Dr. Jae Lim, MD., discusses the practical applications of robotics in minimally invasive spine surgery and their potential to change healthcare in the future.

1. ROBOTICS
IN SPINE
SURGERY?
R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D

2. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
My Background
• BA/BS Stanford University
• MD Yale University
• Neurosurgery residency UCLA University
Hospitals
• Fellowship complex spine Cedar Sinai
Medical Center
• Principle Surgeon at Atlantic Brain & Spine
• Clinical Adjunct Professor of Neurosurgery at
VCU, Northern Virginia Campus

3. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Goals
Provide useful information that you can
use to advise and counsel your patients
regarding robotic spine surgery

4. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Overview
• Current state of spine surgery in America
• Does laser spine surgery exist?
• Robotics
• How we can do better

5. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Spine Surgery Now?

6. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Spinal Fusion in the U.S.
• Between 1998 and 2008, the annual
number of spinal fusion discharges
increased 2.4-fold from 174,223 to 413,171
• During the same time period, laminectomy,
hip replacement, knee arthroplasty yielded
relative increases of only 11.3%, 49.1%,
126.8% in discharges

7. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Spinal Fusion in the U.S.
• Between 1998 and 2008, mean age for
spinal fusion increased from 48.8 to 54.2
years
• National bill for spinal fusion increased 7.9-
fold (P < 0.001)
• 12.8 billion dollars for spinal fusions in 2011
Analysis of trends from 1998 to 2008. Rajaee SS1, Bae HW, Kanim LE, Delamarter RB. Spine, Jan 2012

8. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
End Result of Two Decades
of Spinal Fusion
• Hundreds of thousands of patients helped
by advanced spinal fusion techniques
• But at increasingly unacceptable burden to
the economy
• Too much collateral damage in terms of
failed fusion patients

9. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
What About The Next 10 Years?
• Affordable Care Act – aka ObamaCare
will remove incentive for surgeries
• Patients increasingly have higher
expectations for outcome and higher
reluctance to have fusions

10. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
What About The Next 10 Years?
• Transition to quality of care,
not quantity
• Fewer spine fusions but need
to do it better

11. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Why Are Patients Increasingly Rejecting
Spinal Fusions?
• Horror stories from hundreds of thousands of
failed fusion patients
• Intuitive Rejection of the “Caveman Approach”
• Desire to embrace technology

12. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Laser Spine Surgery
Why Do Patients Ask For This?
• Laser is catch-all phrase for “high tech”
• Minimally Invasive Surgery (MIS)
• Surgical Navigation Systems
• Intraoperative CT or MRI scanners
• Preoperative CT/MRI registered intraop.
• Robotics

13. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Laser Spine Surgery
MYTHS
A laser is a more precise,
elegant tool compared to drills,
scalpels and cauteries that are
currently used
+
It’s non-invasive and
bloodless procedure
* These myths are propagated by
unscrupulous laser spine centers

14. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Laser Spine Surgery
FACTS
• Laser spine surgery does involve incision
• Laser plays a minor role in procedures
• Laser can only be used in minority of patients
in subset of cases
• Very few published studies

15. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Percutaneous Laser Disc Decompression
VS.
Conventional Microdiscectomy in Sciatica:
a randomized controlled study
• 115 Patients in the Netherlands
• At 1 year, a strategy of PLDD, followed by surgery if
needed, resulted in noninferior outcomes compared with
surgery
• Higher speed of recovery in favor of conventional surgery
• Reoperations were significantly less in the conventional
surgery group
Spine, 2015

16. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Laser Spine Surgery
FACTS
Most procedures offered and performed at these
centers are standard surgeries

17. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Laser Spine Centers
FACTS (Bloomberg Business)
6.7x THE RATE OF LAWSUITS
Nationally, outpatient surgery centers
received about six malpractice claims
for every 20,000 surgeries
15 malpractice lawsuits since October
2009, a period in which the company
performed about 7,500 procedures

18. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Crossroads in Spine Surgery
• Prove efficacy
• Control costs
• Minimize complications

19. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Robotics + MIS
• Combine MIS Approaches
• Interbody fusions
• Screw placement

20. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
MIS Advantages
• Potential advantages compared
with “open” surgery
• Smaller incisions
• Minimize scarring
• Less blood-loss during surgery
• Shorter hospital stay
• Less postoperative pain
• Less need for narcotics
• Faster return to work and daily activities

21. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Literature
• Prospective study of MIS vs. open screws on:
• Mutlifidus muscle cross-sectional area
• Trunk extension muscle strength
• Significant decrease in the XS muscle area of open group
• MIS group demonstrated positive effects on postoperative
trunk muscle performance
Comparison of multifidus muscle atrophy and trunk extension
muscle strength; percutaneous versus open pedicle screw fixation
Kim DY, Lee SH, Chung SK and Lee SY. Spine, 2005

22. L O U D O U N S P I N E C O N F E R E N C E ● O C T O B E R 2 2 , 2 0 1 6 ● J A E Y L I M , M D
Pre-Op Post-Op
MIS
Open

23. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Problems with MIS
• MIS procedures require much
longer periods of radiation
exposure for both OR staff
and patients
• Steep learning curve for
surgeons

24. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Why Robotics?
• Preoperative planning
reduces need for
intraoperative x-rays
• Eliminates the error of the
human hand
• Easy learning curve for surgeons

25. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
• Less radiation exposure in the operating room
• No need to wear lead
• Wearing a 15-pound lead apron can place
pressures of up to 300 pounds per square inch
on intervertebral discs
• Less time in the operating room
For Surgeons

26. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
• Increased cancer risk for spine surgeons
• Higher cancer incidence in orthopedic surgeons
vs. non-radiation exposed match controls
Occupational Risks
1. Singer, Occupational radiation exposure to the surgeon, Am Acad Ortho Surg. 2005;13:69-76.
2. Mastrangelo G, et al,. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med.
2005;55(6):498-500.

27. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Increased safety
For Patients

28. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
• 10% misplaced screws
• 0.8%-2% permanent nerve damage
Human Factor
1. Kosmopoulos V, Schizas C. Pedicle screw placement accuracy: a meta-
analysis. Spine. 2007;32(3):E111-20.
2. 2. Gertzbein SB, Robbins SE. Accuracy of pedicular screw placement in vivo.
Spine. 1990;15(1): 11-4.

29. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
• 29 of 32 K-wires were placed with less than 1.5 mm
of deviation
• Average deviation was 0.87 +/- 0.63 mm (range, 0-
1.7 mm) from the preoperative plan in this group
Accuracy in Cadavers
Neurosurgery. 2007 Feb;60(2 Suppl)

30. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
• In axial plane, 91.7% of the screws exactly in
pedicle, 6.8% <2 mm off
• In longitudinal plane, 81.2% of the screws exact,
9.8% <2 mm off, 1 screw 2-4 mm off
Accuracy in Patients
Spine (Phila, PA 1976). 2009 Feb 15;34(4):392-8.

31. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Mazor Robotics Technology:
Clinical Evidence
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%
2011
14 medical centers
3,271 implants (half MIS)
98.3% Accuracy
2010

32. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Mazor Robotics Technology:
Clinical Evidence
Prospective RCT, MIS
99% Accuracy
2012
Revision and deformity
960 implants
98.9% Accuracy
2012

33. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Are Robot-Assisted Screws
Worth the Trouble?
• Greater accuracy = Fewer Complications
• Less radiation = Safer
• Shorter OR time = Faster

34. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D

35. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
L4-S1 TLIF
2cm lateral incisions
3cm midline incision

36. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
L4-S1 PLIF
6cm midline incision

37. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Future Application
SI Joint Pain
Sacroiliac joints are causative for 13-30% of
cases with low back pain

38. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
SI Joint Pain
Under-diagnosed and under-treated

39. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
SI Joint Anatomy
Cannulated Implants Plus Robotics Guidance

40. R E S T O N H O S P I TA L ● A P R I L 2 9 , 2 0 1 5 ● J A E Y L I M , M D
Mazor Overview
• 44 systems in the U.S.
• 15 systems in Europe
• 11 systems in Asia
• 6 systems in the Middle East
• 55,000 implants in 7,500 patients
Worldwide 76 systems

41. I N O VA L O U D O U N S P I N E C O N F E R E N C E ● O C T O B E R 2 2 , 2 0 1 6 ● J A E Y L I M , M D
That’s all folks!
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