The future is now – robotic spinal surgery blazing a trail

Historically, spinal fusion surgery had the worrisome reputation of being high-risk, especially being performed near major structures such as the spinal cord and important nerves. It has also been associated with significant post-operative pain and a difficult, protracted recovery.

However, computer navigation and, more recently, robotic spine surgery has transformed the safety and accuracy of the procedure, according to Professor Joseph Butler, consultant spine surgeon and clinical lead at the National Spinal Injuries Unit, Mater Misericordiae University Hospital and Mater Private Hospital.

The Mater Private Hospital was the first centre in Ireland and the UK, and the second in Europe, to set up a robotic spine programme almost seven years ago. Now Professor Butler says that the surgery is on its way to becoming the standard of care.

“It allows much smaller incisions, reduces blood loss and muscle damage, and leads to less post-operative pain,” explains Professor Butler.

“It also results in much faster recovery. Patients are doing activities anywhere between two to six weeks [as opposed to months], which is way ahead of the standard expectations. The standard inpatient stay after a traditional open spinal fusion would be one week minimum. The average inpatient stay of spinal fusions is two days which is a huge leap forward in clinical care. So the patients are recovering much more quickly than before.”

When you think of the term “robot helper”, visions of robots from the movies spring to mind, but the reality is very different – it could be described as a mechanical hand or tool.

“The robot is more of an assistant. We’re still performing the surgery, but our guidance is assisted by the robot. It takes us to the appropriate space and location and allows us to place implants or do precision surgery,” he explains.

Living longer

The typical conditions where robotics are used in surgery include low back pain, leg pain and conditions that compress the spinal cord and as a result, significantly reduce mobility.

“With people living longer, we have lots of patients who would previously have been considered high-risk for traditional spine surgery. However, they are now candidates for robotic spine surgery because it’s allowing us to operate more precisely and quickly.

“I have an expanding group of patients in their late 70s and early 80s who have done incredibly well with minimally invasive robotic surgery.”

Professor Butler adds that in the last two years, there has been an increase in the number of spine robots that have been acquired by private institutions, particularly in the greater Dublin region (five in total) and this has also extended to the public system.

“Obviously there’s an initial capital outlay to buy a robot but it doesn’t add any further expense to the patient. It doesn’t add anything in terms of insurance plans or patients who direct pay. It just depends on the technology being available in the hospital and a surgeon being appropriately trained.”

More surgeons are getting trained in this technology and it is getting built into clinical practice in a safe and graduated way.

“Some of the pre-marketing testing of the robot was in Philadelphia when I was on my fellowship training. When we returned the following year, that’s when we were able to purchase and integrate the technology in Ireland.”

Next stage

The professor says the next stage of robotics is the augmented and mixed reality space.

“Essentially, these are virtual reality headsets. We’re now using them at the Mater and we give all the students that come through our training a session using the headsets.

“At the moment, there are two types; one set allows us to understand the anatomy and these are good for pre-operative planning. The second set, which we were the first site in Europe to use last September, allows us to use mixed reality and headsets live in surgery.

“We’ve done a significant number of surgeries now with patients using the headset, which allows us to have image overlay on the spine,” he says.

“If you can imagine a patient is asleep, you’re looking at their skin, you can see the overlay of all their structures below that.

“Everybody in the room gets to see what we’re seeing, the overlay of all the bony structures and vascular structures and nerves over the spine. So you’re having that kind of 3D immersive component.

“[In the past], patients have been quite concerned about spinal surgery because of its reputation of being major surgery, but when they hear the benefits of safety and accuracy that robotic surgery brings, it makes them feel much safer, and confident of a quicker recovery.

Robotic spinal surgery sits as part of a broader question: how can experts incorporate modern technology into healthcare to improve how patient care is delivered across Ireland?

As these technologies continue to develop and become integrated into standard healthcare practices, the future of healthcare will hopefully be more accessible, effective, and efficient. It should continue to be developed in a way that is patient-centred and that helps to secure the best outcomes for a healthier future.

Case study: Robotic spine surgery, Audrey Kane

When you hear the words ‘spinal surgery,’ you might think of large incisions, prolonged recovery periods, and painful rehabilitation. That’s certainly what I thought before I had my surgery.

Let me take you back to my life before the procedure in 2019. I had spent years dealing with mild to chronic pain. Some days, the pain was so severe that I dreaded my daily commute. My back would seize up unexpectedly, and I often couldn’t get off the train until two stops after my own. Heat pads and painkillers became my constant companions, alongside regular physiotherapy sessions.

Despite these sessions and the significant expense they incurred, the improvement I was hoping for never came. It was clear I needed a different approach. So in 2018, I started researching surgeons and came across Professor Butler’s profile which talked about robotic spine surgery and I decided to book an appointment.

To streamline the process, I first secured a referral from my GP for an MRI scan. By the time of my initial appointment, I had the results ready.

I’ll be back

After reviewing my MRI scan, he diagnosed me with a disc bulge at the L4/L5 level, causing right-sided L5 nerve root compression.

He first discussed non-operative strategies, including Pilates to improve spinal flexibility, weight loss, and a nerve root block to alleviate the sciatica. Next, he explained the operative strategies, detailing the indications, risks, and potential complications of the surgery.

Although I knew an operation was inevitable, I was determined to explore every non-surgical option first. Truthfully, I was also terrified at the thought of back surgery. Professor Butler assured me that I’d likely return for surgery at some point. He was right.

While the nerve block provided temporary relief, it only delayed the inevitable. The pain persisted and significantly impacted my daily life. By 2019, my surgery – known as a microdiscectomy – was scheduled, along with a date for post-op X-rays.

The operation took place at the Mater Private Hospital and I was fortunate to have health insurance that covered the procedure – the institution’s website has a comprehensive insurance checker to discover if you too are covered and the value of any excess or shortfall you may incur.

I stayed in the hospital for just two days. On the first day post-op, I experienced mild discomfort around the incision site, but it was manageable.

On day two, the physiotherapist guided me through walking up and down stairs and gave me an exercise program to follow. The incision site was cleaned and checked and I was discharged.

Recovery took six weeks at home and while it was a long time to be off work, the benefits outweighed the inconvenience.

Advances in surgical techniques, such as my microdiscectomy, have made a remarkable difference.

While spinal surgery isn’t the first-choice treatment for everyone with back pain, if it begins to disrupt your everyday life, it’s definitely worth considering. For me, it was life-changing.