These technologies will define the future of spine

Spine

When people think about spine surgery in the future they'll likely also think of minimally invasive techniques, navigation, artificial intelligence and more. 

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. Becker's invites all spine surgeon and specialist responses.

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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Wednesday, Jan. 31.

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

Question: What technology will define spine surgery in five to 10 years?

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Artificial intelligence and blockchain will likely play a large role. AI will be used to generate treatment algorithms and tell surgeons what to do and when to do it. Many of the artistic or humanistic aspects of medicine will be pushed to the fringes and labeled "junk" in favor of guideline-dominated everything. It will be a sad state of affairs, and when algorithms created and monetized by physicians and scientists have sold it to payers and other villains who shouldn't have them, [it] will make a select few people very rich. Our patients will pay for cookbook and cookie cutter medicine with poorer outcomes, until we realize that every person and every case is different. We cannot select treatments like pulling T-shirts off the rack at Target. 

Todd Lanman, MD. ADR Spinal Restoration Center (Beverly Hills, Calif.): The next decade of spine surgery will be defined by spinal motion preservation technologies. Artificial discs have already changed the way we manage disk disease, and I think we will continue to see innovative designs. For example, the next five to 10 years will see the development of artificial facet joint devices. I can envision artificial discs and spinal facet joint devices used in combination, relieving pain and preserving nearly natural motion of the spine. These devices will not only enhance the way we treat degenerative spinal conditions but will allow spine surgeons to partially correct abnormal alignments of the spine like scoliosis and kyphosis.

Jason Liauw, MD. Hoag Orthopedic Institute (Laguna Hills, Calif.): Even though I am more of a traditional freehand open spine surgeon, I think navigation and robotics will continue to evolve and create a dependency of surgeons on augmented technologies. Certainly this is a different tune than I was singing 10 years ago when I started practice. Amongst the surgeons whom I work with, I already am seeing a comfort level with navigation and robotics develop that didn't exist a decade ago. This is likely a reflection of the training in residency programs that have embraced navigation and robotics. Even with my neurosurgical partners who are more cranial focused and do occasional spine fusion surgery while on-call at our hospitals, I am seeing an increased comfort level with spine fusion that has been provided with enabling technology. While I hate to admit it, I do believe these technologies will drive a more reproducible and consistent surgical outcome and will reduce misplaced hardware for surgeons who aren't as familiar with free-hand technique.  

Don Park, MD. UCI Health (Orange, Calif.): The technology that will define spine surgery in five to 10 years will be robotics and AI, and I believe they will go hand in hand. I have a rather optimistic perspective of robotics and AI in spine surgery, rather than the apocalyptic vision of Cyberdyne and Skynet. Robotics will evolve from a single-end effector, single-purpose machine as it is now to a multiend effector, multipurpose machine that allows for full spinal decompression, osteotomies and placement of implants; robots will perform the surgery from incision to closure. Robotics will rely on spinal endoscopy as the means to visualize the spinal anatomy with multiple arms controlling surgical instruments to perform the surgery. While uniportal and biportal spinal endoscopy are currently the main endoscopic techniques, multiportal spinal endoscopy will evolve to allow robots to be more efficient and effective. AI will inform the surgeon on the next best move with the best instrument required to provide the best result and the lowest risk, all calculated by machine-learning algorithms from millions of surgical combinations. The correct end-effectors can be set and placed in the surgical field by the robot quickly and efficiently based on these calculations to reduce surgical time. AI will help correctly identify spinal pathology such as spinal tumors on the endoscopic video using computer vision so that full resection can be performed. The surgeon will be in complete control of both the robot and AI rather than be autonomous, and the technologies will enhance the surgeon to complete the surgery in the best possible way. Clinical outcomes can be optimized while minimizing the risk of complications, thereby improving patient care through the proper implementation of these technologies. 

Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): Spine surgery of the future will be defined by widespread use of minimally invasive techniques, robotic and augmented reality-assisted procedures, motion preservation procedures, and endoscopic approaches.  

Issada Thongtrangan, MD. MicroSpine (Scottsdale, Ariz.): In my opinion, it will be ultra minimally invasive surgery such as endoscopic approaches, AI, robots and navigation. I also feel that there will be more research on cell-based/biologics approaches to address degenerative disc and arthritis in the spine.

Bo Zhang, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): AI technology is rapidly growing and has the potential to impact spine surgery significantly. The challenge in spine surgery, besides the technical aspect, is finding the correct indications and performing the best treatment for each patient. Surgeons choose to treat a patient with different types of operation or nonoperative intervention. AI has the possibility to process each aspect of a patient's condition and assist with surgeons' decision-making.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Arguably, the emphasis on robotics, intraoperative navigation and augmented reality are the present focus in both spinal and most other disciplines. There may also be a place for AI-driven, personalized implant creation and placement hovering on the horizon. Neuroexcitatory times for the young at heart, mind and body.  

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