Hospitals across the U.S. have been incorporating spinal robots that were designed to increase surgical precision.
But are they part of the future of spine or just a new technology fad? Four spine surgeons discuss where they stand with robotics today and going forward
William Richardson, MD. Duke Spine Center (Durham, N.C.): Robotics is in its infancy and currently serves as a drill guide to assist with screw placement. It is as accurate as 3D navigated screw placement but not clearly better. Like spinal navigation it helps protect the surgeon and their staff from radiation exposure but has some potential to increase the exposure to the patient. Companies and surgeons need to pay close attention to the protocols they use to obtain the 3D images to use with the robot or other forms of navigation.
I am excited to see where robotics takes us. The hope is that it will allow us to perform other parts of the surgical procedure through minimal incisions safely and effectively (decompression, rod bending and placement, and fusion both inter body and posterolateral). Also, with newer software to plan and then analyze what we need can apply AI — or machine learning — to make us better. Until some of these tools are available, we need to focus on surgical flow and process to decrease the learning curve, improve efficiency and demonstrate the value.
I do worry about the impact of these types of technologies on surgical education. It seems that most studies show some percentage of abortion of the procedure due to technical problems and they have to resort to using older approaches. We need to be sure that we train young surgeons in a variety of techniques to effectively care for outpatients when the computer crashes.
Robert Brady, MD. OrthoConnecticut (Danbury): It has always been my philosophy to practice evidence-based medicine. This has been particularly relevant regarding the procedures I offer my patients. Robotic navigation for placement of pedicle screws has become a major part of my practice over the last year and a half. The robot has allowed me to become more efficient and more accurate, with less intraoperative radiation, making it safer for the patient, staff and me. I am currently working on projects to expand the utility of robotic navigation to a greater portion of my procedures such as interbody insertion.
John Rhee, MD. Emory University School of Medicine (Atlanta): We haven't gotten a robot yet, but we use navigation for certain cases. I think robotics is something that may potentially have some benefit in the future for certain cases. It's certainly a field of interest for us.
With too much technology, sometimes the surgeons aren't learning what they need to learn about anatomy and how to actually do surgery. I don't think the robot is doing surgery on its own but there's something that is important about really understanding and knowing the anatomy, so I don't think there will ever be a substitute for that. There can be a variety of different widgets that allow us to accomplish what we'd like to, maybe in better and less invasive ways, but at the core it's going to be the surgeon that needs to understand not only the disease, but also the details of the anatomy.
Matthew Goodwin, MD, PhD. Barnes-Jewish Hospital / Washington University (St. Louis): As I've said, I am very old school, so I don't like adopting things right away, particularly if there is any perceivable risk to my patients. Currently I don't use robots much, although we have the two industry-leading robots available at Barnes-Jewish. I think robotics is certainly part of the future of spine surgery, but it is not clear the exact path that is going to take. I do not use the robot now only because it does not offer me any big advantage. That does not mean I may not use it moving forward, but I must be convinced it offers me a benefit. I am not in favor of using new things just for the sake of using new things.
When I go into the OR, I don't want there to be videos or excitement about doing something out of the ordinary or using a shiny new piece of equipment. Rather, I want things to stay boring while we do what we've done many times on other patients. We see the anatomy, place our hardware safely, check our placement and then we close up.
To be clear, I think robotics is part of the future of spine surgery, but it should always be to augment the surgeon. It is another tool to use in the OR. The hard part about using a robot is that it introduces a new set of things that must be checked. So, if you do not have much experience using one, you may not realize that when 'X' happens, then 'Y' is what you need to check. In the hands of an inexperienced surgeon I think you are going to get poor results. The surgeon has to be good enough to recognize the error, stop any damage from happening and then complete the case without the robot if needed.
There are lots of surgeons who trained like I did — with freehand placement of screws. We are used to knowing how to place screws freehand and more importantly, where you can err safely and how to avoid dangerous positions. Learning those things is a product of training over years, not something that can be learned in a weekend. The hard part of adopting a new device as prominent as a robot is that you have to recognize the errors and safely control and correct them. There will always be some learning curve to that.