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Peer-reviewedCC BY 4.0Journal of Clinical Medicine

Microscope-Integrated Augmented Reality-Assisted Navigation for C1–C2 Instrumentation: A Retrospective Single-Center Case Series

  • Chi-Ruei Li1,2
  • Song-Ru Jhan3
  • Hsi-Kai Tsou1,4,5
  • Yu-Jui Chang1
  • Mao-Shih Lin1
  • Chung-Yuh Tzeng6,7,8
  • Ting-Hsien Kao1,4
  • Chiu-Chun Chen1
  • Jheng-Yan Chen1
  • Chih-Wei Huang1,2
8 affiliations
  1. 1Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung 407219, Taiwan
  2. 2Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
  3. 3Department of Radiology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
  4. 4Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402202, Taiwan
  5. 5College of Health, National Taichung University of Science and Technology, Taichung 404336, Taiwan
  6. 6Department of Orthopedics, Taichung Veterans General Hospital, Taichung 407219, Taiwan
  7. 7Institute of Biomedical Sciences, National Chung Hsing University, Taichung 402202, Taiwan
  8. 8Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Houlong, Miaoli County 356006, Taiwan
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Abstract

Objective: Posterior C1–C2 instrumentation is technically demanding because of the complex osseous and vascular anatomy of the atlantoaxial region. This retrospective single-center case series aimed to describe the technical feasibility and observed screw-placement outcomes of a combined microscope-integrated augmented reality (AR)-assisted navigation workflow in patients with atlantoaxial instability. Methods: Two neurosurgeons and one radiologist assessed screw placement accuracy on computed tomography (CT) images using the Gertzbein–Robbins classification, applying the Bredow modification for the cervical spine. Cortical breaches were classified as Grade 1, <1 mm; Grade 2, 1 to <2 mm; Grade 3, 2 to <3 mm; Grade 4, 3 to <4 mm; and Grade 5, ≥4 mm, or as transverse foramen obstruction exceeding half the screw diameter. Grades 1 and 2 were considered acceptable for screw insertion. Results: A total of 40 screws were successfully placed in 10 patients, comprising 20 C1 lateral mass screws and 20 C2 pedicle screws, achieving an overall acceptable placement rate of 97.5% (39/40; 95% CI, 86.8–99.9%). All 20 C1 lateral mass screws were accurately positioned, while the acceptable placement rate for C2 pedicle screws was 95.0%. One C2 pedicle screw in a 1.7 mm pedicle was graded as Grade 3. No clinically apparent vascular or neurological injuries were observed. Conclusions: The combined microscope-integrated AR-assisted navigation workflow was feasible in this small case series, with a high observed acceptable screw-placement rate and no observed neurovascular complications. The independent contribution of AR and its effects on outcomes relative to other guidance techniques require evaluation in larger comparative studies.

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Cite

BibTeXRIS
BibTeX
@article{li2026microscopeintegrated,
  title = {{Microscope-Integrated Augmented Reality-Assisted Navigation for C1–C2 Instrumentation: A Retrospective Single-Center Case Series}},
  author = {Chi-Ruei Li and Song-Ru Jhan and Hsi-Kai Tsou and Yu-Jui Chang and Mao-Shih Lin and Chung-Yuh Tzeng and Ting-Hsien Kao and Chiu-Chun Chen and Jheng-Yan Chen and Chih-Wei Huang},
  journal = {Journal of Clinical Medicine},
  year = {2026},
  month = oct,
  doi = {10.3390/jcm15207812},
  url = {https://www.mdpi.com/2077-0383/15/20/7812},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Microscope-Integrated Augmented Reality-Assisted Navigation for C1–C2 Instrumentation: A Retrospective Single-Center Case Series
AU  - Chi-Ruei Li
AU  - Song-Ru Jhan
AU  - Hsi-Kai Tsou
AU  - Yu-Jui Chang
AU  - Mao-Shih Lin
AU  - Chung-Yuh Tzeng
AU  - Ting-Hsien Kao
AU  - Chiu-Chun Chen
AU  - Jheng-Yan Chen
AU  - Chih-Wei Huang
PY  - 2026
DA  - 2026/10/01
JO  - Journal of Clinical Medicine
DO  - 10.3390/jcm15207812
UR  - https://www.mdpi.com/2077-0383/15/20/7812
AB  - Objective: Posterior C1–C2 instrumentation is technically demanding because of the complex osseous and vascular anatomy of the atlantoaxial region. This retrospective single-center case series aimed to describe the technical feasibility and observed screw-placement outcomes of a combined microscope-integrated augmented reality (AR)-assisted navigation workflow in patients with atlantoaxial instability. Methods: Two neurosurgeons and one radiologist assessed screw placement accuracy on computed tomography (CT) images using the Gertzbein–Robbins classification, applying the Bredow modification for the cervical spine. Cortical breaches were classified as Grade 1, <1 mm; Grade 2, 1 to <2 mm; Grade 3, 2 to <3 mm; Grade 4, 3 to <4 mm; and Grade 5, ≥4 mm, or as transverse foramen obstruction exceeding half the screw diameter. Grades 1 and 2 were considered acceptable for screw insertion. Results: A total of 40 screws were successfully placed in 10 patients, comprising 20 C1 lateral mass screws and 20 C2 pedicle screws, achieving an overall acceptable placement rate of 97.5% (39/40; 95% CI, 86.8–99.9%). All 20 C1 lateral mass screws were accurately positioned, while the acceptable placement rate for C2 pedicle screws was 95.0%. One C2 pedicle screw in a 1.7 mm pedicle was graded as Grade 3. No clinically apparent vascular or neurological injuries were observed. Conclusions: The combined microscope-integrated AR-assisted navigation workflow was feasible in this small case series, with a high observed acceptable screw-placement rate and no observed neurovascular complications. The independent contribution of AR and its effects on outcomes relative to other guidance techniques require evaluation in larger comparative studies.
SN  - 2077-0383
ER  -