The current state of navigation in robotic spine surgery

Review of robotic systems for thoracoabdominal puncture interventional surgery

Cancer, with high morbidity and high mortality, is one of the major burdens threatening human health globally. Intervention procedures via percutaneous puncture have been widely used by physicians due to its minimally invasive surgical approach. However, traditional manual puncture intervention depends on personal experience and faces challenges in terms of precisely puncture, learning-curve, safety and efficacy. The development of puncture interventional surgery robotic (PISR) systems could alleviate the aforementioned problems to a certain extent. This paper attempts to review the current status and prospective of PISR systems for thoracic and abdominal application. In this review, the key technologies related to the robotics, including spatial registration, positioning navigation, puncture guidance feedback, respiratory motion compensation, and motion control, are discussed in detail.

Comparative surgical outcomes of navigated vs non-navigated posterior spinal fusions in ankylosing spondylitis patients

INTRODUCTION

Ankylosing Spondylitis (AS) patients with acute spinal fractures represent a challenge for practicing spine surgeons due to difficult operative anatomy and susceptibility to complications.

RESEARCH QUESTION

Does intraoperative CT-navigation improve outcomes in patients with ankylosing spondylitis undergoing surgery?

METHODS

A retrospective review was carried out at our centre from 05/2016-06/2021 to identify AS patients presenting with a traumatic spinal fracture, managed surgically with posterior spinal fusion (PSF). Cohorts were categorised and compared for outcomes based on those who underwent PSF with intraoperative CT-navigation versus those surgically managed with traditional intraoperative fluoroscopy.

RESULTS

37 AS patients were identified. 29/37 (78.4%) underwent PSF. Intraoperative navigation was used in 14 (48.3%) cases. Mean age of the entire cohort was 67.6 years. No difference existed between the navigated and non-navigated groups for mean levels fused (5.35 vs 5.07; p ​= ​0.31), length of operation (217.9mins vs 175.3mins; p ​= ​0.07), overall length-of-stay (12 days vs 21.9 days; p ​= ​0.16), patients requiring HDU (3/14 vs 5/15; p ​= ​0.09) or ICU (5/14 vs 9/15; p ​= ​0.10), postoperative neurological improvement (1/14 vs 1/15; p ​= ​0.48) or deterioration (1/14 vs 0/15; p ​= ​0.15), intraoperative complications (2/14 vs 3/15; p ​= ​0.34), postoperative complications 4/14 vs 4/15; p ​= ​0.46), revision surgeries (3/14 vs 1/15; p ​= ​0.16) and 30-day mortality (0/14 vs 0/15).

CONCLUSION

This is the first study that compares surgical outcomes of navigated vs non-navigated PSFs for AS patients with an acute spinal fracture. Although limited by its retrospective design and sample size, this study highlights the non-inferiority of intraoperative navigation as a surgical aid in a challenging cohort.

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.

User Experience Evaluation of a Spinal Surgery Robot: Workload, Usability, and Satisfaction Study

BACKGROUND

Robotic spine surgery has continued to evolve since its US Food and Drug Administration approval in 2004, with products now including real-time video guidance and navigation during surgery. As the market for robotic surgical devices evolves, it is important to consider usability factors.

OBJECTIVE

The primary objective of this study was to determine the user experience of a surgical-assistive robotic device. The secondary objective was to evaluate workload, usability, the After-Scenario Questionnaire (ASQ), and the System Usability Scale (SUS). In addition, this study compares the workload, usability, and satisfaction survey of the device among different occupational groups using the device.

METHODS

Doctors (n=15) and nurses (n=15), the intended users of the surgical assistant robot, participated in the usability evaluation. Participants performed essential scenarios for the surgical assistant robot and provided scenario-specific satisfaction (ASQ), workload (NASA Task Load Index), and usability (SUS) scores.

RESULTS

Both doctors and nurses had task success rates of 85% or higher for each scenario. ASQ results showed that both doctors and nurses were least satisfied with ease of completing the task of registration (group 1: mean 4.73, SD 1.57 and group 2: mean 4.47, SD 1.8), amount of time it took (group 1: mean 4.47, SD 1.63 and group 2: mean 4.40, SD 2.09), and support information satisfaction (group 1: mean 5.13, SD 1.50 and group 2: mean 5.13, SD 1.89). All participants had low workloads, and the overall Task Load Index score had a P value of .77, which is greater than .05. The SUS results showed that the overall usability mean for doctors was 64.17 (SD 16.52) and the mean for nurses was 61.67 (SD 19.18), with a P value of .84, which is greater than .05, indicating no difference between the 2 groups.

CONCLUSIONS

In this study, doctors and nurses evaluated the interaction of the device in a simulated environment, the operating room. By evaluating the use experience and usability of the device with real intended users, we can develop a more effective and convenient user interface.

Ultra-dense Motion Capture: An exploratory full-automatic approach for dense tracking of breast motion in 4D

Understanding the dynamic deformation pattern and biomechanical properties of breasts is crucial in various fields, including designing ergonomic bras and customized prostheses, as well as in clinical practice. Previous studies have recorded and analyzed the dynamic behaviors of the breast surface using 4D scanning, which provides a sequence of 3D meshes during movement with high spatial and temporal resolutions. However, these studies are limited by the lack of robust and automated data processing methods which result in limited data coverage or error-prone analysis results. To address this issue, we identify revealing inter-frame dense correspondence as the core challenge towards conducting reliable and consistent analysis of the 4D scanning data. We proposed a fully-automatic approach named Ulta-dense Motion Capture (UdMC) using Thin-plate Spline (TPS) to augment the sparse landmarks recorded via motion capture (MoCap) as initial dense correspondence and then rectified it with a sophisticated post-alignment scheme. Two downstream tasks are demonstrated to validate its applicability: virtual landmark tracking and deformation intensity analysis. For evaluation, a dynamic 4D human breast anthropometric dataset DynaBreastLite was constructed. The results show that our approach can robustly capture the dynamic deformation characteristics of the breast surfaces, significantly outperforms baselines adapted from previous works in terms of accuracy, consistency, and efficiency. For 10 fps dataset, average error of 0.25 cm on control-landmarks and 0.33 cm on non-control (arbitrary) landmarks were achieved, with 17-70 times faster computation time. Evaluation was also carried out on 60 fps and 120 fps datasets, with consistent and large performance gaining being observed. The proposed method may contribute to advancing research in breast anthropometry, biomechanics, and ergonomics by enabling more accurate tracking of the breast surface deformation patterns and dynamic characteristics.

Pedicle screw placement accuracy in robot-assisted versus image-guided freehand surgery of thoraco-lumbar spine (ROBARTHRODESE): study protocol for a single-centre randomized controlled trial

BACKGROUND

Robotic spinal surgery may result in better pedicle screw placement accuracy, and reduction in radiation exposure and length of stay, compared to freehand surgery. The purpose of this randomized controlled trial (RCT) is to compare screw placement accuracy of robot-assisted surgery with integrated 3D computer-assisted navigation versus freehand surgery with 2D fluoroscopy for arthrodesis of the thoraco-lumbar spine.

METHODS

This is a single-centre evaluator-blinded RCT with a 1:1 allocation ratio. Participants (n = 300) will be randomized into two groups, robot-assisted (Mazor X Stealth Edition) versus freehand, after stratification based on the planned number of pedicle screws needed for surgery. The primary outcome is the proportion of pedicle screws placed with grade A accuracy (Gertzbein-Robbins classification) on postoperative computed tomography images. The secondary outcomes are intervention time, operation room occupancy time, length of stay, estimated blood loss, surgeon's radiation exposure, screw fracture/loosening, superior-level facet joint violation, complication rate, reoperation rate on the same level or one level above, functional and clinical outcomes (Oswestry Disability Index, pain, Hospital Anxiety and Depression Scale, sensory and motor status) and cost-utility analysis.

DISCUSSION

This RCT will provide insight into whether robot-assisted surgery with the newest generation spinal robot yields better pedicle screw placement accuracy than freehand surgery. Potential benefits of robot-assisted surgery include lower complication and revision rates, shorter length of stay, lower radiation exposure and reduction of economic cost of the overall care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05553028. Registered on September 23, 2022.

Robotic-Assisted Versus Fluoroscopic-Guided Surgery on the Accuracy of Spine Pedicle Screw Placement: A Systematic Review and Meta-Analysis

Spinal fusion is a common method by which surgeons decrease instability and deformity of the spinal segment targeted. Pedicle screws are vital tools in fusion surgeries and advancements in technology have introduced several modalities of screw placement. Our objective was to evaluate the accuracy of pedicle screw placement in robot-assisted (RA) versus fluoroscopic-guided (FG) techniques. The PubMed and Cochrane Library databases were systematically reviewed from January 2007 through to August 8, 2022, to identify relevant studies. The accuracy of pedicle screw placement was determined using the Gertzbein-Robbins (GR) classification system. Facet joint violation (FJV), total case radiation dosage, total case radiation time, total operating room (OR) time, and total case blood loss were collected. Twenty-one articles fulfilled the inclusion criteria. Successful screw accuracy (GR Grade A or B) was found to be 1.02 (95% confidence interval: 1.01 - 1.04) times more likely with the RA technique. In defining accuracy solely based on the GR Grade A criteria, screws placed with RA were 1.10 (95% confidence interval: 1.06 - 1.15) times more likely to be accurate. There was no significant difference between the two techniques with respect to blood loss (Hedges' g: 1.16, 95% confidence interval: -0.75 to 3.06) or case radiation time (Hedges' g: -0.34, 95% CI: -1.22 to 0.53). FG techniques were associated with shorter operating room times (Hedges' g: -1.03, 95% confidence interval: -1.76 to -0.31), and higher case radiation dosage (Hedges' g: 1.61, 95% confidence interval: 1.11 to 2.10). This review suggests that RA may slightly increase pedicle screw accuracy and decrease per-case radiation dosage compared to FG techniques. However, total operating times for RA cases are greater than those for FG cases.

Robot-navigated pedicle screw insertion can reduce intraoperative blood loss and length of hospital stay: analysis of 1,633 patients utilizing propensity score matching

BACKGROUND CONTEXT

Navigation and robotic technologies have emerged as an alternative option to conventional freehand techniques for pedicle screw insertion. However, the effectiveness of these technologies in reducing the perioperative complications of spinal fusion surgery remains limited due to the small cohort size in the existing literature.

PURPOSE

To investigate whether utilization of robotically navigated pedicle screw insertion can reduce the perioperative complications of spinal fusion surgery-including reoperations-with a sizeable cohort.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Patients who underwent primary lumbar fusion surgery between 2019 and 2022.

OUTCOME MEASURES

Perioperative complications including readmission, reoperation, its reasons, estimated blood loss, operative time, and length of hospital stay.

METHODS

Patients' data were collected including age, sex, race, body mass index, upper-instrumented vertebra, lower-instrumented vertebra, number of screws inserted, and primary procedure name. Patients were classified into the following two groups: freehand group and robot group. The variable-ratio greedy matching was utilized to create the matched cohorts by propensity score and compared the outcomes between the two group.

RESULTS

A total of 1,633 patients who underwent primary instrumented spinal lumbar fusion surgery were initially identified (freehand 1,286; robot 347). After variable ratio matching was performed with age, sex, body mass index, fused levels, and upper instrumented vertebrae level, 694 patients in the freehand group and 347 patients in robot groups were selected. The robot group showed less estimated blood loss (418.9±398.9 vs 199.2±239.6 ml; p<.001), shorter LOS (4.1±3.1 vs 3.2±3.0 days; p<.001) and similar operative time (212.5 vs 222.0 minutes; p=.151). Otherwise, there was no significant difference in readmission rate (3.6% vs 2.6%; p=.498), reoperation rate (3.2% vs 2.6%; p=.498), and screw malposition requiring reoperation (five cases, 0.7% vs one case, 0.3%; p=1.000).

CONCLUSIONS

Perioperative complications requiring readmission and reoperation were similar between fluoroscopy guided freehand and robotic surgery. Robot-guided pedicle screw insertion can enhance surgical efficiency by reducing intraoperative blood loss and length of hospital stay without extending operative time.

A Single-Center Experience of Robotic-Assisted Spine Surgery in Korea : Analysis of Screw Accuracy, Potential Risk Factor of Screw Malposition and Learning Curve

OBJECTIVE

Recently, robotic-assisted spine surgery (RASS) has been considered a minimally invasive and relatively accurate method. In total, 495 robotic-assisted pedicle screw fixation (RAPSF) procedures were attempted on 100 patients during a 14-month period. The current study aimed to analyze the accuracy, potential risk factors, and learning curve of RAPSF.

METHODS

This retrospective study evaluated the position of RAPSF using the Gertzbein and Robbins scale (GRS). The accuracy was analyzed using the ratio of the clinically acceptable group (GRS grades A and B), the dissatisfying group (GRS grades C, D, and E), and the Surgical Evaluation Assistant program. The RAPSF was divided into the no-breached group (GRS grade A) and breached group (GRS grades B, C, D, and E), and the potential risk factors of RAPSF were evaluated. The learning curve was analyzed by changes in robot-used time per screw and the occurrence tendency of breached and failed screws according to case accumulation.

RESULTS

The clinically acceptable group in RAPSF was 98.12%. In the analysis using the Surgical Evaluation Assistant program, the tip offset was 2.37±1.89 mm, the tail offset was 3.09±1.90 mm, and the angular offset was 3.72°±2.72°. In the analysis of potential risk factors, the difference in screw fixation level (p=0.009) and segmental distance between the tracker and the instrumented level (p=0.001) between the no-breached and breached group were statistically significant, but not for the other factors. The mean difference between the no-breach and breach groups was statistically significant in terms of pedicle width (p<0.001) and tail offset (p=0.042). In the learning curve analysis, the occurrence of breached and failed screws and the robot-used time per screw screws showed a significant decreasing trend.

CONCLUSION

In the current study, RAPSF was highly accurate and the specific potential risk factors were not identified. However, pedicle width was presumed to be related to breached screw. Meanwhile, the robot-used time per screw and the incidence of breached and failed screws decreased with the learning curve.

Revolutionizing orthopedics: a comprehensive review of robot-assisted surgery, clinical outcomes, and the future of patient care

Robotic-assisted orthopedic surgery (RAOS) is revolutionizing the field, offering the potential for increased accuracy and precision and improved patient outcomes. This comprehensive review explores the historical perspective, current robotic systems, advantages and limitations, clinical outcomes, patient satisfaction, future developments, and innovation in RAOS. Based on systematic reviews, meta-analyses, and recent studies, this article highlights the most significant findings and compares RAOS to conventional techniques. As robotic-assisted surgery continues to evolve, clinicians and researchers must stay informed and adapt their practices to provide optimal patient care. Evidence from published studies corroborates these claims, highlighting superior component positioning, decreased incidence of complications, and heightened patient satisfaction. However, challenges such as costs, learning curves, and technical issues must be resolved to fully capitalize on these advantages.

Prospective Comparison of Two Robotically Navigated Pedicle Screw Instrumentation Techniques

This study aimed to compare screw accuracy and incidence of skive between two robotically navigated instrumented techniques in posterior spine fusion surgery: manual anti-skive instrumentation with an anti-skive cannula (ASC) and the use of a navigated, high-speed drill (HSD). Over a 3-year period, consecutive patients are undergoing RNA posterior fusion surgery with either ASC (n = 53) or HSD (n = 63). Both groups met a value of approximately 292 screws in our analysis (296 ASC, 294 HSD), which was determined by a biostatistician at an academic institution. Screw accuracy and skive was analyzed using preoperative CT and intraoperative three-dimensional (3D) fluoroscopy. Among 590 planned robotically inserted pedicle screws (296 ASC, 294 HSD), 245 ASC screws (82.8%) and 283 HSD screws (96.3%) were successfully inserted (p < 0.05). Skive events occurred in 4/283 (1.4%) HSD screws and 15/245 (6.2%) ASC screws (p < 0.05). HSD screws showed better accuracy in the axial and sagittal planes, being closer to planned trajectories in all directions except cranial deviation (p < 0.05). Additionally, HSD had a significantly lower time per screw (1.9 ± 1.0 min) compared to ASC (3.2 ± 2.0 min, p < 0.001). No adverse clinical effects were observed. The HSD technique showed significant improvements in time and screw accuracy compared to ASC. Biplanar fluoroscopy and 3D imaging resulted in significantly lower radiation exposure and time compared to ASC. These significant findings in the HSD group may be attributed to the lower occurrence of malpositioned screws, leading to a decrease in the need for second authentication. This represents a notable iterative improvement of the RNA platform.

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.

Robotics and navigation in spine surgery: A narrative review

Introduction

In recent decades, there has been a rising trend of spinal surgical interventional techniques, especially Minimally Invasive Spine Surgery (MIS), to improve the quality of life in an effective and safe manner. However, MIS techniques tend to be difficult to adapt and are associated with an increased risk of radiation exposure. This led to the development of 'computer-assisted surgery' in 1983, which integrated CT images into spinal procedures evolving into the present day robotic-assisted spine surgery. The authors aim to review the development of spine surgeries and provide an overview of the benefits offered. It includes all the comparative studies available to date.

Methods

The manuscript has been prepared as per "SANRA-a scale for the quality assessment of narrative review articles". The authors searched Pubmed, Embase, and Scopus using the terms "(((((Robotics) OR (Navigation)) OR (computer assisted)) OR (3D navigation)) OR (Freehand)) OR (O-Arm)) AND (spine surgery)" and 68 articles were included for analysis excluding review articles, meta-analyses, or systematic literature.

Results

The authors noted that 49 out of 68 studies showed increased precision of pedicle screw insertion, 10 out of 19 studies show decreased radiation exposure, 13 studies noted decreased operative time, 4 out of 8 studies showed reduced hospital stay and significant reduction in rates of infections, neurological deficits, the need for revision surgeries, and rates of radiological ASD, with computer-assisted techniques.

Conclusion

Computer-assisted surgeries have better accuracy of pedicle screw insertion, decreased blood loss and operative time, reduced radiation exposure, improved functional outcomes, and lesser complications.

[Effectiveness of robot-guided percutaneous fixation and decompression via small incision for advanced thoracolumbar metastases]

Objective

To evaluate the effectiveness of robot-guided percutaneous fixation and decompression via small incision in treatment of advanced thoracolumbar metastases.

Methods

A clinical data of 57 patients with advanced thoracolumbar metastases admitted between June 2017 and January 2021 and met the selection criteria was retrospectively analyzed. Among them, 26 cases were treated with robot-guided percutaneous fixation and decompression via small incision (robot-guided group) and 31 cases with traditional open surgery (traditional group). There was no significant difference in gender, age, body mass index, lesion segment, primary tumor site, and preoperative Tokuhashi score, Tomita score, Spinal Instability Neoplastic Score (SINS), visual analogue scale (VAS) score, Oswestry disability index (ODI), Karnofsky score, and Frankel grading between groups ( P>0.05). The operation time, hospital stays, hospital expenses, intraoperative blood loss, postoperative drainage volume, duration of intensive care unit (ICU) stay, blood transfusion, complications, and survival time were compared. The pedicle screw placement accuracy was evaluated according to the Gertzbein-Robbins grading by CT within 4 days after operation. The pain, function, and quality of life were evaluated by VAS score, ODI, Karnofsky score, and Frankel grading.

Results

During operation, 257 and 316 screws were implanted in the robot-guided group and the traditional group, respectively; and there was no significant difference in pedicle screw placement accuracy between groups ( P>0.05). Compared with the traditional group, the operation time, hospital stays, duration of ICU stay were significantly shorter, and intraoperative blood loss and postoperative drainage volume were significantly lesser in the robot-guided group ( P<0.05). There was no significant difference in hospital expenses, blood transfusion rate, and complications between groups ( P>0.05). All patients were followed up 8-32 months (mean, 14 months). There was no significant difference in VAS scores between groups at 7 days after operation ( P>0.05), but the robot-guided group was superior to the traditional group at 1 and 3 months after operation ( P<0.05). The postoperative ODI change was significantly better in the robot-guided group than in the traditional group ( P<0.05), and there was no significant difference in the postoperative Karnofsky score change and Frankel grading change when compared to the traditional group ( P>0.05). Median overall survival time was 13 months [95% CI (10.858, 15.142) months] in the robot-guided group and 15 months [95% CI (13.349, 16.651) months] in the traditional group, with no significant difference between groups ( χ 2=0.561, P=0.454) .

Conclusion

Compared with traditional open surgery, the robot-guided percutaneous fixation and decompression via small incision can reduce operation time, hospital stays, intraoperative blood loss, blood transfusion, and complications in treatment of advanced thoracolumbar metastases.

The use of robot-assisted surgery for the unstable traumatic spine: A retrospective cohort study

Background

Robotic assistance has been shown to increase instrumentation placement accuracy in open and minimally invasive spinal fusion. These gains have been achieved without increases in operative times, blood loss, or hospitalization duration. However, most work has been done in the degenerative population and little is known of the utility of robotic assistance when applied to spinal trauma. This is largely due to the uncertainty stemming from the disruption of normal anatomy by the traumatic injury. Since the robot depends upon registration for instrumentation guidance according to the fiducials it uses, trauma can introduce unique challenges. The present study sought to evaluate the safety and efficacy of robotic assistance in a consecutive cohort of spine trauma patients.

Methods

All patients with Thoracolumbar Injury Classification and Severity Scale (TLICS) >4 who underwent robot-assisted spinal fusion using the Globus ExcelsiusGPS at a single tertiary care center for trauma between 2020 and 2022 were identified. Demographic, clinical, and surgical data were collected and analyzed; the primary endpoints were operative time, fluoroscopy time, estimated blood loss, postoperative complications, admission time, and 90-day readmission rate. The paired t-test was used to compare differences between mean values when looking at the number of surgical levels.

Results

Forty-two patients undergoing robot-assisted spinal surgery were included (mean age 61.3±17.1 year; 47% female. Patients were stratified by the number of operative levels, 2 (n = 10), 3-4 (n = 11), 5 to 6 (n = 13), or >6 (n = 8). There appeared to be a positive correlation between number of levels instrumented and odds of postoperative complications, admission duration, fluoroscopy time, and estimated blood loss. There were no instances of screw malposition or breach.

Conclusions

This initial experience suggests robotic assistance can be safely employed in the spine trauma population. Additional experiences in larger patient populations are necessary to delineate those traumatic pathologies most amenable to robotic assistance.

Opportunities and challenges for robotic-assisted spine surgery: feasible indications for the MAZOR™ X Stealth Edition

The clinical use of new technologies has several potential benefits including improved accuracy, precision and efficiency. Robotic assistance during surgery is one such technology and it is making its way into neurosurgical operating rooms with increasing frequency. The Mazor X™ Stealth robot was first used in Canada for spine surgery during July 2022 and since then multiple indications for its use have been identified and evaluated.The outcomes of robot-assisted spine surgery have been promising but there is a lack of supportive studies which would serve to refine indications, establish protocols and disseminate practical information. To begin filling this gap we gathered a list of use-cases for which this new technology was successfully employed. In combination with cases that took place in our Centre, we reviewed the existing reported uses of the Mazor X™ Stealth for spine surgery and recorded their respective procedures and outcomes for patients and surgeons.Through this review we identified common uses of the Mazor X™ Stealth for spine surgery. Usage of robotic-assisted technology had a net positive impact on outcomes for patients as well as surgeons (e.g., improved accuracy of pedicle screw placement and reduced radiation burden). This curation remains a dynamic list, and we foresee the addition of more indications in the future.Clinical Relevance- Enabling the use of technology including robotic systems has the potential to attract clinical research expertise, reduce resource usage and to improve surgical outcomes.

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.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Technological Advances in Spine Surgery: Navigation, Robotics, and Augmented Reality

Accurate screw placement is critical to avoid vascular or neurologic complications during spine surgery and to maximize fixation for fusion and deformity correction. Computer-assisted navigation, robotic-guided spine surgery, and augmented reality surgical navigation are currently available technologies that have been developed to improve screw placement accuracy. The advent of multiple generations of new technologies within the past 3 decades has presented surgeons with a diverse array of choices when it comes to pedicle screw placement. Considerations for patient safety and optimal outcomes must be paramount when selecting a technology.

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.

[Computer-assisted procedures in orthopedics and trauma surgery-Where do we stand?]

Computer-assisted procedures are becoming increasingly more relevant in orthopedics and trauma surgery. The data situation on these systems has improved in recent years but still has a low level of evidence. In particular, data on short-term or medium-term results on the use of these procedures are currently available. These could show that improved precision and reproducibility of the surgical procedures can be achieved by the use of computer-assisted procedures. Nevertheless, there is still no recommendation in the current guidelines for routine use.

Accuracy of end-on fluoroscopy in predicting implant position in relation to the vertebral canal in dogs

Objective

To evaluate the accuracy of end-on fluoroscopy in predicting implant position in relation to the vertebral canal in the canine thoracolumbar vertebral column.

Study design

In vitro imaging and anatomic study.

Animals

Canine cadaveric thoracolumbar vertebral columns (n = 5).

Methods

Smooth Steinmann pins were inserted bicortically into the thoracolumbar vertebral columns between T10 and L7 using recommended insertion angles. Penetration of the spinal canal was not strictly avoided. After pin placement, end-on fluoroscopy images were obtained of each pin. Pin position was subsequently assessed by four evaluators and determined to either being out of the vertebral canal or in, with the latter being additionally divided into partially or completely penetrating the canal. To assess potential differences in modalities, fluoroscopy images were gray-scale inverted and evaluated again later by the same four individuals. Correct identification of pin position in relationship to the vertebral canal was assessed for both fluoroscopy images. Anatomic preparation of the spines was used for verification of pin position in relation to the spinal canal. Some data from this study were compared with historical data on accuracy using orthogonal radiography and computed tomography (CT).

Results

Overall sensitivity and specificity of F to detect vertebral canal penetration was 98.8 % (95% confidence interval (CI), 96.0–99.6) and 98.0% (95% CI, 77.0–99.9), respectively. For Fi, sensitivity and specificity were 97.0% (95% CI, 91.5–99.0) and 98.5% (95% CI, 81.5–99.9) respectively. F exceeded Fi for the sensitivity of detecting pin penetration into the vertebral canal (p = 0.039) but specificities were not different (p = 0.585). When comparing to historical data, the overall accuracy of end-on fluoroscopy (F) and inverted fluoroscopy (Fi) was statistical better than conventional radiographic assessment (p < 0.001).

Conclusion

End-on fluoroscopy is a highly accurate method for the assessment of pin position in relationship to the thoracolumbar spinal canal in cadaveric dogs.

Clinical significance

End-on fluoroscopy, with or without inversion, is accurate in identifying vertebral canal violation by bicortically placed Steinmann pins. When CT is not available, end-on fluoroscopy might be a valuable imaging modality to determine pin position in the canine vertebral column.

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.

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.

[Effectiveness of modified orthopedic robot-assisted percutaneous kyphoplasty in treatment of osteoporotic vertebral compression fracture]

Objective

To evaluate the effectiveness of orthopedic robot with modified tracer fixation (short for modified orthopedic robot) assisted percutaneous kyphoplasty (PKP) in treatment of single-segment osteoporotic vertebral compression fracture (OVCF).

Methods

The clinical data of 155 patients with single-segment OVCF who were admitted between December 2017 and January 2021 and met the selection criteria was retrospectively analyzed. According to the operation methods, the patients were divided into robot group (87 cases, PKP assisted by modified orthopedic robot) and C-arm group (68 cases, PKP assisted by C-arm X-ray fluoroscopy). There was no significant difference in gender, age, body mass index, T value of bone mineral density, therapeutic segment, grade of vertebral compression fracture, and preoperative visual analogue scale (VAS) score, midline vertebral height, and Cobb angle between the two groups (P>0.05). The effectiveness evaluation indexes of the two groups were collected and compared. The clinical evaluation indexes included the establishment time of working channel, dose of intraoperative fluoroscopy, the amount of injected cement, VAS score before and after operation, and the occurrence of complications. The imaging evaluation indexes included the degree of puncture deviation, the degree of bone cement diffusion, the leakage of bone cement, the midline vertebral height and the Cobb angle before and after operation.

Results

The establishment time of working channel in robot group was significantly shorter than that in C-arm group, and the dose of intraoperative fluoroscopy was significantly larger than that in C-arm group (P<0.001). There was no significant difference in the amount of injected cement between the two groups (t=1.149, P=0.252). The patients in two groups were followed up 10-14 months (mean, 12 months). Except that the intraoperative VAS score of the robot group was significantly better than that of the C-arm group (P<0.05), there was no significant difference between the two groups at other time points (P>0.05). No severe complication such as infection, spinal cord or nerve injury, and pulmonary embolism occurred in the two groups. Five cases (5.7%) in robot group and 7 cases (10.2%) in C-arm group had adjacent segment fracture, and the difference in incidence of adjacent segment fracture between the two groups was not significant (χ2=1.105, P=0.293). Compared with C-arm group, the deviation of puncture and the diffusion of bone cement at 1 day after operation, the midline vertebral height and Cobb angle at 1 month after operation and last follow-up were significantly better in robot group (P<0.05). Eight cases (9.1%) in the robot group and 16 cases (23.5%) in the C-arm group had cement leakage, and the incidence of cement leakage in the robot group was significantly lower than that in the C-arm group (χ2=5.993, P=0.014). There was no intraspinal leakage in the two groups.

Conclusion

Compared with traditional PKP assisted by C-arm X-ray fluoroscopy, modified orthopedic robot-assisted PKP in the treatment of single-segment OVCF can significantly reduce intraoperative pain, shorten the establishment time of working channel, and improve the satisfaction of patients with operation. It has great advantages in reducing the deviation of puncture and improving the diffusion of bone cement.

A Hybrid 3D-2D Image Registration Framework for Pedicle Screw Trajectory Registration between Intraoperative X-ray Image and Preoperative CT Image

Pedicle screw insertion is considered a complex surgery among Orthopaedics surgeons. Exclusively to prevent postoperative complications associated with pedicle screw insertion, various types of image intensity registration-based navigation systems have been developed. These systems are computation-intensive, have a small capture range and have local maxima issues. On the other hand, deep learning-based techniques lack registration generalizability and have data dependency. To overcome these limitations, a patient-specific hybrid 3D-2D registration principled framework was designed to map a pedicle screw trajectory between intraoperative X-ray image and preoperative CT image. An anatomical landmark-based 3D-2D Iterative Control Point (ICP) registration was performed to register a pedicular marker pose between the X-ray images and axial preoperative CT images. The registration framework was clinically validated by generating projection images possessing an optimal match with intraoperative X-ray images at the corresponding control point registration. The effectiveness of the registered trajectory was evaluated in terms of displacement and directional errors after reprojecting its position on 2D radiographic planes. The mean Euclidean distances for the Head and Tail end of the reprojected trajectory from the actual trajectory in the AP and lateral planes were shown to be 0.6–0.8 mm and 0.5–1.6 mm, respectively. Similarly, the corresponding mean directional errors were found to be 4.90 and 20. The mean trajectory length difference between the actual and registered trajectory was shown to be 2.67 mm. The approximate time required in the intraoperative environment to axially map the marker position for a single vertebra was found to be 3 min. Utilizing the markerless registration techniques, the designed framework functions like a screw navigation tool, and assures the quality of surgery being performed by limiting the need of postoperative CT.

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.

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.

Comanipulation Robotic Platform for Spine Surgery with Exteroceptive Visual Coupling: Development and Experimentation

In this paper, a novel surgical robotic platform intended to assist surgeons in cervical spine surgery is presented. The purpose of this surgery is to treat cervical spine instabilities. The surgical procedure requires drilling into specific region of the vertebrae in order to attach spinal implants and ensure a normal spacing between each vertebra. In this context, the proposed robotic platform allows to control and restrict surgeon's movements to a specific drilling direction set by the surgeon. The current platform is composed of a collaborative robot with 7 DoF equipped with a drilling tool and directly comanipulated by the surgeon. A motion capture system, as an exteroceptive sensor device, provides the robot controller with the movement data of the vertebra to be drilled. Robot Operating System (ROS) framework is used to enable real-time communication between the collaborative robot and the visual exteroceptive device. In addition, an implemented compliance control program allows to enhance the safety aspect of the robotic platform. Indeed, the collaborative robot follow the patient's movements while constraining the tool movements to an optimal trajectory as well as a limited drilling depth selected by the surgeon. The robot's elbow movements are also restricted by exploiting the null-space in order to avoid collisions with other equipment or medical team members. Experimental drilling trials have been performed by an orthopedic surgeon to validate the usefulness and different functionalities of the developed robotic platform, and provide that a collaborative robot can comply with spine surgery procedure.

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.

Robotic-guided placement of cervical pedicle screws: feasibility and accuracy

INTRODUCTION

It has been shown that pedicle screw instrumentation in the cervical spine has superior biomechanical pullout strength and stability. However, due to the complex and variable anatomy of the cervical pedicles and the risk of catastrophic complications, cervical pedicle screw placement is not widely utilized.

STUDY DESIGN

A retrospective, consecutive patient review.

OBJECTIVE

To review and report our experience with robotic guided cervical pedicle screw placement.

METHODS

We retrospectively reviewed preoperative and postoperative CT scans of 12 consecutive patients who underwent cervical pedicle screw fixation with robotic guidance. Screw placement and deviation from the preoperative plan were assessed using the robotic system's planning software by fusing the preoperative CT (with the planned cervical pedicle screws) to the post-op CT. This process was carried out by manually aligning the anatomical landmarks on the two CTs. Once a satisfactory fusion was achieved, the software's measurement tool was used manually to compare the planned vs. actual screw placements in the axial, sagittal and coronal planes within the instrumented pedicle in a resolution of 0.1 mm. Medical charts were reviewed for technical issues and intra-operative complications.

RESULTS

Eighty-eight cervical pedicle screws were reviewed in 12 patients; mean age = 65 years, M:F = 2:1, and mean BMI = 27.99. No intra-operative complications related to the cervical pedicle screw placement were reported. Robotic guidance was successful in all 88 screws: eight in C2, 14 in C3, 16 in each of C4 and C5, 19 in C6, and 15 at C7. There were 14 pedicle screw breaches (15.9%); all were medial, less than 1 mm, and with no clinical consequences. In the axial plane, the screws deviated from the preoperative plan by 1.32 ± 1.17 mm and in the sagittal plane by 1.27 ± 1.00 mm. In the trajectory view, the overall deviation was 2.20 ± 1.17 mm. Although differences were observed in screw deviation from the pre-op plan between the right and left sides, they were not statistically significant (p > 0.05).

CONCLUSION

This study indicates that robotic-guided cervical pedicle screw placement is feasible and safe. The medial breaches did not result in any clinical consequences.

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.