Why does orthopedics, often referred to as the boss of surgery, seem to be lagging behind a lot in this era of hot surgical robot applications?
In the past decade or so, the use of robotic systems in surgery has increased considerably. General surgery, urology, gynecology and other fields have widely adopted robot surgery as part of daily practice, and even placed in the standardized training of resident doctors; and many of our orthopedic surgeons are still freehand nails, steel plates, joint changes and freehand endoscopic minimally invasive surgery, and the work of orthopedic surgeons in the last century does not seem to have much change, but steel plates are new models, nails are new styles, joints are new interfaces, and there are some new surgical styles.
Internationally, orthopedic robot products have begun to promote the layout, especially in spine surgery. Zimmer Biomet's Rosa Spine, Globus' Excelsius GPS, and Medtronic's Mazor X are already widely used in the clinic. Stryker has also acquired Mobius and its Cardan robotics to further integrate into an integrated platform for minimally invasive spine surgery robots. At present, the latest development trend of foreign manufacturers is the integration of "intraoperative 3D imaging + surgical robot + artificial intelligence + proprietary consumables", and they plan to provide complete platform solutions.
Global distribution of orthopedic robotic surgical institutions Image source: biomedcentral.com
In China, driven by the first share of surgical robots - Tianzhihang, spine robot companies have also sprung up. However, at present, we have not seen a robot system with a complete platform solution that can compete with international brands; in addition, the advantages of robots are mainly reflected in precision, minimally invasive, repeatability, etc., but the current commercial orthopedic robots cannot complete efficient full-process surgical operations, most of which are limited to spinal nail navigation assistance, or assisted joint replacement surgery in several steps.
Surgicalization of internal surgery, minimally invasive surgery is the future surgical trend, the robot of joint surgery only improves the accuracy of implants, and the combination of intervertebral discoscopy and arthroscopy with robots can enable patients to benefit from minimally invasive and precise implantation. Combining these technologies with robotics will enable more patients to benefit, but these minimally invasive technologies have a higher threshold and require more systematic technology integration, training and clinical technology updates. General surgery, urology, obstetrics and gynecology have come to the forefront of minimally invasive robotic surgery with the help of endoscopic robotic systems, and orthopedics still needs further efforts. Of course, from the current treatment, traditional treatment still accounts for the majority of clinical treatment. The new generation of large hospital doctors is actively participating in the research and development of robot products belonging to the next generation, which is also an important opportunity for the development of orthopedics in mainland China.
Orthopedic spinal surgery robot
Industrial layout and article patent situation
Currently laying out orthopedic spine surgery robotics companies include Brainlab (CIRQ), Curexo (CUVIS-spine), Globus Medical (Excelsius GPS), Medtronic (Mazor X), TINAVI Medical Technologies (TiRobot), Zimmer Biomet (ROSA One Spine), Stryker (Mobius - Cardan), driven by this, has seen a sharp increase in the number of patents related to spine surgery in recent years.
Number of innovation patents for spine surgery in the United States and Europe Image source: researchgate.net
Spinal Surgery Robot Advantage
Safe and effective spine surgery relies on a precise image basis, which is mostly based on accurate 3D images, combined with real-time positioning methods, to guide the robot arm for surgical navigation and even assist in surgical operations.
When performing surgical operations, spinal robotics offer a number of advantages, including reducing the surgeon's fatigue and trembling, while providing stability to the instrument by a fixed working angle, thereby improving accuracy and precision, and can effectively reduce the number and time of intraoperative doctor's fluorescence, reducing the radiation dose for doctors and patients. At present, the spine surgery robot is developing from nail navigation to semi-automatic needle placement, the next step is to develop a full-process surgical robot, especially an orthopedic minimally invasive surgical robot, it is understood that at present, there are companies that have begun to develop similar full-process orthopedic endoscopic minimally invasive surgical robots, such as the domestic Great Robotics, foreign Stryker company.
Endoscopic spine surgery robot assists nail placement in spinal fusion surgery
Image source: .semmes-murphey.com
Fusion versus non-fusion options for the spine
Spine surgeons currently use spinal fusion (vertebral fixation) as the "last resort and most important means" of treatment. Internal fixation is mainly based on spinal instability or after a large number of disruptions to the stability of the original spine by traditional incisional surgery.
The question is, do so many spines really need internal fixation?
Under the operation of the new era of endoscopic minimally invasive technology, only a small part of the internal fixation nail technology may be required without destroying most of the stable structure of the spine. However, the current mainstream of orthopedic navigation surgery robots still emphasizes the precision of nail placement and the advantages of nail placement. It is undeniable that from the traditional decades, nails are the foundation and an important means, but not the only way. With the development of intervertebral discoscopic fusion, microscopic instruments, OLIF, etc., nail fusion may gradually need to be diluted or postponed in the future.
Yeung' first article, "Away from Fusion," the founder of American spinal endoscopy technology, was published in Spine Journal in December 2015. Analysis from Yeung's initial review of 58 patients following up for 5 to 10 years found that approximately 36% of patients avoided spinal fusion surgery (laceration of the spine), but 100% were satisfied with the decision to delay fusion as their first surgical option. He advises patients to first choose endoscopic decompression as a "transitional surgery", diagnosis and treatment can help relieve pain and improve the patient's quality of life. This is equivalent to arthroscopic treatment is a transitional surgery for osteoarthritis treatment, and not everyone needs to do joint replacement directly.
Minimally invasive spine surgery with
Combined development of robots
In recent decades, various minimally invasive surgical techniques have been introduced to minimize approach-related tissue trauma while optimizing for surgical-period care and long-term functional outcomes. At present, a new generation of surgical robot systems for minimally invasive spine has also begun to appear at home and abroad, and the field has become a hot spot again. Minimally invasive surgery of the spine requires precise operation and some repetitive operations guided by high-precision intraoperative images during surgery, so it is particularly suitable for surgical robot assistance.
The new generation of spine robotics in the future needs to be excellent not only in terms of nail placement, but also in the localization of minimally invasive surgery, the establishment of channels, endoscopic decompression and microscopic fusion. The combination of a new generation of end devices and optical/magnetic tracking devices makes spine surgery more and more simple.
Other related important technological advances
Endoscopic surgery of the spine. Endoscopic spine surgery is an advanced form of minimally invasive spine surgery designed to provide patients with faster recovery times and less recurrent pain than traditional spinal surgery methods. In most cases, local anesthesia can be used in place of general anesthesia for endoscopic surgery, thereby reducing the overall medical risk for patients with medical conditions who are older or have a combination of medical conditions that have the potential to increase the risk of surgery. Spinal endoscopy technique is a more technically challenging procedure, but it has excellent postoperative results.
Endoscopic spine surgery Image source: outpatient-spine-surgeon.com
Artificial disc replacement. Fusion and replacement have been controversial, and some scholars believe that fusion is obsolete, especially for the cervical spine, because the data is so clear that artificial cervical disc replacement is better than fusion in many outcome indicators, and artificial discs can improve the biomechanics of substitutes by mimicking the viscoelasticity of normal intervertebral discs.
3D printing. 3D printing technology has many uses in the spine. In 2019, New York City Hospital for Special Surgery partnered with LimaCorporate to launch a supplier-based additive manufacturing 3D printing facility for personalized orthopedic implants. 3D printed Cage offers custom sizes and morphologies, and engineers designed the system's Cage, using precise mapping and preoperative surgical planning to restore the appropriate height and angle. Companies such as RTI Surgical have developed Fortilink Interbody Fusion 3D printed implants for the treatment of degenerative disc disease. The latest orthopedic 3D printing can be performed in situ 3D printing, which is more in line with clinical needs.
Mixed reality. Three neurosurgeons at Johns Hopkins Hospital performed the first spinal fusion on a patient using an augmented reality system, and Augmedics caused a stir in the spine field. The company's FDA-approved Xvision Spine System enables surgeons to visualize 3D spinal anatomy during surgery, so they can view devices and implants while looking at patients. The combination of mixed reality technologies has great potential in preoperative assessment, doctor-patient communication, remote consultation, improved patient safety, improved postoperative outcomes, and reduced complications.
artificial intelligence. Artificial intelligence has great potential in healthcare. Artificial intelligence can help make surgical decisions and read imaging studies. The technology will not replace surgeons, but it can enhance the surgeon's data processing capabilities and develop the best treatment flow for patients.
Regenerative medicine. Regenerative medicine is still in its infancy in the field of spine. One treatment is Discseel, in which the surgeon injects fibrin into a torn disc to seal the tear inside the fiber ring.
Telemedicine. The COVID-19 pandemic has forced many experts to temporarily postpone surgery in early 2020 and turn to telemedicine consultations. Patients are now satisfied with the technology and expect spinal surgeons to have remote consultations and virtual surgical protocol consultations. A new generation of spinal robots may also be equipped with 5G remote surgery solutions to perform remote surgery for patients.
The vision of a spinal surgery robot
When robotics is a practical and effective option for all hospital surgeons, it will truly become the future of spine surgery. For example, improving the accuracy and density resolution of CBCT (cone beam CT) imaging, fusing preoperative MRI/CT images with intraoperative CBCT, combined with spinal endoscopy, can significantly improve safety and expand further applications.
The most important feature of the future spinal robot may be the concept of universality, a platform-based product like the Da Vinci robot. They must be able to perform multiple procedures and are better to be more compatible with implant manufacturers for almost all areas of spinal surgery, from minimally invasive to open, and not just the placement of pedicle screws. The main principles of spinal surgery today involve decompression, orthopedics, and stability. For spinal robots to flourish, they must be able to participate in all aspects of surgery end-to-end and be universal.
The cost of surgical robots must be reduced, and when spinal robots are sold at a more reasonable price and have a reasonable cost of use, when applied to many types of surgeries including cervical, thoracic and lumbar vertebrae, and even other orthopedic surgeries, they can be truly promoted. Especially in China, the ability to cover health insurance needs to be considered.
If force feedback-based instruments are developed, robots may be used to automate the decompression parts of surgery, thereby reducing surgical time and blood loss, and may even be widely used in the surgery and recovery of spinal deformity correction.
The surgical efficiency is high, and if the efficiency and success rate of the operation can be improved through multi-arm collaboration, reducing complications will be a good choice.
Epidemiological and cost-benefit analysis
Between 2001 and 2010, approximately 3.6 million spinal fusion procedures were performed in North America, with a total estimated cumulative cost of more than $287 billion. With more than 40% of adults aged 40 and over suffering from spinal disorders, current medical treatments, especially in China, should focus not only on improving surgical outcomes, but also on reducing costs.
Considering that surgical robots are likely to increasingly reduce surgical time, patient hospital stays, fluoroscopic exposures, and surgical revision rates in the future, the potential economic savings from using robots in spine surgery can be predicted. With these changes in mind, the global market for spinal surgery robots is expected to increase from $26 million to $2.77 billion by 2022, and the market for minimally invasive spines will be further expanded if half of fusion surgeries are first treated with endoscopic non-fusion minimally invasive treatments.
Specific to China's medical ecology, the future application of minimally invasive endoscopic surgery robots for the spine will popularize minimally invasive surgery, achieve ladder treatment, improve treatment effect, and reduce additional injuries. This is conducive to reducing the overall burden of national health insurance and personal burden.
Recently, the National Medical Security Administration issued a letter of consultation on orthopedic "surgical robots" and 3D printing auxiliary charges, which roughly divided orthopedic surgical robots into four categories according to the clinical contribution value: 1. planning category; 2. navigation category; 3 parts of surgical assistance; 4. full-process surgical surgical robot / remote control surgical robot, and the proposed charging standard was gradually increased from 1 to 4, which will guide the orthopedic spine surgical robot to a full surgical, systematic, and cost-effective one with higher clinical value. The direction of minimally invasive platform solutions.
Write at the end
Over the past few years, we've seen massive publicity for various surgical robotic solutions that combine augmented reality, telemedicine, machine learning, data analytics, artificial intelligence, and more, and for now, many see it as a commercial hype rather than offering a real clinical advantage. When the personal PC first came out, some people thought so, when the smartphone came, when 5G came, some people thought so, when the driverless came, there were still people who thought so... Only time will tell us the real answer, but it is clear that they have great potential in the future to really change our work and life, because they are the footprints of the innovation of the times. Similarly, I am confident in the future development of a new generation of minimally invasive spinal surgical robots.
*Cover image source: 123rf