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Zhang, et al.
others saying that it made no difference to the surgical why the use of this technology has not progressed more
outcome. However, additionally, the comment was rapidly despite the reported advantages – decreased
made that while they felt that the biomodel did enhance operating time, decreased radiation exposure to patients
surgical planning and the ability to perform the surgical intraoperatively, improved overall surgical outcomes,
intervention, the outcome to the patient was the same as pre-operative implant selection, as well as being an
if they had not used it. excellent communication aid for all medical and surgical
For those who were not using the technology, most team members. Regardless of the reported clinical
reported that this was due to availability issues (44%). success, the lack of usage of 3D RP or printing has been
However, only 54% said that they would use it should it attributed to the availability and cost of the technology,
ever become available in their hospital. Other minority as well as the time delay between the scan of the patient
reasons given for not using biomodels were cost (4%, is performed and the biomodel being produced (several
n = 1) and other reasons (12%, n = 3), predominantly days) and then delivered to the requesting surgeon.
being that they do not or have not had a suitable case for The other main reason given for not using physical 3D
which to use it to date. biomodels was that the particular surgeon did not treat the
These results, together with discussions with the type of spinal deformity patients that would benefit from
surgeons while they were completing the survey, this technology, who are managed by a small contingent
highlighted a number of important considerations: That of highly specialized complex deformity surgeons.
of the suitability of cases for this type of procedure in The future success of this technology is dependent on
a particular surgeon’s practice, as well as the usefulness how useful surgeons find the biomodels to be for pre-
of biomodels for purposes other than developing the operative planning and consent and/or for intraoperative
actual surgical plan. The surgeons who currently used anatomic reference compared with standard visualization
additive manufacturing for surgical planning all worked modalities such as CT scans. Do additively manufactured
with patients who had complex progressive deformities, biomodels have the potential to become part of the standard
whereas those who did not use biomodels treated less of care, or will it always be used only for the most complex
complex and mainly adult degenerative cases, for which deformity cases by specialist spinal surgeons and how will
the added expense and time delay to print the model the success of the technology be measured? Answering
was thought to likely not be of sufficient benefit to their these questions will be vital for additive manufacturing
surgical planning and/or surgical procedure. to become an essential part of spinal deformity surgery
According to surgeons, the usage of additively as the technology continues to improve, becomes more
manufactured models are often extended, which is affordable and faster to produce. It seems clear that even
beyond the surgical planning phase. Hence, patient or if biomodels are only used on a limited basis during the
their guardian needs to be aware of the this situation when surgical procedure for the most complex cases of spinal
signing the informed consent form. Having a physical deformities, there is certainly value in the exercise of
model available of a complex spinal deformity made the virtual planning or 3D computer modeling, a processing
explanation of the current condition as well as the intended step that is generated before final additive manufacturing
surgical procedure to patients and family much simpler occurs. The generation of the 3D computer model allows
and easier to understand. The description of both the for the on-screen manipulation of the patient’s-specific
severity and the reasons for the current symptoms caused anatomy generated from their CT scan for the purpose of
by the spinal deformity could be explained more clearly visualization of the deformity for pre-operative planning
as well as exactly what the surgery would entail and the and rehearsal of the intended surgery. Therefore, whether
possible complications and consequences that may occur or not the final stage of printing goes ahead; utilization of
with or without the intended surgical procedure. This the technology of 3D computer modeling will most likely
sentiment has also been reported in literature discussed become a routine part of spinal surgery for the benefit of
above . Furthermore, using the additively manufactured clinicians and patients alike.
[4]
models with surgical trainees form an important teaching It is worth noting that based on the number of
tool during the surgical planning phase, during the publications found in literature, China has the appearance
surgical procedure, and as retrospective case studies. of leading the medical field in the use of RP technology.
Why are some countries such as China more readily
7.1. Future Perspectives
accepting RP technology and why are they at the forefront
As reflected in this review, the use of additive in using it compared with the western world? Perhaps,
manufacturing as a pre-operative planning tool in spinal it is related to the fact that in western countries, private
surgery is still relatively uncommon, even though the biomedical companies are driving this technology and its
technology has continued to develop over the past use rather than research institutions, which often does not
three decades. This review raises the question as to translate into peer-reviewed publications.

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