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Expert Team Uses Latest Tech to Advance Spinal Fusion

Neurosurgeons at Cedars-Sinai are making a difference in patients’ lives through sophisticated instrumented spinal fusions. With the highest volume of spine cases in Los Angeles County, Cedars-Sinai is equipped with innovative, best-in-class technological tools, including an advanced surgical robot, and supported by deeply experienced and specialized care teams.

Clive N. Svendsen, PhD

Alexander Tuchman, MD

"Cedars-Sinai has everything a patient might need. There’s no human, technological or physical resource that would limit the clinical plan in any way," said Alexander Tuchman, MD.

Tuchman regularly performs the life-changing surgeries for patients with spinal issues related to degenerative lumbar disease, severe spinal deformities, in response to the removal of a tumor causing spinal instability, or to address trauma or an unstable fracture.

"In well-selected patients, I see spinal fusion transform their lives by decreasing pain and increasing independence," he said. Tuchman is recognized within the field for his research evaluating patient outcomes associated with various procedures and his technical precision in the operating room.

"Cedars-Sinai has everything a patient might need. There’s no human, technological or physical resource that would limit the clinical plan in any way"

Improving spinal stability with technical precision

At Cedars-Sinai, nine dedicated operating suites are equipped with innovative technological tools, increasing the options available to surgeons.

In an instrumented fusion, the surgeon first anchors pedicle screws into the bone. Successful pedicle screw placement provides surgeons with a stable base for the rodding portion of the surgery, where the actual spinal correction and stabilization occurs.

"If the surgeon’s screw placement is not excellent, the rest of the surgery becomes more challenging," Tuchman said.

In traditional open surgery, pedicle screws are placed with a freehand technique using anatomic landmarks and fluoroscopy. Intraoperative fluoroscopy requires multiple X-ray shots to determine landmarks for pedicle screw placement.

State-of-the-art operating suites

At Cedars-Sinai, surgeons have the option of employing additional tools in spinal fusion surgery. Neuronavigation, computer-assisted technology that assists in navigating the skull or spine during surgery, requires the use of an intraoperative 3D imaging system and can be used for traditional open surgery or minimally invasive methods.

Preoperative CT scans or intraoperative 3D can be registered to neuronavigation to give 3D guidance and real-time feedback to the surgeon. Coupled with anatomic landmarks and tactical feel, the 3D feedback provides surgeons with additional points of information to cross-reference throughout the procedure.

Cedars-Sinai surgeons can alternatively opt to use an advanced robot to support the placement of pedicle screws. Robotic systems assist the team in planning and mapping the surgery. The robot facilitates minimally invasive techniques, which have the potential to decrease tissue damage to the patient, Tuchman said.

Synced with neuronavigation, the robot maps the optimal placement and gives the surgeon a precise trajectory for placing the pedicle screws. The robot attaches to the patient’s spine at several bony prominences as reference points. Using pre-op and intraoperative imaging, it creates a 3D orientation. Next, the robot arm moves around to guide the surgeon in placing the pedicle screw.

"It’s one of the tools that helps us get good anchors to stabilize the spine," Tuchman said.

For the surgeon and team in the operating room, pairing use of the robot with pre-op imaging and neuronavigation systems can decrease radiation exposure by minimizing necessary intraoperative radiation. 

While earlier surgical robots had limited communication and functionality, the model Cedars-Sinai currently uses is compatible with other devices, allowing for more pre-op planning and real-time visualization.

The teams powering the OR

Technology, though, can only complement the best surgical expertise and clinical judgment.

"A robot doesn’t make a surgery a good surgery," Tuchman said. "Navigation doesn’t make a surgery a good surgery. It takes an experienced, highly disciplined team, an experienced surgeon, and having all the resources available."

Cedars-Sinai combines the personalized, relationship-driven care typically associated with a community hospital with the expertise and outcomes associated with a high-volume program at a quaternary medical center.

Patients who undergo an instrumented fusion at Cedars-Sinai can expect to receive the medical center’s signature collaborative, team-based care. Neurosurgeons consult with the patient’s referring physician and other specialists to determine the ideal approach and whether the patient is a good candidate for an instrumented fusion. 

Specialized care teams are skilled in providing pre-, peri-, and post-op care. Experienced anesthesia and nursing teams at Cedars-Sinai work with thousands of spine cases annually. State-of-the-art neuromonitoring evaluates a patient’s neurologic function during surgery to ensure that any issues are immediately identified and addressed in the operating room.

After surgery, a comprehensive post-op care system improves pain control and patient outcomes. Patients continue to see their surgeon for follow-up care.

The future of spinal surgery

At Cedars-Sinai, Tuchman researches patient outcomes associated with new versus traditional tools and procedures, with published findings in Journal of Spine Surgery, Global Spine Journal, Spine, and elsewhere.   

Tuchman is excited about the future of spinal surgery and is interested in innovative techniques and technology that enable neurosurgeons to better serve patients. He sees the value of tools that can make highly complex technical surgeries standardized and more predictable. In the future, he believes robots could become more automatized and even help with trajectories for additional surgical procedures.

"Robotics and navigation, working in concert together, giving real-time anatomic feedback to the surgeon, have the potential to make surgeries more reproducible and more consistent," Tuchman said. "Ultimately, innovation has the potential to make surgeries faster and safer."

Equipped with today’s robotics and participating in research and trials for tomorrow’s innovations, Tuchman and his fellow neurosurgeons at Cedars-Sinai are at the forefront of the future of spine care.