Initial academic experience and learning curve with robotic spine instrumentation

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Spine surgery is complex and involves various steps. Current robotic technology is mostly aimed at assisting with pedicle screw insertion. This report evaluates the feasibility of robot-assisted pedicle instrumentation in an academic environment with the involvement of residents and fellows.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The Renaissance Guidance System was used to plan and execute pedicle screw placement in open and percutaneous consecutive cases performed in the period of December 2015 to December 2016. The database was reviewed to assess the usability of the robot by neurosurgical trainees. Outcome measures included time per screw, fluoroscopy time, breached screws, and other complications. Screw placement was assessed in patients with postoperative CT studies. The speed of screw placement and fluoroscopy time were collected at the time of surgery by personnel affiliated with the robot’s manufacturer. Complication and imaging data were reviewed retrospectively.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 306 pedicle screws were inserted in 30 patients with robot guidance. The average time for junior residents was 4.4 min/screw and for senior residents and fellows, 4.02 min/screw (p = 0.61). Among the residents dedicated to spine surgery, the average speed was 3.84 min/screw, while nondedicated residents took 4.5 min/screw (p = 0.41). Evaluation of breached screws revealed some of the pitfalls in using the robot.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>No significant difference regarding the speed of pedicle instrumentation was detected between the operators’ years of experience or dedication to spine surgery, although more participants are required to investigate this completely. On the other hand, there was a trend toward improved efficiency with more cases performed. To the authors’ knowledge, this is the first reported academic experience with robot-assisted spine instrumentation.</jats:p></jats:sec>

First spine surgery utilizing real-time image-guided robotic assistance

“…Robotic assistance has been successfully implemented in many surgical specialties, and has significant potential benefit in spinal surgery. Previous robotic systems have shown improved screw accuracy [4][5][6]11,12], but have significant limitations that have hindered acceptance and widespread use [7,11,13]. A recent systematic review of robotics in spine surgery summarized the most common causes of robotic failure from 12 studies-including registration failure, soft-tissue hindrance, and lateral drill guide skiving [12].…”

“…This can be particularly helpful in the placement of technically challenging screws or those requiring a steep surgical trajectory; such as C1-C2 transarticular screws, C2 translaminar screws, L5-S1 transdiscal screws, iliac screws, anterior odontoid screws, or in those with anomalous anatomic structures (i.e. Klippel-Feil syndrome, axially rotated vertebrae, kyphosis, scoliosis) [2,4,[13][14][15][16]. Reduced tremor and a guidance arm may also be beneficial to surgical trainees for greater tactile appreciation of optimally placed screws [2].…”

Robotic Technology

“…Robotics have been implemented throughout the majority of surgical specialties, and spine surgery is no exception. To date, the use of robots in spine surgery has primarily been limited to using a planning platform to assist with pedicle screw placement which is often used to stabilize the vertebral column in spinal fusion surgery (Urakov et al 2017). Metallic screws are inserted into each pedicle involved at each vertebral level involved in an operation, and then rods are inserted through the heads of all screws on each side in order to support the vertebral column.…”

“…To better understand the basic concepts of robotics, it is important to understand or define the terminology that is used to describe robotics pertaining to surgical platforms. By definition, a robot is a machine capable of automating one, or a series of actions or steps in a procedure (Urakov et al 2017). According to the Robot Institute of America, a robot is defined as a reprogrammable, multifunctional manipulator designed to move material, parts, tools, or specialized devices through various programmed motions for the performance of a variety of tasks (Jacofsky and Allen 2016).…”

Robotic Guidance in Minimally Invasive Spine Surgery: a Review of Recent Literature and Commentary on a Developing Technology

“…The bed mount relies on two spatial platforms for robot-patient spatial relationship; a caudal bed mount, and a single point of patient contact with a solitary cranial spinous process k-wire. Small adjustments within the system, relying on a single k-wire point of patient contact, are thought to disrupt the localization of the robotic system and have largely been abandoned in part as a result of the publicity by Ringel et al Skidding or skiving of the cannula is another possible system failure, which can alter the starting point and trajectory of pedicle screws during insertion [24]. With degenerative changes, facet hypertrophy can impact the topography of the pedicle screw starting point, making a steeper surface, with risk for lateralization of the starting point.…”