By Jane Ehrhardt
Ascension St. Vincent’s Birmingham was the first in the nation to equip their neurological team with three Mazor X Stealth robots. That unmatched record only recently changed when Nashville bought their third last month.
Used for spinal fusion surgeries, the robotic guidance system, made by Medtronic, has been in use for two years now at St. Vincent’s. “They do ten to twenty times more surgeries than any other hospital,” says Lauren Hobson, a Medtronic surgical synergy clinical consultant at St. Vincent’s. That efficiency has built the hospital’s neuro team into the largest in the metro area with nine neurosurgeons and seven operating rooms.
The efficiency derives from multiple aspects. With the software-enhanced planning using 3D imagery and the real-time visual tracking of the movement of the tools during a procedure, surgery time for a single-level lumbar fusion can be as short as 90 minutes. In addition, what used to take around twenty scans during a procedure to assess placements, now takes three. Those time savings mean the option to serve more patients. “St. Vincents on average does fifteen to thirty robot posterior fusions a week,” Hobson says, adding that at one point, they were performing the most in the world.
The machine requires a Medtronic robot consultant to serve as a type of software tech for surgeries. That person performs a 200-step preparation process involving pre-surgery scans, image registration to the actual patient, and finalizing the surgical plan details, such as rod alignments, screw placements, and incisions. “The surgeon will know exactly where the screw is going,” Hobson says. “We’re talking millimeters here.”
For surgeons, the transition to robotic surgery can be daunting. “It is a disruptive tech. It changes your workflow,” says Josh Menendez, MD, neurosurgeon with Neurosurgical Associates, which is one of the two practices comprising St. Vincent’s neurosurgical team. “If you’re not willing to go through the growing pains, you’re not going to get the benefit of the tech.”
When St. Vincent’s brought in the first generation of the Mazor, it took about two months for the benefits to consistently emerge. The buy-in to learning the system involved everyone from radiography techs to scrub nurses. “Our whole team was committed to fighting through the learning curve,” Menendez says. “However, shifting from the first generation to this second generation was wonderful. That made us quicker instantly. The second generation robot is better engineered and moves much more rapidly. Doing a long segment fusion with the first generation Mazor device could take 90 minutes to put in the screws. With the second generation, it only needs 30 minutes. That’s why we’re able to do more cases than other centers.”
This version also has better reach. Since the surgeon must dock the robot at a certain location on the patient’s spine, the robot arm has only limited range for reaching along the spine. Moving that anchor means re-registering the patient, which requires multiple scans and time to realign the imagery in the software to the new position of the patient. “But this second generation has a much longer reach, so the process of registering is one or two fewer times, and that’s a ton of time saved,” Menendez says.
The second generation also expanded from the option of only posterior access to lateral as well, which Menendez says is about 20 percent of his surgeries.
But the number of spinal fusion procedures is not all that sets St. Vincent’s apart. “St. Vincent’s uses robots on all their fusions,” Hobson says. “That makes them unique. That volume pushes the hospital to first on the list for software updates, including the major upgrades every few years that cover new options that required FDA approvals. So even if Mazor looks the same as it did when it came out, it’s constantly upgrading.”
Menendez, who performs about seven to nine fusions a week, says what he looks forward to next in robotic spinal surgeries, is single-position surgery. “When you have multiple parts of a surgery with a patient in different positions, changing position is very inefficient,” he says. It’s being done now, but it needs notable improvement. Figuring out how to more efficiently and safely allow for those needed shifts in position while using a robot would decrease the time under anesthesia and the resulting complications, including heart attacks, infections, and blood clot development. That’s the next real promise of robotics.”