Feasibility and accuracy of a robotic guidance system for navigated spine surgery in a hybrid operating room: a cadaver study

Abstract

Adrian elmi-terander 1,2 the combination of navigation and robotics in spine surgery has the potential to accurately identify and maintain bone entry position and planned trajectory. The goal of this study was to examine the feasibility, accuracy and efficacy of a new robot-guided system for semi-automated, minimally invasive, pedicle screw placement. A custom robotic arm was integrated into a hybrid operating room (OR) equipped with an augmented reality surgical navigation system (ARSN). The robot was mounted on the OR-table and used to assist in placing Jamshidi needles in 113 pedicles in four cadavers. The ARSN system was used for planning screw paths and directing the robot. the robot arm autonomously aligned with the planned screw trajectory, and the surgeon inserted the Jamshidi needle into the pedicle. Accuracy measurements were performed on verification cone beam computed tomographies with the planned paths superimposed. To provide a clinical grading according to the Gertzbein scale, pedicle screw diameters were simulated on the placed Jamshidi needles. A technical accuracy at bone entry point of 0.48 ± 0.44 mm and 0.68 ± 0.58 mm was achieved in the axial and sagittal views, respectively. The corresponding angular errors were 0.94 ± 0.83° and 0.87 ± 0.82°. The accuracy was statistically superior (p < 0.001) to ARSN without robotic assistance. Simulated pedicle screw grading resulted in a clinical accuracy of 100%. This study demonstrates that the use of a semi-automated surgical robot for pedicle screw placement provides an accuracy well above what is clinically acceptable. The insertion of pedicle screws remains one of the critical steps in spine surgeries involving thoracolumbar posterior fixation. The procedure poses risks for complications, as both neural and vascular structures are in close proximity to the pedicles. A meta-analysis by Gelalis et al. reported that 1-6.5% of pedicle screws placed using free-hand technique had a cortical violation >4 mm 1. Meanwhile, minimally invasive spine (MIS) surgery is increasingly preferred due to reductions in blood loss, length of hospital stay, and surgical site infections 2. Accuracy and complication rates, however, are not different 3,4. When relying only on fluoroscopy in MIS, the pedicle perforation rate has been reported to be in the range of 12.5-13.5% 5-7. Since MIS reduces anatomical feedback to the surgeon, it can be argued that image guidance, and perhaps also robotic guidance, has a natural role in this kind of surgery 8. The promises of increased accuracy, decreased complication rates, and reduced radiation exposure to the surgical team has led to an increasing use of robots in MIS surgery 9. There are currently several navigated robotic systems available on the market employing various strategies for 3D planning using pre-or intraoperative fluoroscopy or CT. The most frequently reported ones in the literature are the Mazor robots (MAZOR Robotics Ltd., Caesarea, Israel) and the ROSA Spine system (Medtech S.A., Montpellier, France). The Mazor robot...

Design of a robot-assisted system for transforaminal percutaneous endoscopic lumbar surgeries: study protocol

“…Although there is a low morbidity of complications, a misplaced screw can result in neurovascular damage, dural tearing, or visceral involvement. Therefore, robot-assisted techniques are designed to help spinal surgeons with more precision and convenience of pedicle screw placement [14][15][16]. Gao et al performed a metaanalysis including six studies involving 158 patients (688 pedicle screws) in a robot-assisted group and 148 patients (672 pedicle screws) in a freehand group, and showed that the robot-assisted technique was associated with equivalent accuracy rate of pedicle screw implantation, fewer proximal facet joint violations, and less intraoperative radiation exposure, but longer surgical duration than that with the freehand technique [12].…”

“…Recently, robotics in spinal surgery were predominantly designed as navigational devices for pedicle screw insertion, such as the Mazor X (Medtronic and Mazor Robotics, Medtronic, Minneapolis, MN, USA), ROSA (Med Tech Surgical, Inc., Newark, NJ, USA), and Excelsius GPS (Globus Medical, Inc., Audubon, PA, USA) [9][10][11]. Multiple studies have reported early experiences with robot-assisted pedicle screw placement and the outcomes are promising [12][13][14]. Increasingly, researchers have already focused on the combination of MIS and robotic navigation to improve the e ciency and accuracy of spinal surgeries [15,16].…”

Design of a robot-assisted system for transforaminal percutaneous endoscopic lumbar surgeries: study protocol

“…Although there is a low morbidity of complications, a misplaced screw can result in neurovascular damage, dural tearing, or visceral involvement [18]. Therefore, robot-assisted techniques are designed to help spinal surgeons with more precision and convenience of pedicle screw placement [14][15][16]. Gao et al performed a metaanalysis including six studies involving 158 patients (688 pedicle screws) in a robot-assisted group and 148 patients (672 pedicle screws) in a freehand group, and showed that the robot-assisted technique was associated with equivalent accuracy rate of pedicle screw implantation, fewer proximal facet joint violations, and less intraoperative radiation exposure, but longer surgical duration than that with the freehand technique [12].…”

Research on Accuracy of Augmented Reality Surgical Navigation System Based on Multi-View Virtual and Real Registration Technology

“…In order to study the puncture accuracy of robot-assisted ARSN system. In 2020, Gustav et al proposed that the robot be integrated into a hybrid operating room equipped with ARSN system for semi-automatic and minimally invasive pedicle screw placement [52]. The feasibility, accuracy and effectiveness of the guidance system are verified.…”