Abstract.SignificanceOrthopedic surgery is frequently performed but currently lacks consensus and availability of ideal guidance methods, resulting in high variability of outcomes. Misdirected insertion of surgical instruments can lead to weak anchorage and unreliable fixation along with risk to critical structures including the spinal cord. Current methods for surgical guidance using conventional medical imaging are indirect and time-consuming with unclear advantages.AimThe purpose of this study was to investigate the potential of intraoperativein situnear-infrared Raman spectroscopy (RS) combined with machine learning in guiding pedicular screw insertion in the spine.ApproachA portable system equipped with a hand-held RS probe was used to make fingerprint measurements on freshly excised porcine vertebrae, identifying six tissue types: bone, spinal cord, fat, cartilage, ligament, and muscle. Supervised machine learning techniques were used to train—and test on independent hold-out data subsets—a six-class model as well as two-class models engineered to distinguish bone from soft tissue. The two-class models were further tested usingin vivospectral fingerprint measurements made during intra-pedicular drilling in a porcine spine model.ResultsThe five-class model achieved>96%accuracy in distinguish all six tissue classes when applied onto a hold-out testing data subset. The binary classifier detecting bone versus soft tissue (all soft tissue or spinal cord only) yielded 100% accuracy. When applied ontoin vivomeasurements performed during interpedicular drilling, the soft tissue detection models correctly detected all spinal canal breaches.ConclusionsWe provide a foundation for RS in the orthopedic surgical guidance field. It shows that RS combined with machine learning is a rapid and accurate modality capable of discriminating tissues that are typically encountered in orthopedic procedures, including pedicle screw placement. Future development of integrated RS probes and surgical instruments promises better guidance options for the orthopedic surgeon and better patient outcomes.