Does robot-assisted navigation influence pedicle screw selection and accuracy in minimally invasive spine surgery?

Abstract

OBJECTIVE The accuracy of percutaneous pedicle screw placement has increased with the advent of robotic and surgical navigation technologies. However, the effect of robotic intraoperative screw size and trajectory templating remains unclear. The purpose of this study was to compare pedicle screw sizes and accuracy of placement using robotic navigation (RN) versus skin-based intraoperative navigation (ION) alone in minimally invasive lumbar fusion procedures. METHODS A retrospective cohort study was conducted using a single-institution registry of spine procedures performed over a 4-year period. Patients who underwent 1- or 2-level primary or revision minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF) with pedicle screw placement, via either robotic assistance or surgical navigation alone, were included. Demographic, surgical, and radiographic data were collected. Pedicle screw type, quantity, length, diameter, and the presence of endplate breach or facet joint violation were assessed. Statistical analysis using the Student t-test and chi-square test was performed to evaluate the differences in pedicle screw sizes and the accuracy of placement between both groups. RESULTS Overall, 222 patients were included, of whom 92 underwent RN and 130 underwent ION MIS-TLIF. A total of 403 and 534 pedicle screws were placed with RN and ION, respectively. The mean screw diameters were 7.25 ± 0.81 mm and 6.72 ± 0.49 mm (p < 0.001) for the RN and ION groups, respectively. The mean screw length was 48.4 ± 4.48 mm in the RN group and 45.6 ± 3.46 mm in the ION group (p < 0.001). The rates of “ideal” pedicle screws in the RN and ION groups were comparable at 88.5% and 88.4% (p = 0.969), respectively. The overall screw placement was also similar. The RN cohort had 63.7% screws rated as good and 31.4% as acceptable, while 66.1% of ION-placed screws had good placement and 28.7% had acceptable placement (p = 0.661 and p = 0.595, respectively). There was a significant reduction in high-grade breaches in the RN group (0%, n = 0) compared with the ION group (1.2%, n = 17, p = 0.05). CONCLUSIONS The results of this study suggest that robotic assistance allows for placement of screws with greater screw diameter and length compared with surgical navigation alone, although with similarly high accuracy. These findings have implied that robotic platforms may allow for safe placement of the “optimal screw,” maximizing construct stability and, thus, the ability to obtain a successful fusion.

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][21][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.…”

Percutaneous thoraco-lumbar-sacral pedicle screw placement accuracy results from a multi-center, prospective clinical study using a skin marker-based optical navigation system

“…Table 5 provides an overview of the accuracies of 3D navigation for MISS as reported in literature and the 98.1% accuracy obtained with the ON in this study, is in line with these published reports. The accuracy results of ON were also comparable to the pedicle screw placement accuracies of robotic systems [15][16][17].…”

Size selection and placement of pedicle screws using robot-assisted versus fluoroscopy-guided techniques for thoracolumbar fractures: possible implications for the screw loosening rate

“…Molliqaj et al [ 12 ] reported a clinically acceptable screw placement accuracy under robotic guidance of up to 93.4%. Karim et al [ 15 ]found that surgeons, with the assistance of a robot, tended to choose larger-diameter and longer screws in the minimally invasive surgery-transforaminal lumbar interbody fusion when compared with intraoperative navigation alone, particularly when using sizes that they may have previously thought to be too large. Our results are somewhat similar to these studies.…”

“…In recent years, there have been many studies on the robot's advantage in accuracy and selection of pedicle screws, offering benefits for both patients and surgeons [15,[19][20][21]. Preoperative CT is used to plan screw trajectories, and intraoperative fluoroscopy is applied to register images.…”

“…Some studies have reported that robot-assisted techniques provide more precise screw placement [12][13][14], and more recent literature shows that robotic assistance allows for the placement of screws with greater screw diameter and length compared with surgical navigation alone in minimally invasive lumbar fusion procedures [15]. However, to the best of our knowledge, few studies have compared the dimension selection and loosening rate of pedicle screws between robotassisted techniques and fluoroscopy-guided percutaneous techniques for thoracolumbar fractures.…”