Four spine surgeons discuss the advantages and disadvantages to using robotic image guidance during procedures.
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Question: What are some pros and cons of robotic image guidance?
Mark M. Mikhael, MD, Spine Surgeon at NorthShore Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): A big advantage to robotic image guidance is the reduction of radiation exposure to both medical staff and patients during the surgical procedure. This potentially harmful exposure is typical during minimally invasive surgery due to use of intraoperative CT or X-ray based imaging modalities. However, robotics and computer-assisted navigation enables surgeons to use preoperative CT scans to plan surgeries, avoiding intraoperative exposure. In addition, the calibration of instruments leads to more accurate placement of pedicle screws during the procedure.
There is a learning curve to using this technology, so that is a con to hospitals that want to get a program started and train surgeons quickly. Also, the technology does not represent real-time imaging since it is based on preoperative CT imaging. This can be especially problematic in more challenging surgeries, such as deformity cases after osteotomies or surgeries involving larger patients with complex anatomy and grossly unstable spines, for example, upper cervical or fracture cases. Without recalibration in the procedures, robotic image guidance might not assist to correct these conditions.
Michael J. Musacchio, Jr., MD. Spine surgeon at NorthShore University HealthSystem's Neurological Institute (Chicago): Robotic image guidance is becoming a proven pathway to optimal spine care. Some pros to the technology include the surgical planning software that marries with the equipment, making robotics user-friendly; and the imaging leads to greater precision in planning, executing and measuring pre- and postoperatively, especially with spinal deformities. For example, there is the potential for greater accuracy in screw placements with robotics.
The cons are that robotics is expensive and it takes time to integrate a robotics program. As a relatively new surgical tool, there is a learning curve for many surgeons to adapt to the new way of performing surgery. It also takes up space. The robotic equipment can be difficult to fit into a smaller, crowded operating room.
Once robotics is embraced fully by surgeons, hospitals and health systems, the benefits will far outweigh the challenges. Robotics is the wave of the future, and patients will be the ones who gain the most from this technology.
Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: Like with most technologies there is the risk of over-reliance. This is what happened with minimally invasive surgery when it was first being done about 10 to 15 years ago. One of the reasons I chose to do a fellowship was to learn how to do open spine surgery — we used to joke and call it "maximally invasive."
Learning from the masters the most orthodox form of the art became really important to me. I realized that if I had to "bail out" of a minimally invasive surgery, I most likely would struggle with an open type procedure. It's akin to what is happening with vascular neurosurgery. There are many program directors very worried about whether we will see only a few dozen people who can actually clip an aneurysm, because there is so much focus on end-vascular techniques.
Similarly, if we all become robotic spine surgeons, there is a very real risk that the ability to put in pedicle screws, or other forms of instrumentation if those systems should fail, could be compromised. Another issue is the false sense of security a robot engenders. It's a system designed by imperfect minds and is also subject to fallibility. My concern is that surgeons will have too much confidence in the accuracy of such devices and toss out common sense and safety protocols the designers have put in place in favor of expediency.
The pro camp will cite the greater the 90 percent accuracy of screws in robotics. This is one of the most compelling arguments for using the system. Patient safety is and will always be paramount. Economic forces will also drive its adoption. I predict eventually Medicare and other payers will argue that poorly placed pedicle screws are a "never event," much the same way surgical site infection has been erroneously labeled, and will no longer pay for revisions or "take backs."
Payam Farjoodi, MD. Orthopedic Spine Surgeon at Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): Robotic image guidance allows a higher degree of certainty with hardware placement which is vital for complex, long-level constructs and revision surgery. The cons are increased surgical time while going through the learning curve and increased radiation exposure for the patient, particularly robotic systems requiring a preoperative CT scan.