Paul McAfee, MD, director of the Baltimore-based Scoliosis and Spine Center of Maryland, has spent four decades at the intersection of spine surgery and product development, helping develop and advise companies that collectively represent roughly $8 billion in exits.
Now, he is making the case that the future of surgical navigation may not be a $1.5 million robotic system bolted to the floor, it may already be in your pocket.
Dr. McAfee, a full professor of orthopedics and neurosurgery who holds advisory roles with Globus Medical, Medtronic and Stryker, occupies a rare space in spine surgery: a clinician who operates, a researcher who publishes and an entrepreneur who builds.
His latest focus is championing lower-cost navigation technology, so it reaches the procedures, and the patients, that current systems leave behind.
A gap in the middle of the market
The spine surgery landscape stretches from conservative care on one end to elite tertiary centers on the other. Nearly all major navigation and robotics investment targets the high end, the seven-level scoliosis corrections and multihour reconstructions performed at academic medical centers.
But most single- and two-level fusions, the bread and butter of spine surgery, are still performed without any computer-assisted guidance.
“The bulk of the surgery is done freehand,” Dr. McAfee said. “And, frankly, I think that’s a crime.”
His argument is not that surgeons lack skill. It’s that even skilled surgeons benefit from verification.
“Maybe you don’t need it, but what’s wrong with checking your work with a computer?” he said.
An iPhone on the sterile field
The solution Dr. McAfee has been championing is built around the iPhone. A smartphone contains a gyroscope, magnetometer and accelerometer, the same sensors that power GPS mapping and augmented reality.
Housed in a sterile-compatible mount, the phone becomes a handheld navigation system at roughly $1,200.
“By taking images of the patient, I can determine exactly where this needs to go,” Dr. McAfee said. “I don’t need to bring something the size of a piano into the operating room.”
One company he pointed to, Bolt Nav, has developed an iPhone-based platform for navigated pain procedures, including medial branch blocks and basivertebral nerve ablations, targeting ambulatory settings where conventional systems are cost-prohibitive.
The practical advantages extend beyond price. Traditional optoelectronic systems require a direct line of sight between infrared cameras and instrument-mounted sensors; if anything blocks that path, navigation drops out.
They are also sensitive to patient movement. Something as routine as repositioning an arm for an EKG lead can require recalibration, adding up to 45 minutes to a case. A phone-based system mounted to the instrument moves with the patient and the surgeon.
Planning, operating and learning in one loop
Even surgeons with access to million-dollar robotic platforms frequently prefer to plan cases on their phone. “You could have a $1.5 million system from one of the big strategic companies, and doctors still want to plan the surgery on their iPhone,” Dr. McAfee said.
A surgeon can sit down on a Sunday evening and map out an entire week, every cut, every decompression, every screw trajectory. That kind of engagement doesn’t happen when planning software lives inside a console that only powers on in the OR.
But planning is only part of the equation.
Dr. McAfee described a full feedback loop: intraoperative imaging and three-dimensional reconstructions are compared against the plan in real time, allowing adjustments mid-procedure. When the patient stands up afterward, results are measured against what was intended and that data informs the next case.
“It’s an IQ type of feedback that you can adjust in surgery,” he said. “It seems simple, but it’s really elegant if it’s detailed enough.”
Dr. McAfee pointed to Globus Medical as the fullest expression of this approach. He has been the company’s longest-tenured advisory board member, working alongside founder David Paul since Globus was five engineers in a basement.
“His wife made lunch for us,” Dr. McAfee said. “And now it’s a $10 billion company.”
Globus is now building systems that auto-populate surgical plans based on aggregated outcomes from hundreds of surgeons. The operating surgeon reviews, adjusts and personalizes, combining collective intelligence with individual judgment.
Intelligence as a team sport
That emphasis on collective decision-making reflects a philosophy Dr. McAfee traces to his MBA days at New York City-based Fordham University. In medical training, the focus is on individual performance. Business school taught him something different.
“Every other person in the class was better at finance than me,” he said. “But I got an ‘A’ on every single project, because I just ended up on the best team.”
He applies the same principle to product development. His work with Metacria, later acquired by Medtronic, used machine learning to surface patterns from a surgeon’s own case history, not to replace judgment, but to sharpen it.
If a surgeon planned a 30-degree correction, the system could show that their past results consistently fell short and suggest a more reliable approach.
“We’re not trying to insult you,” Dr. McAfee said. “But the last 30 times you did this surgery, you weren’t actually able to get 30 degrees of correction.”
What has to change
When asked what must happen for navigation to become truly widespread, Dr. McAfee pointed to sensor accuracy. Consumer iPhone sensors are commercial grade; military systems use tactical-grade components that are far more precise.
“The GPS that’s used in the military is much more accurate than what we’re allowed to use in the operating room,” he said. “For medical purposes, we should be able to use the same accuracy as the military.”
The test that matters most
With 30 emerging technologies across his portfolio, Dr. McAfee has a simple framework for separating signal from noise: give it to 10 surgeons and watch what happens.
“Some things might seem good to me,” he said. “I don’t make the decision myself.”
The companies that succeed share a defining trait, a willingness to abandon their original idea. He pointed to Globus Medical’s early pivot from motion-preservation technologies to fusion systems when design barriers proved insurmountable.
“Every one of those companies completely changed around their ideas from when they started,” Dr. McAfee said. “A lot of companies would have given up or just stayed small.”
The lesson, distilled across 40 years: Flexibility matters more than brilliance, and the people behind a company matter more than either.
“There’s a million good ideas out there,” Dr. McAfee said. “But if I like the person, and I start talking to them, that’s everything.”
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