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As robotics in spine surgery has progressed over the past 2 decades, studies have shown mixed results on its clinical outcomes and economic impact. In this review, we highlight the evolution of robotic technology over the past 30 years, discussing early limitations and failures. We provide an overview of the history and evolution of currently available spinal robotic platforms and compare and contrast the available features of each. We conclude by summarizing the literature on robotic instrumentation accuracy in pedicle screw placement and clinical outcomes such as complication rates and briefly discuss the future of robotic spine surgery.

Background: Surgical navigation improves pedicle screw insertion accuracy and reliability. Robotic-assisted spinal surgery and screw placement has not been fully assessed in pediatric patients with spine deformity undergoing posterior spinal fusion. The purpose of this study was to describe the learning curve for robotically assisted pedicle screw placement in pediatric patients. Methods: A retrospective review on a consecutive series of the first 19 pediatric patients who underwent posterior spinal fusion by a single surgeon using robotic navigation was performed. Demographics, curve parameters, pedicle diameter, vertebral rotation, and additional outcome measures were recorded. Screw position was assessed with calibrated intraoperative 3-dimensional fluoroscopic images. All complications of planned and placed robotically placed screws were recorded. Results: A total of 194 left-sided screws were planned as robotassisted. One hundred sixty-eight of the robotically planned screws (86.6%) were placed with robot assistance; 29 robotically planned screws (15.0%) were abandoned or converted to freehand. The mean time per robotically placed screw was 3.6 ± 2.4 minutes. Fifteen breaches (8.9%) and 1 anterior perforation occurred with 2 critical ( > 2 to 4 mm) breaches, 1 was associated with a durotomy, and both occurred in the first case.There were no intraoperative/postoperative neuromonitoring changes and no sequela from the durotomy. Six breaches occurred in the first case. The odds ratio of obtaining a breach in screws with a matched trajectory was 0.275 (95% confidence interval: 0.089-0.848). Conclusions: Screw time and accuracy improved and the number of breaches decreased after 10 cases. This series had 2 critical breaches (between 2 and 4 mm) on the first case. Overall, excluding the 2 critical breaches, 98.8% of robotically executed screws were placed without a critical breach, which is comparable to previous pediatric deformity studies. Caution should be exercised during the initial training period to avoid complications as experience and training lead to an improved understanding of surgical planning, skive, and soft-tissue pressure on the end-effector all of which can impact accuracy of robotically assisted pedicle screw placement. Level of Evidence: Case Series, IV.

Background: Robotic-assisted and computer-assisted navigation (CAN) systems utilization has been rapidly increasing in recent years. Most existing data using these systems are performed in the thoracic, lumbar, and sacral spine. The unique anatomy of the cervical spine maybe where these technologies have the greatest potential. To date, the role of navigation-enabled robotics in the cervical spine remains in its early stages of development and study. Purpose: This review article describes the early experience, case descriptions and technical considerations with cervical spine screw fixation and decompression using CAN and robotic-assisted surgery. Methods: Representative cervical cases with early surgical experience with cervical and robotic assisted surgery with CAN. Surgical set up, technique considerations, instrumentation, screw accuracy and screw placement were elevated and recorded for each representative cervical case. Results: Existing robotic assisted spine surgical systems are reviewed as they pertain to the cervical spine. Method for cervical reference and positioning on radiolucent Mayfield tongs are presented. C1 lateral mass, odontoid fracture fixation, C2 pedicle, translaminar, subaxial lateral mass, mid cervical pedicle, navigated decompression and ACDF cases and techniques are presented. Conclusion: In conclusion, within the last several years, the use of CANs in spinal surgery has grown and the cervical spine shows the greatest potential. Several robotic systems have had FDA clearance for use in the spine, but such use requires simultaneous intraoperative fluoroscopic confirmation. In the coming years, this recommendation will likely be dropped as accuracy improves.

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