As part of the virtual MEDed webinar series, this presentation provides updates on the advancements in spine surgery using minimally invasive surgery techniques, navigation and robotics from distinguished spine surgeon,
Ivan Cheng, MD. During this event, you will learn about:
The latest innovations in spine surgery
Risks and benefits of these procedures
Which patients may be appropriate for these procedures
Hi everyone and welcome to the first edition of Med Ed. Advancements in spine surgery. An update on minimally invasive surgery, navigation and robotics. We're glad you're here. Med Ed is a series of CMI events sponsored by ST David's Healthcare. I'm your host for today. Matt Fleming. I'm pleased to introduce dr Ivan chang after obtaining his degree at Harvard Medical School. Dr Cheng completed his residency in orthopedic surgery at UC Davis. His spine surgery fellowship with world renowned spine surgery group at the Washington University in ST louis. He's board certified in orthopedic surgery. Dr chang has received many awards prior to moving to Austin, he was full professor of orthopedic surgery and a tenured line at stanford University. Welcome Dr chang. Thank you, matt, really appreciate the introduction and I'm honored to be here and be able to speak to you about some of the latest developments in spine surgery and uh please feel free to um in the chat long or raise your question. I'm happy to um answer any questions and maybe we can save those for the end and I want to make sure everyone can see my screen appropriately at this time. Okay, That's great. So this is actually a condensed video of one of our former oh ours and us doing spine surgery and you can see the number of people it takes to perform one operation and all the equipment that's that's needed. And we're going to go over some of the latest and greatest technology that we have in spine surgery that I think will benefit all of your patients as well. So this is these are my disclosures as matt stated have nothing to hide. And I work with various companies and I'm gonna do my best to be as unbiased as possible and presenting the data uh and what techniques and what approaches for patients can really be beneficial. So this is an outline of what we'll speak about today. So we'll go over some spine pathology. The three big topics that I want to hit on our minimally invasive spine surgery. I think there's a lot of burgeoning interest in that from both patients and and primary care physicians alike will go over what is normally invasive spine surgery indications for it and contra indications. We'll go through navigation, which is an intra operative tool. What are indications and advantages of using navigation? What our limitations of navigation and then a big buzzword in the spine world is robotic. So what is the current state of robotics and what our future uses for it for all of our patients? So you probably all have heard this before. Right? Never ever have back surgery. And and I think many of you probably listened to the podcast dr death. I hope I can dispel a lot of the misconceptions about spine surgery. And you probably heard some of these quotes, right? Somebody has had spine surgery. They never walked again. My friend is needed surgery after surgery. Fusions away take away too much motion in the back. You'll never be the same again. And then there's the list goes on and on. But I do want to tell you, I mean and there's a reason for that, right? There is there's a lot of bad things that happened out there. This is a prime example of patient that I saw a couple of years ago on the left is an MRI all he had was a single level district creation. All he had was back a little bit of leg pain. And he underwent this gigantic fusion by an outside physician. And you can just see the whole thing is falling apart. And he ended up being 10 times worse than where he was before surgery. And he's standing with terrible posture and he lost bladder and bowel control and it's just a mess. And so you can understand why some patients are very leery of spied surgery, but from a a 30,000 ft view, there actually are absolutely reasonable indications for spine surgery. And this is a short list is by no means comprehensive. But you can see any time somebody has lumbar stenosis with either ridiculous apathy or energetic communication, certainly cervical stenosis and they have arm pain or they have disco ordination discriminations with bad leg pains. One of those theses with slippage of their spine, progressive scoliosis, postural imbalance, fractures, dislocations, tumors, infections. And there are many other indications, but these are very pure indications. And I think patients can really benefit from our surgical interventions in these cases. What are less optimal cases. And I think this is also relevant now, keep in mind we're always happy to see any patient for which there is a question about their spine. But in general these are probably less optimal cases to operate on. So acts you'll go back pain without any instability or deformity, which is very common place. Right. seven out of eight people will have disabling back pain at some point in their life, same thing, actual neck pain without any arm pain or any neurologic symptoms. And then lots of other mitigating factors. And we could name a number. But people with depression, anxiety, secondary game. They may not they can still be surgical candidates, but we know that their outcomes may be actually somewhat mitigated. And then of course, patients with overwhelming comorbidities, but I do want to say at this point that age is not an absolute contra indication. And I'll show you examples of why because some of these newer techniques are actually really advantageous for older sicker patients. So what is minimally invasive spine surgery? Probably for most of you, it means something like this. So instead of on the left, opening up the entire spine, you see the whole thing fileted open the muscles stripped on the right, you actually see one of my procedures which is too smart, tiny incisions and you can place an inner body into between the vertebra and really affect a nice fusion. So that's kind of a kind of big picture of what my s surgery means. But why less invasive? I think we all intuitively know these things that there's less soft tissue trauma and revascularization, less infection, shorter length of stay. They can return to normal activity quicker. And uh actually is very appropriate and large and obese patients can be used in revision circumstances. And really actually at this point can be advanced to really correct deformity as well. So what is it in very specific terms? This is what minimally invasive surgery means to me in the spine. One is per cutaneous screw placement in the back, lateral or trans. So its inner body fusions. And I'll go over what that exactly means. There are poster based, minimally invasive approaches as well. I won't talk so much about endoscopic procedures. That's still a little bit controversial. But you may hear about that or patients asking about that. So this is a good case study of what minimally invasive spine surgery means to me. This is a case I did a couple of years ago, 76 year old woman who had back and both legs hurt. She couldn't walk more than half a block. And this is a procedure I did And I did went through the side, put an inner body in there, a cage in there and put screws through small incisions. Did this whole surgery in less than an hour and she left within 23 hours. She's now able to walk without any leg pain and unlimited distances. And so we can really make a big difference in some of these older patients. So this is what it looks like when we place screws per cutaneous lee. So really small incisions and we place K wires and you can place the screws over those K wires and we can even run the rod right underneath the skin without opening everything up. So I'm going to talk briefly about what to post your base. So going just through the back, minimally invasive inner body fusion can look like. And it's the same goals for any type of fusion you want to decompress the spine. You want to provide stability. You can restore alignment, you can restore disc height and phenomenal space so you can decompress the nerves and you can increase stability below a longer deformity construct as well. So this is what looks like when we target a pentacle. So we use in Tropical Flora Skopje and we can also use neuro monitoring to help us and we target the pericles through a very very small incision. So this is what it looks like when we target intra operatively. And we use inter operative X rays to do this and then this is what it looks like once the screws go in. This is actually when we're going to do a transfer abdominal lumbar everybody fusion. These are actually retractor blades so we can look through this tiny incision to see a limited amount of space within the spine. Traditionally it looks like this A. T. Live for transformational umpiring by fusion is wide open. You can see the big retractors there, you can see all the muscle disruption. This is still appropriate in certain certain circumstances, but now we can do it through a tiny incision such as this and this is what we're looking at during the O'er And so that's all we need to do is take a little bit of bone and we can get right into that disk space. And this is an example of one of my cases. A 68 year old man, you can see at a history of back pain and radiating pain into both legs and buttocks. And he has a spotless thesis down here at the bottom between L. Five and S. One. He was pretty much neurologically intact except for a little bit of HL weakness. And this is his MRI where you can see the stenosis at the bottom around his nerve root And this is what it looked like during surgery. So through two small incisions I was able to access that disk space, placed these screws and you can see the that inner body cage in that space. And he did great and he also left within 23 hours. He was walking that evening uh and all of his symptoms resolved after the surgery. So this is really a revolutionary approach for a lot of these patients who don't have to stay in the hospital multiple days anymore. You can really minimize their complications and get them out earlier and they returned to their regular activities much more quickly as well. So something that I've done a lot of in my career now is use these lateral trans. So its inner body fusions and I'll show you how much this is advanced at this point. There's you know hundreds of papers on this approach and really validating how useful and powerful it is and some of the trade names you will hear our goal if forex life. But really these are just lateral lumbar inner body fusions. This is what it looks like in the operating room when we set a patient like this up. Um and they're really they're on their side and so this is a little counterintuitive but we can access the spine through the side instead of going through the front or through the back. And this is really what the approach looks like. So we're going through the soloist muscle. And of course the dangerous thing about that is that the lumbar plexus lies within the so it's muscles. So we have to be very careful about the neurologic structures. And we use neuro monitoring to be careful and avoid disrupting those neural elements. But we go through the so it's muscle, we approach the disk space and can really do a good job of taking out disk, expanding the despite and decompressing the neural elements. And this is what looks like to access that space. So you can actually put your finger right down into that retro peritoneal space down to the so it's muscle and feel it. These are the nerves that I told you. We're really worried about. And again it's essential to monitor these cases for the nerves to avoid them. And this is what it looks like. This is that in a cadaver. When you open everything up you actually can see within the so as the nerves and these are big nerves that's actually not small. So this is what creates the lumbar plexus and you'll see what starts forming the femoral nerve and the psychotic nerve. That's what the nerves look like within the muscle itself. But this is all we're looking at during surgery. It's down this very small retractor, that's all we see in terms of the disk space and you actually see the twitches of the so it's multiple around that that we retracted. The way all that fat you see coming in is actually retro peritoneal fat. So we're behind all the bowels and everything else. This is now cutting into the disk space. We move disk using a pituitary roger and that's really what the disk looks like. I know a lot of patients ask what does this look like it actually for older patients, it looks like crab meat. So you can see it just picking out there and once we removed enough disk, uh this is a box cutter to remove further disk. Just extra tools. And then after that we place the spacer. But that's really all you see through a small incision and this is what it looks like once the cages in place. So this is a peek cage or really basically medical grade plastic cage filled with bone graft. And as we remove the retractor, you actually see all the soft tissue just fall right back into place. So there's really minimal trauma to the surrounding soft tissue, which is really great for patient recovery. But that's that's the slowest muscle as it folds back in over the disk space. And this is what a final construct looks like. This is one of my cases and you can see how much disk height you can restore. And what I've been doing is things have evolved so much that we have newer instruments. The indications have really expanded for this approach and increasing our efficiency and effectiveness has really been a priority for me. So this is how it's evolved such that, you know, we usually just used to just treat degenerative problems with this approach, but now we can treat scoliosis, we can treat things up into the thoracic spine. We can revise dis replacements and treat tumors, trauma, remove entire vertebra and restore alignment as well. And I'll show you what that means. So this is another one of my cases where it just by distracting across the disk space and this is the same patient on the left and the right preoperative really on postoperative. You can see by just expanding the disk space how much you can actually decompress the spinal canal just by tension, ng all the soft tissue and that relieves a lot of their neurologic symptoms. This is an extreme example of alignment through a minimally invasive approach. So this patient had this fusion done in an outside hospital and you see, she just broke down over the top and she was just bent over miserable with pain and postural deformity. But going through the side, I was able to restore her alignment and then replace the rods through minimally invasive approach. And she did really really well from that surgery. And this kind of lends itself to this anti r column reconstruction, where we can really realign the spine. And as we know, postural changes are really bad for patients in terms of back pain, in terms of the energy expenditure to walk by restoring somebody's normal posture. We can really make a huge difference in somebody's quality of life and the traditional approach where these big Osti Autumn is now, we can do it through a very minimally invasive approach where we have to dissect between the great vessels in the front of the spine, but resect those ligaments. Place a cage that is hyper lord ionic and we can restore quite a bit of normal or doses to the patient's spine. And so that's what it kind of looks like on an X ray. These are the big cages that we place them there to restore that alignment. This is as opposed to the traditional Osti Autumn ease and we still do these. But these are big big surgeries where we're losing leaders and leaders of blood were cutting basically through the entire spine, around the nerves and to the front of the spine to affect basically we're doses restoration while they worked really well. They're very morbid. and we know that even from you know, this is an example where traditionally we would have done a big cost economy to correct this patient's deformity where you see them leaning off to the side, we see them leaning way forward. But I actually did this minimally invasive approach and perks cruise and was able to restore her alignment really nicely with minimal blood loss actually. Um and this is an extreme example. So there's a patient where this was an 82 year old man who had multiple multiple medical problems. He had already had multiple strokes, multiple heart attacks. And our anesthesiologist basically we're saying look if you lose more than 500 CCs of blood and more than likely this patient will die on the table. But this this patient was just desperate for anything for his back because you can see he has a pitch forward posture, he has a terrible scoliosis and he's leaning off to the side. He was absolutely miserable. And he said, Please do something. I just can't live like this anymore. So the traditional approaches probably would have been appropriate for him. And here's what a CT scan looks like and just uh you don't have to know all the details of this. But we do measure all these measurements that we know correlate with patient outcomes and when somebody doesn't have adequate lumbar, lord doses, their outcomes are terrible. So our, one of our major goals is how to restore normal Lord doses and a patient like this. And so I knew that an astronomy wouldn't work. This is one of the classic papers again showing that the worst somebody's posture is um that the worst their disability is, the worst their pain is. So traditional approaches are these Osti Autumn ease that I mentioned that again. You know, these are quite morbid. And we also know that those big cost economies have a very high rate of complications as well. Um I still do these when when needed, but I do tell patients look, there's a good 30 40% chance you're going to have some sort of complication after this. And even despite those complications, patients actually still have improved quality of life. So we actually have these simulators, these apps that we can use to simulate different types of surgery and how we can affect somebody's alignment. And this is what I did on that patient is very, very sick patient again, who probably wouldn't have withstood an open, traditional approach where I did three uh fusions through the side with pretty fast retractor times. That's actually essential to minimize the neurologic effects. And then place screws through small incisions in his back. That's what it looked like. Inter operatively restoring that lord doses that we talked about. And this is what he looked like right after surgery. So he was walking within 24 hours. He really had minimal postoperative thigh problems and he left the hospital on postoperative day number three. And for somebody that's sick, I thought that was really a big win. So I had and this is just measuring again those parameters that we talked about. And I achieved a lot of his a lot of our goals through a very minimally invasive approach. I had the fortune of seeing him actually five years out, which is shocking. I didn't didn't know he would live another five years but he's still going and obviously now he has a pacemaker and everything. But you can see he's still doing quite well even five years after this minimally invasive surgery. So it really has expanded our indications. And and we're able to treat a lot more patients safely than I think we were in the past. So now I've kind of expanded into the single position surgery. So instead of a lot of traditional spine approaches we go in the front, then we flip the patient we go in the back where we do even flip them and go to the side. Can be multiple multiple positions. And that really takes a long time to um contamination and other things in the operating room. So I involved to doing single position surgery for a lot of these operations and even revisions and patients actually do really really well. So there's an example of placing screws while the patients on their side. So the head is over to the left, the feeder to the right. And I'm placing screws. You can see the small incision directly on the side. That's where I did the went in the side to put that cage in between the vertebra. And then those are actually towers attached to screws so I can place the screws through those small incisions and then place the rod underneath. And this is actually really well, really well tolerated even by morbidly obese patients. This is actually where I evolved to revising prior surgeries in this position. I think it benefits the patient more to my physical discomfort, but it works really well. So I'm actually taking out those old screws while the patient is on their side. And then I replaced the screws and expo great. And now we're even accessing both the front and the side and the back all at the same time. So this is me working with one of my former fellows where I'm going in the front of the spine while he's exposing some of the prior instrumentation in the back so we can work simultaneously and incredibly increase our efficiency in the operating room. So I was fortunate enough to publish some of our early data on this single position surgery. And we've really shown really dramatically improved outcomes from this and saving a lot of operative operative time as well. So less anesthesia, especially for these older patients, is really, really good. So there's an example where I worked at the same time as my fellow and one of our vascular surgeons, there's a patient who had this prior surgery done an outside hospital, broke down above the construct, have didn't heal the bottom part of their spine either. So this is us working together at the same time, I'm in the front of the spine. The fellows in the back of the spine. I am actually still working here. He's now taking out screws in the back and then while he's closing that I'm working through the side and working at the levels above. And so we were able to do this. Place a nice big cage at the bottom part of spine and then do that entire column reconstruction that I mentioned earlier at the top and fixated with a four hole plate and screws there. And that whole surgery took three hours. So if you think about traditionally if we went in the front while they're laying on their back then went flip them on the side, go through the side and then put them on their stomach to go through the back. That would have been probably an all day 89 hour surgery. But we're able to do all this in less than three hours. So the patient was walking with within 24 hours and left on postoperative day number two with the other approaches probably would have been in the hospital more closer to a week. So this is where I'm working with one of my vascular surgery partners and I'm working in the back while he's working in the front and we can access all all sides of the spine all simultaneously. Um So that's kind of that uh minimally invasive surgery overview. And again I'm happy to get in more depth about any of those topics if you want to talk offline. So something that is really popular right now is navigation and what I mean by that is using different tools to guide our instruments during surgery. So these are various intra operative basically C. T. Scans to look at a two D. And three D. Image of the spine while the patient is asleep on the table. And after acquiring those images they can use basically infrared guidance for our instruments to play screws and to cut into bone and things like this. And this is what it looks like. You can actually see these reflective balls on our instrument and that is what the infrared light reads. And then that shows you on the screen to the right exactly where that tool is pointing. And it's almost like playing a video game at that point. You're not really always you're not necessarily looking directly at the spine but you're looking at a screen and you're seeing the virtual image of where your tools are going. So why is that important? It's because this has been shown to increase accuracy and mainly it's been used to play screws in the spine. Um so you can see that in this study that the rate of misplacement of screws was less than 1%. Using Navigation vs other techniques, such as open freehand technique was closer to nine misplacement right now. Keep in mind that even when we say misplacement doesn't mean that the patient's symptomatic doesn't mean that something was injured. It just means that the screw wasn't in the ideal position. So why is this also important? It's important not only for patients but also important to us and the staff in the operating room because we're exposed potentially to incredible amounts of radiation. And, you know, after years of doing minimally invasive surgery, you know, we can potentially far exceed our lifetime dose of radiation. Um So using these navigation systems really can minimize the amount of exposure we have during surgery. Now there's always a question of cost because these things do cost a lot of money. Those, those interactive CT scanners can cost upwards of $1 million. And then all the other equipment includes disposable. So each surgery, you know, you can't reuse a lot of those things. So it can be very costly per surgery. But the cost effectiveness can be shown if you do enough cases at a certain hospital, uh, and in the hopes that you're preventing revision type surgeries. So that's navigation. I don't use a lot of navigation, but it's usually in circumstances where the anatomy is very dramatically altered. So somebody had prior surgery, somebody who has tumor, a tumor or trauma where again the anatomy is not normal or intact. It can be helpful to help guide our hands. Now, robotics is the biggest hottest topic I think for a lot of patients, they love hearing about robotics and what it can do. Um and I had to look a little bit back aware of the term robot actually comes from and it's actually coined in a play in 1920. Um this is an image from that play, but it was basically a machine resembling a human that was supposed to replicate human movements and functions. This is one of the first robots that was created for use in surgery. And that's the middle picture is the historic version of it that's now in the Smithsonian and the version on the right is actually a modern version of it where we do use it in in hip arthur plastic is or replacement surgery. This is actually one that is used very often now, especially in knee replacement surgery. And you can see how the arm of the robot can have attachments. And then the surgeon uses the attachment as a guide and it actually prevents you from going in certain directions. So it just guide you over a certain surface. Once you scan in a CT scan or something like that. So this is a davinci robot which is used quite often in urologic procedures. And it looks really cool actually. The surgeons get under this hood and they can use joysticks like a video game to control all these arms and they're not even close to the patient. They can be on the other side of the room or not even in the room to perform these surgeries. That's what I thought this fine robot would would look like. But the first robot I use look more like this and it's really funny because my first robotic case the patient said I really love to see what the robot looks like. So we brought this thing out and they were so disappointed because they thought it would look more like the former robot. Um and then I thought, oh my gosh! It looks like one of my old dancing coke cans that I had as a kid. These are the current iterations of robots that are used in the spine. And you can see the similarities. They all have this arm that helps guide our instruments. And really all they do at this point is guide our drills so we drill down into the spine to play screws. That's really the most that they can do. And while they can't increase accuracy, I would hope that we can use robotics for more than that. Eventually. So what's the evidence for use of robotics in the spine right now? Um, there's multiple papers to show that there is increased accuracy and really sticks to a plan. You have to keep in mind that all these robots, even by FDA standards are, it's supposed to be within two millimeters of error. So it's allowed to have two millimeters B two millimeters off from what your actual plan is. The problem with that in the spine is sometimes you don't have two millimeters of room of error before you start causing problems. Um That being said, all the data shows that robotics can increase accuracy, reduce revision rates for screws. And this is what that original robot look like. We actually have to put it on this stand that sat on the patient and you move it along the stands that that the arm can reach certain angles to for the drill. And uh, there's a meta meta analysis looking at different studies of this and all of them again showed high accuracy reduced flora skopje time. So again, trying to reduce the radiation exposure for both the patient as well as staff. And then there's a learning effect which really plateau about 30 cases Where speed kind of increasing per screw until 30 cases and then you plateau. But there were failures and there were problems. And I'll show you what that means because I experienced this myself. So what were the reasons for the robot to fail? One of the main reasons is soft tissue pressure. So these arms are not completely rigid. So if there's soft tissue, as you see in this image below that starts pushing on your instruments are pushing on the arm, that's enough to go completely off your planned trajectory. And that can cause problems. So I've actually seen that myself in some of my own cases and this is what the planning looks like if you're planning screws and a robot. Their software where you can actually place virtual screws and then the robot follows that plant and it goes to those trajectories and then it just sets the directory and then you drill down that path. But if you go on the trajectory to the left, if you're hitting the essential in which is that bone in the back and you apply a little bit of pressure, it can be just enough to skydive off that bone and then you're going offline from what you actually plan. So sometimes you actually have a plan going away from some of those bony slopes so that the there's no skiving and that the arm is actor. This is a big big question for hospitals is what are the costs of these robots? So that Da Vinci on the left that I described? That's a $2 million robot. Mostly the robots are closer to a million dollars. So these are not chief instruments and you know what at what point do we determine the cost effectiveness of them? And I don't think we really determine that in the spine yet. So how does it work today? This is what it looks like. So you get a C. T. Scan, you can either do it pre operatively or you can do it interactively but you scan in the spine. Um There is software that actually segments the spine for you. So I'll actually show you each burger bro just like this. And then you start planning so you place those virtual screws as I showed and you can actually adjust the trajectories accordingly. You can move around. You can change the size of the screws, you can change the diameter and length and the angles and you can adjust for each patient's unique anatomy. And so that's what that looks like. And you make you can scan back and forth again just making sure that the screw is accurate and not impinge ng on the spinal canal or on the nerve roots. Uh And you can ensure greater safety by doing that just by scrolling back and forth. And these are all those micro adjustments that you can do either pre operatively or intra operatively. And once that's done um the we register the images on the table to where the robot is and then the robot from there uh It moves its arm to each level that you specify. And you can play screws. And this was my first case I did almost four years ago now, but that's the modern version of the Missouri robot. So this is your case examples of how I used the robot, I don't use it routinely at this point. In fact it probably slows me down more than anything. But again patients with unique or unusual anatomy I think it can be appropriate. So there's a patient, I don't know if you can see that image very well. But he had a very high grade is mixed panels thesis at the bottom. So L. Five and S. One you can see it's a grade almost grade three. Spotless thesis. So it's very highly slipped. Um And this was what I planned with the software and I'm a planner anyway. So I love this kind of technology where I can plan the surgery ahead of time and it shifts my stress from inter operative to kind of the preoperative uh timeline. And so this is after placing an everybody above. And then I actually drilled a fibula Allah graft From L. five into S. one as a stabilizer and is a fusion device. And then this is how the screws were placed with the help of the robot. And you can see actually it's pretty accurate. It looks very similar to what I planned pre operatively. This was an extreme example of this is where I thought the robot really helped me was this is a 57 year old woman. She was a T. Four asia A. So complete spinal cord injury um Actually was a suicide attempt many many many years ago. So she had no motor or sensation underneath below T. Four. And this is what her spine looked like. She had such hyper lord doses which is unusual that her spine was so bent that you can see how she was sitting. She was actually sitting on the front of her belly and she was sitting on her super pubic catheter. So it kept breaking down. She kept having wound problems. She wasn't sitting on her pelvis at all. Um This is what her injury looks like on the left, that was her old injury. And then you can see the Lord doses on the right which is very high. Lord doses. Normally we're somewhere between 40 to 60 degrees. But she had more doses of 130 degrees. And this is what the robot helped me plan. So I segmented the spine. These were the screws that I plan and then the robot help me place these and then now you can see the alignment of her spine is much more normal uh and place the fixation of her pelvis to make sure we had a solid foundation especially since she didn't walk anymore. I wanted to places as much instrumentation as possible to make sure that this was stable and she could sit properly. So this was her immediately afterwards. So not perfect. But she was definitely sitting better on her pelvis and she was quite happy. She felt much more stable at that point. So what our future directions for robots and this is where I really hope the indications can expand and the capabilities can expand. What we really need are different and defectors again right now is just a drill guide. So we're just drilling down the tube once the arm is in place and then we place the screw in that same trajectory. But the robot, I would hope eventually and I know everyone's working on this can do other things. So besides that, maybe help us with the decompression, help us remove lamb in a in a safe manner, help us do astronomy. So we're cutting through the vertebra safely and avoiding vital structures. I think that would be a really amazing thing to help us do uh integration of virtual reality and augmented reality. I think that's huge. And we're already getting there. I know that there are a number of companies already working on Augmented reality, so either putting a screen over or putting on goggles and then seeing an overlay of the spinal anatomy before we even make an incision. Uh, I think that be remarkable and integrating that with robotics is really the future. And I'm hopeful that we'll see some iterations of this even in the next 5, 10 years. I think remote surgery and I mentioned this earlier. There are surgeons that can are already operating remotely. I think places that may have difficult access, even surgery in either deep space or on the ocean floor would be capable and you can have somebody not, no, no, thousands of miles away, but you have a robot in place that can help do these surgeries. I think that would be really incredible. And then convergence with artificial intelligence. Um I think this is where hopefully it won't completely take surgeons out of the picture. But I think that that is really the future right is going to be completely autonomous surgery. I mean we're already looking at autonomous cars why not eventually autonomous surgery. Um I think that would be incredible. Would take an incredible leap of faith. But I think that may happen in our lifetime. Um So in my mind these are advantages of using a robot. Again it transfers the radiation exposure from the surgeon of staff to the patient because a lot of times they need a C. T. Scan. But it's hopefully just a singular CT scan. For me. It transfers the inter operative stress from during the case to before the case. And when I can be in a very controlled environment, plan out my case and going comfortable, comfortable knowing that I'm going to do a safe surgery is incredibly stress. Relieving. Can improve your placement of screws and improve screw pull out helps with minimally invasive approaches where you're not looking at directly at the anatomy and again helps with this altered or unusual sometimes congenital deformities and patients overall I think are becoming more interested in the technology as well. But this is a really important statement. And Izzy Lieberman who is one of the leaders in robotic surgery. And I think this is absolutely true. Robotic assistance will not make a bad surgeon good but it will make a good surgeon better. So it's just it's another aid but it doesn't supplant good decision making. Doesn't supplant uh good indications which I think in spine are are absolutely paramount. So there's a special thanks to two of my friends is the Lieberman and a non zero value at stanford. We've done a lot of this work together. Uh, and then this is my family and for those of you wondering why I left stanford and came to Austin and we absolutely could not be happier. Uh This is the reason why. And it was really for family reasons. They are so happy here. I think it's a better place for our boys to grow up. It's been a wonderful community for us and I hope that I can be come an integral part of this community and help you and treat your patients like you would hope they would be treated. So in conclusion, I think spine surgery can have really outstanding outcomes if we have proper patient selection and use employee the proper techniques, minimally invasive surgery is really evolved tremendously. Even in in my career we have achieved better outcomes. We can operate on more people and more pathologies and it can be tolerated by sicker and older patients at this point um navigation and robotics. There's definitely improved accuracy for screw placement. But right now I still am a little cautious. It has limited capabilities. It's very expensive and I don't know what the cost effectiveness is yet. But thank you so much for your attention and I hope I can meet all of you at some point and I opened things up for questions at this point. Thank you very much. Mhm. Thanks dr chang. Really appreciate that. We did have a question that came through the chat and if I'm MS neighbor, if if I'm messing this up, let me know. But a lot of what you were showing is lower spine. Can the same approaches be safely done for the cervical spine? That's a great question. Actually, really appropriate. So cervical and thoracic spine are, the anatomy can be a little more delicate than the lumbar spine, which kind of makes sense that, you know, for robotic reasons and for navigation, it made sense to focus on the low back. At first there is now FDA approval for use of robotics in the thoracic spine. The accuracy and the cervical spine is still being worked out. Um, and the other problem with the cervical spine is that, And so navigation works well. But robotics we're still not sure because the cervical spine is so mobile. Um, it's hard to completely immobilize it to make sure that the accuracy is, and again, accuracy. And the cervical spine needs to be really sub millimeter because you're between the spinal cord and your between the vertebral artery and really dangerous structures. So I think that is going to be true. But uh, we're not quite there yet. Are you able to do the same type of positioning where the patients may be on their side? For robotics or for genuine robotics? Yes. So I'm doing all that single position surgery on their side. I've done it all the way up into the chest and I've done it all the way down to the pelvis and it really helps the patients what I didn't get into. Or some of the other advantages that we found in some of the papers that I published and that is older patients don't tolerate being prone or on their stomach for extended periods of time, right? It's pressure on their face. They have poor lung compliance. There's more tend to be more skin problems, you know extent for surgeries that last hours and hours. So I found that it really benefits patients a lot just keeping on their sides anesthesiologist love it because they can keep them on their side almost perpetually for without problem. Um And I just love keeping on their side for efficiency and the patients do well. One other advantage we found two is when we go through the front, even when they're on their side we don't have to manipulate their peritoneum and their bowels as much. So they actually have a much lower at least in our initial data. They have a much lower rate of alias which is you know where their balance slow down and they get this huge protuberance and then they can't leave the hospital because they can't have a bowel movement and they're super uncomfortable. These patients have a much lower rate of that, so they actually leaving the hospital much sooner for many reasons, not just the shorter operative time, the less anesthesia, but less rates of Ilias and things like that too. So overall, I've just found a number of reasons why it's advantageous, Thanks so much for your time. I appreciate it and have a great day.