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A Pilot Human Cadaveric Study on Accuracy of the Augmented Reality Surgical Navigation System for Thoracolumbar Pedicle Screw Insertion Using a New Intraoperative Rapid Registration Method

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Abstract

To evaluate the feasibility and accuracy of AR-assisted pedicle screw placement using a new intraoperative rapid registration method of combining preoperative CT scanning and intraoperative C-arm 2D fluoroscopy in cadavers. Five cadavers with intact thoracolumbar spines were employed in this study. Intraoperative registration was performed using anteroposterior and lateral views of preoperative CT scanning and intraoperative 2D fluoroscopic images. Patient-specific targeting guides were used for pedicle screw placement from Th1-L5, totaling 166 screws. Instrumentation for each side was randomized (augmented reality surgical navigation (ARSN) vs. C-arm) with an equal distribution of 83 screws in each group. CT was performed to evaluate the accuracy of both techniques by assessing the screw positions and the deviations between the inserted screws and planned trajectories. Postoperative CT showed that 98.80% (82/83) screws in ARSN group and 72.29% (60/83) screws in C-arm group were within the 2-mm safe zone (p < 0.001). The mean time for instrumentation per level in ARSN group was significantly shorter than that in C-arm group (56.17 ± 3.33 s vs. 99.22 ± 9.03 s, p < 0.001). The overall intraoperative registration time was 17.2 ± 3.5 s per segment. AR-based navigation technology can provide surgeons with accurate guidance of pedicle screw insertion and save the operation time by using the intraoperative rapid registration method of combining preoperative CT scanning and intraoperative C-arm 2D fluoroscopy.

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Data Availability

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Kosmopoulos V, Schizas C. Pedicle screw placement accuracy: a meta-analysis. Spine (Phila Pa 1976). 2007. 32(3): E111–20.

  2. Dennler C, Jaberg L, Spirig J, et al. Augmented reality-based navigation increases precision of pedicle screw insertion. J Orthop Surg Res. 2020. 15(1): 174.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Yao Y, Jiang X, Wei T, et al. A real-time 3D electromagnetic navigation system for percutaneous pedicle screw fixation in traumatic thoraco-lumbar fractures: implications for efficiency, fluoroscopic time, and accuracy compared with those of conventional fluoroscopic guidance. Eur Spine J. 2022. 31(1): 46-55.

    Article  PubMed  Google Scholar 

  4. Sun J, Wu D, Wang Q, Wei Y, Yuan F. Pedicle Screw Insertion: Is O-Arm-Based Navigation Superior to the Conventional Freehand Technique? A Systematic Review and Meta-Analysis. World Neurosurg. 2020. 144: e87-e99.

    Article  PubMed  Google Scholar 

  5. Elmi-Terander A, Skulason H, Söderman M, et al. Surgical Navigation Technology Based on Augmented Reality and Integrated 3D Intraoperative Imaging: A Spine Cadaveric Feasibility and Accuracy Study. Spine (Phila Pa 1976). 2016. 41(21): E1303-E1311.

  6. Elmi-Terander A, Burström G, Nachabe R, et al. Pedicle Screw Placement Using Augmented Reality Surgical Navigation With Intraoperative 3D Imaging: A First In-Human Prospective Cohort Study. Spine (Phila Pa 1976). 2019. 44(7): 517–525.

  7. Jin M, Liu Z, Liu X, et al. Does intraoperative navigation improve the accuracy of pedicle screw placement in the apical region of dystrophic scoliosis secondary to neurofibromatosis type I: comparison between O-arm navigation and free-hand technique. Eur Spine J. 2016. 25(6): 1729-37.

    Article  PubMed  Google Scholar 

  8. Liu YJ, Tian W, Liu B, et al. Comparison of the clinical accuracy of cervical (C2-C7) pedicle screw insertion assisted by fluoroscopy, computed tomography-based navigation, and intraoperative three-dimensional C-arm navigation. Chin Med J (Engl). 2010. 123(21): 2995-8.

    PubMed  Google Scholar 

  9. Su AW, McIntosh AL, Schueler BA, et al. How Does Patient Radiation Exposure Compare With Low-dose O-arm Versus Fluoroscopy for Pedicle Screw Placement in Idiopathic Scoliosis. J Pediatr Orthop. 2017. 37(3): 171-177.

    Article  PubMed  Google Scholar 

  10. Balling H. Time Demand and Radiation Dose in 3D-Fluoroscopy-based Navigation-assisted 3D-Fluoroscopy-controlled Pedicle Screw Instrumentations. Spine (Phila Pa 1976). 2018. 43(9): E512-E519.

  11. Burström G, Persson O, Edström E, Elmi-Terander A. Augmented reality navigation in spine surgery: a systematic review. Acta Neurochir (Wien). 2021. 163(3): 843-852.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Müller F, Roner S, Liebmann F, Spirig JM, Fürnstahl P, Farshad M. Augmented reality navigation for spinal pedicle screw instrumentation using intraoperative 3D imaging. Spine J. 2020. 20(4): 621-628.

    Article  PubMed  Google Scholar 

  13. Gibby JT, Swenson SA, Cvetko S, Rao R, Javan R. Head-mounted display augmented reality to guide pedicle screw placement utilizing computed tomography. Int J Comput Assist Radiol Surg. 2019. 14(3): 525-535.

    Article  PubMed  Google Scholar 

  14. Vaccaro AR, Harris JA, Hussain MM, et al. Assessment of Surgical Procedural Time, Pedicle Screw Accuracy, and Clinician Radiation Exposure of a Novel Robotic Navigation System Compared With Conventional Open and Percutaneous Freehand Techniques: A Cadaveric Investigation. Global Spine J. 2020. 10(7): 814-825.

    Article  PubMed  Google Scholar 

  15. Ammirati M, Salma A. Placement of thoracolumbar pedicle screws using O-arm-based navigation: technical note on controlling the operational accuracy of the navigation system. Neurosurg Rev. 2013. 36(1): 157–62; discussion 162.

  16. Ma L, Zhao Z, Chen F, Zhang B, Fu L, Liao H. Augmented reality surgical navigation with ultrasound-assisted registration for pedicle screw placement: a pilot study. Int J Comput Assist Radiol Surg. 2017. 12(12): 2205-2215.

    Article  PubMed  Google Scholar 

  17. Edgcumbe P, Pratt P, Yang GZ, Nguan C, Rohling R. Pico Lantern: Surface reconstruction and augmented reality in laparoscopic surgery using a pick-up laser projector. Med Image Anal. 2015. 25(1): 95-102.

    Article  PubMed  Google Scholar 

  18. Peh S, Chatterjea A, Pfarr J, et al. Accuracy of augmented reality surgical navigation for minimally invasive pedicle screw insertion in the thoracic and lumbar spine with a new tracking device. Spine J. 2020. 20(4): 629-637.

    Article  PubMed  Google Scholar 

  19. Zhang W, Takigawa T, Wu Y, Sugimoto Y, Tanaka M, Ozaki T. Accuracy of pedicle screw insertion in posterior scoliosis surgery: a comparison between intraoperative navigation and preoperative navigation techniques. Eur Spine J. 2017. 26(6): 1756-1764.

    Article  PubMed  Google Scholar 

  20. Lieberman IH, Togawa D, Kayanja MM, et al. Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: Part I--Technical development and a test case result. Neurosurgery. 2006. 59(3): 641–50; discussion 641–50.

  21. Togawa D, Kayanja MM, Reinhardt MK, et al. Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: part 2--Evaluation of system accuracy. Neurosurgery. 2007. 60(2 Suppl 1): ONS129–39; discussion ONS139.

  22. Lai DM, Shih YT, Chen YH, Chien A, Wang JL. Effect of pedicle screw diameter on screw fixation efficacy in human osteoporotic thoracic vertebrae. J Biomech. 2018. 70: 196-203.

    Article  PubMed  Google Scholar 

  23. Jeswani S, Drazin D, Hsieh JC, et al. Instrumenting the small thoracic pedicle: the role of intraoperative computed tomography image-guided surgery. Neurosurg Focus. 2014. 36(3): E6.

    Article  PubMed  Google Scholar 

  24. Saraf SK, Singh RP, Singh V, Varma A. Pullout strength of misplaced pedicle screws in the thoracic and lumbar vertebrae - A cadaveric study. Indian J Orthop. 2013. 47(3): 238-43.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Pérez-Pachón L, Sharma P, Brech H, et al. Effect of marker position and size on the registration accuracy of HoloLens in a non-clinical setting with implications for high-precision surgical tasks. Int J Comput Assist Radiol Surg. 2021. 16(6): 955-966.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Chien JC, Tsai YR, Wu CT, Lee JD. HoloLens-Based AR System with a Robust Point Set Registration Algorithm. Sensors (Basel). 2019. 19(16).

  27. Grubert J, Itoh Y, Moser K, Swan JE. A Survey of Calibration Methods for Optical See-Through Head-Mounted Displays. IEEE Trans Vis Comput Graph. 2018. 24(9): 2649-2662.

    Article  PubMed  Google Scholar 

  28. Sun Q, Mai Y, Yang R, Ji T, Jiang X, Chen X. Fast and accurate online calibration of optical see-through head-mounted display for AR-based surgical navigation using Microsoft HoloLens. Int J Comput Assist Radiol Surg. 2020. 15(11): 1907-1919.

    Article  PubMed  Google Scholar 

  29. Hu X, Baena F, Cutolo F. Head-Mounted Augmented Reality Platform for Markerless Orthopaedic Navigation. IEEE J Biomed Health Inform. 2022. 26(2): 910-921.

    Article  PubMed  Google Scholar 

  30. Xu B, Yang Z, Jiang S, Zhou Z, Jiang B, Yin S. Design and Validation of a Spinal Surgical Navigation System Based on Spatial Augmented Reality. Spine (Phila Pa 1976). 2020. 45(23): E1627-E1633.

  31. Verma SK, Singh PK, Agrawal D, et al. O-arm with navigation versus C-arm: a review of screw placement over 3 years at a major trauma center. Br J Neurosurg. 2016. 30(6): 658-661.

    Article  CAS  PubMed  Google Scholar 

  32. Liu H, Chen W, Liu T, Meng B, Yang H. Accuracy of pedicle screw placement based on preoperative computed tomography versus intraoperative data set acquisition for spinal navigation system. J Orthop Surg (Hong Kong). 2017. 25(2): 2309499017718901.

    Article  PubMed  Google Scholar 

  33. Van de Kelft E, Costa F, Van der Planken D, Schils F. A prospective multicenter registry on the accuracy of pedicle screw placement in the thoracic, lumbar, and sacral levels with the use of the O-arm imaging system and StealthStation Navigation. Spine (Phila Pa 1976). 2012. 37(25): E1580–7.

  34. Chen L, Zhang F, Zhan W, Gan M, Sun L. Optimization of virtual and real registration technology based on augmented reality in a surgical navigation system. Biomed Eng Online. 2020. 19(1): 1.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Jud L, Fotouhi J, Andronic O, et al. Applicability of augmented reality in orthopedic surgery - A systematic review. BMC Musculoskelet Disord. 2020. 21(1): 103.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Wu JR, Wang ML, Liu KC, Hu MH, Lee PY. Real-time advanced spinal surgery via visible patient model and augmented reality system. Comput Methods Programs Biomed. 2014. 113(3): 869-81.

    Article  PubMed  Google Scholar 

  37. Hussain I, Cosar M, Kirnaz S, et al. Evolving Navigation, Robotics, and Augmented Reality in Minimally Invasive Spine Surgery. Global Spine J. 2020. 10(2 Suppl): 22S-33S.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Burström G, Nachabe R, Persson O, Edström E, Elmi Terander A. Augmented and Virtual Reality Instrument Tracking for Minimally Invasive Spine Surgery: A Feasibility and Accuracy Study. Spine (Phila Pa 1976). 2019. 44(15): 1097–1104.

  39. Auloge P, Cazzato RL, Ramamurthy N, et al. Augmented reality and artificial intelligence-based navigation during percutaneous vertebroplasty: a pilot randomised clinical trial. Eur Spine J. 2020. 29(7): 1580-1589.

    Article  PubMed  Google Scholar 

  40. 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 : 1–6.

  41. Spirig JM, Roner S, Liebmann F, Fürnstahl P, Farshad M. Augmented reality-navigated pedicle screw placement: a cadaveric pilot study. Eur Spine J. 2021. 30(12): 3731-3737.

    Article  PubMed  Google Scholar 

  42. Molina CA, Sciubba DM, Greenberg JK, Khan M, Witham T. Clinical Accuracy, Technical Precision, and Workflow of the First in Human Use of an Augmented-Reality Head-Mounted Display Stereotactic Navigation System for Spine Surgery. Oper Neurosurg (Hagerstown). 2021. 20(3): 300-309.

    Article  PubMed  Google Scholar 

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Author information

Author notes

  1. Bing Cao, Bo Yuan, and Guofeng Xu contributed to this article equally.

Authors and Affiliations

  1. Spine Center, Department of Orthopaedics, Shanghai Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China

    Bing Cao, Bo Yuan, Guofeng Xu, Yin Zhao, Yanqing Sun, Zhiwei Wang, Shengyuan Zhou, Zheng Xu & Xiongsheng Chen

  2. Linyan Medical Technology Company Limited, 528 Ruiqing Road, Pudong New District, Shanghai, China

    Yao Wang

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Contributions

CXS (MD, Orthopedic Surgeon) designed the study, carried out most of the data analysis, and was a major contributor in writing the manuscript; CB (MM, Orthopedic Surgeon), YB (MD, Orthopedic Surgeon), and XGF (MM, Orthopedic Surgeon) performed the examination of the data, and substantively revised the manuscript, should be considered as co-first authors. ZY (MD, Orthopedic Surgeon), SYQ (MD, Orthopedic Surgeon), ZSY (MD, Orthopedic Surgeon), XZ (Mm, Orthopedic Surgeon), and WY (MD, Orthopedic Surgeon) proposed the idea of study design and finished the final assessment of the manuscript. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Xiongsheng Chen.

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All procedures involving human participants abided by the 1964 Declaration of Helsinki and its amendments. For this is a retrospective study, ethical approval is not required.

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Cao, B., Yuan, B., Xu, G. et al. A Pilot Human Cadaveric Study on Accuracy of the Augmented Reality Surgical Navigation System for Thoracolumbar Pedicle Screw Insertion Using a New Intraoperative Rapid Registration Method. J Digit Imaging 36, 1919–1929 (2023). https://doi.org/10.1007/s10278-023-00840-x

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