Accuracy of Robot-Assisted Percutaneous Pedicle Screw Placement for Treatment of Lumbar Spondylolisthesis: A Comparative Cohort Study

Efficacy of computer-assisted robotic based clinical training program for spinal oncology education on pedicle screw placement

Pedicle screw placement (PSP) is the fundamental surgical technique that requires high accuracy for novice orthopedists studying spinal oncology education. Therefore, we set forth to establish a computer-assisted robotic navigation training program for novice spinal oncology education. Novice orthopedists were involved in this study to evaluate the feasibility and safety of the computer-assisted robotic navigation (CARN) training program. In this research, trainees were randomly taught by the CARN training program and the traditional training program. We prospectively collected the clinical data of patients with spinal tumors from 1st May 2021 to 1st March 2022. The ability of PSP was evaluated by cumulative sum (CUSUM) analysis, learning curve, and accuracy of pedicle screws. The patients included in both groups had similar baseline characteristics. In the CUSUM analysis of the learning curve for accurate PSP, the turning point in the CARN group was lower than that in the traditional group (70th vs. 92nd pedicle screw). The LC-CUSUM test indicated competency for PSP at the 121st pedicle screw in the CARN group and the 138th pedicle screw in the traditional group. The accuracy of PSP was also significantly higher in the CARN group than in the traditional group (88.17% and 79.55%, P = 0.03 < 0.05). Furthermore, no major complications occurred in either group. We first described CARN in spinal oncology education and indicated the CARN training program as a novel, efficient and safe training program for surgeons.

Advancements in Robotic-Assisted Spine Surgery

Applications and workflows around spinal robotics have evolved since these systems were first introduced in 2004. Initially approved for lumbar pedicle screw placement, the scope of robotics has expanded to instrumentation across different regions. Additionally, precise navigation can aid in tumor resection or spinal lesion ablation. Robot-assisted surgery can improve accuracy while decreasing radiation exposure, length of hospital stay, complication, and revision rates. Disadvantages include increased operative time, dependence on preoperative imaging among others. The future of robotic spine surgery includes automated surgery, telerobotic surgery, and the inclusion of machine learning or artificial intelligence in preoperative planning.

A Propensity Score-Matched Cohort Study Comparing 3 Different Spine Pedicle Screw Fixation Methods: Freehand, Fluoroscopy-Guided, and Robot-Assisted Techniques

OBJECTIVE

This study aimed to compare the accuracy of robotic spine surgery and conventional pedicle screw fixation in lumbar degenerative disease. We evaluated clinical and radiological outcomes to demonstrate the noninferiority of robotic surgery.

METHODS

This study employed propensity score matching and included 3 groups: robot-assisted mini-open posterior lumbar interbody fusion (PLIF) (robotic surgery, RS), c-arm guided minimally invasive surgery transforaminal lumbar interbody fusion (C-arm guidance, CG), and freehand open PLIF (free of guidance, FG) (54 patients each). The mean follow-up period was 2.2 years. The preoperative spine condition was considered. Accuracy was evaluated using the Gertzbein-Robbins scale (GRS score) and Babu classification (Babu score). Radiological outcomes included adjacent segmental disease (ASD) and mechanical failure. Clinical outcomes were assessed based on the visual analogue scale, Oswestry Disability Index, 36-item Short Form health survey, and clinical ASD rate.

RESULTS

Accuracy was higher in the RS group (p < 0.01) than in other groups. The GRS score was lower in the CG group, whereas the Babu score was lower in the FG group compared with the RS group. No significant differences were observed in radiological and clinical outcomes among the 3 groups. Regression analysis identified preoperative facet degeneration, GRS and Babu scores as significant variables for radiological and clinical ASD. Mechanical failure was influenced by the GRS score and patients' age.

CONCLUSION

This study showed the superior accuracy of robotic spine surgery compared with conventional techniques. When combined with minimally invasive surgery, robotic surgery is advantageous with reduced ligament and muscle damage associated with traditional open procedures.

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).

Robot-assisted percutaneous vertebroplasty for osteoporotic vertebral compression fracture treatment and risk factor screening for postoperative refracture

Osteoporotic vertebral compression fracture (OVCF) is a serious complication of osteoporosis, and percutaneous vertebroplasty (PVP) is a major therapeutic method for OVCF. This study aimed to evaluate the clinical efficacy and postoperative complications of robot-assisted targeted PVP for the treatment of OVCF. The data from 202 OVCF patients were analyzed in this study, including 72 cases received traditional PVP (PVP group), 68 cases received robot-assisted PVP (R-PVP group), and 62 cases underwent robot-assisted PVP combined with targeted plugging (R-PVP + TP group). The fluoroscopic exposure conditions, operative duration, lengths of stay, postoperative bone cement leakage, refracture, Visual Analog Scale (VAS) score, and Oswestry Disability Index (ODI) score were obtained and compared between the three groups. The Kaplan-Meier method and logistic regression model were adopted to screen the risk factors related with postoperative refracture. R-PVP and R-PVP + TP group had significantly reduced fluoroscopic frequency and radiation dose, and reduced cement leakage compared with PVP group. R-PVP + TP not only showed more obvious advantages in these aspects, but also had a lower probability of postoperative refracture. In addition, BMD, fracture vertebral distribution, cement leakage, and surgery methods were independent related with refracture. All the results demonstrated robot assistance could improve the application of PVP in the treatment of OVCF, and robot-assisted PVP combined with targeted plugging showed significantly reduced fluoroscopic exposure, bone cement leakage, and rate of postoperative refracture. BMD, fracture vertebral distribution, cement leakage, and operation methods were identified as four risk factors for the onset of refracture after PVP.

The positional consistency between guidewire and cannulated or solid screw in robot-assisted spinal internal fixation surgery

BACKGROUND

This study aimed to investigate the positional consistency between the guidewire and the screw in spinal internal fixation surgery.

METHODS

This study involved 64 patients who underwent robot-assisted thoracic or lumbar pedicle screw fixation surgery. Guidewires were inserted with the assistance of the Tirobot. Either cannulated screws or solid screws were inserted. Guidewire and screw accuracy was measured using CT images based on the Gertzbein and Robbins scale. The positional consistency between guidewire and screw was evaluated based on the fused CT images, which could graphically and quantitatively demonstrate the consistency. The consistency was evaluated based on a grading system that considered the maximum distance and angulation between the centerline of the guidewire and the screw in the region of the pedicle.

RESULTS

A total of 322 screws were placed including 206 cannulated ones and 116 solid ones. Based on the Gertzbein and Robbins scale, 97.5% of the guidewires were grade A, and 94.1% of the screws were grade A. Based on our guidewire-screw consistency scale, 85% in cannulated group, and 69.8% in solid group, were grade A. Both solid and cannulated screws may alter trajectory compared to the guidewires. The positional accuracy and guidewire-screw consistency in the solid screw group is significantly worse than that in the cannulated screw group. The cortical bone of the pedicle has a positive guide effect on either solid or cannulated screws.

CONCLUSION

The pedicle screws may alter trajectory despite the guidance of the guidewires. Solid screws show worse positional accuracy and guidewire-screw consistency compared with cannulated screws. Trial registration The study was retrospectively registered and approved by our center's institutional review board.

Da Vinci Meets Globus Excelsius GPS: A Totally Robotic Minimally Invasive Anterior and Posterior Lumbar Fusion

BACKGROUND

Minimally invasive approaches to the spine via anterior and posterior approaches have been increasing in popularity, culminating in the development of robot-assisted spinal fusions. The da Vinci surgical robot has been used for anterior lumbar interbody fusion (ALIF), with promising results. Similarly, multiple spinal robots have been developed to assist placement of posterior pedicle screws. However, no previous cases have reported on using robots for both anterior and posterior fixation in a single surgery. We present a technical note on the first reported case of a totally robotic minimally invasive anterior and posterior lumbar fusion and instrumentation.

METHODS

A 65-year-old man with chronic low back pain and left greater than right lower extremity radiculopathy was found to have grade 1 spondylolisthesis at L5/S1 that worsened on standing upright. He underwent ALIF using a da Vinci robotic approach, followed by percutaneous posterior instrumented fusion with the Globus Excelsius GPS robot.

RESULTS

The patient did well postoperatively, with improvement of back and leg pain at 3 months follow-up. Radiography confirmed appropriate placement of the interbody cage and pedicle screws.

CONCLUSIONS

All-robotic placement of both ALIF and posterior lumbar pedicle fixation may be safe, feasible, and efficacious.

Spine Surgical Robotics: Current Status and Recent Clinical Applications

With the development of artificial intelligence and the further deepening of medical-engineering integration, spine surgical robot-assisted (RA) technique has made significant progress and its applicability in clinical practice is constantly expanding in recent years. In this review, we have systematically summarized the majority of literature related to spine surgical robots in the past decade, and not only classified robots accordingly, but also summarized the latest research progress in RA technique for screw placement such as cervical, thoracic, and lumbar pedicle screws, cortical bone trajectory screws, cervical lateral mass screws, and S2 sacroiliac screws; guiding targeted puncture and placement of endoscope via the intervertebral foramen; complete resection of spinal tumor tissue; and decompressive laminectomy. In addition, this report also provides a detailed evaluation of RA technique's advantages and disadvantages, and clarifies the accuracy, safety, and practicality of RA technique. We consider that this review can help clinical physicians further understand and familiarize the current clinical application status of spine surgical robots, thereby promoting the continuous improvement and popularization of RA technique, and ultimately benefiting numerous patients.

[Comparison of screw placement guided by O-arm navigation and ultrasound volume navigation in minimally invasive transforaminal lumbar interbody fusion]

Objective

To compare the effectiveness of O-arm navigation and ultrasound volume navigation (UVN) in guiding screw placement during minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery.

Methods

Sixty patients who underwent MIS-TLIF surgery for lumbar disc herniation between June 2022 and June 2023 and met the selection criteria were included in the study. They were randomly assigned to group A (screw placement guided by UVN during MIS-TLIF) or group B (screw placement guided by O-arm navigation during MIS-TLIF), with 30 cases in each group. There was no significant difference in baseline data, including gender, age, body mass index, and surgical segment, between the two groups ( P>0.05). Intraoperative data, including average single screw placement time, total radiation dose, and average single screw effective radiation dose, were recorded and calculated. Postoperatively, X-ray film and CT scans were performed at 10 days to evaluate screw placement accuracy and assess facet joint violation. Pearson correlation and Spearman correlation analyses were used to observe the relationship between the studied parameters (average single screw placement time and screw placement accuracy grading) and BMI.

Results

The average single screw placement time in group B was significantly shorter than that in group A, and the total radiation dose of single segment and multi-segment and the average single screw effective radiation dose in group B were significantly higher than those in group A ( P<0.05). There was no significant difference in the total radiation dose between single segment and multiple segments in group B ( P>0.05), while the total radiation dose of multiple segments was significantly higher than that of single segment in group A ( P<0.05). No significant difference was found in the accuracy of screw implantation between the two groups ( P>0.05). In both groups, the grade 1 and grade 2 screws broke through the outer wall of the pedicle, and no screw broke through the inner wall of the pedicle. There was no significant difference in the rate of facet joint violation between the two groups ( P>0.05). In group A, both the average single screw placement time and screw placement accuracy grading were positively correlated with BMI ( r=0.677, P<0.001; r=0.222, P=0.012), while in group B, neither of them was correlated with BMI ( r=0.224, P=0.233; r=0.034, P=0.697).

Conclusion

UVN-guided screw placement in MIS-TLIF surgery demonstrates comparable efficiency, visualization, and accuracy to O-arm navigation, while significantly reducing radiation exposure. However, it may be influenced by factors such as obesity, which poses certain limitations.

Robot-assisted percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a retrospective matched-cohort study

PURPOSE

This study aims to introduce the principle, clinical efficacy, and learning curve of robot-assisted percutaneous vertebroplasty (PVP).

METHODS

Forty-two patients who underwent robot-assisted single-level PVP were analyzed retrospectively and 42 age-matched patients using freehand technique were selected as the control group. The visual analog scale, operation time, radiation exposure, accuracy, and learning curve were analyzed.

RESULTS

The puncture time and total operation time were significantly shorter, and the puncture and total fluoroscopy number were fewer in the robot group. The deviation between pre-operative planned and actual puncture trajectory well met clinical requirement. The puncture time, total operation time, and puncture fluoroscopy number were significantly more in early cases than in later cases in the robot group.

CONCLUSION

The robot-assisted pedicle puncture technique shortens the operation time and reduces radiation exposure, and the accuracy meets the clinical requirement in PVP. The learning curve is short and not steep.

Cirq Robotic Assistance for Thoracolumbar Pedicle Screw Placement: Overcoming the Disadvantages of Minimally Invasive Spine Surgery

INTRODUCTION

Various minimally invasive spine surgery (MISS) techniques have been developed with the goal of reducing approach-related soft-tissue trauma and its associated complications. However, there is still a debate on some of the potential drawbacks of MISS techniques, such as their longer operating times and increased intraoperative radiation. A solution to these disadvantages could be the implementation of new technologies, such as computer-assisted navigation (CAN) and surgical robotics. We compare the standard fluoroscopy MISS technique with our experience with time per screw and X-ray exposure for pedicle screw placement using the Brainlab Cirq passive robotic arm assistance coupled with the Brainlab Curve navigation system.

METHODS

In the Cirq robot-assisted group (Group I), 109 screws were placed in 24 prospectively analyzed patients. In the fluoroscopy-guided group, 108 screws inserted into 20 consecutive patients were analyzed retrospectively (Group II). The duration of surgery, the time to place one screw, the X-ray exposition, and the pedicle screw accuracy for each patient were recorded and reviewed.

RESULTS

In total, 217 screws were analyzed. The treated levels ranged from T10 to S1. In Group I, 104 screws were grade A (95.4%) and five were grade B (4.6%). In Group II, 96 screws were grade A (88.89%); ten were grade B (9.26%); one was grade C (0.93%), and one was grade D (0.93%). While the screws placed by using the Cirq system were more accurate overall, there was no statistical significance when the two groups were compared, p = 0.3724. There was no significant difference in radiation exposure between the two groups, p = 0.5482; however the radiation exposure for the surgeon was very limited with the Cirq system. There was a significant reduction in the operation length (p = 0.0183) and the time per screw (p < 0.0001) for Group I.

CONCLUSIONS

The CAN systems and emerging robotic platforms have the potential to diminish the main disadvantages of MISS techniques-longer operation times and X-ray exposure, at least for the surgical team.

Comparison of the Accuracy and Safety of TiRobot-Assisted and Fluoroscopy-Assisted Percutaneous Pedicle Screw Placement for the Treatment of Thoracolumbar Fractures

OBJECTIVE

Studies have compared the safety and accuracy of robot-assisted techniques for inserting conventional open pedicle screws for spinal surgery. However, no relevant studies have confirmed that robot-assisted percutaneous screw placement is better than fluoroscopic percutaneous screw placement for the treatment of thoracolumbar fractures. This study compared the accuracy and safety of TiRobot-assisted percutaneous pedicle screw placement with those of the fluoroscopy-assisted percutaneous technique for the treatment of thoracolumbar fractures.

METHODS

This retrospective study included 126 patients with thoracolumbar fractures who underwent percutaneous pedicle screw placement. Sixty-five patients were treated with the TiRobot-assisted technique and 61 patients were treated with the fluoroscopy-assisted technique. Patient demographics, accuracy of screw placement (according to the Gertzbein and Robbins scale of grades A to E), screw insertion angle, radiation exposure, surgical time, intraoperative blood loss, length of hospital stay, incision length, hospital expenses, surgical site infection, and neurological injury of the TiRobot-assisted and fluoroscopy-assisted groups were compared using Student's t-test, Pearson χ² test, or Fisher's exact test.

RESULTS

A total of 729 screws were placed (TiRobot-assisted group: 374 screws; fluoroscopy-assisted group: 355 screws). In the TiRobot-assisted group, 82.8% of screws were optimally positioned (grade A); however, the placement grades of the remaining screws were categorized as grade B (13.3%), grade C (3.2%), and grade D (0.5%). In the fluoroscopy-assisted group, 66.7% of the screws were optimally positioned (grade A); however, the placement grades of the remaining screws were categorized as grade B (21.4%), grade C (7.6%), grade D (3.6%), and grade E (0.5%). The proportion of clinically acceptable screws (grade A or B) was greater in the TiRobot-assisted group than in the fluoroscopy-assisted group. Additionally, the TiRobot-assisted group had a significantly larger mean screw insertion angle (22.27° ± 5.48° vs 20.55° ± 5.15°), larger incision length (13.86 ± 1.24 cm vs 12.77 ± 1.43 cm), and higher hospital expenses (69061.55 ± 7166.60 yuan vs 59383.85 ± 5019.64 yuan) than the fluoroscopy-assisted group. There were no significant differences in the intraoperative blood loss, length of hospital stay, and rates of surgical site infection and neurological injury in both groups (p > 0.05). However, the TiRobot-assisted group had significantly better surgical times, radiation times, and radiation exposure than the fluoroscopy-assisted group (p < 0.05).

CONCLUSIONS

Percutaneous TiRobot-assisted pedicle screw placement is a safe, useful, and potentially more accurate alternative to the percutaneous fluoroscopy-assisted technique for treating thoracolumbar fractures.

Biomechanical evaluation of a short-rod technique for lumbar fixation surgery

Objective: The purpose of this study was to analyze the stability and instrument-related complications associated with fixation of the lumbar spine using the Short-Rod (SR) technique.

Methods: Using finite element analysis, this study assessed the stability of a bilateral lumbar fixation system when inserting the pedicle screws at angles of 10°, 15°, and 20° to the endplate in the sagittal plane. Using the most stable construct with a screw angle, the model was then assessed with different rod lengths of 25, 30, 35, and 45 mm. The optimal screw inclination angle and rod length were incorporated into the SR model and compared against traditional parallel screw insertion (pedicle screws in parallel to the endplate, PPS) in terms of the stability and risk of instrument-related complications. The following parameters were evaluated using the validated L4–L5 lumbar finite element model: axial stiffness, range of motion (ROM), stress on the endplate and facet joint, von-Mises stress on the contact surface between the screw and rod (CSSR), and screw displacement.

Results: The results showed that the SR model with a 15° screw inclination angle and 35 mm rod length was superior in terms of construct stability and risk of complications. Compared to the PPS model, the SR model had lower stiffness, lower ROM, less screw displacement, and lower stress on the facet cartilage, the CSSR, and screws. However, the SR model also suffered more stress on the endplate in flexion and lateral bending.

Conclusion: The SR technique with a 15° screw inclination and 35 mm rod length offers good lumbar stability with a low risk of instrument-related complications.

Safety and risk factors of TINAVI robot-assisted percutaneous pedicle screw placement in spinal surgery

Objective

To determine the rates and risk factors of pedicle screw placement accuracy and the proximal facet joint violation (FJV) using TINAVI robot-assisted technique.

Methods

Patients with thoracolumbar fractures or degenerative diseases were retrospectively recruited from June 2018 and June 2020. The pedicle penetration and proximal FJV were compared in different instrumental levels to identify the safe and risk segments during insertion. Moreover, the factors were also assessed using univariate and multivariate analyses.

Results

A total of 72 patients with 332 pedicle screws were included in the current study. The optimal and clinically acceptable screw positions were 85.8% and 93.4%. Of the 332 screws concerning the intra-pedicular accuracy, 285 screws (85.8%) were evaluated as Grade A according to the Gertzbein and Robbins scale, with the remaining 25 (7.6%), 10 (3.0%), 6 (1.8%), and 6 screws (1.8%) as Grades B, C, D, and E. Moreover, in terms of the proximal FJV, 255 screws (76.8%) screws were assessed as Grade 0 according to the Babu scale, with the remaining 34 (10.3%), 22 (6.6%), and 21 screws (6.3%) as Grades 1, 2, and 3. Furthermore, the univariate analysis showed significantly higher rate of penetration for patients with age < 61 years old, sex of female, thoracolumbar insertion, shorter distance from skin to insertion point, and smaller facet angle. Meanwhile, the patients with the sex of female, BMI < 25.9, grade I spondylolisthesis, lumbosacral insertion, longer distance from skin to insertion point, and larger facet angle had a significantly higher rate of proximal FJV. The outcomes of multivariate analyses showed that sex of male (adjusted OR 0.320, 95% CI 0.140–0.732; p = 0.007), facet angle ≥ 45° (adjusted OR 0.266, 95% CI 0.090–0.786; p = 0.017), distance from skin to insertion point ≥ 4.5 cm (adjusted OR 0.342, 95% CI 0.134–0.868; p = 0.024), and lumbosacral instrumentation (adjusted OR 0.227, 95% CI 0.091–0.566; p = 0.001) were independently associated with intra-pedicular accuracy; the L5 insertion (adjusted OR 2.020, 95% CI 1.084–3.766; p = 0.027) and facet angle ≥ 45° (adjusted OR 1.839, 95% CI 1.026–3.298; p = 0.041) were independently associated with the proximal FJV.

Conclusion

TINAVI robot-assisted technique was associated with a high rate of pedicle screw placement and a low rate of proximal FJV. This new technique showed a safe and precise performance for pedicle screw placement in spinal surgery. Facet angle ≥ 45° is independently associated with both the intra-pedicular accuracy and proximal FJV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03271-6.

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.

Accuracy and safety of percutaneous pedicle screw placement using the K-wireless minimally invasive spine percutaneous pedicle screw system in Japan: A randomized active controlled study

•

We compared the VIPER PRIME™ (VP) with existing percutaneous pedicle screw systems.

•

Screw-placement accuracy was not inferior using VP compared with previous systems.

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Use of VP reduced the screw-insertion time and use of fluoroscopy.

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VP was not associated with any device- or treatment-related adverse events.

•

VP could reduce radiation exposure and provide accurate pedicle screw placement.

Background

Minimally invasive lumbar fusion has recently become a widely used technique worldwide. This randomized active controlled study was conducted to demonstrate the non-inferiority of the K-wireless Minimally Invasive Spine (MIS) Percutaneous Pedicle Screw (PPS) system compared with use of the six pedicle screw systems currently used in our practices with respect to the accuracy of pedicle screw placement.Also to compare the screw-insertion time and number of fluoroscopic observations during screw insertion between the groups.

Methods

A total of 80 patients with degenerative spinal diseases or vertebral fractures were assigned, including 41 patients in the K-wireless MIS PPS system group (K-wireless group) and 39 in the control group (K-wire group).

The accuracy of the screw insertion, screw-insertion time, number of fluoroscopic observations during screw insertion, and the incidence of adverse events were compared between the K-wireless group and the K-wire group. The accuracy rate was calculated as the number of screws with no breach divided by the total number of screws.

Results

The accuracy rates of screw insertion were 85.7% and 75.0% in the K-wireless and K-wire groups, respectively, with an intergroup difference of 10.7% (95% confidence interval: 2.3–19.1%). The K-wireless group demonstrated non-inferiority compared with the K-wire group. The mean screw-insertion time was significantly shorter in the K-wireless group (2.62 and 2.97 min in the K-wireless and K-wire groups, respectively; P=0.005). There were also significantly fewer fluoroscopies in the K-wireless group (10.7 and 17.4 in the K-wireless and K-wire groups, respectively; P<0.001). There were no device-related or study treatment-related adverse events in either group.

Conclusions

The accuracy of pedicle screw insertion using the K-wireless MIS PPS system was not inferior to that of existing products. In terms of safety, no product-related or treatment-related adverse events were identified in this study and no new safety concerns were noted.

Rates and risk factors of intrapedicular accuracy and cranial facet joint violation among robot-assisted, fluoroscopy-guided percutaneous, and freehand techniques in pedicle screw fixation of thoracolumbar fractures: a comparative cohort study

Background

Robot-assisted (RA) technique has been increasingly applied in clinical practice, providing promising outcomes of inserting accuracy and cranial facet joint protection. However, studies comparing this novel method with other assisted methods are rare, and the controversy of the superiority between the insertion techniques remains. Thus, we compare the rates and risk factors of intrapedicular accuracy and cranial facet joint violation (FJV) of RA, fluoroscopy-guided percutaneous (FP), and freehand (FH) techniques in the treatment of thoracolumbar fractures.

Methods

A total of 74 patients with thoracolumbar fractures requiring pedicle screw instruments were retrospectively included and divided into RA, FP, and FH groups from June 2016 to May 2020. The primary outcomes were the intrapedicular accuracy and cranial FJV. The factors that affected the intrapedicular accuracy and cranial FJV were assessed using multivariate analyses.

Results

The optimal intrapedicular accuracy of pedicle screw placement (Grade A) in the RA, FP, and FH groups was 94.3%, 78.2%, and 88.7%, respectively. This finding indicates no significant differences of RA over FH technique (P = 0.062) and FP technique (P = 0.025), but significantly higher accuracies of RA over FP (P < 0.001). In addition, the rates of proximal FJV in RA, FP, and FH groups were 13.9%, 30.8%, and 22.7%, respectively. RA had a significantly greater proportion of intact facet joints than the FP (P = 0.002). However, FP and FH (P = 0.157), as well as RA and FH (P = 0.035) showed significantly similar outcomes with respect to the proximal FJV. The logistic regression analysis showed that FP technique (OR = 3.056) was independently associated with insertion accuracy. Meanwhile, the age (OR = 0.974), pedicle angle (OR = 0.921), moderate facet joint osteoarthritis (OR = 5.584), and severe facet joint osteoarthritis (OR = 11.956) were independently associated with cranial FJV.

Conclusion

RA technique showed a higher rate of intrapedicular accuracy and a lower rate of cranial FJV than FP technique, and similar outcomes to FH technique in terms of intrapedicular accuracy and cranial FJV. RA technique might be a safe method for pedicle screw placement in thoracolumbar surgery.

Level of evidence

3

Accuracy of Robot-Assisted Percutaneous Pedicle Screw Placement under Regional Anesthesia: A Retrospective Cohort Study

Background

Robot-assisted pedicle screw placement is usually performed under general anesthesia to keep the body still. The aim of this study was to compare the accuracy of the robot-assisted technique under regional anesthesia with that of conventional fluoroscopy-guided percutaneous pedicle screw placement under general anesthesia in minimally invasive lumbar fusion surgery.

Methods

This study recruited patients who underwent robot-assisted percutaneous endoscopic lumbar interbody fusion (PELIF) or fluoroscopy-guided minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) between December 2017 and February 2020 at a single center. Based on the method of percutaneous pedicle screw placement used, patients were divided into the robot-assisted under regional anesthesia (group RE-RO) and fluoroscopy-guided under general anesthesia (group GE-FLU) groups. The primary outcome measures were screw accuracy and the incidence of facet joint violation (FJV). Secondary outcome measures included X-ray and visual analogue scale (VAS) scores which were used to evaluate the degree of the postoperative pain at 4 hours and on postoperative days 1, 2, and 3. Intraoperative adverse events were also recorded.

Results

Eighteen patients were included in group RE-RO, and 23 patients were included in group GE-FLU. The percentages of clinically acceptable screws (Gertzbein and Robbins grades A and B) were 94.4% and 91.5%, respectively. There was no significant difference in the percentages of clinically acceptable screws (p=0.44) or overall Gertzbein and Robbins screw accuracy grades (p=0.35). Only the top screws were included in the analysis of FJVs. The percentages of FJV (Babu grades 1, 2, and 3) were 5.6% and 28.3%, respectively. This difference was statistically significant (p=0.01). Overall, the FJV grades in group RE-RO were significantly better than those in group GE-FLU (p=0.009). The mean fluoroscopy time for each screw in group RE-RO was significantly shorter than that in group GE-FLU (group RE-RO: 5.4 ± 1.9 seconds and group GE-FLU: 6.8 ± 2.0 seconds; p=0.03). The postoperative pain between the RE-RO and GE-FLU groups was not statistically significant. The intraoperative adverse events included 1 case of registration failure and 1 case of guide-wire dislodgment in group RE-RO, as well as 2 cases of screw misplacement in group GE-FLU. No complications related to anesthesia were observed.

Conclusion

Robot-assisted pedicle screw placement under regional anesthesia can be performed effectively and safely. The accuracy is comparable to the conventional technique. Moreover, this technique has the advantage of fewer FJVs and a lower radiation time.

Autonomous lumbar spine pedicle screw planning using machine learning: A validation study

Introduction:

Several techniques for pedicle screw placement have been described including freehand techniques, fluoroscopy assisted, computed tomography (CT) guidance, and robotics. Image-guided surgery offers the potential to combine the benefits of CT guidance without the added radiation. This study investigated the ability of a neural network to place lumbar pedicle screws with the correct length, diameter, and angulation autonomously within radiographs without the need for human involvement.

Materials and Methods:

The neural network was trained using a machine learning process. The method combines the previously reported autonomous spine segmentation solution with a landmark localization solution. The pedicle screw placement was evaluated using the Zdichavsky, Ravi, and Gertzbein grading systems.

Results:

In total, the program placed 208 pedicle screws between the L1 and S1 spinal levels. Of the 208 placed pedicle screws, 208 (100%) had a Zdichavsky Score 1A, 206 (99.0%) of all screws were Ravi Grade 1, and Gertzbein Grade A indicating no breech. The final two screws (1.0%) had a Ravi score of 2 (<2 mm breech) and a Gertzbein grade of B (<2 mm breech).

Conclusion:

The results of this experiment can be combined with an image-guided platform to provide an efficient and highly effective method of placing pedicle screws during spinal stabilization surgery.

[The safety of TiRobot-guided percutaneous transpedicular screw implantation]

OBJECTIVE

To evaluate the safety of TiRobot-guided percutaneous transpedicular screw implantation.

METHODS

The medical records of 158 patients with thoracolumbar fractures and lumbar degenerative diseases who underwent percutaneous transpedicular screw implantation were retrospectively analyzed between January 2018 and December 2020. The patients were divided into trial group (TiRobot-guided screw implantation, 86 cases) and control group (fluoroscopy-guided screw implantation, 72 cases). There was no significant difference in gender, age, pathology, lesion segment, and the average number of screw implantation per case ( P>0.05). The operation time, fluoroscopic dose, fluoroscopic time, and fluoroscopic frequency were compared between the two groups. One day postoperatively, the convergence angle was measured and the penetration of the pedicle cortex was evaluated according to Gertzbein-Robbins classification standard.

RESULTS

The operation time, fluoroscopic dose, fluoroscopic time, and fluoroscopic frequency of the trial group were significantly lesser than those of control group ( P<0.05). One day postoperatively, the convergence angle of trial group was (21.10±4.08)°, which was significantly larger than control group (19.17±3.48)° ( t=6.810, P=0.000). According to the Gertzbein-Robbins classification standard, 446 pedicle screws were implanted in trial group, trajectories were grade A in 377 screws, grade B in 46 screws, grade C in 23 screws, and the accuracy of screw implantation was 94.8%; 380 pedicle screws were implanted in control group, trajectories were grade A in 283 screws, grade B in 45 screws, grade C in 44 screws, grade D in 6 screws, grade E in 2 screws, and the accuracy of screw implantation was 86.3%. There was significant difference in the accuracy of screw implantation between the two groups ( χ 2=25.950, P=0.000).

CONCLUSION

Compared with traditional percutaneous transpedicular screw implantation, TiRobot-guided percutaneous transpedicular screw implantation can improve the accuracy of screw implantation, reduce radiation exposure, and improve surgical safety, which has a good application prospect.

[Three-dimensional printed drill guide template assisting percutaneous pedicle screw fixation for multiple-level thoracolumbar fractures]

Objective

To evaluate the feasibility and safety of three-dimensional (3D) printed drill guide template-assisted percutaneous pedicle screw fixation for multiple-level thoracolumbar fractures.

Methods

Clinical data of 19 patients with multilevel thoracolumbar fracture without nerve injury who underwent surgical treatment between May 2017 and January 2019 were retrospectively analyzed. There were 9 males and 10 females and their age ranged from 22 to 63 years, with an average age of 43.6 years. Injury cause included traffic accident injury in 12 cases, and fall from height injury in 7 cases. A total of 40 fractured vertebrae were involved in T ₁₀ to L ₃ levels. According to AO classification, there were 29 fractures of type A1, 9 fractures of type A2, and 2 fractures of type A3. According to TANG Sanyuan classification, multiple-segment thoracolumbar fractures were classified as 17 cases of type ⅠA, 1 case of type ⅠB, and 1 case of type ⅡC. The time from injury to operation was 2-6 days, with an average of 3.1 days. The 3D-printed universal drill guide template was used for assisting percutaneous pedicle screw fixation during operation. Intraoperative blood loss, average operation time and fluoroscopy frequency of each screw were recorded. Visual analogue scale (VAS) score was used to evaluate the improvement of low back pain before operation, at 3 days after operation, and at last follow-up. According to the CT at 3 days after operation, the Gertzbein and Robbins scales were used to evaluate the accuracy of screw insertion (the grade A and grade B were regarded as accuracy, the grade A was regarded as excellent of screw insertion). The Cobb angle in sagittal plane of the fracture segment was measured, and the percentage of anterior edge of injured vertebral height was calculated. The consistency of the inclination of bilateral pedicle screws were analyzed postoperatively, and compared the angle of the intraoperative guide plate with the inclination of screw to verify the effectiveness of the guide plate in controlling the inclination.

Results

All the 19 patients completed the operation successfully, and the intraoperative blood loss was 44-67 mL, with an average of 54.3 mL. The average operation time for each screw insertion was 7.3-11.1 minutes, with an average of 9.6 minutes. The average fluoroscopy frequency of each screw insertion was 1.6-2.5 times, with an average of 2.0 times. No spinal cord, nerve root injury, infection, and other complications occurred. All patients were followed up 24-38 months, with an average of 28.7 months. The accuracy of pedicle screws was evaluated by using Gertzbein and Robbins scales: 145 screws were grade A and 11 screws were grade B. The accuracy of screw insertion was 100% and the excellent rate was 92.9%. The CT data at 3 days after operation showed no significant difference in the inclination between the left and right screws in the same vertebral body ( t=0.93, P=0.36). There was no significant difference between the angle of guide plate and the screw inclination ( P>0.05). The VAS score, Cobb angle in sagittal plane, and the percentage of anterior edge of injured vertebral height were significantly improved at 3 days after operation and at last follow-up, and the VAS score was declined at last follow-up compared with 3 days after operation, all showing significant differences ( P<0.05). There was no significant difference in the sagittal Cobb angle and the percentage of anterior edge of injured vertebral height between two postoperative time points ( P>0.05). At last follow-up, no internal fixators were loosened or broken, and all fractures healed well.

Conclusion

For the multiple-level thoracolumbar fractures, 3D-printed drill guide template assisting percutaneous pedicle screw fixation can reduce the operation time, intraoperative blood loss, and fluoroscopy frequency and the screw insertion is accurate and has a good reduction effect.

Accuracy and deviation analysis of robot-assisted spinal implants: A retrospective overview of 105 cases and preliminary comparison to open freehand surgery in lumbar spondylolisthesis

BACKGROUND

Whether the accuracy of robot-assisted spinal screw placement is significantly higher than that of freehand and the source of robotic deviation remain unclear.

METHODS

Clinical data of 105 patients who underwent robot-assisted spinal surgery was collected, and screw accuracy was evaluated by computed tomography according to the modified Gertzbein-Robbins classification. Patients were grouped by percutaneous and open surgery. Intergroup comparisons of clinical and screw accuracy parameters were performed. Reasons for deviation were determined. Thirty-one patients with lumbar spondylolisthesis undergoing open robot-assisted surgery and the same number of patients treated by open freehand surgery were compared for screw accuracy.

RESULTS

Screw accuracy was not significantly different between the percutaneous and open groups in both intra- and postoperative evaluations. Tool skiving was identified as the main cause of deviation. The proportion of malpositioned screws (grade B + C + D) was significantly higher in the freehand group than in the robot-assisted group. However, remarkably malpositioned (grade C + D) screws showed no significant differences between the groups. No revision surgery was necessary.

CONCLUSIONS

Robot-assisted spinal instrumentation manifests high accuracy and low incidence of nerve injury. Tool skiving is a major cause of implant deviation.

Robotic-Navigated Percutaneous Pedicle Screw Placement Has Less Facet Joint Violation Than Fluoroscopy-Guided Percutaneous Screws

OBJECTIVE

To directly compare robotic-versus fluoroscopy-guided percutaneous pedicle screw (PPS) placement in thoracolumbar spine trauma with a focus on clinically acceptable pedicle screw accuracy and facet joint violation (FJV).

METHODS

A retrospective chart review assessed 37 trauma patients undergoing percutaneous thoracic and/or lumbar fixation. Postoperative computed tomography images were reviewed by authors blinded to surgical technique who assessed pedicle screw trajectory accuracy and FJV frequency.

RESULTS

Seventeen patients underwent placement of 143 PPS with robotic assistance (robot group), compared with 20 patients receiving 149 PPS using fluoroscopy assistance (control group). Overall, the robot cohort demonstrated decreased FJV frequency of 2.8% versus 14.8% in controls (P = 0.0003). When further stratified by level of surgery (i.e., upper thoracic, lower thoracic, lumbar spine), the robot group had FJV frequencies of 0%, 3.2%, and 3.7%, respectively, compared with 17.7% (P = 0.0209), 14.3% (P = 0.0455), and 11.9% (P = 0.2340) in controls. The robot group had 84.6% clinically acceptable screw trajectories compared with 81.9% in controls (P = 0.6388). Within the upper thoracic, lower thoracic, and lumbar regions, the robot group had acceptable screw trajectories of 66.7%, 87.1%, and 90.7%, respectively, compared with 58.8% (P = 0.6261), 91.1% (P = 0.5655), and 97.6% (P = 0.2263) in controls.

CONCLUSIONS

There was no significant difference in clinically acceptable screw trajectory accuracy between robotic versus fluoroscopy-guided PPS placement. However, the robot cohort demonstrated a statistically significantly decreased FJV overall and specifically within the thoracic spine region. Use of robotic technology may improve radiographic outcomes for a subset of patients or spine surgeries.

Robot-assisted minimally invasive transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion: a retrospective matched-control analysis for clinical and quality-of-life outcomes

Aim: To compare the screw accuracy and clinical outcomes between robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA MIS-TLIF) and open TLIF in the treatment of one-level lumbar degenerative disease. Materials & methods: From May 2018 to December 2019, a consecutive series of patients undergoing robot-assisted minimally invasive one-level lumbar fusion procedures were retrospectively compared with matched controls who underwent one-level open TLIF procedures for clinical and quality-of-life outcomes. Results: A total of 52 patients underwent RA MIS-TLIF procedures (robot-assisted [RA] group) and 52 matched controls received freehand open TLIF procedures (open [OP] group). The RA group had more grade A screws with 96.2% one-time success rate of screw placement (p < 0.05). Besides, the RA group experienced less intraoperative blood loss and shorter length of hospital stay, while the OP group had shorter operative duration and cumulative radiation time (p < 0.001). What is more, the average VAS score for low back pain and ODI score in the RA group were lower than that in the OP group 1 month after operation (p < 0.05). Conclusion: The use of real-time, image-guided robot system may further expand the advantages of MIS-TLIF technique in terms of accuracy and safety.

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.

[Robot-guided percutaneous kyphoplasty in treatment of multi-segmental osteoporotic vertebral compression fracture]

Objective

To evaluate the safety and effectiveness of robot-guided percutaneous kyphoplasty (PKP) in treatment of multi-segmental thoracolumbar osteoporotic vertebral compression fracture (OVCF).

Methods

A clinical data of 63 cases with multi-segmental thoracolumbar OVCF without neurologic deficit treated with PKP between October 2017 and February 2019 were analyzed retrospectively. The patients were divided into robot-guided group (33 cases) and traditional fluoroscopy group (30 cases). There was no significant difference in gender, age, fracture segment, bone mineral density, and preoperative visual analogue scale (VAS) score, midline vertebral height, and Cobb angle between the two groups ( P>0.05). The time to establish the tunnel, the times of fluoroscopy, the dose of fluoroscopy, the deviation of puncture, the distribution of bone cement, the leakage of bone cement, the puncture angle, and the postoperative VAS score, midline vertebral height, and Cobb angle were recorded and compared.

Results

The patients in two groups were followed up 11-13 months (mean, 12 months). Compared with traditional fluoroscopy group, the time to establish the tunnel, the times and dose of fluoroscopy in robot-guided group were significantly lower, the deviation of puncture was slighter, the distribution of bone cement was better, and the puncture angle was larger, the differences between the two groups were significant ( P<0.05). There were 8 segments (9.3%, 8/86) of bone leakage in robot-guided group and 17 segments (22.6%, 17/75) in traditional fluoroscopy group, the difference between the two groups was significant ( χ ²=5.455, P=0.020). There was no significant difference in VAS score, the midline vertebral height, and Cobb angle between the two groups at 2 days after operation and last follow-up ( P>0.05).

Conclusion

Robot-guided PKP in treatment of multi-segmental thoracolumbar OVCF can shorten the operation time, improve the accuracy of puncture, reduce the times and dose of fluoroscopy, reduce the leakage of bone cement, and achieve better cement distribution.

[A comparative study of spinal robot-assisted and traditional fluoroscopy-assisted percutaneous reduction and internal fixation for single-level thoracolumbar fractures without neurological symptoms]

Objective

To compare the effectiveness and screw planting accuracy of percutaneous reduction and internal fixation with robot and traditional fluoroscopy-assisted in the treatment of single-level thoracolumbar fractures without neurological symptoms.

Methods

The clinical data of 58 patients with single-level thoracolumbar fractures without neurological symptoms between December 2016 and January 2018 were retrospectively analysed. According to different surgical methods, the patients were divided into group A (28 cases underwent robot-assisted percutaneous reduction and internal fixation) and group B (30 cases underwent fluoroscopy-assisted percutaneous reduction and internal fixation). There was no neurological symptoms, other fractures or organ injuries in the two groups. There was no significant difference in general data of age, gender, fracture location, AO classification, time from injury to surgery, and preoperative vertebral anterior height ratio, sagittal Cobb angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI) score between the two groups ( P>0.05). The screw placement time, operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, hospitalization time, operation cost, postoperative complications, VAS score, ODI score, anterior vertebral height ratio, and sagittal Cobb angle before operation, at 3 days, 6 months after operation, and at last follow-up were recorded and compared between the two groups. The accuracy of the pedicle screw placement was evaluated by Neo's criteria.

Results

The screw placement time, operation time, and intraoperative fluoroscopy frequency of group A were significantly less than those of group B, and the operation cost was significantly higher than that of group B ( P<0.05). But there was no significant difference in intraoperative blood loss and hospitalization time between the two groups ( P>0.05). Both groups were followed up 12-24 months, with an average of 15.2 months. The accuracy rate of screw placement in groups A and B was 93.75% (150/160) and 84.71% (144/170), respectively, and the difference was significant ( χ ²=5.820, P=0.008). Except for 1 case of postoperative superficial infection in group A and wound healing after dressing change, there was no complication such as neurovascular injury, screw loosening and fracture in both groups, and there was no significant difference in the incidence of complications between the two groups ( χ ²=0.625, P=0.547). The anterior vertebral height ratio, sagittal Cobb angle, VAS score, and ODI score of the two groups were significantly improved ( P<0.05); there was no significant difference between the two groups at all time points after operation ( P>0.05).

Conclusion

The spinal robot and traditional fluoroscopy-assisted percutaneous reduction and internal fixation can both achieve satisfactory effectiveness in the treatment of single-level thoracolumbar fractures without neurological symptoms. However, the former has higher accuracy, fewer fluoroscopy times, shorter time of screw placement, and lower technical requirements for the operator. It has wide application potential.

Navigated robotic assistance improves pedicle screw accuracy in minimally invasive surgery of the lumbosacral spine: 600 pedicle screws in a single institution

BACKGROUND

In the emerging field of robot-assisted spine surgery, radiographic evaluation of pedicle screw accuracy in the surgical setting is of high interest. Advances in medical imaging have improved the accuracy of pedicle screw placement, from fluoroscopy-guided to computer-aided navigation.

METHODS

A retrospective, institutional review board-exempt review of the first 106 navigated robot-assisted spine surgery cases was performed. Radiographic evaluation of preoperative and postoperative computerized tomography (CT) scans were collected.

RESULTS

In the first 106 cases, 630 lumbosacral pedicle screws were placed. Thirty screws were placed in five patients without the robot because of surgeon discretion. Of the 600 pedicle screws inserted by navigated robotic guidance, only 1.5% (9/600) were repositioned intraoperatively.

CONCLUSION

This study demonstrated a high level of accuracy (98.2%) in terms of grade A or B pedicle screw breach scores in the clinical use of navigated, robot-assisted surgery in its first 101 cases.

Robotic navigation during spine surgery

Introduction: Potential complications associated with screw malposition may result in neurological deficits or vascular injuries. Spine surgery has significantly developed under the assistance of technological progress. The advantages of applying robotic technology in spine surgery include the possibility of improving screw accuracy, reducing complications, decreasing fluoroscopy use.Areas covered: We critically evaluated the current literature on the radiographic and clinical outcomes of robotic-assisted spine surgery, including accuracy, radiation exposure, operative time, and complication rates.Expert opinion: Robotic-assisted spine surgery shows promising results and has the potentials for further investigations. The robot-assisted spine surgery is appeared to be more accurate in pedicle screw placement than the free-hand technique. In general, the robot-assisted technique is associated with shorter radiation exposure time but longer operative time than free-hand technique. For higher accuracy of robotic-assisted spine surgery, technical advancement and high-quality researches are needed. Artificial intelligent technology, decompression function, and higher accuracy are the directions for the development of robotic-assisted spine surgery.