International Journal of Orthopedics (IJO)
ISSN: 2643-2692 | Vol. 7, Issue 1, 2026, pp. 48-55

Augmented Reality Navigation in Pedicle Screw Placement for Thoracolumbar Trauma

Kranjc A1, Zarins A2, Kral T3

1Department of Spinal Surgery, University of Maribor, Maribor, Slovenia
2Department of Trauma Surgery, University of Latvia, Riga, Latvia
3Department of Biomedical Engineering, Masaryk University, Brno, Czech Republic
DOI: 10.5281/zenodo.22327905 | Published: 2026-08-06 | Article page and PDF

Abstract

Background: Pedicle screw fixation is the mainstay of surgical stabilization for unstable thoracolumbar fractures, but freehand

and fluoroscopy-guided techniques carry measurable malposition and radiation risk. Objective: To synthesise the published evidence on augmented reality (AR)-based navigation for pedicle screw placement, with emphasis on thoracolumbar trauma, comparing it with freehand, fluoroscopy, 3D/O-arm navigation, and robotic guidance. Methods: Narrative review of comparative cohorts, randomised trials, systematic reviews, and meta-analyses indexed through 2026. Findings: Pooled AR clinical accuracy (Gertzbein-Robbins grade A/B) ranges from 93% to over 99%, exceeding freehand rates of 89-96% in matched comparisons, and approaching or matching robotic accuracy. AR reduces fluoroscopy use and, in dedicated trauma cohorts, achieves accuracy and complication rates comparable with robotic navigation, with a learning curve of roughly 20-30 cases. Conclusions: AR navigation is an accurate, radiation-sparing adjunct for thoracolumbar trauma instrumentation, though head-to-head trauma-specific trials remain few.

Keywords: Augmented reality; Pedicle screw placement; Thoracolumbar trauma; Surgical navigation; Gertzbein-Robbins classification

Abstract

Background: Pedicle screw fixation is the mainstay of surgical stabilization for unstable thoracolumbar fractures, but freehand and fluoroscopy-guided techniques carry measurable malposition and radiation risk. Objective: To synthesise the published evidence on augmented reality (AR)-based navigation for pedicle screw placement, with emphasis on thoracolumbar trauma, comparing it with freehand, fluoroscopy, 3D/O-arm navigation, and robotic guidance. Methods: Narrative review of comparative cohorts, randomised trials, systematic reviews, and meta-analyses indexed through 2026. Findings: Pooled AR clinical accuracy (Gertzbein-Robbins grade A/B) ranges from 93% to over 99%, exceeding freehand rates of 89-96% in matched comparisons, and approaching or matching robotic accuracy. AR reduces fluoroscopy use and, in dedicated trauma cohorts, achieves accuracy and complication rates comparable with robotic navigation, with a learning curve of roughly 20-30 cases. Conclusions: AR navigation is an accurate, radiation-sparing adjunct for thoracolumbar trauma instrumentation, though head-to-head trauma-specific trials remain few.

Keywords: augmented reality; pedicle screw placement; thoracolumbar trauma; surgical navigation; Gertzbein-Robbins classification

Introduction

Thoracolumbar fractures account for the majority of spinal column injuries, with a pooled incidence of roughly 6% among trauma admissions and a strong concentration at the thoracolumbar junction [1]. Unstable patterns, defined using systems such as the AOSpine Thoracolumbar Spine Injury Classification System, frequently require posterior pedicle screw instrumentation to restore alignment and neural protection [2]. Accurate screw placement is essential: cortical or medial breach risks neurological, vascular, or visceral injury, and is conventionally graded using the Gertzbein-Robbins system, in which grade A (no breach) and grade B (breach under 2 mm) are considered clinically acceptable [3].

Freehand and two-dimensional fluoroscopy-guided techniques remain the historical standard but depend heavily on anatomical landmarks and surgeon experience, with reported accuracy as low as 79-90% and considerable radiation exposure to the surgical team [4]. Three-dimensional intraoperative imaging combined with computer navigation (O-arm or 3D C-arm) improved accuracy over 2D fluoroscopy, and robotic guidance systems have further reduced malposition rates in comparative series [5]. Augmented reality (AR) navigation, which projects a registered three-dimensional trajectory overlay directly onto the surgeon's field of view via a head-mounted display or microscope-integrated system, has emerged as a further step intended to combine navigation-level accuracy with an ergonomic, radiation-sparing workflow that does not require the surgeon to look away from the operative field [6].

Thoracolumbar trauma poses particular challenges for any navigation modality: fracture-related anatomical distortion can complicate registration, time pressure in polytrauma limits tolerance for setup delays, and percutaneous approaches common in trauma surgery reduce the anatomical landmarks available for freehand technique, increasing reliance on image guidance.

This review synthesises the published literature on AR-assisted pedicle screw placement, with particular attention to thoracolumbar trauma indications, and situates it against freehand, fluoroscopy, 3D-navigation, and robotic comparators across accuracy, radiation exposure, operative time, learning curve, and complications. It is a narrative synthesis of comparative cohorts, randomised trials, and systematic reviews rather than a single-institution case report.

Augmented Reality Navigation: Technology and Workflow

Modern AR spine systems register preoperative or intraoperative CT to the patient using optical markers or surface-matching, then project a virtual trajectory onto a head-mounted display (e.g., Augmedics xVision) or a hybrid operating-room imaging system, allowing the surgeon to visualise the planned screw path superimposed on the actual anatomy without diverting gaze to a separate monitor [7]. Early cadaveric and hybrid-operating-room feasibility work established sub-millimetre registration accuracy and set the stage for clinical adoption [6]. Phantom-based validation in thoracolumbar levels T11-L4 has reported entry-point accuracy of 1.9 mm and screw-tip accuracy of 1.4 mm, translating into 94% clinical accuracy by Gertzbein grading, with a mean per-screw placement time of roughly two minutes once registration is complete [8]. Mixed-reality variants that overlay navigation data onto conventional intraoperative imaging rather than a headset have reported clinically significant deviation rates below 1% versus over 3% for navigation alone, suggesting the overlay principle generalises across hardware implementations [9].

Comparative Accuracy: AR versus Freehand

In a matched-control study of 550 screws, AR navigation achieved 93.9% clinical accuracy compared with 89.6% for fluoroscopy-assisted freehand placement, with cortical-breach-free screws roughly twice as common in the AR group (63.4% versus 30.6%) [6]. A larger single-institution series of 1,109 pedicles similarly found AR superior to freehand (99.3% versus 96.4% grade A/B, unacceptable breaches 0.7% versus 3.6%) (Figure 1) [10]. In deformity surgery using spinopelvic fixation, AR and freehand showed statistically similar overall breach rates, but AR screws terminated appropriately in the cortical pillar significantly more often (96.7% versus 73.9%) [11]. A systematic review of 20 studies (2,095 screws) reported pooled AR clinical accuracy of 93.1%, with cadaveric and clinical series (93.4%) outperforming phantom models (73.2%) [12], and a focused meta-analysis of 1,259 screws across two AR platforms found 97.2% pooled accuracy [13]. A randomised, multicentre, parallel-controlled trial confirmed superior accuracy for AR-navigated screws over conventional technique in 631 patients [14]. Taken together, these studies span cervical, thoracic, lumbar, and sacropelvic levels and a range of indications from degenerative disease to deformity and trauma, and consistently place AR accuracy above freehand and fluoroscopy-based benchmarks while leaving open the precise magnitude of benefit, which varies with registration method, screw level, and operator experience (Table 1).

Table 1: Selected comparative studies of augmented reality (AR)-assisted pedicle screw placement versus freehand and conventional techniques [6,10,11,12,13,14].
Table 1: Selected comparative studies of augmented reality (AR)-assisted pedicle screw placement versus freehand and conventional techniques [6,10,11,12,13,14].
Figure 1: Intrapedicular accuracy (Gertzbein-Robbins grade A) for fluoroscopy-guided percutaneous, freehand, and robot-assisted pedicle screw fixation in a comparative cohort of thoracolumbar fracture patients [25].
Figure 1: Intrapedicular accuracy (Gertzbein-Robbins grade A) for fluoroscopy-guided percutaneous, freehand, and robot-assisted pedicle screw fixation in a comparative cohort of thoracolumbar fracture patients [25].

AR versus Robotic and 3D/O-Arm Navigation

Robotic guidance and AR represent parallel evolutions beyond conventional navigation. A direct comparison of 1,211 lumbosacral screws found robotic navigation achieved more grade A placements than AR (95.2% versus 89.8%), though combined grade A/B rates were statistically similar (99.6% versus 98.7%) [15]. A four-arm network meta-analysis of 61 studies (35,451 screws) ranked robot-assisted and AR systems highest for perfect placement, both significantly outperforming conventional freehand technique, with no significant difference in overall safe placement across modalities [16]. Against 3D fluoroscopy-based navigation, O-arm-guided screws outperformed 2D C-arm fluoroscopy in five of eight comparative studies without a consistent time penalty [4], while sawbone-model comparisons of three combined imaging-navigation platforms found accuracy differences alongside meaningful differences in radiation dose between systems [17,18]. In scoliosis correction, robotic-assisted O-arm or 3D C-arm navigation outperformed fluoroscopy-assisted freehand technique (96.3% versus 88.6% clinically acceptable placement) [19]. Because robotic platforms and AR headsets both depend on accurate image-to-patient registration, misplacement in either modality clusters around registration drift and soft-tissue movement rather than a fundamental limitation of the display technology itself.

Radiation Exposure

A systematic review of twelve studies found AR navigation consistently associated with reduced fluoroscopy time, with the limited studies measuring occupational dose directly reporting substantially lower staff exposure, particularly when AR was paired with low-dose cone-beam CT protocols [20]. This radiation-sparing profile parallels findings for O-arm-based 3D navigation relative to 2D fluoroscopy [4] and for robotic platforms relative to freehand fluoroscopic technique, and is attributed to reduced reliance on repeated intraoperative fluoroscopic shots once registration is complete [21]. Direct dosimetric comparisons across combined imaging-navigation platforms in sawbone models have quantified meaningful dose differences between systems using otherwise similar workflow steps, underscoring that the imaging source driving registration, not only the display technology, materially shapes cumulative radiation burden [18].

Operative Time and Learning Curve

AR workflows add registration overhead but can shorten instrumentation time once the surgical team is experienced. For robot-assisted navigation broadly, outcomes continue to improve well beyond the initial 20-30 case learning curve traditionally cited, with grade A accuracy rising from 87% to 98% and registration time falling from 16.9 to 8.7 minutes across sequential case cohorts [22], while a dedicated analysis of 234 robot-assisted cases found operative time plateauing after an early experience phase [23]. Comparable early-adoption effects have been described for AR platforms, where accuracy and workflow efficiency improve as teams gain registration experience, with reported case-based learning curves generally in the same 20-30 case range cited for robotic systems before both registration time and screw-insertion time stabilise [21]. Institutions introducing AR into a trauma workflow should therefore anticipate an initial phase of longer setup time that is expected to normalise with sustained case volume, analogous to the adoption curve documented for robotic platforms in elective and trauma series alike [22,23].

AR Navigation in Thoracolumbar Trauma

Trauma-specific AR data remain comparatively limited but encouraging. In a cohort of nine patients undergoing AR-head-mounted-display-assisted fixation for thoracolumbar spinal trauma, all 77 screws were confirmed accurately placed on biplanar radiographs, with outcomes statistically indistinguishable from a matched robotic-assisted trauma cohort across operative time (398 versus 331 minutes), blood loss, and length of stay (Figure 2) [24]. In a comparative cohort study of thoracolumbar fracture fixation, robot-assisted technique achieved 94.3% intrapedicular accuracy versus 88.7% for freehand and 78.2% for fluoroscopy-guided percutaneous technique, with correspondingly lower facet-joint violation [25], and a meta-analysis of 608 trauma patients confirmed higher grade A/A+B placement with robotic assistance alongside shorter hospitalisation and lower complication rates [26]. These robotic trauma benchmarks provide the closest available comparator for AR performance in this population until larger AR-specific trauma series accumulate (Table 2). Practical considerations specific to trauma also merit attention: fracture-associated vertebral body collapse or rotation can complicate surface-based registration, polytrauma patients may require rapid repositioning that disrupts headset tracking, and emergency staffing may not include personnel experienced with AR setup, all of which argue for deliberate protocolisation of AR trauma workflows rather than uncritical extrapolation from elective series.

Table 2: Comparative studies of navigation and robotic technique specific to thoracolumbar trauma/fracture pedicle screw fixation [24,25,26].
Table 2: Comparative studies of navigation and robotic technique specific to thoracolumbar trauma/fracture pedicle screw fixation [24,25,26].
Figure 2: Mean operative time for augmented reality head-mounted-display-assisted versus robot-assisted pedicle screw fixation in a matched thoracolumbar spinal trauma cohort [24].
Figure 2: Mean operative time for augmented reality head-mounted-display-assisted versus robot-assisted pedicle screw fixation in a matched thoracolumbar spinal trauma cohort [24].

Complications and Clinical Outcomes

Across navigation modalities, screw-related complications track closely with breach grade: functional-outcome meta-analysis of 5,992 computer-assisted screws found a modest but non-significant reduction in neurological complications versus freehand technique [27], while robot-assisted placement carried significantly lower odds of complication than freehand technique in a large network analysis [5]. Reported AR-specific complication rates in the reviewed series were low, with no unique device-related morbidity beyond registration failures requiring conversion to conventional technique, though reoperation rates favoured AR over freehand in one deformity cohort (6.9% versus 28.6%), a difference that narrowed and lost significance when analysis was restricted to a two-year follow-up window, illustrating how early differences in reoperation can reflect case mix as much as navigation technology [11]. No AR series reviewed here reported a device-attributable neurological or vascular injury, though most cohorts remain too small individually to exclude a low-frequency serious complication, reinforcing the value of pooled and registry-level reporting as AR adoption expands into trauma practice.

Conclusion

Augmented reality navigation for pedicle screw placement has matured from cadaveric feasibility work into a validated clinical technology, with pooled accuracy consistently exceeding freehand technique and approaching that of robotic guidance, alongside a favourable radiation-exposure profile. In thoracolumbar trauma specifically, early comparative series suggest AR can match robotic-assisted accuracy and safety, though the trauma-specific evidence base remains smaller than that for elective deformity and degenerative surgery. Larger, trauma-focused randomised comparisons, standardised learning-curve reporting, and long-term outcome data are needed to define AR's definitive role alongside robotic and conventional navigation in the acutely injured thoracolumbar spine.

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