Contemporary innovations in spine surgery: balancing technological advancement and cost-effectiveness

Introduction

The landscape of spine surgery is undergoing a transformative shift, driven by the rapid evolution of innovative techniques and technologies. As these advancements continue to reshape surgical practice, their clinical efficacy, cost-effectiveness, safety and long-term impact must be critically evaluated (1). While technological innovation promises improved surgical precision, reduced invasiveness and enhanced patient outcomes, its adoption must be balanced against economic sustainability and accessibility (2).

Amongst the many innovations currently being promoted to spine surgeons, we believe the following five offer future potential. The first three technologies already demonstrate significant clinical benefit; however their cost effectiveness remains questionable, especially in the realm of robotics. The final two techniques showed early promise, but over the past two decades have not delivered convincing long-term data. Facet arthroplasty has enjoyed a resurgence; however, stem cell therapy still has very limited uptake globally due to a lack of efficacy in clinical studies.

Robotics in spine surgery

Robotic-assisted spine surgery has gained significant traction, principally in pedicle screw placement. Proponents argue that robotic systems enhance precision, reduce intraoperative radiation exposure, and standardize surgical techniques. Studies have demonstrated that robotic-guided pedicle screw placement reduces malposition rates and intraoperative complications compared to freehand and fluoroscopic guidance methods (3). Beyond pedicle screw placement, robotic platforms and software applications can additionally provide real-time pre-operative and intraoperative planning as well as additional procedural solutions for spinal fusion (4). Despite these benefits, widespread adoption remains limited due to significant financial barriers. The high capital investment and maintenance costs of robotic systems present substantial challenges for hospitals and surgical centres, particularly those with resource constraints (5). Next generation robotic systems will need to expand the scope of robotic assisted surgery beyond pedicle screw placement. Alternative technologies, such as three-dimensional (3D) fluoroscopic navigation, offer comparable accuracy with greater flexibility across multiple operating rooms and procedures, and arguably greater utility, therefore potentially providing a more cost-effective solution (6).

Endoscopic spine surgery

Minimally invasive techniques, particularly endoscopic spine surgery, offer reduced tissue trauma, decreased postoperative pain, with shortened length of stay and recovery times. Endoscopic approaches are broadly categorized into uniportal and biportal techniques. Uniportal endoscopy has evolved over the past 20 years but grown exponentially over the past 5 years and is widely adopted due to improved instrumentation and surgical workflow (7). Biportal endoscopy has been increasingly explored as it utilizes conventional arthroscopy equipment and is familiar particularly for orthopaedic surgeons (8).

However, the steep learning curve associated with both endoscopic techniques remains a key barrier. Surgeons require extensive training to master endoscopic procedures, which carries a high time and monetary cost. Reimbursement impediments remain to the surgeon, hospital and industry. Funding this extra cost may delay widespread implementation and limit adoption of the procedure outside publicly funded institutions. Additionally, uniportal endoscopy requires greater technical expertise and involves higher disposable usage, while biportal endoscopy offers a more accessible alternative (9). Similar training patterns and cost constraints (10) were encountered during the early adoption of abdominal endoscopy; however, these techniques have since become the global standard of care.

Endoscopic techniques show promise for cervical foraminotomy, thoracic disc prolapse and lumbar foraminal decompression—areas where conventional open approaches pose higher surgical risks. Additionally, endoscopy may reduce the need for fusion or instrumentation by preserving spinal stability. Given the increasing familiarity of younger surgeons with advanced imaging and arthroscopy, endoscopic spine surgery is likely to see broader future adoption (11), and transition to standard of care for many pathologies.

Neuromodulation: the future of pain management?

Neuromodulation techniques, including spinal cord stimulation (SCS), have emerged as treatment options for managing chronic back pain and failed back surgery syndrome. SCS involves electrical stimulation of the spinal cord, to modulate pain signals, offering a non-fusion approach to pain management. Studies have demonstrated that SCS may provide relief of neuropathic pain and functional improvement in carefully selected patients (12).

Despite these benefits, the cost-effectiveness of neuromodulation remains contentious. While SCS reduces the need for opioid use and additional surgeries, the high initial costs and variable response rates necessitate further investigation into long-term financial viability (13). Recent advances, such as closed-loop stimulation and dorsal root ganglion stimulation, aim to enhance efficacy and patient outcomes, potentially justifying the investment in these technologies (14).

Facet joint prostheses: fusion vs. arthroplasty

There has been a limited role for facet joint prostheses in spine surgery, particularly in the context of fusion versus arthroplasty. Minimally invasive facet fusion has been explored as an alternative to conventional fusion techniques (15), with early studies indicating reduced surgical trauma and improved recovery times (16). Facet arthroplasty provides a motion preserving option for addressing lumbar stenosis with spondylolisthesis that may otherwise undergo a fusion. Posterior laminectomy and bilateral facetectomy can be performed for complete neural decompression followed by placement of a pedicle screw-based facet replacement device that provides dynamic stabilization. A multi-centre randomized controlled trial with 2-year follow-up demonstrated facet arthroplasty to be safe and effective as compared to transforaminal lumbar interbody fusion (TLIF) while also preserving segmental motion (17). The conceptual advantage of facet arthroplasty is to preserve motion and reduce adjacent segment degeneration, but long-term clinical data remain limited (18). Long-term studies are needed to evaluate the longevity of these devices and the durability of the clinical outcome. The success of facet prostheses will ultimately depend on robust evidence demonstrating superior patient outcomes compared to conventional methods.

Stem cells in degenerative disc disease (DDD) and fusion

Regenerative medicine, particularly stem cell therapy, has emerged as a promising approach for treating DDD and enhancing spinal fusion outcomes. Stem cells have the potential to promote disc regeneration, potentially reducing the need for traditional invasive procedures. Preclinical animal models and early-phase clinical trials have shown encouraging results, demonstrating pain reduction and functional improvement following stem cell injections for DDD (19).

However, several challenges limit the widespread clinical adoption of stem cell therapies. High treatment costs, stringent regulatory requirements, and variability in patient outcomes remain significant barriers (20). Additionally, concerns persist regarding the long-term efficacy of stem cell therapies, particularly in terms of cell viability and durability over time. Future research should focus on optimizing stem cell delivery methods, standardizing treatment protocols, and establishing clear patient selection criteria (21) to demonstrate their definitive clinical value.

Conclusions

As spine surgery advances, the integration of innovative technologies must strike a balance between patient benefit, cost-effectiveness, and long-term value. Robotics and Spine Endoscopy represent significant progress in minimally invasive and precision-guided techniques, with widespread adoption dependent on robust clinical evidence and demonstrated economic feasibility. Neuromodulation, despite its demonstrated benefits in select patient populations, will continue to be scrutinized through cost-benefit analyses to justify its broader implementation. Technologies such as facet prostheses and stem cell therapies remain in experimental stages and their potential role in management of the spine patient requires further investigation. Future research should emphasize comprehensive cost-effectiveness analyses alongside long-term outcome studies to ensure that these innovations not only enhance surgical precision but also lead to tangible, sustainable improvements in patient outcomes and healthcare system efficiency.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Spine Surgery. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-37/coif). R.J.M. serves as the Editor-in-Chief of Journal of Spine Surgery. G.M.M. serves as an unpaid editorial board member of Journal of Spine Surgery. Besides, R.J.M. provides consultancy services to Elliquence for training junior surgeons. G.M.M. reports consulting fees from Globus Medical, Australian Biotechnology and Life HealthCare. 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/.

References

1. Bcharah G, Gupta N, Panico N, et al. Innovations in Spine Surgery: A Narrative Review of Current Integrative Technologies. World Neurosurg 2024;184:127-36. [Crossref] [PubMed]
2. Samartzis D, Alini M, An HS, et al. Precision Spine Care: A New Era of Discovery, Innovation, and Global Impact. Global Spine J 2018;8:321-2. [Crossref] [PubMed]
3. Matur AV, Palmisciano P, Duah HO, et al. Robotic and navigated pedicle screws are safer and more accurate than fluoroscopic freehand screws: a systematic review and meta-analysis. Spine J 2023;23:197-208. [Crossref] [PubMed]
4. Perfetti DC, Kisinde S, Rogers-LaVanne MP, et al. Robotic Spine Surgery: Past, Present, and Future. Spine (Phila Pa 1976) 2022;47:909-21. [Crossref] [PubMed]
5. Rossi VJ, Wells-Quinn TA, Malham GM. Negotiating for new technologies: guidelines for the procurement of assistive technologies in spinal surgery: a narrative review. J Spine Surg 2022;8:254-65. [Crossref] [PubMed]
6. Malham GM, Wells-Quinn TA, Nowitzke AM, et al. Challenges in contemporary spinal robotics: encouraging spine surgeons to drive transformative changes in the development of future robotic platforms. J Spine Surg 2024;10:540-7. [Crossref] [PubMed]
7. Mobbs RJ. The evolution and promise of endoscopic spine surgery. J Spine Surg 2024;10:772-4. [Crossref] [PubMed]
8. Antonacci CL, Zeng FR, Ford B, et al. A narrative review of endoscopic spine surgery: history, indications, uses, and future directions. J Spine Surg 2024;10:295-304. [Crossref] [PubMed]
9. Ahn Y, Lee S. Uniportal versus biportal endoscopic spine surgery: a comprehensive review. Expert Rev Med Devices 2023;20:549-56. [Crossref] [PubMed]
10. Moberg AC, Montgomery A. Appendicitis: laparoscopic versus conventional operation: a study and review of the literature. Surg Laparosc Endosc 1997;7:459-63. [Crossref] [PubMed]
11. Chen KT, Kim JS, Huang AP, et al. Current Indications for Spinal Endoscopic Surgery and Potential for Future Expansion. Neurospine 2023;20:33-42. [Crossref] [PubMed]
12. Ali R, Schwalb JM. History and Future of Spinal Cord Stimulation. Neurosurgery 2024;94:20-8. [PubMed]
13. McClure JJ, Desai BD, Ampie L, et al. A Systematic Review of the Cost-Utility of Spinal Cord Stimulation for Persistent Low Back Pain in Patients With Failed Back Surgery Syndrome. Global Spine J 2021;11:66S-72S. [Crossref] [PubMed]
14. London D, Mogilner A. Spinal Cord Stimulation: New Waveforms and Technology. Neurosurg Clin N Am 2022;33:287-95. [Crossref] [PubMed]
15. Mobbs RJ, Phan K, Malham G, et al. Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg 2015;1:2-18. [PubMed]
16. Heemskerk JL, Oluwadara Akinduro O, Clifton W, et al. Long-term clinical outcome of minimally invasive versus open single-level transforaminal lumbar interbody fusion for degenerative lumbar diseases: a meta-analysis. Spine J 2021;21:2049-65. [Crossref] [PubMed]
17. Coric D, Nassr A, Kim PK, et al. Prospective, randomized controlled multicenter study of posterior lumbar facet arthroplasty for the treatment of spondylolisthesis. J Neurosurg Spine 2023;38:115-25. [Crossref] [PubMed]
18. Pinter ZW, Freedman BA, Nassr A, et al. A Prospective Study of Lumbar Facet Arthroplasty in the Treatment of Degenerative Spondylolisthesis and Stenosis: Results from the Total Posterior Spine System (TOPS) IDE Study. Clin Spine Surg 2023;36:E59-69. [Crossref] [PubMed]
19. Oehme D, Goldschlager T, Ghosh P, et al. Cell-Based Therapies Used to Treat Lumbar Degenerative Disc Disease: A Systematic Review of Animal Studies and Human Clinical Trials. Stem Cells Int 2015;2015:946031. [Crossref] [PubMed]
20. Xin J, Wang Y, Zheng Z, et al. Treatment of Intervertebral Disc Degeneration. Orthop Surg 2022;14:1271-80. [Crossref] [PubMed]
21. Soufi KH, Castillo JA, Rogdriguez FY, et al. Potential Role for Stem Cell Regenerative Therapy as a Treatment for Degenerative Disc Disease and Low Back Pain: A Systematic Review. Int J Mol Sci 2023;24:8893. [Crossref] [PubMed]