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Robotics and MIS – An Exciting Journey! Kornelis Poelstra MD PhD The Spine Institute on the Emerald Coast – Florida, USA Mazor Robotics Webinar
Robotics and MIS – An Exciting Journey!
Kornelis Poelstra MD PhD
The Spine Institute on the Emerald Coast – Florida, USA
Mazor Robotics Webinar
• Traditionally trained as OPEN spine surgeons- Really good at complex spine surgery… even OLD people…
Why is MIS important for you and me?
Because exposure and closure takes a long time:- Infection risk- Inefficiency in this process
- Reproducibility- Accuracy issues…
Especially if we can do the same operation
much more efficient like this… MIS!
MIS Concerns… Percutaneous Spine Surgery works, but Setup with Fluoro takes time & radiation…
Key Set up Understand Fluoro
Advancing to less invasive technique…• Giant advances in Damage Control Spine Surgery
Longer than 5 levels MIS…?X-treme MIS
61 y/o male with DISH - pedestrian struck by SUV
multiple fractures and floating spine…
Damage Control Spine Surgery
Open brain injury with left arm and leg crushed
144 kg
Chest injury…
Intra-operative…
Intra-operative…
Intra-operative…
T4 – L2 120-mins of Surgery
4-mins of Fluoro… (too much!)
Quite many downsidesusing FLUORO MIS…
• Accuracy - Precision• Depending on patient anatomy• Fluoroscopy visualization• Surface abnormalities / Hills-valleys• Ability to match up to existing hardware
• Reproducibility• From case to case• From level to level• From 7am - 7pm in my hands• From surgeon to surgeon…
• Weekend courses…?
• Radiation exposure!!
NEXT came Navigation
(since 1990s)Computer assisted
surgery(CAS)
Imaging guided surgery(IGS)
Neurosurgery
Brain
Spine
ENT Orthopedic
Long bone
Hip
Knee
Spine
Navi accuracy…?
• 1922 screws (T/L/S) in 353 pts
• 94% open, 3% MAST, 3% percutaneous
• 5% O-Arm function suboptimal
• 1 case O-Arm failed
• 2.5% Pedicle screws considered misplaced
• Vs 5-15% for fluoroscopy in published series
O-arm was better than Fluoro-Merge?A comparison of CT-based navigation techniques for minimally invasive lumbar pedicle screw placement.
Wood, Martin. Mannion, Richard. The Mater Private Hospital Brisbane, Queensland, Australia. J Spinal Disorders & Techniques. 24(1):E1-5, 2011 Feb.
Only 1.6% vs 6.4% misplaced screws (P<0.03)
Better results…
but still “Craftsman” surgery
How can we make this
more reproducible & efficient
and add greater clinical value…?
Navigation alone is like Auto-pilot…
But what about your pilot?
Fluoro- or CT-Nav: You still have to do
the precision guidance in the OR…!
Concerns
z-axis
y-axis
x-axis
Navigation Concerns…
Combining everything we’ve learned…
Robotic Spine Surgery
Robotics Accuracy…
Example of NAV issues in multi-level case:
Screw cadence makes or breaks rod placement
140260
So: How does this Really work??
From here….
To… Something The World was
introduced to just 6 weeks ago…
Recap: My experience with Robotics…
• 277 robotic surgeries / 20mo.
• 185 Renaissance• 1535 screws… +
• 92 MAZOR X• 2078 screws – 100% OK
• 74 SAI screws / pelvic fixation
• 18 O-Arm Scan-and-Plan
Sweeney Tm1, Cannestra A2,
Poelstra KA3, Schroerlucke SR4
Southeastern Spine Center, Sarasota, FL
Lyerly Neurosurgery, Jacksonville, FL
The Spine Institute on the Emerald Coast, Destin, FL
Tabor Orthopedics, division of MSK group, Memphis, TN
Retrospective Comparative Review of Robotic-
Guidance vs. Freehand Instrumentation in 705
Adult Degenerative Spine Patients Operated in
Minimally Invasive (MIS) and Open Approaches
Methods
RobotMIS
FreehandMIS
Freehand Open
Total
Surgeon 1 184 46 53 283
Surgeon 2 112 51 25 188
Surgeon 3 59 81 0 140
Surgeon 4 48 46 0 94
Total 403 224 78 705
Retrospective
4-surgeon study
All experienced in MIS
techniques
3 arms:
Robotic MIS
(Renaissance)
Freehand MIS
(fluoro guided)
Freehand Open
(fluoro guided)
Total controls = 302
Surgical Outcomes – Multi-Center
Parameter RO MIS FH MIS FH Open
# patients 403 224P-value vs. RO
MIS78
P-value vs. RO MIS
Age 64.4 61.5 0.010 64.2 0.992
BMI 31.2 30.8 0.841 31.0 0.986
# screws/case 7.2 5.5 <0.001 7.9 0.143
Fluoro time per screw
11.3 27.4 <0.001 21.9 <0.001
Surgery time per screw
32.7 33.8 0.787 36.9 0.230
11.3
Surgical Outcomes – Multi-Center
• Odds of suffering a complication or revision surgery in freehand cases, compared to robot MIS:
• Insignificant parameters in regression model: age, gender, BMI, surgeon, length of surgery
12.8%
5.4%4.0%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
FH Open FH MIS RO MIS
Complication Rate
P=0.014
P=0.009
78 224 403
7.7% 7.7%
3.8%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
FH Open FH MIS RO MIS
Revision Rate
P=0.006
78 224 403
Revisionsvs. robotic arm
OddsRatio 3.8 1.9
P-value 0.006 0.218
CI95% 1.5 -10.0
0.7 - 5.4
Parameter FH MIS FH Open
Complications
vs. robotic arm
OddsRatio 3.0 3.1
P-value 0.014 0.009
CI95% 1.2 - 7.1 1.3 - 7.3
Conclusions
• Robotic-guided MIS vs. freehand MIS:– Significantly larger number of screws per case
– Significantly reduced surgical complications
– Significantly reduced revision surgeries
– Significantly reduced use of intra-op fluoro
• Robotic-guided MIS vs. freehand OPEN:– Significantly reduced surgical complications
– Significantly reduced use of intra-op fluoro
• Equal skin-to-skin time between study arms
Power of WELL-PLANNED surgery is that…
…it leads to a highly Reproducible Case
Case study X-AlignPatient Example…
• 72 y/o female retired nurse• Retired Hospital CFO
• Multiple prior cervical and lumbar surgeries
• Unable to stand-up straight
• Prior solid instrumented fusion L4-S1
• Back pain severe when upright >5minutes
• Cannot shop and...
Cannot walk on the Beach!
Imaging studies…
Pre-op Planning
Patient needs34 degrees correction
Imaging studies…
Pre-planned surgery allows for:
- Fully prepared – correct tools / inventory
- NO Stress during the surgery
- Predictable outcomes!
More efficient!
Intra-operative: Our patient…
L1 – L4 Lateral Posterior T10 – S1 MIS fixation + cement
Clinic Follow-up – 6 months
Posteriorly:15 seconds of fluoroscopy / All MIS
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• Multiple decompressions
• Fractured
• Diskitis…
• Osteoporosis
• Progressive LBP / kyphosis
57y/o Hep C – Smoker – Drug use
L3-4L2-3
Simultaneous lateral MIS L2 + L3 Corpectomy + cage posterior reduction / instrumentation
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Final Result 4 weeks later…
PROLat® also possible with Mazor X
Advantages for using Robotics in Spinewill continue to grow by…
• BETTER Planning and Virtual Execution…
• Completed entirely BEFORE the OR!
• Software planning tools for global correction
• Osteotomies simplified by robotics• Real-time feedback via built-in navigation
• This will go beyond the spine…
- Soft tissue manipulation forDecompression
Disk preparation for fusion
• Stereo-tactic Accuracy with
Robotic Guidance provides for:
• Safety,
• Accuracy,
• Reproducibility.
Improved: - Efficiency for Surgeons,
- Economics for Systems,
- Outcomes for Patients.
Embracing and collaboration using Robotics with be:
Redefining the Standard of Spine Surgery…
Advantages using Robotics in Spine…
