisk H, Lindqvist E, Persson O, et al. Feasibility and accuracy of thoracolumbar pedicle screw placement using an augmented reality head mounted device. Sensors (Basel). 2022;22(2):522.

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  • 1 Johns Hopkins Hospital, Baltimore, MD

Response

We thank Abdulla et al. for their letter. As they point out, the future and promise of AR-HMD lies with its use for real-time surgical planning rather than just instrumentation placement alone. Indeed, research done on the accuracy and precision of pedicle screw placement with this system is purely a conduit for demonstrating the system’s overall accuracy. We believe the benefits of AR-HMD in the operating room lie not only in its accurate and safe placement of instrumentation but also in its ability to allow for safe real-time surgical adjustments. In 2021 Molina and colleagues demonstrated the utility of AR-HMD in visualizing tumor borders in real time and actively planning bony cuts to allow for en bloc resection without excessive resection of healthy surrounding tissues.1 In this way, we anticipate future applications of AR technology will be broad, from allowing more precise osteotomy cuts for deformity correction to navigating surgical maneuvers in the setting of aberrant anatomy. We agree that AR-HMD represents the natural progression of spinal navigation technology with many more applications beyond pedicle screw placement, and we are excited for its continued evolution and adoption.

Finally, from a teaching and education perspective, we are fortunate at our institution to expose our trainees to freehand instrumentation placement techniques, robotics navigation, and AR-HMD navigation for spinal surgery. This allows our trainees to be well versed in a multitude of techniques for instrumentation placement and other maneuvers in the spine. We agree with Abdulla et al. that AR-HMD for spinal surgery applications appears to be cost-conscious.

Disclosures

Dr. Witham is a consultant for, investor in, and medical advisory board member for Augmedics.

References

1

Molina CA, Dibble CF, Lo SL, Witham T, Sciubba DM. Augmented reality-mediated stereotactic navigation for execution of en bloc lumbar spondylectomy osteotomies. J Neurosurg Spine. 2021;34(5):700705.

  • Crossref
  • Search Google Scholar
  • Export Citation
  • 1

    Liu A, Jin Y, Cottrill E, et al. Clinical accuracy and initial experience with augmented reality–assisted pedicle screw placement: the first 205 screws. J Neurosurg Spine. 2022;36(3):351357.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Viirre E, Pryor H, Nagata S, Furness TA III. The virtual retinal display: a new technology for virtual reality and augmented vision in medicine. Stud Health Technol Inform. 1998;50:252257.

    • Search Google Scholar
    • Export Citation
  • 3

    Kosmopoulos V, Schizas C. Pedicle screw placement accuracy: a meta-analysis. Spine (Phila Pa 1976). 2007;32(3):E111E120.

  • 4

    Perdomo-Pantoja A, Ishida W, Zygourakis C, et al. Accuracy of current techniques for placement of pedicle screws in the spine: a comprehensive systematic review and meta-analysis of 51,161 screws. World Neurosurg. 2019;126:664-678.e3.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Bourgeois AC, Faulkner AR, Bradley YC, et al. Improved accuracy of minimally invasive transpedicular screw placement in the lumbar spine with 3-dimensional stereotactic image guidance. J Spinal Disord Tech. 2015;28(9):324329.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Phillips FM, Cheng I, Rampersaud YR, et al. Breaking through the “glass ceiling” of minimally invasive spine surgery. Spine (Phila Pa 1976). 2016;41(Suppl 8):S39S43.

    • Search Google Scholar
    • Export Citation
  • 7

    Frisk H, Lindqvist E, Persson O, et al. Feasibility and accuracy of thoracolumbar pedicle screw placement using an augmented reality head mounted device. Sensors (Basel). 2022;22(2):522.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 1

    Molina CA, Dibble CF, Lo SL, Witham T, Sciubba DM. Augmented reality-mediated stereotactic navigation for execution of en bloc lumbar spondylectomy osteotomies. J Neurosurg Spine. 2021;34(5):700705.

    • Crossref
    • Search Google Scholar
    • Export Citation

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