Augmented Reality Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: Safe and Effective Workflow with Intraoperative Video

Augmented Reality Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: Safe and Effective Workflow with Intraoperative Video | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Augmented Reality Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: Safe and Effective Workflow with Intraoperative Video Iyan Younus, Rafael Garcia de Oliveira, Patricia Lipson, Aiyush Bansal, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7698060/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose This article and accompanying video provide a comprehensive workflow for incorporating headset-mounted augmented reality (AR) navigation for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Methods Consecutive patients undergoing a single level MIS-TLIF with AR navigation for degenerative spondylolisthesis were analyzed between January 2023–2025. Demographic, intraoperative, and postoperative outcomes were collected. The AR workflow features a wireless headset with projection of intraoperative navigation in the surgical field. MIS pedicle screw placement, facetectomy, disc preparation, and contralateral arthrodesis are carried out percutaneously though single line of sight using navigated instruments. Result A total of 138 consecutive patients underwent AR-assisted spinal fusion at our institution and 22 cases of single-level MIS TLIF met inclusion criteria. Mean age was 62.3 ± 15 years, 59% were females, mean BMI was 29.4±5.7 kg/m 2 , and mean CCI score was 2.1±1.5. Analyzing the learning curve revealed similar mean operative time, length of stay, estimated blood loss, and fluoroscopy time between the first half and latter half of cases. The AR protocol was safely implemented in all cases with improvement in back and leg pain and no persistent neurologic deficits at mean 163 day follow up. Conclusion AR headset mounted navigation represents safe and efficient enabling technology to enhance workflow in MIS TLIF. Given the limited field of view in MIS TLIF, AR improves visualization of anatomic landmarks in a 3D environment, highlighting the position of anatomic structures that are outside of the direct field of view. minimally invasive augmented reality lumbar interbody fusion workflow Figures Figure 1 Figure 2 INTRODUCTION Augmented reality (AR) headset mounted spinal navigation has been increasingly utilized since federal drug administration (FDA) approval in December 2019.[ 1 , 2 ] The first case series were reported in 2021 with several studies documenting 97–98% range in pedicle screw accuracy in the thoracolumbar spine.[ 3 , 4 ] AR assisted navigation uses computer generated images displayed in the surgeon’s operative field of view to provide a safe, efficient, and accurate method of placing spinal instrumentation. In comparison to traditional intraoperative navigation technologies, headset mounted AR-assisted navigation eliminates the need to break line of site and minimizes attention shift.[ 5 ] Despite theoretical benefits which have been reported in the literature for pedicle screw placement, there remains a paucity of data on the workflow of AR assistance beyond pedicle screw placement. AR navigation may be especially useful in percutaneous and minimally invasive approaches for interbody fusion owing to the improved visualization of anatomic landmarks that are outside the direct field of view. Given the gap in the literature reporting on the efficacy and workflow of headset mounted AR navigation in minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), the objective of this study was to provide a comprehensive description of the workflow for incorporating headset-mounted AR navigation with the MIS TLIF procedure, supplemented with intraoperative images and video for clarity and reproducibility. METHODS Study Design Consecutive patients undergoing single level MIS-TLIF for degenerative spondylolisthesis with AR navigation were analyzed between January 2023–2025 by a single spine-fellowship trained surgeon. Patients were included if they had undergone prior decompression(s) at the level of the fusion procedure but were excluded if they had undergone prior adjacent level fusion procedures in the lumbar spine. Institutional Review Board (IRB) and patient consent to procedure were obtained. The participants and any identifiable individuals consented to publication of his/her image. Protected health information was removed, blurred, or cropped where applicable. Exposure Variables Baseline demographic variables included age, sex, body mass index (BMI), Charlson comorbidity index (CCI), level of operation, and presence of prior laminectomy defect at the operative level. Intraoperative variables collected included operative time from skin incision to skin closure, which included the time of percutaneous posterior superior iliac spine (PSIS) pin insertion, intraoperative O-arm spin, and registration of navigated instruments. Other intraoperative variables included fluoroscopy time based on the radiation documentation and estimated blood loss (EBL) based on the anesthesia record. Postoperative variables included hospital length of stay, disposition, follow up duration, and reoperation within 90 days. Statistical Analysis Descriptive statistics were performed with mean and standard deviation (SD) for continuous variables and frequency for categorical variables. Normally distributed data with equal variance were analyzed using a two-tailed t-test. For nominal data, χ2 or Fisher’s exact test was utilized in smaller samples. Univariate and analyses were performed. A p-value of < 0.05 was regarded as statistically significant. All analyses were conducted using SPSS version 22 (IBM Inc., Chicago, Illinois). Surgical Workflow The AR workflow features a wireless headset (Augmedics, Arlington Heights, IL) with projection of intraoperative navigation in the surgical field. MIS pedicle screw placement, facetectomy, disc preparation, and contralateral arthrodesis are carried out percutaneously though single line of sight using navigated instruments. The following navigated instruments are registered at the beginning of the case and utilized: high speed drill, tap, screw, and cage trials. Additionally, an electromyography (EMG) probe is used to ensure the exiting nerve root is not encountered prior to disc space preparation. The patient is placed prone on a Jackson table under general endotracheal anesthesia. Baseline somatosensory evoked and motor evoked potentials are obtained. A posterior superior iliac crest pin is percutaneously inserted. The navigation array is attached to this pin. A surface reference array is placed on the skin overlying the region of reference. The surgical site is covered with sterile drapes and a 3D O-arm intraoperative imaging system is used. Once the scan is verified and registration is completed, a navigated instrument is brought into the field and general landmark checks are performed to ensure accuracy. The paramedian/Wiltse based incisions are marked out using a navigated instrument ( Fig. 1 ) . A Wiltse incision on both sides is made connecting the marked pedicle screw entry points. The incisions are opened down to the fascia on both sides, then blunt dissection is performed down to the bony anatomy targeted towards the traditional pedicle screw entry points. Pedicle screws are placed in a similar fashion to what has previously been described in the literature using a navigated high speed burr, tap, and screw. A Kirschner (K)-wire is inserted in place of the screw on the ipsilateral caudal level to avoid obstruction of the working channel for the TLIF approach. Through the TLIF-side incision, a navigated Jamshidi needle and subsequent K-wire are inserted into the facet joint along a trajectory designed to maximize access to the disc space for thorough discectomy, endplate preparation, and eventual interbody placement. Traditional tubular dilators are inserted over this wire to dock a 22 millimeter solid tube overlying the facet joint. The tubular retractor is secured to an arm attached to the bed frame. A tubular-based camera (Viseon, Irvine, CA, USA) is then attached for visualization. Initial subperiosteal dissection is performed with monopolar cautery to identify the inferior articular process of the cranial level and the superior articular process of the caudal level. The facetectomy is planned using navigation to identify the upper endplate being the superior most extent, the inferior pedicle being the inferior most extent, and the junction between the laminal and the medial facet being the medial most extent ( Fig. 2 ) . We then use a navigated high speed burr to perform the partial (sometimes full) facetectomy avoiding any critical neural structures such as the exiting nerve root superiorly and the traversing nerve root with dural sac medially. A bone collector suction is utilized to obtain autograft from the facet joint that will be placed intradiscally for arthrodesis. Bony removal at the lateral border as well as a free floating piece of the amputated superior articular process can be completed with a Kerrison or pituitary rongeur. 5he exiting nerve root is identified and an electromyography (EMG) neuro monitoring probe is inserted into the channel to ensure no other neural structures are encountered in the working zone. A threshold > 5mA is used to ensure a safe corridor prior to discectomy. Next, hemostasis is performed with bipolar cautery and hemostatic agents to control any bleeding from the epidural venous plexus. The disc space is verified using the AR navigation. A nerve root retractor can be used to medially retract the traversing nerve root and thecal sac to provide additional access to the posterolateral annulus. A scalpel is used to incise the annulus to create a window into the disc space. A complete discectomy is performed using shavers, curettes, pituitary rongeurs, and subsequent trials. As with any TLIF, adequate discectomy and preservation of the cortical endplate surface is critical. The cage and disc space are filled with autograft and allograft. Our practice has shifted to using an expandable TLIF banana cage. The cage is inserted and should be placed as anteriorly and centrally as possible and can be confirmed with fluoroscopy. The final pedicle screw is inserted over the K-wire. We then decorticate the facet joints with the navigated high speed burr on the contralateral side and place any remaining autograft and allograft for posterolateral fusion. This is a crucial step and should not be overlooked. Once bilateral rods are inserted and set screws final tightened, final fluoroscopic images are obtained. RESULTS Baseline Characteristics A total of 138 consecutive patients underwent AR-assisted spinal fusion at our institution and of those, 22 cases of MIS TLIF performed at a single-level met inclusion criteria for this study. The mean age was 62.3 ± 15 years old, 59% were females, mean BMI was 29.4±5.7 kg/m 2 , and mean CCI score was 2.1±1.5 ( Table 1 ) . The operative level was L3-4 in 1 (4.5%), L4-5 in 15 (69%) and L5-S1 in 6 (27%). Prior laminectomy defects were present at the operative level in 3 (14%) patients. Table 1 Baseline demographics and perioperative characteristics Variable N (%) Mean age (years) 62.3 ± 14.9 Sex (female) 13 (59%) Mean BMI (kg/m 2 ) 29.4 ± 5.7 Mean Charlson comorbidity index 2.1 ± 1.5 Index level L3-4 L4-5 L5-S1 1 (4.5%) 15 (68%) 6 (27%) Prior surgery at index level 3 (14%) Intraoperative and Postoperative Outcomes The mean operative time from incision to closure for the entire cohort was 129±28 minutes and mean fluoroscopy time was 41±12 seconds ( Table 2 ) . For the entire cohort, EBL was 51±33 ml and the mean length of stay was 1.9±1.8 days. All patients were discharged home and none required inpatient rehab or skilled nursing facility. Two (9%) patients required reoperation at a mean 5 weeks. Reasons for reoperation included posterior cage migration in both patients (one due to a traumatic fall and one returned to full duty work 1 week after surgery) presenting with acute low back pain and radiculopathy. Both patients underwent posterior cage removal and revision of instrumentation. The AR protocol was safely implemented in all cases with improvement in back and leg pain and no persistent neurologic deficits at most recent follow up. The mean follow up time was 163 ± 109 days. Table 2 Intraoperative and postoperative characteristics Variable N (%) Operative time (mins) 129.4 ± 28.1 Fluoroscopy time (seconds) 41.3 ± 11.7 Estimated blood loss (mL) 50.5 ± 33.0 Length of stay (days) 1.86 ± 1.78 Mean follow up (days) 163.1 ± 109.1 Reoperation within 90 days 2 (9%) Analysis of Learning Curve Analyzing the learning curve revealed similar mean operative time (131 vs 128 minutes), fluoroscopy time (43 vs 41 seconds), and EBL (53 vs 50 ml) between the first half and latter half of cases. In regard to postoperative outcomes, the mean length of stay (2.0 vs 1.8 days) was not significantly different between cohorts. DISCUSSION This article and accompanying video provides a comprehensive workflow for the reproducible application of headset mounted AR-assisted MIS TLIF. The findings of this study support that this workflow is safe and efficient with relatively minimal learning curve. In terms of learning curve, patients had similar operative time, fluoroscopy time, EBL, and length of stay when comparing the first and latter half of the cohort. It is important to note that the two patients requiring reoperation for posterior cage migration occurred in the first half of the cohort. One patient was a 43 year old female who suffered a fall down the stairs at 2 weeks post-op and the other was a 72 year old male returned to full duty work 1 week after surgery. We have also since shifted our practice to using an expandable TLIF banana cage with a different unlocking mechanism. To our knowledge, this is the first case series, descriptive workflow, and accompanying video for headset mounted AR-assisted MIS TLIF. Intraoperatively, headset mounted AR navigation has been shown to be safe and efficient in multiple primary studies and subsequent systematic reviews.[ 5 – 10 ] The headset mounted AR navigation helps identify correct anatomic landmarks without interrupting workflow. After pedicle screws are placed, the boundaries for the TLIF approach are identified and high speed burr can be used to efficiently drill to the depth of the ligamentum flavum. In comparison, traditional navigation systems require inserting a navigated pointer into the surgical field and looking up at a navigation monitor outside the surgical field of view. These traditional navigation systems can also present line of sight interference between the reference array and the sensors. This is avoided in headset mounted AR navigation where the sensors are located within the headset itself.[ 1 , 11 , 12 ] A technical report by Sommer et al. previously described a workflow for integrating microscope-based AR navigation in MIS TLIF.[ 13 ] Their study included a case series of 10 patients and an average procedure time of 161 minutes. In comparison, the overall procedure time of a tubular MIS TLIF in the literature ranges between 138 and 211 minutes. Our mean operative time was 129 minutes and did not significantly differ between the first half and latter half of cases. Importantly, we use a tubular-based camera instead of a microscope for the TLIF approach in conjunction with the headset mounted AR navigation to delineate the border of our TLIF approach to efficiently and safely drill to the depth of the ligamentum flavum. Prior reports by Sarikonda et al. and Leroy et al. have also demonstrated the advantages of a tubular-mounted cameras in MIS TLIF.[ 14 , 15 ] There were no differences in intraoperative outcomes in patients in the first half and latter half of our cohorts. These findings imply that implementing this workflow in a new center should have a relatively minimal learning curve for not only the primary surgeon, but also trainees and other surgical members. However, this may be impacted by factors such as the center’s experience with intraoperative navigation and AR. Additionally, institutional familiarity with navigated instrumentation setup, sterile workflow integration, and real-time troubleshooting of AR devices may further influence the ease and speed of adoption. Future studies evaluating multi-center experiences will be important to better understand generalizability across different practice settings. The utilization of AR-assisted navigation may also provide additional tools for academic teaching institutions to better familiarize trainees with the anatomy given limited visualization through MIS approaches.[ 11 , 16 , 17 ] A report by Schmidt et al. investigated the use of AR as an education tool in an MIS TLIF cadaver study.[ 18 ] Their study included 12 residents at two institutions and found significantly lower mental demand and learning curve with AR-assistance in single level MIS TLIF. The benefit of the implementation of our workflow for residents and fellows in training should be evaluated with its own study, since this group may particularly benefit from this technology. Additionally, AR systems may improve intraoperative decision-making, situational awareness, and procedural confidence earlier in training. Future research could also explore whether AR use translates to greater procedural independence, reduced operative times for trainees, or decreased complication rates as they progress through their learning curves. Limitations This study is limited by its single institution, retrospective cohort of relatively small size that limits its generalizability. While we observed encouraging results, future multi-institution studies are required to assess reproducibility. Additionally, headset mounted AR navigation remains relatively new and can be subject to a learning curve that can vary. Our case series included all cases from the beginning of utilizing AR assistance for MIS TLIF at our institution and therefore we draw our conclusions about the learning curve based on no differences between the first and latter half of the cohort. However, there may be unmeasured or unknown variables that may still be within the learning curve that we did not account for. Given that MIS TLIF can have a significant learning curve, it is possible that the benefit of headset mounted AR assistance is that orientation of the anatomy is facilitated. This has been reported to be particularly difficult in the beginning of the learning curve for MIS TLIF in general.[ 19 , 20 ] Although beyond the scope of this study, future studies with a larger number of cases and separate evaluations of surgeons with different levels of experience may be necessary to further elucidate these differences. CONCLUSION AR headset mounted navigation represents safe and efficient enabling technology to enhance workflow in MIS TLIF. Given the limited field of view in MIS TLIF, AR improves visualization of anatomic landmarks in a 3D environment, highlighting the position of anatomic structures that are outside of the direct field of view. Declarations Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by IY, RGO, PL, and AB. The first draft of the manuscript was written by IY and PL. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Azad TD, Warman A, Tracz JA, Hughes LP, Judy BF, Witham TF (2024) Augmented reality in spine surgery - past, present, and future. Spine J 24:1-13. doi: 10.1016/j.spinee.2023.08.015 Katsuura Y, Colon LF, Perez AA, Albert TJ, Qureshi SA (2021) A Primer on the Use of Artificial Intelligence in Spine Surgery. Clin Spine Surg 34:316-321. doi: 10.1097/BSD.0000000000001211 Molina CA, Sciubba DM, Greenberg JK, Khan M, Witham T (2021) Clinical Accuracy, Technical Precision, and Workflow of the First in Human Use of an Augmented-Reality Head-Mounted Display Stereotactic Navigation System for Spine Surgery. Oper Neurosurg (Hagerstown) 20:300-309. doi: 10.1093/ons/opaa398 Bhatt FR, Orosz LD, Tewari A, Boyd D, Roy R, Good CR, Schuler TC, Haines CM, Jazini E (2023) Augmented Reality-Assisted Spine Surgery: An Early Experience Demonstrating Safety and Accuracy with 218 Screws. Global Spine J 13:2047-2052. doi: 10.1177/21925682211069321 Pahwa B, Azad TD, Liu J, Ran K, Liu CJ, Tracz J, Sattari SA, Khalifeh JM, Judy BF, Bydon A, Witham TF (2023) Assessing the Accuracy of Spinal Instrumentation Using Augmented Reality (AR): A Systematic Review of the Literature and Meta-Analysis. J Clin Med 12. doi: 10.3390/jcm12216741 McCloskey K, Turlip R, Ahmad HS, Ghenbot YG, Chauhan D, Yoon JW (2023) Virtual and Augmented Reality in Spine Surgery: A Systematic Review. World Neurosurg 173:96-107. doi: 10.1016/j.wneu.2023.02.068 Moga K, Holgyesi A, Zrubka Z, Pentek M, Haidegger T (2023) Augmented or Mixed Reality Enhanced Head-Mounted Display Navigation for In Vivo Spine Surgery: A Systematic Review of Clinical Outcomes. J Clin Med 12. doi: 10.3390/jcm12113788 Sumdani H, Aguilar-Salinas P, Avila MJ, Barber SR, Dumont T (2022) Utility of Augmented Reality and Virtual Reality in Spine Surgery: A Systematic Review of the Literature. World Neurosurg 161:e8-e17. doi: 10.1016/j.wneu.2021.08.002 Xiao SX, Wu WT, Yu TC, Chen IH, Yeh KT (2024) Augmenting Reality in Spinal Surgery: A Narrative Review of Augmented Reality Applications in Pedicle Screw Instrumentation. Medicina (Kaunas) 60. doi: 10.3390/medicina60091485 Youssef S, McDonnell JM, Wilson KV, Turley L, Cunniffe G, Morris S, Darwish S, Butler JS (2024) Accuracy of augmented reality-assisted pedicle screw placement: a systematic review. Eur Spine J 33:974-984. doi: 10.1007/s00586-023-08094-5 Godzik J, Farber SH, Urakov T, Steinberger J, Knipscher LJ, Ehredt RB, Tumialan LM, Uribe JS (2021) "Disruptive Technology" in Spine Surgery and Education: Virtual and Augmented Reality. Oper Neurosurg (Hagerstown) 21:S85-S93. doi: 10.1093/ons/opab114 Rush AJ, 3rd, Shepard N, Nolte M, Siemionow K, Phillips F (2022) Augmented Reality in Spine Surgery: Current State of the Art. Int J Spine Surg 16:S22-S27. doi: 10.14444/8273 Sommer F, Hussain I, Kirnaz S, Goldberg JL, Navarro-Ramirez R, McGrath LB, Jr., Schmidt FA, Medary B, Gadjradj PS, Hartl R (2022) Augmented Reality to Improve Surgical Workflow in Minimally Invasive Transforaminal Lumbar Interbody Fusion - A Feasibility Study With Case Series. Neurospine 19:574-585. doi: 10.14245/ns.2244134.067 Leroy HA, Vaziri S, Assaker R, Wang MY (2024) Digital Tubular-Based Camera-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 26:481-482. doi: 10.1227/ons.0000000000001027 Sarikonda A, Sivaganesan A, Qureshi S (2024) Advanced Visualization in Minimally Invasive Spine Surgery: The Ergonomics, Economics, and Evolution of Camera-Based Tubes and Retractors. Int J Spine Surg 18:S64-S70. doi: 10.14444/8643 Bui T, Ruiz-Cardozo MA, Dave HS, Barot K, Kann MR, Joseph K, Lopez-Alviar S, Trevino G, Brehm S, Yahanda AT, Molina CA (2024) Virtual, Augmented, and Mixed Reality Applications for Surgical Rehearsal, Operative Execution, and Patient Education in Spine Surgery: A Scoping Review. Medicina (Kaunas) 60. doi: 10.3390/medicina60020332 Durrani S, Onyedimma C, Jarrah R, Bhatti A, Nathani KR, Bhandarkar AR, Mualem W, Ghaith AK, Zamanian C, Michalopoulos GD, Alexander AY, Jean W, Bydon M (2022) The Virtual Vision of Neurosurgery: How Augmented Reality and Virtual Reality are Transforming the Neurosurgical Operating Room. World Neurosurg 168:190-201. doi: 10.1016/j.wneu.2022.10.002 Schmidt FA, Hussain I, Boadi B, Sommer FJ, Thome C, Hartl R (2025) The Use of Augmented Reality as an Educational Tool in Minimally Invasive Transforaminal Lumbar Interbody Fusion. Oper Neurosurg (Hagerstown) 28:183-192. doi: 10.1227/ons.0000000000001317 Ahn Y, Lee S, Kim WK, Lee SG (2022) Learning curve for minimally invasive transforaminal lumbar interbody fusion: a systematic review. Eur Spine J 31:3551-3559. doi: 10.1007/s00586-022-07397-3 Silva PS, Pereira P, Monteiro P, Silva PA, Vaz R (2013) Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion. Neurosurg Focus 35:E7. doi: 10.3171/2013.5.FOCUS13157 Video The video file is not available with this version. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 26 Oct, 2025 Reviews received at journal 20 Oct, 2025 Reviews received at journal 12 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviewers invited by journal 27 Sep, 2025 Editor assigned by journal 25 Sep, 2025 Submission checks completed at journal 25 Sep, 2025 First submitted to journal 23 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7698060","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":526041079,"identity":"9172351b-bfdd-41ed-b1d5-d97d25551ae4","order_by":0,"name":"Iyan 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15:09:02","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72556,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7698060/v1/9c1cf45d2f94e5819e906fdb.html"},{"id":93245468,"identity":"c8233d0c-1cde-49ab-9131-8ccab1db1256","added_by":"auto","created_at":"2025-10-10 15:09:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":835679,"visible":true,"origin":"","legend":"\u003cp\u003eLive intraoperative view through the AR headset with navigation data overlaid directly in the operative field of view to aid in planning pedicle screw start points and bilateral incisions.\u003c/p\u003e","description":"","filename":"Figure1ARTLIF.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7698060/v1/e94e629b0b16245d5b71cfb4.jpg"},{"id":93245503,"identity":"bf35493a-20ad-4beb-b380-15dd465fd617","added_by":"auto","created_at":"2025-10-10 15:09:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":801770,"visible":true,"origin":"","legend":"\u003cp\u003eAR headset view aiding in planning facetectomy and access to disc space.\u003c/p\u003e","description":"","filename":"Figure2ARTLIF.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7698060/v1/f9414d8c7175a42c5a9992f2.jpg"},{"id":93246685,"identity":"f08391cf-e0b1-4d28-9960-79ecb2a8aac7","added_by":"auto","created_at":"2025-10-10 15:17:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2099780,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7698060/v1/f57c9a5f-b99b-43d5-8309-00971a10c9e7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Augmented Reality Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: Safe and Effective Workflow with Intraoperative Video","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAugmented reality (AR) headset mounted spinal navigation has been increasingly utilized since federal drug administration (FDA) approval in December 2019.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] The first case series were reported in 2021 with several studies documenting 97\u0026ndash;98% range in pedicle screw accuracy in the thoracolumbar spine.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] AR assisted navigation uses computer generated images displayed in the surgeon\u0026rsquo;s operative field of view to provide a safe, efficient, and accurate method of placing spinal instrumentation. In comparison to traditional intraoperative navigation technologies, headset mounted AR-assisted navigation eliminates the need to break line of site and minimizes attention shift.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eDespite theoretical benefits which have been reported in the literature for pedicle screw placement, there remains a paucity of data on the workflow of AR assistance beyond pedicle screw placement. AR navigation may be especially useful in percutaneous and minimally invasive approaches for interbody fusion owing to the improved visualization of anatomic landmarks that are outside the direct field of view.\u003c/p\u003e\u003cp\u003eGiven the gap in the literature reporting on the efficacy and workflow of headset mounted AR navigation in minimally invasive transforaminal lumbar interbody fusion (MIS TLIF),\u003c/p\u003e\u003cp\u003ethe objective of this study was to provide a comprehensive description of the workflow for incorporating headset-mounted AR navigation with the MIS TLIF procedure, supplemented with intraoperative images and video for clarity and reproducibility.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eConsecutive patients undergoing single level MIS-TLIF for degenerative spondylolisthesis with AR navigation were analyzed between January 2023\u0026ndash;2025 by a single spine-fellowship trained surgeon. Patients were included if they had undergone prior decompression(s) at the level of the fusion procedure but were excluded if they had undergone prior adjacent level fusion procedures in the lumbar spine. Institutional Review Board (IRB) and patient consent to procedure were obtained. The participants and any identifiable individuals consented to publication of his/her image. Protected health information was removed, blurred, or cropped where applicable.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExposure Variables\u003c/h3\u003e\n\u003cp\u003eBaseline demographic variables included age, sex, body mass index (BMI), Charlson comorbidity index (CCI), level of operation, and presence of prior laminectomy defect at the operative level. Intraoperative variables collected included operative time from skin incision to skin closure, which included the time of percutaneous posterior superior iliac spine (PSIS) pin insertion, intraoperative O-arm spin, and registration of navigated instruments. Other intraoperative variables included fluoroscopy time based on the radiation documentation and estimated blood loss (EBL) based on the anesthesia record. Postoperative variables included hospital length of stay, disposition, follow up duration, and reoperation within 90 days.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were performed with mean and standard deviation (SD) for continuous variables and frequency for categorical variables. Normally distributed data with equal variance were analyzed using a two-tailed t-test. For nominal data, χ2 or Fisher\u0026rsquo;s exact test was utilized in smaller samples. Univariate and analyses were performed. A p-value of \u0026lt;\u0026thinsp;0.05 was regarded as statistically significant. All analyses were conducted using SPSS version 22 (IBM Inc., Chicago, Illinois).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical Workflow\u003c/h3\u003e\n\u003cp\u003eThe AR workflow features a wireless headset (Augmedics, Arlington Heights, IL) with projection of intraoperative navigation in the surgical field. MIS pedicle screw placement, facetectomy, disc preparation, and contralateral arthrodesis are carried out percutaneously though single line of sight using navigated instruments. The following navigated instruments are registered at the beginning of the case and utilized: high speed drill, tap, screw, and cage trials. Additionally, an electromyography (EMG) probe is used to ensure the exiting nerve root is not encountered prior to disc space preparation.\u003c/p\u003e\u003cp\u003eThe patient is placed prone on a Jackson table under general endotracheal anesthesia. Baseline somatosensory evoked and motor evoked potentials are obtained. A posterior superior iliac crest pin is percutaneously inserted. The navigation array is attached to this pin. A surface reference array is placed on the skin overlying the region of reference. The surgical site is covered with sterile drapes and a 3D O-arm intraoperative imaging system is used. Once the scan is verified and registration is completed, a navigated instrument is brought into the field and general landmark checks are performed to ensure accuracy. The paramedian/Wiltse based incisions are marked out using a navigated instrument \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. A Wiltse incision on both sides is made connecting the marked pedicle screw entry points. The incisions are opened down to the fascia on both sides, then blunt dissection is performed down to the bony anatomy targeted towards the traditional pedicle screw entry points.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePedicle screws are placed in a similar fashion to what has previously been described in the literature using a navigated high speed burr, tap, and screw. A Kirschner (K)-wire is inserted in place of the screw on the ipsilateral caudal level to avoid obstruction of the working channel for the TLIF approach.\u003c/p\u003e\u003cp\u003eThrough the TLIF-side incision, a navigated Jamshidi needle and subsequent K-wire are inserted into the facet joint along a trajectory designed to maximize access to the disc space for thorough discectomy, endplate preparation, and eventual interbody placement. Traditional tubular dilators are inserted over this wire to dock a 22 millimeter solid tube overlying the facet joint. The tubular retractor is secured to an arm attached to the bed frame. A tubular-based camera (Viseon, Irvine, CA, USA) is then attached for visualization.\u003c/p\u003e\u003cp\u003eInitial subperiosteal dissection is performed with monopolar cautery to identify the inferior articular process of the cranial level and the superior articular process of the caudal level. The facetectomy is planned using navigation to identify the upper endplate being the superior most extent, the inferior pedicle being the inferior most extent, and the junction between the laminal and the medial facet being the medial most extent \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. We then use a navigated high speed burr to perform the partial (sometimes full) facetectomy avoiding any critical neural structures such as the exiting nerve root superiorly and the traversing nerve root with dural sac medially. A bone collector suction is utilized to obtain autograft from the facet joint that will be placed intradiscally for arthrodesis. Bony removal at the lateral border as well as a free floating piece of the amputated superior articular process can be completed with a Kerrison or pituitary rongeur. 5he exiting nerve root is identified and an electromyography (EMG) neuro monitoring probe is inserted into the channel to ensure no other neural structures are encountered in the working zone. A threshold\u0026thinsp;\u0026gt;\u0026thinsp;5mA is used to ensure a safe corridor prior to discectomy.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eNext, hemostasis is performed with bipolar cautery and hemostatic agents to control any bleeding from the epidural venous plexus. The disc space is verified using the AR navigation. A nerve root retractor can be used to medially retract the traversing nerve root and thecal sac to provide additional access to the posterolateral annulus. A scalpel is used to incise the annulus to create a window into the disc space. A complete discectomy is performed using shavers, curettes, pituitary rongeurs, and subsequent trials. As with any TLIF, adequate discectomy and preservation of the cortical endplate surface is critical. The cage and disc space are filled with autograft and allograft. Our practice has shifted to using an expandable TLIF banana cage. The cage is inserted and should be placed as anteriorly and centrally as possible and can be confirmed with fluoroscopy. The final pedicle screw is inserted over the K-wire. We then decorticate the facet joints with the navigated high speed burr on the contralateral side and place any remaining autograft and allograft for posterolateral fusion. This is a crucial step and should not be overlooked. Once bilateral rods are inserted and set screws final tightened, final fluoroscopic images are obtained.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eBaseline Characteristics\u003c/h2\u003e\u003cp\u003eA total of 138 consecutive patients underwent AR-assisted spinal fusion at our institution and of those, 22 cases of MIS TLIF performed at a single-level met inclusion criteria for this study. The mean age was 62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15 years old, 59% were females, mean BMI was 29.4\u0026plusmn;5.7 kg/m\u003csup\u003e2\u003c/sup\u003e, and mean CCI score was 2.1\u0026plusmn;1.5 \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The operative level was L3-4 in 1 (4.5%), L4-5 in 15 (69%) and L5-S1 in 6 (27%). Prior laminectomy defects were present at the operative level in 3 (14%) patients.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline demographics and perioperative characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean age \u003cem\u003e(years)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;14.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex \u003cem\u003e(female)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (59%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean BMI \u003cem\u003e(kg/m\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean Charlson comorbidity index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndex level\u003c/p\u003e\u003cp\u003eL3-4\u003c/p\u003e\u003cp\u003eL4-5\u003c/p\u003e\u003cp\u003eL5-S1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003e1 (4.5%)\u003c/p\u003e\u003cp\u003e15 (68%)\u003c/p\u003e\u003cp\u003e6 (27%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior surgery at index level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (14%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIntraoperative and Postoperative Outcomes\u003c/h3\u003e\n\u003cp\u003eThe mean operative time from incision to closure for the entire cohort was 129\u0026plusmn;28 minutes and mean fluoroscopy time was 41\u0026plusmn;12 seconds \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. For the entire cohort, EBL was 51\u0026plusmn;33 ml and the mean length of stay was 1.9\u0026plusmn;1.8 days. All patients were discharged home and none required inpatient rehab or skilled nursing facility. Two (9%) patients required reoperation at a mean 5 weeks. Reasons for reoperation included posterior cage migration in both patients (one due to a traumatic fall and one returned to full duty work 1 week after surgery) presenting with acute low back pain and radiculopathy. Both patients underwent posterior cage removal and revision of instrumentation. The AR protocol was safely implemented in all cases with improvement in back and leg pain and no persistent neurologic deficits at most recent follow up. The mean follow up time was 163\u0026thinsp;\u0026plusmn;\u0026thinsp;109 days.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIntraoperative and postoperative characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time \u003cem\u003e(mins)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e129.4\u0026thinsp;\u0026plusmn;\u0026thinsp;28.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFluoroscopy time \u003cem\u003e(seconds)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEstimated blood loss \u003cem\u003e(mL)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50.5\u0026thinsp;\u0026plusmn;\u0026thinsp;33.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of stay \u003cem\u003e(days)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean follow up \u003cem\u003e(days)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e163.1\u0026thinsp;\u0026plusmn;\u0026thinsp;109.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReoperation within 90 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eAnalysis of Learning Curve\u003c/h3\u003e\n\u003cp\u003eAnalyzing the learning curve revealed similar mean operative time (131 vs 128 minutes), fluoroscopy time (43 vs 41 seconds), and EBL (53 vs 50 ml) between the first half and latter half of cases. In regard to postoperative outcomes, the mean length of stay (2.0 vs 1.8 days) was not significantly different between cohorts.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis article and accompanying video provides a comprehensive workflow for the reproducible application of headset mounted AR-assisted MIS TLIF. The findings of this study support that this workflow is safe and efficient with relatively minimal learning curve. In terms of learning curve, patients had similar operative time, fluoroscopy time, EBL, and length of stay when comparing the first and latter half of the cohort. It is important to note that the two patients requiring reoperation for posterior cage migration occurred in the first half of the cohort. One patient was a 43 year old female who suffered a fall down the stairs at 2 weeks post-op and the other was a 72 year old male returned to full duty work 1 week after surgery. We have also since shifted our practice to using an expandable TLIF banana cage with a different unlocking mechanism. To our knowledge, this is the first case series, descriptive workflow, and accompanying video for headset mounted AR-assisted MIS TLIF.\u003c/p\u003e\u003cp\u003eIntraoperatively, headset mounted AR navigation has been shown to be safe and efficient in multiple primary studies and subsequent systematic reviews.[\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] The headset mounted AR navigation helps identify correct anatomic landmarks without interrupting workflow. After pedicle screws are placed, the boundaries for the TLIF approach are identified and high speed burr can be used to efficiently drill to the depth of the ligamentum flavum. In comparison, traditional navigation systems require inserting a navigated pointer into the surgical field and looking up at a navigation monitor outside the surgical field of view. These traditional navigation systems can also present line of sight interference between the reference array and the sensors. This is avoided in headset mounted AR navigation where the sensors are located within the headset itself.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] A technical report by Sommer et al. previously described a workflow for integrating microscope-based AR navigation in MIS TLIF.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Their study included a case series of 10 patients and an average procedure time of 161 minutes. In comparison, the overall procedure time of a tubular MIS TLIF in the literature ranges between 138 and 211 minutes. Our mean operative time was 129 minutes and did not significantly differ between the first half and latter half of cases. Importantly, we use a tubular-based camera instead of a microscope for the TLIF approach in conjunction with the headset mounted AR navigation to delineate the border of our TLIF approach to efficiently and safely drill to the depth of the ligamentum flavum. Prior reports by Sarikonda et al. and Leroy et al. have also demonstrated the advantages of a tubular-mounted cameras in MIS TLIF.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThere were no differences in intraoperative outcomes in patients in the first half and latter half of our cohorts. These findings imply that implementing this workflow in a new center should have a relatively minimal learning curve for not only the primary surgeon, but also trainees and other surgical members. However, this may be impacted by factors such as the center\u0026rsquo;s experience with intraoperative navigation and AR. Additionally, institutional familiarity with navigated instrumentation setup, sterile workflow integration, and real-time troubleshooting of AR devices may further influence the ease and speed of adoption. Future studies evaluating multi-center experiences will be important to better understand generalizability across different practice settings.\u003c/p\u003e\u003cp\u003eThe utilization of AR-assisted navigation may also provide additional tools for academic teaching institutions to better familiarize trainees with the anatomy given limited visualization through MIS approaches.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] A report by Schmidt et al. investigated the use of AR as an education tool in an MIS TLIF cadaver study.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Their study included 12 residents at two institutions and found significantly lower mental demand and learning curve with AR-assistance in single level MIS TLIF. The benefit of the implementation of our workflow for residents and fellows in training should be evaluated with its own study, since this group may particularly benefit from this technology. Additionally, AR systems may improve intraoperative decision-making, situational awareness, and procedural confidence earlier in training. Future research could also explore whether AR use translates to greater procedural independence, reduced operative times for trainees, or decreased complication rates as they progress through their learning curves.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study is limited by its single institution, retrospective cohort of relatively small size that limits its generalizability. While we observed encouraging results, future multi-institution studies are required to assess reproducibility. Additionally, headset mounted AR navigation remains relatively new and can be subject to a learning curve that can vary. Our case series included all cases from the beginning of utilizing AR assistance for MIS TLIF at our institution and therefore we draw our conclusions about the learning curve based on no differences between the first and latter half of the cohort. However, there may be unmeasured or unknown variables that may still be within the learning curve that we did not account for. Given that MIS TLIF can have a significant learning curve, it is possible that the benefit of headset mounted AR assistance is that orientation of the anatomy is facilitated. This has been reported to be particularly difficult in the beginning of the learning curve for MIS TLIF in general.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Although beyond the scope of this study, future studies with a larger number of cases and separate evaluations of surgeons with different levels of experience may be necessary to further elucidate these differences.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAR headset mounted navigation represents safe and efficient enabling technology to enhance workflow in MIS TLIF. Given the limited field of view in MIS TLIF, AR improves visualization of anatomic landmarks in a 3D environment, highlighting the position of anatomic structures that are outside of the direct field of view.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by IY, RGO, PL, and AB. The first draft of the manuscript was written by IY and PL. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAzad TD, Warman A, Tracz JA, Hughes LP, Judy BF, Witham TF (2024) Augmented reality in spine surgery - past, present, and future. Spine J 24:1-13. doi: 10.1016/j.spinee.2023.08.015\u003c/li\u003e\n\u003cli\u003eKatsuura Y, Colon LF, Perez AA, Albert TJ, Qureshi SA (2021) A Primer on the Use of Artificial Intelligence in Spine Surgery. Clin Spine Surg 34:316-321. doi: 10.1097/BSD.0000000000001211\u003c/li\u003e\n\u003cli\u003eMolina CA, Sciubba DM, Greenberg JK, Khan M, Witham T (2021) Clinical Accuracy, Technical Precision, and Workflow of the First in Human Use of an Augmented-Reality Head-Mounted Display Stereotactic Navigation System for Spine Surgery. Oper Neurosurg (Hagerstown) 20:300-309. doi: 10.1093/ons/opaa398\u003c/li\u003e\n\u003cli\u003eBhatt FR, Orosz LD, Tewari A, Boyd D, Roy R, Good CR, Schuler TC, Haines CM, Jazini E (2023) Augmented Reality-Assisted Spine Surgery: An Early Experience Demonstrating Safety and Accuracy with 218 Screws. Global Spine J 13:2047-2052. doi: 10.1177/21925682211069321\u003c/li\u003e\n\u003cli\u003ePahwa B, Azad TD, Liu J, Ran K, Liu CJ, Tracz J, Sattari SA, Khalifeh JM, Judy BF, Bydon A, Witham TF (2023) Assessing the Accuracy of Spinal Instrumentation Using Augmented Reality (AR): A Systematic Review of the Literature and Meta-Analysis. J Clin Med 12. doi: 10.3390/jcm12216741\u003c/li\u003e\n\u003cli\u003eMcCloskey K, Turlip R, Ahmad HS, Ghenbot YG, Chauhan D, Yoon JW (2023) Virtual and Augmented Reality in Spine Surgery: A Systematic Review. World Neurosurg 173:96-107. doi: 10.1016/j.wneu.2023.02.068\u003c/li\u003e\n\u003cli\u003eMoga K, Holgyesi A, Zrubka Z, Pentek M, Haidegger T (2023) Augmented or Mixed Reality Enhanced Head-Mounted Display Navigation for In Vivo Spine Surgery: A Systematic Review of Clinical Outcomes. J Clin Med 12. doi: 10.3390/jcm12113788\u003c/li\u003e\n\u003cli\u003eSumdani H, Aguilar-Salinas P, Avila MJ, Barber SR, Dumont T (2022) Utility of Augmented Reality and Virtual Reality in Spine Surgery: A Systematic Review of the Literature. World Neurosurg 161:e8-e17. doi: 10.1016/j.wneu.2021.08.002\u003c/li\u003e\n\u003cli\u003eXiao SX, Wu WT, Yu TC, Chen IH, Yeh KT (2024) Augmenting Reality in Spinal Surgery: A Narrative Review of Augmented Reality Applications in Pedicle Screw Instrumentation. Medicina (Kaunas) 60. doi: 10.3390/medicina60091485\u003c/li\u003e\n\u003cli\u003eYoussef S, McDonnell JM, Wilson KV, Turley L, Cunniffe G, Morris S, Darwish S, Butler JS (2024) Accuracy of augmented reality-assisted pedicle screw placement: a systematic review. Eur Spine J 33:974-984. doi: 10.1007/s00586-023-08094-5\u003c/li\u003e\n\u003cli\u003eGodzik J, Farber SH, Urakov T, Steinberger J, Knipscher LJ, Ehredt RB, Tumialan LM, Uribe JS (2021) \u0026quot;Disruptive Technology\u0026quot; in Spine Surgery and Education: Virtual and Augmented Reality. Oper Neurosurg (Hagerstown) 21:S85-S93. doi: 10.1093/ons/opab114\u003c/li\u003e\n\u003cli\u003eRush AJ, 3rd, Shepard N, Nolte M, Siemionow K, Phillips F (2022) Augmented Reality in Spine Surgery: Current State of the Art. Int J Spine Surg 16:S22-S27. doi: 10.14444/8273\u003c/li\u003e\n\u003cli\u003eSommer F, Hussain I, Kirnaz S, Goldberg JL, Navarro-Ramirez R, McGrath LB, Jr., Schmidt FA, Medary B, Gadjradj PS, Hartl R (2022) Augmented Reality to Improve Surgical Workflow in Minimally Invasive Transforaminal Lumbar Interbody Fusion - A Feasibility Study With Case Series. Neurospine 19:574-585. doi: 10.14245/ns.2244134.067\u003c/li\u003e\n\u003cli\u003eLeroy HA, Vaziri S, Assaker R, Wang MY (2024) Digital Tubular-Based Camera-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 26:481-482. doi: 10.1227/ons.0000000000001027\u003c/li\u003e\n\u003cli\u003eSarikonda A, Sivaganesan A, Qureshi S (2024) Advanced Visualization in Minimally Invasive Spine Surgery: The Ergonomics, Economics, and Evolution of Camera-Based Tubes and Retractors. Int J Spine Surg 18:S64-S70. doi: 10.14444/8643\u003c/li\u003e\n\u003cli\u003eBui T, Ruiz-Cardozo MA, Dave HS, Barot K, Kann MR, Joseph K, Lopez-Alviar S, Trevino G, Brehm S, Yahanda AT, Molina CA (2024) Virtual, Augmented, and Mixed Reality Applications for Surgical Rehearsal, Operative Execution, and Patient Education in Spine Surgery: A Scoping Review. Medicina (Kaunas) 60. doi: 10.3390/medicina60020332\u003c/li\u003e\n\u003cli\u003eDurrani S, Onyedimma C, Jarrah R, Bhatti A, Nathani KR, Bhandarkar AR, Mualem W, Ghaith AK, Zamanian C, Michalopoulos GD, Alexander AY, Jean W, Bydon M (2022) The Virtual Vision of Neurosurgery: How Augmented Reality and Virtual Reality are Transforming the Neurosurgical Operating Room. World Neurosurg 168:190-201. doi: 10.1016/j.wneu.2022.10.002\u003c/li\u003e\n\u003cli\u003eSchmidt FA, Hussain I, Boadi B, Sommer FJ, Thome C, Hartl R (2025) The Use of Augmented Reality as an Educational Tool in Minimally Invasive Transforaminal Lumbar Interbody Fusion. Oper Neurosurg (Hagerstown) 28:183-192. doi: 10.1227/ons.0000000000001317\u003c/li\u003e\n\u003cli\u003eAhn Y, Lee S, Kim WK, Lee SG (2022) Learning curve for minimally invasive transforaminal lumbar interbody fusion: a systematic review. Eur Spine J 31:3551-3559. doi: 10.1007/s00586-022-07397-3\u003c/li\u003e\n\u003cli\u003eSilva PS, Pereira P, Monteiro P, Silva PA, Vaz R (2013) Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion. Neurosurg Focus 35:E7. doi: 10.3171/2013.5.FOCUS13157\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Video","content":"\u003cp\u003eThe video file is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"minimally invasive, augmented reality, lumbar interbody fusion, workflow","lastPublishedDoi":"10.21203/rs.3.rs-7698060/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7698060/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eThis article and accompanying video provide a comprehensive workflow for incorporating headset-mounted augmented reality (AR) navigation for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eConsecutive patients undergoing a single level MIS-TLIF with AR navigation for degenerative spondylolisthesis were analyzed between January 2023\u0026ndash;2025. Demographic, intraoperative, and postoperative outcomes were collected. The AR workflow features a wireless headset with projection of intraoperative navigation in the surgical field. MIS pedicle screw placement, facetectomy, disc preparation, and contralateral arthrodesis are carried out percutaneously though single line of sight using navigated instruments.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eA total of 138 consecutive patients underwent AR-assisted spinal fusion at our institution and 22 cases of single-level MIS TLIF met inclusion criteria. Mean age was 62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15 years, 59% were females, mean BMI was 29.4\u0026plusmn;5.7 kg/m\u003csup\u003e2\u003c/sup\u003e, and mean CCI score was 2.1\u0026plusmn;1.5. Analyzing the learning curve revealed similar mean operative time, length of stay, estimated blood loss, and fluoroscopy time between the first half and latter half of cases. The AR protocol was safely implemented in all cases with improvement in back and leg pain and no persistent neurologic deficits at mean 163 day follow up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eAR headset mounted navigation represents safe and efficient enabling technology to enhance workflow in MIS TLIF. Given the limited field of view in MIS TLIF, AR improves visualization of anatomic landmarks in a 3D environment, highlighting the position of anatomic structures that are outside of the direct field of view.\u003c/p\u003e","manuscriptTitle":"Augmented Reality Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: Safe and Effective Workflow with Intraoperative Video","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-10 15:08:32","doi":"10.21203/rs.3.rs-7698060/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-26T19:52:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T17:21:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-12T15:10:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56317639908443512415010462482215911810","date":"2025-10-06T15:11:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223120509058401411979545248488703410854","date":"2025-09-27T15:03:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-27T14:38:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-25T05:10:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-25T05:09:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-09-23T23:54:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"27f109dc-2a09-4267-9bd8-f86607481f6b","owner":[],"postedDate":"October 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-19T10:38:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-10 15:08:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7698060","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7698060","identity":"rs-7698060","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}