Jonathan Gottlieb, MD, of Miami, Fla.-based Minimally Invasive Spine Center of South Florida is a board-certified orthopedic spine surgeon specializing in the treatment of spinal stenosis, back pain and radiculopathy among other conditions.
Dr. Gottlieb served as an assistant professor at the University of Miami School of Medicine for six years and is a member of the North American Spine Society, American Medical Association, American Academy of Orthopaedic Surgeons and Florida Orthopaedic Society.
He earned his medical degree at the University of Miami (Fla.) Miller School of Medicine. Following his medical degree Dr. Gottlieb completed a residency in orthopedic surgery at Jackson Memorial Hospital in Miami, Fla., and a fellowship in spinal surgery at Charlotte (N.C.) Spine Center.
Here are his key thoughts on the big trends in spine today.
Question: How can navigation solutions be more cost-effective in spinal fusions?
Dr. Jonathan Gottlieb: We are looking to provide care that is reproduceable. We want to have a degree of precision and accuracy that is sustained irrespective of the situation — whether you're in a hospital or a surgery center — and we have different technologies available in different settings. What navigation allows us to do and what we're starting to see is, within about an accuracy of 99 percent of the time, we can put the screws exactly where we want to put them. Those pressures are in part patient-related — people want to do well; they don't want to have malpositioned hardware — but there's also pressure on us from payers and the government. A malpositioned screw is a potential reason that a healthcare entity might not be reimbursed. There are a lot of reasons [to use robotic navigation], starting with the fact that we want our patients to do well and why we want to be as accurate and precise as we can.
In the hospital setting, there tend to be larger rooms and greater resources available — not always but in many cases — so we can have large computer-based or CT scan-based navigation systems. The issue is a lot of those systems cost about a million dollars, so it's cost prohibitive for a lot of hospitals and pretty much any surgery center, but it doesn't abdicate us of the responsibility to put the hardware where we want it to be. What we have now with Firefly and patient system guides is the ability to place screws just as accurately as we could with the large computer-based navigation systems but without the cost and bulky hardware, and with a relatively short training time before somebody becomes comfortable using them.
Q: How have navigation devices developed in spine since the time of your residency?
JG: It has changed tremendously. I remember when I was a resident and there was relatively early navigation. We would take a CT Scan and go down to radiology and collect it. We would upload it on the computer, which may or may not work. But if we were fortunate enough for the computer to work, we would start trying to guide things and then something would go sideways. We would then stop, have to reload the CT scan, and after two hours we would just decide to do it the conventional way. I remember thinking this was really technology beyond reason. Now what we're really seeing is improved accuracy, ease of use and it's just the beginning. Robots in spine aren't where robots are in other parts of the body, but I believe at some point we'll get there.
Q: Are there any new devices that you see as particularly innovative for minimally invasive procedures? How do you see 3D printing developing in spine?
JG: For minimally invasive there's going to be a bit of lag time. The Medtronic O-arm, I think is probably the flagship for any comparison. It's really accurate, the software is continuously updated and they're developing the capacity to actually self-reconcile, which has been a deficiency in a lot of systems for a long time. We have the robots which to this point have an accuracy which may or may not be as good as the other navigation systems but it's quite expensive. Looking specifically at cost-effective options, as far as I'm aware the 3D printed guides are the most cost-effective, and the only truly cost-effective options out there.
It's not just the actual guides themselves that are important. If you're doing a spinal fusion case there are routinely five, six, seven trays in the room. The nurses are dealing with that and the staff are hurting their backs and it can be overwhelming. But if you have it pre-templated out, not only do we know where the guide is supposed to go to guide the placement of the screw, but at the same time we already know what size screw we want to put in. Instead of having all those trays and instruments and hundreds of redundant screws, you could conceivably go into a case with four, six or eight screws and that's it. It's less cost as well, not only on the navigation side but also on the side of what you bring in that you don't need. You don't have to sterilize additional trays, you don't have the transportation cost or potential loss of instruments along the way. Robots in spine aren't where robots are in other parts of the body, but I believe at some point we'll get there.