雷納生機械手臂與脊椎微創手術之應用

Service • Teaching • Research

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Minimally Invasive Spine Surgery(((( ))))

�MISS�uses advanced technology and

innovative techniques to treat back pain and neck pain caused by a variety of spinal disorders

� from decompressions to fusions


Procedures that may be performed via MISS

� anterior cervical discectomy and fusion (ACDF)

� posterior cervical laminectomy and fusion� anterior and posterior lumbar interbody fusion

(ALIF or PLIF) � direct lateral lumbar interbody fusion (DLIF)� axial lumbar interbody fusion (AxiaLIF)� intradiscal electrothermal annuloplasty (IDET)� transforaminal lumbar interbody fusion (TLIF)� kyphoplasty


The benefits of MISS

�Small incisions and minimal scar tissue formation

�Less damage to surrounding muscle and soft tissues�Decreased blood loss

�Decreased pain and reduced need for pain medication �Quicker recovery and faster return to regular activities

�Shorter hospital stays�Many procedures can be performed as outpatient

surgery�Decreased risk of postoperative infection


Potential Risks and Complications of MISS

�Infection (1-2%)�Nerve root injury (0.5%)�Recurrent disc herniation (5%)�Scar tissue formation causing continued leg

pain (0.5-1%)

�a suboptimal decompression: a major drawback of endoscopic procedures


MISS

�from decompressions to fusions

Decompression1. Spinal process

2. Lamina

3. Ligmentum flavum

4. Hypertrophic facet joint, bone fragements

5. Disc


LAMINECTOMY AND LAMINOTOMY


Traditional open laminectomy and laminotomy

�Drawbacks1. a large incision, as well as

more cutting back muscles and tissues.

2. Recovery from open spine surgery sometimes can be painful and slow.

http://www.southeasternspine.com/procedures-treatments/laminectomy/


Microlaminectomy and Microlaminotomy

�MISS�takes

pressure off the nerves and spinal cord, reduces back pain and/or leg pain


How Are Microlaminectomy and Microlaminotomy Performed?

1. Mini-open: special surgical tools and instruments

2. Tubular: insert a tube3. Endoscopic: an endoscope is inserted

through a tube


DISCECTOMY

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For an open discectomy, a 1- to 2-inch skin incision (black line) is made down the middle of your back.

For a minimally invasive discectomy, a small stab entry (green line) is made in the skin near the midline.


Minimally invasive discectomy-make an incision (1)

For a minimally invasive discectomy, a small stab entry is made in the skin. Muscles are then dilated gradually with increasingly larger tubular retractors to gain access to the spine.


Minimally invasive discectomy-make a laminotomy (2)

A laminotomy makes a small window by removing bone of the lamina above and below. The nerve root and spinal cord can be gently reflected to expose the herniated disc.


Minimally invasive discectomy- remove the disc fragments (3)

�The herniated disc material compressing the nerve root is removed.


Minimally Invasive Spine Surgery: Micro Endoscopic Discectomy (MED)

� Surg Neurol Int 2013, 4:15 The future of spine surgery: New horizons in the treatment of spinal disordersNoojan Kazemi, Laura K Crew, Trent L Tredway a. METRx system

with endoscope,b. View ofmicroendoscopic

decompression for lumbar stenosis, c. Microendoscopicview of filum

detethering, d. Minimally invasive resection ofintradural schwannoma

Fusion1. Spinal fusion

2. Lumbar inter-body fusion (IBF)

3. Transforaminal Lumbar Interbody Fusion (TLIF)

4. Posterior Lumbar Interbody Fusion (PLIF)

5. Anterior Lumbar Interbody Fusion (ALIF)

6. Extreme Lateral Interbody Fusion (XLIF)


Spinal fusion

Spinal fusion corrects spondylolisthesis.

1. Lamina Removed 2. Bone Cleared 3. Bone Grafts Implanted 4. Screws/Rods Inserted


Lumbar inter-body fusion (IBF)

1. Transforaminal Lumbar Interbody Fusion (TLIF)

2. Posterior Lumbar Interbody Fusion (PLIF)

3. Anterior Lumbar Interbody Fusion (ALIF)

4. Extreme Lateral Interbody Fusion (XLIF)

� the damaged disc is completely removed and is replaced with materia


Transforaminal Lumbar Interbody Fusion (TLIF)

Incision Madeone or more small incisions in the back.Disc AccessedParts of the vertebral bone need to be removedto get access to the disc. Disc Partially RemovedThe damaged disc is partially removed.


Posterior Lumbar Interbody Fusion (PLIF) Surgery

1. a three to six-inch long incision in the midline of the back.

2. The lamina is removed. 3. The facet joints may then be

trimmed. 4. the disc space is cleaned of

the disc material.5. a cage is then inserted into

the disc space. 6. The surgeon may implant a

series of screws and rods to the back of the spine for additional support.


Anterior Lumbar Interbody Fusion (ALIF) Surgery

�is often combined with a posterior approach (anterior/posterior fusions) because of the need to provide more rigid fixation


XLIF: Lumbar Spinal Fusion

1. Accessing the SpineThe surgeon creates two smallincisions in the patient's side. A probe is inserted through oneincision. The second incision isused to help guide the surgicalinstruments.2. Avoiding Nerves3. Dilation Tubes Inserted4. Disc Removed5. Implant Inserted

It cannot be used at the lowest level of the spine, L5-S1 or for some people at L4-L5.


Minimally Invasive Interbody Fusions

�Interbody fusions can be done with minimally invasive techniques.

�PLIF and TLIF


Minimally Invasive Spine Fusion

�Minimally Invasive Spine Fusion Systems

Drawings help facilitate accurate incisions for the pedicle.


�Advancing the wire through the pedicle using fluoroscopic confirmation.


�Screw advancing over guide wire in pedicle.


�shaped tower


�Rod passing through the towers into the screw heads


�X-ray of completed construct



2013.5 2015.3 386

Technology advanceTechnology advance

In SpineIn Spine


3D

Misplaced Pedicle screw

Revision

Pedicle Screws Inserted Free-Hand Are Misplaced in 10% of Cases

Pedicle Screw Placement Accuracy: a Meta-AnalysisKosmopoulos V, Schizas C.; Spine 2007 Feb 1;32(3):E111-20

The Need For Robotics In Spine SurgeryThe Need For Robotics In Spine Surgery

www.MazorRobotics.comof

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38www.MazorRobotics.com

Misplaced Pedicle screw

Revision

The Need For Robotics In Spine SurgeryThe Need For Robotics In Spine Surgery

Major medical complications were reported in 5.2% of complex fusion procedures.

Trends, Major Medical Complications, and Charges Associated WithSurgery for Lumbar Spinal Stenosis in Older Adults. JAMA April 2010


•Safe

•Successful

•Definitive

•Increased cancer risk for orthopedic surgeons***

•Anatomical (e.g: deformities and revisions)

•Visualizations (e.g.: MIS)

•10% misplaced screws*

•0.8 – 2 % permanent neurological damage**

Human ErrorClinical

Challenges

Occupational Hazard

Patient Expectations

“Need For Robots “-Spine Surgery Challenges

“Radiation exposure was approximately 10 times higher in spine surgery compared with other musculoskeletal procedures; exposure rates are higher for larger specimens”.* Singer, Gordon, Occupational Radiation Exposure to the Surgeon, Journal of the American Academy of Orthopedic Surgeons 2005, 13 69 - 76

* Kosmopoulos V. Schizas C. Pedicle Screw Placement Accuracy: a Meta Analysis. Spine 2007, 32(3). E 111-20** Gertzbein et al. Accuracy of Pedicle Screw Placement in Vivo.Spine 1990, 15 11-4Orthopaedic Surgeons 2005, 13 69 - 76


CT-based 3D Planning Software

• CT-based 3D planning

• Guided instrumentation

• 1.5 mm accuracy

Workstation Guidance Unit




Step 1:Step 1:PlanPlan

Step 4:Operate

Step 2:Mount

Step 3:3D Sync

Preoperative blueprint of the ideal surgeryis created in a virtual 3D environment

Spine Surgery withHow It Works



Rigid attachment to the patient assures maximum surgical accuracy throughout the procedure

Step 1:Plan

Step 4:Operate

Step 2:Step 2:MountMount

Step 3:3D Sync




Step 1:Plan

Step 4:Operate

Step 2:Mount

Step 3:Step 3:3D Sync3D Sync


Two fluoroscopy images are automatically synchronized with the CT based surgical blueprint (independent of anatomy)



Step 1:Plan

Step 4:Step 4:OperateOperate

Step 2:Mount

Step 3:3D Sync


Tools and implants are guided to theplanned trajectory with 1.5 mm accuracy


Target ProceduresTarget Procedures

-Minimal Invasive Spine Surgery

- Complicated Spine Cases (Scoliosis, Deformity, Osteoporosis, Tumors)

Minimal Radiation , Accuracy , Safety & Minimal Radiation , Accuracy , Safety & Pease of Mind.Pease of Mind.

Innovation & Differentiation Innovation & Differentiation


Surgical & Medical Benefits of MIS

The Elderly and Morbid Benefit the Most from MIS The Elderly and Morbid Benefit the Most from MIS


Renaissance™ Applications in Spine Surgery

Procedures

• Deformities

• Scoliosis PSF

• Osteotomies

• Pedicle screws - short/long fusions

• Upper thoracic fixation

• Obese patients

• Transfacet and translaminar-facet screws

• Kyphoplasty and vertebroplasty

• Tumor resections

• Biopsies

• Revisions

Surgical Approaches

• Posterior and lateral

• T1 to S1• Open

• MIS

• Percutaneous

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Navigation vs Robotics?


Comparison: Robotics vs. Navigation

Renaissance Navigation

精確度 1.5 mm or less 1-2.5 mm – depends on…

手術方式機器手臂直接導引至計劃位置透過視覺畫面導引，手動調整

瞄準線無需瞄準手法必須配合視覺的傳遞

術前計畫軟體可於電腦提供術前藍圖規劃

註冊定位方式註冊定位方式註冊定位方式註冊定位方式

融合形式椎體個別計算定位，不受病人擺位，減壓等影響精準度

因病人的姿勢，椎體間的變形造成精準度的偏差

註冊方式透過C-ARM兩張X光片完成註冊AP View and 60° Oblique

需個別註冊

穩定性高

手術時間平均手術時間：4～9m per screw平均註冊時間：140～250 s


Comparison: Robotics vs. Navigation

Renaissance Navigation

解剖根據 CT-based

手術視線專注在病人端需專注螢幕端

視覺與手的協調性無需要

植入物與任何植入物相容

軟體通用性軟體可搭載於個人電腦於任何時間，地點進行計劃

Planning station – sold separately

市場及病人機械手臂為最新技術，提高院內知名度提供病人高科技，高精準的選擇

Realtime tool No Yes, but fake…

腰椎滑脫腰椎滑脫腰椎滑脫腰椎滑脫手術術前手術術前手術術前手術術前

術後術後術後術後

腰椎滑脫手術腰椎滑脫手術腰椎滑脫手術腰椎滑脫手術術前術後術前術後術前術後術前術後 77 years old

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腰椎滑脫手術術前術後腰椎滑脫手術術前術後腰椎滑脫手術術前術後腰椎滑脫手術術前術後 72 years old

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腰椎滑脫手術術前術後腰椎滑脫手術術前術後腰椎滑脫手術術前術後腰椎滑脫手術術前術後 76 years old

Long and complex operations with a lot of instrumentation

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Scoliosis challenges

Idiopathic Scoliosis Pre-operative Planning 13 Levels and 26 screws

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Idiopathic Scoliosis Post Operative Fluoroscopy images

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Idiopathic Scoliosis Pre-operative Planning

10 years oldScoliosis – 3rd revisionPre-operative Planning


Example of value in multi-level case:Screw cadence facilitates rod placement

140 260


Clinically validated by surgeons’ experience:•Over 10,000 cases & more than 50,000 implants

•No cases of permanent nerve damage

Powered by Mazor Robotics Technology

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Compared to freehand surgery, in 112 cases Mazor Robotics-guided surgery significantly:•Improved implant accuracy by 70%

•Reduced X-ray dosage by 56%

•Reduced complication rates by 48%

•Reduced re-operations 46%

•Reduced average length of stay 27%

Kantelhardt SR, Martinez R, Baerwinkel S, Burger R, GieseA, Rohde V. Perioperative course and accuracy of screwpositioning in conventional, open robotic-guided andpercutaneous robotic-guided, pedicle screw placement.Eur Spine J. 2011;20(6):860-868.

Clinical Evidence



Clinical Evidence

98.3% Accuracy of 3,271 implants in 635 cases in 14 medical centerswith 49% of implants placed percutaneously (typically 10%-20% of spine surgeries are MIS)

Devito DP, Kaplan L, Dietl R, et al. Clinical acceptance and accuracy assessment of spinal implants guided with SpineAssist surgical robot: retrospective study. Spine J. 2010;35(24):2109-2115.


99.7% Accuracy of 1,815 implants in 120 scoliotic adolescentsDevito DP, Gaskill T, Erikson M, Fernandez M. Robotic based guidance for pedicle screw instrumentation of the scoliotic spine. Presented at Pediatric Society of North America (POSNA); May 2011; Montreal, Canada.

Clinical Evidence


Soon to come : Brain ApplicationSoon to come : Brain Application� Applications• Brain biopsies• DBS placements• Shunt placements

� Advantages• Accuracy• Frameless• Surgical speed

� Regulatory Status: � CE cleared� FDA approved


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3D (Renaissance)

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�Thanks for your attention.

雷納生機械手臂與脊椎微創手術之應用

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