Pedicle Screw Placement in Adolescent Idiopathic Scoliosis: A Comparison between Robotics Coupled with Navigation versus the Freehand Technique

Robot-assisted pedicle screw insertion versus navigation-based and freehand techniques for posterior spinal fusion in scoliosis: a systematic review and meta-analysis

PURPOSE

The role of robotics in spine surgery remains controversial, especially for scoliosis correction surgery. This study aims to assess the safety and efficacy of robotic-assisted (RA) surgery specifically for scoliosis surgery by comparing RA to both navigation systems (NS) and conventional freehand techniques (CF).

METHODS

As per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis were conducted via an electronic search of the following databases: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL). All papers comparing RA to either NS or CF for posterior spinal fusion in scoliosis were included. Fixed and random effects models of analysis were utilised based on analysis heterogeneity.

RESULTS

10 observational studies were included in total. RA had significantly greater odds of accurate pedicle screw placement relative to both NS (OR = 2.02, CI = 1.52-2.67, p < 0.00001) and CF (OR = 3.06, CI = 1.79-5.23, p < 0.00001). The downside of RA was the significantly greater operation duration relative to NS (MD = 10.74, CI = 3.52-17.97, p = 0.004) and CF (MD = 40.27, CI = 20.90, p < 0.0001). Perioperative outcomes including estimated blood loss, radiation exposure, length of hospital stay, cobb angle correction rate, postoperative SRS score, VAS pain score, JOA score, as well as rates of neurological injury and revision surgery, were comparable between the groups (p > 0.05).

CONCLUSION

RA offers significantly greater pedicle screw placement accuracy relative to NS and CF, however, surgery can take longer. In terms of perioperative outcomes, all three techniques are comparable.

Analysis of 5,070 consecutive pedicle screws placed utilizing robotically assisted surgical navigation in 334 patients by experienced pediatric spine deformity surgeons: surgical safety and early perioperative complications in pediatric posterior spinal fusion

PURPOSE

This study evaluates the intraoperative and short-term complications associated with robotically assisted pedicle screw placement in pediatric posterior spinal fusion (PSF) from three surgeons at two different institutions.

METHODS

We retrospectively reviewed 334 pediatric patients who underwent PSF with robotic-assisted navigation at 2 institutions over 3 years (2020-2022). Five thousand seventy robotically placed screws were evaluated. Data collection focused on intraoperative and early postoperative complications with minimum 30-day follow-up. Patients undergoing revision procedures were excluded.

RESULTS

Intraoperative complications included 1 durotomy, 6 patients with neuromonitoring alerts not related to screw placement, and 62 screws (1.2%) with documented pedicle breaches, all of which were revised at time of surgery. By quartile, pedicle breaches statistically declined from first quartile to fourth quartile (1.8% vs. 0.56%, p < 0.05). No breach was associated with neuromonitoring changes or neurological sequelae. No spinal cord or vascular injuries occurred. Seventeen postoperative complications occurred in eleven (3.3%) of patients. There were five (1.5%) patients with unplanned return to the operating room.

CONCLUSION

Robotically assisted pedicle screw placement was safely and reliably performed on pediatric spinal deformity by three surgeons across two centers, demonstrating an acceptable safety profile and low incidence of unplanned return to the operating room.

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.

Navigation-Assisted One-Staged Posterior Spinal Fusion Using Pedicle Screw Instrumentation in Adolescent Idiopathic Scoliosis-A Case Series

Background and Objectives: Adolescent idiopathic scoliosis (AIS) is a prevalent three-dimensional spinal disorder, with a multifactorial pathogenesis, including genetics and environmental aspects. Treatment options include non-surgical and surgical treatment. Surgical interventions demonstrate positive outcomes in terms of deformity correction, pain relief, and improvements of the cardiac and pulmonary function. Surgical complications, including excessive blood loss and neurologic deficits, are reported in 2.27-12% of cases. Navigation-assisted techniques, such as the O-arm system, have been a recent focus with enhanced precision. This study aims to evaluate the results and complications of one-stage posterior instrumentation fusion in AIS patients assisted by O-arm navigation. Materials and Methods: This retrospective study assesses 55 patients with AIS (12-28 years) who underwent one-stage posterior instrumentation correction supported by O-arm navigation from June 2016 to August 2023. We examined radiological surgical outcomes (initial correction rate, loss of correction rate, last follow-up correction rate) and complications as major outcomes. The characteristics of the patients, intraoperative blood loss, operation time, number of fusion levels, and screw density were documented. Results: Of 73 patients, 55 met the inclusion criteria. The average age was 16.67 years, with a predominance of females (78.2%). The surgical outcomes demonstrated substantial initial correction (58.88%) and sustained positive radiological impact at the last follow-up (56.56%). Perioperative complications, including major and minor, occurred in 18.18% of the cases. Two patients experienced a major complication. Blood loss (509.46 mL) and operation time (402.13 min) were comparable to the literature ranges. Trend analysis indicated improvements in operation time and blood loss over the study period. Conclusions: O-arm navigation-assisted one-stage posterior instrumentation proves reliable for AIS corrective surgery, achieving significant and sustained positive radiological outcomes, lower correction loss, reduced intraoperative blood loss, and absence of implant-related complications. Despite the challenges, our study demonstrates the efficacy and maturation of this surgical approach.

Safety and accuracy of cannulated pedicle screw placement in scoliosis surgery: a comparison of robotic-navigation, O-arm-based navigation, and freehand techniques

PURPOSE

To compare the safety and accuracy of cannulated pedicle screw placement using a robotic-navigation technique, O-arm-based navigation technique, or freehand technique.

METHODS

This study analyzed 106 consecutive patients who underwent scoliosis surgery. Thirty-two patients underwent robotic-navigation-assisted pedicle screw insertion (Group 1), 34 patients underwent O-arm-based navigation-guided pedicle screw insertion (Group 2), and 40 patients underwent freehand pedicle screw insertion (Group 3). The primary outcome measure was the accuracy of screw placement. Secondary outcome parameters included operation time, blood loss, radiation exposure, and postoperative stay.

RESULTS

A total of 2035 cannulated pedicle screws were implanted in 106 patients. The accuracy rate of the first pedicle screw placement during operation was significantly greater in Group 1 (94.7%) than in Group 2 (89.2%; P < 0.001). The accuracy rate of pedicle screw placement postoperatively decreased in the order of Group 1 (96.7%) > Group 2 (93.0%) > Group 3 (80.4%; P < 0.01). There were no significant differences in blood loss or postoperative stay among the three groups (P > 0.05). The operation times of Group 1 and Group 2 were significantly longer than that of Group 3 (P < 0.05).

CONCLUSION

The robotic-navigation and O-arm-based navigation techniques effectively increased the accuracy and safety of pedicle screw insertion alternative to the freehand technique in scoliosis surgery. Compared with the O-arm-based navigation technique, the robotic-navigation technique increases the mean operation time, but also increases the accuracy of pedicle screw placement. A three-dimensional scan after insertion of the K-wire may increase the accuracy of pedicle screw placement in the O-arm-based navigation technique.

Robot-assisted versus navigation-assisted screw placement in spinal vertebrae

PURPOSE

Both robots and navigation are effective strategies for optimizing screw placement, as compared to freehand placement. However, few studies have compared the accuracy and efficiency of these two techniques. Thus, the purpose of this study is to compare the accuracy and efficiency of robotic and navigation-assisted screw placement in the spinal vertebrae.

METHODS

The 24 spine models were divided into a robot- and navigation-assisted groups according to the left and right sides of the pedicle. The C-arm transmits image data simultaneously to the robot and navigates using only one scan. After screw placement, the accuracy of the two techniques were compared using "angular deviation" and "Gertzbein and Robbins scale" in different segments (C1-7, T1-4, T5-8, T9-12, and L1-S1). In addition, operation times were compared between robot- and navigation-assisted groups.

RESULTS

Robots and navigation systems can simultaneously assist in screw placement. The robot-assisted group had significantly less angular deviation than the navigation-assisted group from C1 to S1 (p < 0.001). At the C1-7 and T1-4 segments, the robot-assisted group had a higher rate of acceptable screws than the robot-assisted group. However, at the T5-8, T9-12, and L1-S1 segments, no significant difference was found in the incidence of acceptable screws between the two groups. Moreover, robot-assisted screw placement required less operative time than navigation (p < 0.05).

CONCLUSION

The robot is more accurate and efficient than navigation in aiding screw placement. In addition, robots and navigation can be combined without increasing the number of fluoroscopic views.