Accuracy and Safety Between Robot-Assisted and Conventional Freehand Fluoroscope-Assisted Placement of Pedicle Screws in Thoracolumbar Spine: Meta-Analysis

Abstract

Background and Objectives: Robotic-assisted surgery (RS) has progressively emerged as a promising technology in modern thoracolumbar spinal surgery, offering the potential to enhance accuracy and improve clinical outcomes. To date, the benefits of robot-assisted techniques in thoracolumbar spinal surgery remain controversial. The objective of this study was to assess the efficacy and safety of RS compared to fluoroscopy-assisted surgery (FS) in spinal fusion procedures. Materials and Methods: In accordance with the PRISMA guidelines, a systematic review and meta-analysis was conducted, using REVMAN V5.3 software. The review protocol was registered in the Prospective Register of Systematic Reviews (PROSPERO) website with the following registration number: CRD42024567193. Results: Eighteen studies were included in the meta-analysis with a total of 1566 patients examined. The results demonstrated a worse accuracy in FS in cases with major violations of the peduncular cortex (D-E grades, according to Gertzbein's classification) [(odds ratio (OR) 0.47, 95%-CI 0.28 to 0.80, I² 0%]. In addition, a lower complication rate was shown in the RS group compared to the FS group, specifically regarding the need for surgical revision due to screw mispositioning (OR 0.28-CI 0.17 to 0.48, I² 98%). Conclusions: Advantages of robot-assisted techniques were demonstrated in terms of postoperative complications, revision surgery rates, and the accuracy of screw placement. While RS represents a valuable and promising technological advancement in thoracolumbar spinal surgery, future studies are needed to further explore its advantages in thoracolumbar spinal surgery and to identify which spinal surgical approach has greater advantages when using the robot.

Keywords: arthrodesis; fluoroscopy; pedicle screw; robotic surgery; screw placement; spine surgery.

Figure 2

Forest plots of the pooled analysis of the investigated outcome variables [11,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32]. RS: robotic-assisted surgery; FS: fluoroscopy-assisted surgery. (A) Accuracy of screw placement (Grade A); (B) accuracy of screw placement (Grade B); (C) accuracy of screw placement (Grade C); (D) accuracy of screw placement (Grades D and E); (E) intraoperative blood loss; (F) hospital stays; (G) operation time; (H) radiation dose exposure; (I) superior facet joint violation (grade 0); (J) superior facet joint violation (grade 1); (K) superior facet joint violation (grade 2); (L) superior facet joint violation (grade 3); and (M) total complications.

Figure 2

Forest plots of the pooled analysis of the investigated outcome variables [11,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32]. RS: robotic-assisted surgery; FS: fluoroscopy-assisted surgery. (A) Accuracy of screw placement (Grade A); (B) accuracy of screw placement (Grade B); (C) accuracy of screw placement (Grade C); (D) accuracy of screw placement (Grades D and E); (E) intraoperative blood loss; (F) hospital stays; (G) operation time; (H) radiation dose exposure; (I) superior facet joint violation (grade 0); (J) superior facet joint violation (grade 1); (K) superior facet joint violation (grade 2); (L) superior facet joint violation (grade 3); and (M) total complications.

Figure 2

Forest plots of the pooled analysis of the investigated outcome variables [11,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32]. RS: robotic-assisted surgery; FS: fluoroscopy-assisted surgery. (A) Accuracy of screw placement (Grade A); (B) accuracy of screw placement (Grade B); (C) accuracy of screw placement (Grade C); (D) accuracy of screw placement (Grades D and E); (E) intraoperative blood loss; (F) hospital stays; (G) operation time; (H) radiation dose exposure; (I) superior facet joint violation (grade 0); (J) superior facet joint violation (grade 1); (K) superior facet joint violation (grade 2); (L) superior facet joint violation (grade 3); and (M) total complications.

Figure 1

PRISMA flowchart.

Figure 3

Funnel plots [11,18,19,20,22,23,24,25,26,28,29,30,31]. (A) Publication bias on accuracy of screw placement (Grade A); (B) publication bias on accuracy of screw placement (Grade B); (C) publication bias on accuracy of screw placement (Grade C); and (D) publication bias on accuracy of screw placement (Grades D and E).