What if Your Surgeon Had X-Ray Vision?

Spine surgeons at UConn Health are using augmented reality technology that provides a 3D rendering of the anatomy, essentially enabling “see-through” surgery. UConn Health is the first in central Connecticut with this suite of tools, which as of July 2022 is the world’s largest. Dr. Isaac Moss, UConn Health’s orthopedic surgery chair and co-director of its Comprehensive Spine Center, describes how augmented reality spine surgery works and what its advantages are.

(Dr. Isaac Moss, Chris DeFrancesco, July 2022)


Chris: What if you went in for a procedure and your surgeon had x-ray vision? Today on the Pulse, we learn about a fascinating new high-tech approach to complex surgeries.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better. And hopefully leave you with some health information you’ll find useful.

I’m Chris DeFrancesco. Now it doesn’t get much more complex than surgery involving the spine. And UConn Health is the first in central Connecticut with a suite of tools that enables spine surgeons like Dr. Isaac Moss to essentially see through the skin while performing minimally invasive procedures and Dr. Moss, who chairs, UConn Health’s department of orthopedic surgery and co-directs its Comprehensive Spine Center, joins us now. Thank you for the time today, Dr. Moss.

Dr. Moss: Thanks for having me, Chris.

Chris: We’re talking about augmented reality spine surgery today. UConn Health is one of the earliest adopters of this. So let’s start with, what do we mean by augmented reality in terms of spine surgery?

Dr. Moss: Right. In the world of tech, virtual reality is something that’s very popular, and virtual reality is an immersive experience, where, for instance, you put on some goggles, you don’t see anything going on around you and you’re in a virtual world. That’s exciting and entertaining, but not a great way to treat a patient, because a person is right in front of you. What augmented reality does, it takes the reality we live in, which is the world, and it overlays information on that world that helps you be more successful with whatever you’re trying to do.

So in this case, as you said, when we operate on someone’s spine, they’re enveloped in skin, in muscle, and all sorts of things. Now that’s good, because we need that to function. But as a spine surgeon, when we need to get down to the nerves, which are very deep in somebody’s body, that sometimes is an impediment in traditional spine surgery. We would open the patients up, we would really expose a lot of their tissue in order to get down to the spine itself. And some of that is collateral damage, meaning it wasn’t even necessary to do that because you really needed to get down to the spine, but in or to get there, that tissue had to be removed.

The concept of minimally invasive spine surgery is trying to limit that kind of collateral damage and just focus on the areas where we’re working. Traditionally, this has been done with a lot of different technologies, like using x-rays, using live x-rays in the operating room, comparing that to preoperative cat scans or MRIs and things like that. But the idea is if we can meld all those technologies together, we can provide a better solution, a safer solution to these patients that we’re doing surgery on.

Chris: What are some of the things that you can treat using this approach?

Dr. Moss: What’s interesting can be used from very, very simple spine problems to very complex spine problems. A very common operation that we do is something called a spinal fusion. A spinal fusion is where a portion of somebody’s spine has some sort of instability, meaning it’s moving in a non-healthy or non-normal way. And that leads to pain, that can lead to pressure on nerves that can lead to a bunch of other problems that will impede people’s functions.

What we do in the surgery is, we stop that abnormal motion, usually by putting in implants, things like we call screws — a little bit different than you get at home Depot, but, same concept — and those screws can weld bones together. Any surgery really that needs spinal implantation of medical devices in order to stabilize the spine can be used in this technology.

Sometimes we may not need to put anything into the spine, but patient’s particular anatomy is so abnormal or so different than what we’re used to, it’s actually just hard to find your way within the patient’s spine. So you can use this technology to kind of guide you towards an area of interest that otherwise would be very difficult to find.

What’s nice about this technology, it can almost be applied to anything from the very simple to the very complex. So there’s people that have, let’s say a one-level fusion, which means they have a problem in one particular area of the spine, and we can use this to make that surgery easier, more reliable, perhaps more efficient, but also some people have things like scoliosis, we call a spinal deformity, meaning their spine is really misshapen, and we want to try to reshape them into a more functional shape, basically. And in order to do so, often you’re addressing multiple levels of the spine, for instance, the entire lumbar spine sometimes. This technology can be used to augment that type of surgery as well.

Chris: We don’t have the advantage of the visual here in this format, but let’s try to paint a picture of kind of what it’s like from your perspective, you’re wearing some type of Goggle or head gear, something like that?

Dr. Moss: Yeah, this is kind of, the cool factor of this I think is very, very high and what’s nice about this one is it’s something that I think is impressive to the surgeon, but also to the patient, right? To anybody who sees it really. The first thing we need to do is actually acquire an image of a patient, a three-dimensional image.

And so part of the technology that we have is that the ability to do this in the operating room itself, people are familiar with getting CAT scans or MRIs before surgery, which are very helpful for planning. But if you think about it, you’re doing that in a different position than you are when you’re on the actual operating table. So what we can do now is, we acquired two technologies which allow us to capture the three-dimensional imaging, like a intraoperative CT scan in the position that you’re actually doing the surgery. So we’re getting more real time information. That information is then uploaded into a computer navigation system, which really turns it into a three-dimensional model.

Now, That’s happening in the background. Meanwhile, the surgeon wears a headset, which basically has a pair of glasses on it and the glasses are see-through, but also projected image. Remember Google Glasses, that kind of were there and gone pretty quickly? But it’s no different than say like a heads-up display in your car that you may have, or something like that where you can still see the road, but now you can see your speed, your navigation instructions, and all those things on the windshield itself. So when we wear this headset, which is synced to the navigation computer, I can still see my patient that I’m operating on, but as well, I can see the CT scan, which is kind of projected into a corner. And then when I look through the patient’s skin, you see a three-dimensional rendering of the person’s spine.

This is really the closest — I was a big Superman fan growing up, and I don’t say growing up, I’m still a big Superman fan — so this is the closest, I think I’ve gotten to x-ray vision. In fact, the technology is called Xvision, and the idea is, now I’m looking at the patient naturally, but also getting this extra information. The reason this is important is, navigation is not a new thing, it’s been around for a long time, but — in traditional navigation systems, the imaging is projected onto a screen. So you’re looking up at a screen while you’re operating on a person, which is not a natural way to operate. And I think there’s some disadvantages, because your attention is now split between the person that you’re taking care of and the screen, which is giving you the information. This brings this all together, so all the information I need. Is there projected onto the patient so I can keep my attention focused on exactly what I’m doing.

Chris: Well, you’ve got me convinced if I need to get spine surgery, I would feel better knowing going in that everything you’ll need to see will be in that field of vision without you having to keep turning away. And I would think that helps make it even less invasive than otherwise might be?

Dr. Moss: The invasiveness, I think, is less of it. I mean there are certain times where yes, you can do more with less, meaning, do more surgery with less incision, but again, there’s times where we would actually open up the patient not to do kind of traditional thing, which is necessary, but also this gives us more information because again, even once we look at your spine, You’re only seeing the surface of it. There’s a lot that goes on. It’s a three-dimensional object, right, and there’s a lot that goes on deep. Where are the nerves? Where are the blood vessels? Where are the things that are important? This gives us all that information at our fingertips. So sometimes it’s minimally invasive, sometimes it may be a more invasive operation, but still gives us the information we need in order to do this safely.

Any surgeon that puts this on — I’ve been at, at meetings and things like that — they’re wowed by this because it’s such a difference compared to what we’re used to. And it really is next-gen in terms of the way we should be treating our patients and the way that we can incorporate this awesome technology into an operating room.

Chris: You’ve been here for a good little while.

Dr. Moss: 11 years now.

Chris: Right. When you were training to be a spine surgeon, if you could go back and tell trainee Isaac Moss that this was something that you would be doing, what would you as a trainee think of this?

Dr. Moss: Oh it’s cool. I mean, it’s, it’s a funny question because. When I started, residency, I had no idea I would be a spine surgeon, actually. I was thinking about hand surgery, something else. The first day I showed up to residency, in Toronto is where I did my training, and Dr. Raj Rampersaud, he was really at the beginnings of navigation technology. This was on a screen, this was two-dimensional, there was, it was like sixth or seven generations behind. But that’s what, when I saw that it really opened my eyes. I’m like, “This is a field I want to be a part of,” because there’s so much room for innnovation, right? And to think where things have come, because this was so rudimentary at the time — this was in 2003 I think when I saw this originally — and to see where things have come is just amazing. But when I think about it, this was the spark that said I should become a spine surgeon because I saw this kind of opportunity in the field to really make change, to really be involved in cutting edge. And while we can use this — in surgery, there’s robotics, there’s all these other things that we use in multiple surgeries — but something about the spine and seeing this come together really just opened my eyes. And it is cool to kind of think back, that was, what is that almost 20 years ago almost? It’s kind of scary, because we’re all aging here. But, that was 20 years ago, and to see where we’ve come and being able to really take advantage of the various generations over the years is kind of something that’s very exciting for me personally.

Chris: Since you’ve been here, this is not the first time that UConn has had innovative technology to help with spine surgery or neurosurgery. So talk a little bit about where Yon health kind of is in the big picture of this type of technology.

Dr. Moss: We were also the first in the area to have robotic spine surgery, which was something, again, another navigation technology, and it’s kind of a separate thing, but towards the same idea is how can we do what we need to do in the spine in a safer way? First of all, just the idea of minimally invasive or less invasive surgery is something that is really relatively new I mean over the past 20 years, and something that I did specific training in in chicago and brought to this institution, and it’s become a large part of my practice. I needed to use a lot of intraoperative x-ray when I came here, because that’s just all we had. Several years ago, we acquired robotic technology, which allowed us to, again, guide our hands, basically using robotic technology and navigation in a similar way, but different, to do the surgeries that we do. And this is kind of the next iteration of that technology.

Chris: Do other spine surgeons here beside you use this technology? Or will they?

Dr. Moss: Yes, all of our spine surgeons, and we’re very fortunate we have six very well trained, excellent spine surgeons, both neurosurgeons and orthopedic surgeons — and my plug is, by the way, people always ask, “Do I need an orthopedic surgeon or a neurosurgeon?” No, you need a spine surgeon, which is someone that has expertise in the spine. And all of our doctors take advantage of the technology available to them.

Chris: Are there other potential applications for this approach to surgery that might even go beyond what you’re using it for now, even outside of spine surgery?

Dr. Moss: Yeah. One of the most exciting things is, this really can be used anytime you’re trying to access an area of someone’s body that may not be easy to get to. So for instance, actually, the first day we had this technology in place, one of my colleagues, Dr. Lindsay, who treats bone cancers, had a patient with a tumor in his pelvis, which is a difficult area to reach. And usually we get this biopsy by a radiologist; they tried, they couldn’t get to the spot. This was a very tough spot to use. So he used this technology to access, to get a diagnosis on this patient’s tumor, which otherwise was very, very difficult. And this was just early on. So really the sky’s the limit. And one of the nice things about having this technology in a university, part of what our mission is, is certainly to treat patients, but it’s also to advance knowledge. And we’re lucky we have a group of doctors who are extremely thoughtful, but also inquisitive. And they look at these things and say, “OK, how can I use this to help my patients?” so I, I think this is something that’s just gonna progress over time and we’ll find other uses for it, for sure.

Chris: In the couple minutes we have left, what is the best way, for someone listening to this, what’s the gateway to a consultation to find out, “Oh, I might be a candidate for this, or my loved one might be a candidate for this.” How do they get in to kind of find out?

Dr. Moss: It is a good question because you have to remember that everybody, or 85% of the population, will have back pain at some point in their life. And thank God most people never need spine surgery. Just because your spine hurts, you don’t need to go see spine doctor. But there are a lot of people who, unfortunately, despite physical therapy, conservative care — which is what we always recommend anyways — that doesn’t work. So the best way is, No. 1, be evaluated probably by your own doctor, see if this is something that he or she thinks is amenable or potentially amenable to surgery. And then call our comprehensive spine center. We call it “comprehensive” because it is true to that, meaning most of the people we see never have surgery, which is good because most people don’t need it. In our spine center, we have spine surgeons that I’ve talked about, both orthopedic and neuro spine surgeons, we have advanced practice nurses, we have physician assistants who can see a variety of patients and understand where they can fit into the continuum of care. We also have physiatrists, and physiatrists are physical medicine and rehabilitation doctors who can prescribe specific rehabilitation who can perform injections to treat people’s pain. We also have a physical therapy department. So we have all these services available where we can really treat almost any pathology. And again, a small number will ever need surgery, but give us a call. Come in and see us. We’ll be very happy to evaluate you and make sure you’re on the right path to getting you back to function, which is really what we’re dealing with.

Chris: And we’ll put some links to find out more in the notes of this show. So as people listen, they can just click their way through and find out what they need to find out in order to connect with you.

Dr. Moss: Perfect.

Chris: Anything else before we say goodbye? Anything else we should know about augmented reality spine surgery, Dr. Moss?

Dr. Moss: I think it’s just an exciting time for surgery. And I think as these technologies become more robust and we’re just gonna see more and more applications of really, of this very advanced, very, I’ll say, cool, because there’s really no better word for it. It’s just, it’s an amazingly cool technology that is not only, I would hate to say fun to use, but it is, and helps people, and makes our job, easier and better. So I think we’re an exciting time in general and, we really try here at UConn to be at the forefront of that, look for these new technologies, evaluate the new technologies and see which are the ones that we think can help our patients, and then bring those to the people of Connecticut.

Chris: And importantly, this is an option at UConn Health that isn’t widely available at the present.

Dr. Moss: No. I mean, there’s very few centers. We’re actually the biggest install in the world. We have the biggest augmented reality program in the world right now, which is fun to say, but it just means that we’re bought in, really. And I think we really want to bring this technology to the patients that we serve. That’s why when we see something — and again, remember, there’s a lot of technologies out there — we spend our time really triaging and figuring out, curating almost, what are the technologies that can help our patients?

And those are the ones we choose. And when we choose them, we really want to understand them to learn, them, and again, use them for the best applications we can to help our patients.

Chris: Augmented reality spine surgery — essentially, x-ray vision for the surgeon. Fascinating! Dr. Isaac Moss, chair of orthopedic surgery and co-director of the comprehensive spine center at UConn Health, thank you so much for the time today.

Dr. Moss: Thanks for having me, Chris.

Chris: For Dr. Isaac Moss. I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Now be sure to subscribe so you can catch us next time, and please share with a friend.