With all the shakeup surrounding OpenAI over the past week, many grew concerned about the widespread impact this could have on innovations in the medical field, like augmented reality for surgical procedures. Many of the key advancements in AR, like real-time guidance for surgeons during procedures, have been powered by Artificial Intelligence. AR still promises to revolutionize the approach to complex surgical procedures by enhancing precision, efficiency and accuracy in the operating room. This could translate to fewer errors, better outcomes and better quality of life for patients who have been suffering from diseases of the spine, brain tumors and a host of other conditions.
When Dr. Timothy Witham, professor of neurosurgery and orthopedic surgery at Johns Hopkins University School of Medicine, performed the first-ever augmented reality surgical navigation spine surgery in the U.S. in June 2020, he had already completed thousands of successful spine surgeries with excellent outcomes. As director of the Johns Hopkins Neurosurgery Spinal Fusion Laboratory, Dr. Witham sees ARSN as, “An opportunity to provide even better and more precise care for my patients.”
ARSN integrates computer-generated images like an MRI or CT scan with intraoperative visualization of the surgical field, essentially merging the virtual and physical worlds. AR overlays the images onto the surgeon’s view of the patient, which provides the surgeon with real-time feedback on precise anatomical locations. Without ARSN, the patient and surgical team may have increased exposure to radiation, as the surgeon may need to periodically stop the surgery to take CT scans or fluoroscopic images to guide the procedure.
AR To Prep For Surgery
There are numerous ways that AR can be integrated into surgical practice. Surgeons can use it to review a 3-D model of the patient’s anatomy to prepare for the surgery. They can consider decisions regarding where to make incisions, size of the incision and potential challenges that may arise during the surgery.
“Augmented reality is poised to improve our approach to brain tumor surgery,” says Dr. Simon Hanft, section chief for neurosurgical oncology at WMCHealth. “It provides an incredibly detailed 3-D simulated environment wherein we can practice our approach to the operation. This goes well beyond viewing traditional MRIs and going over the operation in your mind.”
AR is also an excellent tool for simulating the surgical environment for medical students and residents to gain proficiency in surgical procedures before participating in actual surgeries with or without AR.
AI-Powered AR During Surgery
During the actual surgery, the surgeon wears a headset known as a head-mounted display, like what a fighter pilot wears. The headset is comfortable, well-designed and easy to slip on and off. It weighs about two pounds, so it is not a tremendous strain on the surgeon’s head and neck. Some forms of AR integrate the images into the microscope display that the surgeon uses during the procedure.
Much like physicians and insurance companies using artificial intelligence should disclose this to patients, surgeons using AR should also make this disclosure, which is exactly what Dr. Witham does each time he obtains consent from a patient for a procedure.
The patient is then taken to the operating room, where additional scans may be performed, which are loaded into the headset. The headset projects the patient’s films onto the body, so the surgeon views the films throughout the procedure. Even before making the initial incision, the surgeon feels like they have X-ray vision because they can see inside the patient’s body.
This allows the surgeon to constantly visualize the anatomy without shifting their attention from the patient’s body to view external monitors. Attention shifts can increase the time required to complete a task by 30% to 40%, which can be detrimental to the motor task at hand and may also increase the cognitive burden of the surgeon. ARSN also decreases line-of-sight interruptions, which refers to any item that can interfere with intraoperative navigation by blocking the tracking markers or camera.
Drs. Witham and Hanft both say they can use AR during surgery to improve accuracy and understanding of the surgery in real-time. “I foresee this as a technology that will become widely integrated into the field of brain surgery with transformative potential,” Dr. Hanft adds.
Why This Matters
When it comes to spine surgery, precision is extremely important. Surgeons using freehand technique without any technology assistance have screw placement accuracy rates in the 93% to 98.5% range. More complex spine surgeries like in patients with severe spine deformities have error rates as high as 15%. These errors may translate to neurological and vascular injury, which at times can cause chronic pain and disability. Numerous studies have demonstrated that AR-guided screw placement has accuracy rates that compare favorably to any technique, including robotic techniques, for placing spinal instrumentation. Screw placement using AR has been demonstrated to have 98% accuracy, which could translate to a significantly improved quality of life for patients.
Limitations To ARSN
While there is a great deal of benefit to using AR for surgery, it is important to be mindful that it is not intended to teach the surgeon anatomy and it will not enable surgeons to perform surgeries they are not qualified to perform. For example, if a surgeon is not skilled at complex scoliosis surgery or resecting skull-based tumors, the surgeon will not suddenly be able to manage those complex cases with AR.
Being completely dependent on technology to perform surgery is not recommended because if the technology fails or there is a glitch in the system, the surgeon should be prepared to perform the surgery the old-fashioned way. This is why it is important for surgeons in training to excel in their understanding of anatomy and learn how to perform the surgeries without AR.
“There is enormous potential for augmented reality to improve the quality of spine surgery we deliver,” says Dr. Scott Zuckerman, assistant professor of neurosurgery and orthopedic surgery at Vanderbilt University. “However new technology cannot and should not take the place of surgeons having a strong grasp of the anatomy and technical principles of each operation and being able to perform each surgery as if the technology was not available,” warns Dr. Zuckerman, who also serves as co-director of the Vanderbilt spine outcomes laboratory.
Many surgeons are wary of new technology and may not be interested in transitioning to ARSN, especially given that they may have been practicing for decades with good outcomes without this technology. Community hospitals may not immediately have access to this technology, which has some up-front costs. However, those costs are more economical than some of the robot-assistance technology that has become mainstream at many of the larger academic medical centers. The hope is that as more companies develop similar technology, the price point to purchase the equipment will go down, which will make this technology more accessible.
Despite the many limitations of AR, Dr. Witham summed it up by saying, “ARSN is a game changer in the OR.” It could lead to safer surgeries, more successful surgical interventions and shortened patient recovery time.
While this has not yet been widely adopted, more and more tertiary medical centers and teaching hospitals are using this technology and having excellent outcomes. With ongoing collaboration between physicians, technologists, engineers and the AI industry, it is reasonable to expect further developments in ARSN, which could truly make it a game-changer for patients in need of surgery.
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