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

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.

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Head-mounted display augmented reality to guide pedicle screw placement utilizing computed tomography

International Journal of Computer Assisted Radiology and Surgery ◽

10.1007/s11548-018-1814-7 ◽

2018 ◽

Vol 14 (3) ◽

pp. 525-535 ◽

Cited By ~ 40

Author(s):

Jacob T. Gibby ◽

Samuel A. Swenson ◽

Steve Cvetko ◽

Raj Rao ◽

Ramin Javan

Keyword(s):

Computed Tomography ◽

Augmented Reality ◽

Pedicle Screw ◽

Screw Placement ◽

Pedicle Screw Placement ◽

Head Mounted Display

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Comparative Analysis of Pedicle Screw Placement in Children with Congenital Scoliosis: Freehand Technique (in vivo) and Guide Templates (in vitro)

Traumatology and Orthopedics of Russia ◽

10.21823/2311-2905-2018-24-4-53-63 ◽

2018 ◽

Vol 24 (4) ◽

pp. 53-63 ◽

Cited By ~ 2

Author(s):

D. N. Kokushin ◽

S. V. Vissarionov ◽

A. G. Baindurashvili ◽

A. V. Ovechkina ◽

M. S. Poznovich

Keyword(s):

Lumbar Spine ◽

Pedicle Screw ◽

Pedicle Screws ◽

Congenital Scoliosis ◽

Screw Placement ◽

Pedicle Screw Placement ◽

Placement Accuracy ◽

Thoracolumbar Transition

Objective.To evaluate accuracy between pedicle screw placement in vertebral bodies achieved in vivo with freehand techniques versus their placement in vertebrae plastic models achieved in vitro with the use of guide templates, in toddlers and preschool children with congenital kyphoscoliosis of the thoracolumbar transition and lumbar spine amid the vertebral malformation.Material and Methods. The research is based on a retrospective analysis of the results of treatment of 10 patients with congenital kyphoscoliosis of the thoracolumbar transition and lumbar spine amid the vertebral malformation. Age – from 2 years 2 months to 6 years 8 months old (mean 3 years 8 months old), gender – 6 boys, 4 girls. Based on the postoperative multi-slice spiral computed tomography (MSCT) of the spine, the pedicle screws placement accuracy of the correcting multi-support metalwork was evaluated. These patients constituted the 1st research group (in vivo group). The 2nd research group (in vitro group) was formed from 27 vertebrae plastic models with pedicle screws inserted in them with the use of guide templates. The placement accuracy of the installed pedicle support elements was assessed based on the S.D. Gertzbein et al. scale (1990).Results. In the 1st group, there were 52 pedicle screws placed. The screw placement accuracy according to the rate of misplacement, as follows: 53.8% in Grade 0, 25% in Grade I, 11.6% in Grade II, 9.6% in Grade III. The number of screws with the rate of misplacement in Grade 0 + Grade I was 41 (78.8%). In the 2nd group, there were 54 screws placed and slightly larger than the 1st group. The screw placement accuracy according to the rate of misplacement was 94.4% in Grade 0, 1.9% in Grade I, 3.7% in Grade II, respectively. The number of screws with the rate of misplacement in Grade 0 + Grade I was 52 (96.3%).Conclusions.Comparative analysis showed that the number of pedicle screws successfully placed in vertebrae plastic models in children with congenital deformities of the thoracolumbar transition and lumbar spine achieved with the use of guide templates was significantly higher than the number of screws successfully placed with freehand techniques (96.3% versus 80.8%, p = 0.011). The results obtained with method of navigation templates in vitro showed high precision and accuracy of pedicle screw placement which gives the prospect for using this type of navigation in clinical practice in toddlers with congenital scoliosis.

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

Journal of Neurosurgery Spine ◽

10.3171/2021.2.spine202097 ◽

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.

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

Operative Neurosurgery ◽

10.1227/neu.0b013e31821954ed ◽

2011 ◽

Vol 69 (suppl_1) ◽

pp. ons14-ons19 ◽

Cited By ~ 24

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.

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Radiographic Accuracy of Percutaneous Pedicle Screw Placement in Fluoroscopic- Versus CT Navigation-Guided Lumbar Spine Instrumentation

Neurosurgery ◽

10.1093/neuros/nyz310_617 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Guang-Ting Cong ◽

Avani Vaishnav ◽

Joseph Barbera ◽

Hiroshi Kumagai ◽

James Dowdell ◽

...

Keyword(s):

Lumbar Spine ◽

Minimally Invasive ◽

Pedicle Screw ◽

Spinal Instrumentation ◽

Screw Placement ◽

Pedicle Screw Placement ◽

Intraoperative Computed Tomography ◽

Percutaneous Pedicle Screw ◽

Spine Instrumentation ◽

Surgical Methods

Abstract INTRODUCTION Posterior spinal instrumentation for fusion using intraoperative computed tomography (CT) navigation is gaining traction as an alternative to the conventional two-dimensional fluoroscopic-guided approach to percutaneous pedicle screw placement. However, few studies to date have directly compared outcomes of these 2 minimally invasive instrumentation methods. METHODS A consecutive cohort of patients undergoing primary percutaneous posterior lumbar spine instrumentation for spine fusion was retrospectively reviewed. Revision surgeries or cases converted to open were excluded. Accuracy of screw placement was assessed using a postoperative CT scan with blinding to the surgical methods used. The Gertzbein-Robbins classification was used to grade cortical breach: Grade 0 (<0 mm cortical breach), Grade I (<2 mm), Grade II (2-4 mm), Grade III (4-6 mm), and Grade IV (>6 mm). RESULTS CT navigation was found to significantly improve accuracy of screw placement (P < .022). There was significantly more facet violation of the unfused level in the fluoroscopy group vs the CT group (9% vs 0.5%; P < .0001). There was also a higher proportion of poor screw placement in the fluoroscopy group (10.1% vs 3.6%). No statistical difference was found in the rate of tip breach, inferomedial breach, or lateral breach. Regression analysis showed that fluoroscopy had twice the odds of incurring poor screw placement as compared to CT navigation. CONCLUSION This radiographic study comparing screw placement in minimally invasive fluoroscopy- vs CT navigation-guided lumbar spine instrumentation provides evidence that CT navigation significantly improves accuracy of screw placement, especially in optimizing the screw trajectory so as to avoid facet violation. Long-term follow-up studies should be performed to ascertain whether this difference can contribute to an improvement in clinical outcomes.

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Confirmation of accuracy/inaccuracy of lumbar pedicle screw placement using postoperative computed tomography

Surgical Neurology International ◽

10.25259/sni_290_2021 ◽

2021 ◽

Vol 12 ◽

pp. 518

Author(s):

Mohamed M. Arnaout ◽

Magdy O. ElSheikh ◽

Mansour A. Makia

Keyword(s):

Computed Tomography ◽

Lumbar Spine ◽

Pedicle Screw ◽

Pedicle Screws ◽

Operative Intervention ◽

Screw Placement ◽

Lumbar Spine Surgery ◽

Pedicle Screw Placement ◽

Lumbar Pedicle ◽

Ct Studies

Background: Transpedicular screws are extensively utilized in lumbar spine surgery. The placement of these screws is typically guided by anatomical landmarks and intraoperative fluoroscopy. Here, we utilized 2-week postoperative computed tomography (CT) studies to confirm the accuracy/inaccuracy of lumbar pedicle screw placement in 145 patients and correlated these findings with clinical outcomes. Methods: Over 6 months, we prospectively evaluated the location of 612 pedicle screws placed in 145 patients undergoing instrumented lumbar fusions addressing diverse pathology with instability. Routine anteroposterior and lateral plain radiographs were obtained 48 h after the surgery, while CT scans were obtained at 2 postoperative weeks (i.e., ideally these should have been performed intraoperatively or within 24–48 h of surgery). Results: Of the 612 screws, minor misplacement of screws (≤2 mm) was seen in 104 patients, moderate misplacement in 34 patients (2–4 mm), and severe misplacement in 7 patients (>4 mm). Notably, all the latter 7 (4.8% of the 145) patients required repeated operative intervention. Conclusion: Transpedicular screw insertion in the lumbar spine carries the risks of pedicle medial/lateral violation that is best confirmed on CT rather than X-rays/fluoroscopy alone. Here, we additional found 7 patients (4.8%) who with severe medial/lateral pedicle breach who warranting repeated operative intervention. In the future, CT studies should be performed intraoperatively or within 24–48 h of surgery to confirm the location of pedicle screws and rule in our out medial or lateral pedicle breaches.

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Anatomical and radiologic characteristics of isthmus parameters in guiding pedicle screw placement

Journal of International Medical Research ◽

10.1177/0300060518762986 ◽

2018 ◽

Vol 46 (6) ◽

pp. 2386-2397 ◽

Cited By ~ 1

Author(s):

Paerhati Rexiti ◽

Yakufu Abulizi ◽

Aikeremujiang Muheremu ◽

Shuiquan Wang ◽

Maierdan Maimaiti ◽

...

Keyword(s):

Pedicle Screw ◽

Pedicle Screws ◽

Screw Placement ◽

Lumbar Spine Surgery ◽

X Rays ◽

Pedicle Screw Placement ◽

Chinese Han ◽

Before And After ◽

Placement Accuracy ◽

D Value

Objective To study the clinical application of lumbar isthmus parameters in guiding pedicle screw placement. Methods Lumbar isthmus parameters were measured in normal lumbar x-rays and cadaveric specimens from a Chinese Han population. Distance between the medial pedicle border and lateral isthmus border was recorded as a ‘D’ value and was compared between X-rays and cadavers. Orthopaedic surgeons estimated different distances (2–6 mm) and angles (5–20°), and bias ratios between estimated and real values were compared. Orthopaedic residents placed pedicle screws on cadaveric specimens before and after application of the ‘D’ value, and screw placement accuracy was compared. Results Except for L4 vertebrae, significant differences in the ‘D’ value were found between 25 cadaveric specimens and x-ray films from 120 patients. Distances and angles estimated by 40 surgeons were significantly different from all real values, except 2 mm distance. Accuracy of pedicle screw placement by six orthopaedic residents was significantly improved by applying the ‘D’ value. Conclusions Surgeon estimates of distance were more accurate than angle estimates. Addition of a ‘D’ value to conventional parameters may significantly improve pedicle screw placement accuracy in lumbar spine surgery.

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