Less Invasive Pediatric Spinal Deformity Surgery: The Case for Robotic-Assisted Placement of Pedicle Screws

Abstract

Introduction: Pediatric spinal deformity involves a complex 3-dimensional (3D) deformity that increases the risk of pedicle screw placement due to the close proximity of neurovascular structures. To increase screw accuracy, improve patient safety, and minimize surgical complications, the placement of pedicle screws is evolving from freehand techniques to computer-assisted navigation and to the introduction of robotic-assisted placement. Purpose: The aim of this review was to review the current literature on the use of robotic navigation in pediatric spinal deformity surgery to provide both an error analysis of these techniques and to provide recommendations to ensure its safe application. Methods: A narrative review was conducted in April 2021 using the MEDLINE (PubMed) database. Studies were included if they were peer-reviewed retrospective or prospective studies, included pediatric patients, included a primary diagnosis of pediatric spine deformity, utilized robotic-assisted spinal surgery techniques, and reported thoracic or lumbar pedicle screw breach rates or pedicle screw malpositioning. Results: In the few studies published on the use of robotic techniques in pediatric spinal deformity surgery, several found associations between the technology and increased rates of screw placement accuracy, reduced rates of breach, and minimal complications. All were retrospective studies. Conclusions: Current literature is of a low level of evidence; nonetheless, the findings suggest the accuracy and safety of robotic-assisted spinal surgery in pediatric pedicle screw placement. The introduction of robotics may drive further advances in less invasive pediatric spinal deformity surgery. Further study is warranted.

Advances in robotics and pediatric spine surgery

“…In pediatrics, no such randomized controlled trial exists to the writers’ knowledge, but a recently performed meta-analysis including (but not limited to) patients with pediatric spinal deformities reported accuracies of 98.8% and 98.7% for robotic placement [7 ▪▪ ,18 ▪▪ ,24 ▪▪ ]. These numbers are similar to the reported accuracy of robotic pedicle screw placement in adults [7 ▪▪ ,18 ▪▪ ,24 ▪▪ ]. A study by Macke et al [34] on 48 pediatric patients with adolescent idiopathic scoliosis who underwent robotic-assisted pedicle screw placement and postoperative CT evaluation demonstrated a 92.7% accuracy rate, which improved to 97.2% for patients whose preoperative CT scans were performed in the prone position.…”

“…Most of the studies on use of robots in adult spine surgery describe their use in the lumbosacral spine, and the greatest benefits for robotic spine surgery in adults have been demonstrated for percutaneous screw placement [8,17]. However, to date most pediatric spinal deformity surgery has been performed utilizing open techniques, and most demanding screws in pediatric spinal deformity surgery are typically the proximal to mid-thoracic spine [2,18 ▪▪ ]. In the setting of pediatric scoliosis and syndromic scoliosis (i.e., neurofibromatosis), there is often extreme rotational deformity of the thoracic vertebrae and dysplastic pedicles that necessitate extra-pedicular screw trajectories (“in-out-in” screws) [18 ▪▪ ,19 ▪ ].…”

“…There are multiple tips and tricks that have been described to improve the ease and accuracy of robotic screw placement [6,18 ▪▪ ,22 ▪▪ ,23,24 ▪▪ ]. The major issues that can negatively impact the accuracy of screw placement include stability of the patient, stability of the robot, soft-tissue pressure on the end-effector or the surgical instruments, and skive [3,6,7 ▪▪ ,18 ▪▪ ,24 ▪▪ ].…”

“…There are multiple tips and tricks that have been described to improve the ease and accuracy of robotic screw placement [6,18 ▪▪ ,22 ▪▪ ,23,24 ▪▪ ]. The major issues that can negatively impact the accuracy of screw placement include stability of the patient, stability of the robot, soft-tissue pressure on the end-effector or the surgical instruments, and skive [3,6,7 ▪▪ ,18 ▪▪ ,24 ▪▪ ]. When performing open pediatric spinal deformity surgery, it is essential to perform adequate soft tissue dissection with the goal of minimizing soft tissue pressure on the robotic arm that can cause unrecognized deviation from the planned 3D trajectory [6].…”

“…Unrecognized skive is a major risk factor for malpositioning of surgical instruments and pedicle screws. Modification of the bony starting point using a rongeur or a burr to provide a flatter and more stable landmark for the drill guide can help to minimize the risk of skive [6,18 ▪▪ ,23,24 ▪▪ ]. Skive can occur during pedicle screw track preparation with a drill/burr, but also during tapping and screw placement (internal skive) [1 ▪▪ ,6,18 ▪▪ ,23,24 ▪▪ ].…”