The integration of extended reality (XR) systems into neurosurgical practice reflects the field’s longstanding enthusiasm for embracing cutting-edge technologies.[ 9 ] Current XR systems, with their accurate 3D, dynamic, and interactive imaging capabilities, hold promise for planning and executing surgeries. Evidence from various surgical subspecialties suggests XR’s potential to enhance surgical precision, patient outcomes, and overall procedural efficacy.[ 1 , 3 , 11 , 18 ] However, quantifying the clinical impact of these innovative tools for neurosurgical use remains a formidable challenge given the broad and difficult-to-measure potential benefits and the variability in applications across institutions and surgeons.

Fortunately, the introduction of XR in neurosurgery parallels historical technological advancements that underscore the value of such innovations. The transition from traditional maps to global positioning system (GPS) technology serves as a relevant example, transforming navigation by replacing static maps with a dynamic, real-time, and multi-layered system.[ 6 ] The accuracy and utility of GPS made comparing it to map-based navigation unnecessary. It was simply superior.

Similarly, XR in neurosurgery provides a dynamic visualization of both normal and abnormal anatomy, improving intraoperative decision-making with crucial information overlays that augment the surgeon’s field of view.[ 10 ] These advancements facilitate an unparalleled understanding of complex anatomical structures, even though their superiority over traditional methods are challenging to prove directly. The undeniable superiority of GPS over maps hints at XR’s transformative potential over conventional imaging techniques in neurosurgery. As Korzybski famously said, “the map is not the territory,”[ 8 ] yet advances in XR technologies are bringing us closer than ever to replicating the real thing.

Quantifying the benefits of GPS over maps extends beyond measuring accuracy – it includes evaluating efficiency, safety, and user confidence. Similarly, the benefits of XR in neurosurgery extend beyond improved surgical outcomes to include improved performance and learning experiences for surgical trainees, enhanced cognitive and spatial awareness for surgeons, reduced operative times, and potentially fewer complications.[ 3 , 7 , 16 , 17 ] Digital XR technologies also offer new possibilities for patient engagement and education.[ 2 ] Nevertheless, the challenge of quantifying these benefits is compounded by the diverse metrics required and the subjective experiences of surgeons, trainees, and patients.

The evolution from typewriters to computers, which revolutionized information processing, communication, and creation, serves as another pertinent analogy.[ 14 ] XR in neurosurgery represents a similar advancement, providing an unprecedented level of data interaction and integration. However, its full impact is challenging to measure using conventional metrics. Furthermore, XR technology’s potential for connectivity and upgradability suggests a future where real-time, multi-layered information sharing and enhancement and AI-enhanced algorithms can continually improve the standard of care.

Measuring XR’s impact in neurosurgery is complicated by its variable application across different procedures, patient anatomies, and surgeon experiences. While some aspects, such as the accuracy of pedicle screw placement in spine surgery,[ 5 ] may be more straightforward to assess, evaluating the nuanced benefits of visualizing complex anatomical and functional relationships at the tumor-brain interface during tumor surgery is inherently challenging. Understanding how XR might address global disparities in surgical education and democratize access to surgical training, especially in resource-limited settings, is even more difficult to describe.[ 4 , 12 ] Furthermore, the rapid evolution of XR technology complicates longitudinal studies, as the tools and software may significantly change over time.

The landmark introduction of the operative microscope and the advent of the endoscope in neurosurgery, which significantly reduced patient morbidity and recovery times, illustrate the field’s capacity for rapid evolution and adaptation.[ 13 , 15 ] These milestones in neurosurgery, which were initially met with skepticism, have fundamentally altered surgical techniques and outcomes. The potential merger of these technologies with digital camera exoscope systems to permit augmented digital overlays illustrates the futuristic possibilities of integrating XR in neurosurgery.

Despite its advantages, XR’s full integration into neurosurgical practice is hindered not just by its novelty but significantly by integration challenges with existing navigation systems and intraoperative technologies. This is further complicated by the disproportionate cost relative to the perceived value of these systems. This echoes a broader issue in medical technology adoption, where initial investments and learning curves can obscure long-term benefits.

To overcome these obstacles, a multidisciplinary research approach is essential. By capturing both quantitative data (e.g., operative times and complication rates) and qualitative insights (e.g., surgeon satisfaction and cognitive workload), we can begin to uncover the nuanced impacts of XR in neurosurgery. Collaboration with industry partners is critical to integrating XR into the existing technological landscape and justifying investments without immediate financial returns despite the promise of significant long-term benefits in education and patient safety.

In conclusion, our personal experience suggests that dynamically interacting with an XR representation of complex anatomy or surgical procedures, both preoperatively and intraoperatively, enhances our surgical capabilities. However, empirically proving this enhancement remains a challenge. As we embark on a new era of XR in neurosurgery, we are reminded of technology’s transformative potential. Just as GPS and computers revolutionized their fields in initially intangible ways, understanding and quantifying XR’s impact is like exploring uncharted territory that promises to advance neurosurgery significantly. Embracing the complexity of this endeavor, along with the multidisciplinary effort and shared insights it requires, is not just a challenge but an opportunity to embrace and adapt these revolutionary technologies.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Bian D, Lin Z, Lu H, Zhong Q, Wang K, Tang X. The application of extended reality technology-assisted intraoperative navigation in orthopedic surgery. Front Surg. 2024. 11: 1336703

2. Curran VR, Hollett A. The use of extended reality (XR) in patient education: A critical perspective. Health Educ J. 2023. 83: 338-51

3. Dadario NB, Quinoa T, Khatri D, Boockvar J, Langer D, D’Amico RS. Examining the benefits of extended reality in neurosurgery: A systematic review. J Clin Neurosci. 2021. 94: 41-53

4. Davis MC, Can DD, Pindrik J, Rocque BG, Johnston JM. Virtual interactive presence in global surgical education: International collaboration through augmented reality. World Neurosurg. 2016. 86: 103-11

5. Dennler C, Jaberg L, Spirig J, Agten C, Götschi T, Fürnstahl P. Augmented reality-based navigation increases precision of pedicle screw insertion. J Orthop Surg. 2020. 15: 174

6. GPS: Technology that Truly Changed the World. Available from: https://www.forbes.com/sites/dianafurchtgottroth/2023/09/26/gps-technology-that-truly-changed-theworld/?sh=534b27225a20 [Last accessed on 2024 Mar 20].

7. Gupta N, Barrington NM, Panico N, Brown NJ, Singh R, Rahmani R. Assessing views and attitudes toward the use of extended reality and its implications in neurosurgical education: A survey of neurosurgical trainees. Neurosurg Focus. 2024. 56: E18

8. Korzybski A, editors. Science and sanity: An introduction to non-aristotelian systems and general semantics. New York: International Non-Aristotelian Library Publishing Company; 1933. p.

9. Marcus HJ, Hughes-Hallett A, Kwasnicki RM, Darzi A, Yang GZ, Nandi D. Technological innovation in neurosurgery: A quantitative study. J Neurosurg. 2015. 123: 174-81

10. Marrone S, Costanzo R, Campisi BM, Avallone C, Buscemi F, Cusimano LM. The role of extended reality in eloquent area lesions: A systematic review. Neurosurg Focus. 2024. 56: E16

11. Naito S, Kajiwara M, Nakashima R, Sasaki T, Hasegawa S. Application of extended reality (virtual reality and mixed reality) technology in laparoscopic liver resections. Cureus. 2023. 15: e44520

12. Rojas-Muñoz E, Cabrera ME, Lin C, Andersen D, Popescu V, Anderson K. The system for telementoring with augmented reality (STAR): A head-mounted display to improve surgical coaching and confidence in remote areas. Surgery. 2020. 167: 724-31

13. Shim KW, Park EK, Kim DS, Choi JU. Neuroendoscopy: Current and future perspectives. J Korean Neurosurg Soc. 2017. 60: 322-6

14. Swedin EG, Ferro DL, editors. Computers: The life story of a technology. London: Bloomsbury Academic; 2005. p.

15. Uluç K, Kujoth GC, Başkaya MK. Operating microscopes: Past, present, and future. Neurosurg Focus. 2009. 27: E4

16. Vervoorn MT, Wulfse M, Van Doormaal TP, Ruurda JP, Van der Kaaij NP, De Heer LM. Mixed reality in modern surgical and interventional practice: Narrative review of the literature. JMIR Serious Games. 2023. 11: e41297

17. Woodall WJ, Chang EH, Toy S, Lee DR, Sherman JH, Liu M. Does extended reality simulation improve surgical/procedural learning and patient outcomes when compared with standard training methods?: A systematic review. Simul Healthc. 2024. 19: S98-111

18. Zhang J, Lu V, Khanduja V. The impact of extended reality on surgery: A scoping review. Int Orthop. 2023. 47: 611-21