Robots are still considered to be in their infancy in spine surgery, but most surgeons agree they will have a critical role to play in the future of the specialty. However, certain challenges remain.
Twelve spine surgeons from health systems and private practices across the country detail the improvements they want to see in the next generation of spine surgical robots.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.
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Editor's note: Responses were lightly edited for clarity and length.
Question: What’s one improvement you would like to see for the next generation of spine robots?
Todd Lanman, MD. Lanman Spinal Neurosurgery and the Advanced Disc Replacement Spinal Restoration Center (Beverly Hills, Calif.): The spine surgical robotic systems are primarily designed for pedicle screw insertion and guiding the screws robotically into the bone for fixation, both of which are done posteriorly. However, these robots are not currently designed to tackle artificial disc replacement, which is done anteriorly. Without this improvement, spine surgical robotic systems will not be nearly as useful in ADR as they could be. I have spoken to several companies about developing image-guided surgical techniques and robotics that would help spine surgeons align the artificial disc in the correct locations as they approach from the front (anterior) of the spine.
William Zelenty, MD. Hospital for Special Surgery (New York City): Three areas:
1. Cervical spine applications: Current robotic technology is not widely used for cervical spine procedures such as lateral mass screw placement or, more importantly, atlantoaxial screw placement. The first reported use for percutaneous screws in the literature was in September 2021. This may be due to physical or ergonomic restrictions of current systems; however workarounds may be developed which can find their way into the next generation systems. Access to highly accurate systems for posterior cervical surgery is an excellent application given the scale of the anatomy and the highly sensitive surrounding structures.
2. Interbody device insertion: There has been a proliferation in interbody access techniques and applications including anterior, direct lateral, anterior to psoas, prone-lateral and single position anterior-posterior. Accurate, safe placement of interbody devices through these channels is paramount and has traditionally relied on the fundamentals of patient positioning, orthogonal fluoroscopy and surgeon ability. Incremental advances in retractor technology and our ability to use navigation in these scenarios have increased the safety margin and provided surgeons with the ability to place cages exactly where they want them to achieve their surgical goals. Precision placement is especially key for disc arthroplasty devices, which are gaining popularity in the cervical and lumbar spine. The next logical step is to introduce robotics in these spaces, for which they are well suited. The ability to perfectly place an implant atraumatically through a narrower corridor represents a significant advancement in robotic, minimally invasive surgery.
3. Decompression assistance: My first experience with robotic surgery in orthopedics was during medical school performing a UKA. The robotic system assisted the surgeon using a high-speed burr to resect bone for the components. Currently, robotic systems are limited to smart drill guides for pedicle screws. While this has certainly increased the safety and accuracy of pedicle screws, I see an exciting application for decompression assistance when paired with high fidelity computer navigation. Using a robot to meticulously eggshell a laminotomy or laminectomy bed would be an advancement for surgeon ergonomics and safety. This application has been explored but has limited research. For example, Ponnusamy et al. utilized a remote, surgeon controlled robotic system to test open posterior spinal approaches with bony resection in porcine models in 2009. By extension, this is an exciting application for minimally invasive surgery which demands precision resection to achieve surgical goals while minimizing tissue damage.
Jason Liauw, MD. Orthopedic Institute (Newport Beach, Calif.): Spine surgical robot designs are still in the early generations of design. As such, their use is still somewhat controversial, albeit now established with early adopters. The improvements that I believe will make spine surgical robots more useful will be centered around the fidelity of registration and navigation throughout the surgical procedure. There are instances in surgery when the robot can lose accuracy. The mistakes I have seen made in robotic spine surgery have stemmed from loss of accuracy during the procedure without the surgeon's awareness. Once the technological advancements in robotics brings these critical errors to near zero, robotics holds a lot of promise in spine surgery. I can see a future where robotics allow for more minimally invasive approaches, for safer decompressions of the nerves, and for more precise implant selection and placement. Robotics in the future can make surgery more consistent and repeatable, which is aligned with what all patients want.
Vik Mehta, MD. Hoag Hospital (Newport Beach, Calif.): We need to take a giant leap forward in the application of robotics in spine surgery. The current state of spinal robotics is simply a semi-automated platform to place pedicle screws. Robotics in spine surgery truly has the potential to revolutionize spine surgery but we need to do more work. We need more rapid registration workflow, more predictive and automated features and better data to show that robotics makes spine surgery safer and more efficient. Beyond that, spinal robotics needs to play a more important role in maintenance of balance, correction of deformity and assistance with interbody techniques.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The watershed moment in robotics will come in the ability to do not just pedicle screws, but also decompression portions of the surgery. The cool thing in the orthopedic robot space is the advent of robots that help shape portions of the joint and predict the proper angles for each individual patient and implant. Once we have that firmly in place, it will really be the moment we have waited for. Patients will undoubtedly benefit and be better off. The moment will undoubtedly bring with it the potentially dangerous moment when non surgeons will figure they can do what the surgeons do. It will be important to make sure that only those with the proper training, discernment, knowledge and ethical backbone are allowed in that space. Those that do not, that might find a way into it, should really consider if it is what is best for patients.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The time element and cost per unit case are much higher. Improvements lie in cost oversight and experience requirements prior to usage. These types of surgery routinely take longer hours of operation, depending on the extent of the procedure. Thereupon resulting in longer anesthetic requirements, postoperative amnesia and recovery time. Touting the procedure as ubiquitous invites skill and experience challenges. This may be the future, but issues remain.
Philip Schneider, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): The primary function of robotic surgery is to be a drill guide for pedicle screws. It would be beneficial to surgeons if spine surgical robots were more versatile. Since spine surgeons don’t often need assistance drilling holes and placing screws, spine surgical robots are not particularly helpful. Spine surgeons would benefit more, if surgical robots assisted with advanced surgeries such as osteotomies or corpectomies of the spine predictably and safely.
Saad Chaudhary, MD. Mount Sinai (New York City): Navigation and robotic technologies are here to stay in spine surgery. These enabling technologies are used, not as autonomous devices, but as an extension of the surgeon to perform a safe, reproducible and efficient procedure, while minimizing radiation exposure to the surgeon and the OR personnel at large. The current robotic systems available for spine surgery only facilitate pedicle screw placement. However, pedicle instrumentation is merely just a single (albeit important) component of a complex spinal procedure. In the future, I hope for robotic systems and software to allow us to plan for and execute laminectomies and osteotomies to more precisely decompress the spine and remove bony elements for re-alignment and deformity correction surgeries.
Nick Jain, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Current generations of robots have primarily one role: trajectory alignment for placement of instrumentation. This is often only half the battle when it comes to spine surgery. The age-old adage remains for most surgeries: we need decompression and stabilization. While current generational robots are great at instrumentation placement and assisting surgeons achieve a stable construct, they leave much to be desired for decompression of neurologic structures. I believe future generations of robots will incorporate osteotomes (ultrasonic or sharp), high speed drills, and even rongeurs to allow for bony resection and bony cuts to aid surgeons in decompression in a guided, precise and controlled fashion.
Chester Donnally, MD. Texas Spine Consultants (Addison): I would say helping with the decompression aspect of the case, but then eventually I will be obsolete, and the robot will take my job or more likely insurance will pay us less since we are doing less work. On a half serious note, having the navigation aspect helps us understand if/when indirect decompression might not be enough and how much residual stenosis might be present.
Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): I would like to see the cost improve with spine robots. I have been impressed with the planning interface and precision software from Mazor by Medtronic for the past 10 years. Having performed over 100 robotic spine surgeries, my experience is that the operating room footprint is getting smaller. The planning, registration, and workflow is more efficient. However, the cost of the machine and the annual maintenance contracts are challenging for many hospitals to afford. I am proud that my spine practice in Michigan has two Mazor robots to provide the most innovative technology with accessibility.
Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): The next generation of spine robots should have increased functionality such as using the drill to perform key parts of the surgery.