Surgical robots entered the spine field in 2004, when the FDA cleared the Mazor SpineAssist to guide the placement of pedicle screws. Spine robots have come a long way since but are still very much in their infancy. Although most surgeons consider robots to play a key role in the future of spine surgery, there are challenges that need to be addressed.
Four barriers to the widespread adoption of spine robots:
1. Cost
The initial purchase of a spine robot is about $1 million — a significant expense for any hospital, orthopedic practice or ASC, especially those operating on fine margins as a result of the COVID-19 pandemic. In addition, upcharges to patients and insurance become realities as cost per unit case increases. Most ASCs do not have the budget to install a spine robot, which increases the cost per procedure without bringing in higher reimbursement from insurers. Many ASCs also operate on thin profit margins, and as spine robots offer minimal value to experienced surgeons, they are considered cost prohibitive in surgery centers. However, some ASC administrators argue they will "have to make the investment" to attract top talent as the next generation of spine surgeons trains with robots and wants access to the latest technology.
"It is essential to determine if the touted advantages of robotically assisted spine surgery translate to meaningful clinically significant benefits for patients. Healthcare systems are transitioning to value-based reimbursements, and any new surgical technology must be analyzed with respect to the quality and cost of healthcare delivered," said Alex Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedic Institute. "Robotic spine surgery has a promising future, and I anticipate that succeeding iterations of robotic platforms will overcome the current drawbacks."
2. Procedural limitations
Although robots are expected to expand to other areas of spine surgery — such as preparing the interbody space for fusion; docking of retractors; drilling of bone; and performing fully automated, robotic-guided laminectomies/decompressions — they are still primarily used for pedicle screw placement.
"Difficult cases, including spinal deformities with atretic pedicles and other anatomical anomalies, and revision surgeries where normal anatomical landmarks are significantly altered are well-touted examples where robotics can guide surgeons and improve accuracy," said Vijay Yanamadala, MD, medical director of spine quality and surgical optimization at Hartford (Conn.) HealthCare. "However, it is important to remember that current robotic technology is limited to screw placement. It does not guide other aspects of surgery, including decompression or alignment. Furthermore, it does not rely on real-time imaging and can therefore be subject to inaccuracy."
3. More hype than value?
The benefits of robotic spine surgery have been well-documented, including improved accuracy, less invasive and more reproducible surgeries, reduced radiation exposure and faster procedures. Some early adopters laud the advantages robots have added to their practice, but others are waiting to see what the next generation of robots can do.
"For now, I think robots are more hype than offering real clinical advantages," said Frank Phillips, MD, director of spine surgery at Rush University Medical Center in Chicago. "I think they're sort of image guidance dressed up with an aiming arm, but clearly they have the potential in the future to really change what we do. I think the companies developing robots recognize that. They realize that right now it won't add much, if any, efficiency, and the accuracy that they provide is pretty good with other things that we already use."
4. Overreliance on technology
As enabling technologies such as robotic and navigation systems become more widely adopted in spine surgery, there is a concern that the next generation of surgeons may rely too heavily on these innovations to guide them through procedures, which can run into software errors and technological glitches.
"It certainly is the case that resident and fellow education has the potential to be compromised by overreliance on these tools," said Wesley Bronson, MD, of Mount Sinai Health System in New York City. "If educators focus too much on these technologies without teaching the fundamentals of spine surgery, new spine surgeons entering practice may lack the ability to perform surgery without them. It is the responsibility of both residents and fellows as well those training them to always focus on the basics, even if certain technologies are being used for the case. The thought 'what would I do if the navigation wasn't working today?' should always be present."
Conclusion
For robots to be more widely adopted, they need to become less expensive and cumbersome as well as improve efficiencies and outcomes for all surgeons, including those with the most experience.
"When the cost of robotic surgery decreases to an amount that can be absorbed by private practice facilities and ASCs, and insurance/Medicare provide payment or incentives for its adoption, widespread adoption will follow," said Ali Mesiwala, MD, of DISC Sports & Spine Center in Newport Beach, Calif. "Lastly, the ability to perform operations that require multiple surgeons or approaches in a manner that allows a single surgeon to do so with a robot will accelerate the integration of robots into spinal surgery."