Category: Virtual Reality

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Transforming Neurosurgery With Spatial Computing: Enhancing Intraoperative Visualization and Precision Through Augmented Reality

Operative Neurosurgery 30:760–764, 2026

This technical note reports three neurosurgical cases using the Medivis surgical augmented reality platform with the Microsoft HoloLens 2 to overlay real-time 3D imaging, exoscopic, and endoscopic outputs intraoperatively. The workflow, registration method, hardware and software integration, and case-specific operative details are described, with all patients recovering without complications.

The report evaluates benefits and limitations of wearable XR in the operating room, highlighting improved visualization, surgical precision, and ergonomics, while addressing challenges such as registration accuracy, latency, cognitive overload, and avenues for future hardware and software improvements.

Goal Integrate wearable XR/AR and spatial computing into neurosurgical operating rooms to enhance intraoperative visualization, precision, and ergonomics.

System setup Three neurosurgical cases used the Medivis SurgicalAR platform paired with a Microsoft HoloLens 2 worn by the primary surgeon, enabling overlay of 3D volumes and intraoperative video in the surgeon’s field of view.

Imaging workflow Preoperative CT/MRI (including tractography/connectomic imaging when available) were uploaded from PACS, processed quickly (windowing/coloring/cropping/brightening), and stored for OR use, then linked to the HoloLens.

Registration approach Intraoperative holographic point-matching registration matched physical landmarks on the patient to virtual fiducials via an optical localizer recognized by HoloLens 2, with an FDA-approved navigation system also used in all cases for confirmation.

Video integration Exoscopic/endoscopic outputs were captured and streamed to the AR computer and transmitted to the HoloLens for real-time manipulation and interaction by the surgeon.

Observed benefits Combined overlays improved visualization and supported ergonomic operating posture, optimized sight lines, and reduced OR footprint while maintaining standard team visualization via the exoscope monitor.

Case outcomes All three patients recovered well postoperatively without complications; no critical intraoperative issues from latency/dropped frames prevented procedure completion.

Limitations & next steps Key challenges include potential cognitive overload/inattentional blindness, hologram registration accuracy, and technical issues like latency/dropped frames; future work targets improved/universal registration and broader overlayable data streams (e.g., conferencing, checklists).

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Disruptive technologies in spine surgery: current trends, outcomes, and ethical implications

J Neurosurg Spine 44:756–768, 2026

Disruptive technologies in spine surgery—AR/VR, robotics, neuronavigation, endoscopy, and patient-specific implants—are examined for their roles in enhancing precision, training, and patient outcomes. The review summarizes evidence for preoperative simulation, AR-assisted planning, and 3D segmentation, highlighting improvements in accuracy, reduced fluoroscopy, and trainee confidence.

Intraoperative advances such as robot-assisted techniques, computer-assisted navigation, and endoscopic approaches offer minimally invasive alternatives with favorable recovery profiles but face challenges of cost, learning curves, and equitable access. The authors emphasize ethical considerations, need for standardized outcomes, and strategies to expand accessibility and training.

Scope Disruptive spine-surgery technologies emphasized include AR/VR (XR), advanced navigation, robotics, patient-specific implants/3D printing, and endoscopic spine surgery.

XR definitions VR provides a fully immersive digital environment, AR overlays digital content onto the real world, and MR blends both; all fall under XR.

Training impact VR simulation in spine training improved trainee comfort and autonomy and reduced fluoroscopy use in lateral lumbar interbody fusion simulations; VR-trained learners also made fewer pedicle-screw placement errors than traditional instruction.

Preop planning VR-based planning can reduce fluoroscopy/localization time and improve puncture accuracy in endoscopic lumbar discectomy; segmented 3D models support rehearsal, trajectory planning, and risk assessment around critical structures.

AR navigation outcomes Wearable AR navigation (e.g., FDA-cleared xvision) has shown high pedicle-screw placement accuracy (reported ~96.7% thoracic and ~99.1% lumbosacral) and may reduce operative time and radiation exposure.

Patient-specific surgery Segmentation + 3D printing/predictive modeling enable personalized approaches and implants (e.g., patient-specific rods, templates, custom cages), with early reports of high accuracy for template-guided instrumentation and promising feasibility for custom interbody devices.

Endoscopic techniques ESS supports minimally invasive treatment across multiple pathologies and can match conventional outcomes for lumbar disc herniation while improving recovery (e.g., shorter stays/earlier return to work), but broader adoption is constrained by learning curve and reimbursement challenges.

Implementation ethics/costs High acquisition/maintenance costs and limited reimbursement risk widening access disparities; recommended mitigations include subsidized training, shared equipment models, and reimbursement policies to support equitable implementation alongside standardized outcomes and training.

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Optimizing Surgical Efficiency in Complex Spine Surgery Using Virtual Reality as a Communication Technology to Promote a Shared Mental Model

Operative Neurosurgery 26:213–221, 2024

Virtual reality (VR) is an emerging technology that can be used to promote a shared mental model among a surgical team. We present a case series demonstrating the use of 3-dimensional (3D) VR models to visually communicate procedural steps to a surgical team to promote a common operating objective. We also review the literature on existing uses of VR for preoperative communication and planning in spine surgery.

METHODS: Narrations of 3 to 4-minute walkthroughs were created in a VR visualization platform, converted, and distributed to team members through text and email the night before surgical intervention. A VR huddle was held immediately before the intervention to refine surgical goals. After the intervention, the participating team members’ perceptions on the value of the tool were assessed using a survey that used a 5-point Likert scale. MEDLINE, Google Scholar, and Dimensions AI databases were queried from July 2010 to October 2022 to examine existing literature on preoperative VR use to plan spine surgery.

RESULTS: Three illustrative cases are presented with accompanying video. Postoperative survey results demonstrate a positive experience among surgical team members after reviewing preoperative plans created with patient-specific 3D VR models. Respondents felt that preoperative VR video review was “moderately useful” or more useful in improving their understanding of the operational sequence (71%, 5/7), in enhancing their ability to understand their role (86%, 6/7), and in improving the safety or efficiency of the case (86%, 6/7).

CONCLUSION: We present a proof of concept of a novel preoperative communication tool used to create a shared mental model of a common operating objective for surgical team members using narrated 3D VR models. Initial survey results demonstrate positive feedback among respondents. There is a paucity of literature investigating VR technology as a means for preoperative surgical communication in spine surgery.

ETHICS: Institutional review board approval (IRB-300009785) was obtained before this study.

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Preoperative Microsoft HoloLens 2 planning‑assisted surgical clipping of a fetal posterior cerebral artery aneurysm

Acta Neurochirurgica (2023) 165:3371–3374

The treatment of intracranial aneurysms has predominantly shifted towards endovascular strategies, but complex cases still necessitate microsurgery. Preoperative stimulation can be beneficial for inexperienced young neurosurgeons in preparing for safe microsurgery.

Method A 72-year-old female with a left irregular fetal posterior cerebral artery (PCA) aneurysm underwent clipping repair. Microsoft HoloLens 2, utilizing mixed reality technology, was employed for preoperative stimulation and anatomical study. During the operation, we successfully identified the planned relationship between the aneurysm and the fetal PCA. The patient was cured without any complications.

Conclusion We hope that this report will highlight the significance of Microsoft HoloLens 2 in microsurgical planning and education.

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Three-Dimensional Modeling and Augmented Reality and Virtual Reality Simulation of Fiber Dissection of the Cerebellum and Brainstem

Surgeons must understand the complex anatomy of the cerebellum and brainstem and their 3-dimensional (3D) relationships with each other for surgery to be successful. To the best of our knowledge, there have been no fiber dissection studies combined with 3D models, augmented reality (AR), and virtual reality (VR) of the structure of the cerebellum and brainstem. In this study, we created freely accessible AR and VR simulations and 3D models of the cerebellum and brainstem.

OBJECTIVE: To create 3D models and AR and VR simulations of cadaveric dissections of the human cerebellum and brainstem and to examine the 3D relationships of these structures.

METHODS: Ten cadaveric cerebellum and brainstem specimens were prepared in accordance with the Klingler’s method. The cerebellum and brainstem were dissected under the operating microscope, and 2-dimensional and 3D images were captured at every stage. With a photogrammetry tool (Qlone, EyeCue Vision Technologies, Ltd.), AR and VR simulations and 3D models were created by combining several 2-dimensional pictures.

RESULTS: For the first time reported in the literature, high-resolution, easily accessible, free 3D models and AR and VR simulations of cerebellum and brainstem dissections were created.

CONCLUSION: Fiber dissection of the cerebellum-brainstem complex and 3D models with AR and VR simulations are a useful addition to the goal of training neurosurgeons worldwide.

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Virtual Reality Glasses and “Eye-Hands Blind Technique” for Microsurgical Training in Neurosurgery

World Neurosurg. (2018) 112:126-130

Microsurgical skills and eye-hand coordination need continuous training to be developed and refined. However, well-equipped microsurgical laboratories are not so widespread as their setup is expensive. Herein, we present a novel microsurgical training system that requires a high-resolution personal computer screen, smartphones, and virtual reality glasses.

METHODS: A smartphone placed on a holder at a height of about 15e20 cm from the surgical target field is used as the webcam of the computer. A specific software is used to duplicate the video camera image. The video may be transferred from the computer to another smartphone, which may be connected to virtual reality glasses. –

RESULTS: Using the previously described training model, we progressively performed more and more complex microsurgical exercises. It did not take long to set up our system, thus saving time for the training sessions.

CONCLUSION: Our proposed training model may represent an affordable and efficient system to improve eyehand coordination and dexterity in using not only the operating microscope but also endoscopes and exoscopes

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Assessing Bimanual Performance in Brain Tumor Resection With NeuroTouch, a Virtual Reality Simulator

Assessing Bimanual Performance in Brain Tumor Resection With NeuroTouch, a Virtual Reality Simulator

Operative Neurosurgery 11:89–98, 2015

Validated procedures to objectively measure neurosurgical bimanual psychomotor skills are unavailable. The NeuroTouch simulator provides metrics to determine bimanual performance, but validation is essential before implementation of this platform into neurosurgical training, assessment, and curriculum development.

OBJECTIVE: To develop, evaluate, and validate neurosurgical bimanual performance metrics for resection of simulated brain tumors with NeuroTouch.

METHODS: Bimanual resection of 8 simulated brain tumors with differing color, stiffness, and border complexity was evaluated. Metrics assessed included blood loss, tumor percentage resected, total simulated normal brain volume removed, total tip path lengths, maximum and sum of forces used by instruments, efficiency index, ultrasonic aspirator path length index, coordination index, and ultrasonic aspirator bimanual forces ratio. Six neurosurgeons and 12 residents (6 senior and 6 junior) were evaluated.

RESULTS: Increasing tumor complexity impaired resident bimanual performance significantly more than neurosurgeons. Operating on black vs glioma-colored tumors resulted in significantly higher blood loss and lower tumor percentage, whereas altering tactile cues from hard to soft decreased resident tumor resection. Regardless of tumor complexity, significant differences were found between neurosurgeons, senior residents, and junior residents in efficiency index and ultrasonic aspirator path length index. Ultrasonic aspirator bimanual force ratio outlined significant differences between senior and junior residents, whereas coordination index demonstrated significant differences between junior residents and neurosurgeons.

CONCLUSION: The NeuroTouch platform incorporating the simulated scenarios and metrics used differentiates novice from expert neurosurgical performance, demonstrating NeuroTouch face, content, and construct validity and the possibility of developing brain tumor resection proficiency performance benchmarks.

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Three-Dimensional Reconstruction of the Topographical Cerebral Surface Anatomy for Presurgical Planning With Free OsiriX Software

Three-Dimensional Reconstruction of the Topographical Cerebral Surface Anatomy for Presurgical Planning With Free OsiriX Software

Neurosurgery 10:426–435, 2014

During surgery for intrinsic brain lesions, it is important to distinguish the pathological gyrus from the surrounding normal sulci and gyri. This task is usually tedious because of the pia-arachnoid membranes with their arterial and venous complexes that obscure the underlying anatomy. Moreover, most tumors grow in the white matter without initially distorting the cortical anatomy, making their direct visualization more difficult.

OBJECTIVE: To create and evaluate a simple and free surgical planning tool to simulate the anatomy of the surgical field with and without vessels.

METHODS: We used free computer software (OsiriX Medical Imaging Software) that allowed us to create 3-dimensional reconstructions of the cerebral surface with and without cortical vessels. These reconstructions made use of magnetic resonance images from 51 patients with neocortical supratentorial lesions operated on over a period of 21 months (June 2011 to February 2013). The 3-dimensional (3-D) anatomic images were compared with the true surgical view to evaluate their accuracy. In all patients, the landmarks determined by 3-D reconstruction were cross-checked during surgery with high-resolution ultrasonography; in select cases, they were also checked with indocyanine green videoangiography.

RESULTS: The reconstructed neurovascular structures were confirmed intraoperatively in all patients. We found this technique to be extremely useful in achieving pure lesionectomy, as it defines tumor’s borders precisely.

CONCLUSION: A 3-D reconstruction of the cortical surface can be easily created with free OsiriX software. This technique helps the surgeon perfect the mentally created 3-D picture of the tumor location to carry out cleaner, safer surgeries.

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The use of simulation in neurosurgical education and training

Simulation in neurosurgical training

J Neurosurg 121:228–246, 2014

There is increasing evidence that simulation provides high-quality, time-effective training in an era of resident duty-hour restrictions. Simulation may also permit trainees to acquire key skills in a safe environment, important in a specialty such as neurosurgery, where technical error can result in devastating consequences. The authors systematically reviewed the application of simulation within neurosurgical training and explored the state of the art in simulation within this specialty. To their knowledge this is the first systematic review published on this topic to date.

Methods. The authors searched the Ovid MEDLINE, Embase, and PsycINFO databases and identified 4101 articles; 195 abstracts were screened by 2 authors for inclusion. The authors reviewed data on study population, study design and setting, outcome measures, key findings, and limitations.

Results. Twenty-eight articles formed the basis of this systematic review. Several different simulators are at the neurosurgeon’s disposal, including those for ventriculostomy, neuroendoscopic procedures, and spinal surgery, with evidence for improved performance in a range of procedures. Feedback from participants has generally been favorable. However, study quality was found to be poor overall, with many studies hampered by nonrandomized design, presenting normal rather than abnormal anatomy, lack of control groups and long-term follow-up, poor study reporting, lack of evidence of improved simulator performance translating into clinical benefit, and poor reliability and validity evidence. The mean Medical Education Research Study Quality Instrument score of included studies was 9.21 ± 1.95 (± SD) out of a possible score of 18.

Conclusions. The authors demonstrate qualitative and quantitative benefits of a range of neurosurgical simulators but find significant shortfalls in methodology and design. Future studies should seek to improve study design and reporting, and provide long-term follow-up data on simulated and ideally patient outcomes.

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Novel augmented reality–assisted percutaneous vertebroplasty

A novel 3D guidance system using augmented reality for percutaneous vertebroplasty

J Neurosurg Spine 19:492–501, 2013

Augmented reality (AR) is an imaging technology by which virtual objects are overlaid onto images of real objects captured in real time by a tracking camera. This study aimed to introduce a novel AR guidance system called virtual protractor with augmented reality (VIPAR) to visualize a needle trajectory in 3D space during percutaneous vertebroplasty (PVP). The AR system used for this study comprised a head-mount display (HMD) with a tracking camera and a marker sheet. An augmented scene was created by overlaying the preoperatively generated needle trajectory path onto a marker detected on the patient using AR software, thereby providing the surgeon with augmented views in real time through the HMD. The accuracy of the system was evaluated by using a computer-generated simulation model in a spine phantom and also evaluated clinically in 5 patients.

In the 40 spine phantom trials, the error of the insertion angle (EIA), defined as the difference between the attempted angle and the insertion angle, was evaluated using 3D CT scanning. Computed tomography analysis of the 40 spine phantom trials showed that the EIA in the axial plane significantly improved when VIPAR was used compared with when it was not used (0.96° ± 0.61° vs 4.34° ± 2.36°, respectively). The same held true for EIA in the sagittal plane (0.61° ± 0.70° vs 2.55° ± 1.93°, respectively). In the clinical evaluation of the AR system, 5 patients with osteoporotic vertebral fractures underwent VIPARguided PVP from October 2011 to May 2012. The postoperative EIA was evaluated using CT.

The clinical results of the 5 patients showed that the EIA in all 10 needle insertions was 2.09° ± 1.3° in the axial plane and 1.98° ± 1.8° in the sagittal plane. There was no pedicle breach or leakage of polymethylmethacrylate.

VIPAR was successfully used to assist in needle insertion during PVP by providing the surgeon with an ideal insertion point and needle trajectory through the HMD. The findings indicate that AR guidance technology can become a useful assistive device during spine surgeries requiring percutaneous procedures.

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Interactive presurgical simulation applying 3D techniques

Presurgical simulation 3Dimaging

J Neurosurg 119:94–105, 2013

In this paper, the authors’ goal was to report their novel presurgical simulation method applying interactive virtual simulation (IVS) using 3D computer graphics (CG) data and microscopic observation of color-printed plaster models based on these CG data in surgery for skull base and deep tumors.

Methods. For 25 operations in 23 patients with skull base or deep intracranial tumors (meningiomas, schwannomas, epidermoid tumors, chordomas, and others), the authors carried out presurgical simulation based on 3D CG data created by image analysis for radiological data. Interactive virtual simulation was performed by modifying the 3D CG data to imitate various surgical procedures, such as bone drilling, brain retraction, and tumor removal, with manipulation of a haptic device. The authors also produced color-printed plaster models of modified 3D CG data by a selective laser sintering method and observed them under the operative microscope.

Results. In all patients, IVS provided detailed and realistic surgical perspectives of sufficient quality, thereby allowing surgeons to determine an appropriate and feasible surgical approach. Surgeons agreed that in 44% of the 25 operations IVS showed high utility (as indicated by a rating of “prominent”) in comprehending 3D microsurgical anatomies for which reconstruction using only 2D images was complicated. Microscopic observation of color-printed plaster models in 12 patients provided further utility in confirming realistic surgical anatomies.

Conclusions. The authors’ presurgical simulation method applying advanced 3D imaging and modeling techniques provided a realistic environment for practicing microsurgical procedures virtually and enabled the authors to ascertain complex microsurgical anatomy, to determine the optimal surgical strategies, and also to efficiently educate neurosurgical trainees, especially during surgery for skull base and deep tumors.

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Advanced 3-Dimensional Planning in Neurosurgery

Virtual planning of different possible approaches for the surgical treatment of a giant carotid-ophthalmic aneurysm

Neurosurgery 72:A54–A62, 2013

During the past decades, medical applications of virtual reality technology have been developing rapidly, ranging from a research curiosity to a commercially and clinically important area of medical informatics and technology. With the aid of new technologies, the user is able to process large amounts of data sets to create accurate and almost realistic reconstructions of anatomic structures and related pathologies.

As a result, a 3-dimensional (3-D) representation is obtained, and surgeons can explore the brain for planning or training. Further improvement such as a feedback system increases the interaction between users and models by creating a virtual environment. Its use for advanced 3-D planning in neurosurgery is described. Different systems of medical image volume rendering have been used and analyzed for advanced 3-D planning: 1 is a commercial “ready-to-go” system (Dextroscope, Bracco, Volume Interaction, Singapore), whereas the others are open-source-based software (3-D Slicer, FSL, and FreesSurfer).

Different neurosurgeons at our institution experienced how advanced 3-D planning before surgery allowed them to facilitate and increase their understanding of the complex anatomic and pathological relationships of the lesion. They all agreed that the preoperative experience of virtually planning the approach was helpful during the operative procedure.

Virtual reality for advanced 3-D planning in neurosurgery has achieved considerable realism as a result of the available processing power of modern computers. Although it has been found useful to facilitate the understanding of complex anatomic relationships, further effort is needed to increase the quality of the interaction between the user and the model.

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