Effects of Augmented Reality on Thoracolumbar Pedicle Screw Instrumentation Across Different Levels of Surgical Experience.

OBJECTIVE: Augmented reality (AR) is an emerging technology that may accelerate skill acquisition and improve accuracy of thoracolumbar pedicle screw placements. We aimed to quantify the relative assistance of AR compared with freehand (FH) pedicle screw accuracy across different surgical experience levels. METHODS: A spine fellowship-trained and board-certified attending neurosurgeon, postgraduate year 4 neurosurgery resident, and second-year medical student placed 32 FH and 32 AR-assisted thoracolumbar pedicle screws in 3 cadavers. A cableless, voice-activated AR system was paired with a headset. Accuracy was assessed using χ2 analysis and the Gertzbein-Robbins scale. Angular error, distance error, and time per pedicle screw were collected and compared. RESULTS: The attending neurosurgeon had 91.6% (11/12) clinically acceptable (Gertzbein-Robbins scale A or B) insertion in both FH and AR groups; the resident neurosurgeon had 100% (9/9) FH and AR in both cases; the medical student had 72.3% (8/11) FH accuracy and 81.8% (9/11) AR accuracy. The medical student displayed significantly lower ideal (Gertzbein-Robbins scale A) FH accuracy compared with the resident neurosurgeon (P = 0.017) and attending neurosurgeon (P = 0.005), but no difference when using AR. FH screw placement was faster by both the attending neurosurgeon (median 46 seconds vs. 94.5 seconds, P = 0.0047) and the neurosurgery resident neurosurgeon (median 144 seconds vs. 140 seconds, P = 0.05). Total clinically acceptable AR and FH accuracy was 90.6% (29/32) and 87.5% (28/32), respectively (P = 0.69). CONCLUSIONS: AR screw placement allowed an inexperienced medical student to double their accuracy in 1 training session. With subsequent iterations, this promising technology could serve as an important tool for surgical training.

Large Language Model-Based Neurosurgical Evaluation Matrix: A Novel Scoring Criteria to Assess the Efficacy of ChatGPT as an Educational Tool for Neurosurgery Board Preparation.

INTRODUCTION: Technological advancements are reshaping medical education, with digital tools becoming essential in all levels of training. Amidst this transformation, the study explores the potential of ChatGPT, an artificial intelligence model by OpenAI, in enhancing neurosurgical board education. The focus extends beyond technology adoption to its effective utilization, with ChatGPT's proficiency evaluated against practice questions from the Primary Neurosurgery Written Board Exam. METHODS: Using the Congress of Neurologic Surgeons (CNS) Self-Assessment Neurosurgery (SANS) Exam Board Review Prep questions, we conducted 3 rounds of analysis with ChatGPT. We developed a novel ChatGPT Neurosurgical Evaluation Matrix (CNEM) to assess the output quality, accuracy, concordance, and clarity of ChatGPT's answers. RESULTS: ChatGPT achieved spot-on accuracy for 66.7% of prompted questions, 59.4% of unprompted questions, and 63.9% of unprompted questions with a leading phrase. Stratified by topic, accuracy ranged from 50.0% (Vascular) to 78.8% (Neuropathology). In comparison to SANS explanations, ChatGPT output was considered better in 19.1% of questions, equal in 51.6%, and worse in 29.3%. Concordance analysis showed that 95.5% of unprompted ChatGPT outputs and 97.4% of unprompted outputs with a leading phrase were aligned. CONCLUSIONS: Our study evaluated the performance of ChatGPT in neurosurgical board education by assessing its accuracy, clarity, and concordance. The findings highlight the potential and challenges of integrating AI technologies like ChatGPT into medical and neurosurgical board education. Further research is needed to refine these tools and optimize their performance for enhanced medical education and patient care.

Defining the minimal clinically important difference in smartphone-based mobility after spine surgery: correlation of survey questionnaire to mobility data.

OBJECTIVE: Patient-reported outcome measures (PROMs) are the gold standard for assessing postoperative outcomes in spine surgery. However, PROMs are also limited by the inherent subjectivity of self-reported qualitative data. Recent literature has highlighted the utility of patient mobility data streamed from smartphone accelerometers as an objective measure of functional outcomes and complement to traditional PROMs. Still, for activity-based data to supplement existing PROMs, they must be validated against current metrics. In this study, the authors assessed the relationships and concordance between longitudinal smartphone-based mobility data and PROMs. METHODS: Patients receiving laminectomy (n = 21) or fusion (n = 10) between 2017 and 2022 were retrospectively included. Activity data (steps-per-day count) recorded in the Apple Health mobile application over a 2-year perioperative window were extracted and subsequently normalized to allow for intersubject comparison. PROMS, including the visual analog scale (VAS), Patient Reported Outcome Measurement Information System Pain Interference (PROMIS-PI), Oswestry Disability Index (ODI), and EQ-5D, collected at the preoperative and 6-week postoperative visits were retrospectively extracted from the electronic medical record. Correlations between PROMs and patient mobility were assessed and compared between patients who did and those who did not achieve the established minimal clinically important difference (MCID) for each measure. RESULTS: A total of 31 patients receiving laminectomy (n = 21) or fusion (n = 10) were included. Change between preoperative and 6-week postoperative VAS and PROMIS-PI scores demonstrated moderate (r = -0.46) and strong (r = -0.74) inverse correlations, respectively, with changes in normalized steps-per-day count. In cohorts of patients who achieved PROMIS-PI MCID postoperatively, indicating subjective improvement in pain, there was a 0.784 standard deviation increase in normalized steps per day, representing a 56.5% improvement (p = 0.027). Patients who did achieve the MCID of improvement in either PROMIS-PI or VAS after surgery were more likely to experience an earlier sustained improvement in physical activity commensurate to or greater than their preoperative baseline (p = 2.98 × 10-18) than non-MCID patients. CONCLUSIONS: This study demonstrates a strong correlation between changes in mobility data extracted from patient smartphones and changes in PROMs following spine surgery. Further elucidating this relationship will allow for more robust supplementation of existing spine outcome measure tools with analyzed objective activity data.

Characterizing and Improving Nomenclature for Reporting Lumbar Interbody Fusion Techniques.

OBJECTIVE: Lumbar interbody fusion (LIF) techniques have seen impressive innovation in recent years, leading to an expansion of the LIF lexicon. This study systematically analyzes LIF nomenclature in contemporary literature and proposes a standardized classification system for reporting LIF terminology. METHODS: A search query was conducted through the PubMed database using "lumbar fusion OR lumbar interbody fusion." A total of 1455 articles were identified, and 605 references to LIF were recorded. Following a systematic review of the terminology, we developed a LIF reporting guidelines that capture the existing LIF nomenclature while avoiding redundant or ambiguous terminology. RESULTS: The most referenced anatomical approaches were transforaminal (43.0%), followed by posterior (25.0%), lateral (19.7%), and anterior (10.9%). Overall, there were 72 unique ways to describe LIF. Unique prefixes were recorded by approach (posterior: 26; lateral: 13; anterior: 3). Forty unique prefixes/suffixes overlapped in their usage. "MI" (14.4%), "MIS" (38.1%), and "MISS" (0.6%) all referenced a minimally invasive approach. "O" (12.5%), "CO" (1.3%), and "TO" (1.3%) all described open techniques. "Endo" (0.6%), "Endoscopic-assisted" (1.3%), and "PE" (1.9%) all referenced endoscopic-assisted procedures. CONCLUSIONS: The current LIF nomenclature contains many unique LIF terms that were found to be inconsistently defined, redundant, or ambiguous. We propose the standardization of a 4-part naming system which highlights the crucial parts of LIF: (1) intraoperative repositioning, (2) patient position, (3) anatomical approach, and (4) orientation of the surgical corridor to the psoas muscles.

Standardizing Lumbar Interbody Fusion Nomenclature.

STUDY DESIGN: This article is a research methodology study. OBJECTIVE: We summarize current ambiguities and inaccuracies regarding lumbar interbody fusion nomenclature and propose a standardized reporting method to improve the clarity of future research and communication among spine surgeons and researchers. SUMMARY OF BACKGROUND DATA: Lumbar interbody fusion techniques have seen an impressive degree of refinement over recent years. This innovation has ushered in a plethora of naming conventions for these new surgical approaches. Many of the current trends in naming lumbar fusion techniques are, however, redundant and contradictory, creating unnecessary confusion in the field. METHODS: Following an extensive literature review, we developed a 4-part naming convention that highlights the crucial features of lumbar fusion surgical procedures. RESULTS: Current literature regarding lumbar fusions is rife with inconsistent usage and privatization of terminology that can inadvertently result in ambiguous operative vocabulary, potentially compromising the accuracy of future research. We propose a 4-part naming system that highlights crucial features of lumbar interbody fusions, including (1) intra-operative repositioning, (2) patient position, (3) surgical technique, and (4) orientation of the surgical corridor to the psoas muscle. CONCLUSIONS: This study raises awareness of current inconsistencies in naming conventions and proposes a standardized system for improving the clarity of lumber interbody fusion terminology for the broader spine community. LEVEL OF EVIDENCE: Level V.

Virtual and Augmented Reality in Spine Surgery: A Systematic Review.

BACKGROUND: Augmented reality (AR) and virtual reality (VR) implementation in spinal surgery has expanded rapidly over the past decade. This systematic review summarizes the use of AR/VR technology in surgical education, preoperative planning, and intraoperative guidance. METHODS: A search query for AR/VR technology in spine surgery was conducted through PubMed, Embase, and Scopus. After exclusions, 48 studies were included. Included studies were then grouped into relevant subsections. Categorization into subsections yielded 12 surgical training studies, 5 preoperative planning, 24 intraoperative usage, and 10 radiation exposure. RESULTS: VR-assisted training significantly reduced penetration rates or increased accuracy rates compared to lecture-based groups in 5 studies. Preoperative VR planning significantly influenced surgical recommendations and reduced radiation exposure, operating time, and estimated blood loss. For 3 patient studies, AR-assisted pedicle screw placement accuracy ranged from 95.77% to 100% using the Gertzbein grading scale. Head-mounted display was the most common interface used intraoperatively followed by AR microscope and projector. AR/VR also had applications in tumor resection, vertebroplasty, bone biopsy, and rod bending. Four studies reported significantly reduced radiation exposure in AR group compared to fluoroscopy group. CONCLUSIONS: AR/VR technologies have the potential to usher in a paradigm shift in spine surgery. However, the current evidence indicates there is still a need for 1) defined quality and technical requirements for AR/VR devices, 2) more intraoperative studies that explore usage outside of pedicle screw placement, and 3) technological advancements to overcome registration errors via the development of an automatic registration method.

Simultaneous Anterior Posterior Approach for Single-Position Lateral Lumbar Interbody Fusion with Robotic Assistance: Technical Guidelines and Early Outcomes.

BACKGROUND: Lumbar lateral interbody fusion (LLIF) is traditionally performed in 2 stages: placing the interbody cage in the lateral decubitus position, then placing the percutaneous pedicle screw in the prone position. Performing interbody fusion and posterior fixation simultaneously could improve operative efficiency and clinical outcomes associated with longer operative times. We describe the operative steps and report clinical and radiographic outcomes associated with a simultaneous anterior and posterior approach (SAPA) for LLIF. METHODS: Patients who underwent SAPA LLIF performed by a single surgeon over 1 year were retrospectively reviewed. Demographic, clinical, and radiographic data were analyzed, an operative guideline was created, and a learning curve was constructed using operative times. RESULTS: SAPA LLIF was performed in 11 patients. Three patients experienced transient postoperative femoral nerve plexopathy with symptoms of ipsilateral hip flexion weakness and/or anterior thigh numbness; there were no other complications in the cohort. Radiographically, patients achieved significant increases in disc height (8.3 mm vs. 13.5 mm, P = 0.002) and foraminal height (20.2 mm vs. 25.3 mm, P = 0.0001). Patients showed significant improvements in Oswestry Disability Index (52 vs. 27.8, P = 0.002) and Patient-Reported Outcome Measurement Information System Physical Function (32.6 vs. 39, P = 0.048) and Pain Interference (64.9 vs. 59.6, P = 0.001) at 3 months. A downward trend in operative time was observed for 1-level SAPA LLIF. CONCLUSIONS: SAPA LLIF is a safe approach for LLIF that results in favorable clinical outcomes. This technique can potentially improve operative efficiency further along the course of a surgeon's learning curve.

Minimally Invasive Deformity Correction Technique: Initial Case Series of Anterior Lumbar Interbody Fusion at L5-S1 for Multilevel Lumbar Interbody Fusion in a Lateral Decubitus Position.

OBJECTIVE: Many surgical options exist for multilevel lumbar interbody fusion, including anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF). While current technique of repositioning patients between supine ALIF and lateral decubitus LLIF offers many benefits, intraoperative repositioning can be cumbersome. We present a novel approach that accomplishes both multilevel LLIF and L5-S1 ALIF in a lateral decubitus position. METHODS: This case series retrospectively enrolled 12 consecutive patients who underwent L5-S1 ALIF in the lateral decubitus position and anterior-to-psoas LLIF at more cranial levels as part of a multilevel lumbar interbody fusion surgery between September 2020 and December 2021. All surgeries were performed by a single spine-focused neurosurgeon at an urban academic hospital. RESULTS: Radiographic imaging analysis demonstrated significant changes in coronal Cobb angle (-5.43° ± 3.81°; P = 0.0029), global lumbar lordosis (6.77° ± 12.04°; P = 0.0049), segmental lumbar lordosis (8.91° ± 10.21°; P = 0.0005), spinopelvic mismatch (-7.93° ± 7.91°; P = 0.0010), average disc height (5.30 ± 1.64 mm; P = 0.0005), and L5-S1 disc height (6.68 ± 2.10 mm; P = 0.0005). Two patients developed postoperative complications including wound dehiscence and grade I graft subsidence at L4-L5. CONCLUSIONS: This case series demonstrated that a combined lateral decubitus L5-S1 ALIF and LLIF at more cranial levels is a safe, efficient approach to multilevel lumbar interbody fusions. This technique significantly restored spinopelvic alignments with a low complication rate and no patient repositioning. Efficacy of this minimally invasive deformity correction technique should be further investigated through a multicenter trial.