Why this surgeon prefers freehand spine surgery

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Spine robotics and navigation technologies have grown rapidly, but not all surgeons are keen to adopt them immediately.

Michael Kelly, MD, director of scoliosis and spinal deformities at Rady Children's Hospital-San Diego, spoke with Becker's Spine Review about the spine technology that holds promise and why he has a more conservative approach to using it.

Note: This response was edited for clarity and length.

Question: What technologies have the biggest promise in spinal deformity care?

Dr. Michael Kelly: I think navigation has promise, but not necessarily for the purpose of installing screws. I'm a freehand-trained guy, so I don't use navigation to put screws in. But navigation will go beyond screws. It will go to where that spine is in three-dimensional space. I think that we will be able to use preoperative radiographs and planning measures, and we'll figure out where each vertebra needs to be in space, and navigation will be able to tell us whether or not you have achieved your alignment targets and your alignment plan. That's really where the next game-changing aspect can come — using navigation to achieve alignment targets and not having the days where you go in with a plan and the case is harder and more difficult than you had anticipated, or going a little bit slower. And then you get close, but not right. We need to eliminate the close, but not right, and we definitely need to eliminate not even in the ballpark.

Q: Is it only pedicle screw placements you do freehand? Do you use navigation technologies at all?

MK: I haven't used them at all in my own practice. We had a long history of freehand thoracic pedicle screws and at WashU, so I feel very comfortable with it. I'm currently faster than the machine. The moment the machine gets faster than me or I don't hear the occasional horror story about malpositioned robot screws or navigated screws, I'll switch. But I am just reluctant to change something that I don't feel is a problem for me.

Q: How would you encourage a surgeon to be more conservative with technology use?

MK: If anything we have learned in orthopedic surgery is that being a rapid adopter of technologies is often not the best thing. So I am a little bit of a worrywart about adding new things, particularly when they don't make sense to me at a sort of face validity level.

The most important for navigation when you're training is choosing a program that does both navigated and minimally invasive surgeries and a program that has a large open experience. It's much easier to know how to go from big, open insertion of crooked screws to understanding what's under the skin using a robot or navigation, than to just do it blindly always and then have to do it open. That doesn't always work. It's not an equal back and forth.

Having a strong foundation of being able to do open surgery and knowing landmarks and then moving to navigation or robotics is better in the long run. Everyone hears the stories about the navigation system breaks and cases get canceled. You just don't want to be like that. If the navigation is down or something's just not right, you need to recognize that and know that we have a very, very powerful biological computer in our skulls.


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