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Srinivasa V, Thirugnanam B, Pai Kanhangad M, Soni A, Kashyap A, Vidyadhara A, Rao SK. Flattening the learning curve - Early experience of robotic-assisted pedicle screw placement in spine surgery. J Orthop 2024; 57:49-54. [PMID: 38973970 PMCID: PMC11225720 DOI: 10.1016/j.jor.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 06/12/2024] [Indexed: 07/09/2024] Open
Abstract
Aims and objectives To determine accuracy of pedicle screws placed by freehand, fluoroscopy-assistance and robotic-assistance with intraoperative image acquisition, and determine the presence of learning curve in robotic spine surgery in a prospective single centre study. Materials and methods In a prospective study, a total of 1120 pedicle screws were placed in Freehand group (n = 175), 1250 screws were placed in fluoroscopy-assisted group (n = 172), and 1225 screws were inserted in Robotic-assisted group(n = 180). Surgical parameters and screw accuracy were analyzed between the three groups. The preoperative plan was overlapped with post operative O-arm scan to determine if the screws were executed as planned. Results The frequency of clinically acceptable screw placement (Gertzbein and Robbins grade A, B) in the Freehand, Fluoroscopy-assisted, and Robotic-assisted groups were 97.7 %, 98.6 %, and 99.34 % respectively. Higher pedicle screw accuracy, and lower blood loss were seen with robotic assistance. There was no significant difference in these parameters between surgeries commencing before and after 2 p.m. We found no statistically significant differences between the planned and executed screw trajectories in robotic assisted group irrespective of surgical experience. Conclusion The third-generation robotic-assisted pedicle screw placement system, used in conjunction with intraoperative 3D O-arm imaging, consistently lowered blood loss and increased accuracy of pedicle screw placement in the thoracolumbar spine. It also has easy adaptability into spine practice with minimal learning curve.
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Affiliation(s)
| | | | - Madhava Pai Kanhangad
- Manipal Robotic Spine Fellow, Manipal Comprehensive Spine Care Center, Manipal Hospital, Bangalore, India
- , Department of Orthopaedics, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Abhishek Soni
- , Manipal Comprehensive Spine Care Center, Manipal Hospital, Bangalore, India
| | - Anjana Kashyap
- Spine Anesthesia Fellow, Manipal Comprehensive Spine Care Center, Manipal Hospital, Bangalore, India
- , Department of Anesthesiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
| | | | - Sharath K. Rao
- , Department of Orthopaedics, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
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Al-Naseem AO, Al-Muhannadi A, Ramadhan M, Alfadhli A, Marwan Y, Shafafy R, Abd-El-Barr MM. Robot-assisted pedicle screw insertion versus navigation-based and freehand techniques for posterior spinal fusion in scoliosis: a systematic review and meta-analysis. Spine Deform 2024; 12:1203-1215. [PMID: 38619784 PMCID: PMC11343815 DOI: 10.1007/s43390-024-00879-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Yousef Marwan
- Department of Surgery, College of Medicine, Health Sciences Centre, Kuwait University, Kuwait City, Kuwait.
| | - Roozbeh Shafafy
- Division of Surgery & Interventional Science, University College London, London, UK.
- Department of Spinal Surgery, Royal National Orthopaedic Hospital NHS Foundation Trust, Stanmore, UK.
| | - Muhammad M Abd-El-Barr
- Department of Neurosurgery, Division of Spine, Duke University Medical Centre, Durham, USA.
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于 洋, 吴 兵, 宋 凯, 宋 科, 迟 鹏, 刘 昊, 王 征. [Preliminary comparative study of spinal robot-assisted pedicle screw placement using different surgical approaches]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2024; 38:923-928. [PMID: 39175312 PMCID: PMC11335597 DOI: 10.7507/1002-1892.202404112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/19/2024] [Indexed: 08/24/2024]
Abstract
Objective To compare the effectiveness of spinal robot-assisted pedicle screw placement through different surgical approaches and to guide the clinical selection of appropriate robot-assisted surgical approaches. Methods The clinical data of 14 patients with thoracolumbar vertebral diseases who met the selection criteria between January 2023 and August 2023 were retrospectively analyzed, and all of them underwent pedicle screw placement under assistant of the Mazor X spinal surgery robot through different surgical approaches. The patients were divided into posterior median approach (PMA) group ( n=6) and intermuscular approach (IMA) group ( n=8) according to the surgical approaches, and there was no significant difference in age, gender, body mass index, disease type, and fixed segment between the two groups ( P>0.05). The operation time, intraoperative blood loss, screw-related complications, and reoperation rate were recorded and compared between the two groups; the inclination angle of the screw, the distance between the screw and the midline, and the caudal inclination angle of the screw were measured based on X-ray films at immediate after operation. Results There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). There was no screw-related complication such as nerve injury in both groups, and no patients underwent secondary surgery. At immediate after operation, the inclination angle of the screw, the distance between the screw and the midline, and the caudal inclination angle of the screw in the IMA group were significantly greater than those in the PMA group ( P<0.05). Conclusion There are differences in the position and inclination angle of screws placed with robot-assisted surgery through different surgical approaches, which may be due to the obstruction of the screw path by soft tissues such as skin and muscles. When using spinal robot-assisted surgery, selecting the appropriate surgical approach for different diseases can make the treatment more reasonable and effective.
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Affiliation(s)
- 洋 于
- 中国人民解放军总医院第四医学中心骨科医学部(北京 100071)Department of Orthopedics, Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100071, P. R. China
| | - 兵 吴
- 中国人民解放军总医院第四医学中心骨科医学部(北京 100071)Department of Orthopedics, Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100071, P. R. China
| | - 凯 宋
- 中国人民解放军总医院第四医学中心骨科医学部(北京 100071)Department of Orthopedics, Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100071, P. R. China
| | - 科冉 宋
- 中国人民解放军总医院第四医学中心骨科医学部(北京 100071)Department of Orthopedics, Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100071, P. R. China
| | - 鹏飞 迟
- 中国人民解放军总医院第四医学中心骨科医学部(北京 100071)Department of Orthopedics, Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100071, P. R. China
| | - 昊明 刘
- 中国人民解放军总医院第四医学中心骨科医学部(北京 100071)Department of Orthopedics, Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100071, P. R. China
| | - 征 王
- 中国人民解放军总医院第四医学中心骨科医学部(北京 100071)Department of Orthopedics, Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100071, P. R. China
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Komolafe TE, Zhou L, Zhao W, Guo J, Li Z, Fan Z, Komolafe BF, Wei W, Samuel OW. Advancing robot-guided techniques in lumbar spine surgery: a systematic review and meta-analysis. Expert Rev Med Devices 2024; 21:765-779. [PMID: 39007890 DOI: 10.1080/17434440.2024.2378080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/04/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Lumbar spine surgery is a crucial intervention for addressing spinal injuries or conditions affecting the spine, often involving lumbar fusion through pedicle screw (PS) insertion. The precision of PS placement is pivotal in orthopedic surgery. This systematic review compares the accuracy of robot-guided (RG) surgery with free-hand fluoroscopy-guided (FFG), free-hand without fluoroscopy-guided (FHG), and computed tomography image-guided (CTG) techniques for PS insertion. METHODS A systematic search of various databases from 1 January 2013 to 30 December 2023 was conducted following PRISMA guidelines. Primary outcomes, including PS insertion accuracy and breach rate, were analyzed using a random-effects model. Risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS The overall accuracy of PS insertion using RG, based on 37 studies involving 3,837 patients and 22,117 PS, is 97.9%, with a breach rate of 0.021. RG demonstrated superior accuracy compared to FHG and CTG, with breach rates of 3.4 and 0.015 respectively for RG versus FHG, and 3.8 and 0.026 for RG versus CTG. Additionally, RG was associated with reduced mean estimated blood loss compared to CTG, indicating improved safety. CONCLUSIONS The RG is associated with enhanced accuracy of PS insertion and reduced breach rates over other methods. However, additional randomized controlled trials comparing these modalities are needed for further validation. PROSPERO REGISTRATION CRD42023483997.
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Affiliation(s)
| | - Liang Zhou
- Department of Radiology, Jiading District Central Hospital Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China
- Biomedical Engineering Fusion Laboratory, Jiangning Hospital Affiliated with Nanjing Medical University, Nanjing, China
| | - Wenlong Zhao
- Collaborative Research Center, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Jiachen Guo
- Collaborative Research Center, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Zongdao Li
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Zhiping Fan
- Collaborative Research Center, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Blessing Funmi Komolafe
- School of International Education, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Wang Wei
- Department of Orthopaedic, School of Medicine, Renji Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China
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Gautam D, Vivekanandan S, Mazur MD. Robotic Spine Surgery: Systematic Review of Common Error Types and Best Practices. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01264. [PMID: 39037253 DOI: 10.1227/ons.0000000000001293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/04/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Robotic systems have emerged as a significant advancement in the field of spine surgery. They offer improved accuracy in pedicle screw placement and reduce intraoperative complications, hospital length of stay, blood loss, and radiation exposure. As the use of robotics in spine surgery continues to grow, it becomes imperative to understand common errors and challenges associated with this new and promising technology. Although the reported accuracy of robot-assisted pedicle screw placement is very high, the current literature does not capture near misses or incidental procedural errors that might have been managed during surgery or did not alter treatment of patients. We evaluated errors that occur during robot-assisted pedicle screw insertion and identify best practices to minimize their occurrence. METHODS In this systematic review, we characterized 3 types of errors encountered during robot-assisted pedicle screw insertion-registration errors, skiving, and interference errors-that have been reported in the literature. RESULTS Our search yielded 13 relevant studies reporting robot-assisted screw errors. Nine studies reported registration errors, with 60% of failed screws in those studies caused by registration issues. Seven studies highlighted skiving errors; 26.8% of the failed screws in those studies were caused by skiving. Finally, interference errors were reported in 4 studies, making up 19.5% of failed screws. CONCLUSION On the basis of these findings, we suggest best practices-including close attention to preoperative planning, patient positioning, image registration, and equipment selection-to minimize the occurrence of these errors. Awareness of how errors occur may increase the safety of this technology.
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Affiliation(s)
- Diwas Gautam
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Sheela Vivekanandan
- Neurological Institute, University of Pittsburgh Medical Center, Hershey, Pennsylvania, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Antonacci CL, Zeng F, Block A, Davey A, Makanji H. Robotic-assisted spine surgery-a narrative review. JOURNAL OF SPINE SURGERY (HONG KONG) 2024; 10:305-312. [PMID: 38974496 PMCID: PMC11224789 DOI: 10.21037/jss-23-40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 03/11/2024] [Indexed: 07/09/2024]
Abstract
Background and Objective Emerging technologies have increasingly been adopted in spine surgery in the attempt to increase precision and improve outcomes. Robotic assistance is an area of significant interest, with proposed benefits including increased accuracy, decreased complication rates, and decreased radiation exposure. The purpose of this review is to provide an overview of the currently available robotic assistance systems and their associated outcomes and limitations. Methods A review of national databases was performed using key terms "robotic", "spine", and "surgery" for literature from 2014 to 2023. Studies that aimed to describe the utilities of endoscopic surgeries, associated outcomes, limitations, and future directions were included. Studies that were not in English were excluded. Key Content and Findings This review includes a brief overview of the history of robotic spine surgery as well as its clinical outcomes, limitations, and future directions. Conclusions Robotic-assisted spine surgery has seen increasing use in the attempt to increase precision and improve outcomes and has been associated with increased accuracy in pedicle screw placement and decreased complication rates. Barriers to its adoption include a significant learning curve, possibly longer operative cases, and significant associated costs. As robotic assistance continues to become increasingly popular in spine surgery, it is critical for surgeons to understand the technology available and the associated outcomes to make informed decisions when considering which system to incorporate into their practice.
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Affiliation(s)
| | - Francine Zeng
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Andrew Block
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Annabelle Davey
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Heeren Makanji
- Orthopedic Associates of Hartford, Hartford Hospital Bone and Joint Institute, Hartford, CT, USA
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7
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Chen XQ, Liu J, Wang T, Zhao Z, Li Y, Cheng XY, Li W. Comparative analysis of short-term efficacy between robot-assisted retrograde drilling and arthroscopic microfracture for osteochondral lesions of the talus. Front Surg 2024; 11:1404513. [PMID: 38859999 PMCID: PMC11163064 DOI: 10.3389/fsurg.2024.1404513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/14/2024] [Indexed: 06/12/2024] Open
Abstract
Objective To investigate the short-term clinical efficacy of robot-assisted retrograde drilling and arthroscopic microfracture for osteochondral lesions of the talus (OCLT). Methods This study was divided into two groups: experimental group: robot-assisted retrograde drilling group; control group: arthroscopic microfracture group. A total of 6 OCLT patients who were treated with robot navigation-assisted retrograde drilling and 10 OCLT patients who were treated with arthroscopic microfracture between October 2020 and October 2021 were retrospectively analyzed. There were 11 males and five females, with a mean age of 36 years. The patients were followed up for 6-12 months to compare the changes in the OCLT lesion area by magnetic resonance imaging (MRI), visual analogue scale/score (VAS) and American Orthopedic Foot and Ankle Society score (AOFAS) before and after surgery. Results All 16 patients were followed up for an average of 8 months, and no complications such as joint infection, nerve injury, or active bleeding occurred during the follow-up period. Only one patient suffered discomfort involving transient postoperative pain in the operative area, but did not experience long-term numbness or chronic pain. Postoperative MRI revealed that none of the patients had severe signs of osteonecrosis, osteolysis or cystic changes of the talus, with lesion areas smaller than those before surgery. The difference was statistically significant (P < 0.01). The patients in the experimental group showed a more significant improvement in the last 3 months than in the first 3 months of the follow-up period. At the last follow-up, the VAS score was 3 points in the experimental group and 2.2 points in the control group, and the AOFAS score was 88.6 points in the experimental group and 88 points in the control group, all of which were significantly higher than those before operation, and the differences were statistically significant, but there was no statistically significant difference between the groups. Conclusion Both robot navigation-assisted retrograde drilling and arthroscopic microfracture for bone marrow stimulation (BMS) to treat OCLT in all patients obtained satisfactory effects in the short term. In addition, the follow-up revealed that with excellent efficacy and few complications, robot navigation-assisted retrograde drilling was safe and minimally invasive, and greatly reduced operative time. Consequently, robot navigation-assisted retrograde drilling for BMS was a safe and effective procedure for the treatment of OCLT.
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Affiliation(s)
| | | | | | | | | | | | - Wencui Li
- Hand and Foot Surgery Department, Shenzhen Second People's Hospital, The First Hospital Affiliated to Shenzhen University, Shenzhen, China
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Werthmann NJ, Gum JL, Nagata K, Djurasovic M, Glassman SD, Owens RK, Crawford CH, Carreon LY. Comparison of No Tap (two-step) and tapping robotic assisted cortical bone trajectory screw insertion. J Robot Surg 2024; 18:204. [PMID: 38714574 DOI: 10.1007/s11701-024-01890-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/28/2024] [Indexed: 05/10/2024]
Abstract
Workflow for cortical bone trajectory (CBT) screws includes tapping line-to-line or under tapping by 1 mm. We describe a non-tapping, two-step workflow for CBT screw placement, and compare the safety profile and time savings to the Tap (three-step) workflow. Patients undergoing robotic assisted 1-3 level posterior fusion with CBT screws for degenerative conditions were identified and separated into either a No-Tap or Tap workflow. Number of total screws, screw-related complications, estimated blood loss, operative time, robotic time, and return to the operating room were collected and analyzed. There were 91 cases (458 screws) in the No-Tap and 88 cases (466 screws) in the Tap groups, with no difference in demographics, revision status, ASA grade, approach, number of levels fused or diagnosis between cohorts. Total robotic time was lower in the No-Tap (26.7 min) versus the Tap group (30.3 min, p = 0.053). There was no difference in the number of malpositioned screws identified intraoperatively (10 vs 6, p = 0.427), screws converted to freehand (3 vs 3, p = 0.699), or screws abandoned (3 vs 2, p = 1.000). No pedicle/pars fracture or fixation failure was seen in the No-Tap cohort and one in the Tap cohort (p = 1.00). No patients in either cohort were returned to OR for malpositioned screws. This study showed that the No-Tap screw insertion workflow for robot-assisted CBT reduces robotic time without increasing complications.
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Affiliation(s)
- Neil J Werthmann
- University of Louisville School of Medicine, 500 South Preston Street. Instructional Building, Room 305, Louisville, KY, 40202, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
| | - Kosei Nagata
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
| | - Mladen Djurasovic
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, KY, 40202, USA
| | - R Kirk Owens
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
| | - Charles H Crawford
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, KY, 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite #900, Louisville, KY, 40202, USA.
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9
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Wang P, Xin Y, Zhou S, Duan S, Bai D, Li B, Xu W. Efficacy of computer-assisted robotic based clinical training program for spinal oncology education on pedicle screw placement. J Robot Surg 2024; 18:150. [PMID: 38564025 PMCID: PMC10987351 DOI: 10.1007/s11701-023-01804-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 04/04/2024]
Abstract
Pedicle screw placement (PSP) is the fundamental surgical technique that requires high accuracy for novice orthopedists studying spinal oncology education. Therefore, we set forth to establish a computer-assisted robotic navigation training program for novice spinal oncology education. Novice orthopedists were involved in this study to evaluate the feasibility and safety of the computer-assisted robotic navigation (CARN) training program. In this research, trainees were randomly taught by the CARN training program and the traditional training program. We prospectively collected the clinical data of patients with spinal tumors from 1st May 2021 to 1st March 2022. The ability of PSP was evaluated by cumulative sum (CUSUM) analysis, learning curve, and accuracy of pedicle screws. The patients included in both groups had similar baseline characteristics. In the CUSUM analysis of the learning curve for accurate PSP, the turning point in the CARN group was lower than that in the traditional group (70th vs. 92nd pedicle screw). The LC-CUSUM test indicated competency for PSP at the 121st pedicle screw in the CARN group and the 138th pedicle screw in the traditional group. The accuracy of PSP was also significantly higher in the CARN group than in the traditional group (88.17% and 79.55%, P = 0.03 < 0.05). Furthermore, no major complications occurred in either group. We first described CARN in spinal oncology education and indicated the CARN training program as a novel, efficient and safe training program for surgeons.
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Affiliation(s)
- Pengru Wang
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Yingye Xin
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Shangbin Zhou
- Department of Orthopedics, Naval Medical Center, Naval Military Medical University, Shanghai, China
| | - Shujie Duan
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Danyang Bai
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Bo Li
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
| | - Wei Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China.
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10
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Wilson JP, Fontenot L, Stewart C, Kumbhare D, Guthikonda B, Hoang S. Image-Guided Navigation in Spine Surgery: From Historical Developments to Future Perspectives. J Clin Med 2024; 13:2036. [PMID: 38610801 PMCID: PMC11012660 DOI: 10.3390/jcm13072036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/08/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Intraoperative navigation is critical during spine surgery to ensure accurate instrumentation placement. From the early era of fluoroscopy to the current advancement in robotics, spinal navigation has continued to evolve. By understanding the variations in system protocols and their respective usage in the operating room, the surgeon can use and maximize the potential of various image guidance options more effectively. At the same time, maintaining navigation accuracy throughout the procedure is of the utmost importance, which can be confirmed intraoperatively by using an internal fiducial marker, as demonstrated herein. This technology can reduce the need for revision surgeries, minimize postoperative complications, and enhance the overall efficiency of operating rooms.
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Affiliation(s)
| | | | | | | | | | - Stanley Hoang
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA; (J.P.W.J.); (L.F.); (C.S.); (D.K.); (B.G.)
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11
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Nagata K, Gum JL, Brown M, Daniels C, Hines B, Carreon LY, Glassman SD. Risk Factors for Medial Breach During Robotic-Assisted Cortical Bone Trajectory Screw Insertion. World Neurosurg 2024; 184:e546-e553. [PMID: 38320649 DOI: 10.1016/j.wneu.2024.01.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/08/2024]
Abstract
OBJECTIVE We describe the incidence of, and identify the risk factors for, a medial breach of the pedicle wall during robotic-assisted cortical bone trajectory (RA-CBT) screw insertion. METHODS We analyzed a consecutive series of adult patients who underwent RA-CBT screw placement from January 2019 to July 2022. To assess the pedicle wall medial breach, postoperative computed tomography (CT) images were analyzed. Patient demographic data and screw data were compared between patients with and without a medial breach. The Hounsfield units (HUs) on the L1 midvertebral axial CT scan was used to evaluate bone quality. RESULTS Of 784 CBT screws in 145 patients, 30 (3.8%) had a medial breach in 23 patients (15.9%). One screw was grade 2, and the others were grade 1. Patients with a medial breach had a lower HU value compared with the patients without a medial breach (123.3 vs. 150.5; P = 0.027). A medial breach was more common in the right than left side (5.5% vs. 2.0%; P = 0.014). More than one half of the screws with a medial breach were found in the upper instrumented vertebra (UIV) compared with the middle construct or lowest instrumented vertebra (6.7% vs. 1.3% vs. 2.7%; P = 0.003). Binary logistic regression showed that low HU values, right-sided screw placement, and UIV were associated with a medial breach. No patients returned to the operating room for screw malposition. No differences were found in the clinical outcomes between patients with and without a medial breach. CONCLUSIONS The incidence of pedicle wall medial breach was 3.8% of RA-CBT screws in the postoperative CT images. A low HU value measured in the L1 axial image, right-sided screw placement, and UIV were associated with an increased risk of medial breach for RA-CBT screw placement.
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Affiliation(s)
- Kosei Nagata
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA; Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Morgan Brown
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | | | - Bren Hines
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, Louisville, Kentucky, USA.
| | - Steven D Glassman
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA; Norton Leatherman Spine Center, Louisville, Kentucky, USA
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Faldini C, Barile F, Viroli G, Manzetti M, Ialuna M, Traversari M, Paolucci A, Rinaldi A, D'Antonio G, Ruffilli A. Freehand power-assisted pedicle screw placement in scoliotic patients: results on 5522 consecutive pedicle screws. Musculoskelet Surg 2024; 108:63-68. [PMID: 35943693 PMCID: PMC10881638 DOI: 10.1007/s12306-022-00754-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
Pedicle screws is the current gold standard in spine surgery, achieving a solid tricolumnar fixation which is unreachable by wires and hooks. The freehand technique is the most widely adopted for pedicle screws placing. While freehand technique has been classically performed with manual tools, there has been a recent trend toward the use of power tools. However, placing a pedicle screw remains a technically demanding procedure with significant risk of complications. The aim of this article is to retrospectively evaluate safety and accuracy of free-hand power-assisted pedicle screw placement in a cohort of patients who underwent correction and fusion surgery for scoliosis (both idiopathic and non-idiopathic) in our department. A retrospective review of all patients with scoliosis who underwent surgery and received a postoperative CT scan in our department in a 9-year period was undertaken. Screw density, number and location of pedicle screws were measured using pre and postoperative full-length standing and lateral supine side-bending radiographs. Then, postoperative CT scan was used to assess the accuracy of screw placement according to Gertzbein-Robbins scale. Malpositioned screws were divided according to their displacement direction. Finally, intra and postoperative neurological complications and the need for revision of misplaced screws were recorded. A total of 205 patients were included, with a follow-up of 64.9 ± 38.67 months. All constructs were high density (average density 1.97 ± 0.04), and the average number of fusion levels was 13.72 ± 1.97. A total of 5522 screws were placed: 5308 (96.12%) were grade A, 141 (2.5%) grade B, 73 (1.32%) grade C. Neither grade D nor grade E trajectories were found. The absolute accuracy (grade A) rate was 96.12% (5308/5522) and the effective accuracy (within the safe zone, grade A + B) was 98.6% (5449/5522). Of the 73 misplaced screws (grade C), 59 were lateral (80.80%), 8 anterior (10.95%) and 6 medial (8.22%); 58 were in convexity, while 15 were in concavity (the difference was not statistically significant, p = 0.33). Intraoperatively, neither neurological nor vascular complications were recorded. Postoperatively, 4 screws needed revision (0.072% of the total): Power-assisted pedicle screw placing may be a safe an accurate technique in the scoliosis surgery, both of idiopathic and non-idiopathic etiology. Further, and higher quality, research is necessary in order to better assess the results of this relatively emerging technique.
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Affiliation(s)
- C Faldini
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - F Barile
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - G Viroli
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - M Manzetti
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy.
| | - M Ialuna
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - M Traversari
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - A Paolucci
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - A Rinaldi
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - G D'Antonio
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - A Ruffilli
- IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
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13
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Kann MR, Ruiz-Cardozo MA, Brehm S, Bui T, Joseph K, Barot K, Trevino G, Carey-Ewend A, Singh SP, De La Paz M, Hanafy A, Olufawo M, Patel RP, Yahanda AT, Perdomo-Pantoja A, Jauregui JJ, Cadieux M, Pennicooke B, Molina CA. Utilization of Augmented Reality Head-Mounted Display for the Surgical Management of Thoracolumbar Spinal Trauma. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:281. [PMID: 38399568 PMCID: PMC10890598 DOI: 10.3390/medicina60020281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Augmented reality head-mounted display (AR-HMD) is a novel technology that provides surgeons with a real-time CT-guided 3-dimensional recapitulation of a patient's spinal anatomy. In this case series, we explore the use of AR-HMD alongside more traditional robotic assistance in surgical spine trauma cases to determine their effect on operative costs and perioperative outcomes. Materials and Methods: We retrospectively reviewed trauma patients who underwent pedicle screw placement surgery guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between 1 January 2021 and 31 December 2022. Outcome distributions were compared using the Mann-Whitney U test. Results: The AR cohort (n = 9) had a mean age of 66 years, BMI of 29.4 kg/m2, Charlson Comorbidity Index (CCI) of 4.1, and Surgical Invasiveness Index (SII) of 8.8. In total, 77 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 378 mL, 0.78 units transfused, 398 min spent in the operating room, and a 20-day LOS. The robotic cohort (n = 13) had a mean age of 56 years, BMI of 27.1 kg/m2, CCI of 3.8, and SII of 14.2. In total, 128 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 432 mL, 0.46 units transfused units used, 331 min spent in the operating room, and a 10.4-day LOS. No significant difference was found between the two cohorts in any outcome metrics. Conclusions: Although the need to address urgent spinal conditions poses a significant challenge to the implementation of innovative technologies in spine surgery, this study represents an initial effort to show that AR-HMD can yield comparable outcomes to traditional robotic surgical techniques. Moreover, it highlights the potential for AR-HMD to be readily integrated into Level 1 trauma centers without requiring extensive modifications or adjustments.
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Affiliation(s)
- Michael Ryan Kann
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Miguel A. Ruiz-Cardozo
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Samuel Brehm
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Tim Bui
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Karan Joseph
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Karma Barot
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Gabriel Trevino
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Abigail Carey-Ewend
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Som P. Singh
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Matthew De La Paz
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ahmed Hanafy
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Michael Olufawo
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Rujvee P. Patel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Alexander T. Yahanda
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Alexander Perdomo-Pantoja
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Julio J. Jauregui
- Department of Orthopedic Surgery, University of Maryland Medical System, Baltimore, MD 21201, USA
| | - Magalie Cadieux
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Brenton Pennicooke
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Camilo A. Molina
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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14
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Ito M, Ueno J, Torii Y, Iinuma M, Yoshida A, Tomochika K, Hideshima T, Niki H, Akazawa T. Utility of a Navigated High-Speed Drill in Robotic-Assisted Screw Placement for Spine Surgery. Cureus 2024; 16:e52779. [PMID: 38389634 PMCID: PMC10882251 DOI: 10.7759/cureus.52779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Purpose To elucidate the utility of a navigated high-speed drill used after the version upgrade in surgeries assisted by a spinal robotics system. Methods The subjects were 166 patients who underwent screw placement using a spinal robotics system between April 2021 to July 2023. A significant change during the study was the introduction of a navigated high-speed drill in 80 post-upgrade cases, aimed at improving drilling accuracy. Screw accuracy was analyzed using the Gertzbein and Robbins classification on postoperative CT scans. Screws placed before (pre-upgrade group: 718 screws in 86 cases) and after the system upgrade (post-upgrade group: 747 screws in 80 cases) were compared in terms of perfect accuracy and deviation rates. Results There were no significant differences in demographics or surgical details between the two groups. No significant differences were observed in the overall perfect accuracy rate and deviation rate (2.4% pre-upgrade vs. 2.0% post-upgrade) between the two groups. For the percutaneous pedicle screw (PPS), the perfect accuracy rate was significantly higher, and the deviation rate was significantly lower in the post-upgrade group (26.1% pre-upgrade vs. 4.4% post-upgrade). Notably, the post-upgrade group achieved 100% perfect accuracy and 0% deviation for the cortical bone trajectory screw (CBT) technique. Conclusions The introduction of the navigated high-speed drill did not significantly alter the overall perfect accuracy or deviation rates for robotic-assisted screw placement. However, its use did demonstrate improved outcomes in specific techniques such as PPS and CBT, indicating its potential value in addressing skiving in robotic-assisted minimally invasive surgeries.
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Affiliation(s)
- Makoto Ito
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Jun Ueno
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Yoshiaki Torii
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Masahiro Iinuma
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Atsuhiro Yoshida
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Ken Tomochika
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Takahiro Hideshima
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Hisateru Niki
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Tsutomu Akazawa
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, JPN
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15
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Bai H, Wang R, Dai Y, Xue Y. Optimizing milling parameters based on full factorial experiment and backpropagation artificial neural network of lamina milling temperature prediction model. Technol Health Care 2024; 32:201-214. [PMID: 37302049 DOI: 10.3233/thc-220812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Milling operations of laminae in spinal surgery generate high temperatures, which can lead to thermal injury and osteonecrosis and affect the biomechanical effects of implants, ultimately leading to surgical failure. OBJECTIVE In this paper, a backpropagation artificial neural network (Bp-ANN) temperature prediction model was developed based on full factorial experimental data of laminae milling to optimize the milling motion parameters and to improve the safety of robot-assisted spine surgery. METHODS A full factorial experiment design were used to analyze the parameters affecting the milling temperature of laminae. The experimental matrixes were established by collecting the corresponding cutter temperature Tc and bone surface temperature Tb for the milling depth, feed speed and different bone densities. The Bp-ANN lamina milling temperature prediction model was constructed from experiment data. RESULTS Increasing milling depth increases bone surface and cutter temperature. Increasing feed speed had little effect on cutter temperature, but decreased bone surface temperature. Increasing bone density of laminae increased cutter temperature. The Bp-ANN temperature prediction model had best training results in the 10th epoch, and there is no overfitting (training set R= 0.99661, validation set R= 0.85003, testing set R= 0.90421, all temperature data set R= 0.93807). The goodness of fit R of Bp-ANN was close to 1, indicating that the predicted temperature was in good agreement with the experiment measurements. CONCLUSION This study can help spinal surgery-assisted robot to select appropriate motion parameters at different density bones to improve lamina milling safety.
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Affiliation(s)
- He Bai
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Rui Wang
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yu Dai
- Institute of Robotics and Automatic Information System, Tianjin Key Laboratory of Intelligent Robotics, College of Artificial Intelligence, Nankai University, Tianjin, China
| | - Yuan Xue
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China
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16
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Vardiman AB, Wallace DJ, Booher GA, Toossi N, Bucklen BS. Decreasing the Pedicle Screw Misplacement Rate in the Thoracic Spine With Robot-guided Navigation. Clin Spine Surg 2023; 36:431-437. [PMID: 37348067 PMCID: PMC10681281 DOI: 10.1097/bsd.0000000000001474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/17/2023] [Indexed: 06/24/2023]
Abstract
STUDY DESIGN A retrospective chart review. OBJECTIVE The aim of this study was to evaluate the screw accuracy of thoracic pedicle screws placed with a robot-guided navigation system. SUMMARY OF BACKGROUND DATA Thoracic pedicles are smaller in diameter than lumbar pedicles, making pedicle screw placement difficult. Misplaced pedicle screws may present complications including decreased construct stability, and increased risks of neurological deficits and blood vessel perforation. There is a dearth of knowledge on thoracic pedicle screw accuracy placed with a robot. MATERIALS AND METHODS A retrospective analysis of the robot-assisted placement of thoracic pedicle screws was performed. Preoperative and postoperative computed tomography (CT) scans of the implanted thoracic screws were collected to assess screw placement accuracy, pedicle breadth, and placement deviations. A CT-based Gertzbein and Robbins System was used to classify pedicle screw accuracy in 2 mm increments. A custom image overlay software was used to determine the deviations between the preoperatively planned trajectory of pedicle screws and final placement at screw entry (tail), and tip in addition to the angular deviation. RESULTS Seventy-five thoracic pedicle screws were implanted by navigated robotic guidance in 17 patients, only 1.3% (1/75) were repositioned intraoperatively. Average patient age and body mass index were 57.5 years and 25.9 kg/m 2 , respectively, with 52.9% female patients. Surgery diagnoses were degenerative disk disease (47.1%) and adjacent segment disease (17.6%). There were zero complications, with no returns to the operating room. According to the CT-based Gertzbein and Robbins pedicle screw breach classification system, 93.3% (70/75) screws were grade A or B, 6.6% (5/75) were grade C, and 0% were grade D or E. The average deviation from the preoperative plan to actual final placement was 1.8±1.3 mm for the screw tip, 1.6±0.9 mm for the tail, and 2.1±1.5 degrees of angulation. CONCLUSIONS The current investigation found a 93.3% accuracy of pedicle screw placement in the thoracic spine. Navigated robot assistance is a useful system for placing screws in the smaller pedicles of the thoracic spine. LEVEL OF EVIDENCE Level III-retrospective nonexperimental study.
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Affiliation(s)
- Arnold B. Vardiman
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - David J. Wallace
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Grant A. Booher
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Nader Toossi
- Musculoskeletal Education and Research Center (MERC), Audubon, PA
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17
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Patel RV, Yearley AG, Isaac H, Chalif EJ, Chalif JI, Zaidi HA. Advances and Evolving Challenges in Spinal Deformity Surgery. J Clin Med 2023; 12:6386. [PMID: 37835030 PMCID: PMC10573859 DOI: 10.3390/jcm12196386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes. METHODS We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases. RESULTS Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed. CONCLUSIONS The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients.
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Affiliation(s)
- Ruchit V. Patel
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Alexander G. Yearley
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Hannah Isaac
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
| | - Eric J. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Joshua I. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Hasan A. Zaidi
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
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18
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Lauretti C, Cordella F, Saltarelli I, Morfino R, Zollo L. A semi-autonomous robot control based on bone layer transition detection for a safe pedicle tapping. Int J Comput Assist Radiol Surg 2023; 18:1745-1755. [PMID: 36877289 DOI: 10.1007/s11548-023-02855-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/13/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE Automatic robotic platforms for robot-aided spinal surgery are mostly employed for drilling the pedicle screw path and do not adapt the tool rotational speed depending on the variation of the bone density. This feature is highly desirable in control strategies for robot-aided pedicle tapping, which may result in a poor quality thread if the surgical tool speed is not adequately tuned depending on the bone density to be threaded. Therefore, the objective of this paper is to propose a novel semi-autonomous control for robot-aided pedicle tapping that is able to (i) identify the bone layer transition, (ii) adapt the tool velocity depending on the detected bone layer density and (iii) stop the tool tip before propulsion of the bone boundaries. METHODS The proposed semi-autonomous control for pedicle tapping consists of: (i) a hybrid position/force control loop that allows the surgeon to move the surgical tool along a pre-planned axis and (ii) a velocity control loop that allows him/her to finely tune the tool rotational speed by modulating the tool-bone interaction force along the same axis. The velocity control loop integrates also a bone layer transition detection algorithm that dynamically limits the tool velocity depending on the bone layer density. The approach was tested on the Kuka LWR4+ provided with an actuated surgical tapper which was used to tap a wood specimen simulating the bone layer density characteristics and bovine bones. RESULTS A normalized maximum time delay in the bone layer transition detection of 0.25 was achieved by the experiments. A success rate of [Formula: see text] was achieved for all the tested tool velocities. The proposed control achieved a maximum steady-state error of 0.4 rpm. CONCLUSION The study demonstrated high capability of the proposed approach to i) promptly detect transition among the specimen layers and ii) adapt the tool velocities depending on the detected layers.
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Affiliation(s)
- Clemente Lauretti
- Unit of Advanced Robotics and Human-Centred Technologies (CREO lab), Università Campus Bio-Medico, Via Alvaro del Portillo 21, 00128, Roma, Italy.
| | - Francesca Cordella
- Unit of Advanced Robotics and Human-Centred Technologies (CREO lab), Università Campus Bio-Medico, Via Alvaro del Portillo 21, 00128, Roma, Italy
| | - Ilenia Saltarelli
- Unit of Advanced Robotics and Human-Centred Technologies (CREO lab), Università Campus Bio-Medico, Via Alvaro del Portillo 21, 00128, Roma, Italy
| | - Rosaura Morfino
- Unit of Advanced Robotics and Human-Centred Technologies (CREO lab), Università Campus Bio-Medico, Via Alvaro del Portillo 21, 00128, Roma, Italy
| | - Loredana Zollo
- Unit of Advanced Robotics and Human-Centred Technologies (CREO lab), Università Campus Bio-Medico, Via Alvaro del Portillo 21, 00128, Roma, Italy
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McIntosh MK, Christie S. Opportunities and challenges for robotic-assisted spine surgery: feasible indications for the MAZOR™ X Stealth Edition. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38082935 DOI: 10.1109/embc40787.2023.10340228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
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.
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Wang R, Bai H, Xia G, Zhou J, Dai Y, Xue Y. Identification of milling status based on vibration signals using artificial intelligence in robot-assisted cervical laminectomy. Eur J Med Res 2023; 28:203. [PMID: 37381061 DOI: 10.1186/s40001-023-01154-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 06/03/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND With advances in science and technology, the application of artificial intelligence in medicine has significantly progressed. The purpose of this study is to explore whether the k-nearest neighbors (KNN) machine learning method can identify three milling states based on vibration signals: cancellous bone (CCB), ventral cortical bone (VCB), and penetration (PT) in robot-assisted cervical laminectomy. METHODS Cervical laminectomies were performed on the cervical segments of eight pigs using a robot. First, the bilateral dorsal cortical bone and part of the CCB were milled with a 5 mm blade and then the bilateral laminae were milled to penetration with a 2 mm blade. During the milling process using the 2 mm blade, the vibration signals were collected by the acceleration sensor, and the harmonic components were extracted using fast Fourier transform. The feature vectors were constructed with vibration signal amplitudes of 0.5, 1.0, and 1.5 kHz and the KNN was then trained by the features vector to predict the milling states. RESULTS The amplitudes of the vibration signals between VCB and PT were statistically different at 0.5, 1.0, and 1.5 kHz (P < 0.05), and the amplitudes of the vibration signals between CCB and VCB were significantly different at 0.5 and 1.5 kHz (P < 0.05). The KNN recognition success rates for the CCB, VCB, and PT were 92%, 98%, and 100%, respectively. A total of 6% and 2% of the CCB cases were identified as VCB and PT, respectively; 2% of VCB cases were identified as PT. CONCLUSIONS The KNN can distinguish different milling states of a high-speed bur in robot-assisted cervical laminectomy based on vibration signals. This method is feasible for improving the safety of posterior cervical decompression surgery.
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Affiliation(s)
- Rui Wang
- Key Laboratory of Spine and Spinal Cord, Department of Orthopedic Surgery, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - He Bai
- Key Laboratory of Spine and Spinal Cord, Department of Orthopedic Surgery, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Guangming Xia
- Tianjin Key Laboratory of Intelligent Robotics, Institute of Robotics and Automatic Information System, College of Artificial Intelligence, Nankai University, 94 Weijin Road, Nankai District, Tianjin, 300071, China
| | - Jiaming Zhou
- Key Laboratory of Spine and Spinal Cord, Department of Orthopedic Surgery, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Yu Dai
- Tianjin Key Laboratory of Intelligent Robotics, Institute of Robotics and Automatic Information System, College of Artificial Intelligence, Nankai University, 94 Weijin Road, Nankai District, Tianjin, 300071, China.
| | - Yuan Xue
- Key Laboratory of Spine and Spinal Cord, Department of Orthopedic Surgery, Tianjin Medical University General Hospital, Tianjin, 300052, China.
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La Rocca G, Mazzucchi E, Pignotti F, Nasto LA, Galieri G, Rinaldi P, De Santis V, Pola E, Sabatino G. Navigated, percutaneous, three-step technique for lumbar and sacral screw placement: a novel, minimally invasive, and maximally safe strategy. J Orthop Traumatol 2023; 24:32. [PMID: 37386233 DOI: 10.1186/s10195-023-00696-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 04/02/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Minimally invasive spine surgery is a field of active and intense research. Image-guided percutaneous pedicle screw (PPS) placement is a valid alternative to the standard free-hand technique, thanks to technological advancements that provide potential improvement in accuracy and safety. Herein, we describe the clinical results of a surgical technique exploiting integration of neuronavigation and intraoperative neurophysiological monitoring (IONM) for minimally invasive PPS. MATERIALS AND METHODS An intraoperative-computed tomography (CT)-based neuronavigation system was combined with IONM in a three-step technique for PPS. Clinical and radiological data were collected to evaluate the safety and efficacy of the procedure. The accuracy of PPS placement was classified according to the Gertzbein-Robbins scale. RESULTS A total of 230 screws were placed in 49 patients. Only two screws were misplaced (0.8%); nevertheless, no clinical sign of radiculopathy was experienced by these patients. The majority of the screws (221, 96.1%) were classified as grade A according to Gertzbein-Robbins scale, seven screws were classified as grade B, one screw was classified as grade D, and one last screw was classified as grade E. CONCLUSIONS The proposed three-step, navigated, percutaneous procedure offers a safe and accurate alternative to traditional techniques for lumbar and sacral pedicle screw placement. Level of Evidence Level 3. Trial registration Not applicable.
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Affiliation(s)
- Giuseppe La Rocca
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Edoardo Mazzucchi
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Fabrizio Pignotti
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Luigi Aurelio Nasto
- Department of Orthopaedics and Spine Surgery, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università Della Campania Luigi Vanvitelli, Via De Crecchio 4, 80138, Naples, Italy
| | - Gianluca Galieri
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | | | | | - Enrico Pola
- Department of Orthopaedics and Spine Surgery, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università Della Campania Luigi Vanvitelli, Via De Crecchio 4, 80138, Naples, Italy.
| | - Giovanni Sabatino
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Rome School of Medicine, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
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Lee NJ, Zuckerman SL, Buchanan IA, Boddapati V, Mathew J, Marciano G, Robertson D, Lakomkin N, Park PJ, Leung E, Lombardi JM, Lehman RA. Is There a Difference in Screw Accuracy, Robot Time Per Screw, Robot Abandonment, and Radiation Exposure Between the Mazor X and the Renaissance? A Propensity-Matched Analysis of 1179 Robot-Assisted Screws. Global Spine J 2023; 13:1286-1292. [PMID: 34235996 PMCID: PMC10416583 DOI: 10.1177/21925682211029867] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
STUDY DESIGN Prospective single-cohort analysis. OBJECTIVES To compare the outcomes/complications of 2 robotic systems for spine surgery. METHODS Adult patients (≥18-years-old) who underwent robot-assisted spine surgery from 2016-2019 were assessed. A propensity score matching (PSM) algorithm was used to match Mazor X to Renaissance cases. Preoperative CT scan for planning and an intraoperative O-arm for screw evaluation were preformed. Outcomes included screw accuracy, robot time/screw, robot abandonment, and radiation. Screw accuracy was measured using Vitrea Core software by 2 orthopedic surgeons. Screw breach was measured according to the Gertzbein/Robbins classification. RESULTS After PSA, a total of 65 patients (Renaissance: 22 vs. X: 43) were included. Patient/operative factors were similar between robot systems (P > .05). The pedicle screw accuracy was similar between robots (Renaissance: 1.1%% vs. X: 1.3%, P = .786); however, the S2AI screw breach rate was significantly lower for the X (Renaissance: 9.5% vs. X: 1.2%, P = .025). Robot time per screw was not statistically different (Renaissance: 4.6 minutes vs. X: 3.9 minutes, P = .246). The X was more reliable with an abandonment rate of 2.3% vs. Renaissance:22.7%, P = .007. Radiation exposure were not different between robot systems. Non-robot related complications including dural tear, loss of motor/sensory function, and blood transfusion were similar between robot systems. CONCLUSION This is the first comparative analyses of screw accuracy, robot time/screw, robot abandonment, and radiation exposure between the Mazor X and Renaissance systems. There are substantial improvements in the X robot, particularly in the perioperative planning processes, which likely contribute to the X's superiority in S2AI screw accuracy by nearly 8-fold and robot reliability by nearly 10-fold.
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Affiliation(s)
- Nathan J. Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Scott L. Zuckerman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ian A. Buchanan
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Justin Mathew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Gerard Marciano
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Djani Robertson
- Department of Orthopaedics, NYU Langone Health, New York, NY, USA
| | | | - Paul J. Park
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Eric Leung
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Joseph M. Lombardi
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ronald A. Lehman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
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Abstract
The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system. The authors reviewed the prospectively collected data on 196 adult patients who had pedicle screws implanted with robot-navigated assistance (RNA) using the Mazor X Stealth system between June 2019 and March 2022. Pedicle screws were implanted by one experienced spinal surgeon after completion of a learning period. The accuracy of pedicle screw placement was determined using intraoperative 3D fluoroscopy. A total of 1,123 pedicle screws were implanted: 1,001 screws (89%) were placed robotically, 63 (6%) were converted from robotic placement to a freehand technique, and 59 (5%) were planned to be implanted freehand. Of the robotically placed screws, 942 screws (94%) were determined to be Gertzbein and Robbins grade A with median deviation of 0.8 mm (interquartile range 0.4 to 1.6). Skive events were noted with 20 pedicle screws (1.8%). No adverse clinical sequelae were noted in the 90-day follow-up. The mean fluoroscopic exposure per screw was 4.9 seconds (SD 3.8). RNA is highly accurate and reliable, with a low rate of abandonment once mastered. No adverse clinical sequelae occurred after implanting a large series of pedicle screws using the latest generation of RNA. Understanding of patient-specific anatomical features and the real-time intraoperative identification of risk factors for suboptimal screw placement have the potential to improve accuracy further.
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Affiliation(s)
- Frederik Abel
- Department of Spine Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Fedan Avrumova
- Department of Spine Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Samuel N Goldman
- Department of Spine Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Celeste Abjornson
- Department of Spine Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Darren R Lebl
- Department of Spine Surgery, Hospital for Special Surgery, New York, New York, USA
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Welch N, Mota F, Birch C, Hutchinson L, Hedequist D. Robotics Coupled With Navigation for Pediatric Spine Surgery: Initial Intraoperative Experience With 162 Cases. J Pediatr Orthop 2023; 43:e337-e342. [PMID: 36952248 DOI: 10.1097/bpo.0000000000002381] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND This study assesses intraoperative efficacy, accuracy, and complications of pedicle screw placement using robotic-assisted navigation (RAN) in pediatric spine surgery. METHODS A retrospective review of patients who underwent spine deformity surgery using RAN at a single pediatric institution from 2019 to 2021 was conducted. Patient demographics, perioperative metrics, screw execution and accuracy, technical difficulties, and other outcomes were summarized. In cases with postoperative computed tomography scans, screws were classified using the Gertzbein and Robbins classification scale. Fisher exact tests were used to assess the relationship between procedural changes and lateral screw malposition. RESULTS One hundred sixty-two cases with an average patient age of 15.1 years (range, 4 to 31 y) were reviewed. The most common diagnosis was adolescent idiopathic scoliosis (n=80) with an average major curve of 65 degrees. Of 1467 screws attempted, 1461 were executed successfully (99.6%). All failures were in Type D pedicles and were lateral deviations recognized with routine intraoperative fluoroscopy. In cases with postoperative computed tomography imaging, 100% of screws (n=197) were placed with complete containment (Grade A). Remaining screws were graded as accurate by mirroring fluoroscopy and planned computer software positions. In 4% of cases, loss of registration was detected by a safety check before drilling at the planned level. There were no neurological deficits or returns to the operating room. Two changes occurred as part of the learning curve associated with this technique. (1) Adoption of a high-speed navigated drill: Change 1 (last 74 cases). (2) Drilling all pilot holes robotically first, then placing screws within the robotically established tracts to avoid motion and subsequent registration disruption: Change 2 (last 39 cases). Change 1 was less likely to result in screw malposition as no screws skived lateral with the technique ( P =0.03). Change 2 trended toward statistical significance for avoidance of screw malposition and loss of registration, as no loss of registration occurred after adopting this technique. CONCLUSION This study highlights the safety and screw accuracy associated with the use of RAN in pediatric patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nicole Welch
- Department of Orthopaedic Surgery, Boston Children's Hospital
| | - Frank Mota
- Department of Orthopaedic Surgery, Boston Children's Hospital
| | - Craig Birch
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | | | - Daniel Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
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Xie LZ, Wang QL, Zhang Q, He D, Tian W. Accuracies of various types of spinal robot in robot-assisted pedicle screw insertion: a Bayesian network meta-analysis. J Orthop Surg Res 2023; 18:243. [PMID: 36966314 PMCID: PMC10039560 DOI: 10.1186/s13018-023-03714-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
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.
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Affiliation(s)
- Lin-Zhen Xie
- Department of Spine Surgery, Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi-Long Wang
- Department of Spine Surgery, Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Zhang
- Department of Spine Surgery, Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Da He
- Department of Spine Surgery, Peking University Fourth School of Clinical Medicine, Beijing, China
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Tian
- Department of Spine Surgery, Peking University Fourth School of Clinical Medicine, Beijing, China.
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.
- Research Unit of Intelligent Orthopedics, Chinese Academy of Medical Sciences, Beijing, China.
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Use of a high-speed drill in robotics coupled with navigation for pediatric spine surgery. J Robot Surg 2023:10.1007/s11701-023-01534-w. [PMID: 36862349 DOI: 10.1007/s11701-023-01534-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/08/2023] [Indexed: 03/03/2023]
Abstract
With the increasing number of surgeries for pediatric spinal deformities, the aim has been to reduce the associated complications, such as those caused by screw malposition. This case series is an intra-operative experience with a new navigated high-speed revolution drill (Mazor Midas, Medtronic, Minneapolis, MN) for pediatric spinal deformity to assess accuracy and workflow. 88 patients, ranging from 2 to 29 years of age, were included who underwent posterior spinal fusion with the navigated high-speed drill. Diagnoses, Cobb angles, imaging, surgical time, complications, and total number of screws placed are described. Screw positioning was evaluated using fluoroscopy, plain radiography, and CT. Mean age was 15.4 years old. Diagnoses included 47 adolescent idiopathic scoliosis, 15 neuromuscular scoliosis, 8 spondylolisthesis, 4 congenital scoliosis, and 14 other. The mean Cobb angulation for scoliosis patients was 64° and the mean number of levels fused was 10. 81 patients had registration via intraoperative 3-D imaging and 7 had pre-operative CT scan to fluoroscopy registration. There were a total of 1559 screws with 925 placed robotically. 927 drill paths were drilled with the Mazor Midas. 926 out of 927 drill paths were accurate. The mean surgical time was 304 min with the mean robotic time being 46 min. This is the first intra-operative report to our knowledge documenting the experience with the Mazor Midas drill in pediatric spinal deformity showing decreased skiving potential, decreased torque when drilling, and lastly increased accuracy. Level of evidence: level III.
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Gajjar AA, Huy Dinh Le A, Swaroop Lavadi R, Boddeti U, Barpujari A, Agarwal N. Evolution of Robotics in Neurosurgery: A Historical Perspective. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Beyer RS, Nguyen A, Brown NJ, Gendreau JL, Hatter MJ, Pooladzandi O, Pham MH. Spinal robotics in cervical spine surgery: a systematic review with key concepts and technical considerations. J Neurosurg Spine 2023; 38:66-74. [PMID: 36087333 DOI: 10.3171/2022.7.spine22473] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/06/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Spinal robotics for thoracolumbar procedures, predominantly employed for the insertion of pedicle screws, is currently an emerging topic in the literature. The use of robotics in instrumentation of the cervical spine has not been broadly explored. In this review, the authors aimed to coherently synthesize the existing literature of intraoperative robotic use in the cervical spine and explore considerations for future directions and developments in cervical spinal robotics. METHODS A literature search in the Web of Science, Scopus, and PubMed databases was performed for the purpose of retrieving all articles reporting on cervical spine surgery with the use of robotics. For the purposes of this study, randomized controlled trials, nonrandomized controlled trials, retrospective case series, and individual case reports were included. The Newcastle-Ottawa Scale was utilized to assess risk of bias of the studies included in the review. To present and synthesize results, data were extracted from the included articles and analyzed using the PyMARE library for effect-size meta-analysis. RESULTS On careful review, 6 articles published between 2016 and 2022 met the inclusion/exclusion criteria, including 1 randomized controlled trial, 1 nonrandomized controlled trial, 2 case series, and 2 case reports. These studies featured a total of 110 patients meeting the inclusion criteria (mean age 53.9 years, range 29-77 years; 64.5% males). A total of 482 cervical screws were placed with the use of a surgical robot, which yielded an average screw deviation of 0.95 mm. Cervical pedicle screws were the primary screw type used, at a rate of 78.6%. According to the Gertzbein-Robbins classification, 97.7% of screws in this review achieved a clinically acceptable grade. The average duration of surgery, blood loss, and postoperative length of stay were all decreased in minimally invasive robotic surgery relative to open procedures. Only 1 (0.9%) postoperative complication was reported, which was a surgical site infection, and the mean length of follow-up was 2.7 months. No mortality was reported. CONCLUSIONS Robot-assisted cervical screw placement is associated with acceptable rates of clinical grading, operative time, blood loss, and postoperative complications-all of which are equal to or improved relative to the metrics seen in the conventional use of fluoroscopy or computer-assisted navigation for cervical screw placement.
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Affiliation(s)
- Ryan S Beyer
- 1Department of Neurological Surgery, University of California, Irvine, Orange
| | - Andrew Nguyen
- 2Department of Neurosurgery, UC San Diego School of Medicine, San Diego
| | - Nolan J Brown
- 1Department of Neurological Surgery, University of California, Irvine, Orange
| | - Julian L Gendreau
- 4Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Matthew J Hatter
- 1Department of Neurological Surgery, University of California, Irvine, Orange
| | - Omead Pooladzandi
- 3Department of Electrical and Computer Engineering, University of California, Los Angeles, California; and
| | - Martin H Pham
- 2Department of Neurosurgery, UC San Diego School of Medicine, San Diego
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Index Surgery Cost of Fluoroscopic Freehand Versus Robotic-Assisted Pedicle Screw Placement in Lumbar Instrumentation: An Age, Sex, and Approach-Matched Cohort Comparison. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202212000-00001. [PMID: 36732310 PMCID: PMC9722569 DOI: 10.5435/jaaosglobal-d-22-00137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/14/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Spine surgery costs are notoriously high, and there are already criticisms and concerns over the economic effects. There is no consensus on cost variation with robot-assisted spine fusion (rLF) compared with a manual fluoroscopic freehand (fLF) approach. This study looks to compare the early costs between the robotic method and the freehand method in lumbar spine fusion. METHODS rLFs by one spine surgeon were age, sex, and approach-matched to fLF procedures by another spine surgeon. Variable direct costs, readmissions, and revision surgeries within 90 days were reviewed and compared. RESULTS Thirty-nine rLFs were matched to 39 fLF procedures. No significant differences were observed in clinical outcomes. rLF had higher total encounter costs (P < 0.001) and day-of-surgery costs (P = 0.005). Increased costs were mostly because of increased supply cost (0.0183) and operating room time cost (P < 0.001). Linear regression showed a positive relationship with operating room time and cost in rLF (P < 0.001). CONCLUSION rLF is associated with a higher index surgery cost. The main factor driving increased cost is supply costs, with other variables too small in difference to make a notable financial effect. rLF will become more common, and other institutions may need to take a closer financial look at this more novel instrumentation before adoption.
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Nillahoot N, Pillai BM, Sharma B, Wilasrusmee C, Suthakorn J. Interactive 3D Force/Torque Parameter Acquisition and Correlation Identification during Primary Trocar Insertion in Laparoscopic Abdominal Surgery: 5 Cases. SENSORS (BASEL, SWITZERLAND) 2022; 22:8970. [PMID: 36433567 PMCID: PMC9698636 DOI: 10.3390/s22228970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 06/16/2023]
Abstract
Laparoscopic procedures have become indispensable in gastrointestinal surgery. As a minimally invasive process, it begins with primary trocar insertion. However, this step poses the threat of injuries to the gastrointestinal tract and blood vessels. As such, the comprehension of the insertion process is crucial to the development of robotic-assisted/automated surgeries. To sustain robotic development, this research aims to study the interactive force/torque (F/T) behavior between the trocar and the abdomen during the trocar insertion process. For force/torque (F/T) data acquisition, a trocar interfaced with a six-axis F/T sensor was used by surgeons for the insertion. The study was conducted during five abdominal hernia surgical cases in the Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University. The real-time F/T data were further processed and analyzed. The fluctuation in the force/torque (F/T) parameter was significant, with peak force ranging from 16.83 N to 61.86 N and peak torque ranging from 0.552 Nm to 1.76 Nm. The force parameter was observed to positively correlate with procedural time, while torque was found to be negatively correlated. Although during the process a surgeon applied force and torque in multiple axes, for a robotic system, the push and turn motion in a single axis was observed to be sufficient. For minimal tissue damage in less procedural time, a system with low push force and high torque was observed to be advantageous. These understandings will eventually benefit the development of computer-assisted or robotics technology to improve the outcome of the primary trocar insertion procedure.
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Affiliation(s)
- Nantida Nillahoot
- Department of Biomedical Engineering, Center for Biomedical and Robotics Technology (BART LAB), Faculty of Engineering, Mahidol University, Nakhon Pathom 73170, Thailand
| | - Branesh M. Pillai
- Department of Biomedical Engineering, Center for Biomedical and Robotics Technology (BART LAB), Faculty of Engineering, Mahidol University, Nakhon Pathom 73170, Thailand
| | - Bibhu Sharma
- Department of Biomedical Engineering, Center for Biomedical and Robotics Technology (BART LAB), Faculty of Engineering, Mahidol University, Nakhon Pathom 73170, Thailand
| | - Chumpon Wilasrusmee
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Jackrit Suthakorn
- Department of Biomedical Engineering, Center for Biomedical and Robotics Technology (BART LAB), Faculty of Engineering, Mahidol University, Nakhon Pathom 73170, Thailand
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Benech CA, Perez R, Benech F, Shirk T, Bucklen BS. A quantitative accuracy assessment of the use of a rigid robotic arm in navigated placement of 726 pedicle screws. BMC Surg 2022; 22:385. [DOI: 10.1186/s12893-022-01838-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/29/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Traditional minimally invasive fluoroscopy-based techniques for pedicle screw placement utilize guidance, which may require fluoroscopic shots. Computerized tomography (CT) navigation results in more accurate screw placement. Robotic surgery seeks to establish access and trajectory with greater accuracy.
Objective
This study evaluated the screw placement accuracy of a robotic platform.
Methods
Demographic data, preoperative/postoperative CT scans, and complication rates of 127 patients who underwent lumbosacral pedicle screw placement with minimally invasive navigated robotic guidance using preoperative CT were analyzed.
Results
On the GRS scale, 97.9% (711/726) of screws were graded A or B, 1.7% (12/726) of screws graded C, 0.4% (3/726) of screws graded D, and 0% graded E. Average offset from preoperative plan to final screw placement was 1.9 ± 1.5 mm from tip, 2.2 ± 1.4 mm from tail and 2.9 ± 2.3° of angulation.
Conclusions
Robotic-assisted surgery utilizing preoperative CT workflow with intraoperative fluoroscopy-based registration improves pedicle screw placement accuracy within a patient’s pedicles.
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Kim HJ, Yang JH, Chang DG, Lenke LG, Suh SW, Nam Y, Park SC, Suk SI. Adult Spinal Deformity: A Comprehensive Review of Current Advances and Future Directions. Asian Spine J 2022; 16:776-788. [PMID: 36274246 PMCID: PMC9633249 DOI: 10.31616/asj.2022.0376] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/30/2022] Open
Abstract
Owing to rapidly changing global demographics, adult spinal deformity (ASD) now accounts for a significant proportion of the Global Burden of Disease. Sagittal imbalance caused by age-related degenerative changes leads to back pain, neurological deficits, and deformity, which negatively affect the health-related quality of life (HRQoL) of patients. Along with the recognized regional, global, and sagittal spinopelvic parameters, poor paraspinal muscle quality has recently been acknowledged as a key determinant of the clinical outcomes of ASD. Although the Scoliosis Research Society-Schwab ASD classification system incorporates the radiological factors related to HRQoL, it cannot accurately predict the mechanical complications. With the rapid advances in surgical techniques, many surgical options for ASD have been developed, ranging from minimally invasive surgery to osteotomies. Therefore, structured patient-specific management is important in surgical decision-making, selecting the proper surgical technique, and to prevent serious complications in patients with ASD. Moreover, utilizing the latest technologies such as robotic-assisted surgery and machine learning, should help in minimizing the surgical risks and complications in the future.
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Affiliation(s)
- Hong Jin Kim
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Jae Hyuk Yang
- Department of Orthopaedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
- Corresponding author: Dong-Gune Chang Spine Center and Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea Tel: +82-2-950-1284, Fax: +82-2-950-1287, E-mail:
| | - Lawrence G. Lenke
- Department of Orthopaedic Surgery, The Daniel and Jane Och Spine Hospital, Columbia University, New York, NY, USA
| | - Seung Woo Suh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yunjin Nam
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sung Cheol Park
- Department of Orthopaedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Se-Il Suk
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
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Su YF, Tsai TH, Kuo KL, Wu CH, Tsai CY, Lu YM, Hwang SL, Lin PC, Lieu AS, Lin CL, Chang CH. Potential Roles of Teamwork and Unmet Needs on Surgical Learning Curves of Spinal Robotic Screw Placement. J Multidiscip Healthc 2022; 15:1971-1978. [PMID: 36105672 PMCID: PMC9464635 DOI: 10.2147/jmdh.s380707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022] Open
Abstract
Background The aim of this study was to investigate the learning curve of robotic spine surgery quantitatively with the well-described power law of practice. Methods Kaohsiung Medical University Hospital set up a robotic spine surgery team by the neurosurgery department in 2013 and the orthopedic department joined the well-established team in 2014. A total of consecutive 150 cases received robotic assisted spinal surgery. The 150 cases, with 841 transpedicular screws were enrolled into 3 groups: the first 50 cases performed by neurosurgeons, the first 50 cases by orthopedic surgeons, and 50 cases by neurosurgeons after the orthopedic surgeons joined the team. The time per screw and accuracy by each group and individual surgeon were analyzed. Results The time per screw for each group was 9.56 ± 4.19, 7.29 ± 3.64, and 8.74 ± 5.77 minutes, respectively, with p-value 0.0017. The accuracy was 99.6% (253/254), 99.5% (361/363), and 99.1% (222/224), respectively, with p-value 0.77. Though the first group took time significantly more on per screw placement but without significance on the nonlinear parallelism F-test. Analysis of 5 surgeons and their first 10 cases of short segment surgery showed the time per screw by each surgeon was 12.28 ± 5.21, 6.38 ± 1.54, 8.68 ± 3.10, 6.33 ± 1.90, and 6.73 ± 1.81 minutes. The first surgeon who initiated the robotic spine surgery took significantly more time per screw, and the nonlinear parallelism test also revealed only the first surgeon had a steeper learning curve. Conclusion This is the first study to demonstrate that differences of learning curves between individual surgeons and teams. The roles of teamwork and the unmet needs due to lack of active perception are discussed.
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Affiliation(s)
- Yu-Feng Su
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Division of Neurosurgery, Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Tai-Hsin Tsai
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Division of Neurosurgery, Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Keng-Liang Kuo
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chieh-Hsin Wu
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Yu Tsai
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yen-Mou Lu
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shiuh-Lin Hwang
- Department of Spinal Surgery, Chi-Hsien Spine Hospital, Kaohsiung, Taiwan
| | - Pei-Chen Lin
- Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ann-Shung Lieu
- Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chih-Lung Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hui Chang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Nguyen A, Beyer RS, Streetman DR, Brown NJ, Gendreau JL. Letter to the Editor Regarding “Accuracy of Pedicle Screw Placement and Four Other Clinical Outcomes of Robotic Guidance Technique versus Computer-Assisted Navigation in Thoracolumbar Surgery: A Meta-Analysis”. World Neurosurg 2022; 164:474-475. [DOI: 10.1016/j.wneu.2022.05.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 11/16/2022]
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Comparison of robot-assisted versus fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar spinal diseases: 2-year follow-up. J Robot Surg 2022; 17:473-485. [PMID: 35788970 DOI: 10.1007/s11701-022-01442-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
Abstract
This study was performed to prospectively compare the clinical and radiographic outcomes between robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA MIS-TLIF) and fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion (FA MIS-TLIF) in patients with degenerative lumbar spinal diseases. One hundred and twenty-three patients with lumbar degenerative diseases (lumbar spinal stenosis with instability and spondylolisthesis [degenerative spondylolisthesis or isthmic spondylolisthesis]) who underwent MIS-TLIF in our hospital were included in this study. Sixty-one patients underwent RA MIS-TLIF (Group A) and 62 patients underwent FA MIS-TLIF (Group B). Group A was further divided into Subgroup AI (46 single-level procedures) and Subgroup AII (15 double-level procedures). Group B was further divided into Subgroup BI (45 single-level procedures) and Subgroup BII (17 double-level procedures). The clinical outcome parameters were the visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, operative time, number of intraoperative fluoroscopies, blood loss, postoperative hospital stay, and postoperative complications. The radiographic change measures were the accuracy of screw placement, facet joint violation (FJV), fusion status, and change in disc height at the proximal adjacent segment at the 2-year follow-up. There were no significant differences in the VAS and ODI scores, blood loss, or postoperative hospital stay between Groups A and B (p > 0.05). The operative time was longer in Group A than B (p = 0.018). The operative time was longer in Subgroup AI than BI (p = 0.001). However, there was no significant difference between Subgroups AII and BII (p > 0.05). There was no significant difference in the number of intraoperative fluoroscopies for patients between Groups A and B (p > 0.05). Although the number of intraoperative fluoroscopies for patients was significantly higher in Subgroup AI than BI (p = 0.019), there was no significant difference between Subgroups AII and BII (p > 0.05). The number of intraoperative fluoroscopies for the surgeon was significantly lower in Group A than B (p < 0.001). For surgeons, the difference in the average number of intraoperative fluoroscopies between Subgroups AI and AII was 2.98, but that between Subgroups BI and BII was 10.73. In Group A, three guide pins exhibited drift and one patient developed a lateral wall violation by a pedicle screw. One pedicle screw perforated the anterior wall of the vertebral body and another caused an inner wall violation in Group B. The rate of a perfect screw position (grade A) was higher in Group A than B (p < 0.001). However, there was no significant difference in the proportion of clinically acceptable screws (grades A and B) between the two groups. The mean FJV grade was significantly higher in Group B than A (p < 0.001). During at 2-year postoperative follow-up, there was no significant difference in the fusion status between the two groups (p > 0.05); however, the decrease in disc height at the proximal adjacent segment was significantly less in Group A than B (p < 0.001). Robot-assisted percutaneous pedicle screw placement is a safer and more accurate alternative to conventional freehand fluoroscopy-assisted percutaneous pedicle screw insertion in MIS-TLIF.
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Abstract
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.
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Zhang X, Uneri A, Huang Y, Jones CK, Witham TF, Helm PA, Siewerdsen JH. Deformable 3D-2D image registration and analysis of global spinal alignment in long-length intraoperative spine imaging. Med Phys 2022; 49:5715-5727. [PMID: 35762028 DOI: 10.1002/mp.15819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Spinal deformation during surgical intervention (caused by patient positioning and/or correction of malalignment) confounds conventional navigation due to assumptions of rigid transformation. Moreover, the ability to accurately quantify spinal alignment in the operating room would provide assessment of the surgical product via metrics that correlate with clinical outcome. PURPOSE A method for deformable 3D-2D registration of preoperative CT to intraoperative long-length tomosynthesis images is reported for accurate 3D evaluation of device placement in the presence of spinal deformation and automated evaluation of global spinal alignment (GSA). METHODS Long-length tomosynthesis ("Long Film", LF) images were acquired using an O-arm™ imaging system (Medtronic, Minneapolis USA). A deformable 3D-2D patient registration was developed using multi-scale masking (proceeding from the full-length image to local subvolumes about each vertebra) to transform vertebral labels and planning information from preoperative CT to the LF images. Automatic measurement of GSA [Main Thoracic Kyphosis (MThK) and Lumbar Lordosis (LL)] was obtained using a spline fit to registered labels. The "Known-Component Registration" (KC-Reg) method for device registration was adapted to the multi-scale process for 3D device localization from orthogonal LF images. The multi-scale framework was evaluated using a deformable spine phantom in which pedicle screws were inserted, and deformations were induced over a range in LL ∼25-80°. Further validation was carried out in a cadaver study with implanted pedicle screws and a similar range of spinal deformation. The accuracy of patient and device registration was evaluated in terms of 3D translational error and target registration error (TRE), respectively, and the accuracy of automatic GSA measurements were compared to manual annotation. RESULTS Phantom studies demonstrated accurate registration via the multi-scale framework for all vertebral levels in both the neutral and deformed spine: median (interquartile range, IQR) patient registration error was 1.1 mm (0.7-1.9 mm IQR). Automatic measures of MThK and LL agreed with manual delineation within -1.1° ± 2.2° and 0.7° ± 2.0° (mean and standard deviation), respectively. Device registration error was 0.7 mm (0.4-1.0 mm IQR) at the screw tip and 0.9° (1.0°-1.5°) about the screw trajectory. Deformable 3D-2D registration significantly outperformed conventional rigid registration (p < 0.05), which exhibited device registration error of 2.1 mm (0.8-4.1 mm) and 4.1° (1.2°-9.5°). Cadaver studies verified performance under realistic conditions, demonstrating patient registration error of 1.6 mm (0.9-2.1 mm); MThK within -4.2° ± 6.8° and LL within 1.7° ± 3.5°; and device registration error of 0.8 mm (0.5-1.9 mm) and 0.7° (0.4°-1.2°) for the multi-scale deformable method, compared to 2.5 mm (1.0-7.9 mm) and 2.3° (1.6°-8.1°) for rigid registration (p < 0.05). CONCLUSION The deformable 3D-2D registration framework leverages long-length intraoperative imaging to achieve accurate patient and device registration over extended lengths of the spine (up to 64 cm) even with strong anatomical deformation. The method offers a new means for quantitative validation of spinal correction (intraoperative GSA measurement) and 3D verification of device placement in comparison to preoperative images and planning data. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Xiaoxuan Zhang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Ali Uneri
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Yixuan Huang
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Craig K Jones
- The Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD
| | | | - Jeffrey H Siewerdsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD.,The Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore, MD.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD
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Satin AM, Kisinde S, Lieberman IH. Robotic-Assisted Revision Spine Surgery. Int J Spine Surg 2022; 16:S14-S21. [PMID: 35710729 PMCID: PMC9808791 DOI: 10.14444/8272] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
As the surgical treatment of spinal degenerative conditions increases, more patients will ultimately require revision spine surgery. Revision spine surgery is more technically demanding than primary surgery with increased complication rates and variable clinical outcomes. The freehand placement of pedicle screws into a previously operated and/or fused level is more difficult due to the altered anatomic landmarks and/or bone loss. Additional benefit of robotic spine surgery is appreciated during such revision spine surgical procedures with unusual anatomic considerations, whereby the preoperative planning using robotic planning software and computer-assisted robotic guidance play a crucial role in assisting the surgeon to "visualize the invisible." We highlight 3 roles of this technology in 3 cases: planning strategic osteotomies, redrilling of screw holes, and insertion of revision screws in previously operated thoracolumbar and cervical spine regions.
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Affiliation(s)
| | | | - Isador H. Lieberman
- Texas Back Institute, Plano, Texas, USA, Isador H. Lieberman, Scoliosis and Spine Tumor Center, 6020 W Parker Rd, 200 Plano, TX 75093, USA;
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Satin AM, Kisinde S, Lieberman IH. Can Robotic Spine Surgery Become the Standard of Care? Int J Spine Surg 2022; 16:S44-S49. [PMID: 35764357 PMCID: PMC9808788 DOI: 10.14444/8276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Concerns regarding traditional techniques led to the development of robotic systems to facilitate the safe and accurate placement of pedicle screws. The Mazor Spine Assist was the first robotic spine surgery (RSS) platform to receive US Food and Drug Administration approval in 2004. Since then, there has been a steady increase in the application of RSS with several additional iterations of the Mazor platform and other competing systems receiving approval. As the indications, potential benefits, and utilization of RSS continue to expand, the question naturally arises as to whether RSS will eventually become the standard of care for spine surgery. In this article, we review the available evidence and experience with RSS and discuss the potential for RSS to become the medical standard of care.
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Affiliation(s)
| | | | - Isador H. Lieberman
- Texas Back Institute, Plano, Texas, USA, Isador H. Lieberman, Scoliosis and Spine Tumor Center, 6020 W Parker Rd, 200, Plano, TX 75093, USA;
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Su YF, Tsai TH, Lieu AS, Lin CL, Chang CH, Tsai CY, Su HY. Bone-Mounted Robotic System in Minimally Invasive Spinal Surgery for Osteoporosis Patients: Clinical and Radiological Outcomes. Clin Interv Aging 2022; 17:589-599. [PMID: 35497053 PMCID: PMC9041149 DOI: 10.2147/cia.s359538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/11/2022] [Indexed: 01/02/2023] Open
Abstract
Purpose Severe complications, including screw loosening events and low fusion rates, in spinal fusion surgery using the traditional open method are problematic. This retrospective study aimed to evaluate the rate of screw loosening and the clinical outcomes of bone-mounted miniature robot-assisted pedicle screw placement in patients treated for degenerative spinal disease. Patients and Methods Data were collected from the medical records of 118 patients (mean age, 69 years). Differences in clinical outcomes, including the Oswestry disability index, visual analog scale score, screw loosening rate, cage fusion rate, and complications, were evaluated among different bone mineral densities. Results The screw loosening and cage fusion rates for all patients, normal bone mineral density, osteopenia, and osteoporosis groups were 12%, 8.6%, 13.1%, and 14%, respectively, and 85.3%, 93%, 82.5%, and 81.4%, respectively. There was a higher screw loosening rate and a lower cage fusion rate in the osteopenia and osteoporosis groups than in the normal bone density group. The accuracy of the screw placement was 97.3%. There were no statistically significant differences in the Oswestry disability index and visual analog scale scores, and no major complications for dural tear or vascular or visceral injury. Conclusion Our study demonstrated an acceptable screw loosening rate in patients with osteoporosis compared to that in patients with normal bone mineral density. The robotic system resulted in accurate screw placement in patients with osteoporosis.
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Affiliation(s)
- Yu-Feng Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tai-Hsin Tsai
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ann-Shung Lieu
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Lung Lin
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hui Chang
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Yu Tsai
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Ph.D. Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University and National Health Research Institutes, Kaohsiung, Taiwan
- Post Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Correspondence: Cheng-Yu Tsai; Hui-Yuan Su, Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung, 80708, Taiwan, Tel +886-7-3215049, Fax +886-7-3215039, Email ;
| | - Hui-Yuan Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Cunningham BW, Brooks DM. Comparative Analysis of Optoelectronic Accuracy in the Laboratory Setting Versus Clinical Operative Environment: A Systematic Review. Global Spine J 2022; 12:59S-74S. [PMID: 35393881 PMCID: PMC8998481 DOI: 10.1177/21925682211035083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Bryan W. Cunningham
- Department of Orthopaedic Surgery, Musculoskeletal Research and Innovation Institute, MedStar Union Memorial Hospital, Baltimore, MD, USA
- Department of Orthopaedic Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Daina M. Brooks
- Department of Orthopaedic Surgery, Musculoskeletal Research and Innovation Institute, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Himstead AS, Shahrestani S, Brown NJ, Produturi G, Shlobin NA, Al Jammal O, Choi EH, Ransom SC, Daniel Diaz-Aguilar L, Sahyouni R, Abraham M, Pham MH. Bony fixation in the era of spinal robotics: A systematic review and meta-analysis. J Clin Neurosci 2022; 97:62-74. [DOI: 10.1016/j.jocn.2022.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/01/2022] [Accepted: 01/08/2022] [Indexed: 01/02/2023]
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Computed Tomography-Based Navigation System in Current Spine Surgery: A Narrative Review. Medicina (B Aires) 2022; 58:medicina58020241. [PMID: 35208565 PMCID: PMC8880580 DOI: 10.3390/medicina58020241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 02/03/2022] [Indexed: 11/26/2022] Open
Abstract
The number of spine surgeries using instrumentation has been increasing with recent advances in surgical techniques and spinal implants. Navigation systems have been attracting attention since the 1990s in order to perform spine surgeries safely and effectively, and they enable us to perform complex spine surgeries that have been difficult to perform in the past. Navigation systems are also contributing to the improvement of minimally invasive spine stabilization (MISt) surgery, which is becoming popular due to aging populations. Conventional navigation systems were based on reconstructions obtained by preoperative computed tomography (CT) images and did not always accurately reproduce the intraoperative patient positioning, which could lead to problems involving inaccurate positional information and time loss associated with registration. Since 2006, an intraoperative CT-based navigation system has been introduced as a solution to these problems, and it is now becoming the mainstay of navigated spine surgery. Here, we highlighted the use of intraoperative CT-based navigation systems in current spine surgery, as well as future issues and prospects.
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Yu CC, Carreon LY, Glassman SD, Brown ME, Daniels CL, Polly DW, Gum JL. Propensity-Matched Comparison of 90-Day Complications in Robotic-Assisted Versus Non-Robotic Assisted Lumbar Fusion. Spine (Phila Pa 1976) 2022; 47:195-200. [PMID: 34839310 DOI: 10.1097/brs.0000000000004288] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective single center propensity-matched observational cohort study that included patients who underwent 1- to 3-level lumbar fusion surgery for degenerative conditions. OBJECTIVE To compare 90-day complication rates between robotic-assisted and non-robotic-assisted lumbar spinal fusions in propensity-matched cohorts. SUMMARY OF BACKGROUND DATA A recent administrative database (PearlDiver) study reported increased 30-day complications with the utilization of robotic-assisted enabling technology. METHODS Of 146 robotic-assisted cases that met inclusion criteria, 114 were successfully propensity matched to 114 patients from 214 cases who had 1 to 3 level lumbar fusion without robotic assistance based on age, sex, body mass index, smoking status, American Society of Anesthesiologist grade, number of surgical levels, primary versus revision, and surgical approach (posterior-only or anterior-posterior). We excluded tumor, trauma, infection, or deformity cases. Outcomes included surgical and medical (major/minor) complications at intraoperative, immediately postoperative, 30- and 90-day postoperative intervals, including reoperations, and readmissions within 90 days. RESULTS All cause intraoperative complication rates were similar between non-robotic-assisted (5.3%) and robotic-assisted groups (10.5%, P = 0.366). Immediate postoperative medical complication rate was also similar between non-robotic-assisted (6.1%) and robotic-assisted groups (1.8%, P = 0.089). Thirty-day complication rates, 90-day complication rates, reoperation rates, and readmission rates showed no difference between non-robotic-assisted and robotic-assisted groups. There was no difference between return to OR for infection between the cohorts (non-robotic-assisted: 6 [5%] vs. robotic-assisted: 1 [0.8%], P = 0.119). There was however improved length of stay (LOS) in the robotic-assisted group compared with non-robotic-assisted group (2.5 vs. 3.17 days, P = 0.018). CONCLUSION In propensity-matched cohorts, patients undergoing 1- to 3-level robotic-assisted posterior lumbar fusion for degenerative conditions did not have increased 90-day complication rate, and had a shorter length of stay compared with non-robotic-assisted patients. There findings differ from a prior administrative database study as the robotic-assisted group in the current study had 0% return to OR for malpositioned screws and 0.8% return to OR for infection.Level of Evidence: 2.
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Affiliation(s)
| | | | | | | | | | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN
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Khan A, Soliman MAR, Lee NJ, Waqas M, Lombardi JM, Boddapati V, Levy LC, Mao JZ, Park PJ, Mathew J, Lehman RA, Mullin JP, Pollina J. CT-to-fluoroscopy registration versus scan-and-plan registration for robot-assisted insertion of lumbar pedicle screws. Neurosurg Focus 2022; 52:E8. [PMID: 34973678 DOI: 10.3171/2021.10.focus21506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/13/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Pedicle screw insertion for stabilization after lumbar fusion surgery is commonly performed by spine surgeons. With the advent of navigation technology, the accuracy of pedicle screw insertion has increased. Robotic guidance has revolutionized the placement of pedicle screws with 2 distinct radiographic registration methods, the scan-and-plan method and CT-to-fluoroscopy method. In this study, the authors aimed to compare the accuracy and safety of these methods. METHODS A retrospective chart review was conducted at 2 centers to obtain operative data for consecutive patients who underwent robot-assisted lumbar pedicle screw placement. The newest robotic platform (Mazor X Robotic System) was used in all cases. One center used the scan-and-plan registration method, and the other used CT-to-fluoroscopy for registration. Screw accuracy was determined by applying the Gertzbein-Robbins scale. Fluoroscopic exposure times were collected from radiology reports. RESULTS Overall, 268 patients underwent pedicle screw insertion, 126 patients with scan-and-plan registration and 142 with CT-to-fluoroscopy registration. In the scan-and-plan cohort, 450 screws were inserted across 266 spinal levels (mean 1.7 ± 1.1 screws/level), with 446 (99.1%) screws classified as Gertzbein-Robbins grade A (within the pedicle) and 4 (0.9%) as grade B (< 2-mm deviation). In the CT-to-fluoroscopy cohort, 574 screws were inserted across 280 lumbar spinal levels (mean 2.05 ± 1.7 screws/ level), with 563 (98.1%) grade A screws and 11 (1.9%) grade B (p = 0.17). The scan-and-plan cohort had nonsignificantly less fluoroscopic exposure per screw than the CT-to-fluoroscopy cohort (12 ± 13 seconds vs 11.1 ± 7 seconds, p = 0.3). CONCLUSIONS Both scan-and-plan registration and CT-to-fluoroscopy registration methods were safe, accurate, and had similar fluoroscopy time exposure overall.
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Affiliation(s)
- Asham Khan
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.,2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
| | - Mohamed A R Soliman
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.,2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York.,3Department of Neurosurgery, Cairo University, Cairo, Egypt; and
| | - Nathan J Lee
- 4Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Muhammad Waqas
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.,2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
| | - Joseph M Lombardi
- 4Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Venkat Boddapati
- 4Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Lauren C Levy
- 2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
| | - Jennifer Z Mao
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.,2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
| | - Paul J Park
- 4Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Justin Mathew
- 4Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Ronald A Lehman
- 4Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Jeffrey P Mullin
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.,2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
| | - John Pollina
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.,2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
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46
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Lin MC, Liu HW, Su YK, Lo WL, Lin CM. Robot-guided versus freehand fluoroscopy-guided minimally invasive transforaminal lumbar interbody fusion: a single-institution, observational, case-control study. Neurosurg Focus 2022; 52:E9. [DOI: 10.3171/2021.10.focus21514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 10/18/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE
The use of robotics in spinal surgery has gained popularity because of its promising accuracy and safety. ROSA is a commonly used surgical robot system for spinal surgery. The aim of this study was to compare outcomes between robot-guided and freehand fluoroscopy-guided instrumentation in minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF).
METHODS
This retrospective consecutive series reviewed 224 patients who underwent MIS-TLIF from March 2019 to April 2020 at a single institution. All patients were diagnosed with degenerative pathologies. Of those, 75 patients underwent robot-guided MIS-TLIF, and 149 patients underwent freehand fluoroscopy-guided MIS-TLIF. The incidences of pedicle breach, intraoperative outcomes, postoperative outcomes, and short-term pain control were compared.
RESULTS
The patients who underwent robot-guided surgery had a lower incidence of pedicle breach (0.27% vs 1.75%, p = 0.04) and less operative blood loss (313.7 ± 214.1 mL vs 431.6 ± 529.8 mL, p = 0.019). Nonsignificant differences were observed in operative duration (280.7 ± 98.1 minutes vs 251.4 ± 112.0 minutes, p = 0.056), hospital stay (6.6 ± 3.4 days vs 7.3 ± 4.4 days, p = 0.19), complications (intraoperative, 1.3% vs 1.3%, p = 0.45; postoperative surgery-related, 4.0% vs 4.0%, p = 0.99), and short-term pain control (postoperative day 1, 2.1 ± 1.2 vs 1.8 ± 1.2, p = 0.144; postoperative day 30, 1.2 ± 0.5 vs 1.3 ± 0.7, p = 0.610). A shorter operative duration for 4-level spinal surgery was found in the robot-guided surgery group (388.7 ± 107.3 minutes vs 544.0 ± 128.5 minutes, p = 0.047).
CONCLUSIONS
This retrospective review revealed that patients who underwent robot-guided MIS-TLIF experienced less operative blood loss. They also benefited from a shorter operative duration with higher-level (> 3 levels) spinal surgery. The postoperative outcomes were similar for both robot-guided and freehand fluoroscopy-guided procedures.
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Affiliation(s)
- Ming-Chin Lin
- Department of Neurosurgery, Shuang-Ho Hospital—Taipei Medical University, New Taipei City
- Taipei Neuroscience Institute, Taipei Medical University, Taipei
- AI and Robotic Surgery, Shuang-Ho Hospital, Taipei Medical University, New Taipei City
- Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, Taipei Medical University, Taipei
| | - Heng-Wei Liu
- Department of Neurosurgery, Shuang-Ho Hospital—Taipei Medical University, New Taipei City
- Taipei Neuroscience Institute, Taipei Medical University, Taipei
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei; and
| | - Yu-Kai Su
- Department of Neurosurgery, Shuang-Ho Hospital—Taipei Medical University, New Taipei City
- Taipei Neuroscience Institute, Taipei Medical University, Taipei
| | - Wei-Lun Lo
- Department of Neurosurgery, Shuang-Ho Hospital—Taipei Medical University, New Taipei City
- Taipei Neuroscience Institute, Taipei Medical University, Taipei
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei; and
- The PhD Program of Neural Regenerative Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Min Lin
- Department of Neurosurgery, Shuang-Ho Hospital—Taipei Medical University, New Taipei City
- Taipei Neuroscience Institute, Taipei Medical University, Taipei
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei; and
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47
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Pojskić M, Bopp M, Nimsky C, Carl B, Saβ B. Initial Intraoperative Experience with Robotic-Assisted Pedicle Screw Placement with Cirq ® Robotic Alignment: An Evaluation of the First 70 Screws. J Clin Med 2021; 10:jcm10245725. [PMID: 34945020 PMCID: PMC8703981 DOI: 10.3390/jcm10245725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Robot-guided spine surgery is based on a preoperatively planned trajectory that is reproduced in the operating room by the robotic device. This study presents our initial experience with thoracolumbar pedicle screw placement using Brainlab's Cirq® surgeon-controlled robotic arm (BrainLab, Munich, Germany). METHODS All patients who underwent robotic-assisted implantation of pedicle screws in the thoracolumbar spine were included in the study. Our workflow, consisting of preoperative imagining, screw planning, intraoperative imaging with automatic registration, fusion of the preoperative and intraoperative imaging with a review of the preplanned screw trajectories, robotic-assisted insertion of K-wires, followed by a fluoroscopy-assisted insertion of pedicle screws and control iCT scan, is described. RESULTS A total of 12 patients (5 male and 7 females, mean age 67.4 years) underwent 13 surgeries using the Cirq® Robotic Alignment Module for thoracolumbar pedicle screw implantation. Spondylodiscitis, metastases, osteoporotic fracture, and spinal canal stenosis were detected. A total of 70 screws were implanted. The mean time per screw was 08:27 ± 06:54 min. The mean time per screw for the first 7 surgeries (first 36 screws) was 16:03 ± 09:32 min and for the latter 6 surgeries (34 screws) the mean time per screw was 04:35 ± 02:11 min (p < 0.05). Mean entry point deviation was 1.9 ± 1.23 mm, mean deviation from the tip of the screw was 2.61 ± 1.6 mm and mean angular deviation was 3.5° ± 2°. For screw-placement accuracy we used the CT-based Gertzbein and Robbins System (GRS). Of the total screws, 65 screws were GRS A screws (92.85%), one screw was a GRS B screw, and two further screws were grade C. Two screws were D screws (2.85%) and underwent intraoperative revision. There were no perioperative deficits. CONCLUSION Brainlab's Cirq® Robotic Alignment surgeon-controlled robotic arm is a safe and beneficial method for accurate thoracolumbar pedicle screw placement with high accuracy.
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Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
- Correspondence: ; Tel.: +49-642-1586-9848
| | - Miriam Bopp
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 65199 Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 65199 Marburg, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 65199 Marburg, Germany
- Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, 65199 Wiesbaden, Germany
| | - Benjamin Saβ
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (M.B.); (C.N.); (B.C.); (B.S.)
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Wang TY, Park C, Dalton T, Rajkumar S, McCray E, Owolo E, Than KD, Abd-El-Barr MM. Robotic navigation in spine surgery: Where are we now and where are we going? J Clin Neurosci 2021; 94:298-304. [PMID: 34863454 DOI: 10.1016/j.jocn.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/31/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
Robotic navigation is a new and rapidly emerging niche within minimally invasive spine surgery. The robotic arms-race began in 2004 and has resulted in no less than four major robotic surgical adjuncts. Current Food and Drug Administration (FDA)-approved applications of robotic navigation are limited to pedicle screw instrumentation, but new indications and experimental applications are rapidly emerging. As with any new technology, robotic navigation must be vetted for clinical efficacy, efficiency, safety, and cost-effectiveness. Given the rapid advancements made on a yearly basis, it is important to make frequent and objective assessments of the available technology. Thus, the authors seek to provide the most up-to-date review of the history, currently available technology, learning curve, novel applications, and cost effectiveness of today's available robotic systems as it relates to spine surgery.
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Affiliation(s)
- Timothy Y Wang
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA.
| | | | - Tara Dalton
- School of Medicine, Duke University, Durham, NC, USA
| | | | - Edwin McCray
- School of Medicine, Duke University, Durham, NC, USA
| | - Edwin Owolo
- School of Medicine, Duke University, Durham, NC, USA
| | - Khoi D Than
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
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Zhang KR, Yang Y, Liu H, Ma LT. Comparison of Effect of Navigation Versus No Navigation on Vertebral Body Screw Placement in Anterior Approach Surgery for Thoracolumbar Burst Fractures: A Randomized Controlled Trial. World Neurosurg 2021; 158:e154-e165. [PMID: 34737096 DOI: 10.1016/j.wneu.2021.10.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We evaluated the effects of using a navigation technique with anterior approach surgery for thoracolumbar burst fractures on vertebral body screw placement and discussed its effects on the long-term prognosis of patients. METHODS We performed a prospective study of patients who had undergone anterior approach thoracolumbar surgery from May 2018 to August 2019. The 40 patients were randomly divided into the navigation group (NG) and control group (CG). In the NG, vertebral body screw placement was performed with 2-dimensional navigation guidance. For the CG, no navigation guidance was used. The clinical and radiological evaluations of the 2 groups were compared preoperatively, immediately after surgery, and at the final follow-up. Paired t tests and the χ2 test were used to evaluate the clinical and radiological indicators. RESULTS No differences were found in the hospital stay, operation time, autologous blood recovery, postoperative drainage volume, Cobb angle of the preoperative coronal plane and sagittal plane, postoperative sagittal plane, postoperative Cobb angle of the coronal and sagittal planes measured on radiographs and computed tomography scans between the 2 groups (P > 0.05). The correction of the kyphosis deformity of the fracture segment was better in both groups (P < 0.001). The intraoperative blood loss and Cobb angle of the postoperative coronal plane in the NG was less than that in the CG (P < 0.05). Also, the 4 vertebral body screws in the NG were more parallel to the endplate than were those in the CG. CONCLUSIONS We found that the use of navigation can improve the accuracy of screw placement in anterior approach surgery for thoracolumbar burst fractures and improve patients' long-term prognosis.
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Affiliation(s)
- Ke-Rui Zhang
- Department of Orthopedics, West China Hospital, Sichuan, University, Chengdu Sichuan, People's Republic of China
| | - Yi Yang
- Department of Orthopedics, West China Hospital, Sichuan, University, Chengdu Sichuan, People's Republic of China
| | - Hao Liu
- Department of Orthopedics, West China Hospital, Sichuan, University, Chengdu Sichuan, People's Republic of China
| | - Li-Tai Ma
- Department of Orthopedics, West China Hospital, Sichuan, University, Chengdu Sichuan, People's Republic of China.
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50
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Williams S, Layard Horsfall H, Funnell JP, Hanrahan JG, Khan DZ, Muirhead W, Stoyanov D, Marcus HJ. Artificial Intelligence in Brain Tumour Surgery-An Emerging Paradigm. Cancers (Basel) 2021; 13:cancers13195010. [PMID: 34638495 PMCID: PMC8508169 DOI: 10.3390/cancers13195010] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/02/2021] [Accepted: 10/03/2021] [Indexed: 01/01/2023] Open
Abstract
Artificial intelligence (AI) platforms have the potential to cause a paradigm shift in brain tumour surgery. Brain tumour surgery augmented with AI can result in safer and more effective treatment. In this review article, we explore the current and future role of AI in patients undergoing brain tumour surgery, including aiding diagnosis, optimising the surgical plan, providing support during the operation, and better predicting the prognosis. Finally, we discuss barriers to the successful clinical implementation, the ethical concerns, and we provide our perspective on how the field could be advanced.
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Affiliation(s)
- Simon Williams
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
- Correspondence:
| | - Hugo Layard Horsfall
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - Jonathan P. Funnell
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - John G. Hanrahan
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - Danyal Z. Khan
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - William Muirhead
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - Danail Stoyanov
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
| | - Hani J. Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (H.L.H.); (J.P.F.); (J.G.H.); (D.Z.K.); (W.M.); (H.J.M.)
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK;
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