Advanced Techniques in Spine Surgery

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- Ladies and gentlemen, thank you for joining us for another session of the Virtual Operating Room from the Neurosurgical Atlas. Our guest today is Dr. Moe Bydon from Mayo Clinic. Moe is an incredible clinician, researcher, extremely prolific. I hardly know any other spine surgeon who has achieved so much with such a small period of time, extremely clinically busy, and really has done an incredible job using the data and acuity to publish extremely worthwhile outcome studies, which are very well known and quoted every day. Today, he is going to talk to us about robotics in spine surgery, something that is the future in one way or the other. And I'm all ears and very much listening and hearing and hope to learn from you, Moe. Please go ahead, thank you.

- Thank you very much, Aaron. I very much appreciate you inviting me here today and happy to be with you. I'm Mohamad Bydon as introduced by Aaron, and I thank him for having me here. I'm a professor of neurosurgery, orthopedic surgery and health services research at the Mayo Clinic in Rochester, Minnesota. And we'll talk today about robot-assisted spinal surgery. So, first, robot-assisted spinal surgery has been something that's carried promise for a long time. And now more recently as something that can actually be realized and recognized. It does have advantages, including when done in a minimally invasive fashion, small incisions, reduction in complications of surgery, less exposure to radiation and shorter length of stay. There's a number of available systems, and the number of available systems is actually increasing. And so Globus has the Excelsius system also known as the Globot. Mazor has the Mazor X and the Renaissance. And Zimmer-Biomet has the ROSA system. Those are the leading systems at least in the North America United States market. The ROSA system allows for planning based on intraoperative 3D CT images and is combined with navigation. It can be utilized for cranial or functional neurosurgery as well as spinal surgery. The Globus system or the Globot is used for synchronized preoperative or intraoperative planning, is combined with navigation and is used for spinal surgery. And the Mazor robotic system has both preoperative and intraoperative planning, a rigid attachment to the patient, sophisticated 3D analytics for preoperative planning, and can be combined with navigation in the Mazor X pathway. And then there's Renaissance and SpineAssit that do not have navigation and rely on pre-planned trajectories, but the Mazor X does. So robotics spinal surgery, this is something where there's a number of early publications on, and here's an article from Israel looking at 15 patients undergoing lumbar fusion with a robotic system. And in six cases, the procedures were performed successfully. There was partial success in the remaining nine cases. This was very early in the development of this novel system. And there the authors noted very honestly their experience regarding challenges of logistics, inadequate CT-to-fluoro registration, and the steepness of the learning curve. So this was another article by Rainer et al. looking at comparison of robotic placement to conventional screw placement. And here they looked at perioperative course and accuracy of screw positioning in conventional open robot guided and percutaneous robot guided pedicle screw placement. 35 patients underwent percutaneous placement of screws, 20 patients underwent open robot guided, and 57 patients underwent open conventional procedures freehand. And so there were three arms to this study. The use of robotic guidance reduced the X-ray exposure and increase the accuracy of screw placement. This is another study from the University of Geneva in Switzerland, looking at 169 patients, 98 having robot-assisted screw placement, 71 having freehand fluoro-scopic guided screw placement. Screw placement was assessed using the Gertzbein-Robbins scale, which is a validated demonstrated measure of screw accuracy. Perfect trajectory also known as grade A was observed in 83.4% of pedicle screws, that's 366 screws versus 76% in the freehand- fluoroscopy cohort or 335. And the overall proportion of non-misplaced screws was higher in the robot-assisted group. So the safety and accuracy of robot-assisted versus fluoro-assisted pedicle screw placement in thoracolumbar surgery was looked at in a prospective randomized controlled trial from a group in Beijing. This group looked at 234 patients and 115 robot assisted cases were done. In addition 115 freehand fluoroscopy guided cases were done. Again, the placement of the screws was done using the Gertzbein-Robbins scale. Perfect trajectory was observed in 95.3% of pedicle screws and in the robot-assisted group versus 86% in the freehand fluoroscopy cohort. A group here looked at minimally invasive robotic placement versus open fluoroscopic placement of pedicle screws. This was a randomized control trial that assessed 30 patients in each arm. Robot-guided minimally invasive versus fluoroscopically-guided open. And the pedicle screw placement was completed on 35 levels and 130 screws in the robot-guided group, and then 40 levels in the open group. And there was a significantly shorter duration of fluoroscopy in the robotic-guided group leading to a mean reduction of 62% in radiation exposure and a shorter length of stay. So there are 37 studies in the systemic review that was done in meta-analysis looking at pedicle screw revision for robot guided, navigated and freehand thoracolumbar instrumentation. There were a total of 7,000 patients. So there were reduced postoperative revisions in the robot-guided group and the navigated procedures compared to freehand. Intra-operative revisions were comparable between all three of the technologies or methodologies. So from a healthcare economics standpoint, this was an interesting article from the group in Shreveport, Louisiana, looking at an academic spine surgery practice, a total of 1,985 elective cases, which were analyzed over a one-year period. And of those, 557 thoracolumbar cases were analyzed, 58 of them or 10.4% were minimally invasive. Time-savings averaged to be 3.4 minutes per level, with the robotic technology, which resulted in an annual savings of $5,713, mild or small amount. However, the authors found that there was improved pedicle screw accuracy, secondary to the robotic technology, which resulted in 9.47 fewer revisions or revisions being avoided with a cost savings of $314,661. So that's where the true cost savings comes from in this technology. So our experience with the first 100 lumbar screws with a spinal robot. We had an average age for our patients of 54 years old, 35% of the population was female. You can see the ASA class, the anesthesiology grading system for the patients as they underwent intubation. Types of screws, 97 of the screws were pedicle screws, eight of them were cortical screws. The 22 of the cases were approached MIS, really 24 of them with different MIS methodologies, seven of them were open. 22 cases were primary cases, nine were revision. And you can see the various pre-op diagnoses. In terms of radiation exposure, the pre-op CT + 2D fluoro, you can see there the amount of radiation that we had, but a much lower amount of radiation when we did pre-op CT + intra-op O-arm spin. And then additionally, you can see cases where there was no O-arm spin, with O-arm spin was done for planning and with O-arm spin was done for checking the accuracy of the screw placement. The mean intraoperative fluoro time for 10 cases was 20.4 seconds. So relatively low amount of fluoroscopy time. So we had 105 screws that were placed. No screws required revision. Operative time on average was 295 minutes with average EBL of 150 and average length of stay of two days. So here's a case example, a 53 year old female with left L5 radiculopathy with a grade 1 L4-5 spondylolisthesis, more frequent flare ups of pain, 12 weeks of physical therapy and two injections. And so, obviously we wanted to consider our various options for the patient. And so we planned an L4-5 minimally invasive TLIF with a left sided approach. And then robotic guidance for the percutaneous L4-5 pedicle screws. So in terms of pre-op planning, there's thin-cut CT. The system that we use utilizes a proprietary system software that helps create a surgical plan. The surgeon comes in and plans out the screws. And then that includes the surgeon being able to optimize screw sizes, screw trajectory, and the axial, coronal and sagittal planes. And then there's intra-op registration via anteroposterior and oblique fluoroscopy. So on the left is a cartoon of the robot and the workstation, and where the workstation is, where the surgeon stands and where the patient is laying. On the right is my operating room. That's in St. Mary's Hospital OR 708, and that's the operating room that I'm in three to four days a week. So we did rigid fixation. In this case, these are images from the case for the reference frames. So I insert the Schanz pin into the mid-third of the sacrum lateral to the SI joint. You can see the Schanz pin inserted on the left. In the top right you can see the mid-third of the sacrum, just lateral to the SI joint. And on the bottom right you can see the locking of the Schanz pin to the Schanz arm at the appropriate angle. So then we do what's called a 3-Define scan. This defines the patient anatomy, calculates the depth and evaluates the trajectories. So a blue surgical towel is placed over the region of interest or the ROI providing a uniform surface that doesn't have glare. The surgical arm has a linear optic camera built-in that performs an arching motion above the region of interest, recording a 3D visual scan of the surface environment and defining the work volume for the surgical arm to prevent collisions. So then there's a snapshot step. This is registration of the navigation camera to the robot and to the patient. Then we use a passive planer probe to estimate the level of interest. You can see that being utilized there. Then for registration, we use a target extender that gets attached to the robotic arm and then is utilized for registration. You can do that with an O-arm. You can also do it very simply with an AP X-ray and a oblique X-ray. If you choose to do it with an X-ray, those are the only two X-rays that you need. You do not need any further X-rays after that. So you can see there, we chose to do it with X-ray. You can see the oblique on the left and the AP on the right, and that's the registration of the 2D fluoroscopy combined with the pre-op CT. You can see there where we mark our skin incisions, and you can see the marking that we have there. You can see our final markings for the skin incisions. To the far right of the patient is the first two screws, to the midpoint left of the patient is the left side of two screws. And then the third incision relates to the percutaneous discectomy and interbody fusion that we'll be doing. And you can see the Schanz pin in place. So first we insert a K-wire into the L4-5 disc space. You can see there, the location and placement of that wire. We confirm with fluoroscopy that the K-wire is placed into the disc space. You can see the spondylolisthesis at L4-5. You can also see the Schanz pin that's been placed at the midpoint of the sacrum. Then we do a screw placement into the left L4 pedicle. There's a stab incision that's done via the effector arm of the robot that's followed by extension of the incision superiorly and inferiorly, and then insertion of a cannulated dilator, leaving the cannular in place and taking out the inside dilator. Then screw placement. So we placed the drill guide through the cannular at that point. We insert a three millimeter drill through the drill guide. This is used to drill a pilot hole along the pre-planned trajectory that I, as the surgeon have made onto the software. Then the pedicle is tapped over the pilot hole using a 5.5 millimeter tap. You can see the tap in the left and in the right you can see the software showing you the tap over the preplan trajectory. And then we verify the bone integrity at that point using a K-wire. And then I placed the screw into the tapped hole. And you can see on the image, the placement of the screw into the tapped hole. You can see at L5, I haven't placed that screw yet, but you can see where I drew my trajectory for that screw to be placed. So all screws are placed in a similar fashion. You can see the X-ray on the left, confirming that, and you can see on the right, the placement of the percutaneous screws. Discectomy is then done through sequential dilators over the K-wire to reach an eight millimeter tube and removal of the disc via puncher and shavers. Then cage is placed and filled with aloe graft. And then finally placement of the rods and final tightening of the screws. And this is another case of a high-grade spondylolisthesis. In this case, a 21 year old male with bilateral radiculopathies along with the right leg and ankle weakness, progressive symptoms over six months that worsen over a year, and the patient had had physical therapy, injections, chiropractic care, acupuncture. Those did not give him significant relief and no relief over the last six months. So I planned an L5-S1 minimally invasive robotic perc fusion for this. And you can see, sorry, my apologies. You can see on the left the preoperative image and on the right the postoperative image. We have improvement in disc height and we have improvement in the spondylolisthesis although not full reduction, which in these cases is not always possible, but using minimally invasive techniques it's possible to address high grade, grade three, grade four spondys such as this one. So in terms of the future of robotic surgery, the current generation of robots is focused on auto aligning screw placement trajectories. There are future applications, and those will include laminectomies, osteotomies. There'll be computer-aided manufacturing technologies. There'll be artificial intelligence that gets used to anticipate dynamic changes during surgery that occur. So in conclusion, robotics and spinal surgery is being increasingly employed. It'll be a bigger part of spinal surgery over the next 10 years, not a smaller part. There's preliminary research that's revealed positive outcomes for patients who undergo robot-guided screw placement. And of course, it's important to appreciate that there's a steep learning curve. And so at this point in March, we'll be doing our 150th case. And so it's important to appreciate that the first 50 cases we're not exactly the same in terms of learning curve as the middle 50 and as the last 50 have been.

- Moe, thank you for really spectacular talk on robotics and spine surgery. As you know robotics and minimally invasive spine surgery are so interrelated. So I would love to hear some of your personal pearls about minimally invasive spine surgery. Would you mind sharing that with us please?

- Yes, I'd be very happy to Aaron. So minimally invasive spine surgery, we'll go over a little bit of the history of it and then we'll discuss outside of the history, some of the other elements and components of ways that it can be utilized. So in 1934, Mixter and Barr established the relationship between disc herniation and sciatica, and that was a critical surgical and diagnostic relationship that was made. In 1955, Malis described the use of a microscope and bipolar cautery to assist a surgical approach, and that was the founding of the microdisectomy. In 1997, Foley and Smith described a microdiscectomy through a set of tubular retractors in what's known as a minimally invasive microdiscectomy or tubular microdiscectomy, not to be confused with a percutaneous microdiscectomy or a percutaneous discectomy. The Society for Minimally Invasive Spine Surgery was founded in 2007. So minimally invasive spine surgery, the broad tenants of it are that the smallest exposure necessary is done to perform the surgical goals in order to reduce postoperative pain and scarring. The touted benefits are shorter length of hospitalization, decreased blood loss and infection rates, reduced costs, higher patient satisfaction and earlier returned to work. The examples across all specialties include laparoscopic, spinal, thoracoscopy, robotic, endoscopic, natural orifice surgery. And then a minimally invasive spine surgery, the working definition would be percutaneous, muscle-splitting or sparing through tubular dilators and retractors. So the technique and the guiding principles and concepts are to avoid muscle crush injury that's done through soft retaining retractors. Do not disrupt the tendinous attachments or sites of key muscles, particularly the origin of the multifidus muscle at the spinous process, this provides lumbar extension and dynamic stability. To utilize known anatomic neuro-vascular and muscle compartment planes, and to minimize collateral soft tissue injury by limiting the width of the surgical corridor. You can see here a diagram of a tubular microdiscectomy. On the left, you can see a disc herniation along with the placement of the tube ready for hemilaminectomy. And on the right, you can see the instrument, the tubular retractor, the intevertebral disc and the screw placed. There's positives and negatives to minimally invasive surgery. The positives include reduced postoperative pain and utilization of narcotic medications, a more rapid postoperative mobilization, a shorter length of hospitalization and recovery times, less tissue and posterior column destruction for improved biomechanics, there's cost savings, there's less blood loss, and there's a decreased rate of infection. The downsides or the cons are a higher rate of dural tears and nerve root injury, longer operating times, a limited number of applications, and increased exposure to radiation. There are steep learning curves and equivalent long-term benefits and minimal short-term gains. Minimally invasive surgery for degenerative disease. You can see here a 54 year old male has symptoms of pseudoclaudication and difficulty with walking that improves on bending, as well as a right L4 radiculopathy. On imaging, he has severe stenosis of L2-3 and L3-4. So in this case, we proceeded to do an L3 minimally invasive partial laminectomy, along with a foraminotomy of right L3-4 inner space and lateral recess using a left-sided tube, and a right L2-3 tube with a left L2-3 inner space and a lateral recess and a foraminal decompression, and an L2 partial hemilaminectomy. What you can see in this slide is the fact that from a contralateral approach minimally invasively, you can in many ways more easily than from an ipsilateral approach, approach the contralateral side. And so you can very easily get to the lateral recess and to the foramen on the contralateral side from an ipsilateral approach using minimally invasive techniques. This is a 51 year old male with a significant left leg pain. He had a prior history of four lumbar surgeries between 1988 and 1991 that included a laminectomy followed by two discectomies, followed by a fusion from L3-S1 with wiring. The patient does have adjacent segment disease of L2-3 and presents with worsening back and left leg pain that's relieved with leaning forward. The patient has difficulty standing for any long period of time due to his leg pain. On imaging, the patient has severe spinal stenosis with compression at the L2-3 interspace. There's also postoperative changes in the lumbar spine, including an S1 decompressive laminectomy and a posterior fusion extending from L3 to S1. You can see here that the patient has fused and healed well from his L3 to S1 fusion, and has difficulty, and in fact, is leaning forward in large part due to the stenosis in the pseudoclaudication that's developed at the L2-3 segment. So in this case, I chose to do a minimally invasive L2-3 transforaminal lumbar interbody fusion. So you can see that the left sided screws have been placed, and we are preparing our discectomy and our disc interbody. You can see here that a percutaneous interbody graft has been delivered and instrumentation has been placed at L2 and L3. And I'll show you a CT, which was done one month postoperatively. And so what I'd like to show you here is the indirect foraminal decompression which was done. You can see on the left, the preoperative amount of foraminal compression that's occurring, and you can see postoperatively on the right how much more room there is for the foramen in the nerve. Now, in terms of a central decompression, that's best shown on the MRI, you can see preoperatively the amount of central compression, and you can see one month later, post-operatively the amount of the reduction in central compression. And please note this was all indirect central and foraminal decompression. So this is an example of some of the minimally invasive techniques that we've utilized. You can utilize these in conjunction with robotics. At the same time, I think we've been talking about techniques for thoracolumbar instrumentation and arthrodesis. And so as a part of that, we should also discuss the anterior lumbar interbody fusion and techniques related to that. So the anterior lumbar interbody fusion was first described in 1932 as a treatment for spondylolisthesis. It became increasingly popular from the 1980s until now due to technological advancements in the cages and in instrumentation. And fusion for lumbar degenerative disc disease in the United States between 2000 and 2009, ALIF was performed in 16.8% of cases. And you can see a diagram from the Spine Journal relating to the vessels surrounding the L5-S1 disc space, including the abdominal aorta, the inferior vena cava, the left common iliac artery, the left common iliac vein, and the median sacral vein, and the median sacral artery. Indications for anterior lumbar interbody fusion include spondylolisthesis, degenerative disc disease, adult spinal deformity, coronal and sagittal imbalance, as well as adjacent segment disease, pseudoarthrosis and post-laminectomy kyphosis. There are advantages to the anterior lumbar interbody fusion. So first it allows for direct visualization of the anterior column, which facilitates discectomy and endplate preparation. There's a large surface area for the fusion and for grafting. There's a favorable fusion environment with compression, and the sparing of the posterior elements and musculature. Other advantages also include increased ability to deliver a lordosis. There's the effectiveness of anterior releases, particularly for high-grade deformities. Minimal blood loss generally, and a decreased surgical time. Disadvantages. There's a requirement for great vessel dissection and mobilization, and there may be a requirement to do posterior stabilization, even in the setting of anterior lumbar plating. So fixation options. There's internal fixation options, which are built within either the PEEK or titanium or PEEK-titanium coated spacer. There are external fixation options relevant to a plate and screws, and then there's of course, posterior instrumentation options. So in terms of cage options, there's titanium options, PEEK options, titanium coated PEEK, bone dowels and femoral ring allografts as the primary options. The procedure includes a patient being positioned in Trendelenburg in order to increase lordosis. An abdominal incision, usually a Pfannenstiel, and a retroperitoneal approach to the retroperitoneal space. The procedure includes the ligation or clipping of the median sacral artery and vein, and includes confirmation of the level via fluoroscopy. The procedure itself includes a discectomy and then there are a number of trials of grafts of increasing size that can be delivered to the interbody space. The procedure includes a graft implantation as well as a fixation. And the complications can be vascular, renal, ureteral or intestinal injury. Psoas or retroperitoneal hematoma, abdominal wall hernia or paresis, genitofemoral neuralgia, psoas trauma and weakness or a femoral nerve injury. So in terms of complications, one highly touted complication is the possibility of retrograde ejaculation. In different reports, this occurs in different rates. Most likely the rate is at 1% or a little less than 1%. Much of literature revolving around this relates to the utilization of bone morphogenetic protein, and relates to also injury to the superior hypogastric plexus and innovation of the internal vesicle sphincter. The key in terms of the approach is to avoid monopolar cautery around the sympathetic chain. Primary studies on stand-alone ALIF are Lammli et al. in 2014, we're 115 patients with degenerative disc disease and follow up of two years, they demonstrated a fusion rate of 93% with a mean ODI difference of 17% and a mean VAS pain difference of 3.3. Amaral et al. in 2017, looking at 87 patients with degenerative disc disease, stenosis or spondylolisthesis with followup of three months. Mean VAS back pain was reduced from 7.4 to 4.2, and mean VAS leg pain was reduced from 5.1 to 2.8 with a mean ODI going from 44 to 31. And then Rao et al. in 2015 looking at 27 patients with spondylolisthesis with a fusion rate of 91% and a mean VAS pain rate of 7.6 to 2.2, with a mean ODI of 56.9 to 17.8. So in terms of ALIF versus TLIF, this is a meta-analysis on clinical outcomes and complications, which was done looking at 1,240 patients, and 12 studies were included. There was no statistically significant difference in fusion rate, blood loss and patient report outcomes. ALIF was associated with superior disc height, superior restoration of lordosis and longer hospitalization. ALIF was also associated with fewer dural injuries, but more vascular injuries. In terms of bone morphogenic protein and ALIF. This received FDA approval in 2002. BMP's primary approval was for utilization in conjunction with ALIF. And the family of products that BMP represents is transforming growth factor beta or TGF-beta. The ideas to promote bone healing. The most used is recombinant human BMP-2, rhBMP-2, and recombinant human BMP-7, rhBMP-7. And this is used as an adjunct to allograft or autograft. These are superior fusion rates when compared with a traditional iliac crest autograft. BMP's impact on fusion rate, Burkus et al. in 2002, looked at ALIF in a follow-up of two years. Group one had rhBMP-2 on a collagen sponge, 143 patients with a fusion rate of 94.5%. Group two had autograft alone, 136 patients with a fusion rate of 88.7%. BMP's impact on fusion rates. Burkus et al. in 2006, 131 patients undergoing single level ALIF. Again, allograft with rhBMP-2 versus allograft and autograft. The fusion rate at 12 months was a 100% in the BMP cohort versus 89% in the non BMP cohort. Hofstetter et al. in 2006, doing a meta-analysis on 160 patients undergoing ALIF, the groups were BMP versus no BMP. And the fusion rate was 96.9% in the BMP cohort versus 79% in the non BMP cohort. So titanium versus PEEK in ALIF. There's been no studies that have addressed this question, but the issue can be approached indirectly. So titanium versus PEEK in interbody fusion. The introduction to market of titanium was in the 1980s, PEEK in the 1990s. The elasticity of titanium is higher than with PEEK. Titanium is radiopaque, PEEK is radiolucent. And there's differences in terms of the modulates with titanium versus PEEK. And also in terms of promotion of osseointegration is higher with titanium. Subsidence rates are also higher with titanium. And then a risk of metal allergy of course, is also higher. In terms of fusion rates, titanium versus PEEK. In this study looking at 587 levels of ACDF and TLIF, fusion rates tended to trend towards titanium, but not in a significant fashion. In terms of titanium versus PEEK in subsidence, this is a meta-analysis of 443 levels of ACDF and transforaminal lumbar interbody fusion. A subsidence was found to be significantly higher in the titanium cohort. And then in a cohort of 156 lateral lumbar interbody fusions PEEK usage was found to result in a less subsidence than a titanium utilization. So titanium coated PEEK spacers. These possibly allow better integration of bone than PEEK implants alone. Titanium coating has been shown to detach significantly in experimental models unfortunately, and these have not been compared to either PEEK or titanium spacers. So I'll show you a case example, this is a 53 year old male with back pain, bilateral radicular pain, predominantly left sided, a history of ACDF. The patient has obstructive sleep apnea, hypertension and stage three chronic renal disease. So on preoperative imaging, the patient has a grade one L5-S1 spondylolisthesis with pars defects that can be seen on the images, along with left sided L5-S1 foraminal disc herniation and bilateral spondylolysis or pars defects at L5-S1. So in this case, we would like to do an L5-S1 ALIF with lordotic PEEK spacer and internal screw fixation. So you can see the fusion was done with autograft, allograft and BMP. And the patient reports a resolution of symptoms. This was a standalone case, and instrumentation appears stable on the X-rays. So in conclusion, ALIF is an effective operation to treat spondylolisthesis and spondylosis among other disease entities. Its advantages are based on the anterior approach, allowing direct visualization of the disc and facilitating discectomy. Between ALIF and TLIF, there's no demonstrated superiority of one over the other. BMP seems to increase fusion rates in ALIF. There's no data to guide decision between PEEK and titanium interbody spacers for ALIF. Thank you.

- Thank you so much Moe, really a very nice summary of advanced techniques in spine surgery. Obviously, robotics extremely exciting in minimal invasive surgery. Some of the cutting edge technologies that are coming down the pike and further, obviously getting higher and higher versions of them presenting. If I may ask, what is your personal opinion about the future of robotics in spine surgery?

- I think the robotic technologies are becoming more and more advanced. And over the next 10 years, I do believe we'll see them utilized in more spinal surgeries, not fewer. Today, robotics is really sort of subjected to the advanced users and the early adopters of that technology. So we haven't seen the wide adoptability. But the newer versions that emerge will be able to do more and do more efficiently. And so there'll be faster, easier to integrate into your operating room workflows. You don't have to feel like you're learning a whole new procedure. It'll just integrate into the current procedure that we utilize most commonly as surgeons. And from a workflow perspective, you'll be able to do more. It won't just help guide you on the placement of screws, it'll also be able to help deliver laminectomies, facetectomies, so there'll be able to accomplish more objectives within the surgery. So I do think over time, we'll see them utilized more and more. I would also add as a comment, advanced navigation is also advancing. And so navigation will also get better and better and in some cases reduce the need potentially for robotics.

- Very well said. I think those are very exciting technologies being added to a spine surgery that's become so dynamic these days. So with that, I wanna sincerely thank you, taking the time to be with us today, Moe, and I really appreciate, and I'm sure we're gonna hear a lot more about your incredible successes and look forward to having you with us in the future as well, thank you.

- Thank you very much. I really appreciate you having me here today and thank you very much.

- You're welcome, thank you.

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