Evaluating robotic pedicle screw placement against conventional modalities: a systematic review and network meta-analysis

Abstract

OBJECTIVE Several approaches have been studied for internal fixation of the spine using pedicle screws (PSs), including CT navigation, 2D and 3D fluoroscopy, freehand, and robotic assistance. Robot-assisted PS placement has been controversial because training requirements, cost, and previously unclear benefits. This meta-analysis compares screw placement accuracy, operative time, intraoperative blood loss, and overall complications of PS insertion using traditional freehand, navigated, and robot-assisted methods. METHODS A systematic review was performed of peer-reviewed articles indexed in several databases between January 2000 and August 2021 comparing ≥ 2 PS insertion methods with ≥ 10 screws per treatment arm. Data were extracted for patient outcomes, including PS placement, misplacement, and accuracy; operative time, overall complications, intraoperative blood loss, postoperative hospital length of stay, postoperative Oswestry Disability Index (ODI) score, and postoperative visual analog scale (VAS) score for back pain. Risk of bias was assessed using the Newcastle-Ottawa score and Cochrane tool. A network meta-analysis (NMA) was performed to estimate PS placement accuracy as the primary outcome. RESULTS Overall, 78 studies consisting of 6262 patients and > 31,909 PSs were included. NMA results showed that robot-assisted and 3D-fluoroscopy PS insertion had the greatest accuracy compared with freehand (p < 0.01 and p < 0.001, respectively), CT navigation (p = 0.02 and p = 0.04, respectively), and 2D fluoroscopy (p < 0.01 and p < 0.01, respectively). The surface under the cumulative ranking (SUCRA) curve method further demonstrated that robot-assisted PS insertion accuracy was superior (S = 0.937). Optimal screw placement was greatest in robot-assisted (S = 0.995) placement, and misplacement was greatest with freehand (S = 0.069) approaches. Robot-assisted placement was favorable for minimizing complications (S = 0.876), while freehand placement had greater odds of complication than robot-assisted (OR 2.49, p < 0.01) and CT-navigation (OR 2.15, p = 0.03) placement. CONCLUSIONS The results of this NMA suggest that robot-assisted PS insertion has advantages, including improved accuracy, optimal placement, and minimized surgical complications, compared with other PS insertion methods. Limitations included overgeneralization of categories and time-dependent effects.

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

“…Meanwhile, another study by Devito et al did not publish the levels that were instrumented limiting the conclusions which can be drawn [ 11 ]. This study demonstrates that robot-assisted pedicle screws in the thoracolumbar spine during acute, traumatic surgery are both feasible and accurate which is in agreement with previous studies demonstrating the accuracy of robot-assisted pedicle screws [ 20 - 22 ]. However, a large, randomized trial should be performed to confirm or disprove the superiority of robot-assisted pedicle screw placement as compared to pedicle screws placed with other techniques in the thoracic spine during an acute, traumatic setting.…”

“…Another critique of this paper would be the blood loss. Previous work has demonstrated decreased blood loss for robot-assisted spinal surgery as opposed to freehand techniques [ 22 ]. However, our surgeries were performed in the acute phase and in the context of other injuries.…”

Virtual and Real Bidirectional Driving System for the Synchronization of Manipulations in Robotic Joint Surgeries

“…Surgical robots are increasingly utilized to assist or replace surgeons in completing surgery operations [1][2][3]. Their high-precision operation capability and reliability are very attractive in surgeries [4,5]. In clinics, each surgeon needs to be trained for years so as to acquire qualifications.…”

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

“…Robot-assisted spinal surgery has also been applied in clinical practice [ 8 ]. It has been confirmed to be superior to manual operations in terms of safety, accuracy, the amount of radiation to surgeons, and the learning curve [ 9 , 10 ].…”