Spine robotics have become a significant investment for hospitals and ASCs, but realizing a return can depend on more than acquiring the technology. Nine spine surgeons discuss what separates programs that extract real value from robotics from those that struggle to justify the cost.
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Editor’s note: Responses were lightly edited for clarity and length.
Question: Plenty of hospitals never see a return on their spine robotics investment. What separates the programs that get real value out of robotics from the ones that don’t?
Bayan Aghdasi, MD. Orthopedic Spine Surgeon at DISC Surgery Center at Carlsbad (Calif.): A robot does not create a robotics program. Buying the technology is the easy part; creating enough utilization, surgeon adoption, and operational efficiency to justify it is much harder. The programs that get real value from spine robotics treat it as infrastructure rather than a showpiece. The technology has to become part of a repeatable workflow, with appropriately selected cases, surgeons who use it consistently, an OR team that knows the platform and enough case volume that the entire team becomes highly efficient.
The return also should not be measured simply by asking whether the robot places screws accurately. Modern spine programs should be looking at the entire value proposition: operative efficiency, radiation exposure, complications and revisions, length of stay, the ability to perform increasingly complex procedures through less invasive approaches, surgeon recruitment, patient demand and ultimately growth in case volume.
In my experience, the hospitals and surgery centers that succeed with robotics are not necessarily the ones that bought the most sophisticated machine. They are the ones that built the most sophisticated program around it. Robotics amplifies a good spine program; it does not create one.
Bryce Basques, MD. Spine Surgeon and Director, Minimally Invasive and Endoscopic Spine Surgery, Brown University (Providence, R.I.): The programs that get value out have a few surgeons who use the platform on nearly every applicable case, along with a dedicated team, and a robust perioperative pathway.
That said, the current iteration of robotics has not been proven to be much better than free-hand or AR-based navigation in terms of screw accuracy. I think the value in robotics right now is still mostly marketing, however as more sophisticated systems come out on the market with features such as haptic feedback, decompression assistance and level-specific tracking, robotics may finally eclipse fluoroscopy or free-hand navigation. Robotic systems are expensive and not every hospital will be able to make the current iteration profitable, but this may change with better, cheaper robots.
Marco Burkhard, MD. Attending Spine Surgeon at Hospital for Special Surgery (New York City): Robotics has improved pedicle screw accuracy, but whether that translates into fewer revisions or better patient outcomes remains unproven. In my experience, it also does not consistently shorten operative time, particularly when setup is cumbersome or the OR team does not use the system routinely.
The investment is substantial, and many platforms effectively lock hospitals into a single implant ecosystem. Implant-agnostic systems that allow surgeons to switch between free-hand, navigation and robotics offer greater flexibility. While robotics can strengthen a hospital’s brand, attract trainees and differentiate a spine program, its true clinical return on investment still needs to be demonstrated.
Brian Gantwerker, MD. Neurosurgeon and President of The Craniospinal Center of Los Angeles: I think once the skills that robotics promised come to fruition, we may see some ROI. The price of the tech has not gone down appreciably, and I still do my pedicle screws with navigation as I prefer the real time tactile feedback.
In addition, I remain concerned about enabling technologies enabling surgeons who should not be doing spine surgery to be doing fusions and not being able to revert to an old-school fluoro-guided technique.
Isador Lieberman, MD. Orthopedic and Spinal Surgeon at Texas Back Institute (Plano): A successful robotic spine surgery program requires a surgeon champion who has the patience and vision to initiate and nurture the program; a dedicated operating room team trained in a similar fashion to an F1 pit crew to facilitate an efficient operative workflow; and a visionary hospital management team willing to dedicate the capital resources for acquisition, marketing and personnel.
Issada Thongtrangan, MD. Endoscopic and Minimally Invasive Spine Surgeon at MicroSpine (Scottsdale, Ariz.): The difference really comes down to this: the robot itself doesn’t create value, how you use it does. Programs that win treat robotics as a high-volume, fully integrated system with committed surgeons, trained teams and streamlined workflows, so it actually improves efficiency and expands what they can do, like minimally invasive surgery and complex cases.The ones that struggle tend to use it inconsistently, underestimate the learning curve and never redesign their workflow around it, so it just adds time and cost without real return.
Alex Vaccaro, MD, PhD. President of Rothman Orthopaedics (Philadelphia): The programs that extract real value from spine robotics are the ones that deploy the technology where it actually changes the operation, rather than layering it onto cases where a competent surgeon performs equally well freehand. Robotics earns its cost in three settings: pelvic instrumentation; percutaneous and minimally invasive surgery; and complex deformity. Hospitals that fail to see a return typically purchased the platform as a marketing instrument and then used it for routine one- and two-level degenerative fusions, where the incremental accuracy benefit is marginal, case times lengthen, and the capital and per-case disposable costs are never recovered.
The second differentiator is programmatic discipline. Successful programs concentrate robotic volume among a small number of committed surgeons, embed the technology into a standardized workflow and track their own data so the value proposition is measured rather than assumed. Programs that treat robotics as an episodic novelty never capture these gains; programs that treat it as infrastructure, applied selectively to the cases where precision and endurance matter most, consistently do.
Jacky Yeung, MD. Neurosurgeon at Yale Medicine (New Haven, Conn.): The programs that realize the greatest value from robotics are the ones where it becomes routine practice rather than a technology reserved for select cases. Consistent use allows the entire surgical team to optimize workflows, shorten setup and operative times, and improve efficiency. Not doing so would incur the opposite effect.
In addition, a well-established robotics program can serve as a differentiator in a competitive healthcare market. Patients often seek out centers that invest in advanced technology, and that increased visibility can grow the overall spine practice, even though not every patient or every procedure ultimately requires robotic assistance. The return on investment comes not simply from owning the technology, but from integrating it into everyday practice while building a high-quality, comprehensive spine program.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The significant capital outlay and revolving financial burdens for robotic systems are extraordinary, and most larger institutions require detailed cost justification prior to purchase. Granted, the future may be predicated on these surgical-assist devices for efficiencies, patient convenience and outcomes, whereby the reality of circumferential and prospective cost is a constant reminder. Staffing, education and timely maintenance concerns remain at the forefront of managerial worry.
Differentiators of success versus under-achievement boil down to volume and usage of these apparatuses with surgeon designation and competence being paramount. Overstating the obvious, inducements from industry must remain irrelevant. Historically, larger institutions and academic centers have garnered better up-front cost negotiations for all aspects of these mechanisms, including the expense of maintenance contracts and non-durable materiel. Similarly, service lines with designated surgeons and trusted staff members have emerged as the go-to-individuals in this specialty of use. Over the last decade, this ‘robotic niche’ subspecialty has emerged in other surgical specialties, being sought after by referring physicians and patients alike.
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