Perspectives Bernhard Meyer, M.D. Professor and Chairman, Department of Neurosurgery Director, Neurosurgical Clinic, Technical University of Munich Yes, We CAN! Bernhard Meyer and Yu-Mi Ryang I n 2009, Härtl et al. conducted a survey-based study on the use of navigation in spine surgery by means of a 12-item questionnaire. The questionnaire was distributed by e-mail to AOSpine members worldwide, including orthopedic, trauma, and neurologic surgeons. The aim was to assess the questioned surgeons’ experiences with computer-assisted navigation (CAN) in spine surgery and their attitudes towards it concerning accu- racy of pedicle screw placement, safety in complex spine sur- gery, radiation exposure, use in minimally invasive surgery (MIS), preoperative planning, and the avoidance of wrong-level surgery. The response rate of 3348 questioned surgeons was 20%. An analysis of the survey revealed that 38% of all respondents had access to CAN at their institutions: 70% of surgeons from North America, 42% from Europe and the Asia Pacific regions, and only 14% from Latin America had access. Interestingly, only 9% stated that they used CAN routinely. Overall, surgeons who perform high-volume procedures, neuro- logic surgeons, and surgeons performing MIS with a relatively high frequency were, to differing degrees, more inclined to use CAN. Most of the responding surgeons (69%) stated that they performed 100 fusions per year, whereas only 11% were high-volume performers with 200 annual fusions. Similarly, 88% of all respondents performed 26% MIS fusions. Surgeons were allocated to three groups according to their frequency in using CAN: The majority (66%) turned out to be “nonusers” (66%), in contrast to only 9% “routine users” and 25% “selec- tive users.” In addition, surgeons were classified into four groups according to the strength of their belief in the benefits of CAN: poor, moderate, strong, and very strong believers. Further analysis of the data revealed surgeons who performed a high volume of procedures to be more frequent CAN users (59%) than surgeons who performed a low volume (21%). Of all users 75% considered CAN to have the greatest benefit in terms of accuracy, safety in complex spine cases, and in the reduction of radiation exposure. These beliefs were even stronger in the “routine users” (90%). When asked for reasons not to use CAN, high costs, lack of equipment, increased operating room (OR) time, and inadequate training were the main issues among all respondents, whereas increased OR time was the main reason for “routine” and “selective users” and high costs and lack of equipment for the “nonusers.” Data to support greater accuracy, safety, and the ability to safe OR time were the most important requirements for “routine users” opposed to availability and training for the “nonusers.” The greatest potential benefits of CAN (75%) were considered to be its use in MIS, revision cases, deformity, and thoracic spine surgery. Analysis of respondents’ strength of belief revealed 64% to be poor-to-moderate believers and only 36% to have strong or very strong beliefs in the beneficial effects of CAN. Subgroup analysis interestingly revealed an inverse correlation between strength of belief and CAN availability. The majority (62%) of Latin American surgeons were strong to very strong believers even though availability of CAN was only 14%, whereas only 7% of all North American surgeons were strong to very strong believers even though they had the highest access to CAN (70%). Furthermore, a relatively high rate of “routine users” (12%) and especially surgeons with high volumes of procedures (26%) comprised poor to moderate believers, showing that experience with CAN could result in negative opinions toward it. Availability, adequate training, 10% MIS/year, being an ortho- pedic surgeon, and being a strong or very strong believer were the prerequisites to use CAN more often. In account of the inherent limitations of this study, 80% of all surgeons had positive opinions toward CAN, even though at the time of the survey in 2009 in general CAN systems did not meet the surgeons’ expectations in terms of efficiency, user friendliness, and integration into the surgical workflow. Affordability and cost Key words  Expert opinion  Internet-based opinion survey  Spine surgery  Surgery, computer-assisted Abbreviations and Acronyms CAN: Computer-assisted navigation MIS: Minimally invasive surgery OR: Operating room Department of Neurosurgery, Technical University of Munich, Munich, Germany To whom correspondence should be addressed: Bernhard Meyer, M.D. [E-mail: bernhard.meyer@lrz.tum.de] Citation: World Neurosurg. (2013) 79, 1:85-86. http://dx.doi.org/10.1016/j.wneu.2012.10.045 Commentary on: Worldwide Survey on the Use of Navigation in Spine Surgery by Härtl et al. pp. 162-172. WORLD NEUROSURGERY 79 [1]: 85-86, JANUARY 2013 www.WORLDNEUROSURGERY.org 85