Exoscope-Assisted Spine Surgery: A Systematic Review From Basic to Complex Pathologies

Operative neurosurgery has greatly benefited from technological advancements over the past several decades. However, challenges such as limited visualization, intraoperative navigation difficulties, and the complexity of spinal anatomy continue to pose significant hurdles for surgeons. The utilization of advanced technologies, such as exoscopes, navigation systems, and robotics, can help overcome some of these challenges, thereby enhancing surgical precision and accuracy. Over time, spine surgery has undergone remarkable advancements. Among those, exoscope-assisted spine surgery stands out as a promising approach, providing surgeons with an unmatched visual experience and enhancing the potential for improved patient outcomes. The objective of this systematic review is to examine the current use of exoscopes in spine surgery and compare the available technologies and types. We conducted a systematic review of the literature for exoscopes in spine surgeries using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology across four major reliable databases: PubMed, ScienceDirect, Embase, and Scopus. A total of 42 studies were included in this review. We aim to present a comprehensive overview of exoscope-assisted spine surgeries, focusing on the technology's evolution, advantages, clinical applications, and potential limitations. Adequate lighting, magnification, and precision in the identification of critical surgical tissues are essential for predicting the "maximal safe resection" in neurosurgery. Vital neurovascular structures can be recognized and dissected using the high-resolution illumination provided by the operating microscope (OM). Conversely, the OM has several disadvantages, including a limited field of view, difficulty seeing around corners, and the potential to impose uncomfortable surgical postures. Additionally, an OM is difficult to maneuver around the operating room due to its size and weight. The exoscope distinguishes itself from traditional surgery by positioning the camera externally to the surgical area, providing the surgeon with an improved ergonomic vantage point to visually oversee the operative field. With more visibility, surgeons can navigate the spine and its supporting components, potentially improving treatment precision. Exoscopes offer numerous advantages over traditional OMs, including higher magnification, enhanced 3D visualization, improved ergonomics, and greater flexibility. These benefits increase precision, reduce surgeon fatigue, and enhance surgical outcomes. The use of exoscopes in spine surgery has shown promise in reducing bleeding, improving hemostasis, and potentially shortening surgical times. Additionally, the ability to record and stream surgical procedures facilitates better communication and collaboration among the surgical team, benefiting experienced surgeons and trainees. Surgeons may face a learning curve when transitioning from traditional microscopes to exoscopes, but this hurdle can be overcome with adequate training and experience. The initial high procurement costs and limited availability of exoscopes in resource-constrained areas may also pose barriers to widespread adoption.