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Evolving Minimally Invasive EndoscopicSpine Surgery:
A Surgeon’s Perspective and Technological Considerations
• Chief, Neurospine Surgery, California Spine Institute
• Founding Chairman – President, the American Academy of MinimallyInvasive Spinal Surgery (AAMISMS).
• Immediate past President of the International Society for MinimallyIntervention in Spine Surgery (ISMISS)
• Internationally recognized pioneer and leader in minimally invasive
spinal surgery (MISS).• Interests:
– Promoting interdisciplinary, inter-specialty and international education
– Research and Development in MIST
– Contribution in surgical informatics development of a “digital technological
convergence and control system” for DOR (digital OR)
– Authored and co-authored numerous peer reviewed articles, chaptersand textbooks, and appointed to editorial boards and an Editor-in-Chief
for medical, surgical, and research journals.• Enjoys the practice of martial arts (Grand Master, Martial Arts Hall of Fame and
Martial Arts Legend Award)and its philosophy, playing Chinese classical musical
instruments, collecting Asian Art, tennis, skiing, traveling and social
networking.
• Contact Information: www.spinecenter.comJohn C Chiu, MD, DSc, FRCS (US)
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Society for Progress and Innovationsfor the Near East:
Updates and Cadaveric Bio-skills WorkshopBeirut, Lebanon
June 23 – 26, 2010
Evolving Minimally Invasive
Endoscopic Spine Surgery:A Surgeon’s Perspective and Technological
Considerations
John C Chiu , MD, DSc, FRCS (US)
Chief, Neurospine Surgery
California Spine Institute
Thousand Oaks, California, USA
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What is Minimally Invasive Spine Surgery(MISS)?
• Surgery is trending toward minimallyinvasive surgery worldw ide includingspine surgery
• Advancements in instrumentation,fiber optics, laser technology,fluoroscopic imaging, high resolution
video imaging endoscopy, along withthe accumulated experience inendoscopic laser spine surgery madeMISS possible
• Minimally Invasive Spine Surgery(MISS) requires more precise, delicateand effective method for spinaldecompression
• MISS does not de-stabilize thevertebral segments
• Can safely treat multiple levelsymptomatic spinal discs, spinal stenosisand high risk spinal patients
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Anatomical Basis for
MISSPathophysiology
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Spinal Care and Treatment:
• Back pain is a result of modern lifestyleincluding prolonged sitting, driving, computerwork, watching television, high speed vehicleaccidents, plane crashes, active sporting activitiescausing spinal injury, overeating, obesity, lackof exercise , and emotional stress and even
degenerative process
• There is frequent occurrence of back pain -statistics
– 85% of Americans have some back painduring their lifetime
– 5%-8% of Americans have back painaffecting their lifestyle and work
– 3% or less may require some type of procedural intervention
• The majority of back pain can be treatedconservatively with relief by self-care,acupuncture, exercise, physiotherapy,medication and at times injectional therapy
Current contemporary concept in minimally invasive
spine care
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Introduction:
• The spine is a bony column in the centerof the body with the following functions:
– Supporting the body, keeping it straightinstead of being crooked as in scoliosis orthe hunchback of Notre Dame
– Providing the mechanism for bodilyleverage, bending, lifting and twisting
– Protecting the nervous system, spinalcord, and nerves
– Preservation free spinal motion
• The disc serves as a cushion for thevertebral bodies
• Like a jelly donut. The outer layer isvery firm and fibrous, nucleus fibrosis andthe inner layer gelatinous, jelly like,nucleus pulposus
• If you have a bad back, you will have aback pain
Anatomy and function of the spine
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Introduction:
• If conservative treatment fails,and continue to have persistentsignificant symptoms affecting theirdaily activities and ability to workthis can lead to the need forsurgical decompression of thedisc
• In the past, the only methodwas open traumatic lumbar
surgery with cutting of the muscle,bone and the disc, and even spinalfusion, which are associated withlong periods of recovery, woundhealing, blood loss, hospitalization,and others
Herniated Lumbar Discs Causing Nerve Impingement- Radiculopathy
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Surgical Indications
Reason for Surgery
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MISS Surgical Indications:
– Herniateddiscs /degenerative spinedisease
– Post fusionJunctional
DiscHerniationSyndrome(JDHS) orAdjacentSegmentDisease (ASD)
– Vertebralcompressionfracture(Osteoporoticand post-traumatic)
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MISS Surgical Indications:
– Lumbar spinalstenosis andspondylolisthesis
– Cervicogenic
headache anddiscogenic pain
– Intraspinallesions
– Synovial cyst anddegenerative cyst
– Intraspinal tumor,lipoma
– Others
For treatment of:
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MISS Surgical Indications:
• Intractable symptoms withoutrelief by conservative treatment,exercise program, medication andeven injectional therapy
• Positive neurological findingsof reflex changes, muscularweakness and/or decreased painand touch sensation
• Laboratory testing beingpositive for MRI scan, CT Scan,
EMG and others• Positive 3 legs of bar stool –
symptoms, physical findings,EMG, imaging and provocativediscogram to support thesurgical indications
As 3 legs for a bar stool –
supporting findings forsurgical indication:
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ChallengesFacing
Traditional -Current Open
Spine
Surgery/ Fusion
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Challenges Confronting Open Traditional SpineSurgery/ Fusion, Spinal Arthroplasty and Disc
Replacement
• Obvious challenges:
– Larger surgical incision – longer healing time
– More traumatic than MISS and more blood loss
– Often is performed under general anesthesia
– Higher risk and complication rate
– Long and painful recovery time
– Higher long term complication rate includingpost fusion junctional disc herniation syndrome(JDHS 19-49% after 4-5 years)
– Alarming high rate of “failed back syndrome”
– Long term benefit and outcome in question bynumerous studies published
– Disc replacement technology/ arthroplasty isyet to be proven – only time will tell (another 8-15 years)
– More difficult in high risk patients with morbidobesity, cardiac pulmonary disease, advanceddiabetes, elderly
– Affecting spinal segmental motion
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Logical Evolution of
Spine SurgeryEndoscopic Laser MISS
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Logical Algorithm for Spine Care:
For treatment of degenerative and herniatedspinal discs, and spinal stenosis
Pain Management
Injectional Therapy and RF
Conservative
Treatment
Minimally Invasive
(Laser) Spinal Surgery
Spinal Arthroplasty
Disc Replacement
Artificial Disc
Open Spinal Surgery
Fusion
MISS and NFT
The last resortThe modern concept - algorithm of spine care like walking up a staircase
Maybe
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Advantages of Minimally Invasive LaserSpine Surgery (MISS)
• An out patient or "same day surgery“, no hospitalization
• Less traumatic
• Small or tiny incision
• Costs less - approximately 40% less than a open spinalsurgery/ fusion
• Economic savings for the employee and employer are significantdue to earlier return to work
• Done under local anesthesia
• Early post – op exercise one day after surgery
• Surgical triad approach and critical "fan-sweep maneuver" furtherfacilitate the disc decompression and improves surgical result
• Multiple level spinal discectomy can be performed at one sittingw ith minimal risk
• Can be done for high risk anesthesia patients w ith morbid obesity,emphysema, and cardiac conditions under local anesthesia/ IVsedation at much less risk
• Intra-operative neurophysiological/ EMG monitoring, and directvisualized endoscopic significantly reduces the chance of inadvertent injury of neural structure
• Preserves spinal motion
Obvious advantages of Laser MISS:
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Surgical Procedure/ Technique:
• Anesthesia: Local/ IVconscious Sedation
• Intra-operative
continuous monitoringof vital signs (pulserate, blood pressure,RR), pulse oxymetryC02 content,neurophysiologicalmonitoring – EEG,EMG, on intra-operative
wave formdisplay /monitor
• To insure safety andto facilitate MISS
Preparing for MISS – Anesthesia
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Types of Endoscopic LaserMinimally Invasive Spine
Surgery (MISS)
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LUMBAR ENDOSCOPIC LASER MISSTECHNIQUE:
• Patient positioning and localization
– Patient in prone position
– Or in lateral decubitus position
– Localization – skin marking for portal of entryand placement of needle
– Under fluoroscopic guidance
Posterio-lateral and posterio–median surgical approaches
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Lumbar Endoscopic Laser MISS Technique:
• Under fluoroscopicguidance
• Provocative discography
to confirm the damagedherniated disc
• Point of incision – byplacing the “bull’s-eye” target device to determinethe portal of entry andskin incision
Localization of skin incision and portal of entryProvocative discogram
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Surgical P lane/ Approach/ Technique:
Right posterolateralapproach - proneposition
for endoscopic lumbar
MISS
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Surgical P lane/ Approach/ Technique:
Left lateraldecubitus position
for right posterolateral
endoscopic lumbar MISS
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Surgical P lane/ Approach/ Technique:
Left lateraldecubitusposition
for rightposterolateralendoscopic lumbarMISS
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Surgical P lane/ Approach/ Technique:With GPS
• Extreme obese patient had left
posterolateral endoscopiclumbar disectomy withgeometric line/plane and GPSsystem
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GPS (Grid Position System) for Endoscopic Laser Lumbar MISS
Fluoroscopic monitoring to provide safe and precise lumbar spinesurgery by using GPS
Subarticular
Extraforaminal
Foraminal 1 disc
2
3 pedicle
BCD
A
• Lumbar spine has neuroforamen and intra-laminaforamen openingsrestricting MISS at a portalof entry
• Critical structures withinthe foramen – DRG,neural structure
• GPS provides a preciseand safe path to reachthe lesion and to avoidtrauma to the nervevessels, DRG, dura andeven the spinal cord
• The grid – the GPSSystem – Zones (in A,B,C,D and 1,2,3) provides aaccurate navigation mapfor MISS surgeons
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GPS (Grid Position System) for Laser Endoscopic Lumbar
MISS
Mini Endoscopic Spinal Surgical I nstruments for MISS
• Duck bill tubularretractor with dilator toenter the GPS for lumbardisc surgery to protectdural and neurovascular injury
• Under endoscopy andfluoroscopy, spinalinstruments of trephineforceps, curette, rasp,
knife, discectome, andlaser can safely beutilized for MISSsurgery and laserthermodiskoplasty
Close up view
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GPS (Grid Position System) for Endoscopic Laser Lumbar
MISS
Fluoroscopic/ imaging and endoscopy to provide safe and precise
lumbar MISS and foraminoplasty
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Lumbar Endoscopic Laser MISS Technique:
• Holmium YAG laser equipment for Laser Thermodiskoplasty(LTD)
TrimedyneHolmium YAGlaser generator
Right angle (sidefiring) laserprobe
Application of Tissue Modulation Technology inEndoscopic Laser MISS
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Lumbar Endoscopic Laser MISS Technique:step by step
Fluoroscopic/ imaging and endoscopic monitoring to provide safe andprecise application of endoscopic microdiscectomy and laser
thermodiskoplasty
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Lumbar Endoscopic MISS Technique:
• Small spinaldiscectome for rapiddisc removal
Additional advanced MISS surgical instruments
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Lumbar Endoscopic MISS Technique:
• Under fluoroscopy -With dilatationtechnology
• Introduction of dilatorand then a tubularretractor /workingcannula are passedover the stylette
• Foraminoplasty anddecompressive
discectomy performedwith trephines, forceps,ronguers, discectomeand Holmium laser
Posterio-lateral approach vs. posterio–median aproach
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Lumbar Endoscopic MISS Technique:
For larger extruded herniated lumbar discs (red arrows)
Endolumbar paramedium approach
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Surgical Instruments and Equipment:
Tissue Modulation Technology
laser, radio frequency and cryogenic are utilized in MISS, spinalinjection and spinal denervation
Holmium YAG laser generator Radiofrequency generator
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I llustration Case I Lumbar MISS
• 26 yo “Extreme Athlete”,Motorcycle, Rally car X-
games gold medalist
• Severe posttraumatic
L4-5 disc herniation
• Excellent relief from
outpatient endoscopic
MISS
• Return to rally car racing
in two weeks
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I llustration Case II Lumbar MISS
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CERVICAL ENDOSCOPIC LASER MISSTECHNIQUE:
Anterior Endoscopic Cervical LaserMicrodiscectomy
• Cervical discectomy– begins with anterior medialapproach for needle and stylette insertion into the discunder monitoring (fluoroscopy, EMG) aided by GPS System
I llustrated w ith
Cervical GPS
45°
20°
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Cervical Endoscopic Laser MISS Technique:
Endoscopic/ fluoroscopic/ imaging monitoring to provide safe and preciseapplication of provocative discogram, aggressive micro grasper forceps,
drill, discectome, and bony ronguer for microdecompression
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I llustration Case – Cervical Laser MISS
English rock star had successful endoscopic cervical discectomy C3-4 with hypoplastic odontoid and C3-4 discherniation
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THORACIC ENDOSCOPIC LASERMISS TECHNIQUE:
POSTEROLATERAL ENDOSCOPIC THORACICDISCECTOMY
• Due to tight and confinedanatomical relationship atthoracic spine of the spinal cord
and spinal canal, the use of laminectomy, and various thoracicspinal surgical approaches for thetreatment of herniated thoracic discshas been associated with anunacceptable high rate of pulmonary and neurological
complications• Therefore, spinal surgeons have
long sought to find a betterprocedure to treat thoracic discherniations effectively and lesstraumatically
Portal of entry
O C C OSCO C S
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THORACIC ENDOSCOPIC LASERMISS TECHNIQUE:
• Patient Positioning, localization and portal of entry– PETD is performed under local anesthesia and conscious sedation
Fluoroscopic/ imaging monitoring to provide safe andprecise Posterolateral Endoscopic Thoracic Discectomy
Portal of entry
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Thoracic Endoscopic Laser MISS Technique:
Fluoroscopic/imaging monitoring to insure safe and precise endoscopicthoracic discectomy via GPS within the grid
GPS (Grid Position System)
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DiscfragmentsRemoved
Herniated Thoracicdisc
Thoracic Endoscopic Laser MISS Technique:
POSTEROLATERAL ENDOSCOPIC THORACIC
DISCECTOMY
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I llustration Case – Thoracic Laser MISS
27yr old F-22 fighterpilot suffered severeT7 herniated discsymptoms as aresult oftremendous G-Forcesuccessfully treatedwith endo-MISS
T7 herniated disc
Endoscopic Thoracic MISS for F-22 Fighter Pilot
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New Digital Technology to
Facilitate Endoscopic LaserMISS (Digital OR – DOR)
Image view boxes
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Current Digital Endoscopic DOR suite facility
Courtesy of : Dr. John Chiu, California Spine Institute
MD’s
Staff
RN,Tech
EMG Monitoring
C-Arm Fluoroscopy
MRI Image - PACS
C-Arm Images
Image Manager - ReportVideo EndoscopyMonitor
EEG Monitoring
Left side of OR
Teleconferencing -telesurgery
Lasergenerator
DOR S i l PR C t l S t
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DOR - Surgical ePR Control SystemSurgMatix ® TO FACILI TATE MISS
With Image acquisition, Display, Manipulation and DocumentHistorical and Live Data on two Opposite Large Screens
Pre-OP 52” LCDIntra-op 52” LCD
Operating Table
136 Endoscope
Display /
Storage
142 LaserGenerator
138 EEG/
Display
2800 mm.
120 Large screenintra-opimage/data
143 SelectedImaging/ dictationsystem
133 Video
Mixing
Equipment
132 Surgical
Video
Camera /
Display
141 EKG/
Display
139 Vital
signs and
Display
137 Authoringdocumentmodule
Fluoroscopic
Display /Storage
134 C-ARM-
SurgicalInstrument
table
Assistant Surgeon ScrubNurse
Anesthe-siologist
Circulator
1Large screenPre-opimage/data
140EMG/Display
135Pt Biom ID
100
131NeuroPhysio(SSEP)
133 FluidIntake/Output
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SurgMatix ® IN MISS DOR
• SurgMatix ® was created by an innovative team for seamless
connectivity and teamwork in a MISS DOR
• It provides not only digital connectivity but also integrationof all OR systems including, sophisticated surgicalinstruments, equipment, complex high tech systems for “digitaltechnological convergence, and efficient DOR controlsystem”
• In order to facilitate and to perform a safer and better MISS
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2nd Generation Integrated (SECS) SurgMatix ®
Schematic diagram of
2nd
generation of SurgMatix ® integrated
SECS, two types: in amobile unit, or in a tower
SurgMatix ® mobile unit
SurgMatix ® tower
G l f S M i ® i t ti t
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Goals of SurgMatix ® integration system
to facilitate and control MISS
• Provides a complete picture of the patient’s medicalhistory and status by consolidating data from multipleIT and OR systems – patient transparent
• Improves patient safety by converging pre-op, intra-op and post-op data and OR control – patient centric
• Offers a complete “real-time” picture of thepatient’s medical status, including vital signs, waveform and biosensor data
• Promotes workflow efficiency in the DOR, reducingpersonnel and other costs, leading to a significanteconomic saving in an “organized control insteadof an organized chaos” environment
• Enhances quality of patient care by providinginformation available to all OR staff and facilitatingcommunication in the DOR
• Facilitates post-surgical care and trend analysisthrough increased data collection during surgery
DOR Technology Convergence and Control
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DOR Technology Convergence and Control
System - SurgMatix®
INTRAOPERATIVE MONITOR with l ive data/” real t ime” image/data
- vital signs, 02 sat , EMG, laser, endoscopic and fluro images
Technological data convergence To facilitate and to insure safe
and precise MISS
Potential Complications and their Avoidance:
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Potential Complications and their Avoidance:With SurgMatix® monitoring in DOR
• Excessive sedation:
– By continuous conscious EEG and vitalsigns monitoring
• Neural injury:
– Avoidance of n. injury by fluoroscopicmonitoring, imaging studies and anatomicknowledge
• Sympathetic nerve injury:
– Avoidance of n. injury by fluoroscopicmonitoring, imaging studies and anatomicknowledge
Potential Complications and their Avoidance:
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Potential Complications and their Avoidance:With SurgMatix® monitoring in DOR
• Operation at the wrong level:– A major complication of all spine surgery
– Avoided by using digital C-arm fluoroscopy for accurate anatomiclocalization
– Provocative discogram verifies level
2
4
6
8
10
12
13
1
T10
T12
2
4
6
8
10
12
13
1
CASE I CASE II
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Post Surgical Care andSurgical Outcome
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Post Operative Care:
• Ambulatory within onehour and dischargedsubsequently
• May shower the followingday
• May use a cervical collar in
a vehicle or on a flight asneeded (for cervical AECD)
• Ice pack is helpful
• Mild analgesics and musclerelaxant are required at times
• Progressive spine exercisesecond post operative day on
• Postoperatively on average,resumed usual activity in afew days and in 2-5 weeksresumed full active lives,providing no heavy work
Spinal motion measurement (spine
mouse)
Advanced exercise
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Surgical Outcome:
PRE-OP POST-OP
Lumbar
Cervical
Minimally Invasive Laser Endoscopic Spine Surgery (MISS)
Thoracic
• 5336 patients (10,255 discs),average age 44.8 (16-94)
• Average follow-up 46.5 months(6 to 75 months)
• Response to treatment evaluatedby using: MacNab, modified Mac
Nab criteria, Oswestry disabilityscore/index (ODI), visualanalogue pain scale (VAS),patient satisfaction scoring, paindiagram and/or patient targetachievement score (PTA)
• Average satisfactory score5024 (93.5% ) patients
• Good to excellent results in4889 (91% ) patients (for singlelevel), fair result in 215 (4%)patients
• 269 (5%) patients withpersistent residual pain andparesthesia although overalltheir pain lessened
S i l O t
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Surgical Outcome:(symptomatic improvements) 5336 patients
Minimally Invasive Endoscopic Laser Spine Surgery (MISS)
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RESEARCH AND
DEVELOPMENT IN EVOLVINGMISS
& f
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R&D for MISS:
Microphone headset
Voice activated
Robotic aided endoscopic spine surgery and image guidedtechnology on the horizon
• Advanced 3DImage guidedsystem is beingdeveloped and
will be appliedto enhance andnavigationally toguide thesurgical robot
• Surgical robotics canimprove endo-MISS with bettersurgical precision and minimaltrauma
Image guided endo-MISS
N i i h h i
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New innovations are on the horizon
ceramic
implants
Spinal Arthroplasty – Biologic Product – Genome RX
for minimally invasive spinal technology
Bryan Cervical Disc
Prodisc - C
Prestige
MaverickCharite’
Prodisc - L
Dascor DNR
NR - a
NR - b
NuCor
Biologic Product - Genome RX
SMART Disc
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