Here are 18 updates on the robotic spine field and thoughts from surgeons about the future.
1. The global spinal robotics market is expected to reach $320 million by 2026, up from $75 million in 2017, according to a Transparency Market Research report. From 2017 to 2026, the market is expected to expand at a 17.5 percent compound annual growth rate.
2. North America is expected to lead the spinal robotics market due to a high demand for spine surgery, however there are a limited number of professionals trained in the technology. The Transparency Market Research report noted Medtronic, with Mazor Robotics, and Zimmer Biomet hold around 80 percent market share.
3. Mazor Surgical Technologies was established in 2001 and became Mazor Robotics in 2010. The company received a CE mark for its first product, SpineAssist, in 2004 and made it the first commercially available mechanical guidance system for spine surgery when it launched. The company then released the Renaissance Guidance System in 2011 and collaborated with Medtronic to develop Mazor X, launched in July 2016. The third-generation system, the Mazor X Stealth Edition, was used on more than 1,000 procedures in more than 50 hospitals across the U.S. in its first year.
4. Medtronic placed a purchase order for 15 Mazor Robotics' Mazor X systems in August 2016, as part of its $20 million investment in the company. The Mazor X technology expands on the company's robotic guidance technology to include analytical tools, multiple-source data, precision guidance, optical tracking, intra-op verification and connectivity technologies. In November 2018, Medtronic fully merged with Mazor in a $1.64 billion transaction.
5. ASCs are now installing spinal robotic systems, including Mazor's Renaissance system. GNS Surgery Center in Athens, Ga., a United Surgical Partners International affiliate, installed the Renaissance system in June 2018; Johnstown, Colo.-based Arete Surgical Center and Pensacola, Fla.-based Baptist Medical Park Surgery Center also installed the systems last year.
6. Warsaw, Ind.-based Zimmer Biomet acquired Montpellier, France-based Medtech in October 2016. Medtech's original product, ROSA Brain, offers surgeons robotic guidance and preplanning with brain surgery. Based on a preoperative plan, the robot drives the arm along planned trajectories, allowing the surgeon to implement the planned intervention. The company received FDA clearance for Rosa One Spine earlier this month.
7. Audubon, Pa.-based Globus Medical presented its Excelsius GPS investigational robotics system at the North American Spine Society meeting, held in Boston from Oct. 26 to Oct. 29, 2016. The system features non-patient bedside docking and an optical tracking system. The company received the CE mark for the system in January 2017.
8. NuVaisve revealed a new spinal robotics system called X360 Pulse in the fall of 2019. The fully integrated robotic offering is in development and expected to have application for all spinal surgeries, not just complex or low-acuity cases.
9. Robotics are expensive to acquire. Medtronic's Mazor X robot costs more than $1 million and Globus Medical's ExcelsiusGPScosts $1.5 million, according to a study published in the Journal of Spine Surgery. The high cost ultimately increases the cost of care for patients. Device companies are working on robots that are cheaper so quality care, global fees and episodes of care can be performed and charged reasonably.
10. A study presented at the Society of Minimally Invasive Spine Surgery Annual Forum 2016 compared the surgical outcomes for 403 robotic-guided spine surgeries with 224 fluoroscopic-guided procedures and 78 freehand procedures.
The complication rates for the techniques were:
• Robotic guidance: 4 percent
• Fluoroscopic guidance: 5.4 percent
• Freehand: 12.8 percent
"This retrospective analysis demonstrated that use of robotic guidance MIS can significantly reduce surgical complications and revision surgeries when compared to fluoro-guided MIS in the hands of experienced MIS surgeons," concluded the study authors.
11. Johnson & Johnson has also been making moves to acquire robotics technology in the orthopedics space. In 2019, the company purchased Auris Health to launch its digital surgery strategy and launched the Velys Digital Surgery in orthopedics. The company also purchased stake in Verb Surgical in December after a strategic collaboration with Verily, an Alphabet company.
Seven surgeon perspectives on spine surgery:
12. Christopher Blanchard, DO. Resurgens Orthopaedics (Atlanta): Robotics in spine surgery are still in their infancy compared to robotics in general surgery. Currently, the largest utility of a robot is with screw placement. This is rapidly changing with software and hardware updates. In the next five years, I think robotics will continue to evolve, allowing surgeons to perform surgery in a less invasive way to allow for quicker recovery. I believe as robotics develops, it may completely change how we think about and perform spinal procedures.
13. Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Robotic-assisted spine surgery is an amazing emerging technology. It allows for more precise instrument and implant placement, with soft tissue disruption and more efficiency. This technology has evolved tremendously over the past several years. Even greater enhancements and expansions of this technology will be coming in the near future. In five years, I anticipate that all steps of most common spine surgeries could be done with robotic assistance — from incision and exposure, to nerve decompression, hardware placement and deformity reduction. It will be done in the most minimally invasive way possible. The result will be more efficient, safe and accurate procedures that will help minimize postoperative pain, shorten postoperative recovery and result in superior outcomes for our patients.
14. Brian Gantwerker, MD. Craniospinal Center of Los Angeles: Spinal robotics is already a competitive field. In my mind, it is still a pedicle screw placement template. What I am looking for is a device that can help the actual 'surgery part' of the case. Something that can act like a Mako-type device and help with decompression or corpectomy, as well as assist in graft or interbody placement and finally, instrumentation. Right now, it is still very nascent. In its inevitable future iterations, it will be used more in general surgery, oncological surgery, urology and obstetrics, where it is truly an evolutionary next step. It has a long way to go until that watershed moment.
15. Fred Naraghi, MD. Klamath Orthopedic Clinic (Klamath Falls, Ore.): Robotics in spine surgery are used to aid in the accuracy of screw placement in complex cases. Robotics will continue to improve, although currently the cost is high for most centers. U.S. healthcare is rapidly transitioning from a fee-for-service payment model to a value-based reimbursement model. Value is defined as outcomes divided by cost. To remain successful, more evidence is needed to show improved outcomes as well as lowering the costs of this technology.
16. James Chappuis, MD. Spine Center Atlanta: I think the use of robotics is a very costly solution for procedures that today have relatively good outcomes without its use. In the outpatient setting, it's almost cost-prohibitive. As time goes on, I think there will be a role for that, particularly in more complicated instrumentation procedures, and that its use will continue to develop and flourish.
17. Issada Thongtrangan, MD. Microspine (Phoenix): Robotic-assisted spine surgery will continue to evolve, and I anticipate it will be part of the ultimate planning in spine surgery. The data on pedicle screw placement is already accepted in the spine community. It already expanded to the complex deformity reconstruction as it helps tremendously with preoperative planning. I expect it will also be utilized more in minimally invasive spinal fusion.
18. Harel Deutsch, MD. Rush University (Chicago): Robotics will continue to develop. Currently, I believe it will provide spine companies and representatives with another way to add value to their portfolio of products.