It is a novel system that eliminates the need for common steps in conventional Percutaneous Pedicle Screw Systems such as the use of Jamshidi needles, bone tunnel creation, guidewire positioning, use of a dilator, and tapping. However, there are also notable problems, such as the difficulty in re-inserting the PPS, as a large PPS with a sharp tip is inserted without creating an appropriate trajectory by a needle. Therefore, beginners are encouraged to master basic PPS procedures using a third-generation system before using a wireless fourth-generation system.
The characteristic advantage of fourth-generation PPS is that it is possible to avoid radiation exposure during screw insertion by linking the system to the O-arm® navigation. In addition, it is also possible to link the system to a robotic-assistance system. Power drivers are indispensable in robotic-assisted surgery and have been introduced in the Voyager® and VIPER® systems. It is interesting to note that the new Voyager ATMAS® uses cortical threading to minimize slippage during the use of power tools and single threading (2 mm pitch) for press-fitting