Combining Technologies—Robotic-Assisted Endoscopic Transforaminal Lumbar Interbody Fusion

Presented at SMISS Annual Forum 2019
By Jason Liounakos MD
With Michael Wang MD,

Disclosures: Jason Liounakos MD None Michael Wang MD A; Department of Defense. B; Vallum, DePuy Synthes, Stryker K2M, Spineology, Globus Medical. D; Innovative Surgical Devices. E; University of Miami. F; Children’s Hospital of Los Angeles, DePuy Synthe,


The overarching goal of robotic surgery is to improve outcomes by facilitating minimally invasive procedures, improving manual dexterity, and standardizing workflow. While many surgical fields have embraced robotics, spine surgery has not yet seen a global adoption. This likely owes to the innate complexities and multiple exquisitely distinct steps involved in each operation. Whereas master-slave systems are ideally suited for general surgery, this is not the case for spine surgery, where semi-active robotic guidance systems dominate. Such systems have traditionally only been used for the placement of spinal instrumentation. By combining both robotic and endoscopic technologies, we aim to push the boundaries of minimally invasive spine surgery.


We describe our initial experience utilizing a next-generation robotic guidance system with navigation (Mazor X Stealth, Medtronic, Minneapolis, MN) for the placement of percutaneous pedicle screws, as well as the novel targeting of a disc space for endoscopic discectomy and interbody fusion.


Procedural workflow involves robotic-assisted placement of percutaneous pedicle screws under live navigation. The disc space is then targeted robotically and safety is assessed with triggered electromyography. The endoscope is inserted and discectomy and end-plate preparation proceed, followed by delivery of an expandable interbody device. Demographic and surgical data is being collected for this initial series of patients undergoing robotic-assisted endoscopic transforaminal lumbar interbody fusion (TLIF). Data includes procedure length, robot time, time-per-screw, need for screw revision, blood loss, complications, and length of stay.


Five patients with an average age of 67 years (range, 55-72) underwent surgery. One 2-level and 4 1-level lumbar procedures were performed. Mean procedure length and robot time was 135 minutes and 67.6 minutes for 1-level surgeries, respectively. Twenty-two screws were placed percutaneously under robotic guidance with navigation. Appropriate position was confirmed with fluoroscopy, and no screws required revision. Mean time per screw was 359 seconds. Mean blood loss was 100 cc and mean hospital stay was 2 days. There were no complications.


Utilizing robotic guidance for disc space access for discectomy and interbody fusion is one way to expand the role of robotics in spine surgery to more than pedicle screw placement. Through the ongoing assessment of where different technologies intersect, we may positively alter their trajectories for advancement. Doing so is necessary to harmoniously blend tools with distinct purposes to obtain the best outcome through improved surgical efficiency and minimal invasiveness. Our early positive preliminary results show that this is possible.