By: 5 January 2023
Dr Brian Fiani hosts the America’s first virtual reality spine surgery seminar in the Metaverse

In December 2022, Dr. Brian Fiani made history by becoming the first neurosurgeon in America to host a virtual reality spine surgery seminar in the Metaverse.

The demonstration was a massive success. Dr. Fiani was one of the very first neurosurgeons to publish on virtual reality when he published his paper “Virtual Reality in Neurosurgery: “Can You See It?”-A Review of the Current Applications and Future Potential” in early 2020. Since then, he has continued to be a pioneer in the evolution of surgical technology and an advocate for its use in the operating room. Dr. Fiani has always been intrigued by the power of innovation and what it offers surgeons and patients. As a boy, he was a creative thinker coming up with new inventions and he credits this passion as one of his motivations for pursuing spine surgery. He has worked with several companies over the years to develop software and hardware components for intraoperative technology that has been breaking barriers in the operating room and expanding capabilities. Already a patent holder, Dr. Fiani’s ultimate goal with surgical technology is to improve patient care in the operating room. We requested and were granted the opportunity to have a question and answer session with Dr. Fiani. Here he discusses the details of the America’s first virtual reality spine surgery educational demonstration and what we might see in the future. 


Q: What inspired your interest in virtual reality? 

A: Technology and innovation are constantly evolving and new developments keep the modernisation of medicine interesting. To me, virtual reality is the meeting place of creativity and science. Virtual reality gives participants the ability to do things that we cannot do in the real world. Some of the special surgical teaching features include visualising 3-dimentional reconstructions pre-operatively, surgical planning, surgical simulations, and post-operative analysis all while decentralizing surgical education so that participants can be anywhere in the world at that particular time.  


Q: Where and when did this session take place? 

A: The virtual reality seminar was held at the New York City Minimally Invasive Spine Surgery (NYC-MISS) Symposium in New York City, New York, USA on December 15-17, 2022. During the 2-day lesson plan, participants activated headsets that produced 3-dimentional visualization capabilities and hand controls for limitless movement and action features. 


Q: Who participated? 

A: 50 spine surgeons from 10 different countries joined! Over 30 of the world’s masters in spine surgery joined in the Metaverse and another 20 spine surgeons chose to watch without headsets because the virtual reality world was simultaneously broadcasted into the real world auditorium screens by one of the representatives within the Metaverse. 


Q: What preparation took place for this to occur? 

A: I worked with a company named Non Nocere from Germany. They overnight mailed me my headset and controls to practice one week before the event. The programme technicians and sales representatives from Germany and Turkey trained me and helped me practice using the Metaverse features for several days. It was proof of product that we met in the Metaverse from three different countries at the same time to accomplish a goal. The company made the process very user-friendly for me. They downloaded preoperative and postoperative imaging, as well as, my slideshow presentations from 4 surgical cases. The 4 surgeries were categorized as degenerative spine surgery, spinal tumor surgery, deformity surgery, and revision surgery. Within the few days of preparation, I became comfortable with the Metaverse surgical auditorium which functions as a lecture hall and virtual anatomy lab and also the virtual reality operating room which functions as a surgical simulator lab. 


Q: How is virtual reality transforming spine surgery education? 

A: During the Covid-19 pandemic and even afterwards, people were gathering on Zoom as a platform for meetings. Virtual reality is the natural evolution for enhancing engagement by creating a space for discussions and interaction. Decentralising surgical education allows international participation which is particularly important in the fields of medicine and surgery. The virtual reality Metaverse allows surgeons to simulate surgeries before performing them. 


Q: How is virtual reality different that augmented reality? 

A: To put it simply, virtual reality is an enhanced version of reality that is entirely virtual. Whereas, augmented reality is an enhanced version of reality within the real-world setting. With regards to spine surgery, augmented reality is creating a new reality by overlaying digital information and visualization capabilities on top of a real spine. Virtual reality is a world of its own where isolated interaction and engagement occurs. 


Q: What are the advantages of discussing surgical cases in a virtual reality world? 

A: Virtual reality allows the presenter and participants to be engaged in one place while logging on from anywhere in the world internationally. Reconstructed models based on patient imaging allows better visualization of simulated spine models and practice surgeries beforehand. Surgical simulation can help provided repetitious training in a safe environment to create a quicker more efficient workflow in the real world for younger surgeons and lower learning curves with new products for experienced surgeons. 


Q: What did the symposium consist of? 

A: The virtual reality sessions occurred over two days. On the first day, the participants gathered in the real-world auditorium here in New York City and logged on with their headsets and hand controls and learned the basics of maneuvering to become comfortable with the Metaverse. Two technicians and sales representatives were present in the auditorium room to assist participants. One software programmer was inside the Metaverse to assist there. I presented two case presentations, each with an elaborate slideshow presentation that was downloaded into the Metaverse and projected onto what would appear to be a 100 foot screen by real-world estimation. Pre-operative imaging was shown including xrays, CT scans, and MRI scans with scrolling capability. One case was cervical spondylotic myelopathy and one was lumbar deformity. The software constructed large 30 foot models using preoperative imaging. The imaging was also superimposed onto the model and we used features to select-in or select-out parts of the anatomy to better view what was behind or around it, for example, removing the bone to see the compression on the spinal cord. These two cases were presented so that participants could perform their desired surgical plan in the real-world cadaver lab the following morning. The second day was particularly enjoyable. Participants were now more comfortable with the Metaverse which allowed excellent academic discussion to take place. I hosted 2 more case presentations with slideshow presentations including intraoperative footage. The constructed pre-op model displayed the tumor with great specificity and the postop model displayed its resection and placement on instrumentation for our tumor case. The revision surgery case demonstrated the virtual reality ability to preoperatively measure screw and rod sizes and compare to our postoperative model constructed from imaging. 


Q: What software was used and who supplied the headsets? 

A: The software was provided by a company named Non Nocere which gains its name from the phrase “primum non nocere” which in Latin means “first, do no harm”. They shipped all the state-of-the-art headsets and hand controls to New York City for the event. The headsets connected to the local wifi. 


Q: What was the reaction of the people who attended? 

A: The participants were in awe. The world’s best spine surgeons of master-class level were having the time of their lives. The participants enjoyed the audio-visual quality with haptic feedback, the life-like spine anatomy models, the projection of imported CT and MRI scans, and the surgical simulation features. The surgeons were like children discovering new toys on Christmas morning. The site of smiles, the sound of laughter, and the appearance of curiosity filled the auditorium. 


Q: Can you discuss the system usability? 

A: The system is very intuitive and after a few minutes you feel at one with the virtual reality world and its ongoings. The hand controls make maneuvering simple and the actions give haptic feedback. The system is instantaneously responsive without glitch or delay. 


Q: What is the future direction of virtual reality and augmented reality for spine surgery? 

A: I am excited about the future of virtual reality (VR) and augmented reality (AR) for spine surgery. VR will continue to be more life-like with computer-brain synchronizing and the headsets will become lighter to the point where they become glasses and maybe even contact lens. VR hand controls will likely become gloves for more realistic movements and control to simulate actions and surgical simulations. In regards to AR, headsets will also become lighter and smaller and shift to glasses or contact lens. More companies will be created and competition will grow. In the very near future, quite possibly in the year 2023, I will be hosting the first annual virtual reality spine surgery conference. Stay tuned, planning has already begun.