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Peer-Reviewed Studies
Improved accuracy and lowered learning curve of ventricular targeting using augmented reality—Phantom and Cadaveric Model Testing. Neurosurgery, (2023, April).
Bounajem, M. T., Cameron, B., Sorensen, K., Parr, R., Gibby, W., Prashant, G., Evans, J. J., & Karsy, M.
BACKGROUND:
Augmented reality (AR) has demonstrated significant potential in neurosurgical cranial, spine, and teaching applications. External ventricular drain (EVD) placement remains a common procedure, but with error rates in targeting between 10% and 40%.
OBJECTIVE:
To evaluate Novarad VisAR guidance system for the placement of EVDs in phantom and cadaveric models.
METHODS:
Two synthetic ventricular phantom models and a third cadaver model underwent computerized tomography imaging and registration with the VisAR system (Novarad). Root mean square (RMS), angular error (γ), and Euclidian distance were measured by multiple methods for various standard EVD placements.
RESULTS:
Computerized tomography measurements on a phantom model (0.5-mm targets showed a mean Euclidean distance error of 1.20 ± 0.98 mm and γ of 1.25° ± 1.02°. Eight participants placed EVDs in lateral and occipital burr holes using VisAR in a second phantom anatomic ventricular model (mean RMS: 3.9 ± 1.8 mm, γ: 3.95° ± 1.78°). There were no statistically significant differences in accuracy for postgraduate year level, prior AR experience, prior EVD experience, or experience with video games (P > .05). In comparing EVDs placed with anatomic landmarks vs VisAR navigation in a cadaver, VisAR demonstrated significantly better RMS and γ, 7.47 ± 0.94 mm and 7.12° ± 0.97°, respectively (P ≤ .05).
CONCLUSION:
The novel VisAR AR system resulted in accurate placement of EVDs with a rapid learning curve, which may improve clinical treatment and patient safety. Future applications of VisAR can be expanded to other cranial procedures.
Augmented reality spine surgery navigation: Increasing pedicle screw accuracy for both open and minimally invasive spine surgeries. SPINE (2022, June 15)
Felix, B., Kalatar, S. B., Moatz, B., Hofstetter, C., Karsy, M., Parr, R., & Gibby, W.
Study Design.
Collectively, seven cadavers were instrumented with 124 thoracolumbar pedicle screws using VisAR augmented reality/guidance. Sixty-five screws were inserted into four donors using open dissection spine surgery. Fifty-nine screws were positioned in three donors with a minimally invasive spine surgery (MISS) procedure. For both open and MISS, VisAR was used exclusively for pedicle screw navigation.
Objective.
The objective of this study was to determine the accuracy of pedicle screw placement using VisAR for open spine and MISS procedures.
Summary of Background Data.
Pedicle screw placement can be challenging depending on anatomical location and a surgeon's experience. AR may minimize fluoroscopy use and speed screw insertion.
Methods.
Prior to computed tomography (CT) a series of four image visible April Tag optical fiducials were attached to the backs’ of the donors. Resulting images were used preoperatively for planned virtual pedicle screw pathways including entry point, trajectory, and depth. The study link was encrypted on a quick response (QR) code, printed, and viewed in the operating room (OR) by the surgeon using VisAR (HoloLens 2 headset). Viewing the code wirelessly uploads and launches the study, converting the DICOM data to holographic images which register to the fiducials on the donor's back. The annotated pathways for each pedicle were called up by voice command and the surgeon positioned each screw by aligning with the virtual guidance hologram.
Results.
Overall, 124 pedicle screws were inserted with VisAR navigation with 96% accuracy (Gertzbein-Robbins grades A and B). The combined angle of error was 2.4° and the distance error was 1.9 mm.
Conclusion.
Augmented reality is a highly accurate, emerging technology for navigating both open and minimally invasive spine surgery techniques with off-the-shelf headset hardware.
Felix, B., Kalatar, S. B., Moatz, B., Hofstetter, C., Karsy, M., Parr, R., & Gibby, W. (2022, June 15). Augmented reality spine surgery navigation: Increasing pedicle screw accuracy for both open and minimally invasive spine surgeries. SPINE, 47(12), pp 865-872. Retrieved February 8, 2023, from https://journals.lww.com/spinejournal/Fulltext/2022/06150/Augmented_Reality_Spine_Surgery_Navigation_.5.aspx
The application of augmented reality-based navigation for accurate target acquisition of deep brain site: advances in neurosurgical guidance. Journal of Neurosurgery (2021)
Gibby, W., Cvetko, S., Gibby, A., Gibby, C., Sorensen, K., Andrews, E. G., Maroon, J., & Parr, R.
OBJECTIVE
The objective of this study is to quantify the navigational accuracy of an advanced augmented reality (AR)–based guidance system for neurological surgery, biopsy, and/or other minimally invasive neurological surgical procedures.
METHODS
Five burr holes were drilled through a plastic cranium, and 5 optical fiducials (AprilTags) printed with CT-visible ink were placed on the frontal, temporal, and parietal bones of a human skull model. Three 0.5-mm-diameter targets were mounted in the interior of the skull on nylon posts near the level of the tentorium cerebelli and the pituitary fossa. The skull was filled with ballistic gelatin to simulate brain tissue. A CT scan was taken and virtual needle tracts were annotated on the preoperative 3D workstation for the combination of 3 targets and 5 access holes (15 target tracts). The resulting annotated study was uploaded to and launched by VisAR software operating on the HoloLens 2 holographic visor by viewing an encrypted, printed QR code assigned to the study by the preoperative workstation. The DICOM images were converted to 3D holograms and registered to the skull by alignment of the holographic fiducials with the AprilTags attached to the skull. Five volunteers, familiar with the VisAR, used the software/visor combination to navigate an 18-gauge needle/trocar through the series of burr holes to the target, resulting in 70 data points (15 for 4 users and 10 for 1 user). After each attempt the needle was left in the skull, supported by the ballistic gelatin, and a high-resolution CT was taken. Radial error and angle of error were determined using vector coordinates. Summary statistics were calculated individually and collectively.
RESULTS
The combined angle of error of was 2.30° ± 1.28°. The mean radial error for users was 3.62 ± 1.71 mm. The mean target depth was 85.41 mm.
CONCLUSIONS
The mean radial error and angle of error with the associated variance measures demonstrates that VisAR navigation may have utility for guiding a small needle to neural lesions, or targets within an accuracy of 3.62 mm. These values are sufficiently accurate for the navigation of many neurological procedures such as ventriculostomy.
Gibby, W., Cvetko, S., Gibby, A., Gibby, C., Sorensen, K., Andrews, E. G., Maroon, J., & Parr, R. (2021). The application of augmented reality-based navigation for accurate target acquisition of deep brain site: advances in neurosurgical guidance. Journal of Neurosurgery, 137(2), 489–495. https://doi.org/10.3171/2021.9.jns21510
Head-mounted display augmented reality to guide pedicle screw placement utilizing computed tomography. International Journal of Computer Assisted Radiology and Surgery. (2018, June 22)
Gibby, J. T., Swenson, S. A., Cvetko, S., Rao, R., & Javan, R.
Purpose
Augmented reality has potential to enhance surgical navigation and visualization. We determined whether head-mounted display augmented reality (HMD-AR) with superimposed computed tomography (CT) data could allow the wearer to percutaneously guide pedicle screw placement in an opaque lumbar model with no real-time fluoroscopic guidance.
Methods
CT imaging was obtained of a phantom composed of L1–L3 Sawbones vertebrae in opaque silicone. Preprocedural planning was performed by creating virtual trajectories of appropriate angle and depth for ideal approach into the pedicle, and these data were integrated into the Microsoft HoloLens using the Novarad OpenSight application allowing the user to view the virtual trajectory guides and CT images superimposed on the phantom in two and three dimensions. Spinal needles were inserted following the virtual trajectories to the point of contact with bone. Repeat CT revealed actual needle trajectory, allowing comparison with the ideal preprocedural paths.
Results
Registration of AR to phantom showed a roughly circular deviation with maximum average radius of 2.5 mm. Users took an average of 200 s to place a needle. Extrapolation of needle trajectory into the pedicle showed that of 36 needles placed, 35 (97%) would have remained within the pedicles. Needles placed approximated a mean distance of 4.69 mm in the mediolateral direction and 4.48 mm in the craniocaudal direction from pedicle bone edge.
Conclusion
To our knowledge, this is the first peer-reviewed report and evaluation of HMD-AR with superimposed 3D guidance utilizing CT for spinal pedicle guide placement for the purpose of cannulation without the use of fluoroscopy.
Gibby, J. T., Swenson, S. A., Cvetko, S., Rao, R., & Javan, R. (2018, June 22). Head-mounted display augmented reality to guide pedicle screw placement utilizing computed tomography. International Journal of Computer Assisted Radiology and Surgery. SpringerLink. Retrieved February 8, 2023, from https://link.springer.com/article/10.1007/s11548-018-1814-7
Use of Augmented Reality for Image-Guided Spine Procedures. European Spine Journal. (2020, June 26)
Gibby, J., Cvetko, S., Javan, R., Parr, R., & Gibby, W.
Purpose
Because of its ability to superimpose imaging data on a patient, while anchoring the user’s view to the immediate surroundings, augmented reality (AR) has the potential to dramatically improve the accuracy and reduce the time required for preoperative planning and performance of minimally invasive spine surgeries and procedures. Described and reported herein is the direct clinical application of AR navigation on a series of common percutaneous image-guided spine procedures.
Materials and methods
AR, including a “virtual needle” (VN) asset, was used to guide and navigate a total of 18 procedures performed on 10 patients. Comparative control data were generated using a phantom model (n = 32). These data are used to determine the accuracy of AR for federal drug administration submissions. Optical codes were implemented to allow automatic and real-time registration. A manual process was used when the use of optical codes was not available. Target error, distance to the target and target size were measured for both phantom and clinical groups. Mean errors between the two groups were compared.
Results
Target error between the control and clinical data sets showed no significant difference. Moreover, the distance to the target site and the target size had no effect on target acquisition.
Conclusions
This data set suggests that AR navigation, utilizing a VN, is an emerging, accurate, valuable additive method for surgical and procedural planning for percutaneous image-guided spinal procedures and has potential to be applied to a broad range of clinical and surgical applications.
Gibby, J., Cvetko, S., Javan, R., Parr, R., & Gibby, W. (2020, June 26). Use of Augmented Reality for Image-Guided Spine Procedures. European Spine Journal. SpringerLink. Retrieved February 8, 2023, from https://link.springer.com/article/10.1007/s00586-020-06495-4
Augmented reality head-mounted display–based incision planning in cranial neurosurgery: a prospective pilot study. Neurosurgical Focus (2021)
Ivan, M., Eichber, D. G., Di, L., Shah, A. H., Luther, E. M., Lu, V. M., Komotar, R. J., & Urakov, T. M.
OBJECTIVE
Monitor and wand–based neuronavigation stations (MWBNSs) for frameless intraoperative neuronavigation are routinely used in cranial neurosurgery. However, they are temporally and spatially cumbersome; the OR must be arranged around the MWBNS, at least one hand must be used to manipulate the MWBNS wand (interrupting a bimanual surgical technique), and the surgical workflow is interrupted as the surgeon stops to “check the navigation” on a remote monitor. Thus, there is need for continuous, real-time, hands-free, neuronavigation solutions. Augmented reality (AR) is poised to streamline these issues. The authors present the first reported prospective pilot study investigating the feasibility of using the OpenSight application with an AR head-mounted display to map out the borders of tumors in patients undergoing elective craniotomy for tumor resection, and to compare the degree of correspondence with MWBNS tracing.
METHODS
Eleven consecutive patients undergoing elective craniotomy for brain tumor resection were prospectively identified and underwent circumferential tumor border tracing at the time of incision planning by a surgeon wearing HoloLens AR glasses running the commercially available OpenSight application registered to the patient and preoperative MRI. Then, the same patient underwent circumferential tumor border tracing using the StealthStation S8 MWBNS. Postoperatively, both tumor border tracings were compared by two blinded board-certified neurosurgeons and rated as having an excellent, adequate, or poor correspondence degree based on a subjective sense of the overlap. Objective overlap area measurements were also determined.
RESULTS
Eleven patients undergoing craniotomy were included in the study. Five patient procedures were rated as having an excellent correspondence degree, 5 had an adequate correspondence degree, and 1 had poor correspondence. Both raters agreed on the rating in all cases. AR tracing was possible in all cases.
CONCLUSIONS
In this small pilot study, the authors found that AR was implementable in the workflow of a neurosurgery OR, and was a feasible method of preoperative tumor border identification for incision planning. Future studies are needed to identify strategies to improve and optimize AR accuracy.
Ivan, M., Eichber, D. G., Di, L., Shah, A. H., Luther, E. M., Lu, V. M., Komotar, R. J., & Urakov, T. M. (2021). Augmented reality head-mounted display–based incision planning in cranial neurosurgery: a prospective pilot study. Neurosurgical Focus, 51(2). https://doi.org/10.3171/2021.5.FOCUS20735
Congress of Neurological Surgeons 2021
Presentations, Abstracts, and/or Posters
- Gibby J, Parr R. The Use of Augmented Reality and a “Virtual Needle” for Lumbar Puncture. North American Spine Society. Oral Presentation was given on Sept. 25, 2019.
- Sarani B, Gibby J. Novel Use of Augmented Reality for Surgical Stabilization of Rib Fractures. Chest Wall Injury Society. Oral Presentation was given March 28-30, 2019.
- Gibby J, Swenson S, Cvetko S, Javan R, Gibby W. Head-mounted display augmented reality for image-guided procedures of the spine. Radiologic Society of North America. Oral Presentation was given on November 28, 2018.
- Gibby JT, Swenson SA, Cvetko ST, Rao R, Javan R. Accuracy of Spinal Pedicle Localization Utilizing Holographic Augmented Reality Guidance. American Roentgen Ray Society. The oral presentation was given on April 27, 2018.
- Swenson SA, Gibby JT, Cvetko S, Rao R, Javan R. Surgical Simulation of Lumbar Pedicle Screw Placement Using Novel Holographic Technology. Orthopedic Research Society. The poster presentation was given on March 12, 2018.
- Gibby JT, Swenson SA, Cvetko ST, Rao R, Javan R. Wearable Augmented Reality Goggles Using 3D Computerized Tomography to Simulate Pedicle Screw Placement. George Washington University Research Days. The poster presentation was given on April 11, 2018.
- Gibby JT, Gibby WA, Cvetko ST, Javan R. Augmented reality imaging as an adjunct for localization of small lesions using Laryngoscopy on a 3D printed model of the neck. American Society of Neuroradiology. The oral presentation was given on April 27, 2017.
- Yaacobi, E., & Gibby, W. Augmented Reality Guided Percutaneous Cannulated Screw Placement for Pelvic Trauma. The oral presentation was given on December 14-16, 2022 at IOTA Triennial Meeting 2022.
- Gibby, W. How Augmented Reality is Changing Surgery Across the Globe. The oral presentation was given on June 13-15, 2023 at OMTEC Expo 2023.