Evaluating the advantages and limitations of three-dimensional (3D) endoscopy as an innovative tool in spine surgery
Alison Ma1,2, Ralph J Mobbs1,2,3,4, Nathan Xie2,4
1Faculty of Medicine, University of New South Wales (UNSW), Sydney, NSW, Australia.
Background:
Endoscopic spine surgery reduces tissue damage, blood loss and postoperative pain. However, the two-dimensional (2D) view prevents depth perception and spatial orientation, contributing to a steep learning curve. Three-dimensional (3D) endoscopes improve depth perception but introduce increased scope diameter, workflow disruption and reduced image quality. A novel algorithm-based 3D visualisation system enables real-time conversion of standard 2D endoscopic images into 3D without requiring a dedicated 3D endoscope. Its impact on surgical workflow and intraoperative performance in spine surgery remains unknown.
Case Description:
14 patients with degenerative spinal pathology underwent endoscopic surgery using a real-time 2D-to-3D conversion system (13 uniportal, 1 biportal). Outcomes were assessed across predefined domains: (I) visualisation; (II) instrument handling; (III) haemostasis; (IV) educational impact; (V) workflow; and (VI) ergonomics. Improved visualisation (depth perception and spatial orientation) were observed in all cases. Improved instrument handling (navigation and drill control) was observed in all decompression cases (10/10). Enhanced haemostasis recognition was reported in 6/10 applicable cases. Educational benefit was observed in 6/14 cases. Workflow disruption occurred in 4/14 cases and ergonomic symptoms (mild dizziness or double vision) were reported in 6/14 cases. Field of view was equivalent between 2D and 3D imaging. No dural injuries, neurological deficits or reoperations occurred. All patients demonstrated recovery consistent with expected postoperative trajectories.
Conclusions:
This case series demonstrates the potential for 3D endoscopy to be used as an adjunct in endoscopic spine surgery with improvements in depth perception, instrument handling and visualisation of spatial relationships without altering endoscope diameter or access corridors. While an initial familiarisation phase is required, the system demonstrates potential workflow and educational value. Further prospective studies with quantitative metrics and long-term outcomes are warranted.