Robotic Spine Surgery: Q&A with a Pioneer in the Technology

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Robotic-assisted spine surgery is an emerging spinal advancement that is rapidly growing in popularity with surgeons and patients alike. Isador H. Lieberman, MD, MBA, FRCSC, Orthopaedic and Spinal Surgeon at Texas Back Institute in Plano, Texas, is a pioneer in robotic spine surgery. Here, he clarifies misconceptions about the role of robots in the operating room—and explains why he thinks this technology will be the standard of care for complex spine cases within the next 5 years.
Spine Surgeon, Isador Lieberman, MD“The robot does not make a bad surgeon good, it makes a good surgeon more efficient and precise,” says Orthopaedic Spine Surgeon, Isador Lieberman, MD, who is a pioneer in robotic spine surgery. Photo Source: Used by Permission, Texas Back Institute, Plano, TX.

How do you explain robotic spine surgery and its benefits to your surgical patients?

Dr. Lieberman: The spine surgery robot is a tool that facilitates the surgeon’s pre-operative plan.

Much like a pilot formulates a pre-flight plan depending on the weather, route, payload, and fuel level, a surgeon formulates a pre-surgical plan in a virtual environment based on the anatomy, bone quality, and desired correction of deformity. That plan is done on a pre-operative CT scan and once complete, the plan is loaded into the robot’s computer.

During surgery, the robot facilitates the plan by pointing out the site for screw insertion, and the location and extent of bone removal.

The robot is passive in that it does not do the surgery—the surgeon still performs the surgery much like the pilot of a plane still flies the plane. The robot’s role is to help the surgeon be more efficient and precise.

How old is robotic spine surgery technology?

Dr. Lieberman: The initiation of robotic spine surgery technology was 18 years ago and has evolved through 3 generations, with substantial improvements along the way.

Dr. Moshe Shoham and I authored the first grant for robotic spine surgery in 2000. The grant was funded by the Shalom Foundation with a matching amount of resources from the Technion University in Haifa, Israel.

How prevalent is robotic spine surgery in the United States?

Dr. Lieberman: The use of spine surgery robots is now just becoming mainstream. There are multiple commercial robots available. I suspect within the next 5 years that the use of a robot to perform complex spine surgery will be the standard of care.

Where is robotic spine surgery performed?

Dr. Lieberman: Robotic spine surgery can be performed in a traditional operating room setting in a hospital or in an outpatient or ambulatory spine center. The robot can facilitate less invasive approaches, so surgery can be accomplished as an outpatient procedure. This technology also facilitates even the most complex surgery that needs to be performed in an inpatient setting.

Does using robotic technology lengthen or shorten operative time?

Dr. Lieberman: Robotic spine surgery shortens operating time. The robot does not make a bad surgeon good, it makes a good surgeon more efficient and precise.

What spine surgical procedures utilize robotic technology?

Dr. Lieberman: Any procedure where instrumentation (eg, screws) or implants need to be applied to the spine can be achieved using robotic spine technology. Also, robotic spine surgery may be used for any procedures where bone needs to be removed or cut from the spine.

Are there particular patient indications for robotic-assisted spine surgery? How do you select a patient?

Dr. Lieberman: Robotic spine surgery technology is most beneficial for complex revision surgery, where the anatomy may be distorted due to previous surgery. It’s also beneficial for deformity surgery where you have to predict the final shape of the spine and place screws in optimized locations to obtain the needed correction.

What should patients know about robotic spine surgery?

Dr. Lieberman: When patients hear “robotic spine surgery,” many assume that the robot is actually performing the surgery—but that’s not true. The surgeon still does the surgery. The robot is not a surgeon but rather a tool to assist the precision and efficiency of the surgery. The technology is very safe; however, as with any technology and any surgery, complications and risks exist.

What are the potential benefits and risks associated with robot-assistance?

Dr. Lieberman: The benefits of robotic spine surgery include increased efficiency and accuracy. That translates into less time under anesthesia for the patient and less economic cost to the system.

The risks associated with robotic spine surgery include technology malfunction, and registration issues in those with osteoporosis, obesity, and significant deformities. Registration refers to the process whereby the robot determines where the spine is in 3-dimensional space. The registration typically requires an x-ray or CT scan performed in the operating room once the patient is anesthetized and positioned. Obtaining the x-ray or CT scan in those with obesity, osteoporosis, and/or a substantial deformity can be difficult.

How do you view the future of robotic spine surgery?

Dr. Lieberman: We are currently only limited by our imagination. We are privileged in that all the robotic spine surgery technology already exists. As surgeons, we just need to figure out how to make it all work in favor of our patients who need spine surgery.

Updated on: 11/13/18
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Isador H. Lieberman, MD, MBA, FRCSC
Orthopaedic and Spinal Surgeon
Texas Back Institute
Plano, TX
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