Um, so this is my disclosure slide and I, I'm just, let me just start with, cause I look at the room and it's like the average age in here is probably 50. And, um, you guys are probably aware that there was the first actual optical, uh, visualization of a black hole a week and a half ago, right? This is a huge advance in science. And if you, anybody here wonky and nerdy, probably like most of you guys, right? Like me, like, this is very, very interesting and very cool and, uh, and involved highly sophisticated technology. And so this is one of the, the, the themes that I'm going to get at. Cause I, I, I saw that in the room, it's, there are almost no adopters here of endoscopic technique, right? And I'm, I'm not like Rick says, I'm not a true master. I looked at the endoscope as a bridge purely. Christoph Hofstadter, one of our former fellows is probably the best endoscopist in the Western hemisphere. He's in Seattle. I can't do the stuff he does. So this is a very interesting concept. And when I think about black holes, I think about existential threats because the, the comment by the gentleman in the back is absolutely right that we are faced with all kinds of threats right now. It's just your approval denial, but there's going to be bigger threats coming soon. And I always think about like the dinosaurs becoming extinct because of, of, and it doesn't take much, right? Spine is very susceptible at the razor's edge of problems and, and, and you know, payment issues and how we're perceived. All you got to do is turn on that doctor death podcast and you're like, wow, that might've wiped us out. Right? One angry Senator is all it takes. Grassley almost wiped us out years ago. So there are a lot of things we have to think about and we're economically important. So, you know, I've, I've sort of, you know, under Rick's sort of a lead, I've sort of taken MIS as maybe the strategy of getting around these problems. So brings up these issues. Like if I were to ask who, who in this room does MIS surgery? Everybody, right? All my partners, including the guys who don't even know how to do a tubular discectomy say they do MIS surgery, right? Everybody has to. So is this a technique? This is Rick's cover of his supplement to neurosurgery that really launched the revolution of MIS fusion. Is it a technology like a tube? Is it an approach like a Wiltshire plane? Is it a marketing ploy? Is it a philosophy of surgery like doing less like Lou was showing us or is it a philosophy of care, right? In terms of what you're really doing to people globally and how they recover from your operations, right? So I'm going to issue a little prediction because I know that being at the front lines and, and, and everybody on faculty here is, is that MIS is going to be the big driver of technology. MIS is, is, is sort of the clarion call to say, well, how do we do surgery better? And, and clearly not everybody signed on to these principles. And there's a good reason for that by the way. And I, I like to reference this article out of the New England Journal looking at HIV treatment. And I, you know, I went to UCLA school of public health, not very hard, far from here. And all we learned about was AIDS and smoking, right? Because that was the crisis. If you had HIV, you had AIDS and you will die. And now, you know, you don't have to go very far to look at people like Magic Johnson and you're like, wow, that guy is like living a normal life. And then nowadays, you know, young people, the older folks probably don't know this. All you got to do is engage in risky sex and pop a Truvada and you're good, right? So this is the timeline of what happened, uh, the history. And it came down to combinatorial therapy. The idea that if you combined technologies and techniques in how you attack the HIV virus, you could actually essentially give yourself a statistically high probability, 98, 99 percent chance of elimination of that virus, right? So we're not quite there yet, but we're getting there in the keyest technology. Now, Charlie is absolutely right about going outside the United States. And I'll tell you, the drivers against endoscopy are many. Number one, we're all really paid super well, right? We're the highest paid doctors there are, period, right? Spine surgeons. And second, what's the motivation for you to change for a stupid 13 RVU, uh, CPT code on a discectomy? You're like, really? Like who's going to change your entire practice, learn how to do endoscopy for that advantage? And so there isn't a lot of force driving you, but just like the dinosaurs, T-Rex was stomping around for millions of years until he was extinct. So I went to Asia and I started to see stuff. This is the JoyMax users meeting. So there are three big endoscopic companies today, JoyMax, Wolfenstorz, there'll be many more in the future. This is 900 orthopedic spine surgeons that essentially only do endoscopic surgery. You go to any major hospital in China and there are at least two people who only do endoscopy. They don't do ACDFs, they don't do arthroplasty, they don't do deformity, they don't do plis, they do endoscopy 24-7, like seven cases a day, six days a week, because the Chinese work really hard. And when you see that 900 people, 900 surgeons attending, it's not like I want to learn. These are the users. I mean, there is no company in America that can get 900 surgeons together. Medtronic meeting cannot assemble 900 people in one room. 900 surgeons, all of which are completely devoted to the concept of endoscopy. And I was like, wow, boy, that's a disconnect. So are Chinese humans different than American humans? And then you go to Europe and you're like, well, maybe it's a Caucasian thing. They don't like endoscopy. And then you go to Germany, they're like, wow, there's big centers, like people just do endoscopy and they fight with the people who don't do endoscopic surgery. And you understand it's really an economic proposition. It's not about science. And it's not that endoscopy replaces standard surgery. It's that it's different. And then you take another technology platform, you look at robotics. This is from CNS. These are the 11 companies that have a robot on the market right now. I'll bet you if I go to exhibits hall, it's going to be 14 this year. And so you think about, wow, these technologies, they're very expensive, but they're powerful. They allow you to do things that you couldn't normally do. So I've been working on this concept of this awake fusion principle in an effort to overcome all of these challenges we face every day in your clinic and in your office as spine surgeons, is how do you get people through a surgery with minimal impact? And so these are the six components that we put together. And I've been doing this for some time now. And people have come through and now you're starting to see people like Praveen Moominini talk about awake spine surgery, Alok Charan. People are talking about this, like, wow, let's do surgery completely differently than how we used to. And the impact would be different. And we published this. I don't want to bore you with the details. We did our 208th case last week and the results, you can look it up. The metrics are very impressive in the sense that if you can take someone through a fusion for spondy and do it with minimal impact, they do extremely well, right? Because you're eliminating CSF leaks, you're eliminating long hospitalizations, all those complications that people can get. There's different complications. And this is an example. This is a patient that we're doing with a cardiac ejection fraction of 11% with a grade two spondy, okay? So 11% means your anesthesiologist does not do that surgery. That's basically what that means. That patient's dead. Like you're not gonna, he's in a wheelchair, but you're not gonna help him because you're not gonna take him to surgery. And of course they failed shots, of course, right? Nobody operates on people who don't fail shots. So this is the kind of thing that it allows you to do. Not that we want to operate on these people, not that we're trying to get more patients. It's we're trying to find out how do we manage these sicker and older people. But when I'm talking about this type of surgery, there's a lot of angst and there's a lot of desire to sort of like try to avoid doing this type of surgery because it's different. It's so drastically different from what we normally do. And so there are barriers to adoption. Like Lou just spent a great deal of time talking about Kambin's triangle. I think Lou's probably studied Kambin's more than just about any living surgeon now. And that's a, I don't know, it's a frustrating thing too, right? And what is Kambin's triangle? How do I get the endoscope in? How do I use it? Well, how do I see, right? How do I minimize radiation exposure? Some people are like, well, you know, I could do a standard discectomy with one rate, one floor shot. Why would I care about doing it your way? Because you're getting more radiation exposure. And you know, I can't get technology. I can't, you know, capital equipment, these things that Rick talked about are all barriers to entry. So I've always been interested in this concept of how we can combine technologies. And this is a report looking at endoscope plus robot for discectus. So we've been going down this path iteratively. We didn't just mash everything together, right? It's not like a rat lab. We've been learning and getting better so that hopefully we can perfect the technique that everybody can do. And so this is one of those cases. So this is a robotic endoscopic T-lift. So I don't know if the audio will go. Let's see. It's plugged in. A stab incision is made over the PSIS and a bolt is affixed to it, providing point of rigid fixation for the robotic arm to the patient. The robotic arm maps the surface anatomy to avoid any collisions and an ORM spin is performed, registered to the patient, and used to plan both screw and T-lift trajectories. The arm moves into position for the first screw. The skin is infiltrated with a local anesthetic and the screw track with liposomal bupivacaine. Incision is made in an outer cannula with an inner dilator is inserted through the guidance track. The inner dilator is replaced with a drill guide and gently malleted into position. A pilot hole is made using a drill with a positive stop at 30 millimeters. A reduction tube is inserted followed by a K-wire. The same process is repeated for all screws. Note the two surgeons may operate simultaneously. Bilateral pedicle screws are placed in the standard percutaneous fashion at all levels. The arm then moves into position for the first T-lift trajectory. While not pictured here, both safe and ideal trajectories are tested with neuromonitoring EMG, with the safest and most appropriate trajectory chosen for each level. For this case, a safe trajectory was chosen for lumbar 3-4 and an ideal one for lumbar 4-5. A K-wire is inserted into the disc space at each level. An ORM spin confirms screw and K-wire placement. Using the K-wire as a guide to the disc space, endoscopic discectomy is performed. The robotic arm is disconnected from the operating table and a fluoroscope is brought into the field. End plate preparation is performed percutaneously under fluoroscopic guidance. This is followed by percutaneous delivery of an expandable, allograft-filled mesh inner body implant. The process is then repeated at the second level. Both rods are placed, securing the final construct. Final fluoroscopic images are taken, demonstrating successful inner body placement and pedicle screw instrumentation. So this is definitely slower, right, than what we've been doing with the AWAKE Fusion. We're not getting the benefits of having the AWAKE because the robot has to be pinned to the patient, so patient movement, which is fine in the AWAKE surgery, really would be a problem here because the robot's registered to the patient when you get the ORM spin. But this is something that actually, I will tell you honestly, anybody in this room can just do. There's actually no significant amount of learning curve involved in this other than understanding how the devices work because the angst came in because, you know, we had surgeons visit in Miami regularly and the concern always was about the targeting. How do you target? How do you get, Lou showed this issue and we heard Jean-Pierre talk about a low-lying root and all these things. A lot of technology to let you get through that. So the point of all this is trying to overcome these learning curve barriers, right? Improving the accuracy and really the point is the DRG, right? The dorsal root ganglion is the problem here. So if you can avoid the DRG using a combination of the proper kind of trajectory plus electromapping or MMG mapping, that would be very effective. And then standardizing the procedure. So we're studying this and figuring out how to get this to the point because right now, no company is like building this for us. This is not like a situation where Medtronic or Depew is building a procedure. We're taking stuff off the shelf and we're cobbling it together to allow, obviously, you can make this much more efficient. And removing traditional impediments, right? So you think about, well, if you were to go try endoscopic discectomy, there are a lot of aspects of that that are unclear to you at first, like when have I taken enough disc out, right? When have I completed a decompression? And you hear these questions again and again and again and it makes people unsure of how to do the procedure. It's simply not standardized. And of course, we're all doing this to advance patient-centric care. So when we look at this robotic endoscopic t-list, the idea is that we're going to have to take away the wake anesthesia, right, for now at least, and we're going to replace that with a robot. And so with this, with the endoscope, we get the ability to miniaturize everything, right? Because that's the key is that you can see now without opening things up. I think Rick was saying he uses a seven or eight millimeter port and that's about what you need for access. The second is getting there, right? Accuracy, localization, a robot gives you that piece. Stabilization, percutaneous fixation, that's very important. How you do percutaneous screws and these techniques is very different than a standard MIST lift where the person is asleep and you can cut things open and all that. This is a very, very different kind of a stabilization. Pain control. We use Expro for pain control. So it may come down to the fact that we can inject the Expro more accurately with the robot than freehand with fluoro. That may actually end up making a big difference in pain control in these patients. And we are studying all of this. Expandable inner body, you got to be able to get in small enough. I think every company out there is trying to build the better expandable. Everybody knows that this is the holy grail of inner body fusion. Get distraction, get correction. You can do all of that. And of course, osteobiologics right now, BMP is the front runner. Of course, it's off label, but there's no product I know of that's better than BMP right now. There are some good products, but BMP is absolutely critical. And I'll tell you that in our 208 cases of awake spinal fusion, which has done very technically the same, right? We had, and I'm so glad we got it. We had our first symptomatic non-union. So if I told you that we had none, you'd be like, well, you're not following your patients. And we are following our patients. Trust me. My clinic's filled with these people. It's actually very burdensome to keep tracking these patients forever. But we had our first case about eight months out from surgery, classic non-union patient got better and then started getting worse, had some subsidence, and had a clear non-union, and we had to take her back and do a mini open. Actually, we did a lateral on her, lateral approach for inner body fusion. So we've had one case out of 208. We're five years out from the first case. The first 100 cases were published in Neurosurgical Focus this month, and so you can kind of see our clinical results with that. Yeah, go ahead. If your patients are doing well and there are no issues, are you getting a CT scan to look at fusion? No, no, no. That's why I'm saying symptomatic non-union, because we're tracking them over time, and we're basically, we get x-rays on them. But yeah, the question of how you define a fusion is in itself problematic, right? But that's a great point. I mean, ideally, I'd love to get CTs on 200 patients, but I think it's gonna be problematic. So what's next? It's pretty obvious what's next. Robotic decompression and bone removal, that's coming. The MAKO is probably gonna be the platform for that. It's a striker robot. That is a robot with haptic potential. Actually, haptic built into the DNA of it, and so the MAKO robot is designed to drill out the hip and knee surfaces to allow better implant interfaces. Completely different from the Mazor, Rosa, and Excelsius, which are robot screw placement devices. Improved MRI registration. So this is a big impediment. You saw that O-arm spinning. The O-arm spinning is what slows us down. Getting the arm in, getting it out, and all of that. If you could register off MRI, it would be much better. We haven't even talked about what the endoscope brings in terms of superhuman visualization. When you talk about how we look at things, we're just using normal halogen or xenon-based light in the microscope and fluorescent or LED light in your OR. But have you thought about the, anybody who knows anything about physics knows that you can actually modify the type of light entry using laser to see things differently. And you see a little bit of this with the brain guys. They're starting to inject fluorescein dyes, special microscopes. You can do that kind of stuff in spine, too, to look for things like the DRG. Control of interoperative motion. This is gonna be important when we go to the awake version with the robot. Automated rod bending and implant delivery. You can think about this being a much more automated process in terms of, right now what we're doing is we're building Italian craft Ferraris. Every single one is different, right? And that is a disaster because those cars perform really lousy. What we want to get to is a system where everything's standardized, that people, not that there's no art to surgery, but that it's a fairly reliable, repeatable procedure that you can do and people are gonna do well with that. Efficient disc removal for fusion. The next step will be deformity correction methods. I'll show you what we're doing in Miami. It's really cool stuff. I see the group in here is older, right? So I really like the robot for a lot of reasons. One is that it will extend my career lifespan. I really think it will. And this is one of our chief residents who's hired on at University of Miami and his name is Timur Yurakov and he's doing surgery. This is just last week and he's now connected. This is very simple stuff. He's connected the VGA output from the fluoroscope to various types of heads up displays that he wears in the arm. These are really cheap. They're on market. I think he uses three or four of these and so he can see all the x-rays as he's operating and he can superimpose images onto when he's operating. This sort of augmented reality aspect of surgery is really coming and you'll see it's really impressive, this kind of thing. And people go, well, wait a minute. So I can do, like Lou can do the surgery super cheap, right? He's the super efficient Navy SEAL surgeon, right? And I think about that and I think about robots and BMPs and X-Brill and all these implants and then all this, it's expensive, right? But I'll tell you that, let me work out the details, right? That's my job and I'll show you a slide and I'm sorry if you've seen this before but it's such a compelling slide when you think about this. This is the price of an iPad 2's computing power. So right now if you go to Target, an iPad 2 is $192, okay? Check today. And so if you look at what the iPad 2 can do, it's an extremely powerful device, right? And you go back in time to 1940, okay? The cost of that computing power is $100 trillion, okay? That's more than the entire world economy several times over. The iPad, the thing you throw away or you see some idiot watching movies on in the airplane. The power of that was greater than the whole world economy even back in 1960, right? So this is the clarion call that as surgeons, okay, yeah, I get it, right? We think technology expensive but we have to get better. We are not getting better at what we do. And this is, you can say, well, the issue is, well, you're picking the wrong patients. Okay, got it, got that, right? That's super important. Indications are important. But if we don't advance in technology, it's gonna be like T-Rex. It really will be. And people are gonna really judge us badly in that regard. So I don't have all the answers and I know that the MIS methods have to be judged and measured against the gold standard which today is the open surgery, right? So that's the goal that we're shooting for. So Charlie, feel free to poke all the holes and I'll take the tomatoes and whatever you wanna throw. Thank you. I'm not gonna throw tomatoes or poke holes, I think this is, he's right on the money, it's just that somebody has to go out in front, and I think Ralph Cloward said, you know who's the leader? How do you identify the leader in a group of people? It's the one with all the arrows in his back. So Mike, let me ask you a question. So don't walk out because somebody might zap you. So Mike, I mean, the cost thing, you know, we see a failing economic healthcare system where the costs are exorbitant. I saw a bill for a patient the other day from a hospital for a T-lift, and the hospital billed $200,000, and they, I think, got $170,000. It was absolutely crazy. The insurance company's like, go track this patient down. Yeah, and, but I mean, this is a failing system we have, and while overall, we can look at things that talk about cost, it's getting harder and harder to convince hospitals, insurance companies, whoever it may be, that hey, let's add the robot, let's add this, let's add the new million dollar microscope, let's add the new expandable cage, let's add the BMP. Do you think that this technology is gonna be limited financially, or it's coming regardless, and there's gonna be a way to make it work? Well, of course, of course it is, right? Now, let me ask the people in the room, how many people here have an MBA? Financially, no MBA, right? Okay. So, if you take a perspective, a 40,000-plus perspective, what is the true cost of this device? So, if you were to say, okay, you must go get a store or an Excel system, they're gonna charge our hospital a million dollars, right? That's what they're gonna say is the price tag. Is it really a million dollars? Like, I think that's the question, right? And not that we can access the technology and make them like Venezuela, make it cheaper, right? No, it's not that. We know that if the technologies are adopted, that over time, they will get cheaper and cheaper and cheaper, right, that's the bottom line. And so, if we ever meet the, I mean, if that's the capitalist market, right, that basically, the successful technologies will go away. They will proliferate, and they will get cheaper and cheaper and cheaper. But BMP's been around for 20-something years, and the price has not gone down. But it's going to, if it comes off of this patent, I mean, this year. Yeah, that's right. As soon as it comes off patent protection, the price is gonna go down dramatically. It's gonna drop, yeah. No, I agree with you, but see, the thing is, I think as surgeons, and I would issue another clarion call as surgeons, that we should be more politically active, because that's the answer. Your hospital administrator who's a nurse, who's now a CEO, who knows nothing about what we do, and we're profitable anyways, right? Nobody in this room is not profitable at home. They really shouldn't be talking to us about cost. I mean, we're profitable, right? It's a huge problem. God forbid we get to the point where we're not, then you have no negotiating power. But I mean, look, the bottom line is that either we are gonna keep pushing the envelope, or not. Nurses have always done that. That's one of the reasons why we're not like urology. On the other hand, I think we have to, Mike, depend on guys like you, and Rick, and others, to concentrate this, and do quality evidence development, quality technology. You've gotta sort of figure out, okay, this is, you can do it, you can do it safely. You can do it with this technology. Then we sort of spread it out. And that's been our MO, right? I think we've been innovative. We're here because 15, 20 years ago, everybody in this room was doing open whatevers. Now everybody in the room does some form of MIS. We move, which is good. And I think our challenge is moving responsibly, right? Not just trying everything, and applying a lot of expensive technology that doesn't. How many of us in this room really bought into the CO2 laser 20, 25 years ago? There's enough gray hair. And we used it, and it was all cool, and then it sat in the corner. And we convinced our CEOs to buy a four, five, 600, of that, whatever it was at the time. And we used it, and it kind of didn't. So this is where we are. The proliferation technology, yes, once it's adopted, once it has competition, price drops like a rock. But we gotta sort of figure out how to get there responsibly, if I can use that term. Yes, sir? Navigation technology, underwater technology, and whether those two... I want to bring it forward, thank you very much. Thank you. First of all, I'm going to give him a hand. And the only true robot was invented by neurosurgeons. The only true robot was CyberKnife. CyberKnife, you push a button, it'll receive the stuff. And John Adler, who was a neurosurgeon, he never invented that. So we are believers ahead of DaVinci. DaVinci's never seen a translation device for your hands. But I think at this meeting, Charlie, when they launched the Mazor, the Mazor X was stealthy. Which is what we have. So that is the navigation cluster robot. So we'll see how that DNA plays out, because now you have the navigation live cluster robot. The other thing that the Zorex has, and I have nothing to do with Zorex by the way, is it has something called Hawkeye. If you look at the Zorex, take a look at it, the two little eyes that are watching you, that's what it looks like when you look at it, that's a Wall-E robot, and it is actually optically tracking at this thing. So, the picture now, the robot knows. So I think it's very exciting to get into this because most of us are too smart to be a scientist. I mean, I've heard of Explorer. I think they're a little bit too difficult. Navigation. Navigation has evolved dramatically. How many of you in here were here when they first, somebody came in and tried to convince you that you ought to use the navigation in your surgeries, and it was so clunky, and it was, oh, it was just painful. And now it's, how many of us can't live without it? It's kind of funny. You know, the spine guys sort of pushed navigation into the marketplace, and now in my house, every brain surgery is done with a navigation, like, guys, give me a break. It's interesting, but that's just, technology's evolving. I think what Mike is saying is we're seeing the first navigation robotic marriage that's going to be the beginning of another sort of iteration, and before we know it, we're going to plan the procedure, and we're going to make sure everything's right, we're going to set it up, and we're going to push a button, and a lot of it's going to be automated, combination of robot, navigation, et cetera, et cetera, and our job is to make sure that these things don't go crazy, right? Rick? I think the limiting factor, in my opinion, when I think we are really going to make the jump into real navigation robotics is when navigation becomes truly real-time, and not dependent upon a CT scan that's sometime in the past. When it's truly real-time, we don't have to worry about our Arabian bump that's putting us through the middle of the canal. That's the difference. And the guys that are developing that have told us about all the challenges and problems in surface recognition, but they're companies that are using surface recognition to drive navigation, so it won't be too much longer, and we'll have that, right? And they are actively working on that marriage of navigation. They've been working on this for a couple years. They recognize that for advanced navigation users, the robot today is actually a step backwards in some cases, and they recognize that, but they also recognize that in two to three years, it's going to be a step forward. And if you look at, if you think about our interventional colleagues with catheters and coils and stents and all the things, where that technology started and where it is today, I think we're going to see the same thing with robotics. I've stayed on the sideline of it because it was a significant step backwards for me for what I'm doing with navigation, but I've talked to people at the high levels of these companies, and they're predicting within one to two years, it will be a step forward.

robotic technology

spinal surgery

minimally invasive surgery

endoscopic techniques

MRI registration

implant delivery