Becker's Spine Review

18 THOUGHT LEADERSHIP Why this spine surgeon says the future is bright for artificial disc replacements By Ariana Portalatin A s designs improve and the cost advantages become clear, patients and providers may in the future choose artificial disc replacements over other kinds of surgeries, according to Jack Zigler, MD. Dr. Zigler is an orthopedic spine surgeon and co-director of the Center for Disc Replacement at the Texas Back Institute in Plano. He joined the "Becker's Healthcare Spine and Orthopedic Podcast" to discuss how he sees the future of artificial disc replacements evolving. Question: How do you think lumbar disc replacement will evolve in the future? Dr. Jack Zigler: I think that lumbar disc replacement is going to be more generally used as time goes on. The payers of the future, whoever they are, whether it's a single payer in the government, or a consolidation of insurance companies or hospital systems, whoever is controlling the healthcare dollar is ultimately going to see a significant decrease in the need for expensive spinal reoperations is in the public good. Reoperation is one of the largest drivers of healthcare economics, so by cutting down the necessity for additional surgery, with the data that we've been able to generate, I think it's going to be a no-brainer for the powers who are controlling the healthcare dollar to recommend disc replacement over fusion. So I think in the future there's going to be even a bigger role for disc replacement than we've seen before. Lastly, I think there are going to be evolutionary designs in implant designs, in material science and instrumentation. The discs of the future will be even better than the ones we have available for us today, but we're getting great results and outcomes even with the very early models that we've been using through our FDA study and beyond. The future's really good for this technology, and it's being proven by science, not just by a cheerleader. There is very strong evidence that shows this is the appropriate thing for a patient who has the choice between a fusion and a disc replacement. And as patients become more educated, I think they will continue asking that question, "Why do I have to have a fusion?" n Spine surgeons spotlight 4 key issues with robots By Alan Condon S urgical robots entered the spine field in 2004, when the FDA cleared the Mazor SpineAssist to guide the placement of pedicle screws. Spine robots have come a long way since but are still very much in their infancy. Although most surgeons consider robots to play a key role in the future of spine surgery, there are challenges that need to be addressed. Four barriers to the widespread adoption of spine robots: 1. Cost e initial purchase of a spine robot is about $1 million — a significant expense for any hospital, orthopedic practice or ASC, especially those operating on fine margins as a result of the COVID-19 pandemic. In addition, upcharges to patients and insurance become realities as cost per unit case increases. Most ASCs do not have the budget to install a spine robot, which increases the cost per procedure without bringing in higher reimbursement from insurers. Many ASCs also operate on thin profit margins, and as spine robots offer minimal value to experienced surgeons, they are considered cost prohibitive in surgery centers. However, some ASC administrators argue they will "have to make the investment" to attract top talent as the next generation of spine surgeons trains with robots and wants access to the latest technology. "It is essential to determine if the touted advantages of robotically assisted spine surgery translate to meaningful clinically significant benefits for patients. Healthcare systems are transitioning to value-based reimbursements, and any new surgical technology must be analyzed with respect to the quality and cost of healthcare delivered," said Alex Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedic Institute. "Robotic spine surgery has a promising future, and I anticipate that succeeding iterations of robotic platforms will overcome the current drawbacks." 2. Procedural limitations Although robots are expected to expand to other areas of spine surgery — such as preparing the interbody space for fusion; docking of retractors; drilling of bone; and performing fully automated, robotic-guided laminectomies/decompressions — they are still primarily used for pedicle screw placement. "Difficult cases, including spinal deformities with atretic pedicles and other anatomical anomalies, and revision surgeries where normal anatomical landmarks are significantly altered are well-touted examples where robotics can guide surgeons and improve accuracy," said Vijay Yanamadala, MD, medical director of spine quality and surgical optimization at Hartford (Conn.) HealthCare. "However, it is important to remember that current robotic technology is limited to screw placement. It does not guide other aspects of surgery, including decompression or alignment. Furthermore, it does not rely on real-time imaging and can therefore be subject to inaccuracy." 3. More hype than value? e benefits of robotic spine surgery have been well-documented, including improved accuracy, less invasive and more reproducible surgeries, reduced radiation exposure and faster procedures. Some early adopters laud the advantages robots have added to their

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