As spine navigation and robotics grow, some surgeons are concerned about newer generations becoming over-reliant on the technology. At the same time, some experienced surgeons are thinking about the key robotics skills they should add to their practices.
Ten spine surgeons discuss the essential freehand and robotic skills to master.
Note: Responses were lightly edited for clarity.
Question: What is one robotics skill and one traditional/freehand skill all spine surgeons in training should know?
Vincent Arlet, MD. University of Pennsylvania (Philadelphia): Each surgeon should keep the skill of freehand pedicle screw insertion, whatever the difficulty of the pedicle screw insertion. Surgeons should be familiar with basic robotic and navigation skills that may be helpful for less invasive spine surgery and/or very complex situations. All surgeons should be very familiar and comfortable with working around epidural scars.
Chester Donnally, MD. Texas Spine Consultants (Dallas): When doing a perc case with the robot, I like to "plan a screw" at the facet joint being fused and then drop my burr at this area to burr down the facet as another fusion generation site. Sometimes it's easier to use the navigated burr outside the robotic arm. It's an easy "skill," but the main point is to not forget the underlying fusion goal.
Joseph Ferguson, MD. MedStar Health (Washington, D.C.): I think the one concern about robotics is the difficulty with "checking" the robot in real time. We have to be very diligent about making sure the robot places the arm in the correct position, calibration is correct, and we are placing hardware exactly where we intend to. We know that robotic screws tend to be more accurate than freehand, but left unchecked, disasters can occur. This will be more important as we move into haptic feedback with robotics if and when the technology advances to being able to help us with decompression and osteotomies.
In terms of traditional skill, all surgeons need to be able to place hardware throughout the cervical, thoracic and lumbar spine safely in a freehand manner with use of fluoroscopy. As good and reliable as technology can be, it still may break down and we need to be able to perform the surgery safely and effectively in these scenarios.
Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): I believe that surgeons performing complex deformity and tumor cases should be familiar with robotic-assisted spinal instrumentation. Certainly, there can be advantages in accuracy for implant placement and deformity correction. With respect to traditional and freehand skills, anatomy, anatomy and more anatomy. It is startling how many younger surgeons would be completely lost in an L4 to L5 TLIF if the C-arm went down. One must be able to identify the bony surface anatomy of the spine to accurately place instruments. Many don't know what a "gearshift" or "Steffe probe" is, much less how to use it. Technology of image guidance and robotics are major advances, but they are all based upon the base anatomy. We cannot lose sight of that knowledge.
Ali Mesiwala, MD. DISC Sports & Spine Center (Newport Beach, Calif.): The use of robotics to place multiple percutaneous screws will become the norm, and essential for spine surgeons in community practices. Patients will demand this. Similarly, freehand placement of pedicle screws, using only fluoroscopy, should be a basic skill every spine surgeon has.
Joseph O'Brien, MD. Virginia Hospital Center (Arlington): Robotics make screw placement easier and more reproducible. So I think that fellowship-trained spine surgeons must know how to use a robot appropriately to place spinal instrumentation. In the event that robotics or navigation are not available, surgeons must know how to place freehand screws at all levels of the spine with or without fluoroscopy.
Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): The most important skill with robotic-assisted spine surgery is to have thorough understanding of how intraoperative computer navigation works, how to maintain navigation accuracy, and how to properly recognize and address loss of navigation accuracy. The most important freehand skill would be to be able to perform spine surgery (decompression, hardware placement, dural tear closure) safely and accurately if the advanced technology (such as navigation, imaging, neuromonitoring, robot, etc.) fails intraoperatively.
Issada Thongtrangan, MD. MicroSpine (Scottsdale, Ariz.): As a surgeon, we should be well versed in open, minimally invasive and newer technologies. We should be able to convert from robotic-guided or "fancy" technologies to open surgery if we have to. I am a bit concerned that the newer version spinal surgeons won't feel comfortable doing surgeries if they don't have those "fancy" tools.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Knowledge of navigation techniques is important today as it allows for increased safety, particularly in the placement of difficult screws in revision surgeries, major deformity surgeries and surgeries where landmarks are not typical. Navigation has allowed for reduced radiation exposure for surgeons and patients alike and can make surgeries more efficient. At the same time, all surgeons should have a mastery of freehand instrumentation. If you can't put in a pedicle screw safely based on anatomic landmarks, it is truly a problem in our age of robotics and navigation. Being fully reliant on technology fails us when technology fails us. It is essential for us as surgeons to be able to determine whether the navigation is accurate, whether it makes sense, before blindly relying on it. Training programs must stress this. Increasingly, we may have trainees exposed to freehand techniques less and less, but it is essential to maintain these skills.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The expanding surgical realm of robotics is heavily reliant on the computational derivatives of linear mathematics, informational theory as it relates to a specific field of surgery and levels of training in visual reality coupled with competency.
Traditional surgical technique, competency and experience is years of training-based familiarity and the acquired mastery of anatomic knowledge as the basis of pursuance and continued education in the field. Like all professions, surgery and its associated patient care is a constant learned forbearance where variable recognition and skill maintenance are paramount to competency.