Robot-guided versus freehand fluoroscopy-guided minimally invasive transforaminal lumbar interbody fusion: a single-institution, observational, case-control study

Abstract

OBJECTIVE The use of robotics in spinal surgery has gained popularity because of its promising accuracy and safety. ROSA is a commonly used surgical robot system for spinal surgery. The aim of this study was to compare outcomes between robot-guided and freehand fluoroscopy-guided instrumentation in minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF). METHODS This retrospective consecutive series reviewed 224 patients who underwent MIS-TLIF from March 2019 to April 2020 at a single institution. All patients were diagnosed with degenerative pathologies. Of those, 75 patients underwent robot-guided MIS-TLIF, and 149 patients underwent freehand fluoroscopy-guided MIS-TLIF. The incidences of pedicle breach, intraoperative outcomes, postoperative outcomes, and short-term pain control were compared. RESULTS The patients who underwent robot-guided surgery had a lower incidence of pedicle breach (0.27% vs 1.75%, p = 0.04) and less operative blood loss (313.7 ± 214.1 mL vs 431.6 ± 529.8 mL, p = 0.019). Nonsignificant differences were observed in operative duration (280.7 ± 98.1 minutes vs 251.4 ± 112.0 minutes, p = 0.056), hospital stay (6.6 ± 3.4 days vs 7.3 ± 4.4 days, p = 0.19), complications (intraoperative, 1.3% vs 1.3%, p = 0.45; postoperative surgery-related, 4.0% vs 4.0%, p = 0.99), and short-term pain control (postoperative day 1, 2.1 ± 1.2 vs 1.8 ± 1.2, p = 0.144; postoperative day 30, 1.2 ± 0.5 vs 1.3 ± 0.7, p = 0.610). A shorter operative duration for 4-level spinal surgery was found in the robot-guided surgery group (388.7 ± 107.3 minutes vs 544.0 ± 128.5 minutes, p = 0.047). CONCLUSIONS This retrospective review revealed that patients who underwent robot-guided MIS-TLIF experienced less operative blood loss. They also benefited from a shorter operative duration with higher-level (> 3 levels) spinal surgery. The postoperative outcomes were similar for both robot-guided and freehand fluoroscopy-guided procedures.

Comparison of Robot-Assisted Versus Fluoroscopy-Guided Transforaminal Lumbar Interbody Fusion(TLIF) for Lumbar Degenerative Diseases: A Systematic Review Meta-Analysis of Trails and Observational Studies

“…A nal 21 articles met the inclusion criteria for quantitative analysis. Among them, there were 2 randomized controlled trials (RCTs) [27,29] and 19 observational studies (cohort study) [8,[18][19][20][21][22][23][24][25][26]28,[30][31][32][33][34][35][36][37] . Characteristics of included studies as well as quality assessments are summarized in Table 2, Table 3, and Table 4.…”

“…Currently, there is no evidence suggesting that RA TLIF can reduce surgical time and intraoperative blood loss. The results of this meta-analysis revealed that there was no signi cant difference in surgical time between the two groups [8,18,[20][21][22][23][24][25][26]28,30,[32][33][34][35][36][37] , and the funnel plot remained unchanged after applying the trim-and-ll method, indicating result stability. However, when combining the results of RCTs [27,29] , it showed that RA had a shorter surgical time compared to the FG group.…”

“…It is speculated that as pro ciency in robot usage increases, this time difference may become more prominent. Regarding intraoperative blood loss, the results of this study indicated that both CSs [8,18,[20][21][22][23][24]26,28,30,[32][33][34][35][36][37] and RCTs [27,29] showed lower intraoperative blood loss with the application of RA in TLIF compared to FG. This is primarily attributed to the more accurate screw placement in RA surgeries, where the planned screw trajectory may reduce tension on the pedicle screw insertion, thus decreasing stress on the pedicle and potentially reducing tension and damage to surrounding soft tissues, such as muscles and skin.…”

“…Wang TY [25] Chen XY [26] Hou HT [32] De Biase G [28] Passias PG [8] Lai YP [30] Sha KA [31] Wang L [36] Li T [37] A Li T [34] B Wang Z [35] Zhao XF [24] Mao JP [22] Jiang SD [23] Lin MC [33] a A maximum of 2 stars can be allotted in this category, one for age, the other for other controlled factors…”

History and Evolution of the Minimally Invasive Transforaminal Lumbar Interbody Fusion

“…The experience of Cui et al [ 91 ] with robotic-assisted pedicle screw placement in 23 MIS-TLIF patients revealed significant favorability in pedicle screw accuracy, intraoperative blood loss, postoperative pain, postoperative drainage, recovery time, and paraspinal muscle atrophy relative to 25 open TLIF patients. Lin et al [ 92 ] compared 75 MIS-TLIF patients who underwent robotic-assisted pedicle screw fixation to 149 patients receiving freehand fluoroscopy-assisted fixation, noting similar postoperative outcomes between cohorts, with robotic-assisted patients experiencing significantly reduced blood loss, as well as reduced operative time for procedures on more than 3 vertebral levels. Vo et al [ 93 ] recently commented on the current state of robotic applications in spine surgery, indicating that robotics are most highly investigated in the capacity of instrumentation guidance.…”