Since Intuitive Surgical’s da Vinci robot system received approval from the US Food and Drug Administration (FDA) in the year 2000, robotic-assisted surgical systems (RAS) have indisputably led the passage of innovation in surgical procedures.
According to GlobalData analysis, the surgical robotics market is set to grow at a CAGR of 8% to reach $15.8bn by 2030. Although they dominate the conversation around technology that supports surgical procedures, technologies such as augmented and virtual reality (AR/VR) are beginning to gain traction in areas like spine surgery, with GlobalData analysts stating that these techniques for advanced image visualisation are thought to “enhance surgical planning, provide better intraoperative guidance, and ultimately improve patient care” by increasing understanding of anatomy and surgical pathology.
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Research suggests that thoracolumbar fusion procedures, one of the most common spine surgery types, are in growing demand, with thoracolumbar procedures such as anterior lumbar interbody fusion (ALIF) and posterior lumbar fusion (PLF) in the US projected to see respective rises from 46,903 to 55,528 and 248,416 to 297,994 between 2020 and 2040.
A GlobalData market model indicates that the spinal fusion market segment, of which thoracolumbar fusion is a part of, is growing at a CAGR of 2.3% and is forecast to reach a valuation of around $11.23bn by 2033.
The AR buzz in spine surgery
AR overlays information, whether images or text, on to the physical reality. It is positioned as a technology in spine surgery to give surgeons information including where to cut, where not to cut, or how to cut. The information gets overlaid digitally via a headset or tablet display to give the surgeon a view of a patient’s anatomy in real time.
Although RAS continue to evolve, with speciality systems emerging for spine surgery, the startup cost is high. Intuitive’s da Vinci, for instance, is priced at $2.6m without factoring in annual maintenance costs.
Conversely, AR has been shown to be an accurate approach towards navigating both open and minimally invasive spine surgery techniques as an off-the-shelf solution, available at a price point in the thousands opposed to the millions.
According to Charlie Whelan, senior director of consulting for medical devices at GlobalData, AR is best in spine surgery as a tool to anticipate how the spine will be able to move or not move in relation to hardware that’s placed there, while also aiding surgeons in drilling screws in the right place the first time around.
“What AR is good at [in spine surgery] is spatial orientation, and in providing information on what not to cut and what angles to drive at,” explains Whelan.
Whelan notes that some companies are developing AR with surgical instruments to give surgeons feedback if the instruments are being used in the wrong way.
Giving the example of a surgeon having to put a screw into somebody’s vertebra at a 45-degree angle and having to drill down 32 millimetres, he says that such systems will be able to give feedback as the surgeon is lining up the screw and indicate in real time when the correct drill angle and necessary drill depth has been achieved.
A cost-effective alternative to RAS systems?
Swiss company Neo Medical is the developer of Neo ADVISE, an augmented reality (AR) platform intended to help spine surgeons perform surgeries more effectively.
Part of Neo Universal, the company’s procedural platform for spine surgery that combines advanced surgical instruments and implants with the system, ADVISE is available under a software as a service (SaaS) model that hospitals can subscribe to annually.
Neo developed ADVISE, which can be ran through commercially available tablets like an Apple iPad, as it felt that spine surgery had not seen a huge amount of innovation in almost 40 years.
In thoracolumbar fusion, whether a tumour or deformation is acting as a pain generator, once the pain generator is taken away, the spine must be restabilised in the most anatomical position by placing implants in the spine’s vertebra and connecting them together with a rod.
“Until recently, the way surgeons were selecting or bending and adjusting this rod was based entirely upon their own experience and expertise,” says Neo Medical co-founder and co-CEO Vincent Lefauconnier.
“ADVISE is a data access, analysis and application technology to give surgeons the information they need intraoperatively to achieve the optimal positioning of the implants inside the patients.”
Once this information is obtained using ADVISE, the information can be overlaid in real life and in real time during surgery to give the surgeon the ideal rod that will be a perfect fit to a particular patient, which they can then manipulate accordingly with their usual surgical tool based on the information provided by the platform’s AR overlay.
Lefauconnier views ADVISE as a tool that gives surgeons the technology to help streamline surgical processes to make procedures more efficient, reproducible, and personalised to individual patients.
“The AR technology allows this because you can overlay the rod on the patients, so you can really see how it will fit and directly see the trajectory of the rod inside the screws,” he says.
Neo Medical’s full product portfolio for spine surgery received approval under the European Union’s Medical Device Regulation (EU MDR) in December 2024. In September 2024, the company raised $68m in a Series B equity financing round.
Outside the operating room
Whelan’s view is that the biggest area of application today for VR and AR in relation to surgery is not in the operating room but in training and in planning prior to the surgery itself.
AR and VR are similar technologies, with VR holding the ability to foster similar skills, albeit in a completely virtually constructed world opposed to one augmented with a virtual overlay.
“VR and AR unlock the potential for surgeon training, so learners can follow procedures before they set foot into the operating theatre,” adds Ivan Wall, CEO of FourPlus Immersive and co-Director of RESILIENCE – the UK Medicines Manufacturing Skills Centre of Excellence.
“While AR and VR won’t necessarily give learners the haptics needed to know how difficult it feels to drill through a piece of bone, they can take learners through the point that they have to drill through the piece of bone in a certain sequence, and it can help them learn that sequence and be confident with it before they undertake it in the physical world.”
A study published in the Journal of Bone & Joint Surgery found that when surgeons who did VR training to support traditional training did hip revisions, they trained 570% faster.
The unification of AR and robotics
Lefauconnier anticipates that RAS will eventually be connected to surgeons through AR interfaces, with AR enabling surgeons to “keep their eyes on the patients”.
He says: “What is missing with the current technology is that it takes surgeons away from the operating field, since they’re instead looking at the surgical procedure through a viewing screen.
“AR allows for the implementation and overlay of information directly on the patient through the medium of a tablet or headset.”
“I think AR should and will be a primary technology of entry because it can combine all of the surgical information together,” he says.
In determining the best use cases for AR and its potential future applicability during surgery, Whelan notes that for many soft tissue surgical procedures, laparoscopes are now being used, and between RAS systems and AR, it will be a case of “one or the other”.
“Anything that Intuitive Surgical is doing is done with a laparoscope, and it is unlikely that would be given up to use AR instead,” concludes Whelan.
AR clearly has beneficial applications in spine surgery, presenting an option that adds in guardrails that serve to make spine surgery safer and more duplicable. For now, the vastly lower cost of bringing AR into spine surgery instead of RAS systems appears to be the technology’s strongest selling point, unless it is offered as part of a broader suite of provisions in the surgical toolkit.
