Do spine robots currently offer more hype than clinical value?

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Spine robots have proven effective in assisting surgeons with the placement of pedicle screws, but lag behind the capabilities of robots in other medical specialties such as urology and general surgery.

Six spine surgeons discuss where robots are today and whether the technology will become a gold standard of care in the future.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: What needs to change for value-based care to be more attractive for spine providers?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, June 30.

Note: The following responses were lightly edited for style and clarity.

Question: One view is that spine robots currently offer more hype than real clinical value. What applications would fulfil predictions that robots truly are the future of spine surgery?

Alexander Vaccaro, MD, PhD. Rothman Orthopaedic Institute (Philadelphia): Robotics will truly become the future of spine surgery when it is a practical and efficient option for both academic and community surgeons. Often, healthcare systems market robotic surgery to patients who perceive it as technologically advanced, but the focus must shift towards robotic surgery as a safe, pragmatic alternative to traditional surgery for the bottom line. Infrastructure requirements and costs must be brought in line with a competitive marketplace. Technological advancements focused on workflow issues such as real-time intraoperative seamless imaging incorporating preoperative MR advanced imaging with real-time neurovascular surveillance must be pursued to improve safety and to expand the applications of further use. It is at this point that robotic surgery will have truly arrived in spine.

Ali H. Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): There is no question that robotics will play increasing roles in medicine in the future. The current state of robotics in spine surgery, however, lags behind that of general surgery, urology and OB/GYN. The greatest advantages that robotics offer are improved efficiency and safety, combined with the ability to perform tasks in a unique manner that a single surgeon cannot. Spinal robotic surgery aids in the placement of pedicle screws and similar instrumentation, while minimizing the radiation exposure to the surgeon. Recent studies have shown that the accuracy and long-term complications associated with robotic-assisted cases are superior to that of traditional free-handed approaches.

 In order to gain wider adoption, robots need to be less expensive and cumbersome, and improve efficiencies and outcomes for all surgeons, including those with the greatest experience and outcomes. Similarly, when the cost of robotic surgery decreases to an amount that can be absorbed by private practice facilities and ASCs, and insurance/Medicare provide payment or incentives for its adoption, widespread adoption will follow. Lastly, the ability to perform operations that require multiple surgeons or approaches in a manner that allows a single surgeon to do so with a robot, will accelerate the integration of robots into spinal surgery.

Jamieson Glenn, MD. Scripps Clinic (Encinitas, Calif.): Utilization of navigation and robotics has revolutionized many facets of modern medicine today. As technology continues to develop and move forward, its applications in spine will become more widespread and practical in everyday use. In my opinion, robotics and navigation have limited clinical application and are truly in their infancy. Each of the current systems have shortcomings, such as requiring significant radiation exposure, recalibration, more invasive techniques and longer OR times. To change from 'hype' to reality, a system should have the ability to obtain real-time diagnostics, allow surgical planning with intraoperative adjustments and the ability to safely perform decompression surgery and/or spine instrumentation. In conjunction, these abilities should be balanced with maximizing safety, minimizing operative time and morbidity. 

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): The challenge with robots is two-fold. One is the capital costs that make it prohibitive to be widely adopted. Second is the increased time in the workflow. If the price of robots can come down such that ASCs can buy them without breaking their budget, then you will see greater adoption of this technology. In addition, using the robot cannot extend the time in the OR. I have seen too many cases where the planning for the robot can take longer than the case. Speed and efficiency will always be an issue for spine surgeons. Once these challenges can be overcome, there will be greater adoption of the robot.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Everyone is talking about the singularity of the age of the spine robot. In fact, we feel more like we are on an asymptotic approach, rather than exponential adoption. The function of robots needs to go beyond the function of a fancy electronic guide wire and evolve to reshaping, reconfiguring and predicting how well the decompression, interbody cage, or rod-screw constructs will look before your patient is off the table.

Colin Haines, MD. Virginia Spine Institute (Reston, Va.): Robotics offers many advantages over traditional spine surgery. We can place pedicle screws accurately through open or percutaneous approaches with a high level of accuracy. However, the reality is spinal instrumentation can also safely be placed using traditional free-hand techniques as well as with X-ray or CT scan assistance. In that line of thought, many surgeons have viewed robotics as an accessory, rather than a major advancement to spinal healthcare.

However, there are future applications that should increase robotic use. Once robotics can be utilized for decompressions as opposed to just spinal fusions, the utilization should pick up. I view this to be advantageous in revision decompression settings, hopefully allowing me to navigate scar more expeditiously. In addition, being able to preoperatively plan a laminectomy would minimize the risk of inadequately performed decompressions, thereby improving surgical outcomes on a larger, population scale. Lastly, current robotic applications are based on CT scan technology. Once MRI-based robotics becomes feasible, there is less of a technological barrier of entry to its use as all surgical patients have an MRI performed whereas not all need a preoperative CT scan.  

Certainly, robotics is not without its limitations. However, as the technology improves and its incorporation into medical training programs increases, I do believe that robotics has a very, very bright future. 

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