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

Accurate placement of thoracolumbar pedicle screws using a handheld iOS-based navigation device: a prospective intra-patient agreement study

BACKGROUND

Accurate pedicle screw placement is a challenge with reported misplacement rates of 10% and higher. A handheld navigation device (HND) may provide accuracy equal to CT-based navigation (CT-Nav) but without the cost and complexity.

OBJECTIVE

To study the accuracy of a handheld navigation device for pedicle screw placement.

STUDY DESIGN

This prospective cross-sectional study with consistently applied reference standard enrolled 20 patients undergoing 92 pedicle screw placements.

PATIENTS

Patients who underwent pedicle screw placement between May 2022 and September 2022.

OUTCOME MEASURES

Pedicle screw placement accuracy per Gertzbein-Robbins.

METHODS

Once the screw pilot hole was established, the proposed trajectory of the HND was compared with that proposed by CT-Nav. Postoperatively, screw accuracy was graded according to Gertzbein-Robbins by a blinded radiologist based on CT scans. Accuracy was compared between the two systems and published control for fluoroscopy assisted and CT-Nav placement using Bayesian posterior distribution.

RESULTS

The trajectory proposed by the HND and CT-Nav were in agreement in 98.9% (95% Exact CI; 94.09%-99.97%). The HND accuracy was 98.9% with 91 screws rated "A" and 1 rated "C". Non-inferiority to fluoroscopic placement was achieved because the one-sided normal-approximation 95% CI Lower Bound (LB) of 95.3% is greater than the Performance Goal (PG) of 83.4%. Post-hoc analysis demonstrated that the probability of superiority of the HND relative to the historical accuracy rate of 91.5% for fluoroscopy assisted procedures is >0.999 and that the HND's accuracy rate is within 4.5% of CT-Nav of 95.5% is >0.999. No adverse events or intra-operative complications associated with HND were observed. There was 1 (1.1%) intra-operative repositioning and no re-operations for any reason.

CONCLUSIONS

The accuracy rate of the HND was 98.9%, and the proposed trajectory matched with CT-Nav in 98.9% of the time. This is superior to the historical published accuracy rate for fluoroscopy-assisted procedures and equivalent to the historical published accuracy rate for CT-Nav.

CLINICAL TRIAL REGISTRATION NUMBER

Dutch trial register NL74268.058.20.

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.

Robot-assisted pedicle screw insertion versus navigation-based and freehand techniques for posterior spinal fusion in scoliosis: a systematic review and meta-analysis

PURPOSE

The role of robotics in spine surgery remains controversial, especially for scoliosis correction surgery. This study aims to assess the safety and efficacy of robotic-assisted (RA) surgery specifically for scoliosis surgery by comparing RA to both navigation systems (NS) and conventional freehand techniques (CF).

METHODS

As per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis were conducted via an electronic search of the following databases: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL). All papers comparing RA to either NS or CF for posterior spinal fusion in scoliosis were included. Fixed and random effects models of analysis were utilised based on analysis heterogeneity.

RESULTS

10 observational studies were included in total. RA had significantly greater odds of accurate pedicle screw placement relative to both NS (OR = 2.02, CI = 1.52-2.67, p < 0.00001) and CF (OR = 3.06, CI = 1.79-5.23, p < 0.00001). The downside of RA was the significantly greater operation duration relative to NS (MD = 10.74, CI = 3.52-17.97, p = 0.004) and CF (MD = 40.27, CI = 20.90, p < 0.0001). Perioperative outcomes including estimated blood loss, radiation exposure, length of hospital stay, cobb angle correction rate, postoperative SRS score, VAS pain score, JOA score, as well as rates of neurological injury and revision surgery, were comparable between the groups (p > 0.05).

CONCLUSION

RA offers significantly greater pedicle screw placement accuracy relative to NS and CF, however, surgery can take longer. In terms of perioperative outcomes, all three techniques are comparable.

Effectiveness and safety of robot-assisted versus fluoroscopy-assisted pedicle screw implantation in scoliosis surgery: a systematic review and meta-analysis

This study aimed to assess the effectiveness and safety of robot-assisted versus fluoroscopy-assisted pedicle screw implantation in scoliosis surgery. The study was registered in the PROSPERO (CRD42023471837). Two independent researchers searched PubMed, Web of Science, Cochrane Library, and China National Knowledge Infrastructure. The outcomes included operation time, pedicle screw implantation time, blood loss, number of fluoroscopic, accuracy of pedicle screw position, hospital stays, postoperative hospital stays, Visual Analog Scale (VAS), Japanese Orthopaedic Association (JOA) score, Scoliosis Research Society-22(SRS-22), cobb angle, cobb angle correction rate, sagittal vertical axis (SVA), and complications. Eight papers involving 473 patients met all the criteria. There was no significant difference between the two groups regarding the reduction in operation time. The effect of reducing the pedicle screw implantation time in the RA group was significant (WMD = -1.28; 95% CI: -1.76 to -0.80; P < 0.00001). The effect of reducing the blood loss in the RA group was significant (WMD=-105.57; 95% CI: -206.84 to -4.31; P = 0.04). The effect of reducing the number of fluoroscopic in the RA group was significant (WMD=-5.93; 95% CI: -8.24 to -3.62; P < ). The pedicle screw position of Grade A was significantly more in the RA group according to both the Gertzbein-Robbins scale and the Rampersaud scale. Compared with the FA group, the difference in the hospital stays in the RA group was not statistically significant, but the effect of reducing the postoperative hospital stays in the RA group was significant (WMD = -2.88; 95% CI: -4.13 to -1.63; P < 0.00001). The difference in the VAS, JOA, SRS-22, Cobb angle and Cobb angle correction rate, SVA, and complications between the two groups was not statistically significant. The robot-assisted technique achieved statistically significant results in terms of pedicle screw placement time, blood loss, number of fluoroscopies, accuracy of pedicle screw position, and postoperative hospital stay.

20-year Inflation-Adjusted Medicare Reimbursements (Years: 2000-2020) For Common Lumbar and Cervical Degenerative Disc Disease Procedures

OBJECTIVE

Reimbursement trends for common procedures have persistently declined over the past 2 decades. Spinal instrumentational and fusion procedures are increasingly utilized and have increased in clinical complexity, yet longitudinal inflation-adjusted data for Medicare reimbursements of these procedures have not been evaluated.

METHODS

The Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements for the 5 most common spinal procedures and associated instrumentations from 2000-2020. Current Procedural Terminology (CPT) codes include 22551, 22600, 22633, 63030, and 63047 as well as instrumentation CPT codes 22840 and 22842-6. The nominal values were adjusted for inflation according to the latest consumer price index (U.S. Bureau of Labor Statistics; reported as 2020 USD) and used to calculate average annual percent changes and compound annual growth rates (CAGRs) in reimbursements.

RESULTS

After inflation adjustment, the physician fee reimbursement decreased by 11.05% ± 8.46% (mean ± s.d., from $2,009.89 in 2011 to $1,787.85 in 2020) for anterior cervical discectomy and fusion (ACDF), 28.38% ± 8.42% (from $1,889.38 in 2000 to $1,353.14 in 2020) for posterior cervical fusion, 7.85% ± 8.20% (from $2,111.20 in 2012 to $1,945.49 in 2020) for transforaminal lumbar interbody fusion (TLIF), 28.17% ± 13.88% (from $1,421.78 in 2000 to $1,021.22 in 2020) for lower back disc surgery, and 31.88% ± 8.22% (from $1,700.38 in 2000 to $1,158.25 in 2020) for lumbar laminectomy. Instrumentation reimbursements showed an average decrease of 33.43% ± 8.4% over this period. Average CAGR was -1.7% ± .41% for procedures and -2.02% ± .14% for instrumentation.

CONCLUSION

Our analysis reveals a persistent decline in reimbursement rates of the most common spine procedures and instrumentation since the year 2000. If unaddressed, this trend can serve as a substantial disincentive for physicians to perform these procedures and can significantly limit access to spinal care at the population level.

Emerging Technologies within Spine Surgery

New innovations within spine surgery continue to propel the field forward. These technologies improve surgeons' understanding of their patients and allow them to optimize treatment planning both in the operating room and clinic. Additionally, changes in the implants and surgeon practice habits continue to evolve secondary to emerging biomaterials and device design. With ongoing advancements, patients can expect enhanced preoperative decision-making, improved patient outcomes, and better intraoperative execution. Additionally, these changes may decrease many of the most common complications following spine surgery in order to reduce morbidity, mortality, and the need for reoperation. This article reviews some of these technological advancements and how they are projected to impact the field. As the field continues to advance, it is vital that practitioners remain knowledgeable of these changes in order to provide the most effective treatment possible.

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.

Effects of robot-assisted minimally invasive surgery on osteoporotic vertebral compression fracture: a systematic review, meta-analysis, and meta-regression of retrospective study

OBJECTIVE

To conduct a systematic review on the effect of robot-assisted minimally invasive surgery (R-MIS) on the clinical outcomes and complications of patients with osteoporotic vertebral compression fractures (OVCFs).

METHODS

The researchers searched the papers published on PubMed, The Cochrane Library, Web of Science, Embase, Scopus, Ovid MEDLINE, Wiley Online Library, China National Knowledge Infrastructure (CNKI), Chinese biomedical literature service system (SinoMed), and China Medical Association Data. The standardized mean difference (SMD) or mean difference (MD), relative risk (RR), and 95% confidence interval (CI) were calculated. Besides, the data was merged through the random-effect model or common-effect model. A meta-regression mixed-effects single-factor model was utilized to analyze the sources of heterogeneity.

RESULTS

Twelve studies were included, involving 1042 OVCFs cases. The prognosis of patients treated with R-MIS was significantly improved, such as Oswestry disability index (ODI) score (MD = -0.65, P = 0.0171), Cobb's angles (MD = -1.03, P = 0.0027), X-ray fluoroscopy frequency (SMD = -2.41, P < 0.0001), Length of hospital stay (MD = -0.33, P = 0.0002), and Cement leakage (RR = 0.37, P < 0.0001). However, no obvious improvement was found in the results of Visual analog scale (VAS) score (MD = -0.16, P = 0.1555), Volume of bone cement (MD = 0.22, P = 0.8339), and Operation time (MD = -3.20, P = 0.3411) after being treated by R-MIS. The meta-regression analysis demonstrated that R-MIS presented no significant impact on the covariates of VAS and Operation time.

CONCLUSION

R-MIS can significantly reduce the patients' ODI, Cobb's angles, X-ray fluoroscopy frequency, and Cement leakage ratio, and shorten the Length of hospital stay. Therefore, R-MIS may be an effective method to promote the patients' functional recovery, correct spinal deformity, reduce the X-ray fluoroscopy frequency, shorten the Length of hospital stay, and reduce the complications of OVCFs bone Cement leakage.

Accuracies of various types of spinal robot in robot-assisted pedicle screw insertion: a Bayesian network meta-analysis

BACKGROUND

With the popularization of robot-assisted spinal surgeries, it is still uncertain whether robots with different designs could lead to different results in the accuracy of pedicle screw placement. This study aimed to compare the pedicle screw inserting accuracies among the spinal surgeries assisted by various types of robot and estimate the rank probability of each robot-assisted operative technique involved.

METHODS

The electronic literature database of PubMed, Web of Science, EMBASE, CNKI, WANFANG and the Cochrane Library was searched in November 2021. The primary outcome was the Gertzbein-Robbins classification of pedicle screws inserted with various operative techniques. After the data extraction and direct meta-analysis process, a network model was established in the Bayesian framework and further analyses were carried out.

RESULTS

Among all the 15 eligible RCTs, 4 types of robot device, namely Orthbot, Renaissance, SpineAssist and TiRobot, were included in this study. In the network meta-analysis, the Orthbot group (RR 0.27, 95% CI 0.13-0.58), the Renaissance group (RR 0.33, 95% CI 0.14-0.86), the SpineAssist group (RR 0.14, 95% CI 0.06-0.34) and the conventional surgery group (RR 0.21, 95% CI 0.13-0.31) were inferior to the TiRobot group in the proportion of grade A pedicle screws. Moreover, the results of rank probabilities revealed that in terms of accuracy, the highest-ranked robot was TiRobot, followed by Renaissance and Orthbot.

CONCLUSIONS

In general, current RCT evidence indicates that TiRobot has an advantage in the accuracy of the pedicle screw placement, while there is no significant difference among the Orthbot-assisted technique, the Renaissance-assisted technique, the conventional freehand technique, and the SpineAssist-assisted technique in accuracy.

Single-Position Oblique Lumbar Interbody Fusion and Percutaneous Pedicle Screw Fixation under O-Arm Navigation: A Retrospective Comparative Study

The insertion of pedicle screws in the lateral position without a position change has been reported. We completed a retrospective comparison of the radiologic and clinical outcomes of 36 patients who underwent either single-position oblique lateral lumbar interbody fusion (SP-OLIF) using the O-arm (36 cases) or conventional OLIF (C-OLIF) using the C-arm (20 cases) for L2-5 single-level lumbar degenerative diseases. Radiological parameters were analyzed, including screw accuracy (Gertzbein-Robbins classification system; GRS), segmental instability, and fusion status. Screw misplacement was defined as a discrepancy of ≥2 mm. Clinical outcomes, including visual analog scale, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36), and postoperative complications, were assessed. The spinal fusion rate was not different between the SP-OLIF and C-OLIF groups one year after surgery (p = 0.536). The ODI score was lower (p = 0.015) in the SP-OLIF than the C-OLIF group. Physical (p = 0.000) and mental component summaries (p = 0.000) of the SF-36 were significantly higher in the SP-OLIF group. Overall complication rates, including revision, surgical site infection, ipsilateral weakness, and radicular pain/numbness, were not significantly different. SP-OLIF using the O-arm procedure is feasible, with acceptable accuracy, fusion rate, and complication rate. This may be an alternative to conventional two-stage operations.

Posterior Surgery in the Treatment of Craniovertebral Junction Deformity with Torticollis

OBJECTIVE

To investigate the clinical effect of posterior surgery in the treatment of craniovertebral junction (CVJ) deformities with torticollis and methods for preventing and treating complications in order to obtain a reasonable treatment strategy.

METHODS

From January 2007 to December 2017, 78 patients who suffered from CVJ deformities with torticollis treated by posterior surgery were analyzed. The surgical techniques were all posterior correction and fusion to restore the anatomical alignment of the craniovertebral junction. The visual analog score (VAS) and Short Form-36 (SF-36) health survey questionnaire were utilized to evaluate preoperative and postoperative neck pain, and changes in the torticollis angle and atlas-dens interval (ADI) were evaluated through anteroposterior X-ray and computed tomography. Intra- and postoperative complications were all recorded. One-way ANOVA, LSD-t test, and χ² test were performed to evaluate the difference between the preoperative and postoperative data.

RESULTS

The mean follow-up time was 37.4 ± 15.7 months, the average operation time was 115.6 ± 12.8 min, and the average blood loss was 170.8 ± 26.3 mL. According to the deformity site, the range of posterior correction and fusion was as follows: 38 cases of C₁ -C₂ , 33 cases of C₀ -C₂ , and seven cases of C₀ -C₃ . The preoperative SF-36, VAS, torticollis angle, and ADI were 42.6 ± 8.8, 4.8 ± 1.1, 37.2 ± 11.2°, and 4.9 ± 2.3 mm, respectively. The difference was significant at 3 months post operation (p < 0.05), and there was no significant difference at the final follow-up compared with 3 months post operation (p > 0.05).

CONCLUSION

It can objectively achieve favorable correction and satisfactory clinical effects under posterior correction and fixation for CVJ deformities with torticollis. Intra- and postoperative complications can be settled by proper management.