Introduction
Over the past five years, augmented reality (AR) has evolved from a laboratory curiosity into a surgical ally capable of guiding pedicle screw placement with an error margin of less than 2 mm and reducing X-ray radiation exposure.1. What Do We Mean by Medical AR?
Unlike virtual reality —which immerses the user in a fully digital environment— augmented reality (AR) overlays holograms onto the surgical field in real time while preserving direct view of the patient.
Main hardware
- Head-mounted displays (xvision®, HoloLens 2, Apple Vision Pro).
- RGB-D cameras and inertial sensors for spatial mapping.
- Preoperative planning station with CT/MRI.
2. Step-by-Step AR Navigation Workflow
- 3D segmentation of vertebral anatomy.
- Automatic registration without markers, using neural networks to align imaging with the patient’s body.
- Holographic projection of optimal screw trajectories and anatomical landmarks.
- Intraoperative feedback with continuous instrument tracking updates.
3. Recent clinical evidence (2024–2025)
| Study/Event | Design | Outcomes |
|---|---|---|
| Cureus narrative review (Jun 2025) | 58 articles | Mean accuracy 1.4 mm; radiation −37 %; learning curve: 15 cases |
| Augmedics: 10,000 surgeries | Multicenter registry | 97.5 % optimal screws (Gertzbein-Robbins A/B) |
| UCI Health: first AR-assisted endoscopic fusion (Jun 2025) | Prospective series | 42 % reduction in fluoroscopy time |
| Henry Ford Hospital (Aug 2024) | Complex case | No revisions at 6 months |
| Apple Vision Pro in laparoscopy (Oct 2024) | Off-label use | Proven feasibility and lower cost than dedicated platforms |
4. Tangible benefits
- Increased precision: angular error < 2° and linear error < 2 mm.
- Reduced radiation: up to 60 % less exposure for surgeon and patient.
- Smaller incisions: the heads-up approach enables percutaneous access.
- Lower cognitive load: the surgeon keeps focus on the surgical site.
- Immersive training: residents see the procedure exactly as the expert does.
5. Current limitations
| Challenge | Implication |
|---|---|
| High initial hardware cost (€150,000–230,000) | Significant investment for low-volume centers |
| Ocular fatigue/ergonomics | Sessions > 3 h may require scheduled breaks |
| Learning curve | About 10–20 procedures to match the speed of conventional optical navigation |
| Regulatory approval | Only some systems have CE and/or FDA clearance (xvision®; others pending) |
6. Near future (2025–2030)
- AI integration for automatic planning and real-time adaptation to deformed anatomy.
- Fusion with intraoperative ultrasound for radiation-free navigation.
- Holographic tele-mentoring, enabling remote expert guidance.
- Consumer headsets (Vision Pro 2) with integrated medical sensors, lowering costs.
Conclusion
Augmented reality is emerging as the fourth major technological revolution in spinal surgery, following neuronavigation, robotics, and 3D printing. Early adoption can lead to safer, more precise procedures and faster recoveries.
Abbreviated references
- Nadeem-Tariq A. et al. Augmented Reality in Spine Surgery (Cureus, June 26, 2025). cureus.com
- Augmedics. 10,000th xvision® Surgery (press release, April 22, 2025). augmedics.com
- UCI Health. First AR-assisted Endoscopic Fusion (June 6, 2025). ucihealth.org
- Ivanov V. et al. Surgical Navigation Systems Based on AR (arXiv 2106.00727). arxiv.org
- Liebmann F. et al. Marker-less Navigation for Spine Surgery (arXiv 2308.02917). arxiv.org
- OrthoIndy Blog. AR is Making Spine Surgery Safer (May 7, 2025). blog.orthoindy.com
- Time Magazine. Apple Vision Pro in ORs (Nov 2024). time.com
