With all the upheaval surrounding OpenAI over the past week, many became concerned about the widespread impact it could have on innovations in the medical field, such as augmented reality for surgical procedures. Many of the most important advances in AR, such as real-time guidance for surgeons during procedures, have been driven by artificial intelligence. AR still promises to revolutionize the approach to complex surgical procedures by improving precision, efficiency and accuracy in the operating room. This can lead to fewer errors, better outcomes and a better quality of life for patients who have suffered from diseases of the spine, brain tumors and a variety of other conditions.
When Dr. Timothy Witham, professor of neurosurgery and orthopedic surgery at the Johns Hopkins University School of Medicine, performed the first ever augmented reality surgical navigation spine surgery in the United States in June 2020, he had already completed thousands of successful spine surgeries with excellent results. 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 such as an MRI or CT scan with intraoperative visualization of the surgical field, essentially combining the virtual and physical worlds. AR overlays the images on the surgeon’s view of the patient, giving the surgeon 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 interrupt the operation periodically to take CT scans or fluoroscopic images to guide the procedure.
AR to prepare for surgery
There are many ways that AR can be integrated into surgical practice. Surgeons can use it to review a 3D model of the patient’s anatomy to prepare for surgery. They can consider decisions about where to make incisions, the size of the incision, and potential challenges that may arise during surgery.
“Augmented reality is poised to improve our approach to brain tumor surgery,” said Dr. Simon Hanft, Section Chief of Neurosurgical Oncology at WMCHealth. “It provides an incredibly detailed 3-D simulated environment where we can practice our approach to surgery. This goes far beyond looking at traditional MRIs and going through the surgery in your mind.”
AR is also an excellent tool for simulating the surgical environment for medical students and residents to gain skills in surgical procedures before participating in actual operations with or without AR.
AI-powered AR during surgery
During the actual surgery, the surgeon wears a headset called a head-mounted display, like what a fighter pilot wears. The headset is comfortable, well designed and easy to put on and take off. It weighs about two kilograms, so it is not a huge strain on the surgeon’s head and neck. Some forms of AR integrate the images into the microscope screen that the surgeon uses during the procedure.
Much like doctors 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 every time he gets consent from a patient for a procedure.
The patient is then taken to the operating room, where further scans can be done, which are loaded into the headset. The headset projects the patient’s films onto the body, so that the surgeon sees the films throughout the procedure. Even before the first incision is made, 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. Attentional shifts can increase the time required to perform a task by 30% to 40%, which can be detrimental to the motor task at hand and can also increase the cognitive burden on the surgeon. ARSN also reduces line-of-sight interruptions, which refers to any object that can interfere with intraoperative navigation by blocking the tracking markers or the camera.
Drs. Witham and Hanft both say they can use AR during surgery to improve the accuracy and understanding of the surgery in real time. “I foresee this as a technique that will become widely integrated into the field of brain surgery with transformative potential,” adds Dr. Hemp.
Why this is important
When it comes to spine surgery, precision is extremely important. Surgeons using freehand technique without any technical assistance have screw placement accuracies in the range of 93% to 98.5%. More complex spinal surgeries such as in patients with severe spinal deformities have failure rates as high as 15%. These errors can lead to neurological and vascular damage, which can sometimes cause chronic pain and disability. Several studies have shown that AR-guided screw placement has accuracy rates that are advantageous compared to any technique, including robotics, for placing spinal instrumentation. Screw placement using AR has been shown to have 98% accuracy, which can translate to a significantly improved quality of life for patients.
Limitations of ARSN
Although there is a great advantage to using AR for surgery, it is important to be aware that it is not intended to teach the surgeon anatomy and it will not enable surgeons to perform operations that they are not qualified to perform . For example, if a surgeon is not skilled in complex scoliosis surgery or resection of skull-based tumors, the surgeon will suddenly not be able to handle these complex cases with AR.
Relying entirely on technology to perform surgery is not recommended because if the technology fails or there is a fault 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 tremendous potential for augmented reality to improve the quality of spine surgery we perform,” said Dr. Scott Zuckerman, assistant professor of neurosurgery and orthopedic surgery at Vanderbilt University. “However, new technologies cannot and should not replace surgeons who have a strong grasp of the anatomy and technical principles of each operation and can perform each operation as if the technology were not available,” cautions 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 considering that they may have practiced for decades with good results without this technology. Community hospitals may not immediately have access to this technology, which has some initial costs. However, these costs are more economical than some of the robotic 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 of purchasing the equipment will drop, making this technology more accessible.
Despite the many limitations of AR, Dr. Witham summed it up by saying, “ARSN is a game changer in the operating room.” It can lead to safer operations, more successful surgical procedures and shortened recovery time for the patient.
Although this has not yet been widely adopted, more and more tertiary medical centers and teaching hospitals are using this technique with excellent results. With ongoing collaboration between doctors, 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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