Evaluation of the effect of standard neuronavigation and augmented reality on the integrity of the perifocal structures during a neurosurgical approach

Abstract

Intracranial minimally invasive procedures imply working in a restricted surgical corridor surrounded by critical structures, such as vessels and cranial nerves. Any damage to them may affect patient outcome. Neuronavigation systems may reduce the risk of such complications. In this study, the authors sought to compare standard neuronavigation (NV) and augmented reality (AR)-guided navigation with respect to the integrity of the perifocal structures during a neurosurgical approach using a novel model imitating intracranial vessels. A custom-made box, containing crisscrossing hard metal wires, a hidden nail at its bottom, and a wooden top, was scanned, fused, and referenced for the purpose of the study. The metal wires and an aneurysm clip applier were connected to a controller, which counted the number of contacts between them. Twenty-three naive participants were asked to 1) use NV to define an optimal entry point on the top, perform the smallest craniotomy possible on the wooden top, and to use a surgical microscope when placing a clip on the nail without touching the metal wires; and 2) use AR to preoperatively define an ideal trajectory, navigate the surgical microscope, and then perform the same task. The primary outcome was the number of contacts made between the metal wires and the clip applier. Secondary outcomes were craniotomy size, and trust in NV and AR to help avoid touching the metal wires, as assessed by a 9-level Likert scale. The median number of contacts tended to be lower with the use of AR than with NV (AR, median 1 [Q1: 1, Q3: 2]; NV, median 3 [Q1: 1, Q3: 6]; p = 0.074). The size of the target-oriented craniotomy was significantly lower with the use of AR compared with NV (AR, median 4.91 cm2 [Q1: 4.71 cm2, Q3: 7.55 cm2]; and NV, median 9.62 cm2 [Q1: 7.07 cm2; Q3: 13.85 cm2]). Participants had more trust in AR than in NV (the differences posttest minus pretest were mean 0.9 [SD 1.2] and mean -0.3 [SD 0.2], respectively; p < 0.05). The results of this study show a trend favoring the use of AR over NV with respect to reducing contact between a clip applier and the perifocal structures during a simulated clipping of an intracranial aneurysm. Target-guided craniotomies were smaller with the use of AR. AR may be used not only to localize surgical targets but also to prevent complications associated with damage to structures encountered during the surgical approach.