1. Renaissance Advantages to Spinal Surgery Bonaventure B. Ngu MD

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3. The Dimensions of Back Pain More than 65 million Americans annually suffer from lower back pain Third most-frequent reason for surgery overall Approximately 250,000 lumbar spinal fusions performed Approximately 400,000 lumbar spinal decompression procedures performed 3

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6. Conservative Treatment – Bed rest – Muscle relaxants – Physical therapy – Prescription pain relievers – Interventional Pain Procedures 6

7. Minimally Invasive Surgery: A Breakthrough Innovation Potential advantages compared with “open” surgery May result in – Smaller incisions and scars – Minimal soft-tissue destruction and scarring – Less surgical blood loss – Shorter hospital stay – Less postoperative pain – Less need for postoperative pain medicine – Faster return to work and daily activities 7

8. Spine Surgery Challenges 8 Patient Expectations Clinical Challenges Human Factor Occupational Risk - 10% misplaced screws 1 - 0.8%-2% permanent nerve damage 2 - Safe - Successful - Definitive - Anatomical challenges (eg, deformities, revisions) - Field-of-view (eg, MIS) -Increased cancer risk for spine surgeons 3 -Cancer incidence in orthopedic surgeons vs non- radiation exposed matched controls has Odds Ratio = 5.4 (CI 1.9-15.4) 4 References 1. Kosmopoulos V, Schizas C. Pedicle screw placement accuracy: a meta-analysis. Spine. 2007;32(3):E111-20. 2. Gertzbein SB, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine. 1990;15(1): 11-4. 3. Singer, Occupational radiation exposure to the surgeon, Am Acad Ortho Surg. 2005;13:69-76. 4. Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med. 2005;55(6):498-500.Saia55(6 References

9. Mazor Renaissance Robot Only FDA approved robot for spinal surgery Accuracy in screw placement < 1.5mm Over 20,000 screws placed without a permanent nerve injury Available in only 20 sites in the country Humble is one of them! 9

10. Renaissance Applications in Spine Surgery 10 Thoracic, Lumbar, Sacrum Spinal fixation Pedicle screws Transfacet, translaminar- facet screws Sacroiliac screws Spinal deformities Scoliosis PSF, osteotomies Cement augmentations Kyphoplasty and vertebroplasty Oncological applications Biopsies, tumor resections Revisions Posterior Surgical Approaches Open MIS Percutaneous

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20. Spine Surgery with Renaissance™ 20 Improve Patient Care Overcome Clinical Challenges Enhance Surgeon Capabilities Increase Occupational Safety - Safe 1 -Fewer complications and revisions 2,3 -Faster recovery 4 - 98.3% accuracy 1 - No cases of permanent nerve damage - Easy to learn and integrate 3,5 - CT-based 3D planning - Accuracy independent of anatomical challenges and field of view 1,3,4 - Less radiation 1,4,5 References 1. Devito, DP, Kaplan, L, Dietl R, et al. Clinical acceptance and accuracy assessment of spinal implants guided with SpineAssist surgical robot: retrospective study. Spine. 2010;35(24):2109-2115. 2. Kantelhardt, SR, Martinez R, Baerwinkel S, Burger R, Giese A, Rohde V. Perioperative course and accuracy of screw positioning in conventional, open robotic-guide and percutaneous robotic-guided, pedicle screw placement. Eur Spine J. 2011;20(6):860-868. 3. Devito DP, Gaskill T, Erikson M, Fernandez M. Robotic based guidance for pedicle screw instrumentation of the scoliotic spine. Presented at: Pediatric Society of North America (POSNA); May 2011; Montreal, Canada. 4. Silberstein, B. Bruskin, A. Alexandrovskii, V. Robot guided surgery in treatment of osteoporotic fractures. [CD-ROM] Presented at: European Federation of National Associations of Orthopaedics and Traumatology (EFORT) 2011 Annual Congress; June 1-4, 2011:abs 1097. 5. Pechlivanis I, Kiriyanthan G, Engelhardt M, et al. Percutaneous placement of pedicle screws in the lumbar spine using a bone mounted miniature robotic system, first experiences and accuracy of screw placement. Spine. 2009;34(4):392–398. References