Robotic Spine Surgery

What it is

Robotic spine surgery is spine surgery in which a robotic arm guides the placement of implants, most often the screws used to stabilize the spine during a fusion. It is one of a family of enabling technologies that also includes real-time 3D navigation and augmented reality, all with the same goal: letting the surgeon see the spine in three dimensions and act on that view with sub-millimeter precision.

The process has three parts:

• Planning. A CT scan, taken before surgery or in the operating room, produces a 3D model of your spine. On that model, the surgeon plans the exact path, length and width of every screw before the first incision.
• Registration. The 3D model is matched to your actual anatomy on the operating table, so that a point on the screen corresponds to a point on your spine.
• Guidance. The robotic arm moves to each planned trajectory and holds a guide rigidly in place. The surgeon passes instruments and implants through that guide, while navigation cameras track them against the 3D model in real time.

Augmented reality navigation takes this a step further. Instead of looking away to a monitor, the surgeon wears a headset that projects the 3D anatomy and the planned trajectories directly onto their view of the patient, as if seeing through the skin to the spine underneath.

At no point does the robot operate on its own. It is a precision instrument in the surgeon's hands, in the same way a microscope or an endoscope is.

Dr. Telemi and enabling technology

Dr. Telemi has specific training in robotic spine surgery and extensive experience using robotic guidance and navigation in the operating room. Beyond using these systems, he has worked directly with companies developing augmented reality navigation for spine surgery, and he continues to collaborate with several companies on expanding and improving enabling technologies.

His view is straightforward: when a technology lets an operation be done more precisely, through a smaller exposure, or more safely, patients should have access to it. That same experience is also why he is candid about its limits. Knowing how these systems are built is the best way to know when they help and when a conventional technique is the better choice.

Who it helps

Robotic guidance is most valuable in operations that involve placing implants into the spine, especially when precision is hard to achieve by sight and feel alone:

• Lumbar fusion for spondylolisthesis, instability or degenerative disc disease, including minimally invasive fusions where screws are placed through small skin incisions.
• Revision surgery, where previous operations have removed or distorted the normal bony landmarks surgeons rely on.
• Adult scoliosis and spinal deformity, where the vertebrae are rotated and the safe corridor for each screw changes from level to level.
• Spinal tumors and metastases, where bone may be weakened or destroyed and stabilization has to be planned around it.
• Patients with osteoporosis or unusual anatomy, where the margin for error is small.

Some of the most common spine operations do not involve implants at all. A microdiscectomy or a minimally invasive decompression for spinal stenosis is done under direct magnified vision, and adding a robot would not improve it. Part of a careful consultation is identifying which category your operation falls into.

How it's performed

Robotic spine surgery is performed under general anesthesia, usually with you lying face-down. After positioning, a small reference marker is attached to the spine so the navigation cameras can track its exact position throughout the case.

A 3D scan is then taken, or a preoperative CT is registered to your anatomy, and the surgeon finalizes the plan for each screw. The robotic arm moves to each planned trajectory in turn. Through small incisions or an open exposure, depending on the operation, the surgeon drills, taps and places each screw through the arm's guide while watching its position against the 3D model.

Accuracy is checked repeatedly, both against known landmarks and with imaging. Once the implants are in place, the rest of the operation proceeds as it would otherwise: decompressing the nerves, preparing the disc space, placing bone graft and connecting the screws with rods.

Recovery

Recovery is determined mainly by the operation itself. When robotic guidance allows a fusion to be done through smaller incisions, patients often have less muscle disruption, less early pain and a shorter hospital stay than with an equivalent open operation. Most patients are walking the day of surgery or the next day.

What does not change is biology. A fusion still takes months to become solid bone, and activity is advanced gradually over that period. Your recovery plan will be based on the specific operation, your bone quality and your overall health.

Risks & considerations

The risks of robotic spine surgery are largely the risks of the underlying operation: infection, bleeding, nerve injury, spinal fluid leak, failure of the bones to fuse, and the general risks of anesthesia.

Considerations specific to robotic and navigated surgery:

• Accuracy depends on registration. If the reference marker shifts or the anatomy moves after the scan, the 3D model and your spine can drift apart. Surgeons trained in these systems check for this throughout the case and re-register when needed.
• Technology can fail. Equipment issues are uncommon, but a surgeon must be able to complete the operation with conventional techniques. Robotic training is in addition to, not a replacement for, the fundamentals.
• Long-term evidence is still maturing. The accuracy advantage of robotic screw placement is well documented. Larger studies are still clarifying how much it improves long-term pain, function and reoperation rates.
• Setup time. Robotic cases involve planning and setup that can lengthen parts of the operation, though this often shortens as a team gains experience.

If you have been told you need a fusion, or you are wondering whether robotic surgery is an option for your condition, a consultation with Dr. Telemi is the right place to start.