Robotics for spinal operations: reality or Alice in Wonderland?

摘要

Leonardo da Vinci (1452–1519) was the first to describe the precise curvatures and articulations of the spine 1. It was after him that a new category of minimally invasive alternative to traditional open surgery, the da Vinci ® Surgical System (Intuitive Surgical, Inc, Sunnyvale, California, USA), was named 2, 3. This endoscopic robotic platform has entered the surgical realm for more than a decade in urologic, gynaecologic, cardiothoracic, and general surgery procedures 2-6. However, as it is not image guided and without a haptic interface, its application in spinal operations has been limited 7. The da Vinci ® system's capabilities have been highlighted and its limitations have been clarified in several animal 5, 8, 9 and human studies 4, 10-13. It has been implemented in the performance of anterior lumbar interbody fusion (ALIF) using the retroperitoneal approach in two porcine models in vivo 8, 9. It was also tested on laminotomy, laminectomy, disc incision, and dural suturing procedures on the thoracolumbar spine of a porcine model in vivo 5. In humans, this platform was involved in robot-assisted transoral odontoidectomy for decompression of the craniocervical junction 4. Furthermore, it was applied in a retroperitoneal transdiaphragmatic robotic-assisted laparoscopic resection of a left thoracolumbar neurofibroma 11. Published articles suggest its utility in the thoracoscopical extirpation of paravertebral mediastinal neurogenic tumours (such as schwannomas) 12 and in the transperitoneal resection of paravertebral lumbosacral masses 13. A cadaveric study has also shown the technical feasibility of transoral robotic surgery for decompression of the craniocervical junction as well as resection of both intra- and extradural tumours of this region 10. SpineAssist ® (Mazor Surgical Technologies, Caesarea, Israel) is a bone-mounted miniature robotic guidance system, tested for spinal surgery 2, 3, 14-16. With the aid of this system several cadaveric percutaneous placements of pedicle and translaminar facet screws have been performed 15, 17. SpineAssist ® was employed in spinal fusion procedures (open and percutaneous approaches) for transpedicular screw placement in 15 patients 14. Another study reported that 31 patients underwent posterior lumbar interbody fusion (PLIF) with percutaneous posterior pedicle screw insertion using the SpineAssist ® technology 16. The advantages of robotic surgery include: ergonomics 4, 12, significant dexterity enhancement that eliminates a neurosurgeon's physiological tremor 5, 9, 11, 12, reduction of radiation exposure 15, 16, image-based semi-active guidance for inserting implants 14-16, excellent three-dimensional visualization 4, 11, ability for repetitive motions and holding tools for long periods 2, quick adaptation to change in commands 2, and ability for accurate micromotions minimizing unintentional durotomies 2, 4 and injuries to presacral sympathetic plexus 9. Various published articles propose the following features as additional advantages: small skin incision 13, 15, minimal paravertebral muscle dissection 15, minimal retraction 5, minimal bleeding 5, 8, 15, and minimal infection 17. Reduction of length of stay has also been reported 15, 17. Moreover, education in robotic surgery does not seem to be in line with a steep learning curve 6, 8; sufficient experience is gained with the accumulation of 5–10 cases within 2–3 weeks 14. However, limited hand–eye coordination, poor qualitative decision-making ability, large operating room space requirement 2, 3, increased operation time 4, 16 and increased cost are some of the drawbacks that have to be addressed. More specifically, the investment cost for da Vinci® ranges from $1.1 to $1.7 million 5 and still lacks bone-cutting instruments and adequate force to perform basic curetting and rongeuring actions 9. Modified designs of guiding arms 14, along with implementation of haptic feedback 7 and integration of a stereotactic guidance syste