Spine surgery has long come with a basic tradeoff: To see more anatomy, surgeons often have to expose more of it. Bayan Aghdasi, MD, believes augmented reality is beginning to break that relationship.
After using AR guidance in nearly 200 spine cases, the orthopedic spine surgeon at DISC Surgery Center at Carlsbad (Calif.) said its most meaningful advantage is not simply greater accuracy. It is the ability to see anatomy beneath the surface without creating the exposure traditionally required to visualize it.
Three-dimensional guidance can show the surgeon bony anatomy that cannot be seen directly, allowing instrumentation to be placed through small working portals rather than a larger open incision.
“You can literally see every millimeter of the bone, even the parts you couldn’t see with the naked eye,” Dr. Aghdasi told Becker’s. “It allows for not only more accuracy, but less invasiveness.”
That distinction matters as spine surgery pushes further toward minimally invasive and outpatient care.
The promise of AR is not merely that it helps surgeons do the same operation with another piece of technology. It may allow them to perform sophisticated procedures with less disruption because they no longer have to expose anatomy simply to understand where it is.
Seeing more without exposing more
Experienced spine surgeons were placing pedicle screws accurately long before augmented reality.
Dr. Aghdasi does not argue otherwise. What technology changes, he said, is how much information a surgeon has while doing it, and how much mental work is required to reconstruct anatomy that cannot be seen.
Traditional spine surgery can demand substantial spatial reasoning and anatomical judgment, particularly in complex cases. A screw may appear appropriate from the exposed operative field while a three-dimensional view reveals something the surgeon could not otherwise see.
“The truth is, you just don’t know what you don’t know,” Dr. Aghdasi said.
AR gives the surgeon another layer of information. That can improve confidence in screw trajectories and instrumentation while also reducing the need to create a larger exposure for visualization.
For Dr. Aghdasi, those two benefits are inseparable. Greater precision makes smaller approaches more feasible. Smaller approaches make that precision more valuable.
Nearly 200 cases changed how he thinks about the technology
Experience also taught Dr. Aghdasi something that is less obvious from specifications or demonstrations: AR works best when it complements, rather than replaces, the surgeon’s existing senses.
A surgeon feels changes in resistance as a drill moves through cortical and cancellous bone. Years in the operating room build an understanding of what different structures should feel like through an instrument. AR adds the visual layer.
“The key learning is the integration of tactile feedback from the skill set of being a surgeon with seeing the bony surfaces and anatomy through augmented reality,” he said.
The result is not technology making the decision for the surgeon. It is the surgeon combining two streams of information that were previously harder to access simultaneously: what the hand feels and what the anatomy looks like beneath the skin.
That distinction is increasingly important as robotics, navigation and AI move deeper into the operating room.
The technology does not diminish the importance of experience. It gives experience more information to work with.
There is another person AR may protect: the surgeon
Much of the discussion around surgical technology focuses appropriately on the patient.
Dr. Aghdasi believes the health of the operating room team deserves more attention. Traditional fluoroscopy can expose surgeons, nurses and technologists repeatedly to radiation over the course of thousands of procedures.
The patient experiences one operation. The surgical team returns to the OR again and again.
“There’s kind of a taboo on doctors who prioritize their own health or the health of the team,” Dr. Aghdasi said. Navigation has allowed him to substantially reduce his reliance on traditional intraoperative fluoroscopy. He said he has not needed to use it in several years because of the navigation capabilities available in his practice.
For him, that changes how the value of the technology should be calculated. Accuracy matters. So does the cumulative occupational exposure avoided across an entire surgical career.
“Patients first, but people always have to be at the forefront of our value system,” he said.
The ASC economics are beginning to change
Cost remains one of the biggest constraints on advanced surgical technology. That becomes particularly important in ASCs, where expensive imaging equipment, limited physical space and lower facility reimbursement can make hospital-style infrastructure difficult to justify.
Dr. Aghdasi sees newer navigation workflows beginning to alter that equation. Instead of acquiring a new three-dimensional image in the operating room, a surgeon can use a CT scan obtained before surgery and register that scan to the patient with limited intraoperative imaging.
The surgical plan can then be brought into the OR without requiring a large three-dimensional scanner on site. For an ASC, that matters.
“You can just bring in the augmented reality system, merge it with the pre-op CT, and you’re ready to go,” Dr. Aghdasi said. He believes that approach could reduce radiation exposure while lowering some of the infrastructure costs associated with advanced navigation.
That could become increasingly consequential as more spine procedures move outpatient. Technology that works clinically but requires the capital footprint of a major hospital may have limited reach. Technology that can travel into a smaller operating environment changes the equation.
The bar for accuracy is getting higher
A decade ago, Dr. Aghdasi said surgeons were still debating whether navigation and robotics offered enough functional benefit to justify their cost and complexity.
He believes that debate has shifted. Younger surgeons are training around more sophisticated navigation. Patients have greater expectations. And tolerance for complications related to instrumentation is increasingly low.
Dr. Aghdasi sees navigation approaching the point where it may become expected rather than exceptional, although he acknowledged that cost remains a significant barrier to widespread adoption.
That does not mean every new platform should become standard. It does mean the benchmark is changing.
The relevant comparison is becoming less about whether an experienced surgeon can place instrumentation accurately without navigation. It is whether a technology can make that accuracy more consistent, less cognitively demanding and achievable through a less invasive operation.
The incision may no longer tell the whole story
Minimally invasive spine surgery is often reduced to incision size. Dr. Aghdasi’s experience suggests a more useful measure. The real objective is to preserve the information and control of a larger operation while reducing the amount of healthy tissue that must be disrupted to accomplish it.
Augmented reality is compelling because it attacks one of the reasons larger exposures were necessary in the first place. Surgeons needed to see.
It does not remove the surgeon from the equation. The hand still feels the bone. The surgeon still interprets what the imaging shows. Experience still determines what to do with that information.
But nearly 200 cases in, Dr. Aghdasi believes the relationship between seeing and opening is changing.
For generations, surgeons exposed anatomy in part because visualization required it. The next phase of minimally invasive spine surgery may be defined by how much of that anatomy they can see without ever having to expose it.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
