Robot-assisted technique vs conventional freehand technique in spine surgery: A meta-analysis

Efficacy and safety of navigation robot-assisted versus conventional oblique lateral lumbar interbody fusion with internal fixation in the treatment of lumbar degenerative diseases: A retrospective study

Effective internal fixation with pedicle screw is a key factor in the success of lumbar fusion with internal fixation. Whether navigation robots can improve the efficacy and safety of screw placement is controversial. Thirty-eight patients who underwent oblique lateral lumbar interbody fusion internal fixation from March 2022 to May 2023 were retrospectively analyzed, 16 cases in the navigational robot group and 22 cases in the fluoroscopy group. Using visual analog score (VAS) for the low back and lower limbs, Oswestry Disability Index to compare the clinical efficacy of the 2 groups; using perioperative indexes such as the duration of surgery, intraoperative blood loss, intraoperative fluoroscopy times, and postoperative hospital stay to compare the safety of the 2 groups; and using accuracy of pedicle screws (APS) and the facet joint violation (FJV) to compare the accuracy of the 2 groups. Postoperative follow-up at least 6 months, there was no statistically significant difference between the 2 groups in the baseline data (P > .05). The navigational robot group's VAS-back was significantly lower than the fluoroscopy group at 3 days postoperatively (P < .05). However, the differences between the 2 groups in VAS-back at 3 and 6 months postoperatively, and in VAS-leg and Oswestry Disability Index at 3 days, 3 months, and 6 months postoperatively were not significant (P > .05). Although duration of surgery in the navigational robot group was significantly longer than in the fluoroscopy group (P > .05), the intraoperative blood loss and the intraoperative fluoroscopy times were significantly lower than in the fluoroscopy group (P < .05). The difference in the PHS between the 2 groups was not significant (P > .05). The APS in the navigation robot group was significantly higher than in the fluoroscopy group, and the rate of FJV was significantly lower than in the fluoroscopy group (P < .05). Compared with the traditional fluoroscopic technique, navigation robot-assisted lumbar interbody fusion with internal fixation provides less postoperative low back pain in the short term, with less trauma, less bleeding, and lower radiation exposure, as well as better APS and lower FJV, resulting in better clinical efficacy and safety.

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.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

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

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

Comparison of short-term clinical outcomes between robot-assisted and freehand pedicle screw placement in spine surgery: a meta-analysis and systematic review

STUDY DESIGN

Meta-analysis and systematic review.

BACKGROUND

Robot-assisted pedicle screw placement technique offers greater accuracy than the traditional freehand screw placement technique. However, it is controversial whether there is a difference between the two procedures in terms of improved clinical outcomes.

MATERIALS AND METHODS

We systematically searched PubMed, EMBASE, Cochrane, and Web of Science to identify potentially eligible articles. Indispensable data such as the year of publication, study type, age, number of patients, sex distribution, and outcomes were extracted. The outcome indicators of interest included Oswestry disability index (ODI), visual analog scale (VAS) score, operative time, intraoperative blood loss, and post-operative length of stay. RevMan 5.4.1 was used for the meta-analysis.

RESULTS

A total of eight studies with 508 participants were included. Eight were related to ΔVAS, six were related to ΔODI, seven were related to operative time, five were related to intraoperative blood loss, and seven were related to the length of hospitalization. The results showed that, in terms of ΔVAS (95% CI, -1.20 to -0.36, P = 0.0003) and ΔODI (95% CI, -2.50 to -0.48, P = 0.004), robot-assisted pedicle screw placement technique scored higher than traditional freehand technique. Additionally, the intraoperative blood loss (95% CI, -140.34 to -10.94, P = 0.02) and the length of hospitalization (95% CI, -2.59 to -0.31, P = 0.01) for patients who underwent robotic-assisted pedicle screw placement were less than that of those who underwent the conventional freehand screw placement. No significant difference was found between robot-assisted techniques and conventional freehand techniques in pedicle screw placement in surgical time (95% CI, -2.24 to 26.32, P = 0.10).

CONCLUSIONS

Robot-assisted technique helps improve short-term clinical outcomes, reduce intraoperative blood loss and patient suffering, and shorten recovery time compared to the freehand technique.

Robotic-navigated assistance in spine surgery

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.

Robotic and navigated pedicle screws are safer and more accurate than fluoroscopic freehand screws: a systematic review and meta-analysis

BACKGROUND CONTEXT

Navigated and robotic pedicle screw placement systems have been developed to improve the accuracy of screw placement. However, the literature comparing the safety and accuracy of robotic and navigated screw placement with fluoroscopic freehand screw placement in thoracolumbar spine surgery has been limited.

PURPOSE

To perform a systematic review and meta-analysis of randomized control trials that compared the accuracy and safety profiles of robotic and navigated pedicle screws with fluoroscopic freehand pedicle screws.

STUDY DESIGN/SETTING

Systematic review and meta-analysis PATIENT SAMPLE: Only randomized controlled trials comparing robotic-assisted or navigated pedicle screws placement with freehand pedicle screw placement in the thoracolumbar spine were included.

OUTCOME MEASURES

Odds ratio (OR) estimates for screw accuracy according to the Gertzbein-Robbins scale and relative risk (RR) for various surgical complications.

METHODS

We systematically searched PubMed and EMBASE for English-language studies from inception through April 7, 2022, including references of eligible articles. The search was conducted according to PRISMA guidelines. Two reviewers conducted a full abstraction of all data, and one reviewer verified accuracy. Information was extracted on study design, quality, bias, participants, and risk estimates. Data and estimates were pooled using the Mantel-Haenszel method for random-effects meta-analysis.

RESULTS

A total of 14 papers encompassing 12 randomized controlled trials were identified (n=892 patients, 4,046 screws). The pooled analysis demonstrated that robotic and navigated pedicle screw placement techniques were associated with higher odds of screw accuracy (OR 2.66, 95% CI 1.24-5.72, p=.01). Robotic and navigated screw placement was associated with a lower risk of facet joint violations (RR 0.09, 95% CI 0.02-0.38, p<.01) and major complications (RR 0.31, 95% CI 0.11-0.84, p=.02). There were no observed differences between groups in nerve root injury (RR 0.50, 95% CI 0.11-2.30, p=.37), or return to operating room for screw revision (RR 0.28, 95% CI 0.07-1.13, p=.07).

CONCLUSIONS

These estimates suggest that robotic and navigated screw placement techniques are associated with higher odds of screw accuracy and superior safety profile compared with fluoroscopic freehand techniques. Additional randomized controlled trials will be needed to further validate these findings.

Index Surgery Cost of Fluoroscopic Freehand Versus Robotic-Assisted Pedicle Screw Placement in Lumbar Instrumentation: An Age, Sex, and Approach-Matched Cohort Comparison

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.

Robot-assisted and augmented reality-assisted spinal instrumentation: a systematic review and meta-analysis of screw accuracy and outcomes over the last decade

OBJECTIVE

The use of technology-enhanced methods in spine surgery has increased immensely over the past decade. Here, the authors present the largest systematic review and meta-analysis to date that specifically addresses patient-centered outcomes, including the risk of inaccurate screw placement and perioperative outcomes in spinal surgeries using robotic instrumentation and/or augmented reality surgical navigation (ARSN).

METHODS

A systematic review of the literature in the PubMed, EMBASE, Web of Science, and Cochrane Library databases spanning the last decade (January 2011-November 2021) was performed to present all clinical studies comparing robot-assisted instrumentation and ARSN with conventional instrumentation techniques in lumbar spine surgery. The authors compared these two technologies as they relate to screw accuracy, estimated blood loss (EBL), intraoperative time, length of stay (LOS), perioperative complications, radiation dose and time, and the rate of reoperation.

RESULTS

A total of 64 studies were analyzed that included 11,113 patients receiving 20,547 screws. Robot-assisted instrumentation was associated with less risk of inaccurate screw placement (p < 0.0001) regardless of control arm approach (freehand, fluoroscopy guided, or navigation guided), fewer reoperations (p < 0.0001), fewer perioperative complications (p < 0.0001), lower EBL (p = 0.0005), decreased LOS (p < 0.0001), and increased intraoperative time (p = 0.0003). ARSN was associated with decreased radiation exposure compared with robotic instrumentation (p = 0.0091) and fluoroscopy-guided (p < 0.0001) techniques.

CONCLUSIONS

Altogether, the pooled data suggest that technology-enhanced thoracolumbar instrumentation is advantageous for both patients and surgeons. As the technology progresses and indications expand, it remains essential to continue investigations of both robotic instrumentation and ARSN to validate meaningful benefit over conventional instrumentation techniques in spine surgery.

Spine Image Guidance and Robotics: Exposure, Education, Training, and the Learning Curve

The use of intraoperative robotics and imaging for spine surgery has been shown to be safe, efficacious, and beneficial to patients, offering accurate placement of instrumentation, decreased operative time and blood loss, and improved postoperative outcomes. Despite these proven benefits, it has yet to be uniformly adopted. One of the major barriers for universal adoption of intraoperative robotics is the learning curve for this complex technology, in conjunction with a lack of formalized training. These same obstacles for universal adoption were faced in the introduction of surgical technology in other disciplines, and the use of this technology has become the standard of care in some of those specialties. Part of the success and widespread implementation of prior novel technology was the introduction of formalized training systems, which are currently lacking in advanced spine surgical technology. Therefore, the future success of intraoperative robotics and imaging for spine surgery depends on the creation of a formalized training system. We detail the best techniques for surgical pedagogy, as well as propose a comprehensive curriculum.

Utility of Power Tool and Intraoperative Neuromonitoring for Percutaneous Pedicle Screw Placement in Single Position Surgery: A Technical Note

OBJECTIVE

This study aimed to demonstrate the utility of power tools and intraoperative neuromonitoring of percutaneous pedicle screw (PPS) insertion (so-called PPS monitoring) by SINGLE-position surgery (SPS) after lateral lumbar interbody fusion.

METHODS

A retrospective analysis of medical records from a single center was performed to identify patients who underwent SPS for lateral lumbar interbody fusion and posterior fixation using PPS during intraoperative computed tomography navigation from 2020 to 2021. We investigated the PPS insertion time and screw positional accuracy of patients who underwent SPS involving power tools and PPS monitoring during this period. In this technical note, we report on this surgical technique.

RESULTS

Twenty-four patients (mean age 72.0 ± 8.5 years, range 53-81 years) were included in this study. There were no intraoperative complications in all cases. Posterior fixation using PPS was added in all cases, and a total of 106 PPSs were inserted. It took an average of 6.2 ± 2.4 seconds to insert the PPS from the PPS insertion point to the end using a power tool and PPS monitoring. Moreover, there were no cases of pedicle breaches.

CONCLUSIONS

Similar to previous reports related to power tools in the prone position, the lateral decubitus SPS technique can also use power tools to save PPS insertion time. Furthermore, we suggest that the use of PPS monitoring may prevent erroneous PPS insertions by using intraoperative computed tomography navigation in advance.

Accuracy of Robotic-Assisted Spinal Surgery-Comparison to TJR Robotics, da Vinci Robotics, and Optoelectronic Laboratory Robotics

BACKGROUND

The optoelectronic camera source and data interpolation serve as the foundation for navigational integrity in the robotic-assisted surgical platform. The objective of the current systematic review serves to provide a basis for the numerical disparity that exists when comparing the intrinsic accuracy of optoelectronic cameras: accuracy observed in the laboratory setting versus accuracy in the clinical operative environment. It is postulated that there exists a greater number of connections in the optoelectronic kinematic chain when analyzing the clinical operative environment to the laboratory setting. This increase in data interpolation, coupled with intraoperative workflow challenges, reduces the degree of accuracy based on surgical application and to that observed in controlled musculoskeletal kinematic laboratory investigations.

METHODS

Review of the PubMed and Cochrane Library research databases was performed. The exhaustive literature compilation obtained was then vetted to reduce redundancies and categorized into topics of intrinsic optoelectronic accuracy, registration accuracy, musculoskeletal kinematic platforms, and clinical operative platforms.

RESULTS

A total of 147 references make up the basis for the current analysis. Regardless of application, the common denominators affecting overall optoelectronic accuracy are intrinsic accuracy, registration accuracy, and application accuracy. Intrinsic accuracy of optoelectronic tracking equaled or was less than 0.1 mm of translation and 0.1° of rotation per fiducial. Controlled laboratory platforms reported 0.1 to 0.5 mm of translation and 0.1°-1.0° of rotation per array. There is a huge falloff in clinical applications: accuracy in robotic-assisted spinal surgery reported 1.5 to 6.0 mm of translation and 1.5° to 5.0° of rotation when comparing planned to final implant position. Total Joint Robotics and da Vinci urologic robotics computed accuracy, as predicted, lies between these two extremes-1.02 mm for da Vinci and 2 mm for MAKO.

CONCLUSIONS

Navigational integrity and maintenance of fidelity of optoelectronic data is the cornerstone of robotic-assisted spinal surgery. Transitioning from controlled laboratory to clinical operative environments requires an increased number of steps in the optoelectronic kinematic chain and error potential. Diligence in planning, fiducial positioning, system registration, and intraoperative workflow have the potential to improve accuracy and decrease disparity between planned and final implant position. The key determining factors limiting navigation resolution accuracy are highlighted by this Cochrane research analysis.