Challenges in contemporary spinal robotics: encouraging spine surgeons to drive transformative changes in the development of future robotic platforms
Review Article

Challenges in contemporary spinal robotics: encouraging spine surgeons to drive transformative changes in the development of future robotic platforms

Gregory M. Malham1,2,3,4, Thomas A. Wells-Quinn1, Adrian M. Nowitzke5, Ralph J. Mobbs6,7, Lali H. Sekhon8,9

1Neuroscience Institute, Epworth Hospital, Melbourne, VIC, Australia; 2Spine Surgery Research Foundation, Richmond, VIC, Australia; 3Spine Surgery Research, Swinburne University of Technology, Melbourne, VIC, Australia; 4Department of Surgery, Facility of Medicine, Dentistry and Health Science, University of Melbourne, Parkville, VIC, Australia; 5Brisbane Private Hospital, Brisbane, QLD, Australia; 6NeuroSpine Surgery Research Group (NSURG), Sydney, NSW, Australia; 7NeuroSpine Clinic, Prince of Wales Private Hospital, Randwick, NSW, Australia; 8Reno Orthopedic Center, Reno, NV, USA; 9University of Nevada, Reno, NV, USA

Contributions: (I) Conception and design: GM Malham, TA Wells-Quinn; (II) Administrative support: GM Malham; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Gregory M. Malham, DMed, FRACS. Neuroscience Institute, Epworth Hospital, Suite 8.3, 89 Bridge Road, Richmond, Melbourne, VIC 3121, Australia; Spine Surgery Research Foundation, Richmond, VIC, Australia; Spine Surgery Research, Swinburne University of Technology, Melbourne, VIC, Australia; Department of Surgery, Facility of Medicine, Dentistry and Health Science, University of Melbourne, Parkville, VIC, Australia. Email: gmalham@bigpond.net.au.

Abstract: The field of spinal robotics has witnessed considerable advances, which have primarily focused on enhancing pedicle screw placement. This article critically evaluates the current direction of spinal robotics development, raising concerns about the disproportionate emphasis on pedicle screw placement when existing techniques already yield commendable results. Discussions on various parameters, including quality, cost-effectiveness, and accessibility, highlight the need for a broader perspective in the development of robotics for spinal surgery. Comparative analyses reveal that navigation systems offer cost-effective and time-efficient alternatives to robotics, with similar accuracy levels. Patient demand for robotic interventions is influenced by perceived superiority, warranting careful consideration of public sentiment. This article also underscores the need for future spine surgeons to maintain proficiency in traditional techniques. The influence of industry and key opinion leaders in steering the focus toward pedicle screw placement is discussed, emphasizing the need for a more holistic approach. Accessibility issues and legal considerations in the evolving field of spinal robotics are addressed, and the potential for robotics to enhance various aspects of surgical procedures beyond pedicle screw placement is explored. In conclusion, we advocate for a shift in focus in spinal robotics, emphasizing the untapped potential to streamline common surgical procedures (such as discectomy, laminectomy, and endoscopy), enhance precision, and improve patient outcomes in areas beyond pedicle screw placement. Future advances in spinal robotics have the potential to transform the surgical landscape, benefitting all stakeholders, including patients, surgeons, and hospitals.

Keywords: Cost-effectiveness; robotics; spinal; surgery; technology

Submitted Jan 22, 2024. Accepted for publication May 24, 2024. Published online Jul 05, 2024.

doi: 10.21037/jss-24-4

Introduction

Significant advances in robotics have revolutionized tasks characterized by danger, monotony, and substantial costs when executed by humans. Within the medical domain, robotics holds much promise in enhancing surgical procedures (1,2). Nonetheless, the current trajectory of robotics development in spinal surgery, particularly the focus on replacing or enhancing image guidance for pedicle screw placement (3), raises concerns and may be leading toward misguided objectives. The existing pedicle screw placement process already yields commendable results, prompting a critical evaluation of the necessity and efficacy of incorporating robotics into this specific aspect of spinal surgery.

When assessing emerging technologies, including robotics in spinal surgery, parameters such as quality, cost-effectiveness, and accessibility become crucial benchmarks (4). The current direction of robot-assisted spinal surgery appears to require a substantial temporal investment before meeting the essential criteria for improvements in patient outcomes, surgeon experience, and overall hospital operations.

The developmental trajectory of prevailing spinal robotics platforms is arguably misdirected, as substantial resources are being channeled into refining a process that is already proficient. Rather than intensively refining the placement of pedicle screws, which is a well-established and successful procedure, attention should be redirected toward the laborious and repetitive aspects of spinal surgery. Opportunities to enhance safety, reduce costs through improved ergonomics, and leverage the potential of robotics and automation lie in addressing these relatively neglected aspects. A myopic focus on developing robotics solely for pedicle screw placement risks squandering the potential to optimize these other critical dimensions. Furthermore, underutilization of expensive robotic platforms in hospital inventories raises concerns, as these investments may become obsolete when the genuine challenges of spinal surgery are effectively addressed.

A brief overview of spinal robotics

The current juncture in spinal robotics marks a critical turning point, demanding proactive measures to guide the development of these platforms. It is imperative to steer the trajectory of spinal robotics toward enhancing existing spinal surgery methodologies and extending the capabilities of image guidance systems, rather than supplanting well-established and highly accurate functions. Having played a key role in the evolution of spine technology, spine surgeons have an opportunity and responsibility to advocate for the integration of functions that significantly enhance clinical outcomes, mitigate complications, and optimize ergonomics during spinal surgery.

Spinal image guidance is a rigorously validated technology (3,5,6), yielding notable advances in safety through precise pedicle screw placement. This technology has demonstrated efficacy in reducing radiation exposure and lowering revision rates when compared with conventional fluoroscopy-guided or freehand techniques. While acknowledging the potential benefits of spinal robotics, it is crucial to recognize the robustness of existing image guidance systems, which have substantially improved workflow efficiency, operating times, and revision rates, thereby partially offsetting the associated capital setup and operational costs (7).

A pivotal aspect of the current discourse is the absence of a discernible clinical problem necessitating the integration of robotics into spinal surgery. Notably, spinal image guidance for pedicle screw placement has led to an impressive accuracy rate of 98% in avoiding cortical breach (8), a clear testament to its efficacy (9). However, contemporary spinal robotics platforms have disproportionately emphasized pedicle screw placement (10). It is widely acknowledged among surgeons that the intricacies of instrument placement demand significant mental and physical efforts, diverting attention and energy from critical human tasks, such as neural decompression and interbody fusion (11). The introduction of image guidance alleviated some of these challenges, enhancing safety and accuracy within this existing procedural framework. To date, spinal robotics have been focused on pedicle screw placement, with similar radiation reduction and high accuracy rates—particularly after the initial learning curve. It is now time to look beyond pedicle screws to the broader dimensions of spinal robotics through which automation could substantially contribute to improved surgical efficiency and overall outcomes.

Contemporary spinal robotics: a comparative analysis

The prevailing iteration of robotic platforms in spinal surgery essentially mirrors the functionalities of current navigation systems, primarily serving as trajectory guides (12). During cannulation of a pedicle utilizing freehand or navigational-based techniques, surgeons traditionally receive comprehensive feedback throughout the procedural steps in the form of visual, audible, and tactile cues. Tactile feedback, often augmented by neurophysiologic monitoring (13), plays a crucial role in enhancing the surgeon’s situational awareness. However, while capable of preserving some elements of this feedback, the current generation of robotics falls short in capturing and interpreting haptic information. Consequently, there is an inherent reduction in overall feedback provided by robotic systems. The lack of comprehensive haptic feedback contributes to a critical issue: new users of robotic systems may inadvertently place pedicle screws outside the intended trajectory, thereby risking neural or visceral injury. Unlike experienced spine surgeons, these users may not receive the customary warnings that typically accompany such errors, underscoring a potential safety lapse related to the absence of tactile feedback.

Furthermore, the putative advantages offered by contemporary spinal robotics require a pragmatic examination. A comparative analysis between navigation and robotics published in 2022 revealed that navigation techniques were clearly advantageous in terms of cost-effectiveness (when including the costs of disposables, service, and capital expenditures) (7), as well as time efficiency. Notably, both modalities display similar accuracy (14). Despite this parity, a perceptible disparity exists in public opinion, with robotics being viewed more positively. Patient demand for robotic interventions, often influenced by the allure of ‘laser surgery’ and ‘keyhole’ options, is palpably robust. Notably, the prevailing consumer perception, albeit anecdotal, tends to associate robotic interventions with superior outcomes, an issue that warrants careful consideration within the broader discourse on spinal surgical modalities.

Enhancing surgical quality: evaluating the current landscape of spinal robotics

Automation and integration of robotics into surgical practices should ideally amplify the feedback available to surgeons, thereby augmenting the overall quality of surgical procedures. However, evaluation of the current generation of robotics reveals similar accuracy in placing pedicle screws, when compared with image guidance systems (1,15-17). It is noteworthy that both robotics and image guidance have their challenges, as evidenced by instances of system failure, necessitating conversion to manual instrumentation (18). The considerable learning curve associated with robotics, as demonstrated by Pennington et al. (19), coupled with the higher setup and running costs attributed to the greater complexity of robotic systems in contrast to image guidance (7), underscores the intricate nature of integrating these technologies seamlessly into surgical workflows.

Moreover, early generations of spinal robotic platforms were more conducive to percutaneous screw placement as tissue retraction was less problematic. This reduced their utility in open complex procedures where robotics could bring considerable benefit. Contemporary robotics platforms continue to improve with more rigid arms and fixation mechanisms to reduce trajectory variations. The potential for longer operating times, as reported by several authors (15,16,20), further underscores the nonsuperiority of quality associated with current robotic applications. These observations may account for the relatively modest uptake of spinal robotics within the surgical community. Consequently, there remains a compelling need for future spine surgeons to continue to achieve proficiency in traditional freehand and fluoroscopy-guided transpedicular screw placement, given the inherent risks and complexities associated with assistive technologies.

The economic landscape of spinal robotics

A pivotal question arises: who is steering the relentless focus on pedicle screws in spinal robotics development? Is it a demand emanating from surgeons, or is the research and development trajectory being disproportionately influenced by medical device companies? Notably, leading spinal robotics companies seem to prioritize growth of spinal implant sales as their primary revenue source, overshadowing the revenue generated by robotics per se (7). This prevailing financial structure thereby promotes tailoring current robotic platforms toward screw placement, potentially fostering surgeon and hospital engagement throughout the sales and installation processes.

However, this strategic alignment with implant sales introduces notable caveats. Most existing robotics platforms exhibit a lack of vendor neutrality, compelling surgeons to adhere to the specific implants provided by the robot manufacturer. While creating a competitive edge in a saturated market, this symbiotic relationship between robotics and implant sales prompts a critical reassessment of the priorities driving integration of robotics into spinal surgery. It is imperative for spine surgeons to articulate a clear vision of the requirements and desired outcomes from spinal robotics, emphasizing the overarching goals of improving spinal surgery safety and effectiveness.

Enhancing accessibility in spinal robotics

In the realm of technological advances, accessibility stands as a fundamental criterion for evaluating the success of new developments. However, the current landscape of spinal robotics platforms falls short of this criterion, primarily because of the substantial barriers posed by high capital, service, and consumable costs (7). This financial hurdle significantly limits the availability of robotics platforms to most spine surgeons. Even when these platforms are successfully installed, the associated learning curve can impede their effective utilization, as observed by Perfetti et al. (21). The costs of developing novel medical technologies remain exorbitant, with expenditures to bring a new device to market in the United States hovering around $1 billion. The need to recoup these costs often contributes to the extremely high price of robotics platforms, exceeding $1 million. This financial burden, coupled with the lack of demonstrated clinical superiority over image guidance systems, underscores the need to critically assess the cost-effectiveness of spinal robotics.

Moreover, as highlighted by Staartjes (6), the higher on-site costs related to service maintenance because of the system’s complexity further diminish the cost-effectiveness of spinal robotics, when compared with image guidance. To justify these elevated costs, the next generation of robotics platforms must provide tangible improvements in clinical outcomes and offer benefits beyond existing platforms. This necessitates exploring avenues that enhance accessibility, particularly through advances that prove advantageous for patients, surgeons, and hospitals.

The upcoming era of robotics platforms holds the potential to foster accessibility by focusing on three pivotal issues: (I) enhancing patient experiences through safer, swifter procedures, with improved outcomes and reduced recovery times; (II) affording surgeons improved operative efficiency and ergonomics; and (III) providing hospitals with cost-effective solutions that bolster efficiency and overall outcomes. Meeting these criteria is paramount for addressing current deficits in both accessibility and cost-effectiveness within the realm of spinal robotics.

Present-day navigation and robotics platforms predominantly operate in a passive manner, where control resides with the surgeon. This design choice strategically limits the liability of robotics systems, effectively keeping them within the purview of the operating surgeon. However, the potential integration of active robotics endowed with decision-making capacities into critical procedures, such as neural decompression, introduces an uncharted legal landscape. The possible shift in legal liability from the surgeon to the robotics manufacturer poses a challenge akin to the legal complexities encountered by autonomous vehicles when transferring potentially life-threatening decision-making to nonhuman algorithms. This legal conundrum necessitates careful consideration and ethical deliberation as robotics evolve to embrace more active roles in surgical interventions.

Influence of industry and key opinion leaders (KOLs) in the context of spinal robotics

The field of surgery has traditionally relied on the accumulated wisdom of seasoned surgeons, drawing upon their decades of experience. However, the emergence of KOLs, particularly those advocating for robotics platforms, introduces a complex dynamic wherein financial interests may intertwine with their roles as proponents of specific technologies, potentially introducing bias into their perspectives (22,23). This complexity is not unique to spinal surgery and highlights the importance of peer review and scientific rigor when considering new technologies in addition to KOL advocacy.

In the realm of spinal surgery, robots currently manifest as mechanical arms driven by algorithms, historically developed for navigation purposes and deeply rooted in specific applications, such as biopsy and trajectory setting. Notably, KOLs endorsing robotic platforms often harbor financial interests closely aligned with the technologies they champion, a phenomenon underscored in the works of Bailey and Garattini (22,23).

A notable strategy employed by medical device companies to mitigate costs and regulatory risks involves integrating robotic functionality into existing navigation systems with established regulatory approvals. These navigation systems are inherently designed for trajectory definition and pedicle screw placement, aligning with the prevailing focus of contemporary spinal robotics. However, this approach tends to sidestep the broader spectrum of potential applications that robotics and automation could offer within the domain of spinal surgery. The focus on pedicle screw placement, while understandable given its historical significance and clinical importance, may inadvertently limit exploration of the use of robotics for other aspects of surgical interventions that could benefit from enhanced precision and automation. The nuanced relationships between industry interests, KOLs, and the direction of technological development in spinal robotics warrant meticulous consideration to ensure the continued advancement of surgical technologies with a holistic perspective.

The future of spinal robotics: beyond pedicle screw placement

The field of robotics and automation is rapidly evolving, ushering in transformative changes across various industries. The unique strengths of robotics lie in its ability to assume tasks that are perilous, repetitive, or tedious or that would benefit from additional physical support, such as enhanced strength in manufacturing or precise motor control during microsurgery.

When one considers the workflow of open lumbar fusion operations, it is apparent that the more hazardous and repetitive steps extend beyond the conventionally emphasized pedicle screw placement. Notably, surgical exposure, a phase characterized by its dull and repetitive nature, represents an area ripe for potential enhancements. Integrating planning automation with exposure may facilitate the creation of more targeted incisions, thereby reducing blood loss and minimizing soft tissue manipulation, as proposed by Trybula et al. (24). Active robotic functions addressing challenges associated with bleeding during exposure could prove invaluable. Additionally, the prolonged and nonergonomic manual retraction required for soft tissue manipulation and the technically challenging and high-risk procedures of bony decompression, facetectomies, and osteotomies present compelling opportunities for integrating automated planning and robotics (2).

Inspiration can be drawn from successful applications in joint replacement robotics, during which the focus has shifted from fearing the proximity of neural structures to leveraging robotics for their neural protection. Repetitive and manual processes involved in decortication and bone grafting may similarly benefit from such advances. Recent developments in spinal robotics have extended beyond pedicle screw placement to encompass minimally invasive techniques, cervical pedicle screw insertion, and deformity correction, as observed in the work of Perfetti et al. (21). These tasks, which are often onerous, high risk, and repetitive, highlight the vast potential for spinal robotics to enhance patient outcomes and hospital efficiency, ultimately transforming the experiences of patients, surgical trainees, and surgeons alike (25).

Drawing parallels with endoscopy, a compelling case study for potential robotics innovation emerges. While endoscopy has shown promise in enhancing visualization and potentially reducing hospital length of stay (26), the need to acquire new surgical skills and the steep learning curve remain significant challenges (27). Addressing these challenges, robotics has the potential to shorten the learning curve, enhance precision and accuracy, and mitigate ergonomic difficulties. Target port manipulation, increased feedback to surgeons regarding planned anatomical position, refined control over endoscopy tools, and improved management of decompressive tools are all examples of areas in which robotics could revolutionize endoscopic procedures.

The realm of spinal robotics, with its significant untapped potential, demands a shift in focus beyond pedicle screw placement. Table 1 provides a comprehensive synopsis of potential future applications in the field, illuminating a path toward realizing the full spectrum of advances in spinal robotics.

Table 1

Potential future applications of robotics for spinal surgery

Tasks Examples
Expanded utility Use expanded to include robotically assisted discectomy, endplate preparation, decompression, and osteotomies
Improved ergonomics Assistance with (I) uncomfortable actions (e.g., tissue retraction), (II) repetitive movements (e.g., Kerrison use), and (III) onerous tasks (e.g., suturing of long wounds)
Automation and artificial intelligence Controlled autonomy and decision-making capacity based on up-to-date data and clinical practice to address context-specific issues (e.g., recommended degree of deformity correction)
Simultaneous operating Multiple components of an operation performed concurrently by the surgeon and the robot to improve efficiency
Patient-specific processes Customized approaches (e.g., pedicle screw sizing and targeting in sclerotic pedicles or osteoporotic vertebral bodies) or optimized cage footprint and placement based on patient-specific factors, such as bone density
Robot-controlled assistive functions Robotic control of assistive functions, such as cautery, irrigation, retraction, and wound closure
Procedural innovation Novel tools and approaches made possible with robotics (e.g., robotic endoscopic osteotomy)
Improved patient tracking Real-time updates to registration (e.g., by robotic probes that monitor and update relative vertebral body position)
Increased real-time correction feedback New mechanisms to capture and report intraoperative iatrogenic and anatomic changes (e.g., spondylolisthesis reduction, scoliosis correction)
Improved fusion techniques Optimization of fusion-related procedures unrelated to implants (e.g., endplate preparation, graft site preparation, graft placement)
Enhanced visualization Preoperative virtual reality, intraoperative augmented reality, endoscopy, and other visual assistive functions providing new perspectives
Data collection and analysis Improved data collection and automated analysis of preoperative, intraoperative iatrogenic changes (e.g., restoration of lordosis), and postoperative outcomes (e.g., patient-reported outcome measures), ideally combined with cloud-based services to allow at-scale analysis to inform clinical practice
Integration of cloud-based data collection and analysis (e.g., operative note recording, editing, suggestions)

Conclusions

The realm of robotics has seen unprecedented progress, particularly for tasks characterized by high risk, repetitiveness, and significant financial costs when performed by humans. In the context of spinal surgery, integration of robotics holds substantial promise for advancing safety and curbing operational costs. However, the current landscape of spinal robotics falls short in crucial domains, failing to surpass the benchmarks set by contemporary image guidance systems in terms of quality, cost-effectiveness, and accessibility.

The spinal surgery community must foster an environment that embraces robotics while demanding tangible improvements in key areas. The current generation of spinal robotic systems lacks demonstrable enhancements in quality, as evidenced by their comparable performance to image guidance systems. Moreover, the cost-effectiveness and accessibility of spinal robotics remain concerns that demand reflective attention.

Commercial developments in spinal robotics are significantly influenced by financial considerations and regulatory frameworks. Surgeons, as pivotal stakeholders, should actively shape the trajectory of these platforms to ensure that the next wave of robotics aligns with both their professional requirements and the well-being of patients. Without such proactive involvement, there is a substantial risk of witnessing a cycle wherein ostensibly innovative spinal robotics merely repackage existing image guidance systems, devoid of substantive innovation. This lack of progress would ultimately deprive both surgeons and patients of the anticipated benefits inherent in the evolution of spinal robotics. Hence, a collective and informed effort is paramount to steer the course of spinal robotics toward innovation and truly meaningful advances in spinal surgery.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-4/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-4/coif). R.J.M. serves as the Editor-in-Chief of Journal of Spine Surgery. G.M.M. and L.H.S. serves as the unpaid editorial board members of Journal of Spine Surgery. G.M.M. is a consultant for Australian Biotechnologies, Globus, and LifeHealthcare. T.A.W.Q. is an employee of LifeHealthcare. A.M.N. is a consultant for Mainstay and Evolution Surgical. R.J.M. is a consultant for Australian Biotechnologies, A-Spine, LifeHealthcare, and Medacta. L.H.S. is a consultant for Katomed and Kyocera. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Malham GM, Wells-Quinn TA, Nowitzke AM, Mobbs RJ, Sekhon LH. Challenges in contemporary spinal robotics: encouraging spine surgeons to drive transformative changes in the development of future robotic platforms. J Spine Surg 2024;10(3):540-547. doi: 10.21037/jss-24-4

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