Augmented reality in intradural spinal tumor surgery

  • Barbara CarlEmail author
  • Miriam Bopp
  • Benjamin Saß
  • Mirza Pojskic
  • Christopher Nimsky
Original Article - Spine - Other
Part of the following topical collections:
  1. Spine - Other



Microscope-based augmented reality (AR) is commonly used in cranial surgery; however, until recently, this technique was not implemented for spinal surgery. We prospectively investigated, how AR can be applied for intradural spinal tumor surgery.


For ten patients with intradural spinal tumors (ependymoma, glioma, hemangioblastoma, meningioma, and metastasis), AR was provided by head-up displays (HUDs) of operating microscopes. User-independent automatic AR registration was established by low-dose intraoperative computed tomography. The objects visualized by AR were segmented in preoperative imaging data; non-linear image registration was applied to consider spine flexibility.


In all cases, AR supported surgery by visualizing the tumor outline and other relevant surrounding structures. The overall AR registration error was 0.72 ± 0.24 mm (mean ± standard deviation), a close matching of visible tumor outline and AR visualization was observed for all cases. Registration scanning resulted in a low effective dose of 0.22 ± 0.16 mSv for cervical and 1.68 ± 0.61 mSv for thoracic lesions. The mean HUD AR usage in relation to microscope time was 51.6 ± 36.7%. The HUD was switched off and turned on again in a range of 2 to 17 times (5.7 ± 4.4 times). Independent of the status of the HUD, the AR visualization was displayed on monitors throughout surgery.


Microscope-based AR can be reliably applied to intradural spinal tumor surgery. Automatic AR registration ensures high precision and provides an intuitive visualization of the extent of the tumor and surrounding structures. Given this setting, all advanced multi-modality options of cranial AR can also be applied to spinal surgery.


Augmented reality Head-up displays Intradural spinal tumor surgery Intraoperative computed tomography Low-dose computed tomography Spine registration 



We thank J.-W. Bartsch for proofreading the manuscript.

Compliance with ethical standards

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript, except that B. Carl and Ch. Nimsky have received speaker fees from Brainlab.

Ethical standards

All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. We obtained ethics approval for prospective archiving clinical and technical data applying intraoperative imaging and navigation (study no. 99/18). Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Abe Y, Sato S, Kato K, Hyakumachi T, Yanagibashi Y, Ito M, Abumi K (2013) A novel 3D guidance system using augmented reality for percutaneous vertebroplasty: technical note. J Neurosurg Spine 19:492–501. CrossRefGoogle Scholar
  2. 2.
    Agten CA, Dennler C, Rosskopf AB, Jaberg L, Pfirrmann CWA, Farshad M (2018) Augmented reality-guided lumbar facet joint injections. Investig Radiol 53:495–498. CrossRefGoogle Scholar
  3. 3.
    Burstrom G, Nachabe R, Persson O, Edstrom E, Terander AE (2019) Augmented and virtual reality instrument tracking for minimally invasive spine surgery: a feasibility and accuracy study. Spine (Phila Pa 1976).
  4. 4.
    Cabrilo I, Bijlenga P, Schaller K (2014) Augmented reality in the surgery of cerebral arteriovenous malformations: technique assessment and considerations. Acta Neurochir 156:1769–1774. CrossRefGoogle Scholar
  5. 5.
    Cabrilo I, Sarrafzadeh A, Bijlenga P, Landis BN, Schaller K (2014) Augmented reality-assisted skull base surgery. Neurochirurgie 60:304–306. CrossRefGoogle Scholar
  6. 6.
    Carl B, Bopp M, Chehab S, Bien S, Nimsky C (2018) Preoperative 3-dimensional angiography data and intraoperative real-time vascular data integrated in microscope-based navigation by automatic patient registration applying intraoperative computed tomography. World Neurosurg 113:E414–E425. CrossRefGoogle Scholar
  7. 7.
    Carl B, Bopp M, Sass B, Voellger B, Nimsky C (2019) Implementation of augmented reality support in spine surgery. Eur Spine J.
  8. 8.
    Carl B, Bopp M, Voellger B, Sass B, Nimsky C (2019) Augmented reality in transsphenoidal surgery. World Neurosurg 125:E873–E883.
  9. 9.
    Coelho G, Defino HLA (2018) The role of mixed reality simulation for surgical training in spine: phase 1 validation. Spine (Phila Pa 1976) 43:1609–1616. CrossRefGoogle Scholar
  10. 10.
    Deib G, Johnson A, Unberath M, Yu K, Andress S, Qian L, Osgood G, Navab N, Hui F, Gailloud P (2018) Image guided percutaneous spine procedures using an optical see-through head mounted display: proof of concept and rationale. J Neurointerv Surg 10:1187–1191. CrossRefGoogle Scholar
  11. 11.
    Elmi-Terander A, Burstrom G, Nachabe R, Skulason H, Pedersen K, Fagerlund M, Stahl F, Charalampidis A, Soderman M, Holmin S, Babic D, Jenniskens I, Edstrom E, Gerdhem P (2019) Pedicle screw placement using augmented reality surgical navigation with intraoperative 3D imaging: a first in-human prospective cohort study. Spine (Phila Pa 1976) 44:517–525. CrossRefGoogle Scholar
  12. 12.
    Fahlbusch R, Nimsky C, Ganslandt O, Steinmeier R, Buchfelder M, Huk W (1998) The Erlangen concept of image guided surgery. In: Lemke HU, Vannier MW, Inamura K, Farman A (eds) CAR'98. Elsevier Science B.V., Amsterdam, pp 583–588Google Scholar
  13. 13.
    Fida B, Cutolo F, di Franco G, Ferrari M, Ferrari V (2018) Augmented reality in open surgery. Updat Surg 70:389–400. CrossRefGoogle Scholar
  14. 14.
    Ganslandt O, Stadlbauer A, Fahlbusch R, Kamada K, Buslei R, Blumcke I, Moser E, Nimsky C (2005) Proton magnetic resonance spectroscopic imaging integrated into image-guided surgery: correlation to standard magnetic resonance imaging and tumor cell density. Neurosurgery 56:291. Google Scholar
  15. 15.
    Gibby JT, Swenson SA, Cvetko S, Rao R, Javan R (2019) Head-mounted display augmented reality to guide pedicle screw placement utilizing computed tomography. Int J Comput Assist Radiol Surg 14:525–535. CrossRefGoogle Scholar
  16. 16.
    Greffier J, Pereira FR, Viala P, Macri F, Beregi JP, Larbi A (2017) Interventional spine procedures under CT guidance: how to reduce patient radiation dose without compromising the successful outcome of the procedure? Phys Med 35:88–96. CrossRefGoogle Scholar
  17. 17.
    Kelly PJ, Alker GJ Jr, Goerss S (1982) Computer-assisted stereotactic microsurgery for the treatment of intracranial neoplasms. Neurosurgery 10:324–331CrossRefGoogle Scholar
  18. 18.
    King AP, Edwards PJ, Maurer CR, de Cunha DA, Hawkes DJ, Hill DLG, Gaston RP, Fenlon MR (1999) A system for microscope-assisted guided interventions. Stereotact Funct Neurosurg 72:107–111. CrossRefGoogle Scholar
  19. 19.
    Kiya N, Dureza C, Fukushima T, Maroon JC (1997) Computer navigational microscope for minimally invasive neurosurgery. Minim Invasive Neurosurg 40:110–115. CrossRefGoogle Scholar
  20. 20.
    Kosterhon M, Gutenberg A, Kantelhardt SR, Archavlis E, Giese A (2017) Navigation and image injection for control of bone removal and osteotomy planes in spine surgery. Oper Neurosurg (Hagerstown) 13:297–304. CrossRefGoogle Scholar
  21. 21.
    Kwan K, Schneider JR, Du V, Falting L, Boockvar JA, Oren J, Levine M, Langer DJ (2019) Lessons learned using a high-definition 3-dimensional exoscope for spinal surgery. Oper Neurosurg (Hagerstown) 16:619–625. CrossRefGoogle Scholar
  22. 22.
    Liebmann F, Roner S, von Atzigen M, Scaramuzza D, Sutter R, Snedeker J, Farshad M, Furnstahl P (2019) Pedicle screw navigation using surface digitization on the Microsoft HoloLens. Int J Comput Assist Radiol Surg 14:1157–1165.
  23. 23.
    Ma L, Zhao Z, Chen F, Zhang B, Fu L, Liao H (2017) Augmented reality surgical navigation with ultrasound-assisted registration for pedicle screw placement: a pilot study. Int J Comput Assist Radiol Surg 12:2205–2215. CrossRefGoogle Scholar
  24. 24.
    Mascitelli JR, Bederson JB (2018) In reply: navigation-linked heads-up display in intracranial surgery: early experience. Oper Neurosurg (Hagerstown) 14:E73. CrossRefGoogle Scholar
  25. 25.
    Meola A, Cutolo F, Carbone M, Cagnazzo F, Ferrari M, Ferrari V (2017) Augmented reality in neurosurgery: a systematic review. Neurosurg Rev 40:537–548. CrossRefGoogle Scholar
  26. 26.
    Molina CA, Theodore N, Ahmed AK, Westbroek EM, Mirovsky Y, Harel R, Orru E, Khan M, Witham T, Sciubba DM (2019) Augmented reality-assisted pedicle screw insertion: a cadaveric proof-of-concept study. J Neurosurg Spine:1–8.
  27. 27.
    Nakamura M, Tamaki N, Tamura S, Yamashita H, Hara Y, Ehara K (2000) Image-guided microsurgery with the Mehrkoordinaten manipulator system for cerebral arteriovenous malformations. J Clin Neurosci 7(Suppl 1):10–13. Google Scholar
  28. 28.
    Nimsky C, Ganslandt O, Cerny S, Hastreiter P, Greiner G, Fahlbusch R (2000) Quantification of, visualization of, and compensation for brain shift using intraoperative magnetic resonance imaging. Neurosurgery 47:1070–1079. CrossRefGoogle Scholar
  29. 29.
    Nimsky C, Ganslandt O, Fahlbusch R (2006) Implementation of fiber tract navigation. Neurosurgery 58:292–303. Google Scholar
  30. 30.
    Nimsky C, Ganslandt O, Kober H, Moller M, Ulmer S, Tomandl B, Fahlbusch R (1999) Integration of functional magnetic resonance imaging supported by magnetoencephalography in functional neuronavigation. Neurosurgery 44:1249–1255. Google Scholar
  31. 31.
    Ntourakis D, Memeo R, Soler L, Marescaux J, Mutter D, Pessaux P (2016) Augmented reality guidance for the resection of missing colorectal liver metastases: an initial experience. World J Surg 40:419–426. CrossRefGoogle Scholar
  32. 32.
    Roberts DW, Strohbehn JW, Hatch JF, Murray W, Kettenberger H (1986) A frameless stereotaxic integration of computerized tomographic imaging and the operating microscope. J Neurosurg 65:545–549. CrossRefGoogle Scholar
  33. 33.
    Sarwahi V, Payares M, Wendolowski S, Maguire K, Thornhill B, Lo YT, Amaral TD (2017) Low-dose radiation 3D intraoperative imaging how low can we go? An O-arm, CT scan, cadaveric study. Spine 42:E1311–E1317. CrossRefGoogle Scholar
  34. 34.
    Su AW, Luo TD, McIntosh AL, Schueler BA, Winkler JA, Stans AA, Larson AN (2016) Switching to a pediatric dose O-arm protocol in spine surgery significantly reduced patient radiation exposure. J Pediatr Orthop 36:621–626. CrossRefGoogle Scholar
  35. 35.
    Umebayashi D, Yamamoto Y, Nakajima Y, Fukaya N, Hara M (2018) Augmented reality visualization-guided microscopic spine surgery: transvertebral anterior cervical foraminotomy and posterior foraminotomy. J Am Acad Orthop Surg Glob Res Rev 2:e008. Google Scholar
  36. 36.
    Yoon JW, Chen RE, Han PK, Si P, Freeman WD, Pirris SM (2017) Technical feasibility and safety of an intraoperative head-up display device during spine instrumentation. Int J Med Robot 13:e1770. CrossRefGoogle Scholar
  37. 37.
    Zhao J, Liu Y, Fan M, Liu B, He D, Tian W (2018) Comparison of the clinical accuracy between point-to-point registration and auto-registration using an active infrared navigation system. Spine (Phila Pa 1976) 43:E1329–E1333. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryUniversity MarburgMarburgGermany
  2. 2.Marburg Center for Mind, Brain and Behavior (MCMBB)MarburgGermany

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