Mixed Reality in Spine Surgery: The Apple Vision Pro in Biportal Endoscopic Lumbar Fusion

Summary

This case report describes the first use of a mixed-reality head-mounted display during an endoscopic fusion procedure. The patient demonstrated meaningful clinical improvement following surgery, with complete resolution of leg pain and progressive improvement in back pain and functional status, sustained through the 7-month postoperative follow-up.

Abstract

The use of mixed reality (MR) in endoscopic spine surgery has recently been introduced, promising to enhance visualization, improve workflow, and support intraoperative decision-making. The successful use of the Apple Vision Pro (AVP) MR headset has recently been documented during biportal endoscopic spine surgery. To our knowledge, this case represents the first use of MR technology as an adjunct to biportal endoscopic spine fusion. An 81-year-old male with a history of lumbar stenosis and Grade 1 spondylolisthesis at level 4–5 presented with progressively worsening radicular pain refractory to conservative measures. Based on the clinical findings, the patient underwent a transforaminal lumbar interbody fusion (TLIF) via a biportal endoscopic approach. The procedure included endoscopic laminotomy, bilateral decompression, facetectomy, placement of an interbody cage with bone grafting, and posterior spinal instrumentation and fusion. Throughout the case, the operating surgeon wore the AVP MR Headset, which virtually displayed a live endoscopic view, over the real environment without obstructing the surgical field. The AVP consolidated the endoscopic feed directly into the surgeon's line of sight, eliminating the need to shift gaze between the operative field and external monitors and supporting a more ergonomic, streamlined operative workflow. The patient demonstrated complete resolution of radicular leg pain (VAS Leg 7 → 0) and marked functional recovery (ODI 14% → 2%) by two months postoperatively, with no intraoperative or postoperative complications, and these improvements were maintained through the seven-month follow-up. This case demonstrates the feasibility of using MR as an adjunct to biportal endoscopic lumbar fusion without observed complications. The AVP HMD provided an integrated, line-of-sight visualization platform that reduced reliance on external monitors and supported ergonomic surgical performance. Further investigation is needed to evaluate its effect on surgical efficiency and long-term patient outcomes.

Introduction

Biportal endoscopic spine surgery has been increasingly adopted as a minimally invasive alternative to conventional open approaches^1,2,3. With precise targeting and small-caliber instruments, biportal endoscopic spine surgery minimizes soft-tissue disruption while maximizing visualization^1,2. Additionally, the current literature has reported a potential reduction in postoperative analgesic use and intraoperative blood loss with endoscopy, suggesting a role for endoscopic techniques as a favorable option for outpatient....

Protocol

1. MR Integration Workflow

1. The digital endoscopic video console output was connected to an NDI encoder using an HDMI cable.
2. The NDI encoder was connected to a dedicated Wi-Fi router via Ethernet cable, and the Wi-Fi router was connected to the AVP.
3. The Wi-Fi router settings were optimized to ensure a fast and reliable connection.
4. The HMD was placed on the surgeon's head, and the digital 4K video projection was set to the surgeon's field of view prior to scrubbing into the procedure.
5. Once the surgical portals were established, the endoscopic video feed was projected into the surgeon's fiel....

Results

Clinical Outcomes
Immediately postoperatively, the patient reported a VAS back pain score of 6/10 and a VAS leg pain score of 0/10. Motor examination demonstrated 5/5 strength in all L2–S1 myotomes, with intact sensation throughout the bilateral L2–S1 dermatomal distributions.

At the 2-week follow-up, the patient reported improvement in back pain to 3/10, with leg pain remaining 0/10. The ODI score at this visit was 54%.

At the 2-month postopera.......

Discussion

To our knowledge, this is the first reported case to demonstrate the feasibility of integrating the AVP HMD as an intraoperative adjunct in an endoscopic fusion surgery. The patient demonstrated early symptomatic improvement, with complete resolution of leg pain and improvement in back and functional status by 2 months after surgery, and will continue to be monitored longitudinally for changes in symptom trajectory. It is worth noting that the transient worsening of functional status observed at the two-week postoperativ.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
dualPortal Semitubular Cannula	Amplify Surgical
dualPortal Sequential Dilators	Amplify Surgical
dualPortal T-Handle	Amplify Surgical
DualX TLIF Cage Inserter	Amplify Surgical
DualX TLIF Expandable TLIF Cage	Amplify Surgical
DualX TLIF Locking Screw	Amplify Surgical
DualX Bone graft funnel and inserter	Amplify Surgical
dualPortal Kerrison rongeurs	Amplify Surgical
dualPortal Curved curettes	Amplify Surgical
dualPortal Pituitary ronguers	Amplify Surgical
dualPortal Nerve hook	Amplify Surgical
dualPortal Ball tipped probe	Amplify Surgical
dualPortal Penfield dissectors	Amplify Surgical
dualPortal Annular dissector	Amplify Surgical
dualPortal Scope retractor	Amplify Surgical
dualPortal Hemostatic agent applicator tip	Amplify Surgical
Arthroscope, 0 degree	Stryker
High speed burr, 3 mm diamond matchstick tip	Stryker
Shaver, 4 mm oval fluted bone cutting tip	Arthrex
Radiofrequency wand, 90 degree	Arthrex
Radiofrequency wand, 50 degree small tip	Arthrex
Irrigation pump tubing	Arthrex
Surgifoam	Ethicon
DBM fiber allograft	Seaspine
NDI analyses system
MR Integration hardware
OSI Jackson table
tranexamic acid