This article is a portion of a book titled "Challenges, Risks and Opportunities in Today's Spine World " edited by Stephen Hochschuler, MD, Frank Phillips, MD, and Richard Fessler, MD. You can find links to the previous chapters at the end of this article.
On the heels of successful implementation of robotics in Urology, spine surgery has begun to develop and apply such technology to its patients. Unlike the use of robotics for intrapelvic surgery, in which case there was a single iterative transition from traditional open approaches, the application of robotics in spine was heavily preceded by various navigation platforms. Navigation has been touted, and in some limited cases, been shown to result in greater accuracy, higher safety, and reduction in radiation exposure for the surgical team. Despite these heralded advantages, technical challenges, workflow inefficiencies, and the additional cost burdens associated with navigation resulted in limited market penetration and utilization.
Acquiring of the intraoperative imaging acquisition devices and associated navigation towers was quite often realized through the promise of spinal implant volume utilization, and yet, how many of us have seen the O-arm developing a layer of dust in some dark corner of the OR storage areas. In reality, the true value proposition of navigation as a stand-alone technology was not irrefutably demonstrated, and this created tremendous headwind for hospitals and their physicians to pay for these platforms outright.
Nonetheless, ongoing development of various computerized navigation technologies has occurred through the stewardship of surgeon champions and industry partners over the past two decades. As these platforms have matured, and robotic technology has become more attainable for the world of spine, it seems an intuitive evolution to combine them. Hope remains high that combining them might further improve accuracy in the context of implant placement, as well as addressing workflow inefficiencies inherent to navigation alone.
The first of the widely available robotics systems was developed by Mazor, and the initial focus of the platform was to aid in the placement of transpedicular screws in the thoracolumbar spine. This was initially utilized in the context of traditional open posterior surgeries, but transition toward minimally invasive application of these fixation devices was inevitable. As with most new techniques, greater surgical time was required initially, but the learning curve generally allowed significant improvement toward time neutrality when comparing to standard screw placement. Both cadaver-based and clinical studies have reasonably demonstrated improved radiographic accuracy for implant placement, as well. However, the considerable additional cost requirement for performing the surgeries has challenged many surgeons and institutions, as they see shrinking profit margins for spine fusions.
Importantly, minimally invasive techniques for spinal reconstruction has led to a dramatic increase in radiation exposure to surgeons and operating room personnel in recent years. This occupational hazard led to substantial interest in navigation platforms, and now provides greater incentive for considering adoption of robotics. Many companies are now developing or have developed their own robotics platforms, in hopes of resolving the limitations of prior generations of these systems, as well as remaining competitive with their cohorts. As with all healthy competitive marketplaces, this has led to a variety of shapes, sizes, and expanding capabilities for the newer robotics platforms. Additionally, there are efforts being made to reduce the cost burden of acquiring and applying these tools.
Although somewhat mundane for robotics to assist in placing transpedicular screws alone, consider the various other tasks that may be accelerated or made safer with ongoing improvements in the technology. For instance, a robotic system with navigation could allow for augmentation of our workflow by moving to adjacent locations and in preparing our next site of screw application, while we finish the other side, and thus make us more efficient. It may also allow us to reduce the steps required to access and assess our transpedicular position that is otherwise required in an open condition. One can easily imagine its potential in assisting in decompressions with haptic feedback mechanisms, and navigation-based ‘stops’ that might be of considerable benefit in adding safety to procedures involving decompression or osteotomy, particularly in training environments.
We are in an exciting era of spine surgery, in which there have been vast improvements in both our implants and their application toward the benefit of our patients. As we strive for still further refinements in the accuracy and safety of surgery for our patients, as well as looking to avoid the dramatic occupational exposure we as surgeons likely suffer at the hands of ionizing radiation, robotics married with computerized navigation will surely be a keystone for our future practice. It is imperative that we guide the development of these technologies, such that they can be properly validated to do that which we need in an effective and reasonably efficient manner. Additionally, we must evaluate and iterate its application toward good stewardship of our health economy, keeping in mind that the cost of technology should follow a downward trend with time. Another interesting serendipitous benefit of these augmentative tools has been a subjective diminishment in surgeon fatigue realized by early adopters. Should this outcome be legitimized, application of these technologies could very well result in higher productivity, and perhaps even greater career longevity. In the end, I believe robotics will revolutionize much of what we do in spine surgery, and there will be a time in the not-too-distant future, that they will be incredibly effective extensions of the surgeon, making us better, faster, and more productive.
Previous chapters:
Dr. Richard Guyer: Today's spine fellowship
Challenges, risks and opportunities in today's spine world
Spine care - Balancing cost with innovation
What are big data and predictive analytics
Predictive Analytics and Machine Learning
The HSS Spine Care Model, Part 1
The HSS Spine Care Model, Part 2
The History of Texas Back Institute
Private practice vs. hospital employee: Where we are today and why
Episodes of care and bundled payments
Episodes of care and bundled payments, a sustainable approach
Dr. Scott Blumenthal on specialty hospitals
Spine industry trends in new technologies and market challenges
SeaSpine: The story behind my multimillion-dollar medical device company