• Robots Will Change the Field of Spine Surgery

    Author: Nicholas Theodore

    Conflicts of Interest: The Excelsius GPS™ robot was co-invented by me and is manufactured by Globus Medical. I am entitled to royalty payments on sales of the robot and am also a paid consultant to Globus Medical and own Globus Medical stock.

    At the beginning of the 20th century, our neurosurgical forefathers Harvey Cushing and Walter Dandy helped develop and pass on the skill of cranial localization, an anxiety-provoking exercise for young neurosurgeons that needed to be repeated with every operation. Since that time, however, cranial neurosurgery has been completely transformed-first, by refinements in imaging including computed tomography and magnetic resonance imaging; and secondly, and perhaps even more importantly, by frameless stereotaxy. Given the inherent risks associated with operating deep within the brain, adoption of this technology for surgery on intracerebral pathologies has become nearly universal.1-3

    Although navigation in spinal surgery has been available for more than 20 years, its current adoption is only about 11%.4 This is true even though navigation technology has been proven to increase accuracy in placing pedicle screws when compared with fluoroscopic and freehand techniques.5 There are multiple reasons for the poor adoption rate, including lack of equipment, high cost of the technology, inadequate training, and difficulty integrating navigation into the spine surgical workflow.4

    Moving beyond freehand navigation, the concept of robotics in spine surgery has been around for several years. The Czech writer Karel Capek was the first to coin the term "robot" in his 1920 play Rossum's Universal Robots. His story is about a scientist who fabricates artificial people (i.e., robots) that are put to work performing menial tasks. Initially content to serve their human masters, the robots ultimately lead an organized rebellion that causes the extinction of the human race. This and other science fiction tales may be the reason that robots have become feared entities, with industrial and skilled laborers (and some surgeons) terrified by the notion that they could lose their jobs to these machines.

    In his book Rise of the Robots, Martin Ford argues that the evolution and increased dependence on robots is inevitable and will ultimately benefit mankind. In medicine, which has always embraced new technology, there are many examples of robots in use today. Neurosurgeon John Adler's CyberKnife® (Accuray Inc) debuted in 1994 and revolutionized the concept of the medical robot in a frameless radiosurgery system. The next major advance came with the release of the DaVinci® robot by Intuitive Surgical in 2000. This master-slave device allowed surgeons to work endoscopically, manipulating small end-effectors while sitting at a console several feet (or even miles) away from the patient. It has become extremely popular in urologic and gynecological surgery.

    In the field of spine surgery, my mentor Curtis Dickman used the Aesop® robot (Computer Motion) to hold an endoscope while performing delicate thoracoscopic surgeries in the mid 1990's. Although my co-residents and I were probably the first casualties of robots in medicine, the rigid arm and coordinated movements of the device liberated us from holding the endoscope for hours on end, an undeniably tedious task.

    The concept of using a robot to help place pedicle screws has evolved over the past 15 years. The first robots to aid in this task included the SpineAssist™, Renaissance™ (Mazor Surgical Technologies), and the Rosa™ robots (Medtech). The ExcelsiusGPS™ (Globus Medical) received FDA clearance in August 2017 and has joined the ranks of these sophisticated devices. In their review of the use of robots in neurosurgery, Joseph et al.6 thoughtfully discuss reasons for the limited adoption of this robotic technology in early years, even though there appears to be a distinct benefit related to decreased radiation exposure to the surgeon and improved accuracy of pedicle screw placement.

    The addition of robotics to spinal surgery changes the workflow of the spinal surgeon. Even those who have adopted image guided surgery note that the inclusion of robotics technology fundamentally changes the setup and pace of a procedure. And while there seem to be significant benefits of this technology, there is still a learning curve. The question is whether the benefit of automating accuracy in our procedures outweighs the "fiddle factor" and anxiety of learning something new. I have spoken with many senior spinal surgeons who have said that they have mastered the technique of screw placement; therefore, they don't need the help of a robot. But would less experienced surgeons benefit from some assistance?

    I believe that several factors will ultimately lead to the adoption of robotics in spinal and even cranial neurosurgery. Our current trainees, the millennials, will drive the widespread adoption of this technology in large part. Born between the early 1980s and mid 1990s, this generation will be trained in the era of residency work-hour regulations and explosive technological growth. Having grown up with the luxuries of the internet and smart phones, this generation depends and thrives on technology. In teaching residents the tenets of image-guided and robotic spine surgery, I have been impressed with their ability to easily grasp the computer interface and technical issues associated with imageguided robotics in the operating room. The adoption of advanced technology will hopefully dispel the perception that today's surgeons in training are far less prepared than their forefathers after completion of neurosurgical residency.

    Another driver of robotic technology adoption in spinal surgery will be the consumer. Many patients seek cutting-edge solutions for their spinal problems, even if unproven, including lasers, stem cells, and robotics. While neurosurgery is not the same as many retail industries, patients are asking about and demanding minimally invasive approaches and advanced technologies in neurosurgery on an ever-increasing basis.

    Ultimately, I believe that robotics will become commonplace in spinal surgery. Neurosurgeons in training and those still early in their careers will embrace the latest technological advances in imaging, registration, motion control, and user interfaces that enable navigation and robotic-assisted surgery. Even older surgeons may see a benefit to incorporating this technology into their workflow. No longer should robots be feared as devices designed to replace workers, but rather, as useful tools for surgeons that can help elevate their art.



    1) Galloway RL, Jr. The process and development of image-guided procedures. Annu Rev Biomed Eng. 2001;3:83-108.

    2) Keles GE, Anderson B, Berger MS. The effect of extent of resection on time to tumor progression and survival in patients with glioblastoma multiforme of the cerebral hemisphere. Surg Neurol. Oct 1999;52(4):371-379.

    3) Kosugi Y, Watanabe E, Goto J, et al. An articulated neurosurgical navigation system using MRI and CT images. IEEE Trans Biomed Eng. Feb 1988;35(2): 147-152.

    4) Choo AD, Regev G, Garfin SR, Kim CW. Surgeons’ perceptions of spinal navigation: analysis of key factors affecting the lack of adoption of spinal navigation technology. SAS J. 2008;2(4):189-194.

    5) Tian NF, Huang QS, Zhou P, et al. Pedicle screw insertion accuracy with different assisted methods: a systematic review and meta-analysis of comparative studies. Eur Spine J. Jun 2011;20(6):846-859.

    6) Joseph JR, Smith BW, Liu X, Park P. Current applications of robotics in spine surgery: a systematic review of the literature. Neurosurg Focus. May 2017;42(5):E2.

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