Ensuring navigation integrity using robotics in spine surgery

  • Neil CrawfordEmail author
  • Norbert Johnson
  • Nicholas Theodore
Original Article


There are potential pitfalls associated with the pursuit of accurate surgical navigation, such as vulnerability of the reference array to accidental dislodgment and damage or soiling of tracking arrays on tools. Additionally, there are hazards encountered when attempting accurate robotic screw placement in spine surgery, including skiving of the tool on bone, displacement of the robotic arm, or patient movement. Proven techniques are needed to address and mitigate these issues to ensure that navigation integrity is maintained and screw placement is accurate when using navigated robotic surgical guidance systems. The following research describes some potential hazards commonly encountered in robotic navigated screw placement, suggests techniques for overcoming these hazards, and provides examples of how these techniques have been incorporated into existing surgical robotic guidance systems.


Robotic navigated screw placement Patient reference array Registration Tracking camera Computed tomography X-ray exposure 


Compliance with ethical standards

Conflict of interest

The Excelsius GPS™ robot described in this manuscript manufactured by Globus Medical, Inc. (GMI) was invented by authors Neil Crawford, PhD, and Nicholas Theodore, MD. Author Neil Crawford, PhD, is entitled to royalty payments on sales of the Excelsius GPS™ robot and owns GMI stock. Author Nicholas Theodore, MD, is entitled to royalty payments on sales of the Excelsius GPS™ robot and owns GMI stock. Author Nicholas Theodore, MD, is a paid consultant to GMI. Author Neil Crawford, PhD, is a salaried employee of GMI. Author Norbert Johnson, MS, is a salaried employee of GMI.

Human rights and participants

This article does not contain any studies with human or animal subjects performed by any of the authors.


  1. 1.
    Hyun SJ, Kim KJ, Jahng TA et al (2017) Minimally invasive robotic versus open fluoroscopic-guided spinal instrumented fusions: a randomized controlled trial. Spine (Phila Pa 1976) 42:353–358CrossRefGoogle Scholar
  2. 2.
    Kantelhardt SR, Martinez R, Baerwinkel S et al (2011) Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement. Eur Spine J 20:860–868CrossRefGoogle Scholar
  3. 3.
    Laudato PA, Pierzchala K, Schizas C (2018) Pedicle screw insertion accuracy using O-arm, robotic guidance, or freehand technique: a comparative study. Spine (Phila Pa 1976) 43:E373–E378Google Scholar
  4. 4.
    Lonjon N, Chan-Seng E, Costalat V et al (2016) Robot-assisted spine surgery: feasibility study through a prospective case-matched analysis. Eur Spine J 25:947–955CrossRefGoogle Scholar
  5. 5.
    Molliqaj G, Schatlo B, Alaid A et al (2017) Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery. Neurosurg Focus 42:E14CrossRefGoogle Scholar
  6. 6.
    Ringel F, Stuer C, Reinke A et al (2012) Accuracy of robot-assisted placement of lumbar and sacral pedicle screws: a prospective randomized comparison to conventional freehand screw implantation. Spine (Phila Pa 1976) 37:E496–E501CrossRefGoogle Scholar
  7. 7.
    Villard J, Ryang YM, Demetriades AK et al (2014) Radiation exposure to the surgeon and the patient during posterior lumbar spinal instrumentation: a prospective randomized comparison of navigated versus non-navigated freehand techniques. Spine (Phila Pa 1976) 39:1004–1009CrossRefGoogle Scholar
  8. 8.
    Rahmathulla G, Nottmeier EW, Pirris SM, Deen HG, Pichelmann MA (2014) Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance. Neurosurg Focus 36:E3CrossRefGoogle Scholar
  9. 9.
    Houten JK, Nasser R, Baxi N (2012) clinical assessment of percutaneous lumbar pedicle screw placement using the O-Arm multidimensional surgical imaging system. Neurosurgery 70:990–995CrossRefGoogle Scholar
  10. 10.
    Holly LT, Foley KT (2003) Intraoperative spinal navigation. Spine (Phila Pa 1976) 28:S54–S61Google Scholar
  11. 11.
    Crawford NR, Major C, Bartelme M, Johnson N, Cicchini S (2016) Surgical tool systems and methods. US Patent Publication No. US 2016/0278875 A1, Sept. 29, 2016Google Scholar
  12. 12.
    Takahashi J, Hirabayashi H, Hashidate H, Ogihara N, Kato H (2010) Accuracy of multilevel registration in image-guided pedicle screw insertion for adolescent idiopathic scoliosis. Spine (Phila, Pa 1976) 35:347–352CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Ltd., part of Springer Nature 2019

Authors and Affiliations

  • Neil Crawford
    • 1
    Email author
  • Norbert Johnson
    • 1
  • Nicholas Theodore
    • 2
  1. 1.Globus Medical, Inc.MethuenUSA
  2. 2.Department of NeurosurgeryJohns Hopkins UniversityBaltimoreUSA

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