Augmented reality in non-instrumentation minimally invasive spine surgery: a narrative review and future perspectives

Introduction

Minimally invasive spine surgery (MISS) has expanded beyond pedicle screw instrumentation to encompass a diverse range of techniques (1). This spectrum includes decompressive and discectomy procedures—such as tubular microscopic decompression, endoscopic discectomy, biportal endoscopic surgery, and microscopic surgery—as well as minimally invasive fusion techniques. Examples of the latter include lateral and anterior retroperitoneal approaches like extreme lateral interbody fusion (XLIF), lateral lumbar interbody fusion (LLIF), oblique lateral interbody fusion (OLIF), and anterior lumbar interbody fusion (ALIF). Although these procedures aim to reduce tissue disruption and accelerate recovery, they impose unique technical constraints, including a heavy reliance on precise anatomical orientation and depth perception within narrow, deep, or anatomically complex surgical corridors. Additional challenges include limited visualization, radiation exposure from fluoroscopy, and steep learning curves (Table 1).

While augmented reality (AR) has been actively explored in spine surgery, existing literature and prior reviews have predominantly concentrated on its application in instrumentation-focused procedures, such as pedicle screw placement and conventional minimally invasive fusion (2-6). As a result, the literature remains limited on AR use in the broader set of non-instrumentation MISS procedures, despite the high demands these workflows place on visualization and spatial orientation. Several key questions are still insufficiently explored: how can AR enhance visualization in tubular or endoscopic decompression? Can it improve efficiency and safety in percutaneous or endoscopic techniques? What technical challenges arise when integrating AR with microscopes or endoscopes in confined operative fields?

Addressing these questions is important because MISS frequently requires navigation where millimeters matter and anatomical landmarks are partially obscured. In this context, AR’s ability to overlay virtual guidance onto the real-world surgical field could offer transformative advantages through reduced radiation dependency and improved spatial navigation.

To address this MISS-specific gap, the present review provides a critical appraisal of AR applications across the full spectrum of MISS, with particular emphasis on non-instrumentation, decompression-dominant workflows in which visualization and spatial orientation are most limited. We evaluate current evidence regarding the clinical utility, technical performance, and workflow impact of AR in percutaneous, tubular, endoscopic, and microscopic MISS procedures. By clarifying the current state of evidence, identifying persistent technical and methodological limitations, and outlining future translational and research directions specific to MISS, this review aims to define the unique value proposition of AR in advancing MISS beyond conventional instrumentation-centered applications. We present this article in accordance with the Narrative Review reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-190/rc).

Methods

A comprehensive literature search was conducted across three major databases: PubMed, Embase, and the Cochrane Library. The search strategy incorporated both Medical Subject Headings (MeSH) and free-text terms. The search period was restricted to publications from January 1, 2010 to September 1, 2025.

Inclusion criteria were as follows: peer-reviewed publications, articles written in English, and relevant case reports or case series. Non-English studies were excluded. The selection process was independently performed by three reviewers to ensure consistency and minimize selection bias. Discrepancies were resolved through discussion and consensus (Table 2).

The findings were synthesized narratively using thematic analysis focused on technical applications, clinical outcomes, and comparative advantages across different non-instrumentation MISS procedures.

Discussion

The distinct advantage and integrative role of AR in non-instrumentation MISS

While AR has demonstrated clear advantage in instrumented spine surgery through enhancing pedicle screw placement accuracy, its role in non-instrumentation MISS is distinct. In contrast to instrumentation-centered workflows where accuracy metrics often predominate, non-instrumentation MISS depends on continuous spatial orientation and real-time anatomical clarity within deep, narrow, and visually restricted corridors. Accordingly, the evaluation of AR in this setting should extend beyond screw accuracy to include workflow efficiency, visual attention shifts, registration stability, and surgeon cognitive load.

The anticipated advantages are therefore fundamentally different: rather than preventing implant malposition, AR primarily aims to enhance real-time anatomical understanding, reduce fluoroscopy-associated radiation exposure, and facilitate the procedural learning curve through intuitive in-situ guidance. This distinction underscores the need for dedicated research frameworks and outcome measures tailored specifically to non-instrumentation MISS.

By addressing the core challenges of MISS—limited visualization, constrained spatial orientation, and heightened cognitive load—AR provides intuitive guidance without fundamentally altering established surgical workflows (Table 3). Given the procedural diversity within MISS, its role is best examined within specific operative contexts. The following sections therefore summarize current evidence for AR applications in major non-instrumentation MISS procedures, with study quality and level of evidence detailed in Table 4.

Lumbar puncture and percutaneous vertebroplasty

Early applications of AR in MISS have focused on technically less complex percutaneous procedures, including lumbar punctures and vertebroplasty, in part due to technical and equipment constraints (7,8,10,11). Across available studies, AR-assisted techniques achieve accuracy comparable to conventional computed tomography (CT) or fluoroscopic guidance while also offering distinct workflow advantages.

In simulated lumbar facet joint punctures, AR-assisted navigation achieved an accuracy of 97.5%, compared with 100% under CT-guidance, while eliminating the need for lead garments (12). Similar precision was shown in cadaveric biopsies of spinal metastases under magnetic resonance imaging (MRI)-AR navigation, with a mean deviation of 4.3±1.2 mm and efficient procedural times (13). A comparative study on lumbar models further reported equivalent target deviation between AR and fluoroscopy for epidural punctures, but AR reduced total operative time by two-thirds, suggesting a significantly shortened learning curve (14). Additionally, a pilot AR-guided vertebroplasty study reported successful needle trajectory planning without pedicle breach or cement leakage (15).

AR in tubular surgery

Tubular surgery is a representative technique within MISS and is primarily used to treat herniated discs and lumbar stenosis, and to perform transforaminal lumbar interbody fusion (TLIF) procedures (34). Integration of AR with the surgical microscope has yielded emerging and clinically relevant applications in tubular MISS (16-18,35). Visualization in this setting is inherently constrained by the narrow working corridor and deep operative field, and subtle anatomic cues may be obscured.

AR-assisted surface mapping enables surgeons to visualize preplanned trajectories and critical bony landmarks directly overlaid onto the patient’s anatomy (36). This in-situ guidance supports more accurate entry-point selection and trajectory planning.

After the tubular retractor is docked, surgeons must identify key anatomical structures under the microscope. With conventional CT-based navigation, this process often requires repeated pauses to confirm landmarks using a navigated pointer. This shifts attention between the operative field and the navigation monitor and can disrupt surgical flow. AR mitigates this limitation by directly highlighting relevant anatomical structures—such as the lamina, pars interarticularis, facet joint, pedicle, disc space, and neural elements—within the microscopic field of view (16,23). This real-time overlay reduces workflow interruptions, streamlines intraoperative decision-making, and enhances surgeon comfort by decreasing cognitive and physical demands, potentially minimizing fatigue-related errors (19).

Although AR-microscope navigation requires additional steps, including the fusion of preoperative planning CT with intraoperative navigation CT and subsequent system calibration, these processes are brief (approximately 5 and 2 minutes, respectively) and appear to have minimal impact on the overall operative workflow (16).

AR in endoscopic surgery

Endoscopic spine surgery (ESS) represents one of the most technically demanding procedures within MISS, particularly with respect to visualization and spatial orientation (37). In recent years, only a limited number of studies have begun to explore the potential role of AR in ESS.

In 2021, Jamshidi et al. reported the first clinical application of AR in ESS (20). The authors demonstrated that overlaying navigation data directly onto the surgical field was particularly advantageous during endoscopic TLIF. Furthermore, the ability to simultaneously visualize the operative field and three-dimensional imaging during hardware placement was shown to mitigate attention shift, thereby improving surgical workflow, operative efficiency, and patient safety (37,38).

In a separate case evaluating the Apple Vision Pro headset, Park et al. reported that AR not only effectively minimized attention shift but also enabled simultaneous display of patient medical records and preoperative imaging within the eyepiece, allowing surgeons to access relevant information intraoperatively (21). In addition, the AR display provided high-resolution (5K) endoscopic video with improved line-of-sight ergonomics directly in front of the surgeon’s eyes. This advantage was shown to significantly reduce perceived workload and ergonomic strain among endoscopic surgeons, suggesting a potential role for AR in improving surgeon well-being and the long-term sustainability of surgical practice (22). Notably, no latency or interruption was observed between the real-time endoscopic video and the AR display during surgery, ensuring procedural continuity and operational safety.

AR in microscopic spine surgery

Building upon the applications of AR in tubular and ESS, where visualization is constrained by narrow working corridors and limited lines of sight, the operating microscope represents a natural and widely adopted platform for integrating AR in MISS. As the most commonly used modality for magnification and illumination in MISS, the surgical microscope can be paired with AR technology as a standalone system, avoiding the need for head-mounted displays (29).

Early clinical use of AR-integrated microscopy in MISS focused on improving visualization of resection planes during spinal osteotomies and supporting orientation in complex keyhole procedures, including transvertebral anterior cervical foraminotomy and posterior cervical laminoforaminotomy (24,25). Subsequently, research groups from the University of Marburg and Weill Cornell Medicine respectively published a series of clinical studies evaluating commercially available AR-assisted microscope systems across a broad range of routine minimally invasive spinal procedures, including intradural tumors and lesions, extradural tumors, and degenerative spinal diseases (16-19,23,27-29,31).

Collectively, these studies demonstrated that when standardized workflows are rigorously followed, particularly with respect to achieving high registration accuracy and appropriate system calibration, AR-assisted microscopy can be applied across a wide range of spinal disease entities, anatomical regions, and surgical procedures traditionally addressed with conventional microscope-based techniques. Importantly, satisfactory navigational accuracy was reported for critical and complex anatomical structures, including revision cases, tumors, neural elements, and vascular structures (39). In more technically demanding and anatomically complex procedures, including cervical ossification of the posterior longitudinal ligament (OPLL) drilling and minimally invasive transfacet TLIF, AR-assisted microscope has been reported to provide satisfactory intraoperative guidance and encouraging surgical results (30,40).

AR in lateral approaches to the spine

AR navigation is increasingly used in lateral spinal approaches. Its main contribution often occurs during non-instrumentation steps such as corridor establishment and anatomical exposure, rather than implant placement alone.

Pojskić et al. first systematically reported the application of intraoperative CT-based AR navigation in various lateral spinal approaches, including discectomy and tumor resection, which typically do not involve implant placement. Their study showed that AR clearly delineates disc spaces, tumor margins, and adjacent critical structures (e.g., major vessels and nerve plexuses), thereby assisting surgeons with precise anatomical localization and lesion removal while reducing reliance on intraoperative fluoroscopy (32).

The recent study by Urreola et al. further clarified the utility of AR throughout XLIF/prone transpsoas procedures (33). Their findings indicate that AR navigation not only optimizes interbody cage placement but also plays a key role in critical non‑instrumentation steps such as establishing a transpsoas corridor, exposing the disc space, and preparing the endplates. By providing real‑time three-dimensional anatomical overlays, AR enables surgeons to safely traverse the psoas muscle, avoid neurovascular bundles, and efficiently plan and dock the working channel. These features may improve efficiency and procedural safety.

To date, no published studies have described the use of AR in OLIF or ALIF. As AR technology continues to mature and the demand for surgical precision grows, its applications in various lumbar fusion techniques are expected to grow.

Comparison of AR with existing navigation modalities

In contrast to AR-based navigation, CT-based navigation relies on real-time registration of intraoperative instruments with patient-specific CT imaging, providing the surgeon with multiplanar three-dimensional visualization on a separate monitor. Its principal advantages include a high pedicle screw placement accuracy (>95%), clear depiction of the spatial relationship between instruments and adjacent neural and vascular structures, reduced complication rates, and reduced surgeon radiation exposure (41-43). These benefits are particularly evident in cases with complex anatomy. However, CT navigation is limited by high equipment costs, the requirement for intraoperative CT acquisition, potential prolongation of operative time, and the risk of image drift (41,44).

Robotic navigation systems offer exceptional precision and reproducibility, with reported pedicle screw accuracy rates often exceeding 98% (45). These systems can significantly reduce the risk of neurovascular injury, promote procedural standardization and minimally invasive techniques, and further reduce surgeon radiation exposure (41,46). Nonetheless, adoption remains limited by acquisition and maintenance costs and a steep learning curve. In addition, guidance is often relatively static, with limited real-time feedback and no tactile information (47,48).

Fluoroscopy-based navigation remains widely used because of broad availability, real-time dynamic imaging, lower cost, and ease of use. It is particularly common in procedures requiring frequent adjustment, such as cement augmentation (47). However, major drawbacks include high radiation exposure, lack of three-dimensional visualization, relatively lower accuracy, and frequent interruptions to surgical workflow (41).

Overall, each navigation modality exhibits distinct strengths and limitations with respect to accuracy, cost, radiation exposure, workflow, and learning curve (as summarized in Table 5). In current clinical practice, there is an increasing trend toward hybrid navigation strategies, such as combinations of AR with robotic systems or AR integrated with CT- or fluoroscopy-based navigation (49-51). Future systems may pair AR’s intuitive visualization with robotic execution, supported by low-dose intraoperative imaging for calibration. This approach may help balance accuracy, safety, and operative efficiency (52). These comparisons underscore that AR should not be viewed as a replacement, but rather as a complementary visualization layer within multimodal navigation ecosystems.

Limitations and perspectives

A primary constraint in interpreting the current literature is the predominant reliance on low-level evidence. Table 4 shows that the vast majority of studies are level IV or V. These include small-sample, single-center feasibility reports, case series, and technical descriptions. There is a conspicuous lack of high-level (I–III) comparative studies directly evaluating AR against conventional navigation modalities in non-instrumentation MISS workflows. As a result, the current evidence is promising but remains preliminary. It is still insufficient to draw definitive conclusions regarding the superior clinical effectiveness or cost-benefit profile of AR in this specific domain.

Despite growing interest in AR-assisted spine surgery, several challenges must be addressed before broader clinical adoption.

Registration accuracy remains a central technical challenge. Submillimeter precision is essential to prevent clinically significant errors. This requirement is complicated by intraoperative bone motion and soft tissue deformation (29). In addition, current AR hardware still faces limitations in field of view, image resolution, system latency, and ergonomic comfort during prolonged procedures (53).

Standardization is another major requirement. Future research should focus on establishing unified protocols for image acquisition, registration, calibration, and intraoperative verification, as well as standardized workflows for operating room integration (54). These consensus frameworks would reduce inter-operator variability, facilitate multicenter studies, and improve reproducibility.

With regard to validation metrics, most existing studies emphasize pedicle screw accuracy relative to freehand techniques. More rigorous evaluation should incorporate quantitative measures such as registration error, angular and translational deviation, procedural efficiency, workflow disruption, complication rates, and surgeon cognitive workload. Comparative trials against CT-based navigation and robotic-assisted systems are particularly important to define the incremental clinical value of AR. Well-designed multicenter clinical trials are also strongly recommended. Future multicenter trials in MISS decompression could compare AR-assisted and conventional navigation with endpoints including complication rates, operative time, radiation exposure, and learning curve.

The integration of AR with artificial intelligence (AI) and robotic systems represents a key future direction. AI-based tools may enable automated image segmentation, recognition of critical structures, trajectory planning, and intraoperative risk prediction, Convergence with robotic platforms and force-feedback systems may enable a unified visual–haptic environment that improves precision and consistency (55,56).

Finally, seamless and aseptic workflow integration remains a practical barrier. AR platforms must interface efficiently with existing navigation systems, picture archiving and communication system (PACS), and endoscopic or microscopic setups without increasing cognitive burden (16). Addressing these challenges through standardized protocols, validated performance metrics, and intelligent system integration will be essential for guiding future research and advancing AR toward routine clinical use.

Conclusions

AR is a promising adjunct in MISS, particularly for non-instrumentation and decompression-dominant workflows where visualization and spatial orientation are limited. Current studies suggest that AR may improve intraoperative anatomical understanding, reduce visual attention shifts, and enhance workflow efficiency across a broad range of MISS procedures.

Nevertheless, the available evidence is largely derived from small, heterogeneous, single-center studies. AR should therefore be regarded not as a substitute for established navigation or robotic systems, but as a complementary visualization layer within multimodal navigation ecosystems. To define its role in routine MISS practice, multicenter clinical studies should prioritize clinically meaningful outcomes such as complication rates, operative time, radiation exposure, and learning curve. To translate this potential into clinical practice, we propose a staged research agenda that begins with standardizing workflow and performance metrics, advances to rigorous comparative trials, and culminates in seamless technological convergence. Through collaborative innovation, the integration of AR for intuitive visualization, AI for intelligent analysis, and robotics for precise execution holds the potential to enable a next-generation surgical platform that supports safer, more efficient, and more accessible MISS (57).

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-190/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-190/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-190/coif). D.C. serves as an unpaid editorial board member of Journal of Spine Surgery from December 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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