Becker's Spine Review

35 Thought Leadership think as more spine surgeons learn and apply endoscopic techniques to the easier surgeries, we'll see great opportunities for the more com- plex surgeries. I try to use endoscopic tech- niques whenever possible because they are my happiest patients. Q: What is your opinion on interven- tional pain management physicians performing endoscopic spine surgery? SH: I am a firm believer that physicians should not perform a procedure unless they are com- fortable handling any potential complications from that procedure. Any endoscopic procedure involving the neural elements should be per- formed by spine surgeons. ere are a variety of endoscopic-based pain procedures such as an endoscopic radiofrequency ablation, which have better outcomes than standard RFA. I think it is reasonable for an appropriately trained pain management physician to perform these proce- dures. I would strongly recommend close men- torship with an experienced surgeon as, even in the most benign pain-based application, there is potential for serious nerve injury. n Are robots inevitable in orthopedic and spine ASCs? 3 surgeons on robotic technology By Patsy Newitt D uring the Becker's Orthopedic, Spine + ASC virtual event on March 18, three surgeons discussed the in- evitability and necessity of robotics in the ASC setting. Question: What is your view of robotic technology in the ASC? Richard Wohns, MD. Founder and President of Neospine (Puyallup, Wash.): I've tried to get a robot into our outpa- tient center for five or six years, but it ended up being easi- er to get it into the hospital because of the cost. We have a robot in the hospital where I do my inpatient cases, and I've been basically doing outpatient surgery with the robot in the hospital. It's been about 15 months. I've done about 60 pedi- cle screw cases with 100 percent accuracy and incredibly fast discharges in an outpatient period of time. Some of the cas- es are one- or two-hour stays and then some stay overnight, but it's made the bigger cases that I was doing in the hospital outpatient. I relit the candle to get the robot also into our surgery center, and I'm very happy to say that next month we'll have a robot in our surgery center also. We'll be able to do most of those big cases in the surgery center — other than cases that need to be in the hospital for comorbidities or other factors that preclude outpatient surgery. I love the technology. I did stealth back in the day, and that was my neuronavigation guidance for pedicle screws with minimally invasive in the '90s and early 2000s. I find this technology far superior with just robotics alone. I'm very optimistic about the future of robotics. Frank Phillips, MD. Director of Spine Surgery at Rush Uni- versity Medical Center (Chicago): I have quite a different view of the field and where it is today than Rich. I think no one would disagree that robotics today are basically image guidance with an aiming arm. That's really all they do. I can see how in certain instances when people may not be com- fortable putting in screws percutaneously, it maybe gives some advantage, but really it doesn't move the needle. I think they certainly have potential, and I think it probably will be the future. You have to start somewhere, but I would ar- gue right now they add very little incremental advantage at an enormous cost. I do my pedicle screws in the ASC for [extreme lateral interbody fusion] and [transforaminal lumbar interbody fusion]. Those cases of a simple fusion like that are done in usually under two hours. The patients leave two, three hours later. It's hard to imagine that the robot can make me more efficient. We've had robots in our hospital, and my experience with myself and others is seldom do they actually, when you really measure it, make you more efficient. The accuracy is good, but I think expe- rienced spine surgeons generally are pretty accurate at putting in pedicle screws. I think the enormous cost associated with the cost of a robot, plus the 3D navigation piece you need, just makes them prohibitive to me in a surgery center. To answer your question, I think robots have promise. I think as they do things that are very difficult that make us better sur- geons, then I see an advantage. Right now, they do relatively simple things well. I'm generally a new technology guy and when robots first came along, I was excited like everybody else. But to me they haven't really proven enough incremental advantage of what we've been doing to justify the really enor- mous cost. At the same time, you know, clearly Wall Street loves robots. Every company that's got a robot, their stock price goes up. So it runs incentivized to come out for the next robot. Alfonso del Granado. Administrator of Covenant High Plains Surgery Center (Lubbock, Texas): So I have a slight- ly different perspective than Dr. Wohns and Dr. Phillips. My goal is to bring more cases to the surgical center, and robot- ics is not going to help surgeons who are comfortable doing the same case non-robotically. It's just going to add expense. But in terms of bringing, for example, total joints, total knee and hip replacement, if I don't get a robot, I can't get those cases in. All of the sur- geons in town who do outpatient joint replacement are do- ing it robotically, so not much of a choice there. If I was going to have my druthers, I'd rather not have to use robotics. But by and large, I don't see that we really have a choice. For any surgical center that's in a similar situation to ours, they're going to have to just put the money down. I will say this: The limited application robots — the specific robots that Stryker Corp. makes or the Zimmer Biomet Rosa — their consumable costs have come down significantly. So even though it will eat into our margin, we'll still have a margin. Better to have 20 percent of 100 cases than 100 percent of zero cases. n

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