Robot-Guided Spine Surgery
Christopher R. Good, MD, FACS Spine Surgeon
Blair K. Snyder, PA-C
Director of Research
Director of Scoliosis and Spinal Deformity
Virginia Spine Institute
1831 Wiehle Avenue
Reston, VA 20190
T (703) 709-1114
F (703) 709-1117
The goals of modern spinal surgery are to maximize patient function and accelerate a return to a full life. As spinal surgery has evolved, more focus has been placed on minimizing trauma to the body during surgery and expediting a return to function through the use of minimally invasive techniques. The era of modern spinal surgery has blossomed over the past 15 to 20 years as a result of scientific advancements including minimally invasive surgery, genetic testing, next generation spinal implants, stem cell research and the use of biologic agents to promote spinal healing.
Robot-Guided spinal surgery offers many potential advantages to patients and surgeons including improving the safety of minimally invasive as well as complex surgical procedures, improving the accuracy of spinal instrumentation, and minimizing the use of radiation during surgery. Robot-guided spine surgery utilizes highly accurate, state-of-the-art technology for the treatment of many spinal conditions including degenerative spinal conditions, spine tumors and spinal deformities.
How It Works:
The Mazor Robotics’ Renaissance® system is one of the only robotic guidance products in the United States used for implanting devices during spine surgery. The Mazor Robotics system allows the surgeon to use the images from a computerized tomography scan (CT scan) that is taken before surgery to create a blueprint for each surgical care. The CT scan information is loaded into a computerized 3D planning system which allows to the surgeon to plan the surgical procedure with a high degree of precision before ever entering the operating room (Figure 1).
In the operating room, the surgeon does all of the physical work of the surgery. The Robot-guidance system is a tool that helps to guide the surgeon’s instruments, based on the highly accurate pre-operative planning of spinal implants placement. During the surgery, the Robot is placed near the patient either by attaching it to the bed or directly anchoring it to the spine of the patient. The robot is approximately the size of a 12 oz beverage can with a small arm attached. The robot has the ability to bend and rotate in order to place its arm on the spine in a very specific location and trajectory (Figure 2). This ultra-precise guidance can improve the surgeon’s ability to safely place implants, particularly when working through very small incisions (minimally invasive surgery) or when dealing with complex anatomy (spinal deformity or previous spine surgery).
Minimally Invasive Spine Fusion:
One common technique presently used by spine surgeons to correct spinal conditions is spine fusion. The purpose of a spinal fusion is to create a rigid union between two separate segments of the spine to correct malalignment or instability. Spine fusion has traditionally been performed using “open surgery” with an incision that is big enough to expose the entire area being treated. Open surgical techniques are beneficial and necessary for many conditions, however, in some cases minimally invasive surgery (MIS) can be utilized to safely obtain a similar result. MIS uses smaller incisions which usually result in less damage to surrounding healthy tissue, less post-operative pain and faster recovery.
In many situations, MIS requires an increase in the use of intraoperative x-rays in order to compensate for a surgeons inability to directly visualize the spine. In some cases, this lack of visualization could decrease the surgeon’s accuracy when compared to open surgery. In addition the increased radiation exposure during surgery is a concern for the patient as well as the health care team, as previous studies have shown an increased rate of cancer among spine surgeons, compared to the general population (1).
Robot-guided surgery technology allows the surgeon to perform MIS in a very precise fashion while minimizing the need for radiation during the surgical procedure. Robot-guidance technology guides the surgeon’s tools during MIS to ensure accuracy while also decreasing tissue trauma, resulting in less bleeding, smaller scars, less pain and faster recovery (Figure 3).
A recent study reviewed 635 surgeries involving the placement of 3271 spinal implants and found a 98.3% accuracy rate for implants placed with robot-guidance. In this study, 49% were defined as minimally invasive surgeries. Neurologic issues were noted in 4 cases, but following revision surgery no permanent nerve damage was encountered. The study reported an improvement in accuracy of instrumentation placement and lower risk for neurologic issues compared to previous studies (2). Robot-guidance has been directly compared to open surgical techniques and in one retrospective study demonstrated an improvement in implant accuracy by 70%, reduction in radiation dose by 56%, and decrease in hospital stay by 27% (3).
Scoliosis Correction Surgery:
Scoliosis is an abnormal curvature of the spine that affects approximately seven million people in the United States. Adolescent idiopathic scoliosis is most commonly diagnosed between the ages of 10 to 12 years old and may be discovered by parents, during school screenings, or at pediatric visits. When scoliosis is suspected, patients are referred to orthopedic scoliosis specialists who evaluate the patient to determine the severity of the patient’s curvature. Symptoms of scoliosis may include back pain, uneven shoulders or hips, abnormal gait, breathing issues and neurologic problems.
Treatment options for idiopathic scoliosis include observation, bracing, and surgery. In general bracing is recommended for curves between 25-30 degrees in patients with significant growth remaining and corrective surgery is generally reserved for progressive scoliosis curves greater than 45º or curves that do not respond to bracing treatment. The goals of scoliosis correction surgery are to amend the spinal curvature and to prevent the curve from progressing further during the patient’s life (Figures 4, 5 and 6).
Surgery for scoliosis involves the use of spinal instrumentation such as screws, rods, hooks, and wires which are placed along the spine. Surgery treats but does not cure scoliosis, it corrects the abnormal curvature and prevents further progression of the disease. Surgical treatment of scoliosis requires a high degree of planning and precision. Each specific curve pattern is unique and many patients with scoliosis have atypically shaped vertebrae, making the surgery more challenging.
Robot-guided scoliosis correction offers increased precision of instrumentation placement and therefore an increase in the safety of the surgical procedure. It offers the surgeon the ability to carefully plan ahead before entering the operating room and design the ideal procedure for each patient. Studies have validated superior clinical results for adolescent scoliosis reconstruction with Robotic technology based on improved accuracy of implant placement and safety. In a recent study of 120 teenagers with scoliosis, robot-guided surgery was found to achieve 99.7% accuracy of 1,815 implants placed (4).
Vertebroplasty is an outpatient procedure commonly performed for the treatment of osteoporotic compression fractures. During the procedure synthetic bone cement is injected into a broken spine vertebra through a needle. This cement hardens a few minutes after it is injected which stabilizes the fractured vertebra thereby decreasing pain and the potential for the bone to break further.
Vertebroplasy requires a high level of precision because a needle is guided through the vertebra near the spinal cord or nerves. Additionally, the accuracy of the needle location is important to prevent the bone cement from flowing into the area around the nerves in the spine. Robot-guidance allows the surgeon to position the needle precisely to minimize the risks surrounding vertebroplasty procedures. In a recent study of osteoporotic compression fractures, robot-guidance was shown to yield improved accuracy over traditional methods, which reduced the total time needed for the procedure and in some cases allowed the procedure to be performed on patient’s who would not have been able to be treated conventionally (5). The use of the robot has also been reported to decrease radiation exposure to the patient and operating room staff by 50-70% in vertebroplasy procedures (6) (Figure 7).
In some cases, it is necessary to obtain a small piece of tissue from the spine in order to perform microscopic studies to understand a patient’s disease or make a specific diagnosis. This is particularly true in cases of spinal tumors when it is imperative to determine if a lesion is benign, malignant or infected. Biopsies are usually taken with a needle through a small incision without direct surgeon visualization of the tumor. In many cases, surgeons use CT or X-ray images to guide the needle into the correct location. This process involved additional radiation and in some cases, it can be difficult to find the right spot for the biopsy. Robot-guidance allows the surgeon to pinpoint the exact location the biopsy is to be performed and can decrease the time needed for the procedure and the duration of radiation (Figure 8).
Robot-guided spine surgery is a promising new technology that has many advantages and may allow surgeons to perform less invasive surgical procedures with smaller incisions, less bleeding, faster recovery and shorter hospital stays. Robot-guidance also can increase the accuracy and safety of surgical procedures and allow these procedures to be performed with less intra-operative radiation exposure to patients and health care providers.
- Singer, Occupational radiation exposure to the surgeon. Am Acad Ortho Surg 2005; 13 69-76 .
- Clinical Acceptance and Accuracy Assessment of Spinal
Implants Guided With SpineAssist Surgical Robot
Dennis P. Devito, MD, Leon Kaplan, MD, Rupert Dietl, MD, Michael Pfeiffer, MD,
Dale Horne, MD, Boris Silberstein, MD, Mitchell Hardenbrook, MD,
George Kiriyanthan, MD, Yair Barzilay, MD, Alexander Bruskin, MD,
Dieter Sackerer, MD, Vitali Alexandrovsky, MD, Carsten Stu¨er, MD, Ralf Burger, MD, Johannes Maeurer, MD, Donald G. Gordon, MD, Robert Schoenmayr, MD,
Alon Friedlander, MD, Nachshon Knoller, MD, Kirsten Schmieder, MD,
Ioannis Pechlivanis, MD,In-Se Kim, MD, Bernhard Meyer, MD,
and Moshe Shoham, DSc
SPINE Volume 35, Number 24, pp 2109–2115
- Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement Sven Rainer Kantelhardt • Ramon Martinez • Stefan Baerwinkel • Ralf Burger • Alf Giese • Veit Rohde Eur Spine J DOI 10.1007/s00586-011-1729-2
- Devito DP, Gaskill T, Erikson M, Fernandez M. Robotic based guidance for pedicle screw instrumentation of the scoliotic spine. Presented at Pediatric Society of North America (POSNA); May 2011; Montreal, Canada.
- Silberstein, B. Bruskin, A. Alexandrovskii, V.Robot guided surgery in treatment of osteoporotic fractures. Presented at: European Federation of National Associations of Orthopaedics and Traumatology (EFORT) 2011 Annual Congress; June 1-4, 2011:abs 1097.
- Kaplan, et al. Robotic assisted vertebral cement augmentation: a Major radiation reduction tool. Aging Spine Symposium, March 2011. Jerusalem, Israel.