Are augmented, virtual reality the future of spinal navigation? 4 surgeons discuss


Four spine surgeons discuss innovations in augmented and virtual reality, and how the technologies can advance spine care.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: What strategies have you implemented to tackle declining reimbursements and rising costs in your practice?

Please send responses to Alan Condon at by 5 p.m. CDT Wednesday, April 22.

Note: The following responses were lightly edited for style and clarity.

Question: How do you see augmented reality and virtual reality impacting spine care? What potential innovations excite you in this space?

Tyler Kreitz, MD. Rothman Orthopaedic Institute (Philadelphia): I believe VR is the next step in the evolution of navigation and robotic spine technology. VR technology allows for real time projection of spine anatomy — potentially via a headset — onto the patient based on preoperative or intraoperative advanced imaging. Unlike current navigation systems, the surgeon would not need to look at a separate screen. The surgeon could remain focused on the surgical field on a superimposed image on the patient's own anatomy. 

VR would have obvious benefits in the instrumentation of the spine, but also potentially decompression and interbody fusion procedures. This technology could be applied to any integrated surgical instrument, allowing the surgeon to maintain critical tactile feedback and use of instruments or systems they are most familiar with. It also avoids the limitations of a robotic arm. 

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: The excitement AR and VR in the spine space is exciting. As a matter of disclosure, I am working with a company in this space. However, I think the use of current technology in HUD displays and AR overlays of pertinent spinal anatomy will be game-changing. Design refinement will allow for better and hopefully intuitive user interface.

An important piece in the case of AR will be integration of real-world surface and edge recognition, minimizing lag and interoperability with current hardware. It will complement intraoperative guidance and imaging technology and play a big role in surgical safety, as well as resident and fellow education. Resolution may be an issue, as will be the tendency to experience vertigo while wearing the headsets. Ease of the UI and logical placement of controls is critical. My hope is that surgeons will add AR and VR to their armamentarium, rather than be dependent upon it.  

Mark Mikhael, MD. NorthShore Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): It's too early to know the true impact of AR and VR in spine, but I do see it as another tool to help surgeons with navigation. For AR, instead of relying on the preop scans and imaging as well as the bulky equipment — the monitors and mobile systems — we have a high-tech headset with glasses. I see two advantages with the setup. 

First, we have the ability to look directly at the patient while performing surgery, seeing the anatomy through the glasses, instead of looking up at the monitor; and second, we don't have a lot of equipment in the surgical suite with us. Overall, it seems to cut cost and clutter in the OR. But we still don't know the accuracy of the technology and its reproducibility — how well it will work in the hands of all surgeons with varying degrees of experience. VR is a similar approach. Navigation systems are here to stay, but I expect it will be another five years before AR and VR are fully adopted. We will likely stay with traditional navigation until then. 

Grant Shifflett, MD. Hoag Orthopedic Institute (Irvine, Calif.): In the last 10 years there has been an incredible growth in interest and the availability of AR and VR systems in spine surgery. This has mainly stemmed from a desire to limit complications associated with instrumented spine surgery, while also increasing the efficiency of the procedure and diminishing radiation exposure to the surgeon, operating room staff and the patient. To date, many questions remain about the associated learning curve, efficacy and overall costs of the systems. As a result, they have not been widely adopted. However, a new generation of spine surgeons is coming out of training with extensive experience in available AR and VR modalities — and in some ways have become reliant on these technologies. These innovations are here to stay. Costs may remain prohibitive for some, but demand for these technologies and surgeon involvement in the design and implementation processes will likely lead to greater utilization. The net effect — though it may be awhile — will likely be better outcomes for our patients, lessened occupational hazards to surgeons and their teams and greater cost efficiency due to fewer complications.

While improving accuracy and safety in instrumented cases is appealing, I am also very excited about the prospects of technology that would assist the surgeon in microsurgery. Many 'failed' back surgeries that result in further surgery are associated with incomplete or inadequate decompression, leading to residual stenosis. Greater intraoperative understanding of the anatomy and relevant pathology could potentially diminish the risk of these events. Furthermore, these technologies could offer unparalleled insight and accuracy in cases of complex or distorted anatomy or in tumor surgery.

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