Spine robots are going to become more versatile with expanded applications, spine surgeon Peter Miller, MD, PhD, predicts.
Dr. Miller, of Iredell Memorial Hospital in Statesville, N.C., completed his 100th case using Medtronic’s Mazor robot on April 1. He spoke with Becker’s about his experience with spine robots and what’s next for the technology.
Note: This conversation was lightly edited for clarity.
Question: What has been your experience working with surgical spine robots?
Dr. Peter Miller: I used navigation for many years and I use an O-arm for complex spine surgery. About 10 years ago, I decided to move to minimally invasive procedures. Now I do about 95% of my cases as minimally invasive procedures. My goal is to try to make surgery as easy as possible, on patients as possible. Doing big open procedures is hard on them with the disruption of the muscle and all the other problems that come along with that. What I did is I switched to the minimally invasive procedures, and we started a program of cognitive behavioral therapy for our patients to help manage their fears and expectations around the perioperative period. That’s been very successful.
What we’ve been trying to do is to progressively improve the patient’s experience with surgery and to make it easier for them to get through extensive fusions or procedures that ordinarily would have them out for months at a time. The robot, then, was a logical extension of that thinking. The robot helps by making sure that we can do the smaller incisions and that we can kind of make sure we get precise placement of the pedicle screws. Having done 100 of these now, I’m very happy with how things are going. There’s a little bit of a learning curve with that, having switched from standard navigation to the robot, but it’s worked out very well.
Q: Can you elaborate more about that learning curve? Talk about the first major procedure compared to your 100th.
PM: One of the biggest learning curves is workflow. It took us a while to really establish an efficient workflow because we do a plan and scan so we have an O-Arm. So what we do is we get our O-Arm during the surgery. Some people have CTs done beforehand, and then input that data in at the day of surgery. We usually get it right then on the day of surgery. Part of the learning curve was negotiating how to efficiently incorporate the robotic arm into our normal workflow? And so it took a little while for us to realize, okay, this is our best practice for how we can move along efficiently with the procedure. Other things are, I feel like, compared to standard navigation, it takes a little bit of getting used to with the robotic arm in that, as the robotic arm functions, you have to kind of trust the robot. And having said that, you can’t blindly trust the robot, since we’re not seeing exactly where our trajectories are, we’re not seeing in a standard open procedure, you can see exactly where you are. But once we got past that and realized, you know, there are things that, obviously, if you bump the robotic arm, that can get you off. And so these are things that we realized straight up, straight away, oh yeah, we have to be careful about these things. But now, after having done 100 of them, our workflow is very smooth with incorporating the robot, and I feel like we’re getting better results.
Q: What features in this robot stood out, and what features do you want to see in future generations of spine robots?
PM: One of the things I like about the robotic arm versus standard navigation is having the robotic arm help set up the trajectory of the tube so that we’re just working through the tube. It’s a lot easier on you in terms of fatigue. In particular if you’re doing multiple screws rather than trying to hold the drill, for instance, in a steady position by your own hands while you’re doing a navigator procedure. With Mazor, one of the things that went with it was a better drill tip so we don’t have such a problem with skiving as we did in the past. Even with the earlier days of navigation, as you’re putting the drill tip down, sometimes it could skive off the facet. Having the steadiness of the trajectory really helps make it consistent. It makes it very consistent for us to do the procedures and put in the pedicle screws efficiently.
Now as far as a wishlist, I think a lot of people regard the robotic arm as a “one trick pony” because it’s designed to do pedicle screws, but not a whole lot more. I think as things progress, we’re going to see more applications of this technology. For those surgeons, who are early adopters of the robotic arm, I feel like the skill set will be there. Then as things develop with the software and with hardware we’re going to be able to do many more applications of using the robotic arm that will help with different types of cases.
