Consultant spinal orthopaedic surgeon at the Royal London (Barts Health NHS Trust) Syed Aftab, was the first robotic spinal surgeon in the UK. Here he discusses how the IMAS technique (Inter pedicular Micro Access Surgery) helps the surgeon become both controlled and effective
During my training I spent many hours intra-operatively worrying about decompressing nerves, post-op pain, and wrong level surgery and this anxiety pervaded into sleepless nights on many an occasion. It took me a while to get my dissection and blood loss right. It was assumed that a ‘spine patient’ would stay for a minimum of three nights no matter what surgical procedure was carried out and I always worried about whether I’ve decompressed a nerve enough versus destabilising a segment. Add to that the issue of flow of the patient through theatres, instrumentation, pre-habilitation, rehabilitation and overall the whole process of spinal surgery seemed to be quite an arduous task.
In 2017 October, I had the pleasure of being introduced to Robert Masson in Orlando, FL (www.massonsi.com). This was a chance meeting but I ended up observing him in his operating theatre and then having a discussion over what was touted to me as the best sandwich in Orlando (it was pretty good).
Watching him work was interesting. No matter what case he was doing, no matter what he was decompressing and no matter which thoracolumbar level he was operating on, the set up, approach, surgical timing, economy of movement and instrumentation was exactly the same. He ended up doing three major reconstructions of the lumbar spine in one morning (two revisions of cases done elsewhere), with minimal muscle dissection through an incision the size of a £2 coin, consistently. His theatre turn around was -4 (yes, that’s right , minus 4) minutes – but he did have a slick team who knew exactly what to do and had one patient ready while the first was being closed in parallel lists. Overall processes were streamlined, everyone knew their roles and ultimately patients did very well. His fusions go home in 24 hours with a good result.
It is difficult to explain exactly what he does in this article, but in my mind it all stems from a few basic principles applied to the whole range of management of the patient starting from the moment they think about a problem in the back to the ultimate return to function. He doesn’t ask if the patient is able to sleep, work and travel, he asks “are you able to live your life happily”. Here are the four main principles to keep in mind:
Principle 1) Redundancy – processes follow the same routine every single time. There is no change to the setup, instrumentation and patient flow. This means that there is a lot of play in the system to deal with patient-to-patient differences.
Principle 2) Elimination of unnecessary steps – speaks for itself. This extends to the instrumentation (two trays for every case, be it fusion/decompression/deformity).
Principle 3) Modularity – spinal surgery, the technique, the preparation, the instrumentation and the after care has all been broken down into a set of reproducible core modules, which can be assembled in order of necessity to create the perfectly tailored solution for a patient. It also means that the modules individually all follow a set pattern, which can be taught and reproduced reliably.
Principle 4) This is arguably the most important principle for me – changing our centre of thinking from a disc level to an individual nerve. Therefore, no longer do I ever say to a patient “I will be decompressing your L4/5 disc”. It is always a L5 nerve root decompression including central canal. This is subtle but important. Anatomy at a disc level is not constant but anatomy at pe