Already a leader in minimally invasive spine surgery and the use of virtual and augmented reality and robotics, Mount Sinai Health System has adopted a new real-time, radiation-free navigation technology that enhances accuracy, anatomical verification, and precision of surgical alignment for complex surgical cases.Jeremy M. Steinberger, MD , Director of Minimally Invasive Spine Surgery for the Department of Neurosurgery, and Assistant Professor of Neurosurgery, Orthopedics, and Rehabilitation Medicine, narrates a video on how he used the technology for challenging spine deformity cases of myelopathy and spondylolisthesis in three patients, leading to successful outcomes.
Hi I'm Jeremy Steinberger and I'm going to be describing a new technology that we have at Mount Sinai called 70 and it's efficient radiation free navigation. We acquired this about one year ago and since we adopted it, we have 19 surgeons using it. We are the first health care system in the nation to adopt machine learning machine vision on this sort of large scale. And since we started using it it has taken off. People are seeing the benefits of it. Both the surgeons as well as the patients and that's what I'm gonna be describing today. I have no relevant disclosures to this talk and no disclaimers. Um I serve as the director of minimally invasive spine surgery from Mount Sinai Health Systems department of neurosurgery where we are really building to uh change the way we do spine surgery and uh employ new techniques, new technologies to improve patient outcomes. Right now, if you look at what's on the horizon for spine surgery, minimally invasive spine surgery is gathering traction across the country and across the world. Um surgeries with less blood loss, less length of stay, faster recovery, faster return to work, less opioid use etcetera are really uh changing the way we do spine surgery. Were also employing virtual reality into our patient encounters. In the office. We're employing augmented reality and placing per catania screws with a superimposed vision um of the relevant anatomy projected onto our headset. We're using robotics. We now have a robot at Mount Sinai that's helping us to place screws and do inner body fusion and I think the one that I'm going to talk about and highlight today is the improved navigation and inter operative imaging and there's data to support why we need this. This was a study that showed 9310 pentacle screws and they looked at the accuracy with standard Flora's copy. The accuracy of the medical screw is 68% and it improved to 96% with three D. Navigation. This means that we have basically x ray vision. We can put a probe to the patient and know exactly where we are in space so we can get the perfect screw every time. And at the end of the day these breaches matter. So 96% versus 68% is a huge difference. If you have a screw that's medial or inferior particularly you can injure a nerve permanently. So improving accuracy of instrumentation in the operating room is critical and navigation has helped us to get there. There are pros and cons in an academic setting we can have better accuracy. We can place bigger and wider screws and we can in the process of training residents, we have an adjunct to help us do the education part of surgery and training safely. Um In some instances we can do less exposure and smaller incisions. We now can do a one level spinal fusion through the through an incision. The size of a lamb in ectomy. So an inch and a half. Um and that's in large part due to these navigation developments, there are some cons number one, if you're everyone is using this technology, are we going to lose the art of placing screws without help and using anatomical landmarks? That is a legitimate concern. And the workaround is that when you use this technology you look at the screen only after you plan your screw without it. So you can line up your hand, you can line up your trajectory and your angle. You say, I think this looks good. And then you look at the screen and you can say, oh actually I should be a little bit more lateral or this is perfect. That would have been a good screw either way with or without the navigation. There's also a cost and there's also time I put a big arrow on time because I think one of the biggest obstructions to using this new technology is that it takes time and and surgeons and and and most people don't want to spend three hours doing a surgery if you could do a surgery in two hours. But that's what makes 70s so special is that it doesn't add time to the surgery. And at least in my experience it has decreased the amount of time in the operating room. And I'm gonna show why that is this is uh a X ray on the left cat scan the middle and M. R. I. On the right of a patient who has a very high grade scandalous thesis. A slippage of L. Five on S. One, you can get grade one grade to grade three, grade four. This is a grade 3.5. Which is a significant scandalous thesis basically the L. Five and the rest of the spine is falling off of the sacrum. As you can see here. The ways to fix this. Um There's a lot of different possibilities. The way we chose to fix it is by putting a screw in L. Four L. Five S. One and into the pelvis. And we used navigation to help us. This patient came in pretty advanced. She had urinary issues. She had right right leg atrophy as you see in this picture. And this is what we ended up doing which is a screw into L. Four, L. Five S. One in the pelvis and an inter body fusion at L. Five S. One. And I think this probably took us about 3.5 hours for this complex operation. But I think that the navigation helped us chop an hour off of this surgery also gave us really good feedback and confirmation that all of our screws were in the right place. And also helped us to do what's called a sacred demasiado me. Which is a complex uh basically a breakage of the spine to enter the disk space and correct uh spinal deformities. This is a sample of what it looks like. You're putting a probe into the bone and you're looking live as you're passing your probe into the bone. So you know that you're not getting into the you're not breaching the pelvis, you're not to lateral to medial. And also your you can use a really long screw. I will say my practice for a pelvic screw is to put an 80 millimeter screws. And now we're routinely putting in 100 millimeter screws. Just better Anchorage, better strength to the screw, better with and diameter to screw as well. It's fast, it's efficient and most of all, most important of all, there's no radiation to the patient. So without the 70 technology, a lot of, a lot of the times what we do is we take an inter operative cat scan. Once we do the inter operative cat scan, we link the patient's inter operative cat scan to the navigation screen, which links the patient to their cat scan. And then you you have this ability to know where you are in space with 70 it links. Uh There's no there's no X ray or cat scan in the operating room. You're you're using this camera which I'll show in a minute to take the flash of light which takes thousands tens of thousands of additional points in space. And that links the patient's preoperative imaging to the inter operative Patient positioning on the table. So basically we're able to with one flash of light that lasts I think 2.4 seconds we take the flash of light. We get tens of thousands of additional points. The patient is linked now to the navigation and we can we can start. This is fast and efficient. Here's a few examples of some of the recent surgeries that we've used this technology. This is us putting a screw into the pelvis, this is us placing a thoracic medical screw. You see the ribs over here, the transverse process, the spinal cord lives in here and we're calculating that pentacle with this navigation technique. Knowing we're in the perfect place, this is placing a C. One lateral mass grew. So in the first cervical vertebrae there's the vertebral artery that lives in the transverse foramen. There's the spinal cord over here. So you see the basically we need to be in this bony corridor between critical structures and the navigation. Really helps us to know that we're in the right place with minimal stress, minimal disruption, minimal slowdown in the operating room. Here's another example where we use 70. This is a 61 year old female who presented with severe myeloma Kathy, she was unable to walk. She fell frequently and if you look at her sagittal T. To M. R. I. She has severe spinal cord compression from C. Two to C. Seven here. You see a very healthy looking spinal cord with spinal fluid in front spinal fluid and back, healthy looking discs with um no disk bulging. But up at the upper cervical and lower cervical area. There's severe multilevel spinal cord compression. There's also myeloma lay sha uh an injury to the spinal cord and leo sis. So this patient met surgical criteria and she needed a large posterior cervical, decompression and fusion. This is before and this is after. So this is the same patient, we remove the bone and ligament in the back and you see how the spinal cord drifts away from the pathology. And it's uh wide open. After surgery, there's still myeloma lay sha of the chord because that's a the equivalent of uh damage to the spinal cord. But now the spinal cord is free. And she had tremendous relief after surgery. In order to do that though, we needed to supplement her spine with screws and rods, which is what you see here. And the way we were able to get the thoracic medical screws to be absolutely perfect. Was using the 70 technology took us less than one minute per pet ical screw. So um this was four minutes to place the medical screws, which are hardest to place. And the upper cervical screws replaced with free hand techniques as there's less variability and complexity to them, but you can use navigation for that also. She had significant impairment and she did quite well After surgery. I'll transition to another patient who basically had uh significant weakness of his legs. Um He had a longstanding scoliosis. He failed conservative treatment including physical therapy and multiple epidural steroid injections. He also had medial branch blocks. He had relations. He really went through the he he went through the whole um the whole the whole cycle um and he presented with back pain, leg pain and mala lineman and he really couldn't walk more than a few feet. And for the four weeks before surgery he was what he describes his bed bound due to the severe pain he was experiencing. Here is his pre operative X ray where you see he had a prior fusion done at L. 45 but he has this big uh corona light tilt to his right side. And he needed a pretty aggressive operation to fix this. But this surgery was done in about four hours and and and placing about 18 screws in the spine typically takes longer than that. And we were able to cut time off with no radiation to the patient. Using 70 technology. Here's the lateral image of the same patient. The way we do this is we take these block registrations so we take that flash of light and it gives us all these points. We correlate sidedness to the technology to make sure that everything is aligning perfectly. One thing we do not do is we don't blindly trust technology. We always have to verify that it's accurate so as soon as we do this registration, we touch a probe to the patient. We sweep on the laminar, we sweep on the joint. We touch our probe to the transverse process or to a medical screw and we make sure that it's exactly perfectly accurate. That's a really important step because once you know it's accurate you know you can trust it. Um And so that's what we did. And then you see here we're placing all these screws but each one you know that you're in the perfect location at every single screw you place. And I think that this is invaluable. It takes a lot of the stress out of the operation. It takes a lot of the it takes the educated guessing out of the equation because you know you're in the right position. So basically this patient is fantastic. He walked 100 and 50 ft. The first day after surgery he walked 400 ft the second day he had a miraculous feeling that his pain was better. As soon as he woke up two months later now it's been about five months later he has no backer like pain. He's on the treadmill every day is a very active guy and he's he couldn't be happier. So we have fast navigation that decreased his operating room time. It increases accuracy. It improves patient outcomes. This is a first that we're doing at Mount Sinai and it has revolutionized the way we do spine surgery. And I think it's a really exciting time for everybody. It has been a really rapid growth and evolution, and we're expanding the technology almost weekly. So I thank you for your attention and take care. Bye bye.
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