Initial Single-Institution Experience With a Novel Robotic-Navigation System for Thoracolumbar Pedicle Screw and Pelvic Screw Placement With 643 Screws

Abstract

Background: Robotic-guided navigation systems for pedicle screw placement has gained recent interest to ensure accuracy and safety and diminish radiation exposure. There have been no published studies using a new combined robotics and navigation system (Globus ExcelsiusGPS system). The purpose of this study was to demonstrate safety with this system. Methods: This is a case series of consecutive patients at a single institution from February 1, 2018, to August 31, 2018. All patients who had planned placement of thoracic and lumbar pedicle screws using the combined roboticsnavigation system were included. Chart review was performed for operative details. A subgroup analysis was performed on patients with postoperative computed tomography (CT) scans to assess screw placement accuracy using the Gertzbein and Robbins system. Acceptable pedicle screw position was defined as grade A or B. Results: One hundred six patients were included, with 636 pedicle screws, 6 iliac screws, and 1 S2AI screw. Five cases were aborted for technical issues. In the remaining 101 patients, 88 patients had screws placed using preoperative CT planning and 13 patients using intraoperative fluoroscopy planning. All screws except for 5 pedicle screws in 2 patients were placed successfully using the robot (99%). These 5 pedicle screws were placed by converting to a fluoroguided technique without robotic assistance. Eighty-six patients had screws placed using a percutaneous technique, and 15 patients had screws placed using an open technique. Ninety-eight patients underwent interbody placement: 28 anterior lumbar interbody fusions (ALIFs), 12 lateral lumbar interbody fusions (LLIFs), and 58 transforaminal lumbar interbody fusions (TLIFs). All ALIFs and LLIFs were performed prior to placement of the screws. Four LIF patients had screws placed in the lateral position. No patients had screw-related complications intraoperatively or postoperatively, and no patients returned to the operating room for screw revision. Thirteen patients underwent postoperative CT for various reasons. Of the 66 pedicle screws that were examined with postoperative CT, all screws (100%) had acceptable position. Conclusion: This study demonstrates that the combined robotics and navigation system is a novel technology that can be utilized to place pedicle screws and pelvic screws safely and has the potential to reduce screw-related complications. Level of Evidence: 4 (case series).

The current state of navigation in robotic spine surgery

“…Jain et al reported no screw related complications or returns to the operating room with 643 screws placed. Of the 66 screws that were reviewed with post-operative CT scanning, 100% of those were categorized as GR A or B (40). In their series of 600 screws all reviewed with post-operative CT, Wallace et al reported a GR A or B grade for 98.2% of the screws.…”

Workflow and Efficiency of Robotic-Assisted Navigation in Spine Surgery

“…Intraoperatively, AP and lateral fluoroscopic images of the levels to be instrumented are obtained. Fluoroscopic images and the preoperative CT scan are then merged, and the surgeon verifies the reconstruction based on planned screw trajectories from fluoroscopic images and CT scans [6]. The robot is then draped sterilely, locked into place, and the robotic arm aligns the end effector to the planned trajectory; the desired screw label is selected.…”

“…The robot is then draped sterilely, locked into place, and the robotic arm aligns the end effector to the planned trajectory; the desired screw label is selected. The screw hole is drilled and tapped, and the screw is then placed [6].…”

Role of Robotics in Adult Spinal Deformity

“…30 Like their role in pedicle screw accuracy, robotics and navigation have been implemented to improve the accuracy of S2-AI screw placement with published accuracy rates between 96% and 100%. [31][32][33] Furthermore, because direct visualization is not necessary, robotic-assisted S2-AI screws are ideal for sacropelvic fixation by a percutaneous technique for minimally invasive (MIS) deformity cases.…”

“…Single-position lateral surgery has been shown to be an efficient method for thoracolumbar deformity correction while limiting operative and anesthetic time. 33 This method can be effective in patients who would benefit from anterior or lateral interbody device placement in addition to pedicle screw fixation. The main limitation of single-position lateral surgery is the increased difficulty in performing significant complex posterior work.…”