Mazor Robotics Senior Vice President Christopher Prentice discusses innovative technology in the spine field today and where the market is headed in the future.
Q: How is innovative technology changing the field of spine surgery?
Christopher Prentice: A lot of spine surgeries in the past were performed through larger incisions so surgeons could see the surgical site directly. Now, there are instruments that allow surgeons to make smaller incisions and still achieve visualization with cameras or other imaging devices. In percutaneous posterior spine surgery, in order to overcome the loss of visualization experienced with minimally invasive techniques, surgeons use intraoperative fluoroscopy and other imaging techniques, but the overall radiation exposure can be harmful.
I see spine surgery technology evolving to the point where surgeons can perform minimally invasive procedures without compromising their own safety and drastically reduces their patient’s radiation exposure. An intraoperative MRI that is easy to use will improve minimally invasive procedures and make them safer for the surgeons who perform them. Guidance systems that eliminate the need for fluoroscopy and computed tomography would be the ultimate goal.
Q: What do you think will be the biggest breakthrough in spine surgery and imaging technology?
CP: Active technology that allows for imaging in real time without excessive or unnecessary radiation exposure will be a huge breakthrough. Right now we are in a digitized world. If we are able to integrate all the current technologies — tools, implants and imaging — into an integrated guidance system, surgeons will know exactly what is happening in the anatomy in real-time while executing a detailed surgical plan that was proactively prepared. That hasn't happened yet, but I am confident it will.
There is more that can be done for surgeons to “see” exactly what is going on in the body, where the implant actually is and to make sure the procedure will result in what they want it to do. Technology allows you to plan and check procedures today, but surgeons don't know exactly what is going on in the moment without the use of fluoroscopy or intra-operative CT.
Right now, verification is happening post-action, when it needs to be happening during the action. That will be the convergence of what will happen in spine surgery over the next five to 10 years – the ability to execute your surgical plan while instantaneously knowing you are still “on plan.”
Q: There is a bigger push toward evidence-based medicine in healthcare. How will developments in the spine field meet those needs?
CP: In the future, we'll continue to see technology development as a result of questioning what procedures can do from an economic impact — not just technology for technology's sake — the technology in search of a solution approach. Any procedure that is based on a certain technology will have clinical studies on them. We need to know for the sake of the patient and surgeon how the procedure impacts spine care. We need to get to the point where we standardize and really have evidence-based outcomes.
The only way you can truly look at a new procedure is to standardize the studies, but there are so many factors going in. It becomes difficult to control those factors and truly understand the data.
Surgeons will also start paying more attention to individual data. The efficiency and effectiveness metrics will be based on each surgeon's procedural data, not a paper from somewhere else. Academia is important, but in the future spine care will come down to how well the academic studies are translating into what the majority of individual surgeons are doing. You can go into a hospital and watch five PLIFs done by five different surgeons, you will most likely see five different procedures. Which one is the best approach? Are they all equivalent? If equivalent in clinical outcome, did they cost the same to perform? You don’t know unless you have the data on each surgeon. That's how we'll improve quality outcomes while also being efficient economically.
Technology can help both in the assessment of surgical approaches and in standardizing to the most effective and efficient approaches.
Q: Where is the biggest opportunity for spine technology to improve outcomes?
CP: If true quality is the objective and the six sigma mentality is applied, standardization toward the most efficient approach will ultimately improve quality.That can be done with the help of technology. Better visualization with real-time data will allow surgeons to subjectively assess whether the implant is in the right spot. Such technology can also assist in comparative studies on different surgical approaches, how much decompression is needed, different implant constructs and placement strategies.
Q: There are several challenges for approving medical device technology and bringing it to the U.S. market. Do you think companies will continue to develop in the U.S. or take their technologies overseas?
CP: In my experience, I haven't seen overseas be any quicker or slower than the United States. Across the globe there is a strong sentiment of evidence-based medicine and not having incremental technology for technology's sake. People want to know what exactly the technology does and how it impacts the patient economically to improve their situation. There are growing spine markets in China, India, and Brazil that will be areas where technology may be introduced first in order to assess its effectiveness and efficiency.
Companies will definitely have to show they are doing something bold to improve the patient's situation and it has to be economically feasible.
Q: Are there any challenges for bringing robotic technology to the market?
CP: We are trying to advance the quality of spine cases and give the surgeon the ability to plan the case and execute it in a more safe and efficient manner. It's not in every spine center, but more surgeons are seeing what the technology can do and how different it is.
The challenge is been in getting the through the misconceptions of what a robotic-assisted approach is in spine surgery. It is not da Vinci – it is a much different approach. So part of the misconception comes from what ‘robotic surgery’ has been for the past 14 years, which is the da Vinci approach, the other part comes from a stance that “I don’t need a robot to put in pedicle screws.”
The system does not put in pedicle screws – the surgeon still does that. The system provides the surgeon with the ability to execute a pre-plan in complex cases and percutaneous cases.
As more learn exactly what the technology delivers, we are achieving greater buy-in from surgeons and their hospital executives as well. The technology fits into healthcare reform because it can allow for standardization of care in order to achieve quality outcomes.
New robotic technology in the future must deliver on the triple aim: cost, quality and access. At our company, we focus on how everything we do can address the triple aim and hit each of the targets. With this approach, a company has a better chance of the surgeons and hospitals experiencing an impactful value proposition and employing the technology.
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