AR vs. robots: What spine surgeons prefer today

Alan Condon -  

While still in their infancy, robotics and augmented reality have demonstrated significant potential in spine surgery, with many surgeons excited to see how these two technologies will be integrated in the future. But which technology are surgeons gravitating toward as they stand now?

Question: If you had the opportunity to implement either an AR spine system or a robot at your practice tomorrow, which technology would you choose and why?

Editor's note: Responses were lightly edited for style and clarity.

Frank Phillips, MD. Midwest Orthopaedics at Rush (Chicago): I have used AR for the past two years and it has been a breath of fresh air. This eliminates the cumbersome and time-consuming set up of robots at a fraction of the price. In addition, the use of AR in percutaneous spinal procedures provides surgeons with a 3D view of the spinal anatomy and allows visual and tactile feedback, which are sacrificed by current robots. I'm looking forward to seeing AR technologies combined with robotics to optimize outcomes.

Philip Louie, MD. Virginia Mason Franciscan Health (Seattle):  This is a tough question: I'd like them both! Both are critical components and emerging technologies with early evidence-based benefits to intraoperative care. Similarly, both can be instrumental pieces that are incorporated into a more comprehensive integrated platform (hopefully in the near future). But if I had to choose one tomorrow, I would likely select the robot. Although AR spine systems provide incredible benefits with newer baseline technology, here's why I would choose a robot:

1. From an ergonomic standpoint, I think we are moving toward maintaining the neck in a neutral position while operating, especially in a minimally invasive surgery setting. AR in its current form requires looking down with a headset that adds additional weight to the neck.
2. The evidence is more robust for robotics at this point in time. I recognize that this is an evolving target. 
3. Currently, robotic systems are far more integrated with the ability to perform pre-op/intraoperative planning and evaluate postoperative outcomes; ultimately assessing the intraoperative execution of our plans.

Kris Radcliff, MD. Rothman Orthopaedic Institute (Philadelphia): Robotic technology has tremendous potential to enhance overall spine surgery patient safety and outcomes. The next generation of robots will lead to safer, more reproducible neural identification and decompression by incorporating safe zones, haptic feedback and machine vision. Robots have the potential to contribute to every spine surgery. Robots can also detect physical condition changes such as a loss of resistance or change in sound that are imperceptible to humans. Ultimately, robotic technology will enhance spine surgery in the same manner that machine vision and sensors contribute to self-driving vehicles. 

Kornelis Poelstra, MD, PhD. The Robotic Spine Institute of Las Vegas: It all depends on your individual requirements for enabling tech, and the type of surgical practice you have. We see over and over that many users agree the planning component of current robotic systems is the true game changer. It is potentially less the robotic technology at this point, but more the holistic view and planning ability of the systems that show time and time again reduction in radiation, length of stay and overall complication rates.

The future for AR is very bright, and systems will soon incorporate similar planning software that will allow surgeons to expeditiously complete surgical intervention with AR headsets following a largely automated plan for perfect screw trajectory placement, disc space preparation for fusion and interbody cage placement. This could all be offered at a lower cost than when a robotic arm of any kind is added.

Competition will fuel improvements for both technologies, and combining them will truly change the game of spine surgery. We have shown this already in spring 2021 when I combined Mazor X and xvision from Augmedics in the same case and I cannot tell you how incredibly efficiently and accurately this combination helped me with speed and agility in the operating room. There will truly be a symbiotic relationship between these two technologies soon. I cannot wait!

Peter Derman, MD. Texas Back Institute (Plano): An ideal system would actually incorporate both. The robot would provide stabilization and guidance, while the AR would allow the surgeon to "see" the spine without having to look up at a navigation screen, depend on fluoroscopy or perform open surgery. 

We are just scratching at the surface of what these technologies will enable us to do. Implant placement is only the beginning. In the future, I anticipate that MRI data will be incorporated as well so that AR and robotics will be able to facilitate decompressions. These tools will become a platform for enabling all spine surgeries. I'm particularly excited about the integration of AR and robotics with endoscopic spine surgery. 

Isador Lieberman, MD. Texas Back Institute (Plano): Robotic technology is currently more versatile than the first-generation AR technology. Within the next five years all the proprietary spine surgery platforms will include AR modules, navigation modules and robotic guidance components. This will provide the surgeon with a comprehensive toolbox.

Lali Sekhon, MD, PhD. Nevada Neurosurgery (Reno): I'm not sure AR is much ahead of robots, which are fancy guidance arms. AR puts the LCD screen in our glasses. That's about it. Both rely on navigation to power them and it's navigation I really want. Given the COVID-19 pandemic/loss of staffing, my wishlist is a little more holistic:

1. Regular operating room crew
2. Enough staff in the OR so we can do long lines and add on cases
3. Enough staff in our offices so we can function effectively
4. Enough nursing staff so patients don't sit in recovery all night or cases get cancelled

The pandemic has thrown hospital and office staffing into arrears and the practicalities are that our basics are being undermined. Not enough office staff, not enough nurses, lowered reimbursement, insurance companies still fighting us. These are my needs. AR/robots are wants. Navigation is the jewel. Navigation means I have a wonderful iPhone, but perhaps not the latest one. Give me enough staff, operating room time and hospital beds instead of AR and robotics.

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