1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
2Computing + Mathematical Sciences, California Institute of Technology, Pasadena, California.
Neurosurg Focus. 2021 Aug;51(2):E15. doi: 10.3171/2021.5.FOCUS21210.
OBJECTIVE: Virtual reality (VR) and augmented reality (AR) systems are increasingly available to neurosurgeons. These systems may provide opportunities for technical rehearsal and assessments of surgeon performance. The assessment of neurosurgeon skill in VR and AR environments and the validity of VR and AR feedback has not been systematically reviewed. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted through MEDLINE and PubMed. Studies published in English between January 1990 and February 2021 describing the use of VR or AR to quantify surgical technical performance of neurosurgeons without the use of human raters were included. The types and categories of automated performance metrics (APMs) from each of these studies were recorded. RESULTS: Thirty-three VR studies were included in the review; no AR studies met inclusion criteria. VR APMs were categorized as either distance to target, force, kinematics, time, blood loss, or volume of resection. Distance and time were the most well-studied APM domains, although all domains were effective at differentiating surgeon experience levels. Distance was successfully used to track improvements with practice. Examining volume of resection demonstrated that attending surgeons removed less simulated tumor but preserved more normal tissue than trainees. More recently, APMs have been used in machine learning algorithms to predict level of training with a high degree of accuracy. Key limitations to enhanced-reality systems include limited AR usage for automated surgical assessment and lack of external and longitudinal validation of VR systems. CONCLUSIONS: VR has been used to assess surgeon performance across a wide spectrum of domains. The VR environment can be used to quantify surgeon performance, assess surgeon proficiency, and track training progression. AR systems have not yet been used to provide metrics for surgeon performance assessment despite potential for intraoperative integration. VR-based APMs may be especially useful for metrics that are difficult to assess intraoperatively, including blood loss and extent of resection.
目的：虚拟现实（VR）和增强现实（AR）系统越来越多地被神经外科医生使用。这些系统可能为技术演练和评估外科医生的表现提供机会。然而，VR 和 AR 环境中神经外科医生技能的评估以及 VR 和 AR 反馈的有效性尚未得到系统审查。
方法：按照系统评价和荟萃分析的首选报告项目（PRISMA）指南，通过 MEDLINE 和 PubMed 进行了系统综述。纳入了自 1990 年 1 月至 2021 年 2 月期间以英文发表的描述使用 VR 或 AR 来量化神经外科医生手术技术表现的研究，这些研究不使用人类评估者。记录了这些研究中每种自动性能指标（APM）的类型和类别。
结果：综述纳入了 33 项 VR 研究；没有符合纳入标准的 AR 研究。VR APM 可分为距离目标、力、运动学、时间、失血量或切除体积。距离和时间是研究最多的 APM 领域，尽管所有领域都能有效地区分外科医生的经验水平。距离成功用于跟踪实践中的改进。检查切除体积表明，主治外科医生切除的模拟肿瘤较少，但保留的正常组织较多。最近，APM 已被用于机器学习算法中，以高度准确地预测训练水平。增强现实系统的主要限制包括：用于自动手术评估的 AR 使用率有限，以及缺乏 VR 系统的外部和纵向验证。
结论：VR 已被用于评估广泛领域的外科医生表现。VR 环境可用于量化外科医生的表现、评估外科医生的熟练程度和跟踪培训进展。尽管 AR 系统具有术中集成的潜力，但尚未用于提供外科医生绩效评估的指标。基于 VR 的 APM 可能特别适用于术中难以评估的指标，包括失血量和切除范围。
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