The state of robotics in spine surgery today: 14 observations

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Surgical robots continue to make noise in the spine industry and are expected to pick up steam in the coming years as more devicemakers launch systems to compete with the Medtronic, Globus Medical and Zimmer Biomet systems that control most of the market.

Here are 14 observations on the robotic spine industry and thoughts from surgeons about the future:

1. The global market for spine surgical robots — valued at $124.2 million in 2020 — is expected to reach $451 million by the end of 2026, increasing at a compound annual growth rate of 20 percent from 2021 to 2026. Market growth will be driven by an increased demand for minimally invasive spine technologies, which result in less blood loss, fewer complications and shorter hospital stays.

2. Robots have been lauded by many surgeons for limiting radiation exposure and their improved precision, which translates to better outcomes and quicker recoveries for patients. However, disadvantages of the technology include high costs, steep learning curves and inherent technological glitches.

3. Robotic spine surgery is playing catch up to robotics in other surgical specialties, such as urology and general surgery, but adoption has been steadily climbing in the U.S. in recent years. Current systems on the market offer the potential to improve pedicle screw placement accuracy, reduce operative time and decrease radiation exposure for staff and the patient. However, there are some drawbacks that include a challenging learning curve and various technical factors that are continually reassessed to improve operative efficiency and to meet these goals.

4. Robotics still represents a significant capital expense for hospitals and ASCs. Medtronic's Mazor X robot costs more than $1 million and Globus Medical's ExcelsiusGPS costs $1.5 million, according to a study published in the Journal of Spine Surgery. The high cost ultimately increases the cost of care for patients. But medtech companies are now working on robots that are cheaper so quality care, global fees and episodes of care can be performed and charged reasonably.

5. Medtronic acquired Mazor Robotics for $1.7 billion in 2018, as part of its plan to integrate its spinal implants, navigation and 3D imaging technology with the Mazor X robotic guidance system. In 2019, the company launched the Mazor X Stealth Edition, which allows surgeons to create personalized 3D surgical plans before surgery and holds surgical instrumentation in place with a robotic arm during spine procedures. The Mazor X Stealth Edition was used in more than 1,000 procedures in over 50 U.S. hospitals in its first year.

6. Globus Medical acquired Excelsius in 2014 for an estimated $40 million and earned CE mark approval for ExcelsiusGPS in the European Union in January 2017. The FDA provided clearance for the system in August 2017. The device also combines a robotic arm with navigation to improve accuracy in the placement of screws during spine surgery and reduce radiation exposure for the surgical team. Click here for a breakdown of other robotic systems on the market.

7. Of the 402 screws placed in 77 patients who had robot-assisted spine surgery at Rochester, Minn.-based Mayo Clinic between September 2018 and October 2019, none required postoperative revisions, according to a May 2021 study in Mayo Clinic Proceedings. 

Two of the 402 screws required modifications intraoperatively, but none of the study's patients had complications related to screw placement. The duration of operations decreased significantly as surgeons performed more cases with the robot, according to the study. The number of procedures performed each week also increased, and length of hospital stay after surgery was two days.

8. ASCs and hospitals are now looking to purchase spine robots as a way to attract talent. The next generation of spine surgeons want to have access to the latest and greatest technology on the market, and that's robotics, according to Alfonso del Granado, administrator at Covenant High Plains Surgery Center in Lubbock, Texas. Although robots can be an expensive capital purchase, surgery centers "have to make the investment" to attract talent at the top of the surgeon pool, he said.

9. While spine robots are primarily used for the placement of pedicle screws, many surgeons believe the technology will advance far beyond instrumentation placement and holds particular promise for spinal deformity surgery. Docking retractors, drilling bone and directing certain equipment to take away tissue from the spinal cord and nerves are some of the ways surgeons expect the capabilities of spine robots to evolve.

10-14. Five surgeon insights:

Frank Phillips, MD. Rush University Medical Center (Chicago): Over the last few years, we've seen the robot hype and age, and I think that's here to stay. For now, I think robots are more hype than offering real clinical advantages. I think they're sort of image guidance dressed up with an aiming arm, but clearly they have the potential in the future to really change what we do. I think the companies that have or are developing robots recognize that. They realize that right now it won't add much, if any, efficiency and the accuracy that they provide is pretty good with other things that we already use. I think it's more the promise of what they will be. There's augmented reality technologies that are real and coming out. These are technologies with retina display headset ability to do navigation, which plays to the world we're in because it takes out the need for huge robots — huge 3D imaging machines in limited spaces, particularly in an ASC where the ORs are obviously much smaller.

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.

Ernest Braxton, MD. Vail (Colo.) Summit Orthopaedics and Neurosurgery: 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.

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.

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.

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.

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