Augmented reality-assisted pedicle screw insertion: a cadaveric proof-of-concept study

J Neurosurg Spine. 2019 Mar 29;1-8. doi: 10.3171/2018.12.SPINE181142. Online ahead of print.


OBJECTIVE Augmented reality (AR) is a novel technology that has the potential to increase the technical feasibility, accuracy, and safety of conventional manual and robotic computer-navigated pedicle insertion methods. Visual data are directly projected to the operator’s retina and overlaid onto the surgical field, thereby removing the requirement to shift attention to a remote display. The objective of this study was to assess the comparative accuracy of AR-assisted pedicle screw insertion in comparison to conventional pedicle screw insertion methods. METHODS Five cadaveric male torsos were instrumented bilaterally from T6 to L5 for a total of 120 inserted pedicle screws. Postprocedural CT scans were obtained, and screw insertion accuracy was graded by 2 independent neuroradiologists using both the Gertzbein scale (GS) and a combination of that scale and the Heary classification, referred to in this paper as the Heary-Gertzbein scale (HGS). Non-inferiority analysis was performed, comparing the accuracy to freehand, manual computer-navigated, and robotics-assisted computer-navigated insertion accuracy rates reported in the literature. User experience analysis was conducted via a user experience questionnaire filled out by operators after the procedures. RESULTS The overall screw placement accuracy achieved with the AR system was 96.7% based on the HGS and 94.6% based on the GS. Insertion accuracy was non-inferior to accuracy reported for manual computer-navigated pedicle insertion based on both the GS and the HGS scores. When compared to accuracy reported for robotics-assisted computer-navigated insertion, accuracy achieved with the AR system was found to be non-inferior when assessed with the GS, but superior when assessed with the HGS. Last, accuracy results achieved with the AR system were found to be superior to results obtained with freehand insertion based on both the HGS and the GS scores. Accuracy results were not found to be inferior in any comparison. User experience analysis yielded “excellent” usability classification. CONCLUSIONS AR-assisted pedicle screw insertion is a technically feasible and accurate insertion method.

Keywords: AR-HMD = augmented reality head-mounted display; GS = Gertzbein scale; HGS = Heary-Gertzbein scale; LCL = lower control limit; LS = least squares; LSCL = lower 1-sided 95% confidence limit; NI = non-inferiority margin; PRC = percentage of reference control; UEQ = user experience questionnaire; augmented reality; augmented reality–assisted surgery; cadaveric trial; computer-navigated surgery; neuronavigation; robotic spine surgery; surgical technique.