Episode 20 - Innovations in Spine Surgery with Dr. Christopher Holland
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Episode Summary
Although advancements in technology have made many things possible in medicine, particularly in the surgical aspect, robotics is still somewhat a relatively new concept. This sector is gaining traction in the market, but you won’t find robots in most hospitals in the U.S.
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia is joined by neurosurgeon Dr. Chris Holland to explore surgical robots utilized in spine surgery. Chris goes in-depth into what surgical robots are, how these work, and how they’re adopted in the OR for neurosurgery or spine surgery. He emphasizes that these devices are not like what you would see in sci-fi movies. Rather, they comprise of a multi-articulating arm and an instrument at the end that performs a function.
He also speaks briefly on the history of surgical robots and their differences between the da Vinci robot. For the latter, the spine surgery robot is used as a guide for the correct placement of hardware, like screws or interbody cages. The benefits of using a robot and other challenges to adopting it in the OR were also discussed.
Chris has a positive outlook on future innovations in the industry, which will provide increased safety and accuracy, along with lower morbidity rates among patients.
Key Moments in the Episode
What is a surgical robot 09:22
How surgical robots work 11:26
Robots in spine surgery 13:06
Benefits of using a surgical robot 15:13
Challenges to adopting robotics in spinal surgery 23:03
Certifications and training 25:14
The da Vinci robot 27:14
The difference of spine surgery robots 29:23
Future innovations in spine surgery 30:27
Dr. Chris Holland's tips for health and wellness 33:00
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia talks about magnesium, an important mineral to maintain good health and well-being. He shares the benefits of magnesium, which include muscle relaxation, energy production, improved bone formation, and growth, There’s also a correlation between magnesium levels and back pain.
He also gives recommendations on what formulation of the mineral to take, including magnesium oxide and magnesium citrate.
Links Mentioned in the Episode
Neurosurgical Robotics: A Review of Brain and Spine Applications - Journal of Robotic Surgery
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Although advancements in technology have made many things possible in medicine, particularly in the surgical aspect, robotics is still somewhat a relatively new concept. This sector is gaining traction in the market, but you won’t find robots in most hospitals in the U.S.
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia is joined by neurosurgeon Dr. Chris Holland to explore surgical robots utilized in spine surgery. Chris goes in-depth into what surgical robots are, how these work, and how they’re adopted in the OR for neurosurgery or spine surgery. He emphasizes that these devices are not like what you would see in sci-fi movies. Rather, they comprise of a multi-articulating arm and an instrument at the end that performs a function.
He also speaks briefly on the history of surgical robots and their differences between the da Vinci robot. For the latter, the spine surgery robot is used as a guide for the correct placement of hardware, like screws or interbody cages. The benefits of using a robot and other challenges to adopting it in the OR were also discussed.
Chris has a positive outlook on future innovations in the industry, which will provide increased safety and accuracy, along with lower morbidity rates among patients.
Key Moments in the Episode
What is a surgical robot 09:22
How surgical robots work 11:26
Robots in spine surgery 13:06
Benefits of using a surgical robot 15:13
Challenges to adopting robotics in spinal surgery 23:03
Certifications and training 25:14
The da Vinci robot 27:14
The difference of spine surgery robots 29:23
Future innovations in spine surgery 30:27
Dr. Chris Holland's tips for health and wellness 33:00
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia talks about magnesium, an important mineral to maintain good health and well-being. He shares the benefits of magnesium, which include muscle relaxation, energy production, improved bone formation, and growth, There’s also a correlation between magnesium levels and back pain.
He also gives recommendations on what formulation of the mineral to take, including magnesium oxide and magnesium citrate.
Links Mentioned in the Episode
Neurosurgical Robotics: A Review of Brain and Spine Applications - Journal of Robotic Surgery
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Sanjiv Lakhia: 00:00
(silence)
Sanjiv Lakhia: 00:36
Welcome to today's episode. I'm excited to say we've reached our 20th episode of Back Talk Doc. And when I started this project, maybe under a year ago, my goals were to educate the general public on all the ins and outs of spine care and really arm you, the listener, with accurate, up to date information about the medical options for the treatment of your spine condition so that you can make an informed decision. And I think the feedback and the results have just been fantastic.
Sanjiv Lakhia: 01:10
Surprising to me, our audience at Back Talk Doc is not just patients. I've had people in the healthcare community reach out to me. And I think the topics and the information we've covered have really been helpful for people, not just in the Charlotte area where our practice is, but also across the country. I've looked at the listener profiles and it really makes me feel good to know that those of you out there are sharing the episodes and we're touching a wider audience.
Sanjiv Lakhia: 01:38
So I want to start out this episode by thanking you for taking the time to listen to the information we're providing. And if you found the podcast to be helpful, please go on iTunes and leave us a good review. And even more importantly than that, if you know of a friend or family member who is suffering from pain or injury and could potentially benefit from the information, feel free to share the episode with them.
Sanjiv Lakhia: 02:01
And with that said, I want to dive into today's topic. I'm really anxious to get going here. I have an interview today with Dr. Chris Holland. Chris is a neurosurgeon here at Carolina Neurosurgery & Spine Associates. And Chris, you've been with the group about five years, six years now, right?
Chris Holland: 02:17
Just about five years. So just over four years or so that I've been here.
Sanjiv Lakhia: 02:21
Well, welcome to the show. We're going to cover a topic today that is really modern. It's the idea of robotics in surgery or surgical robotics. And when I think about this topic, my mind goes out like into the future. I feel like I'm at Epcot and I'm looking at Tomorrow Land and The Jetsons and just really kind of crazy stuff. So I want to break this down into something that's meaningful for our listeners so they can understand what it really means.
Sanjiv Lakhia: 02:48
Before I do that, folks, I want to introduce you to Chris. Chris did medical school, where he did a MD PhD program at Boston University's School of Medicine. He did a residency and internship at Emory University and a fellowship in complex and minimally invasive spine surgery at the University of Utah. So he's fellowship trained and he's published over 22 peer-reviewed manuscripts, and has presented at both national and international medical conferences.
Sanjiv Lakhia: 03:16
He was awarded an NIH NINDS pre-doctoral fellowship in the Congress of Neurological Surgeons, the David Cahill Spinal Fellowship Award, and was named in a 2016 top 40 under 40 healthcare innovator. His specialty interests include degenerative spine conditions, spinal instability, spinal deformity, spinal primary and metastatic tumors, artificial disc replacement, and spinal trauma.
Sanjiv Lakhia: 03:42
So he does it all and he does it well, and it's been a real pleasure getting to work with him in our practice, and I think he's a perfect guy. Chris is always on the cutting edge of treatments for our patient population and community. So Chris, thanks for taking the time to join us today.
Chris Holland: 03:57
Well, thank you so much, Sanjiv. I'm really excited to be on your 20th episode. And I think this is a very exciting topic, just because there's been so much innovation in the last several years and things are really starting to move quickly, and it's providing a lot of benefit to our patients in terms of the things that we're able to do, leveraging these new technologies in new and innovative ways to improve care.
Sanjiv Lakhia: 04:19
Before we dive into the topic today, I always like to give the listeners a little sense of who they're listening to. Can you give us a synopsis of kind of how you found your path into the field of neurosurgery and just little bit about your background? I know you have a little bit of an entrepreneurial background as well. You have a very unique and interesting background I want you to share with the listeners if you can.
Chris Holland: 04:39
Sure, no, I'd be happy to. It is sort of a little bit of an atypical background. I started working in medicine, in hospitals, very young. I was introduced to medicine early in my life. Both of my parents were ill when I was young and I spent a lot of time around hospitals and doctors. And so I started shadowing physicians and actually working in an emergency room when I was 17 years old. And I carried that all the way through college. And so I had very early good experiences with physicians, in particular with surgeons, who would take me from the emergency room into the OR for patient cases to observe. And that's really where I got my initial exposure to surgery in general.
Chris Holland: 05:16
After college, I was sort of already directed on this path. I knew that I wanted to go to medical school and pursue a career in medicine, but I took two years after college and I had worked at Lahey Clinic outside of Boston. And there, I was working primarily in the clinical research department, but again, had an active interest in surgery and worked with a number of different surgical departments there. And that afforded me the opportunity to shadow physicians, spend time in the operating room with them. And I spent a lot of time with the neurosurgeons there, got to know them very well, and really got excited about the types of cases, surgical cases they perform and the types of patients they took care of, and the impact they had on the patients' lives.
Chris Holland: 05:57
And so I left that job and headed to Boston University for the MD PhD program. And at that point, I really was convinced that neurosurgery was what I wanted to do. During my two year period at Lahey Clinic, I spent a fair amount of time taking graduate coursework in computer science. I had a computer background. I'd always been interested in computers and technology, and that sort of laid the foundation for my PhD, where I looked at MRI imaging of the brain and applied different mathematics or statistical measures to those images.
Chris Holland: 06:30
And so I did the combined degree program where I completed my PhD in the Center for Neurologic Imaging at Brigham Women's Hospital. And ultimately, when I graduated from there, as you mentioned, I went to Emory in Atlanta for my neurosurgical residency.
Chris Holland: 06:45
While I was a resident there, I continued with my interest in technology and in software development, and built a number of systems there that we used within the department to augment or improve our ability to manage our patients and our patient lists. So some of those things involve building system for tracking our cases or our quality improvement conferences, but I also helped to build a mini imaging system to collect all of the outside images that were constantly being sent with patients as they were transferred in from other facilities.
Chris Holland: 07:17
As you know, most patients get their images on a CD and that disc not only can be damaged, but they all have somewhat proprietary software on them and can't always be read by every computer, which is very challenging in neurosurgery when patients arrive in the middle of the night and it's critical that we can review their imaging to decide whether or not that patient needs emergent or urgent intervention. And so, I helped to develop a system to allow us to do that, as well as the archive and store those images in our department there.
Chris Holland: 07:43
So I've found ways to take my interests in technology and computer science and in development and apply those to real problems within healthcare. And so, being able to do that makes a big difference to me, in that I'm seeing problems and working to actively address them, not just for the immediate need, but for the future in terms of what we can do down the road to continue to improve that experience.
Sanjiv Lakhia: 08:13
I think it's safe to say that technology is somewhat in your DNA, and I think it makes you the perfect person to dive into this topic today, which is robotics and surgery. I somewhat described it in jest, but the future is now. And interestingly enough, in preparing for this interview with you, I pulled an article, a review article from the Journal of Robotic Surgery entitled Neurosurgical Robotics: A Review of Brain and Spine Applications. And the authors were Karas, K-A-R-A-S, and Chiocca, C-H-I-O-C-C-A. And the reason I'm mentioning it is I went through this, and then when I was done reviewing it, I realized this was written in 2007. So it's been around a while, and here we are 2020 and it still seems quite new.
Sanjiv Lakhia: 09:05
So I just want to start out because I'm sure like me, many of my listeners really don't have a general sense for what this means. So can you kind of explain what is a surgical robot and even describe it so someone listening out there can even have almost a picture in their mind about what we're talking about.
Chris Holland: 09:22
Absolutely. And surgical robots aren't the types of robots that we see in the movies that have a human or a humanoid type form to them. Most surgical robots consist of an arm or a multi-articulating arm, with the various types of end effectors or what you would consider similar to a hand on the end, or some type of an instrument that would perform a function.
Chris Holland: 09:44
Robot itself is somewhat of an incorrect description of what these devices are because robots, by definition, are supposed to be autonomous, meaning a robot is supposed to be able to carry out very complex or repetitive actions all by itself without any interaction. And so a robot in that sense would be something you would see on an assembly line, say at an automobile manufacturer, where it's continuing to do the same task over and over again. And it may be a very complex task, but it's programmed to do that all by itself.
Chris Holland: 10:16
In the operating room, we don't have robots like that, meaning robots are designed to be assistive devices in the operating room, but the human there, the surgeon, is still the one that's carrying out the specific tasks.
Chris Holland: 10:29
There are several different types of robots, and in neurosurgery, it's used a little bit differently than some of the earlier robots, one of the most popular being the da Vinci. Those early robots, the surgeon stands away from the table or away from the patient and uses a display screen and a number of controls to manipulate the arms of the robot to carry out the various functions. In spine surgery, it's a little bit different. In spine surgery, we're using a robot that is in close proximity, or a robotic arm that's in close proximity to the patient, but the surgeon is still carrying out the actions using that robot as an adjunct or as an assistant.
Chris Holland: 11:10
And so, there are a number of different things that can be different between different types of robots and how they're used ultimately in the operating room.
Sanjiv Lakhia: 11:18
Is it controlled almost like with a joystick or how does a surgeon interact with the robot and obtain robotic assistance?
Chris Holland: 11:26
Sure. So in neurosurgery and in spine surgery in particular, but there are also a number of cranial or brain surgical applications for robots, we're not controlling the robot with a joystick, but rather, we are oftentimes setting up a plan with the robot in advance, sometimes often even before the patient's brought into the operating room, and then we're using that robot to execute that plan.
Chris Holland: 11:49
And to make that a little more clear, most of what we're using a robot for currently in spinal surgery is the placement of hardware, the placement of instrumentation. And so robotics, at this point, is being used to place typically screws within the vertebral bodies, what are most often pedicle screws, and some of the newer developments, to be able to place spacers, or what we call interbody cages, in between vertebral bodies once a disc has been removed there.
Chris Holland: 12:18
And so the robotic function is really used in a very narrow window in terms of what we're accomplishing with that robot. So the robot is not being used to make an incision or, in general, at this stage, to be removing bone or performing a decompression or a diskectomy or anything like that. The robot is really being used as a guide for the highly reproducible and accurate placement of hardware.
Sanjiv Lakhia: 12:44
Okay. So that answers one of the questions I was going to have is how does a robot assist with spine surgery? So what you're saying is that there's certain specific parts of the surgical procedure where you find benefit in using the robotic assistance, but it's not like the entire procedure is, let's say for a lumbar fusion, is carried out with robotic assistance.
Chris Holland: 13:06
That's exactly correct. The way that it generally works, and robotics grew out of earlier technology which was navigation, and spinal navigation works analogously to how GPS works in your car, in that we would have instruments and we could look on the screen, and the system would show us where those instruments are in the body. And so through a very small hole in the skin, we could use one of these instruments, pass it through the incision, and on the display, we'd be able to see exactly where the tip of that instrument was on the patient's actual anatomy.
Chris Holland: 13:40
And so once we were able to do that reproducibly, we were able to align their imaging with what we were seeing in the actual operating room, robotics was then developed as sort of the next step. And the way that the robotics or the robotic systems work these days is that we would take imaging of the patient, whether it's preoperative or intraoperative at the time of surgery, and we would, on those images, decide where we'd want the hardware to be placed. And so we would very specifically plan where we would want to put each screw, for example. And then once we've done that planning, what we would have the robot do is move to a unique position for each one of those screws that gives us the perfect trajectory or the perfect line down through the skin and into the bone exactly where we want that screw be placed.
Chris Holland: 14:29
And so the advantage of robotics in that sense is that we can plan all of the hardware in advance. We can align each screw with the screws adjacent to it, both above and below it, to facilitate connecting those together with a rod, ultimately, at the end of the case. And it allows us to, without having significant amounts of radiation, place that hardware, reliably, exactly where we want that to be placed.
Sanjiv Lakhia: 14:58
Okay. So that's an interesting point there. So you're touching on benefits, both from a surgical outcome basis, but also from a provider basis in terms of reducing your risk of exposure during the procedure.
Chris Holland: 15:13
Absolutely. We're actually reducing the radiation exposure, not just to the physician and the staff, but also to the patient. And so that's one of the major advantages of technology like robotics.
Chris Holland: 15:25
I think some of the biggest things that that drive us towards using technology like this is that, number one, using this technology decreases the risk of hardware misplacement, meaning a screw or an implant goes where you don't want it to be. The second is that it greatly increases reproducibility. So if you have a plan and that robot is consistently executing that plan, you can reproducibly place that hardware in the exact same position every time.
Chris Holland: 15:53
In addition to reducing radiation exposure, you can decrease OR time, you can increase your efficiency. So once you've verified that your registration is accurate and that the robot is accurately moving to the correct position for each screw, for example, that you're going to place, you can move very quickly because you don't have to be constantly verifying at each step that you're still in the right place. And so it really increases your operative efficiency and decreases the amount of time that patient needs to be under general anesthesia. And so, as a result of all of those factors, you're really improving patient safety and ultimately improving patient outcomes.
Sanjiv Lakhia: 16:30
All right, that's great. He touched on a lot of the advantages of using robotics in surgery. And I want to get into a little bit about if you see any disadvantages with using robotics, and we'll dive into that right after this break.
Sanjiv Lakhia: 16:49
It's been a while since I've taken a break for a health matters segment. I feel like some of our episodes have really been geared towards health and wellness, and in others, we've just had terrific interviews going on so I didn't really want to break up the flow, but today I want to touch base on the topic of magnesium. It's one that I've encountered in the office for several cases here lately and I think it's something that we should talk about.
Sanjiv Lakhia: 17:14
Magnesium, it's obviously a mineral in our body. The adult human body actually contains about 20 grams of magnesium, most of which is bound up in the bone, the rest of it is intracellular within your cells, and it's cofactor for almost 300 different enzymes and chemical reactions in the body. So magnesium is a critical mineral for energy production, for muscle relaxation, from normalizing your heart rhythms. So it's a very powerful nutrient.
Sanjiv Lakhia: 17:46
And in today's society, some data suggests almost 50% of the population is deficient in magnesium. And why is that? Some of that could be due to the soil no longer having as much nutrition as it used to be due to farming practices, and in other cases, many of us just aren't eating optimally. So diets that are high in refined sugars and breads and pastas and so forth really are devoid of good nutrition. And magnesium is one of the elements that is missing.
Sanjiv Lakhia: 18:16
If you want to increase your magnesium, there are some good food sources, nuts, whole grains, legumes, leafy green vegetables, fish, meat, and some dairy products are high in magnesium. Unfortunately, more than 80% of the magnesium is lost in the refining process of whole wheat flour to white flour and in brown rice to white rice. And then also, you lose a lot of magnesium from your vegetables when you're boiling them. So you want to keep those considerations in mind.
Sanjiv Lakhia: 18:45
The recommended dietary allowance is for magnesium, they're really quite low in my opinion. An adult let's say age 19 to 30, recommends about 400 milligrams a day for males and 300 for females. I just think that with the stress we're under and the nutrition issues that are in this country, that a little bit more magnesium is probably warranted.
Sanjiv Lakhia: 19:08
Why is it warranted or where does it really come into play in terms of this podcast which is geared towards spine care? Well, it's quite simple. I think there's a correlation between magnesium levels in your body and pain. So I treat a lot of back pain and I also have people that come to see me who have other types of pain, like migraines and headaches. So if you look at some of the data, it's really compelling.
Sanjiv Lakhia: 19:32
Experimental magnesium deficiency has been proven to cause spasm in the blood vessels and in the arteries, and that, I think, is a good correlation with migraine disorder. So, many times, people with migraines will benefit from supplemental magnesium. And this has played out some in the research and the trials that are in the published literature. And dosing is around 300 to 600 milligrams per day for adults. That can easily be obtained over the counter in a supplement form.
Sanjiv Lakhia: 19:59
There's also some evidence that the use of magnesium can help asthmatics, as it can relax the bronchial smooth muscles or the linings in the lungs. And it also has a bit of an anti-inflammatory effect, and can [inaudible 00:20:12] your response to histamine. Histamine is what triggers some of the allergic reactions in our body.
Sanjiv Lakhia: 20:18
So it's something to really consider. It has broad positive effects, the least of which also is in supporting bone formation and bone growth. So in osteoporosis, your magnesium is a cofactor for alkaline phosphatase, which is an enzyme involved in bone mineralization. So something to keep in mind if you're taking calcium, you're taking vitamin D, vitamin K, also consider magnesium in your efforts to support your bone density overall.
Sanjiv Lakhia: 20:43
So again, this is just a brief overview of magnesium. You should always check with your physician before you take any new supplements or products, even if they're over the counter, but it's something to consider adding into your nutritional food plan.
Sanjiv Lakhia: 20:56
There's some debate about what type of magnesium to get. If you look over the counter, there's multiple preparations, magnesium oxide, magnesium aspartate, citrate, there's lactate, magnesium glycinate, magnesium threonate. So there's a lot of different chelated forms of magnesium. Now, magnesium oxide is probably the most widely used preparation. It's very inexpensive. It has a higher proportion of elemental magnesium. It may not be quite as absorbable as magnesium citrate.
Sanjiv Lakhia: 21:29
And I do think the one thing to consider when you're taking magnesium, the main side effect, if there are any, is that if you take a little bit too much, it can cause loose stool or diarrhea. So some of these other chelated forms like magnesium citrate or magnesium glycinate may not cause as much loose stool as magnesium oxide, therefore you may want to use magnesium oxide if you're struggling a little bit with constipation or sluggishness with your bowels. If you're using the magnesium for migraine prevention or for muscle relaxation, then I may suggest one of the other chelated forms.
Sanjiv Lakhia: 22:05
So again, that's something to really consider. If you're struggling with low back pain, take a look at your nutrition, take a look at your diet. If you think you might be a little deficient in magnesium, check with your physician and see if it's okay for you to go ahead and add a little bit into your food plan. I think you'll find it to be a pleasant surprise with very little downside.
Sanjiv Lakhia: 22:26
Welcome back now. We're continuing our interview with Dr. Chris Holland, and today's topic is robotics and neurosurgery, and specifically in the field of spine care. Chris, do you see any disadvantages or are there any challenges from a surgical basis with using robotics? Like is it a steep learning curve? I wonder, how does it compare in terms of sensitivity and accuracy to the human hand, and just that general feel and touch sensation that I don't ever experience as a physiatrist, except when I'm doing injections. I know there's an art to neurosurgery as well that you've developed and the skills you've cultivated. So what are your thoughts on that?
Chris Holland: 23:03
I think certainly there are disadvantages to robotics and robotic systems. One is certainly the cost. They're novel. There's a lot of technology that's been worked into these devices and so they're quite expensive. Another significant disadvantage is it that does take not only time to set this system up, but the planning and all of the other steps that you wouldn't typically have to do before a case, now need to be done before you can bring the robot into the field and start working.
Chris Holland: 23:34
And so sometimes that can be done the night before, or even the day or a few days before, but oftentimes, it's done the day of surgery and in the operating room. So while there can be efficiency later on in the operation, there's a lot more work that goes into the early part of the operation to get the system registered to the patient's anatomy, get the hardware planned on the workstation before you even start the operation. And so there are certainly time constraints there.
Chris Holland: 24:01
There is a learning curve with robotics, just like any new technology, and you really continue to rely on your tactile feedback. Unlike the da Vinci or other robots where you're not still using your hands on the patient, in spine surgery, the surgeon is still doing actually the work of placing [inaudible 00:24:21] hardware. And so we still get a lot of the tactile feedback or haptic feedback that we are used to. We still can feel the engagement of the bone. We can feel the contact between the hardware and the bone to know that it has good purchase, that it's solidly in place, all of those things we're still feeling. So we're really using the robot as a channel to work through. And so the robot kind of keeps us contained within a specific space, but the surgeon is still working through that tube or that channel with the drill, for example, or the screw, and is still getting that tactile feedback.
Sanjiv Lakhia: 24:58
Are there certifications that you have to go through? So for example, if a patient's out there and wants to find a neurosurgeon who has training in the use of robotics, how can they determine if someone's competent and has gone through the proper training?
Chris Holland: 25:14
There are several robotic systems out there and the companies that produce these systems do offer varying levels of training. So there's an initial training process for using the robot, and then there's obviously more advanced training and more advanced techniques as these robots continue to evolve. They're constantly upgrading the software and also upgrading that, what I referred to as sort of the end effector or the hand at the end of the arm, to accommodate different instruments or different surgical devices.
Chris Holland: 25:49
And so it's an ongoing process. There's no universal certification process at this point for robotics, and each robotic platform tends to have its own training, but it's really industry driven, meaning if you're interested in purchasing a robot, or if you purchase a robot as a surgeon or as a practice, the company then would work with the surgeons there to make sure that everybody received adequate training, but it's not something that there's an established program or an established level of competency at this stage.
Chris Holland: 26:21
Robots are still somewhat rare. They're gaining traction in the market, but they're not ubiquitous, meaning you will not find a robot at most hospitals. Even some of the early doctors of navigation have been slow to move to robotics, but what they found is that some folks are actually leapfrogging or moving past navigation and moving directly into robotics without a background in using navigation, which was an earlier technology. There's still a lot of utility in both technologies. The newest robotics programs actually are working to merge navigation and robotics together and are becoming hybrid platforms, which is really where the most value is.
Sanjiv Lakhia: 27:03
Now, you mentioned earlier the da Vinci system. I know if you're out there trying to research this and Google it, you're going to come across that. Can you explain to listeners what the da Vinci system is?
Chris Holland: 27:14
So the da Vinci robot is used in a number of surgical specialties. It's not currently or widely used in neurosurgery or spine surgery, but the way that the da Vinci robot works is that it's a machine with a number of arms and a workstation. And the workstation is in the OR, but over on the side of the room.
Chris Holland: 27:34
And the way that it works, it's used typically for procedures done through small incisions within the abdomen or pelvis. The robotic arms are placed through these various incisions, and the surgeon then sits across the room, away from the patient, in what almost looks like a pod, with a display screen and a number of controls. This would be more of what you'd imagine with joysticks and knobs and different devices to control those alarms. And those arms can accomplish very complex maneuvers, such as suturing, tying knots, all of those types of things that are common in surgery. And there is some feedback from the controls that give you some of that force or haptic feedback from the patient.
Chris Holland: 28:21
And so, the da Vinci is a robot that's closer to what you imagine in science fiction, where the robot is actually carrying out these tasks and performing various portions of the operation, and the surgeon is controlling that from a distance. Now, that pod or that control panel the surgeon is utilizing for the operation is in the room. Technically, or theoretically, it wouldn't have to be in it because that robot is being controlled. It could technically be controlled essentially from anywhere. Whereas the robots that we're using in spine surgery and in neurosurgery, they require the surgeon to be actually performing the majority of the tasks in the operating room and just using that robot as an adjunct. So the da Vinci is a little bit different in terms of how it's utilized and that technology.
Sanjiv Lakhia: 29:07
Well, it sounds like in neurosurgery and spine in particular, the use of the robotics is more of an extension of the surgeon versus a separation of the surgeon from being more hands-on and being more involved. Is that more of an accurate way to think about it?
Chris Holland: 29:23
Yes, that's exactly how I would describe it. The robot is a tool that we're using, and what it's primarily doing at this stage is just constraining us to a single trajectory or keeping things perfectly in line with where we want them to end up.
Chris Holland: 29:40
And so, you can imagine it, like when you're a child and you go bowling and they put the bumpers in the gutters at the bowling alley and it keeps your bowling ball going straight down the lane. The robot essentially does the same thing. It provides a trajectory directly into the bone where we want to place that hardware and you just pass the instruments through. So just like the child, you're still rolling the bowling ball or placing that screw, and that robot provides just a very narrow tunnel for that to go through and ensure that it ends up exactly in the right place.
Sanjiv Lakhia: 30:12
Okay. That's a great analogy. Thanks for sharing that. I think we've covered a lot today with regards to our topic. Chris, I know you're always on the cutting edge of things. Are there any other exciting innovations in the field of spine surgery that you think the listeners should be aware of?
Chris Holland: 30:27
I think there's a lot going on in spine surgery that's exciting. And I think what we're seeing now is the combination of various technologies. You know, the initial robotics platform did not have a real-time navigation, a real-time instrument tracking view built into it. Those have now been merged together into these hybrid systems. The next stage is really looking at augmented reality, essentially using headsets or heads up displays that really provides a surgeon with x-ray vision so that the surgeon can walk over and look at the patient and be able to see through their skin essentially at their bones and their anatomy, and that's just pushing us further and further to more and more minimally invasive procedures with shorter operations, faster recoveries and better outcomes.
Chris Holland: 31:14
I think another area that's really interesting is that as these robots become more and more advanced, we're going to start using them for additional phases of the operation. For example, you can imagine that we could define areas of the body that we did not want an instrument to go into, for example, let's say an area where the spinal nerves or the spinal canal and spinal cord are, but we want to be able to remove the bone safely from around that area. If we can give those boundaries to a robot and use our instruments through that robotic arm, that arm would stop us from violating those boundaries and would allow us to mark off the areas that were safe to work in and protect us from going into the areas that we don't want to be.
Chris Holland: 31:58
So I think there's a lot of excitement in these areas coming up in the next several years, a lot of exciting development in terms of the technology and all of the different functions that we're going to be able to utilize it for.
Sanjiv Lakhia: 32:11
I think the take home point here is, with these types of technologies, we're striving towards increased safety, improved accuracy, kind of less morbidity associated with surgery, or less bleeding, less time in the hospital, and that's really where the trend is moving towards. So if you're listening to this, Chris, he's on the tip of the spear with this. It's been a real privilege getting to talk with him today about the topic.
Sanjiv Lakhia: 32:36
Those that listen to the podcast know I always like to sprinkle in a little bit of information on health and wellness, and I think it's important to share with our listeners some of the tips and tricks that the physicians in our practice and the people I interview use. What are kind of your favorite health routines, apps, tools, things that you use to kind of stay fit, mentally sharp, and just promote wellness in your life. Anything you want to share with our listeners today?
Chris Holland: 33:00
I think you caught me at a perfect time for this question because just before the quarantine started, I had just built a little area in my house as a gym because I felt myself just getting so out of shape. I had lived, before I came here to Charlotte, I'd been living out in Park city, Utah. And in my time out there, I was so active. I was back country skiing and mountain biking and hiking. And really, by the time I moved to Charlotte, I felt like I was in probably the best shape I had been in a long time. And then over the last four or so years here being busy building a practice, I really felt like I had fallen way out of shape.
Chris Holland: 33:38
And so, over the last several months, being on lockdown at home, I've taken up rowing and lost over 30 pounds in the last three months. And so for me, I found that to be just such a high impact, short duration activity. You know, I can row 20 or 25 minutes and really get in a very strenuous workout. And it's worked wonders for me. I mean, I've lost a lot of weight. I feel great. And overall, it allows me to function at a lot higher level, I feel like.
Chris Holland: 34:07
And so for me, access is the most critical thing. I have such limited time. And if I have to get to a gym and all of those things, I just wouldn't be able to do it. Particularly now when most of the gyms are closed, it would have been impossible for me to be doing something to maintain that level of activity. And so having it available at home and able to do that anytime I find an extra 20 or 25 minutes has been a huge advantage and has allowed me to stick with it.
Sanjiv Lakhia: 34:35
Yeah. I've said this before, and I'll say it again, I ask this question not because I'm searching for the Holy Grail of health and fitness, but I really want people listening to understand it doesn't quite matter as much what you do, it just matters that you're doing something. And rowing in particular, it's a very, like Chris said, it's a very intense exercise. You get significant cardiovascular return, a lot of strength training in the upper body. I do think if you like to row, you have to be a little cautious with your posture on the rowing machine. If you have low back issues, you want to maintain a good neutral spine and perhaps even have a trainer who goes over the technique with you and how to do it safely. But it is a terrific low-impact aerobic exercise that is something that'll definitely help you lose weight if that's something you're looking at.
Sanjiv Lakhia: 35:24
And so I'm glad you're doing that. Absolutely. I mean, we've all been under a lot of stress over the last several months, and having that outlet for you is very necessary. So thanks for sharing that with the listener.
Chris Holland: 35:35
Yeah, no, absolutely. It's been fantastic. And I completely echo your comments about posture and form. It's better to just have a nice regular rate and just go slow and go for form than really trying to go as fast as possible. But it's incredible how quickly, once you start doing something like that regularly, how your body really grows into that, and you really build out your endurance and your strength through doing those types of exercises.
Sanjiv Lakhia: 36:01
Fabulous. Well, Chris, I really appreciate your time today. And actually, I anticipate having you back on down the road when newer things are evolving. I know the listeners enjoyed the information today, and I appreciate you taking the time.
Chris Holland: 36:13
My pleasure. Thanks for having me. I really enjoyed it.
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
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Sanjiv Lakhia: 00:36
Welcome to today's episode. I'm excited to say we've reached our 20th episode of Back Talk Doc. And when I started this project, maybe under a year ago, my goals were to educate the general public on all the ins and outs of spine care and really arm you, the listener, with accurate, up to date information about the medical options for the treatment of your spine condition so that you can make an informed decision. And I think the feedback and the results have just been fantastic.
Sanjiv Lakhia: 01:10
Surprising to me, our audience at Back Talk Doc is not just patients. I've had people in the healthcare community reach out to me. And I think the topics and the information we've covered have really been helpful for people, not just in the Charlotte area where our practice is, but also across the country. I've looked at the listener profiles and it really makes me feel good to know that those of you out there are sharing the episodes and we're touching a wider audience.
Sanjiv Lakhia: 01:38
So I want to start out this episode by thanking you for taking the time to listen to the information we're providing. And if you found the podcast to be helpful, please go on iTunes and leave us a good review. And even more importantly than that, if you know of a friend or family member who is suffering from pain or injury and could potentially benefit from the information, feel free to share the episode with them.
Sanjiv Lakhia: 02:01
And with that said, I want to dive into today's topic. I'm really anxious to get going here. I have an interview today with Dr. Chris Holland. Chris is a neurosurgeon here at Carolina Neurosurgery & Spine Associates. And Chris, you've been with the group about five years, six years now, right?
Chris Holland: 02:17
Just about five years. So just over four years or so that I've been here.
Sanjiv Lakhia: 02:21
Well, welcome to the show. We're going to cover a topic today that is really modern. It's the idea of robotics in surgery or surgical robotics. And when I think about this topic, my mind goes out like into the future. I feel like I'm at Epcot and I'm looking at Tomorrow Land and The Jetsons and just really kind of crazy stuff. So I want to break this down into something that's meaningful for our listeners so they can understand what it really means.
Sanjiv Lakhia: 02:48
Before I do that, folks, I want to introduce you to Chris. Chris did medical school, where he did a MD PhD program at Boston University's School of Medicine. He did a residency and internship at Emory University and a fellowship in complex and minimally invasive spine surgery at the University of Utah. So he's fellowship trained and he's published over 22 peer-reviewed manuscripts, and has presented at both national and international medical conferences.
Sanjiv Lakhia: 03:16
He was awarded an NIH NINDS pre-doctoral fellowship in the Congress of Neurological Surgeons, the David Cahill Spinal Fellowship Award, and was named in a 2016 top 40 under 40 healthcare innovator. His specialty interests include degenerative spine conditions, spinal instability, spinal deformity, spinal primary and metastatic tumors, artificial disc replacement, and spinal trauma.
Sanjiv Lakhia: 03:42
So he does it all and he does it well, and it's been a real pleasure getting to work with him in our practice, and I think he's a perfect guy. Chris is always on the cutting edge of treatments for our patient population and community. So Chris, thanks for taking the time to join us today.
Chris Holland: 03:57
Well, thank you so much, Sanjiv. I'm really excited to be on your 20th episode. And I think this is a very exciting topic, just because there's been so much innovation in the last several years and things are really starting to move quickly, and it's providing a lot of benefit to our patients in terms of the things that we're able to do, leveraging these new technologies in new and innovative ways to improve care.
Sanjiv Lakhia: 04:19
Before we dive into the topic today, I always like to give the listeners a little sense of who they're listening to. Can you give us a synopsis of kind of how you found your path into the field of neurosurgery and just little bit about your background? I know you have a little bit of an entrepreneurial background as well. You have a very unique and interesting background I want you to share with the listeners if you can.
Chris Holland: 04:39
Sure, no, I'd be happy to. It is sort of a little bit of an atypical background. I started working in medicine, in hospitals, very young. I was introduced to medicine early in my life. Both of my parents were ill when I was young and I spent a lot of time around hospitals and doctors. And so I started shadowing physicians and actually working in an emergency room when I was 17 years old. And I carried that all the way through college. And so I had very early good experiences with physicians, in particular with surgeons, who would take me from the emergency room into the OR for patient cases to observe. And that's really where I got my initial exposure to surgery in general.
Chris Holland: 05:16
After college, I was sort of already directed on this path. I knew that I wanted to go to medical school and pursue a career in medicine, but I took two years after college and I had worked at Lahey Clinic outside of Boston. And there, I was working primarily in the clinical research department, but again, had an active interest in surgery and worked with a number of different surgical departments there. And that afforded me the opportunity to shadow physicians, spend time in the operating room with them. And I spent a lot of time with the neurosurgeons there, got to know them very well, and really got excited about the types of cases, surgical cases they perform and the types of patients they took care of, and the impact they had on the patients' lives.
Chris Holland: 05:57
And so I left that job and headed to Boston University for the MD PhD program. And at that point, I really was convinced that neurosurgery was what I wanted to do. During my two year period at Lahey Clinic, I spent a fair amount of time taking graduate coursework in computer science. I had a computer background. I'd always been interested in computers and technology, and that sort of laid the foundation for my PhD, where I looked at MRI imaging of the brain and applied different mathematics or statistical measures to those images.
Chris Holland: 06:30
And so I did the combined degree program where I completed my PhD in the Center for Neurologic Imaging at Brigham Women's Hospital. And ultimately, when I graduated from there, as you mentioned, I went to Emory in Atlanta for my neurosurgical residency.
Chris Holland: 06:45
While I was a resident there, I continued with my interest in technology and in software development, and built a number of systems there that we used within the department to augment or improve our ability to manage our patients and our patient lists. So some of those things involve building system for tracking our cases or our quality improvement conferences, but I also helped to build a mini imaging system to collect all of the outside images that were constantly being sent with patients as they were transferred in from other facilities.
Chris Holland: 07:17
As you know, most patients get their images on a CD and that disc not only can be damaged, but they all have somewhat proprietary software on them and can't always be read by every computer, which is very challenging in neurosurgery when patients arrive in the middle of the night and it's critical that we can review their imaging to decide whether or not that patient needs emergent or urgent intervention. And so, I helped to develop a system to allow us to do that, as well as the archive and store those images in our department there.
Chris Holland: 07:43
So I've found ways to take my interests in technology and computer science and in development and apply those to real problems within healthcare. And so, being able to do that makes a big difference to me, in that I'm seeing problems and working to actively address them, not just for the immediate need, but for the future in terms of what we can do down the road to continue to improve that experience.
Sanjiv Lakhia: 08:13
I think it's safe to say that technology is somewhat in your DNA, and I think it makes you the perfect person to dive into this topic today, which is robotics and surgery. I somewhat described it in jest, but the future is now. And interestingly enough, in preparing for this interview with you, I pulled an article, a review article from the Journal of Robotic Surgery entitled Neurosurgical Robotics: A Review of Brain and Spine Applications. And the authors were Karas, K-A-R-A-S, and Chiocca, C-H-I-O-C-C-A. And the reason I'm mentioning it is I went through this, and then when I was done reviewing it, I realized this was written in 2007. So it's been around a while, and here we are 2020 and it still seems quite new.
Sanjiv Lakhia: 09:05
So I just want to start out because I'm sure like me, many of my listeners really don't have a general sense for what this means. So can you kind of explain what is a surgical robot and even describe it so someone listening out there can even have almost a picture in their mind about what we're talking about.
Chris Holland: 09:22
Absolutely. And surgical robots aren't the types of robots that we see in the movies that have a human or a humanoid type form to them. Most surgical robots consist of an arm or a multi-articulating arm, with the various types of end effectors or what you would consider similar to a hand on the end, or some type of an instrument that would perform a function.
Chris Holland: 09:44
Robot itself is somewhat of an incorrect description of what these devices are because robots, by definition, are supposed to be autonomous, meaning a robot is supposed to be able to carry out very complex or repetitive actions all by itself without any interaction. And so a robot in that sense would be something you would see on an assembly line, say at an automobile manufacturer, where it's continuing to do the same task over and over again. And it may be a very complex task, but it's programmed to do that all by itself.
Chris Holland: 10:16
In the operating room, we don't have robots like that, meaning robots are designed to be assistive devices in the operating room, but the human there, the surgeon, is still the one that's carrying out the specific tasks.
Chris Holland: 10:29
There are several different types of robots, and in neurosurgery, it's used a little bit differently than some of the earlier robots, one of the most popular being the da Vinci. Those early robots, the surgeon stands away from the table or away from the patient and uses a display screen and a number of controls to manipulate the arms of the robot to carry out the various functions. In spine surgery, it's a little bit different. In spine surgery, we're using a robot that is in close proximity, or a robotic arm that's in close proximity to the patient, but the surgeon is still carrying out the actions using that robot as an adjunct or as an assistant.
Chris Holland: 11:10
And so, there are a number of different things that can be different between different types of robots and how they're used ultimately in the operating room.
Sanjiv Lakhia: 11:18
Is it controlled almost like with a joystick or how does a surgeon interact with the robot and obtain robotic assistance?
Chris Holland: 11:26
Sure. So in neurosurgery and in spine surgery in particular, but there are also a number of cranial or brain surgical applications for robots, we're not controlling the robot with a joystick, but rather, we are oftentimes setting up a plan with the robot in advance, sometimes often even before the patient's brought into the operating room, and then we're using that robot to execute that plan.
Chris Holland: 11:49
And to make that a little more clear, most of what we're using a robot for currently in spinal surgery is the placement of hardware, the placement of instrumentation. And so robotics, at this point, is being used to place typically screws within the vertebral bodies, what are most often pedicle screws, and some of the newer developments, to be able to place spacers, or what we call interbody cages, in between vertebral bodies once a disc has been removed there.
Chris Holland: 12:18
And so the robotic function is really used in a very narrow window in terms of what we're accomplishing with that robot. So the robot is not being used to make an incision or, in general, at this stage, to be removing bone or performing a decompression or a diskectomy or anything like that. The robot is really being used as a guide for the highly reproducible and accurate placement of hardware.
Sanjiv Lakhia: 12:44
Okay. So that answers one of the questions I was going to have is how does a robot assist with spine surgery? So what you're saying is that there's certain specific parts of the surgical procedure where you find benefit in using the robotic assistance, but it's not like the entire procedure is, let's say for a lumbar fusion, is carried out with robotic assistance.
Chris Holland: 13:06
That's exactly correct. The way that it generally works, and robotics grew out of earlier technology which was navigation, and spinal navigation works analogously to how GPS works in your car, in that we would have instruments and we could look on the screen, and the system would show us where those instruments are in the body. And so through a very small hole in the skin, we could use one of these instruments, pass it through the incision, and on the display, we'd be able to see exactly where the tip of that instrument was on the patient's actual anatomy.
Chris Holland: 13:40
And so once we were able to do that reproducibly, we were able to align their imaging with what we were seeing in the actual operating room, robotics was then developed as sort of the next step. And the way that the robotics or the robotic systems work these days is that we would take imaging of the patient, whether it's preoperative or intraoperative at the time of surgery, and we would, on those images, decide where we'd want the hardware to be placed. And so we would very specifically plan where we would want to put each screw, for example. And then once we've done that planning, what we would have the robot do is move to a unique position for each one of those screws that gives us the perfect trajectory or the perfect line down through the skin and into the bone exactly where we want that screw be placed.
Chris Holland: 14:29
And so the advantage of robotics in that sense is that we can plan all of the hardware in advance. We can align each screw with the screws adjacent to it, both above and below it, to facilitate connecting those together with a rod, ultimately, at the end of the case. And it allows us to, without having significant amounts of radiation, place that hardware, reliably, exactly where we want that to be placed.
Sanjiv Lakhia: 14:58
Okay. So that's an interesting point there. So you're touching on benefits, both from a surgical outcome basis, but also from a provider basis in terms of reducing your risk of exposure during the procedure.
Chris Holland: 15:13
Absolutely. We're actually reducing the radiation exposure, not just to the physician and the staff, but also to the patient. And so that's one of the major advantages of technology like robotics.
Chris Holland: 15:25
I think some of the biggest things that that drive us towards using technology like this is that, number one, using this technology decreases the risk of hardware misplacement, meaning a screw or an implant goes where you don't want it to be. The second is that it greatly increases reproducibility. So if you have a plan and that robot is consistently executing that plan, you can reproducibly place that hardware in the exact same position every time.
Chris Holland: 15:53
In addition to reducing radiation exposure, you can decrease OR time, you can increase your efficiency. So once you've verified that your registration is accurate and that the robot is accurately moving to the correct position for each screw, for example, that you're going to place, you can move very quickly because you don't have to be constantly verifying at each step that you're still in the right place. And so it really increases your operative efficiency and decreases the amount of time that patient needs to be under general anesthesia. And so, as a result of all of those factors, you're really improving patient safety and ultimately improving patient outcomes.
Sanjiv Lakhia: 16:30
All right, that's great. He touched on a lot of the advantages of using robotics in surgery. And I want to get into a little bit about if you see any disadvantages with using robotics, and we'll dive into that right after this break.
Sanjiv Lakhia: 16:49
It's been a while since I've taken a break for a health matters segment. I feel like some of our episodes have really been geared towards health and wellness, and in others, we've just had terrific interviews going on so I didn't really want to break up the flow, but today I want to touch base on the topic of magnesium. It's one that I've encountered in the office for several cases here lately and I think it's something that we should talk about.
Sanjiv Lakhia: 17:14
Magnesium, it's obviously a mineral in our body. The adult human body actually contains about 20 grams of magnesium, most of which is bound up in the bone, the rest of it is intracellular within your cells, and it's cofactor for almost 300 different enzymes and chemical reactions in the body. So magnesium is a critical mineral for energy production, for muscle relaxation, from normalizing your heart rhythms. So it's a very powerful nutrient.
Sanjiv Lakhia: 17:46
And in today's society, some data suggests almost 50% of the population is deficient in magnesium. And why is that? Some of that could be due to the soil no longer having as much nutrition as it used to be due to farming practices, and in other cases, many of us just aren't eating optimally. So diets that are high in refined sugars and breads and pastas and so forth really are devoid of good nutrition. And magnesium is one of the elements that is missing.
Sanjiv Lakhia: 18:16
If you want to increase your magnesium, there are some good food sources, nuts, whole grains, legumes, leafy green vegetables, fish, meat, and some dairy products are high in magnesium. Unfortunately, more than 80% of the magnesium is lost in the refining process of whole wheat flour to white flour and in brown rice to white rice. And then also, you lose a lot of magnesium from your vegetables when you're boiling them. So you want to keep those considerations in mind.
Sanjiv Lakhia: 18:45
The recommended dietary allowance is for magnesium, they're really quite low in my opinion. An adult let's say age 19 to 30, recommends about 400 milligrams a day for males and 300 for females. I just think that with the stress we're under and the nutrition issues that are in this country, that a little bit more magnesium is probably warranted.
Sanjiv Lakhia: 19:08
Why is it warranted or where does it really come into play in terms of this podcast which is geared towards spine care? Well, it's quite simple. I think there's a correlation between magnesium levels in your body and pain. So I treat a lot of back pain and I also have people that come to see me who have other types of pain, like migraines and headaches. So if you look at some of the data, it's really compelling.
Sanjiv Lakhia: 19:32
Experimental magnesium deficiency has been proven to cause spasm in the blood vessels and in the arteries, and that, I think, is a good correlation with migraine disorder. So, many times, people with migraines will benefit from supplemental magnesium. And this has played out some in the research and the trials that are in the published literature. And dosing is around 300 to 600 milligrams per day for adults. That can easily be obtained over the counter in a supplement form.
Sanjiv Lakhia: 19:59
There's also some evidence that the use of magnesium can help asthmatics, as it can relax the bronchial smooth muscles or the linings in the lungs. And it also has a bit of an anti-inflammatory effect, and can [inaudible 00:20:12] your response to histamine. Histamine is what triggers some of the allergic reactions in our body.
Sanjiv Lakhia: 20:18
So it's something to really consider. It has broad positive effects, the least of which also is in supporting bone formation and bone growth. So in osteoporosis, your magnesium is a cofactor for alkaline phosphatase, which is an enzyme involved in bone mineralization. So something to keep in mind if you're taking calcium, you're taking vitamin D, vitamin K, also consider magnesium in your efforts to support your bone density overall.
Sanjiv Lakhia: 20:43
So again, this is just a brief overview of magnesium. You should always check with your physician before you take any new supplements or products, even if they're over the counter, but it's something to consider adding into your nutritional food plan.
Sanjiv Lakhia: 20:56
There's some debate about what type of magnesium to get. If you look over the counter, there's multiple preparations, magnesium oxide, magnesium aspartate, citrate, there's lactate, magnesium glycinate, magnesium threonate. So there's a lot of different chelated forms of magnesium. Now, magnesium oxide is probably the most widely used preparation. It's very inexpensive. It has a higher proportion of elemental magnesium. It may not be quite as absorbable as magnesium citrate.
Sanjiv Lakhia: 21:29
And I do think the one thing to consider when you're taking magnesium, the main side effect, if there are any, is that if you take a little bit too much, it can cause loose stool or diarrhea. So some of these other chelated forms like magnesium citrate or magnesium glycinate may not cause as much loose stool as magnesium oxide, therefore you may want to use magnesium oxide if you're struggling a little bit with constipation or sluggishness with your bowels. If you're using the magnesium for migraine prevention or for muscle relaxation, then I may suggest one of the other chelated forms.
Sanjiv Lakhia: 22:05
So again, that's something to really consider. If you're struggling with low back pain, take a look at your nutrition, take a look at your diet. If you think you might be a little deficient in magnesium, check with your physician and see if it's okay for you to go ahead and add a little bit into your food plan. I think you'll find it to be a pleasant surprise with very little downside.
Sanjiv Lakhia: 22:26
Welcome back now. We're continuing our interview with Dr. Chris Holland, and today's topic is robotics and neurosurgery, and specifically in the field of spine care. Chris, do you see any disadvantages or are there any challenges from a surgical basis with using robotics? Like is it a steep learning curve? I wonder, how does it compare in terms of sensitivity and accuracy to the human hand, and just that general feel and touch sensation that I don't ever experience as a physiatrist, except when I'm doing injections. I know there's an art to neurosurgery as well that you've developed and the skills you've cultivated. So what are your thoughts on that?
Chris Holland: 23:03
I think certainly there are disadvantages to robotics and robotic systems. One is certainly the cost. They're novel. There's a lot of technology that's been worked into these devices and so they're quite expensive. Another significant disadvantage is it that does take not only time to set this system up, but the planning and all of the other steps that you wouldn't typically have to do before a case, now need to be done before you can bring the robot into the field and start working.
Chris Holland: 23:34
And so sometimes that can be done the night before, or even the day or a few days before, but oftentimes, it's done the day of surgery and in the operating room. So while there can be efficiency later on in the operation, there's a lot more work that goes into the early part of the operation to get the system registered to the patient's anatomy, get the hardware planned on the workstation before you even start the operation. And so there are certainly time constraints there.
Chris Holland: 24:01
There is a learning curve with robotics, just like any new technology, and you really continue to rely on your tactile feedback. Unlike the da Vinci or other robots where you're not still using your hands on the patient, in spine surgery, the surgeon is still doing actually the work of placing [inaudible 00:24:21] hardware. And so we still get a lot of the tactile feedback or haptic feedback that we are used to. We still can feel the engagement of the bone. We can feel the contact between the hardware and the bone to know that it has good purchase, that it's solidly in place, all of those things we're still feeling. So we're really using the robot as a channel to work through. And so the robot kind of keeps us contained within a specific space, but the surgeon is still working through that tube or that channel with the drill, for example, or the screw, and is still getting that tactile feedback.
Sanjiv Lakhia: 24:58
Are there certifications that you have to go through? So for example, if a patient's out there and wants to find a neurosurgeon who has training in the use of robotics, how can they determine if someone's competent and has gone through the proper training?
Chris Holland: 25:14
There are several robotic systems out there and the companies that produce these systems do offer varying levels of training. So there's an initial training process for using the robot, and then there's obviously more advanced training and more advanced techniques as these robots continue to evolve. They're constantly upgrading the software and also upgrading that, what I referred to as sort of the end effector or the hand at the end of the arm, to accommodate different instruments or different surgical devices.
Chris Holland: 25:49
And so it's an ongoing process. There's no universal certification process at this point for robotics, and each robotic platform tends to have its own training, but it's really industry driven, meaning if you're interested in purchasing a robot, or if you purchase a robot as a surgeon or as a practice, the company then would work with the surgeons there to make sure that everybody received adequate training, but it's not something that there's an established program or an established level of competency at this stage.
Chris Holland: 26:21
Robots are still somewhat rare. They're gaining traction in the market, but they're not ubiquitous, meaning you will not find a robot at most hospitals. Even some of the early doctors of navigation have been slow to move to robotics, but what they found is that some folks are actually leapfrogging or moving past navigation and moving directly into robotics without a background in using navigation, which was an earlier technology. There's still a lot of utility in both technologies. The newest robotics programs actually are working to merge navigation and robotics together and are becoming hybrid platforms, which is really where the most value is.
Sanjiv Lakhia: 27:03
Now, you mentioned earlier the da Vinci system. I know if you're out there trying to research this and Google it, you're going to come across that. Can you explain to listeners what the da Vinci system is?
Chris Holland: 27:14
So the da Vinci robot is used in a number of surgical specialties. It's not currently or widely used in neurosurgery or spine surgery, but the way that the da Vinci robot works is that it's a machine with a number of arms and a workstation. And the workstation is in the OR, but over on the side of the room.
Chris Holland: 27:34
And the way that it works, it's used typically for procedures done through small incisions within the abdomen or pelvis. The robotic arms are placed through these various incisions, and the surgeon then sits across the room, away from the patient, in what almost looks like a pod, with a display screen and a number of controls. This would be more of what you'd imagine with joysticks and knobs and different devices to control those alarms. And those arms can accomplish very complex maneuvers, such as suturing, tying knots, all of those types of things that are common in surgery. And there is some feedback from the controls that give you some of that force or haptic feedback from the patient.
Chris Holland: 28:21
And so, the da Vinci is a robot that's closer to what you imagine in science fiction, where the robot is actually carrying out these tasks and performing various portions of the operation, and the surgeon is controlling that from a distance. Now, that pod or that control panel the surgeon is utilizing for the operation is in the room. Technically, or theoretically, it wouldn't have to be in it because that robot is being controlled. It could technically be controlled essentially from anywhere. Whereas the robots that we're using in spine surgery and in neurosurgery, they require the surgeon to be actually performing the majority of the tasks in the operating room and just using that robot as an adjunct. So the da Vinci is a little bit different in terms of how it's utilized and that technology.
Sanjiv Lakhia: 29:07
Well, it sounds like in neurosurgery and spine in particular, the use of the robotics is more of an extension of the surgeon versus a separation of the surgeon from being more hands-on and being more involved. Is that more of an accurate way to think about it?
Chris Holland: 29:23
Yes, that's exactly how I would describe it. The robot is a tool that we're using, and what it's primarily doing at this stage is just constraining us to a single trajectory or keeping things perfectly in line with where we want them to end up.
Chris Holland: 29:40
And so, you can imagine it, like when you're a child and you go bowling and they put the bumpers in the gutters at the bowling alley and it keeps your bowling ball going straight down the lane. The robot essentially does the same thing. It provides a trajectory directly into the bone where we want to place that hardware and you just pass the instruments through. So just like the child, you're still rolling the bowling ball or placing that screw, and that robot provides just a very narrow tunnel for that to go through and ensure that it ends up exactly in the right place.
Sanjiv Lakhia: 30:12
Okay. That's a great analogy. Thanks for sharing that. I think we've covered a lot today with regards to our topic. Chris, I know you're always on the cutting edge of things. Are there any other exciting innovations in the field of spine surgery that you think the listeners should be aware of?
Chris Holland: 30:27
I think there's a lot going on in spine surgery that's exciting. And I think what we're seeing now is the combination of various technologies. You know, the initial robotics platform did not have a real-time navigation, a real-time instrument tracking view built into it. Those have now been merged together into these hybrid systems. The next stage is really looking at augmented reality, essentially using headsets or heads up displays that really provides a surgeon with x-ray vision so that the surgeon can walk over and look at the patient and be able to see through their skin essentially at their bones and their anatomy, and that's just pushing us further and further to more and more minimally invasive procedures with shorter operations, faster recoveries and better outcomes.
Chris Holland: 31:14
I think another area that's really interesting is that as these robots become more and more advanced, we're going to start using them for additional phases of the operation. For example, you can imagine that we could define areas of the body that we did not want an instrument to go into, for example, let's say an area where the spinal nerves or the spinal canal and spinal cord are, but we want to be able to remove the bone safely from around that area. If we can give those boundaries to a robot and use our instruments through that robotic arm, that arm would stop us from violating those boundaries and would allow us to mark off the areas that were safe to work in and protect us from going into the areas that we don't want to be.
Chris Holland: 31:58
So I think there's a lot of excitement in these areas coming up in the next several years, a lot of exciting development in terms of the technology and all of the different functions that we're going to be able to utilize it for.
Sanjiv Lakhia: 32:11
I think the take home point here is, with these types of technologies, we're striving towards increased safety, improved accuracy, kind of less morbidity associated with surgery, or less bleeding, less time in the hospital, and that's really where the trend is moving towards. So if you're listening to this, Chris, he's on the tip of the spear with this. It's been a real privilege getting to talk with him today about the topic.
Sanjiv Lakhia: 32:36
Those that listen to the podcast know I always like to sprinkle in a little bit of information on health and wellness, and I think it's important to share with our listeners some of the tips and tricks that the physicians in our practice and the people I interview use. What are kind of your favorite health routines, apps, tools, things that you use to kind of stay fit, mentally sharp, and just promote wellness in your life. Anything you want to share with our listeners today?
Chris Holland: 33:00
I think you caught me at a perfect time for this question because just before the quarantine started, I had just built a little area in my house as a gym because I felt myself just getting so out of shape. I had lived, before I came here to Charlotte, I'd been living out in Park city, Utah. And in my time out there, I was so active. I was back country skiing and mountain biking and hiking. And really, by the time I moved to Charlotte, I felt like I was in probably the best shape I had been in a long time. And then over the last four or so years here being busy building a practice, I really felt like I had fallen way out of shape.
Chris Holland: 33:38
And so, over the last several months, being on lockdown at home, I've taken up rowing and lost over 30 pounds in the last three months. And so for me, I found that to be just such a high impact, short duration activity. You know, I can row 20 or 25 minutes and really get in a very strenuous workout. And it's worked wonders for me. I mean, I've lost a lot of weight. I feel great. And overall, it allows me to function at a lot higher level, I feel like.
Chris Holland: 34:07
And so for me, access is the most critical thing. I have such limited time. And if I have to get to a gym and all of those things, I just wouldn't be able to do it. Particularly now when most of the gyms are closed, it would have been impossible for me to be doing something to maintain that level of activity. And so having it available at home and able to do that anytime I find an extra 20 or 25 minutes has been a huge advantage and has allowed me to stick with it.
Sanjiv Lakhia: 34:35
Yeah. I've said this before, and I'll say it again, I ask this question not because I'm searching for the Holy Grail of health and fitness, but I really want people listening to understand it doesn't quite matter as much what you do, it just matters that you're doing something. And rowing in particular, it's a very, like Chris said, it's a very intense exercise. You get significant cardiovascular return, a lot of strength training in the upper body. I do think if you like to row, you have to be a little cautious with your posture on the rowing machine. If you have low back issues, you want to maintain a good neutral spine and perhaps even have a trainer who goes over the technique with you and how to do it safely. But it is a terrific low-impact aerobic exercise that is something that'll definitely help you lose weight if that's something you're looking at.
Sanjiv Lakhia: 35:24
And so I'm glad you're doing that. Absolutely. I mean, we've all been under a lot of stress over the last several months, and having that outlet for you is very necessary. So thanks for sharing that with the listener.
Chris Holland: 35:35
Yeah, no, absolutely. It's been fantastic. And I completely echo your comments about posture and form. It's better to just have a nice regular rate and just go slow and go for form than really trying to go as fast as possible. But it's incredible how quickly, once you start doing something like that regularly, how your body really grows into that, and you really build out your endurance and your strength through doing those types of exercises.
Sanjiv Lakhia: 36:01
Fabulous. Well, Chris, I really appreciate your time today. And actually, I anticipate having you back on down the road when newer things are evolving. I know the listeners enjoyed the information today, and I appreciate you taking the time.
Chris Holland: 36:13
My pleasure. Thanks for having me. I really enjoyed it.
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
