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Spinal Robotic Surgery


Acknowledgments

The authors thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript and video preparation.

This chapter includes an accompanying lecture presentation that has been prepared by the authors: .

Key Concepts

  • Robotics has been integrated into numerous surgical specialties over the course of more than 30 years.

  • Advancements in fluoroscopic and CT-based intraoperative imaging have allowed navigation techniques to flourish and are integrated with robotics.

  • First-generation spinal robots use image-based navigation to guide pedicle screw placement.

  • The accuracy of current spinal robots rivals or exceeds that of open and percutaneous techniques with or without navigation assistance.

  • Future directions include automated robotic maneuvers and potential soft-tissue applications.

The next frontier of spinal surgery is the development and incorporation of robotic technologies. The spine surgeon faces many obstacles during surgery, many of which involve anatomic structures. Spinal anatomy may be normal, and, if so, this is a welcome sight. However, patients who present to a spine surgeon often have advanced disease, particularly degenerative and scoliosis pathologies. Abutting and encased by the spinal column are vital structures, including the spinal cord, cauda equina, nerve roots, blood vessels, and visceral organs, which collectively heighten the risks associated with spinal hardware implantation. The goal is to develop robots that safely and efficiently facilitate spinal instrumentation.

Whether open techniques or minimally invasive techniques are performed, consistently accurate implant placement can be challenging. Both patients and surgeons are increasingly intolerant of inaccurately placed instrumentation. Image-guided navigation has provided a platform and set of techniques that have improved the accuracy of screw placement and led to the development of robotic-assisted surgical procedures. , Early results of pedicle screw placement with robotic assistance are promising. , Robotic assistance in spinal surgery, especially in pedicle screw placement, has made its debut (Video 29.1).

History

Decompression

The tenets of spinal surgery have evolved since its genesis. The need for decompression was and remains paramount when evaluating spinal pathology. Decompression via laminectomy was first described in 1829 by A.G. Smith. , Eighty years later, in 1909, Oppenheim and Krause performed the first discectomy. Minimally invasive techniques were later performed by Foley in 1997, who described a microendoscopic discectomy. During the next decade, tubular dilators and retractors were increasingly used for laminectomy and spinal cord tumor resection. How to achieve decompression of the neural elements remains the first decision to be made when evaluating spinal pathology.

Pedicle Screw

As our understanding of spinal pathology continues to grow, spinal fixation and related techniques also evolve. The first spinal fixation is credited to Hadra, who performed spinous process wiring in a case of Potts disease in 1891. , The advent of the pedicle screw in 1949 by Michele and Krueger changed the trajectory of spinal fixation. It was not until 1982 that the first version of a percutaneous screw was placed by Magerl. The development of minimally invasive percutaneous techniques and systems accelerated in the early 2000s, and they continue to evolve.

Interbody

Interbody placement, like pedicle screw placement, has evolved and advanced over the decades. The first interbody placement, via an anterior lumbar interbody fusion, was described by Burns in 1933, and the first posterior lumbar interbody fusion was performed by Cloward in 1952. Circumferential access to the spinal disk spaces benefited from minimally invasive access techniques. In 1995, Matthews and Zucherman were first to describe minimally invasive access for anterior lumbar interbody fusion. Minimally invasive posterior lumbar interbody fusion and transforaminal lumbar interbody fusion were described in 2002 and 2006, respectively. , Credit for the retroperitoneal approach and transpsoas lateral lumbar interbody approach is given to Pimenta in 1998. Oblique lumbar interbody fusion offers a pre-psoas approach to the lumbar spine and has gained popularity since its inception by Mayer in 1997.

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