AR has the potential to improve workflow for minimally invasive transforaminal lumbar interbody fusion

Roger Härtl

Augmented reality (AR) has the ability to improve the surgical workflow during minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) procedures, new research, published in the journal Neurospine by Roger Härtl (New York-Presbyterian Hospital, New York, USA) et al, suggests.

The study authors note that, although AR offers a new approach for the teaching and training of surgeons in spine models and also in live surgery, more work is needed to simplify the software and make AR integration more user-friendly. Future studies should focus on evaluating the efficiency of this technology, they add.

Härtl et al recently introduced the concept of ‘total navigation’ to improve workflow and eliminate fluoroscopy. In this study, the researchers developed and evaluated a protocol to integrate AR into the MIS-TLIF workflow.

A case series of 10 patients was the basis for the evaluation of a protocol to facilitate tubular MIS-TLIF by the application of AR. Surgical TLIF landmarks were marked on a preoperative computed tomography (CT) scan using dedicated software. This marked CT scan was fused intraoperatively with the low-dose navigation CT scan using elastic image fusion, and the markers were transferred to the intraoperative scan.

The cohort of patients included four women and six men with a mean age of 65.9 ± 9.8. The mean body mass index (BMI) was 28.8 ± 10.5 kg/m2 and the mean American Society of Anesthesiologists (ASA) physical status classification grade was 2.5 ± 0.5. All cases were single level; six involved L4/L5, two involved L3/4, one involved L2/L3, and one involved L5/S1.

The AR protocol was safely implemented in all cases and the TLIF landmarks were all able to be preoperatively planned and transferred to the intraoperative imaging. Of the 10 cases, one had a synovial cyst resection and in two cases an additional bony decompression was performed due to central stenosis.

The average procedure time from skin incision to closure was 160.6 ± 31.9 minutes. The average hospital stay was 2.6 ± 1 days and the AR implementation added 1.72 ± 0.37 minutes to the overall procedure time.

There were no cerebrospinal fluid leaks, infections, or returns to the operating room. No patients were readmitted to the hospital for any reason within 90 days and revision surgery was not necessary in the current follow-up period of 8.4 ± 2.4 months on average.

Speaking to Spinal News International, Härtl said: “In the near future AR with total navigation can benefit any type of spinal surgery. Immediate visualisation of key anatomic landmarks and pathologies through either the microscope, the endoscope, exoscope or goggles, will have a big impact on ambulatory and inpatient spinal procedures.”


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