Guest CommentaryFrom OT Europe

Newest technology, developments in spine surgery include MIS, robotic surgery, 3-D printing

During the past 2 decades, many surgical specialties have used newer technologies in parallel with different scientific developments for the purpose of decreasing morbidity and mortality. No doubt, spine surgery also follows this trend.

Minimally invasive surgical (MIS) techniques are a part of the daily practice of many spine surgeons. There are four virtues of MIS in spine: less surgically induced tissue damage; predictable clinical outcomes, such as decreased blood loss, shorter hospital stays and faster postoperative rehabilitation; clinical efficacy; and reasonable cost. It is somewhat difficult to identify what is less invasive when it comes to spine approaches, since there is a wide spectrum, which include percutaneous, tubular, mini-open or a combination of these. Another important point is whether the procedure itself is minimally invasive or it can be regarded as “maximally invasive” because of surrounding vital structures and complex anatomy.

Alpaslan Senkoylu, MD
Alpaslan Senkoylu

Most surgeons turn to MIS techniques exclusively for trauma and degenerative conditions. In particular, vertebroplasty/kyphoplasty, endoscopic disc surgery, percutaneous fixation techniques and minimally invasive interbody fusion have been proved as effective procedures with short hospital stay and decreased morbidity in several studies, such as those by Ruetten and colleagues, McAnany and colleagues, and Tian and colleagues.

There limited indications for MIS in spinal deformities and neoplastic conditions. Nevertheless, MIS techniques in spine surgery have major drawbacks as these need a long and steep learning curve. These might result in major catastrophes when attempted by inexperienced surgeons. Another important disadvantage of MIS spine techniques is that harmful radiation exposure can occur that can affect the patient and surgeon.

Robotic surgery

Spine surgery is an advanced subspecialty that relies on meticulous motor skills to carefully manipulate vulnerable structures, such as the neural elements. Sometimes spine surgeons must work through narrow areas that are surrounded by critical anatomical structures. Furthermore, these procedures may take a long time to complete and can therefore cause of mental and physical fatigue for the surgeon. Based on these facts, spine surgery is a good candidate for robotic surgery.

Robotic surgery gained its popularity with intrapelvic, complex surgeries that consisted of gynecologic oncology, prostatic and rectal surgery. Among spinal interventions, pedicle screw fixation is the most common area in which robotic-assisted surgery is used. Studies show the accuracy of robotic-assisted pedicle screw insertion is sufficient. On the other hand, Laudato and colleagues found no significant difference between fluoroscopy-assisted free hand, O-arm-assisted and robotic-assisted pedicle screw insertion groups in a study. Thus, it can be said robotics in spine surgery is still in its infancy and needs more adaptation to different complex procedures, such as tumor resection and deformity correction, to gain widespread use in this specialty.

Will robotic surgery in spine eventually gain universal appreciation as has been the case with knee arthroscopy or will the appreciation for robotic surgery be limited to medical history books and deemed as an approach that was no more than an expensive, marketing gadget? I think it is too early to answer this question accurately since we need more evidence for drawing any conclusions.

Additive manufacturing

Additive manufacturing — 3-D printing — emerged in the new millennium. Economist and social theorist Jeremy Rifkin described additive manufacturing or 3-D printing as a feature of the “third industrial revolution.” It allows 3-D renderings to be become physical objects by way of a printer that uses CAD software and stereolithographic design files. The 3-D printing technology has revolutionized prototyping and is now found in many non-medical applications. In medicine, the technology has applications in orthopaedic surgery, neurosurgery, maxillofacial surgery, cardiac surgery and spine surgery, among various other disciplines.

In spine surgery, there are three main areas in which 3-D printing is being used: anatomic haptic models for preoperative planning; surgical guides for the placement of pedicle screws; and patient-specific titanium implants for spinal column reconstruct ion.

Spine surgery is inherently dangerous due to the complex surrounding anatomy. Intraoperative patient-specific pedicle screw placement guides created with preoperative data obtained from imaging studies may help surgeons avoid the risks of these procedures. One of the first studies of pedicle screw placement guides used in adolescent idiopathic scoliosis patients was a pilot study presented at the Scoliosis Research Society Annual Meeting in September 2017. It showed use of these low-cost, personalized 3-D guides is as safe and effective as computer/navigation-based techniques with 92% accuracy. However, the major disadvantage of this technology is the requisite CT scan that is needed to model the spinal column because it resulted with high radiation exposure to the patient. Future studies should focus on modelling structures using imaging techniques that have low radiation.

As spine surgeons, we must identify emerging technologies for obtaining better outcomes with decreased morbidity and mortality in complex surgeries. However, the cost-benefit dilemma must be considered in the decision-making process related to adoption of new technologies in spine surgery.

Disclosure: Senkoylu reports no relevant financial disclosures.

During the past 2 decades, many surgical specialties have used newer technologies in parallel with different scientific developments for the purpose of decreasing morbidity and mortality. No doubt, spine surgery also follows this trend.

Minimally invasive surgical (MIS) techniques are a part of the daily practice of many spine surgeons. There are four virtues of MIS in spine: less surgically induced tissue damage; predictable clinical outcomes, such as decreased blood loss, shorter hospital stays and faster postoperative rehabilitation; clinical efficacy; and reasonable cost. It is somewhat difficult to identify what is less invasive when it comes to spine approaches, since there is a wide spectrum, which include percutaneous, tubular, mini-open or a combination of these. Another important point is whether the procedure itself is minimally invasive or it can be regarded as “maximally invasive” because of surrounding vital structures and complex anatomy.

Alpaslan Senkoylu, MD
Alpaslan Senkoylu

Most surgeons turn to MIS techniques exclusively for trauma and degenerative conditions. In particular, vertebroplasty/kyphoplasty, endoscopic disc surgery, percutaneous fixation techniques and minimally invasive interbody fusion have been proved as effective procedures with short hospital stay and decreased morbidity in several studies, such as those by Ruetten and colleagues, McAnany and colleagues, and Tian and colleagues.

There limited indications for MIS in spinal deformities and neoplastic conditions. Nevertheless, MIS techniques in spine surgery have major drawbacks as these need a long and steep learning curve. These might result in major catastrophes when attempted by inexperienced surgeons. Another important disadvantage of MIS spine techniques is that harmful radiation exposure can occur that can affect the patient and surgeon.

Robotic surgery

Spine surgery is an advanced subspecialty that relies on meticulous motor skills to carefully manipulate vulnerable structures, such as the neural elements. Sometimes spine surgeons must work through narrow areas that are surrounded by critical anatomical structures. Furthermore, these procedures may take a long time to complete and can therefore cause of mental and physical fatigue for the surgeon. Based on these facts, spine surgery is a good candidate for robotic surgery.

Robotic surgery gained its popularity with intrapelvic, complex surgeries that consisted of gynecologic oncology, prostatic and rectal surgery. Among spinal interventions, pedicle screw fixation is the most common area in which robotic-assisted surgery is used. Studies show the accuracy of robotic-assisted pedicle screw insertion is sufficient. On the other hand, Laudato and colleagues found no significant difference between fluoroscopy-assisted free hand, O-arm-assisted and robotic-assisted pedicle screw insertion groups in a study. Thus, it can be said robotics in spine surgery is still in its infancy and needs more adaptation to different complex procedures, such as tumor resection and deformity correction, to gain widespread use in this specialty.

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Will robotic surgery in spine eventually gain universal appreciation as has been the case with knee arthroscopy or will the appreciation for robotic surgery be limited to medical history books and deemed as an approach that was no more than an expensive, marketing gadget? I think it is too early to answer this question accurately since we need more evidence for drawing any conclusions.

Additive manufacturing

Additive manufacturing — 3-D printing — emerged in the new millennium. Economist and social theorist Jeremy Rifkin described additive manufacturing or 3-D printing as a feature of the “third industrial revolution.” It allows 3-D renderings to be become physical objects by way of a printer that uses CAD software and stereolithographic design files. The 3-D printing technology has revolutionized prototyping and is now found in many non-medical applications. In medicine, the technology has applications in orthopaedic surgery, neurosurgery, maxillofacial surgery, cardiac surgery and spine surgery, among various other disciplines.

In spine surgery, there are three main areas in which 3-D printing is being used: anatomic haptic models for preoperative planning; surgical guides for the placement of pedicle screws; and patient-specific titanium implants for spinal column reconstruct ion.

Spine surgery is inherently dangerous due to the complex surrounding anatomy. Intraoperative patient-specific pedicle screw placement guides created with preoperative data obtained from imaging studies may help surgeons avoid the risks of these procedures. One of the first studies of pedicle screw placement guides used in adolescent idiopathic scoliosis patients was a pilot study presented at the Scoliosis Research Society Annual Meeting in September 2017. It showed use of these low-cost, personalized 3-D guides is as safe and effective as computer/navigation-based techniques with 92% accuracy. However, the major disadvantage of this technology is the requisite CT scan that is needed to model the spinal column because it resulted with high radiation exposure to the patient. Future studies should focus on modelling structures using imaging techniques that have low radiation.

As spine surgeons, we must identify emerging technologies for obtaining better outcomes with decreased morbidity and mortality in complex surgeries. However, the cost-benefit dilemma must be considered in the decision-making process related to adoption of new technologies in spine surgery.

Disclosure: Senkoylu reports no relevant financial disclosures.