Robot-assisted spine surgery
Systems
Indications
see Robot-assisted spine surgery indications
Robotic-assisted spine surgery has been reported to improve the accuracy and safety of pedicle screw placement and to reduce blood loss, hospital length of stay, and early postoperative pain.
is a rapidly advancing field aimed at improving the precision, safety, and efficiency of spinal procedures. By integrating preoperative imaging, real-time navigation, and robotic-guided tools, these systems enhance the surgeon's capabilities, particularly in complex or high-risk cases. Systems like ExcelsiusGPS® (Globus Medical) and Mazor X (Medtronic) have revolutionized spinal surgery by addressing limitations of traditional techniques, such as reduced accuracy, high radiation exposure, and variability in surgical outcomes.
How Robotic-Assisted Spine Surgery Works Robotic-assisted spine surgery combines:
Preoperative Imaging: CT or MRI scans create a 3D model of the patient's spine, enabling detailed pre-surgical planning. Intraoperative Navigation: Real-time imaging (e.g., fluoroscopy) is synchronized with the robotic arm to maintain accurate navigation during surgery. Robotic Guidance: The robotic arm positions surgical tools or implants (e.g., pedicle screws) according to predefined trajectories, enhancing precision and minimizing manual error. Applications Robotic systems are versatile and can be used for:
Pedicle Screw Placement: Inserting screws in thoracic, lumbar, or sacral regions with high accuracy. Minimally Invasive Surgery (MIS): Performing complex procedures with small incisions, reducing tissue disruption and recovery time. Deformity Corrections: Assisting in scoliosis or kyphosis surgeries with optimal alignment. Cervical Spine Surgery: Advanced systems like ExcelsiusGPS® can navigate the cervical spine, broadening its utility. Adjunct Procedures: Some systems are capable of aiding in cranial procedures, such as brain biopsies or electrode implantation. Benefits of Robotic-Assisted Spine Surgery Increased Accuracy:
Robotic systems achieve placement accuracy rates of 96–100%, significantly reducing the risk of misaligned implants and associated complications. Minimized Radiation Exposure:
Real-time navigation reduces the need for repeated fluoroscopic imaging, lowering radiation exposure for both patients and surgical teams. Enhanced Safety:
Precise screw placement reduces the risk of nerve damage, vascular injury, or hardware failure, contributing to better long-term outcomes. Shorter Recovery Times:
Minimally invasive techniques facilitated by robotics result in less blood loss, smaller incisions, and shorter hospital stays. Reproducibility:
Robotic systems standardize surgical workflows, reducing variability between surgeons and improving overall quality of care. Biomechanical Strength:
Larger screws with optimal trajectories improve implant stability and reduce the risk of hardware loosening. Challenges and Limitations Learning Curve:
Surgeons require extensive training to master robotic systems, and initial cases may have longer operative times as teams adapt to the technology. Cost:
High initial investment, maintenance expenses, and consumable costs make robotic systems financially challenging for many institutions. System Failures:
Technical malfunctions, software errors, or calibration issues can disrupt surgeries, necessitating contingency plans and backup techniques. Anatomical Variations:
While robots excel in predefined trajectories, unexpected anatomical anomalies or intraoperative complications may still require manual intervention. Limited Availability:
Access to robotic systems remains uneven, with adoption concentrated in high-resource centers, potentially widening disparities in surgical outcomes. Clinical Evidence Studies consistently demonstrate the advantages of robotic-assisted spine surgery:
Accuracy: Significantly reduced malpositioning rates compared to freehand or fluoroscopy-guided techniques. Efficiency: Operative times initially increase but improve with experience, often plateauing after 30–40 cases. Safety: Lower rates of revision surgeries, reduced intraoperative blood loss, and shorter hospital stays compared to conventional methods. At Hospital Universitario La Paz, the introduction of the ExcelsiusGPS® system showed:
250 screws implanted across 40 patients, with only one intraoperative malposition (2.5%). Median operative time of 143 minutes and hospital stays of 4 days, indicating efficient early adoption. No cases requiring transfusion, reflecting minimal surgical trauma. Future Perspectives Integration with Artificial Intelligence (AI):
AI can enhance preoperative planning and intraoperative decision-making by predicting optimal trajectories and outcomes. Broader Indications:
Ongoing advancements may expand robotic systems’ applications to include more complex deformity surgeries, trauma, and oncology cases. Cost Reduction:
As adoption increases and technology advances, costs are expected to decrease, making robotic systems accessible to more institutions. Telemedicine and Remote Assistance:
Future systems may incorporate remote capabilities, allowing expert surgeons to assist in surgeries across different locations. Conclusion Robotic-assisted spine surgery represents a paradigm shift in spinal care, combining precision, safety, and efficiency. While challenges like cost and learning curves remain, the clinical benefits—enhanced accuracy, reduced radiation exposure, and better patient outcomes—make it a promising cornerstone of modern spinal surgery. Continued advancements in technology, combined with training and cost optimization, will likely make robotic systems an integral part of surgical practice worldwide.
Technical and instructional studies
A human cadaveric study assessed the accuracy of robotic-assisted bone laminectomy, revealing precision in the cutting plane3. Robotic-assisted facet decortication, decompression, interbody cage implantation, and pedicle screw fixation add automation and accuracy to MI-TLIF.
Description: A surgical robotic system comprises an operating room table-mounted surgical arm with 6 degrees of freedom that is physically connected to the patient's osseous anatomy with either a percutaneous Steinmann pin to the pelvis or a spinous process clamp. The Mazor X Stealth Edition Spine Robotic System (Version 5.1; Medtronic) is utilized, and a preoperative plan is created with use of software for screw placement, facet decortication, and decompression. The workstation is equipped with interface software designed to streamline the surgical process according to preoperative planning, intraoperative image acquisition, registration, and real-time control over robotic motion. The combination of these parameters enables the precise execution of preplanned facet joint decortication, osseous decompression, and screw trajectories. Consequently, this technique grants the surgeon guidance for the drilling and insertion of screws, as well as guidance for robotic resection of bone with a bone-removal drill.
Alternatives: The exploration of robotically guided facet joint decortication and decompression in MI-TLIF presents an innovative alternative to the existing surgical approaches, which involve manual bone removal and can be less precise. Other robotic systems commonly utilized in spine surgery include the ROSA (Zimmer Biomet), the ExcelsiusGPS (Globus Medical), and the Cirq (Brainlab)4.
Rationale: The present video article provides a comprehensive guide for executing robotic-assisted MI-TLIF, including robotic facet decortication and osseous decompression. The introduction of advanced robotic technology capable of both decompressing bone and providing implant guidance represents a considerable advancement in robotic-assisted spine surgery. Software planning for robotic-assisted decortication of fused surfaces, surgical decompression, interbody cage placement, and pedicle screw placement allows for a less invasive and more precise MI-TLIF.
Expected outcomes: Anticipated outcomes include reduction in low back and leg pain, improved functional status, and successful spinal fusion. Radiographic outcomes are expected to show restored foraminal height and solid bony fusion. Further, enhanced surgical precision, reduced approach-related morbidity by expanded robotic capabilities in spinal fusion surgery, and a shift from manual bone removal to precise mechanized techniques can be expected. The introduction of robotic-assisted facet joint decortication and decompression represents a notable milestone in spine surgery, enhancing patient care and technological advancement.
Important tips: Although robotic systems were initially predominantly employed for thoracic or lumbar pedicle screw insertion, recent advancements in robotic technology and software have allowed registration of the posterior elements. This advancement has expanded the utility of robotic systems to the initiation of spinal decompression and the decortication of facet joint surfaces, enhancing fusion procedures.Maintaining anatomical precision and preventing the need for re-registration are critical considerations in this surgical procedure. It is recommended to follow a consistent surgical workflow: facet decortication, decompression, modular screw placement, discectomy, insertion of an interbody cage, placement of reduction tabs, rod insertion, and set screw locking.The incorporation of robotic assistance in MI-TLIF is not exempt from a set of challenges. These encompass issues that pertain to dependability of the setup process, occurrences of registration failures, logistical complexities, time constraints, and the unique learning curve associated with the novel capability of robotic decompression of bone and facet joints 1).