Resident Massachusetts General Hospital Boston, Massachusetts, United States
Introduction: Chordomas represent locally aggressive primary malignant bone tumors that require en bloc surgical resection. Traditionally, stereotactic navigation has been used to guide resection margins through the use of an external display coupled with a stereotactic probe. Recently, augmented reality (AR) has emerged as a promising adjunct within spine surgery. When coupled with a head mounted display (HMD), stereotactic imaging can be overlaid over the surgeon’s field of view thereby minimizing attention shift and line of sight issues commonly associated with traditional navigation. Herein, we describe the first use of an augmented reality HMD coupled with a fully navigated drill for safe and efficient resection of a sacral chordoma.
Methods: A 75 year old male was found on MRI and CT to have a 3.6 cm T2 hyperintense sacral lesion with bony destruction suspicious for chordoma which was later confirmed via CT guided biopsy. The patient presented for a planned partial sacrectomy. After exposure of the sacrum and intraoperative CT, surgical loupes were exchanged for the AR HMD (xvision; Augmedics, Chicago, Illinois). Using AR guided navigation via the HMD, a series of osteotomies were then performed within the sacrum -- first starting at the level of the superior left S3 neural foramen and making a cut laterally through the sacrum. The next osteotomy was performed just above the right S3 neural foramen and drilled out using navigation guidance laterally into the ventral presacral space. The final cut of the osteotomy was performed by drilling across the midline and connecting the S3 foramen at each side along the superior medial aspect using the high-speed drill.
Results: The patient was discharged to rehab on post operative day 6. At one year follow up, the patient is ambulating well and reports normal bowel and bladder function. One year follow up MRI demonstrates no evidence of recurrent tumor.
Conclusion : Stereotactic navigation has required the use of a separate stereotactic probe with images displayed on a monitor. This creates line of sight and attention shift issues. Augmented reality mitigates these issues by overlaying information over the surgeon’s field of view and offers increased accuracy and workflow efficiency.
