Navigation and robot-aided surgery in the spine: historical review and state of the art

Abstract

Spinal anatomy is complex and in close vicinity of vulnerable anatomical structures, such as nerve roots, spinal cord, and blood vessels, requiring high precision in surgical procedures, while the surgical exposure is limited and even more limited in percutaneous procedures. A high risk of misplaced implants and/or high intraoperative radiation exposure are the consequences. Spinal navigation techniques have been introduced to alleviate these problems. The majority of reports on navigation document its role in increasing implant-placement accuracy and reducing intraoperative radiation. The technology is increasingly finding acceptance amongst spinal surgeons. This however does not yet present the end of the road. Robotic applications could be regarded as a coherent continuation of spinal navigation. We reviewed the literature pertaining to spinal navigation, as well as novel and upcoming robotic applications for spinal surgery. For this purpose, a Medline search using the terms "robot" and "spine" and extensive cross-reference analysis (using Medline, Ovid, and Web of Science data banks) were performed. The goal was to provide an overview of present achievements and novel developments in this fast-growing research area. While a number of robotic techniques are under investigation, mainly to aid navigated screw placement, the SpineAssist/Renaissance system has cleared US Food and Drug Administration approval and is in relatively wide clinical use. Another robotic system, the da Vinci, is currently applied in an increasing number of cases under research protocols.

Review of robotic surgery platforms and end effectors

“…The Mazor X [ 22 ] is a robotic platform used for spine surgery that provides pre-operative planning, intra-operative guidance, and real-time imaging. The Renaissance is a guidance system for the spinal surgery that helps surgeons place screws and implants with high precision [ 23 ]. The Mazor Core is a module that integrates with the Mazor X to provide more accurate and efficient surgical planning.…”

A Novel Robotic Neuronavigation System: RONNA G3

“…The robots are equipped with surgical tools (guides, grippers, drill, etc.). A specific characteristic of the RONNA G3 system with respect to the most current state-ofthe art robotic neurosurgical systems [29] to [32] is an additional mobile platform equipped with a compliant and sensitive robotic arm which makes it a dual-arm robot system (master and assistant robots). The robots are standard six degree-of-freedom (DOF) revolute robots.…”

“…These systems are not included in the current state-of-the-art literature survey and review papers [29] to [32]; this demonstrates the very rapid development of the field of robotized neuronavigation medical.…”

Robotic drill guide positioning using known-component 3D–2D image registration

“…2 Although a small fraction of such malplacements are associated with significant comorbidity, due to the potential for neurovascular damage 3 and costly revision surgeries, 4 multiple approaches have been explored to improve placement accuracy. 5,6 Manual placement of pedicle screws often involves x-ray fluoroscopy guidance for identification of anatomical features and assessment of screw location and depth from two-dimensional (2D) projection views. More recently, CT-based navigation (using preoperative CT, intraoperative CT, or intraoperative cone-beam CT) has enabled higher levels of precision in pedicle screw placement.…”