Translating high-precision mixed reality navigation from lab to operating room: design and clinical evaluation

To develop and evaluate a Mixed Reality Navigation (MRN) system for neurosurgical navigation, ensuring its feasibility for preoperative planning and real-time intraoperative guidance. The MRN system integrates a head-mounted display (HMD) with active infrared tracking and a stabilization approach. It was validated in a laboratory setting using simulation models and assessed in a prospective clinical study involving 46 patients with intracranial lesions. Multimodal imaging-based holograms were overlaid onto the patient's head for augmented visualization. Target localization accuracy was compared between MRN and Traditional Optical Navigation (TON) using Euclidean distance measurements. In laboratory evaluations, the MRN system demonstrated consistent and reliable performance. The fiducial registration error (FRE), which reflects the alignment accuracy between corresponding anatomical fiducial points on the physical and virtual models, ranged from 1.70 to 2.20 mm. While the target registration error (TRE)-reflecting the final localization accuracy-ranged from 1.30 to 1.70 mm. Clinical validation confirmed the system's efficiency, with comparable navigation durations between MRN (6.36 ± 1.27 min) and TON (6.23 ± 1.30 min, P = 0.41). The preoperative localization error was 2.14 ± 1.23 mm, which increased to 3.65 ± 1.49 mm under simulated intraoperative conditions (P < 0.05), highlighting the potential influence of intraoperative factors on accuracy. With its low hardware cost, MRN system demonstrates precision comparable to TON, while offering enhanced 3D visualization and multi-tool tracking capabilities. These features suggest that mixed reality technology provides a promising new direction for the development of next-generation neurosurgical navigation systems, as supported by both laboratory and clinical results.