# Incorporating mixed reality head mounted display technology in biportal endoscopic lumbar surgery: an early feasibility study

## TL;DR

This study explores using Apple Vision Pro mixed reality glasses during spine surgery, finding no increase in surgeon workload or complications.

## Contribution

The study is the first to evaluate Apple Vision Pro as a visualization tool in biportal endoscopic lumbar surgery.

## Key findings

- AVP HMD use did not increase surgeon cognitive workload during surgery.
- No significant complications were observed with AVP HMD use.
- Patient outcomes improved significantly after surgery.

## Abstract

Mixed reality (MR) technology has emerged as a promising technology to endoscopic spine surgery by enhancing surgeon visualization. This early feasibility study introduces the Apple Vision Pro (Apple Inc., Cupertino, CA) Head Mounted Display (AVP HMD) as an intraoperative visualization tool during biportal endoscopic spine surgeries. The SURG-TLX is an established workload assessment tool specifically tailored for surgical procedures and is a specialized modification of the NASA-TLX, a widely established multidimensional measure for cognitive workload.

Adult patients undergoing biportal endoscopic lumbar surgery using the AVP HMD were prospectively followed. SURG-TLX Scores were recorded immediately after each operation to document the cognitive workload of using the AVP HMD during surgery. Demographics, intraoperative, and postoperative complications were collected and assessed. Patient reported outcomes (PROs) were recorded with visual analogue scores (VAS) Back and Leg pain, as well as Oswestry Disability Index (ODI).

Forty patients were included in this study. Patients were followed for 3 months after surgery. The mean age of the population was 62.78 ± 16.12 years, with a BMI of 27.90 ± 5.86, with 47.5% being female. Preoperative average VAS Back score was 5.4 ± 3.26, VAS Leg scores was 6.85 ± 2.43, ODI score was 44% ± 18.67%. Average SURG-TLX score was 22.24 ± 7.46. There were 2 intraoperative dural tears with no clinical sequelae, otherwise there were no perioperative complications. At 3 months follow-up, the average post-operative VAS Back was 2.71 ± 3.29, VAS Leg was 2.11 ± 3.19, and ODI was 21.0% ± 22.74, which were significant reductions as compared to the preoperative scores (p < 0.05).

This early feasibility study introduced the use of the AVP HMD during biportal endoscopic spine surgeries and showed that the AVP HDM did not increase the operating surgeon's perceived cognitive workload. The intraoperative use of AVP HMD did not worsen early clinical outcomes and did not increase the risk of complications. We describe the feasibility of incorporating MR technology such as the Apple Vision Pro for surgical visualization during endoscopic spine surgery.