Overview of Robotic Technology in Spine Surgery

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).

Robotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion

Instrumentation of the spine has a long history with the advent and eventual evolution of a number of devices, specifically the pedicle screw which is the primary method of instrumenting the thoracolumbar spine. Traditionally, these were placed using anatomical landmarks; however, as technology has advanced, we have seen the integration of fluoroscopy, navigation, and now robotics for assistance. The integration of robotics into spine surgery has led to increased research and industry investment, which continues to push this promising new technology forward. This paper provides an overview of the robotic arm's effects on surgical outcomes, explores the revolutionary technology behind its remarkable performance, and describes its use in minimally invasive transforaminal lumbar interbody fusion which maximizes efficiency.

Comparison of Cervical Pedicle Screw Placement Accuracy With Robotic Guidance System Versus Image Guidance System Using Propensity Score Matching

STUDY DESIGN

A retrospective study.

OBJECTIVE

To compare the accuracy of cervical pedicle screw (CPS) placement using a robotic guidance system (RGS) with that of using an image guidance system (IGS; navigation system) through propensity score matching.

BACKGROUND

The RGS may provide accurate CPS placement, which may outperform IGS. However, no study has directly compared the accuracy of CPS placement with the RGS to that with the IGS.

PATIENTS AND METHODS

We retrospectively reviewed the data of patients who had undergone cervical fusion surgery using CPS with the RGS or IGS. To adjust for potential confounders (patient demographic characteristics, disease etiology, and registration material), propensity score matching was performed, creating robotic guidance (RG) and matched image guidance (IG) groups. The accuracy of CPS placement from C2 to C6, where the vertebral artery runs, was evaluated on postoperative computed tomography images according to the Neo classification (grade 0 to grade 3). Furthermore, the intraoperative CPS revisions and related complications were examined.

RESULTS

Using propensity score matching, 22 patients were included in the RG and matched groups each, and a total of 95 and 105 CPSs, respectively, were included in the analysis. In both the axial and sagittal planes, the clinically acceptable rate (grades 0 + 1) of CPS placement did not differ between the RG and matched IG groups (97.9% vs 94.3% and 95.8% vs 96.2%, respectively). The incidence of CPS revision was similar between the groups (2.1% vs 2.9%), and no CPS-related complications were documented. Meanwhile, the incidence of lateral breach (grades 1 + 2 + 3) was significantly lower in the RG group than in the matched IG group (1.1% vs 7.7%, P = 0.037).

CONCLUSION

The RGS and IGS can equally aid in accurate and safe CPS placement in clinical settings. Nonetheless, RGS can further reduce the lateral breach, compared with IGS.

Early Experiences With Single-Position Prone Lateral Lumbar Interbody Fusion: Safety and Outcomes

Background

Performing lateral lumbar interbody fusion (LLIF) in a single prone position may pose many advantages over the traditional lateral decubitus position, but there are questions concerning its safety profile and outcomes.

Purpose

We sought to study the safety and efficacy of LLIF performed with the patient in the prone position.

Methods

We conducted a retrospective cohort study including patients who underwent primary LLIF in the prone position for degenerative lumbar conditions. Complications and patient-reported outcome measures (PROMs) (Oswestry Disability Index [ODI], and visual analogue scale [VAS] scores for leg and back pain) were collected. Patients who underwent single-position prone LLIF were then propensity score matched for age, race, comorbidity index, number of levels, body mass index, and smoking status with patients who underwent single-position lateral LLIF. Patient-reported outcome measures and complications were compared between the 2 groups. Two postoperative timepoints were defined: early (<6 months) and late (≥6 months).

Results

Twenty single-position prone LLIF patients were included (35% 1-level, 35% 2-level, 15% 3-level, and 15% 4-level). No intraoperative complications were reported. Eleven (55%) patients experienced transient postoperative anterior thigh weakness. Five (25%) patients experienced postoperative complications such as anemia, urinary retention, ileus, and new-onset sensory symptoms. Oswestry Disability Index, VAS leg, and VAS back scores all improved at the >6-month time point compared with preoperative states. There were no significant differences at any postoperative time point for PROMs between prone and lateral LLIF groups. Among the matched cohort, complications were observed in 3 (21%) of patients compared with only 1 (7%) in the lateral group although this difference was not statistically significant.

Conclusion

This retrospective study suggests that prone LLIF procedures may be safe and effective. Ergonomic and logistic benefits from the approach may make it a beneficial approach for surgeons to begin implementing.

Evaluating the Status and Promising Potential of Robotic Spinal Surgery Systems

The increasing frequency of cervical and lumbar spine disorders, driven by aging and evolving lifestyles, has led to a rise in spinal surgeries using pedicle screws. Robotic spinal surgery systems have emerged as a promising innovation, offering enhanced accuracy in screw placement and improved surgical outcomes. We focused on literature of this field from the past 5 years, and a comprehensive literature search was performed using PubMed and Google Scholar. Robotic spinal surgery systems have significantly impacted spinal procedures by improving pedicle screw placement accuracy and supporting various techniques. These systems facilitate personalized, minimally invasive, and low-radiation interventions, leading to greater precision, reduced patient risk, and decreased radiation exposure. Despite advantages, challenges such as high costs and a steep learning curve remain. Ongoing advancements are expected to further enhance these systems' role in spinal surgery.

Level-specific comparison of 3D navigated and robotic arm-guided screw placement: an accuracy assessment of 1210 pedicle screws in lumbar surgery

BACKGROUND CONTEXT

Robotic spine surgery, utilizing 3D imaging and robotic arms, has been shown to improve the accuracy of pedicle screw placement compared to conventional methods, although its superiority remains under debate. There are few studies evaluating the accuracy of 3D navigated versus robotic-guided screw placement across lumbar levels, addressing anatomical challenges to refine surgical strategies and patient safety.

PURPOSE

This study aims to investigate the pedicle screw placement accuracy between 3D navigation and robotic arm-guided systems across distinct lumbar levels.

STUDY DESIGN

A retrospective review of a prospectively collected registry.

PATIENT SAMPLE

Patients undergoing fusion surgery with pedicle screw placement in the prone position, using either via 3D image navigation only or robotic arm guidance.

OUTCOME MEASURE

Radiographical screw accuracy was assessed by the postoperative computed tomography (CT) according to the Gertzbein-Robbins classification, particularly focused on accuracy at different lumbar levels.

METHODS

Accuracy of screw placement in the 3D navigation (Nav group) and robotic arm guidance (Robo group) was compared using Chi-squared test/Fisher's exact test with effect size measured by Cramer's V, both overall and at each specific lumbosacral spinal level.

RESULTS

A total of 321 patients were included (Nav, 157; Robo, 189) and evaluated 1210 screws (Nav, 651; Robo 559). The Robo group demonstrated significantly higher overall accuracy (98.6 vs 93.9%; p<.001, V=0.25). This difference of no breach screw rate was signified the most at the L3 level (No breach screw: Robo 91.3 vs 57.8%, p<.001, V=0.35) followed by L4 (89.6 vs 64.7%, p<.001, V=0.28), and L5 (92.0 vs 74.5%, p<.001, V=0.22). However, screw accuracy at S1 was not significant between the groups (81.1 vs 72.0%, V=0.10).

CONCLUSION

This study highlights the enhanced accuracy of robotic arm-guided systems compared to 3D navigation for pedicle screw placement in lumbar fusion surgeries, especially at the L3, L4, and L5 levels. However, at the S1 level, both systems exhibit similar effectiveness, underscoring the importance of understanding each system's specific advantages for optimization of surgical complications.

[Brief history and application prospect of robotic spine surgery]

Spinal robotics has rounded out twenty years in clinical, is mainly used for pedicle screw placement at present, can significantly increase the accuracy of screw placement and reduce radiation exposure to the patient and the surgeon. In the future, haptic feedback, automatic collision avoidance, and other technologies will further expand its application to complete precise operations such as decompression and correction, providing safety guarantee for the implementation of complex spinal surgery.

Advantages of robot-assisted PKP under local anesthesia in the treatment of OVCF: a retrospective, non-randomized, controlled, clinical study

Background

Robot-assisted technology has been widely used in orthopedic surgery, which can provide surgeons with higher accuracy and reduce radiation exposure. In spinal surgery, robots are often used to assist pedicle screw implantation, while there are relatively few studies on robot-assisted percutaneous kyphoplasty (PKP) under local anesthesia.

Methods

A total of 96 patients with single-segment OVCF who met the inclusion criteria were included in this study. Fifty-six patients underwent robot-assisted PKP and forty patients underwent conventional PKP by the same group of surgeons. Collect the relevant parameters.

Results

The puncture time and fluoroscopy times during puncture in the robot group were significantly less than those in the manual group (P < 0.001). The success rate of first puncture in the robot group was 92.5%.

Conclusions

PKP under local anesthesia assisted by the new spinal surgical robot effectively reduces the patient's intraoperative discomfort and has a low learning curve.

Evolution of Neurosurgical Robots: Historical Progress and Future Direction

In 1985, Professor KWOH first introduced robots into neurosurgery. Since then, advancements of stereotactic frames, radiographic imaging, and neuronavigation have led to the dominance of classic stereotactic robots. A comprehensive retrieval was performed using academic databases and search agents to acquire professional information, with a cutoff date of June, 2024. This reveals a multitude of emerging technologies are coming to the forefront, including tremor filtering, motion scaling, obstacle avoidance, force sensing, which have made significant contributions to the high efficiency, high precision, minimally invasive, and exact efficacy of robot-assisted neurosurgery. Those technologies have been applied in innovative magnetic resonance-compatible neurosurgical robots, such as Neuroarm and Neurobot, with real-time image-guided surgery. Despite these advancements, the major challenge is considered as magnetic resonance compatibility in terms of space, materials, driving, and imaging. Future research directions are anticipated to focus on 1) robotic precise perception; 2) artificial intelligence; and 3) the advancement of telesurgery.

Top 25 Most-Cited Articles on Robotic-Assisted Lumbar Spine Surgery

BACKGROUND

Robot-guided lumbar spine surgery has evolved rapidly with evidence to support its utility and feasibility compared with conventional freehand and fluoroscopy-based techniques. The objective of this study was to assess trends among the top 25 most-cited articles pertaining to robotic-guided lumbar spine surgery.

METHODS

An "advanced document search" using Boolean search operator terms was performed on 16 November 2022 through the Web of Science and SCOPUS citation databases to determine the top 25 most-referenced articles on robotic lumbar spine surgery. The articles were compiled into a directory and hierarchically organized based on the total number of citations.

RESULTS

Cumulatively, the "Top 25" list for robot-assisted navigation in lumbar spine surgery received 2240 citations, averaging 97.39 citations annually. The number of citations ranged from 221 to 40 for the 25 most-cited articles. The most-cited study, by Kantelhardt et al, received 221 citations, averaging 18 citations per year.

CONCLUSIONS

As utilization of robot-guided modalities in lumbar spine surgery increases, this review highlights the most impactful studies to support its efficacy and implementation. Practical considerations such as cost-effectiveness, however, need to be better defined through further longitudinal studies that evaluate patient-reported outcomes and cost-utility.

CLINICAL RELEVANCE

Through an overview of the top 25 most-cited articles, the present review highlights the rising prominence and technical efficacy of robotic-guided systems within lumbar spine surgery, with consideration to pragmatic limitations and need for additional data to facilitate cost-effective applications.

LEVEL OF EVIDENCE: 5

Perception of Robotics and Navigation by Spine Fellows and Early Attendings: The Impact of These Technologies on Their Training and Practice

BACKGROUND

There is scant data on the role that robotics and navigation play in spine surgery training and practice of early attendings. This study aimed to assess the impact of navigation and robotics on spine surgery training and practice.

METHODS

A survey gathering information on utilization of navigation and robotics in training and practice was administered to trainees and early attendings.

RESULTS

A total of 51 surveys were returned completed: 71% were attendings (average practice years: 2), 29% were trainees. During training, 22% were exposed to only fluoroscopy, 75% were exposed to navigation, 51% were exposed to robotics, and 40% were exposed to both navigation and robotics. In our sample, 87% and 61% of respondents who had exposure to navigation and robotics, respectively, felt that it had a positive impact on their training. In practice, 28% utilized only fluoroscopy, 69% utilized navigation, 30% utilized robotics, and 28% utilized both navigation and robotics. The top 3 reasons behind positive impact on training and practice were: 1) increased screw accuracy, 2) exposure to upcoming technology, and 3) less radiation exposure. The top 3 reasons behind negative impact were: 1) compromises training to independently place screws, 2) time and personnel requirements, and 3) concerns about availing it in practice. In sum, 76% of attendings felt that they will be utilizing more navigation and robotics in 5 years' time.

CONCLUSIONS

Navigation and robotics have a perceivably positive impact on training and are increasingly being incorporated into practice. However, associated concerns demand spine surgeons to be thoughtful about how they integrate these technologies moving forward.

The impact of robotic assistance for lumbar fusion surgery on 90-day surgical outcomes and 1-year revisions

Objectives

To evaluate the (1) 90-day surgical outcomes and (2) 1-year revision rate of robotic versus nonrobotic lumbar fusion surgery.

Methods

Patients >18 years of age who underwent primary lumbar fusion surgery at our institution were identified and propensity-matched in a 1:1 fashion based on robotic assistance during surgery. Patient demographics, surgical characteristics, and surgical outcomes, including 90-day surgical complications and 1-year revisions, were collected. Multivariable regression analysis was performed. Significance was set to P < 0.05.

Results

Four hundred and fifteen patients were identified as having robotic lumbar fusion and were matched to a control group. Bivariant analysis revealed no significant difference in total 90-day surgical complications (P = 0.193) or 1-year revisions (P = 0.178). The operative duration was longer in robotic surgery (287 + 123 vs. 205 + 88.3, P ≤ 0.001). Multivariable analysis revealed that robotic fusion was not a significant predictor of 90-day surgical complications (odds ratio [OR] = 0.76 [0.32-1.67], P = 0.499) or 1-year revisions (OR = 0.58 [0.28-1.18], P = 0.142). Other variables identified as the positive predictors of 1-year revisions included levels fused (OR = 1.26 [1.08-1.48], P = 0.004) and current smokers (OR = 3.51 [1.46-8.15], P = 0.004).

Conclusion

Our study suggests that robotic-assisted and nonrobotic-assisted lumbar fusions are associated with a similar risk of 90-day surgical complications and 1-year revision rates; however, robotic surgery does increase time under anesthesia.

A Review of the Role of Robotics in Surgery: To DaVinci and Beyond!

Since its inception in 1985, robotic surgery has evolved into a mainstream surgical approach that has become virtually synonymous with minimally invasive surgery (MIS) and adopted across several specialties offering decreased patient morbidity and improved post-operative outcomes. This article discusses the current role of robotics in MIS and its varied applications, prevalence in the community and the future of the field.

Floor-Mounted Robotic Pedicle Screw Placement in Lumbar Spine Surgery: An Analysis of 1,050 Screws

OBJECTIVE

To analyze the usage of floor-mounted robot in minimally invasive lumbar fusion.

METHODS

Patients who underwent minimally invasive lumbar fusion for degenerative pathology using floor-mounted robot (ExcelsiusGPS) were included. Pedicle screw accuracy, proximal level violation rate, pedicle screw size, screw-related complications, and robot abandonment rate were analyzed.

RESULTS

Two hundred twenty-nine patients were included. Most surgeries were primary single-level fusion. Sixty-five percent of surgeries had intraoperative computed tomography (CT) workflow, 35% had preoperative CT workflow. Sixty-six percent were transforaminal lumbar interbody fusion, 16% were lateral, 8% were anterior, and 10% were a combined approach. A total of 1,050 screws were placed with robotic assistance (85% in prone position, 15% in lateral position). Postoperative CT scan was available for 80 patients (419 screws). Overall pedicle screw accuracy rate was 96.4% (prone, 96.7%; lateral, 94.2%; primary, 96.7%; revision, 95.3%). Overall poor screw placement rate was 2.8% (prone, 2.7%; lateral, 3.8%; primary, 2.7%; revision, 3.5%). Overall proximal facet and endplate violation rates were 0.4% and 0.9%. Average diameter and length of pedicle screws were 7.1 mm and 47.7 mm. Screw revision had to be done for 1 screw (0.1%). Use of the robot had to be aborted in 2 cases (0.8%).

CONCLUSION

Usage of floor-mounted robotics for the placement of lumbar pedicle screws leads to excellent accuracy, large screw size, and negligible screw-related complications. It does so for screw placement in prone/lateral position and primary/revision surgery alike with negligible robot abandonment rates.

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.

Robotic-assisted bronchoscopy in the diagnosis of peripheral pulmonary lesions

More peripheral pulmonary lesions (PPLs) are detected by low-dose helical computed tomography (CT) either incidentally or via dedicated lung cancer screening programs. Thus, using methods for safe and accurate diagnosis of these lesions has become increasingly important. Transthoracic needle aspiration (TTNA) and transbronchial lung biopsy (TBLB) are routinely performed during the diagnostic workup for PPLs. However, TTNA often carries the risk of pneumothorax, uncontrollable airway hemorrhage, and does not allow mediastinal staging in one procedure. In contrast, traditional TBLB often has a poorer diagnostic yield despite fewer complications. With the ongoing development of technology applied to bronchoscopy, guided bronchoscopy has become widely used and the diagnostic yield of TBLB has improved. Additionally, guided bronchoscopy continues to demonstrate a better safety profile than TTNA. In recent years, robotic-assisted bronchoscopy (RAB) has been introduced and implemented in the diagnosis of PPLs. At present, RAB has two platforms that are commercially available: Monarch™ and Ion™; several other platforms are under development. Both systems differ in characteristics, advantages, and limitations and offer features not seen in previous guided bronchoscopy. Several studies, including cadaveric model studies and clinical trials, have been conducted to examine the feasibility and performance of RAB using these two systems; large multicenter studies are underway. In this review, published experimental results, focusing on diagnostic yield and complications of RAB, are analyzed and the potential clinical application of RAB is discussed, which will enable the operators to have a clear overview of RAB.

Robot-assisted versus navigation-assisted screw placement in spinal vertebrae

PURPOSE

Both robots and navigation are effective strategies for optimizing screw placement, as compared to freehand placement. However, few studies have compared the accuracy and efficiency of these two techniques. Thus, the purpose of this study is to compare the accuracy and efficiency of robotic and navigation-assisted screw placement in the spinal vertebrae.

METHODS

The 24 spine models were divided into a robot- and navigation-assisted groups according to the left and right sides of the pedicle. The C-arm transmits image data simultaneously to the robot and navigates using only one scan. After screw placement, the accuracy of the two techniques were compared using "angular deviation" and "Gertzbein and Robbins scale" in different segments (C1-7, T1-4, T5-8, T9-12, and L1-S1). In addition, operation times were compared between robot- and navigation-assisted groups.

RESULTS

Robots and navigation systems can simultaneously assist in screw placement. The robot-assisted group had significantly less angular deviation than the navigation-assisted group from C1 to S1 (p < 0.001). At the C1-7 and T1-4 segments, the robot-assisted group had a higher rate of acceptable screws than the robot-assisted group. However, at the T5-8, T9-12, and L1-S1 segments, no significant difference was found in the incidence of acceptable screws between the two groups. Moreover, robot-assisted screw placement required less operative time than navigation (p < 0.05).

CONCLUSION

The robot is more accurate and efficient than navigation in aiding screw placement. In addition, robots and navigation can be combined without increasing the number of fluoroscopic views.

Robot-assisted percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a retrospective matched-cohort study

PURPOSE

This study aims to introduce the principle, clinical efficacy, and learning curve of robot-assisted percutaneous vertebroplasty (PVP).

METHODS

Forty-two patients who underwent robot-assisted single-level PVP were analyzed retrospectively and 42 age-matched patients using freehand technique were selected as the control group. The visual analog scale, operation time, radiation exposure, accuracy, and learning curve were analyzed.

RESULTS

The puncture time and total operation time were significantly shorter, and the puncture and total fluoroscopy number were fewer in the robot group. The deviation between pre-operative planned and actual puncture trajectory well met clinical requirement. The puncture time, total operation time, and puncture fluoroscopy number were significantly more in early cases than in later cases in the robot group.

CONCLUSION

The robot-assisted pedicle puncture technique shortens the operation time and reduces radiation exposure, and the accuracy meets the clinical requirement in PVP. The learning curve is short and not steep.

Development of a Robotic Spine Surgery Program: Rationale, Strategy, Challenges, and Monitoring of Outcomes After Implementation

Surgical robots were invented in the 1980s, and since then, robotic-assisted surgery has become commonplace. In the field of spine surgery, robotic assistance is utilized mainly to place pedicle screws, and multiple studies have demonstrated that robots can increase the accuracy of screw placement and reduce radiation exposure to the patient and the surgeon. However, this may be at the cost of longer operative times, complications, and the risk of errors in mapping the patient's anatomy.

Robotics Reduces Radiation Exposure in Minimally Invasive Lumbar Fusion Compared With Navigation

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare robotics and navigation for minimally invasive elective lumbar fusion in terms of radiation exposure and time demand.

SUMMARY OF BACKGROUND DATA

Although various studies have been conducted to demonstrate the benefits of both navigation and robotics over fluoroscopy in terms of radiation exposure, literature is lacking in studies comparing robotics versus navigation.

MATERIALS AND METHODS

Patients who underwent elective one-level or two-level minimally invasive transforaminal lumbar interbody fusion (TLIF) by a single surgeon using navigation (Stryker SpineMask) or robotics (ExcelsiusGPS) were included (navigation 2017-2019, robotics 2019-2021, resulting in prospective cohorts of consecutive patients for each modality). All surgeries had the intraoperative computed tomography workflow. The two cohorts were compared for radiation exposure [fluoroscopy time and radiation dose: image capture, surgical procedure, and overall) and time demand (time for setup and image capture, operative time, and total operating room (OR) time].

RESULTS

A total of 244 patients (robotics 111, navigation 133) were included. The two cohorts were similar in terms of baseline demographics, primary/revision surgeries, and fusion levels. For one-level TLIF, total fluoroscopy time, total radiation dose, and % of radiation for surgical procedure were significantly less with robotics compared with navigation (20 vs. 25 s, P <0.001; 38 vs. 42 mGy, P =0.05; 58% vs. 65%, P =0.021). Although time for setup and image capture was significantly less with robotics (22 vs. 25 min, P <0.001) and operative time was significantly greater with robotics (103 vs. 93 min, P <0.001), there was no significant difference in the total OR time (145 vs. 141 min, P =0.25). Similar findings were seen for two-level TLIF as well.

CONCLUSION

Robotics for minimally invasive TLIF, compared with navigation, leads to a significant reduction in radiation exposure both to the surgeon and patient, with no significant difference in the total OR time.

[Does navigation still have a value in trauma surgery?]

BACKGROUND

Navigation systems are supposed to increase precision and support surgeons while they perform certain interventions. 2D, or nowadays 3D, systems are used in image-based approaches. Image-free navigation uses 3D printing.

INDICATIONS

There are several studies on navigation procedures in trauma surgery. In contrast to limb surgery, the use of 3D navigation in pelvic and spine surgery is already well established. Navigation is especially regularly used to treat fractures of the posterior pelvic ring and for posterior stabilization of the cervical spine.

REQUIREMENTS

To be able to utilize navigation systems optimally, the learning curve should be completed, and the technique should be used regularly. In addition, the surgeon should know the surgical technique without navigation in order to recognize potential errors of the navigation.

ADVANTAGES AND DISADVANTAGES

Advantages include increased patient safety, reduction in radiation exposure and less invasive surgical procedures. However, among other disadvantages, initial costs are high.

Does robot-assisted navigation influence pedicle screw selection and accuracy in minimally invasive spine surgery?

OBJECTIVE

The accuracy of percutaneous pedicle screw placement has increased with the advent of robotic and surgical navigation technologies. However, the effect of robotic intraoperative screw size and trajectory templating remains unclear. The purpose of this study was to compare pedicle screw sizes and accuracy of placement using robotic navigation (RN) versus skin-based intraoperative navigation (ION) alone in minimally invasive lumbar fusion procedures.

METHODS

A retrospective cohort study was conducted using a single-institution registry of spine procedures performed over a 4-year period. Patients who underwent 1- or 2-level primary or revision minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF) with pedicle screw placement, via either robotic assistance or surgical navigation alone, were included. Demographic, surgical, and radiographic data were collected. Pedicle screw type, quantity, length, diameter, and the presence of endplate breach or facet joint violation were assessed. Statistical analysis using the Student t-test and chi-square test was performed to evaluate the differences in pedicle screw sizes and the accuracy of placement between both groups.

RESULTS

Overall, 222 patients were included, of whom 92 underwent RN and 130 underwent ION MIS-TLIF. A total of 403 and 534 pedicle screws were placed with RN and ION, respectively. The mean screw diameters were 7.25 ± 0.81 mm and 6.72 ± 0.49 mm (p < 0.001) for the RN and ION groups, respectively. The mean screw length was 48.4 ± 4.48 mm in the RN group and 45.6 ± 3.46 mm in the ION group (p < 0.001). The rates of “ideal” pedicle screws in the RN and ION groups were comparable at 88.5% and 88.4% (p = 0.969), respectively. The overall screw placement was also similar. The RN cohort had 63.7% screws rated as good and 31.4% as acceptable, while 66.1% of ION-placed screws had good placement and 28.7% had acceptable placement (p = 0.661 and p = 0.595, respectively). There was a significant reduction in high-grade breaches in the RN group (0%, n = 0) compared with the ION group (1.2%, n = 17, p = 0.05).

CONCLUSIONS

The results of this study suggest that robotic assistance allows for placement of screws with greater screw diameter and length compared with surgical navigation alone, although with similarly high accuracy. These findings have implied that robotic platforms may allow for safe placement of the “optimal screw,” maximizing construct stability and, thus, the ability to obtain a successful fusion.