Virtual reality in neurosurgery

Virtual reality (VR), sometimes referred to as immersive multimedia, is a computer-simulated environment that can simulate physical presence in places in the real world or imagined worlds. Virtual reality can recreate sensory experiences, including virtual taste, sight, smell, sound, touch, etc.

Chan et al., highlights a selection of recent developments in research areas related to virtual reality simulation, including anatomic modeling, computer graphics and visualization, haptics, and physics simulation, and discusses their implication for the simulation of neurosurgery 1).


Medicine and surgery are turning towards simulation to improve on limited patient interaction during residency training. Many simulators today utilize virtual reality with augmented haptic feedback with little to no physical elements.

To optimize the learning exercise, it is essential that both visual and haptic simulators are presented to best present a real-world experience. Many systems attempt to achieve this goal through a total virtual interface.

Bova et al., approach has been to create a mixed-reality system consisting of a physical and a virtual component. A physical model of the head or spine is created with a 3-dimensional printer using deidentified patient data. The model is linked to a virtual radiographic system or an image guidance platform. A variety of surgical challenges can be presented in which the trainee must use the same anatomic and radiographic references required during actual surgical procedures.

Using the aforementioned techniques, they have created a ventriculostomy simulators, percutaneous radiofrequency trigeminal rhizotomy, and spinal instrumentation.

The system has provided the residents an opportunity to understand and appreciate the complex 3-dimensional anatomy of the 3 neurosurgical procedures simulated. The systems have also provided an opportunity to break procedures down into critical segments, allowing the user to concentrate on specific areas of deficiency 2).


Shakur et al., developed a real-time augmented reality simulator for percutaneous trigeminal rhizotomy using the ImmersiveTouch platform. Ninety-two neurosurgery residents tested the simulator at American Association of Neurological Surgeons Top Gun 2014. Postgraduate year (PGY), number of fluoroscopy shots, the distance from the ideal entry point, and the distance from the ideal target were recorded by the system during each simulation session. Final performance score was calculated considering the number of fluoroscopy shots and distances from entry and target points (a lower score is better). The impact of PGY level on residents’ performance was analyzed.

Seventy-one residents provided their PGY-level and simulator performance data; 38% were senior residents and 62% were junior residents. The mean distance from the entry point (9.4 mm vs 12.6 mm, P = .01), the distance from the target (12.0 mm vs 15.2 mm, P = .16), and final score (31.1 vs 37.7, P = .02) were lower in senior than in junior residents. The mean number of fluoroscopy shots (9.8 vs 10.0, P = .88) was similar in these 2 groups. Linear regression analysis showed that increasing PGY level is significantly associated with a decreased distance from the ideal entry point (P = .001), a shorter distance from target (P = .05), a better final score (P = .007), but not number of fluoroscopy shots (P = .52).

Because technical performance of percutaneous rhizotomy increases with training, they proposed that the skills in performing the procedure in there virtual reality model would also increase with PGY level, if this simulator models the actual procedure. The results confirm this hypothesis and demonstrate construct validity 3).


Alaraj et al., developed a real-time sensory haptic feedback virtual reality aneurysm clipping simulator using the ImmersiveTouch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomographic angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-dimensional immersive virtual reality environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from 3 residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery.

Residents thought that the simulation would be useful in preparing for real-life surgery. About two-thirds of the residents thought that the 3-dimensional immersive anatomic details provided a close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They thought the simulation was useful for preoperative surgical rehearsal and neurosurgical training. A third of the residents thought that the technology in its current form provided realistic haptic feedback for aneurysm surgery.

Neurosurgical residents thought that the novel immersive VR simulator is helpful in their training, especially because they do not get a chance to perform aneurysm clippings until late in their residency programs 4).


Lemole et al., use the ImmersiveTouch (ImmersiveTouch, Inc., Chicago, IL) virtual reality platform, developed at the University of Illinois at Chicago, to simulate the task of ventriculostomy catheter placement as a proof-of-concept. Computed tomographic data are used to create a virtual anatomic volume.

Haptic feedback offers simulated resistance and relaxation with passage of a virtual three-dimensional ventriculostomy catheter through the brain parenchyma into the ventricle. A dynamic three-dimensional graphical interface renders changing visual perspective as the user’s head moves. The simulation platform was found to have realistic visual, tactile, and handling characteristics, as assessed by neurosurgical faculty, residents, and medical students.

They developed a realistic, haptics-based virtual reality simulator for neurosurgical education. The first module recreates a critical component of the ventriculostomy placement task. This approach to task simulation can be assembled in a modular manner to reproduce entire neurosurgical procedures 5).


1) Chan S, Conti F, Salisbury K, Blevins NH. Virtual reality simulation in neurosurgery: technologies and evolution. Neurosurgery. 2013 Jan;72 Suppl 1:154-64. doi: 10.1227/NEU.0b013e3182750d26. PubMed PMID: 23254804.
2) Bova FJ, Rajon DA, Friedman WA, Murad GJ, Hoh DJ, Jacob RP, Lampotang S, Lizdas DE, Lombard G, Lister JR. Mixed-reality simulation for neurosurgical procedures. Neurosurgery. 2013 Oct;73 Suppl 1:138-45. doi: 10.1227/NEU.0000000000000113. PubMed PMID: 24051877.
3) Shakur SF, Luciano CJ, Kania P, Roitberg BZ, Banerjee PP, Slavin KV, Sorenson J, Charbel FT, Alaraj A. Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training. Neurosurgery. 2015 Sep;11 Suppl 3:420-5; discussion 425. doi: 10.1227/NEU.0000000000000853. PubMed PMID: 26103444.
4) Alaraj A, Luciano CJ, Bailey DP, Elsenousi A, Roitberg BZ, Bernardo A, Banerjee PP, Charbel FT. Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback. Neurosurgery. 2015 Mar;11 Suppl 2:52-8. doi: 10.1227/NEU.0000000000000583. PubMed PMID: 25599200; PubMed Central PMCID: PMC4340784.
5) Lemole GM Jr, Banerjee PP, Luciano C, Neckrysh S, Charbel FT. Virtual reality in neurosurgical education: part-task ventriculostomy simulation with dynamic visual and haptic feedback. Neurosurgery. 2007 Jul;61(1):142-8; discussion 148-9. Review. PubMed PMID: 17621029.

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