Robotic navigation can help reduce the cognitive workload of orthopaedic surgeons and improve surgical mapping

Robotic platforms are being introduced in the ORs of several orthopaedic surgery subspecialties, including spine and total joint arthroplasty. Today’s robotic platforms evolved from navigation systems and offer a variety of advantages to practicing surgeons. In spine surgery, the first robotic platform was approved by the FDA in the early 2000s, and several platforms have been approved and introduced to ORs since. The use of intraoperative navigation has expanded beyond spine surgery and total joint arthroplasty to a variety of orthopaedic procedures, including talocalcaneal coalition resection, glenoid preparation for total shoulder arthroplasty, and tunnel placement during anterior cruciate ligament reconstruction, with the latter undergoing study regarding robotic system implementation.

The utilization of robotic platforms in the OR offers several key advantages. Robotic platforms often assist with repetitive tasks such as screw placement or acetabular reaming. These platforms may reduce fatigue and improve efficiency and ergonomics for surgeons. Decision fatigue is an important factor to consider in optimizing surgical performance, as a surgeon may perform multiple surgeries a day. The ability to minimize both physical and mental workload is important for proficient and safe task completion. This secondary benefit of robotic platforms may further justify the cost of these systems.

Screw placement
Particularly in spine surgery, pedicle screw placement requires precision, as the screws are placed into a narrow corridor and aberrant screw placement can lead to potentially devastating neurovascular complications. According to studies by Asada et al and Matur et al, both published in The Spine Journal, robotic surgical platforms may increase screw accuracy, leading to enhanced patient safety, decreased blood loss, and shorter hospital length of stay with minimally invasive procedures.

A recent study from the authors of this article, published in HSS Journal, evaluated the impact on mental workload by using robotic platforms when placing pedicle screws during single-level primary transforaminal lumbar interbody fusion. The study aimed to assess several tasks during this procedure to include screw planning, robot calibration and registration, pedicle cannulation, and screw placement.

To assess surgeon cognitive load in the OR, after each case, surgeons were surveyed using the NASA Task Load Index (TLX), which is a validated questionnaire initially developed to assess the workload of astronauts that has been further adopted across a wide variety of professions.

The NASA TLX measures several subdomains related to overall cognitive workload, including mental demand, physical demand, temporal demand, performance, effort, and frustration. The use of the NASA TLX to assess mental workload is not unique to this study, as other authors have used this questionnaire to assess increased mental demand in revision total knee arthroplasty.

The results showed a significant reduction in all cognitive workload subdomains for screw planning, pedicle cannulation, and screw placement for robotically placed screws compared with results from surgeons using a CT-based system. Importantly, with both techniques, surgeons rated a high performance for screw placement; however, use of a robotic platform was associated with reduced mental workload.

Surgical planning
Robotic navigation can also enhance surgical planning by mapping the navigation to the patient’s anatomy. Broadly, these systems rely on a CT scan to match a patient’s anatomy, whether that is a joint arthroplasty or pedicle screw construct, and then utilize a robotic arm to aid surgeon dexterity for the specific task. Implant sizing and position can be optimized preoperatively and continually assessed intraoperatively to ensure optimal placement of instrumentation and implants. Navigation and robotics also create a haptic feedback loop for surgeons, which includes visual cues on the robotic screen to further confirm adherence with the template, such as understanding when the tibial cut thickness has been achieved or when a screw deviates from the preplanned trajectory.

A common misconception about robotic platforms is that there is an increased burden when preparing and calibrating the robotic platform to patient imaging. In an HSS Journal study of cognitive workload, there were no significant differences in reported cognitive workload associated with preparation and calibration. This finding further supports these systems’ utility to aid surgical team efficiency in the OR. Concern about potential frustration from calibrating the robotic system can be reduced by building a suitable workflow.

Importance of managing cognitive workload
Assessment of mental workload in the OR is becoming an important consideration in overall surgeon well-being. The OR is a team environment, and developing a better understanding of the impact of integrated technologies to the entire operative care team is vital. Furthermore, understanding cognitive workload and physiological measures of stress is equally vital, such as measuring biometrics (e.g., heart-rate variability) during surgical procedures.

Robotic platforms, regardless of their surgical application, are not a replacement for surgical skills and knowledge. Instead, they serve to enhance surgeons’ ability to perform surgery more effectively and safely. Although robotic platforms have been adopted mostly in spine surgery and total joint arthroplasty, their use will likely expand across all orthopaedic subspecialties. Examining how these platforms impact surgeons’ mental workload is one consideration when implementing this technology in the OR.

Kyle W. Morse, MD, is an assistant attending orthopaedic surgeon at Hospital for Special Surgery and an orthopaedic surgery instructor at Weill Cornell Medical College.

James Dowdell, MD, is an assistant attending orthopaedic surgeon at Hospital for Special Surgery and an assistant professor of orthopaedic surgery at Weill Cornell Medical College.

Sheeraz Qureshi, MD, MBA, FAAOS, is an attending orthopaedic surgeon and the Patty and Jay Baker Chair in Minimally Invasive Spine Surgery at Hospital for Special Surgery.

Sravisht Iyer, MD, is an assistant attending orthopaedic surgeon at Hospital for Special Surgery and an assistant professor of orthopaedic surgery at Weill Cornell Medical College.

References

1. Asada T, Simon CZ, Lu AZ, et al. Robot-navigated pedicle screw insertion can reduce intraoperative blood loss and length of hospital stay: analysis of 1,633 patients utilizing propensity score matching. Spine J. 2024;24(1):118-124.
2. Asada T, Subramanian T, Simon CZ, et al. Level-specific comparison of 3D navigated and robotic arm-guided screw placement: an accuracy assessment of 1210 pedicle screws in lumbar surgery. Spine J. 2024;24(10):1872-1880.
3. Matur AV, Palmisciano P, Duah HO, Chilakapati SS, Cheng JS, Adogwa O. Robotic and navigated pedicle screws are safer and more accurate than fluoroscopic freehand screws: a systematic review and meta-analysis. Spine J. 2023;23(2):197-208.
4. Morse KW, Subramanian T, Zhao E, et al. Robotic-assisted navigation in single-level transforaminal lumbar interbody fusion reduces surgeons’ mental workload compared with fluoroscopic and computed tomographic techniques: a nonrandomized prospective controlled trial. HSS J. Published online Oct. 6, 2024.
5. Panwar KS, Huish EG, Law JL, et al. Revision total joint arthroplasty places a disproportionate burden on surgeons: a comparison using the National Aeronautics and Space Administration Task Load Index (NASA TLX). J Arthroplasty. 2024;39(6):1550-1556.