The European Robotic Spinal Instrumentation (EUROSPIN) study: protocol for a multicentre prospective observational study of pedicle screw revision surgery after robot-guided, navigated and freehand thoracolumbar spinal fusion

When giants talk; robotic dialog during thoracolumbar and sacral surgery

Background

Spinal trauma patients treated in a specialized hybrid operating room (OR) using two robotic systems communicating during surgery.

Methods

Retrospective review of patients with thoracolumbar or sacral fractures who underwent surgical fixation between Jan 2017 to Jan 2020 with robotic-guided percutaneous pedicle screw insertion in the specialized hybrid OR with Robotic flat panel 3D C-arm (ArtisZeego) for intraoperative interventional imaging connected with the robotic-guidance platform Renaissance (Mazor Robotics).

Results

Twenty eight surgeries were performed in 27 patients; 23 with traumatic spinal fractures, 4 with multi-level thoracolumbar compression fractures due to severe osteoporosis. Average patient age 49 (range 12–86). Average radiation exposure time 40 s (range 12–114 s). Average radiation exposure dose 11,584 ± SD uGym² (range 4454–58,959). Lumber levels operated on were between T5 and S2 (shortest three vertebras and longest eight vertebras). 235 (range 5–11) trajectories were performed. All trajectories were accurate in all cases percutaneous pedicle screws placement was correct, without breach noted at the pedicle in any of the cases. No major complications reported. In all cases, follow-up X-rays showed adequate fracture reduction with restoration.

Conclusions

Merging of surgical robotics technologies increases patient safety and surgeon and patient confidence in percutaneous spine traumatic procedures.

Evaluating robotic pedicle screw placement against conventional modalities: a systematic review and network meta-analysis

OBJECTIVE

Several approaches have been studied for internal fixation of the spine using pedicle screws (PSs), including CT navigation, 2D and 3D fluoroscopy, freehand, and robotic assistance. Robot-assisted PS placement has been controversial because training requirements, cost, and previously unclear benefits. This meta-analysis compares screw placement accuracy, operative time, intraoperative blood loss, and overall complications of PS insertion using traditional freehand, navigated, and robot-assisted methods.

METHODS

A systematic review was performed of peer-reviewed articles indexed in several databases between January 2000 and August 2021 comparing ≥ 2 PS insertion methods with ≥ 10 screws per treatment arm. Data were extracted for patient outcomes, including PS placement, misplacement, and accuracy; operative time, overall complications, intraoperative blood loss, postoperative hospital length of stay, postoperative Oswestry Disability Index (ODI) score, and postoperative visual analog scale (VAS) score for back pain. Risk of bias was assessed using the Newcastle-Ottawa score and Cochrane tool. A network meta-analysis (NMA) was performed to estimate PS placement accuracy as the primary outcome.

RESULTS

Overall, 78 studies consisting of 6262 patients and > 31,909 PSs were included. NMA results showed that robot-assisted and 3D-fluoroscopy PS insertion had the greatest accuracy compared with freehand (p < 0.01 and p < 0.001, respectively), CT navigation (p = 0.02 and p = 0.04, respectively), and 2D fluoroscopy (p < 0.01 and p < 0.01, respectively). The surface under the cumulative ranking (SUCRA) curve method further demonstrated that robot-assisted PS insertion accuracy was superior (S = 0.937). Optimal screw placement was greatest in robot-assisted (S = 0.995) placement, and misplacement was greatest with freehand (S = 0.069) approaches. Robot-assisted placement was favorable for minimizing complications (S = 0.876), while freehand placement had greater odds of complication than robot-assisted (OR 2.49, p < 0.01) and CT-navigation (OR 2.15, p = 0.03) placement.

CONCLUSIONS

The results of this NMA suggest that robot-assisted PS insertion has advantages, including improved accuracy, optimal placement, and minimized surgical complications, compared with other PS insertion methods. Limitations included overgeneralization of categories and time-dependent effects.

Utilization trends and outcomes of computer-assisted navigation in spine fusion in the United States

BACKGROUND CONTEXT

Computer-assisted navigation (CAN) has emerged in spine surgery as an approach to improve patient outcomes. While there is substantial evidence demonstrating improved pedicle screw accuracy in CAN as compared to conventional spinal fusion (CONV), there is limited data regarding clinical outcomes and utilization trends in the United States.

PURPOSE

The purpose of this study was to determine the utilization rates of CAN in the United States, identify patient and hospital trends associated with both techniques, and to compare their results.

STUDY DESIGN

Retrospective review of national database.

PATIENT SAMPLE

Nationwide Inpatient Sample (NIS), United States national database.

OUTCOME MEASURES

CAN utilization, mortality, medical complications, neurologic complications, discharge destination, length of hospital stay, cost of hospital stay.

METHODS

The NIS database was queried to identify patients undergoing spinal fusion with CAN or CONV. CAN and CONV utilization were tracked by year and anatomic location (cervical, thoracic, lumbar/lumbosacral). Patient demographics, hospital characteristics, index length of stay (LOS), and cost of stay (COS) were compared between the cohorts. After multivariate adjustment, index hospitalization clinical outcomes were compared.

RESULTS

A total of 4,275,413 patients underwent spinal fusion surgery during the study period (2004 to 2014). CONV was performed in 98.4% (4,208,068) of cases and CAN was performed in 1.6% (67,345) of cases. The utilization rate of CAN increased from 0.04% in 2004 to 3.3% in 2014. Overall, CAN was performed most commonly in the lumbar/lumbosacral region (70.4%) compared to the cervical (20.4%) or thoracic (9.2%) regions. When normalized to region-specific rates of fusion with any technique, the proportional utilization of CAN was highest in the thoracic spine (2.7%), followed by the lumbar/lumbosacral (2.2%) and cervical (0.9%) regions. CAN utilization was positively correlated with patient factors including increasing age and number of medical comorbidities. Multivariate adjusted clinical outcomes demonstrated that compared to CONV, CAN was associated with a statistically significant decreased risk of mortality (0.28% vs 0.31%, OR=0.67, 95% CI: 0.46-0.97, p=.035) and increased risk of blood transfusions (9.1% vs 6.7%, OR=1.19, 95% CI: 1.02-1.39, p=.032). However, there was no difference in risk of neurologic complications. CAN patients had an increased average LOS (4.44 days vs. 3.97 days, p<.0001) and average COS ($34,669.49 vs $26,784.62, p<.0001) compared to CONV patients.

CONCLUSIONS

CAN utilization increased in the United States from 2004-2014. Use of CAN was proportionately higher in the thoracic and lumbar/lumbosacral regions and in older patients with more comorbidities. Given the continued trend towards increased CAN utilization, large-scale studies are needed to determine the impact of this technology on long-term clinical outcomes.

Robotics in spine surgery: A systematic review

Robotic systems to assist with pedicle screw placement have recently emerged in the field of spine surgery. Here, the authors systematically reviewed the literature for evidence of these robotic systems and their utility. Thirty-four studies that reported the use of spinal instrumentation with robotic assistance and met inclusion criteria were identified. The outcome measures gathered included: pedicle screw accuracy, indications for surgery, rates of conversion to an alternative surgical method, radiation exposure, and learning curve. In our search there were five different robotic systems identified. All studies reported accuracy and the most commonly used accuracy grading scale was the Gertzbein Robbins scale (GRS). Accuracy of clinically acceptable pedicle screws, defined as < 2 mm cortical breech, ranged from 80% to 100%. Many studies categorized indications for robotic surgery with the most common being degenerative entities. Some studies reported rates of conversion from robotic assistance to manual instrumentation due to many reasons, with robotic failure as the most common. Radiation exposure data revealed a majority of studies reported less radiation using robotic systems. Studies looking at a learning curve effect with surgeon use of robotic assistance were not consistent across the literature. Robotic systems for assistance in spine surgery have continued to improve and the accuracy of pedicle screw placement remains superior when compared to free-hand technique, however rates of manual conversion are significant. Currently, these systems are successfully employed in various pathological entities where trained spine surgeons can be safe and accurate regardless of robotic training.

Magnetic resonance imaging-based synthetic computed tomography of the lumbar spine for surgical planning: a clinical proof-of-concept

OBJECTIVE

Computed tomography scanning of the lumbar spine incurs a radiation dose ranging from 3.5 mSv to 19.5 mSv as well as relevant costs and is commonly necessary for spinal neuronavigation. Mitigation of the need for treatment-planning CT scans in the presence of MRI facilitated by MRI-based synthetic CT (sCT) would revolutionize navigated lumbar spine surgery. The authors aim to demonstrate, as a proof of concept, the capability of deep learning-based generation of sCT scans from MRI of the lumbar spine in 3 cases and to evaluate the potential of sCT for surgical planning.

METHODS

Synthetic CT reconstructions were made using a prototype version of the "BoneMRI" software. This deep learning-based image synthesis method relies on a convolutional neural network trained on paired MRI-CT data. A specific but generally available 4-minute 3D radiofrequency-spoiled T1-weighted multiple gradient echo MRI sequence was supplemented to a 1.5T lumbar spine MRI acquisition protocol.

RESULTS

In the 3 presented cases, the prototype sCT method allowed voxel-wise radiodensity estimation from MRI, resulting in qualitatively adequate CT images of the lumbar spine based on visual inspection. Normal as well as pathological structures were reliably visualized. In the first case, in which a spiral CT scan was available as a control, a volume CT dose index (CTDIvol) of 12.9 mGy could thus have been avoided. Pedicle screw trajectories and screw thickness were estimable based on sCT findings.

CONCLUSIONS

The evaluated prototype BoneMRI method enables generation of sCT scans from MRI images with only minor changes in the acquisition protocol, with a potential to reduce workflow complexity, radiation exposure, and costs. The quality of the generated CT scans was adequate based on visual inspection and could potentially be used for surgical planning, intraoperative neuronavigation, or for diagnostic purposes in an adjunctive manner.

Robot-Guided Transforaminal Versus Robot-Guided Posterior Lumbar Interbody Fusion for Lumbar Degenerative Disease

Objective

There have been no clinical studies comparing different robotic techniques. We compare minimally invasive, robot-guided transforaminal lumbar interbody fusion (RG-TLIF) and mini-open robot-guided posterior lumbar interbody fusion (RG-PLIF).

Methods

Using data from a prospective institutional registry, we identified 38 patients who underwent RG-PLIF. Propensity score matching using a nearest-neighbor algorithm was implemented to select RG-TLIF controls. Twelve-month patient-reported outcome measures are presented. A reduction of ≥ 30% from baseline was defined as the minimum clinically important difference (MCID).

Results

Among the 76 included patients, there was no difference between RG-TLIF and RG-PLIF in surgical time (132.3 ± 29.4 minutes vs. 156.5 ± 53.0 minutes, p = 0.162), length of stay (55.9 ± 20.0 hours vs. 57.2 ± 18.8 hours, p = 0.683), and radiation dose area product (310.6 ± 126.1 mGy × cm² vs. 287.9 ± 90.3 mGy × cm², p = 0.370). However, while there was no difference among the 2 groups in terms of raw postoperative patient-reported outcome measures scores (all p > 0.05), MCID in leg pain was greater for RG-PLIF (55.3% vs. 78.9%, p = 0.028), and MCID in Oswestry Disability Index was greater for RG-TLIF (92.1% vs. 68.4%, p = 0.009). There was no difference concerning back pain (81.6% vs. 68.4%, p = 0.185).

Conclusion

Our findings suggest that both RG-TLIF and RG-PLIF are viable and equally effective techniques in robotic spine surgery.

Machine learning in neurosurgery: a global survey

Background

Recent technological advances have led to the development and implementation of machine learning (ML) in various disciplines, including neurosurgery. Our goal was to conduct a comprehensive survey of neurosurgeons to assess the acceptance of and attitudes toward ML in neurosurgical practice and to identify factors associated with its use.

Methods

The online survey consisted of nine or ten mandatory questions and was distributed in February and March 2019 through the European Association of Neurosurgical Societies (EANS) and the Congress of Neurosurgeons (CNS).

Results

Out of 7280 neurosurgeons who received the survey, we received 362 responses, with a response rate of 5%, mainly in Europe and North America. In total, 103 neurosurgeons (28.5%) reported using ML in their clinical practice, and 31.1% in research. Adoption rates of ML were relatively evenly distributed, with 25.6% for North America, 30.9% for Europe, 33.3% for Latin America and the Middle East, 44.4% for Asia and Pacific and 100% for Africa with only two responses. No predictors of clinical ML use were identified, although academic settings and subspecialties neuro-oncology, functional, trauma and epilepsy predicted use of ML in research. The most common applications were for predicting outcomes and complications, as well as interpretation of imaging.

Conclusions

This report provides a global overview of the neurosurgical applications of ML. A relevant proportion of the surveyed neurosurgeons reported clinical experience with ML algorithms. Future studies should aim to clarify the role and potential benefits of ML in neurosurgery and to reconcile these potential advantages with bioethical considerations.

Role of Robotics in Improving Surgical Outcome in Spinal Pathologies

BACKGROUND

The desire to improve accuracy and safety and to favor minimally invasive techniques has given rise to spinal robotic surgery, which has seen a steady increase in utilization in the past 2 decades. However, spinal surgery encompasses a large spectrum of operative techniques, and robotic surgery currently remains confined to assistance with the trajectory of pedicle screw insertion, which has been shown to be accurate and safe based on class II and III evidence. The role of robotics in improving surgical outcomes in spinal pathologies is less clear, however.

METHODS

This comprehensive review of the literature addresses the role of robotics in surgical outcomes in spinal pathologies with a focus on the various meta-analysis and prospective randomized trials published within the past 10 years in the field.

RESULTS

It appears that robotic spinal surgery might be useful for increasing accuracy and safety in spinal instrumentation and allows for a reduction in surgical time and radiation exposure for the patient, medical staff, and operator.

CONCLUSION

Robotic assisted surgery may thus open the door to minimally invasive surgery with greater security and confidence. In addition, the use of robotics facilitates tireless repeated movements with higher precision compared with humans. Nevertheless, it is clear that further studies are now necessary to demonstrate the role of this modern tool in cost-effectiveness and in improving clinical outcomes, such as reoperation rates for screw malpositioning.

Accuracy and Safety of Robot-Assisted Drilling Decompression for Osteonecrosis of the Femoral Head

OBJECTIVE

To investigate the safety and superiority of robot-assisted femoral head drilling decompression in the treatment of femoral head necrosis.

METHODS

A total of 63 patients who underwent borehole decompression of the femoral head in our hospital from January 2016 to March 2019 were recruited. Patients were divided into two groups for comparison according to surgical methods. In the robot-assisted surgery group, there were 30 cases with 41 femoral heads. The conventional group had 33 cases and 46 femoral heads. All patients signed the consent form before the operation. The follow-up time was 6 months. The incision lengths, operation times, intraoperative blood loss, intraoperative fluoroscopies, guide needle punctures, postoperative Harris scores, and postoperative complications of the two groups were compared.

RESULTS

The incision length of the robot surgery group was 5.16 ± 0.41 cm, while that of the traditional surgery group was 7.42 ± 0.50 cm. The operation time of the robot surgery group was 46.99 ± 4.94 min, while that of the traditional surgery group was 55.01 ± 6.19 min. The fluoroscopy frequency of the robot surgery group was 10.50 ± 1.78 times, while that of the traditional surgery group was 17.91 ± 2.20 times. The intraoperative blood loss in the robotic surgery group was 20.62 ± 2.52 mL, while that in the conventional surgery group was 52.72 ± 3.39 mL. In the robot operation group, each femoral head guide needle was punctured three times, and the puncture was successful one time. The number of guided needle punctures in the traditional group was 8.02 ± 1.73. The difference between the two groups was statistically significant (P < 0.05). The Harris score was 69.53 ± 7.51 in the robot surgery group and 68.38 ± 7.26 in the traditional surgery group one month after surgery, 78.52 ± 6.49 in the robot surgery group and 76.41 ± 7.95 in the traditional surgery group three months after surgery, and 83.32 ± 8.62 in the robot surgery group and 81.74 ± 6.20 in the traditional surgery group six months after surgery. There was no significant difference between the two groups (P > 0.05). In the traditional group, there was one case of incision infection and one case of femoral head collapse during follow-up. In the robot group, there were no complications, such as incision infection and deep vein thrombosis. No collapse of the femoral head was found in the robot group during follow-up.

CONCLUSION

The positioning system of the orthopaedic robot is an ideal method for the treatment of femoral head necrosis. This method has the advantages of simple operation, accurate drilling, a short operation time, less surgical trauma, less radioactivity, and good recovery of hip joint function.