Virtual reality force feedback spine surgery simulator training for pedicle screw placement: assessing the impact of seniority and spinal region

Abstract

Objective

To evaluate the efficacy of Virtual Reality Force Feedback Spine Surgery Training Simulators (VRFF-SSTS) in enhancing the skills of spinal pedicle screw placement (PSP) among orthopedic fellows in continuing medical education, and whether influenced by seniority and spinal location.

Methods

A multi-centered, cross-sectional study enrolled fellows from three tertiary care referral hospitals. Participants were categorized into three groups (A, B, and C) based on their post-graduation year (PGY), reflecting their hierarchical order of spine-surgical training: A (PGY1-5), B (PGY6-10), and C (> 10). Participants performed SPSP in the spinal saw bone model using the free-hand technique first, followed by training on IVRSS. The outcome before and after training was assessed on placement accuracy and overall competency through an objective rating scale.

Results

Sixty-four participants were included, with PGY A, B, and C 18 (28.1%),30 (46.9%), and 16 (25.0%) participants, respectively. Pre-training data indicated that screw placement accuracy improved with increasing seniority. The accuracy of lumbar pedicle screw placement surpassed that of atlantoaxial, subaxial cervical, and thoracic vertebrae. Post-training, there was a significant enhancement in screw placement accuracy across all groups compared to pre-training (p < 0.001), with no significant differences observed between seniority levels and spinal regions. Overall competency significantly improved following training, with PGY B and C fellows, who had prior experience with pedicle screw insertion, demonstrating more satisfactory performance.

Conclusion

VRFF-SSTS proves to be an invaluable tool for training surgical skills, capable of enhancing the accuracy of pedicle screw placement for junior spine surgeons within a constrained training period. However, the overall competency in pedicle screw placement remains superior among experienced surgeons compared to their junior counterparts, underscoring the ongoing importance of clinical practice.

Clinical trial number

Not applicable.

Background

Pedicle screws are widely employed in spinal surgery due to their ability to provide three-column stability, encompassing a range of applications such as degenerative diseases of the cervical, thoracic, and lumbar spine, spinal trauma, spinal tumors, and spinal deformities. The utilization of pedicle screws offers several advantages, including the provision of robust fixation, the potential to correct spinal deformities, a reduction in the risk of instrumentation failure, and a decrease in the incidence of pseudoarthrosis [1,2,3]. Furthermore, the use of pedicle screws enhances the stability of vertebral segments and facilitates the restoration of spinal alignment. However, the attainment of favorable outcomes with the use of pedicle screws is closely linked to the accuracy of pedicle screw placement. The reported accuracy rates for pedicle screw placement in the literature range from 85–95% [3,4,5,6], which primarily reflects technical proficiency but does not fully elucidate the clinical implications of screw misplacement for individual patients. A study revealed that out of 127 patients, 35 (27.56%) presented with indeterminate misplacements, and 18 (14.17%) had screws categorized as “at risk.” Consequently, more than 40% of the patients had screws that were of either some concern or major concern [4].

Given the proximity of pedicle screws to the spinal canal and surrounding vasculature, any misplacement can result in severe complications. Consequently, ensuring the accurate and safe placement of these screws is a critical aspect of the surgical procedure. The serious complications of pedicle screw malpositioning include potential neurovascular injuries such as vertebral artery (VA) damage from lateral misplacement, dural sac or spinal cord injury due to medial misplacement, and nerve root injury resulting from superior or inferior misplacement [7, 8]. For this reason, it is typically necessary for novice surgeons to undergo comprehensive pedicle screw placement training before performing the procedure. This ensures optimal accuracy in screw placement and mitigates the risk of procedure-related complications.

However, medical education is currently undergoing significant transformations due to advancements in medical technology, the adoption of concepts such as day surgery and enhanced recovery after surgery (ERAS), and the implementation of stringent healthcare quality assurance measures. As a result, there has been a marked reduction in practical training opportunities for junior doctors [9]. Consequently, it has become increasingly unacceptable and inappropriate for junior spine surgeons to practice skills on real patients at any stage of their training. With the advancement of virtual reality (VR) technology, its application has extended to medical education. Virtual Reality Force Feedback Spine Surgery Training Simulators (VRFF-SSTS) are based on VR technology and provide trainees with an immersive surgical experience [10,11,12]. By simulating surgical procedures, trainees can practice and master advanced surgical skills without posing any risk to patients. VRFF-SSTS mainly consists of 2 parts: a VR image system that can recreate the operative scene and a simulation system for pedicle screw placement with a tactile feedback function. Previous studies have assessed the effectiveness of VR in training young doctors for pedicle screw placement [10, 11, 13]. However, these studies were limited by their single-center design and small sample sizes. Additionally, they did not account for the potential influence of surgeon seniority and spinal surgical location on training outcomes, nor did they include evaluations of the VR system by trainees. Therefore, the objective of our study is to evaluate the efficacy of VRFF-SSTS in enhancing the skills of spinal pedicle screw placement (PSP) among orthopedic fellows in continuing medical education, while considering the impact of seniority and spinal location.

Methods

Subjects

This is a multi-centered, cross-sectional study enrolled fellows from three tertiary care referral hospitals. Sixty-four fellows for spinal surgery were voluntarily recruited for this study. Participants were categorized into three groups (A, B, and C) based on their post-graduation year (PGY), reflecting their hierarchical order of spine-surgical training: A (PGY1-5), B (PGY6-10), and C (PGY > 10).

Study design

The institutional review board assessed the project and determined it to be exempt. Participants first performed SPSP on a spinal saw bone model using the free-hand technique, with each trainee inserting four screws into the atlantoaxial, cervical, thoracic, and lumbar regions, respectively. The screw placement process and outcomes were reviewed by an experienced spinal surgeon. The hand dominance of the participants was also recorded. Following this, each participant was scheduled to independently watch a 20-minute standardized surgical training video. This was followed by a 30-minute simulation training session on the VRFF-SSTS platform, resulting in a total training time of 50 min. The virtual reality force feedback instruments used in the simulation were modeled and finalized in advance using commercial software, based on actual device data. Participants wore VR glasses to access the virtual operation platform through the VR imaging system. They then practiced placing pedicle screws using a simulated training device equipped with position sensing and force feedback capabilities (Fig. 1). The movements performed in the VR environment were converted into visual data by the sensing signals, allowing participants to see the screw placement process in the VR glasses as if they were performing the procedure in an actual operating room. At the same time, the force feedback system provided haptic feedback similar to that experienced during real surgery. This system also includes a real-time evaluation and feedback function. If the screw placement was not accurate, the imaging system would issue a failure warning and prompt the participant to repeat the procedure.

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After the training, each trainee inserted four screws into the atlantoaxial, cervical, thoracic, and lumbar regions, respectively. After the insertion of the screw from C1 to L5, each model was photographed before removing the implants. Accuracy was defined as pedicle screw fully contained within the pedicle borders, assessed via macroscopic inspection of sawbone models by four blinded observers. A grading rubric for steps and a global rating scale for fellows’ screw placement performance was evaluated separately both before and after the training, and the rating scale employed is a modified version that has been previously validated in the literature [14]. In addition, participants were given a questionnaire to assess the usefulness of VRFF-SSTS [10]and their results were analyzed.

Statistical analysis

Statistical analysis was performed using SPSS (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Continuous data is expressed as a mean with a standard deviation, whereas categorical data is expressed as a percentage. Categorical data was analyzed using the Chi-Square test or Fisher’s exact test, as appropriate. If the data met the normality criteria for these tests, the student’s t-test was used; otherwise, nonparametric counterparts were used. The two-tailed significance level was set at p < 0.05.

Results

Sixty-four participants were included, with group A 18 (28.1%), B 30 (46.9%), and C 16 (25.0%) participants, respectively. The demographic characteristics and work experience of the participants are shown in Table 1. The age and PGY show significant differences among the groups (p < 0.001), while the number of surgical cases per year is comparable to spinal regions.

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The objective global rating scale showed before training, there were no statistically significant differences among the three groups in Instrument Handling and Knowledge. However, Group C (PGY > 10) significantly outperformed Groups A and B in Time and Motion, Flow, and Overall performance subdomains. After training, all groups showed significant improvements in all domains except Preparation. However, Group C continued to lead significantly in Time and Motion, Flow, and Overall performance compared to Groups A and B. Overall, the training enhanced the performance of fellows across all experience levels, but more experienced doctors continued to demonstrate superior proficiency (Table 2).

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The screw accuracy for seniority and location is shown in Table 3.

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Screw accuracy is defined as the pedicle screw being completely within the pedicle. Pre-training data indicated that screw placement accuracy improved with increasing seniority. Group A (PGY1-5) had the lowest accuracy at 48.06%±14.87%, while Group B (PGY6-10) had a moderate accuracy of 66.83%±13.42%, and Group C (PGY > 10) had the highest accuracy at 77.19%±9.99%. Statistical analysis revealed significant differences between these groups (p < 0.001 for A vs. B and A vs. C; p = 0.013 for B vs. C). Post-training, there was a significant enhancement in screw placement accuracy across all groups compared to pre-training (p < 0.001). The accuracy for Group A increased to 88.33%±6.18%, for Group B to 89.60%±7.09%, and for Group C to 90.00%±6.33%. No significant differences were observed between seniority levels post-training.

According to spinal regions, pre-training lumbar pedicle screw placement accuracy (75.94% ±13.07%) was higher than that of atlantoaxial (58.13% ±15.59%), subaxial cervical (63.13%±15.37%), and thoracic vertebrae (59.38%±18.52%), with significant differences observed (p = 0.002 for L vs. A, p = 0.025 for L vs. LC, p = 0.004 for L vs. T). Post-training, all spinal regions showed significant improvements in screw placement accuracy (p < 0.001 for all regions). The accuracy post-training was 88.75%±6.19% for atlantoaxial, 90.50%±5.54%for cervical, 87.50%±6.83% for thoracic, and 90.63%±7.72% for lumbar vertebrae. No significant differences were observed between spinal regions post-training.

The usefulness of the VRFF-SSTS for spinal pedicle screw placement among fellows with varying levels of experience (PGY1-5, PGY6-10, and PGY > 10) is shown in Table 4. Most participants found VRFF-SSTS helpful for learning spinal skills, with 61.1% of PGY1-5, 40.0% of PGY6-10, and 45.3% of PGY > 10 strongly agreeing. Additionally, the majority supported incorporating VRFF-SSTS into residency programs, with 56.5% of PGY1-5, 46.7% of PGY6-10, and 50.0% of PGY > 10 strongly agreeing. However, most participants rated the haptic feedback from VRFF-SSTS as inferior to the sawbone model, with 88.9% of PGY1-5, 83.3% of PGY6-10, and 87.5% of PGY > 10 rating it as inferior. Despite this, immersive feeling scores were relatively high (71.94 ± 10.45 for PGY1-5, 75.67 ± 9.44 for PGY6-10, 73.13 ± 10.15 for PGY > 10), and force feedback scores were consistent across all groups, with no significant differences among them.

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Discussion

In this research, we examined the impact of VRFF-SSTS training on the performance of fellows in spinal pedicle screw placement (SPSP), and whether influenced by seniority and spinal location. The training enhanced all groups’ performance, yet more experienced Group C (PGY > 10) still led in several subdomains. Screw placement accuracy improved with seniority pre-training, and significantly increased for all groups post-training, with no differences between seniority levels or spinal regions. Most fellows found VRFF-SSTS helpful for learning and supported its integration into residency programs, though they rated its haptic feedback as inferior to the sawbones model while having relatively high immersive feeling scores. Hence, VRFF-SSTS is demonstrated to be an essential instrument for spinal surgical skills training, effectively improving the precision of pedicle screw placement among junior spine surgeons within a limited training timeframe. Nevertheless, the overall proficiency in pedicle screw placement continues to be higher among seasoned surgeons compared to their less experienced peers, highlighting the enduring significance of the clinical experience.

Medical education is currently experiencing a significant transformation, evolving from the conventional experience-driven approach to a more structured program that emphasizes the demonstration of proficiency through documented evidence [9]. This shift is driven by several factors, including advancements in healthcare technology, the increasing prevalence of day-case surgeries, and the implementation of stringent quality assurance standards. As a result, there has been a marked decline in hands-on training opportunities for junior doctors. Consequently, it has become increasingly unacceptable and inappropriate for junior spinal surgeons at any stage of their training to practice new skills on patients, even with their explicit consent.

As we expected, before training, there was a clear difference in the performance of doctors with varying levels of experience in screw placement. Senior doctors demonstrated the highest proficiency, exhibiting strong skills in preparation, time and motion efficiency, and overall performance. Mid-level doctors showed moderate proficiency, with their performance being notably better than that of junior doctors but not as strong as that of their senior counterparts. Junior doctors, on the other hand, displayed the lowest level of proficiency across all assessed areas, indicating a need for significant improvement in their screw placement skills. Overall, the data suggests that increased experience is directly correlated with better performance in screw placement tasks before training. The data indicates that while all groups benefited from the training, the improvements were most pronounced in junior and mid-level doctors, particularly in time and motion, instrument handling, and overall performance. Senior doctors, while already performing at a higher level, also showed significant improvements, especially in time and motion and knowledge.

Spinal pedicle screws are commonly used to effectively stabilize all three columns of the spine but can be technically challenging due to the variability in anatomical structures. Due to the proximity to the spinal canal and surrounding blood vessels, any misplacement of pedicle screws can result in severe complications. Therefore, ensuring the accurate and safe placement of these screws is a critical step in the surgical procedure [15]. Compared to lumbar spine diseases, the probability of needing pedicle screw fixation for atlantoaxial, subaxial cervical, and thoracic spine diseases is relatively lower. Additionally, due to the anatomical complexity of these regions, improper screw placement can injure the spinal cord or major blood vessels, leading to severe complications. As a result, in clinical practice, junior spine surgeons have fewer opportunities to perform pedicle screw placement in the atlantoaxial, subaxial cervical, and thoracic spine regions. This explains why, before training, fellows achieved the highest accuracy in lumbar pedicle screw placement, significantly surpassing that of the other regions. Specifically, the pre-training accuracy for lumbar pedicle screw placement (75.94%±13.07%) was notably higher compared to the atlantoaxial (58.13%±15.59%), subaxial cervical (63.13%±15.37%), and thoracic vertebrae (59.38%±18.52%). Similarly, Casillo et al. [16] conducted a study to evaluate the accuracy of screw placement using the free-hand technique in the lumbar, thoracic, and cervical spine by neurosurgical residents undergoing an enfolded spine fellowship. The results indicated that breaches occurred at all levels of the spinal column, with 20 (45.5%) in the cervical spine (including 1 in the C2 vertebra), 13 (29.5%) in the thoracic spine, and 8 (18.2%) in the lumbar spine.

Several intraoperative-assisted methods have been employed to enhance the accuracy and safety of pedicle screw placement. However, these techniques come with their own set of challenges. For example, conventional intraoperative navigation systems often lead to prolonged radiation exposure for both the surgical team and the patient [17]. Ultrasound Volume Navigation (UVN) significantly reduces radiation exposure compared to both O-arm navigation and X-ray guidance, however, UVN may be influenced by factors like obesity, limiting its application [18]. Tarawneh et al. [6] conducted a systematic review and Meta-analysis of randomized controlled trials on the effect of robot-assisted screw placement and confirmed that robot-assisted technology outperforms the traditional freehand method in achieving higher screw accuracy, as well as in reducing both the duration and dosage of intraoperative radiation. Conversely, the freehand technique demonstrated better outcomes in terms of the total surgical time and the need for revision surgeries. Hence, there is a pressing need to establish a standardized and effective training program aimed at enhancing screw placement proficiency and accuracy. The emergence of virtual reality (VR) surgical simulators has opened new avenues for improving nailing techniques, boosting surgical efficiency, and minimizing complications during procedures [10, 12, 13]. Research indicates that VR simulators can significantly enhance the clinical surgical skills of trainees, even those with prior experience. There is compelling evidence supporting the positive effect of incorporating simulation in enhancing procedural knowledge and technical proficiency [19].

As contemporary medical education increasingly prioritizes standardized, competency-based training paradigms, simulation platforms enabling the development of procedural skills and decision-making proficiency in controlled, risk-free environments have become indispensable adjuncts to operating room experience. Virtual reality (VR) and augmented reality (AR) represent complementary immersive technologies with growing surgical applications. While VR creates a fully simulated environment that replaces physical reality, AR superimposes computer-generated perceptual information onto the user’s real-world view, thereby preserving situational awareness. This critical distinction is exemplified by VR headsets that immerse users in artificial environments versus AR devices that enhance real-world visual fields. In spine surgery specifically, Ma et al. [20] developed an AR navigation system for pedicle screw placement using ultrasound-assisted registration. This innovation demonstrated equivalent targeting accuracy to conventional techniques while significantly decreasing intraoperative radiation exposure – addressing two major limitations of current navigation methods. Existing evidence consistently demonstrates the superior efficacy of VR simulators over conventional training methods for pedicle screw insertion. By enabling high-fidelity replication of surgical scenarios, VR platforms eliminate patient risk during procedural learning while providing unrestricted opportunities for iterative skill refinement – a critical advantage in competency-based curricula [11, 13]. Our study demonstrates that there was a significant enhancement in screw placement accuracy across all groups compared to pre-training (p < 0.001), with no significant differences observed between seniority levels and spinal regions. The results indicate that VRFF-SSTS training is beneficial for enhancing the abilities of novice spinal surgeons and holds significant clinical relevance. Furthermore, the simulator allows for repeated practice sessions, which significantly cuts down on costs and boosts training efficiency compared to traditional operating room nailing exercises. Since the simulator poses no risk to patients, it substantially enhances the safety of the training process.

However, current VR educational systems face a fundamental limitation: the absence of authentic haptic feedback impedes the development of tactile discrimination essential for tasks such as detecting bony resistance during screw trajectory advancement [21]. The user feedback presented in Table 4 suggests that while VRFF-SSTS is widely regarded as helpful for learning spinal skills and suitable for inclusion in training programs, its haptic feedback is generally considered inferior to the traditional sawbone model. Despite this, the immersive feeling and force feedback scores indicate a reasonable level of satisfaction with the simulator’s performance. Our study also corroborates the findings of existing literature [10].

The results show that overall competency significantly improved following training, with PGY B and C fellows, who had prior experience with pedicle screw insertion, demonstrating more satisfactory performance. This indicates that while training was beneficial for all fellows, those with more experience (Group C) still outperformed their less experienced counterparts. Overall, the training enhanced the performance of fellows across all experience levels, but more experienced doctors continued to demonstrate superior proficiency. While VR training has been shown to significantly improve the proficiency of screw placement in the short term, it is crucial to recognize that sustained, long-term clinical experience remains indispensable. The text highlights the importance of integrating both technical and non-technical skills in a standardized and reproducible environment, which VR simulators can effectively provide. However, real-world scenarios often present unpredictable challenges, such as congenital anomalies or morbid obesity, which require a surgeon’s adaptability and experience beyond what VR can offer. The psychological components of motor-skill acquisition, linked to the plasticity of brain cortices, underscore the necessity for continuous practice and exposure to diverse clinical situations. Functional brain mapping developments suggest that VR can measure skill proficiency and determine baseline characteristics like depth perception and hand-eye coordination. Yet, tactile feedback, decision-making under pressure, and a nuanced understanding of patient-specific anatomical variations are aspects that only real-life surgical experiences can fully cultivate. In conclusion, while VR training is a valuable tool for skill development and initial proficiency, it should be viewed as a supplement rather than a replacement for the invaluable insights and expertise gained through long-term clinical practice.

Limitations

The present study has several limitations. Firstly, small sample size, participant heterogeneity, and use of technical outcome measurements. The absence of a non-VR control arm prevents direct quantification of the simulator’s incremental benefit over conventional training repetition alone. Secondly, although our VR cases are derived from imaging data of actual clinical cases, both evaluations of screw accuracy were conducted using sawbones, which may not fully reflect real-world clinical situations. Future iterations could integrate augmented reality (AR) -VR hybrids, overlaying virtual anatomy onto physical models to bridge tactile feedback gaps. Third, while the pre-post design controls for baseline confounders, future RCTs with non-VR control arms (e.g., sawbone-only training) are needed to isolate the simulator’s unique contribution from generic repetition effects. This would address whether VR accelerates learning curves beyond conventional methods. To more comprehensively evaluate the impact of VR simulators on surgical proficiency and pedicle screw accuracy, we suggest employing larger and more varied sample sizes. Additionally, it is advisable to conduct radiographic assessments using cadaver specimens that more closely mimic real clinical scenarios.

Conclusion

The Virtual Reality Force Feedback Spine Surgery Training Simulator (VRFF-SSTS) has demonstrated its value as an essential training tool, effectively improving the accuracy of pedicle screw placement for junior spine surgeons within a limited training timeframe. Nevertheless, it is important to note that following training, experienced surgeons still exhibit a higher overall competency in pedicle screw placement compared to their junior colleagues. This highlights the enduring significance of hands-on clinical experience.

Data availability

Data is provided within the manuscript.

Abbreviations

VRFF-SSTS:

Virtual reality force feedback spine surgery training simulators

PSP:

Pedicle screw placement

PGY:

Post-graduation year

VA:

Vertebral artery

ERAS:

Enhanced recovery after surgery

VR:

Virtual reality

References

Yuan L, Zhang X, Zeng Y, Chen Z, Li W. Incidence, risk, and outcome of pedicle screw loosening in degenerative lumbar scoliosis patients undergoing Long-Segment fusion. Global Spine J. 2023;13:1064–71.

McCormick J, Aebi M, Toby D, Arlet V. Pedicle screw instrumentation and spinal deformities: have we gone too far? European spine journal: official publication of the European spine society, the European spinal deformity society, and the European section of the cervical spine. Res Soc. 2013;22(Suppl 2):S216–24.

Mahesh B, Upendra B, Raghavendra R. Acceptable errors with evaluation of 577 cervical pedicle screw placements. European spine journal: official publication of the European spine society, the European spinal deformity society, and the European section of the cervical. Spine Res Soc. 2020;29:1043–51.

Sarwahi V, Wendolowski SF, Gecelter RC, et al. Are We Underestimating Significance Pedicle Screw Misplacement? Spine. 2016;41:E548–55.

Avila MJ, Baaj AA. Freehand thoracic pedicle screw placement: review of existing strategies and a Step-by-Step guide using uniform landmarks for all levels. Cureus. 2016;8:e501.

Tarawneh AM, Salem KM. A systematic review and Meta-analysis of randomized controlled trials comparing the accuracy and clinical outcome of pedicle screw placement using Robot-Assisted technology and conventional freehand technique. Global Spine J. 2021;11:575–86.

Jung YG, Lee S, Jeong SK, Kim M, Park JH. Subaxial cervical pedicle screw in traumatic spinal surgery. Korean J Neurotrauma. 2020;16:18–27.

Hur JW, Kim JS, Ryu KS, Shin MH. Accuracy and safety in screw placement in the high cervical spine: retrospective analysis of O-arm-based Navigation-assisted C1 lateral mass and C2 pedicle screws. Clin Spine Surg. 2019;32:E193–9.

Aggarwal R, Darzi A. Technical-skills training in the 21st century. N Engl J Med. 2006;355:2695–6.

Alam I, Garg K, Kumar AG, et al. Beyond traditional training: exploring the benefits of virtual reality simulator in lumbar pedicle screw Insertion - A randomized controlled trial. World neurosurgery; 2024.

Xin B, Chen G, Wang Y et al. The Efficacy of Immersive Virtual Reality Surgical Simulator Training for Pedicle Screw Placement: A Randomized Double-Blind Controlled Trial. World neurosurgery. 2018.

Kuhn AW, Yu JK, Gerull KM, Silverman RM, Aleem AW. Virtual reality and surgical simulation training for orthopaedic surgery residents: A qualitative assessment of trainee perspectives. Volume 9. JB JS Open Access; 2024.

Xin B, Huang X, Wan W, et al. The efficacy of immersive virtual reality surgical simulator training for pedicle screw placement: a randomized double-blind controlled trial. Int Orthop. 2020;44:927–34.

Tanner G, Vojdani S, Komatsu DE, Barsi JM. Development of a saw bones model for training pedicle screw placement in scoliosis. BMC Res Notes. 2017;10:678.

Wang S, Wang C, Wood KB, Yan M, Zhou H. Radiographic evaluation of the technique for C1 lateral mass and C2 pedicle screw fixation in three hundred nineteen cases. Spine. 2011;36:3–8.

Casillo SM, Agarwal P, Nwachuku EL, et al. Evaluation of free-hand screw placement in cervical, thoracic, and lumbar spine by neurosurgical residents. Clin Neurol Neurosurg. 2021;204:106585.

Klingler JH, Naseri Y, Reinacher PC, Hoedlmoser H, Urbach H, Hohenhaus M. Patient radiation exposure from intraoperative computed tomography in spinal surgery. Spine Journal: Official J North Am Spine Soc. 2022;22:1576–8.

Lin X, Chang Q, Shang L, Shen S, Fu Z, Zhao G. A comparison of ultrasound volume navigation, O-arm navigation, and X-ray guidance for screw placement in minimally invasive transforaminal lumbar interbody fusion: a randomized controlled trial. European spine journal: official publication of the European spine society, the European spinal deformity society, and the European section of the cervical spine. Res Soc. 2024;33:3457–66.

Davids J, Manivannan S, Darzi A, Giannarou S, Ashrafian H, Marcus HJ. Simulation for skills training in neurosurgery: a systematic review, meta-analysis, and analysis of progressive scholarly acceptance. Neurosurg Rev. 2021;44:1853–67.

Ma L, Zhao Z, Chen F, Zhang B, Fu L, Liao H. Augmented reality surgical navigation with ultrasound-assisted registration for pedicle screw placement: a pilot study. Int J Comput Assist Radiol Surg. 2017;12:2205–15.

Luca A, Giorgino R, Gesualdo L, et al. Innovative educational pathways in spine surgery: advanced virtual Reality-Based training. World Neurosurg. 2020;140:674–80.