Augmented Reality-Assisted Resection of a Large Presacral Ganglioneuroma: 2-Dimensional Operative Video

Presacral ganglioneuromas are rare, well-differentiated tumors that derive from neural crest cells, with less than 30 cases reported in the adult population.1-3 Diagnosis using imaging modalities remains challenging, and gross total resection is considered standard of care.4 Resection of these rare presacral tumors is technically demanding, requiring large exposures and careful dissection of the tumor from its retroperitoneal attachments.5-7 Augmented reality neuronavigation (ARNV) represents a paradigmshift in neuronavigation, allowing on-demand visualization of 3D (3-dimensional) data directly in line with the operative field. Augmented reality (AR) use cases in spine surgery are rapidly emerging.8-25 Here, we describe the workflow to use ARNV navigation-guided surgery to assist in the resection of a presacral ganglioneuroma. This technology allows the surgeon to visualize segmented anatomic information aligned and synchronized with real-time navigation images displayed in 3D in the surgeon's field of view through a surgical microscope. The patient is a 23-year-old female with a 9-month history of coccygeal, right abdominal, and right flank pain without bowel or bladder incontinence. Imaging revealed a 5.6 x 5.9 x 3.3 cm presacral contrast-enhancing mass extending from S3 to coccyx. The patient consented to surgical resection of the mass. AR neuronavigation was used to tailor the skin incision and bony resection and to aid in tumor resection. Postoperatively, the patient was neurologically intact. A final diagnosis of World Health Organization Grade I ganglioneuroma was made. In this case, it was believed that AR resulted in reduced exposure size and increased precision during en bloc resection, allowing for tumor capsule-avoiding dissections and minimizing collateral tissue damage. Patient consent was obtained before the creation of the video and is available on request.