Next up we have Juan Ribe giving the counterpoint robotic spine surgery not ready for prime time. Thank you Marjorie, Jack, and Dan. So you guys are warriors, you know. Wednesday, after I don't know how many days of meeting, still in here, I just can't believe. Great motivation. So that's why I say, you know, whoever is going to be here at this time, I need to put some good talk, at least entertain you a little bit so you don't waste your time. So my other side was robotics not ready for prime time. But first I have to disclose you, besides this disclosure, that actually I'm using the robot. And believe it or not, all of you here will be using the robot sooner or later. And this is why. So you look at the economics, look at this. Right now, today, for the companies, for everything, the market of the robots is 26 meters, not a big deal. But see how this thing, the projection is going to explode. They think it's going to be a billion dollar product for the spine companies by 2022. So in other words, every company from A to Z will have a robot. So what's going to be the problem? Which is the one that you're going to choose, you know? You're going to get the Hyundai or you're going to get the Ferrari? Or the Toyota? Where are you going to be? You know, the SUV or the sport one? So that's going to be very interesting. And look at this. These guys, they make the projection and they say, this is actually very interesting. By the time that every country acquired 35 percent of penetration on the robots, almost every surgeon will call to his dean or his CEO and will demand, give me a robot. Because if I don't have a robot, I cannot function. So in other words, this is going to happen. We cannot stop it. And it is what it is. So the question is, where are we at? You know, because definitely I don't think we're ready for brain time. So this actually was a good paper, not very scientific, but it opens our eyes of, are we really for this? Or are we always on the wonder world? So Mike loved it. And Mike was a little bit on the neutral side. He was thinking, he was like, oh my God, this is the best ever, this and that. But to me, when I look at the robots, it looks something like this. So are we ready for prime time? You know, I think this is what we have right now. You know, they're there, they're functioning, but then you look around and they go down, yeah? So, and then we're looking here, actually the principles of the robotic spinal surgery, they're very clear. You know, one is, first, you try to reduce radiation. Everybody will know and hear that. We want to reduce radiation for us and for our patients. Since we are very selfish, that's why it works better for us, because the patient is the one taking the CT, the OR, you name it, and we are getting less exposed. But in the future, we expect that patients and us, we will get exposed to that. Second, another reason is get more accurate and give you a much precise placement of our hardware. And as Mike mentioned, an average surgeon can do the same surgery than the gifted hands type of surgery. So we need to get more standardized. And then third one, this is actually a really good feature. You actually can do a real pre-planning of what you're doing before the surgery. So you walk into the OR, you know exactly how the screws go, where they're going, and what, how it's going to predict that. So this is, sounds beautiful, but what is the reality? And after being using the robot, you know, for a couple of months, uh, this is what I have. So I'm gonna give you what I think are the top five problems with the robotics as I see it today. I'm sure that's gonna change very soon, but first, the software is very unstable. Just put yourself downloading a new app on your phone. Next day in the morning, three apps come down. The emails don't show up, this and that. So the software that we have right now is very unstable. And sometimes even you go ready for the surgery, you turn this machine on, and then suddenly everything goes away, and then you can do nothing, and then you waste one hour, and nothing happen. You end up using the old-fashioned that. Then second, no standardization. There is no communication, too many system, we can do nothing around it. And I'm gonna discuss one of these points later on, each one one. Then the workflows is horrible. You know, I mean, you're trying to flow with these cases. I mean, just the fact that you have to spin the patient, come out, come in, or let's say that you don't spin the patient on CT and you're trying to do x-rays, you come back and then, uh, the camera cannot see the, the, uh, actuator. The actuator cannot see the instrument. The instrument cannot hold the screw. I mean, it's an nightmare. So few cases that I have a good flow, I say, my God, I can't believe, you know. But the rule is that you're gonna struggle no matter what. Then real-time information. To me, this is the big problem, yeah? Because as you know, you are, if you're using the 3D, 3D means like using a CT image basis, or 2D means like, uh, working with pre-planning AP and lateral fluoroscopy, no matter what, you're living with an image 15, 20 minutes ago. So if things change, patient move a little bit, there is not too much that you can do. The new generation of navigations, as you know, they come with a reference pin that give you a little bit, an update, like, okay, this patient move, then what? You have to start all over again. That's a pain in the ass, yeah? So and then, the next one is, uh, limited applications, yeah? So applications are very limited, as I'll show you later on. So unstable software, sometimes you see something like this, yeah? You turn the machine, you're excited, everybody's great, you have the, the, the video guy in the hospital, you're gonna be in the news, you're gonna be the, you know, the badass guy doing robotics, and then you turn it on, this is what you see. The following information may help you to resolve the situation, and then the situation never goes, every rep calls whoever, someone, and nothing happen, then you end up in your X-rays, yeah? Then no standardization. This is just some of the ones that are available in the market, but there is a lot of options, and they don't communicate each other. So basically, they want you to buy these machines, put $1 million, and then you have to switch all the instrumentation that you really like, you get used to, for some reason you think is good for your patient, you have to accommodate to that one of that industry. So same thing that happened with Apple and Microsoft. You know, they don't communicate each other. Who are the victims? We. We were the victims. Now, the same is the same here. The patients and the surgeons are going to be the victims of this multi-billion now industry trying to get some presence on that. And then, not real-time information. Watch this. This case is actually from Paul. He gave it to me. Thank you, my friend. Paul always is very honest. This screw means to be right here. It means to be right here, and end up being right here. Minor thing, nothing bad, but that happened. One of my cases in here, this case. So we're trying to find this actually fancy 2D, 3D software that we're trying to figure out the accurate placement of these screws and how the pre-planning matches when you deliver the surgery. And you see in this one, for example, look in this corner. This was the planning trajectory, and this is the way that it looks on the CT post-op. So you see here, in this case, there was a tail mismatch. The tip was okay. But you see, it still is not 100% sure. You want to have a system that actually goes like this one, yeah? Dead center, dead center, but you don't want any stalling and any problems like that. Okay, next one. What are the applications? When you're trying to buy this, they're going to tell you, oh, my God, this thing is going to do laminectomy, C1, C2 fusion, arthrodesis, fusion, decompression. You see all these things. But the real truth is, you're buying a million-dollar toy for this, just for putting the screws. Right now, today, it's a glorified drill that costs you at least $1 million. So that's the problem. And you are the alpha testing. You are the one who's going to give them the feedback to make it better. You're not going to get paid for that, yeah? Only the guys who, you know, Nick Theodore, the guy who really put it together. We are just going to throw this, this, and that. They make more millions. We keep getting the Medicaid rates, okay? But that's the way that it is. So I'm using particularly this one. I don't want to go over too much. It's very hard to do this. There's too much volume. So anyway, what I like of this system, for example, is the gesture is very easy. As you see here, you just basically use your iPhone. You move the screws, you make it bigger, shorter, this and that, and then you put your screws. But then the real truth is this one. Take a look. This is my own workflow. So our residents plug every case, and we started just a little bit before December last year. And you see here this timing in minutes. Take a look how we go. The first case was amazing. I was so happy. But then watch. Later on, horrible. I was losing one, two hours more of each case. So if you're in private practice and you have to move your cases and everything, you cannot do a single level to leave and get done by 3 p.m. I mean, that's crazy, yeah? Because we're in the university, we justify academic this and that. But take a look. The time doesn't get better. So definitely it's going to be a big issue with the workflow, and it's going to take a while. So this, and then we go to this. Mike likes always to show these curves because I think it's very logical. I think we are probably right here maybe, Mike. I don't know where we are on the learning curve of the robotics. But definitely this is going to be something for real. So the way that I see robotics, I think we are in front of an iPhone 1 or the 4T model. Sooner or later, we're going to have that one. But then, you know, you have to be careful not to be so passionate about this. And I just took a picture of Mike, and you say, Mike. I say, Mike, seriously, WD-40? I just can't believe. So you have to be careful not to love too much this technology. You can end up like this, yeah? He's going to end up sleeping with the robot. And then, you know, I just can't believe, Molly. WD-40. Okay. Thanks very much, guys. Thank you.

robotic spine surgery

problems with robotic technology

unstable software

lack of standardization

limited applications