Becker's Spine Review

10 SPINE SURGEONS "Probably the most important feature of future spine robots is the concept of universality. They must be able to perform a wide variety of procedures and ideally be agnostic to the manufacturer of the implant." - Dr. Ernest Braxton, Vail Summit Orthopaedics and Neurosurgery The state of robotics in spine surgery today: 14 notes on market share, opportunities & more By Alan Condon S urgical robots continue to make noise in the spine industry and are expected to pick up steam in the coming years as more devicemakers launch systems to compete with the Medtronic, Globus Medi- cal and Zimmer Biomet systems that control most of the market. Here are 14 observations on the robotic spine industry and thoughts from surgeons about the future: 1. e global market for spine surgical ro- bots — valued at $124.2 million in 2020 — is expected to reach $451 million by the end of 2026, increasing at a compound annual growth rate of 20 percent from 2021 to 2026. Market growth will be driven by an increased demand for minimally invasive spine tech- nologies, which result in less blood loss, fewer complications and shorter hospital stays. 2. Robots have been lauded by many surgeons for limiting radiation exposure and their im- proved precision, which translates to better outcomes and quicker recoveries for patients. However, disadvantages of the technology include high costs, steep learning curves and inherent technological glitches. 3. Robotic spine surgery is playing catch up to robotics in other surgical specialties, such as urology and general surgery, but adoption has been steadily climbing in the U.S. in re- cent years. Current systems on the market offer the potential to improve pedicle screw placement accuracy, reduce operative time and decrease radiation exposure for staff and the patient. However, there are some draw- backs that include a challenging learning curve and various technical factors that are continually reassessed to improve operative efficiency and to meet these goals. 4. Robotics still represents a significant capi- tal expense for hospitals and ASCs. Medtron- ic's Mazor X robot costs more than $1 million and Globus Medical's ExcelsiusGPS costs $1.5 million, according to a study published in the Journal of Spine Surgery. e high cost ulti- mately increases the cost of care for patients. But medtech companies are now working on robots that are cheaper so quality care, global fees and episodes of care can be performed and charged reasonably. 5. Medtronic acquired Mazor Robotics for $1.7 billion in 2018, as part of its plan to integrate its spinal implants, navigation and 3D imaging technology with the Mazor X robotic guidance system. In 2019, the company launched the Mazor X Stealth Edition, which allows sur- geons to create personalized 3D surgical plans before surgery and holds surgical instrumen- tation in place with a robotic arm during spine procedures. e Mazor X Stealth Edition was used in more than 1,000 procedures in over 50 U.S. hospitals in its first year. 6. Globus Medical acquired Excelsius in 2014 for an estimated $40 million and earned CE mark approval for ExcelsiusGPS in the Eu- ropean Union in January 2017. e FDA provided clearance for the system in August 2017. e device also combines a robotic arm with navigation to improve accuracy in the placement of screws during spine surgery and reduce radiation exposure for the surgi- cal team. 7. Of the 402 screws placed in 77 patients who had robot-assisted spine surgery at Rochester, Minn.-based Mayo Clinic between Septem- ber 2018 and October 2019, none required postoperative revisions, according to a May 2021 study in Mayo Clinic Proceedings. Two of the 402 screws required modifi- cations intraoperatively, but none of the study's patients had complications re- lated to screw placement. The duration of operations decreased significantly as surgeons performed more cases with the robot, according to the study. The number of procedures performed each week also increased, and length of hos- pital stay after surgery was two days. 8. ASCs and hospitals are now looking to pur- chase spine robots as a way to attract talent. e next generation of spine surgeons want to have access to the latest and greatest tech- nology on the market, and that's robotics, ac- cording to Alfonso del Granado, administra- tor at Covenant High Plains Surgery Center in Lubbock, Texas. Although robots can be an expensive capital purchase, surgery cen- ters "have to make the investment" to attract talent at the top of the surgeon pool, he said. 9. While spine robots are primarily used for the placement of pedicle screws, many sur- geons believe the technology will advance far beyond instrumentation placement and holds particular promise for spinal deformi- ty surgery. Docking retractors, drilling bone and directing certain equipment to take away tissue from the spinal cord and nerves are some of the ways surgeons expect the capa- bilities of spine robots to evolve. 10-14. Five surgeon insights: Frank Phillips, MD. Rush University Medi- cal Center (Chicago): Over the last few years, we've seen the robot hype and age, and I think that's here to stay. For now, I think robots are more hype than offering real clinical advan- tages. I think they're sort of image guidance dressed up with an aiming arm, but clearly they have the potential in the future to really change what we do. I think the companies that have or are developing robots recognize that. ey realize that right now it won't add much, if any, efficiency and the accuracy that they provide is pretty good with other things that we already use. I think it's more the promise of what they will be. ere's augmented real- ity technologies that are real and coming out. ese are technologies with retina display headset ability to do navigation, which plays to

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