Perioperative Comparison of Robotic-Assisted Versus Fluoroscopically Guided Minimally Invasive Transforaminal Lumbar Interbody Fusion

Comparison of robot-assisted versus fluoroscopy-guided transforaminal lumbar interbody fusion (TLIF) for lumbar degenerative diseases: a systematic review and meta-analysis of randomized controlled trails and cohort studies

BACKGROUND

As an emerging technology in robot-assisted (RA) surgery, the potential benefits of its application in transforaminal lumbar interbody fusion (TLIF) lack substantial support from current evidence.

OBJECTIVE

We aimed to investigate whether the RA TLIF is superior to FG TLIF in the treatment of lumbar degenerative disease.

METHODS

We systematically reviewed studies comparing RA versus FG TLIF for lumbar degenerative diseases through July 2022 by searching PubMed, Embase, Web of Science, CINAHL (EBSCO), Chinese National Knowledge Infrastructure (CNKI), WanFang, VIP, and the Cochrane Library, as well as the references of published review articles. Both cohort studies (CSs) and randomized controlled trials (RCTs) were included. Evaluation criteria included the accuracy of percutaneous pedicle screw placement, proximal facet joint violation (FJV), radiation exposure, duration of surgery, estimated blood loss (EBL), and surgical revision. Methodological quality was assessed using the Cochrane risk of bias and ROBINS-I Tool. Random-effects models were used, and the standardized mean difference (SMD) was employed as the effect measure. We conducted subgroup analyses based on surgical type, the specific robot system used, and the study design. Two investigators independently screened abstracts and full-text articles, and the certainty of evidence was graded using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

RESULTS

Our search identified 539 articles, of which 21 met the inclusion criteria for quantitative analysis. Meta-analysis revealed that RA had 1.03-folds higher "clinically acceptable" accuracy than FG (RR: 1.0382, 95% CI: 1.0273-1.0493). And RA had 1.12-folds higher "perfect" accuracy than FG group (RR: 1.1167, 95% CI: 1.0726-1.1626). In the case of proximal FJV, our results indicate a 74% reduction in occurrences for patients undergoing RA pedicle screw placement compared to those in the FG group (RR: 0.2606, 95%CI: 0.2063- 0.3293). Seventeen CSs and two RCTs reported the duration of time. The results of CSs suggest that there is no significant difference between RA and FG group (SMD: 0.1111, 95%CI: -0.391-0.6131), but the results of RCTs suggest that the patients who underwent RA-TLIF need more surgery time than FG (SMD: 3.7213, 95%CI: 3.0756-4.3669). Sixteen CSs and two RCTs reported the EBL. The results suggest that the patients who underwent RA pedicle screw placement had fewer EBL than FG group (CSs: SMD: -1.9151, 95%CI: -3.1265-0.7036, RCTs: SMD: -5.9010, 95%CI: -8.7238-3.0782). For radiation exposure, the results of CSs suggest that there is no significant difference in radiation time between RA and FG group (SMD: -0.5256, 95%CI: -1.4357-0.3845), but the patients who underwent RA pedicle screw placement had fewer radiation dose than FG group (SMD: -2.2682, 95%CI: -3.1953-1.3411). And four CSs and one RCT reported the number of revision case. The results of CSs suggest that there is no significant difference in the number of revision case between RA and FG group (RR: 0.4087,95% CI 0.1592-1.0495). Our findings are limited by the residual heterogeneity of the included studies, which may limit the interpretation of the results.

CONCLUSION

In TLIF, RA technology exhibits enhanced precision in pedicle screw placement when compared to FG methods. This accuracy contributes to advantages such as the protection of adjacent facet joints and reductions in intraoperative radiation dosage and blood loss. However, the longer preoperative preparation time associated with RA procedures results in comparable surgical duration and radiation time to FG techniques. Presently, FG screw placement remains the predominant approach, with clinical surgeons possessing greater proficiency in its application. Consequently, the integration of RA into TLIF surgery may not be considered the optimal choice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023441600.

Closing the Gap: The Incidence of Complications in Minimally Invasive Tubular, Endoscopic, and Robotic-Assisted Transforaminal Lumbar Interbody Fusion Procedures

BACKGROUND

The aim of the current study was to compare the incidence of postoperative complications among minimally invasive surgery (MIS) tubular, endoscopic, and robot-assisted transforaminal lumbar interbody fusion (TLIF) techniques.

METHODS

We studied consecutive patients who underwent single-level or multilevel TLIF between 2020 and 2022. Preoperative and postoperative patient-reported outcomes (Visual Analog Scale leg score and Oswestry Disability Index), demographic, and intraoperative variables were recorded. One-way analysis of variance with Bartlett's equal-variance and Pearson chi-squared tests were used.

RESULTS

The study included 170 TLIF patients: 107 (63%) tubular, 42 (25%) endoscopic, and 21 (12%) robot assisted. All 3 TLIF techniques had similar complication rates: tubular 6 (5.6%), endoscopic 2 (4.8%), and robot assisted 1 (4.8%) all occurring within the first 2 weeks. Tubular TLIF reported the lowest incidence of new-onset neurologic symptoms, primarily radiculitis or numbness/tingling, at 2 weeks postoperatively (P < 0.05) with 21 (20%) tubular, 17 (41%) endoscopic, and 9 (43%) robot-assisted patients. There were 2 revisions in the robot-assisted group, while tubular and endoscopic each had one within 1 year. There was no statistical difference in preoperative or postoperative patient-reported outcomes between the TLIF groups.

CONCLUSIONS

The current study demonstrated that tubular, endoscopic, and robot-assisted TLIF procedures had similar complication rates. The tubular MIS TLIF reported fewer new neurologic symptoms compared with endoscopic and robot-assisted TLIF procedures at 2 weeks postoperative, with all groups declining in symptom persistency at later time intervals. Average Visual Analog Scale scores continuously improved up to 1 year postoperatively among all groups.

Single-Photon Emission Computed Tomography (SPECT-CT) as a Predictor of Pain Generators in Patients Undergoing Anterior Cervical Discectomy and Fusion (ACDF) for Axial Cervical Pain

BACKGROUND

Axial neck pain is often associated with cervical instability, and surgical options are often reserved for patients with either neurological compromise or deformity of the spine. However, cervical facet arthropathy is often implicated with instability and the location of painful generators is often difficult to ascertain. Single-photon emission computed tomography (SPECT-CT) presents an adjunct to conventional imaging in the workup of patients with suspected facetogenic pain. We aimed to report our experience with patients undergoing anterior cervical discectomy and fusion (ACDF) guided by SPECT-CT for axial cervical pain.

METHODS

We retrospectively identified all cases undergoing ACDF that presented with axial neck pain where correlating SPECT-CT high metabolism areas were identified. Patients were treated at a tertiary care institution between January 2018 and January 2021. Patients with positive radiotracer uptake pre-operatively were compared with patients undergoing ACDF without uptake on SPECT-CT. The pre- and post-operative patients who reported neck pain at one year were compared.

RESULTS

Thirty-five patients were included in this retrospective cohort. The median pre- and post-intervention (at one-year follow-up) visual analog score (VAS) of patients undergoing ACDF without uptake on SPECT-CT was 7 and 3 (p<0.01), while the pre- and post-VAS for patients undergoing surgery with positive uptake on SPECT-CT was 8.5 and 0 (p<0.01). Improvement was significantly larger for patients undergoing SPECT-CT-guided ACDF (p=0.02). At one year after surgery, none of the assessed patients required additional surgical intervention.

CONCLUSION

This case series represents the experience of our group to date with patients undergoing SPECT-CT-guided ACDF with results suggesting potential benefit in guiding fusion.

What is the Marginal Cost of Using Robot Assistance or Navigation for Transforaminal Lumbar Interbody Fusion? A Time-Driven Activity-Based Cost Analysis

BACKGROUND AND OBJECTIVE

Our primary objective was to compare the marginal intraoperative cost of 3 different methods for pedicle screw placement as part of transforaminal lumbar interbody fusions (TLIFs). Specifically, we used time-driven activity-based costing to compare costs between robot-assisted TLIF (RA-TLIF), TLIF with intraoperative navigation (ION-TLIF), and freehand (non-navigated, nonrobotic) TLIF.

METHODS

Total cost was divided into direct and indirect costs. We identified all instances of RA-TLIF (n = 20), ION-TLIF (n = 59), and freehand TLIF (n = 233) from 2020 to 2022 at our institution. Software was developed to automate the extraction of all intraoperatively used personnel and material resources from the electronic medical record. Total costs were determined through a combination of direct observation, electronic medical record extraction, and interdepartmental collaboration (business operations, sterile processing, pharmacy, and plant operation departments). Multivariable linear regression analysis was performed to compare costs between TLIF modalities, accounting for patient-specific factors as well as number of levels fused, surgeon, and hospital site.

RESULTS

The average total intraoperative cost per case for the RA-TLIF, ION-TLIF, and freehand TLIF cohorts was $24 838 ± $10 748, $15 991 ± $6254, and $14 498 ± $6580, respectively. Regression analysis revealed that RA-TLIF had significantly higher intraoperative cost compared with both ION-TLIF (β-coefficient: $7383 ± $1575, P < .001) and freehand TLIF (β-coefficient: $8182 ± $1523, P < .001). These cost differences were primarily driven by supply cost. However, there were no significant differences in intraoperative cost between ION-TLIF and freehand TLIF (P = .32).

CONCLUSION

We demonstrate a novel use of time-driven activity-based costing methodology to compare different modalities for executing the same type of lumbar fusion procedure. RA-TLIF entails significantly higher supply cost when compared with other modalities, which explains its association with higher total intraoperative cost. The use of ION, however, does not add extra expense compared with freehand TLIF when accounting for confounders. This might have implications as surgeons and hospitals move toward bundled payments.

Effectiveness and safety of robot-assisted minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar spinal diseases: a systematic review and meta-analysis

Robot-assisted (RA) technology has been widely used in spine surgery. This analysis aimed to compare the effectiveness and safety of RA minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and fluoroscopy-assisted (FA) MIS-TLIF for degenerative lumbar spinal diseases (DLSD). PubMed, Web of Science, Cochrane Library, and China National Knowledge Infrastructure were systematically searched, and the outcomes included surgical parameters [operation time, blood loss, number of fluoroscopic, accuracy of pedicle screw position, superior facet joint violation (FJV)], and clinical indexes (Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) score, clinical efficacy, hospital stays, complications). Eleven articles involving 1066 patients were included. RA group produced better results than the FA group in operation time (WMD = - 6.59; 95% CI - 12.79 to - 0.40; P = 0.04), blood loss (WMD = - 34.81; 95% CI - 50.55 to - 19.08; P < 0.0001), number of fluoroscopic (WMD = - 18.24; 95% CI - 30.63 to - 5.85; P = 0.004), accuracy of pedicle screw position: Grade A (OR = 3.16; 95% CI 2.36-4.23; P < 0.00001), Grade B (OR = 0.39; 95% CI 0.28-0.54; P < 0.00001), Grade C (OR = 0.27; 95% CI 0.13-0.54; P = 0.0002), and Grade D (OR = 0.17; 95% CI 0.03-0.98; P = 0.05), FJV: Grade 0 (OR = 3.27; 95% CI 1.34-8.02; P = 0.010), Grade 1 (OR = 0.24; 95% CI 0.16-0.38; P < 0.00001), Grade 2 (OR = 0.24; 95% CI 0.12-0.51; P = 0.0002), and Grade 3 (OR = 0.26; 95% CI 0.07-0.93; P = 0.04). But no significant differences in VAS score, ODI, JOA score, clinical efficacy, hospital stays, and complications. These results demonstrate a significant improvement in the intraoperative course of the RA technique. However, RA-MIS-TLIF has not yet demonstrated significant advantages in terms of postoperative symptom relief and functional improvement. Future research and clinical practice should further explore the efficacy of this technique to optimize outcomes and quality of life for patients with DLSD. The study was registered in the PROSPERO (CRD42023454405).

Frailty as a Predictor of Postoperative Morbidity and Mortality in Patients Aged 80 Years and Older Undergoing Instrumented Fusion

BACKGROUND AND OBJECTIVES

Degenerative spine disease is a leading cause of disability, with increasing prevalence in the older patients. While age has been identified as an independent predictor of outcomes, its predictive value is limited for similar older patients. Here, we aimed to determine the most predictive frailty score of adverse events in patients aged 80 and older undergoing instrumented lumbar fusion.

METHODS

We proceeded with a multisite (3 tertiary academic centers) retrospective review including patients undergoing instrumented fusion aged 80 and older from January 2010 to present. A composite end point encompassing 30-day return to operating room, readmission, and mortality was created. We estimated the area under the receiver operating characteristic curve for frailty scores (Modified Frailty Index-5 [MFI-5], Modified Frailty Index-11 [MFI-11], and Charlson Comorbidity Index [CCI]) in relation to that composite score. In addition, we estimated the association between each score and the composite end point by means of logistic regression.

RESULTS

A total of 153 patients with an average age of 85 years at the time of surgery were included. We observed a 30-day readmission rate of 11.1%, reoperation of 3.9%, and mortality of 0.6%. The overall rate of the composite end point at 30 days was 25 (15.1%). The AUC for MFI-5 was 0.597 (0.501-0.693), for MFI-11 was 0.620 (0.518-0.723), and for CCI was 0.564 (0.453-0.675). The association between the scores and composite end point did not reach statistical significance for MFI-5 (odds ratio [OR] = 1.45 [0.98-2.15], P = .061) and CCI (OR = 1.13 [0.97-1.31], P = .113) but was statistically significant for MFI-11 (OR = 1.46 [1.07-2.00], P = .018).

CONCLUSION

This is the largest study comparing frailty index scores in octogenarians undergoing instrumented lumbar fusion. Our findings suggest that while MFI-11 score correlated with adverse events, the predictive ability of existing scores remains limited, highlighting the need for better approaches to identify select patients at age extremes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reliability of YouTube videos on robotic spine surgery for patient education

BACKGROUND

Robotic surgical systems developed to improve spine surgery accuracy. Studies have found significant reductions in screw revisions and radiation exposure with robotic assistance compared with open surgery. YouTube is the largest online video platform for medical education. Therefore, there is a need for the continuous critical assessment of healthcare-related YouTube videos. Our objective is to assess the reliability of YouTube videos on robotic spine surgery for patient education.

METHODS

In April of 2022, YouTube was queried for the following keywords: "Robotic Spine Surgery". The "Relevance-Based Ranking" filter was applied, and the first 3 result pages were considered. Videos had to be uploaded by universities or hospitals and be in the English. Three independent healthcare personnel evaluated the videos' education quality using the DISCERN tool.

RESULTS

Our study found that 33 % of videos analyzed scored above a 3 on the DISCERN scoring scale (considered a ''good" video), with overall mean DISCERN score of 2.8 ± 1.3 (SD). The duration of videos was significantly different between the two groups (Good = 16 min ± 21 vs Unhelpful = 4 min ± 4, p = 0.01). In the helpful group, other characteristics were number of views (16331 ± 31308), likes (88 ± 168) and dislikes (5 ± 8). No statistically significant differences were observed compared to the unhelpful group: number of views (6515 ± 9074; P = 0.20), likes (39 ± 55; P = 0.21) and dislikes (3 ± 4; P = 0.33).

CONCLUSION

Our study shows that YouTube videos on robotic spine surgery lack accuracy and have poor educational value. There should be increased institutional oversight to combat the spread of misinformation.

Robotics in spine surgery: systematic review of literature

PURPOSE

Over 4.83 million spine surgery procedures are performed annually around the world. With the considerable caseload and the precision needed to achieve optimal spinal instrumentation, technical progress has helped to improve the technique's safety and accuracy with the development of peri-operative assistance tools. Contrary to other surgical applications already part of the standard of care, the development of robotics in spine surgery is still a novelty and is not widely available nor used. Robotics, especially when coupled with other guidance modalities such as navigation, seems to be a promising tool in our quest for accuracy, improving patient outcomes and reducing surgical complications. Robotics in spine surgery may also be for the surgeon a way to progress in terms of ergonomics, but also to respond to a growing concern among surgical teams to reduce radiation exposure.

METHOD

We present in this recent systematic review of the literature realized according to the PRISMA guidelines the place of robotics in spine surgery, reviewing the comparison to standard techniques, the current and future indications, the learning curve, the impact on radiation exposure, and the cost-effectiveness.

RESULTS

Seventy-six relevant original studies were identified and analyzed for the review.

CONCLUSION

Robotics has proved to be a safe help for spine surgery, both for the patient with a decrease of operating time and increase in pedicular screw accuracy, and for the surgical team with a decrease of radiation exposure. Medico-economic studies demonstrated that despite a high buying cost, the purchase of a robot dedicated for spine surgery is cost-effective resulting in lesser revision, lower infection, reduced length of stay, and shorter surgical procedure.

Assessment of surgeons' attitude towards awake spine surgery under spinal anesthesia

BACKGROUND

General anesthesia (GA) and spinal anesthesia (SA) have been adopted for lumbar spine surgery (LSS), but GA is used far more widely. We conducted a survey of spine surgeons to explore their attitudes and preferences regarding awake spine surgery under SA.

METHODS

A survey was emailed to 150 spine surgeons. Exposure and attitudes towards spine surgery under SA were elicited. A five-point Likert scale of agreement examined perceptions of SA, while attitudes towards SA were recorded by categorizing free text into themes.

RESULTS

Seventy-five surgeons completed the survey, 50 % response rate. Only 27 % said they perform LSS under SA. Most surgeons, 83 %, would recommend GA to a healthy patient undergoing lumbar laminectomy. Only 41 % believes SA to be as safe as GA, and only 30 % believes SA is associated with better postoperative pain control. The most common reasons why SA is not favored was lack of proven benefits over GA (65 %). When asked if a randomized trial finds SA to lead to less postoperative fatigue, 50 % said they would be more likely to offer SA, a significant increase from the baseline response of 27 % (p = 0.002).

CONCLUSIONS

Our survey indicates that the low adoption of SA for LSS is due to lack of surgeons' belief in the benefits of SA over GA, and that a randomized patient-centered trial has the potential of changing surgeons' perspective and increasing adoption of SA for LSS.

Feasibility of outpatient robot assisted minimally invasive transforaminal lumbar interbody fusion

Introduction

Lumbar interbody fusion is a common spine procedure. 199,140 elective lumbar fusions were performed in the United States in 2015. Robot assisted (RA) pedicle screw placement has advanced minimally invasive spine surgery (MIS) making short stay transforaminal lumbar interbody fusions (TLIF) with same day or next day discharge a possibility for select patients.

Methods

This study is a retrospective case series of a single surgeon's experience with RA MIS TLIF using the Globus ExcelsiusGPS system. Patients undergoing RA MIS TLIF at an outpatient surgery center between August 2020 and February 2021 were included in the study.

Results

Twenty-three patients met inclusion criteria. Ninety-six RA pedicle screws and 25 interbody cages were placed. 96/96 (100%) pedicle screws and 25/25 (100%) interbodies were found to be in satisfactory position using intraoperative x-ray. None of the instrumentation required re-placement or revision intraoperatively. 20/23 (87%) patients were able to discharge within 24 hours of the procedure. 2/23 (8.7%) patients discharged on the day of surgery. One patient of 23 (4.3%) required discharge to an inpatient rehabilitation facility post operatively. 0/23 (0%) patients required readmission for pain control.

Conclusions

Our study demonstrates the safety and feasibility of outpatient RA MIS TLIF for select patients. Future directions include a larger study to elucidate characteristics of the best candidates for outpatient RA MIS TLIF.

Learning curves in robotic neurosurgery: a systematic review

The transition to performing procedures robotically generally entails a period of adjustment known as a learning curve as the surgeon develops a familiarity with the technology. However, no study has comprehensively examined robotic learning curves across the field of neurosurgery. We conducted a systematic review to characterize the scope of literature on robotic learning curves in neurosurgery, assess operative parameters that may involve a learning curve, and delineate areas for future investigation. PubMed, Embase, and Scopus were searched. Following deduplication, articles were screened by title and abstract for relevance. Remaining articles were screened via full text for final inclusion. Bibliographic and learning curve data were extracted. Of 746 resultant articles, 32 articles describing 3074 patients were included, of which 23 (71.9%) examined spine, 4 (12.5%) pediatric, 4 (12.5%) functional, and 1 (3.1%) general neurosurgery. The parameters assessed for learning curves were heterogeneous. In total, 8 (57.1%) of 14 studies found reduced operative time with increased cases, while the remainder demonstrated no learning curve. Six (60.0%) of 10 studies reported reduced operative time per component with increased cases, while the remainder indicated no learning curve. Radiation time, radiation time per component, robot time, registration time, setup time, and radiation dose were assessed by ≤ 4 studies each, with 0-66.7% of studies demonstrated a learning curve. Four (44.4%) of 9 studies on accuracy showed improvement over time, while the others indicated no improvement over time. The number of cases required to reverse the learning curve ranged from 3 to 75. Learning curves are common in robotic neurosurgery. However, existing studies demonstrate high heterogeneity in assessed parameters and the number of cases that comprise the learning curve. Future studies should seek to develop strategies to reduce the number of cases required to reach the learning curve.

Development and Clinical Trial of a New Orthopedic Surgical Robot for Positioning and Navigation

Robot-assisted orthopedic surgery has great application prospects, and the accuracy of the robot is the key to its overall performance. The aim of this study was to develop a new orthopedic surgical robot to assist in spinal surgeries and to compare its feasibility and accuracy with the existing orthopedic robot. A new type of high-precision orthopedic surgical robot (Tuoshou) was developed. A multicenter, randomized controlled trial was carried out to compare the Tuoshou with the TiRobot (TINAVI Medical Technologies Co., Ltd., Beijing) to evaluate the accuracy and safety of their navigation and positioning. A total of 112 patients were randomized, and 108 patients completed the study. The position deviation of the Kirschner wire placement in the Tuoshou group was smaller than that in the TiRobot group (p = 0.014). The Tuoshou group was better than the TiRobot group in terms of the pedicle screw insertion accuracy (p = 0.016) and entry point deviation (p < 0.001). No differences were observed in endpoint deviation (p = 0.170), axial deviation (p = 0.170), sagittal deviation (p = 0.324), and spatial deviation (p = 0.299). There was no difference in security indicators. The new orthopedic surgical robot was highly accurate and optimized for clinical practice, making it suitable for clinical application.

Semiautomated intraoperative measurement of Cobb angle and coronal C7 plumb line using deep learning and computer vision for scoliosis correction: a feasibility study

OBJECTIVE

Scoliosis is a degenerative disease with a 3D deformity in the alignment of the spinal column. Surgical spinal correction outcomes are heavily dependent on the surgeon's expertise and use of visual cues because of time requirements, lack of automation, and radiation exposure associated with current intraoperative measurement techniques. In this study, the authors sought to validate a novel, nonradiographic, and semiautomated device that measures spinal alignment intraoperatively using deep learning and computer vision.

METHODS

To obtain spinal alignment metrics intraoperatively, the surgeon placed 3D-printed markers made of acrylonitrile butadiene styrene (ABS) plastic at designated locations in the surgical field. With the high-definition camera of the device, the surgeon can take an image of the markers in the surgical field. Images are processed through a computer vision model that detects the location of the markers and calculates the Cobb angle and coronal plumb line. The marker detection model was trained on 100 images and tested on 130 images of the ABS markers in various conditions. To verify the Cobb angle calculation, 50 models of angle templates from 0° to 180° in 3.6735° increments were created for testing. To verify the plumb line calculation, 21 models of plumb line measurements from -10 to +10 cm in increments of 1 cm were created for testing. A validation study was performed on a scoliotic cadaver model, and the radiographic calculations for Cobb angle and plumb line were compared with the device's calculations.

RESULTS

The area under the curve for the marker detection model was 0.979 for Cobb angle white, 0.791 for Cobb angle black, and 1 for the plumb line model. The average absolute difference between expected and measured Cobb angles on the verification models was 1.726° ± 1.259°, within the clinical acceptable error of 5°. The average absolute difference between the expected and measured plumb lines on the verification models was 0.415 ± 0.255 cm. For the cadaver validation study, the differences between the radiographic and device calculations for the Cobb angle and plumb line were 2.78° and 0.29 cm, respectively.

CONCLUSIONS

The authors developed and validated a nonradiographic, semiautomated device that utilizes deep learning and computer vision to measure spinal metrics intraoperatively.

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

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Robot-Assisted Pedicle Screw Placement Led to Lower Screw Loosening Rate than Fluoroscopy-Guided Technique in Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: A Single-Center Retrospective Study

Robot-assisted pedicle screw placement for spine surgery has become popular in recent years. This study compares clinical, radiographic outcomes and the screw loosening rate between robot-assisted and fluoroscopy-guided pedicle screw placement in patients who underwent transforaminal lumbar interbody fusion (TLIF). We retrospectively examined 108 patients with the degenerative lumbar disease who underwent TLIF. According to whether the robotic system was used, patients were assigned to either the robot-assisted (Ro TLIF, n = 29) or fluoroscopy-guided TLIF (FG TLIF, n = 79) group. Radiographic parameters and patient-reported outcomes, including leg and back pain visual analog scale (VAS) and Oswestry Disability Index (ODI), were assessed. Loosening signs were noted in 48 out of 552 pedicle screws. The screw loosening rate was higher in the FG TLIF (10.2%) than Ro TLIF group (4.3%). A significant correlation was found between screw loosening and age, the number of level(s) fused, and the ratio of the average distance from the pedicle screw to the upper endplate to vertebral body height. VAS-leg, VAS-back, and ODI showed significant improvements in both groups postoperatively (all p < 0.05). These results indicated that robot-assisted pedicle screw placement in TLIF had a lower screw loosening rate and similar patient-reported outcomes compared with the fluoroscopy-guided technique.

SPECT-CT as a Predictor of Pain Generators in Patients Undergoing Intra-Articular Injections for Chronic Neck and Back Pain

BACKGROUND

The ability to accurately predict pain generators for chronic neck and back pain remains elusive.

OBJECTIVE

We evaluated whether injections targeted at foci with uptake on single-photon emission computerized tomography-computed tomography (SPECT-CT) were associated with improved outcomes in patients with chronic neck and back pain.

METHODS

A retrospective review was completed on patients undergoing SPECT-CT for chronic neck and back pain between 2016 and 2020 at a tertiary academic center. Patients' records were reviewed for demographic, clinical, imaging, and outcomes data. Only those patients who had facet injections after SPECT-CT were included in this evaluation. Patients undergoing injections targeted at foci of abnormal radiotracer uptake were compared with patients without uptake concerning immediate positive response, visual analog scale, and the need for additional injection or surgery at the target level.

RESULTS

A total of 2849 patients were evaluated with a SPECT-CT for chronic neck and back pain. Of those, 340 (11.9%) patients received facet joint injections after SPECT-CT. A propensity score regression analysis adjusted for age, gender, body mass index, hypertension, multiple target injections, and injection location showed uptake targeted injections not being associated with an improved immediate positive response (odds ratio: 0.64; 95% confidence interval: 0.34-1.21; P = 0.172). In patients with a failed facet injection preceding SPECT-CT, adding SPECT-CT to guide facet injections was associated with a decrease in visual analog scale pain scores 2 weeks after injection (P = 0.018), particularly when changes were made to the facets being targeted (P = 0.010).

CONCLUSION

This study suggests that there is benefit with SPECT-CT specially to guide facet injections after failed prior facet injections.

Assessment of Patients' Willingness to Participate in a Randomized Trial of Spinal versus General Anesthesia for Lumbar Spine Surgery

BACKGROUND

Prospective nonrandomized studies have found less postoperative fatigue and improved quality of life in patients undergoing awake spine surgery under spinal anesthesia compared with general anesthesia. Randomized trials are needed to validate these findings.

OBJECTIVE

To prospectively investigate patients' willingness to enroll in randomized trials of lumbar spine surgery under spinal versus general anesthesia and identify any potential barriers.

METHODS

We recruited patients undergoing lumbar spine surgery for degenerative disease. We described a randomized trial of spine surgery under spinal versus general anesthesia and assessed patients' willingness to participate in such trial. We elicited preferences for treatment along with demographics. The association between these factors and willingness to participate in the trial was examined.

RESULTS

Fifty patients completed interviews; 58% were female, mean age of 60.9 ± 12.5 years. A total of 52% patients stated that they were definitely willing to participate in the hypothetical randomized trial, and 8% probably willing. Only 16% of patients were aware of spinal anesthesia as an option for low back surgery, and 60% indicated no strong preference for the anesthesia techniques. Patients without strong preferences stated a greater willingness to participate than those with strong preferences (80% vs. 10% definitely willing, P < 0.0001). Age, sex, education, work status, and race were not significantly associated with willingness to participate.

CONCLUSION

Sixty percent of patients stated that they were either definitely or probably willing to participate in the randomized trial. Subjects lacking strong preferences for the anesthesia technique stated a greater willingness to enroll than those with strong preference.

Robotic-Assisted Lumbar Fusion: An Effective Technique for Pedicle Screw Placement

Degenerative lumbar disease is a common condition in which progressive deterioration of the structures in the spine causes severely incapacitating pain and disability. Conservative management, including passive or active physical therapy, activity modification, and medications (eg, anti-inflammatory medications, oral and injectable steroids, opioids), may provide relief. However, when conservative management is unsuccessful or patients experience symptoms for an extended period of time, they may require spine surgery. Surgeons use a variety of techniques to perform lumbar fusion procedures with instrumentation, including open, percutaneous, minimally invasive, and robotic-assisted with navigation. The accuracy of pedicle-screw placement varies according to the technique used, and accuracy rates are high after robotic-assisted with navigation procedures. In addition, robotic-assisted spine procedures result in fewer infections than non-robotic-assisted spine procedures (P = .04). Perioperative nurses should understand basic lumbar spine anatomy, steps completed during robotic-assisted lumbar spine surgery, and the nursing considerations for patients undergoing this type of procedure.

Robotic-Assisted vs Nonrobotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Cost-Utility Analysis

BACKGROUND

Management of degenerative disease of the spine has evolved to favor minimally invasive techniques, including nonrobotic-assisted and robotic-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Value-based spending is being increasingly implemented to control rising costs in the US healthcare system. With an aging population, it is fundamental to understand which procedure(s) may be most cost-effective.

OBJECTIVE

To compare robotic and nonrobotic MIS-TLIF through a cost-utility analysis.

METHODS

We considered direct medical costs related to surgical intervention and to the hospital stay, as well as 1-yr utilities. We estimated costs by assessing all cases involving adults undergoing robotic surgery at a single institution and an equal number of patients undergoing nonrobotic surgery, matched by demographic and clinical characteristics. We adopted a willingness to pay of $50 000/quality-adjusted life year (QALY). Uncertainty was addressed by deterministic and probabilistic sensitivity analyses.

RESULTS

Costs were estimated based on a total of 76 patients, including 38 undergoing robot-assisted and 38 matched patients undergoing nonrobot MIS-TLIF. Using point estimates, robotic surgery was projected to cost $21 546.80 and to be associated with 0.68 QALY, and nonrobotic surgery was projected to cost $22 398.98 and to be associated with 0.67 QALY. Robotic surgery was found to be more cost-effective strategy, with cost-effectiveness being sensitive operating room/materials and room costs. Probabilistic sensitivity analysis identified robotic surgery as cost-effective in 63% of simulations.

CONCLUSION

Our results suggest that at a willingness to pay of $50 000/QALY, robotic-assisted MIS-TLIF was cost-effective in 63% of simulations. Cost-effectiveness depends on operating room and room (admission) costs, with potentially different results under distinct neurosurgical practices.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: Cost of a Surgeon's Learning Curve

BACKGROUND

Minimally invasive transforaminal interbody fusion has become an increasingly common approach in adult degenerative spine disease but is associated with a steep learning curve.

OBJECTIVE

To evaluate the impact of the learning experience on mean procedure time and mean cost associated with each procedure.

METHODS

We studied the first one-hundred consecutive minimally invasive transforaminal interbody fusion procedures of a single surgeon. We performed multivariable linear regression models, modelling operating time and costs in function of the procedure order adjusted for patients' age, gender and number of surgical levels. The number of procedures necessary to attain proficiency was determined through a k-means cluster analysis. Finally, the total excess operative time and total excess cost until obtaining proficiency was evaluated.

RESULTS

Procedure order was found to impact procedure time and mean costs, with each successive case being associated with progressively less procedure time and cost. On average, each successive case was associated with a reduction in procedure time of 0.97 minutes (95% CI=0.54-1.40; p<0.001) and an average adjusted reduction in overall costs of $82.75 (95% CI=$35.93-129.57; p<0.001). An estimated 58 procedures were needed to attain proficiency, translating into an excess procedure time of 2604.2 minutes (average of 45 minutes per case), overall costs associated with the learning experience of $226,563.8 (average of $3974.80 per case), and excess surgical cost of $125,836.6 (average of $2207.66 per case).

CONCLUSION

Successive cases were associated with progressively less procedure time and mean overall and surgical costs, until a proficiency threshold was attained.

What Is the Learning Curve for Lumbar Spine Surgery Under Spinal Anesthesia?

BACKGROUND

Spinal anesthesia (SA) is routinely used in obstetrics and orthopedic surgery but has not been widely adopted in lumbar spine surgery (LSS). One perceived barrier is the learning curve for the neurosurgical and anesthesia team associated with managing a patient in the prone position under SA.

METHODS

A retrospective cohort of 34 LSS cases under SA at our institution was examined. Operative time, corrected operative time per level, and complications were analyzed. The learning curve was assessed using a curve-fit regression analysis.

RESULTS

Of patients, 62% were female, with mean (SD) age and body mass index of 60.7 (10.8) years and 29.9 (4.6) kg/m², respectively. The mean (SD) for each time segment was operating room arrival to incision 35.7 (8.1) minutes, total surgical time 100.4 (35.8) minutes, and procedure finish to operating room exit 3.4 (2.5) minutes. When the times were normalized to procedure type and analyzed sequentially, the mean (SD) slope of all trendlines was 0.003 (0.005) with correlation coefficients of R² = 0.0002-0.01, indicating no appreciable learning curve. Normalized postanesthesia care unit time was significantly shorter for overnight stay versus same-day discharge (0.64 vs. 1.36, P = 0.0005).

CONCLUSIONS

Our data demonstrate the lack of a learning curve when SA is implemented in LSS cases by an anesthetic team already familiar with SA techniques for other procedures. Importantly, the surgical team was already familiar with the minimally invasive surgery approaches used in conjunction with SA. This study highlights that the barriers to transitioning to SA for LSS may be fewer than perceived.