Robotics in spine surgery – 15 things to know


The spinal robotics market is growing, with more companies releasing robots and more surgeons training on the technology.

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Here are 15 updates on the robotic spine field and thoughts from surgeons about the future.

1. The global spinal robotics market is expected to reach $320 million by 2026, up from $75 million in 2017, according to a Transparency Market Research report. From 2017 to 2026, the market is expected to expand at a 17.5 percent compound annual growth rate.

2. North America is expected to lead the spinal robotics market due to a high demand for spine surgery, however there are a limited number of professionals trained in the technology. The Transparency Market Research report noted Medtronic, with Mazor Robotics, and Zimmer Biomet hold around 80 percent market share.

3. Mazor Surgical Technologies was established in 2001 and became Mazor Robotics in 2010. The company received a CE mark for its first product, SpineAssist, in 2004 and made it the first commercially available mechanical guidance system for spine surgery when it launched. The company then released the Renaissance Guidance System in 2011 and collaborated with Medtronic to develop Mazor X, launched in July 2016.

4. Medtronic placed a purchase order for 15 Mazor Robotics' Mazor X systems in August 2016, as part of its $20 million investment in the company. The Mazor X technology expands on the company's robotic guidance technology to include analytical tools, multiple-source data, precision guidance, optical tracking, intra-op verification and connectivity technologies. In November 2018, Medtronic fully merged with Mazor in a $1.64 billion transaction.

5. ASCs are now installing spinal robotic systems, including Mazor's Renaissance system. GNS Surgery Center in Athens, Ga., a United Surgical Partners International affiliate, installed the Renaissance system in June 2018; Johnstown, Colo.-based Arete Surgical Center and Pensacola, Fla.-based Baptist Medical Park Surgery Center also installed the systems last year.

6. Warsaw, Ind.-based Zimmer Biomet acquired Montpellier, France-based Medtech in October 2016. Medtech's original product, ROSA Brain, offers surgeons robotic guidance and preplanning with brain surgery. Based on a preoperative plan, the robot drives the arm along planned trajectories, allowing the surgeon to implement the planned intervention. The company received FDA clearance for Rosa One Spine earlier this month.

7. Audubon, Pa.-based Globus Medical presented its Excelsius GPS investigational robotics system at the North American Spine Society meeting, held in Boston from Oct. 26 to Oct. 29, 2016. The system features non-patient bedside docking and an optical tracking system. The company received the CE mark for the system in January 2017.

"We are starting to see the promise of robotics come to fruition as the technology is being adopted enthusiastically with good early clinical results," said Globus Medical CEO David Demski during the second quarter 2018 earnings call, as transcribed by Seeking Alpha. "A significant number of procedures using ExcelsiusGPS have been performed by surgeons who have not used Globus implants before and we are seeing exceptional growth in the number of accounts utilizing the technology."

8. NuVaisve plans to reveal a new robotics spine surgery platform later this year called Pulse. The fully integrated robotic offering is in development and expected to have application for all spinal surgeries, not just complex or low-acuity cases.

"Pulse is a foundational component of our end-to-end solution to not only enable predictable clinical and economic outcomes, but also pull through innovative procedural solutions to create market stickiness and increase the cost of disruption of switching to another provider," said Chris Barry, CEO of NuVasive, during the company's 2018 earnings call in February 2019, as transcribed by Seeking Alpha. "By integrating many disparate technologies in a single platform, we're executing on an application system environment that addresses current gaps in the market and is applicable in 100 percent of spine cases."

9. A study presented at the Society of Minimally Invasive Spine Surgery Annual Forum 2016 compared the surgical outcomes for 403 robotic-guided spine surgeries with 224 fluoroscopic-guided procedures and 78 freehand procedures.

The complication rates for the techniques were:

• Robotic guidance: 4 percent
• Fluoroscopic guidance: 5.4 percent
• Freehand: 12.8 percent

"This retrospective analysis demonstrated that use of robotic guidance MIS can significantly reduce surgical complications and revision surgeries when compared to fluoro-guided MIS in the hands of experienced MIS surgeons," concluded the study authors.

10. Peter Vikas, MD, penned an article titled "Future of Robotics in Spine Surgery" in the April 1, 2018 issue of Spine. He noted that market trends and increased training could push health systems to purchase robotic technology for spine surgery. "Less-trained spine surgeons are expected to do more and more, especially in physician-based settings. Robotics could allow for increased safety even with increased complexity of surgery, bringing such cases into the capability of less experienced surgeons," he wrote.

He also mentioned researchers are developing robots to perform automated simple procedures, including wound closing.

11. In the December 2018 issue of Spine, researchers published a literature review of robotic technology. Thirty-two articles included in the review showed intrapedicular accuracy in screw placement for the robotic group was comparable, and in some cases superior, to the freehand group. Subsequent complication rates were similar and radiation exposure varied between studies. As the number of robotic cases ascended, radiation exposure decreased.

12. In January, Reston-based Virginia Spine Institute's Director of Scoliosis and Spinal Deformity Christopher Good, MD, led a team that performed the first surgery using the Mazor X Stealth Edition.

Three predictions on robotics in spine:

13. Frank Shen, MD. University of Virginia Health System (Charlottesville): I think that over the next five to 10 years spine surgery will start to incorporate technologies from multiple emerging fields including robotics, advanced imaging techniques, wireless and smart technologies, and nano-engineering just to name a few. We are seeing the application of those technologies in our practices already. Currently, our institution is already utilizing robot-guided technologies to increase the accuracy and precision of what we do in the operating room. In addition, we have been using real-time virtual imaging obtained from intraoperative 3D scans to develop virtual surgical plans and executing the plan intraoperatively. The use of wireless and 'smart technologies' will allow instruments, and likely implants, to communicate with one another seamlessly and in real-time, and will soon become commonplace.

14. Vladimir Sinkov, MD. Nevada Orthopedic & Spine Center (Las Vegas): Minimally invasive techniques, navigation and robotic-assisted spine surgery will continue to evolve and improve over the next several years with expanding indications, shorter learning curve and improved patient safety and operative efficiency. As the need for spine surgery remains high and will likely increase with aging population, minimally invasive procedures will provide safer care with less complications and quicker recovery. Navigation and robotic technology will make it easier for more spine surgeons to adapt to minimally invasive techniques.

15. Michael Goldsmith, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Robotics and biologics will have the biggest impact on the field of spine surgery five years from now. We have advanced image guidance technology that is extremely useful in both simple and complex spinal procedures and provides a high level of accuracy and safety. In addition, our field has exciting robotic technology from companies such as Globus and Mazor, but this is still in its infancy. The technology is rapidly advancing to extend its indications across the field of spine surgery and improve its speed and accuracy. In addition, biologics will [have] a major impact on how the field of spine surgery looks in five years, both from an improved fusion perspective and a motion preservation perspective through regeneration and maintenance of normal anatomy.

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