Commentary

Robotics in spine surgery: Is it a Tesla or just another plug-in hybrid car?

As long as I can remember, I have been an avid car enthusiast, someone who understands the nuances between the different years of the classic Porsche 911, for example. When Tesla Motors presented its first all plug-in electric motor Tesla S in 2009, I and many other car enthusiasts were skeptical of this new motoring concept. After all, there were already several hybrid cars on the market that operated on a combined electric and traditional gas-powered engine. Intrigued with the new all-electric motor of the Tesla, we wondered if this was just another fad and marketing ploy in the automobile industry that likely would not be around in a few years or the true future of automobiles.

With the Models S and X that came out 7 years later and the Model 3 on the way, many experts view Tesla as achieving a rare, but revolutionary car advancement not unlike what Ford did with the Model T in 1908. Not only is the all-electric motor a new form of personal transportation, in many ways it has succeeded by outperforming traditional gas-powered engine cars in many of the customary methods by which performance is compared. Therefore, it comes as no surprise that other traditional car companies are now rolling out their own concepts of personal all-electric transportation.

Robotic spine surgery also may be viewed in this way one day. Only a few surgeons globally have introduced robotic surgery into their routine spine practices. This begs the question of whether robotic spine surgery is just a fad or a revolutionary change on the verge of overtaking spine surgery. Recent development agreements were struck or are underway between traditional device manufacturers and robotic companies, such as Medtronic and Mazor Robotics, as well as Zimmer Biomet and MedTech, a French robotics company with a robotics product called Rosa. Questions now abound concerning the future of robotics in spine surgery.

Robotic to mainstream surgery

In robotic surgery, a computer-controlled robot assists the surgeon. Advantages of robotic surgery over traditional surgery include improved visualization, dexterity and precision. Furthermore, it facilitates performing complex surgical tasks in small spaces through small incisions and some have described it as a better way to perform complex minimally invasive surgery (MIS).

It remains to be seen how that will translate into mainstream spine surgery because, for now, the indications for robotics are limited. These are mostly focused on performing pedicle screw placement open or percutaneously, spine biopsy, some tumor resection and vertebroplasty. For the most part, the robotic technique alters how those surgeries, which are not game-changing operations, are now performed. Using the earlier analogy, it is a plug-in hybrid car, but not a Tesla.

For robotics to be truly revolutionary in spine surgery, it must allow surgeons to alter what they currently do, as well as fundamentally change how spine disease is addressed and foster new ways of managing it. This is the only way robotics will depart from being a mere marketing advantage and transform how surgeons approach spine patients in the future.

Spine MIS and spine navigation are relatively recent developments that have altered how some surgeons approach spine diseases and operate, although these techniques are used only in a minority of spine surgery cases. Robotics can essentially unite the improved precision and surgical dexterity of MIS and spine navigation and advance it in such a way that it helps surgeons tackle complex disease processes or challenging spinal regions beyond what is now possible with those two technologies. Spine tumors that now require an open approach may conceivably be performed using MIS with robotic assistance, much like urological and gynecological oncologists use surgical robots today.

Potential applications

Once improvements occur in navigation that help surgeons better identify soft tissue structures, this will help transition robotics to assist in how we perform surgeries today. For example, using navigation to identify the lumbar plexus and vascular structures will help transform how anterior and lateral lumbar and thoracic interbody fusion (IF) approaches are performed. Laparoscopic approaches may see a resurgence in popularity, appearing in the surgeon’s armamentarium to help safely and effectively access anterior lumbar interbody spaces or resect pre-vertebral tumors. MIS lateral lumbar IF also can benefit from a surgical approach that involves the triad of MIS, navigation and robotics. Previously difficult areas for MIS fusion, such as the upper cervical and sub-axis cervical regions, can be improved upon with help from navigation and robotic technology. This will allow new types of surgery to develop and, coupled with other advancements, the most difficult spinal deformity and tumor surgeries may be tackled utilizing this triad of techniques.

We must wait and see if robotics in spine surgery will be the next Tesla or just another plug-in hybrid automobile. Personally, I would love to see a new “Tesla” in spine surgery.

Disclosure: Liu reports no relevant financial disclosures.

As long as I can remember, I have been an avid car enthusiast, someone who understands the nuances between the different years of the classic Porsche 911, for example. When Tesla Motors presented its first all plug-in electric motor Tesla S in 2009, I and many other car enthusiasts were skeptical of this new motoring concept. After all, there were already several hybrid cars on the market that operated on a combined electric and traditional gas-powered engine. Intrigued with the new all-electric motor of the Tesla, we wondered if this was just another fad and marketing ploy in the automobile industry that likely would not be around in a few years or the true future of automobiles.

With the Models S and X that came out 7 years later and the Model 3 on the way, many experts view Tesla as achieving a rare, but revolutionary car advancement not unlike what Ford did with the Model T in 1908. Not only is the all-electric motor a new form of personal transportation, in many ways it has succeeded by outperforming traditional gas-powered engine cars in many of the customary methods by which performance is compared. Therefore, it comes as no surprise that other traditional car companies are now rolling out their own concepts of personal all-electric transportation.

Robotic spine surgery also may be viewed in this way one day. Only a few surgeons globally have introduced robotic surgery into their routine spine practices. This begs the question of whether robotic spine surgery is just a fad or a revolutionary change on the verge of overtaking spine surgery. Recent development agreements were struck or are underway between traditional device manufacturers and robotic companies, such as Medtronic and Mazor Robotics, as well as Zimmer Biomet and MedTech, a French robotics company with a robotics product called Rosa. Questions now abound concerning the future of robotics in spine surgery.

Robotic to mainstream surgery

In robotic surgery, a computer-controlled robot assists the surgeon. Advantages of robotic surgery over traditional surgery include improved visualization, dexterity and precision. Furthermore, it facilitates performing complex surgical tasks in small spaces through small incisions and some have described it as a better way to perform complex minimally invasive surgery (MIS).

It remains to be seen how that will translate into mainstream spine surgery because, for now, the indications for robotics are limited. These are mostly focused on performing pedicle screw placement open or percutaneously, spine biopsy, some tumor resection and vertebroplasty. For the most part, the robotic technique alters how those surgeries, which are not game-changing operations, are now performed. Using the earlier analogy, it is a plug-in hybrid car, but not a Tesla.

For robotics to be truly revolutionary in spine surgery, it must allow surgeons to alter what they currently do, as well as fundamentally change how spine disease is addressed and foster new ways of managing it. This is the only way robotics will depart from being a mere marketing advantage and transform how surgeons approach spine patients in the future.

Spine MIS and spine navigation are relatively recent developments that have altered how some surgeons approach spine diseases and operate, although these techniques are used only in a minority of spine surgery cases. Robotics can essentially unite the improved precision and surgical dexterity of MIS and spine navigation and advance it in such a way that it helps surgeons tackle complex disease processes or challenging spinal regions beyond what is now possible with those two technologies. Spine tumors that now require an open approach may conceivably be performed using MIS with robotic assistance, much like urological and gynecological oncologists use surgical robots today.

Potential applications

Once improvements occur in navigation that help surgeons better identify soft tissue structures, this will help transition robotics to assist in how we perform surgeries today. For example, using navigation to identify the lumbar plexus and vascular structures will help transform how anterior and lateral lumbar and thoracic interbody fusion (IF) approaches are performed. Laparoscopic approaches may see a resurgence in popularity, appearing in the surgeon’s armamentarium to help safely and effectively access anterior lumbar interbody spaces or resect pre-vertebral tumors. MIS lateral lumbar IF also can benefit from a surgical approach that involves the triad of MIS, navigation and robotics. Previously difficult areas for MIS fusion, such as the upper cervical and sub-axis cervical regions, can be improved upon with help from navigation and robotic technology. This will allow new types of surgery to develop and, coupled with other advancements, the most difficult spinal deformity and tumor surgeries may be tackled utilizing this triad of techniques.

We must wait and see if robotics in spine surgery will be the next Tesla or just another plug-in hybrid automobile. Personally, I would love to see a new “Tesla” in spine surgery.

Disclosure: Liu reports no relevant financial disclosures.