Robotic Spine Surgery

Speaker 1: Welcome back to another episode of HealthTalks NOW brought to you by Baptist Health. We just kicked off season three of the show, and we have a really exciting season lined up for you guys. Today I’m talking with an expert who studies and treats one of the most important structures in the human body, the spine. Neurosurgeon, Dr. John Serak is joining us on the phone today. Dr. Serak provides comprehensive care in the diagnosis and surgical treatment of disorders of the brain, spine and nerves. He has fellowship training in minimally invasive and complex spine surgery, which we’re going to talk about today. He treats all adult spinal disorders, including degenerative disorders, scoliosis, spine trauma, spinal vascular malformations and spinal tumors. And he also treats brain pathology, including brain tumors, hemorrhages, and head trauma. Dr. Serak, welcome. Thank you so much for taking time out of your schedule today to have a little chat.

Dr. John Serak: Hi, thank you for having me.

Speaker 1: Let’s start with the basics. I think back pain has to be probably one of the most universal experiences in terms of medical issues, right up there with headache. Who hasn’t experienced a headache or some type of back pain before. But at what point does back pain become more of a chronic health issue versus an occasional inconvenience and what can be done to help? That’s exactly what we’re going to talk about in today’s episode. So Dr. Serak over to you, I think this is a great place to start. What are some of the conditions that you see that are causing some of that more serious chronic back pain? And at what point do you start to consider surgery as a treatment method?

Dr. John Serak: Yeah, so back pain can be caused by a variety of different issues. It can be from the spine itself or your back, anywhere from the spine, in your neck, your cervical spine, your thoracic spine in the middle or your lumbar spine in the low back. But it can also be caused by structure surrounding the spine, like muscles, ligaments, tendons, that sort of thing. And that’s really the most common cause of back pain is muscular or an issue similar to this overuse, that sort of thing. When things really start to become a problem is when we start seeing issues with the spine or degeneration of the spine on imaging, such as an MRI or an x-ray. And so the conditions I treat are generally more advanced. So in terms of back pain, you have multiple structures in your spine that can break down.
It’s basically a form of arthritis or a way arthritis affects your body, similar to how your wrist or your fingers or your shoulder or your knees would develop arthritis, your spine also develops arthritis. When this becomes severe, we start to see evidence of this on imaging and kind of breakdown of discs and the joints in the spine. And the other thing that we see is we see compression of nerves or the spinal cord. Whereas if you look at somebody with severe arthritis in their hands, you may see that their knuckles are quite large and overgrown and that’s painful, but there’s nothing important for that overgrown knuckle to push on. But in the spine when things overgrow, nerves or the spinal cord can be compressed. And so that can cause more serious issues and these are the reasons why most commonly performed spine surgery is because of compression of nerves or spinal cord as a result of degeneration or in some cases, trauma, that sort of thing.

Speaker 1: That’s such a good explanation of that. I don’t think I had connected the dots that it was similar in how it affects the body as arthritis in other parts of the body, but that makes complete sense. And I think that’s going to help a lot of people understand what’s actually happening when they’re feeling some of this pain and connect to something that they’re more familiar with. You get to a point with a particular case or a patient where surgery is kind of on the table now. Obviously this is not the case for everybody, and this is a conversation they’re going to have, to have with their provider and looking at the full course of their medical history and other factors personal to them.
But when you get to the point where surgery is an option, talk to us about robotic spine surgery, in particular. This is something that you’re an expert in. I know it varies from just the traditional more kind of old school of what we may be used to when we think of surgical technique. But talk to us about the evolution, I guess, of the industry and what we’re seeing with robotic spine surgery today.

Dr. John Serak: Sure. Yeah. Like other areas of medicine, robotics has become more and more accepted and used in spinal surgery. Robotics and spine surgery have really been used over the course of the last, maybe 10 years or so, at least in the United States. In fact, when I was in residency training, we actually tested one of the first robots, beta testing, and that was my first exposure to robotics, and frankly at that time, I had no interest in it. It slowed me down and I didn’t find it to be particularly useful.
But over the course of time, technology has changed and advanced, and now or I’ve incorporated robotics into my practice very heavily, really have become to rely on robotics, to do many of the surgeries that I do. Basically it’s relatively new to the field of spine surgery. But in terms of how we can use it, again, as the technology has improved robotics and spine surgery, has allowed us to be much more accurate and efficient with surgery. We’re able to do surgeries quicker and with more accuracy than we would’ve been able to do previously with more traditional technologies.

Speaker 1: That makes sense. Previously, the same procedure in general is happening, it’s just the method by which it’s occurring that has changed when you look at robotic spine surgery. And previously, I guess the surgeon would’ve done what they just call freehand, which is relying on their knowledge of the human anatomy and then matching that to the particular patient’s x-rays?

Dr. John Serak: That’s correct. There are various ways to kind of do surgery and traditional approaches, but we would rely on x-rays that were taken in the operating room to guide us. And yes, it would be free hand. In other words, your hand ultimately guides where the instruments go and you utilize the patient’s anatomy or x-rays that you’re taking in the operating room to determine where to put a screw or where to put a retractor, et cetera.

Speaker 1: Yeah, that makes sense. I imagine it would allow for a lot more complex procedures to be done with better precision, meaning you don’t have to worry so much if your hand trembles or something like that is. Do you find that to be the case?

Dr. John Serak: Yeah. No, I think it makes very complex procedures, less complex and it also, I think, it gives the surgeon, at least myself, even more confidence in what I’m doing, utilizing the robot. So I can work faster without any concern that, maybe that x-ray isn’t exactly right, or it’s not showing me what I think it is.

Speaker 1: Yeah. What are the potential benefits then? Well, you’ve mentioned a couple, just the precision, the greater complexity with which you can perform the procedures. What are some of the other potential benefits that you see of using robotic techniques to do minimally invasive spine surgery versus what had traditionally been done all these years before?

Dr. John Serak: Yeah. In addition to sort of the precision and accuracy it provides, and also the efficiency, in other words, I’m able to do surgeries more quickly, which is frankly better for the patient, less time under anesthesia and less time, basically being opened up to the air and potentially decreasing infection rates, that sort of thing. The robot also, it kind of allows me and I think other surgeons, to push the envelope in terms of minimally invasive spine surgery and minimally invasive spine surgery is an area of spine surgery that’s become increasingly more popular over the course of time.
Just to give you a quick overview of what it is. Minimally invasive spine surgery seeks to minimize the amount of destruction to normal structures in the body, so it seeks to preserve muscles. So you’re not going and making a big incision and tearing down all the muscles to do what you need to do. And also seeks to preserve what’s normal in the spine. In other words, there’s usually an area or two or maybe more than that, that there is abnormality, but you want to fix that without causing any potential problems in the future or affecting the area that’s normal in the spine.
And so that’s kind of the basis of minimally invasive spine surgery is to achieve those things. And as a result of that, and what’s great for the patient is, typically this decreases the amount of time that they’re in the hospital, or maybe they don’t need to stay in the hospital at all with a minimally invasive procedure versus a more traditional procedure. And typically gets you back to what you want to do much, much faster than traditional methods.
And so robotics has really helped us perform more minimally invasive surgeries. Again, minimally invasive surgeries really rely heavily on use of x-rays in the OR and that sort of thing. And robotics really takes the guesswork out of that. I know exactly where I am in the spine at any given time, simply by looking up at a screen and I’m able to see, this is where I am based on a CT scan that I got before surgery.

Speaker 1: That’s incredible. I think when most people consider minimally invasive surgery, they’ve kind of become accustomed to hearing the words, laparoscopic surgery. I think those have almost become interchangeable in some people’s mind, because for such a long period of time, laparoscopic surgeries were kind of the buzzword when it came to the newest, minimally invasive capabilities, but robotic surgery is not laparoscopic surgery, but it is a type of minimally invasive surgery. So can you explain to us a little bit about, what makes those different or how they compare?

Dr. John Serak: Yeah. Laparoscopic surgery utilizes cameras to look inside of the belly to fix problems, it allows the surgeon to do that without opening the belly up completely through a very large incision. So it allows them to work through small incisions and to split the muscle rather than opening it up, potentially just destroying muscle, et cetera. The same goes for minimally invasive spine surgery. Whereas we don’t typically use cameras for minimally invasive spine surgery, we do work through typically smaller incisions, or at least we are able to achieve less destruction of the muscle that surrounds the spine.
And that of course speeds up recovery and also really is probably helps in decreasing the rate of spine surgeries that are needed in the future, because the muscles of your back are very important in holding you up and assisting the spine in supporting your weight. They’re similar in that they’re working through smaller incisions and they’re not destroying normal anatomy, normal muscles, that sort of thing.

Speaker 1: Yeah. I think that’s really helpful. Obviously we’re talking about completely different parts of the body too, and different techniques. But I think for people like myself, who aren’t really steeped in this stuff, who aren’t as familiar, we started to hear things like minimally invasive and laparoscopic in the same sentences, in the same terminology, and they start to get a little muddied. So it is helpful to kind of break it down that minimally invasive surgery is kind of the larger parent category, and you can lump a lot of things under there, including laparoscopic surgery, including minimally invasive spine, including robotic surgery, so I think that was a really helpful little side note there. So thank you for helping us understand that. Let’s talk about the actual tool you’re using here at Baptist Health, the ExcelsiusGPS from Globus Medical. How does this tool work? What makes it special and does a physician have to undergo specialized training in order to use a machine like this?

Dr. John Serak: Yeah, so we use a specific robot. The Globus ExcelsiusGPS is really state-of-the-art in terms of robotic technology. I’ve used a number of different robots in the past. And this is the one that I feel is best suited to its job and performs the best and really the highest level of technology. Basically what this robot is, it’s a robotic arm. So the base of the robot sits on the floor and there’s a robotic arm that comes in and the robotic arm has special coverings to keep it sterile. In other words, keep it germ free for surgery. And the robotic arm is the thing that actually helps you with surgery. But the other very important component to the robot is what’s called neuro-navigation or a neuro-navigation system.
And basically what that is, is we get a CT scan of the patient prior to surgery. And we load that CT scan up into the robot, into the software or the neuro-navigation software. And then when the patients in the OR, we’re able to put specialized markers on the patient. And so utilizing cameras, the cameras can see where the markers are on the patient and the cameras can actually orient the robotic arm and that neuro-navigation software, to the patient’s body and space. So I can take a little probe and I can put it anywhere on the patient’s spine. And it’ll show me up on the screen exactly where I am based again, on that CT scan that the patient has prior to surgery.

Speaker 1: That is incredible.

Dr. John Serak: Yeah, it’s very, very cool stuff. Again, once the robot is oriented, then the robotic arm can come in and can assist me in performing surgery. What I’m able to do, or what I use the robot for most commonly, is kind of two things. So one is to place screws and rods into a patient. So screws and rods are sometimes used in spine surgery when we perform what’s called a fusion surgery. So certain disorders require what we call a fusion and that typically requires us to place screws and rods. And so, the screws go into very specific areas within the bone of the spine and utilizing the CT scan, that’s performed prior to surgery, I’m able to plan out exactly where I want to put those screws, and then I’m able to bring the robot in. The robot, again, oriented to the patient’s body and space, is able to set up the trajectory for me to put in those screws.
And then I’m able to put in those screws using actually kind of power tools. And so that allows me to very efficiently and accurately place screws when necessary. And then the other thing that the robot helps me to do is to place specialized, minimally invasive retractors. So again, the idea behind minimally invasive surgery is that we’re trying to preserve muscle and normal structures. So we work through smaller incisions and we’re looking through very specialized retractors that allow us to see the area that we’re working on in the spine without tearing down all the muscle and exposing the spine completely.
Speaker 1: It almost sounds like you’re describing a GPS on your car. You’ve got this map laid out and you can see way points along the way. You can see kind of your travel, where you’re going, where you’re headed. Do you look at it kind of like that?

Dr. John Serak: Yeah. It is a lot like GPS and again, the GPS is in the name of the robot itself. Yeah, so you can see exactly where you’re going or I guess in a way, kind of get directions to where you’re going or direct the robot where to go via that kind of GPS idea, but that’s a very good analogy.

Speaker 1: Yeah. And again, just for clarity’s sake, the specific robot that we’re talking about now, the Excelsius GPS, is a tool under that larger category of minimally invasive surgery. So there are lots of these out on the market. You may have heard of some like the DaVinci Robot, for example. So I think when we have all these terms floating around, it can feel very confusing, but it’s really just minimally invasive surgery is kind of the overarching specialty or procedure. And then within that, just like within any other specialty, you’ve got branches of different products or of different techniques, so I think that’s always helpful to kind of come back to, to ground us, as we’re talking about all these new terms and new brand names, helps to kind of guide us from what we’re talking about.
Now that we’ve covered the ins and outs of the procedure itself and the tool that we’re using, let’s jump back to some of those conditions that this procedure can be used to treat. Obviously, this isn’t going to be a fit for everyone, or every ailment, like we mentioned at the top of the show, but just like any other medical procedure, treatment plans are always highly personalized. With that being said, who would be a good candidate for robotic spine surgery and what conditions from some of those that you’ve mentioned before, could benefit from something like the Excelsius GPS?

Dr. John Serak: Yeah. So the primary applications that I’m using the robot for at this point, that it’s really necessary for, are our fusion surgery, so surgeries where we’re putting in screws or rods or specialized spacers to allow for fusion to occur. And fusion surgeries account for a large portion of the surgeries that we do overall. And just depending on the person’s specific issues, as you were kind of alluding to with coming up with very individualized plans, somebody may or may not need it, but I basically use the robot for all fusion surgeries, at least in the low back or mid-back.

Speaker 1: We’ll be right back. You have questions. We have answers. If you’re looking for health and wellness advice, tips, and resources, the Baptist Health blog has you covered. Whether you’re looking to stay up to date on the latest COVID-19 developments, wondering if you should be worried about that headache, looking for advice from trusted medical professionals, or even trying to find a new, healthy recipe, Baptist Health is bringing you the facts and information you need, when and where you need them most. Visit share.baptisthealth.com to start reading today.
We’re back with Dr. John Serak. What kinds of symptoms, or what kinds of diagnosis might someone have that would require them to need those screws and rods that you mentioned?

Dr. John Serak: There’s a number of issues that could potentially require that. Generally speaking, we say that if a patient has instability of their spine, in other words, if there’s abnormal movement that’s going on within the spine, that’s causing pain or causing compression of nerves, those are patients that are good candidates for fusion surgery and do very, very well. The other group of people kind of broadly that require fusion surgeries are those that have abnormal alignment of their spine, often known as scoliosis. But with abnormal alignment, oftentimes, we’ve got to essentially kind of break the spine and pull it back into alignment and then put in the screws and rods to hold everything in place. Those are kind of two broad categories, instability of the spine, and then also, what we call deformity or abnormal alignment of the spine.

Speaker 1: Talk to us about failed back syndrome. Start us with the basics, kind of what is it, how might someone know they have it, and how does surgery specifically the types of procedures you’re doing, how can that help someone with failed back syndrome?

Dr. John Serak: Yeah. Failed back syndrome, it’s kind of a catchall term. And we talk about people with failed back syndrome are people that have either undergone multiple spine surgeries and still have severe pain or issues. And then also people that have maybe tried everything possible to treat their spine issues, and probably even seen a spine surgeon who told them, nothing can really be done for you, but still have severe, severe pain. That’s kind of a general idea of what failed back syndrome is. But the actual cause of failed back syndrome, there can be multiple different causes and there’s multiple different treatments for it, and in a large portion of cases, it’s often that people treating the spine issue or even the spine surgeon, hasn’t really paid attention to the patient’s overall spinal balance.
In other words, does your head sit directly above your pelvis? If it doesn’t, then you can have issues with standing upright and walking and this all tends to create a lot of pain. If you think about it, if you could imagine, if you were walking around with your head sitting six inches in front of where your pelvis is, or kind of hunched forward at all time, that would be very, very painful and kind of would be, as I describe it to my patients often, a tug of war between gravity pulling you forward and the muscles of your back, trying to pull you back into proper alignment. And so I see a lot of people that have, “Failed back syndrome,” that actually have this, what we consider a spinal deformity that’s causing the problem. And maybe they’ve had multiple surgeries in the past, but nobody’s really paid attention to the overall alignment of their spine and kind of missed that, and I’m able to help people by fixing that imbalance that maybe had gone overlooked in the past.

Speaker 1: That’s interesting. Do you find that, that hunching that you talked about, is that generally just how people were born or is that attributed at all to poor posture?

Dr. John Serak: Yeah. By the time you’re seeing me, it’s not just poor posture and maybe there’s some relationship, but this is an issue of basically degeneration of the spine over years and years. As things break down, you lose the normal curvature of your spine, so normally you’ve got specific curves in your neck and in your mid back and in your low back, and those curves help keep your body in alignment, help keep your head over your pelvis. As we get older and as the spine kind of breaks down with arthritis, et cetera, some people lose that normal curvature and that’s what ultimately results in that kind of forward posture or what we refer to as kyphosis.

Speaker 1: That is very interesting as I try to sit up a little bit straighter. Is robotic spine surgery a viable treatment option for folks who are experiencing failed back syndrome? Or do you generally find that people want to shy away from surgery after maybe they’ve had an experience that has failed and they’re still in pain?

Dr. John Serak: Yeah, absolutely robotics is very well suited to dealing with failed back syndrome, especially in cases when patients have had other surgeries before and the surgery to fix the problem is quite complex. So I used the robot very frequently to fix these problems, again, when they need to be fixed. And it is totally understandable that somebody who’s had multiple spine surgeries in the past would shy away from more surgery. But there are many cases in which there is a definitive problem that we can fix and really give people their lives back. And in those cases, despite having failed spine surgery in the past, we can still really make a big, big difference.

Speaker 1: That’s got to be rewarding.

Dr. John Serak: Yeah, absolutely.

Speaker 1: What does life look like after surgery for most patients? Whether this is their first go at spine surgery, or if they’re coming to you as a result of failed back syndrome, where they’ve maybe had a couple before and now we’re looking to kind of improve the quality of life where we can. What do you see as a result of treatment with robotic spine surgery for most patients?

Dr. John Serak: Well again, it is highly variable and it depends on what surgery we’re doing and why, but generally speaking, my goal is to get people back to doing what they want to do. So people find that as they have more and more pain or disability as a result of their spine issues, that they tend to give up more and more of what they love to do. And so my goal is to really get people back doing what they want to do. With my patients, my plan is to fix them and to basically have them to the point that they have no limitations down the road, three to six months generally speaking, and that they can go back and try to get back into what they want to do. I know it’s very discouraging and I see a lot of people who are told, “Well, you’ll never do that again.” But there are many cases in which, “Yeah, you could do that again,” it’s just a matter of finding the right solution for you and being able to fix it, the problem.

Speaker 1: And what an encouragement and a joy it must be for these patients who have probably lived many, many years with not only chronic pain daily, but also with, I imagine, lack of mobility, like you said, loss of activities, especially physical activities or sports that they may have enjoyed and to get even a portion back would be a complete, just a radically different quality of life.

Dr. John Serak: Yeah. No, that’s definitely true and I see it all the time with people. And again, I’m not going to take you from where you are to being an Olympic athlete probably, but at least I can make you feel good enough to maybe get back on the golf course or hang out with your children or grandchildren.

Speaker 1: But I think that, that message is an important one for everybody at home to hear, that all hope is not lost, that it’s worth investigating, it’s worth maybe reaching out and asking the questions and seeing if this might be a viable option for some folks. Like you said, there are probably a lot of people out there who are listening here today, who have been told, “Well, this is just as good as it’s going to get,” or, “You’ll never do that again,” like you said. And maybe in some cases, that might be accurate. But like you said, I bet there are a lot of those out there who could benefit from maybe having a consultation or from just seeing what this robotic technology could do.

Dr. John Serak: Yeah, no, I definitely agree. And I see patients every day that are discouraged and that we find good solutions for them and really help them get back to some of the activities that they had stopped doing.

Speaker 1: That’s great. Was there anything else we haven’t directly covered today that you wanted to mention or you think is important to add?

Dr. John Serak: Yeah, I think we pretty much covered everything that we wanted to talk about. It is difficult describing exactly robotic spine surgery and specific procedures and things, because it’s quite complicated and it really comes down to an individual basis, why I do what for who. And two people with the exact same problem, may get two different procedures because of various, various reasons. But yeah, no, I think we got the point across, I think. I don’t know, you tell me no.

Speaker 1: I think so. I think it’s helpful just to demystify some of it, because I think when people hear robotic surgery, they’re like, “Oh, well that sounds too complicated. My doctor’s not even going to be the one in control,” and there’s a lot of myths out there. A lot of just false information, that I think can kind of make it feel scary or just immediately avoidant. And I think it helps just to talk through not only just the terminology, but kind of break down, what does that mean? What does that look like? And the bottom line is that, we’re looking at problem and then solution. So there’s problem, diagnosis, solution, is really the gist of it. You’ve got back pain. You’ve got, like you said, some of these symptoms that we mentioned today and really it’s just about what tools do we have?
What are our capabilities? What makes the most sense given this person’s medical history and the abilities that we have now with emerging technology to fix that or to do the best that we can to get them to a better state and quality of life. And I think when we look at it like that, and when we talk to you and you share your expertise with us, it helps to put the pieces together to make it something that is extremely complicated and is extremely difficult for most of us to understand. It makes it feel a little more attainable. So I really do appreciate you taking the time to explain to us, to take some of that mystery away.

Dr. John Serak: All right. Well, great and I’m happy to do it

Speaker 1: Well, Dr. Serak, thank you for joining me on the show today. I think I can speak for everyone when I say that we are very excited and grateful to have your expertise here at Baptist Health. If you want to learn more about robotic surgery or the surgical services we offer at Baptist Health, visit baptisthealth.com or check the show notes in today’s episode for a direct link. If you enjoy today’s episode, leave us a review wherever you’re listening or share and tag us on social media for a chance to be featured. I’ll catch you right here next time on HealthTalks NOW, stay well.
Well, that is a wrap with Dr. Serak. Thank you so much for tuning in today. If you enjoyed this episode, as always, please leave us a review where you’re listening and share it with a friend. If you want to make an appointment with Dr. Serak or get in contact with his office, I will leave the contact information for his office in the show notes of today’s episode. Thanks so much again, and we’ll catch you next time on HealthTalks NOW, stay well.