Robot-assisted vs freehand pedicle screw fixation in spine surgery - a systematic review and a meta-analysis of comparative studies

Robotic spine surgery: Technical note and descriptive analysis of the first 40 cases

INTRODUCTION

The global incidence of spinal pathology is increasing due to the progressive aging of the population and increased life expectancy. Vertebral fixation with transpedicular screws is the most commonly used technique in unstable or potentially unstable pathologies. There are different implantation methods, the most recently developed being implantation guided by robotic navigation.

MATERIALS AND METHODS

We describe the technical aspects and the different workflows available with the ExcelsiusGPS® robotic navigation system (GlobusMedical, Inc, Audubon, PA, USA), as well as the results of the first 40 patients operated on at the Hospital Universitario la Paz between July 2023 and February 2024.

RESULTS

A total of 250 screws were implanted at the thoracic and lumbar levels. 12 patients underwent minimally invasive surgery (MIS) (30%) and 28 patients underwent open surgery (70%). The median number of screws implanted per patient was 6.00 (4.00-6.00). The intraoperative malpositioning rate was 2.5% (1 case). The median duration of surgery was 143.00minutes (113.00-165.50). The median hospital stay was 4.00 days (3.00-5.50). The median intraoperative radiation delivered was 899mGy/cm2 (523.25-1595.00). The median blood loss was 150.00ml (100.00-300.00) and the blood transfusion rate was 0%.

DISCUSSION

Compared to conventional techniques, Robotic spine surgery increases accuracy to 96-100% and reduces the radiation dose received by the patient and surgical team. In addition, it allows the implantation of larger screws, which has been associated with increased biomechanical strength and reduced risk of loosening. Initially, it may involve an increase in total surgical time, but this is reduced once the learning curve is reached, around 40 cases.

CONCLUSIONS

ExcelsiusGPS® is the most recent robot model on the market and different studies have demonstrated its effectiveness in different techniques and indications. Unlike other robotic systems used exclusively in dorsolumbar spine pathology, it can be used in the pathology of the entire spinal axis (from C1 to the sacrum) and brain pathology (deep electrode implantation, brain biopsy, SEEG, among others).

Comparison of robotic AI-assisted and manual pedicle screw fixation for treating thoracolumbar fractures: a retrospective controlled trial

Objective

To compare the clinical efficacy and screw placement accuracy of robot artificial intelligence (AI)-assisted percutaneous screw fixation and conventional C-arm-assisted percutaneous screw fixation (manual placement) in the treatment of thoracolumbar single-segment fractures without neurological symptoms.

Methods

This study is a single-center retrospective analysis involving patients with thoracolumbar single-segment fractures without neurological symptoms. Patients were divided into Group A (robotic AI-assisted placement) and Group B (manual placement). Clinical outcomes such as operative time, intraoperative fluoroscopy frequency, screw placement accuracy, postoperative complications, length of hospital stay, and postoperative pain were compared between the two groups.

Results

Group A showed significantly better screw placement accuracy, fewer intraoperative fluoroscopy attempts, shorter fluoroscopy time, and fewer guidewire adjustments compared to Group B (P < 0.05). Additionally, Group A had shorter hospital stays, a lower incidence of postoperative complications, and short-term greater improvement in Visual Analog Scale (VAS) scores (P < 0.05). However, after 1 year of follow-up, there was no statistically significant difference between the two groups in the improvement of VAS scores.

Conclusion

Robotic AI-assisted placement improves pedicle screw placement accuracy, reduces intraoperative fluoroscopy frequency and time, alleviates postoperative pain, and accelerates patient recovery. This approach aligns with the principles of enhanced recovery in orthopedic surgery and holds promise for wider clinical application in the treatment of thoracolumbar fractures.

Development of a classification system for potential sources of error in robotic-assisted spine surgery

PURPOSE

Robotic-assisted spine surgery (RASS) has increased in prevalence over recent years, and while much work has been done to analyze differences in outcomes when compared to the freehand technique, little has been done to characterize the potential pitfalls associated with using robotics. This study's goal was to leverage expert opinion to develop a classification system of potential sources of error that may be encountered when using robotics in spine surgery. This not only provides practitioners, particularly those in the early stages of robotic adoption, with insight into possible sources of error but also provides the community at large with a more standardized language through which to communicate.

METHODS

The Delphi method, which is a validated system of developing consensus, was utilized. The method employed an iterative presentation of classification categories that were then edited, removed, or elaborated upon during several rounds of discussion. Voting took place to accept or reject the individual classification categories with consensus defined as ≥ 80% agreement.

RESULTS

After a three-round iterative survey and video conference Delphi process, followed by an in-person meeting at the Safety in Spine Surgery Summit, consensus was achieved on a classification system that includes four key types of potential sources of error in RASS as well as a list of the most commonly identified sources within each category. Initial sources of error that were considered included: cannula skidding/skive, penetration, screw misplacement, registration failure, and frame shift. After completion of the Delphi process, the final classification included four major types of pitfalls including: Reference/Navigation, Patient Factors, Technique, and Equipment Factors (available at https://safetyinspinesurgery.com/ ).

CONCLUSION

This work provides expert insight into potential sources of error in the setting of robotic spine surgery. The working group established four discrete categories while providing a standardized language to unify communication.

Building consensus: development of a best practice guideline (BPG) for avoiding errors in robotic-assisted spine surgery (RASS)

INTRODUCTION

With the rapid increase in the use of robotic-assisted spine surgery (RASS), reports describing complications have inevitably emerged. This study builds on previous work done to identify, characterize, and classify potential sources of error in spine surgery performed with enabling technology in the operating room. The goal of this study is to leverage expert opinion to develop a set of best practice guidelines that can be employed to minimize complications and optimize patient safety, specifically as it relates to RASS.

METHODS

After assembling a group of attending spine surgeons experienced in the use of RASS across the country, formal consensus regarding the best practices was developed using the Delphi method and nominal group technique. After a review of the relevant literature and evidence, an initial survey of study group members (n=12) helped frame potential areas for investigation. Statements were subsequently edited, removed, or elaborated upon during four iterative rounds of live discussion with the opportunity for panelists to propose new guidelines at any point in the process. Respondents were able to suggest modifications and refine the statements until consensus, defined as ≥ 80% agreement, was achieved.

RESULTS

After a three-round iterative survey and video conference Delphi process, followed by an in-person meeting at the Summit for Safety in Spine Surgery, consensus was achieved on 27 best practice guideline statements. This BPG had the key focus areas of 1) general protocols, 2) screw planning/execution, 3) optimization of surgical technique, and 4) areas for robotic improvement. (available at https://safetyinspinesurgery.com/ ).

CONCLUSION

This work provides expert insight into the best practices for minimizing errors in RASS with the presentation of 27 recommendations that can serve to reduce practice variability, optimize safety, and guide future research.

Robotic Spine Surgery: Systematic Review of Common Error Types and Best Practices

BACKGROUND AND OBJECTIVES

Robotic systems have emerged as a significant advancement in the field of spine surgery. They offer improved accuracy in pedicle screw placement and reduce intraoperative complications, hospital length of stay, blood loss, and radiation exposure. As the use of robotics in spine surgery continues to grow, it becomes imperative to understand common errors and challenges associated with this new and promising technology. Although the reported accuracy of robot-assisted pedicle screw placement is very high, the current literature does not capture near misses or incidental procedural errors that might have been managed during surgery or did not alter treatment of patients. We evaluated errors that occur during robot-assisted pedicle screw insertion and identify best practices to minimize their occurrence.

METHODS

In this systematic review, we characterized 3 types of errors encountered during robot-assisted pedicle screw insertion-registration errors, skiving, and interference errors-that have been reported in the literature.

RESULTS

Our search yielded 13 relevant studies reporting robot-assisted screw errors. Nine studies reported registration errors, with 60% of failed screws in those studies caused by registration issues. Seven studies highlighted skiving errors; 26.8% of the failed screws in those studies were caused by skiving. Finally, interference errors were reported in 4 studies, making up 19.5% of failed screws.

CONCLUSION

On the basis of these findings, we suggest best practices-including close attention to preoperative planning, patient positioning, image registration, and equipment selection-to minimize the occurrence of these errors. Awareness of how errors occur may increase the safety of this technology.

Practice Pattern Variations in the Use of Neuromonitoring, Image Guidance, and Robotics for Lumbar Pedicle Screw Placement Based on a Nationwide Neurosurgery Survey

OBJECTIVE

Lumbar pedicle screw placement surgery involves various assistive technologies, including fluoroscopic, stereotactic, or robotic navigation and intraoperative neuromonitoring (IONM). We aimed to discern neurosurgeons' preferences for screw placement techniques and IONM utility, while also considering the influence of experience.

METHODS

A survey was distributed to members of the Congress of Neurological Surgeons using REDCap software, collecting demographic data and querying preferred techniques for screw placement and IONM modalities. Opinions on IONM use during stereotactic or robotic navigation were also obtained. Responses were analyzed using Pearson's Chi-square and analysis of variance tests via R software.

RESULTS

Of 188 responses, 35.5% (n = 67) reported 1-10 years of experience and 64.5% (n = 121) reported ≥ 11 years. Less experienced neurosurgeons used stereotactic navigation more than those with greater experience (P < 0.001). Seasoned neurosurgeons used fluoroscopic guidance more often (P = 0.038). Less experienced neurosurgeons employed 1.69 (± 0.11) techniques for their fixation surgeries compared to 1.50 (± 0.0.8) for more experienced neurosurgeons. Robotic navigation utilization was low and comparable between the groups. Surgeons employing multiple techniques used triggered electromyography the most (62.1%, P = 0.024). No strong opinions emerged on the necessity of multimodality IONM with robotic or stereotactic navigation.

CONCLUSIONS

This national survey shows that stereotactic navigation is the predominant technique for pedicle screw placement among less experienced neurosurgeons, with seasoned neurosurgeons leaning toward fluoroscopic guidance. Robotic guidance was the least used technique with no observed difference based on experience. Neurosurgeons employing multiple techniques use IONM the most, compared with surgeons who only use stereotactic navigation and/or robotic guidance.

Enhancing Precision and Safety in Spinal Surgery: A Comprehensive Review of Robotic Assistance Technologies

BACKGROUND

The intricate nature of spinal surgery demands unprecedented precision to avoid severe complications such as nerve damage and paralysis. Recent advancements have steered spinal surgery toward robotic assistance, which enhances precision beyond human capabilities. These robotic systems allow for detailed preoperative planning and real-time guidance during surgery, significantly reducing the margin for error and promoting the adoption of minimally invasive techniques. This review aimed to evaluate the application of robotic systems in spinal surgeries, focusing on the accuracy and efficacy of these technologies in clinical settings.

METHODS

The authors used comprehensive literature searches in 2 databases, PubMed and Scopus, focusing on the terms "robot," "robot-assisted," and "spine surgery." The search was aimed at gathering both original research and review articles to assess the current status and advancements in robotic spinal surgery.

RESULTS

Robotic systems, such as the Mazor X Stealth, have demonstrated high precision in pedicle screw placement with minimal deviation. Studies show a significant increase in the accuracy of screw placement compared with traditional methods. Furthermore, the use of robotic assistance in surgery has been linked to reduced operative times, less blood loss, and decreased radiation exposure to both patients and surgical teams.

CONCLUSIONS

Robotic systems significantly enhance the precision and safety of spinal surgeries. They reduce the risk of complications, minimize surgical invasiveness, and maintain or improve operative outcomes. However, challenges such as high costs and the need for specialized training persist. Continuous technological advancements and training are essential for the broader adoption of these systems in spinal surgeries.

Comparison of the Accuracy of Pedicle Screw Placement Using a Fluoroscopy-Assisted Free-Hand Technique with Robotic-Assisted Navigation Using an O-Arm or 3D C-Arm in Scoliosis Surgery

STUDY DESIGN

Retrospective.

OBJECTIVES

To report and compare the application of robotic-assisted navigation with an O-arm or three-dimensional (3D) C-arm-assisted pedicle screw insertion in scoliosis surgery, and compare with free-hand technique.

METHODS

One hundred and forty-four scoliosis patients were included in this study. Ninety-two patients underwent robotic-assisted pedicle screw insertion (Group A), and 52 patients underwent freehand fluoroscopy-guided pedicle screw insertion (Group B). Group A was further divided into Subgroup AI (n = 48; robotic-assisted navigation with an O-arm) and Subgroup AII (n = 44; robotic-assisted navigation with a 3D C-arm). The evaluated clinical outcomes were operation time, blood loss, radiation exposure, postoperative hospital stay, and postoperative complications. The clinical outcomes, coronal and sagittal scoliosis parameters and the accuracy of the pedicle screw placement were assessed.

RESULTS

There were no significant differences in blood loss and postoperative hospital stay between Groups A and B (P = .406, P = .138, respectively). Radiation exposure for patients in Group A (Subgroups AI or AII) was higher than that in Group B (P < .005), and Subgroup AI had higher patient radiation exposure compared with Subgroup AII (P < .005). The operation time in Subgroup AII was significantly longer than that in Subgroup AI and Group B (P = .016, P = .032, respectively). The proportion of clinically acceptable screws was higher in Group A (Subgroups AI or AII) compared with Group B (P < .005).

CONCLUSIONS

Robotic-assisted navigation with an O-arm or 3D C-arm effectively increased the accuracy and safety in scoliosis surgery. Compared with robotic-assisted navigation with a 3D C-arm, robotic-assisted navigation with an O-arm was more efficient intraoperatively.

Advancements in Robotic-Assisted Spine Surgery

Applications and workflows around spinal robotics have evolved since these systems were first introduced in 2004. Initially approved for lumbar pedicle screw placement, the scope of robotics has expanded to instrumentation across different regions. Additionally, precise navigation can aid in tumor resection or spinal lesion ablation. Robot-assisted surgery can improve accuracy while decreasing radiation exposure, length of hospital stay, complication, and revision rates. Disadvantages include increased operative time, dependence on preoperative imaging among others. The future of robotic spine surgery includes automated surgery, telerobotic surgery, and the inclusion of machine learning or artificial intelligence in preoperative planning.

Robot-assisted Temporary Hemiepiphysiodesis With Eight-plates for Lower Extremity Deformities in Children

PURPOSE

This study was performed to compare the radiographic results of robot-assisted and traditional methods of treating lower extremity deformities (LEDs).

METHODS

From January 2019 to February 2022, 55 patients with LEDs were treated by temporary hemiepiphysiodesis with eight-plates. They were divided into a robot group and a freehand group. The fluoroscopy time and operation time were recorded. The accuracy of screw placement was measured after the operation using the following parameters: coronal entering point (CEP), sagittal entering point (SEP), and angle between the screw and epiphyseal plate (ASEP). The limb length discrepancy (LLD) and femorotibial angle (FTA) were measured before the operation, after the operation, and at the last follow-up. Patients were followed up for 12 to 24 months, and the radiographic results of the 2 groups were compared.

RESULTS

Among the 55 patients with LEDs, 36 had LLD and 19 had angular deformities. Seventy-six screws were placed in the robot group and 85 in the freehand group. There was no difference in the CEP between the 2 groups ( P >0.05). The robot group had a better SEP (2.96±1.60 vs. 6.47±2.80 mm) and ASEP (3.46°±1.58° vs. 6.92°±3.92°) than the freehand group ( P <0.001). At the last follow-up, there was no difference in the LLD or FTA improvement between the two groups ( P >0.05). The incidence of complications was significantly lower in the robot group than in the freehand group (0/27 vs. 5/28, P <0.05).

CONCLUSION

Robot-assisted temporary hemiepiphysiodesis with eight-plates is a safe and effective method for treating LEDs in children. Robotic placement of screws is superior to freehand placement with respect to the entering position and direction. Although the correction effect for LLD and angular deformity is similar, screw dislocation is less common when using robot assistance.

LEVELS OF EVIDENCE

Level-III. Retrospective comparative study.

Mixed Reality-Based Navigation for Pedicle Screw Placement: A Preliminary Study Using a 3D-Printed Spine Model

Background and objectives Mixed reality (MR) is one of the image processing technologies that allows the user to manipulate three-dimensional (3D) virtual images (hologram). The aim of this study was to evaluate the accuracy of MR-based pedicle screw (PS) placement using 3D spine models. Materials and methods Using the preoperative CT data of a patient with adolescent idiopathic scoliosis (AIS) who had undergone posterior spinal fusion in our hospital, a 3D-printed spine model was created. On the other hand, a 3D hologram of the same patient was automatically created using the preoperative CT data uploaded to the Holoeyes MD service website (Holoeyes Inc., Tokyo, Japan). Using a Magic Leap One® headset (Magic Leap Inc., Plantation, FL), the 3D hologram with lines of predetermined PS trajectories was superimposed onto the 3D-printed spine model and PS were inserted bilaterally along with the trajectory lines from T5 to L3. As a control, we used a readymade 3D spine model of AIS and inserted PS bilaterally with a freehand technique from T4 to L3. The rate of pedicle violation was compared between the MR-based and freehand techniques. Results A total of 22 and 24 PS were placed into the 3D-printed spine model of our patient and the readymade 3D spine model, respectively. The rate of pedicle violation was 4.5% (1/22 screws) in the MR-based technique and 29.2% (7/24 screws) in the freehand technique (P = 0.049). Conclusions We demonstrated a significantly lower rate of PS misplacement in the MR-based technique than in the freehand technique. Therefore, an MR-assisted system is a promising tool for PS placement in terms of feasibility, safety, and accuracy, warranting further studies including cadaveric and clinical studies.

A user-friendly system for identifying the optimal insertion direction and to choose the best pedicle screws for patient-specific spine surgery

Background and objective

Many diseases of the spine require surgical treatments that are currently performed based on the experience of the surgeon. The basis of this study is to deliver an automatic and patient-specific algorithm able to come to the aid of the surgeons in pedicle arthrodesis operations, by finding the optimal direction of the screw insertion, the maximum screw diameter and the maximum screw length.

Results

The paper introduce an algorithm based on the reconstructed geometry of a vertebra by 3D-scan that is able to identify the best introduction direction for screw and to select, from commercial and/or personalised databases, the best screws in order to maximize the occupation of the bone while not intersecting each other and not going through the walls of the pedicle and the bounds of the vertebral body. In fact, for pedicle arthrodesis surgery, the incorrect positioning of the screws may cause operating failures, an increase in the overall duration of surgery and, therefore, more harmful, real-time X-ray checks. In case of not availability on market, the algorithm also suggests parameters for designing and manufacturing an 'ad hoc' solution. The algorithm has been tested on 6 vertebras extracted by a medical database. Furthermore, the algorithm is based on a procedure through which the surgeon can freely choose the entering point of the screw (based on his/her own experience and will). A real patient vertebra has been processed with almost 400 different entering point, always giving a feedback on the possibility to use the entering point (in case of unavailability of a good trajectory) and on the individuation of the right trajectory and the choose of the better screws.

Conclusions

In very recent bibliography, several papers deal with procedure to screw' trajectory planning in arthrodesis surgery by using Computer Aided surgery systems, and some of them used also modern methodologies (KBE, AI, Deep learning, etc.) methods for planning the surgery as better as possible. Nevertheless, no methodologies or algorithm have been still realized to plan the trajectory and choose the perfect fitting screws on the basis of the patient-specific vertebra. This paper represents a wind of novelty in this field and allow surgeons to use the proposed algorithm for planning their surgeries. Finally, it allows also the easy creation of a customized surgical template, characterized by two cylindrical guides that follow a correct trajectory previously calculated by means of that automatic algorithm generated on the basis of a vertebra CAD model for a specific patient. The surgeon will be able to set the template (drilling guides) on the patient's vertebra and safely apply the screws.

Trends in usage of navigation and robotic assistance in elective spine surgeries: a study of 105,212 cases from 2007 to 2015

OBJECTIVE

Identify trends of navigation and robotic-assisted elective spine surgeries.

METHODS

Elective spine surgery patients between 2007 and 2015 in the Nationwide Inpatient Sample (NIS) were isolated by ICD-9 codes for Navigation [Nav] or Robotic [Rob]-Assisted surgery. Basic demographics and surgical variables were identified via chi-squared and t tests. Each system was analyzed from 2007 to 2015 for trends in usage.

RESULTS

Included 3,759,751 patients: 100,488 Nav; 4724 Rob. Nav were younger (56.7 vs 62.7 years), had lower comorbidity index (1.8 vs 6.2, all p < 0.05), more decompressions (79.5 vs 42.6%) and more fusions (60.3 vs 52.6%) than Rob. From 2007 to 2015, incidence of complication increased for Nav (from 5.8 to 21.7%) and Rob (from 3.3 to 18.4%) as well as 2-3 level fusions (from 50.4 to 52.5%) and (from 1.3 to 3.2%); respectively. Invasiveness increased for both (Rob: from 1.7 to 2.2; Nav: from 3.7 to 4.6). Posterior approaches (from 27.4 to 41.3%), osteotomies (from 4 to 7%), and fusions (from 40.9 to 54.2%) increased in Rob. Anterior approach for Rob decreased from 14.9 to 14.4%. Nav increased posterior (from 51.5% to 63.9%) and anterior approaches (from 16.4 to 19.2%) with an increase in osteotomies (from 2.1 to 2.7%) and decreased decompressions (from 73.6 to 63.2%).

CONCLUSIONS

From 2007 to 2015, robotic and navigation systems have been performed on increasingly invasive spine procedures. Robotic systems have shifted from anterior to posterior approaches, whereas navigation computer-assisted procedures have decreased in rates of usage for decompression procedures.

Spine Surgical Robotics: Current Status and Recent Clinical Applications

With the development of artificial intelligence and the further deepening of medical-engineering integration, spine surgical robot-assisted (RA) technique has made significant progress and its applicability in clinical practice is constantly expanding in recent years. In this review, we have systematically summarized the majority of literature related to spine surgical robots in the past decade, and not only classified robots accordingly, but also summarized the latest research progress in RA technique for screw placement such as cervical, thoracic, and lumbar pedicle screws, cortical bone trajectory screws, cervical lateral mass screws, and S2 sacroiliac screws; guiding targeted puncture and placement of endoscope via the intervertebral foramen; complete resection of spinal tumor tissue; and decompressive laminectomy. In addition, this report also provides a detailed evaluation of RA technique's advantages and disadvantages, and clarifies the accuracy, safety, and practicality of RA technique. We consider that this review can help clinical physicians further understand and familiarize the current clinical application status of spine surgical robots, thereby promoting the continuous improvement and popularization of RA technique, and ultimately benefiting numerous patients.

Pedicle Screw Placement Accuracy in Robot-Assisted Spinal Fusion in a Multicenter Study

Pedicle screw fixation is a spinal fusion technique that involves the implantation of screws into vertebral pedicles to restrict movement between those vertebrae. The objective of this research is to measure pedicle screw placement accuracy using a novel automated measurement system that directly compares the implanted screw location to the planned target in all three anatomical views. Preoperative CT scans were used to plan the screw trajectories in 122 patients across four surgical centers. Postoperative scans were fused to the preoperative plan to quantify placement accuracy using an automated measurement algorithm. The mean medial-lateral and superior-inferior deviations in the pedicle region for 500 screws were 1.75 ± 1.36 mm and 1.52 ± 1.26 mm, respectively. These deviations were measured using an automated system and were statistically different from manually determined values. The uncertainty associated with the fusion of preoperative to postoperative images was also quantified to better understand the screw-to-plan accuracy results. This study uses a novel automated measurement system to quantify screw placement accuracy as it relates directly to the planned target location, instead of analyzing for breaches of the pedicle, to quantify the validity of using of a robotic-guidance system for accurate pedicle screw placement.

Safety and accuracy of cannulated pedicle screw placement in scoliosis surgery: a comparison of robotic-navigation, O-arm-based navigation, and freehand techniques

PURPOSE

To compare the safety and accuracy of cannulated pedicle screw placement using a robotic-navigation technique, O-arm-based navigation technique, or freehand technique.

METHODS

This study analyzed 106 consecutive patients who underwent scoliosis surgery. Thirty-two patients underwent robotic-navigation-assisted pedicle screw insertion (Group 1), 34 patients underwent O-arm-based navigation-guided pedicle screw insertion (Group 2), and 40 patients underwent freehand pedicle screw insertion (Group 3). The primary outcome measure was the accuracy of screw placement. Secondary outcome parameters included operation time, blood loss, radiation exposure, and postoperative stay.

RESULTS

A total of 2035 cannulated pedicle screws were implanted in 106 patients. The accuracy rate of the first pedicle screw placement during operation was significantly greater in Group 1 (94.7%) than in Group 2 (89.2%; P < 0.001). The accuracy rate of pedicle screw placement postoperatively decreased in the order of Group 1 (96.7%) > Group 2 (93.0%) > Group 3 (80.4%; P < 0.01). There were no significant differences in blood loss or postoperative stay among the three groups (P > 0.05). The operation times of Group 1 and Group 2 were significantly longer than that of Group 3 (P < 0.05).

CONCLUSION

The robotic-navigation and O-arm-based navigation techniques effectively increased the accuracy and safety of pedicle screw insertion alternative to the freehand technique in scoliosis surgery. Compared with the O-arm-based navigation technique, the robotic-navigation technique increases the mean operation time, but also increases the accuracy of pedicle screw placement. A three-dimensional scan after insertion of the K-wire may increase the accuracy of pedicle screw placement in the O-arm-based navigation technique.

Comparison of efficacy between unilateral biportal endoscopic lumbar fusion versus minimally invasive transforaminal lumbar fusion in the treatment of lumbar degenerative diseases: A systematic review and meta-analysis

BACKGROUND

To evaluate the clinical efficacy and prognosis of unilateral biportal endoscopic lumbar fusion (ULIF) and minimally invasive transforaminal lumbar fusion (MIS-TLIF) for lumbar degenerative diseases.

METHODS

Chinese and English databases were retrieved for the period from database creation to December 31, 2022. Case-control studies on unilateral biportal endoscopic lumbar fusion were collected. The observation indexes consisted of operation times, intraoperative blood loss, postoperative drainage volume, length of hospital stay, postoperative pain score, postoperative oswestry disability index score, postoperative MacNab excellent and good rate, imaging fusion rate at the last follow-up, and complications. The NO rating table was employed to assess the quality of the included literature, and a meta-analysis was conducted using Revman5.4.1 and Stata17.

RESULTS

Ten studies with 738 surgical patients were considered, including 347 patients in the ULIF group and 391 in the MIS-TLIF group. This Meta-analysis demonstrated statistically significant differences in mean operation duration, intraoperative blood loss, postoperative drainage volume, length of hospital stay, and early postoperative (1-2W) visual analogue scale/score (VAS) scores for back pain. No significant differences were observed in the final follow-up postoperative VAS scores for back pain, postoperative leg VAS score, postoperative oswestry disability index score, excellent and good rate of postoperative modified MacNab, imaging fusion rate, and complications.

CONCLUSION

Compared with the MIS-TLIF group, the ULIF group had longer operation time, lower intraoperative blood loss and postoperative drainage volume, lower lumbar VAS score in the early postoperative period, and shorter hospital stay. ULIF is less invasive than traditional MIS-TLIF, making it a trustworthy surgical option for lumbar degenerative diseases with comparable fusion efficiency, superior MacNab rate, and complication rate.

Is There a Difference in Screw Accuracy, Robot Time Per Screw, Robot Abandonment, and Radiation Exposure Between the Mazor X and the Renaissance? A Propensity-Matched Analysis of 1179 Robot-Assisted Screws

STUDY DESIGN

Prospective single-cohort analysis.

OBJECTIVES

To compare the outcomes/complications of 2 robotic systems for spine surgery.

METHODS

Adult patients (≥18-years-old) who underwent robot-assisted spine surgery from 2016-2019 were assessed. A propensity score matching (PSM) algorithm was used to match Mazor X to Renaissance cases. Preoperative CT scan for planning and an intraoperative O-arm for screw evaluation were preformed. Outcomes included screw accuracy, robot time/screw, robot abandonment, and radiation. Screw accuracy was measured using Vitrea Core software by 2 orthopedic surgeons. Screw breach was measured according to the Gertzbein/Robbins classification.

RESULTS

After PSA, a total of 65 patients (Renaissance: 22 vs. X: 43) were included. Patient/operative factors were similar between robot systems (P > .05). The pedicle screw accuracy was similar between robots (Renaissance: 1.1%% vs. X: 1.3%, P = .786); however, the S2AI screw breach rate was significantly lower for the X (Renaissance: 9.5% vs. X: 1.2%, P = .025). Robot time per screw was not statistically different (Renaissance: 4.6 minutes vs. X: 3.9 minutes, P = .246). The X was more reliable with an abandonment rate of 2.3% vs. Renaissance:22.7%, P = .007. Radiation exposure were not different between robot systems. Non-robot related complications including dural tear, loss of motor/sensory function, and blood transfusion were similar between robot systems.

CONCLUSION

This is the first comparative analyses of screw accuracy, robot time/screw, robot abandonment, and radiation exposure between the Mazor X and Renaissance systems. There are substantial improvements in the X robot, particularly in the perioperative planning processes, which likely contribute to the X's superiority in S2AI screw accuracy by nearly 8-fold and robot reliability by nearly 10-fold.

TiRobot-assisted percutaneous kyphoplasty in the management of multilevel (more than three levels) osteoporotic vertebral compression fracture

PURPOSE

To compare the effectiveness of TiRobot-assisted kyphoplasty with that of the traditional fluoroscopy-assisted approach in treating multilevel osteoporotic vertebral compression fractures.

METHODS

In this retrospective study, we collected data from 71 patients (TiRobot-assisted group, n = 39; fluoroscopy-assisted group, n = 32) with multilevel osteoporotic vertebral compression fracture treated with unilateral traditional TiRobot-assisted or fluoroscopy-assisted percutaneous kyphoplasty. The operative time, infusion volume, length of stay (LOS), hospital expenses, visual analog scale (VAS), Oswestry Disability Index (ODI), radiation exposure, puncture deviation, anterior height of diseased vertebrae, local kyphotic angle, bone cement distribution, and bone cement leakage were compared between the TiRobot- and fluoroscopy-assisted groups.

RESULTS

Of the 257 treated vertebrae, the average amount of bone cement injected in the TiRobot-assisted (142 vertebrae) and fluoroscopy-assisted (115 vertebrae) groups was 4.6 mL and 4.5 mL, respectively. The VAS score was significantly lower in the TiRobot-assisted group at 24 hours post-operatively (p = 0.006). The X-ray frequency was 34.7 times in the TiRobot-assisted group and 51.7 times in the fluoroscopy-assisted group (p < 0.001). In addition to the operative time, cumulative radiation dose for the surgeon and patient was significantly lower in the TiRobot-assisted group. The hospital expenses of the TiRobot-assisted group were significantly higher (p < 0.001). The puncture deviation and bone cement distribution were better in the TiRobot-assisted group (p < 0.001). Bone cement leakage was found in 18 and 29 cases in the TiRobot- and fluoroscopy-assisted groups, respectively (p = 0.010). One patient in the fluoroscopy-assisted group experienced radiculopathy due to a misplaced puncture but recovered in three months. No radiculopathy was observed in the TiRobot-assisted group.

CONCLUSIONS

TiRobot-assisted percutaneous multilevel kyphoplasty is more accurate and has smaller radiometry, a more uniform bone cement distribution, and lower bone cement leakage. This method was therefore accurate and safe.

Index Surgery Cost of Fluoroscopic Freehand Versus Robotic-Assisted Pedicle Screw Placement in Lumbar Instrumentation: An Age, Sex, and Approach-Matched Cohort Comparison

BACKGROUND

Spine surgery costs are notoriously high, and there are already criticisms and concerns over the economic effects. There is no consensus on cost variation with robot-assisted spine fusion (rLF) compared with a manual fluoroscopic freehand (fLF) approach. This study looks to compare the early costs between the robotic method and the freehand method in lumbar spine fusion.

METHODS

rLFs by one spine surgeon were age, sex, and approach-matched to fLF procedures by another spine surgeon. Variable direct costs, readmissions, and revision surgeries within 90 days were reviewed and compared.

RESULTS

Thirty-nine rLFs were matched to 39 fLF procedures. No significant differences were observed in clinical outcomes. rLF had higher total encounter costs (P < 0.001) and day-of-surgery costs (P = 0.005). Increased costs were mostly because of increased supply cost (0.0183) and operating room time cost (P < 0.001). Linear regression showed a positive relationship with operating room time and cost in rLF (P < 0.001).

CONCLUSION

rLF is associated with a higher index surgery cost. The main factor driving increased cost is supply costs, with other variables too small in difference to make a notable financial effect. rLF will become more common, and other institutions may need to take a closer financial look at this more novel instrumentation before adoption.

Robot Versus Fluoroscopy-Assisted Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to conduct a systematic review and meta-analysis to compare the clinical results and complications of robot-assisted (RA) versus fluoroscopy-assisted (FA) percutaneous vertebral augmentation (PVA) in the treatment of osteoporotic vertebral compression fractures (OVCFs).

METHODS

A comprehensive search of online databases including PubMed, Embase, Cochrane Library, web of science, and core journals of China National Knowledge Infrastructure were performed to identify related studies reporting the clinical results and complications of RA versus FA-assisted PVA in the treatment of OVCFs. The rate of bone cement leakage was used to assess the complications. After the surgery, the clinical findings were analyzed using the Visual Analog Scale scores and the Oswestry Disability Index scores. The surgical time, intraoperative fluoroscopy frequency, and x-ray exposure duration were used to evaluate the perioperative results. Forest plots were constructed to investigate the results.

RESULTS

RA-PVA had a significantly lower bone cement leakage rate, shorter fluoroscopy frequency, and shorter radiation exposure time of doctors compared with FA-PVA. However, no significant differences were found between RA-PVA and FA-PVA in operative time and radiation exposure time of patients. Furthermore, no statistically differences were found between the 2 groups in Visual Analog Scale and Oswestry Disability Index scores after surgery.

CONCLUSIONS

This meta-analysis showed that RA-PVA can reduce bone cement leakage rate, fluoroscopy frequency, and doctors' radiation exposure time. With the advancement of RA technology, we anticipate more high-quality randomized controlled trials of RA versus FA-PVA in the future to validate and update the results of this analysis.

Comparison of the Accuracy and Safety of TiRobot-Assisted and Fluoroscopy-Assisted Percutaneous Pedicle Screw Placement for the Treatment of Thoracolumbar Fractures

OBJECTIVE

Studies have compared the safety and accuracy of robot-assisted techniques for inserting conventional open pedicle screws for spinal surgery. However, no relevant studies have confirmed that robot-assisted percutaneous screw placement is better than fluoroscopic percutaneous screw placement for the treatment of thoracolumbar fractures. This study compared the accuracy and safety of TiRobot-assisted percutaneous pedicle screw placement with those of the fluoroscopy-assisted percutaneous technique for the treatment of thoracolumbar fractures.

METHODS

This retrospective study included 126 patients with thoracolumbar fractures who underwent percutaneous pedicle screw placement. Sixty-five patients were treated with the TiRobot-assisted technique and 61 patients were treated with the fluoroscopy-assisted technique. Patient demographics, accuracy of screw placement (according to the Gertzbein and Robbins scale of grades A to E), screw insertion angle, radiation exposure, surgical time, intraoperative blood loss, length of hospital stay, incision length, hospital expenses, surgical site infection, and neurological injury of the TiRobot-assisted and fluoroscopy-assisted groups were compared using Student's t-test, Pearson χ² test, or Fisher's exact test.

RESULTS

A total of 729 screws were placed (TiRobot-assisted group: 374 screws; fluoroscopy-assisted group: 355 screws). In the TiRobot-assisted group, 82.8% of screws were optimally positioned (grade A); however, the placement grades of the remaining screws were categorized as grade B (13.3%), grade C (3.2%), and grade D (0.5%). In the fluoroscopy-assisted group, 66.7% of the screws were optimally positioned (grade A); however, the placement grades of the remaining screws were categorized as grade B (21.4%), grade C (7.6%), grade D (3.6%), and grade E (0.5%). The proportion of clinically acceptable screws (grade A or B) was greater in the TiRobot-assisted group than in the fluoroscopy-assisted group. Additionally, the TiRobot-assisted group had a significantly larger mean screw insertion angle (22.27° ± 5.48° vs 20.55° ± 5.15°), larger incision length (13.86 ± 1.24 cm vs 12.77 ± 1.43 cm), and higher hospital expenses (69061.55 ± 7166.60 yuan vs 59383.85 ± 5019.64 yuan) than the fluoroscopy-assisted group. There were no significant differences in the intraoperative blood loss, length of hospital stay, and rates of surgical site infection and neurological injury in both groups (p > 0.05). However, the TiRobot-assisted group had significantly better surgical times, radiation times, and radiation exposure than the fluoroscopy-assisted group (p < 0.05).

CONCLUSIONS

Percutaneous TiRobot-assisted pedicle screw placement is a safe, useful, and potentially more accurate alternative to the percutaneous fluoroscopy-assisted technique for treating thoracolumbar fractures.

Robotic Spine Surgery: Past, Present, and Future

STUDY DESIGN

Systematic review.

OBJECTIVE

The aim of this review is to present an overview of robotic spine surgery (RSS) including its history, applications, limitations, and future directions.

SUMMARY OF BACKGROUND DATA

The first RSS platform received United States Food and Drug Administration approval in 2004. Since then, robotic-assisted placement of thoracolumbar pedicle screws has been extensively studied. More recently, expanded applications of RSS have been introduced and evaluated.

METHODS

A systematic search of the Cochrane, OVID-MEDLINE, and PubMed databases was performed for articles relevant to robotic spine surgery. Institutional review board approval was not needed.

RESULTS

The placement of thoracolumbar pedicle screws using RSS is safe and accurate and results in reduced radiation exposure for the surgeon and surgical team. Barriers to utilization exist including learning curve and large capital costs. Additional applications involving minimally invasive techniques, cervical pedicle screws, and deformity correction have emerged.

CONCLUSION

Interest in RSS continues to grow as the applications advance in parallel with image guidance systems and minimally invasive techniques.

IRB APPROVAL

N/A.

Sacroiliac Joint Fusion Using Robotic Navigation: Technical Note and Case Series

BACKGROUND

Patients undergoing sacroiliac (SI) fusion can oftentimes experience significant improvements in pain and quality of life.

OBJECTIVE

To describe a novel application of robotic navigation to assist with minimally invasive SI joint fusion.

METHODS

Patients undergoing stand-alone SI joint fusion with ExcelsiusGPS robotic navigation from July 2020 through June 2021 were retrospectively enrolled. Baseline demographic and perioperative variables including radiation exposure, postoperative pain scores, and narcotic requirements in the postanesthesia care unit (PACU) were recorded. Length of stay and any postoperative complications were also noted.

RESULTS

A total of 10 patients (64.4 ± 8.2 years, body mass index 28.7 ± 4.8 kg/m2) met inclusion criteria. Seven patients (70.0%) were female, and there was a 6:4 split between left-sided and right-sided SI joint fusion. The total operative time was 54 ± 9 minutes, and the estimated blood loss was 21.0 ± 16.7 mL. The intraoperative radiation exposure was 13.7 ± 6.2 mGy, and there were no complications. The average pain score in PACU was 5.2 ± 1.0, and the average opioid administration in PACU was 27.6 ± 10.3 morphine equivalents. Length of stay was 0.4 ± 0.7 days, with 7 of 10 patients discharged on the same day as surgery. There were no readmissions. The average length of follow-up was 4.3 ± 2.5 months. At the last follow-up, patients reported an average of 73.1% ± 30.1% improvement in their preoperative pain.

CONCLUSION

Robot-navigated SI joint fusion is a feasible and reproducible method for addressing refractory SI joint disease. Further investigation on clinical outcomes and long-term fusion rates is needed, as are studies comparing robot-navigated SI joint fusion with more traditional techniques.

Ninety-day complication, revision, and readmission rates for current-generation robot-assisted thoracolumbar spinal fusion surgery: results of a multicenter case series

OBJECTIVE

Robotics is a major area for research and development in spine surgery. The high accuracy of robot-assisted placement of thoracolumbar pedicle screws is documented in the literature. The authors present the largest case series to date evaluating 90-day complication, revision, and readmission rates for robot-assisted spine surgery using the current generation of robotic guidance systems.

METHODS

An analysis of a retrospective, multicenter database of open and minimally invasive thoracolumbar instrumented fusion surgeries using the Mazor X or Mazor X Stealth Edition robotic guidance systems was performed. Patients 18 years of age or older and undergoing primary or revision surgery for degenerative spinal conditions were included. Descriptive statistics were used to calculate rates of malpositioned screws requiring revision, as well as overall complication, revision, and readmission rates within 90 days.

RESULTS

In total, 799 surgical cases (Mazor X: 48.81%; Mazor X Stealth Edition: 51.19%) were evaluated, involving robot-assisted placement of 4838 pedicle screws. The overall intraoperative complication rate was 3.13%. No intraoperative implant-related complications were encountered. Postoperatively, 129 patients suffered a total of 146 complications by 90 days, representing an incidence of 16.1%. The rate of an unrecognized malpositioned screw resulting in a new postoperative radiculopathy requiring revision surgery was 0.63% (5 cases). Medical and pain-related complications unrelated to hardware placement accounted for the bulk of postoperative complications within 90 days. The overall surgical revision rate at 90 days was 6.63% with 7 implant-related revisions, representing an implant-related revision rate of 0.88%. The 90-day readmission rate was 7.13% with 2 implant-related readmissions, representing an implant-related readmission rate of 0.25% of cases.

CONCLUSIONS

The results of this multicenter case series and literature review suggest current-generation robotic guidance systems are associated with low rates of intraoperative and postoperative implant-related complications, revisions, and readmissions at 90 days. Future outcomes-based studies are necessary to evaluate complication, revision, and readmission rates compared to conventional surgery.

Comparative Analysis of Optoelectronic Accuracy in the Laboratory Setting Versus Clinical Operative Environment: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The optoelectronic camera source and data interpolation process serve as the foundation for navigational integrity in robotic-assisted surgical platforms. The current systematic review serves to provide a basis for the numerical disparity observed when comparing the intrinsic accuracy of optoelectronic cameras versus accuracy in the laboratory setting and clinical operative environments.

METHODS

Review of the PubMed and Cochrane Library research databases was performed. The exhaustive literature compilation obtained was then vetted to reduce redundancies and categorized into topics of intrinsic accuracy, registration accuracy, musculoskeletal kinematic platforms, and clinical operative platforms.

RESULTS

A total of 465 references were vetted and 137 comprise the basis for the current analysis. Regardless of application, the common denominators affecting overall optoelectronic accuracy are intrinsic accuracy, registration accuracy, and application accuracy. Intrinsic accuracy equaled or was less than 0.1 mm translation and 0.1 degrees rotation per fiducial. Controlled laboratory platforms reported 0.1 to 0.5 mm translation and 0.1 to 1.0 degrees rotation per array. Accuracy in robotic-assisted spinal surgery reported 1.5 to 6.0 mm translation and 1.5 to 5.0 degrees rotation when comparing planned to final implant position.

CONCLUSIONS

Navigational integrity and maintenance of fidelity of optoelectronic data is the cornerstone of robotic-assisted spinal surgery. Transitioning from controlled laboratory to clinical operative environments requires an increased number of steps in the optoelectronic kinematic chain and error potential. Diligence in planning, fiducial positioning, system registration and intra-operative workflow have the potential to improve accuracy and decrease disparity between planned and final implant position.

A tale of two robots: Operating times and learning curves in robot-assisted lumbar fusion

Robotic assistance technologies are being incorporated into minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) to minimize radiation exposure to the patient and operating staff. However, they introduce new issues including increased operating time and difficult incorporation into surgical workflow. This study, conducted with 42 patients under the care of one neurosurgeon in Sydney, Australia, investigates the operating time increase with three different robotic modalities, and the learning curves they pose to the surgeon. Between the comparable modalities of freehand MIS-TLIF and Mazor Renaissance® CT to Fluoro, there was a significant increase in time from patient draping to insertion of the final K-wire (p = 0.0019), and a non-significant increase in time per K-wire (p = 0.55) using Mazor Renaissance®. Comparing the ROSA® and Mazor Renaissance® Scan and Plan, there were significant increases in drape to final K-wire time and time per K-wire using ROSA® assistance (p = 0.000068 and p = 0.011). ROSA® also had a steeper learning curve compared to both Mazor Renaissance® modalities, which were similar. Our study shows that Mazor Renaissance® modalities are superior to ROSA® in minimizing extra operating time, and also have easier learning curves; however, both modalities increase operating time compared with freehand MIS-TLIF. This study, to our knowledge, is the first to compare multiple robotic techniques in MIS-TLIF. Though these results highlight important differences between robotic modalities that are crucial for spinal surgeons to understand, the low sample size and variability in data reveal the need for larger, multi-centre studies in this field.

State of the art review of new technologies in spine deformity surgery-robotics and navigation

STUDY DESIGN/METHODS

Review article.

OBJECTIVES

The goal of this article is to review the available evidence for computerized navigation and robotics as an accuracy improvement tool for spinal deformity surgery, as well as to consider potential complications, impact on clinical outcomes, radiation exposure, and costs. Pedicle screw and rod construct are widely utilized for posterior spinal fixation in spinal deformity correction. Freehand placement of pedicle screws has long been utilized, although there is variable potential for inaccuracy depending on surgeon skill and experience. Malpositioned pedicle screws may have significant clinical implications ranging from nerve root irritation, inadequate fixation, CSF leak, perforation of the great vessels, or spinal cord damage. Computer-based navigation and robotics systems were developed to improve pedicle screw insertion accuracy and consistency, and decrease the risk of malpositioned pedicle fixation. The available evidence suggests that computer-based navigation and robotic-assisted guidance systems for pedicle cannulation are at least equivalent, and in several reports superior, to freehand techniques in terms of accuracy. CT and robotic navigation systems do appear to decrease radiation exposure to the operative team in some reports. Published reports do indicate longer operative times with use of robotic navigation compared with traditional freehand techniques for pedicle screw placement. To date, there is no conclusive evidence that use of CT or robotic navigation has any measurable impact on patient outcomes or overall complication reduction. There are theoretical advantages with robotic and CT navigation in terms of both speed and accuracy for severe spinal deformity or complex revision cases, however, there is a need for studies to investigate this technology in these specific cases. There is no evidence to date demonstrating the cost effectiveness of CT or robotic navigation as compared with traditional pedicle cannulation techniques.

CONCLUSIONS

The review of available evidence suggests that computer-based navigation and robotic-assisted guidance systems for pedicle cannulation are at least equivalent, and in several reports superior, to freehand techniques in terms of radiographic accuracy. There is no current clinical evidence that the use of navigation or robotic techniques leads to improved patient outcomes or decreased overall complications or reoperation rates, and the use of these systems may substantially increase surgical costs.

LEVEL OF EVIDENCE

V.

Percutaneous Robot-Assisted versus Freehand S2 Iliosacral Screw Fixation in Unstable Posterior Pelvic Ring Fracture

OBJECTIVES

To assess the efficiency, safety, and accuracy of S₂ (IS) screw fixation using a robot-assisted method compared with a freehand method.

METHODS

This is a retrospective clinical study. We analyzed the patients treated with S₂ IS screw fixation for unstable pelvic fractures from January 2016 to January 2019 in our institution. Sixty-three patients (17 men and 46 women) aged between 21 and 55 years (with an average age of 39.22 ± 9.28) were included in this study. According to the Tile classification, there were 26 (41.3%) type B fractures and 37 (58.7%) type C fractures. All patients were divided into robot-assisted (RA) group (38 patients) or the traditional freehand (FH) group (25 patients). In RA group, the S₂ IS screws were implanted with a robot-assisted technique. And S₂ IS screws were implanted with a traditional freehand technique in FH group. The screw-related complications were recorded during and after the surgery. The position of all screws and fracture reduction was assessed by postoperative CT scans according to the Gras classification. The number of guide wire attempts and the radiation exposure for S₂ screw implantation during operation were also recorded. Finally, the Matta standard was used to evaluate the fracture reduction of the IS joint.

RESULTS

A total of 89 IS screws were implanted into S2 iliosacral joint. Fifty-four screws were placed by RA (38 patients) and 35 screws were by FH (25 patients). There was no difference between the two groups with respect to demographic data. There was no screw-related complications or revision surgery in any group. In terms of screw placement, the excellent and good rate was 100% in the RA group, better than that in the FH group where it was only 85.7% (P < 0.001). The fluoroscopy time was 8.06 ± 3.54 s in RA group, which was much less than that in the FH group (27.37 ± 8.82 s, P < 0.001). The guide wire attempts in the RA group (0.685 ± 0.820) were much less than those in the FH group (5.77 ± 3.34) (P < 0.001). Both the fluoroscopy time per screw and the number of guide wire attempts in the RA group were much less than those in the FH group (P < 0.001). The overall postoperative excellent and good rate of Matta standard in RA and FH groups were 86.8% (34/4) and 90.0% (23/25), respectively (P = 0.750), and there was no statistical difference.

CONCLUSION

The robot-assisted surgery is an accurate and minimally invasive technique. S₂ IS screw implantation assisted by TiRobot to treat the posterior pelvic ring fractures, have a high success rate than the freehand technique. Percutaneous RA S₂ IS screw fixation for unstable posterior pelvic ring injuries is safe and clinically feasible and has great clinical application value.

Computer-assisted cannulated screw internal fixation versus conventional cannulated screw internal fixation for femoral neck fractures: a systematic review and meta-analysis

Objective

To compare the effects between computer-assisted and traditional cannulated screw internal fixation on treating femoral neck fracture.

Methods

The search was conducted in Embase, Pubmed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI) and Wanfang Database from the beginning to August 2020. RevMan5.4 software, which was provided by the International Cochrane Group, was used for the meta-analysis comparing the differences in operation time, intraoperative bleeding volume, fluoroscopy frequency, fracture healing time, total drilling times, Harris score, fracture healing rate, and femoral head necrosis rate between computer-assisted and traditional methods groups.

Results

A total of 1028 patients were included in 16 studies. Primary outcome indicators: Compared with the traditional method group, the computer-assisted group had less operative time (2RCTs, P < 0.00001; 8 non-RCTs, P = 0.009; Overall, P < 0.00001), intraoperative bleeding (1 RCTs, P < 0.00001; 9non-RCTs, P < 0.00001; Overall, P < 0.00001), femoral head necrosis rate (1 RCT, P = 0.11;7 non-RCTs, P = 0.09; Overall, P = 0.02) and higher Harris scores (1 RCT, P < 0.0001; 9 non-RCTs, P = 0.0002; Overall, P < 0.0001), and there were no significant differences in fracture healing rate between the two groups (5 non-RCTs, P = 0.17). Secondary outcomes indicators: The computer-assisted group had a lower frequency of intraoperative fluoroscopy and total number of drills compared with the traditional method group, while there was no significant difference in fracture healing time.

Conclusion

Compared with the traditional hollow screw internal fixation on the treatment of femoral neck fracture, computer-assisted percutaneous cannulated screw fixation can shorten the operation time and improve the operation efficiency and reduce the X-ray injury of medical staff and help patients obtain a better prognosis. Therefore, computer-assisted percutaneous cannulated screw fixation is a better choice for the treatment of femoral neck fracture.

Study registration PROSPERO registration number CRD42020214493.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02806-7.

Accuracy of Robotic-Assisted Spinal Surgery-Comparison to TJR Robotics, da Vinci Robotics, and Optoelectronic Laboratory Robotics

BACKGROUND

The optoelectronic camera source and data interpolation serve as the foundation for navigational integrity in the robotic-assisted surgical platform. The objective of the current systematic review serves to provide a basis for the numerical disparity that exists when comparing the intrinsic accuracy of optoelectronic cameras: accuracy observed in the laboratory setting versus accuracy in the clinical operative environment. It is postulated that there exists a greater number of connections in the optoelectronic kinematic chain when analyzing the clinical operative environment to the laboratory setting. This increase in data interpolation, coupled with intraoperative workflow challenges, reduces the degree of accuracy based on surgical application and to that observed in controlled musculoskeletal kinematic laboratory investigations.

METHODS

Review of the PubMed and Cochrane Library research databases was performed. The exhaustive literature compilation obtained was then vetted to reduce redundancies and categorized into topics of intrinsic optoelectronic accuracy, registration accuracy, musculoskeletal kinematic platforms, and clinical operative platforms.

RESULTS

A total of 147 references make up the basis for the current analysis. Regardless of application, the common denominators affecting overall optoelectronic accuracy are intrinsic accuracy, registration accuracy, and application accuracy. Intrinsic accuracy of optoelectronic tracking equaled or was less than 0.1 mm of translation and 0.1° of rotation per fiducial. Controlled laboratory platforms reported 0.1 to 0.5 mm of translation and 0.1°-1.0° of rotation per array. There is a huge falloff in clinical applications: accuracy in robotic-assisted spinal surgery reported 1.5 to 6.0 mm of translation and 1.5° to 5.0° of rotation when comparing planned to final implant position. Total Joint Robotics and da Vinci urologic robotics computed accuracy, as predicted, lies between these two extremes-1.02 mm for da Vinci and 2 mm for MAKO.

CONCLUSIONS

Navigational integrity and maintenance of fidelity of optoelectronic data is the cornerstone of robotic-assisted spinal surgery. Transitioning from controlled laboratory to clinical operative environments requires an increased number of steps in the optoelectronic kinematic chain and error potential. Diligence in planning, fiducial positioning, system registration, and intraoperative workflow have the potential to improve accuracy and decrease disparity between planned and final implant position. The key determining factors limiting navigation resolution accuracy are highlighted by this Cochrane research analysis.

Comparison of accuracy and safety between robot-assisted and conventional fluoroscope assisted placement of pedicle screws in thoracolumbar spine: A meta-analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis is to explore the screw positioning accuracy, complications related to pedicle screw implantation, revision rate and radiation exposure between robot screw placement and traditional fluoroscopic screw placement.

METHODS

We searched several databases, including CNKI, Wanfang database, cqvip datebase, PubMed, Cochrane library and EMBASE, to identify articles that might meet the criteria. Meta-analysis was performed using Revman 5.3 software.

RESULTS

A total of 13 randomized controlled trial were included. The results showed that the pedicle screw accuracy of the robot assisted group was significantly better than that of the conventional freehand (FH) group (OR = 3.5, 95% confidence interval [CI] [2.75,4.45], P < .0001). There was no significant difference in the complications caused by pedicle screw implantation between the robot-assisted group and the conventional FH group [OR = 0.39, 95%CI (0.10,1.48), P = .17]. The rate of facet joint invasion in the robot-assisted group was significantly lower than that in the conventional FH group (OR = 0.06, 95%CI [0.01,0.29], P = .0006). The revision rate in the robot-assisted group was significantly lower than that in the conventional FH group (OR = 0.19, 95%CI [0.05,0.71], P = 0.0.01). There was no significant difference in the average radiation of pedicle screws implantation between the robot-assisted group and the conventional FH (mean difference = -7.94, 95%CI [-20.18,4.30], P = .20).

CONCLUSION

The robot-assisted group was significantly better than the conventional FH in the accuracy of pedicle screw placement and facet joint invasion rate and revision rate. There was no significant difference in the complication and fluoroscopy time between the two groups.

Is there a difference between navigated and non-navigated robot cohorts in robot-assisted spine surgery? A multicenter, propensity-matched analysis of 2,800 screws and 372 patients

BACKGROUND CONTEXT

Robot-assisted spine surgery continues to rapidly develop as evidenced by the growing literature in recent years. In addition to demonstrating excellent pedicle screw accuracy, early studies have explored the impact of robot-assisted spine surgery on reducing radiation time, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. Recently, the Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic's Stealth navigation technology into the Mazor X platform, which was introduced in 2016. It is unclear what the impact of these advancements have made on clinical outcomes.

PURPOSE

To compare the outcomes and complications between the most recent iterations of the Mazor Robot systems: Mazor X and Mazor X Stealth Edition.

STUDY DESIGN

Multicenter cohort PATIENT SAMPLE: Among four different institutions, we included adult (≥18 years old) patients who underwent robot-assisted spine surgery with either the Mazor X (non-navigated robot) or Stealth (navigated robot) platforms.

OUTCOME MEASURES

Primary outcomes included robot time per screw, fluoroscopic radiation time, screw accuracy, robot abandonment, and clinical outcomes with a minimum 90 day follow up.

METHODS

A one-to-one propensity-score matching algorithm based on perioperative factors (e.g. demographics, comorbidities, primary diagnosis, open vs. percutaneous instrumentation, prior spine surgery, instrumented levels, pelvic fixation, interbody fusion, number of planned robot screws) was employed to control for the potential selection bias between the two robotic systems. Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively.

RESULTS

From a total of 646 patients, a total of 372 adult patients were included in this study (X: 186, Stealth: 186) after propensity score matching. The mean number of instrumented levels was 4.3. The mean number of planned robot screws was 7.8. Similar total operative time and robot time per screw occurred between cohorts (p>0.05). However, Stealth achieved significantly shorter fluoroscopic radiation time per screw (Stealth: 7.2 seconds vs. X: 10.4 seconds, p<.001) than X. The screw accuracy for both robots was excellent (Stealth: 99.6% vs. X: 99.1%, p=0.120). In addition, Stealth achieved a significantly lower robot abandonment rate (Stealth: 0% vs. X: 2.2%, p=0.044). Furthermore, a lower blood transfusion rate was observed for Stealth than X (Stealth: 4.3% vs. X: 10.8%, p=0.018). Non-robot related complications such as dura tear, motor/sensory deficits, return to the operating room during same admission, and length of stay was similar between robots (p>0.05). The 90-day complication rates were low and similar between robot cohorts (Stealth: 5.4% vs. X: 3.8%, p=0.456).

CONCLUSION

In this multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, using Stealth led to significantly less fluoroscopic radiation time, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including length of stay, and 90-day complications were similar.

[The safety of TiRobot-guided percutaneous transpedicular screw implantation]

OBJECTIVE

To evaluate the safety of TiRobot-guided percutaneous transpedicular screw implantation.

METHODS

The medical records of 158 patients with thoracolumbar fractures and lumbar degenerative diseases who underwent percutaneous transpedicular screw implantation were retrospectively analyzed between January 2018 and December 2020. The patients were divided into trial group (TiRobot-guided screw implantation, 86 cases) and control group (fluoroscopy-guided screw implantation, 72 cases). There was no significant difference in gender, age, pathology, lesion segment, and the average number of screw implantation per case ( P>0.05). The operation time, fluoroscopic dose, fluoroscopic time, and fluoroscopic frequency were compared between the two groups. One day postoperatively, the convergence angle was measured and the penetration of the pedicle cortex was evaluated according to Gertzbein-Robbins classification standard.

RESULTS

The operation time, fluoroscopic dose, fluoroscopic time, and fluoroscopic frequency of the trial group were significantly lesser than those of control group ( P<0.05). One day postoperatively, the convergence angle of trial group was (21.10±4.08)°, which was significantly larger than control group (19.17±3.48)° ( t=6.810, P=0.000). According to the Gertzbein-Robbins classification standard, 446 pedicle screws were implanted in trial group, trajectories were grade A in 377 screws, grade B in 46 screws, grade C in 23 screws, and the accuracy of screw implantation was 94.8%; 380 pedicle screws were implanted in control group, trajectories were grade A in 283 screws, grade B in 45 screws, grade C in 44 screws, grade D in 6 screws, grade E in 2 screws, and the accuracy of screw implantation was 86.3%. There was significant difference in the accuracy of screw implantation between the two groups ( χ 2=25.950, P=0.000).

CONCLUSION

Compared with traditional percutaneous transpedicular screw implantation, TiRobot-guided percutaneous transpedicular screw implantation can improve the accuracy of screw implantation, reduce radiation exposure, and improve surgical safety, which has a good application prospect.

Accuracy and Efficiency of Fusion Robotics™ Versus Mazor-X™ in Single-Level Lumbar Pedicle Screw Placement

Introduction

There has been a surge in robot utilization in spine surgery over the past five years with the rapid development of new spine robotic platforms. This study aimed to compare a new robotic spine platform from Fusion Robotics^TM (Fusion Robotics, Helena, MT) with the widely used Mazor-X^TM Stealth Edition robotic platform (Medtronic, Dublin, Ireland) in terms of workflow and lumbar pedicle screw placement accuracy.

Methods

A cadaver lab was conducted, which included four procedures with single-level lumbar pedicle screw placement using the Fusion Robotics^TM system. These four procedures were compared to four propensity-score matched cases with single-level lumbar pedicle screw placement using the Mazor-X^TM Stealth Edition. A single surgeon performed all surgeries. The cases were matched in terms of demographics (age, sex, race, BMI) and comorbidities (Charlson Comorbidity Index score). The primary outcome measure was the operative workflow efficiency (duration as measured with a stopwatch by an independent observer). The secondary outcome measures were pedicle screw accuracy and accuracy to plan.

Results

After propensity-score matching, there were four cases in each group with no significant between-group differences in terms of sex, race, BMI, or surgical levels; however, there were significant differences in terms of age (p=0.01) and comorbidities (p<0.001). The workflow efficiency measurement showed that the Fusion Robotics^TM platform had a significantly shorter duration in terms of the system set-up time, planning to in-position time, and total procedure time (p<0.05). However, there was no significant difference between the robotic platforms in terms of creating a sterile barrier, scanning and importing images, creating a plan, screw placement, screw accuracy, and screw accuracy to plan.

Conclusion

Based on our findings, the Fusion Robotics^TM platform had a significantly shorter procedure workflow duration while maintaining the same accuracy as the most commonly used robotic platform (Mazor-X^TM). This is the first study to directly compare different spine surgery robotic systems.

Evaluation of K-wireless robotic and navigation assisted pedicle screw placement in adult degenerative spinal surgery: learning curve and technical notes

Background

K-wireless robotic pedicle screw instrumentation with navigation is a new technology with large potential. Barriers to adoption are added registration time with robotic-navigated system and reliable screw positioning. Understanding the learning curve and limitations is crucial for successful implementation. The purpose of this study was to describe a learning curve of k-wireless robotic assisted pedicle screw placement with navigation and compare to conventional techniques.

Methods

A retrospective review of prospectively collected data of 65 consecutive adult patients underwent robotic-navigated posterior spinal fusion by a single spine surgeon. Registration, screw placement, and positioning times were recorded. All patients underwent intra-operative 3D fluoroscopy and screw trajectory was compared to pre-operative CT.

Results

A total of 364 instrumented pedicles were planned robotically, 311 (85.4%) were placed robotically; 17 screws (4.7%) converted to k-wire, 21 (5.8%) converted to freehand, and 15 (4.1%) planned freehand. Of the 311 robotically placed pedicle screws, three dimensional fluoroscopic imaging showed 291 (93.5%) to be GRS Grade A in the axial plane (fully contained within the pedicle) and 281 (90.4%) were GRS Grade A in the sagittal plane. All breached screw deviations from plan were identified on 3D fluoroscopy during surgery and repositioned and confirmed by additional 3d fluoroscopy scan. Reasons for conversion included morphology of starting point (n=18), soft tissue pressure (n=9), hypoplastic pedicles (n=6), obstructive reference pin placement (n=2), and robotic arm issues (n=1). Seventeen (5.5%) critical breaches (≥2-4 mm) were recorded in 11 patients, 9 (2.9%) critical breaches were due to soft tissue pressure causing skive. Two patients experienced 6 (1.9%) critical breaches from hypoplastic pedicles, and 3 (0.9%) unplanned lateral breaches were found in another patient. One patient (0.3%) experienced skive due to morphology and spinal instability from isthmic spondylolisthesis. Imaging showed 143 screws placed medially to plan (1.2±0.9 mm), 170 lateral (1.2±1.1 mm), 193 screws caudal (1.0±0.6 mm) and 117 cranial (0.6±0.5 mm). No adverse clinical sequelae occurred from implantation of any screw.

Conclusions

The learning curve showed improvement in screw times for the first several cases. Understanding the learning curve and situations where the robotic technique may be suboptimal can help guide the surgeon safe and effectively for adoption, as well as further refine these technologies.

Robot-assisted vs freehand cannulated screw placement in femoral neck fractures surgery: A systematic review and meta-analysis

BACKGROUND

Several studies have reported that medical robot-assisted method (RA) might be superior to conventional freehand method (FH) in orthopedic surgery. Yet the results are still controversial, especially in terms of femoral neck fractures surgery. Here, 2 methods were assessed based on current evidence.

METHODS

Electronic databases including Cochrane Library, PubMed, Web of Science. and EMBASE were selected to retrieved to identify eligible studies between freehand and RAs in femoral neck fractures, with 2 reviewers independently reviewing included studies as well as collecting data.

RESULTS

A total of 5 studies with 331 patients were included. Results indicated that 2 surgical methods were equivalent in terms of surgical duration, Harris score, fracture healing time, fracture healing proportion and complications, while RA showed clinical benefits in radiation exposure, intraoperative bleeding, total drilling times, and screw parallelism.

CONCLUSIONS

Current literature revealed significantly difference between 2 techniques and suggested that RA might be beneficial for patients than freehand method.

Robot-assisted technique vs conventional freehand technique in spine surgery: A meta-analysis

BACKGROUND

The impact of robot-assisted techniques versus conventional freehand techniques in terms of the accuracy of pedicle screw placement remains conflicting. This meta-analysis was performed to evaluate this relationship.

METHODS

A systematic literature search up to July 2020 was performed and 15 studies were detected with 6041 pedicle screw placements with 2748 of them were using robot-assisted techniques and 3293 were conventional freehand techniques. They reported relationships between robot-assisted techniques and conventional freehand techniques in pedicle screw placement. Odds ratio (OR) or Mean differences (MD) with 95% confidence intervals (CIs) was calculated comparing the robot-assisted techniques to conventional freehand techniques in pedicle screw placement risks using the dichotomous and continuous method with a random or fixed-effect model.

RESULTS

Robot-assisted techniques had a significantly higher screw position grade A in Gertzbein-Robbins classification of the screw placement accuracy (OR, 2.43; 95% CI, 1.66-3.54, P < .001); shorter postoperative stay (MD, -0.67; 95% CI, -1.16 to -0.19, P < .001); lower intraoperative blood loss (MD, -91.64; 95% CI, -152.44 to -30.83, P = .003); fewer intraoperative radiation dose (MD, -23.52; 95% CI, -40.12 to -6.0.93, P = .005); and low proximal facet violations (MD, 0.08; 95% CI, 0.03-0.20, P < .001) compared with conventional freehand techniques. However, no significant difference was found between robot-assisted techniques and conventional freehand techniques in surgical time (OR, 11.71; 95% CI, 03.27-26.70, P = .13); visual analogue scale scores (MD, -0.15; 95% CI, -0.54 to 0.23, P = .44); and Oswestry disability index scores (MD, 0.21; 95% CI, -5.09-5.51, P = .94).

CONCLUSIONS

The extent of the improvement with robot-assisted techniques in screw position grade A in Gertzbein-Robbins classification of the screw placement accuracy, postoperative stay, intraoperative blood loss, intraoperative radiation dose, and proximal facet violations was significantly better than conventional freehand techniques. This relationship forces us to recommend robot-assisted techniques for pedicle screw placement to avoid any possible negative postoperative results.

A novel master-slave intraocular surgical robot with force feedback

BACKGROUND

Intraocular surgery is one of the most challenging microsurgeries. Unintended movements of human hand and lack of force feedback can seriously affect surgical safety.

METHODS

We developed a novel master-slave robotic system with force feedback to assist intraocular surgeries. Isomorphism design was adopted to achieve intuitive control of the system. Contact force between instrument tip and tissues was measured with a force sensor developed by our group. Real-time force feedback was provided with one linear voice coil motor and two magnetic particle brakes in the master manipulator.

RESULTS

Experiments were carried out to verify the proposed system. In the phantom experiment mimicking realistic surgical operations, the contact force significantly reduced by more than 30% with the force feedback when peeling the egg inner shell membranes.

CONCLUSIONS

Experimental results demonstrate the effectiveness of force feedback and indicate the promise of the presented master-slave robotic system for intraocular surgery assistance.

Safety and accuracy of robot-assisted placement of pedicle screws compared to conventional free-hand technique: a systematic review and meta-analysis

BACKGROUND CONTEXT

The introduction and integration of robot technology into modern spine surgery provides surgeons with millimeter accuracy for pedicle screw placement. Coupled with computer-based navigation platforms, robot-assisted spine surgery utilizes augmented reality to potentially improve the safety profile of instrumentation.

PURPOSE

In this study, the authors seek to determine the safety and efficacy of robotic-assisted pedicle screw placement compared to conventional free-hand (FH) technique.

STUDY DESIGN/SETTING

We conducted a systematic review of the electronic databases using different MeSH terms from 1980 to 2020.

OUTCOME MEASURES

The present study measures pedicle screw accuracy, complication rates, proximal-facet joint violation, intraoperative radiation time, radiation dosage, and length of surgery.

RESULTS

A total of 1,525 patients (7,379 pedicle screws) from 19 studies with 777 patients (51.0% with 3,684 pedicle screws) in the robotic-assisted group were included. Perfect pedicle screw accuracy, as categorized by Gerztbein-Robbin Grade A, was significantly superior with robotic-assisted surgery compared to FH-technique (Odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.20-2.35; p=.003). Similarly, clinically acceptable pedicle screw accuracy (Grade A+B) was significantly higher with robotic-assisted surgery versus FH-technique (OR: 1.54, 95% CI: 1.01-2.37; p=.05). Furthermore, the complication rates and proximal-facet joint violation were 69% (OR: 0.31, 95% CI: 0.20-0.48; p<.00001) and 92% less likely (OR: 0.08, 95% CI: 0.03-0.20; p<.00001) with robotic-assisted surgery versus FH-group. Robotic-assisted pedicle screw implantation significantly reduced intraoperative radiation time (MD: -5.30, 95% CI: -6.83-3.76; p<.00001) and radiation dosage (MD: -3.70, 95% CI: -4.80-2.60; p<.00001) compared to the conventional FH-group. However, the length of surgery was significantly higher with robotic-assisted surgery (MD: 22.70, 95% CI: 6.57-38.83; p=.006) compared to the FH-group.

CONCLUSION

This meta-analysis corroborates the accuracy of robot-assisted pedicle screw placement.

[A comparative study of robot-assisted and freehand pedicle screw placement in upper thoracic surgery]

OBJECTIVE

To compare the safety and accuracy of pedicle screw placement assisted by robot system with freehand pedicle screw placement in upper thoracic surgery.

METHODS

Between December 2017 and December 2019, 39 cases with upper thoracic pedicle screw internal fixation were included in the study, including 19 cases in robot group (group A, robot assisted pedicle screw placement) and 20 cases in freehand group (group B, freehand pedicle screw placement). There were 104 screws implanted in group A and 108 screws in group B. There was no significant difference in age, gender composition, body mass index, disease type, number of screws implanted, and segmental distribution between the two groups ( P>0.05). The operation time, intraoperative blood loss, and postoperative drainage were recorded and compared between the two groups. CT scan was performed in all patients at 2 days after operation to evaluate the screw accuracy based on the Gertzbein-Robbins grading standard.

RESULTS

The operation time of group A was significantly longer than that in group B ( t=2.759, P=0.009). There was no significant difference in intraoperative blood loss and postoperative drainage between the two groups ( t=-0.796, P=0.431; t=-0.814, P=0.421). At 2 days after operation, according to Gertzbein-Robbins grading standard, the accuracy of pedicle screw implantation in group A were grade A in 94 screws, grade B in 9 screws, and grade C in 1 screw; and in group B were grade A in 72 screws, grade B in 26 screws, grade C in 9 screws, and grade D in 1 screw; the difference between the two groups was significant ( Z=4.257, P=0.000). The accuracy rate of group A was 99.04%, and that of group B was 90.74%, showing significant difference ( χ 2=7.415, P=0.006).

CONCLUSION

Compared with traditional freehand pedicle screw placement, robot-assisted pedicle screw placement significantly improves the accuracy and safety of screw placement without increasing the bleeding and postoperative drainage.

The impact of robot-assisted spine surgeries on clinical outcomes: A systemic review and meta-analysis

BACKGROUND

Medical robotics has enabled a significant advancement in the field of modern spine surgery, especially in pedicle screw fixation. A plethora of studies focused on the accuracy of pedicle fixation in robotic-assisted (RA) technology. However, it is not clear whether RA techniques can improve patients' clinical outcomes.

METHODS

We retrieved relevant studies that compare the differences between RA and freehand (FH) techniques in spine surgeries from the following databases: PubMed, Embase, Cochrane Library and Web of Science. The perioperative outcomes of this technology were measured with parameters including radiation exposure, operative time, the length of hospital stay, complication rates and revision rates. Two reviewers independently reviewed the studies in our sample, assessed their validity and extracted relevant data.

RESULTS

Our search resulted in a sample of 23 eligible studies, which involved 1247 patients (5042 pedicle screws) in the RA group and 1273 patients (4830 pedicle screws) in the FH group. With regard to the radiation exposure, the fluoroscopy time was less in surgeries assisted by Mazor robots (standard mean difference [SMD] = -0.96, 95% CI = -1.60 to -0.31) but more in Tianji robots (SMD = 0.91, 95% CI = 0.17 to 1.66) and ROSA robots (SMD = 2.57, 95% CI = 2.01 to 3.13). For radiation dose, a decrease was observed in Tianji robots (SMD = -1.59, 95% CI = -2.13 to -1.05). In the lumbar subgroup, the use of robots increased the operative time (SMD = 0.53, 95% CI = 0.19 to 0.86). In the degenerative diseases (DG) group, there was a significant decrease in the length of hospital stay when robots were introduced (SMD = -0.30, 95% CI = -0.48 to -0.12). While in the DF (deformity) and DG group, a significant increase was found (SMD = 0.17, 95% CI = 0.02 to 0.32). The complication (OR = 0.41, 95% CI = 0.26 to 0.66) and the revision rates (OR = 0.38, 95% CI = 0.24 to 0.60) showed a significant decrease in the RA group compared to the conventional FH group.

CONCLUSIONS

This study suggests that RA spine surgeries would result in fewer complications, a lower revision rate and shorter length of hospital stay. As the technology continues to evolve, we may expect more applications of robotic systems in spine surgeries.

A novel fluoroscopy-based robot system for pedicle screw fixation surgery

BACKGROUND

Robot-assisted pedicle screw insertion has gained popularity in the spinal surgery field. Due to high cost, these spinal robots are not extensively applied in clinical surgeries. Developing an effective robot system with low cost and high clinical acceptability is one of the future trends.

METHODS

We developed a novel fluoroscopy-based robot system for pedicle screw insertion. Four live pigs were conducted with percutaneous pedicle screw insertion. Robot-assisted surgery was performed on the left side of pedicle, while the right opposite side is placed by freehand. The respect accuracy, surgical time and fluoroscopy time were recorded.

RESULTS

Robot-assisted group achieved 100% (23/23) accuracy. The average times (6.4 ± 1.7) for intraoperative fluoroscopy usage per procedure were lesser than freehand group (12.5 ± 3.6), and the surgical time (6.8 ± 2.1 min) per screw was reduced compared with freehand group (12.1 ± 4.8 min).

CONCLUSIONS

Our robot system is cost-effective and feasible for pedicle screw placement. Low economic cost makes it easier for extensive application in primary hospitals.

Robotic spine surgery: a review of the present status

With technological advancements being introduced and dominating many fields, spine surgery is no exception. In view of the patient safety and surgeon's comfort, robotics has been introduced in spine surgery. Due to small corridors for work, little room for inaccuracy, lengthy and tedious procedures, spine surgery is an ideal scenario for robotics to establish as the standard of care. Spine robotics received their first FDA clearance in 2004. New generation of spine robotics with integrated navigation systems has become available now. The primary role of spine robotics, at present, is to aid pedicle screw fixation. High quality studies have been performed to establish its role in increasing the accuracy of pedicle fixation. Studies have also reported decreased radiation and decreased operative time with spine robotics. However, few studies have reported otherwise. It is still in its nascent stage in both industrial view and surgeon familiarity. Continued research to overcome the challenges such as high cost and steep learning curve is crucial for its widespread use. Also, expanding the scope of spine robotics beyond pedicle screw fixation such as osteotomies and dural procedures would be an area for potential research. This review is intended to provide an overview of various studies in the field of robotic spine surgery and its present status.

Accuracy of robot-assisted versus conventional freehand pedicle screw placement in spine surgery: a systematic review and meta-analysis of randomized controlled trials

This systematic review and meta-analysis investigated differences in accuracy, operation time, and radiation exposure time between robot-assisted and freehand techniques for pedicle screw insertion. Two investigators independently searched for articles on randomized controlled trials (RCTs) published from 2012 to 2019. The final meta-analysis included seven RCTs. We compared the accuracy of pedicle screw placement, operation time, and radiation exposure time between robot-assisted and conventional freehand groups. Seven RCTs included 540 patients and placement of 2,476 pedicle screws, of which 1,220 were inserted using the robot-assisted technique and 1,256 were inserted using the conventional freehand technique. The pedicle screw positions were classified using the Gertzbein and Robbins classification (grade A-E). The combined results of Grade A [odds ratio (OR) =1.68; 95% confidence intervals (CI): 0.82-3.44; P=0.16), Grade A+B (OR =1.70; 95% CI: 0.47-6.13; P=0.42), and Grade C+D+E (OR =0.59; 95% CI: 0.16-2.12; P=0.42) for the accuracy rate revealed no significant difference between the two groups. Subgroup analysis results revealed that the TiRobot-assisted technique presented a significantly improved pedicle screw insertion accuracy rate compared with that of the conventional freehand technique, based on Grade A, Grade A+B, and Grade C+D+E classifications. The SpineAssist-assisted technique presented an inferior pedicle screw insertion accuracy rate compared with that of the conventional freehand technique, based on Grade A, Grade A+B, and Grade C+D+E classifications. No difference between the Renaissance-assisted and conventional freehand techniques was noted for pedicle screw insertion accuracy rates, based on both Grade A (OR =1.58; 95% CI: 0.85-2.96; P=0.15), Grade A+B (OR =2.20; 95% CI: 0.39-12.43; P=0.37), and Grade C+D+E (OR =0.45; 95% CI: 0.08-2.56; P=0.37) classifications. Regarding operation time, robot-assisted surgery had significantly longer operation time than conventional freehand surgery. The robot-assisted group had significantly shorter radiation exposure time. Regarding the pedicle screw insertion accuracy rate, the TiRobot-assisted technique was superior, the SpineAssist-assisted technique was inferior, and Renaissance was similar to the conventional freehand technique.

Role of Robotics in Improving Surgical Outcome in Spinal Pathologies

BACKGROUND

The desire to improve accuracy and safety and to favor minimally invasive techniques has given rise to spinal robotic surgery, which has seen a steady increase in utilization in the past 2 decades. However, spinal surgery encompasses a large spectrum of operative techniques, and robotic surgery currently remains confined to assistance with the trajectory of pedicle screw insertion, which has been shown to be accurate and safe based on class II and III evidence. The role of robotics in improving surgical outcomes in spinal pathologies is less clear, however.

METHODS

This comprehensive review of the literature addresses the role of robotics in surgical outcomes in spinal pathologies with a focus on the various meta-analysis and prospective randomized trials published within the past 10 years in the field.

RESULTS

It appears that robotic spinal surgery might be useful for increasing accuracy and safety in spinal instrumentation and allows for a reduction in surgical time and radiation exposure for the patient, medical staff, and operator.

CONCLUSION

Robotic assisted surgery may thus open the door to minimally invasive surgery with greater security and confidence. In addition, the use of robotics facilitates tireless repeated movements with higher precision compared with humans. Nevertheless, it is clear that further studies are now necessary to demonstrate the role of this modern tool in cost-effectiveness and in improving clinical outcomes, such as reoperation rates for screw malpositioning.

Index episode-of-care propensity-matched comparison of transforaminal lumbar interbody fusion (TLIF) techniques: open traditional TLIF versus midline lumbar interbody fusion (MIDLIF) versus robot-assisted MIDLIF

OBJECTIVE

Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF.

METHODS

A retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed.

RESULTS

Of 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors' first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF.

CONCLUSIONS

Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors' first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.

Robotic Spine Surgery and Augmented Reality Systems: A State of the Art

Instrumented spine procedures have been performed for decades to treat a wide variety of spinal disorders. New technologies have been employed to obtain a high degree of precision, to minimize risks of damage to neurovascular structures and to diminish harmful exposure of patients and the operative team to ionizing radiations. Robotic spine surgery comprehends 3 major categories: telesurgical robotic systems, robotic-assisted navigation (RAN) and virtual augmented reality (AR) systems, including AR and virtual reality. Telesurgical systems encompass devices that can be operated from a remote command station, allowing to perform surgery via instruments being manipulated by the robot. On the other hand, RAN technologies are characterized by the robotic guidance of surgeon-operated instruments based on real-time imaging. Virtual AR systems are able to show images directly on special visors and screens allowing the surgeon to visualize information about the patient and the procedure (i.e., anatomical landmarks, screw direction and inclination, distance from neurological and vascular structures etc.). The aim of this review is to focus on the current state of the art of robotics and AR in spine surgery and perspectives of these emerging technologies that hold promises for future applications.