Evolution of Image-Guided Surgical Systems
valuable surgical toolset of minimally invasive approaches
ROBOTIC SPINAL SURGERY
Evolution of Image-Guided Surgical Systems
Robotic technology is the logical step in the evolution of the image-guided surgical systems, which contributes to the surgical toolset of minimally invasive approaches. Advanced imaging technologies with real-time three-dimensional views allow computer workstation to manipulate mechanical robotic system along the pre-planned trajectory.
It does not eliminate the role of the surgeon in the operating theatre but minimises human errors and improves the accuracy of the procedure. Robotic systems utilise state-of-the-art technology to model surgical implants, to calculate the precise position of the vertebral screws and to make sure that procedure goes according to the predefined plan.
The concept of remotely controlled robotic surgery was probably developed in the 1970s by the U.S. National Aeronautics and Space Administration (NASA) to allow manipulations of surgical instruments in space. The same idea was explored by the army doctors to deal with wounded soldiers in remote locations.
The initial applications of surgical robotics go back towards 1984-1985 when the PUMA mechanical arm was used to for a navigated brain biopsy in Pittsburgh, the United States and the Arthrobot system assisted in arthroscopic surgery in Vancouver, Canada. Robotic cholecystectomy was performed in 1987, and the same PUMA system assisted with the urologic transurethral procedure.
The United States Food and Drug Administration (FDA) approved the AESOP system for endoscopic procedures in 1990 and the da Vinci Surgery System general laparoscopic surgery in 2000. In 2004, the FDA cleared a SpineAssist robotic system (Mazor Robotics, Caesarea, Israel) for spinal surgery and in 2008, the ROBODOC for the hip replacement surgeries.
Over the years, robotic gained increasing popularity in many surgical specialities, including prostate cancer treatment, endoscopic coronary artery bypass grafting, mitral valve repair, atrial septal defect repair, liver resection and transplant, pancreatectomy, bariatric surgery, bowel resection, oesophageal fundoplication, cholecystectomy, hysterectomy and fibroid removal etc.
Spinal robotic systems are currently represented in Victoria mainly by Mazor Renaissance (Medtronic) and ExcelsiusGPS (Globus). Mazor-X (Medtronic) should be available for a wider use over the next years.
ACCURATE TREATMENT PLAN
Steps of Robotic Spinal Surgery
Pre-surgery planning
Robotic surgery is extremely valuable in dealing with complex spinal conditions which require stabilisation, decompression and instrumented fixation, for example, advanced degenerative spinal disease, tumours, deformities and previously failed surgeries.
It follows the same principles of virtual reality using high-resolution preoperative images to create a computer-based 3D spine model for each patient. The actual surgery begins before the patient enters the operating room when a CT scan is taken and uploaded to create a detailed virtual model of the spine.
The surgeon analyses the model and creates a treatment plan based on his preferences and specific requirements even before scrubbing and entering the operating theatre. Position and length of the skin incision and the optimal implant sizes can be planned. It saves time during surgery and makes the operation more efficient and predictable.
Robot attachment
The operating robot is usually rigidly attached or registered to the patient’s spine with clamps or pins. The Mazor Renaissance System allows for four different mounting platforms to allow precision even if patient movement occurs. An intraoperative synchronization using fluoroscopic x-rays matches the anatomy with the preoperative model created based on a preoperative CT scan. The system registers each vertebra individually, and the surgeon double-checks the accurate level location.
Procedure
The robotic unit goes to the predetermined position, and its arm can bend in all directions to follow the required trajectory. The surgeon can use drill, wires and other tubular instruments to insert screws and other implants even through very small skin incisions with minimal retraction of the muscles and other surrounding tissues.
The instruments and implants can be displayed live on the monitor. The process continues step-by-step until all implants are safely placed in the planned location. Despite the involvement of automated technology, all parts of the entire procedure are controlled by a human, and even the most advanced robot cannot work without the expertise of a skilled surgeon.
EMG SSEP AND MEP
Neuromonitoring
Intraoperative multimodality monitoring is an essential part of robotic and minimally invasive spine surgery. Electromyigraphy (EMG) and somatosensory (SSEP) and motor evoked potentials (MEP) allow to record the electrical activity of muscles and to assess the health and function of the spinal cord, nerves and muscles.
EMG is regularly used in robotic procedures to confirm good placement of pedicle screws and to avoid nerve impingement. Recording of the elctical muscle activity assesses the nerve proximity and location. Dr Aliashkevich uses both stimulated and free-run EMG to ensure safe surgery and to reduce the risk of postoperative complications.
SSEP and MEP monitor the function of the spinal cord and to recognise early possible changes caused by reduced blood flow (ischemia), compression, manipulations, or body positioning during surgery.
Nerve avoidance and navigation
Nerve monitoring and instrument navigation
Spinal cord monitoring
Peripheral sensory nerve monitoring
Computer-assisted, rod-bending technology
Intraoperative angular assessment tools
EMG, MEP and/or SSEP monitoring can be safely used during minimally invasive and robotic surgery on the cervical, thoracic, or lumbar spine:
– lumbar and thoracic microdiscectomy
– cervical, thoracic and lumbar laminectomy and decompression
– foraminotomy
– spinal decompression
– cervical and lumbar disc replacement (arthroplasty)
– anterior cervical discectomy and fusion (ACDF)
– occipito-cervical fusion
– cervical, thoracic and lumbar corpectomy (vertebrectomy)
– lumbar fusions (ALIF, PLIF, TLIF, XLIF, OLIF)
– pedicle screw instrumentation
– cervical, thoracic and lumbar laminoplasty
– posterior cervical thoracic and lumbar fusion
– removal of AVM, cavernomas and tumours
– odontoid screw fixation
– minimally invasive surgery
– image-guided and robotic spine surgery
– syrinx shunt
– pain pump
– spinal cord stimulation
– cauda equina surgery
– posterior cervical fusion
– spinal cord tumor resections
– scoliosis surgery
– vertebroplasty and kyphoplasty
DIFFICULT CLINICAL SCENARIOS
Advantages of Robotic Surgery for neurosurgeon and spine surgeon
Robotic spine surgery can often be performed in difficult clinical scenarios when open surgery is deemed too risky, e.g. in elderly, obese or medically unfit patients. It causes less operative trauma and blood loss, resulting in reduced postoperative pain and scarring.
Please note, however, that not every patient can be considered as a candidate for image-guided or robotic surgery.
Some simpler procedures such as microdiscectomy, laminectomy, artificial disc replacement, anterior cervical discectomy and fusion are still the domain of traditional microsurgery.
The advantages of robotic surgery are the same as for any other navigated spinal surgery:
– better quality of treatment, including improved precision of screw placement (98% accuracy compared to 92% using fluoroscopy based methods),
– improved outcomes,
– decreased incision size with better cosmetic results,
– reduced risk of infection and wound healing problems,
– reduced risk of medical complications, e.g. chest infections and deep venous thrombosis,
– reduced radiation exposure to the patient and operating theatre staff,
– increased safety and avoidance of critical structures during the approach,
– shorter operation time,
– diminished reliance on pain medications after surgery,
– faster postoperative recovery,
– earlier and more efficient physiotherapy and rehabilitation,
– faster return to normal activities and work,
– shorter hospital stay,
– the reduced overall cost of treatment.