Navigating the cost question: When does technology in spine surgery pay off?

At a Glance

• In pediatric idiopathic scoliosis surgery, navigation was more cost-effective than robotic assistance.
• Robotic systems showed greater clinical benefit but at substantially higher cost.
• Procedural volume plays a major role in determining the value of adoption.

Estimated read time: 4 minutes

As navigation and robotic technologies become increasingly visible in orthopaedic surgery, questions about clinical benefits are now being accompanied by questions about cost. Hospitals face significant capital investments, surgeons face learning curves, and payers want evidence that newer technologies provide value.

Those issues were the focus of a paper presented at the AAOS 2026 Annual Meeting titled “Navigated and Robotic-Assisted Pedicle Screw Placement are More Cost-Effective Than Freehand Technique for Posterior Spinal Fusion in Pediatric Idiopathic Scoliosis: A Payer’s Perspective.”

In a one-on-one conversation with AAOS Now Editorial Board member Cass Igram, MD, FAAOS, Amith Umesh, a fourth-year medical student at UCLA and paper coauthor, discussed how his team evaluated the economics behind emerging spinal technologies.

Looking through the payer’s lens
Umesh said his interest stemmed from a lifelong fascination with technology and its role in healthcare.

“A lot of surgeons that I spoke to mentioned that they anecdotally see a benefit when using this technology,” Umesh said. “It comes with a very big upfront cost, not only to the hospitals but also to the insurers, the payers.”

The study was designed to answer a straightforward question: In pediatric idiopathic scoliosis surgery, are robotic and navigated approaches worth the investment from a payer perspective?

That perspective is often overlooked, particularly in discussions surrounding surgical innovation. As Dr. Igram noted during the interview, surgeons and payers are not always aligned when evaluating new technologies.

Navigation versus robotics
Although many previous studies have focused on pedicle screw accuracy, Umesh said his team’s analysis looked instead at broader clinical outcomes. The analysis focused on posterior spinal fusion for pediatric idiopathic scoliosis, a procedure that commonly requires placement of multiple pedicle screws across several spinal levels.

“A lot of studies look at individual screw placement and their accuracy, whether [there is] medial breach,” he explained. “What we’ve done here is look at clinical outcomes, whether that be infection prevention [or] neurological injury.”

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Their findings suggest both navigation and robotic assistance can offer clinical benefits, but the economic story differs.

For readers less familiar with the technology, navigation and robotics are not synonymous. Navigation systems, such as the O-Arm platform discussed in the study, function much like a GPS system for the surgeon, providing real-time imaging and guidance during screw placement. Robotic-assisted systems build on that technology by adding a robotic platform that helps guide instrumentation according to a planned trajectory. In both cases, the surgeon remains in control of the operation, but robotics introduces an additional technological layer and associated costs.

“We found that navigated surgery, or in this case, with the O-Arm, would be … more cost-effective than using a robot,” Umesh said. “But we did see that, overall, the robot did provide better clinical benefit. Based on our analysis, it just wasn’t worth the cost to go out and make that investment.”

Using a cost-utility model based on quality-adjusted life years (QALYs), the researchers found that the additional benefit provided by robotics required $255,518 per additional QALY compared with navigation, exceeding the study’s willingness-to-pay threshold of $50,000 per QALY.

Although robotic-assisted surgery yielded slightly better clinical outcomes in the authors’ analysis, navigation was the more cost-effective option. Umesh attributed this largely to the substantial financial burden associated with robotic platforms (Table 1).

The price of adoption
According to Umesh, hospitals can expect an initial capital expenditure ranging from approximately $750,000 to $1.5 million, depending on the platform and contract structure. Annual maintenance expenses may exceed $100,000, not including disposable components used during procedures.

Whether that investment makes sense depends largely on procedural volume, he said.

“For high-volume institutions, it ends up becoming worth it over the long term,” Umesh explained, “whereas for lower-volume institutions, the upfront cost ... it’s absolutely not worth it.”

He emphasized that hospital and payer perspectives are not interchangeable. Hospitals evaluate capital investments and operational costs, while insurers focus on reimbursement structures and episode-of-care spending.

Experience still matters
Technology alone does not negate the importance of surgical experience.

Dr. Igram raised a practical question familiar to many orthopaedic surgeons: How should the outcomes of an experienced freehand surgeon be compared with those of a younger surgeon using advanced technology?

Umesh acknowledged that surgical skill remains an important factor.

“[The] surgeon’s preference and … experience definitely have an impact on outcomes,” he said.

He also noted that the learning curve differs between techniques.

“The number of cases that you need to do to be proficient at freehand, at least based on some of the adult as well as scoliosis, [demonstrate] there’s a learning curve,” said Umesh. “Fifty cases is the number most commonly found, whereas for navigated surgery and robotic surgery, [it] tends to be around 20 to 30 cases,” Umesh said.

Importantly, this study focused on pediatric deformity surgery, whereas much of the available literature on learning curves comes from adult spine populations.

Balancing innovation and value
For surgeons already comfortable with freehand techniques, the findings will not necessarily mandate a change in practice. Umesh emphasized that surgeons achieving excellent outcomes with existing methods should continue using techniques that work well for them.

Still, he believes navigation technologies may offer meaningful value at a broader population level.

“If you have great outcomes, you should stick to what you’re good with,” Umesh said. “But I think at least at a population level, based on our data, it does seem that navigated surgery is cost-effective. … Although robotic surgery may, in some surgeons, confer a clinical benefit, the amount of cost that’s needed to confer that clinical benefit, at least right now, is not worth it based on its pretty lengthy run-up to get to the point where you’re adept.”

“Even though there’s a lot of upfront cost, I think if you can do an operation more efficiently with less complication, that ultimately it is for the good of the patients,” said Dr. Igram, “ … [and] is going to lead to lower complications and lower cost.”

A potential path through CMS
One of the more interesting observations from the study involved healthcare policy rather than surgical techniques. Discussing reimbursement decisions by the Centers for Medicare & Medicaid Services (CMS) and private insurers, Umesh said: “Based on the Medicare data ... I think we can show CMS that navigated surgery is cost-effective.”

Umesh suggested demonstrating value to CMS could have implications far beyond Medicare beneficiaries.

“If you can convince CMS to cover a technology, then usually the private payers will follow,” he said.

To support that effort, the researchers relied on Medicare reimbursement data. Umesh explained that Medicaid data can vary considerably by state and institution, making Medicare a more consistent source for analysis.

As orthopaedics continues to evaluate emerging technologies, the conversation is increasingly shifting from whether these tools work to whether they deliver value for patients, hospitals, and payers alike.

Theresa Witham is managing editor of AAOS Now.

References

1. Umesh A, Nian PP, Lu SL, et al. Navigated and robotic-assisted pedicle screw placement are more cost-effective than freehand technique for posterior spinal fusion in idiopathic scoliosis: a payer’s perspective. Paper No. 648. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 2-6, 2026; New Orleans, LA.