The Clinical Impact of Image Guidance and Robotics in Spinal Surgery: A Review of Safety, Accuracy, Efficiency, and Complication Reduction

Abstract

Image guidance (IG) and robotic-assisted (RA) surgery are modern technological advancements that have provided novel ways to perform precise and accurate spinal surgery. These innovations supply real-time, three-dimensional imaging information to aid in instrumentation, decompression, and implant placement. Although nothing can replace the knowledge and expertise of an experienced spine surgeon, these platforms do have the potential to supplement the individual surgeon's capabilities. Specific advantages include more precise pedicle screw placement, minimally invasive surgery with less reliance on intraoperative fluoroscopy, and lower radiation exposure to the surgeon and staff. As these technologies have become more widely adopted over the years, novel uses such as tumor resection have been explored. Disadvantages include the cost of implementing IG and robotics platforms, the initial learning curve for both the surgeon and the staff, and increased patient radiation exposure in scoliosis surgery. Also, given the relatively recent transition of many procedures from inpatient settings to ambulatory surgery centers, access to current devices may be cost prohibitive and not as readily available at some centers. Regarding patient-related outcomes, much further research is warranted. The short-term benefits of minimally invasive surgery often bolster the perioperative and early postoperative outcomes in many retrospective studies on IG and RA surgery. Randomized controlled trials limiting such confounding factors are warranted to definitively show potential independent improvements in patient-related outcomes specifically attributable to IG and RA alone. Nonetheless, irrespective of these current unknowns, it is clear that these technologies have changed the field and the practice of spine surgery. Surgeons should be familiar with the potential benefits and tradeoffs of these platforms when considering adopting IG and robotics in their practices.

Figure 1

Evaluation of the upper thoracic costotransverse joint for assessment of extrapedicular versus transpedicular approaches. Also shown is adjustment of the pedicle screw length from 45 to 40 mm to avoid ventral breach.

Figure 2

Optimization of pedicle screw trajectory for better pedicle fill and length. This also allows visualization of the facet joint for the avoidance of proximal facet violation and adjacent segment disease.

Figure 3

Image-guided trajectory for lateral mass fixation in the posterior cervical spine with avoidance of the facet joints. Also shown is adjustment of the screw length from 16 to 14 mm to avoid a ventral breach. An all in-bone trajectory avoids injury to the exiting nerve root and vertebral artery.

Figure 4

Sacroiliac joint fixation using image guidance. The top left image confirms that the trajectory is ventral enough to access the articular area of the joint. The top right shows the location of the iliac cortical density above which runs the L5 root. The bottom left picture allows the surgeon to plan for more than 1 implant while staying within the intra-articular portion of the joint. The coronal cuts seen in the bottom right can be used not only for implant planning but also for visualization of implant positioning with respect to the sacral foramina.