scholarly journals Does robot-assisted navigation influence pedicle screw selection and accuracy in minimally invasive spine surgery?

2022 ◽  
Vol 52 (1) ◽  
pp. E4
Keyword(s):  
Minimally Invasive ◽  
Pedicle Screw ◽  
Surgical Navigation ◽  
Lumbar Fusion ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Robotic Assistance ◽  
Pedicle Screw Placement ◽  
Screw Length ◽  
The Mean

OBJECTIVE The accuracy of percutaneous pedicle screw placement has increased with the advent of robotic and surgical navigation technologies. However, the effect of robotic intraoperative screw size and trajectory templating remains unclear. The purpose of this study was to compare pedicle screw sizes and accuracy of placement using robotic navigation (RN) versus skin-based intraoperative navigation (ION) alone in minimally invasive lumbar fusion procedures. METHODS A retrospective cohort study was conducted using a single-institution registry of spine procedures performed over a 4-year period. Patients who underwent 1- or 2-level primary or revision minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF) with pedicle screw placement, via either robotic assistance or surgical navigation alone, were included. Demographic, surgical, and radiographic data were collected. Pedicle screw type, quantity, length, diameter, and the presence of endplate breach or facet joint violation were assessed. Statistical analysis using the Student t-test and chi-square test was performed to evaluate the differences in pedicle screw sizes and the accuracy of placement between both groups. RESULTS Overall, 222 patients were included, of whom 92 underwent RN and 130 underwent ION MIS-TLIF. A total of 403 and 534 pedicle screws were placed with RN and ION, respectively. The mean screw diameters were 7.25 ± 0.81 mm and 6.72 ± 0.49 mm (p < 0.001) for the RN and ION groups, respectively. The mean screw length was 48.4 ± 4.48 mm in the RN group and 45.6 ± 3.46 mm in the ION group (p < 0.001). The rates of “ideal” pedicle screws in the RN and ION groups were comparable at 88.5% and 88.4% (p = 0.969), respectively. The overall screw placement was also similar. The RN cohort had 63.7% screws rated as good and 31.4% as acceptable, while 66.1% of ION-placed screws had good placement and 28.7% had acceptable placement (p = 0.661 and p = 0.595, respectively). There was a significant reduction in high-grade breaches in the RN group (0%, n = 0) compared with the ION group (1.2%, n = 17, p = 0.05). CONCLUSIONS The results of this study suggest that robotic assistance allows for placement of screws with greater screw diameter and length compared with surgical navigation alone, although with similarly high accuracy. These findings have implied that robotic platforms may allow for safe placement of the “optimal screw,” maximizing construct stability and, thus, the ability to obtain a successful fusion.

Clinical Assessment of Percutaneous Lumbar Pedicle Screw Placement Using the O-Arm Multidimensional Surgical Imaging System

Neurosurgery ◽  
2011 ◽  
Vol 70 (4) ◽  
pp. 990-995 ◽  
Author(s):  
John K. Houten ◽  
Rani Nasser ◽  
Nrupen Baxi
Keyword(s):  
Minimally Invasive ◽  
Pedicle Screw ◽  
Imaging System ◽  
Intraoperative Imaging ◽  
Lumbar Fusion ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Pedicle Screw Placement ◽  
Percutaneous Pedicle Screw ◽  
Clinical Series

Abstract BACKGROUND: Increasing popularity of minimally invasive surgery for lumbar fusion has led to dependence upon intraoperative fluoroscopy for pedicle screw placement, because limited muscle dissection does not expose the bony anatomy necessary for traditional, freehand techniques nor for registration steps in image-guidance techniques. This has raised concerns about cumulative radiation exposure for both surgeon and operating room staff. The recent introduction of the O-arm Multidimensional Surgical Imaging System allows for percutaneous placement of pedicle screws, but there is limited clinical experience with the technique and data examining its accuracy. OBJECTIVE: We present the first large clinical series of percutaneous screw placement using navigation of O-arm imaging and compare the results with the fluoroscopy-guided method. METHODS: A retrospective review of a 24-month period identified patients undergoing minimally invasive lumbar interbody fusion. The O-arm was introduced in the middle of this period and was used for all subsequent patients. Accuracy of screw placement was assessed by examination of axial computed tomography or O-arm scans. RESULTS: The fluoroscopy group included 141 screws in 42 patients, and the O-arm group included 205 screws in 52 patients. The perforation rate was 12.8% in the fluoroscopy group and 3% in the O-arm group (P &lt; .001). Single-level O-arm procedures took a mean 200 (153–241) minutes, whereas fluoroscopy took 221 (178–302) minutes (P &lt; .03). CONCLUSION: Percutaneous pedicle screw placement with the O-arm Multidimensional Intraoperative Imaging System is a safe and effective technique and provided improved overall accuracy and reduced operative time compared with conventional fluoroscopic techniques.

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

2019 ◽  
Vol 14 (4) ◽  
pp. 567-572 ◽  
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.

scholarly journals A Novel Augmented-Reality-Based Surgical Navigation System for Spine Surgery in a Hybrid Operating Room: Design, Workflow, and Clinical Applications

2019 ◽  
Vol 18 (5) ◽  
pp. 496-502 ◽  
Author(s):  
Erik Edström ◽  
Gustav Burström ◽  
Rami Nachabe ◽  
Paul Gerdhem ◽  
Adrian Elmi Terander
Keyword(s):  
Augmented Reality ◽  
Radiation Exposure ◽  
Pedicle Screw ◽  
Operating Room ◽  
Wound Closure ◽  
Surgical Navigation ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Hybrid Operating Room ◽  
Pedicle Screw Placement

Abstract BACKGROUND Treatment of several spine disorders requires placement of pedicle screws. Detailed 3-dimensional (3D) anatomic information facilitates this process and improves accuracy. OBJECTIVE To present a workflow for a novel augmented-reality-based surgical navigation (ARSN) system installed in a hybrid operating room for anatomy visualization and instrument guidance during pedicle screw placement. METHODS The workflow includes surgical exposure, imaging, automatic creation of a 3D model, and pedicle screw path planning for instrument guidance during surgery as well as the actual screw placement, spinal fixation, and wound closure and intraoperative verification of the treatment results. Special focus was given to process integration and minimization of overhead time. Efforts were made to manage staff radiation exposure avoiding the need for lead aprons. Time was kept throughout the procedure and subdivided to reflect key steps. The navigation workflow was validated in a trial with 20 cases requiring pedicle screw placement (13/20 scoliosis). RESULTS Navigated interventions were performed with a median total time of 379 min per procedure (range 232-548 min for 4-24 implanted pedicle screws). The total procedure time was subdivided into surgical exposure (28%), cone beam computed tomography imaging and 3D segmentation (2%), software planning (6%), navigated surgery for screw placement (17%) and non-navigated instrumentation, wound closure, etc (47%). CONCLUSION Intraoperative imaging and preparation for surgical navigation totaled 8% of the surgical time. Consequently, ARSN can routinely be used to perform highly accurate surgery potentially decreasing the risk for complications and revision surgery while minimizing radiation exposure to the staff.

scholarly journals Evaluation of C2 pedicle screw placement via the freehand technique by neurosurgical trainees

2018 ◽  
Vol 29 (3) ◽  
pp. 235-240 ◽  
Author(s):  
Martin H. Pham ◽  
Joshua Bakhsheshian ◽  
Patrick C. Reid ◽  
Ian A. Buchanan ◽  
Vance L. Fredrickson ◽  
...  
Keyword(s):  
Pedicle Screw ◽  
Medical Center ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Pedicle Screw Placement ◽  
C2 Pedicle Screw ◽  
Canal Diameter ◽  
Screw Length ◽  
Freehand Technique ◽  
Screw Diameter

OBJECTIVEFreehand placement of C2 instrumentation is technically challenging and has a learning curve due the unique anatomy of the region. This study evaluated the accuracy of C2 pedicle screws placed via the freehand technique by neurosurgical resident trainees.METHODSThe authors retrospectively reviewed all patients treated at the LAC+USC Medical Center undergoing C2 pedicle screw placement in which the freehand technique was used over a 1-year period, from June 2016 to June 2017; all procedures were performed by neurosurgical residents. Measurements of C2 were obtained from preoperative CT scans, and breach rates were determined from coronal reconstructions on postoperative scans. Severity of breaches reflected the percentage of screw diameter beyond the cortical edge (I = < 25%; II = 26%–50%; III = 51%–75%; IV = 76%–100%).RESULTSNeurosurgical residents placed 40 C2 pedicle screws in 24 consecutively treated patients. All screws were placed by or under the guidance of Pham, who is a postgraduate year 7 (PGY-7) neurosurgical resident with attending staff privileges, with a PGY-2 to PGY-4 resident assistant. The authors found an average axial pedicle diameter of 5.8 mm, axial angle of 43.1°, sagittal angle of 23.0°, spinal canal diameter of 25.1 mm, and axial transverse foramen diameter of 5.9 mm. There were 17 screws placed by PGY-2 residents, 7 screws placed by PGY-4 residents, and 16 screws placed by the PGY-7 resident. The average screw length was 26.0 mm, with a screw diameter of 3.5 mm or 4.0 mm. There were 7 total breaches (17.5%), of which 4 were superior (10.0%) and 3 were lateral (7.5%). There were no medial breaches. The breaches were classified as grade I in 3 cases (42.9%), II in 3 cases (42.9%), III in 1 case (14.3%), and IV in no cases. There were 3 breaches that occurred via placement by a PGY-2 resident, 3 breaches by a PGY-4 resident, and 1 breach by the PGY-7 resident. There were no clinical sequelae due to these breaches.CONCLUSIONSFreehand placement of C2 pedicle screws can be done safely by neurosurgical residents in early training. When breaches occurred, they tended to be superior in location and related to screw length choice, and no breaches were found to be clinically significant. Controlled exposure to this unique anatomy is especially pertinent in the era of work-hour restrictions.

scholarly journals Minimally invasive guidewireless, navigated pedicle screw placement: a technical report and case series

2017 ◽  
Vol 43 (2) ◽  
pp. E9 ◽  
Author(s):  
Brandon W. Smith ◽  
Jacob R. Joseph ◽  
Michael Kirsch ◽  
Mary Oakley Strasser ◽  
Jacob Smith ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Pedicle Screw ◽  
Kirschner Wire ◽  
Case Series ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Pedicle Screw Placement ◽  
Minimally Invasive Spinal Surgery ◽  
Screw Insertion ◽  
Percutaneous Pedicle Screw

OBJECTIVEPercutaneous pedicle screw insertion (PPSI) is a mainstay of minimally invasive spinal surgery. Traditionally, PPSI is a fluoroscopy-guided, multistep process involving traversing the pedicle with a Jamshidi needle, placement of a Kirschner wire (K-wire), placement of a soft-tissue dilator, pedicle tract tapping, and screw insertion over the K-wire. This study evaluates the accuracy and safety of PPSI with a simplified 2-step process using a navigated awl-tap followed by navigated screw insertion without use of a K-wire or fluoroscopy.METHODSPatients undergoing PPSI utilizing the K-wire–less technique were identified. Data were extracted from the electronic medical record. Complications associated with screw placement were recorded. Postoperative radiographs as well as CT were evaluated for accuracy of pedicle screw placement.RESULTSThirty-six patients (18 male and 18 female) were included. The patients’ mean age was 60.4 years (range 23.8–78.4 years), and their mean body mass index was 28.5 kg/m2 (range 20.8–40.1 kg/m2). A total of 238 pedicle screws were placed. A mean of 6.6 pedicle screws (range 4–14) were placed over a mean of 2.61 levels (range 1–7). No pedicle breaches were identified on review of postoperative radiographs. In a subgroup analysis of the 25 cases (69%) in which CT scans were performed, 173 screws were assessed; 170 (98.3%) were found to be completely within the pedicle, and 3 (1.7%) demonstrated medial breaches of less than 2 mm (Grade B). There were no complications related to PPSI in this cohort.CONCLUSIONSThis streamlined 2-step K-wire–less, navigated PPSI appears safe and accurate and avoids the need for radiation exposure to surgeon and staff.

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

2017 ◽  
Vol 42 (5) ◽  
pp. E14 ◽  
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.

scholarly journals Which of MIS-TLIF and TLIF Can Leads to Better Pedicle Screws Placement Accuracy and Clinical Outcomes with Navigation Guidance?

2021 ◽  
Author(s):  
JiaBin Liu ◽  
JunLong Wu ◽  
Rui Zuo ◽  
ChangQing Li ◽  
Chao Zhang ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Pedicle Screw ◽  
Pedicle Screws ◽  
Entry Point ◽  
Screw Placement ◽  
Transfusion Rate ◽  
Pedicle Screw Placement ◽  
Multifidus Muscle ◽  
Lower Accuracy ◽  
Significant Difference

Abstract Background Although previous studies have suggested that navigation can improve the accuracy of pedicle screw placement, there are still few studies comparing navigation-assisted transforaminal lumbar interbody fusion (TLIF) and navigation-assisted minimally-invasive TLIF (MIS-TLIF). The pedicle screw insertion entry point of navigation-assisted MIS-TLIF may be deflected from the planned entry point due to uneven bone-surface, which may result in misplacement. The purpose of this study was to explore the pedicle screws accuracy and clinical consequences of MIS-TLIF and TLIF both under O-arm navigation to determine which surgical method is better.MethodsA retrospective study of 54 patients who underwent single-segment navigation-assisted MIS-TLIF (NM-TLIF) or navigation-assisted TLIF (N-TLIF) was conducted. In addition to the patient's demographic characteristics, intraoperative indicators and complications, the ODI and VAS scores were recorded and analyzed preoperatively, at 1, 6, 12 months and at the final follow-up postoperatively. The clinical accuracy and absolute accuracy of pedicle screw placement was assessed by postoperative CT. Multifidus muscle injury were evaluated by T2-weighted MRI.ResultsCompared with N-TLIF, NM-TLIF was more advantageous in the incision length, intraoperative blood loss, drainage volume, time before ambulation, length of hospital stays, blood transfusion rate and analgesia rate (p<0.05). The ODI and VAS for low back pain scores were better than those of N-TLIF at 1 month and 6 months after surgery (p<0.05). There was no significant difference in the screw clinical qualitative accuracy (97.3% vs. 96.2%, p>0.05). The absolute quantitative accuracy results show that the axial translational error, sagittal translational error and sagittal angle error of NM-TLIF group are significantly greater than that in N-TLIF group (P<0.05). The mean T2-weighted signal intensity of multifidus muscle in the NM-TLIF group was significantly lower than that in the N-TLIF group (P<0.05)ConclusionsCompared with N-TLIF, NM-TLIF has more minimally invasive advantages, it does not yield a lower accuracy of screw placement and can achieve better symptom relief in the middle stage of postoperative recovery. However，more attention on real-time adjustment should be paid to pedicle insertion in NM-TLIF, rather than just following the entry point and trajectory of the intraoperative plan.

scholarly journals First in-human report of the clinical accuracy of thoracolumbar percutaneous pedicle screw placement using augmented reality guidance

2021 ◽  
Vol 51 (2) ◽  
pp. E10
Author(s):  
Alexander T. Yahanda ◽  
Emelia Moore ◽  
Wilson Z. Ray ◽  
Brenton Pennicooke ◽  
Jack W. Jennings ◽  
...  
Keyword(s):  
Augmented Reality ◽  
Lower Extremity ◽  
Pedicle Screw ◽  
Pedicle Screws ◽  
Screw Placement ◽  
Spinal Tumors ◽  
Pedicle Screw Placement ◽  
Percutaneous Pedicle Screw ◽  
Clinical Accuracy ◽  
The Mean

OBJECTIVE Augmented reality (AR) is an emerging technology that has great potential for guiding the safe and accurate placement of spinal hardware, including percutaneous pedicle screws. The goal of this study was to assess the accuracy of 63 percutaneous pedicle screws placed at a single institution using an AR head-mounted display (ARHMD) system. METHODS Retrospective analyses were performed for 9 patients who underwent thoracic and/or lumbar percutaneous pedicle screw placement guided by ARHMD technology. Clinical accuracy was assessed via the Gertzbein-Robbins scale by the authors and by an independent musculoskeletal radiologist. Thoracic pedicle subanalysis was also performed to assess screw accuracy based on pedicle morphology. RESULTS Nine patients received thoracic or lumbar AR-guided percutaneous pedicle screws. The mean age at the time of surgery was 71.9 ± 11.5 years and the mean number of screws per patient was 7. Indications for surgery were spinal tumors (n = 4, 44.4%), degenerative disease (n = 3, 33.3%), spinal deformity (n = 1, 11.1%), and a combination of deformity and infection (n = 1, 11.1%). Presenting symptoms were most commonly low-back pain (n = 7, 77.8%) and lower-extremity weakness (n = 5, 55.6%), followed by radicular lower-extremity pain, loss of lower-extremity sensation, or incontinence/urinary retention (n = 3 each, 33.3%). In all, 63 screws were placed (32 thoracic, 31 lumbar). The accuracy for these screws was 100% overall; all screws were Gertzbein-Robbins grade A or B (96.8% grade A, 3.2% grade B). This accuracy was achieved in the thoracic spine regardless of pedicle cancellous bone morphology. CONCLUSIONS AR-guided surgery demonstrated a 100% accuracy rate for the insertion of 63 percutaneous pedicle screws in 9 patients (100% rate of Gertzbein-Robbins grade A or B screw placement). Using an ARHMS system for the placement of percutaneous pedicle screws showed promise, but further validation using a larger cohort of patients across multiple surgeons and institutions will help to determine the true accuracy enabled by this technology.

scholarly journals Single Position Lateral Lumbar Fusion Utilizing Robot Guided Screw Placement

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
George V Huffmon
Keyword(s):  
Pedicle Screw ◽  
Interbody Fusion ◽  
Structural Integrity ◽  
Lumbar Fusion ◽  
Posterior Instrumentation ◽  
Pedicle Screws ◽  
Lateral Position ◽  
Screw Placement ◽  
Lumbar Interbody Fusion ◽  
Pedicle Screw Placement

Abstract INTRODUCTION Lateral position interbody lumbar fusion surgery has become popular as an excellent modality for obtaining lumbar fusion and achieving sagital balance. Posterior instrumentation with pedicle screw fixation adds structural integrity to the construct. Maintaining the patient in the lateral position for pedicle screw placement decreases the time that the patient is under general anesthesia. Since August 2017 we have successfully performed 32 single position pedicle screw fixations utilizing robotic guidance. METHODS The lateral position was utilized for interbody fusion using a variety of techniques; oblique lumbar interbody fusion, extreme lateral lumbar interbody fusion, and lateral anterior lumbar interbody fusion. The Mazor X robot (Medtronic) was utilized for guidewire placement maintaining the patient in the lateral position. Pedicle screws of various manufacturers were placed over the guide wires and connecting rods were placed in the lateral position. RESULTS Since August 2017 we have successfully placed pedicle screws in 1 and 2 level single position lateral lumbar fusions in 32 of 39 cases attempted. There were no nerve root injuries nor any complications related to pedicle screw placement. CONCLUSION Single position lateral lumbar fusion cases utilizing robotic guidance for pedicle screw placement is a viable surgical procedure. Placement of the pedicle screws in the lateral position can reduce intraoperative anesthetic time by eliminating the placement of the patient into the prone position. Utilization of robotic guidance can decrease intraoperative fluoroscopy exposure.

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