Computer-Assisted Spine Surgery—A New Era of Innovation

The idea of surgical intelligence is finally coming to fruition. The use of both computer and robotic assistance, and increasing use of the two together, has already demonstrated the promise of surgical intelligence to transform spine surgery. Offering potential improvements in surgical accuracy, reductions in postoperative complications, and decreased revision surgeries, computer assistance provides the novel ability to base decision-making support on hundreds of thousands of prior cases. Poor measures of predictive power have been found for the surgeon’s ability to predict risk and benefit of surgery. The use of patient demographic and operative characteristics when creating complex analytical models allowed for the development of frailty scores that can better predict risks and benefits for a patient. Coupling such decision-making support for surgical uses, such as rod bending angles, with the precise ability of robotics to carry out the task, continues to improve patient outcomes. To date, the use of robotics in surgery has resulted in improved screw placements and improved navigation and reduced radiation dose, length of stay, and need for revision surgeries. However, as with many novel applications of technology, an array of challenges exists. These include reliance on single-centered retrospective data and limited data sharing, limited data for rare diseases and uncommon procedures, straight line trajectories of robotic movements, high costs of computer and robotic assistance (infeasible for small centers), high learning curves, a limited set of procedures for the use of such technologies (currently mainly used for screw placements), and legal issues regarding who is at fault in case of adverse events.

Recently, robotic uses for spine surgery are expanding from screw placements to include tissue-focused uses such as tumor resections, spurred by developments in haptic feedback systems, 3D printing, and mechanical advances. Further expansion of procedure types arose for microscopic-based surgeries with augmented reality support, visualizing tool orientation with respect to the anatomy of interest with no disruptions to the surgical view. Similar technological improvements, catalyzed by 5 G, gave rise to huge advances in telesurgical robotics, with the successful demonstration of the first 12 cases in 2020. With these advances, four dominant uses for computers and robotics in spine surgery have become apparent: telesurgical robotic surgery, shared-control robots with computer navigation, augmented reality systems, and machine learning decision-making support.