CAMILO MOLINA, MD, (RIGHT) WEARS AUGMENTED-REALITY GOGGLES WHILE PERFORMING SPINAL SURGERY.

Photo courtesy of Augmedics

 

JOHN OGUNLADE, DO, (LEFT) PERFORMS ENDOSCOPIC SPINE SURGERY.

Photo by Ryan Moody

BY STEPHANIE STEMMLER

Imagine surgeons performing surgery with the assistance of augmented reality glasses. Or doing complex, minimally invasive procedures through an incision smaller than your fingernail. These aren’t some-day scenarios; they represent the latest advancements in spine surgeries, making these procedures more precise while causing less damage to surrounding healthy muscle and tissue.

For example, recent developments have made it possible for surgeons to use headsets that mirror ones used by military fighter jet pilots. This equipment offers the wearer access to augmented reality, or AR, and they are rapidly being adopted in operating rooms across the country, many for use in a growing number of spinal procedures.

Augmented-reality technology enables computer-generated images or information to be superimposed on top of a real-world image. In the operating room, that means a surgeon can look directly at their patient while also seeing a proportionally scaled CT image of the patient’s anatomy. As the surgeon moves or brings in instruments or implants, sophisticated navigation software keeps the CT image aligned over the view the surgeon has of the patient’s body.

“We have used other computer-aided navigation before, but they required the surgeon to look away from the patient to an adjacent monitor to view an image,” says Camilo Molina, MD, Washington University neurosurgeon at Barnes-Jewish Hospital. Molina helped develop the AR-guided technology and was among the team at Johns Hopkins University that performed the world’s first AR-guided spinal fusion surgery in 2020. “With eyes and navigation now in the same field of view,” Molina says, “we can see 2D images and 3D spinal anatomy together, which makes surgery more accurate.”

The AR-guided technology, called the xvision Spine System, is FDA-approved for use in procedures along the entire spine and in the pelvis, including for the treatment of spinal tumors and degenerative disc diseases, as well as for intricate implantation of rods and screws to treat spinal deformities. In just the last three years, more than 3,000 AR-guided spinal procedures have been performed in the U.S. by both neurosurgeons and orthopedic spine specialists.

Molina expects that number to rise. “The learning curve for surgeons is short; the system quickly becomes comfortable to use, and fewer errors are made because of that,” he says. “The technology is not meant to replace traditional or even minimally invasive spine surgery; rather, it’s designed to complement other spine surgery techniques, acting as a strong tool that makes complex surgery in compact and protected places like the spine much safer and more precise.”

Ultra-minimally invasive surgery

Endoscopic surgery, an ultra-minimally invasive surgical technique, is also rapidly coming into use by spine specialists. These procedures are performed with a rigid endoscope that is guided through a ¼-inch incision, smaller than the 1- to 2-inch incisions common in most minimally invasive procedures.

A number of innovations are in good part responsible for the growing number of spine surgeries performed with an endoscope. These advances include: improvements to the endoscope’s high-definition camera resolution, better surgical instruments and continuous irrigation to keep the surgical view clear. Additionally, mobile CT   scanners employed within the operating room and other real-time imaging options further enhance endoscopic surgery’s accuracy.

“These kinds of surgeries are challenging to perform, but they offer significant benefits to patients, who can remain awake during the procedure,” says John Ogunlade, DO, Washington University neurosurgeon at Barnes-Jewish Hospital, who oversees the growing endoscopic spine surgery program at Washington University. “In ultra-minimally invasive surgery, there is less surgical trauma, less pain—resulting in reduced opioid use—and faster recovery.” He adds: “Many of these surgeries are done on an outpatient basis. In fact, 90% to 95% of my patients go home the same or next day.”

Rapid recovery is possible because the scope used during surgery can be directed in between tissue fibers and underneath or above nerve roots. There is little to no cutting of tissue and minimal damage to nearby healthy muscle or ligaments, factors that are critical to maintaining spine support and function.

Ogunlade says, “Herniated discs, sciatica, spinal fluid leaks, stenosis, synovial cysts and degenerative disc diseases: All these can be treated with endoscopic spine surgery. And we’re continuously evaluating patient outcomes and looking for ways this technique can benefit more people.”

On the horizon

AR-guided technology already is in use in open and minimally invasive spine procedures. Ogunlade and Molina envision its use will expand to include ultra-minimally invasive procedures. In the interim, Molina, who is deputy director of spine innovation for Washington University’s Center for Innovation in Neuroscience and Technology, is part of a new and exciting collaboration with orthopedic spine specialists Matthew Goodwin, MD, PhD, and Nicholas Pallotta, MD, MS. This team is working to combine endoscopic technology with open spine procedures for management of complex spinal deformities. They are also developing patient-specific 3D-printed implants to reconstruct spinal defects that occur after removal of cancerous spine tumors.

“We have been able to map a patient’s anatomy, remove primary tumors in the sacrum and pelvis, and then custom-make 3D-printed titanium implants that reconstruct a patient’s anatomy and replace removed bone,” explains Molina. “It’s visionary and leading edge, and we’ve had good outcomes so far, which means that this is yet another major advancement in complex spinal surgery that could become more widely available in the near future.”