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Understanding Robotic Spinal Surgery

OVER 4.83 MILLION SPINAL operations are performed annually around the world, with 1.34 million operations taking place in the United States alone. In order to optimize and enhance surgeon performance, the FDA approved robot-assisted systems have been developed and deployed worldwide. These systems have been utilized for spinal fusion and instrumentation procedures, and to aid intraoperative navigation, trajectory determination, and screw implantation (D’Souza M, et al. Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends. Robot Surg. 2019; 6: 9–23.). They also allow for allow for smaller, single incision sights.

The spine surgeons at Centers for Neurosurgery, Spine, & Orthopedics are highly trained in robotic assisted spine procedures. They have held academic positions at the top medical teaching universities, chief of surgery positions at top spine surgery hospitals, and neurosurgical society presidential positions. Together they are the only board-certified multi-specialty team in New Jersey with proven success in treating patients using minimally invasive surgical techniques such as robotic and spine navigation imaging systems in New Jersey.

While spine robotics has been available in the United States since 2004, the technology has evolved significantly in the last few years.  By 2015, over 3000 procedures were performed annually in the United States, in a trend mimicking the Intuitive Surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) used for prostate, obstetrics, and gynecologic surgeries, which in 2015 already had 700,000 procedures completed. Today, the use of computer-assisted robotics or an intra-operative CT guided imaging poses no additional cost to the patient or their insurance company, making it even easier for patients with complicated anatomy or previous spine surgery to benefit from its use.

CNSO spine surgeons have used robotics and spine navigation systems for the most complex revisions, scoliosis, and deformities.  They have had great success correcting previous spine surgery with failed back symptoms as well as preventing the need for future additional surgery.

Improving Patient Outcomes Using Robotic Spine Surgery

In recent years, there has been a surgical trend towards minimally invasive instead of traditional open. This trend avoids damage to the muscles and ligaments that surround the spinal structures. This decreases a patient’s postoperative pain significantly and further reduces infection rates, blood loss, and wound healing complications. 

The use of robotically assisted procedures is especially helpful in patients with severe scoliosis or other spinal deformities that may make traditional implant placement more difficult, as well as those who have had prior spine surgery that failed. Even when anatomic landmarks are obscured or prior implants are not in the right location, the surgeon can use the robotic arm to place new implants in a perfect position that creates better outcomes for the patient.

The use of intra operative radiographic imaging or a CT prior to surgery allows the surgeon to map out exactly where the implant needs to be placed using a 3D computer image. The trajectories of the implants are mapped to a very fine detail before the surgery takes place, allowing for more accurate placement and smaller incisions leading to faster recovery time and less post operative pain.  During the surgery, the robotic arm carries out implant placement with the surgeon’s guidance which is further enhanced by the 3D images.

There are multiple advantages of robotic surgery including potential less radiation exposure, highly accurate placement of implants, lower rates of neurological complications, and lower infection rates as larger open incisions are not necessary.  While studies are still being done to further evaluate the utility of robotics and navigation in spine surgery, these techniques have already been shown to be safe and effective and patients can be evaluated by our highly trained and skilled CNSO surgeons to determine if they are a candidate.

Types of Cases for Robotics

The Robotic Spine Surgery Program has board-certified neurosurgeons and orthopedic spine surgeons at CNSO use robotics for minimally invasive and spinal deformity surgeries. This allows surgeons to do the same surgeries without making large incisions to visualize the underlying bones. It has been proven that minimizing the exposure tissue can lead to less postoperative pain, lower infection rates, quicker return to normal function, and decreased risk of breakdown of the adjacent levels as the spine itself is a complicated structure with many moving parts.

Minimally invasive spine surgery has become more popular over the past ten years due to advances in technology that have made it better and more effective.  Instead of using larger incisions down the middle of the spine, smaller 1-2 cm incisions can be made off the sides of the spine to place stabilizing screws and rods as well as to remove pressure from the spinal nerves and place implants in the disc space if needed. Through preoperative planning software, the surgeons at CNSO can plan ideal trajectories of the implants to minimize incision size, allow easier passage of the rods and interbody cages, and even place implants in small or difficult to access pedicles.

Spinal deformity surgery to correct problems after previous surgery are also ideal indications for robotic and navigation. Each patient is evaluated by both an orthopedic and neurosurgical spinal deformity specialist. Either before or during surgery, the necessary CT scan is taken and used to formulate a precise surgical plan. A benefit of this technology is creating new screw tracts in bones that already contained implants in a suboptimal position, which can be very difficult to accomplish with the traditional “freehand” techniques or with x-ray alone. As a greater number of surgical levels are performed, the radiation to the patient is reduced as only one x-ray at the beginning of the surgery is usually needed rather than multiple each time a screw is placed.

Globus Excelsius GPS (Globus, Inc)
Medtronic MazorX (Medtronic PLC) for Robotic Surgery

Images show two robotic platforms commonly used for spine surgery, the Globus Excelsius GPS (Globus, Inc) and the Medtronic MazorX (Medtronic PLC).

Clinical Course

As a patient coming in for a new evaluation, you can expect a thorough and complete evaluation which will likely include a review of any previous x-ray, MRI, and CT images, a review of your medical history, and any new or updated imaging studies to plan your treatment. Candidates for surgery with robotics and navigation are selected based on evaluation of their symptoms, and work closely with primary doctors and pain management specialists to make sure that they have been through the right non-surgical treatments. For some severe cases, more urgent surgery is recommended and non-surgical options may be limited.

Once the patient is found to be a candidate for surgery and preparations are made, our team at CNSO will handle everything from insurance authorization to medical appointments and any preoperative testing required by the hospital. Prior to surgery, it is important to avoid smoking and get good nutrition and routine exercise if possible. Patients should continue to take all medications unless told otherwise by their doctor. Any necessary lab-work and imaging will be ordered, and any necessary braces or pain medications will be arranged. Expectations for recovery will be discussed so patients and their families are aware and understand what will be needed after surgery. The surgeons at CNSO choose their hospital locations carefully for the best and most experienced teams of anesthesiologists and postoperative nursing care to give our patients the best experience possible.

The recovery course for each patient will differ based on the type and magnitude of surgery. For most minimally invasive surgeries, the patient can go home either the day of surgery or the next morning. Patients requiring more extensive operations for scoliosis or kyphosis may require a 2-3 night hospital stay to ensure they have enough physical therapy and other needed resources to go home safely to the care of the family. After discharge from the hospital, follow-up appointments will be scheduled on a routine basis and the office will arrange for any needed x-rays to be done on a case-by-case basis. Our providers at CNSO are available for postoperative follow-up care 24 hours a day to make sure that all of the patient’s needs are met.

If you have been told that you need spine surgery and want to know if robotics and navigation may be an option for you, call Centers for Neurosurgery, Spine, & Orthopedics for patient scheduling at 973-633-1122 today!

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