Exoscope Use in Spine Surgery: A Systematic Review of Applications, Benefits, and Limitations

Exoscopes were recently developed as an alternative to the operative microscope (OM) and endoscope for intraoperative visualization in neurosurgery. Prior reviews studying mixed cranial and spinal surgical cohorts reported advantages of exoscope use, including improved ergonomics and teaching. In recent years, there has been an increase in exoscope research, with no updated systematic review focused exclusively on the benefits and limitations of exoscopes in spine surgery. To systematically synthesize the literature related to exoscope-assisted spine surgery. A literature search was conducted using the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to identify relevant studies published between 2010 and September 2023. Data, such as exoscope model used, procedure types performed, and user observations, were then collected. Thirty-one studies met our inclusion criteria. 481 patients with spine pathologies underwent a surgical procedure utilizing one of nine exoscope models. Lumbar regions were most frequently operated on (N = 234; 48.6%), and discectomies comprised most overall procedures (N = 273; 56.8%). All patients benefitted clinically. Reported advantages of exoscopes compared to OMs or endoscopes were improved focal distance, surgeon posture, trainee education, compactness, and assistant participation. Other aspects such as stereopsis, illumination, and cost had varying observations. Exoscopes have advantages compared to OMs or endoscopes in spine surgery. The user learning curve is minimal, and no negative patient outcomes have been reported. Still, some aspects of exoscope use necessitate longer-term prospective research before exoscopes can be considered a standard in the armamentarium of intraoperative visualization strategies.