It had been four years since we spoke with one of the early adopters of spine robotic assist systems—the director of education for the spine division and director of the spine fellowship at one of the leading medical centers in the world, NYU Langone Health—named, incidentally, for Kenneth and Elaine Langone who in 2008 donated $200 million to fund a world renowned center for science and healthcare.
That surgeon, Dr. Jeffrey Goldstein, is clinical professor in both the departments of orthopedic surgery and neurosurgery at the NYU Grossman School of Medicine.
NYU Grossman School of Medicine is also the institution that, in 2019, cemented its reputation as a global leader for educating the next generation of physicians when it granted EVERY medical student a full-tuition scholarship so that “any student can pursue the dream of becoming a physician without the burden of overwhelming student debt.”
Deciding to Invest in Spine Surgery Robotics
In 2018, we caught Dr. Goldstein literally days after receiving NYU Langone’s first spine robotics system and we wanted to understand the thought process behind his, his colleagues and his institution’s decision to make such a consequential capital investment. And Dr. Goldstein, who had been watching spine robotics for more than a decade, was very clear about why they bought that first system.
In 2018, he and his colleagues expected that robotics:
- would give him and his colleagues the ability to plan surgery without the absolute necessity of a preoperative CT scan
- would cut fluoro exposure in the OR
- would add flexibility—so if, for whatever reason, a preop CT wasn’t possible, a surgeon could still go with an intra-op fluoro CT, or intra-op simulated CT
- could increase precision for 1 to 3 level minimally invasive interbody spine fusions—TLIF, XLIF, OLIF, ALIF, any of the LIF cases.
- would give surgeons the ability to literally watch screws being placed (using a monitor) and to know, precisely, how compliant their placements were with their pre-op plan
- could raise each surgeon’s confidence that their spine surgery cases at NYU Langone were even more error-free.
Then, in 2018, we asked Dr. Goldstein to predict where robotics might go next. Here is what he said:
“I think that where we’ll go next with robotic surgery is revision surgery and complex deformity cases. Certainly, we need to develop user groups because there’s an opportunity to expand this. Where will it go? Add-ons—voice recognition, for example.”
Four years later, after COVID—which upended everyone’s best laid budget plans—after those excruciating few months in 2020 when NYU was both overrun with COVID patients, could not schedule spine surgery and had to absorb hundreds of millions of dollars of unexpected costs—and after a couple years of recovery…has this investment in robotic systems delivered on the promises and what had changed for him and his colleagues since.
Dr. Goldstein began our interview by telling OTW that NYU Langone’s Orthopedic Hospital (ranked #3 in the United States) had purchased two more spine robotic systems (manufacturer: Globus Medical, Model: Excelsius).
Today, “I use the robotic system in most of my cases, assuming it’s available. We have a lot of great spine surgeons here and there’s demand for our three systems, so they are not always available.”
“From the first month of having the robotic system, I was using it for lateral lumbar interbody fusions, and then doing a single position surgery with the screws. Initially, as you remember, I didn’t think that the robot would work. I didn’t have a need for the robot because I felt very comfortable putting screws in. I still believe that in order to be a good robot surgeon or a good navigation surgeon, you have to be good at open surgery first.”
But now, said Dr. Goldstein, “With robotic assist, I can prove before I leave the operating room, that my instrumentation is safely and accurately placed.”
But, NYU’s Robotic System Had Changed Materially Since 2018
In the past four years, there has been an explosion of software based, smart technologies—not only in the form of robotic systems, but also navigation, mixed reality 3D visualization systems and, on the horizon, artificial intelligence algorithms and access to big data systems.
We asked Dr. Goldstein to bring OTW up to date since we last talked four years ago.
Dr. Goldstein: “So we use the Globus Excelsius Robot. It’s the same system we selected in 2018, but over time, the system has really gotten better, it continues to learn.”
“Globus’s engineers continuously tweak the robot’s program based on the data they get from our cases. The robot uses data from preoperative CT scans or from intraoperative imaging and now, with the Excelsius3D(TM) [more about that later], the robot ‘learns’ your patient’s anatomy. That imaging data merges with the robot’s navigation, which has continually gotten better with time.”
“One of the first things we did after we’d used the robotic systems for a while was to check our learning curve. With one of my fellows, we evaluated our first cases and we saw that we were able to get the screws in with more consistent accuracy and precision.”
“There were no cases in our study group where we had to take a patient back to the operating room to replace a screw. We found that the robot allowed us to put screws in what you might otherwise consider an awkward position because the robotic arm can assume an awkward position.”
The Excelsius3DTM Innovation
One of the revolutions that robotic assist devices represent is intelligent software. Unlike updating, for example, an implant design—which can take years and requires rigorous lab testing and regulatory work—software based system can be continuously updated, resulting in steadily rising functionality, indeed, as Dr. Goldstein mentioned, his system seemed to “learn.”
Dr. Goldstein was part of the design team for Globus’s latest innovation in the Excelsius eco-system, Excelsius3DTM. For him, the new system creates a seamless transition for navigation and robotics in his patients.
Dr. Goldstein: “Before Excelsius3DTM, we have to put these frames on the patient and have whatever navigation you’re using see this frame. With Excelsius3DTM, we get rid of that frame. We just see the patient in 3D then get the instrumentation right using the robot.”
“No special device on top of a patient to see where the spine is, the software will ultimately allow the Excelsius3D™ to see the patient, to see where the spine is, and then transmit that to the robot,” explains Dr. Goldstein. “It’s a seamless transition from seeing where the patient is, and then implanting instrumentation, whether it be a screw or a cage.”
“Using Excelsius3DTM, we started doing more deformity surgery, for example, doing pelvic fixation or S2-AI screws. That really was a game changer because it was so much less muscle dissection, less bleeding, and really excellent fixation to put screws in the pelvis.”
“We were able to quickly do long deformity surgeries. Now that we have the Excelsius3D we actually see the entire lumbar spine, even into the thoracic spine. By getting one imaging shot with the Excelius3D, we can plan our entire case. That’s also been a game changer.”
Excelsius3DTM also gives the surgeon three imaging options, in one C-Arm, digital X-ray, fluoro and CT. And it integrates intraoperatively in a way that, as Dr. Goldstein described, was cleaner and simpler. An eco-system, in other words.
“I can plan my screws intraoperatively without necessarily having to get a preoperative CT scan and going through a fluoro routine. I can use the simulation. I can use the intake on the 3D and plan my screws through a much faster and probably more precise technique.”
“I enjoy the fact that the system works seamlessly with 3D imaging. I can do a 3D spin with my Excelsius3D, the acquisition time is faster than the O-arm. The O-Arm, as you remember, is a great machine, but it first came to the market many years ago.”
Dr. Goldstein: “Excelsius3DTM is also very mobile. You can move it between operating rooms easily. They actually have some very cool wheels at the bottom of the robot that allow you to push it just by touching it.”
OTW: Funny you should mention that, about two years ago I think, and I was in the Globus booth at NASS. The president of the company at the time said, ‘Hey, Robin’, watch this.’ he moved the entire system with just two fingers.”
Dr. Goldstein: “That’s exactly right. It’s technician user friendly. I think NYU Langone is the only hospital that I’m aware of that has three Excelsius robots. We did the first case with the Excelsius3D™, and I use it regularly now.”
Other Lessons and Looking Ahead
Robotic systems, Dr. Goldstein told OTW in 2018, are no substitute for being properly trained as a spine surgeon and he reiterated that point in 2022.
Dr. Goldstein: “The current increase in robotic systems in spine surgery is kind of like the wave of laparoscopic cholecystectomies in the sense that you really had to know the anatomy from an open standpoint to picture in your mind’s eye where the screws or the instrumentation was going from the robotics standpoint.”
“I think that in the future, it could be a standard of care in many hospital systems. It is an expensive device, but it is continually improving, and it takes us down the road of improving outcomes and safety.”
OTW: Is this anything that an ASC should look at? I understand the price tag, but aside from that, is this something an ASC should look at?
Dr. Goldstein: “Yes, absolutely. I think it’s fair to say that a lot of the procedures we’re doing now in a hospital situation may be appropriate to do in an ASC or an ambulatory setting or even a 23-hour stay setting. And a robotics system like Excelsius3DTM facilitates these kinds of minimally invasive, single-day procedures.”
OTW: Thank you Dr. Goldstein. I think the old saying that the only constant is change, applies when it comes to these advanced, software based systems. And it is certainly gratifying to hear you say that these systems are moving the needle in terms of patient outcomes. Thank you again and, I hope, we can check back with you in 2026.