The Utilization of Navigation and Emerging Technologies With Endoscopic Spine Surgery: A Narrative Review

Abstract

Endoscopic spine surgery (ESS) is growing in popularity worldwide. An expanding body of literature demonstrates rapid functional recovery with reduced morbidity compared to open techniques. Both full endoscopic spine surgery, or uniportal endoscopy, and unilateral biportal endoscopy (UBE) can be employed in conjunction with various navigation and enabling technologies for assistance with localization of anatomic orientation and assessment of the intraoperative target spinal pathology. This review article describes various navigation technologies in ESS, including 2-dimensional (2D) fluoroscopic imaging, 2D fluoroscopic navigation, 3-dimensional C-arm navigation, augmented reality, and spinal robotics. Employment of enabling navigation and emerging technology with the registration of patient-specific anatomy enables clear delineation of anatomic landmarks and facilitation of a successful procedure. Additionally, avoidance of common pitfalls during use of navigation systems in ESS is discussed in this review.

Keywords: Enabling technology; Endoscopic spine surgery; Full endoscopic spine surgery; Navigation; Unilateral biportal endoscopy.

Fig. 1.

Two-dimensional navigation requires only 3 single xray images, allowing the procedure to begin without any additional radiation exposure.

Fig. 2.

(A) A 2-dimensional surgical navigation system displays instrument trajectory on both an anterior-posterior x-ray view and a lateral view for multilevel endoscopic decompression in the lumbar spine, with (B) appropriately positioned reference and endoscopic trocar tracking arrays.

Fig. 3.

Unilateral biportal endoscopy procedure with utilization of optical navigation (A) and full endoscopic spine surgery (FESS) procedure with utilization of optical navigation (B) for a foraminotomy. (C–E) Positioning of the reference array on the posterior superior iliac spine, dilator, and endoscope are demonstrated in a FESS with navigation decompression procedure in the lumbar spine. (F, G) User interface of the navigation system demonstrating the navigated probe in the laminar area and corresponding endoscopic view at the laminar area.

Fig. 4.

Utilization of augmented reality technology and headset in an endoscopic lumbar fusion case.

Fig. 5.

Intraoperative demonstration of an augmented reality interface from the surgeon’s perspective.

Fig. 6.

The endoscopic trocar is guided by the navigation dilator and reference arrays.

Fig. 7.

(A–C) A custom dilator consisting of an inner diameter large enough to accommodate the shaft of the navigation pointer can be utilized during the initial approach in endoscopic cases. The custom dilator is coupled with the pointer, allowing for easy docking to any anatomical landmark using navigation. After the pointer is docked, the dilator can be pushed down and the pointer removed. This technique can be used to ensure that the targeted landing spot is not lost once it has been found, as the need to switch between pointer and initial dilator is eliminated.