sMater - Advancements in neurosurgery | Dr Martin Wood

In this episode of sMater, Mater Neurosurgeon Dr Martin Wood discusses robotic-assisted spine surgery and how it is transforming outcomes by enabling minimally invasive procedures and improving surgical precision.

He highlights what GPs should look for when referring patients and how this technology is expanding access and reshaping care for patients across Queensland.

#smater #mater #neurosurgery #neurosurgeon 

To learn more about Mater, visit https://www.mater.org.au/

Transcript

Hello and welcome to this episode of SMater, a podcast by clinicians for clinicians

brought to you by Mater, an Australian leader in health care for more than a

century. I'm your host Jillian Whiting coming to you from the engine, the land on

which this podcast has been recorded. And I'm Dr. Maria Boulton, GP specialist and

former president of the AMA Queensland. Today we are joined by Dr.

Martin Wood, Consultant neurosurgeon at Mater Private Hospital, Brisbane. Martin is

widely regarded for pioneering the use of minimally invasive techniques for spinal

surgery since the early 2000s, and for performing Australians' first intrauterine

surgery for spinal bifida. We are Mater. We are Mater. We are Mater.

This is Mater.

- Martin, welcome to SMater. - Thank you, good morning. - Let's start with the

basics. When we talk about robotic assisted neurosurgery, what exactly are we talking

about and how is it being used in spinal procedures today? - Well, it's really, it's

the culmination of a fairly long journey, which I'll try to explain. I think if you

think about What spine surgery used to be, and liken it to driving someone in your

car, it was very reliant on reading a map, a paper map, that didn't tell you where

you were, whilst driving a manual car. So you had to change gear, you had to drive

the steering wheel, you had to apply the throttle, and it was very much, you had

to figure out where you were based on things that were around you by exposing all

the spine and looking at it. That meant that you had to perform wide exposures,

strip a lot of the soft tissues off the spine, really to figure out what your

landmarks were and where you were going to put the implants into the spine. And

then about 20 or so years ago, we started to have the availability of what's called

Stereotaxi for use in the spine. That was a big leap forward and really then takes

us forward into, if you imagine that in your car you've got a GPS, you don't need

to read the map anymore, but that GPS just tells you where you are. It doesn't

really tell you where you're going to get there, so you've still got to drive the

car yourself. And So you could because you knew where you were you didn't have to

expose so much of the spine to actually see it So you could do surgery putting

implants into the spine through smaller cuts But you still were responsible for

manipulating the instruments yourself and guiding them in the right direction And you

could get that wrong. It was very accurate, but not 100 % accurate the robot really

takes that a step further such that now you can imagine as if the The car is

operated by the GPS navigation system. It knows where you're trying to go because

you've told I'm going from here to here. Like when we get in our cars today and

we tell Siri you want to go somewhere and she plans a route for you.

And the robot, if you like, controls the steering wheel. So it knows where you're

going and directs you. You still have your hands on the wheel or it won't work.

You still have to apply the throttle so you're still going to be there physically

involved in the loop. But you've told the robot where you want to go and it then

puts you in a position such that you go exactly to that point. It's not yet an

autonomous system where you can just get in and say, I want to go from this place

to this place with my implants and it will do it for you. It's not an autonomous

robot. The surgeon still needs to be involved in the loop, but it's robot assisted

in that. It almost replaces your non -dominant hand, which he used to use as a

guide for putting things into the spine, and that rigid robotic guide that you've

made a plan for, you can't overcome that. So it's very, very hard to put implants

in an incorrect position. You don't need to see the spine at all. So it really

means you can do quite complex surgery through very small cuts, with a lot less

cognitive burden as a surgeon. - Revolutionary, obviously, with so many procedures?

- Absolutely, and it's really, I think there was a concern when it first came on

the scene a few years ago that was it just going to be a marketing tool? Hospitals

would buy robotic systems and use them to attract patients because it was great

technology but it wouldn't actually change the way we saw the utility with which we

could do a surgical procedure but since getting one all of us have been blown away

by just how much it's improved the surgery that we do, how much easier it is to

do the surgery, how much less thinking you have to do about it because really the

robot just it affects the plan that you've made and it's very very accurate so it's

a great step forward and they're all very excited to have access to it and be able

to use it. - What robotic technology is currently available to neurosurgeons in

Australia? And how does it improve the accuracy and safety for patients? - Well,

there are different sorts of robots. There are cranial surgery robots that you can

use to guide surgical procedures in the head, often used for biopsies or for

implantation of electrodes for people who've got Parkinson's disease or if they're

having epilepsy surgery and you're guiding implants to record epileptic signals in the

brain. Then there are the spine robots, which I guess is what we're more talking

about today,

of which there are a couple of more common ones on the market. They're not widely

available in Australia yet. They're becoming more available in some of the private

hospitals. The system that we got, the Globus Excelsis EGPS system, was the first in

Queensland at here at the matter and we've been extremely impressed with it. So

we're very fortunate here we've got a cranial robot and we've got a spine robot.

You can get robots that will do both but then there can be competing demands for

them on the same day so we're very lucky we've got a cranial designated robot and

a spine robot used for different different things. How common are they in in

tertiary hospitals around Australia? Is this we're seeing them more and more? We are.

I think I think in the public system, they're not widespread at all yet. They're

becoming more common in the private sector. I think since we got ours, there are

probably two or three others now in Queensland. So it's certainly becoming seen as

the next standard of care and taking surgery forward that bit more in terms of

accuracy and safety. The world's first robotic -assisted neurosurgery was performed in

1985, when a stereotactic brain biopsy was carried out using a modified industrial

robot. This procedure marked the beginning of robotic applications in neurosurgery and

was conducted to improve precision and reduce the impact of hand tremors during

delicate intracranial procedures.

- What kind of cases are better suited to robotic assisted surgery? - It's really

anything where you're putting an implant into the spine, which increasingly is how we

managed spinal pathology. So we're talking about putting titanium screws into the bone

of the spine in patients who have got loss of the normal height around nerves.

The nerves are being compressed and you want to restore the height of the spinal

segment or patients who've got malalignment of the spine or instability of the spine

and you need to provide stability or restoration of normal alignment. It's very hard

to do that without putting things into the spine, putting implants into the spine.

And it's really applicable for anybody who's having any sort of implanted spine

surgery, which is here at the Mater would be maybe a dozen a week. So it's quite

common. You can use it for other cases where you're not putting implants in, but

it's really then used more as a navigation system without the implantation capacity,

but it's very useful for that too. - What should you piece be aware of when we're

referring patients for robotic -assisted surgery? Or is Is there anything to look out

for when patients come back to us after the surgery?

I think I would see it as being applicable to anybody who's having spinal surgery.

There's nothing different about it in terms of the patients you manage and minimally

invasive spine surgery, if anything, is better for people who were previously much

harder to operate on. So patients who are obese, who have diabetes, who are more

prone to getting infections after surgery. Because you're making very small cuts,

you're not disrupting muscle tissue. Those patients are much less at risk from those

sort of complications than they were previously. So really sort of the, in a way,

patients who are less ideal for open spine surgery are better for robotic surgery

because you avoid a lot of those complications 'cause the cuts are smaller, they get

less pain, less bleeding, they mobilize faster afterwards and you really reduce the

complication load. Is there any particular information that you would like to see on

GP referrals that may assist you in caring for our patients? The important thing

that we'd like to know is neurosurgeons,

you know, it's often sort of equipped that all neurosurgeons do is compress nerves.

Whatever operation we do, whether it's on bones, whether it's sucking clots out of

the head, really all we're doing is decompressing nerves. So it's important for us

to know, does that patient have nerve compression symptoms? So do they have arm

pain? Do they have leg pain? Rather than just back pain? So the majority of people

with back pain alone, we can't help with surgery. That's certainly very well

accepted. There are certain caveats to that, but the majority of people with back

pain are not generally surgical candidates. So if a patient has what we call

ridiculous pain, so pain in the arm in the case of a neck pathology or pain in

the leg or one of the other or other of the legs for lumbar pathology were much

more likely to be able to help that patient with surgery. You've talked about how

more common the robotic surgery is and the robots are making a huge difference, but

what about patients in rural and remote parts of Queensland? What about access and

equity for them? Yeah, that's a really tricky one. Neurosurgery really, because it's

costly, tends to be based in capital cities or metropolitan areas. So patients from

regional areas get a bit of a raw deal in terms of access to neurosurgery,

particularly when things are urgent, because time is often of the essence when if

it's a brain problem from trauma or a tumor and there's pressure in the head, you

really have to get on and alleviate that quickly. So it is a problem and it's

always something that we wrestle with in terms of planning neurosurgical services. The

way things are at the moment, if we're talking about the spine robot, we're We're

very fortunate that Mata has a network up and down, up and down Queensland, really

across the length of the breadth of Queensland. So patients can be seen in regional

clinics and the practice that I work with here certainly offer regional clinics up

and down Queensland and they can access care in the local community with a visiting

neurosurgeon, so travelling from here. So you've been travelling up and down the

coast? Yeah, in my case I've had a lifelong passion in aviation, So I've had a

plane for a couple of decades and used that to travel to and from clinics, which

was good for me, but also good for the patients. So we can see them in their

hometown, whether it's Rockhampton, Bundaberg, Harvey Bay, Mackay, and they can come

down and have surgery here at the Mater, where we've got all the bells and

whistles. Whether things advance to the point that if robots become more autonomous

and you can operate them remotely, maybe it works out better financially to have

just a robot in a regional town, a surgeon in the capital city who can then run a

robotic case remotely. We're a long way from that yet, but that's really the pie in

the sky destination perhaps for regional communities. It would be great if everybody

had access to this kind of equipment.

How would that be possible? Well, I think the main reason why it's not more widely

available is the cost.

These are very poor.

Foundation and we've had just installed very recently a new imaging system that

provides that 3D, excuse me, imaging of the patient's spine that we then use as the

road map for the computer and the robot and that's just been installed here at Mata

and once again expensive but very useful piece of technology. We revolutionize what

we do and that was also supported by philanthropic donations through the Mata

Foundation so we're exceptionally grateful for that community support. And you talk

more through what that machine is and what does it do and how useful is it? Yes,

of course. So for a long time to try and replace what you see with your eyes,

which meant having to expose all the bones of the spine with radiological pictures

that you could then make smaller cuts with. So you're sort of seeing through the

patient's skin if you like which is what radiology does. Initially we had X -rays

which are two planes. They're in 2d. They don't give you a three -dimensional

perception So it kind of works, but it's difficult going back to the you know

driving while changing gear sort of analogy and then the real leap forward was using

a CT scanner in the operating theater and Mobile devices to do that start came on

the market about 20 years ago and think called the o -arm We had the first o -arm

in the Southern in 2007 here at Mater, and that really kick -started this whole

minimally invasive spine robotic progression journey that we've been on.

That technology has been advanced and improved upon, and so the latest and greatest

version of that is a thing called the E3D, again made by a company called Globus

in North America, and we've just received one of those here at Mater, which is a

great leap forward in terms of the footprint in the theatres, how useful it is, how

maneuverable it is, the footprint around the patient and the quality of imaging is

much better than what we had before. And it just adds that next little layer of

accuracy, safety and efficiency to what we do here at MATA. As a patient, having

access to the fabulous makes such a difference.

Any financial, does it cost me more to get the robots? No, it doesn't. So, we take

the view that the technology is there for everybody, and we treat public patients

and private patients here neurosurgical at the matter, and it's available to

everybody. It costs no extra to have the robot used in your surgery than if you

don't have the robot used in your surgery. So, we use it on everybody who it's

suitable for. The devices are expensive. There is no recognition of that in the

Medicare schedule fees and the health fund

given that that's the case. You know, if there was an increased cost, it'd have to

be borne by the patient, but we don't charge any more for the use. According to

Grandview Research, the global medical robotic systems market, which includes everything

from pharma robots and robotic prosthetics to surgical robots, was valued at US $25

.56 billion in 2023. It is projected to grow to US $76 .45 billion by 2030,

representing a compound annual growth rate of 16 .5%.

For patients who are travelling, I used to live in Makai, so for patients who are

travelling, for example, from Makai to have spinal surgery, how long would they be

in Brisbane for? It depends a little bit on what they're having. If they're having

simple, I say simple, if they're having non -instrumented spine surgery, so they're

having, for example, a lumbar decompression, what we used to call a laminectomy or a

diskectomy. Usually they're in hospital for 23 hours or less. So they come in on

the day of surgery, have their surgery performed, and then they're good to leave

hospital early the following morning.

The only problem is the airlines haven't quite caught up with the concept of less

invasive spine surgery, and the fact that patients are not as sore afterwards, they

could easily fly home the day of discharge. So the airlines often make them wait a

bit. We often say, you know, have you got someone you can go stay with for an

extra day because you may not be able to fly home, even though we sign off their

airline forms. But in hospital, often less than 24 hours. Now, if they're having

implants put into the spine in the lumbar spine, typically they would be in hospital

for two nights postoperatively, so after the day of surgery, which is a huge

improvement on the old sort of seven to 10 days in hospital after an by an

operation which is a much more painful ordeal for them. - Are these advances in

surgical techniques opening up these procedures for more patients? And where do you

see the future? - I think they are. It certainly makes this sort of surgery where

you're putting implants in the spine much easier. And much easier from a surgeon's

perspective in terms of learning how to do it because you're not struggling to read

the anatomical map while you're driving the cars to use that analogy again. But it's

also much easier for patients. So patients who are a bit more elderly and firm, got

comorbidities, maybe got some negative factors that might have weighed against them

previously and possibly excluded them from surgery. Now they can have surgery that's

much less invasive, it's much less damaging to their tissues, much less of an insult

on the cardiovascular system. They go home faster, they get back to their normal

activities faster. So it does certainly widen the envelope of who can have this sort

of surgery. Where are we headed in the future?

I think ideally it'd be nice not to operate on so many people with spinal pathology

and maybe we'll have regenerative

techniques and technologies that can restore disc health or restore ligamentous health

that you don't have to decompress the nerves physically. Maybe that'd be great, but

we'd all be out of a job.

In terms of where the robotic technology is going, I think it's improving year on

year and we're starting to see some artificial intelligence applications where instead

of you telling the robot what the surgical plan is that you want as a surgeon, it

can analyze all the data that's got from all the L5S1 fusions, for example,

that might have been done in the last three years and there'd be millions of them,

and suggest a plan. So saying, if you put into the system, this is what the level

I'm operating on, it'll suggest a plan or a couple of plans, you go, yep, that's

fine, that makes sense. That we're starting to see already with some of the new

software updates. And then the progression of autonomous mechanical activity of the

robot really then would be the next thing. How much does a surgeon still need to

do? You can build cars without humans needing to do anything to the robots. You

just run a program and the robot builds a car. We should be at the stage where a

robot could put a paticle screw to somebody's spine, but really, for a lot of

reasons, most of them due to human confidence, the surgeon still needs to be

involved in the loop. But I think in time, that probably won't be the case. Same

as we'll have self -driving, self -flying aeroplanes and self -driving cars. It's all

just the progression of technology. - Evolving so quickly, it seems to be. Where is

the research happening? Is much done here in Australia, or are we being guided by

global leaders here? I think we just don't have the population density here to

really be drivers in terms of the technology development. Where is it coming from?

It's coming out of North America principally, but there are also very active robotics

projects in Southeast Asia, Korea in particular, and in South Korea it's really an

offshoot of the car making industry. You know, they've clearly got huge car building

industries there, and the automotive construction robots are being adapted and modified

for medical use. So it's a fascinating field and I think like everything in the

modern world, you know, the advances just happen faster and faster and where we'll

be in five years' time is probably hard to comprehend. What about that relationship

between primary care and specialist surgery? How will that change, do you think?

Well, I think we're seeing increasing ease of access of surgeons to general

practitioners. So whether, you know, the GP just, I often get text messages from GPs

saying, "Hey, can you have a look at this patient scan and just let me know what

you think to send me a text back?" You know, we couldn't have done that really

five, ten years ago. The GP would have rung the practice and I may or may not

have been there and they'd leave a message and I may or may not have called them

back and they'd be the sort of this run around the house is trying to get messages

to inform each other. But ease of access and communication is phenomenal now. You

know some practices are experimenting with GPs directly booking appointments on their

practice software We're not doing that yet, but that's you know seems a logical step

that the GP has visual Visibility over where a patient can be slaughtered in if

they're urgent or less urgent So I think communication is the main thing and just

the ease with which we can now look at patient images as well Patients don't have

to lug around envelopes anymore and turn up and go. Oh damn. Sorry. I left my x

-rays at home or they're on the bus So, you know, there's no physical films anymore.

It's so much easier. I can look at X -rays on my phone. So really the technology

that we'll take for granted day in, day out, mostly on our phones and our laptops

is changing the way we practice medicine. - What advice would you give the next

generation of neurosurgeons? - It's difficult because I think they're going to be

practicing a very different specialty to the one that I grew up in and my tours

grew up in, I think I would say to them to live in the moment and to make sure

they make time to enjoy the journey through their training. I look back at my

training years as some of the best years of my career, you know, that the work

just came in and you operated on it and you learned and you, you know, you

interacted with the patients and you didn't have to do quite so much hard yak at a

generate the work and then you go into private practice And it's all on you and

you've got to generate the work for yourself and it's it's not less enjoyable But

you don't realize how good it was when you were training and what a what a

fantastic experience What a great privilege it was So I would tell them to enjoy

the training experience not be too focused on where they're going because the journey

is great

But always and this is sort of becoming better as time goes by anyway Just to try

and make time for life as well not to get too focused on being on being a

neurosurgeon. Neurosurgery is your job, but you can have a life as well.

Excluding the other things in life because of your job and being so focused on it

is often to their detriment. Work -life balance is a lot easier to achieve. It's

often spoken about glibly, but I think it is important not to say don't take your

job seriously, but it's a job and There's a lot more to life than your job. - And

I think that goes for every doctor out there, not just neurosurgeons. - Yeah, but

it's very different to the previous model. You know, generations older than me, where

you were a neurosurgeon and that sort of defined you until you dropped dead at 80

when you were still working. - We want to know a little bit more about your life

now as we wrap up, we'll introduce you to our little segment called the checkup.

So this is to get to know you a little bit more as well as your professional

strength. So Maria's got five quick questions for you.

You ready to go?

- Who's the most underrated member of the hospital team?

- In terms of the people that I interact with regularly as a surgeon, I would say

it would be the orderlies. Either on the wards or in the theaters. They just, they

get patients where they need to be. They make stuff run, they make stuff run on

time. When you need something done, an orderly appears and helps you do it, and we

wouldn't get stuff done. We wouldn't get it done on time without the orderlies.

- They're great multitaskers too. What's your secret superpower?

- I don't know that I have one.

- Lying and playing maybe? - Yeah, that's not so hard. - Is it? - No, other than

driving a car, there's less to crash into.

I think my secret superpower these days is being able to take a positive attitude

to things in a way that I might not have done in the past. Always be grateful for

everything. What was your first concert?

I can tell you what my first record was when I had a record player when I was

single digit ages. It was a single for Flash Gordon.

The theme is tuned to Flash Gordon by Yeah, remember that one? That was my first

record. First concert I couldn't remember. Flash Gordon is great. If you could impart

one piece of knowledge on a medical student, what would it be? A piece of

knowledge.

I don't know that it would be about medicine necessarily. I think it would just be

what I was alluding to before, just always be grateful that you're in a very

privileged position and no matter how crap it is, you're having a better day than

the person on the other end of the scalpel or the needle or whatever has been done

to them. And who was the last person you video called? Probably somebody in my

other job at Event, I worked with Event Medical Legal Insurer and it was probably

just a very mundane video call about somebody getting into trouble about something,

nothing exciting. - Martin, thank you so much for joining us. It's been absolutely

fascinating to see where we're headed really with robotic assisted surgery. Thanks so

much for joining us on SMater. - Enjoyed it, thank you. - For our listeners at home

or in the car or having a well -deserved break between patients, thanks for tuning

in. - See you next time on SMater.