THE RISING USE OF VIRTUAL REALITY IN SPINE SURGERY
For many patients, spinal surgery is an increasingly attractive option for dealing with chronic back pain and rapidly advancing technology is making the procedures more safe and more accurate.
There are now more than 1.5 million spinal fusions performed by surgeons each year, and in the United States, some 500,000 Americans undergo surgery each year for lower back problems alone. For many years, this process has been a highly technical and difficult one requiring the special expertise of surgeons whose skilled and steady hands are trusted by patients to see the process to completion.
While this remains true, the field of spine surgery is changing as exciting new technologies create new possibilities for improved efficiency and success in the operating room. No longer is spine surgery the highly invasive procedure that it used to be. On the contrary, incisions have gotten steadily smaller, surgeries require much less hardware (rods and screws) and the tools used in operations can increase the accuracy and precision of the surgeon’s hand.
Some believe that virtual reality could be the next breakthrough technology in spine surgery and could change the way in which spinal surgeries are performed and the possibilities for these kinds of surgeries in the future.
Will virtual reality soon be one of those technologically advanced tools in a neurosurgeon’s belt? In this article we’ll look at the rising use of virtual reality in spine surgery and how it can be used in spine surgery.
Let’s begin by looking at what virtual reality in spine surgery actually is and how it can be implemented in the operating room.
WHAT IS VIRTUAL REALITY IN SPINE SURGERY?
In a nutshell, virtual reality is used in spine surgery when a surgeon wears a virtual reality headset that allows them to see a three-dimensional anatomical representation of the patient’s CT scan superimposed on the real-time locational data of the surgical tools being used in the operation.
However, the term “virtual reality” actually encompasses a number of different technologies that are used in the operating room. For the purposes of this article, we’ll focus on two specific types of virtual reality technology that have found a place in healthcare: augmented reality and virtual reality.
Think about it: we can visualize a surgeon’s hands snipping and cauterizing while the surgeon looks into a screen away from the patient to better see what’s occurring at a more detailed level. Taking away that disconnect between the information the surgeon needs and the actions they need to take will improve efficiency and accuracy in the OR. That is where virtual reality and augmented reality come into play.
VIRTUAL REALITY
Virtual Reality involves the overlaying of a three-dimensional representation which allows a surgeon to see greater detail when preparing for or performing a surgery. This is especially effective on parts of the body such as the brain or spinal cord that are generally stable and therefore lend themselves to this kind of visual representation.
Some twenty-five years ago, virtual reality was not even considered a tool to be used in live spine surgeries. Rather, it was merely used to “simulate a surgical procedure in a computer-generated world in order to improve training.” For many physicians, virtual reality improved imaging alternatives for data that already existed about patients, and this could be used to help those training for careers in surgery to better see and understand the specific parts of the body on which they’d be operating.
Over time virtual reality has proven to be a highly effective complement in training efforts. For example, research has shown that medical students who used virtual reality headsets for training purposes completed a live operation repairing a bone fracture 20% faster than those who did not, and they completed 38% more steps correctly than those that did not.
AUGMENTED REALITY
Like its name suggests, augmented reality is a technology that “augments” or superimposes a computer-generated image over real-world images. Common examples of augmented reality include Snapchat, Google Glass and Pokemon Go.
AR fits under the virtual reality umbrella, but it is different from some VR because instead of overlaying a general image, AR uses the surgeon’s own surgical environment. Oftentimes, surgeons rely on video feeds while operating; according to stanford medicine, these are often presented in a two dimensional fashion. Augmented Reality allows the surgeon to view the video footage they need in an even more detailed and practical way, in three dimensions, while they operate, without needing to look back and forth.
When using AR, a surgeon can access useful information like scans while performing procedures, without looking away from the task at hand. According to Johns Hopkins, operating while using augmented reality technology is similar to driving with a gps directly in front of you. Instead of looking back and forth between an OR board and a patient, the surgeon can spend all of their energy giving the patient the best care, and doing so in a more efficient way.
HOW DOES VIRTUAL REALITY IN SPINE SURGERY WORK?
As we’ve seen above, virtual reality differs from a similar technological tool in surgery, augmented reality. While the latter is a computer generated virtual image projected onto the users’s real surroundings, virtual reality technologies artificially integrate virtual images overlaid with real-time locational data of surgical instruments.
In other words, virtual reality technologies immerse a surgeon in a simulated visual-spatial environment in order to help them better perform operations on a real person in real-time.
For example, in one spinal operation, in which patients were to be treated with bone cement (a procedure that notably requires exceptionally accurate navigation to yield the best patient outcomes), a virtual projection of the patient’s spine is used to “accurately guide needles into the patient’s injured vertebra.”
One of the advantages of virtual reality when it comes to spine surgery is that it can be used to assist with preoperative surgical planning and aid in the actual performance of the operation. Furthermore, virtual reality devices have a “variety of built-in motion sensors,” which allows kinematic data to be recorded while users “are wearing VR devices and performing some actions for the evaluation of cervical spine activity and exercise ability.” This advanced imaging allows for greater precision in planning and in the execution of operations.
Scholarship notes that the exclusive use of virtual reality is rare when it comes to modern surgeries, as it remains an emerging technology. However, researchers have recently found that “spinal surgery outcomes are improved when the surgeon uses virtual reality (VR) during the operation.”
Additionally, research finds that virtual reality in spine surgery—specifically cervical spine surgery—has great potential, although additional research needs to be conducted in order to continue better understanding the potential applications, benefits, and any drawbacks of virtual reality in spine surgery.
WHY ARE SURGEONS USING VIRTUAL REALITY IN SPINE SURGERY?
The simple truth of the matter is that even for the very best physicians, long operations on patients can be physically and mentally taxing. This shouldn’t be a surprise, given the enormous complexity of conducting surgical procedures on delicate parts of the body such as the spine. So why are surgeons turning to new tools like virtual reality in spine surgery? The literature notes that there are several reasons why this is the case. First and foremost, physicians are always seeking ways to improve outcomes for their patients, and the accuracy and efficiency offered by virtual reality systems (not yet for all surgeries, but for a growing number) makes them an attractive candidate to aid not only in training but in live surgeries. The performance advantages alone make virtual reality systems a strong complement to the human touch of surgeons.
Second, and not surprisingly, there are a great many technical challenges involved in spinal surgery. Scholars note that these challenges include “physical and mental fatigue, hand tremor, difficulties with manual dexterity, and surgical precision.”
Each of these challenges can in some way be addressed by virtual reality in spine surgery, which does not have to navigate the same challenges of growing tired, hands that begin to shake after hours of work, or calibrating precision with the human eye in every movement. Virtual reality can thus be used as a way to mitigate the burden placed on surgeons while allowing them to focus on overseeing the most important aspects of the surgery.
This is not all that dissimilar from recent advances in aviation, where many features of flying a plane have become automated, but pilots remain essential for overseeing the core functions of the aircraft as it carries passengers to their destination. Just as fatalities from flying have declined precipitously in recent years, virtual reality systems have the potential in coming years to improve the efficacy and efficiency of spine surgeries, improving outcomes for patients and saving costs for operators.
IS VIRTUAL REALITY IN SPINE SURGERY SAFE?
So, is virtual reality in spine surgery safe? While the FDA has already cleared augmented reality systems, such as the Augmedics xvision™ Spine System, which has been successfully used in a spinal fusion operation, these technologies are still in their infancies. They will require more time and improvement before they’ll be of great use to neurosurgeons in the operating room.
The literature on virtual reality and spine surgery appears to have arrived at three central points of consensus. The first is that virtual reality undoubtedly serves “various promising functions in the realm of spine surgery.” This is hardly a surprise given its effectiveness as a training mechanism and the successes it has thus far brought to the realm of spine surgery.
The second is that the use of virtual reality in spinal surgery is growing—this speaks to both its potential and the successes it has already achieved.
And third, because these simulation systems “remain in infancy,” more research will be necessary in order to ensure that virtual reality continues to improve in its efficacy and efficiency, as well as the kinds of spine surgeries it can be a useful aid in. The capabilities of this fairly new technology will be refined over time, and there is the possibility of it providing even clearer images and better data in the future. As the technology advances the use of virtual reality in spinal surgery could rise in response to its developments.
While up to 31 percent of freehand spinal surgeries result in inaccurate screw positioning and up to three percent of freehand surgeries require reoperation within 30 days to reposition screws, the story of surgical navigation systems is much different. They have a greater than 95 percent success rate, cut screw insertion time by 50 percent, and provide a 92 percent decrease in X-ray radiation.
The challenge may be that virtual reality platforms and other augmented reality platforms are not being used enough; only 9 percent of spine surgeons routinely use them and 66 percent never do. While a decision must ultimately be made in consultation with one’s physician, all indications point to virtual reality being an increasingly safe and effective tool for spine surgeries. For those considering undergoing spine surgery, then, opting for a method that incorporates virtual reality (or a surgical navigation system of some kind) would be well-worth considering (again, in consultation with one’s physician).
WHAT IS THE FUTURE FOR VIRTUAL REALITY IN SPINE SURGERY?
While basic effectiveness has been established for more straightforward spine operations, there are still new frontiers for virtual reality in spine surgery to reach. Scholars believe that virtual reality in spine surgery has “shown promising results” regarding its applicability beyond its current functions, which makes the expansion of those functions the next step for surgical navigation systems like virtual reality. At a slightly more technical level, additional research is needed “in order to increase surgical accuracy, decrease overall length of surgery, and minimize overall radiation exposure” during spine surgeries. Each of these aspects of spine surgery can be addressed by virtual reality, but will require further research and application.
Another element of development for virtual reality is moving from the primarily educational space to more regular areas of surgical practice. While virtual reality has become increasingly common for training students given its effectiveness as a complement to freehand training, its usefulness is far less confined to the educational space than it used to be.
Additionally, while virtual reality has established utility in aiding the assessment of spinal imaging, there are improvements that could be made in this field. As research notes, virtual reality modeling “can demonstrate pathology with ease, however, with more subtle findings VR has yet to demonstrate excellent utility.” This is yet another area for future improvements regarding virtual reality in spine surgery.
In conclusion, surgical navigation systems offer significant improvements to the freehand surgical techniques that have been used for many years. From improving the training of medical students to increasing accuracy and effectiveness of actual surgical procedures, virtual reality in spine surgery offers a promising new way for physicians to deliver better care to the many patients who find themselves suffering from back pain and irritation each year.