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 Table of Contents  
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 37-47

Role of robotics and spinal navigation in reducing surgical complications

Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd. , Coimbatore, Tamil Nadu, India

Date of Submission06-Oct-2022
Date of Decision09-Dec-2022
Date of Acceptance11-Jan-2023
Date of Web Publication11-Feb-2023

Correspondence Address:
Shanmuganathan Rajasekaran
Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., 313, Mettupalayam Road, Coimbatore641043, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/isj.isj_72_22

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Spine surgery has witnessed exponential technological innovation over the past few decades to overcome the challenges of complex surgeries, reduce complications, and increase safety. Advancements have occurred in biologics, implants, operative techniques, and equipment such as navigation and surgical robotics. In addition to patient safety, these technologies protect the operating personnel from the harmful effects of radiation. Navigation provides simultaneous and multiplanar visualization of anatomy, real-time feedback of instruments, and implant position, which, in turn, improves the accuracy and hand–eye coordination of the surgeon. Robotics further improves outcomes by reducing human error through increased precision in execution, indefatigability, motion scaling, and tremor filtration via mechanical actuation. This review provides an overview of the current navigation and robotic systems in spine surgeries and their role in the safety and prevention of surgical complications.

Keywords: Computer-assisted navigation, robotics and spinal navigation, surgical complications

How to cite this article:
Pratheep G, Murugan C, Rajasekaran S, Shetty AP, Kanna RM. Role of robotics and spinal navigation in reducing surgical complications. Indian Spine J 2023;6:37-47

How to cite this URL:
Pratheep G, Murugan C, Rajasekaran S, Shetty AP, Kanna RM. Role of robotics and spinal navigation in reducing surgical complications. Indian Spine J [serial online] 2023 [cited 2023 Mar 27];6:37-47. Available from: https://www.isjonline.com/text.asp?2023/6/1/37/369577

  Introduction Top

Surgical interventions in the spine are challenging because of the complex anatomy and close proximity of the neurovascular structures. The last few decades have seen tremendous growth in various technologies that have significantly contributed to increasing the safety and clinical outcome of spinal interventions. Computer-assisted navigation (CAN) is one such technology that continues to evolve and transform surgical interventions into more accurate, safe, and less invasive procedures. Navigation aims to provide simultaneous and multiplanar visualization of anatomy, real-time feedback of instruments, and implant position in relation to the anatomical structures. This, in turn, improves the surgeon’s hand–eye coordination and accuracy, reduces the radiation exposure to the surgeons, assistants, as well as patients, and reduces the surgical time and surgeon’s fatigue, thereby improving the outcome of the surgery.

The navigation technique has its origin in stereotaxy in neurosurgery, which used three-dimensional (3D) spatial orientation to facilitate navigation in a specified field, developed in the first decade of the 19th century.[1] However, navigation in spine surgery was introduced much later, for pedicle screw instrumentation in 1995 by Nolte et al.[2] Around the same time, Kalfas et al.[3] also investigated the use of frameless stereotaxy image-guided techniques to improve the safety of lumbar pedicle screw placement. Since then, CAN has grown steadily, and the spectrum of its applications has expanded to a multitude of indications.

Although image-guided screw placements are high-precision techniques, a constant pursuit to improve outcomes has prompted the incorporation of robotics into the field of spine surgery. These systems are theoretically capable of reducing human error through increased precision in execution, indefatigability, motion scaling, and tremor filtration via mechanical actuation.[4] The first shared-control robot designed for use in spine surgery, the SpineAssist (Mazor Surgical Technologies, Caesarea, Israel), emerged in the early 2000s. The SpineAssist was developed and was integrated with CAN systems—both of which evolved to address the unsatisfactory rate of screw malposition rate and radiation exposure associated with minimally invasive spine surgeries.[5],[6],[7],[8],[9] Since then, robotics has continuously evolved with the aim of broadening its applications. This review provides an overview of the current navigation and robotic systems in spine surgeries and their role in the safety and prevention of surgical complications.

  Evolution of Navigation and Robotics in Spine Surgery Top

The first step in navigation is to acquire high-resolution images. First-generation spine navigation systems use computed tomography (CT)-based preoperative image acquisition. During the surgical procedure, manual registration is necessary, which is cumbersome and error-prone. Moreover, preoperative images are taken in a supine position and matched with anatomical landmarks exposed in the prone position. This altered orientation of the motion segments of the spine further contributes to the errors in registration. Second-generation navigation uses intraoperative reconstruction images of the spinal anatomy using 2D and 3D fluoroscopies. The major advantage of this system is that the computer system can be paired with the existing fluoroscopy units but the drawbacks include the absence of axial reconstruction images of the spine and impaired image quality, especially in the osteoporotic spine and in obese individuals. The Iso-C navigation and the cone beam-based systems have, however, overcome these disadvantages but are limited by their ability to scan short segments requiring multiple scans in the case of long-segment fixations, increasing the radiation exposure and operative time. Third-generation systems perform intraoperative CT scans with subsequent automatic registration. These systems can provide excellent quality images with a scan field that extends over multiple segments. The advances in software and availability of intraoperative CT scans have made total navigation possible. The O arm (Medtronic Sofamor Danek, Inc., Memphis, TN) is an example of a third-generation navigation system [Figure 1] that has gained much attention in recent days. The newer generation software with a wide range of navigated instruments (high-speed burr, awl, bone-drill, pedicle finders, and bone-tap) and implants have helped surgeons improve their dexterity.[10]
Figure 1: Example of a third-generation intraoperative computed tomography scan-based navigation system—O arm (Medtronic Sofamor Danek, Inc., Memphis, TN, USA)

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During inception, as the robotic systems did not provide any real-time visual feedback for instrument localization and depth gauging, the robots required a certain level of trust from surgeons. However, the integration of CAN with modern spine robot platforms has led to the resurgence of spinal robotics. Robots used in surgical procedures are usually one among the following three categories: supervisory controlled systems, telesurgical systems, and shared-control robots.[4],[11] In supervisory controlled systems, the procedure is fully automated and executed solely by the robot based on the inputs the surgeon has fed into the software before the procedure. The inability to make real-time adjustments is one of the major drawbacks of these systems. Telesurgical systems allow the control of the robot by the surgeon in real time. But the surgeon’s control is from a console at a remote location outside the surgical field. The widely used systems in modern-day robotic spine surgeries are shared-control robots, where the surgeon and robot simultaneously control the surgical instruments in the operative field.[11] Pre-/intraoperative CT scans are required for planning the stereotactic trajectories and are guided intraoperatively by the robotic arms. A mount with a robotic arm, a navigation tracking camera, and a display monitor are the essential components of these robotic systems. Excelsius GPS (Globus Medical, Audubon, PA) [Figure 2], Mazor X Stealth Edition (Medtronic, Dublin, Ireland) [Figure 3], and the ROSA ONE Spine (Zimmer Biomet, Warsaw, IN) [Figure 4] are a few commercially available spine surgery robots. The essential features of these robotic systems are given in [Table 1].
Figure 2: Excelsius GPS shared-control robot—the surgeon and robot simultaneously control the surgical instruments in the operative field (Globus Medical, Audubon, PA, USA)

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Figure 3: Mazor X surgical robot—note the robot mounted to the operating table (Medtronic, Dublin, Ireland)

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Figure 4: ROSA ONE spine surgical robot—floor-mounted robot (Zimmer Biomet, Warsaw, IN, USA)

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Table 1: Commonly used robots in spine surgery

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  Application of Navigation and Robotics in Spine Surgery Top

Spinal trauma

Cervical spine

Cervical spine instrumentation is technically challenging due to small osseous elements, high incidence of anatomic variations, proximity to the spinal cord, and vital structures such as the vertebral artery. Wajanavisit et al.[12] reported a 6% prevalence of high riding vertebral artery and a 22.8% prevalence of narrow pedicles in thin-sliced pedicular-oriented CT. The use of a 3D real-time visualization could aid in determining the safe tract for screw placement[13] in these situations. The efficacy of navigation in cervical trauma especially in challenging situations such as coexistent ankylosing spondylitis was established by Jaiswal et al.[14] who observed a 94% rate of accurate screw placement. A randomized controlled study by Fan et al.[15] demonstrated the superiority of robot-assisted (RA) cervical screws in terms of accuracy as well as intraoperative blood loss and duration of hospital stay compared with fluoroscopy-assisted (FA) screws. Surgeries around the occipito-cervical junction are perilous to a posterior approach, due to a higher incidence of congenital bony anomalies in the upper cervical spine limiting spinal instrumentation, whereas the complex anatomy makes the anterior approach arduous. Lee et al.[16] performed RA transoral odontoidectomy for basilar invagination and reported a superior control through a narrow working space.

Thoracic and lumbosacral injuries

The insertion of pedicle screws in unstable thoracic and lumbar injuries could be technically difficult because of gross destruction of anatomical landmarks, gross unstable segments, and discrepancies in anatomical orientation when using conventional entry points. Misplaced pedicle screws using free-hand (FH) or FA technique can range widely from 2% to 31% and are heavily dependent on the experience of the surgeon, assistant, and technician.[17] By registering intraoperative patient landmarks with a preoperatively obtained CT scan, RA surgery can theoretically improve the accuracy and precision of pedicle screw placement[3],[18] [Figure 5].
Figure 5: (A and B) Axial and sagittal views showing navigation across normal pedicles, (C and D) axial and sagittal views showing navigation across dysmorphic pedicles

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Previous meta-analyses have compared screw placement among FH, FA, and RA surgeries. In 2010, a meta-analysis by Verma et al. evaluated 5992 pedicle screws from 23 studies applied using the RA and FH techniques and the authors observed a significantly higher accuracy rate of RA surgery.[19] Two years later, Shin et al. performed a meta-analysis that mostly mirrored these results. On an analysis of more than 7000 pedicle screws, the incidence of misplaced screws was 6% in the RA group compared with 15% in the FH group.[20] This study also subcategorized screws based on cervical, thoracic, and lumbar placements, demonstrating an increased accuracy for all three regions of the spine with robot assistance.[20] Randomized controlled trials (RCTs) by Zhang et al.[21] and Han et al.[22] have demonstrated more than 98% accuracy of RA screw insertions compared with the 93% accuracy rate with FA screws. None of the screws in the RA violated the proximal facet joint, whereas 12 screws (2.1%) in the FA violated the proximal facet joint.

Pelvi-acetabular trauma

The complex 3D anatomy of the pelvis, narrow bony corridors, and close proximity to visceral structures make stereotactic advancement, an important tool for screw placement in pelvi-acetabular trauma. 3D navigation systems are associated with lower radiation and rate of screw malposition compared with the traditional 2D fluoroscopy-based techniques.[23] Liu et al.[24] performed RA minimally invasive fixation of pelvic ring injuries using cannulated screws and observed a satisfactory position in 95.6% of the screws in the first attempt, increasing the success rate of one-time screw placement. Du et al.[25], in a study of 17 patients, showed the feasibility of percutaneous iliolumbar double rod fixation combined with anterior internal fixator fixation in unstable pelvic ring injuries.

  Fusion Surgery Top

The rate of interbody fusion surgeries performed on the lumbar spine has seen a dramatic increase over the past few decades. Kantelhardt et al.[26] performed a comparative study on the accuracy of pedicle screws between conventional and RA techniques and reported a moderate-to-severe deviation in 1.1% of RA screws compared with 3.5% in conventionally placed screws. Zhang et al.[21] in their study of 77 patients undergoing TLIF for degenerative lumbar disease observed that about 98.3% of RA screws were in a clinically acceptable position compared with 93.6% in the fluoroscopy group. Violation of proximal facet joints is an established cause of adjacent segment degeneration, the incidence of which may be significantly reduced with better visualization of the anatomy in a 3D orientation using navigation and robotics.[21],[27] In addition to the safe insertion of pedicle screws, navigation integrated robotics enables successful outcomes following minimally invasive approaches. Walker et al.[28] successfully demonstrated RA lateral lumbar interbody fusion in lateral decubitus position, where cannulation of the down-side pedicles would otherwise be technically challenging. Feng et al.[29] noted a significant difference in the immediate postoperative visual analogue score in elderly patients undergoing RA percutaneous oblique lumbar interbody fusion compared with the conventional open group. Long fusion surgeries extending to the lumbosacral junction need adequate distal fixation sites to improve the construct stability and avoid pseudoarthrosis. Ray et al.[30] described the safe placement of bilateral S2 alar-iliac screws in 18 patients undergoing fusion across the lumbosacral junction using an intraoperative navigation technique without any neurological or vascular complications.

  Deformity Surgery Top

In congenital anomalies and severe deformities of the spine caused by disorders such as neurofibromatosis, the pedicular anatomy is distorted compromising screw placement. With the use of CAN, the 3D pedicle morphology can be visualized enabling optimal screw trajectory and placement of optimal screw size. Rajasekaran et al.[31] established the safety of 3D fluoroscopy-based navigation in cervical pedicle screw insertion in 16 pediatric patients with complex cervical deformities. There were no critical pedicle breaches in any of the cases, whereas only an 11% rate of noncritical breaches was seen. Navigation also reduces the rate of malposition from 23% to 2% in complex thoracic spine deformities in addition to significantly reducing surgical duration in these complex deformity surgeries.[32] A meta-analysis by Tian et al.[33] demonstrated similar outcomes in terms of accuracy without an increase in the duration of surgery or a change in the correction achieved. Studies have demonstrated up to 21% incidence of pedicle screw breaches in adolescent idiopathic scoliosis surgeries, which may be significantly reduced by the use of robotics as demonstrated by Macke et al.[34] who evaluated 662 RA pedicle screws in 50 patients and observed only a 7.2% incidence of screw malposition.

Apart from pedicle screw placement, navigation and robotics have been applied in performing osteotomies in complex spinal deformities as resection of the wedge and closing of the osteotomy have a high incidence of neurological injury [Figure 6].[39] Takahashi et al.[35] reported no neurological or vascular complications following computer-assisted hemivertebra resection in eight patients with congenital spinal deformities (scoliosis/kyphoscoliosis). Navigation-assisted pedicle subtraction osteotomy for rigid adult kyphotic deformities was performed in 28 patients by Faundez et al.[36] and they reported a significant improvement in global sagittal balance without any transient or permanent neurological injury.
Figure 6: Images showing planning of the osteotomy planes in deformity.[39]

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  Spine Tumor Surgery Top

Metastasis accounts for the majority of spinal tumors, resulting in a debilitated general condition in the affected individuals. Extensive surgeries if indicated are demanding in these patients resulting in poor outcomes; hence, stereotactic techniques have a major impact on the management of this patient subgroup. By providing a targeted approach, navigated techniques enable adequate tumor removal with tumor-free margins through narrow and minimally invasive corridors. Navigation-guided curettage and tumor resections have also been reported in benign lesions such as osteoblastoma, giant cell tumors, and osteoid osteoma[37],[38],[39] [Figure 7]. Primary traditional radio-frequency ablation of osteoid osteomas carries an inherent risk of spinal cord injury, whereas excision of the bony nidus by conventional open techniques requires extensive dissection of soft tissues with removal of excess normal bone compromising spinal stability. Rajasekaran et al.[40] demonstrated successfully targeted curettage of the osteoid osteoma nidus allowing early patient mobilization without the need for any reconstruction procedures or recurrence at two years. Bandiera et al.[41] reported the use of navigation in benign, malignant, and metastatic spine lesions and concluded better surgical accuracy in screw placement as well as improved tumor localization and excision through the use of navigation. Robotics, in addition to all the benefits of navigation, enables tumor resections in previously inaccessible regions of the spine. Kaoudi et al.[42] reported successful outcomes following robotic-assisted radio-frequency ablation in the treatment of sacral hemangiomas in areas of difficult access. Nasser et al.[43] in their multicentric trial of 50 patients with spine tumors observed that stereotactic navigation allowed better tumor localization enhancing adequacy of tumor removal with lesser blood loss, surgical duration, and complications. Hu et al.[44] demonstrated the application of robotic systems in biopsy and vertebral augmentation (vertebroplasty and kyphoplasty) procedures in both primary and metastatic spinal tumor patients.
Figure 7: (A) Computed tomography image of osteoid osteoma of left C5 lateral mass lying close to the foramen transversarium; (B) tubular retractor placement; (C) reference system attachment; (D) burred out posterior cortex of lateral mass after localizing the lesion under navigation; (E) curettage of the lesion with maintenance of the anterior cortex; (F) empty cavity following curettage; (G) intact lateral wall after surgery ensuring stability, and (H) postoperative CT showing adequacy of curettage with the probe reaching the anterior cortex

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  Radiation Exposure Top

Spine surgery and intraoperative imaging are intimately linked. Radiation exposure is a major concern for the patient as well as the operating personnel, especially during long spinal surgeries. Reducing the exposure to patients and operating staff is important although the acceptable yearly and lifetime radiation exposure is widely debated. As seen in most of the surgical robotic systems, preoperative CT scans allow a significant decrease in intraoperative radiation exposure. Once the surgical exposure is completed, the preoperative CT scan is registered with intraoperative landmarks using fluoroscopy. This allows the robot to account for any intraoperative differences in surgical approach or positioning. Some robotic systems can complete anatomic registration using fluoroscopy alone without the need for a CT. Smith et al.[45] observed a reduced radiation exposure to the torso of surgeons during pedicle screw placement in the RA group (0.33 mRem) than in the FA group (4.33 mRem). However, there was no significant difference in the radiation exposure to the thyroid. An RCT performed by Villard et al. showed that radiation exposure to the surgeon was 10 times higher in the FA group than in the RA group during posterior lumbar instrumentation procedures.[46] Lieberman et al. reported a 30 times lower radiation exposure to the surgeon in RA surgery than in FH procedures.[6] When comparing conventional FA screw placement with RA procedures, the average exposure time in RA pedicle screw placement is significantly lower (24–24 s) compared with FA screw placement (56–77 s).[8],[26],[47]

  Clinical Impact Top

RA surgery boasts of greater accuracy and safety during pedicle screw insertion; however, it is important to understand if these improvements translate into better clinical outcomes. There is no literature comparing FA or FH surgery to RA surgery for common patient-reported outcomes, such as the SF-12 and Oswestry disability index, though other clinical outcomes such as readmission rates, length of hospital stay, and infection rates have been measured. Patients who were operated using RA had a significant decrease in the length of hospital stay compared with FH- and FA-guided surgeries (4.72 vs. 5.43 days) in a single-center clinical outcome analysis of thoracolumbar fusion surgeries.[48] Keric et al. obtained similar results in spondylodiscitis patients, where the length of hospital stay was found to decrease from 18.1 days in the FH group to 13.8 days in the RA group.[47] Xiao et al. observed a reduced readmission (0.8% vs. 4.2%) and reoperation rate (5.2% vs. 10.9%) in the RA group.[49] Han et al. observed a 0.35% revision rate in the FH group due to misplaced screws, whereas there was none in the RA group.[22] Staartjes et al.[51] analyzed data from 37 studies (7095 patients) and found a decrease in the number of revision surgeries required in the RA and CAN groups,[50] though the RA group surgery was not significant following sensitivity analyses.

Centers with high patient volumes and surgeries may be more inclined to benefit financially from the integration of a robotic system due to the significant initial financial investment required. However, with around 2.1% of patients with lumbar pedicle screw fixation requiring revisional surgery for misplaced screw, it is reasonable to believe that utilizing RA surgery may decrease health care costs on a widespread scale[51] considering the lower revision rates with this technology. Studies have observed 2%–3% rate of nerve root injury in the FA group warranting revision surgery, whereas none of the patients in the robotic group had a similar outcome.[52],[53]

Postoperative infections have also been found to be considerably lower in RA surgeries compared with FH and FA surgeries as demonstrated by Kantelhardt et al. who observed a postoperative infection rate of 2.7% in the RA group and 10.7% in the FA group.[26] The intraoperative blood loss also was found to be lower when using RA compared with FH or FA surgery.[22],[53],[54] Very few studies in the literature have directly compared the use of O arm with robotic systems in spine surgery.[55] In a retrospective study comparing O arm with robotic screw placement in posterior thoracolumbar surgeries, Mao et al. reported no significant difference in clinically acceptable instrumentation placement comparing the two techniques and concluded that robotics does not have any clear advantage in terms of infection rates, intraoperative blood loss, or operative time.[55] However, prospective studies on a larger sample population to determine the accuracy as well as to study factors such as the surgeon and patient radiation, fiddle factor, teaching sustainability, and cost are required in the future.

  Other Advantages Top

The epidural fibrosis, altered soft tissue, and bony anatomical landmarks as well as the associated bone loss make revision spine surgery more technically demanding than primary surgeries. Robot assistance in revision surgeries has gained significant popularity as demonstrated by Satin et al. in screw insertion into the fusion mass with altered screw trajectories, osteotomies for the correction of flat backs, and adjacent segment disease.[56] Navigated surgeries result in reduced postoperative pain and early patient recovery by enabling minimally invasive approaches in these patients. Studies have observed lower postoperative opioid consumption in the RA group compared with the FA group undergoing lumbar fusion.[26] Robotics is expected to lengthen the careers and improve the performance of aging spine surgeons.[57] Robots may also aid in standardizing treatment, reducing the variation in performance between surgeons, thus evolving uniformity in patient outcomes.

  Limitations Top

The major limitation of image-guided technologies is the significant cost incurred in setting the workflow. However, navigation and robotic surgery can become cost-effective in the long run due to the shorter surgical duration, length of hospital stay, fewer revisions, and lower infection rates.[58],[59],[60],[61]

Another important concern in RA surgery is the possible intraoperative discrepancy between preoperative CT imaging and intraoperative registration. This can arise due to excessive soft tissue in the patient, poor image quality, surgeon error during registration, or a combination of these factors.[62] In most situations, these inaccuracies may be fixed prior to screw insertion by simple reprogramming of the screw trajectory by hand, in effect turning the robotic assistance into a CAN technique.

Though most of the studies have shown many potential benefits including accurate screw precision using the robotic systems, few studies have shown similar results with freehand pedicle screw placement. Recent meta-analyses and systemic reviews have shown no significant differences in the accuracy of pedicle screw placement between RA and FH techniques, and the accuracy varies with the type of robotic system used.[63],[64],[65]

Many studies have found an increased operative time while using robotic systems, which may be attributed to the steep learning curve for the use of this technology.[66],[67] However, the pedicle screw accuracy and the surgical duration improve after an initial learning period, with continuous exposure to these systems and persistent improvements in technology.

Radiation exposure is another concern in the use of RA spine surgeries. Though many studies report a lower radiation, Erik et al.[68] showed a higher intraoperative and total-procedure radiation exposure with RA spine surgery compared with open procedures. This needs to be further investigated on larger sample population in future studies.

Finally, the economic viability of these systems is a major concern, as their use is now limited to resource-rich settings. The cost of robotic systems ranges between $550,000 and $1,000,000, with maintenance and annual service expenses costing the institute an additional 10% of this price annually.[69] However, robotic surgery may become cost-effective in the long run, even with these high initial and maintenance costs, if fewer revisions, reduced length of stay, lower infection rates, and shorter duration of surgeries can be achieved. Overall, there is a significant lacunae in the literature analyzing the cost-effectiveness of RA spine surgery, warranting future studies on the topic.

  Future Prospects Top

Augmented reality (AR) is gradually gaining popularity as an operative as well as a teaching tool.[70] This technology is relatively new and is under constant evolution. The virtual 3D anatomy of the spine is visualized on the surface of the patient, and it avoids the distraction of the surgeon from the surgical field. Recent studies of AR integrated with robotics show a significantly higher pedicle screw accuracy.[71],[72] Most of the literature on AR available is based on the studies in phantom and cadaveric specimens, but future clinical RCTs and prospective studies will improve the scope of these technological advances in the field of spine surgery.[73],[74],[75] However, as these continue to evolve, skill development and translation into the operating room, as well as a learning curve for the surgeon, are important concerns in their applicability.

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  References Top

Clarke RH, Horsley V. THE CLASSIC: On a method of investigating the deep ganglia and tracts of the central nervous system (cerebellum). Clin Orthop 2007;463:3-6.  Back to cited text no. 1
Nolte LP, Visarius H, Arm E, Langlotz F, Schwarzenbach O, Zamorano L. Computer-aided fixation of spinal implants. J Image Guid Surg 1995;1:88-93.  Back to cited text no. 2
Kalfas IH, Kormos DW, Murphy MA, McKenzie RL, Barnett GH, Bell GR, et al. Application of frameless stereotaxy to pedicle screw fixation of the spine. J Neurosurg 1995;83:641-7.  Back to cited text no. 3
Nathoo N, Cavuşoğlu MC, Vogelbaum MA, Barnett GH. In touch with robotics: Neurosurgery for the future. Neurosurgery 2005;56:421-33, discussion 421–33.  Back to cited text no. 4
Devito DP, Kaplan L, Dietl R, Pfeiffer M, Horne D, Silberstein B, et al. Clinical acceptance and accuracy assessment of spinal implants guided with SpineAssist surgical robot. Spine (Phila Pa 1976) 2010;35:2109-15.  Back to cited text no. 5
Lieberman IH, Hardenbrook MA, Wang JC, Guyer RD. Assessment of pedicle screw placement accuracy, procedure time, and radiation exposure using a miniature robotic guidance system. J Spinal Disord Tech 2012;25:241-8.  Back to cited text no. 6
Hu X, Ohnmeiss DD, Lieberman IH. Robotic-assisted pedicle screw placement: Lessons learned from the first 102 patients. Eur Spine J 2013;22:661-6.  Back to cited text no. 7
Ringel F, Stüer C, Reinke A, Preuss A, Behr M, Auer F, et al. Accuracy of robot-assisted placement of lumbar and sacral pedicle screws: A prospective randomized comparison to conventional freehand screw implantation. Spine 2012;37:E496-501.  Back to cited text no. 8
Schizas C, Michel J, Kosmopoulos V, Theumann N. Computer tomography assessment of pedicle screw insertion in percutaneous posterior transpedicular stabilization. Eur Spine J 2007;16:613-7.  Back to cited text no. 9
Lee DJ, Kim SB, Rosenthal P, Panchal RR, Kim KD. Stereotactic guidance for navigated percutaneous sacroiliac joint fusion. J Biomed Res 2016;30:162-7.  Back to cited text no. 10
Huang M, Tetreault TA, Vaishnav A, York PJ, Staub BN. The current state of navigation in robotic spine surgery. Ann Transl Med 2021;9:86-86.  Back to cited text no. 11
Wajanavisit W, Lertudomphonwanit T, Fuangfa P, Chanplakorn P, Kraiwattanapong C, Jaovisidha S. Prevalence of high-riding vertebral artery and morphometry of C2 pedicles using a novel computed tomography reconstruction technique. Asian Spine J 2016;10:1141-8.  Back to cited text no. 12
Asuzu DT, Buchholz AL. MAZOR-X robotic-navigated percutaneous C2 screw placement for hangman’s fracture: A case report. J Spine Surg 2021;7:439-44.  Back to cited text no. 13
Jaiswal A, Shetty AP, Rajasekaran S. Role of intraoperative Iso-C based navigation in challenging spine trauma. Indian J Orthop 2007;41:312-7.  Back to cited text no. 14
[PUBMED]  [Full text]  
Fan M, Liu Y, He D, Han X, Zhao J, Duan F, et al. Improved accuracy of cervical spinal surgery with robot-assisted screw insertion: A prospective, randomized, controlled study. Spine 2020;45:285-91.  Back to cited text no. 15
Lee JYK, Lega B, Bhowmick D, Newman JG, O’Malley BW, Weinstein GS, et al. Da Vinci robot-assisted transoral odontoidectomy for basilar invagination. ORL J Otorhinolaryngol Relat Spec 2010;72:91-5.  Back to cited text no. 16
Khan A, Meyers JE, Yavorek S, O’Connor TE, Siasios I, Mullin JP, et al. Comparing next-generation robotic technology with 3-dimensional computed tomography navigation technology for the insertion of posterior pedicle screws. World Neurosurg 2019;123:e474-81.  Back to cited text no. 17
Murphy MA, McKenzie RL, Kormos DW, Kalfas IH. Frameless stereotaxis for the insertion of lumbar pedicle screws. J Clin Neurosci 1994;1:257-60.  Back to cited text no. 18
Verma R, Krishan S, Haendlmayer K, Mohsen A. Functional outcome of computer-assisted spinal pedicle screw placement: A systematic review and meta-analysis of 23 studies including 5,992 pedicle screws. Eur Spine J 2010;19:370-5.  Back to cited text no. 19
Shin BJ, James AR, Njoku IU, Härtl R. Pedicle screw navigation: A systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion. J Neurosurg Spine 2012;17:113-22.  Back to cited text no. 20
Zhang Q, Han XG, Xu YF, Liu YJ, Liu B, He D, et al. Robot-assisted versus fluoroscopy-guided pedicle screw placement in transforaminal lumbar interbody fusion for lumbar degenerative disease. World Neurosurg. 2019;125:e429–34.  Back to cited text no. 21
Han X, Tian W, Liu Y, Liu B, He D, Sun Y, et al. Safety and accuracy of robot-assisted versus fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery: A prospective randomized controlled trial. J Neurosurg Spine2019:1-8.  Back to cited text no. 22
Thakkar SC, Thakkar RS, Sirisreetreerux N, Carrino JA, Shafiq B, Hasenboehler EA. 2D versus 3D fluoroscopy-based navigation in posterior pelvic fixation: Review of the literature on current technology. Int J Comput Assist Radiol Surg 2017;12:69-76.  Back to cited text no. 23
Liu H, Duan S, Xin F, Zhang Z, Wang X, Liu S. Robot-assisted minimally-invasive internal fixation of pelvic ring injuries: A single-center experience. Orthop Surg 2019;11:42-51.  Back to cited text no. 24
Du W, Sun T, Ding Y, Jiang C, Qu W, Zhang S. Robot-assisted treatment of unstable pelvic fractures with a percutaneous iliac lumbar double rod fixation combined with a percutaneous pelvic anterior ring INFIX fixation. Int Orthop 2020;44:1223-32.  Back to cited text no. 25
Kantelhardt SR, Martinez R, Baerwinkel S, Burger R, Giese A, Rohde V. Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement. Eur Spine J 2011;20:860-8.  Back to cited text no. 26
Fatima N, Massaad E, Hadzipasic M, Shankar GM, Shin JH. Safety and accuracy of robot-assisted placement of pedicle screws compared to conventional free-hand technique: A systematic review and meta-analysis. Spine J 2021;21:181-92.  Back to cited text no. 27
Walker CT, Godzik J, Xu DS, Theodore N, Uribe JS, Chang SW. Minimally invasive single-position lateral interbody fusion with robotic bilateral percutaneous pedicle screw fixation: 2-dimensional operative video. Oper Neurosurg (Hagerstown) 2019;16:E121.  Back to cited text no. 28
Feng S, Tian W, Wei Y. Clinical effects of oblique lateral interbody fusion by conventional open versus percutaneous robot-assisted minimally invasive pedicle screw placement in elderly patients. Orthop Surg 2020;12:86-93.  Back to cited text no. 29
Ray WZ, Ravindra VM, Schmidt MH, Dailey AT. Stereotactic navigation with the O-arm for placement of S-2 alar iliac screws in pelvic lumbar fixation: Technical note. J Neurosurg Spine 2013;18:490-5.  Back to cited text no. 30
Rajasekaran S, Kanna R, Shetty A. Safety of cervical pedicle screw insertion in children a clinico-radiological evaluation of 51 cervical pedicle screws in 16 children. Orthop Proc 2012;94-B:85-85.  Back to cited text no. 31
Rajasekaran S, Vidyadhara S, Ramesh P, Shetty AP. Randomized clinical study to compare the accuracy of navigated and non-navigated thoracic pedicle screws in deformity correction surgeries. Spine 2007;32:E56-64.  Back to cited text no. 32
Tian W, Zeng C, An Y, Wang C, Liu Y, Li J. Accuracy and postoperative assessment of pedicle screw placement during scoliosis surgery with computer-assisted navigation: A meta-analysis. Int J Med Robot 2017;13:e1732.  Back to cited text no. 33
Macke JJ, Woo R, Varich L. Accuracy of robot-assisted pedicle screw placement for adolescent idiopathic scoliosis in the pediatric population. J Robot Surg 2016;10:145-50.  Back to cited text no. 34
Takahashi J, Hashidate H, Hirabayashi H, Ogihara N, Mukaiyama K, Kato H, et al. Computer-assisted hemivertebral resection for congenital spinal deformity. J Orthop Sci 2011;16:503-9.  Back to cited text no. 35
Faundez A, Byrne F, Sylvestre C, Lafage V, Cogniet A, Le Huec JC. Pedicle subtraction osteotomy in the thoracic spine and thoracolumbar junction: A retrospective series of 28 cases. Eur Spine J 2015;24:42-8.  Back to cited text no. 36
Smitherman SM, Tatsui CE, Rao G, Walsh G, Rhines LD. Image-guided multilevel vertebral osteotomies for en bloc resection of giant cell tumor of the thoracic spine: Case report and description of operative technique. Eur Spine J 2010;19:1021-1028.  Back to cited text no. 37
Nagashima H, Nishi T, Yamane K, Tanida A. Case report: Osteoid osteoma of the C2 pedicle: Surgical technique using a navigation system. Clin Orthop 2010;468:283-8.  Back to cited text no. 38
Rajasekaran S, Kanna RM, Kamath V, Shetty AP. Computer navigation-guided excision of cervical osteoblastoma. Eur Spine J 2010;19:1046-7.  Back to cited text no. 39
Rajasekaran S, Kamath V, Shetty AP. Intraoperative Iso-C three-dimensional navigation in excision of spinal osteoid osteomas. Spine 2008;33:E25-9.  Back to cited text no. 40
Bandiera S, Ghermandi R, Gasbarrini A, Barbanti Bròdano G, Colangeli S, Boriani S. Navigation-assisted surgery for tumors of the spine. Eur Spine J 2013;22(Suppl 6):919-24.  Back to cited text no. 41
Kaoudi A, Capel C, Chenin L, Peltier J, Lefranc M. Robot-assisted radiofrequency ablation of a sacral S1-S2 aggressive hemangioma. World Neurosurg 2018;116:226-9.  Back to cited text no. 42
Nasser R, Drazin D, Nakhla J, Al-Khouja L, Brien E, Baron EM, et al. Resection of spinal column tumors utilizing image-guided navigation: A multicenter analysis. Neurosurg Focus 2016;41:E15.  Back to cited text no. 43
Hu X, Scharschmidt TJ, Ohnmeiss DD, Lieberman IH. Robotic assisted surgeries for the treatment of spine tumors. Int J Spine Surg 2015;9:1.  Back to cited text no. 44
Smith HE, Welsch MD, Sasso RC, Vaccaro AR. Comparison of radiation exposure in lumbar pedicle screw placement with fluoroscopy vs computer-assisted image guidance with intraoperative three-dimensional imaging. J Spinal Cord Med 2008;31:532-7.  Back to cited text no. 45
Villard J, Ryang YM, Demetriades AK, Reinke A, Behr M, Preuss A, et al. Radiation exposure to the surgeon and the patient during posterior lumbar spinal instrumentation: A prospective randomized comparison of navigated versus non-navigated freehand techniques. Spine 2014;39:1004-9.  Back to cited text no. 46
Keric N, Eum DJ, Afghanyar F, Rachwal-Czyzewicz I, Renovanz M, Conrad J, et al. Evaluation of surgical strategy of conventional vs. percutaneous robot-assisted spinal trans-pedicular instrumentation in spondylodiscitis. J Robot Surg 2017;11:17-25.  Back to cited text no. 47
Galetta MS, Leider JD, Divi SN, Goyal DKC, Schroeder GD. Robotics in spinal surgery. Ann Transl Med 2019;7:S165-S165.  Back to cited text no. 48
Xiao R, Miller JA, Sabharwal NC, Lubelski D, Alentado VJ, Healy AT, et al. Clinical outcomes following spinal fusion using an intraoperative computed tomographic 3D imaging system. J Neurosurg Spine 2017;26:628-37.  Back to cited text no. 49
Staartjes VE, Klukowska AM, Schröder ML. Pedicle screw revision in robot-guided, navigated, and freehand thoracolumbar instrumentation: A systematic review and meta-analysis. World Neurosurg 2018;116:433-443.e8.  Back to cited text no. 50
Watkins RG, Gupta A, Watkins RG. Cost-Effectiveness of Image-Guided Spine Surgery. Open Orthop J. 2010;4:228–33.  Back to cited text no. 51
Solomiichuk V, Fleischhammer J, Molliqaj G, Warda J, Alaid A, von Eckardstein K, et al. Robotic versus fluoroscopy-guided pedicle screw insertion for metastatic spinal disease: A matched-cohort comparison. Neurosurg Focus 2017;42:E13.  Back to cited text no. 52
Schatlo B, Molliqaj G, Cuvinciuc V, Kotowski M, Schaller K, Tessitore E. Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: A matched cohort comparison. J Neurosurg Spine 2014;20:636-43.  Back to cited text no. 53
Zong S, Wu Y, Tao Y, Chen X, Fang Y, Du L, et al. Treatment results in different surgical approaches for intraspinal tumor in 51 patients. Int J Clin Exp Med 2015;8:16627-33.  Back to cited text no. 54
Mao G, Gigliotti MJ, Myers D, Yu A, Whiting D. Single-surgeon direct comparison of O-arm neuronavigation versus Mazor X robotic-guided posterior spinal instrumentation. World Neurosurg 2020;137:e278-85.  Back to cited text no. 55
Satin AM, Kisinde S, Lieberman IH. Robotic-assisted revision spine surgery. Int J Spine Surg 2022;16:S14-21.  Back to cited text no. 56
Ha Y. Robot-assisted spine surgery: A solution for aging spine surgeons. Neurospine 2018;15:187-8.  Back to cited text no. 57
Dea N, Fisher CG, Batke J, Strelzow J, Mendelsohn D, Paquette SJ, et al. Economic evaluation comparing intraoperative cone beam CT-based navigation and conventional fluoroscopy for the placement of spinal pedicle screws: A patient-level data cost-effectiveness analysis. Spine J 2016;16:23-31.  Back to cited text no. 58
Al-Khouja L, Shweikeh F, Pashman R, Johnson JP, Kim TT, Drazin D. Economics of image guidance and navigation in spine surgery. Surg Neurol Int 2015;6:S323-6.  Back to cited text no. 59
Vo CD, Jiang B, Azad TD, Crawford NR, Bydon A, Theodore N. Robotic spine surgery: Current state in minimally invasive surgery. Glob Spine J 2020;10(2_suppl):34S-40S.  Back to cited text no. 60
Menger RP, Savardekar AR, Farokhi F, Sin A. A cost-effectiveness analysis of the integration of robotic spine technology in spine surgery. Neurospine 2018;15:216-24.  Back to cited text no. 61
Tian W, Han X, Liu B, Liu Y, Hu Y, Han X, et al. A robot-assisted surgical system using a force-image control method for pedicle screw insertion. PLoS One 2014;9:e86346.  Back to cited text no. 62
Gao S, Lv Z, Fang H. Robot-assisted and conventional freehand pedicle screw placement: a systematic review and meta-analysis of randomized controlled trials. Eur Spine J 2018;27:921–30.  Back to cited text no. 63
Peng YN, Tsai LC, Hsu HC, Kao CH. Accuracy of robot-assisted versus conventional freehand pedicle screw placement in spine surgery: A systematic review and meta-analysis of randomized controlled trials. Ann Transl Med 2020;8:824–824.  Back to cited text no. 64
Tarawneh AM, Salem KM. A systematic review and meta-analysis of randomized controlled trials comparing the accuracy and clinical outcome of pedicle screw placement using robot-assisted technology and conventional freehand technique. Glob Spine J 2021;11:575–86.  Back to cited text no. 65
Hu X, Lieberman IH. What is the learning curve for robotic-assisted pedicle screw placement in spine surgery? Clin Orthop 2014;472:1839–44.  Back to cited text no. 66
Schatlo B, Martinez R, Alaid A, von Eckardstein K, Akhavan-Sigari R, Hahn A, et al. Unskilled unawareness and the learning curve in robotic spine surgery. Acta Neurochir (Wien) 2015;157: 1819–23.  Back to cited text no. 67
Wang E, Manning J, Varlotta CG, Woo D, Ayres E, Abotsi E, et al. Radiation exposure in posterior lumbar fusion: A comparison of CT image-guided navigation, robotic assistance, and intraoperative fluoroscopy. Glob Spine J 2021;11:450–7.  Back to cited text no. 68
Fiani B, Quadri SA, Ramakrishnan V, Berman B, Khan Y, Siddiqi J. Retrospective review on accuracy: A pilot study of robotically guided thoracolumbar/sacral pedicle screws versus fluoroscopy-guided and computerized tomography stealth-guided screws. Cureus 9: e1437.  Back to cited text no. 69
Burström G, Persson O, Edström E, Elmi-Terander A. Augmented reality navigation in spine surgery: A systematic review. Acta Neurochir (Wien) 2021;163:843-52.  Back to cited text no. 70
Ghasem A, Sharma A, Greif DN, Alam M, Maaieh MA. The arrival of robotics in spine surgery: A review of the literature. Spine 2018;43:1670-7.  Back to cited text no. 71
Madhavan K, Kolcun J, Chieng LO, Wang M. Augmented-reality integrated robotics in neurosurgery: Are we there yet? Neurosurg Focus 2017;42:E3.  Back to cited text no. 72
Ma L, Zhao Z, Chen F, Zhang B, Fu L, Liao H. Augmented reality surgical navigation with ultrasound-assisted registration for pedicle screw placement: A pilot study. Int J Comput Assist Radiol Surg 2017;12:2205-15.  Back to cited text no. 73
Elmi-Terander A, Nachabe R, Skulason H, Pedersen K, Söderman M, Racadio J, et al. Feasibility and accuracy of thoracolumbar minimally invasive pedicle screw placement with augmented reality navigation technology. Spine 2018;43:1018-23.  Back to cited text no. 74
Elmi-Terander A, Skulason H, Söderman M, Racadio J, Homan R, Babic D, et al. Surgical navigation technology based on augmented reality and integrated 3D intraoperative imaging: A spine cadaveric feasibility and accuracy study. Spine 2016;41:E1303-11.  Back to cited text no. 75


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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