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Robotic Spine Surgical Considerations

Dr. Goldstein’s lengthy record as an innovator, investigator, and teacher is apparent from his CV. As the Director of Education, Division of Spine Surgery and Director of the Spine Surgery Fellowship at one of the nation’s top spine centers, it is no surprise to find Dr. Goldstein once again at the leading edge of robotic usage in spine surgery.

Spine surgery is one of the most complex and delicate types of surgery. It, involves the manipulation of the bones, nerves, and soft tissues that support the spinal cord and the entire body. Traditionally, spine surgery has been performed using open or minimally invasive techniques, relying on the surgeon’s skill, experience, and vision to achieve optimal results. Historically it has relied on manual dexterity, fine motor control, and endurance maintained over long periods of time during surgery. However, new technologies have emerged that promises to revolutionize the field of spine surgery: surgical robots for spine surgery.

Robotic spine surgery, or robot-assisted spine surgery, is the use of robotic technology to assist with guidance during spinal neurosurgery. Obviously, these are not the bipedal robots of science fiction. These are very real machines designed to offer exceptional accuracy and control to the surgeon.

The robotic system includes a surgical console, where the surgeon controls the movements of the robotic arm and instruments. A specialized camera provides enhanced and magnified 3D views of the surgical area, and surgical arms with extremely small instruments attached can perform precise and flexible motions impossible to achieve with the human hand. The robotic system is integrated with preoperative and intraoperative imaging, such as CT or fluoroscopy, to create a surgical plan and navigate through the intricate structures of the spine. It can perform precise actions over and over again minimizing errors and fatigue.

Robotic spine surgery is indicated for patients who have symptomatic cervical, thoracic, or lumbar spine conditions, such as disc herniation, spinal stenosis, spondylolisthesis, scoliosis, or spinal tumors, and who have failed conservative management and/or require surgical intervention. Currently robotic spine surgery is most commonly used for posterior instrumented fusions, in which screws and rods are implanted in the bones of the spine to stabilize and fuse them together. However, robotic spine surgery can also be used for other types of procedures, such as discectomy, laminectomy, corpectomy, or deformity correction. Robotic spine surgery is available to navigate interbody devices.

As with any medical technique or procedure, there are advantages and disadvantages:

Advantages of robotic spine surgery:

  • Precision: Robotic spine surgery was developed for increased accuracy and precision. Using currently available imaging techniques, the robot can be pre-programmed to navigate through the intricate structures of the spine with ease, and this precision ensures that the surgeon can perform the surgery with a level of accuracy that may be difficult to achieve with traditional surgical methods. According to a 2019 review of the literature, the overall accuracy of screw placement using robotic spine surgery was 98.3%, compared with 92.9% for free-hand surgery. 1
  • Smaller incisions: Smaller incisions are generally acknowledged to be preferable to large. Because robotic spine surgery relies on advanced imaging technology and machine guidance, it typically requires smaller incisions than traditional surgery, minimizing the separation of muscle tissue and thereby reducing the risk of related complications. Smaller incisions also result in less blood loss, less scarring, and less postoperative pain.
  • Shorter operative time: Robotic spine surgery may reduce the operative time compared with traditional surgery, as the robot may be able to perform certain tasks faster and more efficiently.
  • Limited data suggest that certain specific robotic surgeries may take 36% to 56% lesser time compared to traditional free-hand surgery.
  • Less exposure to radiation: Robotic spine surgery reduces the need for fluoroscopic (live x-ray) guidance during surgery. The exposure of surgeons and the operating staff to radiation is a known risk of much current surgery, and the medical profession is seeking methods of reducing that risk. Robotic spine surgery can provide a clear and enhanced view of the surgical field without relying on fluoroscopy.
  • Quicker recovery time: As a result of smaller incisions and corresponding reduction in tissue damage, robotic spine surgery may result in a quicker recovery time for patients. Quicker recovery time typically results in the added benefits of reduced length of hospital stay and a reduction in the need for narcotic pain medication after surgery.

Disadvantages of robotic spine surgery:

  • Limited availability: Robotic spine surgery is a relatively new and expensive technology, requiring a significant initial investment and maintenance costs. It requires specialized training of the operating staff as well as many other hospital employees. Currently, this technology is most often available in large, academically connected institutions like NYY Langone. It is not available in all locations across the country. For example, Dr. Goldstein uses the first Globus ExcelsiusGPS™ robot in New York City. Additionally, Dr. Goldstein performed the first case in the world utilizing the Globus E3D intra operative CT imaging device.  If you wish to explore the benefits of robots in spine surgery, you will likely need to have your surgery in a large hospital center like the one where Dr. Goldstein practices.
  • Technical issues: Robotic spine surgery is dependent on the proper functioning of highly advanced robotic systems and imaging techniques. A technical malfunction may compromise the safety or the ability to proceed with the surgery. For example, the robotic arm may malfunction, the camera may lose the signal, or the imaging may be inaccurate or distorted. It’s important that the entire surgical team has the knowledge and experience to be able to switch to traditional methods in the event of technical malfunction.
  • Learning curve: Robotic spine surgery requires a steep learning curve for the surgeons and the operating staff, as they have to master the use of the robotic system and the imaging modalities. The learning curve may affect the operative time, the accuracy, and the outcomes of the surgery, especially in the initial stages of the adoption of the technology.
  • Potential complications: Like any surgery, robotic spine surgery involves risks, some of which may be similar to conventional, open surgery. The usual surgical risks of infection, bleeding, nerve injury, spinal cord injury, hardware failure, or nonunion may be reduced by robotic technique, but they continue to exist.

Robotic spine surgery is one of the newest technologies to find a home in the field of spine surgery. It offers many potential benefits for both surgeons and patients. However, it also has some limitations and challenges. Your condition may or may not be amenable to the use of robotic techniques.

If you are suffering from a spinal condition that affects your function and quality of life, you may be a candidate for robotic spine surgery.

Dr. Goldstein is now performing spine surgery with the first and only Globus ExcelsiusGPS™ robot in New York City. The robot allows some surgeries to be performed with enhanced precision and accuracy through a robotically enhanced minimally invasive approach. Robot usage can improve patient safety and shorten recovery time. Dr. Goldstein often augments his use of the robot with intra operative CT imaging using the Globus E3D.  The first clinical case performed in the world using the Globus E3D was performed by Dr. Goldstein at NYU Langone.

To determine the suitability of robotic surgery to your condition we recommend that you consult with a specialist who possesses extensive experience with differing treatment modalities AND with the use of the new robotic technologies. To explore whether you might be a candidate for robotic surgery by Dr. Goldstein please contact our office.

See also Dr. Goldstein's interview with Orthopedics Weekly where he explains the latest innovations in robotic surgery along with the advantages of the ExcelsiusGPS™ system.

A patient brochure about Robotics is available here.