By Jeffrey L. Gum, MD, Norton Leatherman Spine Center
“Are you going to use the robot?” is a common question encountered in my office. Typically, my answer is “yes, of course” and then I go on to explain the procedure in detail and the benefits of utilizing such technology. Robotic-assistance in spine surgery is a relatively new technology that is emerging, and for obvious reasons. Beyond the typical marketing hype behind robotics, there is well-documented clinical value that patients experience when surgeons incorporate this technology in their surgical workflow and operating room.
Currently, the capabilities of all spinal robotic platforms are primarily focused on guiding the placement of screws into a specific part of the spine called the pedicle. Pedicle screws are a type of fixation placed to hold the spine in a fixed position while the vertebrae fuse together. The goal of a spinal fusion is to eliminate instability or motion that causes pain. There are numerous ways surgeons can place pedicle screws, and some of the most common methods include:
- freehand: the surgeon uses tactile feedback from their hands and the visualization of surrounding landmarks to place screws
- fluoroscopy-assisted: the surgeon uses live x-ray to place screws
- navigation-assisted: the surgeon uses 3D imaging to place screws
- robotic-assisted: the surgeon places screws through the arm of the robot
BENEFIT #1: ACCURACY
Each of these techniques have been very well studied and robotic-assisted, along with navigation-assisted, are consistently the most accurate. Why is this important? If a screw is placed incorrectly, it could cause a permanent neurologic deficit which may result in pain, weakness, and lead to another surgery to reposition the bad screw. Of course not all misplaced pedicle screws lead to this result, but why would surgeons not want to minimize this possibility and utilize the best available technology when appropriate?
BENEFIT #2: MINIMALLY INVASIVE
The second reason, and my favorite part of utilizing robotics in spine surgery, is that it allows the surgical goals to be accomplished in a more minimally invasive (MIS) and efficient manner. Over the last few decades, spine surgery has adopted a lot of techniques to improve the postoperative recovery process. The goal of these MIS techniques is to minimize disruption of the spinal muscles and utilize smaller incisions but still achieve the desired outcome. Robotic-assisted surgery has really helped surgeons incorporate these techniques and deliver better outcomes for patients. These MIS procedures allow patients to return to work and normal activities more quickly.
BENEFIT #3: REDUCED RADIATION
A third advantage that is not noticed by the patient, but is very important, would be reduction in radiation exposure. It is well known that excessive radiation exposure can have detrimental long term effects such as increased risk for certain types of cancer. Most patients that need to undergo a spinal fusion have been exposed to quite a bit of radiation already. Minimizing radiation exposure during the actual spinal fusion procedure itself can be beneficial for long-term health and potentially reduce the cancer risk.
BENEFIT #4: REDUCED TIME
The last reason that highlights the advantages of robotic-assisted spinal fusion surgery is reduction in the length of the surgery or OR time. OR time alone can be a risk factor for complications after surgery. In essence, if a surgeon can perform the same surgery quicker while still maintaining safety, the outcome is better. Less time under anesthesia expedites the recovery process and reduces the risk for medical complications in the postoperative period.
Overall, surgeons that incorporate robotic-assisted surgery into their toolbox of techniques for spinal fusion can potentially deliver more consistent, reliable, and better outcomes for patients undergoing fusion procedures. From a patient perspective, it is important to not just jump to any spine surgeon that claims they use robotics in their practice, but to have a conversation with them regarding how they utilize the technology. Appropriate questions include:
- How often do they use robotics?
- Why do they suggest using it for your procedure (or why not)?
- What benefits have they observed in similar patients or surgeries?
These baseline questions will serve as a good dialogue between patient and surgeon to get all questions answered and both sides comfortable with the shared decision-making process for surgery.
- Lee NJ, Leung E, Buchanan IA, et al. A multicenter study of the 5-year trends in robot-assisted spine surgery outcomes and complications. Journal of Spine Surgery. January 2022. doi: 10.21037/jss-21-102
- Garg S, Kleck CJ, Gum JL, Larson AN. (2022). Instructional Course Lectures, Volume 71. Wolters Kluwer, Navigation Options for Spinal Surgeons: State of the Art 2021. (pp. 399-411).