As he bent down to pick up the last package of his day’s round, deliveryman Richard Fuller suddenly felt a stabbing pain in his lower back.
“It was like someone had stuck a knife in my kidney,” recalls Richard, now 57, who managed to drive home but was “in absolute agony.”
Assuming he had pulled a muscle, he took some paracetamol and went to bed, hoping rest would help. The next day, however, his back was so stiff and painful that he could barely stand up.
“I live alone, so my parents came to help me because I could only hunch over and shuffle around,” says Richard, who lives in Canterbury, Kent.
When things had not improved within a few days, he went to his GP, who referred him to hospital, where he was diagnosed with a hernia (or prolapse).
In March this year, Richard Fuller became the first NHS patient to undergo a new way of performing spinal fusion surgery using robotic technology
The robot, called Mazor, is used to perform a minimally invasive technique known as oblique lumbar interbody fusion (OLIF), which involves fusing two or more vertebrae together to stop the movement that is causing the pain.
The discs act as shock absorbers between the bones (the vertebrae) of the spine. Discs have a hard exterior and a jelly-like interior: when the shell becomes weak and cracks, often due to wear and tear, the jelly bulges, pressing against the spinal nerve and causing severe pain.
Eight in ten Britons will suffer from back problems at some point in their lives, with hernia being the main cause.
For Richard it would have a devastating impact on his life. Forced to give up his job – he was in too much pain to lift packages or drive – he had to claim state benefits (which he hated) and took increasing amounts of painkillers, including high doses of morphine .
“Everything was a struggle, from putting on socks and shoes to bending down to feed my cat,” he recalls. ‘I stopped going out and became very isolated.’
After the first incident in August 2019, Richard underwent two surgeries. Neither helped. The first, in November 2019, was lumbar decompression surgery, which involves removing a piece of bone from the vertebrae to relieve pressure from the intervertebral disc pressing against the affected nerve.
This was followed a month later by a double discectomy, which removed the damaged portion of two of his intervertebral discs.
While around three-quarters of those who undergo decompression surgery experience significant improvement, two months after his second operation, Richard was in ‘a new level of pain’ after developing a serious infection.
In early summer 2020, a year after his problems started, he also started experiencing a shooting pain in his spine every time he put his left foot on the ground.
The pandemic made any further treatment unnecessary. But Richard was then referred to Michael Mokawem, a spine surgeon at the Royal National Orthopedic Hospital in Stanmore, north-west London, a specialist center for complicated spine cases.
In March this year he became the first NHS patient to undergo a new way of performing spinal fusion surgery using robotic technology.
The robot, called Mazor, is used to perform a minimally invasive technique known as oblique lumbar interbody fusion (OLIF), which involves fusing two or more vertebrae together to stop the movement that is causing the pain.
Using the robot reduces surgery and recovery time and can be performed at half the cost of the traditional approach.
Fusion surgery is already used for a variety of back problems, including spinal stenosis (when the spinal canal that houses the nerves and spinal cord narrows with age).
Traditionally, it is performed as two separate operations, each lasting at least three hours and often a week or more apart (partly due to the logistics of orchestrating such a lengthy procedure).
In the first operation, the patient lies on his side while a 5-7 cm incision is made in the abdomen (to prevent damage to the back muscles). The damaged disc is then removed and a flexible titanium cage is inserted to act as a spacer between the two vertebrae to be joined.
In the second operation, the cage is secured in place with screws and rods, and additional bone (from a bone bank or using artificial bone made from chemicals such as hydroxyapatite) is packed around and into it.
A two-stage procedure like this leaves the patient in hospital for 10 to 12 days, “with two of those nights in a high-dependency unit after each operation,” Mr Mokawem says.
Eight in ten Britons will suffer from back problems at some point in their lives, with hernia being the main cause (Stock Image)
Performing the entire operation in one day could mean up to eight hours in the theater.
But thanks to robotic surgery, OLIF can now be performed as a single procedure in three hours and the patient can go home after a few days.
Robotic surgery could also be more precise, suggests Professor David Choi, a consultant neurosurgeon at the National Hospital for Neurology and Neurosurgery and the private Wellington Hospital, both in London, who uses robotics for both spine and brain surgery.
He points to a 2018 study published in the journal World Neurosurgery in which 87.2 percent of screws placed by robots were in perfect position, compared to 66.9 percent placed by surgeons.
Because spinal surgery involves placing screws in the spine, “a 1mm shift where it’s placed ‘because you’re drilling right next to the nerves, can cause a big problem,'” Professor Choi explains.
Before the procedure, scans and labels where the screws should go are uploaded to the robot’s software. It calculates the length and width of the screws needed and produces a blueprint of how they will be placed.
The computer’s navigation software is used to create a 3D map of the patient’s spine, using reflective markers placed on their skin for the surgeon to work on.
Under the surgeon’s guidance, the screws are placed in the vertebrae by the flexible robotic arm of the Mazor robot.
“The surgeon is still in control; the robot is just a tool,” says Professor Choi.
‘The robot arm will screw in the screws at any angle and with precision. As long as the ‘map’ of the spine is accurate (it may be inaccurate if the markings have been bumped by the theater team, for example), the screws are placed in the optimal location,” he explains.
Mr Mokawem adds that manually inserting screws can be difficult for a surgeon, especially if the patient is lying on their side.
“When I use the robot, I tell it exactly where I want the screws because this is all pre-planned,” he says.
‘Patients spend less time in theater and do not spend days or weeks in hospital between the two operations. If they are mobile enough, they can go home after two days.
‘The robot also frees up surgeons’ time and could help reduce the NHS waiting list for these types of operations. Currently, patients on my list can wait 18 months.”
There are also potential cost savings, with a single operation with Mazor costing £11,000 – around half the cost of a traditional two-step procedure.
Professor Choi says the risks are similar to those of traditional surgery, even though a surgeon may realize he has made a mistake (“if I screw in a screw that is too big and I hear part of a bone snapping, I know that I did it’) there is something wrong’), a robot does not have such a feeling.
But he says this problem shouldn’t arise if the robot is given the right data to create an accurate map.
Nicholas Carleton-Bland, a neurosurgeon at The Walton Center NHS Trust in Liverpool, who regularly performs spinal fusions, says: ‘There is no doubt that the use of robotics makes spinal surgery more precise.
‘Like any profession, there is variation in accuracy – some surgeons can place screws better than others – but robots provide more consistency.
‘Robots are very good at following a plan they have to execute, so it’s only human error that can mean the plan is wrong.
‘At the moment the costs of robotics are the big stumbling block. But over time, costs will come down, so I think robotic spine surgery will be the standard in ten to fifteen years.
“My only other concern,” he adds, “is whether robotic surgery could not be used for some reason. At the moment, I and many colleagues can still perform spine surgery the ‘old way’, without robotics.
‘But surgeons in training may use robots and not perform surgery in the traditional way; That’s fine until a robot may no longer be usable for some reason.”
For Richard, he was able to bend down and put on his boots within a few months of surgery.
“That seemed like a big achievement,” he says.
It may take twelve to eighteen months for him to get back to full strength, but he is improving every day. “After three months, I started driving for short trips and doing odd jobs around the house,” he says.
He is now looking for a job. “I feel fixated, so I’m eager to get my life back on track after it’s been on hold for so long,” he says.