In recent months, the use of 3D printed spinal equipment and implants has increased, allowing for more personalized surgical planning. Many spine surgeons see the potential of 3D printing technology, but also foresee the challenges that need to be solved to ensure its success.

Here is how 15 spine surgeons view the development of 3D printing in the next three years:

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Alan Down, MD. University of California, San Francisco Medical Center: More and more residents and researchers are using 3D printed precision anatomical models for patient education and surgical planning. The use of these models will continue to increase, especially in complex cases. In terms of more widely applicable implants, 3D printed implants will mature in the same way as traditionally manufactured implants. Most 3D implants today are made of titanium alloys. In the next three years, there will be more lattice and 3D printed mediator devices made of polyaryletherketone family materials with surface enhancement functions. Spine surgeons will have a wider range of implants to choose from.

Peter Deman, MD. Texas Back Institute (Plano): 3D printing allows the creation of spinal implants with unique structures and surfaces to optimize fusion. I think the next step in using this technology will be to widely manufacture implants that are truly patient-oriented. Although the "off the shelf" option is usually sufficient, the 3D printed implant will have a geometry tailored to the patient's anatomy and required corrections. The stiffness can be modified according to the bone density. However, logistical obstacles must be resolved first. This includes developing a system through which manufacturers can obtain patient images and convert them into implant designs, possibly with the help of artificial intelligence. Then the implants need to be printed, sterilized, packaged, and transported. The entire process must be completed within a reasonable turnaround time. Despite these challenges, I think it’s only a matter of time before surgeons can provide patients with customized 3D printed implants.

Samuel Joseph Jr., MD. Joseph Spine Institute (Tampa, Florida): In the next three years, I think 3D printing will grow significantly to meet the needs of patients for specific implants. This will be used for pedicle screw, cervical plate and cage design. With better technology, including artificial intelligence and preoperative planning, we will be able to develop implants that reduce surgical time and cost, and allow us to restore proper alignment while reducing complications.

James Harrop, MD. Thomas Jefferson University Hospital (Philadelphia): I think 3D printing will play a greater role in spinal surgery in the short term and more importantly in the long term. I believe that technology will improve in the next three years; however, as we better understand biomaterials, it will truly expand and develop. In addition, a better understanding of sagittal balance and patient-specific implant design will be synergistic. It is hoped that through robotics, a better understanding of deformed anatomy and optimal patient-specific sagittal and coronal balance, the ability to create patient-specific implants will accelerate the development of this field. In the future, we will develop from selecting ready-made products to designing specific surgery for specific patients and using customized implants.

Nitin Khanna, Doctor of Medicine. Orthopedic specialist in northwestern Indiana (Munster): As we move towards truly patient-oriented spinal surgery, 3D printing must be considered an important part of the puzzle. The ability to print "universal" 3D intervertebral cages only touches the surface of this technology. As we combine machine learning, 3D preoperative planning with patient-specific rod and sagittal alignment goals, we will soon also be able to recognize and 3D print from the perspective of endplate coverage, stiffness matching, and coronal/sagittal specific parameters The ideal cage.

With the advancement of technology, a patient-specific 3D disc replacement can be constructed, and the ultimate goal is to construct a real biological disc replacement. Someday in the near future: after tissue engineering expands the patient's own cells and 3D printed tissue that can reconstruct human intervertebral discs. This patient-specific human intervertebral disc can then be replaced to restore the physiological dynamics of the spine.

Ronald Lehman, MD. Columbia Orthopedic Surgery (New York City): In the next few years, 3D printing will continue to develop in the field of spinal surgery in many ways. We have seen that current implants rely on 3D printing to better replicate the microstructure of the end plates (and cross each other and connect to the end plates themselves) to promote fusion. However, the ability to design, plan, and print patient-specific implants will only continue to meet our needs. This will be particularly beneficial for trauma, tumor and deformity cases, as we have used similar 3D printed, patient-specific implants in orthopedic trauma and tumors for many years. During the wars in Iraq and Afghanistan, I first encountered this technology at the Walter Reed Army Medical Center because it was used to solve severe-sized bone defects and amputees. Advances in surgical planning software will further enable us to determine patient-specific goals for spinal surgery, educate and train on surgical planning and design, and produce 3D printed implants or guidelines to facilitate the plan and ensure that the plan is executed accordingly.

Philip Louis, MD. Virginia Mason Medical Center (Seattle): I think 3D printing will continue to grow in the next three years and will serve as a useful aid to other technologies (especially navigation-based technologies).

The unique capabilities that 3D printing provides in pre-operative planning, as well as the safety and time-saving benefits during surgery, have been fully demonstrated. I hope that the field of spinal surgery can follow in the footsteps of other specialties, which are now combining custom implants based on the patient's unique anatomy, especially in a deformed environment.

As surgeons continue to improve radiation safety and minimize exposure, 3D printing capabilities will continue to provide a low-cost and effective platform to assist surgery. Ultimately, the customization of implants and the ability to complement other spinal surgery techniques to improve the safety and value of spinal surgery will be my biggest interest.

Matthew MacDonald, MD. University Orthopaedic Association (Somerset, NJ): 3D printing has many emerging uses in the field of spinal surgery. We have the ability to print and accurately replicate the spinal model, which can be used for preoperative planning of complex spinal deformities and tumor cases. Before surgery, the surgeon can actually hold an exact replica of the patient’s spine in his or her hand to better understand the patient’s unique anatomy. In addition, the 3D model can be used in the setting of training for residents and peers. Spinal implant companies are already 3D printing titanium cages. The 3D printing process allowed them to construct implants with complex geometries and porous surfaces to promote faster and higher spinal fusion rates. I suspect that in the future, 3D printing will be used to produce customized implants for patients and anatomy. If custom implants can be introduced into the field in a way that can improve patient treatment while reducing costs, the use of this technology will certainly expand in the next few years.

Issada Thongtrangan, Doctor of Medicine. Microspine (Scottsdale, Arizona): I see the continuous growth of 3D printed spinal implants. In my opinion, the ideal implant must have a porosity suitable for bone ingrowth and continued growth, and match the bone modulus. However, advanced technology is not cheap, but I predict that the cost will decrease with the competitive nature of the market.

Robert Watkins Jr., MD. Marina Spine Center (Marina del Rey, California): As costs decrease and production speeds increase, 3D printing will become more common. Compared with the typical subtractive technology currently produced, the additive production technology can create unique shapes, unique surfaces, and retain large gaps for intracorporeal fusion.

Usman Zahir, MD. ScopeSpine-The Orthopedic Group (Dulles, Virginia): 3D printing will continue to help move spinal surgery from inpatients to outpatient ASC environments. In addition to the benefits of custom implant design and reduced storage and inventory requirements, I found the prospect of using small 3D printed spinal molds for intraoperative instrument positioning. Taking into account the unique anatomy of each patient, customized spine targeting molds help reduce surgery time and radiation exposure to perform less invasive midline methods. Many robotics and navigation spine platforms are too expensive for many ASCs. 3D printing provides a very practical, efficient and cost-effective solution.

Brian Gantwerker, MD. Los Angeles Cranial Spinal Cord Center: With the advent of 3D printing technology, spinal surgery is ready to fully adopt this exciting technology. Although 3D printing is expected to revolutionize the field of spine surgery, its application is progressing slowly. Currently on the market, several manufacturers use 3D printing technology, which is expected to achieve better bone conduction and stronger implant integrity.

In the next three years, I believe we will see wider adoption by "big box" manufacturers. What we need to see is the widespread availability of custom 3D implants. Combined with robotic technology, low-cost, more suitable intervertebral and vertebral body/vertebral body/vertebral body resection cages will make the implants better fit and reduce the possibility of different implant complications, such as pseudoarthrosis , Kick out or failure of the windshield wiper. In addition to the accuracy of the robot's tissue resection, 3D custom implants can significantly and positively affect the patient's treatment effect.

Charles Sansour, MD. University of Maryland School of Medicine (Baltimore): 3D printing in spinal surgery will allow us to provide patients with better choices in many ways. It allows us to match the patient's bone quality to the modulus of the implant. We will have greater ability to fill the gaps in tumor cases and complex deformities. The improved porosity and surface texture of 3D printed implants will ultimately lead to better fusion rates and hopefully bring better results for our patients.

Miki Katzir, Doctor of Medicine. University of Nebraska Medical Center (Omaha): As a spinal tumor neurosurgeon, I perform partial or complete body resections through intralesional and en-bloc methods. I don't know how economical this is, but implanting custom 3D printed vertebrae may be beneficial for patients with abnormal anatomical structures, such as severe kyphosis or scoliosis in the area. For these patients, there is no perfect standard framework.

I do think that the currently available cages are suitable for 80% of patients, but for the remaining 20%, we must be creative. I am currently using polymethyl methacrylate bone cement for these patients. Polymethyl methacrylate is easy to form in the vertebral resection cavity, but it has its shortcomings, such as: it does not promote the fusion of the entire space and does not anchor. Into the end plate, and rarely cause exothermic damage to the surrounding structure. In these days when we have very advanced immunotherapy and stereotactic radiotherapy, cancer patients are living longer and longer. Current cage technology seems to be lagging behind. An interesting idea that I recently started to consider is the 3D printer located at the core of the operating room. In 30 minutes, we have our customized perfectly fitted cage. Only the future can tell whether it is the future or just a dream.

Arya Varthi, Doctor of Medicine. Yale University School of Medicine (New Haven, Connecticut): I believe 3D printing will play a greater role in spinal surgery in the next three years. From an educational point of view, 3D printing can be used to create models to give trainees a better understanding of anatomy and hardware placement. From an operational point of view, 3D printing has many uses. The patient-specific pedicle screw insertion guide can be used to improve the speed and accuracy of screw insertion. 3D printing can be used to create models that surgeons can study before surgery in large deformities. In the next three years, 3D printing technology may be used more widely to manufacture patient-specific implants.

Note: This article was updated at 9 am on April 30th to include additional responses.

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