What will spine robots need to flourish in the next decade?

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Robot-assisted spine surgery is growing exponentially, and many surgeons laud the efficiencies and improved safety measures the technology provides. However, spine robots still have yet to reach their full potential.

Ten spine surgeons told Becker's Spine Review the updates they want to see in robots over the next decade.

Note: Responses were edited for style.

Question: What improvements will spine robots need to thrive in 10 years?

Ernest Braxton, MD. Vail (Colo.) Summit Orthopaedics and Neurosurgery: The primary principles of spine surgery today involve decompression, alignment, and stability. For spine robots to thrive they must be involved in each of these aspects of surgery and have universality. Universality in terms of a wide variety of procedures and access to a wide variety of healthcare systems from a cost standpoint.

Currently robots are used primarily to improve safety and reliability for placement of pedicle screws, although some robots are beginning to offer improved planning of deformity corrections. The FDA does have a ban on fully autonomous robots in spine surgery but there is a role for utilizing computer assisted surgery for decompression of neural elements. Decompression is really the major hurdle that many robots have to become invaluable in the operating room. I believe that the surgeon still must have an active role in decompression. Incorporation of exoscopes will probably facilitate surgeon involvement by keeping the surgeon visually engaged in the decompression portion of the procedure. Upgrades in software and hardware will make planning for alignment and placement of other types of implants such as interbody fusion devices, rods, and set screws easier.

Probably the most important feature of future spine robots is the concept of universality. They must be able to perform a wide variety of procedures and ideally be agnostic to the manufacturer of the implant. To be commonplace, they must be useful in all areas of spine surgery, not just pedicle screw placement. I think that they have a similar pathway that the operating microscope had in the 1980s and 1990s.

Finally for many facilities to have access to this technology, the cost must come down. Only when the spine robots are sold at a more reasonable price point (between $350,000-$500,000) and have applications for multiple types of procedures including decompression of neural elements (in the cervical, thoracic and lumbar spine) will they truly thrive in the practice of spine surgery. The price is coming down as more competitors enter the marketplace, but today robots still have a limited role in spine surgery.

Kern Singh, MD. Midwest Orthopaedics at Rush (Chicago): As spine surgery shifts towards increasingly minimally invasive modalities, robotic instruments will see enhanced utility in the operating room. Advancements in robotics that can assist spine surgeons with enhanced visualization of anatomical structures and spatial positioning of their instrumentation will enable surgeons to perform minimally invasive spine surgery efficiently and precisely.

The next generation of spine surgical robots likely will merge real-time intraoperative image data from CT and MRIs to provide assistance with surgical exposure. Additionally, advancements in artificial intelligence and feedback sensor design will synergistically increase the scope of robotic presence in minimally invasive spine surgery, potentially leading to more complex tasks under robotic purview such as bony decompression or dural closure.

Andrew Simpson, MD. Brigham and Women's Hospital (Boston): The current state of automation in spine care principally involves automating the position of guides for the placement of pedicle screws. This feature is not actually automating pedicle screw placement, but simply automating guides for the surgeon to utilize when placing the screws. In the current state, this does not offer substantially more value than intraoperative navigation, where the surgeon utilizes multiplanar anatomic information to choose the trajectory for screw placement.

One important advantage for navigation over robotics is a more open platform, with the capability to more rapidly incorporate tracking of other instruments, such as bone removal tools, which are processes that would have to be predetermined in the software and hardware components of a robotic system. The two greatest headwinds facing spine robotics are these limited capabilities and high capital equipment costs.

As spine surgery continues to move from larger facilities toward surgery centers and smaller facilities with greater budget constraints, robotic technologies will have to provide a greater value proposition and companies will have to develop more creative and affordable purchasing/leasing programs.

Peter Derman, MD. Texas Back Institute (Plano): Continued improvement on several fronts will be necessary to spur more widespread adoption of spine robots. First, robot set up and registration will need to be streamlined. The robot might be justified from an operating room efficiency standpoint in a spinal deformity case where the extra initial setup time can be offset by faster placement of each individual screw; but this process will have to improve if it is not going to prolong one- and two-level cases.

Second, additional applications beyond pedicle screw placement will need to be developed. The ability to assist with decompression as well as instrumentation will make these robots more versatile and therefore more valuable.

Finally, the cost of such devices will need to decline. An increasing proportion of spine surgeries are performed in the outpatient setting, and spine robots must be cost effective (or at least not prohibitively expensive) if they are going to be utilized in ambulatory surgery centers and other such environments.

Brandon Hirsch, MD. The CORE Institute (Mesa, Ariz.): I think the future of robotics in spine surgery is promising. I believe in order to thrive, robotic systems will have to incorporate ease of use related to workflow. Efficiency in the operating room is of utmost importance to spine surgeons. New technology often comes with a significant alteration to workflow depending on the size and maneuverability of the device. As with most technology I expect the physical footprint of robotic arms to shrink as new iterations are developed.

Cost is also going to be a major driver of success. Device makers will need to ensure that they can deliver this technology at a reasonable cost, particularly as more spine care moves out of large hospital centers. The technology will make little impact on the field if it is only available to those at a few well-resourced centers.

Marcus Mazur, MD. University of Utah Health (Farmington): I think spine robots need to expand beyond thoracolumbar pedicle screw insertion. Experienced spine surgeons already place pedicle screws very accurately with low rates of revision, whether using image-guidance, fluoroscopy, or freehand. Robotic-assisted cervical spine instrumentation, such as C2 and subaxial pedicle screws, should be on the horizon. Robots cannot yet determine whether a screw has skived off the intended trajectory or if the pedicle wall has breached. Incorporating real-time feedback mechanisms to prevent screw misplacement would be a significant step forward.

Furthermore, if pressure-based feedback mechanisms are developed, robots could potentially automate the decompression portion of the operation, which could decrease operative times and blood loss. Another development could be to use robots in a capacity that would optimize restoration of spinal alignment or deformity correction. For robots to thrive, they need to increase the safety and efficiency for the complicated portions of the operation.

Philip Louie, MD. Virginia Mason Franciscan Health (Seattle): When considering where spine robots should be in 10 years as a thriving technology, I think that we need to take a step back and think about how we envision where spine technology should be at that time.

1. At the end of the day, I believe that an integrated platform that can be utilized for the entire episode of surgical care is the ultimate goal. Right now, the robot is still often used as an individual piece of technology to help place pedicle screws. Other applications are fast-approaching including assistance with decompression and osteotomy maneuvers. Ultimately, the robot should serve as an integral intraoperative tool that is part of an integrated platform designed to assist for the entire episode of care, beginning with preoperative planning, through the surgery itself, and assessing patient reported outcomes. For example, in deformity procedures; providing additional assistance with preoperative planning of alignment goals and intraoperative assistance with rod bending and correction maneuvers.

2. As a strong proponent of evidence-based medicine that is borne out of large amounts of data. I think that it would be incredible if the robot was able to collect large amounts of data from the preoperative planning and the actual execution of the surgical intervention in a form that can be easily analyzed. The ability to learn from the preoperative planning as well as the intraoperative instrumentation, decompression, and osteotomies, then compare this data over multitude of patients undergoing similar cases would be incredible. Back to the previous example on the prior point, the robot could then collect all the data between the planning and the actual outcomes for several cases and provide a dashboard like feedback on operative goals, based on the extensive preoperative planning.

David Essig, MD. Northwell Health (Great Neck, N.Y.): Spine robots will likely become an integral part of our practice. However, in order to further improve patient outcomes and surgical throughput several changes will need to occur. Improvements in size and cost will need to happen for robots to efficiently participate in the outpatient surgical space. Agnostic software that allows surgeons to utilize a variety of implants interchangeably with robotics will allow for preserved surgeon autonomy and assist with cost mitigation strategies.

Finally, improvements in the “shared operative experience” between robots and surgeons are needed to allow for increased flexibility to adapt real-time changes in the operative plan based on intraoperative findings and complications.

Richard Chua, MD. Northwest NeuroSpecialists (Tucson, Ariz.): We are still in the infancy of adapting and implementing robots for spine surgery. While it serves as an enabling technology, just like any other technology, the industry will need to continue to concentrate on safety, reproducibility, all while also considering direct and indirect costs. Specialist support, by engineers, clinical specialists, and experienced users will need to be readily available to help new users during implementation and early experience.

However, the future looks bright for spine robots. In order to thrive in the next 10 years, the technology will need to incorporate machine learning, data analytics and AI. We are starting to see this evolution already. Having the robot be semi-autonomous or even fully autonomous to the highest degree of accuracy and safety should be the goal.

If stereotactic radiosurgery (now over 25 years experience) can treat brain tumors to 1 mm accuracy from critical structures of the brain, using image-guidance, computerized planning, and robotically-controlled delivery of radiation, then I believe we can use similar principles and apply them to robotic-assisted spinal surgery for many indications.

Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Robotic-assisted spine surgery is a very exciting and promising field with a lot of potential. Spine robots and navigation systems started off with a very limited function of either a K-wire or a pedicle screw placement. Some of the systems have already advanced to assist with other steps of spine surgery such as navigation of disc space, preparation of instruments and placement of interbody spacers. Robotic and 3D navigation technology in spine surgery offers benefits of high precision, accuracy, efficiency, and reproducibility of instrument and hardware placement while reducing radiation exposure. This technology enables a surgeon to perform minimally invasive cases with more accuracy, shorter learning curve and greater safety.

The challenges of the current systems include dependence on line-of-sight for accurate navigation, time needed to register anatomic structures and merge them with pre-operative scans, limited capabilities, and the expense of the initial investment into the system.

I believe that the robotic technology for spine surgery is still in its infancy and will continue to improve with time and further research and development. I anticipate the future spine robotic systems will provide accurate real-time navigation without the line-of-sight limitations. These systems will have the ability to assist with all aspects of spine surgery including pre-operative planning, optimal incision placement, accurate and safe navigated nerve decompression and disc removal, and accurate, safe, and reproducible implant placement while enabling the entire procedure to be performed in a minimally invasive fashion. I expect augmented reality and voice and gesture command recognition to be a part of those systems as well. Robotic technology will also allow for easier training and a smaller learning curve for new spine surgeons.

While the price of such systems might remain significant, the ability to perform safe, accurate, and the least invasive spine surgery will bring significant clinical benefits for the patients. The financial savings associated with lower complications rates, quicker recovery, and the ability to perform the majority of spine cases on an outpatient basis will be greater than the costs of the initial investment into such robotic systems.


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