The new technology helps take the guesswork out of spinal implants at Texas Health Plano.
Dr. Isador Lieberman uses SpineAssist at Texas Health Presbyterian Hospital Plano. He says robotics “can’t make a bad surgeon good. It’s a navigation device that can make a good surgeon more precise and efficient.” photography by Adam Fish
Meredith Lane, a 12-year-old Arlington scoliosis patient, was draped for surgery to correct the curve in her spine at Shriner’s Hospital in Philadelphia in 2007.
After peering more closely at X-rays of her back, the surgeons had second thoughts. They recommended against the procedure, telling her father, Wynne Lane, that it was too risky. They reassured him that the 12-degree curve in her back would not get worse.
Fast-forward three years. In March, her local physician told Meredith he could not do anything more for her, and that she would have to live with a spine was now curved at a 43-degree angle. She and her family were crestfallen. Lane regretted his decision not to go ahead with his daughter’s operation three years earlier. Meredith was counting on the fact that she could have it corrected as an adult.
Scoliosis is a curvature of the spine that usually appears prior to a puberty growth spurt. Symptoms can include uneven shoulders, waist or hips. Its cause is unknown, although it can be a result of muscular dystrophy, cerebral palsy, or a birth defect. Short of surgery, treatment to control the symptoms include exercise and physical therapy, a brace, or medication.
After seeing a television news story about SpineAssist at Texas Health Presbyterian Hospital Plano, Lane set up an appointment for his daughter. Dr. Isador Lieberman told Meredith she was a perfect candidate for the procedure, which employs surgical software and a robotic arm for spine implants.
After the September 2010 surgery, the curve in Meredith’s spine was less than 10 degrees and no longer noticeable. A former volleyball player at Arlington Martin High School, despite her condition, the now-15-year-old is expected to have no limitations.
SpineAssist was designed specifically for spine operations. The device is used for surgeries during which implants are attached to the spine, such as spinal fusion and correcting scoliosis.
It was co-developed by Lieberman, after one of his patients challenged him to create a new technology for spinal surgeries and offered to supply a matching grant. Lieberman drafted his idea overnight to secure the patient’s financial backing. Technion University in Haifa, Israel, matched the grant, and one of its professors helped Lieberman develop SpineAssist. The product is now produced and owned by Mazor Surgical Technologies, an Israeli company.
SpineAssist has two main components: a computer workstation that enables surgeons to plan the procedure using a three-dimensional simulation of the patient’s spine, and a robotic arm that executes the preprogrammed instructions during surgery. The arm guides the placement of implants, which is completed manually by the surgeon.
Lieberman, the medical director of the Scoliosis & Spine Tumor Center at Texas Health Plano who also practices at the Texas Back Institute, said a common misconception is that the robot performs the surgery. The equipment assists the surgeon in planning the surgery and enhancing accuracy, but the surgeon still does the work.
He likens the SpineAssist process to that of a pilot doing pre-flight planning, mapping the proper route, fuel needs, and course direction. “It allows me to recognize and appreciate the subtleties of the anatomy that I might not see during the surgery,” he said. “As robotics become mainstream, everyone is going to call themselves a robotic surgeon. However, a robot can’t make a bad surgeon good. It is a navigation device that can make a good surgeon more precise and efficient. It’s like the sight on the end of a rifle, a navigation device that is another tool in the surgeon’s tool box,” he added.
The robotic arm allows precision within less than one-half millimeter. Such accuracy minimizes the size of the incision, protecting underlying muscles and reducing the chance for surgical error. The system cuts the tedious job of screw insertion by about 50 percent. It also lessens the risk of infection and hastens post-operative recovery under most circumstances. For example, Meredith was able to return to school less than two weeks after the surgery.
Another benefit of SpineAssist is a reduction of CT scans and resulting radiation. During normal implant surgeries, CT scans guide and confirm each implant’s location. SpineAssist has already done the guidance and implant location pre-operatively, eliminating the need for multiple CT scans. According to one study, there was up to 98 percent reduction in radiation used in surgeries with SpineAssist.
The technology has been used in more than 1,200 operations worldwide without surgical nerve damage. It was the first—and remains the only—robotic surgical device approved by the Food and Drug Administration for spine surgery. Only about 25 percent of SpineAssist surgeries occur in the United States.
The technology also is expected to be approved for brain surgery. It can be used in biopsies, to treat thoracic-lumbar fusion and vertebral compress fractures, as well as correcting scoliosis. Dr. Jeffrey Canose, president of Texas Health Plano, believes SpineAssist technology would work well in knee and hip replacement, as well as surgeries that navigate in very tight spaces such as sinuses.
Although SpineAssist has been used most often to correct scoliosis, it is also used to treat herniated discs, lumbar degenerative disorders, and vertebral compression fractures.
Lieberman was a recruiting coup for Texas Health Plano when it lured him in April from his former position as chairman of the Cleveland Clinic’s Medical, Interventional and Surgical Spine Center.
The 368-bed Collin County hospital has earned a reputation for cutting-edge technology. Canose, who aims to create an orthopedic “center of excellence” on the Plano campus, says Lieberman’s recruitment was a critical piece of the puzzle. Texas Health Plano performs about 2,000 orthopedic surgeries a year.
Lieberman, who began doing SpineAssist surgeries in Plano this summer, said he expects to perform about 125 scoliosis surgeries this year. He receives worldwide referrals. Lieberman uses the equipment in about 60 percent of his surgical work. Plano’s SpineAssist robot is only one of three in the United States. The other two are in Cincinnati and Atlanta.
Texas Health Plano is also the only worldwide training center for SpineAssist. Experienced surgeons receive a four-hour training course. Because the Plano hospital is the only certified training site for SpineAssist, there is a high level of interest in observing the procedure, says Canose, which places the Plano hospital in the medical community spotlight, he says.
Spine surgery is an intricate and delicate operation. There is about a 10 percent risk of misplacement, and about half of those create clinical complications afterward.
Back pain affects about 80 percent of Americans, with an estimated economic burden of $100 billion annually. It is the leading cause of disability of those ages 19-45 and is the second most-common reason for work absences.
There are about 750,000 back surgeries in the U.S. annually, of which 20,000 involve spinal fusion or rod implants. Minimally invasive spinal fusion systems, a market valued at more than $200 million in 2009, is expected to grow annually by about 15 percent.