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35 Thought Leadership Dr. Frank Shen: Emerging spine technologies include smart devices, robotics & nano-engineering By Laura Dyrda F rank Shen, MD, division head for spine surgery at the University of Virginia Health System's department of orthopedic surgery in Charlottesville, discussed the big technology trends in spine surgery that will have an impact on the future. Question: What emerging technol- ogy or technique do you think will have the biggest impact on the spine field five years from now? Dr. Frank Shen: I think that over the next five to 10 years spine surgery will start to incor- porate technologies from multiple emerging fields, including robotics, advanced imaging techniques, wireless and smart technologies, and nano-engineering just to name a few. We are seeing the application of those technologies in our practices already. Currently, our institution is already utilizing ro- bot-guided technologies to increase the accuracy and precision of what we do in the operating room. In addition, we have been using real-time virtual imaging obtained from intraoperative 3D scans to develop virtu- al surgical plans and execute the plan intraoperatively. e use of wire- less and smart technologies will allow instruments, and likely implants, to communicate with one another seamlessly and in real-time, and will soon become commonplace. From a basic science standpoint, our research laboratory at the Univer- sity of Virginia School of Medicine has been developing tissue engineer- ing techniques and nanoparticles to help address challenges associated with large gra defects that can occur during revision spine surgery as well as developing percutaneous and systemic treatments for addressing inflammation and scars that can occur around nerves due to injury or aer surgery. As these technologies advance, it will not be long before we start to combine, and incorporate, them into our clinical practices. Q: What do you think will fade or disappear from the spine field over the next five years? FS: Much of what we are doing will continue to exist; however, it could evolve to such a degree that it may become slowly unrecognizable. As mentioned above, nano-technology, tissue engineering and percuta- neous robotic and image-guided techniques will allow us to continue to decompress nerves, realign deformity and stabilize instability while transitioning away from more traditional open surgical techniques. And as such, it could be easily imagined that this transition to remote surgery would be the next natural evolution of the technology. While this may seem distant in the future, rapid advances make it more likely than ever before. Q: Where do you see the biggest room for innovation in spine? What do you need to provide better care that doesn't currently exist? FS: I think that improved interfaces must be developed between the physician and the patient. For example, currently the EMR acts as a clumsy, and clunky, method for recording and storing medical, social and economic information. Physicians currently must interact both with the patient and the EMR simultaneously. is creates a physi- cian-patient and physician-EMR relationship that is both simultane- ous and competing at the same time. e current workaround for this problem is to utilize either third-person scribes or delayed charting, both of which have limitations. However, we need to develop a different paradigm. One that is more seamless; one where the EMR actually helps to improve and facilitate the interaction and relationship between the physician and the patient. is could be viewed schematically simply as a physician-EMR-patient interface. Whether this is utilizing a handheld iPad, video and audio re- cording, touchscreen tablets, virtual visits or combinations of all or none of these technologies, it must be realized that medical records are not simply about recording and storing information. A sufficiently advanced medical record should also focus on developing improved techniques for retrieval, sharing and processing of information as well. I think it is an unfortunate misunderstanding that the EMR is viewed predominantly as a means for storing information. As we move forward, and gather greater and greater volumes of data, we must focus on devel- oping methods for easy retrieval of information as well. n convinced. From an engineering standpoint, it makes sense to have a crenelated surface that will interdigitate with the bone; it takes more than some pretty color microscope pictures showing bone "growing" into the titanium to convince me of their efficacy. At the end of the day, there are business and advertising opportunities for the industry, but making a difference in clinical outcomes remains divorced from surface technology claims. Q: How do you think 3D printing will fit in spine moving forward? BG: e initial promise of custom-printed patient implants has fallen down the black hole of cost. What is happening now is there are 3D printed cages that offer a porous metallic environment that promises higher rates of fusion. Clinical studies have yet to bear out their superiority. In cranial surgery, we have been using custom implants for reconstructions for almost 20 years. It works great, looks good, and most of the time, it fits. In spine it is nearly im- possible to custom-print an implant due to unanticipated factors in surgery — such as bone quality, having to take more or less bone off than anticipated and surgical technology issues intraoperative — that it's been slower to catch on. Where it can and should shine is potentially having a 3D printer intraoper- ative that can construct a custom cage based on intraoperative CT scans or imaging. Whether we will get there anytime soon, and if we can get paid or the hospital get paid to do it, remains to be seen. I do hope it finds its niche in helping us do our actual jobs, rather than being ballyhooed as the latest and greatest. n