雷納生機械手臂與脊椎微創手術之應用

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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

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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 Service • Teaching • Research

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

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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 Service • Teaching • Research

MISS

from decompressions to fusions

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Decompression 1. Spinal process 2. Lamina 3. Ligmentum flavum 4. Hypertrophic facet joint,

bone fragements 5. Disc

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LAMINECTOMY AND LAMINOTOMY

Traditional open laminectomy and laminotomy Drawbacks 1. 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/

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Microlaminectomy and Microlaminotomy MISS takes

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

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How Are Microlaminectomy and Microlaminotomy Performed?

1. Mini-open: special surgical tools and

instruments 2. Tubular: insert a tube 3. Endoscopic: an endoscope is inserted through a tube

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DISCECTOMY

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 discectomymake 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.

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Minimally invasive discectomymake 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.

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Minimally invasive discectomy- remove the disc fragments (3) The herniated disc material compressing the

nerve root is removed.

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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 disorders Noojan Kazemi, Laura K Crew, Trent L Tredway

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a. METRx system with endoscope, b. View of microendoscopic decompression for lumbar stenosis, c. Microendoscopic view of filum detethering, d. Minimally invasive resection of intradural schwannoma

Fusion 1. 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

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Lumbar inter-body fusion (IBF) 1.

2.

3.

4.

Transforaminal Lumbar Interbody Fusion (TLIF) Posterior Lumbar Interbody Fusion (PLIF) Anterior Lumbar Interbody Fusion (ALIF) Extreme Lateral Interbody Fusion (XLIF) the damaged disc is completely removed and is replaced with materia

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Transforaminal Lumbar Interbody Fusion (TLIF) Incision Made one or more small incisions in the back.

Disc Accessed Parts of the vertebral bone need to be removed to get access to the disc.

Disc Partially Removed The damaged disc is partially removed.

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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.

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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

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XLIF: Lumbar Spinal Fusion 1. Accessing the Spine The surgeon creates two small incisions in the patient's side.

A probe is inserted through one incision. The second incision is used to help guide the surgical instruments.

2. Avoiding Nerves 3. Dilation Tubes Inserted 4. Disc Removed 5. Implant Inserted It cannot be used at the lowest level of the spine, L5-S1 or for some people at L4-L5.

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Minimally Invasive Interbody Fusions Interbody fusions can be done with

minimally invasive techniques.

PLIF and TLIF

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Minimally Invasive Spine Fusion Minimally Invasive Spine Fusion Systems

Drawings help facilitate accurate incisions for the pedicle.

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Advancing the wire through the pedicle using

fluoroscopic confirmation.

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Screw advancing over guide wire in pedicle.

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shaped tower

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Rod passing through the towers into the screw

heads

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X-ray of completed construct

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2013.5 Service • Teaching • Research

2015.3

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Technology advance

In Spine

3D

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The Need For Robotics In Spine Surgery Pedicle Screws Inserted Free-Hand Are Misplaced in 10% of Cases Pedicle Screw Placement Accuracy: a Meta-Analysis Kosmopoulos V, Schizas C.; Spine 2007 Feb 1;32(3):E111-20

Misplaced Pedicle screw

Revision

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The 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 With Surgery for Lumbar Spinal Stenosis in Older Adults. JAMA April 2010

Misplaced Pedicle screw

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Revision

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“Need For Robots “-Spine Surgery Challenges •Anatomical (e.g: deformities and revisions) •Visualizations (e.g.: MIS)

•10% misplaced screws* •0.8 – 2 % permanent neurological damage**

Human Error

Clinical Challenges

Patient Expectations

Occupational Hazard

“Radiation exposure was approximately 10 times higher in •Safe spine surgery compared with other musculoskeletal •Successful procedures; exposure rates are higher for larger specimens”.

* Singer, Gordon, Occupational•Definitive Radiation Exposure to the Surgeon, Journal * Kosmopoulos V. Schizas C. Pedicle Screw Placement Accuracy: of the American Academy of Orthopedic Surgeons 2005, 13 69 - 76

•Increased cancer risk for orthopedic surgeons***

a Meta Analysis. Spine 2007, 32(3). E 111-20 ** Gertzbein et al. Accuracy of Pedicle Screw Placement in Vivo.

Spine 1990, 15 11-4 Orthopaedic Surgeons 2005, 13 69 - 76

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• CT-based 3D planning • Guided instrumentation • 1.5 mm accuracy

CT-based 3D Planning Software www.MazorRobotics.com

Workstation

Guidance Unit 40

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Spine Surgery with How It Works Step 1: Plan Step 2: Mount Step 3: 3D Sync Step 4: Operate

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

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Spine Surgery with How It Works Step 1: Plan Step 2: Mount Step 3: 3D Sync Step 4: Operate

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

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Spine Surgery with How It Works Step 1: Plan Step 2: Mount Step 3: 3D Sync Step 4: Operate

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Two fluoroscopy images are automatically synchronized with the CT based surgical blueprint (independent of anatomy) 47

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Spine Surgery with How It Works Step 1: Plan Step 2: Mount Step 3: 3D Sync Step 4: Operate

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Tools and implants are guided to the planned trajectory with 1.5 mm accuracy

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Target Procedures -Minimal Invasive Spine Surgery - Complicated Spine Cases (Scoliosis, Deformity, Osteoporosis, Tumors)

Minimal Radiation , Accuracy , Safety & Pease of Mind.

Innovation & Differentiation www.MazorRobotics.com

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Surgical & Medical Benefits of MIS

The Elderly and Morbid Benefit the Most from MIS Service • Teaching • Research

Renaissance™ Applications in Spine Surgery Surgical Approaches

Procedures

• Posterior and lateral • T1 to S1

• Deformities • Scoliosis PSF • Osteotomies • Pedicle screws - short/long fusions • Upper thoracic fixation • Obese patients • Transfacet and translaminar-

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Open MIS Percutaneous

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facet screws Kyphoplasty and vertebroplasty Tumor resections Biopsies • Revisions 52

X 3D Renaissance System)

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Navigation vs Robotics?

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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 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

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Comparison: Robotics vs.

Navigation Renaissance 解剖根據

CT-based

手術視線

專注在病人端

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

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

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Navigation 需專注螢幕端

Planning station – sold separately

Yes, but fake…

腰椎滑脫 手術術前 術後

腰椎滑脫手術 術前術後 77 years old

腰椎滑脫手術 術前術後 58 years old 62

腰椎滑脫手術 術前術後 69 years old 63

腰椎滑脫手術術前術後 72 years old 64

腰椎滑脫手術術前術後 76 years old 65

Scoliosis challenges Long and complex operations with a lot of instrumentation

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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 old Scoliosis – 3rd revision Pre-operative Planning

Example of value in multi-level case: Screw cadence facilitates rod placement 140

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Powered by Mazor Robotics Technology Clinically validated by surgeons’ experience: •Over 10,000 cases & more than 50,000 implants •No cases of permanent nerve damage

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Clinical Evidence 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, Giese A, Rohde V. Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement.

Eur Spine J. 2011;20(6):860-868.

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Clinical Evidence

98.3% Accuracy of 3,271 implants in 635 cases in 14 medical centers with 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.

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Clinical Evidence

99.7% Accuracy of 1,815 implants in 120 scoliotic adolescents Devito 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.

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Soon 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)

Thanks for your attention.

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