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Sadagopan et al. Art Int Surg 2024;4:387-400 https://dx.doi.org/10.20517/ais.2024.34 Page 395

DISCUSSION
Levels of automation specific for spine surgery
The development and implementation of autonomous devices in spine surgery are rapidly expanding due to
the confluence of mechanistic, robotic, and AI innovations. Though the stratification of Yang et al. can be
utilized to classify the stages of automated surgical devices in the broader surgical community, there
remains a need for a spine-specific classification encompassing the unique challenges and future directions
[17]
of the field . Here, we propose our own classification for different levels of surgical automation currently
employed, or soon to be developed, in spine surgery [Table 4].

Level 0 - manual
All surgical tasks are performed manually by the surgeon without any automated assistance. The surgeon
relies on their expertise to navigate and execute the procedure. Procedures encompassed within this level
would include freehand pedicle screw placement.

Level 1 - computer-assisted navigation
In level 1, the system provides passive support, such as enhanced imaging and navigation tools, to assist the
surgeon in planning and executing the surgery through neuronavigation, endoscopic, or exoscopic
visualization. The surgeon retains full control of the surgical instruments while receiving assistance in
advanced visualization.

Level 2 - task-specific automation
In level 2, automation assists with specific tasks, such as pedicle screw placement or drilling, under the
surgeon’s direct supervision. The surgeon initiates these tasks and monitors their execution, intervening if
necessary.

Level 3 - semi-autonomous spine surgery
In level 3, the system can autonomously perform more complex sequences of tasks, such as those required
for decompression or arthrodesis procedures, but still requires human surgeon oversight. The surgeon
supervises the procedure and can intervene to ensure precision and safety.

Level 4 - highly autonomous spine surgery
In level 4, the system performs the majority of the surgical tasks autonomously with minimal human
intervention. The surgeon's role is primarily supervisory, stepping in only for unexpected situations or
critical decision making. The robot at this stage does not technically need a human and should be able to
reach a safe position without human intervention (e.g., packing a bleeding wound in preparation for an
angiogram).

Level 5 - fully autonomous spine surgery
Level 5 represents the highest level of autonomy within spine surgery, where the system can conduct the
entire spine surgery autonomously (regardless of complexity), from planning to execution, without human
intervention. This would represent “true autonomy” in spine surgery.

Our classification presents a reinterpretation of the initial stratification by Yang et al. made specifically for
[17]
autonomous advancements in spine surgery . The complicated anatomy and critical locations of
paraspinal neurovasculature make implementing autonomy in spine surgery exceedingly difficult. As
progress is made toward increasingly autonomous surgical devices in spine, there is a greater need for
surgeons to identify the proper devices for their respective procedures and to understand the capabilities of