European Spine Journal

https://doi.org/10.1007/s00586-020-06440-5

ORIGINAL ARTICLE

Smartphone application technique for localising magnetically

controlled growth rod actuators: the Oxford Magnetic Counter App
Technique (TOMCAT)
Gregory Cunningham1 · Dan Wright1 · Colin Nnadi2

Received: 1 September 2019 / Revised: 2 April 2020 / Accepted: 27 April 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose The purpose of this study is to report a novel smartphone app technique to localise a magnetically controlled grow-
ing rod (MCGR) actuator, along with determining this novel technique accuracy compared to current tactile localisation
techniques through an experimental study.
Methods Five spinal surgery fellows recorded attempts localising the MCGR magnetic actuator using a novel smartphone
app technique, MAGEC Wand and magnetic disc. Three attempts per technique were performed and repeated in both the
average and overweight patient models.
Results In total, 90 separate localisation attempts were recorded. The smartphone app produced less localisation error than
both the MAGEC Wand and magnetic disc. Mean difference was − 0.71 cm (95% CI − 1.24 to − 0.18 cm p = 0.06) and
− 0.58 cm (95% CI − 1.11 to − 0.04 cm p = 0.031), respectively. Mean localisation error for the smartphone app, MAGEC
Wand and magnetic disc, was 0.9 cm, 1.61 cm, 1.47 cm, respectively, for both average and overweight models combined.
Conclusions This novel smartphone app localisation technique is accurate. Current MAGEC Wand and magnetic disc tech-
niques produced more localisation error than the reported tolerance of the external remote control lengthening unit in this
experiment.

Keywords Scoliosis · Early onset scoliosis · Growing rods · Magnetic controlled growing rod · Lengthening · Smartphone

Introduction disparity between true and intended distractions increases

Magnetically controlled growing rods (MCGR) have
improved the treatment of early onset scoliosis [1, 2]. One
of the challenges facing this technology like all growing rod
systems has been termed ‘the law of diminishing returns’
[3]. It has been shown that the amount of true distraction
achieved when lengthening the MCGR by the external
remote control (ERC) is less than that intended [4, 5]. This
* Gregory Cunningham
Greg@GregoryCunningham.com
Colin Nnadi
colin.nnadi@ouh.nhs.uk
1 ening is taking place or what true lengthening has occurred
Division of Spinal Surgery, Department of Orthopaedic
and Spinal Surgery, University of Oxford Hospital NHS
Foundation Trust, Oxford, England, UK
2
Division of Spinal Surgery, University of Oxford Hospital
NHS Foundation Trust, Oxford, England, UK
with the implant time in situ [6]. A number of plausible
causations have been theorised including increasing patient
weight, spinal stiffness and spontaneous fusion [3].
These theories, however, do not completely account for the
difference between true and intended distractions observed at
the first distraction before these patient factors have occurred.
It has been noted that the ideal distance between the internal
magnet of the MCGR and the external magnet of the ERC is
less than 1 cm to achieve optimal lengthening [7, 8]. There-
fore, it is reasonable to consider that some portion of the
unattained intended lengthening may be due to an inaccuracy
when localising the actuator magnet and the subsequent mis-
placement of the ERC when performing a lengthening pro-
cedure. The ERC is unable to determine if successful length-
if inaccurately positioned relative to the magnetic actuator.
The technique of actuator localisation described by the
most current magnetic growing rod (NuVasive, CA USA)
technique guide is with the utilisation of a ‘MAGEC Wand’

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magnet device held above the skin surface [8]. Previous tech-
nical guides had described the actuator localisation using a
magnetic disc before the ‘MAGEC Wand’ became available.
Both of these tactile techniques rely upon a practitioner sens-
ing the attraction force generated by either the Wand or disc.
We have identified a novel technique of magnetic actua-
tor localisation utilising a smartphone (iPhone Apple, CA
USA) magnet detector application (abbreviation: app). This
is made possible by modern smartphones that contain a mag-
netometer chip capable of detecting the magnetic field of the
actuator. Such apps do not rely upon a practitioner’s tactile
perception of force but rather an objective numeric display
of magnetic field strength upon a smartphone.
This novel technique of localisation has not been previ-
ously described, and currently no other published study is
available reporting the accuracy of the two current tactile
techniques to localise the actuator magnet.
The aim of our study is to report this novel smartphone
app-based localisation technique and compare its accuracy
to the existing tactile techniques. The secondary aim of this
study is to report and compare the accuracy of the two tactile
localisation techniques.
Materials and methods
Experimental model
An experimental model was designed to test the accuracy
of the localisation methods. A plastic phantom thoracic and
lumbar human model was fitted with a MCGR to the dorsal
surface. The posterior surface of the model was covered with
a contoured opaque silicone mat. This completely obscured
the growing rod to visualisation simulating the clinical expe-
rience of rod lengthening. Two different thicknesses of soft
tissue covering were replicated with either 4-cm or 7-cm-
thick silicone. A laminated 0.5-cm lined graph paper sheet
was applied to allow marking for recording of the participant
localisation attempts (Fig. 1).
Five spinal surgery fellows took part in the experiment.
Each participant made three separate attempts per device
(Wand, disc and iPhone) to localise the magnetic actuator.
All participants made attempts with each of the different
devices in random order. The markings on the laminated
graph paper were cleaned away after every single localisa-
tion attempt, and each participant performed the localisation
test independently. There was no communication of results
between participants. The experiment was conducted firstly
using a 4-cm silicone covering to imitate average patient
adiposity and then a second time on a different occasion with
a 7-cm silicone covering to imitate an overweight patient.
The position of every localisation attempt was recorded as x
and y coordinates from the graph paper. The distance from the
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European Spine Journal
Fig. 1  Experimental setup
true actuator position was then calculated to yield the localisa-
tion error.
Localisation techniques
Participants were given simple instructions on how to use
the ‘MAGEC Wand’ (Fig. 2a) and magnetic disc (Fig. 2b) to
localise the magnetic actuator. They were also provided with
a separate MCGR to understand the tactile feeling generated
by the disc and wand when the magnets converged. To use the
smartphone magnet finder app (Fig. 2c), they were instructed
to rest the smartphone on the model’s surface, moving the
smartphone only in a craniocaudal direction until a maximal
reading was generated. Once at this craniocaudal position, they
were then to move the smartphone in a mediolateral direction
only until the maximal magnetometer reading was generated.
For clarity, participants were instructed that the exact location
of the magnetometer e-Compass within the smartphone, as
marked at 1.5 cm diagonally from the top left screen corner,
would correlate with the location of the underlying magnetic
actuator. This e-Compass hardware location may vary between
smartphone models, but the technical information specifying
the exact locations is readily available [9].
Statistical analysis and clinical significance
Analysis of descriptive statistics, Students T Test and ANOVA
were performed using SPSS 23 for Mac (IBM, Armonk, New
York). A p value of less than 0.05 was considered statistically
significant. A localisation error of more than 1 cm, based on
published manufacturer recommendations, was considered
clinically significant.
Results
A total of 90 separate localisation attempts were recorded
within the experiment; 45 attempts were recorded for each
of the average (4-cm silicone covering) and overweight
(7-cm silicone covering) models. A mean localisation error
European Spine Journal

Fig. 2  a MAGEC Wand. b

Magnetic disc. c Smartphone
app

Table 1  Mean measurement error by device disc; mean difference was − 0.71 cm (95% CI − 1.24 to
Average Overweight Combined
− 0.18 cm p = 0.006) and − 0.58 cm (95% CI − 1.11 to
patient model patient model patient models − 0.04 cm p = 0.031), respectively. There was no significant
(cm) (cm) (cm) difference in the accuracy of localisation when using the
MAGEC Wand and magnetic disc p = 0.824 (Table 2).
MAGEC Wand 1.29 (0.90) 1.93 (0.90) 1.61 (0.94)
In the overweight patient model, the smartphone app
Magnetic disc 0.88 (0.50) 2.07 (1.11) 1.47 (1.04)
produced significantly less localisation error than both
Smartphone app 0.76 (0.55) 1.03 (0.53) 0.90 (0.55)
the MAGEC Wand and magnetic disc; mean difference
Total 0.98 (0.70) 1.68 (0.98) 1.32 (0.91)
was -0.89 cm (95% CI − 1.67 to − 0.11 cm p = 0.021) and
cm centimetres. SD standard deviation − 1.03 cm (95% CI − 1.81 to − 0.25 cm p = 0.007), respec-
tively. There was no significant difference in the accuracy
of localisation when using the MAGEC Wand and magnetic
of 0.98 cm and 1.68 cm occurred in the average and over- disc p = 0.90 (Table 3).
weight models, respectively (Table 1). In the average adiposity patient model, there was no sig-
The combined data of localisation accuracy for each of nificant difference in accuracy of localisation between the
the devices in both the average and overweight models were smartphone app, MAGEC Wand and magnetic disc tech-
analysed. The smartphone app produced significantly less niques. The average error in localising the position of the
localisation error than both the MAGEC Wand and magnetic magnetic actuator was 0.98 cm in this model (Table 1).

Table 2  Measurement error in both overweight and average adiposity models

Technique Mean difference P 95% confidence interval

(cm)
Lower bound Upper bound

Smartphone App MAGEC Wand − 0.72* 0.006 − 1.24 − 0.18

Magnetic disc − 0.58* 0.031 − 1.11 − 0.04
MAGEC Wand Magnetic disc 0.13 0.824 − 0.40 0.67

*Indicates statistical significance (p ≤ 0.05)

Table 3  Measurement error in overweight adiposity model

Technique Mean difference P 95% confidence interval
(cm)
Lower bound Upper bound

Smartphone App MAGEC Wand − 0.89* 0.021 − 1.67 − 0.11

Magnetic disc − 1.03* 0.007 − 1.81 − 0.25
MAGEC Wand Magnetic disc − 0.14 0.900 − 0.92 0.64

*Indicates statistical significance (p ≤ 0.05)

13

When taking into account all measurement techniques,
there was significantly less error in localisation on the
average patient model compared to the overweight patient
model (a mean of 0.98 cm on the average patient model and
1.68 cm on the overweight model, p = 0.007).
Discussion
This study is the first to identify this novel MCGR magnetic
actuator localisation technique. In this trial, the smartphone
app localisation technique has proved equivalent to existing
techniques in the average patient adiposity model and supe-
rior in accuracy in the overweight patient model.
MCGR may avoid the psychological stress associ-
ated with conventional growing rods by reducing hospital
admissions and repeated anaesthetics [10]. The non-invasive
lengthening procedure can still be a stressful experience
for a child in an unfamiliar environment. The possibility
of using the ubiquitous smartphone that most children are
familiar with, instead of an unfamiliar device, may prove
useful in reducing anxiety levels. The use of various smart-
phone applications in the spine surgery has already been
validated for measuring range of neck movements, Cobb
angles and thoracic rotation in scoliosis patients [11–13].
This study has also demonstrated the increased error
in localisation of the magnetic actuator in the overweight
patient model. This newly confirmed source of error may be
partially responsible for the increased difference in intended
and true rod lengthening observed in patients with higher
BMI [6].
One drawback from the smartphone-based technique is
the need to know the exact location of the magnetometer
e-compass which will vary between smartphone models.
Fortunately, this information is readily available from tech-
nical instructions relating to smartphone repairs. The precise
location of this internal hardware would need to be displayed
on the smartphone screen, specific to each phone model, for
accurate clinical use.
This study is of course limited by its experimental nature.
The phantom model was useful in creating a known soft tissue
thickness, not usually known in routine clinical practice. This
allowed the variable to be accurately investigated for its influ-
ence on localisation accuracy. A dedicated smartphone app
specifically designed and tested for this purpose is required
to ensure accuracy and reproducibility before wider clinical
use. Alternatively, a dedicated device utilising a similar mag-
netometer could be considered. Following development, fur-
ther clinical testing with confirmation of successful lengthen-
ing on imaging would be needed before widespread adoption.
Funding No funding was received for this study.
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European Spine Journal
Compliance with ethical standards
Conflict of interest No conflicts of interest to declare.
Ethical standards Ethics board approval not required.
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