From robotics to spinal arthroplasty and augmented reality, 11 spine surgeons discuss what technologies have the potential to make the biggest impact on the field.
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. We invite all spine surgeon and specialist responses.
Next week's question: How is your practice looking at growth in the next three years?
Please send responses to Alan Condon at firstname.lastname@example.org by 5 p.m. CST Wednesday, May 5.
Note: The following responses were lightly edited for style and clarity.
Question: What is the most exciting technology in spine today?
James Mok, MD. Northshore Orthopaedic & Spine Institute (Skokie and Des Plaines, Ill.): New approaches to interbody cage materials. Despite all the advances in instrumentation and biologics, achieving a solid fusion remains an unsolved problem in spine surgery. 3D printing has enabled companies to modulate the implant's micro-architecture and mechanical properties. Traditionally, we think of implant materials as the scaffolding for new bone growth (osteoconductive), and that only biologics can induce the actual bone growth (osteoinductive). New interbody cage designs may give them osteoinductive properties. Taking the worry out of fusion would represent a significant development for spine surgery. However, it's important that these claims are backed up by high-quality, peer-reviewed and reproducible research, since so many new cages are being marketed faster than the research can keep up.
David Kaye, MD. Rothman Orthopaedic Institute (Philadelphia): Historically, spine surgery decision making has evolved from initially incorporating single-surgeon experience or expert opinion, to transitioning to an era of evidence-based medicine, focusing on large retrospective studies and randomized controlled trials. The transformation, from singular to collective intelligence, has been helpful in driving improved outcomes, but is still subject to significant bias and our limited ability to synthesize and utilize the resultant scores and metrics (e.g. pelvic incidence–lumbar lordosis mismatch, Oswestry Disability Index, Short Form-36, modified frailty index, American Society of Anesthesiologists grades, etc.).
Today, I believe the most exciting technology in spine surgery is in artificial intelligence and machine learning and their applications in predictive analytics. For example, in spinal deformity, algorithms have been developed, capturing over 100 variables, which can quickly and accurately — in real time — inform the surgeon of the risk and benefit of a particular operation for a specific patient. Similar algorithms have been created to suggest 'ideal' alignment parameters for a specific patient based on their unique profile, and tools such as patient specific rods have been developed to help the surgeon achieve these end goals. As outcomes from these surgeries are collected and added to the datasets, machine learning allows the algorithm to become even more accurate. In a drive to improve patient outcomes, AI allows for assimilation of big data and interpretation in a meaningful and trainable way. These tools will become an increasingly important part of the preoperative, intraoperative and postoperative management of our patients, and may allow safer, more effective and more cost-efficient surgery moving forward.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: I will buck the trend and say it is not robotics. The most exciting technology is the application of AR in spine. It is my opinion that navigation will morph into real-time vision. There will be fewer and fewer fluoroscopy shots, and hence less surgeon, staff and patient exposure. You will see surgeons using the AR even in nonfusion cases to help us see where we are operating, real-time. Coupled with the surgeon's experience, AR will enhance our surgical outcomes and our patient will benefit tremendously.
Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): Robots and navigation technologies are exciting, but their capital costs represent a barrier to widespread adoption. I believe AR/virtual reality tools will become better and be able to provide some of the usefulness seen with robots and navigation. In addition, AR/VR tools will allow for remote surgery to be done, whereby a surgeon can have a surgeon in another country or state help proctor them through a procedure.
Also, I believe that regional anesthesia techniques in spine surgery will allow for faster recovery. A lot of the success of awake spine surgery has come from the adoption of these regional anesthetic techniques. For hip and knee replacements, regional anesthesia has been a game changer. I am very excited about how these techniques will impact spine surgery.
William Taylor, MD. University of California San Diego: The most exciting new technology in spine today is the prone lateral. We have championed PTP, or prone transpsoas, which is a trademark of Alphatec. The prone transpsoas allows improved lordosis, better outcomes and easy access to a large interbody implant to the anterior spine with its correction and fusion rates advantages. Most importantly, it allows you easy access without change of position to the posterior aspect of the spine, so that you can either do decompressions or other procedures including pedicle screw instrumentation. This can be done simultaneously while working in the lateral access port. We much prefer large anterior implants to gain correction and improve lordosis than posteriorly placed transforaminal lumbar interbody fusion or other alternatives. Finally, the use of navigation robotics and the combination of both approaches is much easier in the prone position.
Neel Shah, MD. DISC Sports & Spine Center (Newport Beach, Calif.): There are many innovations in the pipeline when it comes to orthopedic spine surgery. Currently, the most exciting technology would be motion-preserving devices in the spine. Cervical disc arthroplasty has really taken off, and long-term data continues to impress. Lumbar artificial disc replacement also seems to be coming along.
Amer Khalil, MD. DISC Sports & Spine Center (Newport Beach, Calif.): The evolution of motion-preservation technology has paved its way in the spine field in the form of disc arthroplasty. Artificial disc technology and its ability to mimic the natural disc have yielded more effective and safer results than spinal fusions. It has been exciting to be able to apply motion-preservation technology to my surgical practice for both cervical and lumbar spine arthroplasty. We will continue to see greater advancements in design and functionality of artificial discs.
Ali Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Technology is ubiquitous in our lives. It is the natural evolution of humanity's abilities, and generally provides for improved safety, cost reduction and more consistent outcomes in medicine. It is a given that robotics, AR and AI-based systems will find their way into spine surgery, and become the norm.
What is most exciting to me, however, is our enhanced understanding of spinal biomechanics and materials, and ability to restore, repair and augment function through regenerative means, surgical implants and nondestructive procedures. We are transitioning from removal and reshaping components of the spine through decompressions and fusions, to restoring movement and function by rebuilding tissue and providing biologically active replacements for degenerated or diseased components of the spine.
Todd Lanman, MD. Lanman Spinal Neurosurgery (Beverly Hills, Calif.): The most exciting technology for the spine is currently related to motion-preservation surgery and restorative motion surgery. In both cases, aspects include the use of artificial disc replacement. Some other motion-preserving spinal technologies and implants have been developed, but advancements for artificial disc implants are really progressing.
The newest generation disc implants have pliable cores that allow vertical compression and some lateral shear (twisting) movement, as we see with natural discs. The current generation implants have solid cores because the emphasis is the stability of the implant. The new generation implants give patients even greater stability while also providing natural multidirectional flex as it preserves range of motion.
What is exciting is the marriage of the latest artificial disc technology with enhancements for surgical techniques. We're now seeing AR imaging with 3D goggles. Such enhancements give surgeons more capacity for accuracy and precision during the surgical procedure. Currently, we use intraoperative X-ray to ensure precise placement of the implant for optimal functional outcome. Intraoperative AR will significantly reduce the amount of radiation exposure to the patient during surgery while enhancing surgical accuracy and precision.
Burak Ozgur, MD. Hoag Neurosciences Institute (Newport Beach, Calif.): Improved navigations, robotics, and AR are quickly picking up pace in evolving into effective and efficient use in the operating room. I find these technologies exciting as they will enhance our abilities to be more efficient and precise when used properly.
Andrew Hecht, MD. Mount Sinai Health System (New York City): The most exciting technology in spine are motion preservation procedures such as laminoplasty and cervical total disc replacement. Other technologies such as minimally invasive TLIF and lateral inter body fusion are also important technologies.