Robot-assisted and conventional freehand pedicle screw placement: a systematic review and meta-analysis of randomized controlled trials
- 456 Downloads
Several studies have revealed that robot-assisted technique might improve the pedicle screw insertion accuracy, but owing to the limited sample sizes in the individual study reported up to now, whether or not robot-assisted technique is superior to conventional freehand technique is indefinite. Thus, we performed this systematic review and meta-analysis based on randomized controlled trials to assess which approach is better.
Electronic databases including PubMed, EMBASE, CENTRAL, ISI Web of Science, CNKI and WanFang were systematically searched to identify potentially eligible articles. Main endpoints containing the accuracy of pedicle screw implantation and proximal facet joint violation were evaluated as risk ratio (RR) and the associated 95% confidence intervals (95% CIs), while radiation exposure and surgical duration were presented as mean difference (MD) or standard mean difference (SMD). Meta-analyses were performed using RevMan 5.3 software.
Six studies involving 158 patients (688 pedicle screws) in robot-assisted group and 148 patients (672 pedicle screws) in freehand group were identified matching our study. The Grade A accuracy rate in robot-assisted group was superior to freehand group (RR 1.03, 95% CI 1.00, 1.06; P = 0.04), but the Grade A + B accuracy rate did not differ between the two groups (RR 1.01, 95% CI 0.99, 1.02; P = 0.29). With regard to proximal facet joint violation, the combined results suggested that robot-assisted group was associated with significantly fewer proximal facet joint violation than freehand group (RR 0.07, 95% CI 0.01, 0.55; P = 0.01). As was the radiation exposure, our findings suggested that robot-assisted technique could significantly reduce the intraoperative radiation time (MD − 12.38, 95% CI − 17.95, − 6.80; P < 0.0001) and radiation dosage (SMD − 0.64, 95% CI − 0.85, − 0.43; P < 0.00001). But the overall surgical duration was longer in robot-assisted group than conventional freehand group (MD 20.53, 95% CI 5.17, 35.90; P = 0.009).
The robot-assisted technique was associated with equivalent accuracy rate of pedicle screw implantation, fewer proximal facet joint violation, less intraoperative radiation exposure but longer surgical duration than freehand technique. Powerful evidence relies on more randomized controlled trials with high quality and larger sample size in the future.
KeywordsRobot assisted Pedicle screw Spine surgery Systematic review Meta-analysis
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 7.Nolte LP, Visarius H, Arm E, Langlotz F, Schwarzenbach O, Zamorano L (1995) Computer-aided fixation of spinal implants. J Image Guid Surg 1:88–93. doi: 10.1002/(SICI)1522-712X(1995)1:2<88::AID-IGS3>3.0.CO;2-H CrossRefPubMedGoogle Scholar
- 9.Verma R, Krishan S, Haendlmayer K, Mohsen A (2010) Functional outcome of computer-assisted spinal pedicle screw placement: a systematic review and meta-analysis of 23 studies including 5,992 pedicle screws. Eur Spine J 19:370–375. https://doi.org/10.1007/s00586-009-1258-4 CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Barzilay Y, Liebergall M, Fridlander A, Knoller N (2006) Miniature robotic guidance for spine surgery–introduction of a novel system and analysis of challenges encountered during the clinical development phase at two spine centres. Int J Med Robot Comput Assist Surg MRCAS 2:146–153. https://doi.org/10.1002/rcs.90 CrossRefGoogle Scholar
- 11.Lieberman IH, Togawa D, Kayanja MM, Reinhardt MK, Friedlander A, Knoller N, Benzel EC (2006) Bone-mounted miniature robotic guidance for pedicle screw and translaminar facet screw placement: Part I-Technical development and a test case result. Neurosurgery 59:641–650. https://doi.org/10.1227/01.neu.0000229055.00829.5b (discussion 641–650) CrossRefPubMedGoogle Scholar
- 13.Liu H, Chen W, Wang Z, Lin J, Meng B, Yang H (2016) Comparison of the accuracy between robot-assisted and conventional freehand pedicle screw placement: a systematic review and meta-analysis. Int J Comput Assist Radiol Surg 11:2273–2281. https://doi.org/10.1007/s11548-016-1448-6 CrossRefPubMedGoogle Scholar
- 19.Kim HJ, Kang KT, Park SC, Kwon OH, Son J, Chang BS, Lee CK, Yeom JS, Lenke LG (2017) Biomechanical advantages of robot-assisted pedicle screw fixation in posterior lumbar interbody fusion compared with freehand technique in a prospective randomized controlled trial-perspective for patient-specific finite element analysis. Spine J 17:671–680. https://doi.org/10.1016/j.spinee.2016.11.010 CrossRefPubMedGoogle Scholar
- 23.Ringel F, Stuer C, Reinke A, Preuss A, Behr M, Auer F, Stoffel M, Meyer B (2012) Accuracy of robot-assisted placement of lumbar and sacral pedicle screws: a prospective randomized comparison to conventional freehand screw implantation. Spine 37:E496–E501. https://doi.org/10.1097/BRS.0b013e31824b7767 CrossRefPubMedGoogle Scholar
- 25.Tian W, Fan MX, Han XG, Zhao JW, Liu YJ (2016) Pedicle screw insertion in spine: a randomized comparison study of robot-assisted surgery and fluoroscopy-guided techniques. J Clin Orthop Res 1:4–10. https://doi.org/10.3969/j.issn.2096-269X.2016.01.002 Google Scholar
- 30.Perisinakis K, Damilakis J, Theocharopoulos N, Papadokostakis G, Hadjipavlou A, Gourtsoyiannis N (2004) Patient exposure and associated radiation risks from fluoroscopically guided vertebroplasty or kyphoplasty. Radiology 232:701–707. https://doi.org/10.1148/radiol.2323031412 CrossRefPubMedGoogle Scholar
- 32.Alaid A, von Eckardstein K, Smoll NR, Solomiichuk V, Rohde V, Martinez R, Schatlo B (2017) Robot guidance for percutaneous minimally invasive placement of pedicle screws for pyogenic spondylodiscitis is associated with lower rates of wound breakdown compared to conventional fluoroscopy-guided instrumentation. Neurosurg Rev. https://doi.org/10.1007/s10143-017-0877-1 PubMedGoogle Scholar
- 34.Keric N, Doenitz C, Haj A, Rachwal-Czyzewicz I, Renovanz M, Wesp DMA, Boor S, Conrad J, Brawanski A, Giese A, Kantelhardt SR (2017) Evaluation of robot-guided minimally invasive implantation of 2067 pedicle screws. Neurosurg Focus 42:E11. https://doi.org/10.3171/2017.2.focus16552 CrossRefPubMedGoogle Scholar
- 35.Kim HJ, Chun HJ, Kang KT, Moon SH, Kim HS, Park JO, Moon ES, Kim BR, Sohn JS, Ko YN, Lee HM (2012) The biomechanical effect of pedicle screws’ insertion angle and position on the superior adjacent segment in 1 segment lumbar fusion. Spine 37:1637–1644. https://doi.org/10.1097/BRS.0b013e31823f2115 CrossRefPubMedGoogle Scholar
- 36.Shah RR, Mohammed S, Saifuddin A, Taylor BA (2003) Radiologic evaluation of adjacent superior segment facet joint violation following transpedicular instrumentation of the lumbar spine. Spine 28:272–275. https://doi.org/10.1097/01.brs.0000042361.93572.74 PubMedGoogle Scholar
- 37.Babu R, Park JG, Mehta AI, Shan T, Grossi PM, Brown CR, Richardson WJ, Isaacs RE, Bagley CA, Kuchibhatla M, Gottfried ON (2012) Comparison of superior-level facet joint violations during open and percutaneous pedicle screw placement. Neurosurgery 71:962–970. https://doi.org/10.1227/NEU.0b013e31826a88c8 CrossRefPubMedPubMedCentralGoogle Scholar
- 38.Levin JM, Alentado VJ, Healy AT, Steinmetz MP, Benzel EC, Mroz TE (2017) Superior segment facet joint violation during instrumented lumbar fusion is associated with higher reoperation rates and diminished improvement in quality of life. Clin Spine Surg. https://doi.org/10.1097/bsd.0000000000000566 Google Scholar