Augmented reality-assisted pedicle screw insertion: A cadaveric proof-of-concept study

Camilo A. Molina*, Nicholas Theodore, A. Karim Ahmed, Erick M. Westbroek, Yigal Mirovsky, Ran Harel, Emanuele Orru, Majid Khan, Timothy Witham, Daniel M. Sciubba

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

84 Scopus citations


OBJECTIVE: Augmented reality (AR) is a novel technology that has the potential to increase the technical feasibility, accuracy, and safety of conventional manual and robotic computer-navigated pedicle insertion methods. Visual data are directly projected to the operator's retina and overlaid onto the surgical field, thereby removing the requirement to shift attention to a remote display. The objective of this study was to assess the comparative accuracy of AR-assisted pedicle screw insertion in comparison to conventional pedicle screw insertion methods. METHODS: Five cadaveric male torsos were instrumented bilaterally from T6 to L5 for a total of 120 inserted pedicle screws. Postprocedural CT scans were obtained, and screw insertion accuracy was graded by 2 independent neuroradiologists using both the Gertzbein scale (GS) and a combination of that scale and the Heary classification, referred to in this paper as the Heary-Gertzbein scale (HGS). Non-inferiority analysis was performed, comparing the accuracy to freehand, manual computer-navigated, and robotics-assisted computer-navigated insertion accuracy rates reported in the literature. User experience analysis was conducted via a user experience questionnaire filled out by operators after the procedures. RESULTS: The overall screw placement accuracy achieved with the AR system was 96.7% based on the HGS and 94.6% based on the GS. Insertion accuracy was non-inferior to accuracy reported for manual computer-navigated pedicle insertion based on both the GS and the HGS scores. When compared to accuracy reported for robotics-assisted computer-navigated insertion, accuracy achieved with the AR system was found to be non-inferior when assessed with the GS, but superior when assessed with the HGS. Last, accuracy results achieved with the AR system were found to be superior to results obtained with freehand insertion based on both the HGS and the GS scores. Accuracy results were not found to be inferior in any comparison. User experience analysis yielded “excellent” usability classification. CONCLUSIONS: AR-assisted pedicle screw insertion is a technically feasible and accurate insertion method.

Original languageEnglish
Pages (from-to)139-146
Number of pages8
JournalJournal of Neurosurgery: Spine
Issue number1
StatePublished - 2019


FundersFunder number
Eli Lilly and Co.
Gordon and Marilyn Macklin Foundation


    • Augmented reality
    • Augmented reality-assisted surgery
    • Cadaveric trial
    • Computer-navigated surgery
    • Neuronavigation
    • Robotic spine surgery
    • Surgical technique


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