Virtual/Mixed Reality Technologies for Minimally Invasive and Complicated Spinal Surgery

Presented at SMISS Annual Forum 2019
By Norihiro Isogai
With Haruki Funao , Maki Sugimoto , Wataru Narita , Aeru Hayashi , Yutaka Sasao , Makoto Nishiyama , Keijyu Aokage , Masahiro Tsuboi , Ken Ishii ,

Disclosures: Norihiro Isogai None Haruki Funao None, Maki Sugimoto None, Wataru Narita None, Aeru Hayashi None, Yutaka Sasao None, Makoto Nishiyama None, Keijyu Aokage None, Masahiro Tsuboi None, Ken Ishii None,


Although intraoperative fluoroscopy and computed tomography (CT)-based navigation are useful in spinal surgery, the drawbacks of fluoroscopy are radiation exposure and limitation of two-dimensional images for a three-dimensional (3D) configuration, and CT-based navigation systems are not universally available due to costs. Virtual reality (VR) is computer-generated scenario that simulates a realistic experience. Mixed reality (MR) is another terminology, merging of real and virtual worlds to produce new environments and visualizations in real time. MR can be applied for image overlay technique, in which we can utilize true 3D viewing in spine surgery.


To describe a new technology which combines VR and MR "image overlay technique," in which dynamic 3D images were superimposed on the patient's actual body surface, as a reference for minimally invasive and complicated spinal surgeries.


Three patients with degenerative spondylolisthesis, degenerative lumbar scoliosis, and lung cancer metastasis to the thoracic spine were included in this study. Two-level lateral lumbar interbody fusion, circumferential spinal fusion from Th10 to the pelvis, and total en block spondylectomy combined with right upper lobectomy were performed. Raw data obtained from CTs were reconstructed to volume rendering as polygon data. A Mac and DICOM workstation OsiriX was used for image analysis. OsiriX was set to reproduce the patient body surface, and the positional coordinates of the pelvis or rib cage were fixed as physiological markers on the body surface.


The surgeons and surgical team could plan surgical strategies based on VR/MR images simulating minimally invasive and complicated surgical procedures preoperatively. Intraoperative image overlay technique was helpful for anatomical identification of surgical targets, and for 3D trajectories of both cage and screw insertion. Unexpected nerve, vessel, and organ injuries could be avoided in all procedures. Postoperative radiographs and CT images showed accurate instrumentation placements.


Although VR/MR technologies for spine surgery is still in research and development phase, preoperative planning and intraoperative image overlay technique were useful for both minimally invasive and complicated spine surgeries. These technologies could be used safely to provide more information, especially for hidden structures and unusual anatomy.