4 key questions on spine surgical technology

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Four spine leaders answer four key questions on surgical technology and share predictions on the future of the specialty.

Note: Responses are lightly edited for style and clarity.

Question: Which minimally invasive technology trends are a fad and which are here to stay?

Joseph Lee, MD. Rothman Orthopaedic Institute (Philadelphia): Minimally invasive surgery has continued to evolve in the last 30 years. However, the goals of minimally invasive spine surgery remain constant: nerve decompression and spinal stability. Advances in navigation, robotics and augmented reality will continue to evolve together and allow surgeons to perform minimally invasive surgery safely and efficiently. The next frontier will be merging information from MRI and CTs to allow robots to assist in exposure, neural decompression and disc space preparation. Advances in interbody technology such as surface modification and multiplanar expansion capabilities facilitate achievement of fusion and sagittal plane correction.

The traditional lateral MIS approach remains a successful surgical technique for a variety of degenerative spinal conditions. The recent introduction of the single-position prone lateral technique has been successful, with its proposed advantages of superior OR efficiency, better sagittal correction and ability to incorporate navigation/robotics. Endoscopic spine surgery, or "ultra-minimally invasive surgery," has become more popular in the last few years, but it has yet to be determined if this technique provides superior clinical outcomes compared to traditional minimally invasive techniques. 

Q: What spine technologies should ASCs invest in over the next three years as cases accelerate toward the outpatient setting?

Sanjay Khurana, MD. LA Spine and Orthopedic Institute (Los Angeles): As the majority of elective spine surgery migrate to the outpatient arena over the coming decade, surgeons will need access to technologies that allow higher-acuity surgeries to be performed with precision and predictability in the least traumatic manner. Intraoperative imaging that allows real-time 3D navigation, whether with a pre-op CT scan or an intra-op CT spin, will allow surgeons to perform fusions and motion-preservation surgeries with full confidence in desired interbody device as well as posterior instrumentation placement. Whether this is done with the assistance of a robot or done manually, the ability to confidently predict or actually visualize postoperatively will be paramount. Endoscopy and advanced microscopic technology will also be critical in these surgeries for careful and minimally invasive neurological decompression. The exciting forefront of coupling endoscopic/microscopic technologies with advanced imaging and AR speak to an even more promising future for patients and physicians.

Q: What's one bold prediction you have about the future of the spine industry?

Philip Louie, MD. Virginia Mason Franciscan Health (Seattle): I think that machine learning and artificial intelligence will play a large role in further expanding the use of enabling technologies and driving down the cost of surgery, all in the name of providing greater safety and value to our patients. The expansive data we are currently collecting through diverse avenues will allow multidisciplinary teams to assess how we can perform surgery through the use of more integrated real-time systems that will reduce the number of trays necessary, improve surgical accuracy, reduce operative times and radiation exposure, as well as decreasing the risk of iatrogenic complications during surgery.

The same data (that will be the background of these integrated systems) will ultimately drive our decision-making throughout the whole continuum of patient care  — from preoperative planning and risk stratification to real-time solution proposals intraoperatively, and guiding patient engagement and support postoperatively. We will see the collaboration of multiple industries and research minds that will drive these changes in an evidence-based manner that can keep up with the demands for higher quality care in a cost-constrained landscape.

Q: What are key considerations when trying new surgical technology in your practice?

Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): First and foremost, the surgeon has to think about safety. Oftentimes there is a lot of enthusiasm for new technologies that surgeons want to try. I think it is important for surgeons to look at the data themselves and try to understand the research behind the new technology. 

Second, when you try a new technology, I think it is important for surgeons to be hyper critical of their results and to track their outcomes to make sure that safety is not being compromised. Ideally, you also want to make sure that the outcomes are better with the new technology.

The use of regional anesthesia and spine surgery, the awake spine surgery movement, is something that I’ve been working on for the past six years. From the beginning, we have tried to be diligent by collecting our data and outcomes to make sure our results are better. We are at a point now where we are publishing our data and teaching others. Critical for me was to make sure that what we are doing is, No. 1, safe and, No. 2, an improvement based on the usual standard.

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