European Spine Journal

, Volume 28, Issue 7, pp 1697–1711 | Cite as

Implementation of augmented reality support in spine surgery

  • Barbara CarlEmail author
  • Miriam Bopp
  • Benjamin Saß
  • Benjamin Voellger
  • Christopher Nimsky
Original Article



To implement a straightforward workflow that allows to establish augmented reality (AR) support in spine surgery.


Intraoperative computed tomography (iCT) applying a 32-slice movable scanner was used for navigation registration in a series of 10 patients who underwent surgery for extra- or intradural spinal lesions. Preoperative multimodal image data were integrated by nonlinear registration with the iCT images. Automatic segmentation was used to delineate the 3-dimensional (3-D) outline of the vertebra, and in addition, the tumor extent, as well as implants, was segmented and visualized.


Automatic patient registration without user interaction resulted in high navigation accuracy with a mean registration error of only about 1 mm. Moreover, the workflow for establishing AR was straightforward and could be easily integrated in the normal surgical procedure. Low-dose iCT protocols resulted in a radiation exposure of 0.35–0.98 mSv for cervical, 2.16–6.92 mSv for thoracic, and 3.55–4.20 mSv for lumbar surgeries, which is a reduction in the effective radiation dose by 70%. The segmented structures were intuitively visualized in the surgical field using the heads-up display of the operating microscope. In parallel, the microscope video was superimposed with the segmented 3-D structures, which were visualized in a semitransparent manner along with various display modes of the image data.


A microscope-based AR environment was successfully implemented for spinal surgery. The application of iCT for registration imaging ensures high navigational accuracy. AR greatly supports the surgeon in understanding the 3-D anatomy thereby facilitating surgery.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Augmented reality Intraoperative computed tomography Low-dose computed tomography Navigation registration Spine tumor surgery 



We would like to thank J.-W. Bartsch for thoroughly proofreading the manuscript.

Compliance with ethical standards

Conflict of interest

B Carl, M. Bopp, B. Saß and B. Voellger declare that they have no conflict of interest. Ch. Nimsky received speaker fees from Brainlab.

Supplementary material

586_2019_5969_MOESM1_ESM.pptx (3 mb)
Supplementary material 1 (PPTX 3023 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryUniversity MarburgMarburgGermany
  2. 2.Marburg Center for Mind, Brain and Behavior (MCMBB)MarburgGermany

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