When Tom Furness first created a flight simulator in 1966 to help pilots gain access to 3D avionic data, he likely never imagined that this virtual reality (VR) technology would come to have applications in surgery.

Furness’s technology projected a 3D view field in front of pilot’s eyes and allowed them to use eye, head and hand-tracking motions to communicate with the machinery. After his work gained national attention, his phone began to ring off the hook. Everyone, including surgeons, were eager to apply this technology to their own career fields.

“[Virtual reality] is unlike any visual platform I’ve ever experienced—it is an actual immersive experience,” Kurtis Auguste, department of surgery chief at UCSF Benioff Children’s Hospital Oakland told UCSF. “I can use this to plan a surgery and determine the best roadmap to a target in a way I never could before.”

For neurosurgeons, surgical theater VR means being able to see and manipulate a 360° virtual reconstruction of the human brain—something that has never been possible before.

Virtual reality can also allow neurosurgeons to further their medical education, create more accurate and safe preoperative approaches to care and allow for more effective intraoperative surgical techniques, which can lead to better patient outcomes in the future.

Neurosurgical Education

In 2016, Stanford University became the first institution in the greater Pacific Northwest area to open its Neurosurgical Simulation and Virtual Reality Center, which would use patient-specific virtual reality technology for its neurosurgery clinics, in the operating room and for the education of its neurosurgery residents.

Virtual reality allows Stanford’s residency instructors to showcase different parts of the brain to their students while being able to rotate the view as needed to demonstrate how a tumor or aneurysm looks from different angles.

What’s more, residents can work together on difficult cases in virtual reality, going through each step as they progress through each corresponding part of the skull and brain.

Traditional neurosurgical training, which involves teaching students with 2D models and imaging and having them mentally translate those images into a 3D conceptualization of the human brain, can cause cognitive overload and lead to longer operation times as well as a greater likelihood for error, according to Weigl et al. 2015.

Yet, the virtual reality system Stanford is using allows for CT, MRI and angiogram images to be combined into a 3D model that can be analyzed and manipulated.

“It’s a window into the brain—and a window into the brain of the particular patient that we’re going to operate on,” Anand Veeravagu, the head of the Stanford Neurosurgical Stimulation Lab told Stanford Medical News Center.

And this new teaching tool is proving to have a significant impact.

A 2020 study published in BMC Medical Education examined the knowledge and skills of clinical undergraduates with 30 taught traditionally and 30 taught via virtual reality. Using data from 10 cases of skull base tumors, students were asked to identify surrounding tumors, understand the skull base structure, combine the location of the tumors and improve the conversion from 2D to 3D thinking.

Significantly more students in the virtual reality group self-reported being able to accomplish all of these tasks than in the traditional teaching group. For example, 83.3% of students in the virtual reality group indicated that they were able to improve the transformation from 2D to 3D thinking, while only 36.7% of students in the traditional teaching group reported being able to do so.

Additionally, students were scored using a basic theoretical knowledge test. Students in the virtual reality group scored higher in every category, including basic theory, tumor location, adjacent structure of tumor, clinical manifestation, diagnosis and analysis and operative approach.

While researchers believe that using virtual reality for neurosurgical education can greatly improve students’ mastery, interest and critical thinking skills, they note that virtual reality should only supplement and not replace traditional training.

For example, while 3D surgical simulation could teach residents the visuospatial skills required, it lacks physical feedback and interaction, according to Dr. Antonio Bernardo in his article, “Virtual Reality in Neurosurgical Training.”

“Neither is VR yet able to create the stress associated with surgery or the concomitant physiologic sequelae and necessary treatment intervention that accompany, for example, major hemorrhage or dangerous brain swelling,” he adds.

VR in Hospitals: Preoperative Planning

Sandi Rodoni thought she knew what to expect when going in for her third aneurysm surgery. But then her neurosurgeon introduced her to a virtual reality system where she was able to, for the first time, actually see the bulging blood vessel in her brain and where it needed to be clipped.

“Because I had been through this before, I thought I knew it all until I saw this,” Sandi told Stanford Medicine News Center. “I felt better knowing it was so clear to the doctor.”

And doctors are beginning to benefit from this clarity as well.

A 2020 study published in Neurosurgery examined the procedure time in 21 patients undergoing middle cerebral artery aneurysm clipping. In the study, 360° virtual reality models were used for preoperative planning in 10 patients, while the standard computed tomography angiogram and digital subtraction angiogram was used for preoperative planning in the remaining 11 patients.

The procedure time in the virtual reality group was significantly lower than in the control group, at 247.80 minutes vs. 328.27 minutes, respectively. Researchers believe that these results show that the use of virtual reality in preoperative planning for aneurysm cases could not only make the procedures faster, but safer.

What’s more, one study found that using VR in hospitals to practice with surgical equipment prior to an intracranial aneurysm repair procedure decreased mortality rates to 0%, according to Kockro et al, 2016.

The Kockro et al study examined use of the Dextroscope virtual reality neurosurgical planning system for the preoperative planning of 115 aneurysms in 105 patients. Of the 85 aneurysms in 77 patients that were performed electively and operated without previous subarachnoid hemorrhage, the overall favorable outcomes rate at six months was 97.4%. The obliteration rate of the aneurysms in this group was 91.8% and the mortality rate was 0%.

Of the 63 aneurysms that were clipped by neurosurgeons still in neurovascular training, 93.7% were obliterated and 100% of these patients had a favorable clinical outcome at six months.

While researchers note that their study was completed without the presence of a control group, they found that their results were comparable to that of similar studies published worldwide. They believe that their findings prove that virtual reality can provide both useful and accurate preoperative information for neurosurgeons.

Surgical Theater VR: What’s Next?

In cranial surgery, there is an increased demand for the use of intraoperative simulations that can be modified during surgery.

 JFK University Medical Center’s Neuroscience Institute is one of the few hospitals to use Surgical Theater®’s virtual reality technology that allows surgeons to create a 360° reconstruction of a patient’s brain and then use a headset and joysticks to “fly through” the patient’s unique anatomy.

Intraoperatively, the virtual reality system can be used in conjunction with conventional surgical software to create a “3D GPS system for the brain,” Dr. Yevgenia Shekhtman describes to Hackensack Meridian Health.

“The traditional software shows us where we are in the brain in black-and-white MRI slices,” he continues, “with virtual reality, we can also see the 3D version of that, so we have multiple screens working at the same time.”

What’s more, Surgical Theater® had recently received FDA approval for the integration of its 3D virtual reality technology with operative microscopes. This will allow neurosurgeons to see where they are in the brain in relation to the 3D image at any time during the surgery and will even allow them to “zoom” inside the brain.

“I think in five to 10 years, almost every site that does high-level neurosurgical care will be using it,” Dr. Thomas Steineke, a neurosurgeon and chairman of the Neuroscience Institute, told Hackensack Meridian Health.

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