Debate: Should robotics technology be more widely adopted in spine surgery?

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Junseok Bae (left) and Daniel Park (right)

The use of robotics in the field of spine surgery is a much discussed and controversial topic, with numerous physicians arguing both for and against its increased use in procedures. In this debate, two world renowned spine surgeons offer their views extolling the virtues and highlighting the pitfalls of this technology and whether or not it should have a greater usage in spine surgery practice both now and in the coming years.

Robotics technology SHOULD be more widely adopted in spine surgery: Junseok Bae, president of Wooridul Spine Hospital (Seoul, South Korea)

In the era of the industrial revolution 4.0, the medical field and operating theatres can no longer be free of the influence of technology. Due to the nature of their work, medical professionals, and surgeons, in particular, tend to be very conservative when adopting new technology, ensuring that the safety of the technology has been satisfactorily demonstrated, with evidence to guide the application to practice. At the same time, through continuous research and development, surgical techniques have been rapidly developed in recent years, with indications expanded through research. As Alvin Toffler stated, “the great growling engine of change is technology”.  In the field of spinal surgery, the complex and sophisticated instruments and implants for minimally invasive surgery (MIS) are continually evolving. Moreover, endoscopic spinal surgery, which is receiving the most attention as an MIS technique, has been made possible through the development of optical technology and micro-mechanical process.

As an extension of this technological development, the use of robotic surgery is now being realised in many operating theatres, faster than we had previously anticipated. However, robotic surgery is still in its early stage of development and, thus, its applications remain limited. In spinal surgery, the use of robots is extremely narrow, being limited to certain procedural aspects, such as providing guidance for percutaneous screw fixation. Indeed, navigation and fluoroscopy guidance can sufficiently complement the freehand placement of pedicle screws. It is on this basis that some have criticised robotic technology for its very limited cost-effectiveness. However, considering that the indications for MIS and endoscopic surgery have been expanded after an initial stage of adaptation, it is conceivable that robots will also follow the same path. The expanded indications for robot surgery can be easily predicted by the popularity of robot assistance in general and urologic surgery.  Despite the current limitations of robots in spinal surgery, robot technology over the longer term remains very promising.

It is important to not forget that when surgical navigation was first introduced, it was considered as a novel and revolutionary technique. However, there was resistance to accepting this technology, considered as an expensive ‘toy’ that would not make a significant difference beyond surgeons’ experience. Today, a wide variety of navigation is available in most large and developed hospitals, with application in a variety of surgeries. This is the general cycle of novel technologies, from conception, and development, to application in practice. It is clear that robotic technology for surgery will follow the same cycle. Furthermore, when combined with other technologies, such as artificial intelligence, mixed reality, and augmented reality, robots are expected to provide powerful assistance to surgeons, with greater safety and higher accuracy than current navigation systems.

Robots are considered as the ‘next-generation technology’ for spinal surgery. Various studies and meta-analyses have reported on the stability provided by robotic platforms, with robot assistance providing greater accuracy for pedicle screw placement than the freehand technique. Freehand pedicle placement is a difficult surgical method that requires a long learning curve and clinical experience. Yet, with robot assistance, similar surgical results can be obtained for novice and experienced surgeons. This is a noteworthy finding as ensuring patient safety is the primary goal for all surgeons. Human error, due to various factors, such as lack of concentration and inexperience, is one of the major causes of iatrogenic harm during surgery. In this regard, robots can provide ‘very good surgical assistance’ to lower the risk of harm due to human error. In fact, for surgeons, surgical assistants who maintain their awakeness, visual acuity, and attention during repetitive, lengthy surgeries are considered to be ‘excellent’ colleagues and not competitors. The advent of computer image induction has allowed spinal surgeons to improve their surgical techniques, including increased accuracy of spinal hardware placement while reducing radiation exposure to the patient and operating room staff.

Criticisms regarding long setup time and high costs are common in the early stage of the adoption of new technologies, such as the advent of personal computers, smart devices, electric vehicles, and autonomous vehicles. As Bill Gates said, the adoption of technology requires that the technology seamlessly ‘fit in’ for the user, so that it becomes ‘part of everyday life’.  In a few years from now, robots will be deeply embedded in our operating rooms. The spinal robot is great, but the best is yet to come.

Spinal News International recently ran a poll asking physicians whether or not robotics technology should be more widely adopted in spine surgery. The results were as follows:

Robotics technology SHOULD NOT be more widely adopted in spine surgery: Daniel Park, board-certified orthopaedic spine surgeon at William Beaumont Hospital (Royal Oak, USA)

In recent years, technology has impacted spine surgery tremendously. After minimally invasive surgery was introduced, the next ‘big’ thing to influence spine surgery has been navigation. Currently, the next iteration of ‘advancement’ has been robotics. Although robotics has become mainstream in our urologic colleagues with the DaVinci robot (Intuitive Surgical) and has gradually increased its presence in the joint arthroplasty operative theater, the question of robotics becoming the gold standard for spine is debatable. Industry will push hospitals and surgeons to adopt this technology and spend large capital to invest in them, yet it is far from perfect to become the standard of care at this time or the near future.

First, the cost of robotic spine surgery is extraordinary. Financial pressures of healthcare as well as adoption of more minimally invasive surgery has accelerated the migration of spine surgery, including spinal fusions, into the ambulatory setting. With this cost containment strategy, to incorporate robotics is contra intuitive. The average cost of a spinal robot is around US$500,000–$1.2 million, while the navigation equipment typically costs an additional $500,000. If intra operative computed tomography (CT) or 3D scan is needed, an additional $500,000–$1 million of capital is required.

Second, although the accuracy of the robot cannot be disputed1, the clinical relevance of malpositioned screws can. A systematic review by Marcus et al found there was insufficient evidence to conclude the effectiveness of robot-assisted over conventional fluoroscopic guided pedicle screw insertion2. Studies should be scrutinised for their reporting of accuracy as when screws are changed intraoperatively or the robot fails to reach its trajectory or fails to register, those screws may be not reported in their accuracy rates. Accuracy rates focus on acceptable trajectory of the screw without regard to clinical significance. However, the most important factor is not accuracy but complications. Complications associated with pedicle screws historically have ranged from 1–54% from neurological and vascular injuries3, yet asking current spine surgeons utilising freehand techniques will not yield a revision rate that high. The cost of the robot can be justified potentially by eliminating the cost of revision surgery, yet to a busy spine surgeon, the number of revisions due to malpositioned screws for routine spine cases are very low. Wang et al found that when comparing 1–2 level transforaminal lumbar interbody fusion (TLIF) using navigation, robots, or free hand open, there was no difference in perioperative outcomes6,8. Potential complications that can occur during the learning curve of the adoption has to be noted.

Third, time is money and the adoption of navigation adds cost to a surgery. Although time decreases in the learning curve1, the added operative time factors into the total opportunity cost of the robot. Typically, the use of robots or navigation is the same at best compared to that of open or fluoroscopic procedures, but typically takes more operative time6,7. Furthermore, with robots—although increasing the accuracy rate at the end—many surgeons know the skiving issues related to robotic use and the potential for inaccurate placement of the original screw. When this occurs, the screws can be adjusted, but this change adds to the added cost of time and also requires using fluoroscopic guidance or landmarks to place a screw in an open manner which diminishes the efficacy of robotics.

Last, the radiation exposure to the patient has to be considered. It is accepted that radiation exposure to the surgeon and operating staff will be mitigated, yet preoperative and/or intraoperative advanced imaging for robotic registration can add radiation exposure to the patient compared to using a freehand technique. Ringel et al and Schizas et al observed no significant difference in radiation exposure however4,5. The Schizas et al study control comparison used fluoroscopy to gain screw trajectory for each screw as part of their fluoroscopic assisted free hand technique and they did not calculate the radiation dose of the preoperative CT into the calculation. Ringel et al also did not calculate the preoperative CT radiation exposure as well. In Wang et al, the minimally invasive surgery without navigation or robot had the highest radiation while open free hand technique had the least amount of radiation6. When compared to fluoroscopic screw placement, the skill of the surgeon should be factored in as the learning curve of placing robotic screws and fluoroscopic screws has to be factored in.

While robotics has widely been adopted by hospitals, it is known in many facilities that robots may sit idle due to the added learning curve and inaccuracy of the robot at times. One real concern of widespread adoption of robotics to me lies in the lost ‘art’ of placing pedicle screws without navigation and robots to our training surgeons. While robots can tell us this is how a screw should be placed, unless the user knows how to confirm accuracy and fix mistakes, this can create and propagate error. Until the spine robot can help navigate accuracy and safety of other parts of the surgery reproducibly such as decompression and discectomies, robots will not become the standard of care. Currently, the spine robot only has one effector and it is to place a drill or k wire in a desired trajectory without meaningfully advancing spine surgery for the masses at this time.

 

References: 

  1. Maalouly J, Sarkar M, Choi J. Retrospective study assessing the learning curve and the accuracy of minimally invasive robot-assisted pedicle screw placement during the first 41 robot-assisted spinal fusion surgeries. Mini-invasive Surgery. 2021; 5:35
  2. Marcus H, Cundy T, Nandi D et al. Robot-assisted and fluoroscopy-guided pedicle screw placement: a systematic review. European Spine Journal. 2013;23(2):291-297.
  3. Molliqaj G, Schatlo B, Alaid A et al. Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery. Neurosurgical Focus. 2017;42(5):E14.
  4. Ringel F, Stüer C, Reinke A et al. Accuracy of Robot-Assisted Placement of Lumbar and Sacral Pedicle Screws. Spine. 2012;37(8):E496-E501.
  5. Schizas C, Thein E, Kwiatkowski B et al. Pedicle screw insertion: Robotic assistance versus conventional C arm fluoroscopy. Acta Orthopaedica Belgica 2012 78(2): 240
  6. Wang E, Manning J, Varlotta C et al. Radiation Exposure in Posterior Lumbar Fusion: A Comparison of CT Image-Guided Navigation, Robotic Assistance, and Intraoperative Fluoroscopy. Global Spine Journal. 2020;11(4):450-457.
  7. D’Souza M, Gendreau J, Feng A et al. Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends. Robotic Surgery: Research and Reviews. 2019;Volume 6:9-23.
  8. Yu L, Chen X, Margalit A et al. Robot-assisted vs freehand pedicle screw fixation in spine surgery – a systematic review and a meta-analysis of comparative studies. The International Journal of Medical Robotics and Computer Assisted Surgery. 2018;14(3):e1892.

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