Spinal deformity will be the next robotic evolution, says Dr. Raymond Walkup


Polaris Spine & Neurosurgery Center was among the first ASCs to perform robotic spine surgery with the ExcelsiusGPS system, which it acquired in 2018.

The practice remains at the forefront of robotic spine surgery and recently installed Globus Medical's latest update for the robot designed to reduce operative time and radiation exposure.

Raymond Walkup, MD, a neurosurgeon at the Sandy Springs, Ga.-based practice, shared his thoughts on how robotics will develop in spine and what surgeries he sees the technology expanding to in the future.

Note: Responses are lightly edited for style and clarity.

Question: What does the future hold for robotics in spine? Do you see robots having greater autonomy in the OR? 

Dr. Raymond Walkup: There's a great quote out there, "a robot in the OR doesn't make a bad surgeon good; it makes a good surgeon more precise and efficient." That's what I envision. Right now we can plan, based on individual anatomy, exactly where we will be placing each pedicle screw (as they range in length, diameter, etc.) and each interbody cage preoperatively, without the patient being under anesthesia. That's huge. Interestingly, there are even studies showing reduced length of stay associated with robotically-placed instrumentation. That's likely due to the minimally invasive nature of the techniques used in robotics. The implications are very promising.  

While most applications of robotics have focused on pedicle screw placement, the extension of this technology for planning lumbar laminectomies and more technically demanding techniques, like osteotomies for deformity surgery, are coming soon. 

Q: What spine surgeries do you see robotics being used to address in the future?

RW: I strongly suspect the next spine development will revolve around robotics in spinal deformity surgery. We are already pre-planning screws with the robot, but soon we will have the ability to plan the deformity correction and predict the amount of lordosis we can achieve with the fusion construct. Adequate lordosis is critical to patients' postoperative outcomes — it's what enables us to stand upright with our shoulders over our hips. If the surgeon ascertains that sufficient lordosis or scoliosis correction cannot be achieved with the instrumentation as configured, they can adapt the surgery plan accordingly.

Q: How will robotics develop in spine as the industry looks for more value-based and cost-effective options to care?

RW: The best way to ensure value in surgery is doing it right the first time, doing it in an outpatient setting and maximizing the patient's postoperative outcome. Shorter OR times, better instrumentation placement and better use of minimally invasive techniques help us achieve that.

Q: What do you see as the next big advancement in minimally invasive spine surgery?

RW: While robots will never supplant surgeons, they can serve as very useful partners. For example, by using the navigation capabilities rather than fluoroscopy, we can position patients in a fashion that not only gives us better access to the anatomy, but is also more ergonomic. Patient positioning will no longer be restricted to prone, supine or lateral. For example, three quarter prone position, also known as "park bench," can be used to make a lateral lumbar interbody fusion surgery with percutaneous pedicle screws more ergonomic and efficient, not to mention the drastic reduction in X-ray exposure. 

Robotic navigation and placement has also expanded what types of procedures surgeons are comfortable doing in an outpatient setting, making lumbar fusions almost commonplace in an arena where they had previously been a rarity. 

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