Comparison of Mixed Reality-Assisted Spinal Puncture with Landmark-Guided Spinal Puncture by Novice Practitioners: A Pilot Study

Abstract

Background: Performing spinal anaesthesia in elderly patients with ligament calcification or hyperostosis is challenging for novice practitioners. This pilot study aimed to compare the effectiveness of mixed reality-assisted spinal puncture (MRasp) with that of landmark-guided spinal puncture (LGsp) by novice practitioners in elderly patients.

Methods: In this pilot study, 36 patients (aged ≥65 years) scheduled for elective surgery under spinal anaesthesia by anaesthesiology residents were included. Patients were randomly assigned to the MRasp group (n = 18) or the LGsp group (n = 18). The outcomes included the number of needle insertion attempts, redirection attempts, passes, the rate of successful first-attempt needle insertion, the rate of successful first needle pass, the spinal puncture time, the total procedure time, and the incidence of perioperative complications.

Results: The median number of needle insertion attempts was significantly fewer in the MRasp group than in the LGsp group (1.0 vs 2.0, P = 0.023). The proportion of patients with successful first-attempt needle insertion was 72.2% in the MRasp group and 44.4% in the LGsp group (P = 0.176). The incidence of perioperative complications did not significantly differ between the two groups.

Conclusion: This pilot study found that novice practitioners made significantly fewer needle insertion attempts in the MRasp group compared to the LGsp group when performing spinal anaesthesia on elderly patients. A future randomized controlled trial (RCT) is warranted to validate its effectiveness.

Trial registration: This trial was registered at https://www.chictr.org.cn/showproj.html?proj=178960 (ChiCTR-IPR-2300068520). Public title: Mixed reality-assisted versus landmark-guided spinal puncture in elderly patients: a randomized controlled pilot study. Principal investigator: Lei Gao. The registration date was February 22, 2023. The date of the first participant enrolment was February 27, 2023.

Keywords: augmented reality; computer simulation; mixed reality; spinal puncture.

Figure 1

MR visual presentation at puncture time with MRasp technology. The virtual image was fixed above the real body in space, and the trajectory was displayed on the image.

Figure 2

The gesture software used to convert and immobilize the virtual image. (A) Direction gesture. Palm opened and inwards. The direction of the index finger represented the superior direction of the patient’s real lumbar spine. The HoloLens quickly recognized the gesture and automatically adjusted the superior direction of the virtual spine image to be consistent with the direction of the index finger. The virtual image could follow the movement of the palm close to the patient’s body. (B) Lock/unlock gesture. Make two fists in two seconds. The HoloLens automatically fixed the virtual image, which would no longer move with the palm. (C) The visual effect of the image conversion functions conducted by the gestured software in the HoloLens.

Figure 3

Automatic trajectory design of MRasp. The optimal spinal puncture trajectory for MRasp was calculated automatically by using the Reacool medical mixed reality system and Huadong MRsp pathway algorithm. A: The skin zone corresponds to the spinous process of L3-L4 (entry zone). P: The subarachnoid space corresponding to the intervertebral space of L3-L4 (target point). B: All bony obstacles, such as the vertebral lamina, pedicle, articular process, spinous process, and irregular osteoproliferation, on the trajectory from A to P. L: The shortest distance between zone A and point P.

Figure 4

Three-dimensional visual effects of the MRasp. Relationships between the optimal spinal puncture trajectory and the 3D virtual lumbar spine. The upper right corners of both A and B display the angle between the trajectory and the X, Y, and Z axes, respectively, and the needle insertion depth.

Figure 5

Flow diagram of the study according to the CONSORT 2010 guidelines.