A team of Mount Sinai surgeons, led by neurosurgeon Jeremy Steinberger, MD, Director of Minimally Invasive Spine Surgery for the Department of Neurosurgery, present the first reported case of a fully robotic anterior and posterior (circumferential) spinal fusion surgery. An anterior lumbar interbody fusion (ALIF) was performed using da Vinci robotic approach with John Sfakianos, MD, and Peter Wiklund, MD, PhD, and disc removal and interbody cage placement was performed through a port by Dr. Steinberger, followed by percutaneous posterior instrumented fusion with the Globus ExcelsiusGPS® robot. Dr. Sfakianos is Assistant Professor of Urology, and Dr. Wiklund is Professor of Urology. “This is truly the first of its kind—we are using the latest technology to expand robotic applications in spine surgery thus increasing efficiency and precision,” says Dr. Steinberger. The patient was a 65-year-old male who presented with several months of incapacitating back pain and left greater than right lower extremity radiculopathy. His pain radiated from the buttocks and down the posterior lateral legs to the toes. He was found to have bilateral fractures at L5 and grade 1 spondylolisthesis at L5/S1 that worsened on standing upright (implying worsening with loading and instability). Results: The patient did well postoperatively with improvement of back and leg pain at six-month follow-up. Imaging confirmed excellent placement of interbody cage and pedicle screws. This allowed the team to conclude that fully-robotic anterior and posterior surgery for the lumbar spine may be safe, feasible, accurate, and efficacious. Hi, my name is Jeremy Steinberger. And today I'm gonna be describing a very exciting case that we did in Mount Sinai, a 65 year old male presented to me with debilitating back pain and left leg pain. He could barely walk more than a quarter of a block before he had to stop and rest. And after a few minutes, he could continue again. If you look at his MRI, which is the picture here, you see five lumbar vertebrae in the low back, there's a bone, a disc, a bone, a disc, a bone, a disc. And you see this disc is degenerated that in and of itself is not a finding that we stress too much because a lot of people get degenerative disc disease with aging and arthritic progression over their lifespan. What's a little more concerning is that there's a slippage forward of L five and S one. So the bottom vertebrae is slipping forward on the sacrum. But as you could see on this picture, if you think about this area behind the bones and the discs where my mouse cursor is like a highway where the nerves travel, there's actually no compression of the nerves in the central area of the spinal canal. However, if you go off to the side, well, first you see his X ray and, and, and on the x-ray, you see that there is a worsening slippage compared to the MRI. The reason for that is when you lie down on an MRI table, your spine can go into a better alignment and the bone can shift into a better position. But when you stand up and you're bearing weight and gravity, that's when the slippage can worsen because you have the stress of your gravity and on the rest of the spine, pulling that vertebrae forward. So it's a pretty uh impressive slippage when he stands up. But when he lies down, it kind of reduces into a better position. And that's why we often will get X rays in addition to an MRI. But if you look at this picture, this is showing that even though that central canal where the nerves travel is open on the side, where the nerves exit your spine to go to your leg, there's significant compression on both sides. Here's the right side. And you see here this oval white uh shape. This is the canal that the nerve takes to leave the spine to go down to your leg. Similarly, you see it pretty well at L four L five, the next level down. But at L five S one, you see there is this impingement of the nerve. You also see there's a, it's harder to see on this picture, but there's a fracture of L five. And what happens is if you have a fracture on both sides of L five, it's called spondylolysis, you disarticulated the back of your verte vertebrae from the front. And that's why the slippage occurs on the left side, which if you recall is, is more symptomatic side, there's even more severe compression there and you could barely make out where the nerve is. This is in his best position when he lies down on a table. As soon as he stands up, you can imagine with the force on it, this nerve will get even more compressed. So this was his issue. This is why he couldn't walk. Now, the treatment for a spondylolisthesis with a spondylolysis or slippage of one bone on another due to a fracture on both sides of the vertebrae, specifically in a part of the vertebrae called the pars, which is the weakest part of the bone. The treatment for this is not surgery right up front. Usually we try physical therapy, we try pain management, we try medications, we try acupuncture or whatever, you know, conservative modality uh suits you. Uh, you give it a shot because surgery is the last resort. But if the pain is debilitating, despite conservative measures, that's when we talk about surgery, the way is to do the surgery. One way you can do it is you make you can make a 34 inch incision on the back. You could take the muscles and ligaments away. So you can look at the spine like it's a, a spine model and you can put in screws and rods to stabilize the L five S one, but also decompress the nerves by removing bone and ligament to follow the nerve out through the canal where it travels. You can also do that same surgery with tubes and small incisions in the side where you work with tubes going through the muscle. And at the end of the surgery, you pull the tubes out and uh, it's less disruptive to the musculature around the spine. But the way we elected to do it is called an Aiff, an anterior lumbar interbody fusion where you go from the front of the belly, it's very minimally invasive because aside from the incision in the belly, we basically go retroperitoneal or around the bowels and the intestines and you're staring at the front of the spine and then you can remove the entire disk while staring right at it. And then you can basically, the principle is like a car jack, you take a cage and you sequentially dilate up, up, up and you take a disk that's three or four millimeters and you turn it into 8, 10, 12 millimeters, which gives an in increase in the disc height, which in turn in, increases the foraminal height or the height where the nerve travels to basically give the nerve more space. In addition to restoring better alignment, reducing the slippage of one bone on another back into a better position. So it accomplishes all the, all the goals. However, if you do that surgery alone, it's usually not enough to give good Anchorage to the spine and it can actually the cage can actually come out. So what we do is at once the patient's asleep, we do that but then we flip the patient over and we put percutaneous screws. That means we do one centimeter incisions in the back, pass a screw through it and uh we stabilize it from the back to give it what's called a 360 degree or a circumferential spinal fusion stability from the front and stability from the back. This just in comparison is a different patient's MRI where you see that all the foramen or the canals where the nerves travel through a wide open. And this is what it should look like, not with the severe distortion of the nerve that this other patient had. This is what we did. We used a robot. This was actually um the first time we had done this in Mount Sinai, we used a robot. We did these little ports. It's kind of like if you have a hernia surgery or an appendix. Nowadays, you're doing it through these ports. This is what it looks like where you work through a port or numerous ports. And the advantage is instead of making one large incision, we make numerous small incisions, but these heal quicker and faster with less pain to the patient after surgery. Then we brought in the Da Vinci robot, which is an incredible robot and it has all these arms and we can work. We had urologists in the room to help us gain exposure to the spine safely. They're masters of using this machine. Uh This robot, they were there. We had vascular surgeons as well to make sure that the blood vessels were protected. And if there was uh if there were in any danger, they were on standby to help us out. And then once we had a beautiful exposure to the spine, this is the L five S one disk space with surrounding inter abdominal contents. Uh We were able to gain, get, get into the disc so that we can remove the disc and put in our cage. Uh This is a 15 degree 11 m, 11 millimeter height trial. So we took a space that was 34 millimeters and now it's 11 millimeters. So you can see that what we did is we pushed L five back onto S one and significantly, you know, by about three fold, increase the height of the disc which increased the height of the canal where the nerves travel. Um There's obviously a lot of critical structures in this neighborhood like ureters, kidneys, iliac vessels, the vena cava a little higher up. But we have experts who know how to protect these structures to make the surgery safe. After this, we impacted our trial and then we were done. But now we move to phase two. And this is what was so exciting about this surgery. This was the first fully robotic spinal fusion ever performed anywhere to my knowledge. Um So we use the robot for the front and then we flipped the patient over and we use this robot called the Globus robot or the Excelsior. And we use that to make these one centimeter, they're called stab incisions where we put a screw in, in four different locations, two screws on each side connected by a rod using robotic navigation to make it extremely accurate. And that was phase two of this operation, which thankfully went beautifully. And then you see, after surgery, the X ray and what you see is there are two screws on each side connected by a rod with a big interbody cage placed at L five S one. There's a very nice reduction of L five onto S one. So it's no longer slipped forward, it's no longer collapsed, it matches all the other discs in the spine. We often measure it so that it's fitting with each individual patient's anatomy. And that's what we did. The patient was happy. He has essentially no pain. He is walking like any one of us and he's uh very happy. He had it done and we were proud to make history uh in Mount Sinai.