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good morning my name is Camila Molina current chief resident Johns Hopkins Hospital and like to thank dr. Rosen dr. Johnson for inviting me do you know talk about something I'm really excited about here today about I think we've you know we've heard these really fantastic talks all morning and I think it's it's pretty well cemented that navigation is the future and it's gonna be part of pretty much every you know upcoming surgeon training and the people who haven't used it before I think they're gonna want to catch up and catch up to the times and learn it because it really is allowing surgeons to do things that we hadn't really thought to be possible before you know we we saw the talk in cervical spinal oncology these incredible bony cuts that you were able to plan and navigate that you really could not do very safely before and you know people thought they were but they would get unplanned tumor transgressions and things like that but now with you know with accurate navigation you really are able to do things you weren't able to do before and now there's a merging of robotics and navigation that's even making things potentially more accurate so it's I think we're in a really exciting time and so we're going to talk about something that it was a research project that I started very early eight during my residency that led me to find nice answers here today as a teen a startup company in Israel who were basically working on the same thing I was thinking a little bit about outside the box and how we could take you know the standard you know cutting-edge computer navigation that we had currently available and how do we took it to the next level how to avoid the pitfalls that we've heard about today and the a yeeah was to make a system that used augmented reality to implement Dannette computer navigation that we use every day so this is disclosure I did eventually join the Sharpe company I'm the senior medical advisor at of medics and I know every you know person who's a surgeon in this room trained at some point without navigation learn how to do freehand pedicle screws in thoracic lumbar you know not the cervical spine at least not in America except for you know c2 sometimes c7 but you know it people are comfortable knowing that they could you know if they absolutely had to freehand pedicle screws you know pretty much up and down the spine we know how to look at the dorsal anatomical elements in the spine and you know merge that with what we see in a preoperative CT scan and be able to you know get nice medial lateral and cranial caudal trajectories you know by far and large safely instrument to spine without the use of navigation but you know every once in a while mistakes do happen and these potentially can be catastrophic mistakes for the patient and for your surgical career you know medial significant medial breech or you know thoracic spinal canal patients paralyzed many of you know into your breaching you have a you know horrible vascular injury and I think no matter how good of a surgeon you are you could be made safer and better using avocation because it's just an extra added layer of you know confidence confirmation and safety and I think that that should not ever be disregarded as an opportunity to bring that into your operating room so you know I think we're familiar with what compute you know traditional manual computer navigation can give you you know you have these you know traditional windows where they chose you the medial lateral trajectory of your pedicle screw on your on the left there on the middle you see your sagittal trajectory actually we see the same thing on the right and you're able to you know kind of place that screw wherever you truly really want it get nice alignment and do a good job but you know as a disclaimer you know at Hopkins we I like to think that up until very recently were in the medieval ages because we were not navigating anything up until maybe three or four years ago we didn't even have an alarm until Nick Theodore came was the new spine director and he brought the robot he's actually the one of the people who designed the Globus robot that we just saw a live demonstration and he not only did he bring the robot that he basically invented he also brought an arm and then we started you know thinking about how how we could use these things we started using it to navigator spinal oncology cases or bony cuts just like we heard earlier today we started doing some of my as things I mean it really opened things up for us but being an early adopter this technology you know one of the things that really didn't sit well with me is whenever we were using this you were looking at a screen and it just it didn't vibe very well because that's how the pheno at least at the very beginning when we did make mistakes using navigation is because we weren't looking at the patient we were focused on a screen and current that computer navigation forces you to do that you know you you Google an image about computer obligation and the first thing you'll see is the surgeons are looking at a screen and they're not looking at the patient and I think that can set you up for a lot of errors so you know we idea was to take this current operating room model which we've seen all day today we've seen it in everybody's pictures we saw it in all the live demonstrations to people actually having navigation directly overlaid in front otherwise same thing that we're familiar with a 3d model that is 3d segmented from an intraoperative CT scan and then use that as you know as you traditionally work for a free hand placement to find your you know external anatomical landmarks to pick an entry point as you would if you were free handing and then you get a nice axial in sagittal CT projection that you can use to get that nice medial lateral and sagittal trajectory and that's all directly overlaid onto this head mounted display it's a well it's a it's a directly head mounted display it has transparent lenses that have a direct retinal projection of all the navigation information directly into your visual field without having to take your attention away from the patient to look at an external monitor we've heard all day about one of the major pitfalls and limitations and things that we haven't figured out completely and some people are really good at it if they get their workflow correctly in terms of line-of-sight interruptions you know where you set the eyes in the sky so that you you don't have people you know blocking your live navigation while you're placing the screw and things like that you know I think we solved this problem by putting the tracking camera directly on the headset so there really should minimal to no line-of-sight interruption what you're looking at the wherever your attention is focused the camera is right there focused with you so whatever your hands are doing that you're watching your hands the camera is watching your hands and it's watching the read the registration marker so you know one uses you land you know I hope you guys get to try it today we have it in the categoric stations you'll see that you'll have really no line-of-sight interruptions because there is no camera in the sky it's all in the headset you know we wanted to make it economic we thought about you know if you develop something like this it has to be lightweight enough and easy to wear enough so that people are gonna want it wear it for an extended period of time we wanted to make it wireless we didn't want to be have people tethered to an external you know machine that they felt that their mobility in the operating room was limited so we made it wireless who made it organ Amma kits battery-powered you can use it up to three hours and the batteries are exchangeable so we thought a lot about the potential obstacles to implementing this and have it be comfortable so the surgeons and you know that at least at this point I think we've done a good job comes with the same things that we're familiar with an external cart where you know you have someone you know managing whatever it is they're navigating maybe making sure that they're able to troubleshoot if the navigation is off or something that if they need to read 3d segment the spine this is the card that the wireless headset is wirelessly communicating with to give you the navigation that you need and in terms of the navigation we we found that the NDI system as we said had you know the traditional eye in the sky model was not gonna be good enough for us because for that to communicate with the headset and the registration marker and the tools it's created a lot of latency and when you have something directly overlaid onto your visual field in an optic retinal display your eyes are gonna pick up any type of Lane scene it's gonna be extremely uncomfortable so out of that we saw the necessity to develop our own navigational system completely retired proprietary started from scratch develop their own navigation system you know we're we just wanted all the registration markers in the navigated tools to be tracked directly by that camera on the headset and through many iterations we've made this extremely accurate submillimetre pose accuracy and then her software immediately once you take that intraoperative through a CT scan its able to automatically 3d segments that spine as people are used to and then give you your nice axial and sagittal planes to optimize your screw trajectories as of this moment you know we wanted to make this potentially adoptable by you know basically any surgeon regardless of what their instrument and hardware preferences whether they use Medtronic e2m cynthia's whatever it was we wanted to make the usuals very the instruments that we were gonna bring in very modular so that they we could navigate using this technology with any type of hardware so you know we we have Universal tool holders that really will fit any of those surgical tools you want to use whether it's a sauna pet to guide your bony cuts for an oncological case or whether it's you know this companies you know gearshift or this you know power drill for Streicher whatever it is we really thought a lot about designing universal tools one of the things that I think we heard earlier and you know dr. kim asked the question and cervical spine navigation how do you keep the spine from moving around a lot it's so mobile we actually develop when you grab the spinous process you're actually not grabbing just one you're grabbing four to five depending on the size that you want you can grab less and that allows you to keep that spine very fixated while you're doing your whatever it is that you're navigating so that you keep your accuracy because you're gonna lose accuracy because the spine is not a rigid body and if you can't find a way to keep it still your accuracy is not gonna be as good as you think particularly in a place like the cervical spine or you're doing a trauma case and that you have a mechanical instability already from the get-go so you know that was a something that I thought was a really big addition for us so you know what do I think are the big proposed benefits of what I think we'll bring it to the table no minimal to no line of sight or interruption decreased learning curve you know I've we've put this in front of some of particularly my attendings who don't do any spine or having instrumented you know a spine in twenty years you know and they they're like while it's so intuitive it's like it's right in front of you you know one of the things that we talk about the learning curve they say we don't really let Hugh saying that he doesn't let the residence through thoracic pedicle screws until their PDF fours because there's in traditional computer navigation there is something that that I like to call the replication of inline maneuvers right so you have you know he was saying to it you know you memorize the initial trajectory where you you know cannulated a screw and you have to kind of memorize that so you go back in especially if you're not using a k-wire to find that exact trajectory so you have to get good a lot of good muscle memory at memorizing this these inline maneuvers and if you're shifting your attention in and out to watch a screen and I think it takes it's a big learning curve to do that so we found that when people are keeping their attention on the surgical field the entire time that muscle memory to replicate that inline maneuver becomes a lot easier you can learn that a lot faster one of the things that we that I saw initially doing the early adoption of computer navigation for us was that you know people would go in and they would cannulate the pedicle maybe tap it and then they're ready for the screw and they're like oh I think I need two media lies more I think I need to lateral eyes more they're watching the screen and they were drop their hand and medial eyes a little more and it looked this grooc look really good but the person watching the spine was like you didn't actually media lies this good you did you you're just moving the spine and so that they think tracking the you know the NDI system the camera in the sky that's tracking the navigation thinks that you're now media lysing that screw and it looks really good or your lateral izing it or whatever but you're actually not moving the screw at all you're just moving the spine and then you take and you know post-operative CT scan you're like how did that screw end up like that I did look perfect when I was doing it it's because you weren't watching the patient so we you know the hope is that by keeping your attention the entire time on the surgical field you're going to be able to minimize these type of you know avoidable errors and then lastly you know at this point we were able to really be compatible with all the 3d image acquisition systems you know we we get a DICOM we can automatically 3d segment that so it should be we're hoping to be able to be implemented regardless of what it is that you're using whether it's a brain lab arrow the Medtronic arm you know the new RS 3d capable C arms we really want to be compatible with all these things because we want to be able to be easily integrated into whatever you're used to already in your workflow so how have we done in terms of data like are we any good so our preclinical data or cadaveric work this was actually before or even most recent read kind of optimization of our in vitro accuracy of our positional accuracy this was before we even made the system better we we did a cadaveric study it's pending peer review right now for publication five cadavers instrument at t six twelve five hundred and twenty pedicle screws total we use two different grading scales to greater accuracy the girls being scaled at probably most people are familiar with that grades the pedicle breaches they regardless of directionality based on how big the pedicle breaches of grade a meaning the pedicles completely not violated whatsoever grade B is zero to two millimeter violation grade C two to four great D four to six millimeters in grade East experience six millimeters no directionality in terms of the grading but just how much of a violation there was and then because we did want to think about you know different there is a it matters if you violate something laterally versus something medially versus something interiorly we you know one of the nice skills that exists out there is uh the Jiri grading scale so that they like the greatest skill based on where the breach occurred is that no no way that's I'll pause for a second that's perfect is that John is that dr. Johnson their coin all right so that in terms of the hue grading scale you know grade one again very similar to the Gertz and grading scale there's absolutely no breach at grade - there's a lateral breach but the pedicle screw tip is still entirely within the vertebral body a great three breech the screw tip breaches anteriorly or laterally great for breach by that you know one of the most potentially critical breaches is a medial breach where you're potentially in the spinal canal or an inferior pedicle breach where you're in the foramen and potentially causing a particular injury or a great fry breach where it's a breach that you know requires a media division it completely trans canal breach or something like that in this scale you know people use it a lot in the literature predominantly - great thoracic pedicle screw placement so when we use these scales using a huge scale for thoracic screws and nerve and the Gertz mean scale for lumbar screws and you know the busy slide but average everything together or accuracy for the thoracic screw place and was 97.1% and our accuracy for the lumber scoop place when it was 96 percent and - and averaging those together for thoracolumbar screw placement it was total ninety six point six percent accuracy if we do the entire accuracy grading just using the Gertz beam scale with ninety two point five percent accuracy for thoracic screws 96 percent accuracy for our lumbar screws for a mean total accuracy or ninety four point six percent and you know it's not perfect but we went back income you know did a statistical analysis to compare how we did in terms of what's reported out there in the literature one of the not you know the biggest meta-analysis that I found is published with the aorta at all ten thousand four hundred eighteen thoracolumbar screws placed and including both freehand and computer manual navigated screws when the when they stratified their data that they had a mean accuracy for freehand of 80 9.3% rain in different studies reporting a range from seventy four point nine to ninety nine point three percent and for manual navigation they had ninety six point six percent mean with a range of 85 to 100 percent similarly they found one of the larger series that I found for robotic Place crews they didn't include the globalist robots predominantly using the maser and the first iteration of it six hundred and six screws 92.3% mean accuracy ranging eighty four point nine to one hundred percent and when you know to not you know make a long story short or to make long story shorter when we do the statistical analysis we found that we were not inferior to any of the data that was out there so that was encouraging but it wasn't yet perfect we went back to the drawing board we wanted to make our positional accuracy even better and then we actually were approved by the Israeli Medical Board to actually do live clinical cases so this is an image of the first live clinical use of this recently in Israel and we've done now three cases live so here you know here's the data you can interpret for yourself three level lumbar fusion 100% accuracy no pedicle breaches either immediately or laterally or anteriorly nice trajectories nice sagittal trajectories same thing for the second patient that we did the same thing for the third patient that we did so it you know or in vitro accuracy what was not perfect we thought you know we went back we made it better and so far you know our clinical live clinical data we're having 100% accuracy so what do I think of the potential applications I think it's gonna be phenomenal for minimally invasive cases percutaneous instrumentation it's gonna be not only able to help you you know place your screws but you know that's the earlier kind of robot help guide you to the Fassett complex and the disk base conflict similarly I think you're gonna be able to intuitively use this to you know plan your osteotomy cots plan you access to the disk space and then I think it's gonna be equally useful for not all but many complex cases you know I I don't think I'll use it for all my cases because you know I come from a training where you know we freehand so much but there's so many instances where I think having some kind of additional navigation is gonna be crucial you know people with small atrophic pedicles people you know significant coronal rotational deformity stumer cases planning osteotomy cots and spinal oncology difficult cervical spine instrumentation we heard a lot about that earlier cervical pedicle screws trans reticular screws complex occipital cervical Junction anatomy and in terms of our future directions that we're not we want to take this not just for spine we do won't think that it has a lot of potential for cranial applications particularly in stereotactic procedures functional neurosurgery hydrocephalus brain biopsies thermal ablative procedures image-guided vascular and oncologic legionary sections and then we've actually you know started to collaborate with people outside of you know neurosurgery an orthopedic surgery to just do general orthopedic procedures and image-guided craniofacial procedures and then you know in case i didn't really do a good enough job of explaining the concept of what this is about you know i have a small video to kind of show you what the workflow of this would look like play that video please because there's no sound so you're gonna have to read the captions yourself so that's the you know the spinous process clunk that we're talking about you know that curvature allows you to also be able to guide it in based on the patient's lumbar lordosis curvature and get it around multiple spinous processes which i think is huge I mean I don't know if people who've used the traditional clamps sometimes they break if a person is very osteoporotic so that's another benefit being able to clamp multiple spinous processes at the same time allows you to kind of spread that force into multiple segments so that not only you can keep those segments rigid but you know avoid you know that very annoying the spinous process you know just broke now we're going to put our clamp on so it gives you that 3d set 3d segmentation so you can pick your entry point and then you can use the axial and sagittal projections to optimize your ideal you know screw trajectory we were talking about that virtual K wires were you know we designed it so that you don't need a K wire to avoid you know that potential pitfall of placing at K wire in an unfortunate place and you know lastly you know thank you to this Seattle Science Foundation dr. Johnson and dr. girls and one more time for I'll mute today did you know the team and the entire team at automatics who have been incredibly fortunate to collaborate with Nissan Tammy and Stewart and then dr. schewe who couldn't make it here today he's been you know my mentor champion one of my attendings who didn't think I was crazy when I told him that I wanted to do augmented reality computer navigation and you know four or five years later here we are alright thank you [Applause] so because the doctor is the only person wearing it is there an additional screen that like the doctor is able to show whoever is like whoever's doing the operation they're able to show what they see to like say a resident for interaction it's actually two things so we've configured the system so that both the operators can have a headset in the OP without their operator can see exactly what the other person is doing and it will and it will be mirrored so it's intuitive it it doesn't look like you know you're just watching what they're doing but it doesn't make sense up from your side it's gonna be mirrored for one and for two there is a cart that has a large screen on it that the anybody else was watching the procedure externally can see what it is that they're doing and you can see that today and then in the live demo and I had a question sort of about the design so the back of it looks like it is fully like solid whereas I think a lot of female surgeons would have an issue wearing that for a long time it especially if they have to have their hair up and if you're in a surgery for you know three hours that's gonna become a serious you know irritant to the surgeon so I was wondering if like there was a model or something where you had like a bike helmet type you know gap for someone to just a little room for their hair no I gotta be honest hadn't thought about the female follicular Anatomy in the design but I'll take a good point yeah we'll make sure that you don't squeeze your headset too hard so to be honest we designed it to be similar way to in feel to the way that a headlight feels currently in fact we like design the headset initially with using the Integra kind of headlight model that most people are kind of who grew up through a surgical training get used to wearing for the entire case and you're not gonna wear this the entire case you're only gonna wear it there in certain parts of it that your instruments in the spine and then we designed the balance of it because there is some weight with the processor in the back of it we designed that weight to be balanced by the interior part of the headset so that it's way it's balanced appropriately so it doesn't it's not very prominent you don't feel it very much you'll and you'll get that sense today that was a big part of the design is how to balance that weight appropriately so that if it's balanced correctly it doesn't pull you in one direction or the other so I just have a question regarding the reference clamp so first of all is it possible to work around the clamp or what you're gonna do when you've use l2 to l5 we have to put it more thoracic or no the clamp that you can work around the clamp to clamp can be very close to your field when it closes down it's very midline it should not interrupt with the placement of your instrumentation for one and then for two having a clamp in there as we saw earlier for checking the hex and what you know what people do now it's nice as an ex-fix landmark to make sure always that your registration and your navigation is still accurate because a lot of the problem with these systems is that they don't have a lot of redundancy right so when you know the pelvic pain gets misplaced or there's a phase shift the surgeon doesn't always know it and they continue working with this you know false confidence that they're placing things correctly so you know if the system doesn't have built redundancy into it you need to make the redundancy yourself and continually check to see if the things that are fixed are still lining up just the way you were talking around with your little screws and I think the globe is robot does a nice job lab because they have two reference frames and if the reference frames move in relation to each other they tell that the system knows that something's off and that's what they think you is calling it a what did you call that part where if the system tells you if you're a little off I should know because I've used yeah Scoville meter but you know that we have the glow throughout so this the robot will actually stop it if it thinks that those two frames moved apart from each other that redundancy it it turns yellow and it says that you can't continue until you fix whatever it is so you know having that fixed clamp in the middle so that's crucial I'm gonna stop the questions is because we have to keep moving on in anybody else who has questions for him could catch them afterwards thank you very much community