Dr Kornelis Poelstra is one of the world's most experienced experts in robotic assisted spinal surgery. In this exclusive interview he explains the enormous potential of robots to improve patient outcomes, run more efficient ORs and help even the most experienced surgeons to always bring their ‘A game’

 

How did you first become interested in the spine, and what caused your interest in robots?

I actually worked in car detailing and as a basic mechanic at Ford when I was 14 and subsequently Volvo until I was 23. I enjoyed engineering and working with my hands so when I started medical school I knew I wanted to specialize in orthopaedics.

A Nuffic (Dutch organization for internationalization in education) grant brought me to the US, where I completed my PhD in Biomedical Engineering and began a residency at the University of Virginia. It’s a powerhouse for Orthopaedics and Spine/Neurosurgery, which is how my interest in spine began. The residency was fantastic; spine was just for me. I was offered an Ortho-Neuro Fellowship at Thomas Jefferson with great mentors and after completion, I became assistant professor at the University of Maryland/Shock Trauma. I spent four years in Baltimore doing spine deformity and trauma, where I learned to do big surgeries and do them well.

 

My interest in robotics really goes back to my fascination with mechanics, but it was also a solution to two common problems we faced when doing complex reconstructions. Firstly, it seemed superfluous to have to expose everything, particularly when you have a really sick trauma patient. These patients come in as sick as can be, with multisystem organ failure and then on top an unstable spine – they’re too sick for an open spine operation. However if you can operate in the first 24 hours after a trauma with minimally invasive surgery, by just stabilising the patient, they do a lot better. I saw there were huge advantages, but the next challenge was fluoro-radiation with ‘conventional MIS’.

 

​Even though we were pretty fast, a 10 level spine reconstruction took about four minutes of fluoroscopy. Navigation could only do so much with these patients, as any change in alignment of the spine made the registration back then very difficult. I thought, there must be a better way, and the answer was robotics.

 

I thought to myself that just like everywhere else, everything will at least partially become automated, even in medicine. I decided to stop saying ‘I’m a really good surgeon; I can do this without robotic devices’, because robots, like everywhere else in society, are here to stay. I want to be one of the first surgeons adopting this new technology while still in its infancy, so that I’ll be ready when the real machines are coming.  I am going to be better prepared and I will know the nuances of robotic spine surgery better, I could teach more people about it and I could essentially serve my patients much better.

 

What technology are you using and how has it evolved since you started working with it?

I’ve been interested in  Mazor systems since about 2008, when their first robotic system (Mazor Renaissance) became available. Because I was such a heavy user of their system since 2014, Mazor approached me and introduced me to the earliest Mazor X, and I've been collaborating very closely with them in the development. I’ve done about 200 Mazor X cases now, more than anyone else in the world. Early on, the systems couldn’t keep up with the huge amount of calculations; we had crashes, power outages, smoke coming from the machine, robot arms just stopping…. Luckily nobody ever got hurt. The ability to hang in there and see the value is what set us apart. Now the technology is so smooth and cases so quick that it’s a whole different philosophy. The future robot arms will be so stable that we can start thinking about doing decompression with them rather than just trajectory guidance, which is what it mostly is today.

 

What percentage of your procedures is robotic-assisted?

I've done about 400 robotic-assisted surgeries in total so far. I do pretty much all screw placements with the robot.

 

​We’ve put in more than 3,000 screws and had zero failures. I do evidence-based surgery, and we’ve actually shown that the risk of running into any kind of complication is reduced three fold compared to minimally invasive cases using “freehand MIS” without the robot, and re-operation rates are also three- to four fold less.

 

Additionally, my readmission rates for these types of cases became significantly reduced. We simply are better prepared when we go into the OR due to the planning stage for the Mazor system. Once I have planned my case, I can execute it in a flawless fashion.

I am more relaxed in the OR because the robot will go exactly where I planned it, and it is just as easy to place a screw through a 2mm pedicle as it is to instrument a 10mm pedicle.

 

How important is surgical experience for doing robotic-assisted spine surgery?

I believe you need to be able to do a good technical surgery first to know what the anatomy looks and feels like, because then you’re going to be much better at appreciating the nuances of robotics. It’s a concern that some surgeons are emerging from training programmes having only experienced “MIS” via navigation and robotics. I think there should be a requirement to have done, say, 100 open cases and conventional freehand MIS cases so you can get yourself out of trouble if the technical tools fail you. On the flip side of that, for an experienced surgeon the move to robotics is very easy; the surgical team will need two or three cases to get used to the new tools and the surgeon will need about five cases to learn the nuances and a further 10-15 or so to fully appreciate the dos and don’ts. After about 20 procedures you really have it and can focus on honing your skills.

 

How do you believe robotics will change

spine care?

It’s a tremendous challenge as the early adoption of the technology comes with a cost, but you have to seriously look at the evidence of reduced complications and readmissions. It’s a test of humility to recognise that you might not be at your best after 12 hours surgery or a fight with your staff. We’re all human and we can’t be on our “A-game” at all times, so we should look for tools that will make us better. The ‘secret sauce’ is coming to the playground as you realize you will be a better prepared surgeon, and therefore more able to focus on the medical aspects of the case, and maybe be a better champion in the OR for your team. As surgeons, we are bred to be number one at what we do, and the challenge is to become humble and realize that there are highly advanced tools that actually make you better if you are willing to go through the learning curve.

 

In today’s world of Big Data, how does robotics help to capture statistics and ensure reproducibility of the outcomes?

 

​Initially the robots were true trajectory guidance tools. Today's robotic systems go way beyond that. They are used as a data hub capturing and reporting everything we do. Robots have the potential to drive efficiencies and manage inventory better.

 

In the future, say I put in 10 screws over 5 levels during a surgery: imagine if the robot simply brings me the exact 10 screws and corresponding screwdrivers, instead of opening several trays of sterilized equipment at $100 each that have been shipped cross-country each time like we do today. Due to the pre-operation planning, the robot will be able to know and order everything that I will need for my operation. Having the exact equipment there without excess and make all of it disposable afterwards is so much more efficient and cost effective. The potential is enormous.

 

What are the characteristics of your ideal

future robot?

No matter all the advances, the number one thing is patient safety. The FDA doesn’t allow a robot to drill itself currently but in an ideal scenario I’d have the ability to touch the screen with my finger and have the robot drill- or decompress the spine where needed. Regulation-wise, we need to move forward safely and cautiously, with experienced surgeons working alongside industry and regulatory bodies.

 

Where do you believe the field of robotic surgery

is headed in the short and longer term?

 

​I hope we’ll have two or three more systems hit the market soon because competition in this field is a good thing. Then, I think we’ll see much greater adoption of the technology to make it more mainstream than navigation ever was. I think that will happen within two years, and by five years, we will see the robot starting to do ‘active things’ for us like osteotomies or discectomies for interbody reconstructions.

 

The next generation of tools will be safer and faster than working by hand, and the surgeon’s role is fine-tuning and checking it. Open exposure of the spine will still be necessary in some procedures of course.

Lastly, robots can only become great if they can make a really good, fast surgeon even better. And the way the technology is going… This is very much worth pursuing!