Accuracy of Pedicle Screw Placement and Clinical Outcomes of Robot-assisted Technique Versus Conventional Freehand Technique in Spine Surgery From Nine Randomized Controlled Trials

As robotics in spine surgery has progressed over the past 2 decades, studies have shown mixed results on its clinical outcomes and economic impact. In this review, we highlight the evolution of robotic technology over the past 30 years, discussing early limitations and failures. We provide an overview of the history and evolution of currently available spinal robotic platforms and compare and contrast the available features of each. We conclude by summarizing the literature on robotic instrumentation accuracy in pedicle screw placement and clinical outcomes such as complication rates and briefly discuss the future of robotic spine surgery.

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Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery

Neurosurgical FOCUS ◽

10.3171/2017.3.focus179 ◽

2017 ◽

Vol 42 (5) ◽

pp. E14 ◽

Cited By ~ 51

Author(s):

Granit Molliqaj ◽

Bawarjan Schatlo ◽

Awad Alaid ◽

Volodymyr Solomiichuk ◽

Veit Rohde ◽

...

Keyword(s):

Pedicle Screw ◽

Spinal Instrumentation ◽

Pedicle Screws ◽

Screw Placement ◽

Robotic Assistance ◽

Anatomical Landmarks ◽

Pedicle Screw Placement ◽

Robot Assisted ◽

Screw Insertion ◽

Freehand Technique

OBJECTIVEThe quest to improve the safety and accuracy and decrease the invasiveness of pedicle screw placement in spine surgery has led to a markedly increased interest in robotic technology. The SpineAssist from Mazor is one of the most widely distributed robotic systems. The aim of this study was to compare the accuracy of robot-guided and conventional freehand fluoroscopy-guided pedicle screw placement in thoracolumbar surgery.METHODSThis study is a retrospective series of 169 patients (83 women [49%]) who underwent placement of pedicle screw instrumentation from 2007 to 2015 in 2 reference centers. Pathological entities included degenerative disorders, tumors, and traumatic cases. In the robot-assisted cohort (98 patients, 439 screws), pedicle screws were inserted with robotic assistance. In the freehand fluoroscopy-guided cohort (71 patients, 441 screws), screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. Patients treated before 2009 were included in the fluoroscopy cohort, whereas those treated since mid-2009 (when the robot was acquired) were included in the robot cohort. Since then, the decision to operate using robotic assistance or conventional freehand technique has been based on surgeon preference and logistics. The accuracy of screw placement was assessed based on the Gertzbein-Robbins scale by a neuroradiologist blinded to treatment group. The radiological slice with the largest visible deviation from the pedicle was chosen for grading. A pedicle breach of 2 mm or less was deemed acceptable (Grades A and B) while deviations greater than 2 mm (Grades C, D, and E) were classified as misplacements.RESULTSIn the robot-assisted cohort, a perfect trajectory (Grade A) was observed for 366 screws (83.4%). The remaining screws were Grades B (n = 44 [10%]), C (n = 15 [3.4%]), D (n = 8 [1.8%]), and E (n = 6 [1.4%]). In the fluoroscopy-guided group, a completely intrapedicular course graded as A was found in 76% (n = 335). The remaining screws were Grades B (n = 57 [12.9%]), C (n = 29 [6.6%]), D (n = 12 [2.7%]), and E (n = 8 [1.8%]). The proportion of non-misplaced screws (corresponding to Gertzbein-Robbins Grades A and B) was higher in the robot-assisted group (93.4%) than the freehand fluoroscopy group (88.9%) (p = 0.005).CONCLUSIONSThe authors’ retrospective case review found that robot-guided pedicle screw placement is a safe, useful, and potentially more accurate alternative to the conventional freehand technique for the placement of thoracolumbar spinal instrumentation.

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Accuracy of pedicle screw placement comparing robot-assisted technology and the free-hand with fluoroscopy-guided method in spine surgery

Medicine ◽

10.1097/md.0000000000010970 ◽

2018 ◽

Vol 97 (22) ◽

pp. e10970 ◽

Cited By ~ 30

Author(s):

Yong Fan ◽

Jin Peng Du ◽

Ji Jun Liu ◽

Jia Nan Zhang ◽

Huan Huan Qiao ◽

...

Keyword(s):

Pedicle Screw ◽

Spine Surgery ◽

Screw Placement ◽

Pedicle Screw Placement ◽

Robot Assisted

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Comparison of Accuracy and Clinical Outcomes of Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Posterior Cervical Surgery

Global Spine Journal ◽

10.1177/2192568220960406 ◽

2020 ◽

pp. 219256822096040 ◽

Cited By ~ 1

Author(s):

Xin-Jin Su ◽

Zhen-Dong Lv ◽

Zhi Chen ◽

Kun Wang ◽

Chao Zhu ◽

...

Keyword(s):

Success Rate ◽

Pedicle Screw ◽

Clinical Outcomes ◽

Operative Time ◽

Screw Placement ◽

Pedicle Screw Placement ◽

Robot Assisted ◽

Cervical Surgery ◽

Posterior Cervical Surgery ◽

Radiation Time

Study Design: This was a prospective controlled study. Objective: To compare the accuracy and clinical outcomes of robot-assisted (RA) and fluoroscopy-guided (FG) pedicle screw placement in posterior cervical surgery. Methods: This study included 58 patients. The primary outcome measures were the 1-time success rate and the accuracy of pedicle screw placement according to the Gertzbein-Robbins scales. The secondary outcome measures, including the operative time, intraoperative blood loss, hospital stay, cumulative radiation time, radiation dose, intraoperative advent events, and postoperative complications, were recorded and analyzed. The Japanese Orthopedics Association (JOA) scores and Neck Disability Index (NDI) were used to assess the neurological function of patients before and at 3 and 6 months after surgery. Results: The rate of grade A was significantly higher in the RA group than in the FG group (90.6% and 71.1%; P < .001). The clinically acceptable accuracy was 97.2% in the RA group and 90.7% in the FG group ( P = .009). Moreover, the 1-time success rate was significantly higher in the RA group than in the FG group. The RA group had less radiation time ( P < .001) and less radiation dose ( P = .002) but longer operative time ( P = .001). There were no significant differences in terms of intraoperative blood loss, hospital stay, intraoperative adverse events, postoperative complications, JOA scores, and NDI scores at each follow-up time point between the 2 groups. Conclusions: The RA technique achieved higher accuracy and 1-time success rate of pedicle screw placement in posterior cervical surgery while achieving comparable clinical outcomes.

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Does the accuracy of pedicle screw placement differ between the attending surgeon and resident in navigated robotic-assisted minimally invasive spine surgery?

Journal of Robotic Surgery ◽

10.1007/s11701-019-01019-9 ◽

2019 ◽

Vol 14 (4) ◽

pp. 567-572 ◽

Cited By ~ 4

Author(s):

Arnold B. Vardiman ◽

David J. Wallace ◽

Grant A. Booher ◽

Neil R. Crawford ◽

Jessica R. Riggleman ◽

...

Keyword(s):

Minimally Invasive ◽

Pedicle Screw ◽

Spine Surgery ◽

Pedicle Screws ◽

Screw Placement ◽

Robotic Assistance ◽

Pedicle Screw Placement ◽

Robot Assisted ◽

Left And Right ◽

Spine Surgeon

Abstract Robotic assistance with integrated navigation is an area of high interest for improving the accuracy of minimally invasive pedicle screw placement. This study analyzes the accuracy of pedicle screw placement between an attending spine surgeon and a resident by comparing the left and right sides of the first 101 consecutive cases using navigated robotic assistance in a private practice clinical setting. A retrospective, Institutional Review Board-exempt review of the first 106 navigated robot-assisted spine surgery cases was performed. One attending spine surgeon and one resident performed pedicle screw placement consistently on either the left or right side (researchers were blinded). A CT-based Gertzbein and Robbins system (GRS) was used to classify pedicle screw accuracy, with grade A or B considered accurate. There were 630 consecutive lumbosacral pedicle screws placed. Thirty screws (5 patients) were placed without the robot due to surgeon discretion. Of the 600 pedicle screws inserted by navigated robotic guidance (101 patients), only 1.5% (9/600) were repositioned intraoperatively. Based on the GRS CT-based grading of pedicle breach, 98.67% (296/300) of left-side screws were graded A or B, 1.3% (4/300) were graded C, and 0% (0/300) were graded D. For the right-side screws, 97.67% (293/300) were graded A or B, 1.67% (5/300) were graded C, and 0.66% (2/300) were graded D. This study demonstrated a high level of accuracy (based on GRS) with no significant differences between the left- and right-side pedicle screw placements (98.67% vs. 97.67%, respectively) in the clinical use of navigated, robot-assisted surgery.

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