Chetan K. Patel, MD, executive medical director for spine surgery at the Neuroscience Institute at AdventHealth, and section chair for Robotics and Navigation for the North American Spine Society, talks about how virtual reality glasses could benefit surgeons.
So, I wanted to ask you how you got involved and what the genesis was of using technology to improve what you do as a spine surgeon.
PATEL: Sure. You know, looking at what happens in the world, in my daily life, it seems like every year is better than the year before, and it seems like the answer is it’s technology that’s driving that. I’ve always loved technology. I remember my very first computer that I actually got to work on. It was an Apple IIe. And then since then, there have been lots of iterations. I’ve always been kind of trying to keep myself at the forefront of technology ’cause I feel like that’s where people’s lives get better, right? So I went through residency, and I did a fellowship in spine surgery, and I’ve been practicing for almost 20 years now. So in that period of time, I’ve seen technological advances, and I’ve actually taken part in a lot of those technological advances. So, for example, I actually helped develop a spine robot for spine surgery that we use to put in screws. So I’m used to thinking about technology and looking at technology for solutions to my problems in the operating room. But to date, the things that I worked on typically were only on one task. So, for example, the robot that I worked on was to improve the accuracy of putting in a screw, which we oftentimes have to do in spine surgery. So pretty good. I mean, it was very satisfying to be able to do that and to actually achieve the result and make it more accurate. But that’s still only one small part of spine surgery. So I wanted to have a way in which I can impact a greater part of surgery in general and specifically spine surgery. So, you know, oftentimes, I think back to technological revolutions. And for me, that was the iPhone. Prior to that, you know, I would do my email and I would do my text messages and calls all separately. And really, that was the first device where I picked it up and I was like, oh, my God, this is so easy. It’s easy. And more importantly, it’s value in my daily life because it actually saves time, right? So it’s efficient. And it’s on-demand. I have it. I can pull it out any time and use it. So I’m like, wow, look at this. You know, my daily life is so much easier and better because of this. Why can’t I have something like this in the operating room? So that’s where the idea started of having a digital assistant in the operating room. There are some constraints in the operating room because I have, you know, sterile gloves on. I’m doing surgery, so it’s not like I’m going to pull out my phone and do that. So the question was, you know, how do I do something similar where make my surgery easier, I improve efficiency and have it on demand? Well, so I started thinking back and saying, well, what are the problems that I’m trying to solve, right? So my problems are that I have a lot of different pieces of information in surgery, just like I do in my daily life, right? So just like the iPhone combines all these different aspects in surgery, typically the patient’s asleep. So there’s, you know, how are they doing physiologically? In other words, what’s their health like? And that’s what the anesthesia monitor shows. Typically, that’s a way for me – I can’t even see that unless I ask them to put them on a different monitor. There is what I’m doing, which is what did this patient look like before surgery on an MRI or a CAT scan or X-rays that led me to make the decision to have surgery and have that information available during surgery so I can compare what I’m looking at to what I’m supposed to find and fix, right? So to make sure that I get my job done as well as possible. So there’s that second component. The third component is that oftentimes my surgery involves using X-rays to figure out exactly where I’m at or whether or not we got the job done. So I need to be able to see that third screen. And finally, the fourth screen in surgery is where I use navigation. What navigation is, is essentially GPS in the operating room where I have a device that’s helping me put in screws. I have a device that helps me actually remove bone. It’s an operation called laminectomy. So these are basic parts of what we do in spine surgery, but that’s yet another screen. So my first problem is that I have a lot of different information I’m supposed to be looking at, at any given time, while I’m actually looking at the patient, right? So in order for me to go look at something else, I actually have to look away – right? – and sometimes often twist and look in a different direction to figure out what’s going on. So there’s a physical limitation to how many times you want to actually do that because you don’t really want to take your eyes away from the patient, right? So first of all, when you take your eyes away from the patient, you’re not doing what you’re supposed to do. And second, you’re adding time to the operating room. And that’s a big deal because adding time means longer anesthesia, more blood loss and a longer recovery for the patient, right? So those are my basic problems. So my question was, how do I solve that with the technology that’s out there? And really, you know, right after the iPhone, I started reading a lot more about technology kind of related in that world and came across augmented reality. I thought, wow, this is perfect because I won’t have to use my hands. I can have something that are glasses that I can wear and potentially be able to see all the data in the operating room if I can get it to a point where it’s easy to see what I want to see on demand so that at the appropriate times during surgery, I have the correct information in front of me. It would make a huge difference. So that’s where kind of the problem was that I was trying to solve, and that’s kind of how I thought the solution would be in the end. Ultimately, you know, the one concrete part of this solution that I think really was important to me was to make sure that I continue on the theme of what I was doing with robotics. So what was my goal with robotics? My goal with robotics was that I was going to improve the accuracy of screw placement. So I’ve taught for about 15 years now how to use either the navigation technology or more recently, the robotic technology to put in the screws to improve accuracy. And, you know, every time I teach a course on this, I have to share with the – with my participants were can it go wrong. And when I look at where can it go wrong, the answer often is that I’m looking away at a different screen, and so what happens is that I can’t tell that I’m hitting some tissue or I’m hitting a retractor that’s metal and it’s actually pushing me back so that what I’m seeing on the screen is actually misleading. So I wanted to make sure that whatever I created definitively addressed that so that I could keep looking at the patient, not have to worry about making those mistakes and get the job done.
So with all of that in mind, what did you come up with? Can you tell me about the device that is your assistant that blends all that together?
PATEL: So what ultimately came together is kind of a three-part solution. So in order to connect all the screens, I developed a box that basically takes information and sends it to an app. So I’m using a smartphone that has an app. And so that app allows me to see that information, and then I can modify it. So I can enhance the images. I can change images. So I’m looking at exactly what I want to look at. And finally, in order to visualize it and control what I want to see, I’ve got the augmented reality glasses, right? So there’s three different components. So as a surgeon and as a small company, I’m not going to be at the forefront of developing the latest and greatest in the optics, so what I do is I look at what’s out there. And I made the system in a way that I can pair with anyone’s augmented reality glasses and use them, so I can always use the latest technology possible, right? ‘Cause if my goal is to make sure that I provide the best technological solution to achieve the best outcomes, I have to make sure that the system I develop can work with any augmented reality glasses. So, you know, what am I using now and why? Well, when you look at the different types of augmented reality glasses – and by the way, there’s a ton out there, it’s just an explosion – there’s some specific needs that I have in surgery that are different than what you would potentially use at home. So first of all, typically, I’m using some sort of magnification loops – and most fine surgeons do – so I already have something on. So whatever device I put on has to actually work with that, and there’s very few devices that actually do that. Second, it has to be light. Why? ‘Cause I’m already having weight that’s on my head through the magnification loops, and if I add more weight, it’s going to be uncomfortable. In fact, one of the studies that was done with HoloLens was to look and see how accurate it was. But the interesting finding was that the surgeons didn’t want to wear it for more than 30 to 40 minutes because it caused a lot of neck pain. And why are surgeons sensitive to that? Well, generally speaking, spine surgeons have three times the incidence of needing spine surgery, and it’s because of all the ergonomic challenges we have of bending over, twisting all the time to look at different screens, wearing devices on our head that weigh a lot and we’re looking down all the time. So I wanted to make sure that whatever I did actually subtracted from it and not add to it. So I picked the pair of glasses that are really lightweight that you can wear with the magnification loops that don’t add any extra weight. In fact, by taking away that kind of repetitive, neck bending motion back and forth and looking up and down and sideways, really, I’m hoping to diminish the need to seek actually treatment for spine surgeons by – you know, this is essentially becoming preventative care for spine surgeons to have something that helps them. So I’m really excited about not only being able to help patients but also surgeons.
So you talked about the three-part system, and you walked me through a little bit of how it works.
Tell me what you’re seeing in the glasses and how that works while you’re performing surgery.
PATEL: Absolutely. So I’ll start with the simplest example, which is when I’m putting in a screw. So when I’m putting in a screw, I’m usually using technology – either a navigation or robotics. So what I would do is I would still have my loops on that I would always have to do the surgery. On top of that, I’ll put my augmented reality glasses on. So essentially, it gives me a 55-inch screen right in front of my eyes. So it’s really blown up. It’s a really big screen. It’s really easy to see. And then I usually modify the image that’s on the screen so that it’s better contrast and it’s zoomed in. So I’m only looking at the part that I really need to do the surgery. So it’s kind of all teed up to be perfect. So what it allows me to do is instead of looking away from the patient and towards the screen, I basically put these glasses on, and I can just do every single step and not even move my head. So you can imagine there’s several opportunities there for improvement. You know, one is improved accuracy because you’re seeing what you’re doing. You’re not hitting metal objects. You’re not hitting tissue. No – nothing’s pushing you back. You can actually see that, right? Two, you save time by not turning your head back and forth and looking up and down. Three, it allows the entire operating room to be more efficient because they can more harmonize with you. They can synchronize with you. They know that you’re going to be – as soon as you take this out, you’re going to be ready to go. You’re not hunting around for an image or hunting around for where it should go. The next step is ready. So when I’m looking down, all I have to do is this and this, so I can just keep going back and forth, right? So that’s fantastic. And like I said, the fourth part is – that I really enjoy – is that it really is more comfortable to do it that way ’cause I don’t have to twist my neck, and I don’t have to look up and down. So that’s one example of how – for example, a screw placement. Another thing I do is remove bone using the same technology. Now, for that particular application, it’s literally impossible to use the screen well because it’s a very delicate area. The nerves are only a millimeter away. So in fact, up until I developed this technology, I wasn’t using that to unpinch the nerves because, quite frankly, the amount of time it takes to look back and forth would add too much time to the operating room. The only feasible way to use that is actually to be able to see that simultaneously because the stakes are too high. So that’s an example of a second use of the technology, right? The other places where I use the same thing is I’ll put it on in – for example, when I do surgery for spinal cord pressure, the blood pressure that’s maintained during surgery is really critical because, if the blood pressure drops too low, the spinal cord can get damaged. If the – if the blood pressure is too high, you get too much bleeding and you can’t actually do your job. So having the glasses that show me what that blood pressure is all the time instead of looking away allows me to quickly glance back and forth. So if I see a little more bleeding than I expect, then I can quickly glance right there without having to look anywhere and notice that, hey, maybe we need to work on this. Or if it’s, quite frankly, the bone’s not oozing enough like it should, like normal healthy bone, then I worry that, hey, maybe the pressure’s too low. So, again, I’m able to glance right there. So again, it’s – the opportunity’s there during the entire operation to basically keep a closer eye on your patient and make sure that you can get them through safely, quickly, and have the best outcome possible.
You touched on this a little bit, doctor, but could you tell us again – just spell out the patient benefits in terms of safety, less time on the table…
PATEL: Yeah, I would summarize it by saying ultimately gives you the best outcome possible. So the question’s how. The how is, number one, by allowing the surgeon to focus more on the patient – right? – on you during the surgery. You can imagine that it’s not safe to look away from you unless you know what’s going on there. So the first measure of safety comes by just allowing you to look at the anatomy, look at the patient at all times, and not having to look away. The second measure really comes from the efficiency it brings to your surgery. Efficiency means saving time. Saving time means less anesthetic, less blood loss, and both of those mean better recovery, right? You hurt less, you can get back to your life faster, you can get back to doing the things that you love.
How much time on average do you find this saves in surgery?
PATEL: Great question. It depends a little bit on the type of surgery. So let me give you some scenarios, right? So, for example, my typical surgery where I may only be putting in, for example, six screws – something along those lines – probably save about 10 minutes which, if you think about that time – on the one hand, in your normal everyday life, you think 10 minutes is not a big deal. But in the operating room, that’s a huge deal, OK? Ten less minutes of anesthetic time, 10 less minutes of bleeding. One – for larger surgeries – we do scoliosis surgeries where we have to put in, you know, 20 screws, and all of those areas are bleeding at the time of surgery. I mean, you can save a good 25 minutes. Again, that’s a lot. That’s a lot of time. And so I think that this technology really is going to get adapted fast because once surgeons see that they – it’s a real benefit to them, number one, in terms of efficiency and, number two, for their patients with having less issues with blood loss and better recovery, why would you not want to use it, right? It’s kind of like the iPhone. Could I live my life without an iPhone or an Android phone? Sure, I absolutely could. But no one’s forcing me to go out and buy an iPhone, OK? I want it because it makes my life better. So my goal was to create a technology that surgeons want because it makes their life better and, more importantly, gives their patient a better outcome so that it’s a win-win for everybody.
Is there a name to the system? Because I know you said this pairs with any kind of goggles out there, but is there a name?
PATEL: Yeah. The name is iSight. And you can imagine why I called it iSight – you’ve seen a lot of analogy with the iPhone, and this is visual instead of touch-based, right? So that’s why I call it eyesight. Because my goal literally was to bring that functionality to the operating room and make my life easy.
Just so that I can put explain to our viewers, if you could again just quickly walk me through the steps before surgery. There’s an OR to choose, there’s images that are taken – just give me a quick – what you have to do to get them to…
PATEL: So, I just want to take a step back, when I come in and when I scrub into surgery, I would put my loops on, I would put my glasses on. So really, from that point on, I have information that I’ve never had in the operating room before. So this would be just one of the steps. But prior to that, I’m already seeing what’s happening with the anesthesia machine, I’m seeing what’s happening with my CAT scans and MRIs that I may have gotten before surgery, right? So, for example, let’s say I’m doing surgery to unpinch nerves and there’s one particular bone spur that I want to get. Well, it’s really important that, at the time of surgery, when you’re looking at the anatomy and saying, this is the spur I want to get, you double check with the information – the MRI that you got before surgery and make sure you’re in the same spot, right? So that visual check is something I can do. So when I’m using an X-ray to say, hey, am I at the right level of surgery and confirm that this is exactly where I want to go, I’ve already used this technology to confirm that that’s where I’m at. So by the time I get to the part where I’m placing screws, I’ve already used it. So it doesn’t really start there. But let me help you see what it would do specifically for screw placement. So for – in my case, it depends on either – either I’m doing a case with navigation, which is what you see behind me right now, or I’m doing a case with robotics. So if I’m doing robotics, there’d be a CAT scan that would be done before surgery or maybe I would get it during the surgery with this machine right here. It’s called an arm – it obtains what we call a cone-beam CT. So it’s kind of like a way of getting a CT scan in surgery while you’re in the correct position. So either way – and then I would – then I would send that information on to either the navigation machine or the robotic machine, right? And that’s where my critical part starts, because now I get to use that information to go ahead and put in the screws. And when I put in the screws, what happens at that point is that I start with my instrument. So I would make a – typically a hole. That would be a guided hole that I could see either using the robot or navigation or both. And then I’d be looking at the screen and saying, yeah, this is the perfect spot, right? And then I would go and say, OK, well, now go ahead and let’s – let me feel that hole, make sure it’s perfect. And then I would grab the next instrument and then I would line it up with the hole and then I would line it up on the screen and say, yeah, that’s the right spot. And then I would be going. And then if something felt funny, I would look down, make sure it’s correct and go back and forth, right? So that’s basically how we kind of do this type of surgery is there are sequential steps. So you’d make a hole, you’d feel it, you’d go ahead and put in typically what we call a tap to kind of create a thread in that hole, feel it, make sure it’s perfect, and then put it in the screw. So for each screw we put in, there are multiple steps we have to go through. For each one of those steps, we’re going back and forth, back and forth, back and forth to the screen. And what you’ll see – I’ll show you a demo where you can see that you don’t have to do that with this technology anymore. Very simple.
Couple of questions about the clinical trials. You are wrapping up? Can you tell me a little bit about that? How many people you tested, what you’re looking – any early results you’re able to share.
PATEL: Absolutely. So, you know, I’m strict when it comes to science. So as much as I love this technology, it’s not worth anything unless I can actually demonstrate that there’s proof that it actually does what it’s supposed to do, right? So after inventing this technology with a couple of my colleagues in work with them, my goal was to say, you know, let’s set up a science test that lets me see whether or not it works – so a clinical trial. So I looked at a little over 25 patients before deploying this technology and measured the success, measured the different times that it takes me to do the different parts of the procedure. And then once this technology was deployed, now I’m going on and finishing an equal number of patients with the technology to look and say, OK, well, does it really do what it’s supposed to do, right? So the good news is it actually does deliver on the promise. My surgery has become more efficient and easier. In fact, you know, anywhere between 25 and 50% is usually the improvement that I get per surgery in that time for replacement. Most surgeries actually hover around 50%. So you can imagine that that’s a – that makes a big difference. So we’re certainly collecting all the rest of the data. And once we finish, I’ll be publishing those results to share with everyone in terms of what’s the overall clinical picture look like, in addition to the very specific thing that matters the most, which is did I make surgery more efficient?
What are the next steps then?
PATEL: Well, the next step is really to kind of go above and beyond, right? So we’ve started – we’ve just scratched the surface of what we can do. The surface is taking all the information that’s available and putting it on demand, easy access where I can access it. But then what I’d really like to do is make sure that the system starts anticipating what I need and presents it to me before I need it, right? So that’s a challenge and that’s a work in progress. There’s also opportunities on better ways of controlling the system. So, again, that’s – the user interface is also something I’m working on. So, you know, we’re at the first phase where we wanted to pull something together that can deliver on a promise and make sure that we can actually improve efficiency in the operating room, make it easy, make it on demand. But now it’s – I’m starting the evolution that the iPhones did. I don’t know if you remember the very first iPhone, but it, you know, didn’t really have an app store. There were no apps, right? In fact, if you wanted to send a picture, you couldn’t actually message a picture. So a lot of those functionalities that kind of came along over time as the system got more sophisticated is the journey I’m on now. And I really want this to be a tool that really helps the surgeons the way it helped me, which is not only do this part, but really use it for improvement for myself. So the question is, how does it do that? So what I’ve built into the system is the ability to record what I do. So if you look at any elite athletes or any elite teams in NASCAR – pit crews, what do they do? They get really good at something, but then they record themselves, they watch the tapes, right? And then say, how can I do this better? How can the team work better together? How can I individually do better together, right? Well same thing should apply in surgery, right? So in the way traditionally we kind of learn how to do surgery is we go through a residency and then, for example, either spine fellowships – I spent an extra year perfecting that. But at the end of that, that’s it. You graduate and you’re kind of deemed certified and you go out and do it and then you do it and do it. But this really allows us to change that. What this allows me to do is actually record what I do and then, after surgery’s done, do a critical analysis of myself as well as my team and say, could we have done better? And get better and better and better. And just like elite athletes, take good and make it great. I like to take every surgeon and take what our good work is and make it great every single time, right? If our goal is to deliver the best outcome for our patient and do it every single time, we have to learn from ourselves and get better and better and better. Certainly, I think this technology has great application for residents and fellows that are learning how to do this at the very beginning, for proctors and teaching institutions. So I used to teach residents and fellows before I came here. This is a great opportunity to see what they see and to really be able to help them along and learn faster. I think you could do teleconferencing with this. You can have step-by-step guides – make sure that, you know, technology guides are available. So there’s lots and lots of directions I can go with this in the future, and I hope to go in all those directions because all those directions mean better life for every day surgeon.
So doctor, you invented it, you were the first here to use it. Is there a commercial potential where this rolls out to other doctors and other spine surgeons and other hospitals – other…
PATEL: Sure, absolutely. You know, my goal was to, first of all, kind of stay true to what I wanted to do and prove that it can actually do what it’s supposed to do. And now that I can see the finish line, I should have the trial closed by the end of this month, then the next phase is going to be to share that with everyone. So absolutely. I think that, you know, at the end of the day, I would love for this technology to be used by every surgeon for every patient every time. Because if this can be easier for surgeon and better outcome for the patients, why wouldn’t you want to use it, right? So that means I’ve got to share. So, yes, we’re in the process of sorting out how to commercialize this and mass produce it so we can share it with everyone.
Is there anything I did not have to do to make sure that our viewers know?
PATEL: I think that, you know, at the end of the day, there are very few times in surgery where we kind of make the next leap. And I’ve been practicing for almost 20 years, and the leap for me was when navigation and robotics came along and really went from – it was a clunky technology initially, didn’t work well, and I was a huge critic of it and I actually worked with one of the companies to improve this system to get it to a point where I said, wow, OK, now we can really use this. So I’m really excited that I think we are right at the cusp of that next jump up with this technology. I think augmented reality is going to be widely adopted in the operating room. I think it’s really going to allow us to kind of deliver better results. So I think, you know, I’m lucky as a surgeon that within what I would consider a relatively short period of time, I’ve seen not one but two technological influctions to help surgeons.
UNIDENTIFIED PERSON #1: You talked a lot about how important it is to look at the patient and all this information during a spinal, but in my head I hear, as a layperson, 50-inch screen – isn’t that in your way? Can you talk about the positioning and the layout?
PATEL: Sure, absolutely. If you give me a minute, I can show you because I think it may be a lot easier for you to see than for me to talk through it.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Sheri Peterson
sheri.peterson@adventhealth.com
(407) 303-5452
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