Robotic versus fluoroscopy-guided pedicle screw insertion for metastatic spinal disease: a matched-cohort comparison

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Robot-guided pedicle screw placement is an established technique for the placement of pedicle screws. However, most studies have focused on degenerative disease. In this paper, the authors focus on metastatic spinal disease, which is associated with osteolysis. The associated lack of dense bone may potentially affect the automatic recognition accuracy of radiography-based surgical assistance systems. The aim of the present study is to compare the accuracy of the SpineAssist robot system with conventional fluoroscopy-guided pedicle screw placement for thoracolumbar metastatic spinal disease.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>Seventy patients with metastatic spinal disease who required instrumentation were included in this retrospective matched-cohort study. All 70 patients underwent surgery performed by the same team of experienced surgeons. The decision to use robot-assisted or fluoroscopy-guided pedicle screw placement was based the availability of the robot system. In patients who underwent surgery with robot guidance, pedicle screws were inserted after preoperative planning and intraoperative fluoroscopic matching. In the “conventional” group, anatomical landmarks and anteroposterior and lateral fluoroscopy guided placement of the pedicle screws. The primary outcome measure was the accuracy of screw placement on the Gertzbein-Robbins scale. Grades A and B (&lt; 2-mm pedicle breach) were considered clinically acceptable, and all other grades indicated misplacement. Secondary outcome measures included an intergroup comparison of direction of screw misplacement, surgical site infection, and radiation exposure.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 406 screws were placed at 206 levels. Sixty-one (29.6%) surgically treated levels were in the upper thoracic spine (T1–6), 74 (35.9%) were in the lower thoracic spine, and the remaining 71 (34.4%) were in the lumbosacral region. In the robot-assisted group (Group I; n = 35, 192 screws), trajectories were Grade A or B in 162 (84.4%) of screws. The misplacement rate was 15.6% (30 of 192 screws). In the conventional group (Group II; n = 35, 214 screws), 83.6% (179 of 214) of screw trajectories were acceptable, with a misplacement rate of 16.4% (35 of 214). There was no difference in screw accuracy between the groups (chi-square, 2-tailed Fisher’s exact, p = 0.89). One screw misplacement in the fluoroscopy group required a second surgery (0.5%), but no revisions were required in the robot group. There was no difference in surgical site infections between the 2 groups (Group I, 5 patients [14.3%]; Group II, 8 patients [22.9%]) or in the duration of surgery between the 2 groups (Group I, 226.1 ± 78.8 minutes; Group II, 264.1 ± 124.3 minutes; p = 0.13). There was also no difference in radiation time between the groups (Group I, 138.2 ± 73.0 seconds; Group II, 126.5 ± 95.6 seconds; p = 0.61), but the radiation intensity was higher in the robot group (Group I, 2.8 ± 0.2 mAs; Group II, 2.0 ± 0.6 mAs; p &lt; 0.01).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Pedicle screw placement for metastatic disease in the thoracolumbar spine can be performed effectively and safely using robot-guided assistance. Based on this retrospective analysis, accuracy, radiation time, and postoperative infection rates are comparable to those of the conventional technique.</jats:p></jats:sec>

Assessment of Surgical Procedural Time, Pedicle Screw Accuracy, and Clinician Radiation Exposure of a Novel Robotic Navigation System Compared With Conventional Open and Percutaneous Freehand Techniques: A Cadaveric Investigation

“…20 Breaches were also quantified (Grades A-E) in accordance with the literature. 4,6,18,19,[21][22][23][24][25][26][27] Screw malposition as described by Kim et al 11 found deviations of 0 to 2 mm to be clinically insignificant; 2 to 4 mm, probably safe; and greater than 4 mm, questionably safe. In the present study, conventional MIS and open techniques resulted in an overall breach rate (>2 mm) of 20% and 32.5%, respectively, within the ranges reported by Gelalis et al 15 ; 19 of 20 breaches occurred laterally, a trend in agreement with reported literature.…”

Research on the accuracy of three‐dimensional localization and navigation in robot‐assisted spine surgery

“…In the existing studies, a relatively high proportion indicated that the accuracy of screw placement in the robot group has been improved substantially or significantly. The accuracy of robot‐assisted surgery proposed by Solomiichuk et al was only 84.4% . Meanwhile, Lonjon et al found that Rosa robot‐assisted screw placement was accurate 97.3% of the time, compared with 92% for the freehand group .…”

Minimally invasive percutaneous robotic thoracolumbar pedicle screw implantation combined with three‐dimensional fluoroscopy can reduce radiation: A cadaver and phantom study

“…Kim et al compared a prospective randomized controlled trial of 78 patients conventional fluoroscopy‐guided against robot‐assisted PS implantation and showed that robotic‐assisted PS placement was associated with fewer proximal facet joint violations and better convergence orientation; the 1‐year follow‐up showed no clinical difference . Solomiichuk et al compared in 70 patients the SpineAssist with fluoroscopy‐guided PS implantation in spinal metastasis and showed equipoise in accuracy, radiation time, and postoperative infection rates. Similar findings were published by Molliquaj et al in 71 patients.…”

“…We demonstrated that combining the ROSA One Spine system and showed that robotic-assisted PS placement was associated with fewer proximal facet joint violations and better convergence orientation; the 1-year follow-up showed no clinical difference. 23 Solomiichuk et al 24 Lefranc et al reported very satisfying results concerning accuracy and the rate of complications and concluded that PS positioning did not require years of experience and the learning curve was steep. 19 The main advantage of using a…”