Robotics and navigation have given spine surgeons new levels of precision and reproducibility in the operating room. Colin Rhoads, DO, sees significant value in those advances, when surgeons understand both what the technology can do and where their own judgment remains essential.
Robotic and navigation platforms can help surgeons place pedicle screws with greater precision and plan screw trajectory, diameter and length before placement. But getting the most from those tools also requires knowing when the information guiding them may no longer be accurate.
“It’s just a tool, really,” Dr. Rhoads told Becker’s. “It can be precisely wrong as well.”
If a patient moves or something shifts during an operation, navigation can become inaccurate. The surgeon has to recognize when what the technology is showing no longer corresponds with the anatomy.
“You have to be able to know when it’s off,” Dr. Rhoads said. “If it’s off and you don’t realize that, that can be a bad day.”
For Dr. Rhoads, that balance, embracing what technology adds while maintaining the knowledge to recognize its limits, is central to where spine surgery is headed.
Dr. Rhoads recently joined Akron, Ohio-based Crystal Clinic Orthopaedic Center as a spine surgeon after completing an orthopedic spine surgery fellowship at Twin Cities Spine Center in Minneapolis. His practice includes minimally invasive and robotic surgery, spinal deformity and reconstructive spine surgery.
What precision changes
Dr. Rhoads sees one of the clearest advantages of robotics and navigation in pedicle screw placement. The technology can give surgeons greater precision and reproducibility while also allowing them to plan the dimensions and trajectory of the screw.
Dr. Rhoads said that can allow surgeons to safely use longer screws with larger diameters when appropriate, potentially creating a more stable construct.
He sees benefits for the surgical team as well. Navigation and robotics can reduce reliance on fluoroscopy, limiting radiation exposure over time. They can also ease some of the demands on the surgeon during an operation.
“Mental fatigue is a real thing,” Dr. Rhoads said. “I do think that having that decreases the mental load on the operating surgeon.”
He is more measured about what the technology means for long-term patient outcomes. Dr. Rhoads said data comparing navigated and robotic surgery with traditional freehand or fluoroscopic techniques show similar long-term outcomes.
For him, the value today lies largely in what the technology can add during the operation: precision, reproducibility and planning.
When smaller isn’t better
Dr. Rhoads takes a similar view of minimally invasive surgery: The technology should serve the pathology, not determine the operation.
Less-invasive surgery can reduce soft-tissue disruption and help patients return to normal life sooner. Dr. Rhoads said it can be particularly beneficial for certain patients with obesity and for older or frail patients, when the underlying pathology can be adequately treated without a larger open operation.
But the smallest operation is not always the right one.
“If it’s something that’s a big deformity that needs osteotomies, minimally invasive is not going to be the best option for that patient,” he said. “It’s pathology-driven, really.”
What is changing is the range of pathology that surgeons can address through smaller approaches. Dr. Rhoads pointed to multilevel lumbar stenosis as one example. Where a patient may once have required a larger open decompression, tubular or endoscopic techniques can allow surgeons to address multiple levels through smaller incisions.
He also pointed to lateral and anterior approaches in deformity surgery, which can allow surgeons to address alignment through smaller incisions in appropriately selected cases.
“If you can get back to your normal life in a quicker period of time, I think that that’s beneficial,” Dr. Rhoads said.
Where the technology stops
For all the advances in robotics and navigation, today’s systems still have important limitations.
CT navigation and navigated instruments can assist with decompression by helping surgeons visualize the anatomy, but the robot itself cannot yet perform the decompression. Current navigation also relies on static images, Dr. Rhoads said, meaning movement during an operation can change the position of the anatomy relative to what the system is showing.
Recognizing when those two no longer align remains the surgeon’s responsibility.
That is where the promise of greater precision meets the continued need for surgical judgment.
What comes next
The limitations of today’s technology are precisely where Dr. Rhoads expects the next advances.
He sees robotics eventually taking a more direct role in decompression, potentially helping surgeons establish boundaries as they work. He is also watching the development of segmental navigation, which could account for changes in spinal position during an operation rather than relying solely on a static image.
That capability could be particularly important in unstable trauma cases, where movement can carry significant consequences.
“If there’s a very unstable spine, such as a three-column injury, it can move very easily during surgery,” Dr. Rhoads said. “Right now, that’s a big risk if you don’t recognize it. I think in the future, you’ll be able to see that movement in real time with your navigation.”
For Dr. Rhoads, then, the next leap in spine technology is not simply greater precision. It is technology that can better account for something surgeons already have to recognize themselves: the anatomy does not always stay where the image says it is.
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