Robot-assisted and augmented reality–assisted spinal instrumentation: a systematic review and meta-analysis of screw accuracy and outcomes over the last decade

Abstract

OBJECTIVE The use of technology-enhanced methods in spine surgery has increased immensely over the past decade. Here, the authors present the largest systematic review and meta-analysis to date that specifically addresses patient-centered outcomes, including the risk of inaccurate screw placement and perioperative outcomes in spinal surgeries using robotic instrumentation and/or augmented reality surgical navigation (ARSN). METHODS A systematic review of the literature in the PubMed, EMBASE, Web of Science, and Cochrane Library databases spanning the last decade (January 2011–November 2021) was performed to present all clinical studies comparing robot-assisted instrumentation and ARSN with conventional instrumentation techniques in lumbar spine surgery. The authors compared these two technologies as they relate to screw accuracy, estimated blood loss (EBL), intraoperative time, length of stay (LOS), perioperative complications, radiation dose and time, and the rate of reoperation. RESULTS A total of 64 studies were analyzed that included 11,113 patients receiving 20,547 screws. Robot-assisted instrumentation was associated with less risk of inaccurate screw placement (p < 0.0001) regardless of control arm approach (freehand, fluoroscopy guided, or navigation guided), fewer reoperations (p < 0.0001), fewer perioperative complications (p < 0.0001), lower EBL (p = 0.0005), decreased LOS (p < 0.0001), and increased intraoperative time (p = 0.0003). ARSN was associated with decreased radiation exposure compared with robotic instrumentation (p = 0.0091) and fluoroscopy-guided (p < 0.0001) techniques. CONCLUSIONS Altogether, the pooled data suggest that technology-enhanced thoracolumbar instrumentation is advantageous for both patients and surgeons. As the technology progresses and indications expand, it remains essential to continue investigations of both robotic instrumentation and ARSN to validate meaningful benefit over conventional instrumentation techniques in spine surgery.

Augmented reality–assisted craniofacial reconstruction in skull base lesions — an innovative technique for single-step resection and cranioplasty in neurosurgery

“…In this context, AR holds high capability for future concepts. In spinal neurosurgery, AR-assisted procedures have been applied especially for screw placement in combination with navigation or robot assistance within the last decade [ 12 , 23 , 35 ]. Phantom studies and cadaver simulations have also demonstrated promising applications of AR in cranial neurosurgery with techniques for cranial biopsy or accurate catheter placement.…”

Robotic Surgical Systems for Orthopedics

“…Several systematic reviews have found that robotic-assisted spine fusion surgery was associated with statistically significant improvements in accuracy of pedicle screw placement and lower rates of revision surgery than conventional fluoroscopy-assisted placement or freehand techniques. 16,[38][39][40] Also, emerging evidence suggests that robot-assisted pedicle screw placement results in significant reductions in perioperative complications, such as blood loss. 16 However, there is some evidence that indicates that the clinical outcomes and complications following robot-assisted pedicle screw placement are not significantly different from those of conventional techniques.…”

“…16,[38][39][40] Also, emerging evidence suggests that robot-assisted pedicle screw placement results in significant reductions in perioperative complications, such as blood loss. 16 However, there is some evidence that indicates that the clinical outcomes and complications following robot-assisted pedicle screw placement are not significantly different from those of conventional techniques. 39,40 Contradictory evidence exists around whether robotic-assisted spine surgeries are associated with reduced radiation exposure through shorter intraoperative radiation time and fewer radiation dose than with conventional techniques.…”

“…14,15 While the specifics of each system vary by manufacturer, they typically are machines that physically guide the surgeon's hand through the operation or are remote-controlled machines that guide the trajectory of or directly manipulate instruments or implants. 16 They do not replace the surgeon who remains in control of the procedures, but rather are part of the devices used by the surgeon. [17][18][19] For the purposes of this report, the term robotic surgical systems is used to refer to the set of technologies that use robotics to support and perform surgical procedures.…”

Virtual and Real Bidirectional Driving System for the Synchronization of Manipulations in Robotic Joint Surgeries

“…Surgical robots are increasingly utilized to assist or replace surgeons in completing surgery operations [1][2][3]. Their high-precision operation capability and reliability are very attractive in surgeries [4,5]. In clinics, each surgeon needs to be trained for years so as to acquire qualifications.…”