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Evolving augmented reality (AR) technologies are transforming spine surgeons from skilled carpenters to sci-fi visionaries. They don futuristic headsets and view surgery like it’s never been seen before.
“The advent of AR has significantly improved the ease of use and simplicity of intraoperative navigation,” said Kevin Hykes, CEO of Augmedics. “AR allows surgeons to view 3D-rendered anatomical images projected onto the patient’s body as if they have x-ray vision.”
Augmedics’ xvision Spine System is an AR headset that digitally projects a patient’s anatomy onto the surgical field. The platform has been used to treat more than 5,000 patients and made Time magazine’s list of best inventions in 2020.
AR presents exciting possibilities for surgeons and an enticing product development pathway to explore for orthopedic companies that want to offer a cost-effective alternative to traditional navigation platforms. Still, medical device technology experts believe the spine surgery market has only begun to scratch the surface of AR’s true potential, perhaps because of the technology’s relative infancy and pushback from traditionalist surgeons.
“Surgeons are quite protective of their workflow and their preferred surgical techniques,” Hykes said. “One of the biggest challenges with any enabling technology is encouraging a surgeon to change how they perform surgery. They must be convinced that the benefits outweigh the work of modifying the way they operate.”
Promoting the Pluses
Hykes said traditional spine navigation provides significant benefits, including increased accuracy and spatial awareness. However, he explained that navigation platforms can disrupt the preferred workflows of surgeons, who often need to conjure three-dimensional images from two-dimensional images displayed on flat-panel monitors.
That’s one reason only one out of five spine surgeons use navigation tools, according to Hykes. “Some of the legacy systems are inelegant and require a lot of work on the part of the surgeon to tap into the technology’s benefits,” he explained. “We’ve entered a new chapter in which AR addresses the hurdles to more widespread adoption of navigation.”
Hykes added that AR is a far more natural way for surgeons to work with navigation tools, and he believes there are significant opportunities to expand AR in spinal surgery beyond applications related to pedicle screw placement.
“A ton of value could be added to AR navigation if surgeons could use the technology when they’re removing bone and tissue or implanting trajectories, cages and instrumentation systems,” he said. “AI applications could also soon guide spine surgeons with real-time data-driven suggestions.”
OnPoint Surgical sells its AR Spine System as a cost-effective alternative to surgical robots. The company’s philosophy is to combine the key functionalities of advanced navigation systems with unprecedented levels of accuracy in a high-functioning heads-up display.
The AR Spine System superimposes virtual surgical guides onto the surgeon’s visual field using transparent head-mounted optical displays.
It offers surgeons unique clinical and intraoperative benefits, including intuitive use, improved hand-eye coordination, increased accuracy and the potential for better patient outcomes.
The system takes up very little space in the O.R. and is easily implemented in hospital settings and ASCs. Its ergonomic and lightweight head-mounted display is a surgeon pleaser, and its 4K image resolution is ideally suited for spine surgery.
OnPoint AR Spine received FDA 510(k) clearance last September and will launch this year, according to company President Philipp Lang, M.D. “The proprietary information that is being overlaid onto the patient unlocks a whole new level of clinical performance, including significantly greater surgical accuracy,” he said.
Dr. Lang added that a peer-reviewed study recently presented at the Congress of Neurological Surgeons reported that OnPoint’s system delivered an increase in accuracy between two and five times compared to major existing navigation, robotic and AR systems. The study, which examined the positional and angular error of installing pedicle screws, reported a significant accuracy improvement when surgeons used OnPoint AR Spine.
Improved surgical efficiencies will be where the rubber meets the road when it comes to widespread adoption of AR, according to Dr. Lang. He explained that spine surgeons typically need to re-register intraoperative imaging platforms numerous times throughout various surgical stages. The time-consuming steps can add 20 minutes or more to procedures. Dr. Lang said OnPoint AR Spine features rapid re-registration that can be completed in about a minute.
He acknowledged that spine surgery is unique in the way that each surgeon brings their preferred approaches into the O.R. OnPoint’s platform allows for workflow customization that can accommodate a wide range of methodologies.
“Surgeons have the flexibility to continue performing surgery in ways that match their preferred techniques,” Dr. Lang said. “Our system allows them to refine their current skills. It’s a great teaching tool in that respect.”
Surgeons can tap into the benefits of AR before procedures begin. “Surgeons use the technology to create comprehensive surgical plans that bridge various planes of functionality and biomechanics to eliminate blind spots and gaps in care, leading to more predictable and controllable outcomes,” said Luke Maher, Vice President of Sales and Strategic Partnerships at Surgical Theater, which develops 360°/3D visualization technology for various surgical disciplines. “They have access to the biomechanics afforded by CT and MRI images and can use AR to loop in the different soft tissue elements that contribute to improved outcomes.”
Surgical Theater’s SyncAR Spine platform allows surgeons to “walk and fly through anatomy,” according to Maher. The platform was used during its first spine procedure last October.
Maher described SyncAR Spine as a visual aid that gives patients a clearer idea of what will happen during surgery and how to make informed decisions regarding their care.
“There’s so much variability in spine compared to other orthopedic specialties,” he said. “Patients can go to four different surgeons and get four different opinions on how to treat the same problem.”
SyncAR Spine provides surgeons with a medium to improve the ways that they communicate with their patients, according to Maher.
“Surgeons can build a comprehensive virtual plan of how they’re approaching individual procedures,” he explained. “Patients can use AR to interact with the virtual plan instead of listening to their surgeon talk about what to expect and hope they effectively communicate the key points.”
Breaking Down Barriers to Adoption
Dr. Lang predicts that AR will eventually be used in more than 90% of spine surgeries, but said significant barriers remain that prevent the widespread adoption of the technology in other orthopedic specialties.
“Based on feedback from surgeons, I think the biggest issue is technical limitations,” he said. “Some heads-up displays simply relay information that’s already shown on a computer monitor across the O.R. I don’t think that adds any real value, and not adding value is a significant barrier to entry.”
Companies with AR offerings are introducing the technology into an existing market that has been developing over the last 20-plus years with navigation systems that are very sophisticated, Dr. Lang explained. “If you introduce a platform that has a great looking display but lacks functionality, surgeons will be hesitant to try it and that’s a huge barrier to entry,” he said.
The expense of enabling technology can be a significant barrier to adoption, even for the relative cost-effectiveness of AR. Maher is interested in leading an initiative to improve the technology’s reimbursement models. He said that Surgical Theater advocates for new CPT codes that will reimburse surgeons and facilities for using AR in the O.R.
“We also want to drive more AI capabilities into the technology,” Maher said about his company’s plans. “AI modeling and content is our next big focus.
Dr. Lang believes major developments in AR technology are underway that are poised to unlock a new level of performance. “This is a technology that will become pervasive over the next five years,” he said.
With the work that’s being done to enhance AR beyond its current capabilities, even the biggest naysayers might have to admit that the technology’s benefits are too impressive to ignore.
