Lohre Ryan, Wang Jeffrey C, Lewandrowski Kai-Uwe, Goel Danny P
Department of Orthopaedics, University of British Columbia, Vancouver, BC, USA.
USC Spine Center, Keck School of Medicine at University of Southern California, Los Angeles, USA.
J Spine Surg. 2020 Jan;6(Suppl 1):S208-S223. doi: 10.21037/jss.2019.11.16.
Minimally invasive spine surgery (MISS) and endoscopic spine surgery have continually evolving indications in the cervical, thoracic, and lumbar spine. Endoscopic spine surgery entails treatment of disc disease, stenosis, spondylolisthesis, radiculopathy, and deformity. MISS involves complex motor skills in regions of variable anatomy. Simulator use has been proposed to aid in training and skill retention, preoperative planning, and intraoperative use.
A systematic review of five databases was performed for publications pertaining to the use of virtual (VR), augmented (AR), and mixed (MR) reality in MISS and spinal endoscopic surgery. Qualitative data analysis was undertaken with focus of study design, quality, and reported outcomes. Study quality was assessed using the Medical Education Research Quality Instrument (MERSQI) score and level of evidence (LoE) by a modified Oxford Centre for Evidence-Based Medicine (OCEBM) level for simulation in medicine.
Thirty-eight studies were retained for data collection. Studies were of intervention-control, clinical application, and pilot or cross-sectional design. Identified articles illustrated use of VR, AR, and MR in all study designs. Procedures included pedicle cannulation and screw insertion, vertebroplasty, kyphoplasty, percutaneous transforaminal endoscopic discectomy (PTED), lumbar puncture and facet injection, transvertebral anterior cervical foraminotomy (TVACF) and posterior cervical laminoforaminotomy. Overall MERSQI score was low-to-medium [M =9.71 (SD =2.60); range, 4.5-13.5], and LoE was predominantly low given the number of purely descriptive articles, or low-quality randomized studies.
The current scope of VR, AR, and MR surgical simulators in MISS and spinal endoscopic surgery was described. Studies demonstrate improvement in technical skill and patient outcomes in short term follow-up. Despite this, overall study quality and levels of evidence remain low. Cohesive study design and reporting with focus on transfer validity in training scenarios, and patient derived outcome measures in clinical studies are required to further advance the field.
微创脊柱手术（MISS）和脊柱内镜手术在颈椎、胸椎和腰椎的适应证不断发展。脊柱内镜手术包括治疗椎间盘疾病、狭窄、椎体滑脱、神经根病和畸形。MISS涉及解剖结构多变区域的复杂运动技能。有人提议使用模拟器来辅助训练和技能保持、术前规划以及术中使用。
对五个数据库进行系统综述，以查找有关在MISS和脊柱内镜手术中使用虚拟（VR）、增强（AR）和混合（MR）现实的出版物。进行定性数据分析，重点关注研究设计、质量和报告的结果。使用医学教育研究质量工具（MERSQI）评分和证据水平（LoE）评估研究质量，证据水平采用经修改的牛津循证医学中心（OCEBM）医学模拟水平。
保留38项研究进行数据收集。研究包括干预对照、临床应用以及试点或横断面设计。已识别的文章说明了VR、AR和MR在所有研究设计中的使用。手术包括椎弓根置管和螺钉植入、椎体成形术、后凸成形术、经皮椎间孔内镜下椎间盘切除术（PTED）、腰椎穿刺和小关节注射、经椎体前路颈椎椎间孔切开术（TVACF）和后路颈椎椎板间孔切开术。总体MERSQI评分为低至中等[M = 9.71（标准差 = 2.60）；范围为4.5 - 13.5]，鉴于纯描述性文章或低质量随机研究的数量，证据水平主要为低。
描述了VR、AR和MR手术模拟器在MISS和脊柱内镜手术中的当前应用范围。研究表明，在短期随访中技术技能和患者预后有所改善。尽管如此，总体研究质量和证据水平仍然较低。需要有凝聚力的研究设计和报告，重点关注训练场景中的迁移效度以及临床研究中患者衍生的结局指标，以进一步推动该领域的发展。
