Spine. 2026;51(21):1524–1532
Augmented reality navigation was associated with fewer substantial pedicle breaches during open lumbosacral instrumentation. This comparison supports its value as an aid to trajectory control, although improved imaging accuracy has yet to translate into demonstrated patient benefit. For surgeons considering adoption, the distinction between technical precision and clinical effectiveness remains central.
Study and key findings
This retrospective single-center study included 202 adults undergoing L1–S1 instrumentation between 2016 and 2024. Ninety-nine patients received augmented reality guidance and 103 underwent freehand placement, accounting for 548 and 561 screws, respectively. Independent reviewers assessed multiplanar imaging using the Gertzbein–Robbins scale, and statistical modeling accounted for screws clustered within patients.
Clinically acceptable placement, defined as grades A or B, occurred in 99.3% of augmented reality screws and 96.4% of freehand screws (P = 0.013). Grades C–E occurred in four versus 20 screws. Completely contained screws represented 90.9% versus 84.1%. Neither group experienced reported screw-related adverse events or revision surgery.
The augmented reality workflow used a spinous-process reference clamp, intraoperative three-dimensional imaging, and a head-mounted display to guide entry-point selection, pedicle access, tapping, and insertion. Freehand placement relied on anatomical landmarks and preoperative imaging, without intraoperative navigation or fluoroscopy.
Interpretation and limitations
The association is encouraging, but allocation was nonrandomized and augmented reality cases were performed later. Differences in surgeons, upper instrumented levels, and imaging availability could influence the comparison. Results from one platform and open approaches cannot automatically be extended to minimally invasive procedures or other systems.
The study primarily establishes radiographic accuracy. It does not demonstrate reduced neurological injury, lower costs, or durable clinical benefit. An internal discrepancy between the narrative and Table 4 also limits interpretation of the freehand breach-direction breakdown.
Clinical takeaway
Augmented reality offers a practical method of maintaining trajectory information within the operative field during manual instrumentation. Its adoption should be judged against local accuracy and clinical outcomes. The authors’ proposed influence of soft-tissue pressure on trajectory deviation remains a technical hypothesis requiring further validation.
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