Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends

A novel affordable user interface for robotic surgery training: design, development and usability study

Introduction

The use of robotic systems in the surgical domain has become groundbreaking for patients and surgeons in the last decades. While the annual number of robotic surgical procedures continues to increase rapidly, it is essential to provide the surgeon with innovative training courses along with the standard specialization path. To this end, simulators play a fundamental role. Currently, the high cost of the leading VR simulators limits their accessibility to educational institutions. The challenge lies in balancing high-fidelity simulation with cost-effectiveness; however, few cost-effective options exist for robotic surgery training.

Methods

This paper proposes the design, development and user-centered usability study of an affordable user interface to control a surgical robot simulator. It consists of a cart equipped with two haptic interfaces, a VR visor and two pedals. The simulations were created using Unity, which offers versatility for expanding the simulator to more complex scenes. An intuitive teleoperation control of the simulated robotic instruments is achieved through a high-level control strategy.

Results and Discussion

Its affordability and resemblance to real surgeon consoles make it ideal for implementing robotic surgery training programs in medical schools, enhancing accessibility to a broader audience. This is demonstrated by the results of an usability study involving expert surgeons who use surgical robots regularly, expert surgeons without robotic surgery experience, and a control group. The results of the study, which was based on a traditional Peg-board exercise and Camera Control task, demonstrate the simulator's high usability and intuitive control across diverse user groups, including those with limited experience. This offers evidence that this affordable system is a promising solution for expanding robotic surgery training.

Advancing robot-guided techniques in lumbar spine surgery: a systematic review and meta-analysis

BACKGROUND

Lumbar spine surgery is a crucial intervention for addressing spinal injuries or conditions affecting the spine, often involving lumbar fusion through pedicle screw (PS) insertion. The precision of PS placement is pivotal in orthopedic surgery. This systematic review compares the accuracy of robot-guided (RG) surgery with free-hand fluoroscopy-guided (FFG), free-hand without fluoroscopy-guided (FHG), and computed tomography image-guided (CTG) techniques for PS insertion.

METHODS

A systematic search of various databases from 1 January 2013 to 30 December 2023 was conducted following PRISMA guidelines. Primary outcomes, including PS insertion accuracy and breach rate, were analyzed using a random-effects model. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

The overall accuracy of PS insertion using RG, based on 37 studies involving 3,837 patients and 22,117 PS, is 97.9%, with a breach rate of 0.021. RG demonstrated superior accuracy compared to FHG and CTG, with breach rates of 3.4 and 0.015 respectively for RG versus FHG, and 3.8 and 0.026 for RG versus CTG. Additionally, RG was associated with reduced mean estimated blood loss compared to CTG, indicating improved safety.

CONCLUSIONS

The RG is associated with enhanced accuracy of PS insertion and reduced breach rates over other methods. However, additional randomized controlled trials comparing these modalities are needed for further validation.

PROSPERO REGISTRATION

CRD42023483997.

Robotic-assisted spine surgery-a narrative review

Background and Objective

Emerging technologies have increasingly been adopted in spine surgery in the attempt to increase precision and improve outcomes. Robotic assistance is an area of significant interest, with proposed benefits including increased accuracy, decreased complication rates, and decreased radiation exposure. The purpose of this review is to provide an overview of the currently available robotic assistance systems and their associated outcomes and limitations.

Methods

A review of national databases was performed using key terms "robotic", "spine", and "surgery" for literature from 2014 to 2023. Studies that aimed to describe the utilities of endoscopic surgeries, associated outcomes, limitations, and future directions were included. Studies that were not in English were excluded.

Key Content and Findings

This review includes a brief overview of the history of robotic spine surgery as well as its clinical outcomes, limitations, and future directions.

Conclusions

Robotic-assisted spine surgery has seen increasing use in the attempt to increase precision and improve outcomes and has been associated with increased accuracy in pedicle screw placement and decreased complication rates. Barriers to its adoption include a significant learning curve, possibly longer operative cases, and significant associated costs. As robotic assistance continues to become increasingly popular in spine surgery, it is critical for surgeons to understand the technology available and the associated outcomes to make informed decisions when considering which system to incorporate into their practice.

Accuracy and postoperative assessment of robot-assisted placement of pedicle screws during scoliosis surgery compared with conventional freehand technique: a systematic review and meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

BACKGROUND

The complexity of human anatomical structures and the variability of vertebral body structures in patients with scoliosis pose challenges in pedicle screw placement during spinal deformity correction surgery. Through technological advancements, robots have been introduced in spinal surgery to assist with pedicle screw placement.

METHODS

A systematic search was conducted using PubMed, Cochrane, Embase, and CNKI databases and comparative studies assessing the accuracy and postoperative efficacy of pedicle screw placement using robotic assistance or freehand techniques in patients with scoliosis were included. The analysis evaluated the accuracy of screw placement, operative duration, intraoperative blood loss, length of postoperative hospital stay, and complications.

RESULTS

Seven studies comprising 584 patients were included in the meta-analysis, with 282 patients (48.3%) in the robot-assisted group and 320 (51.7%) in the freehand group. Robot-assisted placement showed significantly better clinically acceptable screw placement results compared with freehand placement (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.75-3.91, P < 0.0001). However, there were no statistically significant differences in achieving "perfect" screw placement between the two groups (OR: 1.52, 95% CI: 0.95-2.46, P = 0.08). The robot-assisted group had longer operation durations (mean deviation [MD]: 43.64, 95% CI: 22.25-64.74, P < 0.0001) but shorter postoperative hospital stays (MD: - 1.12, 95% CI: - 2.15 to - 0.08, P = 0.03) than the freehand group. There were no significant differences in overall complication rates or intraoperative blood loss between the two groups. There was no significant difference in Cobb Angle between the two groups before and after operation.

CONCLUSION

Robot-assisted pedicle screw placement offers higher accuracy and shorter hospital stay than freehand placement in scoliosis surgery; although the robotics approach is associated with longer operative durations, similar complication rates and intraoperative blood loss.

Implementing a Barcode-Based Whole-Life Cycle Management Process to Improve Robotic Instrument Tracking

Minimally invasive surgery can involve the use of robotics to improve patient outcomes. Some robotic systems require special instruments with a designated number of uses. In China, during the reprocessing of the robotic instruments, health care personnel determined that the existing tracking processes were inadequate. They conducted a quality improvement project with the goal of establishing a barcode-based standardized process for tracking robotic instruments. They implemented technology that generated a unique identifier each time a robotic instrument was reprocessed after use. Nurses scanned the identifier when surgeons used the instrument. The findings included the increased accuracy of use documentation and decreases in untraceable sterilization and use records, charging concerns, and average daily and monthly inventory times. An increase in adverse event reports associated with robotic instruments also was noted. The use of barcode technology for robotic instrument tracking continues at the facility and may be expanded for additional specialty instruments.

Comparison of No Tap (two-step) and tapping robotic assisted cortical bone trajectory screw insertion

Workflow for cortical bone trajectory (CBT) screws includes tapping line-to-line or under tapping by 1 mm. We describe a non-tapping, two-step workflow for CBT screw placement, and compare the safety profile and time savings to the Tap (three-step) workflow. Patients undergoing robotic assisted 1-3 level posterior fusion with CBT screws for degenerative conditions were identified and separated into either a No-Tap or Tap workflow. Number of total screws, screw-related complications, estimated blood loss, operative time, robotic time, and return to the operating room were collected and analyzed. There were 91 cases (458 screws) in the No-Tap and 88 cases (466 screws) in the Tap groups, with no difference in demographics, revision status, ASA grade, approach, number of levels fused or diagnosis between cohorts. Total robotic time was lower in the No-Tap (26.7 min) versus the Tap group (30.3 min, p = 0.053). There was no difference in the number of malpositioned screws identified intraoperatively (10 vs 6, p = 0.427), screws converted to freehand (3 vs 3, p = 0.699), or screws abandoned (3 vs 2, p = 1.000). No pedicle/pars fracture or fixation failure was seen in the No-Tap cohort and one in the Tap cohort (p = 1.00). No patients in either cohort were returned to OR for malpositioned screws. This study showed that the No-Tap screw insertion workflow for robot-assisted CBT reduces robotic time without increasing complications.

Deep Learning Prediction of Cervical Spine Surgery Revision Outcomes Using Standard Laboratory and Operative Variables

BACKGROUND

Cervical spine procedures represent a major proportion of all spine surgery. Mitigating the revision rate following cervical procedures requires careful patient selection. While complication risk has successfully been predicted, revision risk has proven more challenging. This is likely due to the absence of granular variables in claims databases. The objective of this study was to develop a state-of-the-art model of revision prediction of cervical spine surgery using laboratory and operative variables.

METHODS

Using the Stanford Research Repository, patients undergoing a cervical spine procedure between 2016 and 2022 were identified (N = 3151), and recent laboratory values were collected. Patients were classified into separate cohorts by revision outcome and time frame. Machine and deep learning models were trained to predict each revision outcome from laboratory and operative variables.

RESULTS

Red blood cell count, hemoglobin, hematocrit, mean corpuscular hemoglobin concentration, red blood cell distribution width, platelet count, carbon dioxide, anion gap, and calcium all were significantly associated with ≥1 revision cohorts. For the prediction of 3-month revision, the deep neural network achieved an area under the receiver operating characteristic curve of 0.833. The model demonstrated increased performance for anterior versus posterior and arthrodesis versus decompression procedures.

CONCLUSIONS

Our deep learning approach successfully predicted 3-month revision outcomes from demographic variables, standard laboratory values, and operative variables in a cervical spine surgery cohort. This work used standard laboratory values and operative codes as meaningful predictive variables for revision outcome prediction. The increased performance on certain procedures evidences the need for careful development and validation of one-size-fits-all risk scores for spine procedures.

Radiographic and clinical outcomes of robot-assisted pedicle screw instrumentation for adolescent idiopathic scoliosis

Introduction

Pedicle screw instrumentation (PSI) serves as the widely accepted surgical treatment for adolescent idiopathic scoliosis (AIS). The accuracy of screw positioning has remarkably improved with robotic assistance. Nonetheless, its impact on radiographic and clinical outcomes remains unexplored. This study aimed to investigate the radiographic and clinical outcomes of robot-assisted PSI vs. conventional freehand method in AIS patients.

Methods

Data of AIS patients who underwent PSI with all pedicle screws between April 2013 and March 2022 were included and retrospectively analyzed; those with hybrid implants were excluded. Recruited individuals were divided into the Robot-assisted or Freehand group according to the technique used. Radiographic parameters and clinical outcome measures were documented.

Results

In total, 50 patients (19, Freehand group; 31, Robot-assisted group) were eligible, with an average age and follow-up period of 17.6 years and 60.2 months, respectively, and female predominance (40/50, 80.0%). The correction rates of Cobb's angles for both groups were significant postoperatively. Compared to freehand, the robot-assisted technique achieved a significantly reduced breech rate and provided better trunk shift and radiographic shoulder height correction with preserved lumbar lordosis, resulting in significantly improved visual analog scale scores for back pain from the third postoperative month.

Conclusion

Overall, robot-assisted PSI provides satisfactory radiographic and clinical outcomes in AIS patients.

Advances in Anterolateral Approaches to the Lumbar Spine: A Focus on Technological Developments

A historical overview of the evolution of anterolateral approaches to the lumber spine and associated patient outcomes is presented. In addition, the modern incorporation of new technologies is discussed, including interbody cages, intraoperative image guidance, robotics, augmented reality, and machine learning, which have significantly improved the spine surgery safety and efficacy profile. Current challenges and future directions are also covered, emphasizing the need for further research and development, particularly in robotic assistance and machine learning algorithms.

Enhancing palliative care in vulnerable patients: Robot-assisted radiofrequency ablation for multiple spinal metastases - Technical insights and preliminary outcomes

Background

Radiofrequency thermal ablation (RFA) coupled with vertebroplasty or kyphoplasty offers a minimally invasive, safe, and efficacious approach to palliate polymetastatic spine disease, particularly in medically fragile individuals. However, the application of robotic assistance to RFA for spinal metastases remains unexplored. This study elucidates the technical viability of robot-assisted RFA combined with vertebroplasty in patients afflicted by multiple spinal metastases and presents preliminary outcomes. An illustrative case was also presented.

Materials and Methods

Ten patients aged over 65 years with multiple vertebral metastases were enrolled in this study. Preoperatively, patients exhibited a median Visual Analog Scale (VAS) pain score of 6 and a Median Oswestry Disability Index (ODI) score of 58%. From February 2021 to April 2022, all patients underwent RFA, followed by vertebroplasty for spinal metastases. Surgical procedures were executed using the ExcelsiusGPS® robotic platform.

Results

Patients experienced substantial pain relief, with a median VAS score of 2.5 at 24 h postoperatively (Δ --3.5; P < 0.001) and a median VAS score of 2 at 1 month postoperatively (Δ -4; P < 0.001). All patients were discharged on the first postoperative day and continued their oncological treatments. In addition, the median ODI score at 1 month postoperatively was 34% (Δ --24%; P = 0.006), indicating an enhanced quality of life and a satisfactory impact on daily activities. No procedural or postoperative complications were documented.

Conclusions

This case series represents the inaugural successful application of robot-assisted RFA in conjunction with concurrent vertebroplasty/kyphoplasty. Our preliminary experience demonstrates that patients with oligo- and polymetastatic conditions can derive benefits from this minimally invasive intervention, characterized by rapid postoperative recovery and effective short- to medium-term pain management, without encountering complications.

Utilization of Augmented Reality Head-Mounted Display for the Surgical Management of Thoracolumbar Spinal Trauma

Background and Objectives: Augmented reality head-mounted display (AR-HMD) is a novel technology that provides surgeons with a real-time CT-guided 3-dimensional recapitulation of a patient's spinal anatomy. In this case series, we explore the use of AR-HMD alongside more traditional robotic assistance in surgical spine trauma cases to determine their effect on operative costs and perioperative outcomes. Materials and Methods: We retrospectively reviewed trauma patients who underwent pedicle screw placement surgery guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between 1 January 2021 and 31 December 2022. Outcome distributions were compared using the Mann-Whitney U test. Results: The AR cohort (n = 9) had a mean age of 66 years, BMI of 29.4 kg/m2, Charlson Comorbidity Index (CCI) of 4.1, and Surgical Invasiveness Index (SII) of 8.8. In total, 77 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 378 mL, 0.78 units transfused, 398 min spent in the operating room, and a 20-day LOS. The robotic cohort (n = 13) had a mean age of 56 years, BMI of 27.1 kg/m2, CCI of 3.8, and SII of 14.2. In total, 128 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 432 mL, 0.46 units transfused units used, 331 min spent in the operating room, and a 10.4-day LOS. No significant difference was found between the two cohorts in any outcome metrics. Conclusions: Although the need to address urgent spinal conditions poses a significant challenge to the implementation of innovative technologies in spine surgery, this study represents an initial effort to show that AR-HMD can yield comparable outcomes to traditional robotic surgical techniques. Moreover, it highlights the potential for AR-HMD to be readily integrated into Level 1 trauma centers without requiring extensive modifications or adjustments.

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.

A Comprehensive Review of the Historical Description of Spine Surgery and Its Evolution

Major strides in the advancement of spine surgery came about in the 21st century. However, the extensive history of spine surgery can be traced back to long before this time. A clear description of the journey from a primitive yet accurate understanding of the human musculoskeletal system to today's modern aspects of spinal techniques is lacking. A narrative literature review was conducted to elucidate where spine surgery began and the techniques used that evolved over time. This review was conducted using PubMed and Google Scholar. Search terms used included "history of spine surgery," "evolution of spine surgery," "origins of spine surgery," "history of laminectomy," "history of spinal fusion," "history of lumbar interbody fusion," "minimally invasive spine surgery," and "navigation in spine surgery." We highlight the evolution of the basic understanding of anatomy and non-surgical and surgical techniques, including bracing, laminectomy, discectomy, and spinal fusion. The current evolution and integration of minimally invasive techniques, lumbar interbody fusion techniques, robotics, navigation, and motion preservation are discussed, as these are the major areas of focus for technological advancement. This review presents an overarching synopsis of the events that chronicle the progress made in spine surgery since its conception. The review uniquely contributes to the growing body of literature on the expansion of spine surgery and highlights major events in its history.

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).

Autonomous Spinal Robotic System for Transforaminal Lumbar Epidural Injections: A Proof of Concept of Study

STUDY DESIGN

Phantom study.

OBJECTIVE

The aim of our study is to demonstrate in a proof-of-concept model whether the use of a marker less autonomous robotic controlled injection delivery system will increase accuracy in the lumbar spine.

METHODS

Ideal transforaminal epidural injection trajectories (bilateral L2/3, L3/4, L4/5, L5/S1 and S1) were planned out on a virtual pre-operative planning software by 1 experienced provider. Twenty transforaminal epidural injections were administered in a lumbar spine phantom model, 10 using a freehand procedure, and 10 using a marker less autonomous spinal robotic system. Procedural accuracy, defined as the difference between pre-operative planning and actual post-operative needle tip distance (mm) and angular orientation (degrees), were assessed between the freehand and robotic procedures.

RESULTS

Procedural accuracy for robotically placed transforaminal epidural injections was significantly higher with the difference in pre- and post-operative needle tip distance being 20.1 (±5.0) mm in the freehand procedure and 11.4 (±3.9) mm in the robotically placed procedure (P < .001). Needle tip precision for the freehand technique was 15.6 mm (26.3 - 10.7) compared to 10.1 mm (16.3 - 6.1) for the robotic technique. Differences in needle angular orientation deviation were 5.6 (±3.3) degrees in the robotically placed procedure and 12.0 (±4.8) degrees in the freehand procedure (P = .003).

CONCLUSION

The robotic system allowed for comparable placement of transforaminal epidural injections as a freehand technique by an experienced provider, with additional benefits of improved accuracy and precision.

The impact of robotic assistance for lumbar fusion surgery on 90-day surgical outcomes and 1-year revisions

Objectives

To evaluate the (1) 90-day surgical outcomes and (2) 1-year revision rate of robotic versus nonrobotic lumbar fusion surgery.

Methods

Patients >18 years of age who underwent primary lumbar fusion surgery at our institution were identified and propensity-matched in a 1:1 fashion based on robotic assistance during surgery. Patient demographics, surgical characteristics, and surgical outcomes, including 90-day surgical complications and 1-year revisions, were collected. Multivariable regression analysis was performed. Significance was set to P < 0.05.

Results

Four hundred and fifteen patients were identified as having robotic lumbar fusion and were matched to a control group. Bivariant analysis revealed no significant difference in total 90-day surgical complications (P = 0.193) or 1-year revisions (P = 0.178). The operative duration was longer in robotic surgery (287 + 123 vs. 205 + 88.3, P ≤ 0.001). Multivariable analysis revealed that robotic fusion was not a significant predictor of 90-day surgical complications (odds ratio [OR] = 0.76 [0.32-1.67], P = 0.499) or 1-year revisions (OR = 0.58 [0.28-1.18], P = 0.142). Other variables identified as the positive predictors of 1-year revisions included levels fused (OR = 1.26 [1.08-1.48], P = 0.004) and current smokers (OR = 3.51 [1.46-8.15], P = 0.004).

Conclusion

Our study suggests that robotic-assisted and nonrobotic-assisted lumbar fusions are associated with a similar risk of 90-day surgical complications and 1-year revision rates; however, robotic surgery does increase time under anesthesia.

Prospective Comparison of Two Robotically Navigated Pedicle Screw Instrumentation Techniques

This study aimed to compare screw accuracy and incidence of skive between two robotically navigated instrumented techniques in posterior spine fusion surgery: manual anti-skive instrumentation with an anti-skive cannula (ASC) and the use of a navigated, high-speed drill (HSD). Over a 3-year period, consecutive patients are undergoing RNA posterior fusion surgery with either ASC (n = 53) or HSD (n = 63). Both groups met a value of approximately 292 screws in our analysis (296 ASC, 294 HSD), which was determined by a biostatistician at an academic institution. Screw accuracy and skive was analyzed using preoperative CT and intraoperative three-dimensional (3D) fluoroscopy. Among 590 planned robotically inserted pedicle screws (296 ASC, 294 HSD), 245 ASC screws (82.8%) and 283 HSD screws (96.3%) were successfully inserted (p < 0.05). Skive events occurred in 4/283 (1.4%) HSD screws and 15/245 (6.2%) ASC screws (p < 0.05). HSD screws showed better accuracy in the axial and sagittal planes, being closer to planned trajectories in all directions except cranial deviation (p < 0.05). Additionally, HSD had a significantly lower time per screw (1.9 ± 1.0 min) compared to ASC (3.2 ± 2.0 min, p < 0.001). No adverse clinical effects were observed. The HSD technique showed significant improvements in time and screw accuracy compared to ASC. Biplanar fluoroscopy and 3D imaging resulted in significantly lower radiation exposure and time compared to ASC. These significant findings in the HSD group may be attributed to the lower occurrence of malpositioned screws, leading to a decrease in the need for second authentication. This represents a notable iterative improvement of the RNA platform.

Robotic assisted surgery in the United Arab Emirates: healthcare experts' perceptions

The adoption of Robotic Assisted Surgery (RAS) has grown around the world. This is also the case in the Middle East and Gulf region and specifically to the United Arab Emirates (UAE). The perception of RAS has been studied in the USA, Europe, and Canada. However, there is limited research on the perception of RAS in the UAE. The study aims to examine the perception of RAS among healthcare experts in the UAE and potential challenges. This qualitative study is based on interviewing healthcare experts in the UAE. Most of the study participants were clinicians and surgeons. In the UAE, RAS is adopted in general surgery, urology, brain surgery, and obstetrics and gynecology. Our findings show that healthcare experts have positive perceptions of RAS. The cost and lack of RAS training program are considered as challenges to adopting RAS in healthcare practices. More research is encouraged to examine perception variations with surgical practices in the UAE, Gulf and the Middle East.

Advancements in Robotic Surgery: A Comprehensive Overview of Current Utilizations and Upcoming Frontiers

Robotic surgery, a groundbreaking advancement in medical technology, has redefined the landscape of surgical procedures. This comprehensive overview explores the multifaceted world of robotic surgery, encompassing its definition, historical development, current applications, clinical outcomes, benefits, emerging frontiers, challenges, and future implications. We delve into the fundamentals of robotic surgical systems, examining their components and advantages. From general and gynecological surgery to urology, cardiac surgery, orthopedics, and beyond, we highlight the diverse specialties where robotic surgery is making a significant impact. The many benefits discussed include improved patient outcomes, reduced complications, faster recovery times, cost-effectiveness, and enhanced surgeon experiences. The outlook reveals a healthcare landscape where robotic surgery is increasingly vital, enabling personalized medicine, bridging healthcare disparities, and advancing surgical precision. However, challenges such as cost, surgeon training, technical issues, ethical considerations, and patient acceptance remain relevant. In conclusion, robotic surgery is poised to continue shaping the future of health care, offering transformative possibilities while emphasizing the importance of collaboration, innovation, and ethical governance.

Efficacy and safety of robot-assisted versus fluoroscopy-assisted PKP or PVP for osteoporotic vertebral compression fractures: a systematic review and meta-analysis

Percutaneous vertebral augmentation (PVA), which includes percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP). Robot-assisted (RA) and fluoroscopy-assisted (FA) are important methods for treating osteoporotic vertebral compression fractures (OVCFs), though it is still unclear which is superior. This analysis aimed to compare the efficacy and safety of RA and FA. PubMed, Web of Science, Cochrane Library, and China National Knowledge Infrastructure were systematically searched, the outcomes included surgical parameters (leakage rate, operation time, number of fluoroscopic, injection volume, inclination angle), and clinical indexes (hospital stays, Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Cobb angle, the midline height of vertebral). Thirteen articles involving 1094 patients were included. RA group produced better results than the FA group in the leakage rate (OR = 0.27; 95% CI 0.17-0.42; P < 0.00001), number of fluoroscopic (WMD = - 13.88; 95% CI - 18.47 to - 9.30; P < 0.00001), inclination angle (WMD = 5.02; 95% CI 4.42-5.61; P < 0.00001), hospital stays (WMD = - 0.32; 95% CI - 0.58 to - 0.05; P = 0.02), VAS within 3 days (WMD = - 0.19; 95% CI - 0.26 to - 0.12; P < 0.00001), Cobb angle within 3 days (WMD = - 1.35; 95% CI - 2.56 to - 0.14; P = 0.003) and Cobb angle after 1 month (WMD = - 1.02; 95% CI - 1.84 to - 0.20; P = 0.01). But no significant differences in operation time, injection volume, ODI, the midline height of vertebral, and VAS score after 1 month. Our analysis found that the RA group had lower cement leakage rates, number of fluoroscopic and hospital stays, a larger inclination angle, better short-term pain improvement, and Cobb angle improvement. It is worth acknowledging that robotic-assisted surgery holds promise for the development of spine surgery. The study was registered in the PROSPERO (CRD42023393497).

Pedicle Screw Placement Accuracy in Robot-Assisted Spinal Fusion in a Multicenter Study

Pedicle screw fixation is a spinal fusion technique that involves the implantation of screws into vertebral pedicles to restrict movement between those vertebrae. The objective of this research is to measure pedicle screw placement accuracy using a novel automated measurement system that directly compares the implanted screw location to the planned target in all three anatomical views. Preoperative CT scans were used to plan the screw trajectories in 122 patients across four surgical centers. Postoperative scans were fused to the preoperative plan to quantify placement accuracy using an automated measurement algorithm. The mean medial-lateral and superior-inferior deviations in the pedicle region for 500 screws were 1.75 ± 1.36 mm and 1.52 ± 1.26 mm, respectively. These deviations were measured using an automated system and were statistically different from manually determined values. The uncertainty associated with the fusion of preoperative to postoperative images was also quantified to better understand the screw-to-plan accuracy results. This study uses a novel automated measurement system to quantify screw placement accuracy as it relates directly to the planned target location, instead of analyzing for breaches of the pedicle, to quantify the validity of using of a robotic-guidance system for accurate pedicle screw placement.

State-of-the-Art of Non-Radiative, Non-Visual Spine Sensing with a Focus on Sensing Forces, Vibrations and Bioelectrical Properties: A Systematic Review

In the research field of robotic spine surgery, there is a big upcoming momentum for surgeon-like autonomous behaviour and surgical accuracy in robotics which goes beyond the standard engineering notions such as geometric precision. The objective of this review is to present an overview of the state of the art in non-visual, non-radiative spine sensing for the enhancement of surgical techniques in robotic automation. It provides a vantage point that facilitates experimentation and guides new research projects to what has not been investigated or integrated in surgical robotics. Studies were identified, selected and processed according to the PRISMA guidelines. Relevant study characteristics that were searched for include the sensor type and measured feature, the surgical action, the tested sample, the method for data analysis and the system's accuracy of state identification. The 6DOF f/t sensor, the microphone and the electromyography probe were the most commonly used sensors in each category, respectively. The performance of the electromyography probe is unsatisfactory in terms of preventing nerve damage as it can only signal after the nerve is disturbed. Feature thresholding and artificial neural networks were the most common decision algorithms for state identification. The fusion of different sensor data in the decision algorithm improved the accuracy of state identification.

The use of robot-assisted surgery for the unstable traumatic spine: A retrospective cohort study

Background

Robotic assistance has been shown to increase instrumentation placement accuracy in open and minimally invasive spinal fusion. These gains have been achieved without increases in operative times, blood loss, or hospitalization duration. However, most work has been done in the degenerative population and little is known of the utility of robotic assistance when applied to spinal trauma. This is largely due to the uncertainty stemming from the disruption of normal anatomy by the traumatic injury. Since the robot depends upon registration for instrumentation guidance according to the fiducials it uses, trauma can introduce unique challenges. The present study sought to evaluate the safety and efficacy of robotic assistance in a consecutive cohort of spine trauma patients.

Methods

All patients with Thoracolumbar Injury Classification and Severity Scale (TLICS) >4 who underwent robot-assisted spinal fusion using the Globus ExcelsiusGPS at a single tertiary care center for trauma between 2020 and 2022 were identified. Demographic, clinical, and surgical data were collected and analyzed; the primary endpoints were operative time, fluoroscopy time, estimated blood loss, postoperative complications, admission time, and 90-day readmission rate. The paired t-test was used to compare differences between mean values when looking at the number of surgical levels.

Results

Forty-two patients undergoing robot-assisted spinal surgery were included (mean age 61.3±17.1 year; 47% female. Patients were stratified by the number of operative levels, 2 (n = 10), 3-4 (n = 11), 5 to 6 (n = 13), or >6 (n = 8). There appeared to be a positive correlation between number of levels instrumented and odds of postoperative complications, admission duration, fluoroscopy time, and estimated blood loss. There were no instances of screw malposition or breach.

Conclusions

This initial experience suggests robotic assistance can be safely employed in the spine trauma population. Additional experiences in larger patient populations are necessary to delineate those traumatic pathologies most amenable to robotic assistance.

How can clinical safety and efficacy concerns in stem cell therapy for spinal cord injury be overcome?

INTRODUCTION

Spinal cord injury (SCI) can lead to severe neurological dysfunction. Despite scientific and medical advances, clinically effective regenerative therapies including stem cells are lacking for SCI.

AREAS COVERED

This paper discusses translational challenges related to the safe, effective use of stem cells for SCI, with a focus on mesenchymal stem cells (MSCs), neural stem cells (NSCs), Schwann cells (SCs), olfactory ensheathing cells (OECs), oligodendrocyte precursor cells (OPCs), embryonic stem cells (ESCs), and induced pluripotent stem cells (iPSCs). We discuss approaches to enhance the efficacy of cell-based strategies by i) addressing patient heterogeneity and enhancing patient selection; ii) selecting cell type, cell source, cell developmental stage, and delivery technique; iii) enhancing graft integration and mitigating immune-mediated graft rejection; and iv) ensuring availability of cells. Additionally, we review strategies to optimize outcomes including combinatorial use of rehabilitation and discuss ways to mitigate potential risks of tumor formation associated with stem cell-based strategies.

EXPERT OPINION

Basic science research will drive translational advances to develop stem cell-based therapies for SCI. Genetic, serological, and imaging biomarkers may enable individualization of cell-based treatments. Moreover, combinatorial strategies will be required to enhance graft survival, migration and functional integration, to enable precision-based intervention.

Robotic Surgery: A Comprehensive Review of the Literature and Current Trends

Robotic surgery (RS) is an evolution of minimally invasive surgery that combines medical science, robotics, and engineering. The first robots approved by the Food and Drug Administration (FDA) were the Da Vinci Surgical System and the ZEUS Robotic Surgical System, which have been improving over time. Through the decades, the equipment applied to RS had undergone a wide transformation as a response to the development of new techniques and facilities for the assembly and implementation of the own. RS has revolutionized the field of urology, enabling surgeons to perform complex procedures with greater precision and accuracy, and many other surgical specialties such as gynecology, general surgery, otolaryngology, cardiothoracic surgery, and neurosurgery. Several benefits, such as a better approach to the surgical site, a three-dimensional image that improves depth perception, and smaller scars, enhance range of motion, allowing the surgeon to conduct more complicated surgical operations, and reduced postoperative complications have made robotic-assisted surgery an increasingly popular approach. However, some points like the cost of surgical procedures, equipment-instrument, and maintenance are important aspects to consider. Machine learning will likely have a role to play in surgical training shortly through "automated performance metrics," where algorithms observe and "learn" individual surgeons' techniques, assess performance, and anticipate surgical outcomes with the potential to individualize surgical training and aid decision-making in real time.

Intraoperative triggered electromyographic monitoring of pedicle screw efficiently reduces the lumbar pedicle breach and re-operative rate-a retrospective analysis based on postoperative computed tomography scan

BACKGROUND

To investigate whether intraoperative triggered electromyographic (T-EMG) monitoring could effectively reduce the breach rate of pedicle screws and the revision rate.

METHODS

Patients with posterior pedicle screw fixation from L1-S1 were enrolled between June 2015 and May 2021. The patients in whom T-EMG was utilized were placed in the T-EMG group, and the remaining patients were considered in the non-T-EMG group. Three spine surgeons evaluated the images. The two groups were divided into subgroups based on screw position (lateral/superior and medial/inferior) and breach degree (minor and major). Patient demographics, screw positions, and revision procedures were reviewed.

RESULTS

A total of 713 patients (3403 screws) who underwent postoperative computed tomography (CT) scans were included. Intraobserver and interobserver reliabilities were perfect. The T-EMG and non-T-EMG groups had 374(1723 screws) and 339 (1680 screws) cases, respectively. T-EMG monitoring efficiently reduced the overall screw breach (T-EMG 7.78% vs. non-T-EMG 11.25%, p = 0.001). in the subgroup analysis, the medial/inferior breach rate was higher in the T-EMG group than in the non-T-EMG group (T-EMG 6.27% vs. non-T-EMG 8.93%, p = 0.002); however, no difference was observed between the lateral and superior breaches (p = 0.064). A significant difference was observed between the minor (T-EMG 6.21% vs. non-T-EMG 8.33%, p = 0.001) and major (T-EMG 0.06% vs. non-T-EMG 0.6%, p = 0.001) medial or inferior screw breach rates. Six screws (all in the non-T-EMG group) underwent revision, with a significant difference between the groups (T-EMG 0.0% vs. non-T-EMG 3.17%, p = 0.044).

CONCLUSIONS

T-EMG is a valuable tool in improving the accuracy of screw placement and reducing the screw revision rate. The screw-nerve root distance is vital in causing symptomatic screw breach.

TRIAL REGISTRATION

The study is retrospective registered in China National Medical Research Registration and Archival information system in Nov 17th 2022.

Single position robot-assisted pedicle screw placement with S2-alar-iliac fixation in lateral decubitus: cadaveric feasibility study and early clinical experience

OBJECTIVES

Single position lateral fusion with robotic assistance eliminates the need for surgical staging while harnessing the precision of robotic adjuncts. We expand on this technique by demonstrating the technical feasibility of placing bilateral pedicle screws with S2-alar-iliac (S2AI) fixation while in the lateral position.

METHODS

A cadaveric study was performed using 12 human specimens. A retrospective clinical series was also performed for patients who had undergone robot-assisted placement of S2AI screws in lateral decubitus between June 2020 and June 2022. Case demographics, implant placement time, implant size, screw accuracy, and complications were recorded. Early postoperative radiographic outcomes were reported.

RESULTS

In the cadaveric series, a total of 126 screws were placed with robotic assistance in 12 cadavers of which 24 screws were S2AI. There were four breaches from pedicle screws and none with S2AI screws for an overall accuracy rate of 96.8%. In the clinical series, four patients (all male, mean age 65.8 years) underwent single position lateral surgery with S2AI distal fixation. Mean BMI was 33.6 and mean follow-up was 20.5 months. Mean radiographic improvements were lumbar lordosis 12.3 ± 4.7°, sagittal vertical axis 1.5 ± 2.1 cm, pelvic tilt 8.5 ± 10.0°, and pelvic incidence-lumbar lordosis mismatch 12.3 ± 4.7°. A total of 42 screws were placed of which eight screws were S2AI. There were two breaches from pedicle screws and none from S2AI screws for an overall accuracy rate of 95.2%. No repositioning or salvage techniques were required for the S2AI screws.

CONCLUSIONS

We demonstrate here the technical feasibility of single position robot-assisted placement of S2-alar-iliac screws in the lateral decubitus position for single position surgery.

Occlusion-robust scene flow-based tissue deformation recovery incorporating a mesh optimization model

PURPOSE

Tissue deformation recovery is to reconstruct the change in shape and surface strain caused by tool-tissue interaction or respiration, which is essential for providing motion and shape information that benefits the improvement of the safety of minimally invasive surgery. The binocular vision-based approach is a practical candidate for deformation recovery as no extra devices are required. However, previous methods suffer from limitations such as the reliance on biomechanical priors and the vulnerability to the occlusion caused by surgical instruments. To address the issues, we propose a deformation recovery method incorporating mesh structures and scene flow.

METHODS

The method can be divided into three modules. The first one is the implementation of the two-step scene flow generation module to extract the 3D motion from the binocular sequence. Second, we propose a strain-based filtering method to denoise the original scene flow. Third, a mesh optimization model is proposed that strengthens the robustness to occlusion by employing contextual connectivity.

RESULTS

In a phantom and an in vivo experiment, the feasibility of the method in recovering surface deformation in the presence of tool-induced occlusion was demonstrated. Surface reconstruction accuracy was quantitatively evaluated by comparing the recovered mesh surface with the 3D scanned model in the phantom experiment. Results show that the overall error is 0.70 ± 0.55 mm.

CONCLUSION

The method has been demonstrated to be capable of continuously recovering surface deformation using mesh representation with robustness to the occlusion caused by surgical forceps and promises to be suitable for the application in actual surgery.

Robot-assisted versus navigated transpedicular spine fusion: A comparative study

BACKGROUND

The aim of this study was to compare the intraoperative and postoperative outcomes between a robot-assisted versus a navigated transpedicular fusion technique.

METHODS

This retrospective analysis included patients who underwent transpedicular posterior fusion of the spine due to trauma, pyogenic spondylodiscitis and osteoporosis. Surgery was done either with a robot-assisted or a percutaneous navigated transpedicular fusion technique. The outcome analysis included the duration of surgery, the radiation exposure, the postoperative screw position and complications.

RESULTS

A total of 60 patients were operated and 491 screws were analysed. No statistical difference was seen in the applied cumulative effective radiation dose per patient. The radiological assessment revealed a more accurate screw placement with robot assistance. A learning curve could be observed in robot-assisted fusion.

CONCLUSION

Robot-assisted and navigated transpedicular fusion techniques are both effective and safe. Robot-assisted transpedicular spine fusion goes along with higher placement accuracy but its implementation needs an adequate learning curve.

Technological Advances in Spine Surgery: Navigation, Robotics, and Augmented Reality

Accurate screw placement is critical to avoid vascular or neurologic complications during spine surgery and to maximize fixation for fusion and deformity correction. Computer-assisted navigation, robotic-guided spine surgery, and augmented reality surgical navigation are currently available technologies that have been developed to improve screw placement accuracy. The advent of multiple generations of new technologies within the past 3 decades has presented surgeons with a diverse array of choices when it comes to pedicle screw placement. Considerations for patient safety and optimal outcomes must be paramount when selecting a technology.

Reported Events Associated With Spine Robots: An Analysis of the Food and Drug Administration's Manufacturer and User Facility Device Experience Database

STUDY DESIGN

Cross-Sectional Analysis.

OBJECTIVES

To summarize medical device reports (MDRs) between August 1, 2017 and November 30, 2021 relating to robot-assisted spine systems within the Manufacturer and User Facility Device Experience (MAUDE) database maintained by The Food and Drug Administration (FDA).

METHODS

The MAUDE database was abstract for all MDRs relating to each FDA-approved robot-assisted spine system. Event descriptions were reviewed and characterized into specific event types. Outcome measures include specific robot-assisted spine systems and reported events as detailed by the MDRs. All data is de-identified and in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

RESULTS

There were 263 MDRs consisting of 265 reported events. Misplaced screws represented 61.5% (n = 163) of reported events. Of the 163 reported events, 57.1% (n = 93) described greater than 1 misplaced screw, 15.3% (n = 25) required return to the operating room, 8.6% (n = 14) resulted in neurologic injury, 4.3% (n = 7) resulted in dural tear, and 1.2% (n = 2) resulted in hemorrhage or bleeding. Reported events other than misplaced screws included system imprecision detected prior to screw placement (58/265, 21.9%), mechanical failure (23/265, 8.7%), and software failure (18/265, 6.8%).

CONCLUSIONS

As more robot-assisted spine systems gain FDA approval and the adoption of these systems continues to grow, documenting and understanding the range of reported events associated with each "tool" is imperative to balancing patient safety with surgical innovation. This study of the MAUDE database provides a unique summary of reported events associated with robot-assisted spine systems that is not directly linked to a research setting.

Accuracies of various types of spinal robot in robot-assisted pedicle screw insertion: a Bayesian network meta-analysis

BACKGROUND

With the popularization of robot-assisted spinal surgeries, it is still uncertain whether robots with different designs could lead to different results in the accuracy of pedicle screw placement. This study aimed to compare the pedicle screw inserting accuracies among the spinal surgeries assisted by various types of robot and estimate the rank probability of each robot-assisted operative technique involved.

METHODS

The electronic literature database of PubMed, Web of Science, EMBASE, CNKI, WANFANG and the Cochrane Library was searched in November 2021. The primary outcome was the Gertzbein-Robbins classification of pedicle screws inserted with various operative techniques. After the data extraction and direct meta-analysis process, a network model was established in the Bayesian framework and further analyses were carried out.

RESULTS

Among all the 15 eligible RCTs, 4 types of robot device, namely Orthbot, Renaissance, SpineAssist and TiRobot, were included in this study. In the network meta-analysis, the Orthbot group (RR 0.27, 95% CI 0.13-0.58), the Renaissance group (RR 0.33, 95% CI 0.14-0.86), the SpineAssist group (RR 0.14, 95% CI 0.06-0.34) and the conventional surgery group (RR 0.21, 95% CI 0.13-0.31) were inferior to the TiRobot group in the proportion of grade A pedicle screws. Moreover, the results of rank probabilities revealed that in terms of accuracy, the highest-ranked robot was TiRobot, followed by Renaissance and Orthbot.

CONCLUSIONS

In general, current RCT evidence indicates that TiRobot has an advantage in the accuracy of the pedicle screw placement, while there is no significant difference among the Orthbot-assisted technique, the Renaissance-assisted technique, the conventional freehand technique, and the SpineAssist-assisted technique in accuracy.

TiRobot-assisted percutaneous kyphoplasty in the management of multilevel (more than three levels) osteoporotic vertebral compression fracture

PURPOSE

To compare the effectiveness of TiRobot-assisted kyphoplasty with that of the traditional fluoroscopy-assisted approach in treating multilevel osteoporotic vertebral compression fractures.

METHODS

In this retrospective study, we collected data from 71 patients (TiRobot-assisted group, n = 39; fluoroscopy-assisted group, n = 32) with multilevel osteoporotic vertebral compression fracture treated with unilateral traditional TiRobot-assisted or fluoroscopy-assisted percutaneous kyphoplasty. The operative time, infusion volume, length of stay (LOS), hospital expenses, visual analog scale (VAS), Oswestry Disability Index (ODI), radiation exposure, puncture deviation, anterior height of diseased vertebrae, local kyphotic angle, bone cement distribution, and bone cement leakage were compared between the TiRobot- and fluoroscopy-assisted groups.

RESULTS

Of the 257 treated vertebrae, the average amount of bone cement injected in the TiRobot-assisted (142 vertebrae) and fluoroscopy-assisted (115 vertebrae) groups was 4.6 mL and 4.5 mL, respectively. The VAS score was significantly lower in the TiRobot-assisted group at 24 hours post-operatively (p = 0.006). The X-ray frequency was 34.7 times in the TiRobot-assisted group and 51.7 times in the fluoroscopy-assisted group (p < 0.001). In addition to the operative time, cumulative radiation dose for the surgeon and patient was significantly lower in the TiRobot-assisted group. The hospital expenses of the TiRobot-assisted group were significantly higher (p < 0.001). The puncture deviation and bone cement distribution were better in the TiRobot-assisted group (p < 0.001). Bone cement leakage was found in 18 and 29 cases in the TiRobot- and fluoroscopy-assisted groups, respectively (p = 0.010). One patient in the fluoroscopy-assisted group experienced radiculopathy due to a misplaced puncture but recovered in three months. No radiculopathy was observed in the TiRobot-assisted group.

CONCLUSIONS

TiRobot-assisted percutaneous multilevel kyphoplasty is more accurate and has smaller radiometry, a more uniform bone cement distribution, and lower bone cement leakage. This method was therefore accurate and safe.

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.

Minimally invasive trans-superior articular process percutaneous endoscopic lumbar discectomy with robot assistance

BACKGROUND

To compare the clinical outcomes of patients with lumbar disc herniation treated with robot-assisted percutaneous endoscopic lumbar discectomy (r-PELD) or conventional PELD under fluoroscopy guidance (f-PELD).

METHODS

Our study group included 55 patients, 22 in the r-PELD group and 33 in the f-PELD group. The following clinical and surgical outcomes were compared between the two groups: the visual analog scale for radiculopathy pain; Oswestry Disability Index; intraoperative volume of blood loss; frequency of fluoroscopy used during the procedure; and MacNab classification. The follow-up period was 6-8 months.

RESULTS

Compared with f-PELD, r-PELD was associated with a lower volume of intraoperative blood loss and frequency of fluoroscopy (p < 0.01). There were no differences in complications, MacNab classification, postoperative disability and leg pain, and duration of hospitalization between the two groups.

CONCLUSION

Based on our findings, r-PELD provides a safe and effective alternative to conventional PELD for the treatment of lumbar disc herniations, with the accuracy for placement of punctures lowering radiation exposure.

R2 advances in robotic-assisted spine surgery: comparative analysis of options, future directions, and bibliometric analysis of the literature

Spine surgery has undergone rapid advancements over the past several decades with the emergence of robotic and minimally invasive surgery (MIS). While conventional MIS spine surgery has had relative success, its complication profile has warranted continued efforts to improve clinical outcomes. We discuss the functional, clinical, and financial aspects of four robotic options for spinal pathologies, namely ROSA, Mazor X, Da Vinci, and ExcelsiusGPS, and conduct a bibliometric analysis to better understand current trends and applications of these robots as the field of robotic spine surgery continues to grow. An extensive search of English-language published literature on robotic-assisted spinal surgery was performed in Elsevier's Scopus database. A bibliometric analysis was then performed on the top 100 most cited papers. The search yielded articles regarding robotic-assisted spine surgery application, limitations, and functional outcomes secondary to spine pathology. Accuracy analyses of 1733 screw placements were reviewed. The top 100 papers were published between 1992 and 2020, with a significant increase from 2015 onwards. The top publishing institution was John Hopkins University (n = 8). The top contributing author was Dr. Isador H. Lieberman (n = 6). The USA (n = 34) had the most articles on robotic spinal surgery, followed by Germany (n = 12). This review examines robotic applications in spine surgery, including four available options: ROSA, Mazor X, Da Vinci, and ExcelsiusGPS. Publication output over time, surgical outcomes, screw accuracy, and cost-effectiveness of these technologies have been investigated here. Certain robots have functional, clinical, and financial differences worth noting. Given the dearth of existing literature reporting postoperative complications and long-term comparative outcomes, there is a clear need for further studies on this matter.

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

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

Robot-Assisted Thoracolumbar Fixation After Acute Spinal Trauma: A Case Series

BACKGROUND

Pedicle screw fixation has become the workhorse for the stabilization of the thoracolumbar spine. Since accurate pedicle screw placement is necessary for a successful surgery, three-dimensional navigation has become a mainstay for placing pedicle screws. However, the published studies have an overrepresentation of lumbar screws despite the prevalence of thoracic fractures. Furthermore, no robotic-assisted pedicle screw study has focused solely on traumatic fractures. The goal of this study was to address whether (1) robot-assisted pedicle screw placement had comparable accuracy in the thoracic and thoracolumbar region and (2) robot-assisted spine surgery was feasible in an acute, traumatic setting.

METHODS

We performed 14 consecutive, thoracolumbar spinal stabilization procedures in which 126 pedicle screws were placed using the Globus ExcelsiusGPS® spine robot in an acute, traumatic setting. Operative times were measured, and the accuracy of pedicle screws was assessed with the Gertzbein and Robbins classification system by two board-certified neuroradiologists.

RESULTS

A total of 60-thoracic (T3-T11), the 24-thoracolumbar junction (T12-L1), 40-lumbar (L2-L5), and two-sacral pedicle screws were placed. Pedicle screw placement was accurate with a < 1% (1/126) pedicle breach rate. Thoracolumbar robotic spine surgery in an acute, traumatic setting was demonstrated to have a good safety profile with only one minor neurological deficit which was related to positioning. Furthermore, surgical times were inversely related to the case number.

CONCLUSIONS

These results together suggest that robot-assisted spine surgery is accurate in the thoracic spine. Furthermore, placement of thoracolumbar screws in an acute trauma is non-inferior to other methods when based on accuracy.

Evolution and Revolution of Imaging Technologies in Neurosurgery

We understand only a small fraction of the events happening in our brains; therefore, despite all the progress made thus far, a whole array of questions remains. Nonetheless, neurosurgeons invented new tools to circumvent the challenges that had plagued their predecessors. With the manufacturing boom of the 20th century, technological innovations blossomed enabling the neuroscientific community to study and operate upon the living brain in finer detail and with greater precision while avoiding harm to the nervous system. The purpose of this chronological review is to 1) raise awareness among future neurosurgeons about the latest advances in the field, 2) become familiar with innovations such as augmented reality (AR) that should be included in education given their ready applicability in surgical training, and 3) be comfortable with customizing these technologies to real-life cases like in the case of mixed reality.

Application of 3D printed models in the surgical treatment of spinal deformity

OBJECTIVE

To test if preoperative planning with 3 dimensional (3D)-printed spine models can increase the effectiveness and safety of spinal deformity surgery.

METHODS

A total of 53 patients who were treated in our center for spinal deformities from January 2010 to January 2018 were included in the current study. They were divided into two groups based on whether 3D-printed models were used in the surgical planning. A total of 28 patients who were treated with 3D-printed models were assigned to the experimental group, and 25 patients who were treated with conventional methods were assigned to the control group. Duration of surgery, intraoperative hemorrhage, incidence of surgery related complications, Oswestry disability index (ODI), visual analogue scale (VAS), and Cobb's angle were compared between the two groups before and after surgery.

RESULTS

There were significant differences in the duration of surgery, intraoperative hemorrhage and intraoperative x-ray exposure between the two groups (P<0.01). Cobb's angle was smaller in the experimental group than in the control group when measured three days and a year after surgery (P<0.01). Although there was no significant difference between the experimental and control groups (P>0.05), Oswestry disability index and VAS pain scores were lower a month and a year after the surgery than before the surgery (P<0.01).

CONCLUSION

Surgical planning using 3D-printed spine models can decrease the operation time, intraoperative hemorrhage, and x-ray exposure, and help achieve satisfactory structural restoration in patients with severe spinal deformity.

Individualized CT image-guided free-hand catheter technique: A new and reliable method for minimally invasive evacuation of basal ganglia hematoma

Objective

To validate the clinical reliability of an individualized CT image-guided‘ free-hand catheter technique (CTGFC) for basal ganglia hematoma (BGH) evacuation.

Methods

From January 2017 to December 2020, 58 cases of patients with BGH who underwent catheter evacuation were enrolled. The surgery was conducted using the CTGFC (n = 31) or stereotactic catheter technique (STC, n = 27). The authors evaluated the baseline characteristics, operation-related indicators, postoperative complications, hospitalization-related indicators, short-term and long-term functional outcomes, and mortality rate 1 year after surgery.

Results

All patients underwent BGH evacuation under non-general anesthesia in the CTGFC group. The operative time (p &lt; 0.01) and operation costs (p &lt; 0.05) were significantly shorter in the CTGFC group than that in the STC group (p &lt; 0.01). Comparable results were found in the catheter indwelling duration, residual hematoma volume, hematoma evacuation rate, incidence of postoperative complications, hospital ICU stay, and hospital costs between these two groups (p &gt; 0.05). The duration of hospital stay was remarkably shorter in the CTGFC group than that in the STC group (p &lt; 0.01). There were no differences in terms of the short-time functional outcomes score at discharge, including the Glasgow outcome scale (GOS) score, the activities of daily living (ADL) score, and the Karnofsky performance score (KPS). Moreover, comparable findings were also found in the 1-year postoperative GOS score, ADL score, KPS score, and mortality rate between these two groups.

Conclusion

The simple CTGFC-assisted surgery was a safe and reliable option for BGH evacuation, especially in primary medical institutes and emergency situations with limited medical resources.

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 knee arthroplasty improves component positioning and alignment, but results are inconclusive on whether it improves clinical scores or reduces complications and revisions: a systematic overview of meta-analyses

PURPOSE

The purpose of this systematic overview was to identify, synthesise and critically appraise findings of meta-analyses on robot-assisted versus conventional unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The hypothesis was that robotic assistance would reduce complications and revision rates, yield better clinical scores, and improve component positioning and alignment.

METHODS

Two researchers independently conducted a literature search using Embase^®, MEDLINE^®, Web of Science, Allied and Complementary Medicine™ and Cochrane Database of Systematic Reviews on 2 November 2020 for meta-analyses (Level I-IV) on robotic assistance in UKA and/or TKA. Outcomes were tabulated and reported as weighted mean difference (WMD), risk ratio (RR) or weighted odds ratio (WOR), and were considered statistically significant when p < 0.05.

RESULTS

A total of ten meta-analyses were identified; four on robot-assisted UKA (n, 1880 robot-assisted vs. 2352 conventional UKA; follow-up, 0 to 60 months), seven on robot-assisted TKA (n, 4567 robot-assisted vs. 5966 conventional TKA; follow-up, 0 to 132 months). Of the meta-analyses on UKA, one found that robotic assistance reduced complication rates (relative risk (RR), 0.62), one found that it improved clinical scores (weighted mean difference (WMD), 19.67), three found that it extended operation times (WMD, 15.7 to 17.1 min), and three found that it improved component positioning and alignment (WMD, - 1.30 to - 3.02 degrees). Of the meta-analyses on TKA, two found that robotic assistance improved clinical scores (WMD, 1.62-1.71), two found that that it extended surgery times (WMD, 21.5-24.26 min), and five found that it improved component positioning and alignment (WMD, - 0.50 to - 10.07 degrees). None of the meta-analyses reported differences in survivorship between robot-assisted versus conventional knee arthroplasty.

CONCLUSION

Robot-assisted knee arthroplasty enabled more accurate component positioning and placement within target zones, but extended operation time considerably. Although robotic assistance improved component positioning, its benefits regarding clinical scores, patient satisfaction and implant survivorship remains to be confirmed. Finally, this overview revealed that six of the ten meta-analyses were of 'critically low quality', calling for caution when interpreting results.

LEVEL OF EVIDENCE

IV.

Advanced Technologies for Outpatient Lumbar Fusion: Barriers and Opportunities

BACKGROUND

In recent years, there has been increasing interest in outpatient spine surgery. Minimally invasive techniques have created an opportunity for ambulatory lumbar fusion, and these techniques increasingly involve advanced technologies such as navigation and robotics.

OBJECTIVE

To explore the barriers, advantages, and future predictions for such technology in the context of outpatient lumbar fusions.

METHODS

This is a narrative review of studies examining the advantages, limitations, and cost-effectiveness of navigation and spinal robotics in conjunction with the outcomes and costs of outpatient lumbar fusion.

RESULTS

Outpatient lumbar fusion is a growing trend with ample evidence of its safety, favorable patient outcomes, and cost savings. Navigation and spinal robotics are associated with improved instrumentation accuracy and fewer complications, and the long-term cost savings can make these technologies financially practical in the outpatient setting. Future capabilities with robotics will only increase their value.

CONCLUSIONS

Advanced technologies such as navigation and robotics are strategic long-term investments in the context of outpatient lumbar fusion.

CLINICAL RELEVANCE

The favorable outcomes and costs associated with navigation and robotics will be relevant to any spine surgeon interested in developing an outpatient lumbar fusion program.

LEVEL OF EVIDENCE: 5

Comparison of robot-assisted versus fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar spinal diseases: 2-year follow-up

This study was performed to prospectively compare the clinical and radiographic outcomes between robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA MIS-TLIF) and fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion (FA MIS-TLIF) in patients with degenerative lumbar spinal diseases. One hundred and twenty-three patients with lumbar degenerative diseases (lumbar spinal stenosis with instability and spondylolisthesis [degenerative spondylolisthesis or isthmic spondylolisthesis]) who underwent MIS-TLIF in our hospital were included in this study. Sixty-one patients underwent RA MIS-TLIF (Group A) and 62 patients underwent FA MIS-TLIF (Group B). Group A was further divided into Subgroup AI (46 single-level procedures) and Subgroup AII (15 double-level procedures). Group B was further divided into Subgroup BI (45 single-level procedures) and Subgroup BII (17 double-level procedures). The clinical outcome parameters were the visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, operative time, number of intraoperative fluoroscopies, blood loss, postoperative hospital stay, and postoperative complications. The radiographic change measures were the accuracy of screw placement, facet joint violation (FJV), fusion status, and change in disc height at the proximal adjacent segment at the 2-year follow-up. There were no significant differences in the VAS and ODI scores, blood loss, or postoperative hospital stay between Groups A and B (p > 0.05). The operative time was longer in Group A than B (p = 0.018). The operative time was longer in Subgroup AI than BI (p = 0.001). However, there was no significant difference between Subgroups AII and BII (p > 0.05). There was no significant difference in the number of intraoperative fluoroscopies for patients between Groups A and B (p > 0.05). Although the number of intraoperative fluoroscopies for patients was significantly higher in Subgroup AI than BI (p = 0.019), there was no significant difference between Subgroups AII and BII (p > 0.05). The number of intraoperative fluoroscopies for the surgeon was significantly lower in Group A than B (p < 0.001). For surgeons, the difference in the average number of intraoperative fluoroscopies between Subgroups AI and AII was 2.98, but that between Subgroups BI and BII was 10.73. In Group A, three guide pins exhibited drift and one patient developed a lateral wall violation by a pedicle screw. One pedicle screw perforated the anterior wall of the vertebral body and another caused an inner wall violation in Group B. The rate of a perfect screw position (grade A) was higher in Group A than B (p < 0.001). However, there was no significant difference in the proportion of clinically acceptable screws (grades A and B) between the two groups. The mean FJV grade was significantly higher in Group B than A (p < 0.001). During at 2-year postoperative follow-up, there was no significant difference in the fusion status between the two groups (p > 0.05); however, the decrease in disc height at the proximal adjacent segment was significantly less in Group A than B (p < 0.001). Robot-assisted percutaneous pedicle screw placement is a safer and more accurate alternative to conventional freehand fluoroscopy-assisted percutaneous pedicle screw insertion in MIS-TLIF.

Minimally-Invasive Assisted Robotic Spine Surgery (MARSS)

Minimally-Invasive robotic spine surgery (MARSS) has expanded the surgeons armamentarium to treat a variety of spinal disorders. In the last decade, robotic developments in spine surgery have improved the safety, accuracy and efficacy of instrumentation placement. Additionally, robotic instruments have been applied to remove tumors in difficult locations while maintaining minimally invasive access. Gross movements by the surgeon are translated into fine, precise movements by the robot. This is exemplified in this chapter with the use of the da Vinci robot to remove apical thoracic tumors. In this chapter, we will review the development, technological advancements, and cases that have been conducted using MARSS to treat spine pathology in a minimally invasive fashion.

Association of robot-assisted techniques with the accuracy rates of pedicle screw placement: A network pooling analysis

BACKGROUND

Traditional paired meta-analyses have yielded inconsistent results for the safety and effectiveness of robotic-assisted pedicle screw placement due to the high heterogeneity within studies. This study evaluated the clinical effectiveness and safety of robotic-assisted pedicle screw placement.

METHODS

The Embase, PubMed, and Cochrane Library databases were searched with no language limitations from inception to Jan 4, 2022. Odds ratio (OR), mean difference (MD), and 95% confidence interval (CI) were used to report results. The main outcomes were accuracy of pedicle screw placement, proximal facet joint violation, and complications. The study protocol was published in PROSPERO (CRD42022301417).

FINDINGS

26 trials including 2046 participants evaluating robotic-assisted pedicle screw placement were included in this study. Our pooled results showed that Renaissance (OR 2.86; [95% CI 1.79 to 4.57]) and TiRobot (OR 3.10; [95% CI 2.19 to 4.40]) yielded higher rates of perfect pedicle screw insertion (Grades A) than the conventional freehand technique. Renaissance (OR 2.82; [95% CI 1.51 to 5.25]) and TiRobot (OR 4.58; [95% CI 2.65 to 7.89]) yielded higher rates of clinically acceptable pedicle screw insertion (Grades A+B). However, ROSA, SpineAssist, and Orthobot were not associated with higher perfect pedicle screw insertion and clinically acceptable pedicle screw insertion rates. Robot-assisted techniques were associated with low rates of proximal facet joint violation (OR 0.18; [95% CI 0.10 to 0.32]; I²:9.55%) and overall complications (OR 0.38; [95% CI 0.23 to 0.63]; I²:27.05%). Moreover, robot-assisted techniques were associated with lower radiation doses (MD -14.38; [95% CI -25.62 to -3.13]; I²:100.00%).

INTERPRETATION

Our findings suggest that only Renaissance and TiRobot systems are associated with high accuracy rates of pedicle screw placement. Robotic-assisted techniques hold great promise in spinal surgery due to their safety and effectiveness.

FUNDING

This work was supported by grants from the National Natural Science Foundation of China (No. 81871818), Tangdu Hospital Seed Talent Program (Fei-Long Wei) and Natural Science Basic Research Plan in Shaanxi Province of China (No.2019JM-265).

Bone-Mounted Robotic System in Minimally Invasive Spinal Surgery for Osteoporosis Patients: Clinical and Radiological Outcomes

Purpose

Severe complications, including screw loosening events and low fusion rates, in spinal fusion surgery using the traditional open method are problematic. This retrospective study aimed to evaluate the rate of screw loosening and the clinical outcomes of bone-mounted miniature robot-assisted pedicle screw placement in patients treated for degenerative spinal disease.

Patients and Methods

Data were collected from the medical records of 118 patients (mean age, 69 years). Differences in clinical outcomes, including the Oswestry disability index, visual analog scale score, screw loosening rate, cage fusion rate, and complications, were evaluated among different bone mineral densities.

Results

The screw loosening and cage fusion rates for all patients, normal bone mineral density, osteopenia, and osteoporosis groups were 12%, 8.6%, 13.1%, and 14%, respectively, and 85.3%, 93%, 82.5%, and 81.4%, respectively. There was a higher screw loosening rate and a lower cage fusion rate in the osteopenia and osteoporosis groups than in the normal bone density group. The accuracy of the screw placement was 97.3%. There were no statistically significant differences in the Oswestry disability index and visual analog scale scores, and no major complications for dural tear or vascular or visceral injury.

Conclusion

Our study demonstrated an acceptable screw loosening rate in patients with osteoporosis compared to that in patients with normal bone mineral density. The robotic system resulted in accurate screw placement in patients with osteoporosis.

A multicenter study of the 5-year trends in robot-assisted spine surgery outcomes and complications

BACKGROUND

Although a growing amount of literature that suggests robots are safe and can achieve comparable outcomes to conventional techniques, much of this literature is limited by small sample sizes and single-surgeon or single center series. Furthermore, it is unclear what the impact of robotic technology has made on operative and clinical outcomes over time. This is the first and largest multicenter study to examine the trends in outcomes and complications after robot-assisted spine surgery over a 5-year period.

METHODS

Adult (≥18 years old) patients who underwent spine surgery with robot-assistance between 2015 and 2019 at four unique spine centers. The robotic systems used included the Mazor Renaissance, Mazor X, and Mazor Stealth Edition. Patients with incomplete data were excluded from this study. The minimum follow-up was 90 days.

RESULTS

A total of 722 adult patients were included (117 Renaissance, 477 X, 128 Stealth). Most patient and operative factors (e.g., sex, tobacco status, total instrumented levels, and pelvic fixation,) were similar across the years. Mean ± standard deviation Charlson comorbidity index (CCI) was 1.5±1.5. The most commonly reported diagnoses included high grade spondylolisthesis (40.6%), degenerative disc disease (18.4%), and degenerative scoliosis (17.6%). Mean (standard deviation) number of instrumented levels was 3.8±3.4. From 2015 to 2019, average robot time per screw improved from 7.2 to 5.5 minutes (P=0.004, R²=0.649). Average fluoroscopy time per screw improved from 15.2 to 9.4 seconds (P=0.002). Rates of both intraoperative screw exchange for misplaced screw (2015-2016: 2.7%, 2019: 0.8%, P=0.0115, R²=0.1316) and robot abandonment (2015-2016: 7.1%, 2019: 1.1%, P=0.011, R²=0.215) improved significantly over time. The incidence of other intraoperative complications (e.g., dural tear, loss of motor/sensory function, blood transfusion) remained consistently low, but similar throughout the years. The length of stay (LOS) decreased by nearly 1 day from 2015 to 2019 (P=0.007, R²=0.779). 90-day reoperation rates did not change significantly.

CONCLUSIONS

At four institutions among seven surgeons, we demonstrate robot screw accuracy, reliability, operative efficiency, and radiation exposure improved significantly from 2015 to 2019. 90-day complication rates remained low and LOS decreased significantly with time. These findings further validate continued usage of robot-assisted spine surgery and the path toward improved value-based care.