Low-Cost Augmented Reality System in Endoscopic Spine Surgery: Analysis of Surgeon Ergonomics, Perceived Workload and A Step-by-Step Guide for Implementation

Abstract

Study DesignProspective controlled study.ObjectivesTo evaluate the impact of an augmented reality (AR) visualization system on surgeon workload and ergonomics during endoscopic spine surgery, compared to conventional display monitors.MethodsTen experienced endoscopic spine surgeons (five neurosurgeons and five orthopedic surgeons; mean age 54 years) each performed 20 surgeries: the first 10 using traditional displays and the following 10 with a novel AR system. A step-by-step guide for AR system setup and utilization is provided. Workload was assessed using the NASA Task Load Index (NASA-TLX), and ergonomics were evaluated using the Rapid Upper Limb Assessment (RULA) score after each procedure. Paired t-tests or Wilcoxon signed-rank tests were used to compare traditional and AR systems, with normality assessed via the Shapiro-Wilk test.ResultsUse of the AR system resulted in significantly lower NASA-TLX scores, particularly in physical demand, effort, and performance domains (P < 0.001). RULA scores improved substantially, decreasing from a mean of 6.0 with traditional displays to 3.0 with AR (P < 0.001), indicating improved ergonomic posture. All surgeons demonstrated consistent reductions in perceived workload and ergonomic risk when utilizing the AR system.ConclusionsIntegration of an AR visualization system in endoscopic spine surgery significantly reduces cognitive workload and improves ergonomic posture compared to traditional displays. These findings suggest that AR technology may enhance surgical efficiency, promote surgeon well-being, and support the long-term sustainability of minimally invasive spinal procedures.

Keywords: augmented reality; endoscopic spine surgery; ergonomics.

Figure 1.

Information Flow in the AR System is Depicted. At the Top of the Diagram are the Connections Required to Wirelessly Receive the Endoscopic Camera’s Image on the Headset (X-ray Image is Optional). At the Bottom of the Diagram is the Preoperative Loading of Software and Medical Images onto the Headset

Figure 2.

Intraoperative Use of the AR System. Note that the Surgeon’s Neck and Head Can Remain Neutral and Relaxed or Be Adjusted Without Relying on Physical Monitors

Figure 3.

Different Virtual Display Setups are Shown. As Stated, Dimensions and Positions can be Freely Adjusted Without Limitations. In the Background of the Image, a Physical Reference Monitor Can be Seen

Figure 4.

AR 3D Model of the Patient’s Spine, Generated from a CT Scan. The Model can be Decomposed into Individual Vertebrae, and Both the Size and Position of Each Component Can be Adjusted as Needed

Figure 5.

RULA Score Measurements Using Intraoperative Pictures from Three Different Angles. A, B and C: Surgery Using Conventional Displays. D, E and F: Procedure Using the AR Device

Figure 6.

Surgeon-Specific Changes in NASA-TLX and RULA Scores Between Visualization Systems. Each Line Represents an Individual Surgeon’s Average Score under Traditional Display (Left) and Augmented Reality (AR) System (Right). Left Panel: NASA-TLX Total Workload Score. Right Panel: RULA Ergonomic Risk Score. A Consistent Reduction in Both Metrics is Observed Across All Surgeons When Using the AR System