Moving right along, speaking of learning curves, we'll have a talk looking at MIS learning curves and navigation by Dr. Johnson and Dr. Kim. And then following that we'll move to the back of the room to where the O-arm is and we'll have a demonstration by these two doctors. Just going to be really simple. I'll pull out. Okay. Well good morning everybody. Thank you very much for giving me the opportunity to give a talk. Actually I'm giving a couple of talks. In fact I'm going to give Dr. Terry Kim's talk right now about MIS surgery, which he has become a real expert at and actually I do a lot of these cases with him and I get to give another talk about complications, which I don't know how I ended up with that one. Do I create more than I solve, Danielle? I'm not sure which. There we go. Okay. Good. I just needed a little bit of time to think. You know it's been kind of fun being involved in the image guidance business since actually the first stuff we did was in 1997, which you can count the number of years how far it goes back now. And so this has become an everyday part of our practice, which we use other imaging like fluoroscopy so little. There are a few cases that we do, but I would say that just about everything that you can imagine, other than doing laminectomies and things like that, which sometimes we do. I mean if we have something complicated that we can't reach something or we can't find it, I even had an osteophyte in a case that I did the other day or the other week that we navigated it just because there was some distal location to it and the patient had been operated on a couple times before and it's like we just want to do this stuff right. And so we say how can I find things that I may not otherwise and if I have to wander around. So sometimes it's just, I say it's a really expensive pointer. I've said that since the very beginning, since we started to do this stuff. So I'm going to give Terry Kim's talk. He actually is in Catalina today with his son, which was fortunate for him. And so he asked me to give his talk, which I'm quite happy to do. And we both do some consulting work for Medtronic on occasion. It's more of an ad hoc. And this is kind of an overview talk that is about minimally invasive surgery and it's mostly about TLIF. And this just kind of goes back about the navigation. It's not new. It's been around for a long time. My friend Ian Calfus has actually published an article in 1995 when I was getting interested in image guidance as well or just starting out in 95. But these things, they just improve everything that we do. They don't make us into surgeons. They just make us better surgeons is what this is really all about. And it involves using intraoperative scanning and imaging and you can use preoperative imaging, which we used to. But the advent of intraoperative scanning and imaging is really what has propelled this technology to being available for use almost every day. And so we use this stuff. We use it in MIS. We use it in deformity. That's why I'm actually just rolling in here this morning. We're doing a big deformity case that got delayed because some other things went into the evening last night. We use it for cervical. I use it for craniovertebral junction. I use it for transoral. I use it for everything that I think I can be a better surgeon at. We use it for thoracolumbar and that's some of the minimally invasive. So these are a bunch of neat different pictures that kind of show you all the things that we use this stuff for. So why do we navigate minimally invasive? I think you can have high accuracy. It's when we have minimal visualization. It's like I tell patients that if we do an A-lift or something and we have a patient and we're going to do posterior instrumented fusion and indirect decompression, we never see the spine. And that's what I tell the patients. We do it through two small incisions on either side and we never see the spine. I mean it's all navigated. It's essentially a virtual operation if you think about it. And we can see deep bony anatomy inside of a patient. Then we can slide rods down into people percutaneously, which is just amazing stuff that's developed. The radiation stuff, we all know that that just has basically been eliminated. So there's been a lot of accuracy studies. This is actually a paper that we wrote. Don Yell is on this paper, which he is on all of them. So we have a whole flurry of things that we've published in recent years. But the accuracy, I don't have to tell you too much about this. I think that this has kind of been beaten to death by a number of different articles. And it looks at the accuracy going from navigation for freehand, for fluoroscopy, and CT navigation that we have now, or image guidance. The accuracy rates have just gone up, up, up, and they're so good. And the revision rate for surgery has gone down, down, down. And this is actually a little bit of the paper that we've written about percutaneous pedicle fixation with a series that we've published, what was this, back in, actually way back in 2014. It's almost ancient history now in the image guidance and computer technology world. But we put in 290 percutaneous screws with a 96.6% accuracy. And we had one grade 3 lateral breach with an L5. So the accuracy is pretty remarkable for all these things. And these are just other papers that were published. This was the group in Minnesota we've done some collaboration with. They're a great bunch of guys that have also done a lot to push the technology forward. And so they've had a lot of similar outcomes as well. There's another article that simply goes through some of the accuracy and the fluoroscopy difference between that and navigation. And a lot of these papers actually go back a few years. And I think we're getting even better at these things. This looks at facet violation. And there's actually a grading system that was created to be able to show that we can just more accurately look at the trajectories from these things. And we just don't do this anymore. I think that that's not the idea of how we intend to do these operations when you do minimally invasive and percutaneous procedures using navigation. It just gives us the ability to do these things. The learning curves for these things, the operating room time, I mean it starts out in the beginning. We've been doing it a long time. And we do it more expeditiously. We've even looked at some of the data and research work that we've done is about workflow in the operating room and how to do these things more efficiently. So what are the things that we do with minimally invasive navigated T-lifts is that the idea is to get the patients in and out of the operating room time with at least the same, maybe even better OR time. We'd hopefully like to do this even better. And I think that as you learn how to do these things, that's when you can have these added benefits of the increased accuracy and decrease the radiation, all those things. But these are the things we don't want to do is stick a screw across the wrong place in the patient. These things do have their learning curve. So you don't want to do these things as your first operation. Learn how to do these things open. Learn how to set up your room layout. I can't emphasize that enough. I talk about that every time I give a talk about image guidance. You have to learn where to put the furniture in the operating room, literally. Where do you put the patient? Where do you put the anesthesia? Where do you put your scrub tech? Where do you put the navigation system? And do you put it at the top of the bed? Do you put it at the bottom of the bed? You just have to think about your workflow. And I can go over some of these things. But it really comes down to where you're working. And as you gain more experience, you'll figure out how to do these things that fit your needs. And that's really what it is. So what about some of the general considerations for it? And the navigation, it confirms your anatomic knowledge of what you know. But if you're doing percutaneous screws, you don't necessarily have those things. But sometimes you can even feel the anatomy when you're probing and you're putting pedicle screws into somebody's lumbar spine. You can actually feel the transverse process. You can feel the facet. You can feel even the mammillary process that you do when you're doing an open operation. So you can learn how to do these things even in closed operations. And if you sense some discrepancy from anatomic knowledge, you develop an algorithm. You check your instruments. And you go back and you check it with verification. I mean, we will use spinous process clamp navigation. We've kind of moved away from using percutaneous pins because we've had a few problems with them along the way. And we still use them, but it's just one of those things that you have to use the most reliable methods that you have. And if you ever have problems, you have a low threshold to do another CT scan. And when you set up the operating room, you need to have line of sight items addressed. What are some of the workflow things? You have to put a reference frame or a perc pin. You acquire the CT scan. You verify the navigation. Navigated instruments. You put the screws in. You have to put your screws in first because if you're going to do a T lift, it obviously has the potential for you to change the orientation of where things are when you put an inner body graft in down through a tubular retractor. So that's a pretty basic thing that you just think those things through as well. But sometimes you don't think about them and you learn as you go. You do your decompression, the discoctomy later. You do your inner body afterward. And you just have to recognize that some of your screws will end up being a little bit different if you do these in the wrong sequence. You can do imaging afterward. You can take an x-ray if you want. We usually don't. We've gotten to the point that we rarely do. We do in our big deformity cases and we're looking for correction of deformity. But when we do our MIS navigated T lift cases, we almost never do any kind of intraoperative imaging other than using the navigation just because we're so comfortable with it. The instruments, as you heard, we can navigate anything. In fact, I was doing a biopsy the other day. I put a reference frame on a pituitary that I put down an L5 pedicle into a tumor case. I needed to have something because we had a couple of missed biopsies that were done by IR. So we took the patient to the operating room and I put a reference frame on a pituitary and put it down the pedicle and that's how we did the biopsy. So anyway, these are just some of the, it's kind of a busy slide here. You have to just go through every one of these steps with a procedural workflow of verifying your instruments and it's the flow. I'm not going to go over those too much. Navigation workflow is that when we use fluoroscopy, we used to have just a few different components in the operating room. And now when you're in the operating room, we have a surgeon, you have a navigation tech, a radiology tech, an anesthesiologist, scrub tech, and all these people, implant rep. So you have a lot of people and that's what it's about workflow and making these things just happen with the harmony that you need to have in the operating room. The positioning of the patients, you got to have those things and where you put things in the room is important. I don't necessarily leave the CT scanner in the operating room. Navigation, spinous process clamp and the perk pins, I went over that a little bit. These are some of the different techniques. We will still use any and all of them, whichever one we think is the best. Spinous process clamp is your real workhorse for doing MIS cases though. And even though it makes another incision in the patient that you might not otherwise, I tell the patients, I say if we're going to do a MIS operation that we're going to do through a wilts approach and explain what we're doing, I said we're going to make a little small incision that we put the spinous process clamp on that's essentially an antenna for us to be able to do these procedures. And this shows some of the guide wire cases that we do and we're actually moved largely to guide wireless placement as well. So anyway, when you're doing the CT, everybody leaves the room. The navigation with the incision planning, we can actually plan our incisions and we do this in a lot of different cases, not just for MIS-T lifts. I use it for thoracoscopic cases that we put a reference frame on, put a patient in a lateral position, I do thoracoscopic disc surgery, and we will plan our incisions based on the ability to show trajectories through the patient wherever the approach is. Here's a T-lift case that we're doing, but you can plan these things and you can do it from the skin and make your skin incisions in the ideal place where you're not battling against some of the soft tissues. So those are some of just the little tricks of how to do this. And that allows you to do these operations through a tube placement with ideal placement, is that you use some of the preoperative imaging that you do before you ever make an incision in the patient. You know exactly where your incision is going to be because this is a trajectory that you want to be able to do the decompression, put the hardware in to do every step of the operation. So if you even have it right down to making the incision in the appropriate, the exact appropriate place, it makes life much easier. This is what it looks like looking at a left-sided facet joint that you're going to do a T-lift through. Here's a superior facet coming up from the bottom on the, from the right side and the inferior facet coming down, and that's a facet that's been nicely cauterized and cooked. And so this is where you can do the osteotomy cuts, you can, after you've placed your hardware. So these are all the steps. This is the medial side, the lateral side, and toward the feet. And so this is where the resection of the facet joint, and that gets you down to where you can do the interbody procedure. And so these are some of the trajectories that we shoot just during surgery to confirm where we are and how we're doing this operation. And it's done pretty darn slick is what really it is. And you have this kind of, this kind of procedure that's done with several incisions in a patient, and they get up and they walk around after the operation like they didn't have an operation, which is pretty remarkable. Navigated part of the interbody implants, preparation of the end plate, all these things are done the way you would do it with an open, open operation. The appropriate graft height, you do this the same way with a tactile interference, it's the same thing that you do with open operations. You're just doing big operations through a small hole is what it really turns out to be. The axial images confirm your trajectories and the distraction will change the position of your screws, so you have to put those in first. As I mentioned, we're actually moving to guide wireless where we do a lot of these things and we'll use just trajectories that we will save for the location of your screw entry points. In fact, we're going to single screw entry where we go down and we will use a guided screw that you can dock and place it without even having to tap or sound or tap initially. This is just, again, another comment is that you have to make sure you put your graft in later. Also, if you have any problems, do another CT scan. We don't do that often, but we'll end up doing it on occasion enough that it's one of those things in the back of your mind all the time. And here's Dr. Kim's thank you list of references. And here's Dr. Kim with his whole family. Thank you very much.

MIS learning curves

navigation

O-arm

image guidance

minimally invasive navigated TLIF procedures