Manual of Spine Surgery


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Our Healthcare Providers. No items were found matching the selected filters. Ali A. Baaj, M. Eric Elowitz, M. Kai-Ming Fu, M. The authors found that the surgeon surpassed the occupational exposure limit after just cases averaging 1. Their results demonstrated a significant decrease in harmful radiation exposure when the surgeon wore appropriate protective equipment, allowing for placement of screws and screws before surpassing the occupational exposure limits for the eyes and hands, respectively.

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Though appropriate radiation protection, such as lead gowns, thyroid shields, protective gloves, and eyewear, decreases radiation exposure to an acceptable level for the surgeon, CAN technology exists that allows for a complete elimination of this concern. Kim et al 80 first sought to expand upon CAN as a means of reducing radiation exposure to the surgeon. While their navigation techniques were less advanced compared to current platforms, as it necessitated some intraoperative fluoroscopy for registration, they still found that navigation significantly reduced fluoroscopy time by almost s per case 57 vs s.

Additionally, they found that because the fluoroscopy time was only for registration of images for stereotactic guidance, which does not necessitate close surgeon proximity to the beam, the radiation exposure to the surgeon was undetectable in the navigation group compared to an average of While radiation exposure to the surgeon may be effectively mitigated with CAN, modern platforms rely on CT-scan registration, which subjects the patient to ionizing radiation. This concern was the basis for a study performed by Kraus et al, 81 seeking to compare patient radiation exposure in posterior lumbar fusion procedures utilizing CAN vs fluoroscopy.

Their findings suggest that the radiation saved from negating the need for intraoperative fluoroscopy far surpasses the dose required for registration. In their cohort of 40 patients, they found an average effective dose of 0. The authors concluded that CAN should be used whenever possible, not only to reduce occupational exposure to the OR team, but also to decrease the patient's effective dose of radiation exposure.

The advances in technology that have led to the refinement of CAN techniques previously discussed offer a safe and efficacious alternative to traditional radiation-intense FH for pedicle screw instrumentation. These platforms are not without flaw; however, accuracy depends on several variables including a direct line of sight from the tracking system camera to the instrumentation tools, relative angles between the camera and registered instruments, camera quality, surgeon skill and expertise in acquiring and registering images, and environmental conditions such as heat, humidity, and light.

In an attempt to mitigate some of these shortcomings, miniature robotic systems that attach directly to bony landmarks were conceptualized in the early s. It utilizes 3 different outrigger arms, each accommodating a drill guide sleeve. The robotic software, in sync with a CAN, determines which arm produces the most accurate pathway for pedicle instrumentation based on the chosen implant and relative location of the SpineAssist robot to the predetermined entry point and screw trajectory.

The robot may be attached directly to a spinous process in the case of open surgery, or attached to a frame triangulated by percutaneously placed guide wires 1 Kirschner wire at a spinous process and 2 Steinmann pins in the posterior superior iliac spines for MIS procedures. The first step of the process is to obtain and register CT images of the desired spinal levels with the SpineAssist software to create a virtual spinal map for the robot. However, unlike intraoperative real-time navigation, these images may be obtained preoperatively for preoperative templating.

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The second step involves the templating of desired screw entry point, trajectory, and screw size. This may be done in the OR or even preoperatively based on the 3-D spinal map constructed by the software and transferred to the intraoperative SpineAssist workstation. Once the virtual template for instrumentation has been created, a short verification procedure is performed intraoperatively, which utilizes tracked Kirschner wires that are inserted into the mounted robot, verifying accuracy of the system.

This process assures accuracy to the set specifications, less than 1. The final registration involves obtaining 6 still fluoroscopic images for calibration and intraoperative registration purposes. The SpineAssist software then determines the optimal position of the selected arm for insertion of the drill sleeve and a cannulated drill guide is placed in the arm, which is now aligned along the predetermined implant trajectory.


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The drill is then used to create a cortical punch at the desired entry point; a guide wire is inserted into the vertebral body so a screw pilot hole may be drilled along the guide wire. The appropriate length and diameter screw is then inserted into the pilot hole after pedicle probing and surgeon confirmation of accuracy. Cadaver studies first verified the accuracy of this novel robotic-assisted technique, reporting an average deviation of 1 mm or less of actual implant position compared to preoperative template.

The authors also reported that 10 of the screws placed with robotic assistance necessitated intraoperative removal and FH reimplantation. The authors utilized a percutaneous means of affixation of the robot to the spine using the hover T method 1 K-wire attached to the spinous process and 2 Steinmann pins in the posterior superior iliac spines , and noted instability in the Kirschner wire leading to malposition of the drill sleeves.

They also noted skidding of the drill cannula, which they attributed to skidding of the sleeve lateral to the facet joints. They postulated that these errors might be corrected by use of superior fixation for the hover T K-wire and a more lateral entry point with increased medialization to avoid bony overgrowth and extreme slope of the lateral edge of the facet for sturdy docking of the drill sleeve. This may help mitigate concerns of fixation strength to bony anatomy like those encountered by Ringel et al.

This technology platform, however, has yet to be validated for use in spinal pedicle instrumentation but early clinical results are promising.

In their preliminary study on the novel application of the ROSA robot for spinal surgery, Lonjon et al 89 reported an accuracy rate of Though seemingly better suited for percutaneous and MIS procedures due to improved robotic arm fixation, these are the first published data of the ROSA robot for spinal applications and more data are needed to validate its use. A discussion of surgical robotics would not be complete without mention of the Da Vinci Surgical System Intuitive Surgical. The Da Vinci robot was FDA approved in for general laparoscopic procedures and is most commonly used for prostatectomies and hysterectomies, but spinal applications of the technologically advanced system have been proposed.


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  • The booth is equipped with 3-D vision screens and portals for the surgeon's hands to control robotic instruments. Additionally, the telesurgical model allows for close oversight from a separate both affording override, making it an ideal form of trainee education. The Da Vinci telesurgical robotic system Intuitive Surgical with remote surgeon kiosk and robotic arms.

    The primary obstacles to ALIF remain the ureters and large vessels aorta, vena cava, and branches thereof overlying the anterior spine. The first laparoscopic ALIF was reported in , with hopes of shorter hospital stay, quicker recovery, less postoperative pain, and smaller incisions through the MIS approach. However, with the improved usability of the Da Vinci robot, the procedure and its hypothesized improved efficacy for mobilizing aforementioned approach-related dangers, the Da Vinci-assisted laparoscopic ALIF has again become relevant in the spine realms.

    Several small case-series studies have evaluated this application of the Da Vinci robot demonstrating successful dissection of overlying large vessels and no ureter- or vessel-related complications. While all of the CAN systems previously described are mobile, the stereotactic tracking camera, CT scanner, and image registration hub still demand more physical space than a simple fluoroscopy machine.

    Reflexively, the first key element that surgeons should look for in a state-of-the-art operating suite is size and layout of the room.

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    The OR table itself is also a consideration. This is an attractive feature as it allows for easy adjustment of patient position after scanning without requiring removal of the scanner in case of the event that the reference point is incidentally moved necessitating an intraoperative rescan and registration. Other factors that may make an OR suite more well adapted for CAN procedures are fixed high-definition monitors to increase ease of view during the procedure.

    From the numerous studies investigating the safety and efficacy of CAN in pedicle instrumentation, the utility of this technology seems irrefutable. However, the improvements over conventional means of instrumentation are minimal and the cost, at least up front, is great.

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    This begs the question of the cost-effectiveness of navigated instrumentation. One way to hedge the cost of such platforms is to expand upon their applications. Future studies looking at increased utilities of the technology, such as with tumor resection and osteotomies in deformity surgery, may equip the surgeon with the armamentarium necessary to substantiate the cost of the equipment.

    Additionally, in a field that relies so heavily upon MRI, coregistration capabilities or even MRI-based navigation may prove to be the future of intraoperative CAN surgery.

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    This would allow the surgeon to not only instrument based on navigation, but potentially perform disk work, mobilize neural elements, and resect tumors safely through even less invasive corridors. Advances in registration of images are also a consideration that could improve upon current techniques.

    This could be attainable by utilizing fine-cut high-radiation CT obtained preoperatively and combining the high-resolution image with a lower radiation dose scanning image obtained intraoperatively. Additionally, if preoperative MRI could be coregisterded using similar techniques, the surgeon would be provided with a complete 3-D map of both the bony and neural elements of the spine while further reducing exposure to all OR staff. Robotic-assisted spinal surgery, though proven to be safe and efficacious for pedicle screw instrumentation, has an even larger cost burden to overcome prior to widespread adoption.

    Results of pedicle screw accuracy utilizing these robotic arms are at best equal to those reported for CAN alone and currently add little to the effort to improve safety and effectiveness of spinal surgery. Continued efforts to approach zero-error pedicle instrumentation are necessary to validate the use of such robotics in spine surgery, and telesurgical robotic models such as those used by the Da Vinci Surgical System Intuitive Surgical may prove to offer more value to spine surgeons.

    While its indications are currently limited to exposure-related procedures, the Da Vinci robot and similar robotic systems would be valuable for posterior-based surgery and even potentially extra- and intradural tumor surgery where the improved dexterity, tremor elimination, indefatigability and image magnification may improve upon current surgical technique.

    Dr Paul Arnold is a paid consultant for Medtronic and Styker, manufacturers of products discussed in this manuscript, though he has no direct conflicts of interest with content discussed in this manuscript. He has intellectual property right and interest patents, copyrights, royalties, or license income , equity stock, stock options, or other ownership interest , position of responsibility with Evoke Medical.

    Manual of Spine Surgery Manual of Spine Surgery
    Manual of Spine Surgery Manual of Spine Surgery
    Manual of Spine Surgery Manual of Spine Surgery
    Manual of Spine Surgery Manual of Spine Surgery
    Manual of Spine Surgery Manual of Spine Surgery
    Manual of Spine Surgery Manual of Spine Surgery
    Manual of Spine Surgery Manual of Spine Surgery
    Manual of Spine Surgery Manual of Spine Surgery

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