Clinical accuracy and initial experience with augmented reality–assisted pedicle screw placement: the first 205 screws

2021 ◽  
pp. 1-7
Author(s):  
Ann Liu ◽  
Yike Jin ◽  
Ethan Cottrill ◽  
Majid Khan ◽  
Erick Westbroek ◽  
...  
Keyword(s):  
Augmented Reality ◽  
Pedicle Screw ◽  
Spinal Instrumentation ◽  
Deformity Correction ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Pedicle Screw Placement ◽  
Lower Extremity Weakness ◽  
Head Mounted Display ◽  
Clinical Accuracy

OBJECTIVE Augmented reality (AR) is a novel technology which, when applied to spine surgery, offers the potential for efficient, safe, and accurate placement of spinal instrumentation. The authors report the accuracy of the first 205 pedicle screws consecutively placed at their institution by using AR assistance with a unique head-mounted display (HMD) navigation system. METHODS A retrospective review was performed of the first 28 consecutive patients who underwent AR-assisted pedicle screw placement in the thoracic, lumbar, and/or sacral spine at the authors’ institution. Clinical accuracy for each pedicle screw was graded using the Gertzbein-Robbins scale by an independent neuroradiologist working in a blinded fashion. RESULTS Twenty-eight consecutive patients underwent thoracic, lumbar, or sacral pedicle screw placement with AR assistance. The median age at the time of surgery was 62.5 (IQR 13.8) years and the median body mass index was 31 (IQR 8.6) kg/m2. Indications for surgery included degenerative disease (n = 12, 43%); deformity correction (n = 12, 43%); tumor (n = 3, 11%); and trauma (n = 1, 4%). The majority of patients (n = 26, 93%) presented with low-back pain, 19 (68%) patients presented with radicular leg pain, and 10 (36%) patients had documented lower extremity weakness. A total of 205 screws were consecutively placed, with 112 (55%) placed in the lumbar spine, 67 (33%) in the thoracic spine, and 26 (13%) at S1. Screw placement accuracy was 98.5% for thoracic screws, 97.8% for lumbar/S1 screws, and 98.0% overall. CONCLUSIONS AR depicted through a unique HMD is a novel and clinically accurate technology for the navigated insertion of pedicle screws. The authors describe the first 205 AR-assisted thoracic, lumbar, and sacral pedicle screws consecutively placed at their institution with an accuracy of 98.0% as determined by a Gertzbein-Robbins grade of A or B.

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

2021 ◽  
Vol 51 (2) ◽  
pp. E10
Author(s):  
Alexander T. Yahanda ◽  
Emelia Moore ◽  
Wilson Z. Ray ◽  
Brenton Pennicooke ◽  
Jack W. Jennings ◽  
...  
Keyword(s):  
Augmented Reality ◽  
Lower Extremity ◽  
Pedicle Screw ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Spinal Tumors ◽  
Pedicle Screw Placement ◽  
Percutaneous Pedicle Screw ◽  
Clinical Accuracy ◽  
The Mean

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.

scholarly journals A Novel Augmented-Reality-Based Surgical Navigation System for Spine Surgery in a Hybrid Operating Room: Design, Workflow, and Clinical Applications

2019 ◽  
Vol 18 (5) ◽  
pp. 496-502 ◽  
Author(s):  
Erik Edström ◽  
Gustav Burström ◽  
Rami Nachabe ◽  
Paul Gerdhem ◽  
Adrian Elmi Terander
Keyword(s):  
Augmented Reality ◽  
Radiation Exposure ◽  
Pedicle Screw ◽  
Operating Room ◽  
Wound Closure ◽  
Surgical Navigation ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Hybrid Operating Room ◽  
Pedicle Screw Placement

Abstract BACKGROUND Treatment of several spine disorders requires placement of pedicle screws. Detailed 3-dimensional (3D) anatomic information facilitates this process and improves accuracy. OBJECTIVE To present a workflow for a novel augmented-reality-based surgical navigation (ARSN) system installed in a hybrid operating room for anatomy visualization and instrument guidance during pedicle screw placement. METHODS The workflow includes surgical exposure, imaging, automatic creation of a 3D model, and pedicle screw path planning for instrument guidance during surgery as well as the actual screw placement, spinal fixation, and wound closure and intraoperative verification of the treatment results. Special focus was given to process integration and minimization of overhead time. Efforts were made to manage staff radiation exposure avoiding the need for lead aprons. Time was kept throughout the procedure and subdivided to reflect key steps. The navigation workflow was validated in a trial with 20 cases requiring pedicle screw placement (13/20 scoliosis). RESULTS Navigated interventions were performed with a median total time of 379 min per procedure (range 232-548 min for 4-24 implanted pedicle screws). The total procedure time was subdivided into surgical exposure (28%), cone beam computed tomography imaging and 3D segmentation (2%), software planning (6%), navigated surgery for screw placement (17%) and non-navigated instrumentation, wound closure, etc (47%). CONCLUSION Intraoperative imaging and preparation for surgical navigation totaled 8% of the surgical time. Consequently, ARSN can routinely be used to perform highly accurate surgery potentially decreasing the risk for complications and revision surgery while minimizing radiation exposure to the staff.

scholarly journals Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery

2017 ◽  
Vol 42 (5) ◽  
pp. E14 ◽  
Author(s):  
Granit Molliqaj ◽  
Bawarjan Schatlo ◽  
Awad Alaid ◽  
Volodymyr Solomiichuk ◽  
Veit Rohde ◽  
...  
Keyword(s):  
Pedicle Screw ◽  
Spinal Instrumentation ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Robotic Assistance ◽  
Anatomical Landmarks ◽  
Pedicle Screw Placement ◽  
Robot Assisted ◽  
Screw Insertion ◽  
Freehand Technique

OBJECTIVEThe quest to improve the safety and accuracy and decrease the invasiveness of pedicle screw placement in spine surgery has led to a markedly increased interest in robotic technology. The SpineAssist from Mazor is one of the most widely distributed robotic systems. The aim of this study was to compare the accuracy of robot-guided and conventional freehand fluoroscopy-guided pedicle screw placement in thoracolumbar surgery.METHODSThis study is a retrospective series of 169 patients (83 women [49%]) who underwent placement of pedicle screw instrumentation from 2007 to 2015 in 2 reference centers. Pathological entities included degenerative disorders, tumors, and traumatic cases. In the robot-assisted cohort (98 patients, 439 screws), pedicle screws were inserted with robotic assistance. In the freehand fluoroscopy-guided cohort (71 patients, 441 screws), screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. Patients treated before 2009 were included in the fluoroscopy cohort, whereas those treated since mid-2009 (when the robot was acquired) were included in the robot cohort. Since then, the decision to operate using robotic assistance or conventional freehand technique has been based on surgeon preference and logistics. The accuracy of screw placement was assessed based on the Gertzbein-Robbins scale by a neuroradiologist blinded to treatment group. The radiological slice with the largest visible deviation from the pedicle was chosen for grading. A pedicle breach of 2 mm or less was deemed acceptable (Grades A and B) while deviations greater than 2 mm (Grades C, D, and E) were classified as misplacements.RESULTSIn the robot-assisted cohort, a perfect trajectory (Grade A) was observed for 366 screws (83.4%). The remaining screws were Grades B (n = 44 [10%]), C (n = 15 [3.4%]), D (n = 8 [1.8%]), and E (n = 6 [1.4%]). In the fluoroscopy-guided group, a completely intrapedicular course graded as A was found in 76% (n = 335). The remaining screws were Grades B (n = 57 [12.9%]), C (n = 29 [6.6%]), D (n = 12 [2.7%]), and E (n = 8 [1.8%]). The proportion of non-misplaced screws (corresponding to Gertzbein-Robbins Grades A and B) was higher in the robot-assisted group (93.4%) than the freehand fluoroscopy group (88.9%) (p = 0.005).CONCLUSIONSThe authors’ retrospective case review found that robot-guided pedicle screw placement is a safe, useful, and potentially more accurate alternative to the conventional freehand technique for the placement of thoracolumbar spinal instrumentation.

scholarly journals P.174 Accuracy of pedicle screw placement with X-ray versus O-arm image-guided navigation

2021 ◽  
Vol 48 (s3) ◽  
pp. S69-S70
Author(s):  
L Neuburger ◽  
Y Cheng ◽  
DR Fourney
Keyword(s):  
Pedicle Screw ◽  
Odds Ratio ◽  
Three Dimensional ◽  
Spinal Instrumentation ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Two Dimensional ◽  
Pedicle Screw Placement ◽  
X Ray ◽  
Image Guided

Background: Image-guided navigation is routinely used in spine surgery to improve placement of pedicle screws. However, most reports have relied on two-dimensional X-ray evaluation to determine accuracy of screw positioning. In this study, computed tomography (CT) and O-arm imaging enabled a detailed three-dimensional comparison of screw placement. The objective was to compare the accuracy of pedicle screw placement with intraoperative X-ray versus O-arm image-guided navigation. Methods: This was a retrospective analysis of image-guided pedicle screw placement in patients who underwent spinal instrumentation. Post-operative CT and O-arm imaging allowed grading of screw accuracy based on pedicle breaches. Clinical outcomes included patient and operative factors. Results: Pedicle screws were placed in 208 patients (1116 screws). Three-dimensional O-arm guidance was utilized for 126 patients, while the remainder underwent two-dimensional X-ray imaging and post-operative CT assessment. O-arm navigation was associated with improved pedicle screw accuracy: pedicle breaches were more likely to be low grade (odds ratio 2.84, p=0.001) and less likely to be medium grade (odds ratio 0.35, p=0.007) or high grade (odds ratio 0.31, p=0.025). Conclusions: This study provided a detailed comparison of surgical accuracy with X-ray versus O-arm guidance. Navigation with O-arm imaging is associated with benefits in spinal instrumentation, without impacting operative risks for patients.

scholarly journals Real-time navigation guidance with intraoperative CT imaging for pedicle screw placement using an augmented reality head-mounted display: a proof-of-concept study

2021 ◽  
Vol 51 (2) ◽  
pp. E11
Author(s):  
Daniel S. Yanni ◽  
Burak M. Ozgur ◽  
Robert G. Louis ◽  
Yevgenia Shekhtman ◽  
Rajiv R. Iyer ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Augmented Reality ◽  
Real Time ◽  
Pedicle Screw ◽  
User Feedback ◽  
Screw Placement ◽  
Pedicle Screw Placement ◽  
Head Mounted Display ◽  
Placement Accuracy ◽  
Grading Scale

OBJECTIVE Augmented reality (AR) has the potential to improve the accuracy and efficiency of instrumentation placement in spinal fusion surgery, increasing patient safety and outcomes, optimizing ergonomics in the surgical suite, and ultimately lowering procedural costs. The authors sought to describe the use of a commercial prototype Spine AR platform (SpineAR) that provides a commercial AR head-mounted display (ARHMD) user interface for navigation-guided spine surgery incorporating real-time navigation images from intraoperative imaging with a 3D-reconstructed model in the surgeon's field of view, and to assess screw placement accuracy via this method. METHODS Pedicle screw placement accuracy was assessed and compared with literature-reported data of the freehand (FH) technique. Accuracy with SpineAR was also compared between participants of varying spine surgical experience. Eleven operators without prior experience with AR-assisted pedicle screw placement took part in the study: 5 attending neurosurgeons and 6 trainees (1 neurosurgical fellow, 1 senior orthopedic resident, 3 neurosurgical residents, and 1 medical student). Commercially available 3D-printed lumbar spine models were utilized as surrogates of human anatomy. Among the operators, a total of 192 screws were instrumented bilaterally from L2–5 using SpineAR in 24 lumbar spine models. All but one trainee also inserted 8 screws using the FH method. In addition to accuracy scoring using the Gertzbein-Robbins grading scale, axial trajectory was assessed, and user feedback on experience with SpineAR was collected. RESULTS Based on the Gertzbein-Robbins grading scale, the overall screw placement accuracy using SpineAR among all users was 98.4% (192 screws). Accuracy for attendings and trainees was 99.1% (112 screws) and 97.5% (80 screws), respectively. Accuracy rates were higher compared with literature-reported lumbar screw placement accuracy using FH for attendings (99.1% vs 94.32%; p = 0.0212) and all users (98.4% vs 94.32%; p = 0.0099). The percentage of total inserted screws with a minimum of 5° medial angulation was 100%. No differences were observed between attendings and trainees or between the two methods. User feedback on SpineAR was generally positive. CONCLUSIONS Screw placement was feasible and accurate using SpineAR, an ARHMD platform with real-time navigation guidance that provided a favorable surgeon-user experience.

Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws

2014 ◽  
Vol 21 (3) ◽  
pp. 320-328 ◽  
Author(s):  
Mohamad Bydon ◽  
Risheng Xu ◽  
Anubhav G. Amin ◽  
Mohamed Macki ◽  
Paul Kaloostian ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Pedicle Screw ◽  
Spinal Instrumentation ◽  
Pedicle Screws ◽  
Ct Scanning ◽  
Screw Placement ◽  
Cervical Region ◽  
Consecutive Series ◽  
Pedicle Screw Placement ◽  
Intraoperative Ct

Object A number of imaging techniques have been introduced to minimize the risk of pedicle screw placement. Intraoperative CT has been recently introduced to assist in spinal instrumentation. The aim of this study was to study the effectiveness of intraoperative CT in enhancing the safety and accuracy of pedicle screw placement. Methods The authors included all cases from December 2009 through July 2012 in which intraoperative CT scanning was used to confirm pedicle screw placement. Results A total of 203 patients met the inclusion criteria. Of 1148 screws, 103 screws (8.97%) were revised intraoperatively in 72 patients (35.5%): 14 (18.42%) were revised in the cervical spine (C-2 or C-7), 25 (7.25%) in the thoracic spine, and 64 (8.80%) in the lumbar spine. Compared with screws in the thoracic and lumbar regions, pedicle screws placed in the cervical region were statistically more likely to be revised (p = 0.0061). Two patients (0.99%) required reoperations due to undetected misplacement of pedicle screws. Conclusions The authors describe one of the first North American experiences using intraoperative CT scanning to confirm the placement of pedicle screws. Compared with a similar cohort of patients from their institution who had pedicle screws inserted via the free-hand technique with postoperative CT, the authors found that the intraoperative CT lowers the threshold for pedicle screw revision, resulting in a statistically higher rate of screw revision in the thoracic and lumbar spine (p < 0.0001). During their 2.5-year experience with the intraoperative CT, the authors did not find a reduction in rates of reoperation for misplaced pedicle screws.

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

2020 ◽  
pp. 1-9 ◽  
Author(s):  
Camilo A. Molina ◽  
Frank M. Phillips ◽  
Matthew W. Colman ◽  
Wilson Z. Ray ◽  
Majid Khan ◽  
...  
Keyword(s):  
Augmented Reality ◽  
Pedicle Screw ◽  
Pedicle Screws ◽  
Angular Deviation ◽  
Screw Insertion ◽  
Head Mounted Display ◽  
Percutaneous Pedicle Screw ◽  
Field Of Vision ◽  
Clinical Accuracy ◽  
Screw Position

OBJECTIVEAugmented 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.METHODSInstrumentation 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.RESULTSThe 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.CONCLUSIONSPercutaneous ARMSS pedicle implant insertion is a technically feasible, accurate, and highly precise method.

scholarly journals Learning Retention of Thoracic Pedicle Screw Placement Using a High-Resolution Augmented Reality Simulator With Haptic Feedback

2011 ◽  
Vol 69 (suppl_1) ◽  
pp. ons14-ons19 ◽  
Author(s):  
Cristian J Luciano ◽  
P Pat Banerjee ◽  
Brad Bellotte ◽  
G Michael Oh ◽  
Michael Lemole ◽  
...  
Keyword(s):  
Augmented Reality ◽  
Pedicle Screw ◽  
Haptic Feedback ◽  
Screw Placement ◽  
Pedicle Screw Placement ◽  
Data Set ◽  
Learning Retention ◽  
Performance Accuracy ◽  
Thoracic Pedicle Screw ◽  
Thoracic Pedicle Screws

Abstract BACKGROUND: We evaluated the use of a part-task simulator with 3D and haptic feedback as a training tool for a common neurosurgical procedure - placement of thoracic pedicle screws. OBJECTIVE: To evaluate the learning retention of thoracic pedicle screw placement on a high-performance augmented reality and haptic technology workstation. METHODS: Fifty-one fellows and residents performed thoracic pedicle screw placement on the simulator. The virtual screws were drilled into a virtual patient's thoracic spine derived from a computed tomography data set of a real patient. RESULTS: With a 12.5% failure rate, a 2-proportion z test yielded P = .08. For performance accuracy, an aggregate Euclidean distance deviation from entry landmark on the pedicle and a similar deviation from the target landmark in the vertebral body yielded P = .04 from a 2-sample t test in which the rejected null hypothesis assumes no improvement in performance accuracy from the practice to the test sessions, and the alternative hypothesis assumes an improvement. CONCLUSION: The performance accuracy on the simulator was comparable to the accuracy reported in literature on recent retrospective evaluation of such placements. The failure rates indicated a minor drop from practice to test sessions, and also indicated a trend (P = .08) toward learning retention resulting in improvement from practice to test sessions. The performance accuracy showed a 15% mean score improvement and more than a 50% reduction in standard deviation from practice to test. It showed evidence (P = .04) of performance accuracy improvement from practice to test session.

The accuracy of pedicle screw placement using intraoperative image guidance systems

2014 ◽  
Vol 20 (2) ◽  
pp. 196-203 ◽  
Author(s):  
Alexander Mason ◽  
Renee Paulsen ◽  
Jason M. Babuska ◽  
Sharad Rajpal ◽  
Sigita Burneikiene ◽  
...  
Keyword(s):  
Pedicle Screw ◽  
Image Guidance ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Data Sets ◽  
Pedicle Screw Placement ◽  
Fluoroscopic Image ◽  
Fluoroscopic Navigation ◽  
Guidance Systems ◽  
Accuracy Rates

Object Several retrospective studies have demonstrated higher accuracy rates and increased safety for navigated pedicle screw placement than for free-hand techniques; however, the accuracy differences between navigation systems has not been extensively studied. In some instances, 3D fluoroscopic navigation methods have been reported to not be more accurate than 2D navigation methods for pedicle screw placement. The authors of this study endeavored to identify if 3D fluoroscopic navigation methods resulted in a higher placement accuracy of pedicle screws. Methods A systematic analysis was conducted to examine pedicle screw insertion accuracy based on the use of 2D, 3D, and conventional fluoroscopic image guidance systems. A PubMed and MEDLINE database search was conducted to review the published literature that focused on the accuracy of pedicle screw placement using intraoperative, real-time fluoroscopic image guidance in spine fusion surgeries. The pedicle screw accuracy rates were segregated according to spinal level because each spinal region has individual anatomical and morphological variations. Descriptive statistics were used to compare the pedicle screw insertion accuracy rate differences among the navigation methods. Results A total of 30 studies were included in the analysis. The data were abstracted and analyzed for the following groups: 12 data sets that used conventional fluoroscopy, 8 data sets that used 2D fluoroscopic navigation, and 20 data sets that used 3D fluoroscopic navigation. These studies included 1973 patients in whom 9310 pedicle screws were inserted. With conventional fluoroscopy, 2532 of 3719 screws were inserted accurately (68.1% accuracy); with 2D fluoroscopic navigation, 1031 of 1223 screws were inserted accurately (84.3% accuracy); and with 3D fluoroscopic navigation, 4170 of 4368 screws were inserted accurately (95.5% accuracy). The accuracy rates when 3D was compared with 2D fluoroscopic navigation were also consistently higher throughout all individual spinal levels. Conclusions Three-dimensional fluoroscopic image guidance systems demonstrated a significantly higher pedicle screw placement accuracy than conventional fluoroscopy or 2D fluoroscopic image guidance methods.

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