Mixed Reality in Spine Surgery: The Apple Vision Pro in Biportal Endoscopic Lumbar Fusion

The use of mixed reality (MR) in endoscopic spine surgery has recently been introduced, promising to enhance visualization, improve workflow, and support intraoperative decision-making. The successful use of the Apple Vision Pro (AVP) MR headset has recently been documented during biportal endoscopic spine surgery. To our knowledge, this case represents the first use of MR technology as an adjunct to biportal endoscopic spine fusion. An 81-year-old male with a history of lumbar stenosis and Grade 1 spondylolisthesis at level 4-5 presented with progressively worsening radicular pain refractory to conservative measures. Based on the clinical findings, the patient underwent a transforaminal lumbar interbody fusion (TLIF) via a biportal endoscopic approach. The procedure included endoscopic laminotomy, bilateral decompression, facetectomy, placement of an interbody cage with bone grafting, and posterior spinal instrumentation and fusion. Throughout the case, the operating surgeon wore the AVP MR Headset, which virtually displayed a live endoscopic view, over the real environment without obstructing the surgical field. The AVP consolidated the endoscopic feed directly into the surgeon's line of sight, eliminating the need to shift gaze between the operative field and external monitors and supporting a more ergonomic, streamlined operative workflow. The patient demonstrated complete resolution of radicular leg pain (VAS Leg 7 → 0) and marked functional recovery (ODI 14% → 2%) by two months postoperatively, with no intraoperative or postoperative complications, and these improvements were maintained through the seven-month follow-up. This case demonstrates the feasibility of using MR as an adjunct to biportal endoscopic lumbar fusion without observed complications. The AVP HMD provided an integrated, line-of-sight visualization platform that reduced reliance on external monitors and supported ergonomic surgical performance. Further investigation is needed to evaluate its effect on surgical efficiency and long-term patient outcomes.