12 surgeons' wish list for the next generation of robotics

12 surgeons’ wish list for the next generation of robotics

Robotics is still considered to be in its infancy in spine surgery, but most surgeons agree that it will have a critical role in the future of the specialty. However, there are still some challenges.

Twelve spine surgeons from health systems and private practices across the country describe the improvements they want to see in the next generation of spinal surgical robots.

Ask spine surgeons is a weekly series of questions posed to spine surgeons across the country about clinical, business, and policy issues affecting spine care. Baker Calls all spine surgeons and specialist responses.

Next week’s question: What does consolidation look like in the market? How do you expect it to change?

Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 PM CST on Wednesday, November 30.

Editor’s note: Responses have been lightly edited for length and clarity.

Question: What is one improvement you would like to see in the next generation of spine robots?

Todd Lanman, MD. Lanman Spinal Neurosurgery and Advanced Center for Spinal Disc Replacement (Beverly Hills, CA): Spine surgical robotic systems are designed primarily to insert the cervical screw and mechanically drive the screws into the bone for fixation, both of which are done posteriorly. However, these robots are not currently designed to handle artificial disc replacement, which is performed anteriorly. Without this improvement, spinal 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 technologies and robotics that will help spine surgeons align the artificial disc in the correct locations as they approach the front (front) of the spine.

William Zelenti, MD. Hospital for Special Surgery (New York City): Current robotic technology is not widely used in cervical spine procedures such as lateral lumbar screw placement or, more importantly, pivotal screw placement. The first use of percutaneous screws in the literature was reported in September 2021. This may be due to physical or ergonomic limitations of current systems; However, solutions that can find their way into next generation systems can be developed. Access to highly accurate systems for posterior cervical surgery is an excellent application due to the scale of the anatomy and the highly sensitive surrounding structures.

Jason Liao, MD. Orthopedic Institute (Newport Beach, CA): Spine surgical robot designs are still in the early generations of design. As such, their use remains somewhat controversial, albeit now established with early adopters. The improvements that I believe will make spinal surgical robots more useful will center around the accuracy of recording and navigation during the surgical procedure. There are situations in surgery where the robot can lose accuracy. The errors you’ve seen in robotic spine surgery stem from a loss of precision during the procedure without the surgeon’s awareness. Once technological advances in robotics bring these critical errors to near zero, robotics holds a lot of promise for spine surgery. I can see a future where robots allow for more minimally invasive approaches, for safer decompression of nerves, and for more precise placement and placement of implants. Robotics in the future could make surgery more consistent and repeatable, which is in line with what all patients want.

Vic Mehta, MD. Hoag Hospital (Newport Beach, CA): We need to make a huge leap forward in the application of robotics in spine surgery. The current state of forklift robots is simply a semi-automated platform for placing pedicle screws. Robotics in spine surgery has the potential to revolutionize spine surgery but we need more work. We need faster registration workflows, more predictive and automated features, and better data to show that robotics make spine surgery safer and more effective. Furthermore, spinal robots should play a more important role in maintaining balance, correcting deformity, and assisting with interbody techniques.

Brian Gantwerker, MD. Craniospinal Center in Los Angeles: The watershed moment in robotics will come in the ability to not only use dental screws, but also pressure-relieving parts of surgery. The cool thing about the orthopedic robot space is the advent of robots that help shape parts of the joint and predict the right angles for each individual patient and implant. Once we prove it, this will really be the moment we’ve been waiting for. Patients will undoubtedly benefit and be better off. This moment will undoubtedly bring with it the potentially dangerous moment when non-surgeons realize they can do what surgeons do. It will be important to ensure that only those with the appropriate training, discernment, knowledge, and ethical backbone are allowed into that space. Those who don’t, who might find a way to do this, should really consider whether this is what’s best for patients.

Christian Zimmermann, MD. St. Alphonsus Medical Group and Institute of Neurosciences SAHS (Boise, Idaho): The time component and cost per unit case are much higher. Improvements lie in cost control and pre-use experience requirements. These types of surgery routinely take hours longer than the procedure, depending on the extent of the procedure. As a result, longer anesthesia requirements, postoperative amnesia and recovery time. Promoting the procedure everywhere calls for challenges of skill and experience. This may be the future, but issues remain.

Philip Schneider, MD. Advanced Orthopedics Centers (Bethesda, MD): The primary function of the robotic surgery is to be a drill guide for the pedicel screws. It would be beneficial for surgeons if spinal surgical robots were more versatile. Because spine surgeons often don’t need help drilling holes and placing screws, spinal surgical robots aren’t particularly helpful. Spine surgeons would benefit most, if surgical robots assisted in advanced surgeries such as osteotomy or spinal resections safely and predictably.

Saad Chowdhury, MD. Mount Sinai (New York City): Navigation technologies and robotics are here to stay in spine surgery. These enabling technologies are used, not as standalone devices, but as an extension to the surgeon to perform a safe, reproducible, and effective procedure, while reducing radiation exposure for the surgeon and operating room personnel in general. The current robotic systems available for spine surgery only facilitate placement of the cervical screw. However, pedicle instruments are just one (albeit important) component of a complex spinal procedure. In the future, I hope that robotic systems and software will allow us to plan and perform laminectomy and osteotomy procedures for more precise spinal decompression and removal of bony elements for realignment and deformity correction operations.

Ali Hassan Miswala, MD. Disick Sports and Spine Center (Newport Beach, CA): Current generations of robots primarily have one role: aligning the path for positioning devices. This is often only half the battle when it comes to spine surgery. The adage of most surgeries remains: We need to relieve pressure And the stability. While current generations of robots are great at positioning devices and helping surgeons achieve a stable physique, they also leave a lot to be desired for decompressing neural structures. I believe that future generations of robots will incorporate osteotomy (ultrasound or blunt), high-speed drills, and even rongeurs to allow osteotomy and osteotomy to assist surgeons in decompression in a directed, precise, and controlled way.

Chester Donnelly, MD. Texas Spine Consulting (Addison): I would say help on the decompression side of the case, but then eventually I’ll be out of whack, and the robot will take my job or more likely the insurance will pay us less since we’re doing less work. On a half-serious note, having the mobility aspect helps us understand if/when indirect decompression may not be sufficient and how much residual stenosis may be present.

Brian Vianney, DO. Weill Cornell Medicine/New York Presbyterian Hospital (New York City): I’d like to see cost improve with spine bots. I’ve been impressed with Medtronic’s Mazor planning interface and accurate software for the past 10 years. Having performed over 100 robotic spine surgeries, my experience is that the operating room space has gotten smaller. Planning, recording and workflow more efficient. However, the cost of the machine and annual maintenance contracts are a challenge for many hospitals. I am proud that my Michigan spine practice has two Mazor robots to provide the most innovative technology with accessibility.

Harel Deutsch, MD. Midwest Orthopedics in Rush (Chicago): The next generation of spine robots should have increased functionality such as using drills to perform key parts of surgery.

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