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Impact of robot-assisted spine surgery on health care quality and neurosurgical economics: A systemic review

  • Brian Fiani
  • Syed A. Quadri
  • Mudassir Farooqui
  • Alessandra Cathel
  • Blake Berman
  • Jerry Noel
  • Javed Siddiqi
Review

Abstract

Whenever any new technology is introduced into the healthcare system, it should satisfy all three pillars of the iron triangle of health care, which are quality, cost-effectiveness, and accessibility. There has been quite advancement in the field of spine surgery in the last two decades with introduction of new technological modalities such as CAN and surgical robotic devices. MAZOR SpineAssist/Renaissance was the first robotic system to be approved for the use in spine surgeries in the USA in 2004. In this review, the authors sought to determine if the current literature supports this technology to be cost-effective, accessible, and improve the quality of care for individuals and populations by increasing the likelihood of desired health outcomes. Robotic-assisted surgery seems to provide perfection in surgical ergonomics and surgical dexterity, consequently improving patient outcomes. A lot of data is present on the accuracy, effectiveness, and safety of the robotic-guided technology which reflects remarkable improvements in quality of care, making its utility convincingly undisputable. The technology has been claimed to be cost-effective but there seems to be lack of data in the literature on this topic to validate this claim. Apart from just the outcome parameters, there is an immense need of studies on real-time cost-efficacy, patient perspective, surgeon and resident learning curve, and their experience with this new technology. Furthermore, new studies looking into increased utilities of this technology, such as brain and spine tumor resection, deep brain stimulation procedures, and osteotomies in deformity surgery, might authenticate the cost of the equipment.

Keywords

Robotic spine surgery Minimally invasive spine surgery Mazor robotics Neurosurgical economics 

Notes

Funding source

The authors have not received any funding for this work from any organization.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures were done in accordance with the ethical standards. The radiological images used in this review were reviewed and approved by the local institutional review board (IRB) and have all been de-identified to maintain patient confidentiality.

References

  1. 1.
    Barzilay Y, Schroeder JE, Hiller N, Singer G, Hasharoni A, Safran O, Liebergall M, Itshayek E, Kaplan L (2014) Robot-assisted vertebral body augmentation: a radiation reduction tool. Spine 39:153–157CrossRefPubMedGoogle Scholar
  2. 2.
    Bederman SS, Hahn P, Colin V, Kiester PD, Bhatia NN (2017) Robotic guidance for S2-alar-iliac screws in spinal deformity correction. Clinical spine surgery 30:E49–E53CrossRefPubMedGoogle Scholar
  3. 3.
    Bindal RK, Glaze S, Ognoskie M, Tunner V, Malone R, Ghosh S (2008) Surgeon and patient radiation exposure in minimally invasive transforaminal lumbar interbody fusion. J Neurosurg Spine 9:570–573CrossRefPubMedGoogle Scholar
  4. 4.
    Cortez M (2016) Medtronic to Buy Mazor Shares, Promote Surgical System. Bloomberg. https://www.bloomberg.com/news/articles/2016-05-18/medtronic-to-buy-mazor-robotics-shares-promote-surgical-system. Accessed 2/20/2018
  5. 5.
    D’Annibale A, Morpurgo E, Fiscon V, Trevisan P, Sovernigo G, Orsini C, Guidolin D (2004) Robotic and laparoscopic surgery for treatment of colorectal diseases. Dis Colon Rectum 47:2162–2168CrossRefPubMedGoogle Scholar
  6. 6.
    Devito D, Gaskill T, Erickson M (2010) Robotic-based guidance for pedicle screw instrumentation of the scoliotic spine. In: spine arthroplasty society (SAS) 10th annual global symposium on motion preservation. TechnologyGoogle Scholar
  7. 7.
    Devito DP, Kaplan L, Dietl R, Pfeiffer M, Horne D, Silberstein B, Hardenbrook M, Kiriyanthan G, Barzilay Y, Bruskin A (2010) Clinical acceptance and accuracy assessment of spinal implants guided with SpineAssist surgical robot: retrospective study. Spine 35:2109–2115CrossRefPubMedGoogle Scholar
  8. 8.
    Dreval ON, Rynkov IP, Kasparova KA, Bruskin A, Aleksandrovskiĭ V, Zil'bernshteĭn V (2014) Results of using spine assist Mazor in surgical treatment of spine disorders. Zh Vopr Neirokhir Im N N Burdenko 78:14–20PubMedGoogle Scholar
  9. 9.
    Fan Y, Du J, Zhang J, Liu S, Xue X, Huang Y, Zhang J, Hao D (2017) Comparison of accuracy of pedicle screw insertion among 4 guided Technologies in Spine Surgery. Medical science monitor: international medical journal of experimental and clinical research 23:5960–5968CrossRefGoogle Scholar
  10. 10.
    Fan Y, Du JP, Liu JJ, Zhang JN, Liu SC, Hao DJ (2018) Radiological and clinical differences among three assisted technologies in pedicle screw fixation of adult degenerative scoliosis. Sci Rep 8:890CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Faria CEW, Rito M, De Momi E, Ferrigno G, Bicho E (2015) Review of robotic technology for stereotactic neurosurgery. IEEE Rev Biomed Eng 8:125–137.  https://doi.org/10.1109/RBME.2015.2428305 CrossRefPubMedGoogle Scholar
  12. 12.
    Fiani B, Quadri SA, Ramakrishnan V, Berman B, Khan Y, Siddiqi J (2017) Retrospective review on accuracy: a pilot study of robotically guided thoracolumbar/sacral pedicle screws versus fluoroscopy-guided and computerized tomography stealth-guided screws. Cureus:9Google Scholar
  13. 13.
    Fujishiro T, Nakaya Y, Fukumoto S, Adachi S, Nakano A, Fujiwara K, Baba I, Neo M (2015) Accuracy of pedicle screw placement with robotic guidance system: a cadaveric study. Spine 40:1882–1889CrossRefPubMedGoogle Scholar
  14. 14.
    Garrity M (2018) da Vinci Surgical System vs. Renaissance Robotic Surgical System—is Mazor Robotics the next Intuitive Surgical? Becker's Spine Review. https://www.beckersspine.com/orthopedic-a-spine-device-a-implant-news/item/39853-da-vinci-surgical-system-vs-renaissance-robotic-surgical-system-is-mazor-robotics-the-next-intuitive-surgical.html. Accessed 2/20/2018
  15. 15.
    Goldstraw M, Patil K, Anderson C, Dasgupta P, Kirby R (2007) A selected review and personal experience with robotic prostatectomy: implications for adoption of this new technology in the United Kingdom. Prostate Cancer Prostatic Dis 10:242–249CrossRefPubMedGoogle Scholar
  16. 16.
    Grelat M, Zairi F, Quidet M, Marinho P, Allaoui M, Assaker R (2015) Assessment of the surgeon radiation exposure during a minimally invasive TLIF: comparison between fluoroscopy and O-arm system. Neuro-Chirurgie 61:255–259CrossRefPubMedGoogle Scholar
  17. 17.
    Herron D, Marohn M (2008) A consensus document on robotic surgery. Surg Endosc 22:313–325CrossRefPubMedGoogle Scholar
  18. 18.
    Hu X, Lieberman IH (2014) What is the learning curve for robotic-assisted pedicle screw placement in spine surgery? Clin Orthop Relat Res 472:1839–1844CrossRefPubMedGoogle Scholar
  19. 19.
    Hu X, Lieberman IH (2017) Robotic-guided sacro-pelvic fixation using S2 alar-iliac screws: feasibility and accuracy. Eur Spine J 26:720–725CrossRefPubMedGoogle Scholar
  20. 20.
    Hu X, Ohnmeiss DD, Lieberman IH (2013) Robotic-assisted pedicle screw placement: lessons learned from the first 102 patients. Eur Spine J 22:661–666CrossRefPubMedGoogle Scholar
  21. 21.
    Hu X, Scharschmidt TJ, Ohnmeiss DD, Lieberman IH (2015) Robotic assisted surgeries for the treatment of spine tumors. Int J Spine Surg 9.  https://doi.org/10.14444/2001
  22. 22.
    Hyun S-J, Kim K-J, Jahng T-A (2017) S2 alar iliac screw placement under robotic guidance for adult spinal deformity patients. Eur Spine J 26:2198–2203CrossRefPubMedGoogle Scholar
  23. 23.
    Hyun S-J, Kim K-J, Jahng T-A, Kim H-J (2017) Minimally invasive robotic versus open fluoroscopic-guided spinal instrumented fusions: a randomized controlled trial. Spine 42:353–358CrossRefPubMedGoogle Scholar
  24. 24.
    Irani M, Prabakar C, Nematian S, Julka N, Bhatt D, Bral P (2016) Patient perceptions of open, laparoscopic, and robotic gynecological surgeries. Biomed Res Int 2016:4284093.  https://doi.org/10.1155/2016/4284093 CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Jayaraman S, Davies W, Schlachta CM (2009) Getting started with robotics in general surgery with cholecystectomy: the Canadian experience. Can J Surg 52:374PubMedPubMedCentralGoogle Scholar
  26. 26.
    Jeong IG, Khandwala YS, Kim JH, Han DH, Li S, Wang Y, Chang SL, Chung BI (2017) Association of robotic-assisted vs laparoscopic radical nephrectomy with perioperative outcomes and health care costs, 2003 to 2015. JAMA 318:1561–1568.  https://doi.org/10.1001/jama.2017.14586 CrossRefPubMedGoogle Scholar
  27. 27.
    Joseph JR, Smith BW, Liu X, Park P (2017) Current applications of robotics in spine surgery: a systematic review of the literature. Neurosurg Focus 42:E2CrossRefPubMedGoogle Scholar
  28. 28.
    Kantelhardt SR, Martinez R, Baerwinkel S, Burger R, Giese A, Rohde V (2011) Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement. Eur Spine J 20:860–868CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Keric N, Doenitz C, Haj A, Rachwal-Czyzewicz I, Renovanz M, Wesp DM, Boor S, Conrad J, Brawanski A, Giese A (2017) Evaluation of robot-guided minimally invasive implantation of 2067 pedicle screws. Neurosurg Focus 42:E11CrossRefPubMedGoogle Scholar
  30. 30.
    Keric N, Eum DJ, Afghanyar F, Rachwal-Czyzewicz I, Renovanz M, Conrad J, Wesp DM, Kantelhardt SR, Giese A (2017) Evaluation of surgical strategy of conventional vs. percutaneous robot-assisted spinal trans-pedicular instrumentation in spondylodiscitis. J Robot Surg 11:17–25CrossRefPubMedGoogle Scholar
  31. 31.
    Kim MJ, Ha Y, Yang MS, Kim KN, Kim H, Yang JW, Lee JY, Yi S, Jung WJ, Rha KH (2010) Robot-assisted anterior lumbar interbody fusion (ALIF) using retroperitoneal approach. Acta Neurochir 152:675–679CrossRefPubMedGoogle Scholar
  32. 32.
    Kim H-J, Kang K-T, Park S-C, Kwon O-H, Son J, Chang B-S, Lee C-K, 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 17:671–680CrossRefPubMedGoogle Scholar
  33. 33.
    Kim HJ, Jung WI, Chang BS, Lee CK, Kang KT, Yeom JS (2017) A prospective, randomized, controlled trial of robot-assisted vs freehand pedicle screw fixation in spine surgery. The International Journal of Medical Robotics and Computer Assisted Surgery 13Google Scholar
  34. 34.
    Kuo K-L, Su Y-F, Wu C-H, Tsai C-Y, Chang C-H, Lin C-L, Tsai T-H (2016) Assessing the intraoperative accuracy of pedicle screw placement by using a bone-mounted miniature robot system through secondary registration. PLoS One 11:e0153235CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Lai F, Entin E (2005) Robotic surgery and the operating room team. In: Proceedings of the human factors and ergonomics society annual meeting, 2005. Vol 11. SAGE Publications Sage CA, Los Angeles, pp 1070–1073Google Scholar
  36. 36.
    Laratta JL, Shillingford JN, Lombardi JM, Alrabaa RG, Benkli B, Fischer C, Lenke LG, Lehman RA (2018) Accuracy of S2 alar-iliac screw placement under robotic guidance. Spine deformity 6:130–136.  https://doi.org/10.1016/j.jspd.2017.08.009 CrossRefPubMedGoogle Scholar
  37. 37.
    Laudato PA, Pierzchala K, Schizas C (2017) Pedicle screw insertion accuracy using O-arm, robotic guidance or freehand technique: a comparative study. SpineGoogle Scholar
  38. 38.
    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 59:641–650CrossRefPubMedGoogle Scholar
  39. 39.
    Lieberman IH, Hardenbrook MA, Wang JC, Guyer RD (2012) Assessment of pedicle screw placement accuracy, procedure time, and radiation exposure using a miniature robotic guidance system. Clin Spine Surg 25:241–248Google Scholar
  40. 40.
    Lonjon N, Chan-Seng E, Costalat V, Bonnafoux B, Vassal M, Boetto J (2016) Robot-assisted spine surgery: feasibility study through a prospective case-matched analysis. Eur Spine J 25:947–955CrossRefPubMedGoogle Scholar
  41. 41.
    Macke JJ, Woo R, Varich L (2016) Accuracy of robot-assisted pedicle screw placement for adolescent idiopathic scoliosis in the pediatric population. J Robot Surg 10:145–150CrossRefPubMedGoogle Scholar
  42. 42.
    Meehan JJ, Sandler A (2008) Pediatric robotic surgery: a single-institutional review of the first 100 consecutive cases. Surg Endosc 22:177–182CrossRefPubMedGoogle Scholar
  43. 43.
    Mehmet Resid O, SıMSEK M, NADER S (2014) Robotic spine surgery: a preliminary report. Turk Neurosurg 24:512–518Google Scholar
  44. 44.
    Molliqaj G, Schatlo B, Alaid A, Solomiichuk V, Rohde V, Schaller K, Tessitore E (2017) Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery. Neurosurg Focus 42:E14.  https://doi.org/10.3171/2017.3.focus179 CrossRefPubMedGoogle Scholar
  45. 45.
    Mortazavi MM, Quadri SA, Suriya SS, Fard SA, Hadidchi S, Adl FH, Armstrong I, Goldman R, Tubbs RS (2018) Rare concurrent retroclival and pan-spinal subdural empyema: review of literature with an uncommon illustrative case. World Neurosurg 110:326–335.  https://doi.org/10.1016/j.wneu.2017.11.082 CrossRefPubMedGoogle Scholar
  46. 46.
    Nasser R, Yadla S, Maltenfort MG, Harrop JS, Anderson DG, Vaccaro AR, Sharan AD, Ratliff JK (2010) Complications in spine surgery. J Neurosurg Spine 13:144–157.  https://doi.org/10.3171/2010.3.spine09369 CrossRefPubMedGoogle Scholar
  47. 47.
    Nathoo N, Cavusoglu MC, Vogelbaum MA, Barnett GH (2005) In touch with robotics: neurosurgery for the future. Neurosurgery 56:421–433 discussion 421-433CrossRefPubMedGoogle Scholar
  48. 48.
    OpenPR (2017) Global Surgical Robots for the Spine Industry Trend, Growth, Shares, Strategy and Forecasts 2016 to 2022. https://www.openpr.com/news/442943/Global-Surgical-Robots-for-the-Spine-Industry-Trend-Growth-Shares-Strategy-and-Forecasts-2016-to-2022.html. Accessed 11/26 2017
  49. 49.
    Overley SC, Cho SK, Mehta AI, Arnold PM (2017) Navigation and robotics in spinal surgery: where are we now? Neurosurgery 80:S86–S99.  https://doi.org/10.1093/neuros/nyw077 CrossRefPubMedGoogle Scholar
  50. 50.
    Patel VR (2006) Essential elements to the establishment and design of a successful robotic surgery programme. Int J Med Rob Comput Assisted Surg 2:28–35CrossRefGoogle Scholar
  51. 51.
    Pechlivanis I, Kiriyanthan G, Engelhardt M, Scholz M, Lücke S, Harders A, Schmieder K (2009) Percutaneous placement of pedicle screws in the lumbar spine using a bone mounted miniature robotic system: first experiences and accuracy of screw placement. Spine 34:392–398CrossRefPubMedGoogle Scholar
  52. 52.
    Ponnusamy K, Chewning S, Mohr C (2009) Robotic approaches to the posterior spine. Spine 34:2104–2109CrossRefPubMedGoogle Scholar
  53. 53.
    Quadri SA, Capua J, Ramakrishnan V, Sweiss R, Cabanne M, Noel J, Fiani B, Siddiqi J (2017) A rare case of pharyngeal perforation and expectoration of an entire anterior cervical fixation construct. J Neurosurg Spine 26:560–566.  https://doi.org/10.3171/2016.10.spine16560 CrossRefPubMedGoogle Scholar
  54. 54.
    Randell R, Alvarado N, Honey S, Greenhalgh J, Gardner P, Gill A, Jayne D, Kotze A, Pearman A, Dowding D (2015) Impact of robotic surgery on decision making: perspectives of surgical teams. AMIA Ann Symp Proc 2015:1057–1066Google Scholar
  55. 55.
    Rawlings A, Woodland J, Vegunta R, Crawford D (2007) Robotic versus laparoscopic colectomy. Surg Endosc 21:1701–1708CrossRefPubMedGoogle Scholar
  56. 56.
    Ringel F, Stüer 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–E501CrossRefPubMedGoogle Scholar
  57. 57.
    Robotics M (2015) Mazor Robotics Renaissance® Guidance System Helping Patients with OCD. https://www.mazorrobotics.com/index.php/resources-for/media/press-releases/147-mazor-robotics-renaissance-guidance-system-helping-patients-with-ocd. Accessed 12/16 2017
  58. 58.
    Robotics M (2016) Mazor-X-Overview-and-Strategy. https://www.mazorrobotics.com/Reports/investment/Mazor-X-Overview-and-Strategy.pdf. Accessed 18 Nov 2017
  59. 59.
    Robotics M (2017) FAQ for patients https://www.mazorrobotics.com/index.php/resources-for/for-patients/faq-for-patients. Accessed 18 Nov 2017
  60. 60.
    Robotics M (2017) Mazor-X. https://www.mazorrobotics.com/index.php/mazor-product-portfolio/mazor-x. Accessed 18 Nov 2017
  61. 61.
    Roser F, Tatagiba M, Maier G (2013) Spinal robotics: current applications and future perspectives. Neurosurgery 72:A12–A18CrossRefGoogle Scholar
  62. 62.
    Schatlo B, Molliqaj G, Cuvinciuc V, Kotowski M, Schaller K, Tessitore E (2014) Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison. J Neurosurg Spine 20:636–643CrossRefPubMedGoogle Scholar
  63. 63.
    Schatlo B, Martinez R, Alaid A, von Eckardstein K, Akhavan-Sigari R, Hahn A, Stockhammer F, Rohde V (2015) Unskilled unawareness and the learning curve in robotic spine surgery. Acta Neurochir 157:1819–1823CrossRefPubMedGoogle Scholar
  64. 64.
    Schizas C, Thein E, Kwiatkowski B, Kulik G (2012) Pedicle screw insertion: robotic assistance versus conventional C-arm fluoroscopy. Acta Orthop Belg 78:240–245PubMedGoogle Scholar
  65. 65.
    Schröder ML, Staartjes VE (2017) Revisions for screw malposition and clinical outcomes after robot-guided lumbar fusion for spondylolisthesis. Neurosurg Focus 42:E12CrossRefPubMedGoogle Scholar
  66. 66.
    Schroerlucke SR, Good CR, Wang MY (2016) A prospective, comparative study of robotic-guidance versus freehand in minimally invasive spinal fusion surgery: first report from MIS ReFRESH. Spine J 16:S253CrossRefGoogle Scholar
  67. 67.
    Schroerlucke SR, Wang MY, Cannestra AF, Good CR, Lim J, Hsu VW, Zahrawi F (2017) Complication rate in robotic-guided vs Fluoro-guided minimally invasive spinal fusion surgery: report from MIS Refresh prospective comparative study. Spine J 17:S254–S255CrossRefGoogle Scholar
  68. 68.
    Schroerlucke SR, Wang MY, Cannestra AF, Good CR, Lim JY, Hsu VW, Zahrawi F (2017) Revision rate in robotic-guided vs Fluoro-guided minimally invasive spinal fusion surgery: report from MIS ReFRESH prospective comparative study. Spine J 17:S255CrossRefGoogle Scholar
  69. 69.
    Sensakovic WF, O’Dell MC, Agha A, Woo R, Varich L (2017) CT radiation dose reduction in robot-assisted pediatric spinal surgery. Spine 42:E417–E424CrossRefPubMedGoogle Scholar
  70. 70.
    Shoham M, Burman M, Zehavi E, Joskowicz L, Batkilin E, Kunicher Y (2003) Bone-mounted miniature robot for surgical procedures: concept and clinical applications. IEEE Trans Robot Autom 19:893–901CrossRefGoogle Scholar
  71. 71.
    Solomiichuk V, Fleischhammer J, Molliqaj G, Warda J, Alaid A, von Eckardstein K, Schaller K, Tessitore E, Rohde V, Schatlo B (2017) Robotic versus fluoroscopy-guided pedicle screw insertion for metastatic spinal disease: a matched-cohort comparison. Neurosurg Focus 42:E13CrossRefPubMedGoogle Scholar
  72. 72.
    Srinivasan D, Than KD, Wang AC, La Marca F, Wang PI, Schermerhorn TC, Park P (2014) Radiation safety and spine surgery: systematic review of exposure limits and methods to minimize radiation exposure. World neurosurgery 82:1337–1343CrossRefPubMedGoogle Scholar
  73. 73.
    Sukovich W, Brink-Danan S, Hardenbrook M (2006) Miniature robotic guidance for pedicle screw placement in posterior spinal fusion: early clinical experience with the SpineAssist®. The International Journal of Medical Robotics and Computer Assisted Surgery 2:114–122CrossRefPubMedGoogle Scholar
  74. 74.
    Taylor RH, Stoianovici D (2003) Medical robotics in computer-integrated surgery. IEEE Trans Robot Autom 19:765–781.  https://doi.org/10.1109/TRA.2003.817058 CrossRefGoogle Scholar
  75. 75.
    Times F (2017) First Prospective Study of Robotic-Guided Spine Surgery Reveals Five-Fold Reduction in Surgical Complications with Mazor Core™ Technology. https://markets.ft.com/data/announce/detail?dockey=600-201710250430BIZWIRE_USPRX____BW5354-1. Accessed 11/26 2017
  76. 76.
    Urakov TM, KH-k C, Burks SS, Wang MY (2017) Initial academic experience and learning curve with robotic spine instrumentation. Neurosurg Focus 42:E4CrossRefPubMedGoogle Scholar
  77. 77.
    Watkins RG, Gupta A, Watkins RG (2010) Cost-effectiveness of image-guided spine surgery. The open orthopaedics journal 4:228–233.  https://doi.org/10.2174/1874325001004010228 CrossRefPubMedPubMedCentralGoogle Scholar
  78. 78.
    Young R (2012) The March of Robotics into the Spine Surgery. RRY Publications. https://ryortho.com/2012/09/the-march-of-robots-into-the-spine-surgery-suite/. Accessed 2/20/2018 2018
  79. 79.
    Yu E, Khan SN (2014) Does less invasive spine surgery result in increased radiation exposure? A systematic review. Clin Orthop Relat Res 472:1738–1748CrossRefPubMedPubMedCentralGoogle Scholar
  80. 80.
    Zahrawi F (2014) Comparative analysis of robotic-guided pedicle screw placement accuracy and freehand controls in percutaneous adult degenerative spinal instrumentation. Spine J 14:S63CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.NeurosurgeryDesert Regional Medical CenterPalm SpringsUSA
  2. 2.University of Oklahoma Health Sciences CenterOklahoma CityUSA

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