The spine is a complex structure that provides support for your torso and connects your arms and legs. It has many parts: the bones, disc in between the bones, ligaments that connect the bones, facet joints on the back of the spine, and muscles and nerves intertwined throughout.
When I see patients, I try to treat them with conservative (non-surgical) treatment first. Conservative treatment can be very, very successful, but patients who don’t get better with conservative treatment, or patients who have severe pain, weakness, instability, tumors or infections need surgery.
Types of spine surgery
The two main baskets that spine surgeries fall into are decompression surgeries like laminectomies or microdiscectomies, where the surgeon is removing pressure from the nerves, and fusion surgeries, where the surgeon is using a device to hold bones together until they fuse.
In the past, surgeons had to make large incisions to perform spine surgery, using an open approach. However, since the early 2000s, surgery has migrated to a more minimally invasive approach with much smaller incisions. The smaller incision leads to a faster recovery for patients and less pain after surgery. The technology has also evolved to allow more predictable outcomes for patients.
The people involved
The operating room isn’t just the patient and the doctor. There are many people working behind-the-scenes to make each surgery a success, like scrub techs, anesthesia providers, physician assistants, surgical assistants, representatives from companies helping run machines, fluoroscopy technicians, and robot technicians.
Enabling technology
Enabling technologies include surgical planning software, computer-assisted navigation, intraoperative three-dimensional (3D) imaging, and robotic systems.
Imaging
As you may have expected, imaging is important. Spine surgeons are usually putting screws into bones, so x-rays provide important information to make sure the screw can go into the correct place. X-rays have been around for a long time and are very established in spine surgery. The two types used are plain film radiographs, where you shoot an x0ray and get an almost instantaneous picture, and fluoroscopes, which is a live X-ray with pictures on the screen in a digital format.
Another form of in-office imaging is an O-arm, a type of mobile, 3-D CAT scan to show the spine. These machines can be used while the surgeon is putting the screws in or after the screws are in to verify they are where they should be. O-arms work well with navigation.
Navigation
Navigation uses live feedback to guide where the screws and spinal devices go in real time. The spine surgeon is able to see a cross-section of the spine, and as they move their hand around they can see where their hand is on the screen and be able to precisely place the material where they want it to be. There are several different types of navigation available.
Robotics
The next step after navigation is robotics. If your surgeon were taking a screw and watching on a screen as they moved it around in space and put it into the spine, the next step is using a robot to help with that placement. In order to use the robot you have an preoperative CT scan, then using a planning software your surgeon tells the robot where the screws should go. During surgery the robotic arm moves to the exact position needed to insert the screw, based on the plan your surgeon made before surgery. Your surgeon is able to insert the screw where it belongs, but it has been positioned by the robot.
Augmented Reality and Artificial Intelligence
The augmented reality displays are the most recent technology for spine surgery. In the system I use, called Holo, you’ll look through a translucent screen at the surgery site while wearing special glasses. On the screen you’ll see a cartoon rendition of the spine projected on top of the real spine. When you move an instrument into position, it’s in position in real life as well as shown as a cartoon on the screen.
The Holo system is artificial intelligence as well as augmented reality. The computer does some planning that your surgeon oversees. The computer will use the cartoon to color code the different parts of the spine, so it is easier for the surgeon to see what they are doing. The system can also help plan where and how the screws are placed, with the surgeon overseeing it, instead of the surgeon alone.
The Holo system is similar to cars like Tesla with artificial intelligence. The car will identify obstructions in the road and show issues on the windshield, and the Holo works the same way. The car can suggest a detour but it’s up to the driver to do it. In the same way, the system suggests where screws go, but it is up to the surgeon if that is the path they want to follow.
Layers of Safety
It’s always good to have another set of eyes and another layer of safety. Fluoroscopy, 3-D imaging, navigation, or robotics are all additional layers of safety in the operating room for the patient and the surgeon.
The surgeon is the final layer of safety and ultimately makes the decisions. However, it’s like flying an airplane – the pilot is in charge but there is a lot of background work and support ahead of time and by technology to make the flight as safe and as smooth as possible.
Frequently Asked Questions
What types of spine surgeries can be done with this technology?
Most of the spine surgeries done with this technology are fusions. There is work being done to have the technology available for decompressions but fusions are the primary type right now.
Do you use custom hardware with this technology?
Some of the robotics, navigation and augmented reality are a closed system, where you must use a certain vendor’s hardware. The fluoroscopy, O-arm, and X-ray machines are interchangeable across any hardware. The pedicle screws used in fusions are very modular and come in a wide variety of lengths and diameters, so the right one can be chosen for a patient. The beauty of the doing the AI or robotic spine surgeries is that the exact screws can be planned ahead of time and are ready to be put in when the surgery is started, instead of being prepared during the surgery.