Introduction to Robotics in Spine Surgery

I am Doctor B Bawa Girk and I work as a Spine surgeon at Department of Orthopedics at All Indian Institute of Medical Sciences in New Delhi, and I welcome you all, uh, towards this brief course regarding the Robotics and Spine Surgery.

So it's all matters, you know. Many people, they say that the Robotics are not needed. They, they rely on their, their clinical skills as well as the surgical skills, uh, but it's all a matter of perspective. You need to change the perspective, and perspective actually determines whether you need to go for more safety and more.

Uh, accurate surgeries, and we, we know that as the humankind has always the quest to improve and from the same thing is true about the Spine Surgery as well. From freehand critical screws initially we moved to the, uh, CA navigation, then we came to the OAM navigation, and now we are moving towards the era of the robotic guided Surgery. So it's a revolution in Spine Surgery which is taking place and which reflects the, the basically the Spine surgeon's, um.

quest for improving the pedo screw accuracy.

As such, the, the robotic term was first used by a Czech author, uh, in his play, uh, which meant actually a forced labor or the slave as per their old, the, the, the, uh, the Slavonic language, and the Robot Institute of America defined the robot like a reprogrammable multifunctional manipulator which has been designed to move materials, parts, tools, or specialized devices through various programs.

Emotions for the performance of a variety of the tasks.

If you look at the basically 3 laws of Robotics, so this is a book by the, the EIOs, and he gave the 3 laws of Robotics that a robot may not injure a human being.

A robot must obey the orders given it by the human beings, and the robot must protect its own existence. These three laws, they're a must for any robot to be useful for the human system, for the human society.

As for the history, uh, the first, uh, programmable universal machine was, uh, used for a neurosurgical brain biopsy procedure.

Then came the Darwin's surgical system, and it was the first system to get the FDA approval for the, for the general, uh, laparoscopic Surgery. And then when we talk about Spine in 2004, uh, the major Robotics, uh, came with the first robotic system for Spine Surgery to get the FDA approval. And then we have a lot of, uh, you know, uh, the modifications and the successors to this, uh, Spine assisted by the major Robotics. So basically, we can divide the robots into 4 categories.

Like the remote manipulators when you do the Surgery by, when you're sitting somewhere else.

Then come the festive robots. When the surgical manipulations, they are guided by the surgeon.

Then there are semi-active robots when the certain stage of an operation they are performed by the surgeon, while some manipulations or some part of the procedure is performed by the robot independently and then there comes the active robots when there is a complete surgical intervention which is under the control of the computer.

So when we talk about the Spine robots, they are mostly, they're almost every, every uh Spine robot is in the category of the passive robots, uh, right now. That means that the, the surgeons, they control the robot and basically there are various Other robots also available, but majority of the robots and the majority of the literature is about these 3, types of robots. One is by the Medtronics, one is by the, the Zimmer, uh, and the one is by the Globus, the Excelsius GPS system.

So when we talk about the workflow, the workflow basically all sort of, uh, robots that require some sort of registration in the form of a preoperative or the Intraoperative imaging to be fed to the com the, to the robot on which he decides his further action. So, uh, many, uh, most of the, the robots they require preoperative CT scan.

And then for you require different hardware, uh, requirements and the software requirements. Uh, the intraoperative CT is also possible with some, uh, robotic systems. Then, uh, some robots, they can also work with the intraoperative CR or the fluoroscopy, this, uh, this thing. So they have the different modules for, for the same similar requirements. We talk about the three most common types of robots. Uh, the MSorex basically requires, uh, fixation to the patient's table.

While the Excelsius and the ROSA, they can move and they can come in whenever you need as per your requirement. Uh, the Excelsius GPS doesn't require any use of K wires, while the, the Other two systems, they require the, the use of K wires. All the three systems, they are.

Again, the, the preoperative workflow is there. The intraoperative plural integration is possible with excessive GPS systems. Uh, again, the inter-op CT and the OA integration is possible with all the three systems. Uh, the Excel system isorex. They have, they're fully.

Integrated instrumentation systems and uh the haptic capabilities is not there with Rosa's Spine as compared to the Other two systems. These are basically some of the features and the uh the Spine surgeons, depending upon the requirements, they can choose uh the uh the robot as per their uh necessity. These are basically the, uh, the, the, the 4 major parts of a robot. The one is the, uh, the reference array, uh, like the AA part you can see here, this is the reference array, and there is a camera, infrared camera.

And then there is a robotic arm and then the fourth is the, the display system where you see actually where your uh uh screw is moving.

So this is like the intraoperative CT fixture. Uh, if this is needed if you are basically doing an intraoperative CT scan or the OAM imaging, and then there is a dynamic reference based array on which the trackers are put. You take an intraoperative CT scan, um, after you have fixed.

This thing to your uh to your anatomical landmarks. Then DRB, actually the dynamic reference base, it remains in place throughout the, the time of the school insertion. While once you have done your OR procedure, you take out that, uh, uh, the CT fixture, you take it out after you have done your O spin.

Once you've done the arm spin, you can see actually all the imaging in all the planes uh on the, on the computer screen and then you can plan your trajectory of all the three sections so you can be certain that your screw is inside the bone in all the three planes, uh, the sagittal, coronal, and the actual plane, and you can determine your, your diameter, your length.

Uh, of the screws, uh, accordingly, and then, uh, there's an end effector, uh, which is a rigid robotic arm through which you place your instruments is there and it comes to, it guides you towards the placement of your, of your screws, and you can actually a real-time navigate the each instrument implant inserted into the, into the screen, uh, of the, of the computer.

And then once you have done the procedure, once you've done the, all the screws, then it can tell you the, the, the, the summary of your screw, uh, everything on, on your computer screen. So this is again a good advantage for recording. So basically you look at the, um, the advantages of the Robotic Surgery. It means smaller scars are there. The hospitalization time is shorter. There's a lower risk of the, uh, this, uh, the side effects uh of going screws haywire.

Uh, the overall recovery time is faster. There's less Pain. Um, the blood loss is also less blood losses there, and the, the, the patient, it can recover quickly to its normal activities because the, the time and the accuracy is much faster. So basically the proposed advantages are, in short, there's increased accuracy and safety of the screws. The consistency is reproducible. The radiation exposures is quite less.

And it facilitates the minimally invasive surgeries which can translate into the less invasive, faster recovery and the lower blood loss. The surgeon can get uh real-time information as well as the feedback and it ensures the navigational integrity of the procedure.

We look at the, the, uh, the evolution, evolving Technology like the minimally invasive surgeries and the Artificial intelligence. So now they are being integrated into the Robotics and they can change actually the future of the Robotics, but that is something which we are looking ahead and, uh, uh, the things which can come in the future. And now we're also talking about the Augmented reality. So, uh, the ped violations, uh, uh, they can have grave consequences. We all know that there is a higher rate of screw mal positioning in the.

Thoracic and the cervical Spine, if, uh, when done freehand, and there are, there is pretty evidence from the studies and people have compared the robotic surgeries with, uh, the traditional, uh, techniques. So they, they have said, they have demonstrated that the, uh, the Robotic Surgery actually, uh, increases the, uh, the, uh, this accuracy rate of this placement. However, the, uh, the, the people have done the randomized controlled trials as well, and, um, 2 out of them, they say that there is no difference in accuracy of this thing.

Uh, again, uh, the consistency, uh, is quite reproducible when we talk about the roboticscw replacement. Um, there is no significant difference in ped screw accuracy between the senior surgeon and the resident fellow when they are using the robot. So we can say that the Learning curve, it becomes quite short when somebody's using the robot as a, as an assisted Surgery.

So, uh, the Robotic-assisted Spine Surgery, they require some sort of, uh, Learning curve which can be cut short by using the prior training, preferably in cadavers or in wet labs, and people have, uh, done the, the studies on the, on the, on the Learning curve evidence, and they have said that the Learning curve is usually, uh, reached something after 30 cases or the, the time to screw placement also decreases after the 1st 13 cases.

Radiation exposure is definitely uh reduced and uh it is only needed when you're doing the on-table registration. And you can always use a low dose Protocols if you're using an intraoperative CT or the OR and uh people have demonstrated in various studies. However, there was no difference in the MIS versus open robotic, and the people have shown that the, uh, in freehand we require approximately, on an average of 5.4 images per patient, which can be reduced to 2 images per patient in robotic surgeries.

Operating time is definitely more uh because we take time for setting the robot and the registration and uh people have done various studies which we have, they have shown that the Robotic Surgery actually if you are doing open Surgery, then the time is more as compared to the free and technique and which is again, uh, you know, uh, more as compared to the Robotic-assisted Surgery. So if we can combine the robotic surgeries with the minimal invasive surgeries, then the time is actually quite short.

Some general concerns are there when we talk about the robots. So yes, uh, the initial cost can be prohibitive. Uh, there is a, there is a um

Uh, um, I doubt that the Technology may become obsolete with time. The, uh, the indications may be limited because it may not be useful for very difficult trajectories, and it can make the young surgeon's Technology dependent and, uh, yes, there are some Research which could be market-driven and there could be some ethical concerns, but again, these things you have to take into account and you have to move ahead with the Technology and you have to advance your, uh, surgical skills as well as the patient's safety.

We talk about certain technical problems when we talk about robot. Yes, uh, like if the reference array moves or dislodges during the Surgery, then it can be a problem and it can guide your, uh, your, uh, screw placement in the wrong way. So you have to ensure that you fix it adequately to the bone. You can use a surveillance marker which can guide you whether the, uh, the reference array is moved or not, and you can always check the landmarks when you're putting your screws that they are matching it or not. So you can always use it as an adjunct.

Sometimes the, uh, the, uh, the navigation tool, they can be damaged or they could be poorly viewed on the infrared cameras. So always, always perform a tool check first. You can always change the tracker balls so they get soaked with blood. Uh, you always check for the obstruction that there is no, uh, blood suction tube, gown, sleeve, or the assistant in between your camera and the, and the.

And the reference space and keep tight threshold for any obstruction if if it is there. Like you can see here that this is the uh the uh the, the, the, the surveillance marker. This can tell you that uh they may not be visible in the same single frame and if this uh this uh this area gets damaged, then this can move and then this can cause problem with the, with the, uh, with the navigation.

Uh, sometimes, uh, the, uh, there could be a problem of the skiing, uh, or the tool deflection. The tool can strike the bone at a steep angle, and the, the robot measures forces Other than the thrust force, and, uh, the, so the extremely rigid arm and the tight fit is preferred, and, uh, always the drill noises, they should have the sharp cutting, um, edges, so you, you have to check them, uh, periodically. Uh, sometimes the, uh, the anatomy may shift which can be racked. So always, always insert the screws prior to the bone resection or the antibody fusion.

So that you know your trajectory doesn't shift and uh always proceed from farthest from the, from the dynamic reference space and then work towards it so there are less chances of dislodgement.

So basically we talk about the current status of spinal robots. So currently they are able to just as a as helping us in the pedicostal placement, uh, they can also help us in guiding the, the, the cage placement, but they are right now they are unable to perform the rod contouring and insertion. They are not able to do any decompression or fusion as such in the current, uh, scenarios.

So my take home points are that the, the Robotics, they are actually coming a big way and they are actually quite influencing our future of the Spine Surgery. Uh, if you combine them with the Minimally Invasive Spine Surgery, it can be a big advantage with the enhanced safety.

Obviously there is a less radiation exposure to the 2nd and the Other victims like uh to the surgeon and to the, to the team. Uh, the Learning curve is quite short and the wider adoption of the Robotics, it will require the, uh, if we can somehow integrate the ability to decompress, fusion, as well as the complete instrumentation including rods, then I hope that the Robotics will be adopted in a right way.

Thank you.