The benefits of spine robots are widely touted, but some surgeons see the technology in its current format as providing more hype than real clinical advantage.
Six surgeons discuss the disadvantages of spine robots and how the technology could advance in the future.
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Editor's note: The following responses were lightly edited for style and clarity.
Question: The benefits of robotic spine surgery are widely touted, but what do you see as the technology's major drawbacks?
Christian Zimmerman, MD. Saint Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The disadvantages of robotic surgery are an increase in the costs to the operation, the inexperience of the surgeon and substitution for that experience; reliance on that equipment is another likelihood and consideration. Equipment failure, programming lapses, radiation exposure and upcharges to patients and insurance become realities as cost per unit case increases. Postoperative care is the viable trade-off, yet cost expansion of healthcare delivery is expansive and soon to add to the already incurable impasse.
Alex Vaccaro, MD, PhD. Rothman Orthopaedic Institute (Philadelphia): The consequences of pedicle screw misplacement can result in a wide range of consequences, ranging from no clinical abnormality in the vast majority of cases to pedicle blow-out to permanent neurologic injury. To minimize the error of screw misplacement, navigated robotic-assisted spine surgery systems have been designed to increase the accuracy of pedicle screw placement while simultaneously limiting the associated surgical footprint. The touted benefits of robotic surgery include reduced radiation exposure (for the operative team), soft tissue damage, lengths of stay and complication rates compared to traditional freehand pedicle screw placement.
However, the adoption of new technologies is not without its associated costs, both financial and temporal. The initial purchase of a robotic surgical platform is upwards of $1.5 million. Given that these costs are not amortized, it is essential to determine if the touted advantages of robotically assisted spine surgery translate to meaningful clinically significant benefits for patients. Healthcare systems are transitioning to value-based reimbursements, and any new surgical technology must be analyzed with respect to the quality and cost of healthcare delivered. Recent literature has failed to find significantly greater improvements in patient-reported outcomes for patients undergoing robotic versus traditional freehand pedicle screw placement. The current body of literature does not provide sufficient evidence to justify the large economic buy-in, as well as the potential harm to patients during the learning curve of adoption.
We are currently in the first generation of robotic-assisted surgical platforms for spine surgery, and it remains far from the gold standard. Successful robotic-assisted spine surgery still relies on the skill and technical capabilities of the surgeon as a shared-control device. A false sense of security can easily subject patients to iatrogenic injury, as this technology remains fallible and still requires expert understanding of anatomy and constant critical analysis. Furthermore, the lack of real-time imaging is problematic, as tasks as simple as drilling are associated with displacement of the vertebral body not captured by imaging software, let alone more complex tasks such as placement of interbody cages or osteotomies. Robotic spine surgery has a promising future, and I anticipate that succeeding iterations of robotic platforms will overcome the current drawbacks.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Robotics have an important place in spine surgery as an enabling technology. Difficult cases, including spinal deformities with atretic pedicles and other anatomical anomalies, and revision surgeries where normal anatomical landmarks are significantly altered are well-touted examples where robotics can guide surgeons and improve accuracy. However, it is important to remember that current robotic technology is limited to screw placement. It does not guide other aspects of surgery, including decompression or alignment. Furthermore, it does not rely on real-time imaging and can therefore be subject to inaccuracy. Patients are frequently not aware of the limited scope where the robot is currently utilized in spine surgery.
As we train young surgeons in robotics, it is important to remember that traditional freehand techniques are important to maintain and understand thoroughly. Emergency cases where these technologies are not available do occur, and it is important for surgeons to understand how to place screws without utilizing the robot as a 'crutch.' Surgeons cannot rely completely on the robot to ensure accurate placement of pedicle screws. Images are not in real time and can become inaccurate. It is important for surgeons to verify the accuracy of placement — we cannot simply assume the robot is accurate. Failure of surgeons to verify the accuracy of the robot potentially leads to catastrophic outcomes for patients.
Raj Arakal, MD. Texas Back Institute (Plano): Robotics in the field of surgery has advanced significantly, and I suspect we are at the tip of the iceberg for advances not currently in sight. At present, robotics may aid with screw placement but soon may help with every aspect or layer of surgery, including decompressions, exposures and closures. With that said, the current drawbacks are appropriate to capture: all the variables that may make certain cases have unexpected delays, suboptimal pedicle screw insertions and persistent reliance on a static fiducial or registration to merge images. The human brain and surgeon are still quicker at identifying the best trajectories for screws, and current surgical robots still require the surgeon to individually plan each trajectory.
A.J. Rush, MD. Texas Back Institute (Plano): Robotic surgery is a natural iteration in the future of spine surgery and offers a number of benefits. The potential drawback that we must be vigilant to protect against is the possible overreliance on this technology and potential inability to appropriately troubleshoot in times of technological error.
Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): Several studies showed promising outcomes using robotic systems, especially in deformity and minimally invasive cases. The drawback is the add-on expenses and the cost of the platform, especially when reimbursement continues to be cut. In addition, the facility must have the trained staff and infrastructure to support the surgeons. It will be even more challenging in the ASC setting due to the limited budget and capital funds.