|
 
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| SYMPOSIUM: COMPLICATIONS IN SPINE SURGERY |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 37-47 |
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Role of robotics and spinal navigation in reducing surgical complications
Guna Pratheep, Chandhan Murugan, Shanmuganathan Rajasekaran, Ajoy Prasad Shetty, Rishi Mugesh Kanna
Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd. , Coimbatore, Tamil Nadu, India
| Date of Submission | 06-Oct-2022 |
| Date of Decision | 09-Dec-2022 |
| Date of Acceptance | 11-Jan-2023 |
| Date of Web Publication | 11-Feb-2023 |
Correspondence Address:
Shanmuganathan Rajasekaran
Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., 313, Mettupalayam Road, Coimbatore641043, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/isj.isj_72_22
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 | |  |
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 | | |
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)
Click here to view |
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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| Application of Navigation and Robotics in Spine Surgery | | |
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 | | |
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 | | |
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 | | |
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 | | |
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 | | |
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 | | |
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 | | |
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 | | |
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.
Ethical policy and institutional review board statement
Not applicable.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1]
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