Spine Surgery “Hype”? Robotics, Biologics, Navigation, Lasers

International Society for the Advancement of Spine Surgery (ISASS17) Meeting Highlight

Written by Lynne Schneider, PhD

“Don’t Believe the Hype” was one of the popular symposiums held during the 17th Annual Meeting of the International Society for the Advancement of Spine Surgery (ISASS). Moderated by Alexander Vaccaro, MD, the elite panel members were Jeffrey A. Goldstein, MD, Alpesh A. Patel, MD, Safdar N. Khan, MD, Gregory D. Lopez, MD, and Isador H. Lieberman, MD.

Robotics: Isn’t this like the erector set when we were kids?
Dr. Jeffrey Goldstein opened the discussion. During open spine surgery, Dr. Goldstein commented that it is easier in open procedures to see the complex three-dimensional structures owing to exposure of surface anatomy and two-dimensional fluoroscopy. He noted that cases of spinal deformity or advanced degenerative disease can be challenging using this conventional approach. Consequently, the use of image-guided techniques has gained traction, particularly for percutaneous or minimally invasive surgeries. Robotic systems work alongside image-guided navigation techniques to improve clinical outcomes, enhance surgical accuracy, and reduce radiation exposure.
He reviewed the numerous stages involved in integrating robotics into surgery, noting that there can be problems at many of the steps. Currently, robots are used for procedures that require accuracy to reach a predefined location: pedicle screw insertion (with 94% accuracy compared with 93% accuracy with fluoroscopy guidance) and needle trajectory (vertebral body augmentation, biopsy, or tumor excision). Robot-assisted surgeries appear to have lower levels of intra-operative radiation, but Dr. Goldstein noted the studies fail to consider radiation exposure related to preoperative CT scans.

Dr. Goldstein noted the learning curve, along with recommendations for fluoroscopic control during the initial 25 procedures using a robotic system. Finally, there are no studies comparing cost-effectiveness of robotic-assisted spine surgeries with traditional spine surgery. He highlighted the large up-front cost of procuring the robot, along with the substantial cost of per case disposables—and wondered if these costs are absorbed over the long-term.

“For new technology to be adapted, they [robotic-assisted developers] need to prove improved clinical outcomes, efficiency, and/or cost compared to what is currently being utilized—robotics does none.” In light of the lack of strong evidence supporting improved clinical outcomes or efficiency with the use of robotics in spine surgery, don’t believe the hype.

Biologics: Let’s be honest, have we become lazy and don’t want to take ICBG?
Next, Dr. Alpesh Patel addressed iliac crest bone graft (ICBG), iliac crest autograft. He explained that fusion biology is a “complex process involving an intricate cascade of molecular and cellular events.” The ideal bone graft material requires osteogenic cells, osteoinductive factors, an osteoconductive matrix, and structural support. Consequently, iliac crest autograft is the most effective method of achieving solid arthrodesis: it has all the critical components needed and thus remains the gold standard. Iliac crest autograft is accessible, inexpensive, and easy to use; however, there are concerns regarding acute or chronic pain, potential complications (infection, hematoma, fracture), estimated blood loss, and length of hospital stay. 

Current and emerging biological choices include allograft, bone graft extenders, bone morphogenetic proteins (BMPs), and cell-based treatments. However, Dr. Patel questioned whether ICBG is “as bad as we think?” Looking at 12 studies that examined morbidity associated with ICBG complications, Dr. Patel reported the range of complication rates was from 9%-49%, with a range of 0.7% to 25% for major complications, and a 2% to 5% rate of reoperation for wound complications. However, the studies were retrospective and heterogeneous with regard to patient population, diagnoses, and procedures. The limited prospective studies on BMP-2 indicate it is associated with greater blood loss and longer OR times, higher costs, but no difference in pain. Dr. Patel concluded noting the absence of concerns with ICBG regarding immunogenicity or disease transmission. If performed well, ICBG has high efficacy, minimal pain, and low cost—it is the best value-based biologic option.

Navigation: Are we just coming up with an excuse for not learning anatomy?
The third panelist, Safdar Khan, MD, addressed surgical navigation. Dr. Khan noted that all new technologies promise to “improve access to information, reduce errors and improve quality of life.”

With regard to advances in navigation, he noted the questions to consider are:

  1. Does the innovation improve accuracy/decrease complications?
  2. Does it increase ease of screw placement?
  3. Does it decrease radiation exposure?
  4. Does it yield better clinical outcomes?

He cited studies, which concluded that although computer-assisted insertions improve accuracy over conventional (freehand or fluoroscopy-assisted) pedicle screw insertions, navigation-assisted insertions are not associated with improved clinical outcomes (including revision rates and neurological complication rates). They are, however, associated with greater up-front costs and “super steep surgical learning curves,” and can involve significant workflow disruption. Dr. Khan recommended computer-assisted surgery is best to use as an adjunct to conventional approaches.

“Are we creating surgeons who don’t look at the patient, just at a screen?”
—Safdar N. Khan, MD

Lasers: We should be embracing technology.
Examining the facts versus hype concerning lasers, Gregory Lopez, MD asked, “Has anyone really used one in a real spine surgery?” He wryly explained that laser stands for “Latest Advance for Surgeons to Enhance Revenue”.

Dr. Lopez explained the different types of lasers being used—neodymium (ND) or Holmium yag lasers, as well as CO2 and Argon lasers—but noted they are rarely used in minimally invasive spinal surgeries. He opined lasers may be good for percutaneous discectomy, decreasing annulus site, and excising tumors, but concluded there is no literature supporting lasers as being superior to the standard of care.

Rebuttal: We should be embracing technology.
Dr. Isador Lieberman was tasked with presenting the rebuttal. Dr. Lieberman noted the goals of technological advances include “a faster recovery, more efficient surgery, less collateral tissue damage, reduced intra/postoperative morbidity (eg, blood loss, infection), arresting deterioration and promoting regeneration—overall, improving patient outcomes.”

He noted the new techniques are expensive, have a learning curve, and are currently in their infancy stage. But many—such as robotics and navigation instruments, which Dr. Lieberman believes will eventually be merged together—are here to stay. However, when discussing the hype regarding lasers, Dr. Lieberman recommended, “don’t get burned!” The question remains: “Will these [advances] make us more efficient?”

Surgeons need to determine “what is the most effective and least invasive means of performing the surgery? Which bit of technology can help my patient?” Dr. Lieberman summarized the panel discussion stating, “We need the right operation for the right reason by the right surgeon.”

About the Moderator and Panel Members
Dr. Vaccaro is the Richard H. Rothman Professor and Chairman in the Department of Orthopaedic Surgery, and Professor of Neurosurgery at Thomas Jefferson University’s Sidney Kimmel Medical College in Philadelphia, PA. He is the President of the Rothman Institute.

Dr. Goldstein is President of the International Society for the Advancement of Spine Surgery. He is Clinical Professor of Orthopaedic Surgery at NYU School of Medicine, Director of Spine Service for Education and Director, Spine Fellowship at NYU Langone Medical Center and Hospital for Joint Diseases in New York, NY.

Dr. Patel is Professor of Orthopaedic Surgery and Neurological Surgery at Northwestern University, Feinberg School of Medicine in Chicago, IL.

Dr. Khan is the Benjamin R. and Helen Slack Wiltberger Endowed Chair in Orthopaedic Spine Surgery, Associate Professor of Orthopaedics and Chief, Division of Spine at Ohio State University Wexner Medical Center in Columbus, OH.

Dr. Lopez is Assistant Professor of Spine Surgery at Midwest Orthopedics at Rush in Winfield, IL.

Dr. Lieberman is Director of the Scoliosis and Spine Tumor Center at the Texas Back Institute in Plano, TX.

Continue Reading

Why Perform Spinal Injections at All? Evidence is Weak