Hi, my name is Dan Shuba, and I am coming from Northwell Health in the New York area. I'm presenting today part of the seminar of new and evolving technologies for minimally invasive lumbar disc surgery. And my approach is really looking at virtual reality exoscopes. Here are my disclosures. I don't think any are significant, really relevant, except maybe the bottom part, which is consulting for Augmatics, which is one of the companies that I'm gonna present today. So obviously, put that in mind when you think about this type of presentation. The other thing that I think I should be really honest about is that I'm gonna show you a lot of cases I've done using these two technologies, but none of them are specifically for MIS discectomy. So please use your own imagination in thinking how some of these cases, which many of them are very complex, can be really narrowed down to doing an MIS discectomy using these technologies. When we think about where is spine surgery going, the way that I think about it, which I think everyone else is as well, is improving safety, firstly. The second thing is decreasing variability. And anyone who deals with a hospital administration role knows that this is best standards. This is really what we try to get to efficiency-wise in hospitals, not having people take five minutes to do a surgery or 15 hours, but really kind of decreasing variability. And as we start getting technologies, they can really help us with that. The third thing is probably improved planning and potentially even predictive or prescriptive analytics, really trying to use technologies to help us tell the patients what they're gonna get before they even have it. And so when we think about addressing these three issues, whether it's improving safety, decreasing variability, improved planning, there's different ways to accomplish those. And I would argue that machine learning and artificial intelligence has definitely helped us in decreasing variability, whether it's something like this, a software planning technology where we can kind of sit there and say, this is the way the computer helps us get there. And maybe that decreases the variability as we all figure out the same type of ways to do that. When I think, when we think about automation, whether it be a robot or something like a robot that can help us guide things technically, it's probably doing two things. It's probably decreasing variability and improving safety. Those are the goals. However, in order to get all three, I think one way we can get all three is improving visualization. Assuming that when we see something better than we do previously, that it can improve our outcomes, improving visualization probably improves the safety. It probably decreases variability and it probably improves planning. And so for that, I'm going to discuss today the augmented reality platform as well as the Exascope. And for those who don't really understand augmented reality or haven't had a chance to do it, it's different than virtual reality. Remember virtual reality is you put a bunch of goggles on your face and you really just see what is projected on that toy and you don't really see anything outside. It's pitch black until you see something and then you're in a virtual world. Augmented reality is really looking at your world and now having different things laid on top of, almost like an onlay. So for me, this was, I was introduced to when there was this Pokemon game and people in Baltimore were walking through the towns, walking into the street or walking into potholes because they could see a Pokemon on their phone right in front of them and they'd be staring at their phone. But this has been used for other things, looking at where your furniture wants to go, looking at a room or blueprints, or even in some ways plastic surgery can kind of onlay or a tattoo can onlay what things will look like before and after. And so when we think about probably the most natural thing, when we think about how to combine this, we think about navigation and navigation we always think about in terms of our car and we can look at the dashboard and see where to go. But ideally what we'd love is to have that onlaid, not just on our dashboard, maybe onlaid on the windshield or on our glasses. So it's really more of an augmented reality rather than just a navigation over on the side. And so this really kind of came about probably mostly, and mostly well known in fighter pilots where they'd have it onlaid on their cockpit so they would not have to look and take their attention away from their task with their own eyes and they don't have to look down at the cockpit controls. And this is the same idea that I'm going to get to with augmented reality, something called attention drift, where you don't want to have to be looking down like we do in the operating room. We have to look at navigation, we look away and our hands are still in the same position that they were, but our head is being pulled to one side, it's called attention drift. And I have something like this in my car, I have an Audi, which is what this, I have no relationship with Audi except that I own one. And in my car you can look at the speedometer and all that stuff on your windshield. So I guess if you're driving real fast or it's raining out or what have you, you can see your speed without having to look down at your instruments. So the idea that really came out was first published in this paper, looking at augmented reality and spine surgery. And really what they did was they combined some software with a microscope and in looking at the patient, they could actually see these blue outline pedicles based on some of the software. And this was an idea that now you could obviously instrument this area or manipulate the spine in some way without having seen this before. Another study came out looking at this in terms of a cadaveric feasibility study. And they obviously took, involved this type of setup where you'd have an imaging source and some monitors. But the idea again is to project really the navigation that was obtained with those imaging sources onto the one's view so that they could see it as they were putting say screws in here and they could see that navigation. Very again, similar to navigation, but again, on laid into your normal visual area. And they saw a pretty decent accuracy. I was fortunate to be involved with Augmedics when they were still in a prototype and they created this X-Vision headset, which projects a navigation onto the retina via these small little eye shields. And this was the kind of image you'd see if this were a percutaneous patient. For example, you'd see three sets. You'd see the sagittal, say the axial, but then you'd also see a topographic type image of the 3D spine. From a percutaneous point of view, you could see at the bottom. If you were doing it open, you could take that bottom part away and you could play with whatever your display wants to be and you could work on that. And here you can see the setup, which would be a clamp and then another type of clamp that would go to your instruments. In this case, a jam shady type needle. And we were able to publish this using cadaveric study where we looked at this back and forth. And I'll just tell you that my own experience was that when we did this, I did it percutaneously and a medical student did it opposite me. And we put the screws in and I thought, hey, listen, I'm going to at least have the tactile feedback and all this experience putting screws in. So mine might be a little bit better and we'll see how good it is. When we looked at these on CT, the images look the same. In other words, both screws were identical on both sides. And it's really showed me how this technology evens the playing field from someone who's never put a screw in to someone like me who's put in a lot of screws and how this technology really made it great. And here you could see you could hook it to an awl or a gear shift or a pedicle finder or screwdriver, power drill, et cetera. And this is, again, what you're kind of seeing is, again, you're seeing the axial and sagittal and you're not having to look at a monitor off to the side and you can see the topographic view of the saw bones right there and you can click a foot pedal and that circle would go away if it were open so it wouldn't obscure your view. And we looked at this and we used the Heery grading scale and we had very good accuracy in this study. And in addition to that, also asked about what people thought about it and if they liked it, efficiency, dependability, attractiveness, and we had good scores in that. I was fortunate to then help them go, help Augmatics go to the FDA and present this in front of our colleagues at the FDA for approval and now it's been approved. So this is something that is available for all of you out there if you want to try it. And here you can see these are open case or mini open cases with clamps. And this was the first case done in man, which was a fusion done, just a lumbar fusion for DGEN. And as we've gotten to use this more, we've gotten more complex. And here's a patient with a chordoma where the cuts for me are very important because you want to always be outside the tumor, you don't be touching this tumor, you don't be seeing the tumor, but you also don't want to take a lot of normal tissue. So you try to make the cuts as close to the tumor as possible. And so you can see, again, this is not a microdiscectomy, but is it something that you could use to get in that area like you would with a microdiscectomy? Yes. And also work within the disc space if you're doing a full discectomy or inner body work. And you can see a picture where the upper right shows kind of a cut through the pedicle that we're seeing by using our navigation and the setup there. And here's a publication. We also have another paper really showing that the workflow and how that should happen. And there's a paper describing our first several patients. And then Camilo Molina, one of my colleagues involved throughout this entire process, who's now at Washington University in St. Louis, just published this, basically looking at his percutaneous thoracic pedicle screws. And so again, look at that upper left. He's using a high-speed drill to make pilot holes using navigation. So staring at the patient, but using a high-speed drill under navigation. So maybe some sense, maybe some avoidance of drift. And then you can use a tap and a power screwdriver to put the screws in. And here you can see he's got pretty good accuracy in the curt spine. Robin's great. Again, this is the idea. I'm not showing you a micro discectomy, but I'm showing you some of the technologies where one can normally use navigation for a discectomy or interdiscal work and use augmented reality. The second thing I'll briefly just touch on is the idea of an exoscope. And this is now a different type of visualization, but it's a microscope, but it's coming right over perpendicular to the patient or in any position you want, actually, so that you can look at a 3D screen and operate like this. And I've had the opportunity to do this. And really the reason I like this is because this is usually what I'm doing. I'm leaning over and in all different positions and often hitting my head into my partner. And so this is an idea, can I increase my visualization, increase my posture? Here's a paper out of JAMA showing how we take these postures, whether using loop magnification, what have you. And the idea being that we put ourselves at risk when we bend over like this. Here's a picture of David Langer doing an operation at Lenox Hill, and I just joined this group. I was able to do a number of cases over there recently. Here's a setup. You can see the surgeon and the assistant at the circles, and you can set up your exoscope base and set up the rest of the room however you'd like, but pretty standard stuff. And here's a picture of me and David Langer. We had a couple of spine tumors doing one day, and you can see the exoscope right in between us. It's quite small. You can see that it very easily can be put in a position that you like with very little resistance and it's very lightweight. And you can see the 3D images with high quality behind us, and that picture was taken through the goggles, so it has high resolution, but it's a spine tumor right there. And here it's a little less resolution because once again, it's in 3D, but you can see again how the setup is. That's me. This is me from my vantage point looking right across, and I'm just operating looking right across. So avoiding bumping heads and really getting you in positions, especially imagine doing a discectomy with a high pelvic incidence where the microscope is angled and you're operating sideways with a microscope. This is something that you can line up angle and still look up straight. So again, discectomies or interdiscal work would be greatly improved by this potentially. So in the end, I think that if we're really going to try and prove safety, variability and planning, and oh, by the way, not have your neck hurt, and oh, by the way, have less attention drift, we probably want to improve visualization. And I think augmented reality is one way to improve visualization because it's helping us with navigation in a more accessible way, one not looking off to the wall or a console. And then the exoscope is another way to improve visualization. It's the same principles as a microscope, but once again, helping you with your posture and your position in the operating room. And with that, I'll thank you. And thank you again for inviting me to this.

minimally invasive lumbar disc surgery

virtual reality exoscopes

augmented reality platforms

machine learning

automation