Becker's ASC Review

32 ORTHOPEDICS Robotics in spine surgery: 17 notes for surgeons, ASCs & administrators By Alan Condon S pine surgery has advanced significant- ly over the past decade, with minimal- ly invasive surgery and robotic spine surgery drawing increased interest. In 2004, e FDA approved the Mazor SpineAssist for the placement of pedicle screws. e technology has developed rapid- ly since then, with several device companies introducing their own robots with promising clinical outcomes. Currently, the technology is approved for pedicle screw placement but could soon expand to other areas of spine. Here are 17 notes for surgeons, ASCs and administrators: 1. Market growth. e global spinal robotics market value is expected to reach $320 mil- lion by 2026, up from $75 million in 2017. Market growth will be driven by increased demand for minimally invasive spine proce- dures, which robots support. 2. Robots are here to stay. Interest continues to grow in reduced radiation exposure for patients and staff, precise implant placement and minimally invasive technologies. While robotic technology "may not be optimal, it has reached a point where it is reasonable and available," said Jonathan Carmouche, MD, of Carilion Clinic in Roanoke, Va. 3. Cost. Robotics are expensive purchases. Globus Medical's ExcelsiusGPS costs $1.5 million and Medtronic's Mazor X robot costs more than $1 million, with added disposable costs of about $1,000 per case, according to a study published in the Journal of Spine Surgery. e high cost ultimately increases the cost of care for patients. However, as the healthcare industry continues its move away from fee-for-service toward a value-based care model, device companies are working on producing robots that are less expensive. "Robotics are going to have to get cheaper so that your quality of care, global fees and episodes of care can be reasonably done and reason- ably charged," said Stephen Hochschuler, MD, founder of Texas Back Institute in Plano. When we consider more cost-effective options to care, device companies believe that the increased precision provided by robots will lead to fewer surgical errors and less reoperations, therefore leading to lower costs in the long term. 4. Attracting top surgeons. e next genera- tion of spine surgeons want to have access to the latest and greatest technology on the market. For total joint and spine surgeons, that's robotics, according to Alfonso del Granado, administrator at a Texas surgery center. Although robots can be an expensive capital purchase, surgery centers "have to make the investment" to attract talent at the top of the surgeon pool, he said. 5. Advantages/disadvantages: Although still in its infancy, robotic spine surgery has well- documented benefits. Improved precision translates to better outcomes and quicker re- coveries for patients, smaller incisions mean smaller scars and reduced risk of infection, and robots contribute to less radiation expo- sure for patients and staff. Robots can help surgeons safely transition to more minimally invasive procedures while maintaining low reoperation rates. Disadvantages include high costs, steep learning curves and inher- ent technological glitches. 6. Future applications. While robots are primarily used for pedicle screw placement, the technology has the potential to advance far beyond instrumentation placement. "e future is very exciting for robotic spine surgery," said K. Samer Shamieh, MD, of Avala Hospital in Covington, La. "I believe that robots will soon be used for docking of retractors, drilling of bone as well as direct- ing certain equipment to take away tissue from the spinal cord and nerves." 7. Spinal deformity surgery could be the next frontier for robotics. "Planning lumbar laminectomies and more technically demanding techniques, like osteotomies for deformity surgery," are on the horizon, ac- cording to Raymond Walkup, MD, of Polaris Spine & Neurosurgery Center in Sandy Springs, Ga. "Soon, we will have the ability to plan the deformity correction and predict the amount of lordosis we can achieve with the fusion construct." 8. Robotic autonomy. While many physi- cians believe that robots will never replace surgeons, other industry leaders see the technology developing greater autonomy in the operating room, similar to robots in the auto industry. 9-12. A breakdown of spinal robotics at four device companies: Medtronic: In December 2018, Medtronic acquired Mazor Robotics in a $1.7 billion deal, as part of its plan to combine its spinal implants, navigation and 3D-imaging tech- nology with the Mazor X robotic guidance system. e Mazor X costs about $1 million with each surgery resulting in about $1,500 in disposables sales. e third-generation system, the Mazor X Stealth Edition, was used in more than 1,000 procedures in over 50 U.S. hospitals in its first year. Globus Medical: Globus Medical acquired Excelsius in 2014 for an estimated $40 mil- lion and earned CE Mark approval for Excel- siusGPS in the European Union in January 2017. e FDA cleared the system for use in spine surgery in August 2017. ExcelsiusGPS is priced at about $1.5 million and supports screw placement in several approaches in- cluding posterior cervical, posterior thoracic sacroiliac and posterior lumbar. Zimmer Biomet: In 2016, Zimmer Biomet acquired Medtech SA for at least $132 mil- lion. Medtech developed the Rosa Brain and Rosa Spine robotic-assisted surgery systems, which cost about $700,000 each. Rosa Spine was cleared by the FDA in 2016, and the company's new technology — the Rosa One Spine System — received FDA approval in March 2019. e Rosa system has been used more in cranial neurosurgical procedures than in spinal procedures. NuVasive: NuVasive revealed a new spinal robotics system called Pulse in the fall of 2019. e robot is an open imaging platform integrated with Siemens' 3D mobile C-arm, Cios Spine. e Pulse system is expected to have applications for all spinal surgeries, not just complex or low-acuity cases. e system features neuromonitoring, surgical planning, radiation reduction and rod bending tech- nologies, as well as imaging and navigation functions. CEO Chris Barry said in NuVasive's second-quarter earnings call that robot has been delayed due to "soware and hardware updates following beta testing, as well as the impact of COVID-19." e Pulse system is expected to launch in summer 2022, with the first-in-human use of Pulse Robotics in 2022. 13-17. Five surgeon insights: Christopher Good, MD. Virginia Spine Institute (Reston): "Spinal robots have already advanced well beyond being used solely for instrumentation placement. I have used robotic soware and guidance to help plan and execute osteotomies for spinal realignment and to guide spinal decompression. I also use robotic guidance to assist with minimally invasive lumbar facet preparation in the setting of mini- mally invasive fusion. I've also used robotic/

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