OTW: These are not cheap systems and maintaining them every year is costly. How did you introduce it to your institution? Were you the champion?
Dr. Goldstein: The members of our spine surgery group were all the champions. There was broad leadership support including our division chief Dr. Thomas Errico and administration including SVP David Dibner. As for the university, when they see an opportunity to improve patient care they’ll work very closely with us to achieve that.
OTW: What types of spine surgeries lend themselves to robotics?
Dr. Goldstein: I think the sweet spot for the robot is 1 to 3 level minimally invasive spine fusions. And if you’re looking to supplement an interbody fusion, whether it be a TLIF, XLIF, OLIF, ALIF, any one of those LIFs.
OTW: Deformity?
Dr. Goldstein: If your practice is minimally invasive, deformity with percutaneous screws and I think robots fit right in there.
OTW: How do robots improve your precision? You’ve been doing complex spine surgeries for many years, you teach and do original research. How do these new systems improve your work?
Dr. Goldstein: I think it maintains my precision but with significantly less radiation exposure. And, since it’s image guided, I can watch the screw being placed through the monitor and see that screw is going along the path I designed. I am more confident it is in the pedicle.
OTW: How much set up fiddle factor is involved?
Dr. Goldstein: Much less than you think. There is a learning curve and there’s a workflow. The workflow with the robot is not bad now and will only get better. I’m very impressed so far.
OTW: Do your marketing folks here at NYU get excited about robots in surgery?
Dr. Goldstein: I think they’re excited about it and we’ll develop a marketing program. Back in October I remember being in a meeting and having a patient call me while I was at the meeting and asking me if I was going to be using a navigation for his surgery. Patients will seek this out. Patients want the opportunity for the best outcomes. They know what’s new.
OTW: Now that you’ve used robots, where do they go from here 5 years or 10 years from now?
Dr. Goldstein: Certainly, we need to develop user groups because there’s an opportunity to expand this. Where will it go? Add-ons—voice recognition, for example.
OTW: Like Alexa? Is that the kind of thing you would want?
Dr. Goldstein: Yeah! I think it’s important to remember, however, that this is robot-assisted surgery. The robot doesn’t touch the patient. And it’s important for people to understand that this is really setting up the surgeon to put the screw in the best place. And it’s where the software is very exquisite.
OTW: Does a robot free you up to do some other things or to think in more challenging ways about these cases?
Dr. Goldstein: That’s really a two-part question because the burden it takes off my shoulder is really a cognitive burden. I tell my fellows, there’s a sequence of how you learn to get to robotic surgery. If you start with robotic surgery, you’re never going to learn how to do open surgery. You need to go in sequence. You need to be facile at open surgery. Then you need to be good at minimally invasive surgery and fluoroscopically guided surgery. Only after that natural progression are you ready for robotic assist surgery. If you do it backwards, you’re cutting corners and you’re never going to get it right. So, you need to go in that order.
Dr. Goldstein: I think that where we’ll go next with robotic surgery is revision surgery and complex deformity cases.
OTW: Plus, it’s so precise.
Dr. Goldstein: This allows you do it through smaller incisions with greater precision. I had a good level of confidence using fluoroscopy in minimally invasive surgery. With robotic assistance I have a higher level of confidence. And it’s faster.
OTW: Thank you so much Dr. Goldstein. This was fascinating.
All Photos by Andrew Huth: www.andrewhuth.com
