Thank you, everybody. We'll go ahead and get started right on time here for the joint section on spine and peripheral nerve. So we'll go ahead and get started. Our first speaker today is Dr. Michael Wang from the University of Miami, who will be discussing the advantages of robotic surgery. Thank you, Dan. Oh, Juan did show up. I thought maybe I scared you off, and you were afraid to do this debate. So, yeah, yeah. Curry, change your slides now. So let me just start out with some disclosures. But you know, it's getting to the end of a meeting in New Orleans, so I'm just going to say I have some more relevant disclosures than this. First of all, I do surgery. I'm paid for it. In the right, patient surgery works. I want my patients to do well. I want to maximize efficiency, reduce complications. I think that spine surgery is good but needs improvement. I think technology can make things better. And I think the most efficient path for us is working with tech and engineering-related industry. So that's my disclosure. That's the real disclosure, because that's what really matters here. So let's dispense with some preliminaries, right? It's easy, right? So today's robots are expensive, and they're somewhat limited in capability, but they're accurate, they're reliable, they're safe, and they definitely add some element of value to our practice. And you can look up online in PubMed and see all the papers that have been written about this stuff, and it is really quite extensive, right? So let's just cover real quickly, this is a great paper by Paul Park, reviewed the systematic review of the literature on pedicle screw placement accuracy, and you can see, wow, look at all those papers. Now, of course, most of these are on the Mazor, right? There's one on the Rosa. But you can see that all these papers are publishing, you know, in the high 90s in terms of accuracy of pedicle screw placement with maybe one or two papers in the low 90s or upper 80s, so very acceptable. What about things like facet violations, right? These are things we often don't even look at, and if we talk about facet violations, this paper showed very nicely on a forest plot that when you use the robot, and you can see it's to the left of the midline there, that it does better than when you use standard 2D imaging. So it's less likely that you would disrupt the proximal facet and cause other problems. Radiation exposure, this is pretty obvious, right? That if you use the robot, that you're not going to have to use as much radiation, at least certainly to the surgeon. Maybe it's more to the patient, but it's less to the surgeon. But of course, we're contending with this, right? Hollywood is replete with all these examples of robots and AI gone awry, and Elon Musk has even said that AI is the biggest threat to the human species. And so I think it's interesting, we know that the first Uber death happened in Arizona last month, right? So there's a lot of things for you to think about in using robots, but remember that there are almost no true robots out there. All of the devices you see are actually what we call co-bots. They assist, they don't do the whole surgery, they assist with the operation, and the surgeon is still in control. Actually, that's a hard deck for the FDA. The FDA requires that element of human control and oversight over these robots. And so when people think about robots, they think about the stuff on the left, the Da Vinci Intuit Surgical has made it almost a standard of care in certain subspecialties. But I'll tell you that robots are in our DNA as neurosurgeons, and the Cyberknife is the only true robot out there, because you push a button and it goes, right? So here's the thing about robots. They're good at knowing their position in space, they're good at repetitive tasks, they're good at maintaining a constant position indefinitely, they can do micro-maneuvers we can't do. They're good at controlled force application, meaning a lot of force or very little force, something that we don't have that bandwidth with muscle. And they're not confined by biology and anatomy, meaning our biology and anatomy, not the patient's. Humans are good at decision making, we're good at identifying visual landmarks, for now we're still better at that. We're good at communication, we're good at adapting to OR structure and architecture, meaning if you were in a small room or a big room it makes very little difference. And we're good at adapting to changes. Suddenly the game plan changes, the instruments drop, the nurse didn't show up, whatever. We're good at adapting to those things. And we're good at adapting between modes, that is switching modes between a decompression part of a surgery or a screw placement part of a surgery or an exposure or closure, whereas right now there's no robot that does all of that, right. So I was in Houston recently with Dan at the SUNS meeting and we had the pleasure of having a visit of the Michael DeBakey Museum as well as talking to Bud Frazier. And he talked about these DeBakey quotes, you know, get an EEG to see if the resident still has signs of brain activity. I'm going to use this quote tomorrow probably in the OR. And how about this one? This is a good one for this talk. It's like, every good new idea can be recognized because it will be surrounded by a confederacy of dunces fighting against it, right. So this is a great quote, just like I'm sure Juan is going to sling the arrows. And then this one, right, if I had three hands I wouldn't need you at all, right, for the residents, right. Well that is a funny thing about this, right. We have two hands and ten fingers if you have all your fingers. And we're kind of limited in that way, right. So we get assistants and whatnot involved. And I was just enamored with this picture of the da Vinci assembling a sandwich. And the da Vinci has four or six arms. And that's something that we simply just don't have. And what is the evolution of man? Well it's very slow, right. Someday maybe there will be humans with six arms and 30 fingers. But right now you can build a robot that can do that. So think about that for a minute because every single spine robot out there right now has one arm. As soon as you add two or three or four or six or eight, you change everything about how surgery could be done, right. So I did a little personal tour of the exhibit hall. And these are the robots that I saw that are here today in 2018. So here is Synaptive. And then this is Olympus has a new visualization robot here. This is Nico for BrainPath. 7D Surgical. This is that hologram. If you haven't seen it, it's really amazing. Hologram Surgical that does the projection of a virtual reality image onto the anatomy. This is the Cyberknife. We already talked about that. The Mazor now being used for brain. This is the Brain Lab robot arm which is partially passive and partially active. Much $130,000 robot, right. This is the Rosa which is getting its FDA clearance this year for spine. This is the, um, uh, this is the Mazor X which is the, the biggest selling and widest sold robot, robot there is. And of course Globot, uh, the Globot or the Excelsius from Globus, right. So this is, uh, just an idea of this 13 robot technologies that are already monetized or materialized or commercialized that we can see today in New Orleans if you want. And we got our renaissance, uh, years ago and this is of course so primitive now when you look back on it and think about it. And, and it changed how we did surgery. Like things, simple, simple workflow things like planning. Like, you know, I, I think many people have said that the software from Mazor is even more valuable than the robot itself. That it forces you to plan and think about screws and avoid facets. And here's an example from when you're doing MIS surgery. Depending on how you plan those screws in a, in a normal freehand case, all you're trying to do is just kind of get through the case and get the screws in. But here you can plan so your rods are gonna pass easily and on a straight line without deflection. And now of course we know that new Mazor X is gonna have a row, a rod bending device that bends the rods for you after it picks the screw trajectories and, and start point. So this is really where we're headed and this idea of practice and rehearsal before an operation is a departure on the human side instigated by robotic technology. And think about, you know, deformity planning like, like Steve Andrew used to do it on pen and paper, but doing it on a computer and trying to figure this stuff out. I don't just mean like sagittal balance, because that's really simple. I'm talking about how do you plan out all these little details so your rep knows, okay, look, I'm gonna need 15 5040 screws and they know ahead of time. They've been email sent out, right? So it changes everything about what we do, right? But there are pros and cons, right? You, pros of course improve planning, management and all that. The cons, of course you need the imaging, you need fine cut CT at least today. It's expensive. And there's this question of whether you get dependent on this technology and it can be a real debate about that, right? Now I'll tell you what happened when we took it to Miami. Miami's an interesting town if you've ever been there. And our residents are really a very diverse group of people and we looked at what happened when we brought the robot into our academic hall. So we have 21 residents and six fine fellows and this is the data we had just using the robot without even getting them officially trained. They didn't go through a training process or anything like this. So some of you have seen this before, this is a neurosurgical focus. This is the difference, okay, in speed of putting screws in between a PGY 1 to 5 or a 6 to 8, right? So yeah, the guys who've done their 10,000 Malcolm Gladwell hours of screw placement, they're a little bit better but not statistically significant. How about if you look at here, this is gonna be how many cases they've done on the robot. Look at that, between the first three cases and more than three cases, really the learning curve is completely flattened now. And then look at interest, because we know there's a lot of brain guys that say, I don't even want to do spine but I'm stuck in a room today, Dr. Wang, I'd rather do stereotactic functional or endovascular. And look at the difference, the guys who are not dedicated, yeah, you know, they're a little bit slower but not much. So this is really very interesting and in some ways contrary to what anybody would think about the whole training process of neurosurgery. And this is now just for screw placement. And I'd like to put up this slide because it really brings it home. This is John Sarek, he was our chief resident last year. He's dedicated to spine, he hates doing brain, the brain surgeons hate operating with him and he is a spine maven. John Sarek did over 500 spinal surgeries in his residency, he's from Missouri, he's married, two dogs, IQ 145. John is compared to Greg Basil. Greg is awesome, Greg was an intern, he's now a second year, he performed less than 10 spine surgeries, he worked at BlackRock for three years before joining us. He's single but monogamous and his IQ is 154, he's a little smarter than John, right? But John, he hates the robot. John spent seven years of his life trying to figure out how to put a screw in. Greg is just as fast as John now, he loves the robot, okay? So think about this and what this means in terms of how you do surgery. And I heard a great comment about sort of end of career, like I'm getting a little older, it's a little harder for me to stand for eight hours or five hours. And my vision's going, all of ours are. And does the robot then make a 70-year-old surgeon able to do a deformity case safely and easily and fluidly? Because you have the wisdom but your physical structure, your biologic structure, the surgeon's, is now different than when you were 32 years old, right? So, you know, this is like the story of Paul Bunyan with his red, blue ox, babe, versus the locomotion, I'm sorry, the locomotive and the chainsaw, right? And we know the story on that because there aren't a lot of lumberjacks left using, swinging an axe, right? It just doesn't happen anymore but I'm sure Juan can do that. And I think about the, you know, the ghetto blaster, right? It's not a racist term, it's what we had and people would walk around with this big stereo and you'd hear them and that was so cool, right? And I, you know, I'm Chinese and my parents came back from Japan with one of the first Walkman. Nobody had a Walkman. And so I would have the Walkman on and everybody was like, what is that? What is that thing on this little Asian kid's head? And what is, you got a tape, cassette recorder in there? What is that, right? And of course we know the story on this, the iPod, right? And then the iPhone and now all the streaming. Technology changes and then people are like, well, but wait a minute, Mike. Technology is expensive, right? Look at this computer on the left, computer on the right. Anybody know what that is on the left? It's a first generation computer. I actually had one of those, right? And guess what? The cost of the computer on the left compared to the Macbook Air on the right, the one on the left is more expensive. It's more expensive. So people say, well, it's too expensive, right? Well, you know what? It's too expensive not to have it. Because if you look at it, right, what is the cost of this, right? What is the cost of one of these, right? Well, you can do the math in your head if you've ever had this experience, right? So I think the bottom line is if you look at these technologies, they're additive. And if, and when I look at, for example, this is a case we did with infection of a, of a mother of one of our hospital employees. You can see it's like a T5 dysgitis, just horrible, right? Big fat lady, hard to get to. What are you going to do with that? And so we're going to combine technologies here and we're going to use the robot to get us targeted in, okay, localize, because the robot knows where T4 is and I don't, get the trajectory to avoid the cord and the lungs and all that, and then plan, register, get that done so we can use the endoscope to clean out the pus and do this very efficiently, right? So now you're combining technology. So just don't think about the robot as like a screw or K-wire placement device. It lets you know all kinds of things that you can't easily know without it. And so that's the kind of thing I want you to think about is this is the first generation of robots coming out. Think about how technologies might be married. And this is the key, right? High-tech biologics and minimally invasive. But remember also that a fool with a tool is still a fool. Ed Benzel taught me this. So, you know, even if you are using a robot, here's your surgeon, you can't see because he's doing MIS surgery, and there are a lot of important things under there like nerve roots and blood vessels and things of that sort. And if you can't see what you're doing, right, and you don't know how to use these tools properly, you run into the occasional problem where people get hurt and things don't go so well, right? So the bottom line is that think about what we do and think about how we're moving forward. And I welcome you all to the spine section meeting next year in Miami. Thank you.

robotic surgery

advantages

accuracy

spine surgery

efficiency