Nils Ehrke, President EMEA at Brainlab, shares why he sees robotics in spinal surgery as part of an evolution rather than a disruptive catalyst that will revolutionize the field.
Robotics in surgery is often hailed as a groundbreaking revolution, particularly in the field of spinal surgery. However, Nils Ehrke, President EMEA at Brainlab, urges caution in viewing robotics as the ultimate solution for advancing spinal surgery. He emphasizes that healthcare providers can only fully reap the benefits of robotics when it is integrated as one step in a broader strategy for the continuous advancement of spinal surgery as a whole.
In a recent conversation, Mr. Ehrke shared insights on how robotics fits into the spinal surgery workflow, offered valuable advice to healthcare providers looking to incorporate this technology into their departments and explained how they can achieve high-performance surgery through principles borrowed from the world of sports.
Nils Ehrke studied biomedical engineering at the University of Applied Sciences in Hamburg and the University of California San Diego. After joining the Brainlab sales team in 1996, he became responsible for the Middle Eastern and African markets in 2018 and our European business in 2000. His engineering background helps him understand his customers’ needs and provide input for tailor-made solutions that embrace and develop technology trends. He is currently focused on navigation and robotics in spine surgery.
What advice would you give to clinics considering purchasing robotic solutions for their spinal surgery department?
Many providers are proclaiming a revolution in spinal surgery, but in reality—despite the current hype—robotics is no more than one step in the procedure workflow. The workflow is a process chain, which means it can only be as good as its weakest link. To get the most out of robotics, providers need to see it as one link in that chain. It’s the combination of all single parts seamlessly integrated into the overall surgical procedure that makes the decisive difference in robot-assisted spine surgery.1
Taking this approach one step further, true high-performance surgery is the result of small improvements made to every single step in the workflow that add up to a higher level of patient care.2 This principle, which originated in high-performance sports under the name “Aggregation of Marginal Gains,” became famous a few years ago for pushing the limits of sports past what was previously considered unattainable.
Today, when clinics consider investing in robotics, I remind them of this principle and that robotics is only one aspect of the overall system. Before investing in this area, I recommend that they look at the "basics": accurate imaging, software planning, patient registration and navigation. If these things are in place and the budget allows, the robotic arm can be the last link in the chain.
What kind of solution do you offer to support this approach?
We developed the Robotic Suite to reflect this holistic approach. It consists of the Loop-X® mobile imaging robot, the Curve® navigation system and the Cirq® robotic arm. All components are seamlessly coordinated and integrated into the workflow. Not only do surgeons have a robotic arm at their disposal, but also an infrastructure that pays close attention to every step in the process. This holistic view and attention to detail, just like the principle of marginal gains in sports, can enable treatment successes in the future that were unthinkable just a few years ago.
So ultimately, the focus is not on robotics?
That’s right, because every detail of the workflow is critical to the procedure’s success, especially when it comes to critical structures like the cervical spine. One of robotic spine surgery’s biggest challenges is that the spine is a very flexible organ. An inexperienced surgeon cannot rely on the technology alone, but must be aware of all factors that affect accuracy. In this context, robotics is only useful for navigation, but it has the potential to enable the surgeon to improve on other vital factors such as standardization, increased efficiency and ergonomics. Most importantly, surgeons need to understand the clinical workflow and the technology involved in order to use it correctly.
How can this understanding of robotics be taught?
The foundation for this should be laid during training. These days, everyone wants to use robotics; everyone wants to work with navigation, but in inexperienced hands, without training and with a sub-optimal process, problems arise. That is why we are working with partners such as the AO Foundation to develop a new era of digital training practices, leveraging new technologies such as augmented reality functionalities or app-based gamification programs. We look at the operational workflow and integrate it into our training. With our digital training methods, we help surgeons build a "mental model" of an operation so that they are well prepared for it—in the future, this will even be on a patient-specific level. Data also plays an important role.
How?
At the heart of modern spine surgery is not robotics per se, but the entire software ecosystem. In addition to digital learning concepts, this includes planning software and databases. Structured data collection on large numbers of patients could improve the quality of care, which is why it should be part of the clinical workflow. We are already working with the German Spine Society to build a database that will analyze and segment data from many thousands of surgeries and correlate it with patient-reported outcome measures. For example, surgeons can use this database to analyze whether screws or cages fit properly and how patients ultimately fare. Other data aggregations provide physicians with input and support for data-driven and potentially better treatment decisions3 that take patient-specific factors such as age or gender into account.4 We are paving the way for patient-specific medicine.
It sounds like spine surgery is in a state of flux right now. Where are we headed?
In fact, a paradigm shift is taking place: when it comes to advancing modern spine surgery, the focus is no longer exclusively on implants. The key driver is software—especially now with the rapid progress in generative AI development. With the Robotic Suite concept, we want to offer an open platform that is compatible with implants from as many manufacturers as possible. This will allow healthcare providers to freely choose implants based on surgical, technical and economic criteria, without being tied to one implant manufacturer for navigation or robotics. Thanks to this freedom of choice, clinics can use resources more efficiently and provide treatments that are tailored to the needs of each patient.