going to have our second lecture on robotics from Dr. Wang from the University of Miami. And then we'll move on to the demonstrations for the robotics. Great. Thank you. Thank you Donnell for putting this on. This is such an important symposium or course because, you know, it really is the future, I believe. So I'm going to give a slightly different talk today. You know, I've been giving talks about robotics and Nick and I have been on the stage together and I have a great deal of respect for what he's been able to accomplish over the years because I think, you know, people want to push the envelope and I think that's a good idea. So this is my disclosure slide but more importantly I'll disclose that I'm pro-robot. And this is an important point because there are going to be battle lines drawn as Nick showed and it's amazing how so many of our slides have similar themes I think because they're shared issues that we're dealing with. And the robot's very threatening. In fact, I've gotten in big fights with orthopedic surgeons. I was at the spine safety conference and I showed this slide of, you know, the one you've probably seen before about the resident as an intern can do this just as well as a seventh year. And some of the orthopedic surgeons that are very old got very mad. They said, where are the ethics in making things easier? Like that takes away the competence of what we do. And I think that's an interesting point but it belies a bigger argument about what we really are afraid of, right, in terms of fear of what's coming. So, um, this is something I put together at CNS and I'm very excited to see what the exhibit hall's going to look like, um, tomorrow when it opens. So these are the robots that I saw. Uh, this is I believe Synaptive and then there's 4K from Olympus. Uh, there's 7D. Uh, this is one of those augmented reality platforms. I can't remember the name. This is the Cyberknife Gamma Knife. Uh, Mazor Renaissance. Uh, this is the Brain Lab passive robot arm. Of course there's the ROSA that got FDA clearance I think two weeks ago, right? Uh, for spine application. We have a ROSA in our institution. Uh, there is the, um, Mazor X. And then there's the Excelsius. And there are actually many more companies than this even. And, uh, there's some Chinese companies that are about to enter the U.S. market. Um, Stryker is building the Mako and I'm on that team for spine. And, uh, DePue bought Ortho Taxi and Uvasive I think is working with KUKA which is a big industrial robot company. So every major organization is looking at robotics as a future type of technology. Whether that bet is correct or wrong, uh, is going to be interesting for us to see because we saw failures with say Lumbar Artificial Disc and Dynamic Stabilization. Great ideas that, uh, were, were sort of killed off at least temporarily, right? So this will be interesting to see. And, um, so when I think about it, like nobody came here, right, without some assistance with a computer. And this is a early Chinese compass. This is one of the first Chinese compasses made. It's quite large in terms of the needle because of the magnetization. And then you have, um, things like the sextant. Gets you around, gets you figuring out where you are relative to stars and, uh, the sun. And then you have the development of GPS with the Earth satellite systems, right? People forget all this. Like these are really major advances that now everybody is reliant on GPS. And then you hook that up to communication, right, because GPS is a passive system on Earth. And then you have Waze, right? Who doesn't use Waze or Google Maps or something to get their way around traffic. And Waze was actually developed by Israeli company in L.A. after the earthquake to get around the 5 freeway being shut down. Pat Johnson probably remembers that. So they built the technology that got people around choke, choke points in traffic. And of course we all, everybody uses Waze now, right? You, you're stuck in traffic. You Waze and you're like, oh, now I know what's going on. Somebody up there is telling me that there's a problem coming up or there's a red light camera. And then self-driving cars, right? So you're thinking about all these technologies iteratively adding elements of information or, and pieces that can maybe make our lives better. But that's scary because, you know, last year when Danell put this on, they had the first Uber death, uh, the week before in Arizona. And so that's a situation where the Uber, uh, self-driving car ran over a lady that was on the side of the road, that came off the side of the road and it didn't stop in time and killed her, right? So first Uber related death. This is another type of death in a Tesla. This is in northern Florida where the guy was, uh, watching Game of Thrones or something like that, right? Or Avengers movie or something, right? And he was just watching and not paying attention and they came down a hill at high speed, ran underneath a semi-tractor and killed him, right? So that's another example how technology can be perceived as dangerous. But everybody knows that if this really happens, and I don't know if you want to have this happen or not, there will be fewer driving fatalities, period. Even though there will be these cases, right? And it brings it up because you think about what people are talking about now, like the 747 Max, right? This is a perfect example of where computer assistance and our interaction with it maybe was less than perfect and how is it viewed politically, right? So everybody's like, whoa, Boeing, like that, so how did they allow that to happen? Well, you know, that was an advancement that is going to have some hiccups and we're going to see what happens with things like that. Now, who in here likes robots? Nobody? A few of you guys. Okay, good. So you're probably aware that in 1979 there was the first industrial robot death. And this was a gentleman named Robert Williams. He was at the Ford Casting plant in Milwaukee, Wisconsin, and he was killed and crushed by a robot. There have been many cases of this happening in the industrial world. You've probably never heard of it, right? This is a very interesting phenomenon. When it gets into medicine, what are the odds the robot is somehow blamed, right, for the death or destruction or maiming or complication of a patient? Well, here's another thing just for food for thought because I'm pro-robot. There's actually been an instance of an intentional robot killing of a human. Does anybody know that? Oh, yeah, okay. So you probably remember in 2016 there was a gentleman, former armed forces guy, who went and said, and this gentleman was shooting police officers, right? And the police could not get to him. And he was a sniper. And there was this whole thing about he wanted to kill white police officers and this whole Black Lives Matter thing. It happened during a rally of Black Lives Matter. And I don't care about the politics of it. That's not what mattered. What mattered was the police could not get to him. He had the advantage. He set up as a sniper inside of a building and was just picking people off, right? Nobody could get to him, right? So what did they do? They hooked up their bomb robot, the robot that goes in when you're dealing with a bomb, and they put a bomb on it. And they said, we're sending you the food that you asked for. So the robot comes up into the building where he was because nobody could get near him, right? He would take you out right away. Comes up to them, detonates and kills him. That is the first intentional human use of a robot that we know of to directly kill somebody. Now you could say drones do that, but they're designed to kill, right? This is something totally different. So this is a different scenario and I think that when you think about what we do with robots, there is some issue with that, right? So let's get rid of some preliminaries. We all know that today's robots, right, are expensive and limited. Like Nick said, we have to start with one goal maybe, right? But they're accurate, they're reliable, they're safe and they have some value. So if you look in the literature, you'll see this, right? You can Google this or you can PubMed it, which is probably the better way to do it. And if you talk about something like screw placement accuracy, right, this is sort of the basic du jour, level one, kindergarten level of approach. If you look at that, there are papers written on this. This is from Paul Park in Michigan and he did a meta-analysis, if you will, or literature review, depending on how you look at it. And almost all of these are with the Mazor Renaissance because that was what was available and has been published on before. And you can see that the accuracy is quite good. It's in the 90, high 90s in general. There are a couple outliers. There's one Rosa paper in here somewhere. There it is. There's the Rosa paper, 97.2% accuracy in France. But you can see there are thousands upon thousands of screws being studied. And this is in the published literature, right? What about something like Nick was talking about in terms of facet violations? So MIS surgeons have always been blamed, I think, because I believe Rick Fesser, who I love, was teaching people the owl's eye view. And so Bob Isaacs said that he was getting a lot of facet violations and then, you know, maybe it's technique related, right? But the point is, with the robot, you can start to think about, well, I want to intentionally avoid that facet. And this forest plot shows that, yes, when you look at robot-assisted surgery, you're getting less risk of facet violations. So that's a mark of something a little more subtle, which is that when you're putting a screw in freehand, you don't always think about that. You're just thinking, I'll get the screw in, right? But when you are able to plan and execute, it's good. Radiation exposure. I don't think anybody has to talk about radiation exposure. I mean, to the surgeon anyways, that you're out of the room when there's navigation orientation, whether it be the O arm or arrow or something. Something is doing this radiation acquisition of data, but you're not there, right? So I think that when we talk about those aspects of it, that's pretty boring and pretty du jour. You guys can look that stuff up. So let me spend the rest of my time talking about what we've been doing at University of Miami. So, um, what are we looking at in terms of robots? So this is a, this is a picture of us when we got our Renaissance years ago. And this is our Mazor X with stealth edition, which we got on January 16th. So I think there's only a handful of them in the world. So we were very fortunate to get one, uh, because we didn't, we didn't, we weren't able to pay for it, but we were able to get it because, uh, we threw a good deal with Medtronic. And so this is the delivery of the robot and we're very excited about it. And this is the sort of initial training, right? So what's the robot for in our institution? So we are at an institution that has so much spine surgery going on, it's ridiculous. I mean, we will literally have up to 15 first OR starts in a day doing spine, right? So the robot is not going to make us too much faster, but it can reduce the learning curve, reduce radiation exposure, get us our navigation in three space, provide a stable mechanical platform like Nick was talking about, not having to hold something in space for a long time, improve our accuracy, make my life easier, maybe extend my career, maybe allow me to operate when I'm older. And my, my, my take on this is always, what if I get Parkinson's disease and I'm still pretty smart and I still have something to offer, can I still do surgery, right? If my hands aren't as steady. No, why not? Why not, right? I've got a couple of good years left, right? But it's an interesting point, right? I mean, you have a gentleman at your hospital who has to sit to operate, an orthopedic spine surgeon, correct? He's a dwarf? Oh, okay, but he operated for years in a sitting position. You could make the argument that his handicap should have kept him from operating. That would have been discrimination, right? But think about it more broadly. What about your, you don't have the stamina, right? What about the cumulative effects, occupational hazards on the surgeons? So I'm going to make a prediction, right? That MIS will be one of the major drivers of new tech adoption. So when you talk about robotics, you can talk about robots doing more difficult surgeries, but I think MIS is really going to drive this, much like Nick said. But why don't people use this stuff more? Why is it not more, more popular than it, than it is today? Now, I've, I've been thinking about this a lot and I think that it really goes back to this issue of having the, the right technology in your hands. And this is a paper out of the New England Journal of Medicine discussing the advent of combinatorial HIV therapy. You can see the history here. Now, I went to UCLA School of Public Health and I studied public health for a year and, you know, look, at the time, all anybody cared about was smoking and AIDS. That was the only discussion and AIDS was a death sentence, right? But now you can talk about Magic Johnson. I mean, he's what, a two decade survivor of HIV, right? And so you think about why is that, right? Because the technology changed that you could attack a problem from a number of different angles, a number of different mechanistic angles. And that led to this idea that we can, we can deal with this. And you probably heard that the, the second patient to be cured of HIV infection occurred in London last month through a bone marrow transplant. And now you have a lot of people engaged in risky sexual behaviors and they pop a Truvada when they're done, right? Because that's going to kill off any virus in their system and they're going to go about their way, right? So this is changing the whole fabric of how people interact with technology. So I've been trying to do that for a long time. Sorry, I'm digressing, right? But it's robotic. So, I've been working on this concept of percutaneous awake endoscopic spine surgery for some time, right? So combining these six pieces, endoscopic awake, percutaneous, expiral, expandable inner bodies and BMP. And you know, look, a lot of people have come to see me do it and a lot of people have learned to do it and people are starting to do it now, right? But a lot of people don't like it. They're like, why do I have to do that surgery the way you do it? And I don't think I can, right? I don't think I want to engage in that. And despite the published great results and getting people out of the hospital, right, there are major barriers to adoption. I mean, things like, okay, how do I get into Camden's triangle? So Andrew Phineus has written more about Camden's than just about anybody here. But Camden's triangle is not easy to safely access, right? What about placing and using the endoscope, right? We just saw a video of Curtis Dickman doing thoracoscopic surgery. How many people did that operation? I think like three people in the world, right? Nobody would do it. Four? Maybe four. Okay. Minimizing your radiation exposure, right? And getting your technology, right? Like you can't get BMP, you can't get this, you can't get that. So let me show you a video of what we've been doing. So this is, sorry, this is endoscopic percutaneous robotic fusion. Are you, volume on? No volume? Oh, I did, I plugged it in. It's okay, don't worry about it. So here you can see we've got, we basically are registering our robot. This is the Mazorex. You've got to do a sweep to make sure you know the confines and then the O arm is going to come in and we're going to get our registration and we come back in the room. So it's a little slower, right? Because you've got to do all this. And now what we're going to do is we're going to put all of our screws in. So this is like Nick showed you. This is I think probably no different with the Excelsius. We're using experial injection and we're going to get to a robotic based injection so it's injected exactly on that screw tract. So the experial is the long acting local anesthetic works for 72 hours. So that's going to have benefit right there. We're going to drill our pilot holes and put in our K wires and then drop in our screws. So far this is all pretty standard stuff, right? So essentially purely percutaneous type of technique to get all of our screws in. In this particular case it's going to be six screws for two level fusion. So there goes the K wires. And one of the things interesting about this, you can see that I can with confidence, just like Nick showed, let our fellows and residents participate in this. Whereas if I'm doing floral based, you know, AP view screw placement, it's not as straightforward. Like I really have to count on them knowing what they're doing. So then what we're going to do is we're going to get our K wire access for the trajectories for Kanban. So the robot's taking us to Kanban's triangle and we're going to dilate up and we're going to place, we're going to stimulate there, we're going to place the endoscope and you're going to see we're going to start to work endoscopically with the robot having us, having given us a trajectory. We can start to envision very quickly how we're going to move that robot while the port is in the disk and let us get to very efficient disk cleaning, right? So that's all done endoscopically and then, I'm sorry, there it goes. Yeah, there it goes, sorry. And then you can see the endoscope working a lot. So you can envision the robot starting to do some of this work actively now. So this gets beyond the idea of just saying, okay, just positions for screw placement. We're going to pull the robot out at this point, we're going to clean the disk and then we're going to put our cages in, cage inner body and do all of that kind of work, right? So one of the advantages here is that Kanban's triangle is pretty small, right? So how do you get through there three-dimensionally understanding that every facet is a little bit different, right? So we're going to put our cages in and you can see the K wires in there from the robotic trajectory, we use BMP, everything else is just like the other surgery. Now we're not doing this awake, right? Because right now we don't want to have people moving around while we're doing the robotics and talking and all that and then we're going to put our rods in and all that. So that allows us, and we've been doing these cases this way, to do something very different and much more, much more translatable in terms of the effects. So basically I don't want to say that anybody can do this surgery now, but yeah, pretty much any one of you and just about anybody out there with some basic surgical skills can do this kind of surgery essentially entirely percutaneously, right? So that's a huge advance, right? So what's the point of all this, right? So we're overcoming the learning curve. There's huge learning curve barriers to what people are able to do. We're improving our accuracy. The risk in these types of surgeries is the dorsal root ganglion. You can't always know exactly where that is. Standardizing it, so it becomes a prototypical procedure that is easily taught, flat learning curve and standardized. Removing traditional impediments to success. So everybody knows the story, maybe you have some of your own where you went to go learn how to do a procedure and you started to do it and you just couldn't do it. And you ask, well, why did that happen? Why did I not adopt this as a way of doing things? And there's a lot of reasons. Didn't pay me better. Hospital didn't like it. You had a bad outcome. But a lot of these barriers are technical. They're like, wow, I don't know. I just can't get it to work in my hands, right? And of course we want to advance patient care, right? So the next steps are pretty obvious, right? We're going to move to the bone removal decompression pieces. We're going to improve our registration process, maybe do it off of MRI instead of having to get an O-arm or CAT scan. What about super-impediment visualization, right? This is really important. This is one area where robotics is going to help us. Using laser light, using special wavelengths of light to see better, right? We're currently still dependent on a, on a basically a visual spectrum, a standard visual spectrum of light. Controlling intraoperative motion, right? Automating the rod bending, rod bending, rod placement and planning, getting efficient disc removal, getting better deformity correction, right? But, you know, people always say this. They're like, well, how is it possible that, like, we're going to do this when things cost so much money? And I got to tell you, I work at a hospital that has 14 days of cash on hand. University of Miami is essentially a bankrupt operations, right? Even though we do a ton of surgery, it has, it's a very complex thing we talk about offline, but basically we're one of the only universities where the university is paid for by the medical school. Usually it's the other way around. Columbia was desperate to get rid of their medical school because it's a loss leader, right? For us, we are fueling that stupid coach they grabbed from Temple for way too much money and he just fired all his staff and brought in all new staff. All that money comes out of the operations of the UM neurosurgery and spine program and cardiac maybe now, right? And so we have almost no capital, right? But yet we can get people to buy into this. So if I can do that, certainly you can do that because you guys certainly have a lot more local power than I have inside of the university. Let me tell you why it's important. This is a slide I like to show because it's so compelling. Anybody have an iPad? Everybody, right? Okay. An iPad 2 at Target costs $192, okay? This is the cost of computing for an iPad 2. If you go back in time to the 1940s, it's $100 trillion. Think about that for a second. The computing power of an iPad 2, which is tremendous by the way, I don't want to minimize it, $100 trillion, meaning the entire world economy, you know, ten times over wouldn't buy one iPad 2. This is what technology does. So if you look at every other field besides medicine, think about that. Think about how quickly cars roll off the Ford assembly plant now compared to 50 years ago or 20 years ago, 10 years ago. We are the laggards. You go to Congress, you go to Google, you go to the Department of Defense, everybody's asking the same questions. Why do we suck? Why do doctors suck? In other words, who here has doubled their productivity since they started? I have, maybe tripled, okay? I haven't increased it by a trillion fold. So that's a successful industry. We are a sucking industry. The reason why people want to change healthcare is because we suck. We are complaining about 7% growth in volume. You go talk to your administrators, like, you need to do 7% more. And we're like, groaning, like, oh, God, I got to see 7% more patients in clinic and 7% more surgery? I can't do it, right? Guess what? Get ready to be obsolete. Get ready to be annihilated. Because that is not the way this world works. Now, I'm not making the argument we should be. I'm taking the lead on this and saying, we need to have the tools to be better. We need to have the tools to do more. Because the world will not tolerate that. It simply will not. It will not tolerate that medicine is like this. And I'm trying to find the solutions. Now, how do we do that? So, I mean, in symposia like this, we can try to figure that out. So Danel is leading this. And I always think about Danel in the sense that he's a pretty athletic guy. And I found this picture online. That's you, right? Yeah, was it Iron Man? Triathlon? Some kind of badass thing. Looks kind of like a Navy SEAL, right? And I love the analogy because the Navy SEALs are pretty awesome. These guys are superhuman. They can, they are, we're in San Diego right now, right? SEAL camp is right here. Hell Week happens right here on these shores. The SEALs are amazing. They are the ultimate razor's edge of human performance, right? But what does it take to make a Navy SEAL? And what can they actually do? Well, that's Danel. Master surgeon Navy SEAL. This is the Mazor X. This is like a drone. The drone is going to beat the Navy SEAL almost every time. Why? You can make more of them. They duplicate. They have infinite learning capabilities that never fail year on year on year. You can clone the drone. You can't clone Danel's knowledge. You have to start over again at PGY1 and have that guy screw everything up for about ten years until they figure it out. This is the difference. Just like Nick showed with throwing the darts. I'll bet you it took a long time to teach that computer, the robot, how to get, how to hit it, right? But once they figured it out, once they got the algorithm down of how much force and what kind of motion, it just duplicated it again and again and again. And nobody in this room, no matter how much of a master surgeon you are, can duplicate the result every time because we're not robots, right? And that's where robots are going to help us. So I'm pro robot. One day the robots are going to make me obsolete. But before that happens, the robots are going to make me better. They're going to make me more reliable, more accurate, more consistent. And live longer. And work longer. So that's my take on it. But I know it's very controversial. So thank you very much, Danel, for putting me up here and for your time. APPLAUSE

robotics

spine surgery

advances in technology

standardization

surgical procedures

robotic fusion surgery